Ever Forward

For almost a decade, Dariel Peay was afraid to hug people. Assigned the male sex at birth, Peay began presenting as a woman once she started working in the dermatology department at the Johns Hopkins Hospital in 2007, spending two-and-a-half hours every morning positioning pads onto her hips and pushing cotton-ball-stuffed stockings into her bra. Although filling out her dresses made her feel more feminine, she worried about someone going in for a hug and feeling the “rocks” on her chest.

“One morning, I couldn’t find the pads, and I thought I was going to lose my mind,” says Peay. “I tore up the house because I felt so uncomfortable going anywhere without them.”

She spent the next nine years trying to convince plastic surgeons and her health insurance company that her need for breast augmentation surgery was not simply cosmetic. But despite dozens of disappointing appointments, she was determined to create an outward figure that matched her true inner self.

So when she heard that Hopkins was planning to launch the Center for Transgender Health in 2017, Peay ran to the department of plastic and reconstructive surgery to get an appointment. After a months-long intake and consultation process, the day finally came. Peay woke up from surgery that October and, after calling for her mother, cautiously looked down at her chest. Two years later, she still remembers that moment as one of the first times she felt like a person.

“As reality kicked in, I couldn’t believe it really happened,” she says. “If I could’ve, I would’ve run to my doctor and thanked him so many times. He changed my life.”

While the gender-affirming surgeries and care made available by the Center for Transgender Health have created transformative opportunities for patients like Peay, many still question why these resources were missing from local health care for so many decades prior.

“Where has this been?” says Peay, reflecting on the years before her surgery. “Johns Hopkins is one of the top hospitals in America and globally—why were we not making sure that all patients were being taken care of?”

“If I could’ve, I would’ve run to my doctor and thanked him so many times. He changed my life.”

It turns out, Hopkins has a long and complicated history with what were once called “sex change” operations, now referred to as gender-affirming surgery. During the early 1960s, patients who had travelled abroad to receive gender-affirming surgeries started checking into the Baltimore hospital. Many had experienced serious side effects following the overseas procedures and turned to Hopkins to repair the damage and, in some cases, provide further reconstruction. Although a few U.S. surgeons had performed less than a dozen gender-affirming surgeries by 1965, many hospital boards refused to permit it.

But when faced with questions of how to evaluate and care for transgender patients, a small group of Hopkins professionals decided to address their own lack of knowledge. Milton Edgerton, then the hospital’s chairman of plastic surgery, asked assistant professor John Hoopes to develop a research protocol to resolve questions about the appropriate treatment of gender dysphoria—the feeling that one’s gender identity and given sex don’t match. Hoopes gave the green light for further study into how surgical procedures could play a role, and the two men began assembling an interdisciplinary committee—including psychologist John Money and endocrinologist Claude Migeon. They wanted to not only provide gender-affirming care, but also establish factors that could predict positive medical outcomes.

The Gender Identity Clinic was officially established on June 20, 1966, making Hopkins the first academic institution in the U.S. to perform gender-affirming surgeries. “I created the team and established the clinic only after much study and soul-searching and with the realization that current methods of therapy were not solving the problem,” says Hoopes, who received emeritus status and retired from the hospital in 1990.

Although the clinic began accepting patient applications almost right away, the news of the opening didn’t go public until later that year. On November 21, the front page of The New York Times read, “A Changing of Sex by Surgery Begun at Johns Hopkins.”

“In a period of two weeks [following the article], we got about 3,000 letters from all over America from transsexual patients,” said Edgerton, now deceased, during an interview with the American Association of Plastic Surgeons in 2016. “[The letters] were eight to 10 pages long; people begging for surgery.”

With the world watching, the Gender Identity Clinic spent the next few years operating on trans patients from across the country. Although thousands applied, only a small percentage met the requirements for surgery, which included living as their identified gender for at least six months while undergoing hormonal therapy, as well as extensive psychological, genetic, and physical examinations. It was also difficult to find patients who could afford the cost—about $4,325 for male surgeries in 1970 (equivalent to roughly $28,190 today)—especially since most insurance companies would not pay for it.

By the beginning of 1972, the team had completed gender-affirming surgeries on seven trans women, 16 trans men, and nine others who received revisions of procedures performed elsewhere. The limited number of patients prevented them from making any definitive conclusions, but the clinic did demonstrate the importance of taking an interdisciplinary approach to transgender health care, with input from specialists in medicine, mental health, and surgery. And as word of its initial successes spread, the clinic became a template for other national institutions.

But despite its progress, many still disapproved of the Gender Identity Clinic’s work. Most prominently, Paul McHugh, the hospital’s then chair of the department of psychiatry, had a self-proclaimed anti-transgender bias, even publicly stating, “It was part of my intention, when I arrived in Baltimore in 1975, to help end [gender-affirming surgery].” McHugh’s view on what he called “guilt-ridden homosexual men” seeking such procedures was that being transgender was a psychological problem that should be treated with psychiatry.

Meanwhile, the clinic was facing new challenges at every turn: it lacked a stable funding source, several original team members (including Hoopes and Edgerton) left Hopkins, and new department staffers were not supportive of the surgery program. In 1979, Sexual Behaviors Consultation Unit (SBCU) chair Jon Meyer conducted a study to evaluate the difference in quality of life between trans patients who did and did not undergo surgery. Later that year, he announced that, after studying 50 subjects, he could not conclude that those who had surgery were any more adjusted to society than those who had not.

Meyer’s results starkly contradicted the findings of other researchers at the clinic, including Money, who previously reported that all but one of 24 surgery recipients said they were sure they made the right decision. The conflict between Meyer’s and Money’s scientific findings played out in national newspapers and professional journals, stirring a public debate about the role and morality of these procedures.

But with the study in hand, McHugh asserted that Hopkins was “fundamentally cooperating with mental illness” and shut down the Gender Identity Clinic within two months. Many other university-based academic programs that had followed Hopkins’ lead, such as Stanford University, also closed their doors over the next few years.

“One of my big disappointments,” said Edgerton, “is that although some American surgeons took up treatment of the transsexual patient, very few did.”

“Part of the legacy of the center is helping people who are better off for having come through it.”

Without the Gender Identity Clinic, Maryland’s transgender community was at a loss. For the next three decades, those seeking gender-affirming care in the region could access hormone therapy and other health services at centers such as the SBCU or Chase Brexton Health Care, but surgery was limited to plastic surgeons and specialists willing to perform select procedures. Peay remembers being excited to start her transition process in 2008, but she was discouraged by not only the lack of coverage for trans services, but also the dearth of knowledge among local physicians.

“I remember going to one hormone appointment and the resident said, ‘Well, I don’t really know anything about that,’” she recalls. “That experience made me realize that these people didn’t have a clue about trans health.”

But by 2015, the societal shift that increased public acceptance of LGBTQ individuals had taken hold within the halls of Hopkins. Hospital leaders recognized the growing need to provide gender-affirming operations to its patients, and they pledged to resume the surgical program. They quickly assembled committees to plan the structure of what would become the Center for Transgender Health while the hospital’s Office of Diversity and Inclusion worked to educate staff about transgender care.

Paula Neira, now the center’s clinical program director, co-chaired a task force that spent months examining the strengths and weaknesses of how Hopkins treated transgender patients. As a transgender woman who previously worked as a naval officer and a lawyer on the legal team that fought to repeal the military’s “Don’t Ask, Don’t Tell” policy, she is well-versed in such challenges.

“How a transgender person interacts with the health system—from being in the cafeteria and not being misgendered to interacting with security personnel to ask for directions—plays into their overall experience,” says Neira. “That means everybody in the organization has to at least have a basic understanding of how to talk to people with dignity and respect. Everyone wants to do that, but they don’t always know how.”

Hopkins leaders also recognized the need to rebuild trust within the LGBTQ community. After a 38-year hiatus in its surgical program, there was a built-up skepticism about the hospital’s commitment to its transgender patients. They conducted third-party surveys and held focus groups to learn the expectations of potential patients, such as alerting the trans community to job openings at the center.

“It was a cautious optimism [from the LGBTQ community],” says Neira. “They were happy to see Hopkins providing gender-affirming care again, but they wanted to see if we were going to put our money where our mouth is.”

But even as plans for the center came together in the fall of 2016, the 85-year-old McHugh, now a professor of psychiatry and behavioral sciences at Hopkins, co-authored a special report called “Sexuality and Gender” for the New Atlantis, a magazine published by a conservative Christian think tank. The study contended that sex and identity are innately tied and biologically determined. While it was met with alarm from many in the medical community, conservative media groups cited the paper as a reason to support legislation against transgender people.

That October, seemingly in reaction to the article, Hopkins released a statement that reiterated its “strong and unambiguous” commitment to the LGBTQ community amidst “the varied individual opinions expressed publicly by members of the Hopkins medicine community.”

As proof of the life-altering work done at the center, O’Brien-Coon points to its first-ever vaginoplasty patient—the first at the hospital in 40 years—who declared that her birthday is now the day she received her surgery. “Part of the legacy of the center is helping people who are better off for having come through it,” he says. “People can doubt it or think whatever they want, but the proof speaks for itself.”

The center involves about 30 Hopkins professionals across eight departments who work with patients to provide services such as hormone therapy, hair removal, and a host of gender-affirming surgeries. Neira says they underestimated the pent-up demand for care among the LGBTQ community and, although they only planned to serve 200 patients during the first year, they interacted with more than four times that within 14 months. As of April, the center had seen 1,400 patients and performed more than 300 surgical procedures.

Along with day-to-day care, O’Brien-Coon and a team of Hopkins researchers have spent the past two years conducting a review of transgender health care literature to determine how the center’s patient experiences can contribute to modern medical study. Because, for some questions related to gender-affirming care—such as surgery recovery times—there are still no definite answers.

One topic they aren’t running research on, though, is whether gender-affirming surgery is an effective treatment for gender dysphoria. “There is no legitimate debate for those who argue that gender affirmation is still experimental,” says Neira. “There are people who discount four decades of research because it doesn’t match their worldview. And that’s not going to change.”

With the history of the clinic behind them, the center’s team keeps Neira’s credo—“ever forward”—in mind, which serves as a reminder that it’s the only direction they can go. “Today, victory is connecting one patient to the care they need,” says Neira. “We’ll do it one person at a time until we have a change in the system and the resources to do it on a larger scale.”

Looking ahead, they’ll continue to work through the center’s ongoing challenges, such as the need for more staff and resources, while carrying out the philosophy of the clinic’s founding members from all of those years ago: treating patients with the recognition that gender-affirming care can improve their quality of life.

For Peay, that means taking hours off of her getting-ready routine and feeling like her body is one step closer to matching her true self. “I see Dr. O’Brien-Coon all the time at work, and when I do, I want to hug him and thank him,” she says. “And all he did was give me the opportunity to have the body that I’ve always wanted.”

“I’m a hugger now,” she says, beaming. “I finally feel free.”