The earliest known gender-affirming surgeries took place in Germany in the early 1920s, making the practice roughly a century old. What began as highly experimental procedures at a single institute in Berlin gradually spread across Europe, then to the United States, and eventually became a recognized field of medicine with standardized guidelines and increasingly refined techniques.
The First Surgeries in 1920s Berlin
The story begins at the Institute for Sexual Science in Berlin, founded by physician and sexologist Magnus Hirschfeld. It was here that Dora Richter became the first known person to undergo what we would now call male-to-female gender-affirming surgery. In 1922, surgeons removed her testicles. Nine years later, in 1931, she underwent a penectomy followed by the construction of a vagina. These procedures made Richter the first documented case of complete surgical transition in recorded history.
Around the same time, Danish painter Lili Elbe underwent a series of five highly experimental surgeries beginning in 1930. Hirschfeld examined Elbe before her operations, which were performed by German gynecologist Kurt Warnekros. The surgeries removed her testicles and penis, then attempted to transplant ovaries and a uterus into her body. Elbe died of complications shortly after the fifth procedure in 1931. Her story later became widely known through the 2015 film “The Danish Girl.”
These early cases were radical for their time. No established protocols existed, and surgeons were essentially improvising. The destruction of Hirschfeld’s institute by the Nazis in 1933 set the field back significantly, scattering its researchers and burning its extensive library of case studies.
Techniques Developed After World War II
Progress resumed in unexpected places after the war. Denmark became a center for advances in vaginoplasty during the late 1940s and 1950s. But the most consequential leap came from a gynecologist working quietly in Casablanca, Morocco. In 1956, Dr. Georges Burou independently developed a technique that used inverted penile skin to create a vaginal canal. This replaced earlier methods that relied on skin grafts, and it became the gold standard for decades. Burou deliberately kept a low profile so he could continue this controversial work without interference, but over his lifetime he performed more than 800 vaginoplasties for patients who traveled to his clinic from around the world.
Harold Gillies, a pioneering British plastic surgeon, also contributed landmark work during this period. Working with colleague Ralph Millard, Gillies refined the penile skin inversion approach in England around the same time Burou was developing it in Morocco. In the 1970s, surgeons added the creation of a clitoris from the glans of the penis and developed techniques for a more natural-looking vulva, representing the next major step forward in surgical outcomes.
The First Surgery for Transgender Men
Surgical options for transgender men followed a different timeline. A Russian surgeon named Bogoraz performed the first total penile reconstruction in 1936 using a tube-shaped flap of abdominal skin reinforced with rib cartilage. This was not specifically for gender transition, but it laid the groundwork.
The first female-to-male gender reassignment procedure came in 1946, when Harold Gillies operated on Laurence Michael Dillon, a British physician who had been assigned female at birth. The process required 13 separate operations. Gillies’ technique remained the standard approach for 40 years. In the 1970s and early 1980s, surgeons introduced pedicled flaps and free flap techniques, and by the late 1980s, a method using skin from the forearm became the preferred approach because it allowed urethral construction in a single stage. More recently, thigh-based flaps have started replacing the forearm technique because they leave a less visible scar and don’t require microsurgery.
Institutionalization in the United States
For the first several decades, transgender surgeries were performed by individual practitioners, often discreetly. That changed in 1966, when Johns Hopkins Hospital established the first gender-affirming surgery clinic in the United States. This was a turning point: a major academic medical center was now formally offering and studying these procedures, lending institutional credibility to a field that had operated largely in the shadows.
Standardization followed. In 1979, the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health, or WPATH) published its first Standards of Care, a set of guidelines for evaluating and treating people seeking gender transition. These guidelines, now in their eighth version, established criteria for surgical candidacy and laid out a framework that clinics worldwide still reference today.
Facial Surgery Enters the Picture
Until the mid-1980s, gender-affirming surgery focused almost entirely on the genitals. That changed when Dr. Douglas Ousterhout, a craniofacial surgeon, pioneered facial feminization surgery (FFS). Ousterhout recognized that the major visual differences between male and female faces come primarily from bone structure rather than soft tissue. Male facial skeletons tend to be angular with sharp contours, while female skeletons are rounder with broader, gentler transitions.
His work identified specific regions of the face, including the brow ridge, eye sockets, nose, chin, and jawline, as carrying the strongest sex-linked characteristics. This led to a suite of procedures: forehead reshaping, brow repositioning, rhinoplasty, jaw contouring, chin reshaping, and tracheal shaving, among others. Ousterhout’s initial research emphasized that the upper third of the face (forehead and brow) plays the largest role in how others perceive gender, and this finding guided the development of the field for decades after.
A Century of Development
From Dora Richter’s surgery in 1922 to today, transgender surgery has evolved from a handful of improvised operations into a global specialty practiced at major medical centers on every continent. The techniques have improved dramatically. Early vaginoplasties relied on skin grafts with limited function and sensation. Modern procedures use nerve-sparing approaches and refined tissue handling that produce significantly better outcomes. Phalloplasty has gone from crude tube-shaped flaps to sophisticated reconstructions with urinary function and sensation.
The trajectory of this field mirrors the broader history of plastic and reconstructive surgery. Many of the same surgeons who advanced war wound reconstruction, like Harold Gillies, also pushed gender-affirming techniques forward. Each generation of surgical innovation, from pedicled flaps to microsurgery to perforator flaps, has been applied to gender-affirming procedures shortly after its development in other contexts.