Dr. Alan L. Hart and the complicated history of gender affirming care in the U.S.

By Eva Jones, LCSW

Dr. Alan L. Hart, who most of us have never heard of, single handedly changed the landscape of tuberculosis (TB) detection and treatment, and saved countless lives, at a time when TB was the gravest health concern in the nation. 

Dr. Hart was also a trans man, and the first documented recipient of a transmasculine gender affirming surgery in the U.S.

Alan L. Hart was born in 1890 in Kansas, and after his father’s death in 1892, his mother moved their family to Oregon. Hart recalled living on his maternal grandfather’s farm in Oregon as a “happy time,” where he was allowed to wear “boys clothes” and do “farm work with the menfolk” as a child. Dr. Hart identified as a boy from his earliest memories, and described his mother and grandparents as being mostly accepting and supportive. In his grandparents’ obituaries in 1921 and 1924, Hart was listed as their grandson. During the early 1900s, Dr. Hart transferred back and forth between Albany College (now Lewis and Clark College) in Oregon, and Stanford University in California, before obtaining his medical degree in 1917. Although he had taken many steps to socially transition during his college years, and had written and published works under his preferred name, Alan Hart, his medical degree listed his legal name instead. Because of this, Dr. Hart continued to face discrimination throughout his career whenever his credentials were checked and seen to not align with his presenting gender. Due to safety concerns and unemployment resulting from being outed as a trans man, Dr. Hart often had to change locations. Between 1918 and 1927, he worked in at least seven different states. 

But during these years, Dr. Hart was hard at work researching and developing innovative treatments for TB. Dr. Hart was one of the first physicians to document how TB spread from the lungs via the circulatory system, leading to lesions in the kidneys, spine, and brain, and eventually, to death. This knowledge completely shifted how medical professionals were diagnosing and treating a myriad of illnesses, such as “consumption,” “Koch’s disease,” and “lupus vulgaris,” realizing now that these were all, actually, cases of TB. Dr. Hart’s research helped the medical field understand that, since there is no cure for TB, early detection is essential for treatment and survival. Because TB often shows no symptoms in the early stages, Dr. Hart started using X-rays for early detection. X-ray technology had been discovered in 1895, but was mainly used to detect broken bones and tumors. Using X-rays for early detection allowed for TB patients to be identified before they showed symptoms, isolated from the general population, and treated, often saving the patients’ lives and the lives of countless others who would have otherwise been exposed to the disease. 

Dr. Hart also contributed significantly to changing language and reducing stigma around TB, which at the time, was a highly stigmatized disease. Likely informed by his own lived experience, Dr. Hart understood the harmful impact of stigma, and the importance of “discretion and compassion” for treating a stigmatized disease like TB. For this reason, he referred to himself as a “chest doctor” and to his TB patients as “chest patients.” This neutral language encouraged increased access to TB screenings and treatment for the general population. As a result of Dr. Hart’s methods, by the time antibiotics were introduced in the 1940s, TB deaths had already been reduced to “one fiftieth.” From 1937, until his death in 1962, Dr. Hart held state leadership positions overseeing TB care, first in Idaho, and then in Connecticut, continuing to save lives and develop practices and protocols that would be used successfully for many years to come. 

Dr. Hart’s contributions to medicine are rightfully renowned; but his legacy as a figure in queer history is more complicated. Although Dr. Hart’s surgery was the first of its kind in the U.S., it wasn’t the first in the world. Eleven years earlier, in October 1906, Karl Baer underwent “multi-stage rudimentary gender affirmation surgery” performed by Magnus Hirshfeld of the Institute for Sex Research in Germany. Karl Baer was born intersex and assigned female at birth, but later self-identified as a man. Although enough records survived to provide proof of Baer’s historic surgery, much of the medical information of his case was lost when, in 1933, the Nazis raided Hirschfeld’s institute and burned his library of research. What records remain, show that Karl Baer’s case set a new precedent for gender affirming surgery by “enlisting simultaneous support from psychiatric, legal, and surgical quarters.” In 1917, Dr. Hart appears to have drawn on Baer’s approach, by seeking the counsel of Dr. Joshua Allen Gilbert for psychiatric and surgical support with medical transition. At first, Dr. Gilbert was hesitant to perform gender affirming surgery, and tried a variety of conversion therapy tactics including hypnosis, all of which, of course, failed in their mission to make Dr. Hart “happy as a woman.” Dr. Hart eventually persuaded Dr. Gilbert to perform a hysterectomy by leveraging a eugenics argument, that people with “abnormal inversion,” like himself, should be sterilized. 

The terms “invert,” “inversion” or “abnormal inversion,” came from the field of sexology in Germany in the late 1800s- early 1900s, and were used to describe a “theory of homosexuality.” Essentially, an “invert” was someone who was “attracted to their own sex,” and experienced “an inborn reversal of gender traits: male inverts were, to a greater or lesser degree, inclined toward traditional female pursuits and dress, and vice versa.” At this time, there was no differentiation between gender and sexuality, and all queerness was largely viewed as a moral issue and criminalized in most western countries. The language of “inversion” was used to describe queerness in general, but it also served to medicalize queerness. The medicalization of queerness was considered progressive for the time, because it rebranded queerness from a legal issue, to a pathology issue. German psychiatrist Richard von Krafft-Ebing, in his 1886 book, Psychopathia Sexualis, “defined homosexuality as an innate neuro psychopathic disorder—essentially a hereditary nervous disease,” and “portrayed homosexuals as hereditarily burdened perverts who were not responsible for their innate ‘reversal’ of sexual drive, and therefore were the purview not of criminal judges, but rather of the Neurologists and Psychiatrists.” This was the context in which Dr. Hart made his eugenics argument- during a time when eugenics and social darwinism were regarded by many not as harmful pseudoscience, but as a fact of nature, and the white supremacist logic of eugenics was socially acceptable; during a time when pathologizing queerness was progress. 

Dr. Hart successfully used this to advocate for himself to receive the medical care that he needed to live a life that was more aligned with his authentic self, and to keep himself mentally and physically well. So successful was this strategy in achieving his goals, that Dr. Hart reported in an interview with a local paper in 1918, that he was, “happier since I made this change than I ever have in my life, and I will continue this way as long as I live….” Dr. Hart’s wellness and happiness are something to be celebrated. However, the eugenics logic that Dr. Hart resorted to, positions gender expansive people as “abnormal” and needing to be eliminated through sterilization. When we look at Dr. Hart’s experience trying to access gender affirming care, and the historical context that he was doing this in, we can notice some of the earliest intersections between ableism, transphobia, and medicine, which have shaped the way that our society still provides gender affirming care today. 

That pathologization of queerness, coupled with the psychiatric, medical, and legal precedent of Karl Baer’s case, have informed the state of gender affirming care in the U.S. today, where in order for gender expansive people to access care, they often have to navigate within the legal system of their state, and always have to navigate within the “disease model” of medicine and mental health. According to the American Psychiatric Association (APA), the “disease model” suggests that a psychiatric diagnosis is best understood as a “syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” Under this framework, any experience of human distress or impairment that is clinically significant, gets understood as an internal pathology; as a failure of that person’s mind, body, or development. Many mental health professionals, especially those who understand the reality that social, economic, and cultural factors directly impact mental health, rightfully criticize or outright reject the disease model of mental health. The Diagnostic and Statistical Manual of Mental Disorders (DSM), created by the APA and an example of the disease model in practice, lists “gender dysphoria” as a mental health diagnosis as of 2013, replacing the more clearly pathologizing prior “gender identity disorder” diagnosis. While many critics argue that “gender identity disorder” and “gender dysphoria” are the latest chapters in the APA’s long-standing tradition of pathologizing queerness (“homosexuality” was a mental health diagnosis in the DSM until 1973), others argue that the creation of these diagnoses has provided a much needed pathway for queer people to receive care, within a system that intentionally limits care for everyone. 

The structure of our current healthcare system requires a disease to be labeled in order for the person’s experience to be considered legitimate enough by insurance companies to justify paying for care, aka “medical necessity.” Most insurance companies require a diagnosis of something to prove medical necessity. In the case of gender affirming care, most insurance companies require a diagnosis of “gender dysphoria.” While many trans people do experience gender dysphoria, and find this diagnosis very validating, not all trans people do. As gender affirming care advocate Dallas Ducar points out in her 2022 article, “Dysphoria is not the experience of all trans people. With appropriate care and affirmation, in fact, many may go on to experience ‘gender euphoria’ because they are not stigmatized and seen as ‘other’ but instead are welcomed and personal experience is not questioned.” Ducar explains that many trans people experience dysphoria in the absence of affirming social structures in their lives. In other words, gender dysphoria is connected to the presence of transphobia, because transphobia eliminates affirming social structures; and many people may not experience gender dysphoria, if not for transphobia. For this reason, Dallas Ducar and many others advocate for eliminating “medical necessity” all together as a requirement in order to receive gender affirming care, and/or eliminating the requirement for a “gender dysphoria” diagnosis. This advocacy is growing within the field of trans healthcare rights.  

It is my view that, especially when it comes to queerness, human distress and impairment can be better understood as a measure of society’s failure to provide adequate support and safety, rather than as a measure of a queer person’s failure of their mind and body, or their failure to adapt to society. As philosopher Jiddu Krishnamurti noted, “It is no measure of health to be well adjusted to a profoundly sick society.” Our society is profoundly sick with transphobia, cisheteropatriarchy, white supremacy, and other interconnected systems of oppression. All industries within our society, including and especially mental health, are profoundly sick with these systems of oppression, and have been since the earliest psychiatrists came on the scene. Many trans people are experiencing dysphoria, not because of their transness, but because our society is so sick, so polluted with transphobia, that it has been made uninhabitable for many trans people’s minds, bodies and spirits. Although change has been made since 1917, the cultural and historical context that Dr. Alan Hart lived in, is the same profoundly sick society that we are living in now. In another hundred years, I wonder how much of the language we use now will sound as outdated and pathologizing as “abnormal inversion” sounds today?

We don’t know the extent to which Dr. Hart himself believed in the eugenics argument he cited for his own gender affirming care, but we do know that his surgeon Dr. Gilbert believed it; enough to perform the surgery. We don’t know all of Dr. Hart’s inner thoughts, but we do know that the intersections of transphobia and ableism in our healthcare system put him in a position to have to prove that he was abnormal enough, diseased enough, to necessitate surgical intervention. We do know that still today, the disease model’s requirement of “medical necessity” continues to put trans people in a position to have to prove that they experience gender dysphoria to access care, even if they don’t relate to this experience, and even if they find this language and framing harmful. Queer people still have to appeal to a system which pathologizes us in order to access care. 

To some, perhaps Dr. Alan Hart was a resourceful trans icon who, under the yoke of transphobia, did what he needed to do to be able to live authentically, and who made medical history in multiple ways in the process. To others, perhaps Dr. Alan Hart was an internalized eugenicist who, from his place of privilege as white, middle class, and highly educated, got what he needed for his authentic life, at the expense of less privileged queer, BIPOC, disabled, and poor people who suffered the most violence from eugenics. Perhaps, like me, you can notice both interpretations coming up from different parts of yourself. 

Dr. Hart once said, “Each of us must take into account the raw material which heredity dealt us at birth and the opportunities we have had along the way, and then work out for ourselves a sensible evaluation of our personalities and accomplishments.” Maybe we can work out a sensible evaluation, a nuanced view, of our own complicated feelings about Dr. Hart and about the current system of gender affirming care. Maybe it’s more helpful to hold “both, and,” rather than “either, or” with this human being, and with this human-made system of healthcare. We can celebrate Dr. Hart’s significant medical contributions and honor his position in history as a significant trans figure; and at the same time, we can hold the reality that his self advocacy, while a success for him and likely his only viable option, did contribute to the harmful ideology of eugenics, which is still negatively impacting marginalized people today. Similarly, we can recognize the positive impact of the gender dysphoria diagnosis in giving queer people access to life-saving care, and in validating some peoples’ real and impactful experiences of dysphoria; while also recognizing the systemic and personal harm of queer pathologization that the disease model perpetuates.