By Asher Kohn

Culturally, transgender issues are certainly having a moment. Last March, Caitlyn Jenner made a star turn on the cover of Vanity Fair. Transparent is one of Amazon’s most successful shows. And Orange is the New Black was a breakout role for transgender actor Laverne Cox.

But aside from reporters’ impertinent questions about genitals, the medical aspects are less discussed. Today, there are well over 100 doctors in the United States who perform sexual reassignment surgery, according to TransHealthCare. But at one point, that number was more like…three.

Two of those worked with Christine Jorgensen, who is often credited as the first recipient of such surgery. She had to go to Denmark to begin treatment, but returned stateside in 1953 as a blond vamp. Becoming a nightclub singer and TV star with a Lauren Bacall fashion sense, she was an international sensation. But it turns out she was not the first person to have her sex reassigned.

Sex reassignment surgery had an earlier life, in an unexpected time and place: 1920s Germany. Several doctors there performed such surgeries using analog technology and organic hormones. They worked under a new paradigm: What if they could make someone’s body fit their mind instead of forcing their mind to fit their body?

“Sex-change surgery did not take root…because of new or unusual medical technology,” writes Yale professor Joanne Meyerowitz in her 2002 book How Sex Changed. “It took root because Germany had a vocal campaign for sexual emancipation.”

Film still from Anders als die Andern or Different from the Others.

Germany had a vibrant LGBT community in the years after World War I. One of the era’s biggest film stars, Conrad Veidt, even portrayed cinema’s first gay character in 1919’s Different from the Others — a film written by renowned sexologist Magnus Hirschfeld, whose later work would be vital to the early research into the biological aspects of trans identity.

Meanwhile, early experiments in hormone replacement were underway in Vienna. One surgeon had successfully introduced transplanted testes into a female guinea pig, noting “the line of demarcation between the sexes is not as sharp as is generally taken for granted.” He was interested in gender but ultimately chose a more profitable route and helped aging men boost their testosterone using a surgery that was basically Steampunk Viagra.

Other doctors seemed less compassionate than curious. One attempted to “cure” homosexuality by replacing a gay man’s testicles with those of a heterosexual donor. There are also accounts of transplanting ape testicles into men, womb insertion, and voluntary castration. Constructed vaginal openings, done with rudimentary painkillers, bordered on the macabre.

Via the Magnus Hirschfeld Foundation

But Hirschfeld took a different route. The Stonewall Society refers to him as part educator and part “father-confessor” who claimed to have discussed homosexuality and transsexual issues with over 30,000 people. He understood surgery as a promising field in the portfolio of sex studies, not as a new practice with which he could make his name.

Hirschfeld saw himself as an activist, constantly referring to a motto of “justice through science.”—which also made him a target of Germany’s rising far right. In 1921, he was jumped after a lecture and left for dead on the street.

He persisted, though, and became an intermediary between the German government and the trans community. One story tells of a trans woman who was arrested on counts of female impersonation. The judge contacted Hirschfeld, who consulted with the woman. She requested and received reassignment surgery, and later worked in Hirschfeld’s Institute for Sexual Science.

Two of Hirschfeld’s colleagues performed numerous reassignments and began to realize that their patients tended to be wealthy Germans. They publicized their surgeries in newspapers, hoping poorer trans people could learn about the procedures and get in touch.

By the early 1930s, people came from around the world to undergo reassignment surgery in Berlin. Then Adolf Hitler was appointed Chancellor of Germany in January 1931. Two years later, his brownshirts broke into Hirschfeld’s institute and burned his journals and research. When Hirschfeld was out of Germany on tour, the Nazi student group marched on the Institute. Over 20,000 books were set aflame, as well as medical diagrams and photographs crucial to understanding sex reassignment surgery. Hirschfeld and his colleagues were Jewish, but it wasn’t just that. Hitler also publicly raged against the “vice” of homosexuality and the “degenerate” lives of transsexuals. They weakened the Aryan cause.

The patients were largely saved from targeting by the Nazis by the fact that the documentation of their procedures went up in smoke, but the trans community’s Great Library of Alexandria was burned, and the medical research was pushed back decades.