Table of contents
From Margins to Mainstream:
A History of Transgender Medicine in the United States
From Margins to Mainstream: A History of Transgender Medicine in the United States
From Margins to Mainstream: A History of Transgender Medicine in the United States
Table of Contents
Whose Voices are Heard? Race, Class, and Erasure in the History of Transgender Health
The published history of transgender medicine, like all published history, has largely been written by white, cisgender men. This is true despite the fact that people of all genders, races, ethnicities, religions, professions, sexual orientations, and socioeconomic classes have been integral in developing transgender medical practices and have been profoundly affected by the presence or absence of trans-affirming medical care.
To understand the history of transgender medicine one must explore the sociopolitical context in which that history evolved. To understand the roots of current practices, medical care for transgender people must be considered through the lenses of erasure, enslavement, Jim Crow, Christianity, patriarchy, colonialism, structural racism, and intersectional violence. Throughout this volume, readers will reflect on how race, class, criminalization, religion, sex, labor, and categories of personhood as determined by white, European ancestors defined and differentiated persons “worthy” of treatment from the “unworthy”, and “appropriate” intervention from “inappropriate.”
Further, this book will challenge authors and readers to move beyond understanding and toward response. Throughout this text, key questions will continue to emerge: who writes our history? Whose stories are told and whose are silenced? Which words get chosen, and what meanings do they convey? Why do we practice transgender medicine this way? Perhaps most important of all: how does knowledge of the past inform our future?
The pieces in this book will not provide all of the answers. However, they will begin to fill in the gaps purposefully carved out of popular history, coloring in a vibrant mosaic of passionate, courageous, and joyful individuals determined to live authentically and fully.
It is only through an honest, unflinching, holistic view of history relayed by a wide array of witnesses that we will begin to know where we’ve been, where we are, and where we are going, together.
Chapter 1: Pre-Colonial Gender Identities and the International Roots of Transitional Practices
Serena Nanda, PhD
Chapter 2: The Rise of Sexology in Europe
Clayton Whisnant, PhD
Le Chevalier D’Eon de Beaumont, 1728-1810, described by biographer Gary Kates thusly: “Born in 1728, French aristocrat Charles d'Eon de Beaumont had served his country as a diplomat, soldier, and spy for fifteen years when rumors that he was a woman began to circulate in the courts of Europe. D'Eon denied nothing and was finally compelled by Louis XVI to give up male attire and live as a woman, something d'Eon did without complaint for the next three decades. Although celebrated as one of the century's most remarkable women, d'Eon was revealed, after his death in 1810, to have been unambiguously male.”
Richard von Krafft-Ebing, 1840-1902, a 19th century scientist and one of the most prominent figures in the field of sexology. He first published his sweeping book, Psychopathia Sexualis, in 1886, in which he sought to catalogue the many forms of sexual psychopathology. Despite categorizing sexual orientations, such as homosexuality, fetishes, and impotence as psychological illness, he was progressive in his stance that homosexuality should not be criminalized, and that sufferers of psychological illness should be treated with therapy rather than imprisonment.
Karl Ulrichs, 1825-1895, was a 19th century lawyer and academician who first coined the term Urning as an attempt to define individuals with same-sex desire without invoking the sexual act. This is considered the earliest version of the more contemporary words homosexual or gay. In the 1860s he formulated his influential concept of a female soul in a male body, expressed in Latin as anima muliebris virile corpore inclusa. This attempt to understand homosexuality as a mental sex at odds from physical sex served as a precursor to future scientists’ distinctions between sex and gender.
Max Marcuse, 1877-1963, a 20th century German sexologist, published an article in 1916, on Geschlectsumwandlungstrieb, or drive for sex transformation, in which he distinguished the request for sex-change surgery from more generalized sexual inversion or crossgender identification.
Havelock Ellis, 1859-1902, the British sexologist who once wrote that the theory of “universal bisexuality” was “widely accepted” and speculated that human bisexuality might provide the biological basis for transvestism, which he called “sexo-aesthetic inversion.” Ellis also coined the term “Eonism” based upon his study of the fascinating life of the Chevalier D’Eon.
Otto Weinenger 1880-1903: The Concept of Universal Bisexuality Scholars, including Sigmund Freud, Charles Darwin, and Otto Weininger, presented evidence on the overlap of masculine and feminine traits, and tended to view gender as a continuum rather than a binary. Their theories lead to more open cultural attitudes about gender and sexuality compared to those present in the U.S.
Eugene Steinach 1861-1944, a 20th century Austrian physiologist who used experimented with using hormones to change the sex of rodents. Recognizing the profound effects of hormones on physical characteristics, he wrote, “The line of demarcation between the sexes is not as sharp as is generally taken for granted… A one hundred percent man is as non-existent as a one hundred percent woman.” All humans, he said, have “the primordial anlage or potentiality for either sex.”
1. The Steinach operation: Assigned
Chapter 3: Dr. Magnus Hirschfeld and Trans-Specific Care in the Weimar Republic
Robert Beachy, PhD
The highly influential Magnus Hirschfeld, a German physician and the man Hitler identified as “Germany’s most dangerous Jew.” Hirschfeld identified as a homosexual and worked from the late nineteenth century on to further homosexual rights. Unlike some of his predecessors and contemporaries, however, he differentiated homosexuals form transvestites, as distinct types of “sexual intermediaries.” Hirschfeld considered transvestism to be a “harmless inclination” and included in the transvestite group those with crossgender identification and those who crossdressed. Hirschfeld thought that variations in human sexuality were rooted in biology, and that a just society was one that recognized the natural order of things. A pioneering advocated for transgender people, Hirschfeld created the Institute for Sexual Science in Berlin, a combination of library, archive, lecture hall, and medical clinic, where he amassed an unprecedented collection of historical documents, ethnographies, case studies, and literary works detailing the diversity of sexuality and gender around the world. He hired transgender people to work at the Institute and played a personal role in arranging some of the earliest-known transition-related medical care for trans individuals, including Lille Elbe, a trans woman portrayed as the protagonist in the (historically inaccurate) 2015 movie, the Danish Girl. Unfortunately, Hirschfeld’s story has a tragic end. In 1933, the Institute was ransacked and destroyed by fascist vigilantes, the contents of Hirschfeld’s extensive library lost to history in the most famous Nazi book burning. Hirschfeld died in exile in 1935.
1. Sidebar: Surgeons Felix Abraham (1901-1937 Suicide) and Erwin Gorhbandt (1890-1965) Not yet assigned
2. Sidebar: The First Patients: Dörchen Richter (1891-?), Lili Elbe (1882-1931) Not yet assigned
Chapter 4: Pioneers of Trans-Specific Care
Cecile Ferrando, MD and Alex Boscia
The Remarkable Surgical Innovations of Sir Harold Gillies (1882-1960):
- While repairing the faces and bodies of grievously wounded veterans of World War I, Royal Army Medical
Corps surgeon Harold Gillies pioneered many plastic surgical techniques, setting the stage for the eventual
rise of cosmetic surgery. After the war he continued to practice. In 1946 he performed the first phalloplasty
on transgender man Michael Dillon, and in 1951 a vaginoplasty on transgender woman Roberta Cowell.
Christian Hamburger, (1904-1992): Physician to Christine Jorgensen
- Christian Hamburger was a endocrinologist who began his career doing research on human gonadotropins.
Because of this, he was approached by American Danish George Jorgensen, who persuaded him to give her
feminizing hormonal treatment. Christine Jorgensen returned to the U.S. in December 1952.
The Casablanca Connection: Georges Burou, (1910-1987)
- French gynecologist Georges Burou maintained his Clinique du Parc in Casablanca, Morocco, where from
the mid-1950s through the mid-1980s he performed surgery on more than 3000 transsexual women. His
patients included Coccinelle, April Ashley, and Jan Morris. He shared his techniques with Western
colleagues in 1973, and they continue to be influential.
1. Michael Dillon, (1915-1962). Not yet assigned
2. Roberta Cowell, (1918-2011). Not yet assigned
3. Christine Jorgensen (1926-,1992): focus here on how and why she got to Denmark and her two-year
transition under care of Hamburger. Assigned
4. Coccinelle, (1931-2006) April Ashley, (1935-), Jan Morris, (1926-), experience for people of color. Not yet
Part I: The international Roots of Transgender Medicine
Part II: The Beginnings of Transgender Medicine in North America
Chapter 5: Gender Diversity in Pre-colonial America
More than 150 indigenous North American tribes had specific categories and language to describe individuals living outside the binary. Jesuits and missionaries described gender variance in colonial terms. Historical records have neglected the history of nonbinary Native Americans. Recent efforts by LGBT Native Americans now ensure that these histories are included in their tribes’ collective memories.
1. We’Wha, Zuni Ihamana, 1884-1896 - Not yet assigned
2. Osh-Tisch, 1854-1929 - Not yet assigned
Chapter 6: Transgender Pioneers: Defining Appropriate Care Without Medical Interventions
Teri Wilhelm, Carolyn Wolf-Gould Editors Multiple Authors
Before the availability of hormones, surgery, or trans communities, many transgender and gender nonconforming people in the United States consolidated their identities and took steps toward authenticity, often crossliving. This chapter will describe the contributions of early transgender Americans to the field of transgender health.
- Jemimah Wilkensen (died 1776), AFAB; Teri Wilhelm?
- Mary Jones; Unassigned
- Joseph Lobdell/Lucy Lobdell, 1829-1885; Bambi Lobdell BAMBI LOBDEL
-Georgia Black, 1906-1951; Unassigned
- Alan Hart, 1890–1962; Unassigned
-Lou Sullivan: JAMISON GREEN
- Lucy Hicks Anderson, 1886-1954; Unassigned
- Virginia Prince (including her academic work and activism), 1912-2009; DALLAS DENNY
- Louise Lawrence, 1912-1976; MS BOB DAVIS AND JULIAN GILL-PETERSON
- James McHarris/Annie Lee Grant; Unassigned
- Marsha P. Johnson; Unassigned
- Sylvia Rivera; TERI WILHELM
Chapter 7: The Beginnings of Trans-Affirming Care the United States
Taryn Gundling, PhD
a) Christine Jorgensen’s (1926-1989) return to the US, serves as catalyst for change.
When Christine Jorgensen returned to the U.S. from Denmark in 1952 after successful gender reassignment under the care of Dr. Christian Hamburger, the ensuing media blitz brought the possibilities of gender transition to the forefront of American culture. Christine had been born and raised in the Bronx as a boy named George but was driven to seek gender-altering treatment abroad by her profound cross-sex identification. Captured by the story of the Ex-GI turned into Blond Bombshell, and fascinated by Christine’s refined manner and the sober, dignified way in which she presented herself, the American people were riveted to her story for years. Patients with gender dysphoria began to seek medical care in droves, and American doctors were suddenly faced with requests for treatment about a condition they knew nothing about. The press also turned to the medical community, asking questions about issues raised by Jorgenson’s story. As a result, doctors and scientists in the US began to discuss and debate the etiology, biology, and psychology of transsexualism, and were forced to explore the available treatments and develop language to reflect increasingly complex ideas about sexuality and gender.
b) b) Harry Benjamin (1885-1986) Defines a New Syndrome
Harry Benjamin, was a notable 20th century German-born endocrinologist who moved to the United States and became the leading medical authority on transsexuality in the 1950s. Dr. Benjamin treated many patients seeking gender transition with hormonal therapy. Most famously, Dr. Benjamin treated Christine Jorgensen, a trans woman whose story attracted international press attention in the 1950s due to her outspoken nature, beauty, and history as a GI. In July 1966, Dr. Benjamin published The Transsexual Phenomenon, a foundational work in which he described his decades of research with transgender patients and argued that a person’s gender identity could not be changed and that the doctor’s responsibility was thus to help trans people live fuller and happier lives in the gender they identified as their own.
1. Carlett Brown 1927-? (Two women of color who tried to transition when Christine did, but were unable—contrast experience of POC with that of Christine Jorgensen) 2. Ava Betty Brown (as above) 3. Elmer Belt. (may be included in surgical chapter instead)
Chapter 8: The Remarkable Philanthropy of Reed Erickson (1917-1992)
Aaron Devor, PhD
In 1963, Reed Erickson, a wealthy transman, became a patient of Dr. Benjamin and underwent masculinizing hormone transition under his care. Their subsequent collaboration led to radical changes in the field of transgender health. Erickson, with his fortune and vision for social change, established the Erickson Educational Foundation in 1964, a non-profit philanthropic organization with the mission “to provide assistance and support in areas where human potential was limited by adverse physical, mental or social conditions, or where the scope of research was too new, controversial or imaginative to receive traditionally oriented support.” For the next twenty years EEF supported scores of programs on transsexuality, specifically related to patient care resources, referrals, advocacy, education, medical research, and the creation of professional infrastructure. The EEF developed lists of providers who served transgender patients, launched campaigns to educate the general public through media presentations, and sponsored a series of international professional symposia, which ultimately lead to credibility to the field.
Chapter 9. Early Sexology in the United States
a) Alfred Kinsey’s (1894-1956) Work with Gender Diversity
b) Robert Stoller, MD, UCLA, Psychiatrist
c) Virginia Prince, PhD
d) Ira Pauly, MD, U of Oregon,
e) Richard Green, MD UCLA, 1936-present, Sissy Boy Syndrome
f) John Money, PhD (Money to be discussed in more detail in next chapter; just touch on him here)
g) Behavioral Treatment (refer to Dallas’ paper on aversion therapy to “cure” crossdressing
h) Psychiatric drugs and lobotomy for cross dressers.
i) Conversion therapy
j) DO Cauldwell
Chapter 10: Nature vs. Nurture and Gender vs. Sex
Joshua Safer, MD & Hansel Orroyo
John Money, (1921- 2006), and, later, Milton Diamond, (1934-) had opposing views regarding the question of nature vs. nurture to the field of gender identity. Diamond, an academic sexologist, believed gender was inborn. Money believed gender identity was learned and used the case of the Reimer twins to advance this theory, in the process becoming one of the most prominent sexologists in the world. David (1965-2004) and Brian (1965-) Reimer were identical twins. After David’s penis was destroyed during a botched surgery to remove unretractable foreskin at 8 months of age, his parents consulted Money, who advised them to surgically castrate their child and raise him as a girl. Money insisted on a strict program of feminine acculturation, which included complete secrecy about David’s assigned gender at birth and rigid attention to gender roles. For years, Money described the twins experiment in the medical literature as an unequivocal success, thus influencing popular and feminist thought about the etiology of gender and guiding the treatment of intersex children for years. But all was not well with David Reimer, who became increasing dysfunctional. At age 14, after voicing to his psychiatrist that he didn’t feel like a girl, he was told his story. He socially transitioned back to his natal gender of male, finding some comfort in this, though although he still struggled with dark moods and explosive anger. In 1997, Diamond found David and interviewed him. David allowed Diamond to publish the true outcome of his case. Money’s theory that gender was learned was debunked in a flurry of controversy about his honesty, ethics, and research methods.
Chapter 11. Gender Clinics: The First Wave
a) John Hopkins and the First Wave of the Gender Clinics
b) John Money, PhD, (1921-2006)
c) The Medical Model of Transsexualism
d) An Interdisciplinary Model for Treatment of Transsexualism at Hopkins
a. Conflation of sex and gender in the clinics
b. The plot to close the clinics:
c. Domino Effect across country- closing first wave of gender clinics
1. The medical model makes it impossible to talk about trans people in a healthy manner 2. Transsexualism and Sex Reassignment 3. Surgeons and surgical techniques at the Gender Clinics 4. Paul McHugh
Chapter 12. The Cultural Response to the Rise of Trans Care
Carolyn Wolf-Gould, MD
During the 20th Century, medical treatment for transgender people elicited strong positive and negative reactions throughout the United States.
a) David Oliver Cauldwell and the popular press
b) Psychoanalytic Assessment of Gender Variance
c) Theological Response: Erickson Educational Foundation’s Religious Aspects of Transsexualism.
d) McCarthyism, Conservatism and Gender as plot to destroy the World Order
e) Paul McHugh MD (Chair Psychiatry, John Hopkins) (Side bar?) (May be addressed in chapter on John Hopkins, need to coordinate)
f) The Mayhem Statues and effect on trans-affirming care
g) Socio-Cultural Academics and Criticisms of the Medical Model (Kessler & McKenna, Anne Bolin, Feinbloom).
h) Janice Raymond and TERFS, effect on medical care
i) Ray Blanchard, PhD/Ann Lawrence, MD: Autogynephilia Controversy (?later in book?)
j) The Clark Institute in Toronto, Zucker and Steiner/Blanchard
k) American Academy of Pediatrics
Chapter 13: Lack of Services and the Cost of Self-Care
a) The Back-Street Butcher: John Ronald Brown, (1922-2010) DALLAS DENNY
b) Silicone Injections DALLAS DENNY
c) Self-Treatment with Hormones (from necessity) DALLAS DENNY
d) Paying the Bills: Sex Work in the Trans Community CECILIA GENTILE
e) The AIDS epidemic and transgender women of color (CDC Policy on blood donation). LOTUS DAO
f) Health Care Disparities: Alcohol, Tobacco, Substance Abuse and Mental Health LOTUS DAO
g) Suicide KIM LEON
h) “State of Emergency” (Janet Mock) : The killing of transgender women of color CECILIA GENTILE
i) Prison Health: TBD
Part III: The Tipping point
Chapter 14. The Evolution of Professional Organizations, Endocrine Guidelines and the Standards of Care
Although providers for transsexuals were generally felt to be practicing on the fringe, the creation of the clinics and development of professional infrastructure led to collaboration, research and some grudging respect in the medical community. The EEF helped to finance the Harry Benjamin Foundation, a professional organization devoted to case review and research. The Harry Benjamin Foundation held monthly meetings, attended by a number of prominent sexologists, care providers, and researchers from across the country, including John Money and Richard Green.
The Harry Benjamin International Gender Dysphoria Association, Inc. HBIGDA, the first professional organization devoted to the organization and education of providers for transsexuals, was formed in 1979.
In 1979, HBIGDA published the first Standards of Care for diagnosis and treatment, guidelines designed to regulate and standardize psychological evaluation and medical treatment. In 2007, HBIGDA changed its name to World Professional Association of Transgender Health, an organization whose mission continues “to promote evidence-based care, education, research, advocacy, public policy and respect in transsexual and transgender health.” In 2010, WPATH issued a statement on the medical necessity of gender-confirming surgeries, thus exerting pressure on insurance companies to include these procedures as a covered benefit. The Seventh Edition of the WPATH Standards of Care, published in 2012, offers flexible clinical guidelines that reflect further evolution of treatment guidelines, particularly the move to de-stigmatize, referring to gender nonconformity as a form of diversity rather than pathology. The development of the endocrine society guidelines for the treatment of gender diverse people further mainstreams medical care for this population.
1. Early Transgender Representation in HBIGDA/WPATH - Assigned: Jude Patton
Chapter 15: From Disease to Diversity: The History of Diagnostic Nomenclature, The DSM, and ICD Coding
Kelley Winters, PhD
The classification of gender nonconformity as described in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) reflects a persistent resistance to incorporate changing views around our understanding of gender diversity. In 1980, the diagnosis of transsexualism was included for the first time in the DSM-3, under the heading of gender identity disorders (GID). Providers hoped that inclusion in the DSM would legitimize transgender identities, and facilitate access to medical care, including insurance coverage. This occurred to some extent, but diagnostic inclusion also reinforced the popular notion of transsexualism as a mental illness, which led to further marginalization, and discrimination. Ironically, in 1980, the diagnosis of Ego Dystonic-Homosexuality was removed from the DSM-3 on the grounds that it was not a disorder. In 2014, GID was removed from the DSM for similar reasons and replaced with the term gender dysphoria, which refers to the distress caused by a discrepancy between assigned sex at birth and gender identity. There is ongoing discussion about the diagnostic and coding terms used to describe gender variance—a constant battle to balance the need for medical treatment against language that implies pathology and leads to stigmatization.
Chapter 16: Medico-legal Advocacy, “Medical Necessity” and The Evolution of Insurance Coverage for Trans-Affirming Care
Although gender-diverse people continue to suffer civil rights abuses and discrimination, slow but noticeable progress has been made in access to legal advocacy and the right to receive affirming medical care. As research now clearly demonstrates the efficacy of medical interventions, numerous professional associations have voiced support for access to health care (including the American Medical Association, the American Psychiatric Association, and the American Public Health Association) and insurance companies have been challenged to cover transgender health services. In 2014, Medicare removed its reflexive denial of coverage for trans health, and over the subsequent years, other private and public insurance have followed suit.
This chapter traces the evolution of state and federal protections for transgender health in the United states. It includes the evolution of insurance coverage (regulations which vary by state), and protections under the ACA. Janice Raymond and others worked against insurance coverage for transgender people, and these efforts are reviewed. Medico-legal advocacy is an important service offered by many gender clinics across the country, and this chapter includes descriptions of these services and explain why they are crucial to affirmative care.
Part IV: The twenty-first century
Chapter 17: The Development of Surgical Services in the United States
Marci Bowers, MD, Samuel Burnim, Columbia Medical Student
a) Transmasculine Genital Surgeries
b) Transfeminine Genital Surgeries
c) Transmasculine Top Surgeries
d) Facial Feminization Surgeries
e) Transfeminine Top Surgeries
1. GRS Surgeons: Stanley Beiber, Yvon Menard, Preecha Tiewtranon, Stanley Laub, Michel Seghers, Eugene Schrang, David Gilbert, Neal Wilson, and others
2. Transgender Surgeons (Marci Bowers/Christine McGinn
3. Binders/Packers/Breast forms
Chapter 18: The Evolution of Hormonal Care
Asa Radix, MD, Zil Goldstein, FNP
a) Early Hormonal Care
b) HIV Care as conduit for hormone therapy
c) FQHCs: Mazzoni, Fenway, Callen Lorde
d) Planned Parenthood
e) Hormone Therapy as Part of Primary Care
f) The second wave of Gender Clinics
g) Centers of Excellence: UCSF, and others
Chapter 19: The Treatment of Gender-Diverse Youth in the United States
Diane Ehrensaft, PhD, Colt Meier, PhD,MD Nic Rider, PhD
In this chapter we address the introduction of medical interventions for youth in the early twenty-first century, specifically puberty blockers for transgender and gender expansive youth (first developed by the Dutch), the rise of the gender affirmative model, the fall of reparative therapy, and the availability of gender-affirming hormones (and more recently surgeries) for minors. These practices have radically changed the landscape of care and conceptualizations of gender development/gender health in the United States. We explore the recent explosion in gender affirmative care and support programs at this moment in history—what is happening now and why—and implications for future of youth gender care in the U.S.
Chapter 20: The Evolution of Mental Health Treatment: Diagnosis, Gatekeeping, Advocacy
Laura Jacobs, LCSW-R
The psychological treatment of transgender, transsexual, and gender nonbinary people has changed significantly over the past few decades. Since Harry Benjamin first suggested that you couldn't change a trans person's mind to fit their body, and you had to change their body to fit their mind, a new theory of both medical and mental health began. Initially, researchers and scientists used psychological tools with the detailed precision of microscopes, and scalpels, attempting to determine the causes of "transsexualism," probing and analyzing to determine who was a "true transsexual" and therefore worthy of treatment. Given that trans people often require the assistance of the medical profession, and most physicians do not feel adequately able to access for mental health issues, psychologists, social workers, and other mental health specialists are brought in to assess and approve medical and surgical interventions. As the trans liberation movement began to develop, this gatekeeping was increasingly challenged, creating tension between the mental health profession and the burgeoning trans communities. An evolving process, assisted by the emergence of many trans identified therapists contributing to the profession, has opened up the beginning of a new therapeutic process which supports assessments that value self-determination, diverse identities, and minimizes gatekeeping.
Chapter 21: The History of Voice Modification Therapies
Jack Pickering, PhD, Terren Lansdaal
a) Vocal training
b) Vocal surgeries
Chapter 22: Depilation/Epilation: The History of Hair Removal
This chapter describes methods for hair removal over time, beginning with techniques used in ancient times and ending with the latest innovations. Describes the use of radiation, laser treatments, electrolysis, waxing and depilatories. The chapter discusses regulation (licensure), and working with special needs of the trans-community, such as hair removal in the pubertal region in preparation for female-vectored genital reassignment surgery.
Chapter 23: Guinea Pig to Participant: The Evolving Ethics of Transgender Research
Noah Adams, LMSW and co-authors
This chapter reviews the manner in which research about gender-diverse people has evolved over the past 150 years. Early research viewed gender diversity as a form of deviance, and research methods and academic papers contributed to societal perceptions that transgender people were mentally ill. As the understanding of gender diversity has become healthier and more nuanced and transgender people have developed powerful voices in academic and health care institutions, the focus of research has changed. Current ethical guidelines around research for gender-diverse subjects include involving the transgender community in the design, interpretation, and dissemination of clinical studies, use of appropriate language to describe people and gender identities, and recommendations to depathologize Institutional Review Board processes.