The words per scientiam ad justitiam—through science to justice—are chiseled on the simple gray tomb of Magnus Hirschfeld. The physician is best known for founding Berlin’s Institute for Sexual Research in 1919, breaking the ice on the modern study of sexuality. This year marks another achievement—the centenary of the first gender-affirming surgery, which Hirschfeld and his Institute made possible.

Transgender lives during Hirschfeld’s time were often made criminal, and arrests were common for wearing clothes of a gender different from the one physicians assigned at birth. One of Hirschfeld’s early victories was persuading the German police to issue “transvestite passes,” based on medical opinion, which gave permission for some to dress as they wished. The Institute also provided support for trans people and helped them find employment. For the sexual minorities of the time, says Brandy Schillace, historian and editor of the BMJ’s Medical Humanities journal, Hirschfeld’s Institute was something like the opposite of conversion therapy: “It let you be yourself among other people who also recognized you as yourself.”

Dora Richter, who worked as a maid at the Institute, became the first recorded case of complete gender affirmation surgery. She was born male in the Erzgebirge region of Germany in 1891 to a relatively poor farming family. Her desire to live as a girl was apparent from an early age: She had a strong dislike for boys’ clothes and attempted to remove her penis by using a cord as a tourniquet at the age of 6. During her childhood, her family let her live as a girl.

How Richter made her way to the Institute is a matter of speculation. Some propose that she wanted someone to help her after an arrest for cross-dressing, which was punishable by up to six weeks  in prison. Rainer Herrn, a senior lecturer at the Institute for History of Medicine and Ethics in Medicine at the Charité University Hospital Berlin, says that her visit was more likely prompted by seeing a popular film featuring the work of Eugen Steinach.

Steinach was a pioneer in the study of sex hormones who, in one experiment, had transplanted a male guinea pig’s testes into a female. “The film proposed the revolutionary idea that animals can be transformed from one sex to another,” says Herrn. Hirschfeld’s Institute also played a role in the film, so Richter may have gone there to ask whether it was possible to have the procedure herself.

Richter’s years at the Institute seem to have passed pleasantly—she was finally able to live as a woman, around other people who accepted her, and a few transwomen also lived and worked there. Ludwig Levy-Lenz, a physician associated with the Institute at the time, described their easy camaraderie: “I shall never forget the sight one day when I happened to go into the Institute’s kitchen after work: there they sat close together, the five ‘girls,’ peacefully knitting and sewing and singing old folk-songs.” During this time, Richter also received a series of surgeries that would, just as she had hoped, transform her. She received an orchiectomy in 1922, followed by a penectomy and vaginoplasty performed several months apart in 1931.

This period of relative calm did not last, however. The circumstances of her death remain a mystery, but many speculate that she was killed when Nazi supporters ransacked the Institute in May 1933 or shortly thereafter. Hirschfeld himself died in exile in France in 1935.

While legal protections for trans people have improved in many areas of the world, they still face discrimination, harassment and violence. Similarly, while surgical frontiers are advancing every year, with tissue engineering techniques creating more functional genitalia and facial and vocal  procedures providing better alignment with gender identity, access to that medical care remains fraught.

One main obstacle is coverage by health insurance plans. The public health exchanges set up under President Barack Obama barred participating insurance plans from discriminating based on gender identity, a step taken to protect gender-affirming care. But the next administration removed that protective language, and a recent proposal to reinstate it for the 2023 exchanges has met with pushback from insurers and conservative groups. 

In 2015, more than half of coverage requests for gender-affirming surgery were denied. Insurance coverage for facial surgery is an especially difficult obstacle as many insurance companies do not deem it to be medically necessary, despite evidence of its importance.

In all, Hirschfeld might be proud of the movement he—and Dora Richter—helped to usher in. While many of his ideas on sexuality became dated, some of his remarks suggesting gender and sexuality as a spectrum seem prescient. In 1910 he wrote that “the number of actual and imaginable sexual varieties is almost unending; in each person there is a different mixture of manly and womanly substances, and as we cannot find two leaves alike on a tree, then it is highly unlikely that we will find two humans whose manly and womanly characteristics exactly match in kind and number.” That full spectrum in gender-affirming care is only now beginning to find its place in medicine.