In “Trans Medicine: The Emergence and Practice of Treating Gender,” stef m. shuster evaluates the medical and scientific communities’ “treatment” of gender, as well as the development of trans medicine as a field. This book was written in an effort to understand what has been normalized in the practice of trans medicine that has unintentionally perpetuated healthcare inequalities. It dives into issues the medical and scientific community face in regards to experience, skill, knowledge, and uncertainty in trans medicine, such as lack of experience, guidance, and scientific evidence. It addresses social constructs, such as the medical and scientific community holding ultimate authority over patients despite individual needs with respect to identity. It also acknowledges the uncertainty medical providers face with respect to providing gender affirming care to non-binary individuals and how the providers often operate under the normalization of a gender binary. While providers have difficulty keeping up with social changes as their practices become standardized, it is important that they strive to break from traditional ways of thinking about specific groups of people. This book makes an important intervention in how we understand the field of trans medicine.
The author of this book is stef shuster, an Assistant Professor at Michigan State University and the Lyman Briggs College and the Department of Sociology. They received their M.A. and Ph.D. in sociology from the University of Iowa with a certificate in Gender Studies. stef Shuster’s research and interests involve topics of medical sociology, gender, inequality, and social movements. Their main point of interest is on the social, culture, and historical lens through which scientific evidence is constituted and utilized by the scientific and medical communities.
This book was constructed using research from interviews as well as archival and ethnographic research dating back to the mid 20th century. A wide variety of medical providers were interviewed about their experiences treating trans people, as well as their sentiments on the development and future of the field. Letters of correspondence between providers were also utilized as the basis of information for the book, and were cited heavily throughout it. Providers were also observed and recorded during their presentations at conferences discussing trans-specific healthcare.
The first part of the book addresses the historical context of trans medicine, specifically the uncertainty and suspicion surrounding trans patients and potential gender-affirming interventions or procedures during the mid-20th century. It begins by acknowledging the “doctor knows best” paternalistic model of medicine present at this time, and the strong sense of authority associated with medical providers. New scientific and medical advancements introduced a sense of excitement in exploration. The trans community and trans medicine, while viewed as abnormal, became the target for exploration by the medical and scientific communities. While the medical community viewed trans people as deeply troubled, it was excited to “be on the forefront of medical information and knowledge.” However, when seeking gender affirming care, trans patients were pressured to prove their “credibility” to providers, as they “sought assurances that trans people would be able to successfully live in their target gender.” However, “successful” was defined so rigidly that many trans patients were set up for denial of care if they were unable to fulfill expectations for “gender conformity, heterosexual desire, stable jobs, and no interest in raising children.” A knowledge base formed within the medical and scientific communities was established to filter out trans people who did not meet the expectations for a model citizen; these people were perceived as unworthy of gender affirming medical treatment. The sense of power and authority in medical professionalism also coincided with a need for the reliance on empirical evidence; many providers practicing trans medicine fought uncertainty due to such lack of scientific evidence. As many providers sought credibility in their work with trans patients, they “began to frame their work within the spirit of scientific research.” In an effort to avert questions of morality and distract people from their uncertainty, providers “instituted the trope of the ‘trickster’ trans person, deflecting professional critiques by focusing attention on the moral character of trans people.” This gave providers the authority to set boundaries and requirements for deeming a trans patient “credible” for gender-affirming treatment, and to establish these under the name of science. There was an overarching idea that transness should be diagnosed or proven before being able to undergo gender affirming medical interventions. Due to the lack of information to “verify” someone as trans, providers were keen to refuse to treat people who they suspected were lying about being trans. Noncompliance with the rigid expectations placed on trans people to prove their trans identities resulted in denial of care. Such expectations included matching the standard narrative of a trans person’s life: one feeling disgusted with one’s genitals from an early age and wanting to dress in the clothing of the “opposite” gender. Trans people were also required to tell providers everything about their lives in order to have the possibility of accessing medical care. Gender affirming operations were also only granted to those who showed most promise in conforming to gender norms and expectations, and being able to move through society in their “target gender.”
In the second part of the book, shuster elucidates the contemporary practices and stigma surrounding trans medicine. This part discusses the rise in reliance on evidence based medicine and how this has impacted trans medicine and trans access to gender-affirming interventions. As technology becomes more advanced and more information on trans medicine is collected, providers have established professional documents to serve as guidelines and diagnostic criteria. This was motivated by the evidence-based medicine movement that emerged in the 1980s to make medicine more objective and standardized. Many believed that using the EBM approach would solve problems in trans medicine. With the increase in reliance on scientific evidence and trust in medical diagnoses, many providers have worked under the assumption that diagnoses are “anchored in science and therefore devoid of social values regarding proper bodily expression or behaviors.” However, shuster also highlights that the existence of diagnoses in trans medicine insinuates that being trans is an illness. This reinforces the harmful idea that being trans means that one is biologically deviant. In the tenth version of the International Classification of Diseases, “‘transexualism’ was one of several subcodes within a broader diagnostic category of ‘gender identity disorder.’” This conveys “broader implications in defining realt rans people as those individuals who understand their bodies as simply needing to be changed to fix a problem.” shuster then evaluates the unintended consequences of constructing evidence that can be used to form these diagnoses. They highlight the idea that evidence is never morally or ethically neutral, and that it relies heavily upon who has the control over the definition and qualification of evidence. As evidence-based medicine is constructed within a medical model that implies that a patient carries a “problem,” this reinforces providers’ power to control trans patients and their lives. Also, shuster adds that the lack of scientific evidence existing in trans medicine in the first place makes procedures and guidelines extremely uncertain and up to interpretation, which may lead to the unintended consequences. shuster argues that in using medical guidelines, providers “use strategies in trans medicine that raise broader questions about how the rhetoric of EBM and interpretations of clinical guidelines for medical decision-making may unintentionally perpetuate healthcare inequalities.”
The main strength reflected in this book is the amount of detail displayed from the research, and the well organized structure of such information within each chapter. Each chapter dives into a wide range of information that include results from studies, interviews of providers, or the personal experiences of trans patients. All of this information is very well integrated within shuster’s own analysis of it. Upon bringing up a new point, shuster then shifts to cite entire letters written by medical providers or long personal accounts of medical providers to back up his argument.
“Trans Medicine: The Emergence and Practice of Treating Gender” demonstrates how medical providers are very uncertain in their work with trans people. Through their analysis of ethnographic and archival research as well as other personal accounts from medical providers, shuster shows how providers lack the scientific research and clinical experience to interact with trans patients and create treatment plans. This has resulted in providers relying on social and cultural norms or their intuition to inform their decisions in terms of care. This book offers a glimpse into the uncertainty surrounding trans medicine as well as an opportunity to understand the challenges to their expertise which providers face. It shows how in the process of navigating how to create an evidence based system of treatment for trans individuals while dealing with uncertainty, providers have acquired power of gender itself.