Transgender and non-binary issues are beginning to come to the forefront of today’s world and access to medical care is one of the most important and nuanced matters for many transgender individuals. Adequate access to transitional surgery and hormones for those who want it is crucial to garnering equality and a comfortable life for gender minorities. While certain aspects of transgender care has improved and changed over the past century, there are still many complex issues that need to be addressed if transgender people are to have full bodily autonomy and access to adequate care. In their book, Trans Medicine, Stef M. Shuster discusses how transgender medical care has evolved from its beginnings in the early 1900’s to the more contemporary issues that the transgender population are dealing with today.

Stef M. Shuster is an assistant professor of sociology at Michigan State University. They obtained their B.A. in Sociology from Indiana University and their Ph.D. in Sociology from the University of Iowa with a certificate in Gender Studies. They are currently a member of the editorial board for Journal of Health and Social Behavior and Gender and Society. In Trans Medicine, Shuster implements a multi-sited research design in which they did historical and sociological work reading archives of 20th century correspondences between physicians, conducted participant observation by interviewing 23 physicians from across the US in various specialties, observed healthcare conferences, and read clinical guidelines, standards of care, and diagnostic criteria for medical providers. By combining these different sources, their goal was to create a “blending of sociology of knowledge with feminist science and technology studies perspectives” (13) and a diverse array of perspectives on the topics at hand.

The main argument that Shuster makes is that throughout history and into contemporary medicine, physicians and medical professionals have held authority over the bodies of transgender and non-binary people and have claimed expertise in areas in which they have little to no real scientific evidence. Due to this lack of experience in the area, they are forced to either go with their gut instinct, which can be biased and lead to discrimination, or extrapolate existing data as their evidence, which may not always be accurate. With no real evidence for the guidelines created for physicians to follow, this leaves them often uncertain in how to proceed with patients and care can vary between providers. Cisgender patients can always take for granted that medical guidelines and the data that is used to support them were created with them in mind, and transgender patients are left to wonder where they fit into things. Access to transgender medical care has throughout history been restricted to those who are deemed worthy by their physicians and therapists, who most often perpetuate gender norms and stereotypes in their expectations for transgender patients. For example, one youth counselor recounts her work in which she encourages trans youth to wear stereotypical clothing for their gender in order to help fit in and have a smoother transition – while she is attempting to ease the discomfort that these youth may feel as a transgender child being perceived in society, she  is attempteIn these ways, physicians can ultimately cause harm to those in which they intend to help. Shuster believes that the professionals who are the most suited to working with transgender patients are those who are willing to do the work to learn all that they can about transgender and non-binary identities and lean into not knowing, therefore they can learn how to best treat their patients and challenge the culture of cisnormativity by reevaluating how we see gender and the assumed expertise of medical professionals.

The book is broken into two main parts with five sections and a conclusion. The first part deals with the history of trans medicine and the second on the nuances of more contemporary trans medicine practices. Part I is broken into two sections, the first explaining how in the 1950s, the first forms of transgender care in the United States required patients to be seen as perfect citizens in order to receive care; they needed to fit stereotypical gender roles, leave their families, be physically attractive, and have no physical or mental conditions. The second section goes into the disagreements between physicians and therapists over whether the best course of treatment for those wanting to transition was therapy or medical intervention, it outlines the various diagnoses that were given to transgender individuals, such as hysterical psychosis, and how they were evaluated according to what these providers considered to be normal. Part II explores the contemporary methods and ideologies regarding trans care, and is broken into three sections. The first section examines the rise of the evidence-based medicine movement and discusses the idea that diagnoses and guidelines are not only scientifically, but also socially based. This section also goes into the lack of true evidence that is involved in medical decision-making for transgender patients since randomized trials are difficult to perform and how this lack of evidence leads to large amount of medical uncertainty for physicians. The second section within Part II looks into the different ways that physicians can follow the guidelines and procedures laid out for working with transgender patients, there are the ‘close followers’ who were concerned with being the gatekeepers for hormones and transitional surgery, and the ‘flexible interpreters’ who saw the guidelines as recommendations and used more of their own discretion in their distribution of care. The final part of this section goes into how physicians deem themselves experts, Shuster uses two models of physicians: ‘self-assured experts’ and ‘uncertain experts’ to explain how some providers had no problem seeing themselves as experts in transgender medicine and topics, whereas others could recognize that there is still much that they do not know and actively work to better understand their patients individual stories and the ways in which what they think they know can change. They bring in Foucault’s ideas regarding authority when discussing how paternalistic medicine allows physicians to have authority over the transition and bodies of their patients. Finally, Shuster’s conclusion includes anecdotes from the Trump administration and the COVID-19 pandemic to illustrate other ways in which physician uncertainty shows up in our healthcare system. Doctors in hospitals are having to decide which patients are worth saving and which ones they don’t have the resources to help as understaffed hospitals exceed their capacities. The pandemic has also brought to light some major healthcare inequities in terms of access to care and the economic ability to take time off of work for health reasons. They also think about how these ideas of uncertainty exist in other areas of medicine, such as when working with children with disabilities, and how these ideas have existed in the past in instances such as forced sterilization in which it was abused in order to discriminate against certain groups of people. The book closes with a cautiously optimistic view on how physicians are progressing – they are becoming willing to listen to their patients, become advocates for their patients, reconsider what it means to use evidence, redefine what is ‘normal’, and learn to accept that they are still learning. Applying the ideas discussed about medical authority and the use of evidence to all areas of medicine, not just transgender care, we can begin to think about how our healthcare system functions and how it can be improved.

The most notable strength of Trans Medicine is its ability to come at issues and topics from multiple different disciplines. Shuster achieves this by including perspectives of transgender individuals, medical providers, therapists, social workers, sociologists, and more, from all different time periods that are discussed throughout the book. As opposed to simply condemning people who made certain controversial decisions, they look at the way these different people see their work and justify their decisions and this allows the reader to begin to see things from their point of view. This allows us to think critically about the topics and hand and all of the nuance that goes into medical decision-making regarding transgender and non-binary individuals. This range of perspectives also allows for an intersectional view in which aspects of class and ability are brought into the conversation.

The main weakness of the piece is the style of the writing and the way in which some points were made. I found myself having moments of déjà vu while I was reading, as if certain sentences were being repeated word for word. This caused a feeling of being beaten over the head with some points. It was a style choice for the writer that allowed their points to get across, but tended to spoil the flow of the writing. The points made and the breadth of the research still come across and it remains a powerful piece of work, but there are some stylistic and syntax choices that could be stronger to allow the stories being told to shine through better.

In conclusion, Trans Medicine was a thorough and insightful summary of the history of transgender medicine in the United States over the last century. It provided multiple viewpoints and direct quotes from those involved in the issues at hand, making it a well-rounded and informative piece of work. Physicians and mental health professionals would especially benefit from reading this book, as it provides insight into the history of transgender and gender medicine and healthcare and the problematic ways in which it has been treated. In hearing about how certain trains of thought and action can be harmful to their transgender patients, even if the intentions are good, it can help them to think about these decisions from a different viewpoint and come to more well-informed decisions in their treatment of transgender and non-binary patients.