For decades, transgender medicine has been a site of confusion, fascination, and intense conflict. There remains disagreement in how to provide gender-affirming medical interventions as well as how to determine who should receive it. Stef Shuster (they/them) tackles these questions in their book Trans Medicine: The Emergence and Practice of Treating Gender. They argue that the uncertainty in trans medicine has led to a medicalization of gender that identifies medical providers as experts and ignores trans people’s expertise in their individual bodies and experiences. Because contemporary medical perspectives are influenced by old assumptions about gender, this power dynamic perpetuates inequalities in healthcare.

When the era of what we now know to be trans medicine first began, the few healthcare providers who entered the field faced intense backlash from those who viewed such interventions to be inappropriate or even immoral (26). To protect themselves from the critique, medical providers who treated transgender patients corresponded extensively with each other, creating a shared understanding of trans medicine and establishing a sense of authority within the field (24). The focus became on “normalizing” trans people’s bodies and experiences—strict guidelines were set for who could be provided with medical intervention. Providers needed to be assured that their patient would be able to “successfully” live in their target gender; this definition of successful was entirely based in the medical and scientific community’s expectations for gender conformity and sexuality (24). Anything that deviated was met with suspicion that the patient was not truly transgender. Due to this, trans patients were judged based on appearance and were subject to intensive questioning about their personal life in order to establish their credibility (34). Trans people who did not fit these expectations were deemed unworthy of access to gender-affirming medical interventions (24). The author argues that due to the strict guidelines enacted to establish medical authority, trans people were forced to acquiesce to public expectations of gender conformity in order to receive gender-affirming medical care.

Still, uncertainty on how to determine who should receive gender-affirming care remained, leading physicians to reach out to psychiatrists and psychologists for assistance in assessment with the expectation that they would support their recommendations (50). Rather than working together, however, each group of healthcare providers argued that their field’s method of understanding transgenderism was sufficient. The author argues that this disagreement resulted in a battle over which field of medicine should claim power and authority over transgender treatment (49). Not long after psychiatrists and psychologists began assisting with the evaluation of trans patients, they began to offer recommendations for allowing or denying access to gender-affirming care, much to the physicians’ dismay, who thought their only role should be in assessing patients’ mental health (51). This resulted in a battle for not only power, but legitimacy as both sides questioned whether the other was equipped to claim authority.

Psychiatrists and psychologists, like physicians, focused on transgender patients’ personal lives in assessing them for receiving gender-affirming intervention: they also made recommendations based off gender conformity and physical appearance (59). However, they needed another way to distinguish their authority from that of physicians, so they turned to taking explicit sexual histories in order to ensure the credibility of transgender patients. They wanted to ensure that people were not using gender-affirming medical transition as a method of ignoring homosexuality (60-1). Shuster argues that this further subjected transgender people to adhering to the strict binary of gender and gender roles: therapists assumed that trans people would leave their existent families and go establish new, heterosexual ones where they would fulfill the familial role of their new gender. Therapists based their recommendation off trans patients’ intentions to do so (61-2). The efforts of both physicians and therapists were to assert their authority in trans medicine by establishing scientific guidelines in which to abide by and quell the uncertainty that existed in the field.

In contemporary transgender medicine, this uncertainty remains. Evidence-based medicine (EBM) has rapidly increased in popularity arising from critique that medicine needed to be more objective and standardized (77). Rather than basing guidelines off personal expectations as before, EBM represented an effort to base recommendations off scientific evidence. The author argues that in contemporary trans medicine, providers attempted to confirm the legitimacy of trans medicine by constructing evidence and codifying expectations (78). Codifying the trans experience led to it becoming a diagnosis: “gender dysphoria.” Shuster argues that this is a “double-edged sword:” a diagnosis increases the likelihood that insurance companies will reimburse out-of-pocket expenses for gender-affirming care, but it also implies that transgenderism is an illness (80).

Despite this, there was no clear path for clinical guidelines to follow in trans medicine because there was no scientific evidence: there were no randomized control trials determining risks or benefits of medical intervention (85). Trans medicine has rather been supported by case studies and patient reports (86). Because of the lack of scientific evidence, there remains ambiguity in the guidelines for providing gender-affirming care, leaving decision-making regarding trans care largely up to the discretion of the provider and allowing decision-making to be influenced by norms and societal factors. With healthcare providers vying to claim expertise, patients cannot claim the expertise over their gender identities themselves (88).

Shuster argues that this discomfort in the lack of scientific evidence has also resulted in a lack of confidence in healthcare providers in treating trans patients (90). Having been taught EBM, providers feel unequipped. Trans medicine is not taught broadly in medical schools (90). This discomfort and lack of experience in working with trans people leads to providers unintentionally exhibiting trans exceptionalism—where trans patients are perceived to be so unique that it is difficult for providers to use their knowledge and experience in other areas of medicine to inform their decision-making regarding trans patients (4). This makes it difficult for trans people to find a provider who feels comfortable working with them (91). The lack of scientific evidence backing gender-affirming care and lack of knowledge of the risks makes providers even more hesitant to offer access, particularly when trans people have coexisting conditions that may be affected. Though the guidelines no longer dictate gender conformity, their ambiguity allows providers to turn away trans people with mental health disorders or other health conditions due to the potential risk (95-97).

In summary, the author argues that due to the fact that medical providers are not trained in trans medicine, there exists uncertainty in how to assess trans patients and how to go about providing gender-affirming medical interventions. Because of this, there has a been an ongoing power struggle between different fields of healthcare in who can claim expertise in trans medicine and offer recommendations for care. This has medicalized understanding of gender and has given medical providers authority over gender, leaving trans patients at the whim of physicians’ interpretations of the ambiguous clinical guidelines based in EBM (104). This unintentionally perpetuates healthcare inequalities because decision-making is influenced by societal factors, cultural norms, and historical contexts (159). Their conclusive argument is that medical providers should not have authority over gender identity, nor should they impose medicalized understandings of gender onto trans people’s experiences: providers must advocate for their trans patients’ needs and place more trust in their patients’ expertise over their own bodies (164-6).

To support their arguments, the author employed several different methods of research. First, to provide historical context of transgender medicine, they examined letters of correspondence between medical providers in the 20^th century found in the archives of the Kinsey Institute (11). These documents provided the discourse present in the medical and scientific communities on how providers were to make decisions regarding eligibility for gender-affirming medical interventions. From these Shuster gained knowledge of the assumptions that medical providers had when working with trans patients (11). They then conducted interviews with therapists and physicians from a wide variety of specialties and geographical locations. These interviews informed them how old assumptions of gender continue to influence contemporary structure of trans medicine and its lack of certainty today (12). The author also attended healthcare conferences and observed how providers taught each other to work with patient populations. Lastly, they examined diagnostic criteria and clinical guidelines related to transgender medicine from leading health organizations (13).

In conclusion, Shuster argues for the focus in trans medicine to be shifted away from the expertise of medical providers and onto the individual experiences of trans people. They call for better training in medical schools, increased research into the long-term effects of medical interventions such as hormones, and increased focus to be put on the healthcare disparities that trans people experience. Trans medicine is a place where science and values can coexist, and it needs to be redefined that way.