GSS Book Review
Hale Robinson
Although the emergence of trans-medicine as a discipline and the discourse surrounding it appears rather recent, transgender healthcare has existed since the early 20th century (Schuster 23). Despite this, physicians and other medical professionals are both hesitant and inexperienced in regard to the treatment of transgendered individuals. The book Trans Medicine, The Emergence and Practice of Treating Gender details how and why this disinclination to treat transgendered patients has occurred and the consequences of medical authority over gender and sexuality. Furthermore, the author seeks to identify practices and ideologies that have been normalized and “legitimized” in the decades of trans-medicine. Through this short publication, Schuster analyzes both contemporary and historical trans-medicine systems and norms in addition to specific examples highlighting the interactions between varying forms of healthcare and their implications on trans-medicine as a whole. From this we can understand how trans-healthcare provides a middle ground for intersection of personal values and scientific thought.
To compile the examples and evidence presented in the book, author Stef M. Schuster used a multi-sited research design (Schuster 11). The majority of Schuster’s research is his collection of correspondence between healthcare providers in the 20th and 21st century (Schuster 2). Schuster also relies upon biological artifacts, collections of discourse, and other forms of scientific literature. (Schuster 6). Additionally, the author is an associate sociology professor at Michigan State University with a M.A. and Ph.D. in sociology and has conducted a number of interviews with both therapists and physicians as well as attended scholarly conferences on the topic of trans-medicine (Schuster 12). His final source of data collection came in the form of analyzing clinical guidelines, standards of care, and diagnostic criteria used by both contemporary and historical physicians (Schuster 13). Finally, the author notes that terminology surrounding gender and sexuality is fluid and specific word choice in the book may not be representative of the terminology used in the past or future.
Early development of trans-medicine began in the mid-1950s in the post-World War II era (Schuster 23). Public trust in scientific communities to solve social and biological ills was at an all-time high (Schuster 23). According to Schuster, this increase in medical authority over gender and sexuality and the power difference between doctor and patient is one of the root causes of why trans-medicine has made little progress from the 20th to 21st centuries (Schuster 24). While there have been attempts to decentralize authority of medical providers, many still hold the view that the “doctor knows best” (Schuster 9). In terms of trans-healthcare, this mindset has resulted in a number of subsequent issues. Medicalization refers to “the process of how non-medical problems become defined and treated as medical problems” (Schuster 9). Through medicalization and especially regarding transgender-healthcare, social issues about bodies and bodily autonomy become scientific issues.
Schuster argues that the medicalization of transgenderism resulted in early physicians perceiving transgender patients as “severely troubled” and transgenderism was understood in terms of symptoms of “delusional thinking” (Schuster 24). On one hand, Schuster details how the medicalization of trans-sexuality excited physicians as it was a new uncharted form of medicine. On the other hand, many physicians were hesitant and felt unequipped to treat transgendered patients. As Schuster details in chapter 1, few endocrinologists and physicians in the U.S. were willing to assist transgender individuals out of fear of criticism from peers, revoking of medical licenses, and possible patient regret and future lawsuits following procedures (Schuster 24). It is from this medicalization and hesitance to treat patients that specific guidelines and evidence-based medicine (EBM) emerged. Providers began placing increased expectations onto their transgender patients in an attempt to ensure that the patient was truly willing to undergo hormone/surgical procedures. Schuster states that from these expectations, new scientific language, approaches, and guidelines for trans-medicine were created (Schuster 64). The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Professional Association for Transgender Healthcare (WPATH) sought to define transgenderism and create a step-by-step protocol to treating transgender patients respectively (Schuster 80). While guidelines may serve as a “handrail” in other forms of medicine, Schuster explains that the steps outlined in the guidelines suggest a linear pathway, while gender transitions tend to be anything but linear and vary from individual to individual (Schuster 105). Furthermore, standardizing and defining transgenderism is ineffective as trans people’s experiences and self-concepts may not fit into binary modes of thought. Not all transgender patients have similar experiences and the notion that gender is fluid (not just extremes) is hard to process for many.
In addition to the medicalization of trans-sexuality, Schuster argues that certain strategies and mindsets have become normalized in trans-healthcare. One of these strategies is what he calls the “fake it till you make it” mindset (Schuster 131). Because few providers are trained in the social contexts and manifestation of gender, this lack of understanding causes discomfort amongst medical professionals. Many have trouble admitting their lack of knowledge in a field which further causes incorrect practices to become normalized over time (Schuster 134). Schuster also details the trope of the “self-assured expert” who present information in ways that leave little room for discourse and change (Schuster 138). Additionally, some solely follow clinical guidelines and understand trans identification as a clear, straight pathway “from point A (assigned gender at birth) to point B (undergoing a physical transition to the “other” binary gender)” (Schuster 138). The final and perhaps most prevalent strategy that Schuster recalls is “gate-keeping” and defining who is “truly” transgender (Schuster 106). To protect themselves from being sued by a patient, many providers were strict (and still are today) about who is able to obtain treatment procedures (Schuster 94). Schuster identified the following techniques that providers used to determine who would be able to receive hormone therapy. To begin, individuals who did not engage in illegal or risky activities indicated to providers that they could function as a “normal” person upon transitioning (Schuster 72). Second, those who were able to pass the “real life test” or live their life as if they had already received transgender treatment proved to providers that the patient was committed to go all the way with the procedures (Schuster 39). Finally, trans-patients whose ideologies closely aligned with traditional gender roles were significantly more likely to receive hormone therapy and surgical interventions (Schuster 16).
Schuster argues that progress in transgender medicine in recent times has been minimal. While he does not explicitly provide any solutions, he does detail specific providers who are making beneficial progress in trans-healthcare by utilizing smarter and favorable practices. He defines “flexible interpreters” as providers of trans-medicine who are able to “embrace the uncertainty in trans medicine and interpret the guidelines in ways that puts patients’ needs, and their varied ways of identifying as trans, first” (Schuster 117). In other words, these are medical professionals who are able to find a balance between social values and scientific fact and who refer to guidelines as recommendations rather than laws (Schuster 117). According to Schuster, flexible interpreters realize that guidelines take away focus on the individual and their healthcare needs (Schuster 118). When considering that each patient is unique, it is impossible to follow clinical guidelines exactly.
Schuster’s book thoroughly and concisely explains the emergence and history of trans-medicine from the 20th to 21st century. It highlights specific examples of social and medical trends that have impacted trans-healthcare over the years. For example, the book delves into topics such as the medicalization of sexuality through the DSM and WPATH and explains how this has had an effect on treatment strategies. Schuster draws upon various sources to formulate his claims and arguments with one of the sources being scholarly/medical conferences. However, the most convincing sources are direct quotes and letters of correspondence from the 1960s. These primary sources allowed the author to form arguments with supporting examples. This is demonstrated on page 31 in which Schuster presents a letter written by a transgender patient, “This letter is no trick and all I write is the truth and not made up. I want you to understand that my need to have this operation is not in passing, but is something of the deepest importance to me and has been for a long time…” This quote directly supports the author’s argument of the trope of transgender “trickster” where transgender people deliberately misrepresented information about themselves in order to gain access to hormones and surgery (Schuster 31). The abundance of direct quotes and examples make the book an informative and credible read.
While the author’s support of “flexible interpreters” is clear, the author says little about potential solutions and courses of action for the future of trans-medicine. Instead of offering specific solutions to the problems in trans-medicine that have been normalized over the years, Schuster simply critiques and summarizes these issues. While proposing healthcare solutions may be beyond the author’s expertise, with the immense amount of research collected to write this book, I would have expected the author to describe future plans and implications of his findings. In the conclusion and in the section titled “Redefining the treatment of gender,” the author states that “changing the protocols and shifting attention away from trans people as a problem to fix enables some providers to redefine the ‘treatment’ of gender in a way that shifts the attention to broader social inequalities that trans people experience in everyday life, rather than perpetuating inequalities in healthcare encounters” (Schuster 164). While I agree with this claim, it is a simple blanket statement that does not enact any specific changes or solutions.
Overall, Trans Medicine, The Emergence and Practice of Treating Gender, by Dr. Stef M. Schuster was an enjoyable and informative read. The book answers the questions of how medical authority over gender has occurred as well as what practices have become normalized over the years in trans-medicine and their specific consequences. While the author takes a clear stance against the current and past states of trans-healthcare, he does not dive in depth into solutions. In summary, I would recommend this book to anyone who is interested in history and specifically in the history of medicine and sexuality. Furthermore, I feel it is imperative that those pursuing a career in healthcare read this book. As healthcare and social values are increasingly interconnected, it is critical that our future healthcare providers adapt with the times to help serve diverse communities.
Works Cited
Shuster, Stephen M. Trans Medicine: The Emergence and Practice of Treating Gender. New York University Press, 2021.