Book Review
Book Review | Trans Medicine: The Emergence and Practice of Treating Gender, by stef m. shuster (New York University Press, 2021)
University of Nevada, Reno
danaahern@unr.edu
Historicizing the emergence of American trans medical criteria in the mid-twentieth century before moving through ongoing development in and around debates surrounding professional guidelines that structure the access and distribution of medical transition, Trans Medicine: The Emergence and Practice of Treating Gender provides an insightful examination of trans medicine at the site of the provider. Building on the emerging scholarship within feminist science studies, transgender studies, and disability studies, stef m. shuster illustrates the professional confusions, conflicts, and disagreements within the field of trans medicine and explores the ways in which power operates to normalize non-normative bodies via medicine. shuster effectively uses a combination of archival analysis of correspondences and case histories from the mid-twentieth century, interviews with providers, participant observation at trans medical conferences, and analysis of formal guidelines, standards of care, and diagnostic criteria, to demonstrate how medical authority is built on a lack of research on transgender bodies. Instead, shuster demonstrates how medical authority depends on and perpetuates heteronormative, binaristic, and inherently pathologized understandings of transgender identity.
shuster traces trans medical history starting in the mid-twentieth century with the establishment of medical legitimacy within the field of trans medicine. They describe the tension that exists for trans medicine providers throughout history as providers attempted to defend themselves from criticism by those who consider trans medicine “quackery.” shuster explores how, in the attempt to establish authority in deciding who was authentically transgender, trans medicine produced the trope of the “trickster,” who supposedly lied to meet the strict requirements set up by providers to access trans medicine. Trans medicine argued that “trickster” was motivated by mental illness or a desire to avoid the stigma of homosexuality, as opposed to the “real” trans person who would fully submit to medical authority. The strict requirements included living heteronormatively and giving up one’s family so as to leave behind their pasts and to prove one’s seriousness in pursuing transition; those unwilling to leave their families were denied transition, but this denied transition allowed their otherwise “normal” families to be left undisrupted. shuster continues to elucidate the histories of trans medicine’s investment in determining the proper treatment for transgender people—who should access treatment, when, etc.—by exploring the debates between physicians versus therapists. Preoccupied with banishing the specter of the trickster in order to establish guidelines of true transness, these debates resulted in increased barriers to treatment as well as an increasing institutionalization and construction of transness as pathological. This transgender pathology became defined by appearance, mannerisms, sexuality—in brief, being/seeming attractive, straight, and gender conforming—being otherwise mentally “well,” and having the ability to become a “model citizen.” In turn, shuster discusses the alliance that ultimately developed between mental health providers and physicians as diagnosing transness and treating it, respectively.
Moving into the present moment, shuster explores how providers began to assert their authority and expertise through guidelines established by the World Professional Association for Transgender Health (WPATH), the World Health Organization (WHO), and the Endocrine Society, among others. While these organizations and many of the providers currently treating trans patients tout expertise in their approach to trans medicine, they lack evidence, particularly in the decision of when to initiate medical transition. shuster points to the ways that the little “evidence” available is largely in the form of less reliable/replicable research such as case studies as opposed to more effective research such as clinical trials. Notably, this uncertainty around the decision to initiate medical transition mirrors the lack of evidence in the mid-twentieth century. Despite this lack of evidence and even in some cases relying on their own “gut feeling” to treat trans patients, many providers persist in constructing themselves as experts and as authorities. shuster also emphasizes how “healthiness” has become, for some providers, something to be prioritized in pursuing transition so as to mitigate “risks” to the patient, as patients with mental illness, for example, are often deemed unable to comprehend the implications of gender transition, and patients with health conditions are often told they need to get them under control, implying they do not understand or care enough for their own health. shuster helpfully reiterates the urgency in understanding how earlier legacies of trans medicine that attempted to “normalize” the patient and protect the provider continue to impact and inform current trans medicine.
shuster continues their analysis with a comparison between providers who strictly adhere to the guidelines established by WPATH, WHO, the American Psychiatric Association, and the Endocrine Society, versus providers who use these guidelines more flexibly. The belief in strict adherence accompanies a weaponizing of “regret” as a danger for trans people, especially as providers continue to attempt to mitigate “risk” for patients. Gatekeeping becomes particularly problematic for nonbinary patients who risk being labelled noncompliant due to a perceived lack of “certainty,” which comes to stand in for “real” transness from the mid-twentieth century. In contrast, providers who use institutional guidelines as more general templates as opposed to strict requirements (e.g., questioning the requirement to live as one’s gender for certain amount of time before being allowed to transition or the requirement for a therapist to approve the transition) call into question the need to prove one’s transness to doctors in order to access trans medicine, particularly therapists, who note the way this requirement acts to erode trust in therapy. Strict adherers to guidelines continually place the burden of proof onto the patient, which particularly impacts nonbinary patients who are persistently interpreted as “uncertain.” These providers attempt to perform expertise to maintain authority and continue to rely on tropes from the mid-twentieth century of mentally ill “tricksters” in trans medicine to demonstrate their own authority above their patients’. shuster’s discussions with flexible adherents to these guidelines demonstrates how experience in treating trans patients has become a stand-in for evidence, and shuster makes an important insistence on understanding the ways that those who prioritize the performance of expertise do so to the detriment of their patients. Framed through work in disability studies, shuster connects this performance of expertise in trans medicine with a similar mobilization of authority by providers when faced with symptoms they are unable to diagnose or explain, prioritizing their own appearance as authorities above the care of their patient.
I appreciate shuster’s entry point of the text at the site of the trans medical provider, deftly shifting the focus onto this figure to whom the transgender subject, by engaging in trans medicine, must make themselves vulnerable. In this rhetorical move, shuster forces the provider—rather than the trans person—be subjected to in-depth historical probing into their motivations, interests, and commitments to transness, exposing the gaps and weakness in trans medical research that prioritizes the making of medical authority rather than the treatment and health of the patient. shuster also expertly draws out the lingering legacies of trans medicine of the mid-twentieth century that continue to inform trans medicine under new terms. shuster carefully parses out the providers who consider themselves experts to the disadvantage of their patients from those who acknowledge the impossibility of expertise in trans medicine because of the enormous gaps in trans medicine. In particular, shuster’s analysis of the physical space of trans medicine at conferences they attended, as well as the affects they captured from providers during interviews, provide a rich and nuanced exploration of trans medicine’s various figures and the ongoing conversations that are made (im)possible by the boundaries and distinctions upon which medicine insists.
While shuster elegantly and thoroughly explores the makings of trans medicine’s constructions of normative transness, the histories and ongoing effects of trans medical guidelines and gatekeeping as they impact people of color is urgent to further explore. Where shuster discusses the various limitations imposed by the artificially constructed notions of “real” trans people—“productive citizens” without uncertainty, physical or mental health issues, and with clear and unambiguous gender identity—a trans person of color’s experience would have been subjected to even further inspection, particularly in the ways racialized transness is always already constructed as deviant. For example, Jules Gill-Peterson’s Histories of the Transgender Child (2018) examines the histories of transgender children and the ways trans people of color were rejected from the same clinics that shuster discusses. The ongoing legacies of racialization within trans medicine that Gill-Peterson explores are critical to engage and develop a more robust analysis of this history of institutions, identity, power, and marginalization. In particular, the nonbinary transgender figure that shuster frequently mentions as that which providers hesitate to treat, citing a lack of certainty in the nonbinary person’s own gender, would have been enriched with attention to the ways that racialized trans bodies are always already non-normatively gendered.
Trans Medicine: The Emergence and Practice of Treating Gender makes important connections across histories of trans medicine. It critiques the establishment and expansion of medical authority, in spite of a lack of medical research, at the cost of the trans patient’s authority in their own transition. shuster leaves open possibilities for trans medicine and providers who refuse an investment in authority and gatekeeping in the field, investing instead in supporting the transgender person. While inviting other areas of inquiry, this text is an exciting contribution both to the field of transgender studies as well as in the disability studies.
Author Bios
Dana Ahern is a postdoctoral fellow in Queer/Trans Studies at the University of Nevada, Reno.