Trans Medicine: The Emergence and Practice of Treating Gender

by Stef M. Shuster

A rich examination of the history of trans medicine and current day practice


Surfacing in the mid-twentieth century, yet shrouded in social stigma, transgender medicine is now a rapidly growing medical field. In Trans Medicine, stef shuster makes an important intervention in how we understand the development of this field and how it is being used to "treat" gender identity today.

Drawing on interviews with medical providers as well as ethnographic and archival research, shuster examines how health professionals approach patients who seek gender-affirming care. From genital reconstructions to hormone injections, the practice of trans medicine charts new medical ground, compelling medical professionals to plan treatments without widescale clinical trials to back them up. Relying on cultural norms and gut instincts to inform their treatment plans, shuster shows how medical providers' lack of clinical experience and scientific research undermines their ability to interact with patients, craft treatment plans, and make medical decisions. This situation defies how providers are trained to work with patients and creates uncertainty. As providers navigate the developing knowledge surrounding the medical care of trans folk, Trans Medicine offers a rare opportunity to understand how providers make decisions while facing challenges to their expertise and, in the process, have acquired authority not only over clinical outcomes, but over gender itself.

Genres: Transgender, Nonfiction, Queer, Medicine, History, LGBT, Gender

224 pages, Kindle Edition

First published June 15, 2021

Reviews

[Anna]

shuster's exploration of the ways in which health practitioners -- both mental health workers and physicians -- manage their anxieties around providing care to trans people, and in particular providing medical interventions related to gender, is a fascinating blend of history and sociology. The author draws upon archival resources from the Kinsey Institute, interviews with present-day practitioners, professional documents that outline best practices, and observational notes from trans health conferences to consider what has and has not changed since the 1950s when it comes to treating gender in the heathcare community. This focus on practitioners (all of those discussed in the book seem to be cis) rather than trans people offers a unique window into the challenges that the medicalization of transness during the twentieth century have created for both care providers and the trans patients seeking medical interventions to shape their experience of embodied gender. Both mental health practitioners and medical doctors historically expressed, and continue to express, a high degree of anxiety regarding how to diagnose and treat transness as a health problem. shuster describes how medical and mental health professionals struggled to determine whether transness was best treated as a condition of the mind, or the body, or both (they don't seem to have considered the possibility it is neither). Sometimes at odds, sometimes in collaboration, health practitioners in both areas have historically acted, and continue to act, as gatekeepers to care for trans patients -- with the authority for that gatekeeping role grounded in very little medical/scientific evidence. Rather, health practitioners continue to draw on understandings of transness developed in the mid 20th century that depend heavily on a binary and fixed understanding of gender -- one that does not fit particularly well with most trans peoples' lived experience or needs. I highly recommend this book to anyone interested in the history or present-day practice of treating gender.

I was provided a copy of this book by the publisher via NetGalley in exchange for an honest review.

[David · Rating 5 out of 5]

Wonderful book covering the evolution of trans medicine and the current practice. Very well structured and nicely documented. I was expecting a much more academical read, but I am positively surprised about how accessible is.

Very often we take science and the medical discourse as unquestionable. But science is indeed about questioning, and that is exactly what this book does: opening up the debate on how the pathologization of trans identities was built through the 20th century to our days.

Some of the most interesting points that I recall are:

• The chronological analysis, showing the construction of a narrative not only to control trans bodies and lives through medicine, but also building some of the prejudices trans people face still nowadays, at least in Spain.

• The ‘legitimacy wars’ between physicians and therapists, as well as the clashes they had on the definitions and treatment for trans people at the time.

• The random construction of protocols based on providers’ personal criteria that have survived over time, impacting in trans lives today. An example of this is providers’ expectation for trans people to align with their gender roles and gender norms’ ideas, which still happens currently – despite the lack of science backing these prejudices.

• The “real life test” (asking trans patients to live their life as if they had already physically transition, but without the aid of hormones or surgery) is another unscientific approach taken by providers that we can still see nowadays in many countries, where trans people are expected to wait for a given amount of time before they are provided with hormones or access to surgical interventions.

• How regret is weaponized by “pro-life” activists against abortion, using potential regret of the person who has an abortion to fight against abortion itself. It seems providers are also concerned by trans people regretting their transitions, which is also weaponized by transphobes very often to fight against trans access to hormones or surgery.

The only aspect I missed a little bit the book to cover were interviews with trans people. What are their views on the current way medicine treats them? How the different approaches taken by providers (flexible interpreters and close followers, as the author names them) impacts on them? I would have loved having their voices included here.

In short, could we move the spotlight to the way that medicine is pathologizing trans identities (without scientific evidence) and finally move forward towards trans liberation?

[Robyn · Rating 5 out of 5]

I loved learning so much about trans medicine in this book! I expected it to be dense throughout, but it felt accessible to non-academics seeking to learn more. A must-read for anyone who knows and loves someone trans.

[celia · Rating 4 out of 5]

Thank you to NetGalley and NYUPress for an e-ARC of this book in exchange for an honest review!

I had the pleasure of hearing stef present some of this work a few years back, and I jumped at the chance to get my hands on this book, even though I tend to struggle with non-fiction reads. I was pleasantly surprised at how easy it felt to read this book!

As a grad student, I'm used to slogging through academic texts and cross-referencing dictionaries, google, and other books to figure out what an academic is actually talking about. It was such a relief to NOT have to do this for TRANS MEDICINE. shuster does an excellent job of breaking down complicated ideas around the production of knowledge and expertise to contextualize the history and present of trans medicine– their use of jargon is intentional and explained in a way that I think non-sociologists and non-academics would find more approachable than they'd expect.

Although I was expecting something more in depth chronologically, one of the biggest strengths of this book for me was how it is positioned in the context of wider medical and sociological practices. shuster has a keen eye for the ways in which evidence based medicine impacts the experience of people of color and disabled people negotiating their way through the medical field.

I was a little disappointed not to have read conversations or interviews with trans and nonbinary medical/therapy providers, but I think shuster does a good job explaining why they interviewed who they did, and the lack of such perspectives is likely more reflective of the current state of trans medicine and how the medical field understands expertise.

Honestly, I would recommend this book widely beyond the medical field! I think this is an excellent example of an strong citational practice, and offers a plethora of delight for readers who think about evidence and how we understand the experiences of gender and sexual minorities within normative systems. For data nerds like me, I would also strongly recommend giving the appendices a thorough read to think about how researchers position themselves within social and institutional groups.

[Sara · Rating 4 out of 5]

Trans Medicine is a sociological book analysing the medical field(s) that work with trans people, namely the professionals involved - following trans medicine since it's conception in the 1950s up until contemporary times.
As a sociological work, this feels academic, but the writing is very accessible to non-academics; however, this book is not a "one-sitting" type of book, nor do I think it should be.
Throughout, shuster (non-binary trans person) lays out the assumptions and bias of medical professionals in the 1950s, contextualizing them in post-WWII medicine, and shows how that starting point is still affecting trans medicine today. For this, I think this book is an invaluable resource to any health professionals (or training to be), both physicians and in mental health. I also think it is appropriate for a non-medical audience, as it will clarify the way medicine operates, not only regarding trans patients but other demographics.
There are some things described in this book that can be very disconcerting, mostly the older records, but also some of the discourse of newer physicians (especially because you're given the historical context beforehand and you can see the root of it) regarding who should have access to trans medical care, and how - gatekeeping for "non-worthy patients" in the 50s and, currently, for some outside of the binary. So I advise care for anyone not in a good place with their gender identity, if they suspect they won't be able to digest some of the content.

I voluntarily read and reviewed an advanced copy of this book. All thoughts and opinions are my own

[isabella · Rating 4 out of 5]

pride month isn't just for fun queer romances it's also about learning!!!
this was a super informative read for me on an area that I knew almost nothing about but I think it's a great starting point for people wanting to learn more about the transgender community and become better, more informed allies! It is a super easy and accessible read even if you have no medical or scientific background and really shocks you with how so much and so little progress has been made in regards to trans medicine. My only critiques of this book are that the author tends to repeat the point of each section over and over again every time a new point is brought up which can give you a little bit of fatigue when reading it. As well, when introducing a new quote the author spells out what is meant instead of leaving room for any interpretation (I can see why this was done but after a few chapters it felt a little draining). Overall, this is a great, informative read that I would def recommend for anyone that is trying to educate themselves a little more!

Thank you NetGalley for the review copy!!

[Amelia · Rating 2 out of 5]

I definitely want to start out by saying that shuster and I do operate under different viewpoints, so my review and rating is largely based on my thoughts while reading this book. I think it's important to read things that make us uncomfortable, and in doing so it expands our worldview and how we navigate the various communities in which we exist. I also want to start out by saying that I admired the research and structure of this book as well. For a first book of its kind--especially one that is accessible to those not in the medical field--I think it accomplished what it set out to do, especially for its main audience (of which I am not a part).

However, as a reader, I was not convinced.

For me, the most interesting part was regarding the ever-changing and quickly evolving stance doctors and therapists took when treating trans patients. How they worked historically hand in hand to confirm that someone is "really" trans prior to going on hormones or receiving surgery was intriguing, and I can't deny that I found some of the steps to be unfair as well. shuster is clearly a huge fan of bodily autonomy (ie, it's my body so I can do what I want with it!), but I find that shuster's attitudes regarding doctors and therapists--even the ones who try very hard to do right by their patients--is that they are not doing enough, even when they go out of their way to learn what medical school has not taught them, they are not doing enough, even when they try to take into account the ways in which medicine affects various bodies, they are not doing enough. The goal post continues to shift.

"Into the 1960s," shuster states in relation to research, "more providers began to mandate that their patients live for a year in their target gender. Referred to as the 'real life test'--where a trans person was expected to live their life as if they had already physically transitioned but without the aid of hormones or surgeries--the milestone of one year in one's target gender was used by providers to determine if trans people were committed to 'going all the way' in accessing surgical interventions.[55] Yet contained within the naming of this test is the tacit idea that trans people's lives, up until the moment that they sought medical care, were not real." While I can sympathize the notion that anything prior to seeing a doctor didn't actually happen is unfortunately used across all aspects of medicine, I can also understand the doctors' point of view: prove to me that you can successfully live as your target gender, and I will know that the pros of you living your fullest life offset the cons of not knowing how gender affirming surgery affects not only one's livelihood but physical self nor not knowing how hormones more typically present in the opposite sex will affect someone down the line.

shuster also discusses the Bathroom Scare, in which women view trans women entering their bathrooms not as an act of safety on trans women's parts, but as an act of violation against women's parts. This violation invokes decreased senses of safety due to sharing a space in which women must reveal themselves--albeit behind closed doors--to relieve themselves. If trans women are allowed to enter their sex-segregated space as male-bodied and male-socialized people, then what is to stop men from entering their space under the guise of trans womanhood as well?

Yet shuster's affirmation that trans women only want to use the bathroom to relieve themselves is effectively shut down with this example: "My [faithful] patient stated that the patient arrested had recognized someone clear across the room and called out, 'Yoo hoo! I'm a woman now; I have been operated on by a surgeon. Yoo hoo!' Then she used the toilet and got arrested." Is this example supposed to make women feel better? This example does not correspond with the idea that trans women just want to use the bathroom--it corresponds with the idea that they want to use the bathroom and purposefully make others uncomfortable. Of course, not all trans women, but of course, not all men, too.

One thing I do appreciate this book is the discussion of lack of financial accessibility surrounding the medical field. Especially when it comes to specialists where one may have to travel to in order to receive care of any kind. Yet in highlighting this disparity, shuster uses the following example in which a trans person writes directly to a doctor for some assistance:

"Dear Dr. [Name],

I want to have the sex change operation from male to female. I want to know how much this will cost and how long. I have very little money and I want this done free, and if you know of a doctor who will do this free, let me know. I want to meet you, let me know when you are coming to L.A. I would like to have this done here or in your office. Also, I need a home and money and employment. Do you know of anyone I can stay with?"

I was baffled that this example was used. Yes, it highlights the disparities that trans people face--lack of housing, employment, finances. But the fact that this patient first and foremost desires the sex change operation/gender affirming surgery before working to amend any of their other problems was absolutely shocking. Not receiving a gender affirming surgery will not kill you in the way a double mastectomy for breast cancer will kill you. Not receiving a feminizing facial surgery will not harm you in the way a rhinoplasty for a deviated septum will harm you. Then again, it is important to recognize that we're operating on two different definitions of life-threatening. My definition in these situations lends its hand more to what our bodies do to us rather than shuster's definition, which lends its hand more to what we will do to our lives. (Internal forces rather than external/personal in these cases).

A trend I noticed in this book is that shuster seems to demonize doctors who are reticent in prescribing hormones or signing off on gender affirming surgeries in patients who otherwise have other present health problems. We do not know what these do to an otherwise healthy person in the long-term, much less when there is a chronically ill person or someone who requires other medical assistance through medication. shuster assumes a stance of "let trans people do whatever they want to their bodies, no questions asked" when that is just...not the reality. I mean, clearly, that's why shuster is arguing in favor of this stance. But shuster largely fails to realize that it isn't just that trans person a surgeon would be affecting. A double mastectomy for someone's mental health is not as life saving as it is for someone with stage 3 breast cancer. There, I said it. You can't therapy or cope your way into not having cancer. I'm not saying that therapy or coping methods can cure dysphoria either, but there is a very real and deadly disease inside some people and if a surgeon's time is being taken up with someone who would otherwise be alive..? It just shows me that trans folks, at least in these examples shuster provides, are selfish. Instead of arguing for a radical rearrangement of the health care system, shuster places trans people's needs on a pedestal and is willing to let others suffer in ways that can only be cured through medical intervention. This is of course, not to mention that this requires doctors to act in ways that they may not find ethical in regards to patient care.

shuster cites an example from his research and his response to this example seems to only clarify my point: "We had a patient who had an A1C (a blood test for glucose levels) of 13 percent and was pretty hypertensive when she presented at our office. We were not her primary care provider. Her gender identity seemed to be intact, but the answer was no. There's a lot of comorbidities that are unmanaged and unaddressed that make me think she didn't understand the relationship between all of these things and taking estrogen." shuster then goes on to address this citation: "In addressing the concerns with other medical professionals at a healthcare conference, the nurse suggested that while the patient's gender identity wasn't being called into question, the existence of high blood glucose was enough evidence to halt hormone therapy." Honestly? How could you not agree with the doctor in this situation? At the time of this doctor's interaction with this patient, how much had been written or researched regarding glucose levels and hormones? Of glucose levels and trends in the male body? How hormones interact with insulin, diabetes, pre-diabetes, retinopathy, blood circulation--literally anything that high blood glucose could possibly affect? Is getting estrogen more important than your baseline health?

Not to mention, of course, the times when shuster wants to break down the barriers between female and male, which begs the question of how do we know which hormones are prevalent in which people? How do trans women know they want estrogen and how do trans men know they want testosterone, if these are not present in their desired sex? The blurring of not just gender but sex offers a very scary reality in which women are already not present in medical research. It would be great if navigating the world of gender and medicine could be easier in terms of changing one's body. But it's not, because that's just...not how reality works?

According to shuster, it is. Also according to shuster, evidenced subtextually in these various examples, trans folks should be able to get whatever whenever. Do we know the effects of hormones or surgeries beyond 5-10 years? Are we taking into account anecdotal or resesarched evidence from detransitioners who now suffer from bone density problems, chronic pain, organ failure, and more?

Perhaps part of my problem is that I want shuster to do more. I understand the problem he wants to fix, but he does not seem to understand how to actually go about fixing them. The problem is that trans people are not being given these life-saving therapies (by therapists who don't care about them, apparently), hormones (by doctors who don't care about them, apparently), or surgeries (by surgeons who don't care about them, apparently). The problem is that trans people do not have access to inclusive doctors, or money to pay for these treatments, or a job to save money, or a home.

To shuster, the solution seems to be that we give trans people what they want because they think it is a need. But these things--though they may be distressing to not receive and therefore warrant accessible support groups, therapies, and communities to find solidarity--are not necessary. What is, is non-discrimination laws regarding housing and employment. What is, is access to information that ensures that trans folks know exactly what the side effects are for their surgeries and hormones and treatment rather than an all-affirming "empowering" idea of bodily autonomy. What is, is access to therapists and counselors who are sympathetic/empathetic and can offer coping strategies, a safe ear, and a means to reduce their emotional turmoil.

I suppose I'll wrap it up here, as I could go on. Ultimately, shuster and I hold similar but extremely different ideologies. The easing of trans pain and suffering is a must, but how we go about it is entirely different for vastly differing reasons. However, it was well-cited, and I again enjoyed learning about the history of the medical field regarding the trans community. It was an informative but largely exasperating read.

[Richard Derus · Rating 4 out of 5]

Real Rating: 4.5* of five

The Publisher Says: A rich examination of the history of trans medicine and current day practice

Surfacing in the mid-twentieth century, yet shrouded in social stigma, transgender medicine is now a rapidly growing medical field. In Trans Medicine, stef shuster makes an important intervention in how we understand the development of this field and how it is being used to "treat" gender identity today.

Drawing on interviews with medical providers as well as ethnographic and archival research, shuster examines how health professionals approach patients who seek gender-affirming care. From genital reconstructions to hormone injections, the practice of trans medicine charts new medical ground, compelling medical professionals to plan treatments without widescale clinical trials to back them up. Relying on cultural norms and gut instincts to inform their treatment plans, shuster shows how medical providers' lack of clinical experience and scientific research undermines their ability to interact with patients, craft treatment plans, and make medical decisions. This situation defies how providers are trained to work with patients and creates uncertainty. As providers navigate the developing knowledge surrounding the medical care of trans folk, Trans Medicine offers a rare opportunity to understand how providers make decisions while facing challenges to their expertise and, in the process, have acquired authority not only over clinical outcomes, but over gender itself.

I RECEIVED A DRC FROM THE PUBLISHER VIA EDELWEISS+. THANK YOU.

My Review: "Gender-affirming care" is a phrase that, to me, ought to be unexceptionable, even anodyne. Instead it causes fury and terror among people who subscribe to high-control religious and social systems.

I've never understood why.

I'm an old, cisqueer, white guy. I participate in several streams of privilege. I have no tiniest sense that my privilege is in any way threatened by the existence and/or acceptance and/or celebration of people not like me. The threats to my privilege come from those who want to deny the legitimacy of any of the founts of the privileges I enjoy. Trans folk aren't among those people as far as I can tell.

And this is despite the long, tragic history of gender-affirming care's resisters. That same kind of control is what we all agree is terrible about anti-Semitism. But it's okay when directed against those transgender...? Why? Because you, o great-hater, aren't yourself trans? Are you Jewish? Does that make hating Jews okay? Difference is not evidence of turpitude, or some kind of curse; spectra are the norm in all systems of what we call (without knowing what it means) the real world. We've barely begun to understand the world as it is. Part of that learning is, of necessity, not knowing, having certainty taken from us.

Somehow this kind of person doesn't ever answer these kinds of questions or address these realities. Their old certainties feel too comfy to give them up.

Most of us who aren't trans have no concept of what it takes to get access to gender-affirming care. I had only an inkling before I read this book. My inkling is still more than most have, and I'm now au fait with a much greater swath of how the concept of affirming the gender of a trans person came about. How it's been debated and designed to exclude, how it's been denied...a human-rights violation if there ever was one...how it's been weaponized and reshaped by the great-haters.

I have never met a trans person who is anything but kind, caring, and decent. Not one trans person I know, or know of, has ever advocated for anything remotely like enforcing their identity on anyone. The canard that education about trans people makes more trans people is a (deliberate, says my inner cynic) misframing of the truth: Education gives trans people access to an identity. To a word, an idea, that they know from the inside describes and delineates them. Had I grown up twenty years before I did, I would never have been aware or brave enough to invent gayness for myself. Education doesn't create difference, it enables the different to define themselves, to discover they are not the first, the only, the freak.

Gender affirmation will never be easy for some, there are trans people who struggle with it, too. This is a huge reason it needs affirming care from trained professionals. "It costs too much" is an absurd sentence coming from anyone in the richest country...the richest culture...there has ever been on the planet. No one should go without in a world of obscene abundance. That most definitely includes trans folk.

This book's essay-and-excerpt fabric will keep some readers from fully investing in the concepts. I found the sheer breadth of identities all speaking in support of trans-affirming care to be one of the greatest strengths of the read. I encourage other allies, and those who simply do not understand the idea of transness, to pick the book up. It can, if you decide to allow it to, help you find your empathy for these, our sibling humans.

[Colin · Rating 3 out of 5]

Focused on the historical and contemporary role of physicians, psychiatrists, and psychologists navigating the uncertainty around gender transition, I found this read to be intensely academic.

I felt as though I were reading a dissertation, which is not neccesarily a bad thing, as it is clearly researched, informative, authoritative, and well-cited above all… though difficult to not go bleary-eyed at times. I felt the publisher summary was a bit misleading in this regard. This is a useful resource for a student or sociological or medical professional and would make for excellent industry conference material, but not as meaningfully accessible for the general public.

While the research and argument were clearly presented, I wish this book had included greater reflections from the author or the trans community itself, which would have made it more approachable, and not just the perspective of the provider-side.

I had trouble rating this book. If you’re researching for a paper or presentation, this is a great resource. If your goal (as mine was) is to better understand the trans experience, a summary of concepts from this book might suffice.

ARC provided by NetGalley in exchange for an honest review.

[Karen · Rating 3 out of 5]

This is a sociological study of the ways medical providers (doctors and therapists) approach medical care for trans people. A lot of it is horrifying, such viewing non-binary people as not having a stable identity and therefore not good candidates for any physical changes. There is so much paternalism and judgment from the doctors, and these are the ones who want to help! I was unsure who the audience was for this book. I don't know that it would be useful for a trans person to read, any more than a black person would want to read a book of white people saying racist things. But I do think it's good that it exists, that it is making medical discourse and mindsets visible to people who aren't in that field. It was interesting reading the quotes from the supportive doctors who genuinely didn't know what to do, because prescribing hormones to help someone transition is considered "off-label" and is not well studied. I wish there had been more to this book, both more data and more theory. It felt like she was publishing a dissertation.

[Pat House · Rating 4 out of 5]

I am old enough to remember when Christine Jorgensen returned to the US from Europe to become the first known American to have a Male-to-Female "sex reassignment surgery." She and then later, Renee Richardson were the only recipients of a "sex change" that I knew of for the longest time. When I read Dr. Richardson's autobiography Second Serve, I learned more about how she felt than anything else. It was the first time I thought about gender identity, but of course, I did not have the language to fully articulate those thoughts. Trans Medicine helped give me the verbiage that I still lacked.

This book could be easily read by those who have a basic understanding of gender -- no need for a medical degree. It is informative and surprisingly entertaining. The interviewees were varied and each added their own stories to help understand the topics. I recommend reading this book to anyone who wants to learn more about this timely and important subject.

[Aolund · Rating 4 out of 5]

I liked that this book turned the gaze on to how knowledge is accumulated, "evidence" and authority constructed, and decisions made within the therapeutic and medical establishments. While specifically about the wide range of medical and therapeutic treatments and interventions that Shuster groups under the term "Trans Medicine," the analysis presented here would be useful for thinking about how the medical and therapeutic establishments construct authority in any area of medicine that is deemed "emergent" by these establishments. Definitely upsetting to read a lot of the quotes from transphobic doctors and therapists. Fascinating to delve in to the limitations and drawbacks of the medical and therapeutic establishments' reliance on standardization and "evidence based medicine" to the detriment of individual people and their care.

[William Palmer · Rating 3 out of 5]

Although clearly well researched, I don't feel the book used its content well to argue the points it was making. Although it was entirely correct in its points and interesting in what was elicited in interviews and from observations, etc, there was no strong argument between the point and the evidence to clarify them. I also felt in the historical sections of the book the absence of strong chronology (for instance from giving dates or a timeline) hampered it as a tool to understand the development of the field.

That being said, it was a very useful book to read, making very interesting and impactful points for trans medicine and the medicine profession in general, particularly in questioning reliance on diagnostic guidelines and EBM

[Liana · Rating 4 out of 5]

Interesting, relatively short read. Useful, I think, for getting the context to understand how the community has been burned by medical practitioners in the past, how that has influenced and shaped how the community grew, and some of the pitfalls and positive trends in contemporary medicine. Would be useful for providers now and people who want to understand how the trans community feels as they interact with them and consider options.

[Michelle · Rating 5 out of 5]

shuster provides a deep overview of the ways in which the medical community both expanded and limited access to care for trans people over the course of a century. stef talks with providers to get a sense of how they understand their role in providing care, deciding who is "worthy" of care, and in advocating for patients. This is a tremendous foundational text for anyone interested in the care of trans people.

[Sarah · Rating 3 out of 5]

This is a really interesting, academic look at the history of trans medicine beginning in the 1950s. It continues to present day to show the ways in which a historical lack of information and data continues to affect the medical care of trans people today.

[Dinah · Rating 5 out of 5]

Fantastic sociological/anthropological study of the practitioners of gender affirming care. Good historical overview of the movement from gatekeeping / paternalistic medicine to EBM and the problems of EBM in relation to the trans* population.

[Chelsea · Rating 4 out of 5]

4.5 stars

Extremely informative, accessible, and thoughtful discourse about the limitations of modern medicine in regards to gender-affirming care. A recommended read for anyone working in healthcare.

[Philip Cohen · Rating 5 out of 5]

Great for understanding the context of medical standards and decision making regarding trans medical issues. Recommend!

[Amaavi Miriyagalla · Rating 4 out of 5]

really well-written and nuanced: some heartbreaking patient anecdotes and horribly ignorant physician comments that hit hard. a must-read before practicing medicine, of any sort, I think

[J. Joseph · Rating 3 out of 5]

I read this book as part of a book club over the past 2 months with my colleagues in the hospital and, for full transparency, I will note at the outset that our discussions have shaped my final review. Trans Medicine is a study of this history and present treatment of gender by the medical profession in the United States from the mid-20th century to now. The first two chapters comprise the historical analysis, focusing on the emergence of trans medicine and the legitimacy wars between physicians and therapists. The last three chapters focus on contemporary issues of evidence, uncertainty, and expertise (and, as shuster argues, the distinct lack of all three in this field).

I really wanted to like this book, and I genuinely did for the first two chapters. The historical analyses were clear, covered many important issues, and had excellent syntheses drawn from the dearth of evidence at the time. However, the third chapter was a bit iffy for me as I began to have trouble with the analysis, and by chapters four and five I was actively frustrated with the methods and attempts at theoretical rhetoric. One of the biggest things I struggled with was the definitional and categorization work done on clinicians who shuster either interviewed or observed at conferences. When drawing these categories there was always only a binary of options: close followers versus flexible interpreters, or self-assured (bad) versus uncertain (good) experts. For a section that explicitly discusses how harmful binaries can be, I'm frustrated that shuster would fall into the same trap they were criticizing.

For example, in chapter four there are two clinicians who are placed in the close followers camp, which is a camp we ought to avoid. However, these individuals were genuinely worried about their patients rather than their personal liability. This is evidenced in the quote where one of them suggests to a ninth grader that perhaps they shouldn't wear thigh-high, five-inch stilettos to school. It felt like there was an implicit yet undiscussed, and much more appropriate, discussion just under the surface about the distinction between only worrying about one's professional liability, on one end of a spectrum, and only worrying about a patient's desires, as the other end of the spectrum. Perhaps these two individuals would have landed somewhere near the middle if this was the analysis, rather than being lumped in with the "bad" clinicians.

There were also a lot of confusions that shuster made within their own work. A quick example is in chapter five where, on page 143 they were criticizing the use of gut instincts by self-assured experts, but then on page 146 they praised uncertain experts for going with their gut to recognize the subjectivity of healthcare.

Overall, in my opinion, shuster is an excellent historian who could help us understand much through continued work in that field. But, I don't think they are theoretically adept enough yet for the more philosophical or abstract analyses they wanted to present in this book.