Trans Medicine: The Emergence and Practice of Treating Gender by Stef M. Shuster (review)

In recent years, the standards of care in transgender medicine have shifted toward a gender affirming model that aims to minimize a gatekeeping regime that, since the mid-twentieth century, has employed rigid diagnostic criteria to exclude as many trans people as possible from access to care. Typically, this shift is heralded as unambiguous progress, but what has materially changed? Sociologist Stef M. Shuster's Trans Medicine is a unique monograph that combines historical analysis with ethnography. Flipping the conventional scene of research, Shuster focuses exclusively on health care providers, rather than trans people, to study their management of uncertainty in clinical practice and the production of evidence. The first half of the book comprises two chapters that frame the intramural contest over scientific legitimacy and authority through which the field of transgender medicine emerged in the United States during the 1950s and 1960s. These chapters are based in an archive of correspondence between clinicians. The second half of the book comprises three ethnographic chapters based on fieldwork conducted from 2012–15, focusing on how medical providers manage a prevailing lack of certainty and evidence in an institutional health care world increasing defined by demands for standardization, peer-reviewed evidence, and the minimization of patient risk.

In its pairing of the contemporary clinic with a historical context, Trans Medicine delivers an important set of challenges to the progress narrative surrounding the field. Shuster shows that the authority of medical professionals over trans people's lives has only increased over time, continuing a process that began in the midcentury (p. 89). Likewise, because American medical care has overall moved toward an Evidence Based Medicine (EMB) paradigm since the 1980s and transgender medicine has no body of evidence to call on under that model—namely, randomized clinical trials—the individual discretion of clinicians has also grown, rather than been reigned in. Hence clinicians continue to gatekeep and make de facto decisions about which patients are "trans enough" to deserve medical care, often using contemporary concepts of "risk" (pp. 93–95), or lack of evidence and data, in ways that produce outcomes of harm akin to the midcentury gatekeeping model (p. 98). Even among clinicians who are not outrightly phobic, a sense of anxiety over the uncertainty of transgender medicine produces absurd clinical situations, where providers fashion themselves unable to use their experiential knowledge in treating cisgender patients with common medications like hormones to support their trans patients (pp. 136–37). The continued exceptionalization of trans health care means that very few clinicians Shuster encountered were able to recognize that the meaningful distinction between trans and non-trans medicine is entrenched transphobia (p. 150).

Historians interested in the contemporary clinic, not to mention scholars in the many fields that comprise transgender studies, will no doubt take up Shuster's findings in assessing how little has materially changed in transgender healthcare since the 1960s. The pitfall for Trans Medicine's incisive choice to flip the script of the ethnographic scene, turning its gaze upon contemporary providers, is that it does the same with history, which produces in places an odd myopia that falls out of step with recent scholarship. The narrowness of the first two chapters' archive, which comprises only letters between doctors, reinforces narratively that medical researchers are the signal historical actors, without trans people in fame, but also leads to significant factual errors. For instance, the second chapter of the book is based on the premise that psychiatrists and psychologists began entering transgender medicine in the 1960s (p. 49) in response to the perceived shortcomings of physicians and surgeons. This is incorrect, as historians have already established that psychiatrists and psychologists were involved in trans medicine as early as the 1930s.¹ Overall, the historical component of the book contributes little new to the historiography. In that sense, the history in Trans Medicine is likely of most interest to social scientists who...