The debate concerning trans people often seem to halt at the question of who the “real” or “true” man or woman is. The debate has always bothered and perplexed me, why trans people are expected to assume not only stereotypical or normative masculinity or femininity but even hypermasculinity and hyperfemininity, and how little tolerance there is when gender norms are being questioned.  

I was therefore very excited to get the opportunity to review the book Trans Medicine: The Emergence and Practice of Treating Gender by Stef M. Shuster, and I was not disappointed. For me, Shuster brings a fresh new perspective. In “flipping the lens onto the medical community to shift the focus of study on them, rather than trans people” (preface, p. x) the author sports a historical perspective that discusses the norms that have shaped the “treatment of gender”. 

While reading Trans Medicine, I gained a much greater understanding of gender affirming treatment and the history of trans people in general. The reading was eye opening and at times deeply disturbing.

What Shuster has done is to attempt to understand how the medical community has created and refined the gatekeeping guidelines that lead to refusal or allowance of gender affirming care over time. The medical community is interesting because it is a community that orients towards treating disease and diagnosing illness, Shuster writes. Questions asked in the preface of the book are: How has medical authority over gender happened? What has become normal and legitimate through decades of practice in trans medicine? And what are the consequences of these trends for trans medicine and the medical establishment more broadly?

Personal belief systems, norms, stereotypes, and values are typically not believed to affect the medical community which is assumed to act upon scientific facts, data, and empirical evidence. Shuster shows however, that trans medicine is a place where science and values meet and that standardized measures have been adopted into a field where there is little data or evidence to rely upon. Trans medicine, the author claims, has been heavily influenced by gendered norms. 

Throughout the book, Shuster successfully demonstrates how trans people have been expected to meet certain high standards to be considered for gender affirming care, standards based on nothing more than gendered norms and stereotypes. The phrase Shuster uses is model citizens. 

Included in being model citizens are expectations of mental stability and mental health, an assurance that the individual wanted, without doubt, a complete transition, keeping a job that was typical of the preferred gender (gender-normative work) and being able to pass as the other sex. Trans people were also expected to live in heterosexual relationships and leave the already existing family to fully live as the other sex. Heterosexual penetrative intercourse was also indicative of “normalcy” and gatekeeping against those who did not conform in their sexual practices has been common. Basically, traditional gender displays were viewed as the ultimate criterion for credibility while non-compliance led to refusal of care. 

The usefulness of gender affirming treatment was questioned for individuals deemed too masculine or too feminine to be able to successfully transition. Attractiveness was also important, people deemed too unattractive were not believed to be able to have successful transitions. Perceived masculinity, femininity and attractiveness are good examples of normative understandings that do not truly have an impact on the medical process of a person’s transition.

Shuster has an excellent way of putting words together to inspire the reader to keep reading and has drawn from previous research in a mix with quotes from counsellors, physicians, psychologists, endocrinologists and more. This backs up the author’s claims and arguments and makes for a very interesting read. One quote that especially caught my attention, which nicely sum up Shuster’s arguments, is the following: 

I ask my nonbinary clients who are seeking medical interventions, “What are we trying to do, and what is the goal?” If it truly is someone who wants to—for the rest of their life—maintain an androgynous appearance, I can’t do that. Living in an androgynous place in the world is great, but difficult. And anyone who is really transitioning will tell you that that’s not their purpose. That year starting hormones is hard—socially, for employment, for family. So, I want to talk to nonbinary folks for quite some time about why they would want to stay there [in an ambiguous gender presentation] for an extended period of time. I usually let them for three years. There’s no evidence to suggest why three years—that’s just my feeling. But after that? They need to go back to the therapist, talk about what they really want, and make a decision. (p. 142).

The book is described as an effort to move towards, and find opportunities for, a more just and inclusive healthcare system. In my opinion, this is where the book lacks. I want to hear more on what the author, and trans people, consider good practice and I would have wished for such examples. Instead, I feel that Shuster picks different practices apart but does not provide alternative ways to meet the situation in a positive manner. I would have wished for (although I understand that there is also limited space to any book) trans people’s reactions to the quotes and their feedback on how the situation could have been a positive one. 

Trans Medicine is a brilliant book that can be of much benefit to a number of different professionals such as psychologists, counsellors, social workers and basically anyone who wants to challenge their own biases and gain a greater understanding of the gatekeeping process to gender affirming care. The introduction and the first two chapters that talk about data collection could be of great value to any university class on data collection, biases in data collection and research methods. I strongly recommend this book. 

Elin Weiss has a Master’s in Gender Studies and a Master’s in Rights, Gender and Law and works as an equal rights and equality advisor.

Categories: Sexuality, Gender

Keywords: trans, medicine