Finding the Familiar in the Strange

Abstract

In their first monograph Stef Shuster offers us a bridge between the more thoroughly studied decades of the mid-twentieth century to the contemporary manifestation of transgender medicine in the era of evidence-based medicine. Much has changed since, and indeed many barriers to accessing trans-specific medicine have been lifted. However, some disputes that figure centrally in the US health system remain unresolved and continue to shape how trans people navigate the contemporary biomedical landscape. Shuster offers us a history of the recent past, and in many ways the present, to situate the ongoing turf wars between somatic and mental health clinicians, who have fought over the lives and bodies of trans people seeking any kind of health care, transition related or not. Trans Medicine unfolds in three parts that loosely follow the three sources of data on which Shuster's analyses rely. Through textual analysis of correspondence between Harry Benjamin and colleagues, qualitative interviews with clinicians, and participant observation at trans health conferences, Shuster underscores the work of scientific evidence, medical expertise, and uncertainty as a triadic interplay that has created the emergence and practice of treating gender. Shuster's ability to wed the theoretical with the empirical shines throughout the book and solidifies an emerging trend in transgender studies that takes seriously both the humanistic and social scientific valences of scholarship on transgender life.Where much of the theoretical insights within transgender studies on health care and medicine stem from history (notably Jules Gill-Peterson's Histories of the Transgender Child and Joanne Meyerowitz's How Sex Changed, among others), Shuster brings their sociological imagination to see with new eyes the familiar within the strange, rather than the other way around. While transgender medicine, as either an object of analysis or a subfield of scientific inquiry, could be read against the grain of contemporary bioethical and sociological thought, Shuster instead dives into the contemporary literature on consumer-based models of health-care delivery and the rise of evidence-based medicine. What is perhaps most refreshing about Shuster's analysis in part 2 of the book is that they work diligently to reveal that which is decidedly aligned with the dominant paradigm of biomedicine. Within trans studies, it has become a foregone conclusion that to study transness and trans life is to study the aberrant, the abnormal. But Shuster unearths the influence that evolution in health care, which orients toward evidence-based medicine over and against assumed infallibility of providers, has on the formation of contemporary transgender medicine.Even while naming, and critiquing, the paradox that is scientific evidence within transgender medicine, Shuster reminds us that this is a feature of modern medicine writ large rather than something clinicians working with trans clientele created to eschew culpability. This lack of evidence coupled with a lack of familiarity with trans people leads to provider uncertainty, something that a clinician committed to their own expertise cannot abide. Shuster argues that this uncertainty prompted the creation of guidelines for transition-related medical care that can shore up and confer expertise on clinicians working with trans clientele in the absence of scientific evidence. They further suggest via their interviews that these guidelines are not without controversy and that some clinicians are “close followers” of the text and comfortable deny accessing to hormones or surgery based on diagnostic criteria (104), while others are “flexible interpreters” who may be willing to bend the rules in order to eschew the gatekeeping that their profession and expertise expects of them (117). Shuster ultimately concludes that, despite this bifurcation in approach, when confronted with uncertainty both close followers and flexible interpreters fall back on their presumed expertise and thereby reify the existing power dynamics that pathologize transness, limit access to necessary medical care, and reinforce existing health inequities.Shuster brilliantly interrogates not only the scientific evidence on which the field of transgender medicine is built but also the discursive work that it does in upholding the expertise, and by extension the gatekeeping tendencies, of its providers. While they successfully contextualize the limit and promise of evidence in transgender medicine, the book falls short in its disconnect between its generalizing claims and its purely US American focus. For example, the shift toward evidence-based medicine does have a profound impact on the scientific literature; however, it is an almost exclusively US American phenomenon. Further, the ideal form of evidence in this paradigm is the result of a randomized control trial, about which Shuster writes, but which is not only implausible but also unethical in the case of transgender-specific medical care (Reisner et al. 2016). The same can be said of some of the central claims about what constitutes transgender medicine, including the argument that gender incongruence as a new category included in the eleventh version of the International Classification of Diseases repathologizes trans people by conflating gender with sexuality. What the chapter in which this argument features does not address is the long, global social movement Stop Trans Pathologization (STP), which was instrumental in both pushing for this change and strategically placing some prominent trans leaders from around the world on the committee to draft the language of the diagnosis (Cabral and Eisfeld 2013). The argumentation proceeds as if transgender medicine in the United States exists within a vacuum without influencing or being influenced by health systems in other sociolegal and geopolitical contexts. Even within the specific context of the United States, there are some unaddressed limitations of Shuster's analysis that likely shaped it. Notably, while the book does advance our understanding of what the field of transgender medicine is and looks like in the twenty-first century, there is little meaningful engagement with scientific racism, either its history or its continued presence in the new millennium. Other contemporaneous works, such as C. Riley Snorton's Black on Both Sides and Gill-Peterson's book mentioned above, should be read alongside this one to get a fuller picture of how trans people of color may navigate the paradoxes that Shuster outlines in Trans Medicine. Further, I would suggest pairing the book with Siobhan Somerville's Queering the Color Line to understand how the divisions between sex, gender, and sexuality were racialized from their inception.Trans Medicine would be a fantastic addition to any history of medicine or medical sociology course and would be accessible to undergraduate audiences while remaining dense enough to warrant unpacking in graduate seminars. It would also be of interest to budding anthropologists and ethnographers for the ways in which it bridges archival work, participant observation, qualitative interviews, and rhetorical analysis. It may be useful in science and technology studies classes, and even public health classrooms, for the ways in which it deconstructs medical authority and the recent turn toward evidence-based and even personalized medicine.Ultimately, Trans Medicine illustrates that there may be a new wave of transgender studies forming, one that is explicitly bridging humanistic inquiry and theory building with social science and its methods. My hope is that the field of transgender studies can anticipate this new wave of what we may call “applied” work, which will bring refreshing new perspectives to a field that is ostensibly about transgender people but only infrequently involves interacting with them directly for research purposes. May Shuster's book be the first of many like it in the field that will demonstrate the utility of empirical approaches when paired with critical, theoretical aims.