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A review by lattelibrarian
Trans Medicine: The Emergence and Practice of Treating Gender by Stef M. Shuster
2.0
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.
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.