Trans medicine: the emergence and practice of treating gender

This history of trans medicine makes clear the problem from its inception has been that many medical providers don’t really know what they’re doing. Author stef m. shuster writes: “Confronted with a lack of scientific evidence to guide their decisions, and often having little experience with this population, providers face a considerable degree of uncertainty in medical decision making.” Uncertainty makes medical professionals uncomfortable, and to combat it they established standards and guidelines. In the past, these standards usually strictly enforced the gender norms of the dominant society and were responsible for the gatekeeping that characterized trans medicine for so long.

While there may be much to criticize about the way trans people were treated in the early years of trans medicine – generally regarded as the mid-20th century – its early practitioners should also be afforded some sympathy. Working with trans people was not regarded as a wise career choice, and there was a fine line between what some doctors regarded as innovation and others as quackery. Doctors needed to protect themselves from legal liability. In attempting to establish legitimacy to hormones and surgery as suitable therapeutic procedures, they enlisted the aid of mental health professionals to help identify the “worthy” patient.

It wasn’t long before physicians became concerned about the expanding role psychologists and psychiatrists assumed in trans medicine. They had been asked only to assess a patient’s mental health, not to demand extensive therapy sessions which drained the finances of an already low income population.

And so began our misery. For the mental health professionals of the time, “identifying as trans was a symptom of delusional thinking, and anyone who wanted to ‘change their sex’ was met with suspicion and labeled as having some form of psychosis.” Physicians gradually began to lose their authority over trans medicine.

It all makes for a fascinating history that explains much about how we got to where we are. While treatment for trans folks has improved so that our own agency is now considered, the central weakness of trans medicine still creates problems for its practitioners. In a profession that is evidence-based, there is actually very little scientific evidence to rely on. Consequently, the standards that were developed to help practitioners feel they were on solid ground mostly reproduced a binary definition of transgender and imposed a set of normative expectations on trans patients.

shuster characterizes current professionals working with trans clients as either “close followers” or “flexible interpreters”.

Close followers regard gatekeeping as a tool to benevolently aid clients from having regret. However, this inevitably limits a trans persons agency and often reinforces dominant gender norms. Flexible interpreters don’t see guidelines as rigid rules, but rather as recommendations. They are better able to embrace uncertainty. Some even regard gatekeeping as unethical and “were keen to avoid creating barriers to care.”

While medical practitioners were struggling with how to treat trans people, non-binary people came along and threw another wrench into the works. They are sometimes dismissed as not knowing their gender identities. As one practitioner put it, “Give me a man who says he wants to be a woman, or a woman who wants to be a man, and I know what to do. Give me a genderqueer person and – what is that?”

This book is an excellent study of trans medicine, and of how the uncertainty of the medical profession shaped its treatment of trans people.