Trans Medicine: The Emergence and Practice of Treating Gender

231 Pages·2021·1.48 MB·English

by  Stef M. Shuster

Trans Medicine

Trans Medicine
The Emergence and Practice of Treating Gender
stef m. shuster
NEW YORK UNIVERSITY PRESS
New York
NEW YORK UNIVERSITY PRESS
New York
www.nyupress.org
© 2021 by New York University
All rights reserved
References to Internet websites (URLs) were accurate at the time of writing. Neither the
author nor New York University Press is responsible for URLs that may have expired or
changed since the manuscript was prepared.
Library of Congress Cataloging-in-Publication Data
Names: shuster, stef m., author.
Title: Trans medicine : the emergence and practice of treating gender / stef m. shuster.
Description: [New York, New York] : New York University Press, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2020047263 | ISBN 9781479845378 (hardback) |
ISBN 9781479899371 (paperback) | ISBN 9781479842810 (ebook) |
ISBN 9781479836291 (ebook)
Subjects: LCSH: Transgender people—Medical care—United States. | Gender-
nonconforming people—Medical care—United States. | Health services accessibility—
United States. | Right to health—United States. | Medical ethics—United States.
Classification: LCC RA564.9.T73 S48 2021 | DDC 362.1086/7—dc23
LC record available at https://lccn.loc.gov/2020047263
New York University Press books are printed on acid- free paper, and their binding materials
are chosen for strength and durability. We strive to use environmentally responsible
suppliers and materials to the greatest extent possible in publishing our books.
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Also available as an ebook
Contents
Glossary vii
Preface ix
Introduction 1
Part I. Historical Contexts of Trans Medicine,
1950s– 1970s
1. Creating Worthy Patients, 1950– 1970 23
2. Legitimacy Wars between Physicians and Therapists 49
Part II. Contemporary Trans Medicine
3. Making It Up: Evidence in Contemporary Trans Medicine 77
4. Medical Uncertainty: Working with Trans Patients 101
5. Uncertain Expertise in Trans Medicine 129
Conclusion: Rethinking the Treatment of Gender 155
Acknowledgments 169
Appendix: The Strength of Multi-S ited Studies 175
Notes 185
References 201
Index 213
About the Author 223
v

Glossary
American Psychiatric Association (APA): The professional
association for US- based psychiatrists that publishes the Diagnostic
and Statistical Manual of Mental Disorders.
Clinical guidelines: Guidelines represent recommendations for
medical decision- making. They are often supported by scientific
evidence and informed by a systematic review of evidence and
medical consensus. They outline a sequence of steps a provider is
encouraged to take in the diagnosis and prognosis of illness and
disease.
Diagnostic and Statistical Manual of Mental Disor-
ders (DSM): Published by the APA to offer standard criteria for
diagnosing and classifying mental health disorders.
Evidence- based medicine (EBM): A model of medicine that
that uses scientific evidence to help standardize medical decision-
making. Typically evaluates evidence as a hierarchy, with random-
ized controlled trials at the top and case studies at the bottom.
Gender- affirming care: I use this term to refer to all interven-
tions that fall under trans medicine including therapy, hormone
therapy (e.g., estrogen or testosterone), and surgery (e.g., vagino-
plasty or chest masculinization surgery). Some may use the similar,
but less agentic, phrase “sex reassignment surgery” or “gender reas-
signment surgery.”
International Classification of Diseases (ICD): Pub-
lished by the World Health Organization to offer standard criteria
for diagnosing and classifying all mental and physical health issues.
It is also used internationally for insurance reimbursement systems
and gathering morbidity and mortality statistics.
vii
viii | Glossary
Nonbinary: This term references people who identify with a gender
that is beyond the binary categories of woman or man (e.g., gender-
queer).
Target gender: I use this term to refer to the gender that one is
transitioning toward.
Trans: I use this term in an all- encompassing way to refer to people
whose gender identities differ from their gender assignment at
birth. This may include binary trans people (i.e., trans women or
trans men) and nonbinary people (i.e. genderqueer or genderfluid
people). I do not assume that all trans people seek medical interven-
tions.
Transsexual: This term was used more frequently from the 1950s
through the early 2000s to refer to trans people who sought medical
interventions for a gender transition.
World Health Organization (WHO): An international orga-
nization that publishes the International Classification of Diseases.
World Professional Association for Transgender
Health (WPATH): An international organization of medical pro-
fessionals that created the first guidelines (referred to as the Stan-
dards of Care) for trans medicine in 1979. They continue to revise
the guidelines every few years.
Preface
Arriving in Iowa in 2007 to begin my PhD program in sociology, I began
asking various units on the University of Iowa’s campus what resources
were available for trans people, especially in health services. Iowa City is
a small college town that many local residents describe as a liberal bub-
ble in the middle of a cornfield. The UI has a teaching hospital and does
not mirror other small cities that face a scarcity of medical providers.
But it was incredibly difficult to find any providers who wanted to work
with me, let alone those willing to do so. I had identified as nonbinary
and trans for quite a few years before arriving in Iowa City, but up until I
accepted a spot in the PhD program, my income had been tenuous, and
I was unable to access any gender- affirming healthcare.
The early 2000s were a time in trans medicine when few providers
were aware of the existence of trans people, and even less aware of non-
binary people, even though the rise of hormone therapy and surgical
interventions began in the middle of the 20th century. The handful of
providers of trans medicine in Iowa City followed the clinical guidelines
from a literal interpretation, which meant that they requested I undergo
six months of therapy before I could begin taking hormones or find a
surgeon who would work with me. This was confusing to me, as a young
adult who at that point in my life was financially independent and begin-
ning to work on a doctoral degree. These requests also felt infantilizing.
But, like many other trans and nonbinary people with limited options, I
decided it was worth it to comply with these requests. I was fortunate to
find a therapist who met my skepticism about the gatekeeping prevalent
in trans medicine with an open mind. In fact, he changed my orientation
on the value of therapy in general. Within a year I had gender- affirming
top surgery. A few years beyond that, I also began taking testosterone
ix
x | Preface
with a provider in Iowa City who, like my therapist, practiced medicine
from a gender- affirming stance.
Around the same time, I had been heavily involved in healthcare or-
ganizing and advocacy with a group that I started, TransCollaborations.
This was both a community and a campus advocacy group that offered
workshops across campus and in the community, touching on any and
all aspects of life that trans people negotiate. We brought speakers to
Iowa City, held zine- making parties, and organized on behalf of trans
people in healthcare services— generalist, specialist, sexual assault ser-
vices, and mental health. Through this organization, I developed several
close working relationships with medical providers. What I heard in the
workshops and planning sessions was that providers felt unequipped to
work in trans medicine, anxious about making decisions, and urgently
in need of information and evidence so that they could do their work
with more confidence. This was an early preview for me to learn about
the perspectives that providers brought into their work, the kinds of
questions they had about how to work with trans people, and the uncer-
tainty they grappled with.
In 2012, I was unaware of anyone who had brought a sociological
perspective to the medical provider side of trans medicine. The curi-
ous fascination that the social scientific community has had with how
people undergo gender transitions felt like an exhausted (and exhaust-
ing) topic. My healthcare advocacy work with TransCollaborations and
being engaged in conversations with health providers in the Iowa City
area served as the catalyst to shift the focus of this project, which began
with interviewing trans people, to the medical establishment.
I had my own uncertainties about how medical sociologists and soci-
ologists of gender might respond to this “weird” area of study. The 2008
recession brought new anxieties into the academic job market, where
“playing it safe” was the typical advice offered to early- career scholars.
In spite of these concerns, I felt compelled to take the risk. In flipping
the lens onto the medical community to shift the focus of study on them,
rather than trans people, I wanted to find out how providers make sense