Intersections and evolution of ‘Butch-trans’ categories in Puerto Rico: Needs and barriers of an invisible population

Abstract

Public health research among transgender populations globally has primarily focused on HIV/AIDS. However, trans men remain outside of this conceptual framework, with distinct but overlapping social contexts and needs. In Puerto Rico (PR), the trans men population has remained largely hidden within the ‘butch’ lesbian community. The objective of this article is to document the identity construction of trans men and ‘buchas’ (local term to refer to butch lesbians) in PR and its relation to their bodily practices and overall health. We conducted an exploratory qualitative study with 29 trans men and buchas based on ethnographic observation; focus groups; audio-recorded in-depth interviews; and critical discourse analysis. Findings emphasize two domains to be addressed by health policies and initiatives: 1) bodily representations and gender performance, and 2) the meanings of female biological processes. This small-scale ethnographic study represents an initial step toward understanding the social context of this ‘invisible’ community and significant implications for their health and well-being. We provide several recommendations to address public health concerns of this understudied, marginalized community.

Global public health research among transgender / transsexual (heretofore referred to as ‘trans’) populations has almost exclusively focused on HIV/AIDS (Bockting, Huang, Ding, Robinson & Rosser, 2005; Melendez & Pinto, 2007). Because trans women (people who were assigned a ‘male’ sex at birth and have a female gender identity and/or expression) have been described in public health literature as more vulnerable to engaging in risk behaviour for HIV infection, research and funding have focused primarily on addressing this concern (Kosenko, 2011; Wilson, Garofalo, Harris, & Belzer, 2010). In Puerto Rico (PR), most studies on the trans community have similarly focused on the impact of HIV on trans women and factors influencing their vulnerability (TRANSforma Project, 2014; Rodríguez-Madera, 2009). The focus on HIV among trans women has come at a cost to trans men, who are often neglected in research on trans communities, partly due to their presumed low prevalence (Rowniak, Chesla, Rose, & Holzemer, 2011), resulting in a lack of research on the social context of health and illness among trans men.

Examining the embodied experiences of gender and sexuality among trans men is critical to understand the health disparities this community faces. The objective of this article is to document identity constructions of trans men and ‘buchas’ (a local category analogous to masculine-identified butch lesbians) in PR and to critically examine the effects these constructions have in their bodily practices and health. We will explore how these categories are manifested, and identify some health-related needs and vulnerabilities they face.

Cultural Context of Puerto Rican Trans Men and Buchas

PR is the smallest of the Greater Antilles in the Caribbean, characterized by strong cultural adherence to traditional gender roles, including machismo (a gender ideology that encourages cisgender males to engage in a range of social practices such as dominance over women or sexual prowess) and marianismo (a gender identity that encourage cisgender females to be pious, maternal, and faithful) (Burgos & Díaz Pérez, 1986; Saez, Casado, & Wade, 2009; Wood & Price, 1997). One of the consequences of the social value placed on these models is a high degree of intolerance for gender non-normativity (Kulick, 1998; Parker, 1999). Such intolerance results in stigma and discrimination, heightened vulnerability to HIV, lack of social support, reduced access to health care services, unemployment, and poverty (Bockting, Huang, Ding, Robinson, & Rosser, 2005; Padilla et al., 2008).

The transgender concept has been often described as a macro-level category (Sevelius et al., 2010) that encompasses a wide range of gender presentations and identifications that are culturally variable. In PR, the population of trans men has remained largely hidden within the lesbian community, which has itself been described in Latin America as ‘invisible’ (Padilla, Vásques del Aguila, & Parker, 2007). Given the lack of information and resources, trans men and buchas have found social support in a community that shares some of their struggles but does not represent their particular realities or needs (Rodríguez, Ramos, & González, 2012). In PR, the term bucha derives some of its social meanings from the English term butch which refers to a woman who assumes social roles typically attributed to cisgender males (Torres, 2007)ⁱ.

Locally trans women have been studied more extensively (Rodríguez-Madera, Ramos-Pibernus, Padilla, & Varas Díaz, 2016) and there is a gap in knowledge of trans men. It was not until 1990s that the presence of gender transgressive identities became evident in local vernacular (Aponte-Parés, Arroyo, Crespo-Kebler, La Fountain-Stokes, & Negrón-Muntaner, 2007). Studies regarding the lesbian community have been mainly approached from a feminist perspective and presented in the form of poetry or literature. Configurations of the bucha identity in PR have been studied largely from the perspective of migration. Certain strands of Puerto Rican culture undergird intolerance towards diverse sexual orientations and gender identities, resulting in migration of gender non-conforming people to the United States (La Fountaion, 2005). Migrations have played a role in the configuration of non-normative sexual and gender identities, but there is still much descriptive ethnographic research to be done to understand their transformations.

Trans people face major barriers to employment, non-discrimination, public accommodations and general social acceptance (Bradford, Reisner, Honnold, & Xavier, 2013; Mizok, Lauren & Mueser, 2014; Rodríguez-Madera, 2009; 2012). However, vulnerabilities of trans men have been largely overlooked (Califia, 1997; Cromwell, 1999)ⁱⁱ. Emphasis on trans women prevents the development of a fuller understanding of needs and appropriate public health initiatives for trans men (Pollock & Eyre, 2011). The lack of attention granted to trans men has contributed to a slower diffusion of transgender terminology and self-identification in PR. Prior research on HIV has been shown to shape identification practices of sexual minorities, which social science researchers have described as the medicalization of sexuality and sexual terminology (Epstein, 1996; Muñoz-Laboy, 2004; Patton, 1990, 1996). Trans men have been largely ignored in HIV/AIDS research and intervention, and this has contributed to their relative invisibility in public discourse and health initiatives.

Border wars: Intersections and distinctions between trans and bucha categories

There is an ongoing debate in the scientific literature regarding differences and similarities between trans men and butch lesbians (Halberstam, 1998; Hale, 1998). Halberstam (1998) and Hale (1998) have described the semantic tensions between these gender categories as ‘border wars’ (Cromwell, 1999). The debate is in part due to the overlap of identity constructions and social characteristics between both. Crawley (2002) states that trans and butch categories are similar in their gender presentation and ambivalence towards the feminine body, but markedly differ in their gender identification. Trans men often self-identify as men and butch lesbians as women (Cromwell, 1999). Halberstam (1998) stresses that trans men are associated with a desire for ‘re-embodiment’, while butch women are associated with a playful desire for masculinity and gender deviance.

In PR a distinction between categories is far from clear, with much overlap and inconsistency in self-definitions of gender. These fine-grained distinctions between the Puerto Rican cultural context and those described in other settings are critical in addressing health vulnerabilities and gaps in public health services.

Health related issues in the trans and butch community in PR

In PR the absence of social research on trans men and buchas health is related to lack of theoretical conceptualizations of health and illness. Health, as a social process with biological implications, has been conceptualized as a system of classification that assigns specific labels to individuals (Turner, 2001; 1999). Sick/healthy, normal/deviant, and male/female are just a few examples of binary pairs used through medical and health discourses to redistribute individual variability into bipolar categories (Lupton, 2003; Peterson & Lupton, 2000). Once individuals fall outside the confines of normative, ‘healthy’ categories, medical and health discourses have difficulties with categorization, an essential step in identifying health problems and establishing treatment plans or guidelines (Riggs, 2005). Such categorization of individuals, and their embodiment of ‘disease’ or ‘deviance’, is an integral part of social regulation of marginalized communities and maintenance of bipolar gender categories that these groups challenge through their embodied practices (Nettleton, 2000). Social stigma is a common response from the medical and health establishment when faced with people who transgress such categorizations (Nettleton, 2000). Medical institutions are often sites that exclude or delegitimize trans bodies and identities and their unique clinical needs. Too often health care services and health promotion campaigns contribute to trans invisibility and marginality, with adverse health consequences for them.

A wide range of health conditions associated with stigma and discrimination disproportionately affect trans populations, including substance abuse (Ann, Colón, Robles & Soto, 2007), mental health conditions (Bockting et al., 2013; Blosnich et al., 2013), and cancer (Brown & Tracy, 2008). Lack of preventive care and the delay of urgently needed care constitute major health risks for trans men and butch lesbians (Grant et al., 2011). This is due in part to fear of being discriminated against, misunderstood, or stigmatized by health professionals. Moreover, because trans men and butch lesbians have remained understudied, there is lack of information regarding incidence of chronic health conditions such as cancer or strategies to address them (Ashbee & Goldberg, 2006). These realities have created a gap between the needs and access to social and health related services and require competent professionals who understand identity constructions and factors related to health in the community of trans men and buchas. PR is perhaps an extreme case of such gaps in services and knowledge.

Method

We conducted a qualitative exploratory study using different methodological approaches, implemented sequentially in three phases: (1) ethnographic observations, (2) focus groups, and (3) individual semi-structured in-depth interviews. The study protocol was reviewed and approved by the Institutional Review Board of our institution. All participants were recruited by convenience using snowball sampling from key contacts identified through ethnographic observations in social settings frequented by the population, including a popular lesbian night club in San Juan, key gathering point for trans men and buchas. Total sample consisted of 29 participants who self-identified as hombres trans (trans men) or buchas. Inclusion criteria were: being at least 21 years of age (legal age of adulthood in PR) and self-identifying as a trans man or bucha (see Table 1 for socio-demographic characteristics). Inclusion of both trans men and buchas was informed by initial ethnographic observations and key informant interviews that revealed that, in PR, the border between these categories is extremely fluid and permeable. We sought to understand how individuals moved between and among these identities. As it can be seen in Table 1, participants used a wide array of labels to describe their gender categorization. We discuss subtle distinctions between these terms, but they cannot be presumed to be absolute or stable. Ours is an exploratory study aimed at documenting nuances and describing ‘shades of gray’ in our sample as a starting point to research on this population.

Table 1.

Sociodemographic characteristics of qualitative interviews

Variable	Frequency
City of residence
San Juan	4
Río Piedras	2
Cidra	1
Aguada	1
San Diego, CA	1
Education
High School	1
Some years of college	4
Bachelor’s degree	4
Civil status
Single	5
Living together	4
Employment
Yes	6
No	3

Note: n=9

Ethnographic procedures

We conducted ethnographic observations during three months in bars and pubs located in the metropolitan area of San Juan, frequented by trans men and buchas. Observations and informal interactions were critical to examine the social and structural factors underlying daily life and identity constructions and health-related practices in this population. Observation involves a structured manner of immersion in local cultural worlds in order to learn about what people do and what it means to them, while also attending to ways in which contextual factors shape and constrain individual and group practices (Bernard, 1994). During ethnographic outings, led by the first author with participation of co-authors, we engaged in informal interactions with owners, employees of establishments, and members of the community of trans men and buchas. To gain access to the community, a trans woman who worked as a consultant in another research project introduced us to key gatekeepers of the lesbian/trans men bar scene where most observations were conducted. Gatekeepers or key informants (bar owners) demonstrated genuine interest in our research. They linked our team to key contacts in the community and collaborated with referral of eligible participants. Through frequent and active participation in social and community activities at this key site we gained trust with potential participants in focus groups, who became interested in the study and informed their peers. Focus groups and interviews were conducted in Spanish.

Data collection involved writing ethnographic field notes and analytic memos and development of provisional hypotheses based on observations further explored in subsequent fieldwork. Toward the beginning of the ethnographic phase, we developed an ethnographic guide to systematize subsequent observations and reflect on the effects of various social and structural factors on health behaviours and practices. The guide focused on issues regarding gender identity constructions; the meanings of community and social affiliation; and tensions or variations in gender representation and performance.

Focus groups

We carried out two focus groups composed of trans men and buchas to gather detailed information about topics that have been less explored or might benefit from collective analysis (Babour, 2010). This strategy allowed our team to evaluate shared views regarding a range of topics related to identity construction and health (Robinson, 1999). We recruited 20 participants. Inclusion criteria were: being at least 21 years of age, self-identifying as a trans man or bucha, and providing verbal consent. Given that this was an exploratory study and that our preliminary research suggested no clear distinction between buchas and trans men, both were integrated into our focus groups. Nevertheless, we diversify the sample by recruiting ten participants who identified primarily as ‘bucha’ and ten as ‘trans men’. We used a focus group guide to lead discussion of relevant topics. The guide included questions on: 1) gender identity, 2) meanings of the words bucha and trans men, 3) bodily modification practices, 4) experiences of stigma and discrimination, and 5) exploration of health- related needs. Focus groups were conducted in the bar’s facilities prior to its opening. Discussions were audio recorded for transcription and analysis.

Individual in-depth interviews

In the final phase, we conducted individual semi-structured in-depth interviews with 9 participants (see Table 2) to gather additional narrative on experiences related to their social lives and health vulnerabilities in a one-on-one encounter. We selected participants during fieldwork or by referral. Selection criteria were the same used for focus groups. We used an in-depth interview guide to provide uniformity and to guide conversations while allowing flexibility based on contents addressed by participants. The guide included questions on: 1) identity perception 2) bodily transformations 3) health issues 4) work related experiences, 5) experiences in affective relationships and 6) general experiences with society. We included a Demographic Data Questionnaire with questions addressing economic status, gender identification, area of residence, educational level, and sexual orientation among other variables. Confidential interviews lasting 60–75 minutes were conducted in private locations. We provided a monetary incentive of $25.

Table 2.

Gender Identity and Sexual Orientation of Interviews

Variable	Frequency
*Self-Description
Transgender	1
Genderqueer	1
Transgender man	2
Butch	3
Men	1
Fluid Identity	1
Sexual Orientation
Heterosexual	2
Bisexual	2
Homosexual	3
Pansexual	1
Not defined	1

Note: n=9

^*The terms under the self-Description variable are the ones used by each of the participants to describe themselves in terms of gender identity.

Data Analysis

Audio files were transcribed verbatim into word-processing files. Data obtained were coded and organized using a codebook (Barry, 1998) developed from a grounded, analytic reading of transcripts to identify a core set of issues and inter-related themes. We coded the data using critical discourse analysis (CDA) to focus on relations between discourse, power, dominance, social inequality and the position of the researcher in social relationships. Since we collected and analysed data in Spanish, we translated relevant narratives to English for publication purposes. We made an effort to capture the exact message and included some words in Spanish that we considered had no equal translation to English.

Results

To facilitate the analysis of narratives, we will begin by presenting an ethnographic fieldnote excerpt in order to illustrate the lack or partial incorporation of the category ‘hombre trans’ (trans man) in this population. Our analysis focuses on two main domains or processes that reflect the intersection and social context of gender identities and the health of trans men and buchas. These were: 1) bodily representations and gender performance, and 2) the meanings of female biological processes. We identified each narrative with the participant’s self-identified gender category to illustrate the diversity of concepts used to describe their gender identities.

Ethnographic fieldnote excerpt

The following ethnographic field note describes an interaction between the research team, a key informant of another study that is a trans woman, and two participants. This vignette is helpful in situating our analysis within the categorical ambiguity between trans men and buchas. It exemplifies the incomplete or inconsistent integration of trans identity in this community:

We started the night at a local bar frequented by the community of lesbian women. Once we got there we noticed that the topic of conversation we were interested in exploring had already started. Owners of the bar, “Laura” and “Milagros”¹ [a couple who identified themselves as ‘femmes’], welcomed us and the first thing they told us was that we had arrived at the appropriate moment. They were talking with two costumers, “Sandro” and “Leon” [who self-identified as buchas], about the roles of lesbian women in their relationships. While they identified as buchas, they used masculine pronouns to refer to themselves. Sandro and Leon mentioned that two femmes together was a transgression of what is expected for a lesbian couple. For them it was essential that a couple included a bucha or that one of the parties assumed the male role. Laura and Milagros disagreed. Leon -who was more vehement in his opinion that lesbian couples should follow heteronormative gender roles- told us that while two femmes together was acceptable, a couple composed of two buchas was not. To sustain his viewpoint, he told us a story about a time another bucha asked to go to the bathroom with him and that this had disgusted him.

Teresa [a trans woman and key informant] asked Sandro and Leon if they defined themselves as trans men. The answer was: ‘we are buchas’. Teresa continued to explain the meaning of the trans concept [according to her] and why she thought that Sandro and Leon were actually trans men. Leon clarified that he was a man. ‘Here and wherever I go I am attracted to very feminine women’, he explained. Leon provided the following explanation to Teresa of what it meant to him to be a bucha. He asked Teresa: ‘You are a man, right?’ to which Teresa replied ‘no’, and Leon continued: ‘You have a dick down there but you see yourself as a woman… Well for me is the same, but the other way around’…

This fragment of the ethnographic field note illustrates a common mixture of different notions of gender that are highly fluid and with blurred boundaries, a phenomenon regularly documented in our field notes. The concept of trans men is not clearly integrated into everyday discourse in the community, leading many participants to identify as bucha but describe themselves as men. While bucha is generally used to refer to a female-bodied lesbian woman who exhibits a masculine gender performance, we found a regular discursive slippage between this category and a more reified notion of ‘being a man’. In the above field note, Sandro denies his identity as a ‘trans man’ by simply excluding the prefix trans, and sees no inconsistency between being a bucha and being a man. Another participant changed the gender of the word bucha to bucho (a change in the grammatical gender of the term) in order to better described what he felt he was; once again, he avoided using the term trans. When we asked if he defined himself as trans, he stated that he did not know the definition of the term but added that he was ‘a man trapped in a woman’s body.’

All participants manifested a desire to modify their bodies to be more aligned with a ‘masculine’ sense of self, which is often described as definitional of transgender identity in the scientific literature. In PR, bucha is a broader category that encompasses many of the meanings associated with trans identity in the near absence of a distinct label to refer to trans men. While three of our interview participants self-identified as trans (one as ‘transgender’ and the other two as ‘trans men’), the majority did not use these labels, and many were unsure of its meaning. Interestingly, the category of trans woman is recognized and generally understood, whereas trans man is a nascent social category that is rarely used in social practice, perhaps because of the broad sub-cultural definition of bucha, which subsumes many characteristics associated with trans. While this phenomenon needs further study, we believe it may have important implications for policies, programs, and interventions, particularly regarding the prominence of the local category bucha.

Bodily representation and gender performance

West and Zimmerman (1987) describe ‘doing gender’ as the interactional process of performing gender identities that reaffirm culturally defined notions of the masculine-feminine binary, even as they may seek to overcome or resist them. The following quote from one of our participants self-identified as a trans man, illustrates how gender identification was described by many of our participants, incorporating a gender binary through which one’s own marginal gender identity was experienced or reworked:

‘I’m going to describe what I think I am… I feel that I have a masculine mind inside of a feminine body, with feminine sensitivity and the hardness that is needed in order to survive. Maybe If I was completely feminine, I’d still be living with my mother, hide under her skirt because maybe I would be afraid of life, to confront things, or I would have been able to empathize more with who she was, that is, submissive…’ [Participant self-identified as trans]

This participant attributed characteristics such as “weakness” (i.e. lack of ‘hardness’ and a ‘submissive’ nature) to a feminine role, while exalting male attributes presumably ‘needed in order to survive.’ Several participants similarly appropriated bipolar notions of gender into their descriptions of self-identity, as illustrated by several participants who described their gender identities in relation to their role as household provider:

‘You start to feel like the strongest person in the relationship because you are the one that has more responsibility. At least in my case, I’m the one with the most responsibility. My house lacks nothing… I dress like this and I’m the strong part of the relationship.’ [Participant self-identified as bucha]

‘…you try to assimilate all you can from manhood, at least in my case that’s what I do and in my house it’s like that, I’m the one that provides and the one that says how things are…’ [Participant self-identified as trans man]

Bodily presentation as a masculine individual was extremely important for trans men and buchas. Our participants shared a wealth of intimate information regarding their bodily practices for physical and gender performance and their techniques for projecting a masculine identity.

‘At 23 I started to change completely. I changed the way I dressed, but then I have never gone shopping for male clothing. I cut my hair shorter and started to transition.’ [Participant self-identified as trans man]

‘When I was in high school I stole my cousin’s swimsuits… I stole them and wore them and my mother preferred to buy me some male pants to avoid having to steal from my cousin. [Participant self-identified as bucha].

‘I hated to dress like a girl… wearing dresses and high heals…. I was a tomboy teenager. Since I was little I dressed as a boy and I used to buy male clothing… Nowadays, I buy pants in women’s department stores because they fit me, but I prefer to buy in the men’s area. I also wear male underwear [Participant self-identified as a fluid identity]

Several participants described biomedical technologies or procedures for body modification in which they had engaged – such as testosterone supplementation, binding of the breasts, and penile prostheses – to embody a more masculine social role. In many instances, the use of these technologies represented significant challenges for daily life and activities:

‘I started to change slowly. I began with a haircut and when I felt comfortable, then I started to change my clothing. I started to look to other [trans] men to see what they were doing and it was basically hormone therapy. Until then I just worked on my body by doing exercises and finally, I began self-administering hormones.” [Participant self-identified as trans man]

‘I wear a super small sports bra and it takes my breath and life away… I guess it’s better than using bandages because they become loose … Thus you look at yourself like, ‘Wow this shit is a descojón [huge mess]!’ I used to skate board wearing a bandage and always was very… It was like… ‘I have to go home now or I have to go to the bathroom to fix it’. It’s not easy to put it on. I always have to ask my jeva [girlfriend] to help me… They are tiny and painful. Right now I’m talking to you and I look normal and the damn thing hurts. It always hurts. That feeling is not cool.’ [Participant self-identified as gender queer]

‘I use a prosthesis. I bought it on the Internet. I wear it only when I’m going out… It depends on the shirt I’m wearing and whether it covers my pants or not. It is for my mental peace because people can be looking at you and notice ‘that’ … [Participant self-identified as trans man]

‘In my case I wear a small prosthesis, but I have to be very careful when I go to the bathroom because on one occasion it fell out. I was lucky that I could grab it quickly.’ [Participant self-identified as trans man]

In most cases, participants had gone through long periods struggling alone and in silence to align their bodies with their gender, and lacked safe spaces to obtain accurate information about practices and technologies that might be available to them. These practices are entirely invisible in health care settings and public health programs in PR. The social context of use of biomedical technologies, such as testosterone supplementation, was nearly impossible for our participants to discuss with health care providers, which strongly constrained their access to appropriate treatment and public health services.

The meanings of female biological processes

The physical body might be described as a signifier that tells others what to expect in terms of social roles. For who is challenging dominant symbols of gender and sexuality, the body betrays or ruptures gender expectations, and becomes a site for social conflict, stigmatization, and stress (Meyer, 2003). During puberty mind-body dissonance becomes more evident, as the symbol of the body more intensely contrasts with an underlying sense of one’s gender identity (Morgan & Stevens, 2008). A study conducted by Devor (1997) found that most trans participants mentioned not being able to cope with the physical changes they observed during adolescence. Some participants expressed the same feeling of being betrayed by the body during puberty:

‘Before puberty I used to wear a pony tail, and I had really long hair and I put it up in a pony tail and pretended I was a boy. You know what? I used to pray to god, please that tomorrow I wake up as a boy. It’s really like depressing, but then I say to myself, ‘well maybe I will never get my period, maybe my body has a physical problem and that’s why I feel this way’, but when I got my period all my hopes went away…’ [Participant self-identified as trans men]

‘For me it was something that I was embarrassed of my own body, I couldn’t assimilate, I mean, that my breast began to show, that I was developing a woman’s body, I couldn’t… Sometimes I would lock myself up in my room and cry and say, ‘Why, god, if you know I like women, why this, god?’ I said, ‘why I was born like this, like a woman, I feel like a man and I’m chained to a woman’s body.’ [Participant self-identified as bucha and man]

An important implication of the rejection that these individuals felt towards female anatomy was their attitude toward gynaecological exams and follow-ups. Trans men and butch lesbians visit the gynaecologist less frequently for pap spears and preventive care, which is potentially linked to higher risks for cervical and uterine cancers (Dutton, Koenig, & Fennie, 2008; Tracy, Schluterman, & Greenberg, 2013). One of the reasons for this is the denial of the female body as an expression of gender ambivalence or dissonance (van Trotsenburg, 2009).

‘I say, ‘Why go to the gynaecologist if I’m a man and I have confidence in myself?’ I’m a man, you know. My body is a carapace… I don’t have to. Why let anybody see my body?’ [Participant self-identified as bucha and man]

Another reason for avoiding gynaecological exams was related to discomfort participants experience with their genitals and the pain that accompanies the examination:

‘To have those pap spear exams is for me very stressful…I have had it two times, the first one was uncomfortable, but I dealt with it. It did not hurt. But this time it was horrible, it was very painful. I don’t know why it hurt so much and I don’t know if it was the tension that I had for trying to avoid it. I want to have a hysterectomy to avoid doing it all because I don’t want to go through that again.’ [Participant self-identified as trans man]

Such experiences of being probed in areas of the body that provoked shame and bodily dissonance contributed to a pervasive sense that health care facilities are menacing spaces. The lack of clinics specializing in trans health in PR functioned as a significant barrier to accessing basic preventative care and quality treatment, as participants simply did not see the available clinical services open to non-cisgender individuals.

‘No, I can’t [go to the clinic] because there’s a bunch of women waiting at the gynaecologist [office] and I can’t like be sitting there waiting to be called. I couldn’t… And finding a gynaecologist that can work with you, because you know it’s not the same. People look at you… Unless I had gone with a family member and pretended that it [the appointment] was for her. But then when they called my name… So no, I couldn’t go’ [Participant self-identified as trans men]

Even when participants have strategies such as seeking the company of a family member, they do not feel safe. Most of our participants only sought health care during emergency situations. One of them acknowledged that he did not seek preventive care regularly and attributed it to lack of guidance on that matter:

‘I had never seen [the gynaecologist] but my insurance was going to expire… So I went and they discovered that I had something that needed surgery. Now I have to go because of the surgery but I had not gone before… You’re right, we don’t go regularly to the gynaecologist… Nobody talks about it, nobody brings this up anywhere’ [Participant self-identify as bucha]

Non-cisgender constructions were directly linked to problems accessing health care. Participants faced difficulties in understanding how specific health care services intended for cisgender females were still applicable to trans men and buchas who had female genitalia but masculine gender identities. Clinics and hospitals became sites for uncomfortable, embarrassing, or oppressive social interactions that functioned to stigmatize, undermine, or delegitimize their expressions of self. Individuals who challenge binary notions of gender might face difficulties in accessing services or even understanding the need to access routine health and prevention services that they do not associate with their own bodies or identities. This makes it very unlikely that public health policies and programs, particularly those related to reproductive and sexual health, to reach trans men and buchas, who would not see themselves as target of programs designed for cisgender women.

Conclusions and Recommendations

This study – the first to our knowledge focused on trans men and buchas in PR – represents an initial step in understanding the social context of this ‘invisible’ community and implications of their experiences for health and well-being. First, our participants described gender identities in their communities using local butch-femme categories, in which the masculine figure – the bucha – expressed an embodied notion of masculinity that incorporated a variety of practices and bodily technologies. Some of these practices involved non-clinical use of testosterone for body modification, analogous to informal hormone injections that have been described for trans women (Kulick, 1998; Poteat, German & Kerrigan, 2013), that may contribute to other health risks, particularly when needles are shared. Others described the use of penile prostheses and chest binding, experiencing discomfort and challenges with these practices. Bucha is a broad sub-cultural category that is often associated with bodily dissonance and identifications that are akin to most definitions of transgender or transsexual in the global scholarly literature. While trans terminology exists in PR, bucha is a dominant cultural category that is inclusive of those who identify themselves as men and engage in body modification practices and technologies.

The appropriation of heteronormative models for organizing gender relations, and the importance of such models for legitimating masculine identities, need to be considered in the development of psychological, clinical, or public health initiatives to reach this community. Clinical and public health services for trans men and buchas need to include training for personnel on the meanings of these terms and the bodily ambivalence or dissonance that commonly accompany them. Such training should require adaptation to local context and terminology. Sub-cultural realities of trans men and buchas are likely to be misunderstood and stigmatized by health care providers. This would contribute to avoidance of health care and underlines the importance of developing interventions aimed at promoting preventive care for this population. Stigma reduction interventions and anti-discrimination policies for trans men and buchas should be implemented across the health care system, even as more trans-specific services are developed.

Participants told many stories of being highly uncomfortable of having their bodies inspected by medical personnel, particularly during gynaecological exams. Bodily ambivalence or dissonance generated strong resistance to health care facilities, described as menacing places or sites where they did not belong. It was difficult for them to understand why health care services for cisgender females were necessary for buchas and trans men, partly due to a tendency to invoke strong contrasts between cisgender women and buchas, creating reified notions of differently gendered bodies. In this context, it may be more difficult for trans men and buchas to understand how or whether clinical and public health recommendations for cisgender women are applicable to themselves. Future initiatives oriented toward this community should incorporate sub-cultural knowledge inclusive of trans men and buchas, to adapt current interventions and outreach programs, and to create safe spaces where gender non-conformity is welcomed and explored openly. We believe our findings underscore the urgent need for trans-oriented health care and public health programs in PR.