Therapeutic Itinerary of Trans Men from Northeastern Brazil

Abstract

Purpose:

To analyze the route that transgender men take to gain access to the treatments that are available for going through the transsexualizing process at a public care and attendance center in one of the capital cities of north-eastern Brazil.

Methods:

A qualitative case study which used the therapeutic itinerary as a theoretical-methodological path. The research was carried out between the months of September 2019 and March 2020 in a care and attendance center for trans people. The inclusion criteria were as follows: self-recognition as transgender men, over 18 years of age, and whose transsexualizing process was being carried out in the service stage of this study. Semistructured interviews were conducted. All interviewees participated voluntarily and signed a Free and Informed Consent Form before the study.

Results:

This study included 18 transgender men whose average age was 26.3 years. Of these, five (27.7%) were students, with one (5.5%) of them, as well as the others (nonstudents), performing some type of paid work. Three thematic categories emerged: (i) The (self-re-) cognition of the trans world through the internet and social media; (ii) the expression of male gender identity and the (non) support network; and (iii) access to transsexualizing process in SUS (Brazilian Public Healthcare System).

Conclusion:

The identification of the path taken by trans men, from their self-recognition and to the therapeutic care accessed through SUS' transsexualizing process, made it possible to identify the impacts of their experiences upon the construction of their gender identities.

Introduction

Transgender people are those whose gender identity does not match the gender assigned to them at birth. Regarding transgender men, they remain in a context of both social invisibility and exposure to vulnerabilities. Unemployment, dropping out of school, and deprivation of basic needs are imposed on these individuals who often need to “blend as” cisgender people as a survival strategy.¹

In recent publications on therapeutic itinerary (TI), emphasis was placed that their constructed life path has a history of prejudices, stigmas, and family violence. In addition, a supposed first identification as homosexual and some difficulty in differentiating it from gender identity reveal that the beginning of the transition process presents similar painful experiences.²

In this sense, the objective was to use the TI to analyze the paths transgender men from a care and attendance center in northeastern Brazil take to access the health care strategies that enable bodily modifications through transgenitalization surgeries and hormone therapy,² known as transexualising Process (TrPr) in the Brazilian Public Healthcare System (SUS).

Methods

It is a qualitative case study which sought to conduct an in-depth analysis on trans men.³ TI was used as a methodological tool to understand the trajectories throughout searching, accessing, and maintenance of participants' health care.^4,5

The research took place in a care and attendance center for transgender people at a University Hospital of a capital city in northeastern Brazil. The center has a multidisciplinary team and provides services related to psychological and psychiatric support and other medical specialties.

The sample inclusion criteria were as follows: self-recognition as transgender men, over 18 years old, and whose TrPr was performed at the service center of this study. All interviewees participated voluntarily with prior signing of an Informed Consent Form.

Semistructured interviews were used for data collection from September 2019 to March 2020. Thematic data analysis technique was applied.⁶

The TIs were synthesized and represented graphically for a better understanding of the main paths taken by participants. Their names were replaced by “E” followed by the respective interview number.

The study follows the Resolution Act No. 466/12 of the National Health Council's ethical principles and was approved by the Federal University of Pernambuco's Research Ethics Committee under the Act No. 3,204,377/19. It also matches the Quality Criteria for Qualitative Research Articles' (QCQRA) guidelines.

Results and Discussion

The average age of total participants (n=18) was 26.3 years (Table 1). Five (27.7%) were students, with one (5.5%) of them, as well as the others (nonstudents), performing some type of paid work. Their educational levels varied among incomplete high school (1–5.5%), complete high school (7–38.8%), incomplete higher education (7–38.8%), and complete higher education (2–11.1%).

Table 1.

Demographic data

Code	Age	Profession	Educational level	Marital status	Who do you live with	Average income (minimum wage)a
E.01	27	Tattoo artist	Incomplete higher education	Single	Alone	Family allowance plus freelance
E.02	24	Sign language interpreter	Incomplete higher education	Married	Wife	4
E.03	19	Student	Incomplete high school	Single	Mother and Grandmother	2
E.04	23	Self-employed worker	Incomplete higher education	Single	Alone	No fixed income
E.05	28	Cashier	Completed high school	Single	Mother and Father	2
E.06	25	Hawker	Completed high school	Married	Wife and 2 Stepchildren	1
E.07	33	Cop	Completed higher education	Stable union	Wife and 2 Children	3
E.08	18	Student/Trainee	Not informed	Single	Brother	1
E.09	37	Motorbike courier	Completed high school	Married	Wife, Mother, and 2 Children	3.5
E.10	27	Student	Incomplete higher education	Single	Mother	1.5
E.11	42	Janitor	Completed high school	Married	Cônjuge and sogra	1
E.12	22	Student	Incomplete higher education	Single	Wife-to-be	1.8–2
E.13	25	Support analyst	Completed higher education	Single	Mother, Grandmother, and Sister	2
E.14	26	Motorbike courier	Incomplete higher education	Single	Alone	1.5–2
E.15	18	Administrative assistant	Completed high school	Single	Mother	0.5 plus mother's income
E.16	26	Salesman	Completed high school	Single/Married	Girlfriend	4 to 5
E.17	25	Student	Incomplete higher education	Single	Mother	1
E.18	29	Bartender	Completed high school	Single	Wife	2.7

^a Data referring to the minimum monthly wage of R$998.00 set in Brazil in 2019.

A collective TI illustrates the trajectories, social relationships, and support bonds experienced during this journey, the mechanisms facilitating the process, and the barriers to accessing the TrPr in SUS (Fig. 1).

FIG. 1.

Collective itinerary of trans men—Recife case study.

Three thematic categories emerged as follows: (i) The (self-re-)cognition of the trans world through the internet and social media; (ii) the expression of male (trans)identity and the (non)support network; and (iii) access to TrPr in SUS.

The (self-re-) cognition of the trans world through the internet and social media

Internet and social media were cited as tools of influence to the participants for inspiring changes in their lives.⁷ The flow of information through videos, blogs, or social networks makes them a precursor resource for the TI of trans men searching for body modifications in formal health care spaces.⁸ Approximately half of the sample recognized themselves as trans men through social media.

“I saw in an interview that it was possible to a woman, in quotes, to become a man. Then I went after it.”—E.05

“I started searching on YouTube because I din't know much about trans men. When I found that they existed I saw myself fit into that.”—E.12

The discovery process has been driven by the plurality of virtual information, taking it from complete invisibility for the media exerts sufficient strength to guide public debates.⁹ In this sense, the popularization of the media in Brazil provides breaks in the barriers of information and promotes accessibility by facilitating the contact and exchange of experiences among people from different places.¹⁰

“I googled it and put the pieces of information together. It helped me a lot to discover what it was like to be transgender. I got a lot of contact from abroad once there were very few of us in Brazil.”—E.04

“I watched a video of a trans man showing how he transitioned in a year. He was from Canada.”—E.10

“The first one I met through videos and research, then I thought ‘does he really exist?’ ‘Cause if he's real, so am I’.”—E.01

Sharing their personal reports on the internet and social networks is a way to create positive references, making it possible to increase trans representativeness.¹¹ Yet, the social invisibility and lack of knowledge about trans-subjects are the main impasses to self-identifying as a transgender man. The scarcity of information reflects the difficulties in the identification and transition process itself.¹¹

“I watched videos on the internet and found it interesting, I googled the acronym ‘ftm,’ which is female-to-male. I didn't know about it at the time.”—E.1

Therefore, the media is configured as a biographical space of trans representativeness, accessibility, and virtual existence that allows and makes looking at themselves and others real and possible.¹²

The expression of male gender identity and the (non) support network

The expressiveness of male trans-identity may be related to the search for social support network. To participants this phenomenon occurred in different ways as their itinerary is surrounded by family relationships, conjugalities, friendships, and representativeness.

From the moment of self-recognition as a trans man and the first manifestations of a “non-congruent” gender identity, it is reported that family, close relatives, and friends may express episodes of rejection, repression, violence, violations, and coercion.¹³

“I went through some difficulties with my family when I had to come clean about being a lesbian at the time because I didn't know who I was. I felt something was wrong, but I wasn't sure of what it was. I wanted to cut my hair short, but my mother didn't agree. My family criticized me. […] Nobody helped me, nobody asked me how I felt.”—E.01

“My family was terrible. My brother attacked me when I had just told him who I really was. My mother blamed me for the assault. Nowadays I am better off because she respects me when I'm present. She'll call me by my name but behind my back she'll refer to the dead name. My father is the same. He only treats me by he/him when it is a situation he will be ashamed of. He does it for himself.”—E.08

A survey on mental health with 242 trans men resulted in 80.7% of them reporting their home as the place of greatest disrespect and nonsupport.¹⁴ The hostile family environment can generate psychological distress to the transgender individuals. The fear and lack of support may then lead to intense psycho-emotional suffering and self-injurious behaviors. Reports on suicidal ideation is a common fact in the transgender environment compared to the cisgender population.¹⁵

“I tried to commit [suicide] about 5 times. My mom doesn't know of all of them, she only realized once, because I couldn't get out of bed for taking too many pills. She suspected it, but didn't take me to the doctor. So I dealt with it by myself, suffering for many hours and she didn't care. I was always by myself at home, just me and myself.”—E.15

“My mom threw me to a guy when I was 12 and the guy was 18 or 19. […] To relieve the pain, I cut myself thinking there was something wrong, I wanted to die.”—E.01

Suicidal behavior can be the result of different situations. The prejudice reported by individuals belonging to minority groups may be expressed in three ways: the perceived prejudice—discrimination, rejection, and nonacceptance of their identity; the anticipated prejudice—vigilance and expectation of recrimination and rejection; and the internalized prejudice—an introjection by the individual of the prejudice existing in their social environment.¹⁶

However, social support, family cohesion, and care and affection act in the opposite way. The capacity for mutual involvement, support, and emotional bonding, as well as the feeling of belonging, can have the protective function for self-injurious and suicidal behaviors.¹⁷ The acceptance from their social network encourages them to deal resiliently with possible situations of discrimination, violence, and stigmas.¹⁸

“My mom has always supported me. Same with my ex-boss. Nowadays I work in a company that recognizes me as [name] and helps me to overcome each difficulty I face. And my friends as well. They help me to overcome all obstacles.”—E.16

“I have several people supporting me. Specially my friends, my aunts and uncles. Everyone has always supported me. I've never faced any major difficulties in this regard.”—E.17

“Everyone in my family supports me. My mother supports me in everything I do. My aunt is a wonderful person and supports me as well. I have no problems with that.”—E.08

It is important to extend the analysis of support and recognition to marital relationships. In this study, most participants reported conjugality as the main and first source of support for TrPr.

“Initially, it was my ex-wife. Then my current wife. Now my whole family supports and helps me.”—E.07

“The only people supporting me were a few friends and my wife. And my children. They always understood.”—E.09

Furthermore, family support for conjugalities built in disagreement with the sociocultural norms attributed to genders is capable of promoting a better environment for confronting social prejudices. Love's resistance to the norms and bonds of cisheteronormative culture is a libertarian process; when family and friends support these relationships, coping with adverse situations occurs more easily.¹⁹

In the absence of family support, friendship bonds become the main axis in the social network of these men, and they play a role as active supporters to the TrPr.

“I have a friend and she understands, accepts and respects me a lot. She insisted that I'd call again to try to get into the service, but she ended up calling when I didn't have the courage. I'm here now because of her. Also my co-workers are very nice and respect me a lot. It is incredible and replaces my family in a way.”—E.15

As for a social support network made up of people who are also part of the transgender community, being a part of LGBTQIA+groups breaks stigmas and helps on dealing with negative experiences. Such groups generally configure both a space of representation and a primary source of information due to the similar experiences they share.²⁰ By contacting other trans men when identifying themselves as one, they start looking for physical, behavioral, and documentary changes that contribute to their gender expression. In addition, there is also a change in their social network when they start accessing the service due to contact with people from similar experiences.

“I discovered that it was possible to transition when I was 32 years old. That was when I started looking around with some friends who had already transitioned and they've informed me of the places I could go to.”—E.09

“I had no trans men friends. I met them here. I arrived here not knowing anything. I was much shyer and anxious before. When I came here I met other people who have had similar experiences as mine.”—E.03

Along with it, professionals whom participants dealt with during the TrPr also became a part of their support network. Teachers involved in discussions and production of knowledge about transgender identity, especially in the academic environment, have contributed to the broader understanding of trans existences as well.²¹

“I spent a season in a foster home due to family problems and I met a teacher there. She learned about me from the other teachers. We talked about it and she introduced me to this place.”—E.15

“She [psychologist] has always helped me with my relationship with my mother, which was complicated at first. She did all the follow-ups. They were always open, and even willing to talk to our relatives.”—E.17

As a matter of course, the support network and the support to the gender expression are related to the feeling of belonging and satisfaction with life, and may have a protective function to situations of discrimination.^17,18,20

Access to TrPr in SUS

The barriers to access the TrPr are a constant cause of participants' frustration. The long waiting time is one of the main barriers these individuals face, as well as the bureaucratization.²² The tension between participants' anticipated waiting time and the protocol time exists due to expectations surrounding it, and the delay may generate anxiety and lack of perspective on them.²³

“There are many people on the waiting list for surgery, […] psychology, endocrinology.”—E.07

“It takes months to do an exam, and to get the result it takes much longer.”—E.13

This difficulty evidences the lack of adequate communication between primary health care and other levels of care. It also may lead to self-medication and hormone use as the only possibility of achieving the desired body.²² Also the oppression they experience regarding esthetic standards is directly related to hormone use and esthetic interventions performed at the illicit market.²⁴

“In the past, I took hormones on my own too, it even went a little wrong.”—E.12

“I bought the hormone and self-applied it. […] I see that happening a lot; the illicit market is highly active.”—E.17

“I paid for two years of private psychotherapy to be able to get a report so that the plastic surgeon would operate me. Even then, he still operated me in a clandestine clinic in the countryside because he was afraid. Surgery for trans people was not allowed at the time. He was afraid of being sued.”—E.07

Professionals' lack of knowledge on the matter and their prejudice and pathological vision of trans people also impelled the participants to resort to the illegal market. Having to deal with such contemptuous circumstances is one of the main causes of psychological suffering, evidencing the health service as a producer of symbolic violence to the trans population.²⁵

“It was complicated because they'd always call me by she/her.”—E.5

“We need professionals who have a more humanized behaviour, because we are people like any other and we need this type of care. We change our bodies because we are not satisfied with them but we are not aberrations.”—E.14

In 2013, the Brazilian Ministry of Health redefined the TrPr incorporating trans men and transvestites as users of the free health care system, meaning they could legally access hormone therapy and procedures such as mastectomy, hysterectomy, and neophalloplasty since then.²⁶ However, some participants have chosen to hire private health insurance to achieve their goals more quickly. For financial reasons this choice did not last long, which makes the financial sphere another barrier to the TrPr once most trans men are unable to do it by their own funding.²³

“I couldn't access private insurance because of financial issues. […] I couldn't even take the exams, it is very expensive to afford.”—E.04

Another financial challenge trans people face to access the TrPr service surrounds a geographical matter, meaning some participants live far away or had to move to another city to access it.²⁷ Most units qualified to offer TrPr through SUS are located in the southeastern region of Brazil, which makes traveling necessary. Hence, high transportation costs are the main cause for the absence of trans people from the health servicer.²⁸

“It is hard to get an appointment with the endocrinologist because we have to come here personally to be able to book it and sometimes I can't.”—E.13

“These are the transportation tickets I get to get to work but I am spending them every week to come here. Soon I'll run out of them. That's why I have been thinking about not coming to any group or individual psychotherapy until I'm financially stabilized.”—E.15

It is worth mentioning that Brazil is a country of continental dimensions and although the Public Policies aimed at the trans population are national, they are implemented (or not) at the state and municipal levels. This is the case with national regulations on the use of the social name. Social adhesion to the name chosen by the trans person can be validated in Brazil through the Social Name Card as an alternative to the General Registry; its officialization, however, is mediated by the Public Security Secretariats of each state and can even lose its validity when used in a different jurisdiction than the one where it was made.^29,30

Nevertheless, some participants claim that they did not experience any type of difficulty and, even the ones who did, say their lives changed for the better after accessing the TrPr.³¹

“I only have good things to say. The place is incredible. You feel welcomed here.”—E.03

“I wasn't a happy person. I was an antisocial, wouldn't leave the room. I had depression and it all got better after I started the TrPr. I understood myself through therapy, and it also improved my relationship with my family.”—E.7

In conclusion, barriers such as the waiting time to access plastic surgeries and scheduling examination appointments, in addition to the financial costs and professionals' unpreparedness and disrespect, become obstacles to having adequate health care support. It was not possible to find in the literature any other region of Brazil that has public policies aimed at resolving such barriers in care. Nonetheless, there is an improvement in the physical and mental well-being during and after the TrPr despite those barriers.

Conclusion

The construction of the TI of transgender men contributes to the recognition of the path taken by trans men from their perspective of the therapeutic care accessed through the TrPr in SUS. It allows a broader perception of who they are, what are their experiences, desires, and realities, and to identify moments, tools, and circumstances that affect in different ways the experiences and construction of their gender identities, especially considering the few published articles on the subject.

From self-recognition to the expression and performance of their identities, social medias were configured as tools that contributed to this process as a facilitator of contact, representativeness, information on the TrPr, and exchange of experiences among trans men from different places.

Although the narratives mention better physical and mental well-being during and after the TrPr, the long waiting time and the unpreparedness of health care professionals become barriers to the access and contribute to the clandestine search for the desired body modifications. The acknowledgment of such barriers can contribute to professionals' training on the subject and to the promotion of public policies aimed at improving the access to the health care system.

A limitation of this study is due to the itineraries being built based on participants' narratives with no further validation from them.

Abbreviations Used

QCQRA

Quality Criteria for Qualitative Research Articles'

SUS

Brazilian Public Healthcare System

TI

therapeutic itinerary

TrPr

transsexualising process

Authors' Contributions

Study concept and design: H.M.C., M.C.N.B.d.M., L.C.S.D.L., L.P.S., R.O.S., and P.H.P. Obtaining data: H.M.C., M.C.N.B.d.M., L.C.S.D.L., L.P.S., R.O.S., and P.H.P. Data analysis and interpretation: H.M.C., M.C.N.B.d.M., L.C.S.D.L., L.P.S., R.O.S., and P.H.P. Drafting the article: H.M.C., M.C.N.B.d.M., L.C.S.D.L., L.P.S., R.O.S., and P.H.P. Critical review of the article as to its relevant intellectual content: H.M.C., M.C.N.B.d.M., L.C.S.D.L., L.P.S., R.O.S., and P.H.P. All authors approved the final version of the text.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Cortes HM, de Melo MCNB, De Lacerda LCS, Santiago LP, Santos RO, Pinho PH (2022) Therapeutic itinerary of trans men from northeastern Brazil, Transgender Health 7:4, 357–363, DOI: 10.1089/trgh.2021.0042.