Experiences of families in the gender transition process

Abstract

Objective

To analyze experiences of families during the gender reassignment process of one of their family members.

Methods

A descriptive study with a qualitative approach was carried out with 29 members of ten families with at least one member undergoing gender transition. Data collection occurred from January 2018 to February 2019. Content analysis was carried out using the analytical technique.

Results

Five thematic categories emerged from the narrative analysis process: “physical changes as a common experience”, “fear of prejudice and violence”, “search for listening and specialized treatment”, “reconstruction of ideas and values”, and “respect, tolerance, and zeal as care”.

Conclusion

Families of individuals undergoing a gender transition process present changes of paradigms and values, face prejudice, and learn to provide care for the family member in gender transition with true zeal. Difficulties are faced through the search for specialized care, which is still scarce, and exercising citizenship in their own family system.

Gender identity; Transgender persons; Family relations

Resumo

Objetivo

Analisar as vivências familiares durante o processo transexualizador de um de seus integrantes

Métodos

Estudo descritivo, de abordagem qualitativa, realizado com 29 entrevistados que compunham dez famílias com ao menos um ente em transição de gênero. A coleta foi realizada no período de janeiro de 2018 a fevereiro de 2019. A Análise de Conteúdo foi feita por técnica analítica.

Resultados

No processo de análise das narrativas, foram identificadas cinco categorias temáticas: “mudanças do corpo como vivência de todos”, “medo do preconceito e da violência”, “busca de escuta e tratamento especializado”, “reconstrução de ideias e valores” e “respeito, tolerância e zelo como cuidado”.

Conclusão

As famílias de pessoas em processo de transição de gênero apresentam mudanças de paradigmas e valores, enfrentam preconceitos e aprendem a cuidar do ente em transição com grande proteção. As dificuldades são enfrentadas com a busca de ajuda especializada − ainda escassa −, e exercitando a cidadania no próprio sistema familiar.

Identidade de gênero; Pessoas transgênero; Relações familiares

Resumen

Objetivo

Analizar las vivencias familiares durante el proceso transexualizador de uno de sus integrantes.

Métodos

Estudio descriptivo, de enfoque cualitativo, realizado con 29 entrevistados que formaban parte de diez familias con al menos un ente en transición de género. La recolección se realizó en el período de enero de 2018 a febrero de 2019. El análisis de contenido se realizó mediante técnica analítica.

Resultados

En el proceso de análisis de las narrativas, se identificaron cinco categorías temáticas: “cambios del cuerpo como vivencia de todos”, “miedo a los prejuicios y a la violencia”, “búsqueda de escucha y tratamiento especializado”, “reconstrucción de ideas y valores” y “respeto, tolerancia y celo como cuidado”.

Conclusión

Las familias de personas en proceso de transición de género presentan cambios de paradigmas y valores, enfrentan prejuicios y aprenden a cuidar del ente en transición con una gran protección. Las dificultades son enfrentadas mediante la búsqueda de ayuda especializada, aún escasa, y ejercitando la ciudadanía en el propio sistema familiar.

Identidad de género; Personas transgénero; Relaciones familiares

Introduction

Transgender people (trans) are those whose gender identity differs from their sex assigned at birth. It does not mean being in the “wrong body”, but it is about the construction of gender identity from several social and psychological aspects. Some transgender people sense their sexual identity since childhood. However, this identification may occur in other stages of the life cycle, such as adolescence, adulthood, or old age. Dissatisfaction with one’s body generates desires and impulses for changes, which must be understood beyond physical aspects, overcoming barriers regarding psychic and social meanings.

The gender transition process often begins with or without professional help, through the use of hormones and physical changes that may lead to health risks and consequences over the years, justifying the importance of qualified professional follow-up.( ¹ )

Basically, the gender reassignment process is a set of actions that includes both outpatient care, with the follow-up of physicians, psychologists, social workers, and nurses, and hospital care, in which gender reassignment surgery and pre-and post-hospital follow-up are included.( ² )

The gender reassignment process must include a care plan that aims at the health care of transgender people who wish to change their gender identity at some point in their lives. The inclusion of the gender reassignment process in the Brazilian Unified Health System occurred by means of public policies that ensure the right to specialized follow-up for the changes desired, including the right to gender reassignment surgery. In spite of being especially marked by the biomedical model, this process has the purpose of providing a set of procedures associated with the health care of these individuals who suffer when their gender identity differs from their sex assigned at birth.( ² - ⁴ )

The gender transition process includes multiple experiences for both individuals and their family members, which may lead to positive or negative experiences. Daily challenges and sharing of doubts and feelings may be more effective with family acceptance. However, the opposite may also occur if values and needs are not understood by other family members, leading to the rupture of relationships.( ³ , ⁴ )

Families of transgender people may be affected by structural and dynamic changes during the gender reassignment process, and must also receive professional health care, especially from nurses, because this long-term process requires physical and social reorganization, in addition to leading to new care needs.( ³ , ⁴ )Currently, there are few national and international nursing publications on the theme, generating a lack of knowledge and certain academic invisibility.( ⁴ )Therefore, the following question emerged among the authors: How do families of transgender people experience the gender transition process of their family members?

The objective of the present study was to analyze experiences of families during the gender reassignment process of one of their family members.

Methods

This was a descriptive study with a qualitative approach carried out with families experiencing the gender transition process of one of their family members. The selection criteria were families, regardless of their configuration, types, or classification, who had a family member undergoing a gender reassignment process with follow-up at the outpatient service of the Center of Studies, Research, Extension, and Care for Transgender People of the Federal University of São Paulo. This outpatient service was launched in March 2017, with the purpose of providing multidisciplinary health care and promoting the well-being of transgender people. The service counts on professionals of the anthropology, plastic surgery, nursing, speech therapy, gynecology, endocrinology, psychology, psychiatry, and social service areas. In addition, it includes research and extension actions, which allow the gradual improvement of care practices to transgender people and their family members. Families whose members interviewed had some cognitive or neurological impairment that could hinder interviews and those who did not accept the participation of their family members undergoing the gender transition process were excluded, because researchers recognize their importance in the context of the interviews. Therefore, 10 families were selected, totaling 29 participants. Of the total number of families who met the selection criteria, four did not participate in the study, two due to refusal and the others for not meeting the appropriate schedule for the interviews, even after trying to find alternative schedules with the researchers.

Individuals undergoing gender transition with follow-up at the abovementioned service and their family members were invited to participate in the study. The main researcher is an acting member of the Center of Studies, Research, Extension, and Care for Transgender People, which facilitated approaching and inviting the participants. Later, dates and times for the interviews were scheduled, according to the availability of the participants and care service. Data collection occurred from January 2018 to February 2019.

A semi-structured interview was applied to the families, which was carried out in a private place. The interviews had an average duration of 90 minutes and were recorded with an electronic device, and later transcribed. The interviews were carried out by a psychologist who was specialized in family therapy and a nurse with a doctorate degree in sciences, both with experience in qualitative research and training in conduction of semi-structured interviews. The following guiding question was used: “How have you experienced the gender transition process of your family member?” Other questions emerged from the speeches or for further deepening.

The analysis of the interviews was followed by the stages of content analysis proposed by Bardin( ⁵ )with inclusion of pre-analysis, material exploration, and treatment of results. In pre-analysis, the authors carried out a thorough reading of the material and sought the elements that could be included in the corpus analysis. In material exploration, categories were defined, classifying the constituent elements into analogical groups by the frequency of record units. At last, the data were inferred and interpreted. The narratives were presented according to the family relationship plus increasing numbers.

The development of the present study met national and international ethical principles on research involving human beings and was approved by a research ethics committee under protocol no. 2.451.951. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was applied to verify the study’s scientific quality.

Results

Most of the families interviewed were from lower-middle class (70%), white (50%), and lived in rented houses (60%). There was a prevalence of the nuclear (30%) and female single-parent (40%) family models. The number of members per family was as follows: two members in four families, four members in three families, and three members in three families. None of the families interviewed reported conflicting relationships among their family members.

There was a prevalence of transgender men (woman to man) with a mean age of 25 years (70%). Approximately 50% identified their gender identity different from their sex assigned at birth between 6 and 14 years, and reported that their family members noticed a compatible behavior with the other gender in the same period. Most transgender people were undergoing hormone therapy (80%) and waiting for surgical interventions. However, 60% were undergoing physical changes without medical or other healthcare professionals’ follow-up. They also reported psychological follow-up for at least one year; however, any of the family members reported having received family care and acceptance during the transition process.

The following five thematic categories emerged from the narrative analysis process: “physical changes as a common experience”, “fear of prejudice and violence”, “search for listening and specialized treatment”, “reconstruction of ideas and values”, and “respect, tolerance, and zeal as care”.

In the category “physical changes as a common experience”, the participants reported that the gender reassignment process had a significant impact on body image, that is, physical changes affected not only the individuals undergoing the gender transition process, but also the entire family system. Feelings such as fear and concern emerged due to physical changes. He took hormones without medical follow-up. We were really worried about it. We were together since the first application. I was worried about the changes in him... (Partner 6). For mothers, these physical changes are more difficult to handle” (Trans 1). I talk to her about breast: It is not like this! You have to wait. Wait for the right time. Then, she gets angry, him, actually! I am always worried about hormone therapy and he gets angry... I am afraid of the surgery, you know? Because she will remove her breast. (Mother 5)

However, physical changes were important for families, because they are considered an accomplishment achieved by transgender people. In addition, the reports showed a feeling of greater social acceptance, according to the progress of the transition process. Each body hair has significant importance because society demands a binary image, whether man or woman. It was very difficult to get out of home before the process of hormone therapy and physical changes. (Partner 6) . Now that people see us as a “heterosexual” couple, I feel a softer social approach that I have never experienced before (Trans 6) . This is my first relationship with a trans man, and society’s response is completely different. Now, it seems that people respect me more because I am a man’s wife, not of a woman’s wife (Partner 9).

In the category “fear of prejudice and violence”, the participants were afraid of their transsexual family members being socially or physically abused, thus acting as protectors and source of support and security. The problem is that we also live in a bubble... It is a protective bubble that we create (Sister 2) . This is so true that I bought her first underwear. We went there because she was afraid. She thought she would be discriminated, which would probably happen (Mother 7) . We can feel that people do not accept. Then, I try to treat them as naturally as possible, because there are already many people who do not accept them. It is normal for me. I try to keep their lives as normal as possible (Aunt 9).

However, in some cases, this discrimination occurs inside their own family, especially among first-degree family members, making transgender people feel lonely and abandoned by their family. The first time I had a haircut, she (mother) hit me. We also had a huge fight when I had changed my name (Trans 8) . It is worse than violence suffered in the street, because if you suffer violence in the street, at least you have a place to return. What happens when you suffer violence at home? (Partner 4).

Another factor reported was the difficulty of transgender people in getting a job, which was often seen as a lack of initiative or procrastination by some family members, leading to an excessive demand imposed on individuals. It was the last time we had a talk and he (father) told me that I was lazy, avoiding work (Trans 6) . It was a kind of pressure for him to look for a job, because we needed money. He needed to get a job, but at the same time, every time he went to a job interview, he came home more shattered (Partner 9).

Regarding the category “search for listening and specialized treatment”, there was lack of information regarding the gender reassignment process and difficulty reported by family members and trans people themselves in finding healthcare services able to provide guidance on the health of trans people, such as hormone therapy, leading them to act independently and without institutional support. He began taking hormones by himself. He did not have medical follow-up. We cannot control it because it is something you buy, apply to the body, and wait until it works. (Partner 6). I had started taking hormones secretly with a former girlfriend who works in a pharmacy. She applied my first testosterone (Trans 5).

Even when families were able to find a specialized service, they came across another barrier: Professional unpreparedness regarding the needs of the transgender population and their family members, in addition to the incorrect use of pronouns. It seems there is not enough information for employees... Some of them call you by the feminine pronoun even knowing you are a man with a social name (Trans 6) . He does not use his Christian name anymore. They should not address him by his former name! It seems they do not understand. (Sister 5).

Increasing demand, few specialized services, and interinstitutional and multidisciplinary communication difficulties caused discomfort during the search for individualized care. It seems there is no communication among them (healthcare professionals) . We did not have psychological follow-up for a long time, we were not provided with psychological care, let alone our families. Services exist; however, because of the absence of information exchange, everything is delayed. We have to tell professionals what was done and what must be done. They really want to help, do you know? However, they seem to be lost (Trans 6) . There is lack of preparedness. They are not trained to provide them (transgender people) and us with care. We suffer together, because family and partners also suffer prejudice… (Partner 4).

In the category “reconstruction of ideas and values”, it was found that the transition process generates belief conflicts in the family nucleus, leading to an understanding change on gender identity and transforming preconceived values and ideas. I had never expected this. I expected to have a son who was like us. Later, I noticed several different changes during his adolescence. Then, we start thinking differently and got used to. Mothers do not have much to do, we just have to accept it, because…daughter, son, whatever they are, do you understand? (Mother 3).

Another evident aspect was the access to information as a facilitating agent for the change of paradigms. (...) He told us about himself, and the entire family thought it was a transitory situation, that he was not sure about it, and, at that time, we thought he was a little bit confused, without direction. I had already made some research through friends, social groups, and we tried to acquire and share information and knowledge. We were never against him; quite the contrary, we have supported him through the whole process (Father 5).

However, religion proved to be a complicating factor for acceptance in some families, especially followers of Protestant Christianity, because they considered transsexuality a sin and an insult to God, thus not being able to understand trans people beyond the religious idea. My mother did not accept my transition well because of her religion influence, since she is Evangelical. She thinks: “My God. It is an atrocity!” However, her parents (girlfriend) think differently. In spite of being religious, they are Buddhist. They accepted us with great kindness, with much more affection. They only had some difficulty in addressing me as a man because I still looked like a woman. (Trans 6).

In the category “respect, tolerance, and zeal as care”, it was observed that the support provided by families helped individuals to face the gender reassignment process. Respect and zeal provided by families (of origin, current, or substitute) of transgender people proved to be an important way of care in this period, acting as a source of comfort and security. He removed his breast and will remove his uterus, and we have to respect it. My son is a man and I do not let anybody mock him because he was once a woman. If people do not accept differences, it is their problem. I accept, and will not let people hurt him. I know that not every father thinks like this (Father 2). I do not like people mocking and looking differently, because they are not an aberration. They are pretty, intelligent and hard workers. They are just striving to be someone. Is this an aggression? We talk and give them support. I am always giving them support because there are already people putting them down in their daily living. Therefore, when they come here, I am always smiling and happy, you know? (Mother 7).

Finally, zeal provided to individuals undergoing the transition process was significant, acting as strengths in this period and reducing fragility. (...). I wanted to end my suffering... Every time I was defeated, she gave me strength (partner) . She always met me, called me and talked to me, because I did not confide in anybody. She was the one who got my first job, before I began taking hormones, because I was desperate… (Trans 5). When you are accepted at your own home, you have support and strength to face the world! (Trans 10).

Discussion

The present study presented limitations, because it was carried out in only one specialized care service for transgender people in the city of São Paulo and there was a limited participation of fathers in the interviews. Nonetheless, the present study helps nurses and other healthcare professionals to understand the gender transition process beyond individuals, including their family members in this delicate period.

The gender reassignment process of an individual leads not only to physical changes, but also their lives’ meaning and understanding of their rights and affection. Physical changes are experienced by the entire family system, with positive expectations and fears due to risks that may be caused. That is, feelings are ambiguous, thus generating discomfort. Family members who are able to understand the importance of this transition process participate intensively, sharing both joy and pain. Like the present study, studies showed that hormone therapies are those that most generate ambiguous feelings in families, because they are often the first stage of the transition process, in which male or female characteristics begin to change.( ⁶ - ⁹ )Ambiguity does not seem to be a negative feeling, but a reality confrontation stage that causes discomfort to those involved. Changing a physical image causes strangeness but helps in the gradual acceptance of changes.

Surgical interventions lead to special zeal, because they are considered radical or irreversible. Therefore, families may help or not at this time, which depends on the level of acceptance and understanding of that experience for those undergoing the transition process.( ¹⁰ - ¹² )

One important datum found in the present study and corroborated by other studies( ¹¹ - ¹³ )is that the advance of the physical change process provides partners of trans people with comfort, because people see them as heterosexual and cisgender, and no longer as homosexual couples. This normativity, when perceived, causes surprise rather than dissatisfaction. Therefore, there seems to be a cultural deconstruction of what was understood as a vision of world for a still prevalent cis-normativity.

However, the experience of fear of violence and prejudice affects the well-being of transgender people and their family system. The transition process does not occur at a single time, since the image of the other does not become binary for some time or different from collective standards. In the face of differences, people may be violent and little understanding, including their own family. Swearing, indifference, looks, and rejection attitudes are common. American studies show that family rejection and violence in the gender transition process may cause damages as pain, psychic suffering, deep sadness, depression, and even suicide attempts.( ¹⁴ )However, family acceptance increases the resilience of transgender people and is positively reflected in everyone, promoting self-esteem of the nucleus and improvement in interpersonal relationships.( ¹⁴ , ¹⁵ )

Violence and prejudice also affect the economic condition of families, especially due to the difficulty of transgender people in finding jobs. The families studied were mostly from lower-middle class and depended on everyone’s income to meet their needs. However, unemployment of transgender people is still much higher than in cisgender people, causing delay in the entrance into the job market, informality, and marginality.( ¹⁶ )

The same marginality may be experienced during physical changes, through hormone therapies, silicone applications, and other procedures used illegally and without specialized care.( ¹² - ¹⁶ )To reduce these damages, families serve as attentive guiders who help in the search for specialized care. However, reports are unanimous when mentioning the lack of specialized services and human resources in the healthcare area, which are able to meet the needs of transgender people and their families. Studies corroborate these findings when showing the lack of qualification of healthcare professionals not only regarding care, but also education and studies with focus on the theme, which shows the need for rethinking teaching practices, training, and continuous education.( ¹⁷ , ¹⁸ )Therefore, healthcare professionals, especially nurses, must receive appropriate education and continuous training for the safe care of people undergoing gender reassignment process and their families.

In the face of the emergency of gender identity, families begun reconstructing ideas and values they had about sexuality − and even about gender relationships. This reconstruction proved to be a slow difficult process, and full of self-confrontations.( ⁹ , ¹² - ¹⁵ )One of the challenges faced by families was associated with Christian religious conceptions on gender binary. Questionings and lack of prompt answers particularly led genitors to the search for information, many times during the transition process of their family members. It is worth mentioning that in studies where genitors and other family members sought to reconstruct their way of feeling, thinking, and acting, transgender people were more accepted, which led to positive feedbacks to the family system.( ¹⁹ )

Therefore, families mentioned respect, tolerance, and zeal as care units in the search for balance, conviviality, and human condition of the family nucleus. Respect proved to be a feeling that led families to treat everyone, especially transgender people, with special care and reference to their emotions, allowing an attentive dialogue, still scarce in society. Tolerance came up in changes of precepts when there was a perception of the other as someone important, even being different. However, zeal was strongly expressed as commitment for the well-being and happiness of the other, sometimes meaning over-protection, although making sense within the context.( ¹⁴ , ¹⁵ , ¹⁹ , ²⁰ )

Conclusion

Families, including individuals undergoing the gender transition process, experience physical changes in an intense and apprehensive way due to risks, but they also share happiness resulting from expected achievements. However, prejudice is a reality that affects the gender reassignment process, causing outbreaks of violence, especially in the family system, leading to the increase in emotional fragility of transgender people. The present study showed that, in spite of the transition process beginning without the follow-up of healthcare professionals, families search for specialized treatment, although with little success due to the lack of services for the demand and lack of multidisciplinary qualification. Gradually, the world perspective changes, leading to a better acceptance of transgender people, which allows a better confrontation in this process. Zeal for the other helps families to recognize their care potential, with tolerance to differences and search for the well-being of transgender people and the entire family nucleus. Therefore, culturally coherent care allows nurses to plan their actions based on the perspective of families and rethink practices that make sense to those involved, favoring humanistic interventions.

Acknowledgements

The present study was funded by the National Council for Scientific Development and Technological Development (CNPQ) under protocol no. 124667/2018-0.

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Publication Dates

• Publication in this collection
  28 Aug 2020
• Date of issue
  2020

History

• Received
  29 Aug 2019
• Accepted
  4 Nov 2019