Abstract

We analyze how the interactions between the trans population and the Chilean healthcare system shape specific processes of malaise associated with gender transition (“tránsito de género”). Adopting psychoanalytic and transfeminist conceptual approaches, as well as a biographical methodology, we examine autobiographical narratives of three trans subjects. We discuss three topics: childhood as a critical period for gender transition and malaise; the role of institutions; and the ways through which subjects manage malaise. We argue that trans subjects face specific sociocultural conditions that lead to unique processes of malaise associated with gender transition. We show how politicization and the construction of an institutional framework, bodily aesthetical modifications, and the self-administration of medical knowledge emerge as some of the paths to navigate the gender transition process. Besides, we foreground the notion of “transitioning” (“transicionar”) by considering the criticism voiced by the participants. By using this notion, they interrogate the rigidity and psychopathologization of identity that is implicitly present in the notion of gender transition, as well as they enrich the transfeminist discourse in favor of their agency/autonomy.

Key words:
Healthcare system; Mental health; Transgender; Psychic suffering; Personal narratives

Resumo

Analisamos como as interações entre a população trans e o sistema de saúde chileno conformam processos específicos de mal-estar associados à transição de gênero (“tránsito de género”). Adotando abordagens conceituais psicanalíticas e transfeministas, bem como uma metodologia biográfica, examinamos narrativas autobiográficas de três sujeitos trans. Discutimos três tópicos: a infância como um período crítico para a transição e mal-estar de gênero; o papel das instituições; e as maneiras pelas quais os sujeitos lidam com o mal-estar. Argumentamos que sujeitos trans enfrentam condições socioculturais específicas que levam a processos únicos de mal-estar associados à transição de gênero. Mostramos como a politização e a construção de um arcabouço institucional, as modificações estéticas corporais e a autogestão do saber médico surgem como alguns dos caminhos para navegar o processo de transição de gênero. Além disso, colocamos em primeiro plano a noção de “transição” (“transicionar”) considerando as críticas expressas pelos participantes. Ao utilizar essa noção, interrogam a rigidez e a psicopatologização da identidade que está implicitamente presente na noção de transição de gênero, bem como enriquecem o discurso transfeminista em favor de sua agência/autonomia.

Palavras-chave:
Sistema de Saúde; Saúde mental; Transgênero; Sofrimento psíquico; Narrativas de vida

Introduction

The Chilean State has implemented a set of health and legal institutions, policies, strategies, and practices over the last decade to address the so-called “trans question”¹1 Gherovici P. Transgender psychoanalysis. A lacanian perspective on sexual difference. New York: Routledge; 2017.. However, institutions and user groups have claimed that these actions have not guaranteed conditions for protecting trans population’s physical and mental health during the gender transition in the public healthcare system²2 Fundación Iguales. Informe alternativo de Fundación =Iguales sobre el seguimiento de las recomendaciones al Estado de Chile del Examen Periódico Universal del 2009 [Internet]. 2012 [acceso 2015 maio 15]. Disponible en: https://bibliotecadigital.indh.cl/handle/ 123456789/173
https://bibliotecadigital.indh.cl/handle... ^,33 Universidad Diego Portales (UDP). Salud mental y derechos humanos: La salud de segunda categoría. In: Informe anual sobre derechos humanos en Chile 2013. Santiago: Ediciones Universidad Diego Portales; 2013. p. 187-222.. Specifically, a deficient legal framework and a lack of specialized public policies have led to access issues and poor treatment quality, shaping specific processes of malaise associated with gender transition.

While several studies focused on the trans population have been conducted internationally⁴4 Barr SM, Budge SL, Adelson JL. Transgender community belongingness as a mediator between strength of transgender identity and well-being. J Couns Psychol 2016; 63(1):87-97.

5 Reisner SL, Deutsch MB, Bhasin S, Bockting W, Brown GR, Feldman J, Garofalo R, Kreukels B, Radix A, Safer JD, Tangpricha V, T'Sjoen G, Goodman M. Advancing methods for US transgender health research. Curr Opin Endocrinol Diabetes Obes 2016; 23(2):198-207.^-66 Jesus JG. Pessoas transexuais como reconstructoras de suas identidades: Reflexões sobre o desafio do direito ao gênero. In: Galinkin A, Santos KB, organizadoras. Anais do Simpósio Gênero e Psicologia Social. Brasília: UnB; 2010 nov 16-19. p. 80-89., few have explored the interactions between healthcare services and trans people’s lived experiences around gender transition in Chile⁷7 Donoso C, Nuñez S, Parra-Villarroel J. Significado que otorgan las personas trans a sus experiencias en la atención en el sistema de salud chileno. Rev Chile Salud Pública 2018; 22(2):126-134.^,88 Zapata Pizarro A, Díaz Díaz K, Barra Ahumada L, Maureira Sales L, Linares Moreno J, Zapata Pizarro F. Atención de salud de personas transgéneros para médicos no especialistas en Chile. Rev Med Chile 2019; 147(1):65-72.. In this article, we seek to analyze how the interactions between the trans population and the Chilean healthcare system shapes specific processes of malaise associated with gender transition. Rather than reducing trans people’s lived experiences to a psychological level, we examine gender transition from a perspective that revitalizes sociocultural and material conditions⁹9 Castel PH. ¿Freud sin malestar?. In: Radiszcz E, editor. Malestar y destinos del malestar. Políticas de la desdicha (Vol. 1). Santiago: Social-Ediciones; 2016. p. 19-31. of the Chilean healthcare system.

In conceptual terms, we follow both psychoanalytic and transfeminist approaches. From psychoanalysis, we rely on the concept of malaise. Malaise is an unassimilable remainder of the mismatch between the drive dimension and sociocultural configurations¹⁰10 Freud S. El malestaren la cultura. In: Freud S. Obras completas. Volumen XXI. Buenos Aires: Amorrortueditores; 2012.. The heuristic value of this concept enables us to organize both sociocultural components and subjective aspects around a specific issue. In addition, it allows us to distance ourselves from discussions that have reduced the trans subject to a structural and psychopathological diagnostic dimension, which have left out relevant aspects of subjectivity and everyday life while privileging the medical-legal and normative influence of psychiatry, psychology, and psychoanalysis¹1 Gherovici P. Transgender psychoanalysis. A lacanian perspective on sexual difference. New York: Routledge; 2017.^,1111 Allouch J. Avergonzados. Periódico Imago Agenda; 2005.^,1212 Ayouch T. Psychanalyse et transidentités: hétérotopies. L'évolutionpsychiatrique 2015; 80(2):303-316.. From a transfeminist approach, we highlight the agency/autonomy of the trans subjects, not only over their own bodies, but also regarding the discourse production and creation about themselves¹³13 Kaas H. O que é Transfeminismo? Uma Breve Introdução [Internet]. 2015 [acessado 2020 maio 15]. Disponível em: https://edisciplinas.usp.br/pluginfile.php/ 371874/mod_resource/content/0/Encontro%206%20-% 20O-que-é-Transfeminismo.pdf.
https://edisciplinas.usp.br/pluginfile.p...

14 Jesus JG. Géneros em essencualismo: feminism transgénero como crítica do sexo. Universitas Humanística 2014; 78:241-257.

15 Serano J. Whipping girl. New York: Seal Press; 2007.^-1616 Koyama E. The transfeminist manifesto [Internet]. 2001 [cited 2020 maio 15]. Available from: http://eminism.org/readings/pdf-rdg/tfmanifesto.pdf.
http://eminism.org/readings/pdf-rdg/tfma... .

We argue that trans subjects face specific sociocultural conditions that lead to unique processes of malaise associated with gender transition. Through these trajectories, we show how politicization and the construction of an institutional framework (e.g. trans NGOs), bodily modifications of an aesthetic nature, and the self-administration of medical knowledge emerge as some of the paths through which subjects navigate gender transition processes. We foreground the notion of “transitioning” (“transicionar”) by considering the criticism voiced by the participants. By using this notion, they interrogate the rigidity and psychopathologization of identity that is implicitly present in the notion of gender transition, as well as they enrich the transfeminist discourse in favor of their agency/autonomy.

The article is divided into four sections. First, we will focus on research that has both empirically and conceptually shed light on the “trans question”, gender transition, malaise, and healthcare systems. Later, we will describe in methodological terms the biographical approach that oriented our fieldwork. Third, we will present three biographical narratives produced during the study. Finally, we will discuss on three topics: (a) childhood as a critical period in the configuration of gender transition and malaise; (b) the role played by institutions such as family, school, and health care services, as well as by nongovernmental organizations (NGOs) in the shaping of multiple forms of malaise associated with gender transition; and (c) the ways through which subjects manage malaise, emphasizing how they politicize various areas of their gender transition process.

The “trans question”

The “trans question” has begun to play a central part in social life over the last decades by interrogating some of the main assumptions of western culture regarding the notions of body, sexuality, gender, subjectivity, and social bonds¹1 Gherovici P. Transgender psychoanalysis. A lacanian perspective on sexual difference. New York: Routledge; 2017.. Challenging these certainties - which are mainly grounded in biomedical and psychiatric practices aimed at reducing transgender subject to a set of structural and psychopathological traits - feminist and transfeminist approaches have questioned essentialist and cis-heteronormative conceptions of sexuality and gender. Besides, they have criticized representations of normality and the pathological linked to identity configurations and sexual manifestations¹³13 Kaas H. O que é Transfeminismo? Uma Breve Introdução [Internet]. 2015 [acessado 2020 maio 15]. Disponível em: https://edisciplinas.usp.br/pluginfile.php/ 371874/mod_resource/content/0/Encontro%206%20-% 20O-que-é-Transfeminismo.pdf.
https://edisciplinas.usp.br/pluginfile.p... ^,1616 Koyama E. The transfeminist manifesto [Internet]. 2001 [cited 2020 maio 15]. Available from: http://eminism.org/readings/pdf-rdg/tfmanifesto.pdf.
http://eminism.org/readings/pdf-rdg/tfma... . In this regard, the emergence of the “trans question” has enabled researchers to underscore the subjective, social, and material conditions that the trans population deal with in their daily lives¹⁷17 Scandurra C, Amodeo AL, Valerio P, Bochicchio V, Frost DM. Minority Stress, Resilience, and Mental Health: A Study of Italian Transgender People. J Soc Issues 2017; 73(3):563-585.^,1818 Reisner SL, Poteat T, Keatley JA, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a review. Lancet 2016; 388(10042):412-436..

The modern transsexual is a key figure to understand the contemporary trans subject. Shaped amid the budding discipline of psychiatry and its ties to legal discourse, the modern transexual started gaining validity through the classification of perversions. In 1886, Richard von Krafft-Ebing stated that a man “with the feeling of the opposite sex”, was to be labeled as a “metamorphosissexualis paranoica”⁹9 Castel PH. ¿Freud sin malestar?. In: Radiszcz E, editor. Malestar y destinos del malestar. Políticas de la desdicha (Vol. 1). Santiago: Social-Ediciones; 2016. p. 19-31.^,1919 Ayouch T. L'injure diagnostique. Pour une anthropologie de la psychanalyse. In: Anthropologie et psychanalyse: de´bats et pratiques [Internet]. 2015 [accès 2016 maio 15]. Disponible en: http://revues.mshparisnord.org/cultureskairos/index.php?id=1055.
http://revues.mshparisnord.org/culturesk... . Nowadays, the anatomopathological conception of the modern transsexual casts a long shadow over the categories that most of the specialized literature employs to refer to the trans subject. This is exemplified by the current category of “gender dysphoria” promoted by the DSM V²⁰20 STP2012. Recent Developments related to the DSM and ICD Revision Processes [Internet]. 2013 [cited 2020 maio 15]. Available from: http://www.stp2012.info/STP_Communique_DSM_ICD.pdf.
http://www.stp2012.info/STP_Communique_D... .

One of the first psychoanalysts to explore this field was Robert Stoller, who proposed “gender” to conceptualize “transsexualism” and labeled “gender identity” the other side of “sexual identity”. Later on, Colette Chiland argued for understanding transsexualism as a narcissistic disease: the construction of the self in borderline personalities which, at the edge of psychosis, are in a state of short-circuit between self and body¹²12 Ayouch T. Psychanalyse et transidentités: hétérotopies. L'évolutionpsychiatrique 2015; 80(2):303-316.. The psychoanalytic approach, due to its tendency to naturalize of sexual difference, gender, as well as its narrowed conception of agency, has currently taken two paths: a) the psychology of self and personality interpretation, and b) the Lacanian approach and structural diagnosis. While “Freudians” consider that the issue involves personality, identity, or the self and its functions, “Lacanians” understand transsexualism upon the basis of the transsexual error: the signifier-organ confusion. That is, taking the penis for the phallus. Therefore, from this confusion, transsexuals were considered as psychotics in structural terms¹¹11 Allouch J. Avergonzados. Periódico Imago Agenda; 2005.^,1212 Ayouch T. Psychanalyse et transidentités: hétérotopies. L'évolutionpsychiatrique 2015; 80(2):303-316..

Currently, although there are several Lacanian psychoanalytic approaches to the trans, they all criticize the mistake of privileging the structural diagnosis and neglecting psychosocial factors that influence the theorization and clinic¹1 Gherovici P. Transgender psychoanalysis. A lacanian perspective on sexual difference. New York: Routledge; 2017.^,1111 Allouch J. Avergonzados. Periódico Imago Agenda; 2005.^,2121 Butler J. El género en disputa. El feminismo y la subversión de la identidad. Barcelona: Paidós; 2014.. Coherently, from a feminist perspective, discourses have highlighted and advocated trans experiences, stressing their autonomy/agency over their own bodies¹⁵15 Serano J. Whipping girl. New York: Seal Press; 2007.. Indeed, Judith Butler²²22 Butler J. Conversatorio: Pandemia, democracia y feminismos [Internet]. 2020. [acceso 2015 maio 15]. Disponible en: https://www.youtube.com/watch?time_ continue=1240&v=zeaVh1EC2fQ&feature=emb _logo.
https://www.youtube.com/watch?time_ cont... has stated that there cannot be a feminism that would not be transfeminist, implying that the struggle for identity and its subversion is a shared experience for women and trans subjects.

Gender transition and malaise in Chile

Recent studies estimate that nearly 80,000 transgender people live in Chile, with approximately 30 new patients requesting medical care each year⁸8 Zapata Pizarro A, Díaz Díaz K, Barra Ahumada L, Maureira Sales L, Linares Moreno J, Zapata Pizarro F. Atención de salud de personas transgéneros para médicos no especialistas en Chile. Rev Med Chile 2019; 147(1):65-72.. The “T Survey”, conducted by the NGO OTD²³23 Linker D, Marambio C, Rosales F. Encuesta T. 1era encuesta para personas trans y de género no-conforme en Chile [Internet]. 2017 [acceso 2018 maio 15]. Disponible en: http://encuesta-t.cl.
http://encuesta-t.cl... , drew attention to the absence of basic epidemiological and demographic data and characterized the Chilean trans population through a 315-person sample. The study concluded that, for 80% of the participants, the experience of not belonging to the assigned gender at birth appeared between 1 and 11 years of age. Most of the participants (78.7%) recognized their gender identity around 12 and 25 years of age, with a large temporal gap existing between when they became aware that their gender did not belong to the gender assigned at birth and when they acknowledged-adopted their gender. When it asked how old they were when they first received medical assistance, only 11.7% of the participants stated that this occurred between 12 and 18 years of age, whereas 52.1% either reported not knowing when this happened or failed to respond. Regarding mental health, 33.3% of the participants either reported ignoring how old they were when they first received psychological help or chose not to answer, and 32.4% of the participants received mental health care between ages 19 and 25.

Several studies on the LGBTI community conducted in Chile over the last two decades have highlighted the impact of discrimination on the quality of life and well-being²⁴24 Barrientos J, Cárdenas M. Homofobia y Calidad de Vida de Gay y Lesbianas: Una Mirada Psicosocial. Psykhe 2013; 22(1):3-14.. A large part of the trans population (21.1% to 57.9%) report having experienced discrimination; also, many (35.3%) report being frequent victims of acts of physical violence. As a result of this violence, trans people in Chile display high rates of anxious-depressive disorders⁴4 Barr SM, Budge SL, Adelson JL. Transgender community belongingness as a mediator between strength of transgender identity and well-being. J Couns Psychol 2016; 63(1):87-97.^,2424 Barrientos J, Cárdenas M. Homofobia y Calidad de Vida de Gay y Lesbianas: Una Mirada Psicosocial. Psykhe 2013; 22(1):3-14.. Indeed, according to the “T Survey”²³23 Linker D, Marambio C, Rosales F. Encuesta T. 1era encuesta para personas trans y de género no-conforme en Chile [Internet]. 2017 [acceso 2018 maio 15]. Disponible en: http://encuesta-t.cl.
http://encuesta-t.cl... , 56% of the people surveyed reported having attempted suicide, with 75% of them doing so between 11 and 18 years of age.

The Chilean healthcare system and the trans population

Several NGOs have reported the systematic violation of the rights of trans people in Chile²2 Fundación Iguales. Informe alternativo de Fundación =Iguales sobre el seguimiento de las recomendaciones al Estado de Chile del Examen Periódico Universal del 2009 [Internet]. 2012 [acceso 2015 maio 15]. Disponible en: https://bibliotecadigital.indh.cl/handle/ 123456789/173
https://bibliotecadigital.indh.cl/handle... ^,2525 Movimiento de integración y liberación homosexual. XIII Informe anual de derechos humanos de diversidad sexual en Chile. Historia anual de las minorias sexuales chiles. Hechos 2014 [Internet]. 2015 [acceso 2017 maio 15]. Disponible en: https://bibliotecadigital.indh.cl/bitstream/handle/123456789/808/Informe.pdf?sequence=1&isAllowed=y.
https://bibliotecadigital.indh.cl/bitstr... . In 2013, a report denounced the absence of vulnerable groups - including the so-called “sexual minorities” - from the 2011-2020 National Healthcare Plan. Even though people belonging to “sexual minorities” received treatment in the healthcare network, these centers lack specialized plans and interventions³3 Universidad Diego Portales (UDP). Salud mental y derechos humanos: La salud de segunda categoría. In: Informe anual sobre derechos humanos en Chile 2013. Santiago: Ediciones Universidad Diego Portales; 2013. p. 187-222..

As an example of the insufficient coverage of the Chilean healthcare system, until 2017, trans subjects demands for name and sex changes (hormonal and/or surgical) depended on legal loopholes that involved high economic and (mental) health costs. These procedures could only happen through individual legal action and a decision made by a judge or a State agency. For instance, changing one’s legal name could involve multiple and seemingly random requirements: witnesses, physical modifications, and a medical, psychiatric, and/or psychological checkup. For this reason, in 2012, the Ministry of Health issued order No. 21, which instructed healthcare staff to safeguard the rights of trans people²⁶26 Ministerio de Salud de Chile. Circular N 21. Reitera sobre la atención de personas trans en la red asistencial [Internet]. 2012 [acceso 2016 maio 15]. Disponible en: https://saludtranschile.files.wordpress.com/2012/09/circular-21.pdf.
https://saludtranschile.files.wordpress.... .

Although studies conducted over the last decade have revealed that trans subjects who receive medical care linked to gender transition - e.g. psychological assistance, hormone therapy, and surgery - display substantially improved quality of life and psychological well-being⁴4 Barr SM, Budge SL, Adelson JL. Transgender community belongingness as a mediator between strength of transgender identity and well-being. J Couns Psychol 2016; 63(1):87-97.^,2727 Cornejo M, Mendoza F, Rojas RC. La Investigación con Relatos de Vida: Pistas y Opciones del Diseño Metodológico. Psykhe 2008; 17(1):29-39., the “T Survey”²³23 Linker D, Marambio C, Rosales F. Encuesta T. 1era encuesta para personas trans y de género no-conforme en Chile [Internet]. 2017 [acceso 2018 maio 15]. Disponible en: http://encuesta-t.cl.
http://encuesta-t.cl... revealed that only 22.9% of the trans population report having received medical assistance between ages 11 and 25. As previously noted, while the MINSAL²⁶26 Ministerio de Salud de Chile. Circular N 21. Reitera sobre la atención de personas trans en la red asistencial [Internet]. 2012 [acceso 2016 maio 15]. Disponible en: https://saludtranschile.files.wordpress.com/2012/09/circular-21.pdf.
https://saludtranschile.files.wordpress.... has launched a clinical guideline and two orders to encourage adequate and timely care for trans people, the implementation of these actions has been poor, even after the promulgation of the gender identity law⁷7 Donoso C, Nuñez S, Parra-Villarroel J. Significado que otorgan las personas trans a sus experiencias en la atención en el sistema de salud chileno. Rev Chile Salud Pública 2018; 22(2):126-134.^,88 Zapata Pizarro A, Díaz Díaz K, Barra Ahumada L, Maureira Sales L, Linares Moreno J, Zapata Pizarro F. Atención de salud de personas transgéneros para médicos no especialistas en Chile. Rev Med Chile 2019; 147(1):65-72.. In 2018, the first polyclinic in the Metropolitan Region and similar centers at three other hospitals opened to the trans community. However, according to Donoso et al.⁷7 Donoso C, Nuñez S, Parra-Villarroel J. Significado que otorgan las personas trans a sus experiencias en la atención en el sistema de salud chileno. Rev Chile Salud Pública 2018; 22(2):126-134., these centers still lack a legal framework to organize their available treatments.

Methods

Based on a biographical approach, this study aimed at exploring and incorporating the tension that emerges when considering the construction of gender in its biographical dimension, both socially and individually²⁷27 Cornejo M, Mendoza F, Rojas RC. La Investigación con Relatos de Vida: Pistas y Opciones del Diseño Metodológico. Psykhe 2008; 17(1):29-39.^,2828 Moyano C, Ortiz F. Los Estudios Biográficos en las Ciencias Sociales del Chile reciente: Hacia la consolidación del enfoque. Psicoperspectivas 2016; 15(1):17-29.. Biographical narratives, regarded as “life knowledge” about an experience that occurs in a specific historical moment, are also a product of the conversation with the interviewer²⁹29 Santamarina JM, Marinas C. Historias de vida e historia oral. In: Delgado JM, editor. Métodos y técnicas cualitativas de investigación en ciencias sociales. Madrid: Síntesis, S.A; 1999. p. 257-285.. Memory - as an act whereby one remembers one’s life - is understood as a dialogic process that takes place within a social framework, as part of a collective memory³⁰30 Halbwachs M. La memoria colectiva. Zaragoza: Prensa Universitarias de Zaragoza; 2004.. Thus, we addressed trans subjects’ lived experiences based on a biographical approach influenced by psychoanalytic and transfeminist sensitivities¹1 Gherovici P. Transgender psychoanalysis. A lacanian perspective on sexual difference. New York: Routledge; 2017.^,1414 Jesus JG. Géneros em essencualismo: feminism transgénero como crítica do sexo. Universitas Humanística 2014; 78:241-257..

The participants were selected as typical subjects³¹31 Fonseca C, Quintero M. El uso de la observación participante, el grupo de discusio´n y la historia de vida como herramientas metodolo´gicas del investigador social: Historia de Vida de una mujer transexual, trabajadora del sexo. Cad Espaco Fem 2007; 18(2):45-101. with a “snowball” sampling. The first contact was made through an NGO devoted to political action for trans people’s rights. We contacted eight subjects. Two of them did not respond to our invitation, and the other three were initially interested, but failed to keep in touch. In consequence, fieldwork began with three subjects who had already started the gender transition process and who had interacted with the healthcare system. We selected three participants: (1) a trans subject who sought medical help in the public system; (2) a trans subject who chose not to receive treatment in the healthcare system; and (3) a trans subject who self-administered medical knowledge and practice.

Narrative autobiographical interviews³²32 Appel M. La entrevista autobiográfica narrativa: Fundamentos teóricos y la praxis del análisis mostrada a partir del estudio de caso sobre el cambio cultural de los Otomíes en México. FORUM: Quali Soc Res 2005; 2(5):1-35. were conducted, since they make it possible to identify and describe the biographical and cultural processes present in a specific society. The interviews sought to trace the subjects’ life histories, highlighting aspects of their gender transition and health. The interviews were held in Santiago de Chile. Participants were interviewed over video call (Sofía), in the participant’s home (Kalfulikan), and in a cafe and the interviewee’s home (M). We conducted an average of four interviews per subject. All interviews lasted between one and three hours.

To analyze the material, we used the principles of discursive redundancy and closure, which involve constructing a representation of the object of study³¹31 Fonseca C, Quintero M. El uso de la observación participante, el grupo de discusio´n y la historia de vida como herramientas metodolo´gicas del investigador social: Historia de Vida de una mujer transexual, trabajadora del sexo. Cad Espaco Fem 2007; 18(2):45-101.. We followed the Pujadas’ recommendations for the analysis of life narratives³³33 Pujadas J. El método biográfico y los género de la memoria. Rev Antropol Soc 2000; 9:127-158.. That is, the text was first edited in two forms: the original transcript and the thematic record. The original transcript is a verbatim record of the audio obtained during the interviews. We invited participants to read this transcript as a way of enabling them to reexamine their narrative, possibly increase its depth, and highlight the unique authorship of the story narrated. Finally, the thematic record was produced through the narrative processing of the biographical story. Three texts were produced within the framework of the interviews. They reflect the participants’ narratives, focusing on the structure of their autobiographical stories: sequences, milestones, motives, causality, and moral order³⁴34 Piña C. Sobre la naturaleza del discurso autobiográfico. Anuario Antropol 1991; 13(1):95-126.. The sources of malaise and the ways in which the participants deal with it can be found in the intersections between the syntagmatic axis (gender transition) and the paradigmatic axis (the institutional dimension).

As for the methodological limitations of this study, five subjects refused to participate. Although there may be several reasons for their decision, they were probably influenced by their limited familiarity with research contexts and their fears linked to revealing biographical elements, in spite of the confidentiality safeguards in place. This view is consistent with the findings of prior studies with trans populations¹⁸18 Reisner SL, Poteat T, Keatley JA, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a review. Lancet 2016; 388(10042):412-436.^,3535 Tebbe EN, Budge SL. Research with trans communities: Applying a process-oriented approach to methodological considerations and research recommendations. Counseling Psychol 2016; 44(7):996-1024.. For subjects, narrating their lives involves putting into words significant and sometimes painful experiences, which are inevitably re-interpreted throughout their narratives -causing them to be analyzed and deconstructed. In consequence, the information production and collection process may have become yet another source of malaise for the subjects, even though it offered an opportunity for them to visualize paths for addressing it, with concrete effects on their (mental) health being possible. This study valued the process whereby the participants shared their stories. For this reason, we worked to protect the participants as individuals and strove to finish the process adequately with each of them, clarifying their doubts, respecting their anonymity decisions, staying within the limits that they had set in terms of involvement quality and quantity, and respecting their choices regarding which topics to cover and/or examine in detail, among other actions.

Regarding ethical considerations, we took into account the principles of autonomy and beneficence/nonmaleficence, safeguarded the sensitive material collected, and preserved the participants’ anonymity³⁶36 Winkler MI, Letelier A. ¿Una misma deontología para distintas ciencias?: Revisión de pautas nacionales e internacionales en ética de la investigación científica. Acta Bioeth 2014; 20(1):81-91.. The interviews were conducted after the subjects decided to participate in the study by signing an informed consent.

Findings

“Turning this struggle into flesh”: trans contradictions, gender transitioning, and the healthcare system

Sofía described herself as “a failure of masculinity, transvestite in training, and political activist”. She defines herself as trans, transvestite, and/or “a painted fag”, currently a trans activist in several political organizations. The autobiographical interview process was interrupted because Sofía was affected by an act of violence motivated by her dissident gender expression. For this reason, she declined to read the material and only participated in the editing of her biographical narrative.

Her first memory is from a Physical Education class in first grade. She remembers that, as the students were being separated into boys and girls, she felt attracted to the former. Afterward, she remembers being an eight-year-old, wearing her mother’s clothes and makeup. Sofía looked at herself in a full-body mirror until she heard someone opening the front door for her house. She had the vivid sensation that it might be a non-relative who might find her doing something wrong.

When discussing her childhood, Sofía mentions the soap operas that her family watched at home along with the stories of princes and princesses that her mother told her. These are linked to memories of beatings at school: “[…] many kids hit me, but I thought one of them was really beautiful, he looked like a prince. […] but that’s one of the things my mom did, she told me lots of stories […]. So, there were lots of princess and prince characters, […] the soap operas were right there in our living room. […] and I had created a sort of alternative story in my head, based on one soap opera. Obviously, the male protagonist was this young man, who looked like that… well, he was the leader of that gang”. Without being explicit, she situates herself as a woman-princess who is seduced and/or rescued by a man-prince. There is a clear mismatch between the figure conveyed by her mother and the child who embodies it, an image that grows more intense because it exists within the reality of school, where she is victimized.

Tellingly, Sofía reports having been diagnosed with social phobia as a child, which is consistent the school bullying. As an eight-year-old, she first thought about ceasing to exist. This can be explained by the warnings of her mother, who did not allow her to play or spend time with other children, as they would do “something” to her. She knows that it was after she turned eight that other children physically harmed her: after that moment, the ambiguity of her mother’s words began to be filled with bullying experiences.

Sofía came out as a homosexual when she turned eighteen, which led her to discover clubs and gay chatrooms. During her life in these spaces, she experienced various forms of psychological, physical, and sexual violence exerted by hetero/homosexual men. She also portrays trans men as attackers, including them as parts of an overall masculinity that exerts violence. Even after joining left-wing political groups, she continued to be a victim of verbal violence due to her identity. She entered the sexual dissidence field because it enabled her to confront patriarchal and heteronormative discourse. For Sofía, politicization was an outlet for her malaise: “I found it so logical to be able to turn this struggle into flesh, I realized that this was not abstract, these were specific things that happened in our bodies, they happened to some people […] so what we say is important”. This was the time when Sofía started hormone therapy to feminize her body.

Sofía’s access to the healthcare system is marked by a mismatch between her expectations and what she actually receives: an environment that she describes as hostile, unintuitive, and violent, even though tertiary centers had the necessary resources to serve trans people at the time, two units in the country. Sofía attended both centers. The very architecture of the hospital compounds the staff’s discriminatory behavior. In that context, her gender transition was largely psychopathologized: she was immediately referred to a psychologist for a mental assessment. In her view, this resulted in a loss of her central role in the process, marked by the empirical-statistical logic of medical knowledge, which coldly offers a treatment and/or determines the success of the process.

Upon reading her narrative, Sofía specified that she decided to drop out of her hormone treatment, because the hospital context and the way she was treated there did not foster her gender expression, rather becoming a new source of hostility: “[…] starting this hormone treatment represented a brutal contradiction; I want to manage it myself and determine when I have the amount of estrogen I need, not to become that woman […]”. For her, the treatment was no longer a viable trajectory for malaise. In fact, it heightened the sidelining of her subjectivity in her bodily modification process. Now, she understands gender transition as a heteronormative notion in which a binary perspective of the sexes predominates and determines doctors’ work. She decides to keep her contradictions and ambiguities, rejecting the gender coordinates and states that gender “transitioning” (“transicionar”) is an unfinished task for her - a common element within the trans community to which she belongs.

The aesthetics of stigmatization: bodily modification as a subversion of discrimination

Kalfulikan was born in what he described as a conservative and religious town of southern Chile. His mother, a healthcare professional, and his father, a farmer, have trouble supporting Kalfulikan early on. His father emerges as a cold figure who denies his son’s problems: “When I was little and didn’t understand what was happening to me, my dad played dumb”. He describes his mother as an affectionate person who was also invasive as a result of her medical knowledge. She was prone to pathologize his condition: “[…] I saw my mom as a person who wanted to fix me; I think she would have taken me to the doctor... She’d check my cellphone and tried to ask me direct questions about things that weren’t too clear to me either”. In her view, disease was a logical explanation for her son’s sexual ambiguity.

Starting school at age 7 was a milestone in his life. That was the first time he was called a “man” and the first time the differences between the sexes were conveyed through physical and psychological violence. School delineates a public space where violent behavior was allowed: “What they first said to me was ‘fag’. All possible variations of its word. I had to grin and take it all, all the violence from my classmates, teachers, and my classmates’ families, and that makes you think you have problems. That caused me to become super resentful…”. This discrimination became to self-discrimination.

He felt that he was sick all through his adolescence until he became a legal adult. Then, he resorts to using his body as a space to be challenged and shaped at will: “I felt I was not in the shoes of the person I was representing; I somehow rejected everything that was masculine in me. So, I started wearing tighter clothes, getting piercings, dying my hair. I then tattoo, and I’m still doing that. All that has allowed me to rebuild myself. Now I look at myself and it’s like I can finally see myself”, “I wasn’t happy with my [male] body, I needed to modify it a little. All this gives me peace when I see myself in the mirror. So, it’s like relieving that tension by expressing your body in the way you want to look”.

Thus, Kalfulikan’s bodily transformation results from an examination of how to behave and show himself in front of others. When he turned 18, he decided to enroll in a university program. To do this, he left his native town. He is sharply critical of the notion of gender transition and even of the legal modification of birth certificates since he sees these milestones in the process as reaffirmations of a binary view of gender according to which only men and women exist. Even more so, he holds that transitioning can only occur after erasing the life history of those who allow it to happen. He creates the “non-man” political category to refer to his gender, since it preserves the male privileges that he acknowledges while at the same time challenging them through a negative suffix. He manages to transition without resorting to medical knowledge, instead choosing to singularize his bodily aesthetics, wholly avoiding healthcare services and institutions.

Transitioning: Can it begin? Can it be completed? Is it endless?

M defines herself as a lesbian trans woman. Her “transit” (“tránsito”) - as she calls this process - began with two milestones: reading the book Whipping Girl¹⁵15 Serano J. Whipping girl. New York: Seal Press; 2007. and starting her self-administered hormone therapy. Along with her interest in controlling her personal information and ensuring her anonymity, which leads her to edit her narration carefully, M. permanently focuses on her femininity. M.’s devaluation of the State and non-voluntary association institutions is present all through the material. Defining herself as anarcho-libertarian, contractualist libertarian, or libertarian, M. advocates for free association as a form of political organization capable of granting her the freedom that she needs to transition.

She first violent encounter was at age 4 when she was forbidden to feminize her body under threat of physical punishment. This violence continued at the school through the norms, impositions, and bullying exerted by her male peers and her family’s mistreatment. Her grandfather, a healthcare professional, offered M. medical knowledge in her everyday life since she was a child. Her body was also prone to be interpreted and discussed; however, when M. decided to start her hormone therapy, he refused to assist/support her in the feminization process. This situation not only disrupted M.’s life, it also encouraged her to construct her own hormonal protocol based on Chilean and international protocols and interviews with endocrinologists. In general, she acquired medical knowledge, interpreted and administered it herself.

Her participation in a trans NGO was another relevant factor in the construction of this protocol. In this organization, M. took part in discussions and joined practical workshops that enabled her to intervene her own body. In the BodyMod community, she realized the option of being a lesbian trans woman, which represented a milestone in the management of her malaise. The ability to engage in emotional and sexual relationships with women, being a woman herself, has a subversive and corrective effect compared to prior feminization attempts.

In this context, she started a significant relationship with J., another active member of the BodyMod community. The end of this relationship was a major loss for M. but as a goodbye joke, J. offered her the chance to “live as a woman for a year” because of her feminine gestures. Although she was unable to understand this course of action at the time, M. managed to re-signify it during the biographical interview. Her narrative suggests that, even today, the feminization of herself is still unfinished. She cannot visualize the end of the process: the lesbian transwoman she desires to embody is always one step ahead, despite the efforts made to reach her. This not only illustrates her malaise, but also shows that this unfinished sexual position is untenable for her.

Discussions and conclusion

Chilean State has addressed the gender transition process in the last decade through the implementation of a set of health and legal institutions, policies, strategies and practices. However, this set has tended to neglect and nullify trans subjects’ subjective and social aspects involved in their gender transition processes. From this, the politicization, aesthetization, and medical self-administration of gender “transitioning” emerge from the biographical narratives as ways of coping with malaise.

Participants revealed sources of malaise derived from the Chilean society’s norms imposed on those who identify themselves as trans. The gender expression is identity-related process that begins in early childhood, which begins before age 3, with families being the first source of malaise, embodying a patriarchal and cis-heteronormative society. Through prohibitions, families convey performativities that later on configure gender roles. Schools, as the second source of malaise, are regarded as spaces that reproduce sexual dimorphism, imposing behaviors based on this logic. Their negligence is evident: since they protect violent behaviors, it is possible to link this violence to their own segregation policies and impositions. The school becomes thus the place where the gender performativity transmitted in the family is reproduced. Thus, exerting violence emerges as a trait of masculinity: the attackers are subjects authorized and ordered to engage in abusive practices.

The great difficulties that the participants encountered in childhood and youth cause lead trans subject to evaluate healthcare system as an eventually inaccessible space. For them, medical knowledge seems only to recognize parameters that fit its biological epistemology, neglecting their own subjective and social paths. In other words, the healthcare system seems to not provide an idiom through which trans subjects represent their malaise. This situation leads usually to drop out of the healthcare system, fostering the creation and implementation of self-administered measures, which are supported and constructed by communities. for instance, trans NGOs, articulated by subjects who create and seek support from it, are a domain where subjects identify several ways for addressing malaise.

Bodily modification emerges as a destination of malaise, representing not only a way out of institutional constraints, but also - especially - a path for negotiating it. Being focused on aesthetic changes, the participants’ bodily modification reflects a process whereby they subjectivize their own bodies and opens up a path for accessing the community - the body operates as a canvas where conflicts that would otherwise remain in a clandestine sphere, are formulated/visualized. Besides, anxious and depressive symptomatology, death-related thoughts, or suicide attempts are elements present all through the biographical material. This trajectory is marked by the threat of physical, sexual, or gender violence. Patriarchal society, in which dimorphic sex and gender cis-heteronormativity predominate, is a source of malaise that, through violence, eventually becomes subjective suffering.

The trans biographical narratives are, in part, reflections on gender transition. Through them, participants voiced their criticism towards dimorphism and heteronormativity reduce the gender transition process to a mechanical passage from one gender to the other, thus limiting their gender expression to specific gender identity. From a transfeminist viewpoint, the criticism of the trans subject towards the gender transition notion is a call of attention about the authorship of the transgender culture and subjectivity - a true political struggle for their identity and whose creativity opens a possibility in their narratives. At the same time, it is a criticism of the production of psychological, psychiatric, and public health knowledge.

The participants’ notion of “transitioning”, as well as the quotidian jargon of the Chilean trans community, provide new signifiers that, despite being absent from the formal register of language, enables to de-ontologize gender transition. Therefore, trans biographies make mandatory to interrogate the role of community (e.g. family members, neighborhood, among others) as well as public institutions (e.g. educational and health systems). By its part, “transitioning” concept highlights childhood and youth as a crucial period through which it is possible to question empirically and conceptually gender transition, subjectivity and health.

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