Abstract:

In this article I provide a comparative interpretation of the itineraries used by trans men to deal with the issue of waiting, when confronted with challenges related to access to health services in Brazil and Argentina. The article was the result of anthropological research in the greater metropolitan areas of Goiânia and Buenos Aires, aimed at contributing to discussions on access to health for trans men in these two contexts, seeking to identify ambivalences related to their treatment itineraries in search of biomedical care.

Keywords:
Transgender Persons; Transexualism; Health Services Accessibility

In March 2018, Chilean President Michelle Bachelet received the crew from the film Una Mujer Fantástica [A Fantastic Woman], which had just won the Academy Award for Best Foreign Language Film. On the occasion, trans actress Daniela Vega, the film’s leading actress, stated: “Film, like art, seeks to understand human beings better. Their dreams, their abilities, their desires, and also their limits. This film explores the limits of empathy. Which bodies can be inhabited? Which loves can and cannot be won? Who determines this barrier? In this country, today, to which I return with the film crew, happy, my passport bears a name that is not mine. And that is because the country in which I was born does not give me this possibility. And time goes on. And the clock is ticking. And people go on, waiting for this” ¹1. CHV NOTICIAS. La potente reflexión que dio a conocer Daniela Vega en La Moneda. https://www.youtube.com/watch?v=0UtyBNjlUK8 (acessado em 21/Mai/18).
https://www.youtube.com/watch?v=0UtyBNjl... .

Such words announce issues that are close to those that will be addressed in this article: the itineraries mobilized by trans men to deal with the issue of waiting, when confronted with challenges related to access to health services in Brazil and Argentina.

“Trans man” is an expression used in this article as an analytical category “in the effort to condense the experience of ‘male transsexuality’” ²2. Almeida GS. 'Homens trans': novos matizes na aquarela das masculinidades? Revista Estudos Feministas 2012; 20:513-23. (p. 513). It is also a political category that has been mobilized in Brazil to demand rights for these individuals, as will be addressed next. I agree that for the social sciences, the views of trans experiences involve “an understanding of transsexuality that seeks to find its contemporary meanings, perceiving it as a [plural] historical and cultural phenomenon” ³3. Almeida G, Murta D. Reflexões sobre a possibilidade de despatologização da transexualidade e a necessidade da assistência integral à saúde de transexuais no Brasil. Sex Salud Soc (Rio J.) 2013; 14:380-407. (p. 385). Thus, also based on the premise that not all trans men submit to biomedical protocols for the recognition of their gender identities and the realization of their embodiment, I consider it relevant, given a series of obstacles reported by those who seek follow-up in health services to experience “transition” (which should be understood here as an emic category), to discuss their itineraries in light of the ambivalences expressed in their narratives.

I will interpret, anthropologically and sociologically, the fieldwork material produced in two studies, one at the Federal University of Goiás (UFG - Goiânia, Brazil), with the support of the Brazilian National Research Council (CNPq), and the other in my post-doctoral work at the University of Buenos Aires (UBA - Argentina), funded by the Brazilian Graduate Studies Coordinating Board (Capes).

Both studies complied with the relevant guidelines and were approved by the Ethics Research Committee of UFG under protocol number 1.410.804/2016.

The Brazilian context: brief remarks

Studies in Brazil on the LGBTT movement (lesbians, gays, bisexuals, transvestites, and transsexuals) show that beginning in the 1990s there was a context of expansion and reorientation of the movement’s relations with the state, which began to involve linkage and collaboration, thus differing from the scenario in which homosexual activism emerged in São Paulo in the late 1970s, under the military regime ⁴4. Facchini R. Sopa de letrinhas? Movimento homossexual e produção de identidades coletivas nos anos 90. Rio de Janeiro: Garamond; 2005.. This new scenario witnessed the institutionalization of transvestite activism in Brazil ⁵5. Carvalho M. Que mulher é essa? Identidade, política e saúde no movimento de travestis e transexuais [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2011. at a time when the debates began to focus increasingly on the specificities of the experiences and demands for rights and public policies for the different subjects in the movement ⁶6. Simões J, Facchini R. Na trilha do arco-íris: do movimento homossexual ao LGBT. São Paulo: Fundação Perseu Abramo; 2009.. Trans activism emerged in Brazil in the following decade ⁵5. Carvalho M. Que mulher é essa? Identidade, política e saúde no movimento de travestis e transexuais [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2011.; terms like “transvestite” or “transsexual” are quite complex, involving disputes over their meanings that include (but are not limited to) biomedical and psychiatric discourses ⁷7. Barbosa B. Nomes e diferenças: uma etnografia dos usos das categorias travesti e transexual [Dissertação de Mestrado]. São Paulo: Universidade de São Paulo; 2010.. For the purposes of this article, it is important to keep in mind that although initiatives by these activisms presented demands in other areas ⁵5. Carvalho M. Que mulher é essa? Identidade, política e saúde no movimento de travestis e transexuais [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2011., health-related issues have in some way been at the center of the production concerning the rights of these persons in recent years. In this scenario, a strategic alliance between activists and academia resulted in 2008 in the creation of the transsexualizing process via the Brazilian Unified National Health System (SUS) ⁸8. Carvalho M, Carrara S. Em direção a um futuro trans? Contribuição para a história do movimento de travestis e transexuais no Brasil. Sex Salud Soc (Rio J.) 2013; 14:319-51.. At the time, surgical procedures had only been incorporated for trans women; trans men were included in the transsexualizing process in 2013, when the guidelines were expanded and reformulated ⁹9. Ávila S. Transmasculinidades: a emergência de novas identidades políticas e sociais. Rio de Janeiro: Editora Multifoco; 2015..

Trans men joined transsexual activism in Brazil in the 2000s ⁹9. Ávila S. Transmasculinidades: a emergência de novas identidades políticas e sociais. Rio de Janeiro: Editora Multifoco; 2015., and their political visibility has increased recently ¹⁰10. Braz C, Souza E. Transmasculinidades, transformações corporais e saúde: algumas reflexões antropológicas. In: Caetano M, Melgaço P, organizadores. De guri a cabra macho: masculinidades no Brasil. Rio de Janeiro: Lamparina; 2018. p. 28-42.^,1111. Carvalho M. "Travesti", "mulher transexual", "homem trans" e "não binário": interseccionalidades de classe e geração na produção de identidades políticas. Cadernos Pagu 2018; (52):e185211.. The Brazilian Association of Trans Men (ABHT) was founded in 2012, followed the next year by the Brazilian Institute of Transmasculinities (IBRAT) ⁹9. Ávila S. Transmasculinidades: a emergência de novas identidades políticas e sociais. Rio de Janeiro: Editora Multifoco; 2015.. In 2015, the 1st National Meeting of Trans Men was held at the University of São Paulo (USP), promoted by IBRAT, during which the decision was made to use “trans men” as a political category ¹⁰10. Braz C, Souza E. Transmasculinidades, transformações corporais e saúde: algumas reflexões antropológicas. In: Caetano M, Melgaço P, organizadores. De guri a cabra macho: masculinidades no Brasil. Rio de Janeiro: Lamparina; 2018. p. 28-42.^,1111. Carvalho M. "Travesti", "mulher transexual", "homem trans" e "não binário": interseccionalidades de classe e geração na produção de identidades políticas. Cadernos Pagu 2018; (52):e185211..

In this scenario of visibility of transmasculinities, it is essential both to consider the impact of recent discussions and debates raised by the campaign to de-pathologize transsexuality ¹²12. Jesús BM. Campanha pela despatologização da transexualidade no Brasil: seus discursos e suas dinâmicas [Dissertação de Mestrado]. Goiânia: Universidade Federal de Goiás; 2012.^,1313. Sousa D, Iriart J. "Viver dignamente": necessidade e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00036318. and to focus on the fact that currently, “the process of [trans] men’s self-identification has occurred through internet contacts in virtual peer communities (...), hospital environments associated with the transsexualizing process, universities, and public spaces in the LGBT movement, besides personal networks and news stories and TV programs” ²2. Almeida GS. 'Homens trans': novos matizes na aquarela das masculinidades? Revista Estudos Feministas 2012; 20:513-23. (p. 519).

Fieldwork in Brazil

In June 2014, the University Board of UFG passed a resolution authorizing the use of social names, based on an initiative by the Office of the Dean of Undergraduate Studies, in dialogue with research groups and trans students. In October, I was invited to participate in a meeting with these students to learn their perspectives concerning how the resolution was being implemented. Still, their concerns related to another matter: rumors about the possible suspension of the Transsexuality Project, which had been created at the UFG University Hospital in May 1999 following authorization by the Brazilian Federal Medical Council to perform so-called sexual reassignment surgeries, in 1997. The project, part of the transsexualizing process, had been closed down for new treatments since 2012, due to lack of funds. One of the students at the above-mentioned meeting was quite restless because he had not been able to enroll in the project. He said that he could no longer stand waiting for medical care. The issue of waiting thus worked itself into my research. My fieldwork began in this scenario of uncertainty as to the Transsexuality Project. The objectives of the study, which had been conceived to interpret meanings of the body and masculinity, now began to focus on the challenges in terms of public policies for trans men, especially regarding the issue of access to health services.

My teaching work facilitated access to the first interviewees, although I was a gay cisgender (not trans) man and was sometimes questioned about the motives that led me to study this topic. My point of departure was a network of trans persons I knew from the university and reached the first of them, and next their acquaintances, using the snowball technique. I interviewed a total of 12 trans men, for whom I list some characteristics in the Box 1.

Importantly, all the interviewees emphasized the need to obtain specialized medical follow-up, while the majority had been unable to obtain it with their own resources. Even those who did have the resources reported difficulties in finding adequate care.

Their narratives led me to argue that the issue of waiting may be essential for anthropologically interpreting trans experiences in contemporary Brazil ¹⁴14. Braz C. Transmasculinidades, salud y espera - antropología del tiempo y el acceso a la salud para hombres trans en Brasil. In: Pecheny M, Palumbo M, organizadores. Esperar y hacer esperar: escenas y experiencias en salud, dinero y amor. Buenos Aires: Teseopress; 2017. p. 147-64., considering the tension between subjective time and bureaucratic time, between each individual’s time ¹⁵15. Sampaio LLP, Coelho MTAD. As transexualidades na atualidade: aspectos conceituais e de contexto. In: Coelho MTAD, Sampaio LLP, organizadoras. Transexualidades - um olhar multidisciplinar. Salvador: EDUFBA; 2014. p. 13-23. and institutional time, important for interpreting expectations concerning the transition and health care. If this bureaucratic time is taken as part of a wider gender system inscribed by the device of transsexuality ¹⁶16. Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006., waiting can be read as a microsocial process that is part of it, and its effects can be studied in the ways by which they manifest locally and specifically, produced in actions by individuals living their daily lives, inscribed in their bodies and in their words. Following the leads from Abu-Lughod, I am concerned here with a form of writing that seeks to portray this ¹⁷17. Abu-Lughod L. Writing against culture. In: Fox R, editor. Recapturing anthropology. Santa Fe: School of American Research; 1991. p. 137-54..

The contrast between temporalities appears in the critiques of the mandatory nature of at least two years of psychological care before potentially receiving a report to enter the waiting line for surgeries in the transsexualizing process ¹⁸18. Borba R. O (des)aprendizado de si: transexualidades, interação e cuidado em saúde. Rio de Janeiro: Editora Fiocruz; 2016.. The contrast lies in the expectations concerning the effects of hormone therapy. And it persists in waiting line for the transsexualizing process, when the limited budget resources for trans health care create a constant risk of closing such services’ doors, as with the Transsexuality Project at UFG ¹⁹19. Almeida AS. Vidas em espera: uma etnografia sobre a experiência do tempo no processo transexualizador [Dissertação de Mestrado]. Goiânia: Universidade Federal de Goiás; 2018..

The process of reopening the Project, which did not occur until early 2016, involved mobilization of activists (especially from the TransAction Collective, consisting of trans students and cis allies), which has partnered with the Project’s coordinators to seek alternatives to keep it operating. This scenario included the beginning of outpatient care for the academic community at the UFG health clinic and access to psychological care in an extension project of the School of Psychology. A second project was created in partnership with the Goiás State government, connected to the transsexualizing process in the city, and that began to function in the Goiânia General Hospital (HGG) in early 2017 ¹⁹19. Almeida AS. Vidas em espera: uma etnografia sobre a experiência do tempo no processo transexualizador [Dissertação de Mestrado]. Goiânia: Universidade Federal de Goiás; 2018.^,2020. Marques P, Silva W. A construção coletiva do serviço especializado do processo transexualizador no SUS em Goiás - reflexões e ressignificações sobre a gestão de políticas públicas de saúde para pessoas trans. In: XII Reunión de Antropología del Mercosur. Posadas: RAM; 2017. https://ram2017.com.ar/?p=2144.. Finally, a networking process began to create trans outpatient clinics in smaller towns in the state of Goiás.

In order to interpret narratives of waiting, I have used the concept of treatment itineraries, present in the anthropological literature on health, which interprets the processes of choosing, assessing, or adhering to certain forms of health treatment in the lifeworld ²¹21. Alves PC, Souza IM. Escolha e avaliação de tratamento para problemas de saúde: considerações sobre o itinerário terapêutico. In: Rabelo A, Souza IM, organizadores. Experiência de doença e narrativa. Rio de Janeiro: Editora Fiocruz; 1999. p. 125-38.. One example is hormone therapy.

“In reality, [hormone use] was always hidden. My mother knows I use them, but not that somebody prescribed them. I’m not in the project. I’m not even helped by the project. I tried to enroll over a year ago. I think it was about a year and a half ago that I asked to be referred there. (...) But I searched [on the Internet], you know? I started searching for which hormones to use and all, and I asked friends, and Facebook, and I found one at the gym. I met a dude that sold anabolic steroids” (Interviewee 2).

“But you didn’t have any kind of follow-up, so...” (Interviewer).

“No, I did my own follow-up, you know? I went and found a list of tests and said to the doctor, ‘Look, I want this, that, and the other test’, so he wrote the order, and I went there and picked up the tests, and sometimes I didn’t even show him the results” (Interviewee 2)

“Do you still have to buy like that, let’s say...” (Interviewer).

“Clandestinely? (...) The first eight vials I used were originals. The others came from Paraguay. (...) So, for them, you don’t have any guarantee of the origin or whether they even work. (...) It’s contraband. It’s contraband. So, I started using them, and I couldn’t see any effect” (Interviewee 2).

The treatment itineraries also relate to the different strategies used by the men to achieve their embodiment: hormones, a varied set of other objects, like binders (elastane bands used to compress the breasts), minoxidil (used for beard growth), or even packers, which are used to urinate while standing, create volume, or for sexual relations ²²22. Costa BDL, Braz C. Um olhar antropológico sobre práticas de consumo de homens trans. Goiânia: Universidade Federal de Goiás; 2017. (Relatório de Iniciação Científica).. The itinerary in this process includes aspects that may be related to agency, since it involves the dimension of choice in the paths used to seek care that are not necessarily the schemes defined by health services. Social media are extremely important in this process. Through social media, trans men exchange various kinds of information that comprise a body of “local knowledge” on transition, with a sort of creative appropriation of biomedical knowledge: what are the best hormones and their effects?; where to purchase them?; how to obtain prescriptions?; which periodic tests should be done?; which health professionals treat adequately?; and how to request an appointment at health clinics that allow referral to the transsexualizing process?; besides exchanging information on the agenda of local and national meetings and events with discussions on trans rights. It is also through networks that some trans men hold fundraising campaigns to access masculinizing chest surgery in the private sector (known as online “crowd-sourcing”). Importantly, having the resources does not guarantee access to surgical procedures or endocrine follow-up in private clinics.

“I started using hormones a month ago. There’s a black market, you know? [laughs]. But I have a friend who does cycles. From the gym. So, he had a contact, and I told him I wanted such-and-such, and I bought it, and gave him the money, and he bought it, and I picked it up from him. And that’s how it was. Because the drugstore won’t sell without a prescription. I started looking for medical follow-up, because I have a health plan, so I went to several doctors. But for example, the psychiatrist I saw said he couldn’t treat me, because he couldn’t, I mean he could only prescribe, he asked me if I was depressed, and he said he couldn’t treat me clinically, which is what I wanted to get the report for, you know? For the surgeries. So, he said that’s not part of his practice. The endocrinologist said he couldn’t see me, because he wasn’t familiar with the subject. So, I said to myself, ‘Okay, I’ll do it on my own.’ And so it was. On my own. (...) They can’t treat trans persons because there’s no doctor. No doctor wants to treat us. (...) Because it’s really dangerous to take the stuff on your own. But I gave up on private doctors. And it’s really complicated” (Interviewee 3).

The interviewees’ narratives are full of embarrassing episodes in medical appointments. One told of a visit to a psychiatrist in a municipal clinic in Goiânia. The doctor asked him about his childhood experiences: “So, he said, ‘But didn’t you like to play ball, and I don’t know what all?’ (...) I nearly said to him, ‘No, but what does that have to do with anything? If I’d played with dolls, I would’ve felt like a man anyway’. (...) I almost said it, but (...) how is it that (...) the dude doesn’t even know what transsexuality is? Am I going to explain what gender is to him?!” (Interviewee 2).

Many of the interviewees stopped looking for medical care after experiencing episodes like this (or hearing about them from friends). In relation to medical appointments, such narratives show the extent to which hetero-cis-normative expectations shape gestures that weigh heavily on individuals.

“In the public health system [SUS] there’s no social name, you know? If you..., I mean that doesn’t exist. Like, only if you demand it, if you go there and insist to put the [social] name on your patient chart, and what good does it do? It’s on your patient chart, but the computer’s got your ID number! It doesn’t do any good (...) it’s an embarrassment, it’s like they’re cursing you. And here’s another one: the problem is not calling you by that name [from your ID]. The problem is that everybody’s watching, because they shout out, ‘Miiisssterrrr So-and-So!’” (Interviewee 2).

“Has that ever happened to you?” (Interviewer).

“All the time! Like, when it’s time for them to call my name, I stand close to the door, because then people (...) like, they won’t see me get up. I stand close to the door. Or, for example, let’s say I know I’m fourth in line. When they call out number three, I already get up, so they don’t have to call my name. That is, when I can. Because then I can talk to somebody there and say, ‘Hey, I’m going in first, because I don’t want you to call out my name’” (Interviewee 2)

“And do people respect that?” (Interviewer).

“No, not usually” (Interviewee 2).

The quote shows once again the importance of the notion of itineraries in its dimensions of agency, for us to take strategies into account to attempt to minimize embarrassments resulting from gender expectations (re)produced by the transsexuality device. My point of departure is Butler’s proposals ²³23. Butler J. Problemas de gênero - feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira; 2003.. Gender is a regulatory fiction, and sex is the effect of a matrix of intelligibility that takes heterosexuality and cisgenderism for granted (which relates to persons that identify with the gender that was assigned to them), based on hetero-cis-normative discourses. For the interviewees, many of the conflicts experienced in doctor’s offices could be avoided if they had their gender identities respected. Which brings up waiting again, in its dimension of expectation, reinforcing the argument that waiting is a fundamental category for including in discourse the experiences narrated by trans men I met in Brazil.

For Pecheny ²⁴24. Pecheny M. Introducción. In: Pecheny M, Palumbo M, organizadores. Esperar y hacer esperar: escenas y experiencias en salud, dinero y amor. Buenos Aires: Teseopress; 2017. p. 13-36., waiting is a prime sociological theme, as long as one takes into account what is implied in terms of power relations in the processes of waiting and especially making others wait.

On March 1st, 2018, the Brazilian Supreme Court (STF) ruled in favor of the possibility of altering one’s name and gender on civil registry documents, without the need for surgical procedures or reports that “attest” to one’s transsexuality. The ruling was regulated by the Brazilian National Council of Justice (CNJ). Despite the ruling’s relevance, it is important not to lose sight of the fact that in Brazil’s Legislative Branch, one of the main demands by the trans movement is still the passage of the Bill of Law on Gender Identity, known as the João Nery Law. The bill takes inspiration from the Argentine law, identified in international forums as one of the most world’s most progressive laws in terms of recognition of trans rights ²⁵25. Farji Neer A. Las tecnologías del cuerpo en el debate público. Análisis del debate parlamentario de la ley de Identidad de Género argentina. Sex Salud Soc (Rio J.) 2014; 16:50-72.^,2626. Tabbush C, Díaz MC, Trebisacce C, Keller V. Matrimonio igualitario, identidad de género y disputas por el derecho al aborto en Argentina. La política sexual durante el kirchnerismo (2003-2015). Sex Salud Soc (Rio J.) 2016; 22:22-55.^,2727. Ortega J, Tiseyra MV, Morcillo S, Gálvez M. (Im)pacientes trans en hospitales públicos de Buenos Aires. La experiencia de la espera y la accesibilidad en contextos de estigmatización. Vivência 2017; 49:239-52..

The Argentine context: brief remarks

According to Laura Saldivia Menajovsky ²⁸28. Menajovsky LS. Subordinaciones invertidas - sobre el derecho a la identidad de género. Los Polvorines: Universidad Nacional de General Sarmiento/Ciudad de México: Universidad Nacional Autónoma de México; 2017., the history of the recognition of LGBTT rights in Argentina is part of a long process of formation of constitutional definitions shaped by interaction between civil society and national and international spheres. The country’s Gender Identity Law was passed in 2012 as the result of a historical process of struggle, organization, and mobilization by trans activism ²⁹29. Berkins L. Un itinerario político del travestismo. In: Maffía D, organizador. Sexualidades migrantes. Género y transgénero. Buenos Aires: Scarlett Press; 2003. p. 127-37.^,3030. Berkins L, Fernández J. La gesta del nombre próprio: informe sobre la situación de la comunidad travesti em la Argentina. Buenos Aires: Associación Madres de Plaza de Mayo; 2005., materialized in the National Front for the Gender Identity Law, formed in 2010 to support its drafting and passage ²⁶26. Tabbush C, Díaz MC, Trebisacce C, Keller V. Matrimonio igualitario, identidad de género y disputas por el derecho al aborto en Argentina. La política sexual durante el kirchnerismo (2003-2015). Sex Salud Soc (Rio J.) 2016; 22:22-55.. The process of passing this law in Argentina did not have the same media and political repercussions as other initiatives related to other LGBTT rights, as for example, equal marriage rights (passed in Argentina in 2010). Regulation of the law by Argentina’s Ministry of Health took place some three years after its passage in 2015, which involved not only waiting, but intense mobilization by activists ²⁶26. Tabbush C, Díaz MC, Trebisacce C, Keller V. Matrimonio igualitario, identidad de género y disputas por el derecho al aborto en Argentina. La política sexual durante el kirchnerismo (2003-2015). Sex Salud Soc (Rio J.) 2016; 22:22-55.^,3131. Farji Neer A. Reconfiguraciones del rol de la psicoterapia en el marco de los tratamientos de construcción corporal trans (Argentina, 1997-2017). In: Braz C, Henning CE, organizadores. Gênero, sexualidade e saúde: diálogos latino-americanos. Goiânia: Editora da UFG; 2017. p. 122-42..

One of the law’s pioneering characteristics is that it does not define transsexuality as a disease. Recognition of trans rights in Argentina, such as access to specialized medical care and free surgeries and hormone therapy, and correction of civil registry documents, no longer defines their experiences within the framework of a diagnostic category ³¹31. Farji Neer A. Reconfiguraciones del rol de la psicoterapia en el marco de los tratamientos de construcción corporal trans (Argentina, 1997-2017). In: Braz C, Henning CE, organizadores. Gênero, sexualidade e saúde: diálogos latino-americanos. Goiânia: Editora da UFG; 2017. p. 122-42.. Article 11 of the law legalizes hormone and surgical treatments for persons over 18 years of age (while minors need court authorization before undergoing surgeries). Argentina’s health system consists of three sectors that are not necessarily integrated with each other and are internally fragmented: the public sector, the mandatory social security sector (known as “obras sociales” or “social works”, available to workers and their families), and the private sector ³²32. Bello M, Becerril-Montekio V. Sistema de salud de Argentina. Salud Pública Méx 2011; 53:96-109.. The Law provides for coverage in all three, requiring only one’s signature on an informed consent form ³³33. Instituto de Investigaciones Gino Germani; Fundación Huésped. Análisis de la accesibilidad y la calidad de atención de la salud para la población lesbiana, gay, trans y bissexual (LGBT) en cinco regiones sanitarias de la Provincia de Buenos Aires. Relatório de pesquisa. Buenos Aires: Instituto de Investigaciones Gino Germani/Fundación Huésped; 2017. 10.1590/0102-311X00110518..

One of the Law’s expected effects is to streamline access to procedures comprising transition, as well as a reduction in waiting time to access medical follow-up ²⁷27. Ortega J, Tiseyra MV, Morcillo S, Gálvez M. (Im)pacientes trans en hospitales públicos de Buenos Aires. La experiencia de la espera y la accesibilidad en contextos de estigmatización. Vivência 2017; 49:239-52.. At any rate, anthropologically speaking, it is important to consider possible gaps between what is specified in the Law and the daily life. A relevant theme in Argentina is still to study conditions in access to health services in practice, based on trans persons’ narratives ²⁷27. Ortega J, Tiseyra MV, Morcillo S, Gálvez M. (Im)pacientes trans en hospitales públicos de Buenos Aires. La experiencia de la espera y la accesibilidad en contextos de estigmatización. Vivência 2017; 49:239-52.^,3131. Farji Neer A. Reconfiguraciones del rol de la psicoterapia en el marco de los tratamientos de construcción corporal trans (Argentina, 1997-2017). In: Braz C, Henning CE, organizadores. Gênero, sexualidade e saúde: diálogos latino-americanos. Goiânia: Editora da UFG; 2017. p. 122-42.^,3333. Instituto de Investigaciones Gino Germani; Fundación Huésped. Análisis de la accesibilidad y la calidad de atención de la salud para la población lesbiana, gay, trans y bissexual (LGBT) en cinco regiones sanitarias de la Provincia de Buenos Aires. Relatório de pesquisa. Buenos Aires: Instituto de Investigaciones Gino Germani/Fundación Huésped; 2017. 10.1590/0102-311X00110518..

The fieldwork in Argentina

I arrived in Buenos Aires in July 2017 and began to consider strategies to conduct interviews. I made contact with a network of colleagues from the Gino Germani Research Institute who knew some trans men and was able to contact some collaborators, as I had done in Brazil. Via Facebook, I also met two Brazilian trans men who were living in Argentina. I held nine interviews, seven of which with Argentines. Box 2 lists some of their characteristics.

I soon realized the importance of the notion of agency (as evidenced in the approach to treatment itineraries) for reflecting on the use of social networks and in access to trans associations in Argentina by trans men. One afternoon I received an audio via WhatsApp from a collaborator from the study in Goiânia who said he wanted to come live in Buenos Aires. He wanted to know the procedures for obtaining a DNI (National Identification Document) and for accessing health services. An Argentinian friend offered to welcome him in Buenos Aires until he found a job. That itinerary was similar to the one adopted by Interviewee 1, a 21-year-old Brazilian, who was the first person I interviewed in Buenos Aires. While he was still in Brazil and doing searches on the Internet, he discovered that Argentina had its Gender Identity Law. Assisted by a friend from Buenos Aires he had met on the Internet, he left Rio de Janeiro for Buenos Aires to study medicine. He dreamed of becoming a surgeon and specializing in phalloplasty (a sexual reassignment surgical technique in trans men). When I met him, he was living with his girlfriend and was active in a trans association, responsible for administering a group of foreign trans men via Facebook, posting for them the knowledge acquired in these itineraries.

One difference he highlighted between the experiences in the two countries was in waiting for medical follow-up. When he arrived in Buenos Aires, his Argentinian friend told him about a hospital near his home where there was a service for trans persons. He telephoned there on a Friday, and the following Monday he already had his first appointment.

“I went. And they welcomed me like this [opening his arms]. They hugged me. I felt totally welcome, the marvelous compañeras, and the compañeros, too, and the doctors. My doctor is a feminist, she’s fabulous. And I only had my passport at the time. I told them my whole story, and right away they gave me the order to do the tests. They gave me everything. The following week, on a Wednesday, I went to do the tests at the same hospital. Two weeks later I got the results back, and right then they gave me the hormones” (Interviewee 1).

“Do they also supply the hormones there?” (Interviewer).

“Yes, and I don’t have to pay. They gave me the hormones right there, and I started taking them, and they prescribed my diet. I have to go back tomorrow to do more tests” (Interviewee 1).

“How long have you been in this follow-up here?” (Interviewer).

“Going on four months now” (Interviewee 1).

Another Brazilian I spoke with was Interviewee 2, 32 years old. Our conversation was via Skype, since he had recently moved with his wife to Bariloche. Paulo did not know much about transsexuality before he immigrated to Argentina in 2010, at 24 years. Two years later, after the Gender Identity Law passed, he read new stories and articles on the subject. He went for help at a trans association in Buenos Aires to find medical follow-up, in May 2013. Besides hormones, he was interested in having masculinizing chest surgery. The physician recommended that he wait until after the surgery to start hormone therapy. At the time, the Gender Identity Law was still not fully regulated. Thus, Interviewee 2 obtained the surgery and the hormone therapy with his own resources. At any rate, the surgery was done three months after his first appointment. When I interviewed him, he was still in medical follow-up at a public hospital in Bariloche. He said that the treatment there was quicker and that access to hormones (free of cost since regulation of the Law) was even simpler than in Buenos Aires.

In the interviews with Argentines, I was particularly struck by the shorter waiting time between appointments in specialized outpatient service and receiving hormones free of cost. In the reports by the interviewees, the waiting time for medical care is shorter and the bureaucratic process for accessing care and hormones is simpler in Argentina than in Brazil. However, there were social markers of differences materialized in distinct itineraries: some interviewees mentioned that the quality of care with the same health professional was different in appointments in a public clinic versus private offices, for example. And not all the interviewees reported the same experiences with masculinizing chest surgery or with waiting time for the procedure, especially when they referred the time prior to regulation of the Gender Identity Law, when many had to pay for the surgery. The fact that it is sometimes viewed as a plastic surgery rather than as a health need appeared in the interviews, even when referring to the current situation.

“For example, if you don’t have ‘social security’ coverage and you go to a public hospital, first of all they’re going to tell you that they aren’t sure, that they aren’t sure but that they’re going to try. But with this ‘they’re going to try’, while you’re doing all the tests, the hospitals have other surgeries as priorities. ‘We have other urgent surgeries, we can’t occupy the OR with a plastic surgery’ (...) But it’s easier with the hormones” (Interviewee 5).

Another issue is the surgery’s aesthetic results when performed in public hospitals: there is a certain gap between the expected results and the actual results when the intervention is more of a mastectomy than masculinizing chest surgery. In relation to phalloplasty, although some of the interviewees said they did not intend to undergo this procedure, those that did want it commented that in Argentina it is still experimental, with few surgeons trained to perform it (as in Brazil). Many reported their fear of a possible loss of sensitivity. And in the case of this surgery, the waiting time can reach two years, according to their reports. Some interviewees even mentioned that this could be related to the current government’s budget cuts in the area of public health.

The interviews thus touched on labor rights, trans childhoods, the comparison of supply and quality of access to health in Buenos Aires and other provinces, and the need for more training on gender issues for medical teams. Alongside these issues, the activists discussed the challenges for public policies in health for this population.

“Here, even though we have the Gender Identity Law, access to health is extremely complicated, and we have increasingly less access. We may have the best Identity Law in the world, they treat us free in the social security system and the public system. Right? But…access and the health professionals prevent us from reaching places. For example, our Law here is not pathologizing, but the health professionals are, the university graduates, the clinical endocrinologists and all, they don’t teach them about trans persons. They don’t teach them that there’s a Gender Identity Law. They don’t teach them that it’s not a disease. They come with a pathologizing perspective, while we have a law that is not pathologizing. So, when we go to the doctor, the doctor says, ‘No, bring me the gender dysphoria report’. Understand? There are health professionals that get worked up. Because there’s a lot of fear. There are doctors who don’t care, there are doctors that discriminate, and although you may have the world’s best Gender Identity Law, you give them the protocol and the procedures for treating a trans person and they’re going to say, ‘I don’t like trans people’, and they’ll refuse to see you” (Interviewee 5).

There thus appears to be a mismatch between the provisions of the Gender Identity Law and the hetero-cis-normative symbolic repertoires, still quite present in daily health care and its micro-policies ²⁷27. Ortega J, Tiseyra MV, Morcillo S, Gálvez M. (Im)pacientes trans en hospitales públicos de Buenos Aires. La experiencia de la espera y la accesibilidad en contextos de estigmatización. Vivência 2017; 49:239-52.^,3131. Farji Neer A. Reconfiguraciones del rol de la psicoterapia en el marco de los tratamientos de construcción corporal trans (Argentina, 1997-2017). In: Braz C, Henning CE, organizadores. Gênero, sexualidade e saúde: diálogos latino-americanos. Goiânia: Editora da UFG; 2017. p. 122-42..

Finally, it is striking that in Argentina, at least formally, the issue of pathologizing transsexuality appears to have been resolved better than in Brazil, where the fear of not having access to the transsexualizing process (if it is no longer considered a disorder) ¹²12. Jesús BM. Campanha pela despatologização da transexualidade no Brasil: seus discursos e suas dinâmicas [Dissertação de Mestrado]. Goiânia: Universidade Federal de Goiás; 2012. appeared in the interviews, even though the interviewees in Brazil were quite critical of pathologizing trans identities ¹³13. Sousa D, Iriart J. "Viver dignamente": necessidade e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00036318..

Final remarks

When the Argentines asked me about the possibilities for access to health care for trans men in Brazil, many said that my report sounded almost like the situation they experienced before the Gender Identity Law was passed in Argentina. At first sight, this impression might suggest that the Law’s existence would solve all the problems and obstacles to access to medical care for trans persons. But as the saying goes in Brazil, a closer look at their own narratives shows that “all is not a bed of roses”. Despite the importance of the Gender Identity Law, there still seems to be mismatch between the Law’s provisions and the symbolic repertoires updated and (re)produced in the micro-policies of daily relations, whether in spaces of biomedical care or in other settings that were not addressed here (family, work, formal education, etc.). This is consistent with the literature in the field of social sciences, which in Argentina has focused on studying obstacles to the enforcement of regulatory frameworks determined by the Law, based on observation of the daily reality in medical offices and trans persons’ narratives in their itineraries in search of medical care. This may confirm the pertinence of anthropology’s claim in examining the effects of laws in the daily lifeworld. Although laws have formally expanded access to rights and are thus essential and must be defended, although they imply important normative and even symbolic changes, prejudices often resist the letter of the laws, insidiously and insistently. Cultural changes appear to bear their own relations to time and require slower and certainly deeper transformations.

If waiting, materialized in the gaps between expectations and the lived reality, or between subjective and official times, can be understood as part of a wider gender system, the discussion here sought to emphasize possible agencies based on various itineraries vis-à-vis the nefarious effects of hetero-cis-normative expectations. The article’s potential contributions to the discussions on access to health for trans men may lie in the attempt to identify how these itineraries need to be analyzed for their ambivalences. As Daniela Vega said in her powerful words quoted at the beginning of this article, until public policies and laws are passed and enforced and cultural changes occur that make their bodies inhabitable and their lives important, the clock is ticking for trans persons. And their experiences continue to materialize in lives that resist waiting in undeniably creative ways, but which certainly feel the weight of it.

Acknowledgments

I wish to thank the CNPq for a research scholarship providing funds for the study in Brazil and Capes for a post-doctoral scholarship, with supervision by Mario Pecheny, to whom I owe my deepest gratitude.

References

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