Abstract

Transsexuality is an identity experience that emerges as an inevitable response to a way of organizing social life and, consequently, health care based on the production of subjects. We aim to understand how a certain trans identity context mobilizes identity performances, in articulation with family and health service. We performed an ethnography with a semi-structured interview and participant observation in a health service specialized in trans-specific care in the Brazilian National Health System (SUS), between December 2017 and July 2018. The story of Marilda was highlighted for being emblematic when narrating the transition from “homosexual man” to “transvestite” and, currently, to “trans woman,” in an identity performance that aims for family recognition and belonging, access to health, education, and a profession other than prostitution. Her story allows us to understand that trans people construct different meanings for their identity experiences, with elements that can reiterate binarism and heteronormativity. It is important to recognize, within the family and health context, that different identity performances are possible and that their senses may compose the integral health care of each trans person.

Keywords:
Public Health; Transgender People; Transvestility; Family; Comprehensive Health Care

Introduction

From the 20th century on, the feminist movement has highlighted the importance of social, historical, and cultural aspects in the construction of what we understand as the identity categories of “man” and “woman.” Gender and performativity perspective has explained that these identity categories are constructed as a repetition of actions inside a highly regulated set of “possibilities,” in which they create an illusion of an internal, organizing nucleus, an essence, an immutable identity, stable, fixed, and unquestionable (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.).

However, based on each individual’s capacity of acting, the subjects’ agency, the focus on experiences in the field of personal and interpersonal relationships, and the possibilities of performance, there is an incompleteness in the construction of these identity categories. This has given way to a rupture, a subversion, an inscription of new meanings, and a change in practices and concepts (Brah, 2006BRAH, A. Diferença, diversidade, diferenciação. Cadernos Pagu, Campinas, v. 26, p. 329-376, 2006.; Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.; Scott, 1998SCOTT, J. A. Invisibilidade da experiência. Projeto História, São Paulo, n. 16, p. 297-325, 1998.). From this perspective, the subjects’ identities can be considered relational, multiple, fragmented, and/or dislocated, in the sense that there is not something fixed and permanent, but something in constant construction, reconstruction, and/or deconstruction (Brah, 2006BORBA, R. Receita para se tornar um “transexual verdadeiro”: discurso, interação e (des)identificação no processo transexualizador. Trabalhos em Linguística Aplicada, Campinas, v. 55, n. 1, p. 33-75, 2016.; Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.).

In this context, transsexuality is constituted as an identity experience that emerges as an inevitable response to a way of organizing social life based on the production of subjects and which situates the truth of identities in body structures (Teixeira, 2016TEIXEIRA, F. B. (Re)encontrando Berenice Bento: uma década de afetações. Cadernos Pagu , Campinas, v. 48, e164818, 2016.). Therefore, thinking about trans identity from the very experience of the subjects allows us to think about the limits of the norms related to what we understand as “man” and “woman,” especially in the locus where these constructions begin, that is, in the family.

Trans people and their family can undergo challenges during the experience of a gender transition in the midst of heteronormative and cisgenderness. This happens because identity constructions and performances also interfere in the family context, in the midst of the expectation that its members express performances that correspond to social constructs expected of the biological gender, be it male or female (Dierckx et al., 2016DIERCKX, M. et al. Families in transition: a literature review. International Review of Psychiatry, Abingdon, v. 28, n. 1, p. 36-43, 2016.).

Besides these problems within the family context, there are several other problematic situations faced by trans people in the social context, such as access to health care, school, emotional, and professional prejudice, which contributes negatively in these people’s process of illness, health, and care (Carvalho, 2006CARVALHO, E. C. “Eu quero viver de dia”: uma análise da inserção das transgêneros no mercado de trabalho. In: SEMINÁRIO INTERNACIONAL FAZENDO GÊNERO, 7., 2006, Florianópolis. Anais eletrônicos… Florianópolis: UFSC, 2006. p. 1-8. Disponível em: <Disponível em: https://bit.ly/3kYwdWW >. Acesso em: 15 jun. 2020.
https://bit.ly/3kYwdWW... ). In this context, we can see how the care within social relations, and especially family relations, can positive or negatively impact people during the aforementioned process, particularly trans people.

When we talk about care, humanization or integrality, one almost always references a set of principles and strategies that guide, or should guide, the relationship between an individual and the health care professional that sees them (Ayres, 2004AYRES, J. R. C. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde e Sociedade, São Paulo, v. 13, n. 3, p. 16-29, 2004.). Thus, we reiterate the proposition of a care re-orientated to emancipatory practices, breaking unilateral relationships where only the health care professional determines the care and, consequently, promoting more horizontal relationships (Contatore; Malfitano; Barros, 2017CONTATORE, O. A.; MALFITANO, A. P. S.; BARROS, N. F. Os cuidados em saúde: ontologia, hermenêutica e teleologia. Interface: Comunicação, Saúde e Educação, Botucatu, v. 21, n. 62, p. 553-563, 2017.).

Transsexual people’s access to health care is often marked by discrimination and disrespect, and there is a constant need to educate health care professionals to understand transsexual people’s specificities in the context of the social determination process (Monteiro; Brigeiro, 2019MONTEIRO, S.; BRIGEIRO, M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cadernos de Saúde Pública, Rio de Janeiro, v. 35, n. 4, e00111318, 2019.). Also, indexed literature on the subject has pointed to the importance of health care approaches for trans people that consider the relationship with their family (Dierckx et al., 2016DIERCKX, M. et al. Families in transition: a literature review. International Review of Psychiatry, Abingdon, v. 28, n. 1, p. 36-43, 2016.). The challenge, then, becomes understanding how to promote this care for transsexual people, with special attention to family issues and trans performativity issues present in their existences.

When searching for answers to face the problem of expressing trans performativity in the family and its relation to health care, we see in the National Policy of Integral Health for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals (Brasil, 2013aBRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013a.) that the word “family” is only mentioned twice. In one of them, it refers to homoparental families and, in the other, to the challenges of gay people in expressing their sexual orientation in a family context. At the same time, this public policy also talks about social and cultural determination of health without, however, going into identity expressions and its meaning in health care and family relationship for trans people (Brasil, 2013aBRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013a.).

Not only that, since 2008, the transsexualizing process aims to ensure the right of trans people to sexual reassignment surgery at the Brazilian National Health System (SUS) and also expresses a series of actions needed so that the right to health is fulfilled in the context of their gender transition experiences. Currently, health attention of the trans population in Brazil is regulated by Decree No. 2083, from November 19^th, 2013, which redefines and broadens the transsexualizing process at SUS, being the main norm of health care for trans people in the system today (Brasil, 2013aBRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013a., ^2013bBRASIL. Portaria nº 2.803, de 19 de novembro de 2013. Redefine e amplia o Processo Transexualizador no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 19 nov. 2013b. Disponível em: <Disponível em: https://bit.ly/3erPUUn >. Acesso em: 15 jun. 2020.
https://bit.ly/3erPUUn... ). When we search for the word “family” in the decree there are also no results; we also did not identify a relation between family, performativity, and health care (Brasil, 2013bBRASIL. Portaria nº 2.803, de 19 de novembro de 2013. Redefine e amplia o Processo Transexualizador no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 19 nov. 2013b. Disponível em: <Disponível em: https://bit.ly/3erPUUn >. Acesso em: 15 jun. 2020.
https://bit.ly/3erPUUn... ).

In this sense, when talking about these topics concerning family, performativity and health care for trans people, it is important to highlight how they are materialized in the interaction between the individual and the collective. Nevertheless, we observe that national public policies related to trans population disregard the inter-relationship between performativity, family, and health. Thus, our objective is to analyze how a certain trans identity context mobilizes ways of constructing and expressing identity, considering the inter-relationship between performativity, family, and health.

Method

This is an ethnographic research (Denzin; Lincoln, 2018DENZIN, N. K.; LINCOLN, Y. S. (Ed.). The SAGE handbook of qualitative research. 5. ed. Thousand Oaks: Sage Publications, 2018.) that used participant observation and semi-structured interview as resources to address a multifaceted reality and thus explore and understand the complexity of senses and meanings related to it. The field activities were carried out between December 2017 and July 2018 in a SUS health service and dedicated to the integral health care for transsexuals, which patients go to with their own demands or are referred to from Basic Health Units (BHU), offering elements of care in the areas of medicine, psychology, nursing, and social service, and, whenever necessary, referring the users to other health services or counter-referring them to Primary Care.

For this article, we have built the analysis from Marilda’s history¹1It is a fictitious name, in order to safeguard the interviewee’s identity., because it translates the symbolic effectiveness of several elements articulated around the perspective of analysis adopted here. Thus, this story brings important reflections about identity performances, in a health service, for transsexual people, their families, and health care professionals. The interview was semi-structured with seven main topics: (1) social identification; (2) conceptions of family, health, and transsexuality; (3) memories related to trans performativity; (4) memories related to family and trans performativity; (5) family and health care; (6) future perspectives; (7) feedback regarding the interview and possibility of approaching some aspect related to the previous topics and not explored during the interview. In addition, participant observation was conducted to broaden the understanding of trans identity performance in relation to health care, taking into account interactions with the family and the health service itself. The field diary was used as an instrument to register the impressions collected throughout the observations.

Thus, initially, we will present our (non-)meeting²2We call Marilda’s meeting with the health service as a “(non-) meeting” due to her dissatisfaction in not finding an answer to her demand there, that she considers as her “safe haven.” We reflected on the challenge of apprehending trans performativities in the context of health care, which could promote a mismatch between SUS professionals and users. with Marilda to then problematize the reflections triggered by this story in dialogue with field research and literature. It is important to emphasize that in this article we do not intend to analyze Marilda’s choices, her intentions, her subjective meaning or why certain decisions were made in her life. Our goal is to understand how this trans identity context mobilizes, in the articulation with the family and the health service, other ways of building and expressing her identity and how this can enhance integral health care, training in trans people’s health care, and the development of public policies that take these aspects into account in their composition.

This research was approved by the Ethics Committee on Research with Human Beings of the Faculdade de Medicina of the Universidade de São Paulo.

Results and discussion

The (non)meeting with Marilda

In assertive sentences in a loud tone of voice, Marilda makes statements like the one above and the newly arrived doctor tries to justify her referral to another specialist. Marilda then enters the care room with the coordinator. Marilda had been interviewed the week before by our research and shared a story of a painful break with her family when she expressed her transvestite identity. She also told us about her regrets for not taking it seriously when her mother went to that service eight years ago.

Crying, she told us that for days she had been suffering from swelling in her body and difficulty breathing, and had not been able to solve her problem in that health service. Amidst her dismay, she asked us: “If I can’t count on you people, who are my safe haven, who will take care of me?” Minutes later, the coordinator returned to the room, bringing an answer regarding the referral. Marilda nodded slightly, while saying goodbye in silence.

In this sense, some questions must be raised: “Did the health service and its professionals comprehend the identity performances that mobilized Marilda’s search for the health service?”; “Was it possible to understand in this (non)meeting that Marilda sought to perform an identity that would guarantee her care-which in the past was sought by her family in that same service, and refused by her as a transvestite-and which seemed to her to be denied when they referred her to another professional?” “What can we learn about the relationship between performativity, family, and health care for trans people in the training of these professionals?”; “How could the debate on these issues improve public policies for trans people in SUS?”

Trans performativity

Marilda told us her trajectory toward expressing a trans identity:

Marilda’s speech allows us to problematize the expression of the “male” identity, expected by her family, exemplifying the highly rigid regulatory framework related to gender identity performances (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.). Being a “man with balls” and “giving them a bunch of grandchildren and nephews” represents the expectations around the figure of the “masculine,” the “man,” characterized by his genitalia and his reproductive function built in the relationship with the family. Disregarding social, historical, and cultural aspects, the gender of individuals ends up being reiterated by this “nature,” reinforcing binarism and a presumed, compulsory heterosexuality (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.).

Even in the face of this apparently immutable, stable, fixed, unquestionable identity projected on Marilda around the expectation of the “heterosexual man,” Marilda begins to find gaps and resistance in the face of powers and knowledge about bodies and sexualities that her family expresses (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.). Identity is a place that assumes itself as an articulation of positions and contexts in a given culture, thus having a political and relational character within power relations (Das, 2016DAS, V. Gênero e identidade: mapeando as questões. In: SALLUM JÚNIOR, B. et al. (Org.). Identidades. São Paulo: Edusp, 2016. p. 67-79.).

As in other reports about trans identity (Das, 2016DAS, V. Gênero e identidade: mapeando as questões. In: SALLUM JÚNIOR, B. et al. (Org.). Identidades. São Paulo: Edusp, 2016. p. 67-79.), Marilda initially affirms herself as a homosexual man and later starts to claim the expression of a feminine identity, which, linked to prostitution, marks for her the transvestite identity. Her speech takes up an aspect highlighted by other authors in the research on transvestites in Brazil that still permeates this field of study, according to which prostitution is a recurring story for the construction of what can be understood as having a “transvestite” identity (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013.; Benedetti, 2005BENEDETTI, M. Toda feita: o corpo e o gênero das travestis. Rio de Janeiro: Garamond, 2005.).

In this practice of “naming” and “being named,” of representing, of producing meaning through language from the performances available to each subject, both Marilda’s family and Marilda herself are performing, creating and embodying subjects, identities, and categories that are configured sometimes as a locus of abandonment and suffering, and sometimes as protection (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013.; Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.). One of the features of this process of naming “yourself” and “other,” present in Marilda’s history, is the attribution of characteristics that differentiate people based on presumed and not explicit norms (Scott, 1998SCOTT, J. A. Invisibilidade da experiência. Projeto História, São Paulo, n. 16, p. 297-325, 1998.), which can even operate as a process of stigmatization, of marking difference related to a “negative” aspect, to an “inferiority status” (Goffman, 2015GOFFMAN, E. Estigma. São Paulo: LTC, 2015.).

Trans performativity and family

From this, we can identify the precarious position of trans people in the community, which becomes worse when coupled with family rejection (Veldorale-Griffin; Darling, 2016VELDORALE-GRIFFIN, A.; DARLING, C. A. Adaptation to parental gender transition: stress and resilience among transgender parents. Archives of Sexual Behavior, Berlin, v. 45, n. 3, p. 607-617, 2016.), like Marilda says:

In the face of this speech of pain and rupture, we observe that heteronormative values also interfere in the family’s context. It is common to find reports of a break with the “blood family” or of expulsion from home at the beginning of the process of “transition” to a transvestite identity (Sander; Oliveira, 2016SANDER, V.; OLIVEIRA, L. H. “Tias” e “novinhas”: envelhecimento e relações intergeracionais nas experiências de travestis trabalhadoras sexuais em Belo Horizonte. Sociedade e Cultura, Goiânia, v. 19, n. 2, p. 69-81, 2016.), as exemplified in Marilda’s speech. The break with the family seems to persist after the expression of a transvestite identity:

As observed, Marilda describes her family, currently, as “just me and my mother, the rest are aggregates.” Family can initially be understood as a crucial concept of analysis because it defines the initial and basic structure of the inter-relationship between individuals and their space and social environment (Pareja et al., 2016PAREJA, J. M. D. et al. A produção do espaço e sua relação no processo de saúde-doença familiar. Saúde e Sociedade, São Paulo, v. 25, n. 1, p. 133-144, 2016.). In addition, it is important to consider kinship as an element of analysis in (re)combinations, (dis)connections and (un)continuities in family relationships. According to Strathern (2015STRATHERN, M. Parentesco, direito e o inesperado: parentes são sempre uma surpresa. São Paulo: Unesp, 2015.), the term “kinship” in Western (Euro-American) society refers to people connected without an assumption of what social group or type of family is formed, and may have specific connections (genealogies) and degrees of intimacy (degrees of connectivity).

From the notion of relatedness (Carsten, 2000CARSTEN, J. Cultures of relatedness: new appoaches to the study of kinship. Cambridge: Cambridge University Press, 2000.), it is important to consider how the process by which both the bonds established by blood relations and those forged from other social contexts, which may constitute a certain “family” chosen by the individual themselves, articulate and transform each other, allowing an identity project to be built, promoted, recognized, and accepted. In the case of transvestites, specifically, one must take into consideration the “street family”, which can be constituted from the intergenerational relations between transvestites (Sander; Oliveira, 2016SANDER, V.; OLIVEIRA, L. H. “Tias” e “novinhas”: envelhecimento e relações intergeracionais nas experiências de travestis trabalhadoras sexuais em Belo Horizonte. Sociedade e Cultura, Goiânia, v. 19, n. 2, p. 69-81, 2016.).

Regarding the acceptance of transvestites and transsexuals by people from their families, it should be considered that it can occur from processes that circumscribe forms of relatedness (Carsten, 2000CARSTEN, J. Cultures of relatedness: new appoaches to the study of kinship. Cambridge: Cambridge University Press, 2000.) and not simply as a matter of “accepting or not accepting” (Oliveira, 2013OLIVEIRA, L. Os sentidos da aceitação: família e orientação sexual no Brasil contemporâneo. 2013. Tese (Doutorado em Antropologia Social) - Universidade Federal do Rio de Janeiro, Rio de Janeiro, 2013.). In this way, the dynamics of family relationships of trans people seems to be complex, composed of nuances that express the search for belonging and recognition in a certain family, blood-related or not.

Trans performativity, family, and health care

In relation to Marilda, the care of the blood family at times of illness seems to have been crucial as one of the procedural elements, which exemplifies the issue of relationality, of a recognition and belonging in her family nucleus, and perhaps for this reason, being cared by the health service can mean for her a certain belonging and family recognition:

Marilda shares her family’s search, in the past, for her care, rescuing a notion that care implies some kind of responsibility, commitment to the other, and even showing an emotional involvement and an expenditure of energy to accomplish it (Tronto, 1997TRONTO, J. C. Mulheres e cuidados: O que as feministas podem aprender sobre a moralidade a partir disso? In: JAGGAR, A. M.; BORDO, S. R. (Org.). Gênero, corpo, conhecimento. Rio de Janeiro: Record: Rosa dos Tempos, 1997. p. 186-203.). Perhaps it was this care that seemed to be denied when the newly arrived doctor requested referral to the health service.

To understand the care of which Marilda speaks in her relationship with her family, the health service, and her identity expression, we establish a dialogue with Ayres (2004AYRES, J. R. C. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde e Sociedade, São Paulo, v. 13, n. 3, p. 16-29, 2004.) by pointing out that not only the normative horizons that guide the concepts of health and illness are socially constructed, but the obstacles to a life project that these horizons allow us to identify are also the fruit of life in common, and only collectively can we effectively build responses to overcome them. Added to that, the health perspective can be understood from the experiences of integrality of the person who produces (re)actions that mobilize meaning, bringing out complex and distinct meanings and actions, therefore not understood as a fixed concept (Duarte, 2003DUARTE, L. F. D. Indivíduo e pessoa na experiência da saúde e da doença. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 1, p. 173-183, 2003.).

In Marilda’s speech, we can see that for recognition and belonging in her family nucleus, there is a concept of “repair,” of “the right track” in her identity performance, in her life project, which triggers health care to materialize itself:

The perspective of health care for transgender people is often based on and reiterated through the understanding of the “pathology” present in bodies and identities because these bodies do not fit into the heteronormative cisgender assumptions, which demand a linearity without cracks between genital sex, gender, desire, and sexual practices. Thus, behaviors that are not in accordance with these norms are often pathologized (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.). It is possible to identify the pathologizing of trans identities in Marilda’s speech, which evidences the search to put things “back on track.” This, as it appears, links the expression of a transvestite performance to a non-linearity that pathologizes these bodies and identities. At the same time, the expression of a female binary performance seems to lead to possible family belonging and, consequently, to health care because it precisely fits in with the expected norms, even in trans bodies that seem to try and transgress them.

Marilda expresses an idea connected to the social reading that the transvestite can only be a sex professional; thus, she wants to deny this fate and reads the social world with the understanding that she has to shape her desire. There is, then, a binary construction between a more feminine and a less feminine pole, defined, for example, by the physical appearance, the desire for surgery, the “use” of the penis in sexual relations, among others thigs that say the “apex of femininity” would be the “heterosexual woman” (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013., p. 366).

In this sense, it is pertinent to address the issue of passing cisgender, i.e., in the face of the violence and strangeness experienced by a transgender person, “passing as a cisgender person” becomes a relevant goal for many transsexual people (Vergueiro, 2015VERGUEIRO, V. Por inflexões decoloniais de corpos e identidades de gênero inconformes: uma análise autoetnográfica da cisgeneridade como normatividade. 2015. Dissertação (Mestrado em Cultura e Sociedade) - Universidade Federal da Bahia, Salvador, 2015.). In this light, the expression of an identity closer to what is expected of “a real man or woman” inhabits a tenuous line between respect and absolute disregard for trans lives, not being a mere reproduction of the norms in force, but can be understood as a way to resist and, perhaps, one of the only possibilities to survive a violent social environment (Vergueiro, 2015VERGUEIRO, V. Por inflexões decoloniais de corpos e identidades de gênero inconformes: uma análise autoetnográfica da cisgeneridade como normatividade. 2015. Dissertação (Mestrado em Cultura e Sociedade) - Universidade Federal da Bahia, Salvador, 2015.). Therefore, to think of trans bodies and identities as fixed, simply going from a direct male/female pole to a direct female/male pole, is not to admit the interfaces present among the most diverse ways of existing and expressing oneself in relation to gender (Teixeira, 2016TEIXEIRA, F. B. (Re)encontrando Berenice Bento: uma década de afetações. Cadernos Pagu , Campinas, v. 48, e164818, 2016.).

We highlight the use of the term “transvestility” as a strategy to broaden the aspects of identity categorization in relation to the term transvestite, since there are countless possibilities of experiencing this identity (Vergueiro, 2015VERGUEIRO, V. Por inflexões decoloniais de corpos e identidades de gênero inconformes: uma análise autoetnográfica da cisgeneridade como normatividade. 2015. Dissertação (Mestrado em Cultura e Sociedade) - Universidade Federal da Bahia, Salvador, 2015.). It is relevant to ponder there are, in the scientific and social discourses, disputes, landslides, reconfigurations, and a political clash between the categories of “transvestite” and “transsexual” identities (Leite Junior, 2011LEITE JUNIOR, J. Nossos corpos também mudam: a invenção das categorias “travesti” e “transexual” no discurso científico. São Paulo: Annablume, 2011.), and the subjects assume different identity positions to be located within the various contexts, social, cultural, political, and economic systems, among others, in which we are inserted (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013.; Leite Junior, 2011LEITE JUNIOR, J. Nossos corpos também mudam: a invenção das categorias “travesti” e “transexual” no discurso científico. São Paulo: Annablume, 2011.).

The issue then becomes performing an identity that allows the feeling of recognition and belonging; thus, denying a certain identity performance should not be understood as an acritical reproduction of binarism and heteronormativity, but as a possible way to survive in an adverse social environment (Vergueiro, 2015VERGUEIRO, V. Por inflexões decoloniais de corpos e identidades de gênero inconformes: uma análise autoetnográfica da cisgeneridade como normatividade. 2015. Dissertação (Mestrado em Cultura e Sociedade) - Universidade Federal da Bahia, Salvador, 2015.). Therefore, family and social rejection are important aspects, since they cause suffering to trans people and makes them, in some situations, seek to live according to the social norms expected for their genitals at birth, i.e., to protect themselves from situations of violence and discrimination, even if this condition causes them suffering, discomfort, and helplessness (Sampaio; Coelho, 2012SAMPAIO, L. L. P.; COELHO, M. T. A. D. Transexualidade: aspectos psicológicos e novas demandas ao setor saúde. Interface:- Comunicação, Saúde e Educação, Botucatu, v. 16, n. 42, p. 637-649, 2012.).

In addition, we can identify that transgender women have had better access to the transsexualizing process than transvestites, who are often associated, in a hostile way, with marginalization, crime, and prostitution (Rocon et al., 2020ROCON, P. C. et al. Vidas após a cirurgia de redesignação sexual: sentidos produzidos para gênero e transexualidade. Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, n. 6, p. 2347-2356, 2020.). Being able to perform a “true trans woman” through the reproduction of gender norms linked to the female gender means to disengage from “transvestility” and thus have better approval for the transsexualizing process (Bento, 2008BENTO, B. O que é transexualidade. São Paulo: Brasiliense, 2008.; Rocon et al., 2020).

The notion of family rescue for Marilda pervades the expression of a transgender woman’s performance, to the detriment of the transvestite performance, which culminated in the break-up of family relations; in turn, the identity performance she seeks legitimizes her as a health service user and, consequently, as having the right to the transsexualizing process in SUS. From this perspective, identity, family, and health care are shown as extremely interrelated domains in the trans experience. Marilda’s desire to rescue her family is expressed through the performance of a transgender woman, in an attempt to overcome disappointment and abandonment, and, in this way, leave the margin and exist in the least violent and abject way possible.

Thus, her search for family and health care is structured from a binary conception. This can express the strength of the regulation in our society in relation to the existential possibilities of family, identity, and health care, capable of conferring a certain degree of legitimacy, as well as the sensation of a supposed security. Marilda’s interview and participant observation exemplify the negotiations with these norms and moral ideals, which were demonstrated by “passing,” that is, seeking to adapt to hegemonic expectations.

Marilda’s story contributions for the health of trans population

In Marilda’s speech, we can see a set of ritualized practices of “purification,” which evidences classifying practices that permeate a certain social, historical, and cultural context in which certain practices of control, vigilance, and punishment over bodies are reiterated in order to guarantee what, in this context, is understood as “purity,” guaranteeing the order of things, being on a trail, and the mastery of polluting risks (Douglas, 1966DOUGLAS, M. Pureza e perigo. Lisboa: Edições 70, 1966.). A supposed fixed and exact separation between transsexuality and transvestility is a reflection of a construction that does not admit interfaces between the most diverse forms of existing and expressing in relation to gender (Bento, 2008BENTO, B. O que é transexualidade. São Paulo: Brasiliense, 2008.; Teixeira, 2016TEIXEIRA, F. B. (Re)encontrando Berenice Bento: uma década de afetações. Cadernos Pagu , Campinas, v. 48, e164818, 2016.).

The understanding of transsexuality as an identity experience also confronts that concept used mostly by medicine and the “psi” sciences (psychoanalysis, psychology, and psychiatry), which almost always relate sexuality to biology. Despite enforcing the perspective that the expression of identities and trans-bodies are incorrect as to the genitals amplifies existential possibilities, there is still a reduced space for the agency of subjects within the field of medicine and the “psi” sciences, which explains trans people’s search for the transsexualizing process (Brasil, 2013aBRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013a.). It is about the search for an identity, a recognized and/or authorized existence within the medical and “psi” discourses (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013.).

Also, it is evident that this recognition and/or authorization happens through a process of feedback between professionals and users in the health services, through what is “to be,” “not to be” or “to be beyond of” a trans person in the context of the transsexualizing process (Teixeira, 2016TEIXEIRA, F. B. (Re)encontrando Berenice Bento: uma década de afetações. Cadernos Pagu , Campinas, v. 48, e164818, 2016.). In this self-(re)learning, a series of discursive dynamics and inter-relational practices are (re)produced and/or (de)constructed in the perspective that some bodies “need” to be classified by medical and “psi” sciences in order to have the right for a health care provided by the State. This exemplifies the control and selection of lives that matter or not, exist or not, are possible or not (Butler, 2016BUTLER, J. Problemas de gênero: feminismo e subversão da identidade. 11. ed. Rio de Janeiro: Civilização Brasileira, 2016.; Teixeira, 2016TEIXEIRA, F. B. (Re)encontrando Berenice Bento: uma década de afetações. Cadernos Pagu , Campinas, v. 48, e164818, 2016.).

In this context, trans individuals, while questioning, reiterating, and disorganizing the naturalized category of the human, implicitly or explicitly denounce that gender norms do not establish an absolute consensus in social life, and this challenges the boundaries between individual experience and the need for social recognition (Benedetti, 2005BENEDETTI, M. Toda feita: o corpo e o gênero das travestis. Rio de Janeiro: Garamond, 2005.). Thus, it is possible to observe a variety of meanings about what it is to be/to have a trans identity in practical life, and Marilda’s story makes these negotiations explicit (Barbosa, 2013BARBOSA, B. C. “Doidas e putas”: usos das categorias travesti e transexual. Sexualidad, Salud y Sociedad, v. 14, p. 352-379, 2013.; Leite Junior, 2011LEITE JUNIOR, J. Nossos corpos também mudam: a invenção das categorias “travesti” e “transexual” no discurso científico. São Paulo: Annablume, 2011.).

Thus, the question made by Borba (2016BORBA, R. Receita para se tornar um “transexual verdadeiro”: discurso, interação e (des)identificação no processo transexualizador. Trabalhos em Linguística Aplicada, Campinas, v. 55, n. 1, p. 33-75, 2016., p. 36) about “how does an individual become a legitimate subject (transsexual) for the institutional purposes of Brazilian trans-specific health care?” leads us to reflect that, no matter how different the services (the one reported here and the one studied by him) are, the phenomenon of deconstruction-reconstruction and gender identity discontinuities are common elements. This phenomenon can illustrate how subjects interact, (re)produce, (re)create, (re)fabricate, and/or resist the forms of a fixed, unique, homogeneous, stable, and true identity (Borba, 2016BORBA, R. Receita para se tornar um “transexual verdadeiro”: discurso, interação e (des)identificação no processo transexualizador. Trabalhos em Linguística Aplicada, Campinas, v. 55, n. 1, p. 33-75, 2016., p. 67).

In this scenario of different performances and disputes, health services and professionals present themselves as a possible locus of meetings and disagreements for integral health care (Ayres, 2004AYRES, J. R. C. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde e Sociedade, São Paulo, v. 13, n. 3, p. 16-29, 2004.), therefore, these services and professionals could contribute to the process of (de)constructing identities and expectations of the subject and his/her family. The difference, from this perspective, is more than just a marker of hierarchy and oppression, requiring the questioning of how differences have operated in each context so that, when faced with situations of oppression, strategies can be formulated (Brah, 2006BRAH, A. Diferença, diversidade, diferenciação. Cadernos Pagu, Campinas, v. 26, p. 329-376, 2006.), understanding, then, that “our struggles over meaning are also our struggles over different ways of being: different identities” (Brah, 2006BORBA, R. Receita para se tornar um “transexual verdadeiro”: discurso, interação e (des)identificação no processo transexualizador. Trabalhos em Linguística Aplicada, Campinas, v. 55, n. 1, p. 33-75, 2016., p. 371).

From this trajectory, we understand that it is necessary to enrich the National Integral Health Policy for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals (Brasil, 2013aBRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013a.) with reflections on the different identity performances, their relationship with the transsexualization process, and how this is reflected in the service and integral health care of trans people. We believe that debating identity expression of trans people, in interface with family and health care, is an important way of improving the aforementioned public policy and the integral health care of trans people. Therefore, we need a process of awareness and (de)construction towards the services, health professionals, and health students for the questioning of biologicist “reductionisms” in/of the professional education and work, also understanding that care is a relational practice based on the concepts of difference and interdependence that affects the one who cares and the one who is being cared for and, therefore, is permeated by a series of moral issues such as what it means to “care for” others (Tronto, 1997TRONTO, J. C. Mulheres e cuidados: O que as feministas podem aprender sobre a moralidade a partir disso? In: JAGGAR, A. M.; BORDO, S. R. (Org.). Gênero, corpo, conhecimento. Rio de Janeiro: Record: Rosa dos Tempos, 1997. p. 186-203.).

Conclusions

From our dialogue with Marilda’s story, we can highlight the elements that allow us to correlate identity performativity and family in the context of health care. The notions of parenting and relatedness express themselves in the process of identity (re)construction from established bonds, indicating their relation to family and health care. This process, in the story we analyzed, ends up showing the reiteration and proposition of identity constructions based on hierarchical processes of power and knowledge, which seek to harden identities based on certain stereotypes. This is used, apparently, as resource for survival and existential possibility at a place where one can experience acceptance, recognition, and belonging, like the family and/or the health service.

Marilda’s story shows a specific situation and contingency related to time and space and carries a symbolic power in regards to many trans identity experiences. In this sense, despite a broader debate on the subject and the existence of a specific public policy, we can still identify the permanence of narratives similar to the ones observed during the first studies on trans and transvestite populations in Brazil. In this light, it is important that health services and professionals be aware of recognizing how each user’s identity expression articulates and negotiates with blood relations and belonging to a certain family, understanding its relation to trans people’s process of illness, health, and care. This way, they can establish bonds with users and families that allows them to (re)signify relationships and care from the (re)construction of trans identities, geared toward welcoming the individual’s integral perspectives and promoting the performativity of relational, dynamic identities.

Acknowledgments

We thank the professionals of the health service, as well as the trans people and family members who generously participated in and contributed to this study. We thank professor Gustavo Antonio Raimondi for his insightful comments. We thank the Colegio Doctoral Tordesillas de Salud Pública e Historia de la Ciencia for supporting the first author over the time spent studying at the Universidad Miguel Hernández de Elche in Spain, in the course of his doctoral studies. The first author received a scholarship from the Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior (Capes) from Brazil, in the Programa de Doutorado Sanduíche no Exterior, process number 88881.187710/2018-01.

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