Abstract

The well-being of trans women has been affected by stigma and discrimination, and great gaps in health, employment and educational opportunities and the absence of social support. The role of health professionals plays an important role in the well-being and health of trans women, therefore, the objective is to recognize the meaning that health professionals have on the well-being of trans women. Method: Qualitative research, narrative design. Eight health professionals (medicine, psychology, and nursing assistant) with experience in community care participated in an in-depth interview. In conclusion, the health professionals recognize that the well-being of trans women is affected by multiple sociocultural and economic factors related to mental health, discrimination to which they are still exposed, internalized transphobia, and the lack of family and social support. Concrete actions are required from health, higher education, and governmental entities capable of favoring affirmative processes for trans women and promoting in healthcare processes the sensitivity and commitment to their human development based on the protection of their rights.

Keywords:
Transgender; Gender Nonconforming; Wellness; Health Personnel; Healthcare Professionals

Introduction

Throughout history, well-being has been subject of different disciplines and fields of knowledge, leading to a great variety of definitions and ways of approaching it. This concept is directly related to other fields of knowledge and interest such as health and happiness, and it is even used indistinctly between well-being, happiness, and quality of life. The two most frequent and widely used positions on well-being in the psychological literature are psychological well-being (Aristotle’s eudaimonia view) and subjective well-being (hedonic perspective). Thus, this article addresses well-being in a gendered key, specifically the well-being of trans women from the perspective of health professionals with work experience with the community.

Well-being is commonly recognized as the absence of any situation or thought that may generate some kind of discomfort (Tov, 2018TOV, W. Well-being concepts and components.In: DIENER, E.; OISHI, S.; TAY, L. (Ed.), Handbook of well-being. Salt Lake City:DEF Publishers, 2018. p. 43-57.) while, for other authors such as Keyes (2005KEYES, C. L. M. Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology, Washington, DC, v. 73, n. 3, p. 539-548, 2005. DOI: 10.1037/0022-006X.73.3.539
https://doi.org/10.1037/0022-006X.73.3.5... ), it is related to the feeling of satisfaction. For example, having physical and mental health is one of the definitions assigned to well-being.

Psychological well-being, also known as eudaimonic well-being, is related to full satisfaction through six qualities: autonomy, self-acceptance, positive relationships, mastery of the environment, purpose in life, and personal growth (Ryff, 1989RYFF, C. D. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, Washington, DC, v. 57, n. 6, p. 1069-1081, 1989. DOI: 10.1037/0022-3514.57.6.1069
https://doi.org/10.1037/0022-3514.57.6.1... ). Well-being is thus achieved when the person sets goals that are in accordance with his or her qualities and vision of life, enabling the development of their own potential (Bahamón et al., 2019BAHAMÓN, M. J. et al. Bienestar psicológico en adolescentes colombianos. Archivos Venezolanos de Farmacología y Terapéutica, [s.l.], v. 38, n. 5, p. 519-523, 2019.).

Subjective well-being, in turn, refers to the perception a person has of their own well-being. This perception is permeated by the existence of positive and negative effects and personal satisfaction (Bahamón et al., 2019BAHAMÓN, M. J. et al. Bienestar psicológico en adolescentes colombianos. Archivos Venezolanos de Farmacología y Terapéutica, [s.l.], v. 38, n. 5, p. 519-523, 2019.) and has two components: affective and cognitive. The first one refers to pleasant and unpleasant emotions or feelings; therefore, a person with high affective well-being is expected to experience more pleasant than unpleasant emotions. On the other hand, the cognitive component is the valuation of achievements or goals that the person is fulfilling in life, based on the expectations they have to fulfill (Tov, 2018TOV, W. Well-being concepts and components.In: DIENER, E.; OISHI, S.; TAY, L. (Ed.), Handbook of well-being. Salt Lake City:DEF Publishers, 2018. p. 43-57.).

It worth highlighting that when facing a negative event or occurrence, the affective component is directly affected. A change in the perception of cognitive well-being could also be generated, since this emotional information could indicate the way in which the person’s life is being developed. In the same way, when meeting the proposed goals (cognitive well-being), positive emotions are produced (affective well-being); therefore, both components are not exclusive of each other (Tov, 2018TOV, W. Well-being concepts and components.In: DIENER, E.; OISHI, S.; TAY, L. (Ed.), Handbook of well-being. Salt Lake City:DEF Publishers, 2018. p. 43-57.).

Johnson and Rogers (2019JOHNSON, A. H.; ROGERS, B. A. “We’re the Normal Ones Here”: Community Involvement, Peer Support, and Transgender Mental Health. Sociological Inquiry, Los Angeles, v. 90, n. 2, p. 271-292, 2019. DOI: 10.1111/soin.12347
https://doi.org/10.1111/soin.12347... ) found that normalizing the experiences of the trans community of friends or peers enables a change in the trans person’s perception of their psychological well-being, empowering them with the social support received. Being part of a community, feeling accepted or included in it, and having a good socioeconomic level decrease the levels of depression and anxiety, and increase the perception of self-esteem and quality of life. The above is in line with other studies in the United States and Brazil, which found that trans people with higher income, a job, older age, and, therefore, with stronger sense of belonging have higher well-being (Barr; Budge; Adelson, 2016BARR, S. M.; BUDGE, S. L.; ADELSON, J. L. Transgender community belongingness as a mediator between strength of transgender identity and well-being. Journal of Counseling Psychology, Washington, DC, v. 63, n. 1, p. 87-97, 2016. DOI: 10.1037/cou0000127
https://doi.org/10.1037/cou0000127... ).

Other studies addressing well-being from the concept of quality of life have found that in trans people quality of life is significantly lower, mainly in social functioning, emotional role, vitality, and mental health (Lindqvist et al., 2017LINDQVIST, E. K. et al. Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery, v. 40, n. 3, p. 223-226, 2017. DOI: 10.1007/s00238-016-1252-0
https://doi.org/10.1007/s00238-016-1252-... ). When quality of life of trans women and trans men was compared, it was found to be lower in trans women (Valashany; Janghorbani, 2018VALASHANY, B. T.; JANGHORBANI, M. Quality of life of men and women with gender identity disorder. Health and Quality of Life Outcomes, Berlin, v. 16, n. 167, 2018. DOI: 10.1186/s12955-018-0995-7
https://doi.org/10.1186/s12955-018-0995-... ). In contrast, quality of life has been found to be positively affected by the outcomes of gender-affirming, breast augmentation, liposuction, and other surgeries (Bockting et al., 2016BOCKTING, W. et al. Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology, Diabetes, and Obesity, London, v. 23, n. 2, p. 188-197, 2016. DOI: 10.1097/MED.0000000000000232
https://doi.org/10.1097/MED.000000000000... ; Papadopulos et al., 2017PAPADOPULOS, N. A. et al. Quality of life and patient satisfaction following male-to-female sex reassignment surgery. The Journal of Sexual Medicine, Oxford, v. 14, n. 5, p. 721-730, 2017. DOI: 10.1016/j.jsxm.2017.01.022
https://doi.org/10.1016/j.jsxm.2017.01.0... ).

By increasing what is known as gender congruence through sex matching, trans people have been reported to have increased social interactions, improved well-being, and greater acceptance of their identity. In turn, the risk of suffering violence by others and feeling anxiety, depression and suicidal risk is decreased (Watt; Tskhay; Rule, 2018WATT, S. O.; TSKHAY, K. O.; RULE, N. O. Masculine voices predict well-being in female-to-male transgender individuals. Archives of Sexual Behavior, Berlin, v. 47, n. 4, p. 963-972, 2018. DOI: 10.1007/s10508-017-1095-1
https://doi.org/10.1007/s10508-017-1095-... ). Similarly, it is mentioned that even if the trans person faces violence or discrimination, the possibility of having the desired body changes and respect for their social name increases the positive evaluation of their lives.

After gender affirmation surgery, an increase in quality of life has been found in comparison to the levels presented before undergoing surgery. Hormone intake was associated with higher levels of quality of life in both trans men and women (Breidenstein et al., 2019BREIDENSTEIN, A. et al. Psychosocial resources and quality of life in Transgender Women following gender-affirming surgery. The Journal of Sexual Medicine, v. 16, n. 10, p. 1672-1680, 2019. DOI: 10.1016/j.jsxm.2019.08.007
https://doi.org/10.1016/j.jsxm.2019.08.0... ; Lindqvist et al., 2017LINDQVIST, E. K. et al. Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery, v. 40, n. 3, p. 223-226, 2017. DOI: 10.1007/s00238-016-1252-0
https://doi.org/10.1007/s00238-016-1252-... ). It was also found that after surgery they may continue with symptoms of stress, personal or physical limitations. These symptoms, however, are decreased, as it does not vary significantly from the population considered as typically healthy (Papadopulos et al., 2017PAPADOPULOS, N. A. et al. Quality of life and patient satisfaction following male-to-female sex reassignment surgery. The Journal of Sexual Medicine, Oxford, v. 14, n. 5, p. 721-730, 2017. DOI: 10.1016/j.jsxm.2017.01.022
https://doi.org/10.1016/j.jsxm.2017.01.0... ).

Discrimination and violence are other factors that negatively influence mental health and well-being. These expressions of hatred toward trans people occur worldwide, given the heteronormative and cisgender vision assumed as “normal” and correct in society (Bockting et al., 2016BOCKTING, W. et al. Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology, Diabetes, and Obesity, London, v. 23, n. 2, p. 188-197, 2016. DOI: 10.1097/MED.0000000000000232
https://doi.org/10.1097/MED.000000000000... ), historically consolidated from hegemonic models associated with gender and impacting on the violation of their rights. Some studies have reported that professionals have discriminatory attitudes related to pathological looks on these gender identities and little training on these topics (Antoniucci, 2017ANTONIUCCI, M. El acceso a la salud de las personas trans: el caso del CADS de la ciudad de Mar del Plata. 2017. 108 f. Tesis (Licenciatura en Sociología) - Universidad Nacional de Mar del Plata, Mar del Plata, 2017.; Aylagas-Crespillo; García-Barbero; Rodríguez-Martín, 2017AYLAGAS-CRESPILLO, M.; GARCÍA-BARBERO, Ó.; RODRÍGUEZ-MARTÍN, B. Barriers in the social and healthcare assistance for transgender persons: A systematic review of qualitative studies. Enfermería Clínica (English Edition), Hueva, v. 28, n. 4, p. 247-259, 2017. DOI: 10.1016/j.enfcli.2017.09.004
https://doi.org/10.1016/j.enfcli.2017.09... ; Hoyos-Hernández et al.,, 2021HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021.; Padilla et al., 2016PADILLA, M. B. et al. Trans-migrations: border-crossing and the politics of body modification among Puerto Rican transgender women. International Journal of Sexual Health: Official Journal of the World Association for Sexual Health, London, v. 28, n. 4, p. 261-277, 2016. DOI: 10.1080/19317611.2016.1223256
https://doi.org/10.1080/19317611.2016.12... ; Profamilia and State of the Kingdom of the Netherlands, 2019PROFAMILIA Y ESTADO DEL REINO DE LOS PAÍSES BAJOS. ¿Cómo adaptar los servicios de salud sexual y reproductiva a las necesidades y circunstancias de las personas con experiencia de vida trans? Recomendaciones para la atención centrada en las personas trans. Bogotá, D.C., 2019. Disponible en: <Disponible en: https://profamilia.org.co/wp-content/uploads/2019/09/Como-adaptar-los-servicios-de-salud-sexual-y-reproductiva-a-las-necesidades-y-circunstancias-de-las-personas-con-experiencia-de-vida-trans.pdf >. Acceso en: 17 ene. 2022.
https://profamilia.org.co/wp-content/upl... ; Ritterbusch; Correa Salazar; Correa, 2018RITTERBUSCH, A. E.; CORREA SALAZAR, C.; CORREA, A. Stigma-related access barriers and violence against trans women in the Colombian healthcare system. Global Public Health, London, v. 13, n. 12, p. 1831-1845, 2018. DOI: 10.1080/17441692.2018.1455887
https://doi.org/10.1080/17441692.2018.14... ; Zapata Pizarro et al., 2019ZAPATA PIZARRO, A. et al. Atención de salud de personas transgéneros para médicos no especialistas en Chile. Revista médica de Chile, Santiago, v. 147, n. 1, p. 65-72, 2019. DOI: 10.4067/S0034-98872019000100065
https://doi.org/10.4067/S0034-9887201900... ).

Well-being is vital to the human development, and sexual rights are vital human rights for the health and for the good living of populations (Ford et al., 2019FORD, J. V. et al. Why Pleasure Matters: Its Global Relevance for Sexual Health, Sexual Rights and Wellbeing. International Journal of Sexual Health, London, v. 31, n. 3, p. 217-230, 2019. DOI: 10.1080/19317611.2019.1654587
https://doi.org/10.1080/19317611.2019.16... ; Gruskin et al., 2019GRUSKIN, S. et al. Sexual health, sexual rights, and sexual pleasure: Meaningfully engaging the perfect tri- angle. Sexual and Reproductive Health Matters, London, v. 27, n. 1, p. 29-40, 2019. DOI: 10.1080/26410397.2019.1593787
https://doi.org/10.1080/26410397.2019.15... ; Starrs et al., 2018STARRS, A. M. et al. Accelerate pro- gress - sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission. The Lancet Commissions, Amsterdam, v. 391, n. 10140, p. 2642-2692, 2018. DOI: 10.1016/S0140-6736(18)30293-9
https://doi.org/10.1016/S0140-6736(18)30... ; WAS, 2014WAS - WORLD ASSOCIATION FOR SEXUAL HEALTH. Declaration of Sexual Rights. Minneapolis, 2014. Disponible en: <Disponible en: https://worldsexualhealth.net/wp-content/uploads/2021/09/declaration_of_sexual_rights_sep03_2014_b.pdf >. Acceso en: 2 enero. 2022.
https://worldsexualhealth.net/wp-content... ).

In the case of trans communities, well-being in integration with sexual rights and sexuality should be urgently addressed by key actors and involved in healthcare processes. That aiming to provide health practices and scenarios capable of guaranteeing autonomy and integrity, freedom of expression, self-determination, being free from hostility, violence or any act of discrimination that have affected them in a systematic and structural way and negatively impacted their comprehensive health and well-being. This study aims at delving into the meaning of well-being in trans women constructed by a group of health professionals based on their occupational trajectories.

This study considers that the recognition of the work experiences of health professionals with extensive experience in working with the trans community allows us to know and understand, from their perspectives, what they consider to be the core paths for the women’s well-being. At the same time, their healthcare experiences with women can be recognized, delimiting some fields of professional action. This would allow strengthening the processes of health and disease, well-being and healthcare.

Method

This is a qualitative research, with narrative design of work life stories dealing with the meaning of well-being in trans women constructed by a group of health professionals, based on their occupational trajectories (Creswell; Poth, 2018CRESWELL, J. W.; POTH, C. N. Qualitative inquiry, and research design: choosing among five approaches. 4 ed. London: SAGE Publications, 2018.; Hernández Sampieri; Fernández Collado; Baptista Lucio., 2014HERNÁNDEZ SAMPIERI, R.; FERNÁNDEZ COLLADO, C.; BAPTISTA LUCIO, M. P. Metodología de la investigación. 6 ed. México, D. F.: McGraw-Hill, 2014.; Moriña, 2017MORIÑA, A. Alcance y usos de las historias de vida. In: MORIÑA, A. Investigar con historias de vida: metodología biográfico-narrativa. Madrid: Narcea, 2017. p. 25-32.).

Participants

This study counted with the voluntary participation of eight health professionals (medical, psychology, and nursing assistant), with experience in transgender community care for three to 10 years. The sampling used was intentional based on the following inclusion criteria: (1) being a professional in health contexts; and (2) having at least one year of experience working on issues related to trans women’s health in Colombia. More information about the participants is detailed below.

Data collection technique

In-depth interviews were conducted with each of the professionals. The semi-structured interview guide that inquired about the meaning of well-being in trans women was drafted by the research team, based on scientific evidence and the team’s research and clinical experience. Interviews were conducted using the Zoom platform, with the prior authorization of the participants and the signing of the Informed Consent Form. Data collection was carried out between October and November 2020, and each session lasted approximately one hour and thirty minutes.

Information analysis

The data were analyzed by means of thematic analysis after the narratives were inserted into the Atlas.ti 8 program and CQR was performed: Consensual Qualitative Research (Santiago et al., 2011SANTIAGO, J. et al. El método de investigación cualitativa consensual (Consensual Qualitative Research, CQR): una herramienta para la investigación cualitativa en psicología clínica. Anuario de Investigaciones, Buenos Aires, n. 18, p. 47-56, 2011.). The following categories and subcategories of analysis emerged a) Definition of well-being; b) Discrimination; c) Support networks; d) Self-perception; e) Risk factors; and, f) Resilience.

Ethical considerations

The ethical aspects of the intervention were oriented according to Law 1090 of September 6, 2006, which regulates the practice of the Psychology profession, and Resolution N° 008430 of 1993 issued by the Ministry of Health. This research was classified as minimal risk according to Resolution No. 8430 of 1993, and was approved by the Ethics Committee.

Results

Based on the interviews conducted with eight healthcare workers on the meaning of well-being in trans women that they have constructed from their professional trajectories in the cities of Cali, Bogotá, Medellín, Cúcuta, and Tuluá, the following emerging categories were configured during data analysis: definition of well-being, discrimination, self-perception, risk factors, resilience, and support networks. Each item is developed below.

Definition of well-being

The participating professionals consider well-being as the absence of discomfort, and the presence of personal satisfaction. It was found that three of the participants agreed that well-being could be achieved through knowing oneself, that is, understanding the way the person feels, empathizing with themselves, understanding the particularities of each story, and understanding what it means for the person to reach the highest degree of satisfaction. Similarities are found in the dialogue of the participants when prioritizing the need to know oneself in order to know what each person considers as satisfaction or happiness. “It would be necessary to evaluate what that person considers or how that person would consider that could be in the highest level of well-being, of satisfaction with the self to evaluate if they feel good or not with that” (Participant 2).

Although well-being would have to do with that personal dimension, one of the professionals insistently highlights the importance of considering their history and the sociocultural, family, economic, contextual aspects:

Discrimination

On the other hand, coincidence was found in four participants when mentioning discrimination against trans people as one of the factors affecting their well-being. Health professionals state that discrimination is generated by trans persons being exposed to a sexist, hetero-cis-normative culture that does not accept identities other than those legitimized and the norms typical to this type of culture. In addition, stereotypes, prejudices, discrimination, and violence, that are generated from these cultures, cause social, cultural, and economic barriers. These barriers, in turn, produce a fear of experiencing the transformation process, given the possible vulnerability of being a trans person in a society such as the Colombian society, of being exposed to possible violence and the probability of losing their status, social and political level. “In our sexist and violent society, being a transgender woman makes her construction of well-being much more difficult” (Participant 5) or as another health worker also mentions “I have patients who cannot make their transition because fear will not let them, they already have a status at a social level, at a political level and making that change would mean losing virtually everything” (Participant 6).

Self-perception

Four of the participants comment that discrimination and the constant attack on the trans community lead to a change in the self-perception of trans persons and in their self-esteem, “sometimes with the physical features the person is completely uncomfortable, completely dissatisfied (…) it is more unsatisfactory” (Participant 4). One of the participants adds another scenario in which trans people may feel uncomfortable about themselves:

Risk factors

Other commonalities found in the participants’ dialogue are the risk factors that trans people are exposed to in their view. As commented throughout the results, trans people are attacked or violated for not complying with the rules of a heteronormative, sexist and cisgender society. These constant aggressions, as mentioned by health professionals, cause:

In turn, it is worth highlighting that there are feelings of anxiety before starting the transformation process, since they do not know what they are going to face when they make the transformation. “What is going to happen to my future? How will I be perceived? Am I going to get equal respect? Am I going to become a highly vulnerable woman? I was hearing that at the consultation a few days ago” (Participant 1).

Similarly, this rejection has impacts at the psychological and physical level, in addition negative effects at the social level, accompanied by a fear of losing everything they have built because of rejection and transphobia. “Their situation is absolutely hard, with low possibility of reaching that welfare because these are very hard cultural, social, and economic barriers to reach and be able to reach” (Participant 5).

Resilience

On the other hand, health professionals commented on resilience as one of the common factors that trans people have to develop in order to be able to “have endurance” or cope with the sexist and violent society and be able to find well-being, as it is through the development of different strategies such as creativity and sensitivity, that trans people find a refuge to face such a complicated procedure as the transformation process in the current culture: “Our sexist and violent culture means that these people do have to develop different strategies (…) to be able to build well-being” (Participant 5).

One of the health professionals have mentioned that pride and community connectivity reduce the impact of stress caused by being constantly exposed to violence. While community-based connectivity is a factor of resilience, some forms of activism are harmful to trans people, being configured in violence and generating strong pressure to sustain gender stereotypes. Gender-affirming surgery is an example of this. Considering the diversity of gender identities, not all trans people consider this surgery as an alternative for them: “it is definitely a universe of expectations unique to each trans woman” (Participant 5); “being a trans woman does not necessarily mean that the person is mandated to have genital reassignment surgery; it varies from person to person” (Participant 1).

Support networks

Participants agree that support networks, mainly family support, are one of the most important factors for trans people’s well-being to occur. The support provided by the family through accompaniment and respect is an extremely important factor for the development of well-being from early childhood, transformation and the rest of life. Protected by support networks, trans people can overcome problems more easily when they are focus of discrimination for not complying with the society’s expectations. “There are other people who have the trans identity and, thanks to having a family that backs them up and supports them, they achieve well-being from early childhood; and they are people who go through life in a very good way” (Participant 5), and another participant mentioned: “Those who have family support, have a normal life, that is, with its ups and downs, but they have a normal life” (Participant 6).

Based on the results presented, it is considered that health workers, based on their professional trajectories in the cities of Cali, Bogotá, Medellín, Cúcuta and Tuluá, recognize that the well-being of trans women is affected by multiple sociocultural, economic, mental health-related factors, the discrimination to which they are still exposed, internalized transphobia, and the lack of family and social support. In face of this, they deploy psychological and social resources, including resilience, to strengthen their health and well-being processes.

Discussion

This study investigated the meaning of well-being in trans women constructed by a group of health professionals based on their occupational trajectories. For this purpose, eight health workers were interviewed. The categories of definition of well-being, discrimination, self-perception, risk factors, resilience, and support networks were established based on the interviews.

The results are in line with other studies in highlighting how hegemonic models of societies are configured in sources that negatively affect the well-being of trans people (Hoyos-Hernández et al., 2021)HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021., and the way they perceive themselves. Specifically, chauvinism and hetero-cis-normativity give rise to different types of violence toward identities or orientations that do not comply with the imposed norms. These affect trans people in their daily lives, e.g., in access to decent work, education, spaces for citizen participation, search for professional support, and in turn generate violations of their human rights (Bockting et al., 2016BOCKTING, W. et al. Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology, Diabetes, and Obesity, London, v. 23, n. 2, p. 188-197, 2016. DOI: 10.1097/MED.0000000000000232
https://doi.org/10.1097/MED.000000000000... ; Hoyos-Hernández et al., 2021HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021.).

Professionals perceive what other studies have reported about the well-being and/or quality of life of trans people, i.e., that it is significantly lower in aspects, such as social functioning, mental health, vitality, and emotional role (Lindqvist et al., 2017LINDQVIST, E. K. et al. Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery, v. 40, n. 3, p. 223-226, 2017. DOI: 10.1007/s00238-016-1252-0
https://doi.org/10.1007/s00238-016-1252-... ). Participants affirm that rejection toward trans people impacts psychological and physical aspects and affects social aspects by means of the fear of losing what they have achieved due to the existing perceived transphobia.

Considering the above, the fear that women feel may limit their processes of transition or expression of their identity, facilitating a delay in their gender congruence and, thus, fulfilling the corresponding achievements of their life courses, both individual and family, leading to a stagnation in their personal development. According to the biopsychosocial model, this may contribute to the increase of risks and dangers during life journeys, demanding redirecting the approach to the trans person according to the self-determination of their gender identity and expression.

For this reason, it is considered that in order to ensure well-being, access to trans-affirmative care processes should be improved, including gender affirmation surgeries, as each person builds it on themselves and, for example, on their ideals of beauty (Bockting et al., 2016BOCKTING, W. et al. Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology, Diabetes, and Obesity, London, v. 23, n. 2, p. 188-197, 2016. DOI: 10.1097/MED.0000000000000232
https://doi.org/10.1097/MED.000000000000... ; Cardozo Rocon et al., 2017CARDOZO ROCON, P. Y. et al. (Trans)formações corporais: reflexões sobre saúde e beleza. Saúde e Sociedade, São Paulo, v. 26, n. 2, p. 521-532, 2017. DOI: 10.1590/S0104-12902017171907
https://doi.org/10.1590/S0104-1290201717... ; Hoyos-Hernández et al., 2021HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021.), expectations and desires. In line with this, participants mention that trans people may feel uncomfortable or dissatisfied with some of their physical characteristics, as they tend to consider that they need to have features culturally established as feminine in order to be accepted by society. This dissatisfaction may have a negative impact on their self-esteem and well-being. Monitoring, on the other hand, should generate a space that allows open and critical dialogue that problematizes the binary and hegemonic constructions regarding gender and the way of expressing it, living it or inhabiting it.

It is also important to identify the close support network as a central axis to be able to give a new meaning or reinforce the perception of well-being constructed or reconstructed for the trans person, highlighting accompaniment in the generation of resilience-frequently mentioned by the participating health professionals-education, empowerment and, therefore, acceptance and self-esteem.

Resuming and deepening the importance of support networks, the family is the area with the greatest influence on the feeling of happiness and well-being, followed by work, leisure and friends (Hoyos-Hernández et al., 2021HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021.; Moyano; Mendoza; Paez, 2021MOYANO, E.; MENDOZA, R.; PAEZ, D. Psychological well-being and their relationship with different referents and sources of happiness in Chile. Revista de Psicología, Lima, v. 39, n. 1, p. 162-182, 2021. DOI: 10.18800/psico.202101.007
https://doi.org/10.18800/psico.202101.00... ). It has been found that support from the family produces less suicidal ideation and depressive symptoms, and an increase in self-esteem, quality of life and perception of safety in crowded places in transgender women (Glynn et al., 2016GLYNN, T. R. et al. The role of gender affirmation in psychological well-being among transgender women. Psychology of Sexual Orientation and Gender Diversity, Washington, DC, v. 3, n. 3, p. 336-344, 2016. DOI: 10.1037/sgd0000171
https://doi.org/10.1037/sgd0000171... ). This is a pivotal support in face of the different violence they may experience throughout their lives.

In agreement with the above, participants mention the family as an important support for the construction of well-being in transgender people. It is clear for health professionals that, when women receive this support early on, it favors the construction of their gender identity, facilitates its expression and/or transition, and makes it less likely that they will be exposed to situations of violence. Thus, the more the family supports them in their transition processes, the greater their well-being and health will be.

The previously mentioned elements can have an impact by breaking or redirecting the vicious circle of psychosocial risk factors in trans women such as depression, anxiety, suicidal ideation, and some of their coping strategies such as the use of psychoactive substances (PAS) (Johnson; Rogers, 2019JOHNSON, A. H.; ROGERS, B. A. “We’re the Normal Ones Here”: Community Involvement, Peer Support, and Transgender Mental Health. Sociological Inquiry, Los Angeles, v. 90, n. 2, p. 271-292, 2019. DOI: 10.1111/soin.12347
https://doi.org/10.1111/soin.12347... ; Hoyos-Hernández et al., 2021HOYOS-HERNÁNDEZ, P. A. et al. TranSER: experiencias de vida de mujeres en tránsitos de género en Colombia. Sello Editorial Javeriano, 2021.), thus improving the well-being of trans women.

It is essential to incorporate sexual rights as fundamental human rights along with sexuality as a human dimension into approaches for the well-being, health, and human development of trans women (Ford et al., 2019FORD, J. V. et al. Why Pleasure Matters: Its Global Relevance for Sexual Health, Sexual Rights and Wellbeing. International Journal of Sexual Health, London, v. 31, n. 3, p. 217-230, 2019. DOI: 10.1080/19317611.2019.1654587
https://doi.org/10.1080/19317611.2019.16... ; Gruskin et al., 2019GRUSKIN, S. et al. Sexual health, sexual rights, and sexual pleasure: Meaningfully engaging the perfect tri- angle. Sexual and Reproductive Health Matters, London, v. 27, n. 1, p. 29-40, 2019. DOI: 10.1080/26410397.2019.1593787
https://doi.org/10.1080/26410397.2019.15... ; Starrs et al., 2018STARRS, A. M. et al. Accelerate pro- gress - sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission. The Lancet Commissions, Amsterdam, v. 391, n. 10140, p. 2642-2692, 2018. DOI: 10.1016/S0140-6736(18)30293-9
https://doi.org/10.1016/S0140-6736(18)30... ; WAS, 2014WAS - WORLD ASSOCIATION FOR SEXUAL HEALTH. Declaration of Sexual Rights. Minneapolis, 2014. Disponible en: <Disponible en: https://worldsexualhealth.net/wp-content/uploads/2021/09/declaration_of_sexual_rights_sep03_2014_b.pdf >. Acceso en: 2 enero. 2022.
https://worldsexualhealth.net/wp-content... ). This can be achieved through trans-affirmative health practices that are based on gender self-determination, decreasing gender-associated gaps, education aimed at developing clinical competencies in health professionals, and the development of evidence-based clinical protocols in collaboration with the communities involved.

The findings of this article represent only the participants of this study offering relevant information in the view of those who accompany different affirmative processes of trans communities. Further qualitative studies should be developed including the trans population, as proposed by Rodríguez-Otero et al. (2015)RODRÍGUEZ OTERO, L. M. et al. Violencia en parejas transexuales, transgénero e intersexuales: una revisión bibliográfica. Saúde e Sociedade, São Paulo, v. 24, n. 3, p. 914-935, 2015. DOI: 10.1590/S0104-12902015134224
https://doi.org/10.1590/S0104-1290201513... . Mixed approaches are also required to characterize the living conditions and needs of the community in a diversity perspective, not only with respect to gender and sexual orientation, but also in dialogue with other ethnic, territorial, sociocultural and educational aspects.

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