A MULHER TRANSEXUAL E O SEU AUTOCUIDADO

Abstract

Objective: To describe the self-care of transgender women. Methods: Qualitative study carried out at the Sexuality Outpatient Clinic of a University Hospital in Brazil, from December 2018 to September 2019. Twelve transgender women participated in the study. Orem's SelfCare Deficit Theory was used as a theoretical framework and the Appraisal of Self-care Agency Scale (ASA-A) was used to assess self-care ability. Results: There was a prevalence of women aged between 18 and 30 years (75.0%), mean age of 28 years, brown skin color (58.3%), complete high school and incomplete higher education (33.3%), student (50.0%), single (83.3%), agnostic (33.3%), income of 1 to 2 minimum wages (50.0%) and live with parents and relatives (50.0%). Most women have good self-care skills and are able to take care of and maintain well-being and quality of life. Conclusion: Self-care is effectively carried out with engagement and the need to adapt to different situations.

Keywords

Self-care, Nursing theory, Transgender people, Gender identity

Introduction

Transsexuality is one of the most discussed topics on the international scene that deals with debates about the body, sexuality, sex and gender. The relations of knowledge itself began to demand greater accuracy in the mechanisms of debate, in order to understand the reconfiguration of forms and control of the body, considering it not only as a mechanical object, but as an object that carries with it various representations, of a social nature. , cultural, and even religious, with nuances that alternate and allow them to be interpreted by the most diverse contexts^[1]. Transsexuals are people who do not accept their secondary sexual characteristics, identify with the opposite sex and seek to adapt their body to their psychological state. They do not seek a surgical method to alter their genital organ^[2].

The term “transsexual” appeared in 1953, with the American endocrinologist Harry Benjamin, who used the expression to refer to people dissatisfied with their genitalia, with a perception of not belonging to the sex assigned at birth and, thus, identifying with the gender different from yours. In transsexuality, the body represents a source of dissatisfaction, above all, the peculiarities of the genital organ are dramatically rejected in most cases, that is, it has the female gender identity, whose sex assigned at birth was male and vice versa^[3]. The transsexual person wants to undergo surgery and hormonal treatment in order to make his body as conformable as possible to the desired sex. He vehemently seeks to get rid of his genitals through self-mutilation therapy, hormone replacement and surgeries to become a new someone^[4].

Persons who do not conform to their biological sex must be guaranteed the right to comprehensive care in accordance with the provisions of the Ministry of Health, so that they are willing to be evaluated and monitored by a multidisciplinary team composed of doctors, nurses, psychologists and social workers with therapeutic follow-up aimed at their social reintegration^[1].

Law nº 6.015/73, in its art, 58 offers to change the civil first name to the social first name, aiming at adapting to the gender that corresponds to their identity and their externalized reality in society^[5].

Understanding the nature of the person, their interaction with the environment and the impact on their life, helps to plan care that improves their health and well-being be. The improvement of care should be the main objective of a nursing theory^[6].

Self-care is the main concept of Dorothea Orem's Self-Care Deficit Theory (TDAC), that is, the way in which the act of taking care of oneself aims to preserve life and well-being. When not able to self-care, the person has a self-care deficit, being essential to provide care and stimulation to achieve self-care. The self-care deficit is when the capacity for self-care is lower than the therapeutic demands of self-care. So, to infer whether or not there is a self-care deficit, the ability to perform it with demand is measured. Basic conditioning factors influence self-care skills and the way to fulfill their requirements^[7].

Nonconformity with the biological sex, added to social stigmatization, are factors that can interfere with taking care of one's own body. The social and scientific relevance of the study is anchored in the gender perspective in providing a reflection on the understanding of self-care for transsexuals, contributing to the organization of integrated, humanized care, free of prejudice. The objective of the study is to describe the self-care of transsexual women.

Materials and Methods

Exploratory-descriptive study with a qualitative approach, carried out at the Sexuality Outpatient Clinic of the University Hospital, in Brazil. As inclusion criteria, we considered transsexual women with a medical diagnosis of gender identity disorder who attended the Outpatient Clinic for hormone therapy and/or sex reassignment surgery. The minimum age for outpatient procedures in the transsexualization process is 18 years old. Twelve transgender women participated in the study.

The data collection period took place from September to December 2019, consisting of an interview. Data were collected by the researcher after explaining the ethical procedures, ensuring anonymity and confidentiality of information. Initially, an approximation was made to the research field, through a meeting with the nurse from the Sexuality Outpatient Clinic of the aforementioned hospital, presenting the research project. The women were interviewed individually, in a consulting room at the Outpatient Clinic, respecting their privacy, and were invited to answer a questionnaire about their self-care capacity.

The data collection instrument used included two parts. The first part consists of 10 questions with socio-demographic and economic data (age, color, place of birth, marital status, education, income, profession/occupation, housing, number of children, religion). The second part comprised the Appraisal of Self-care Agency Scale (ASA-A) validated in several countries, consisting of 24 questions related to eating habits, sleep and rest, hygiene and environment care, physical activity, physical protection, care, maintenance of health and well-being.

Data interpretation was based on readings related to the theme based on Orem's Self-Care Deficit Theory. In compliance with Resolution n°466/12 of the National Health Council, the project was forwarded to the Research Ethics Committee (CEP) of the Hospital, having received a favorable opinion under nº 2.855.321.

Results And Discussion

There was a predominance of transsexual women aged between 18 and 30 years old – 9 (75.0%), mean age of 28 years old, brown skin color – 7 (58.3%), complete high school and incomplete higher education – 4 (33.3% ), student – 6 (50.0%), single – 10 (83.3%), agnostic – 4 (33.3%), income of 1 to 2 minimum wages – 6 (50.0%) who live with parents and family members – 6 (50.0%), as shown in Table 1. The women were mostly under 30 years old – 9 (75.0%), average of 28 years old, comprising a young audience corroborating with other research.

It is important to emphasize that according to the Brazilian Institute of Geography and Statistics (IBGE), the life expectancy of this population does not exceed 35 years, which corresponds to less than half of the national average of 74.9 years for the general population. Transgender people who manage to reach the age of 35 and grow old are seen as privileged, with few who manage to do so due to situations of violence or some fatality related to the abusive use of hormones and industrial silicone ^[8-10]. With regard to schooling, the majority – 8 (66.7%) have incomplete higher education or more, that is, medium to high schooling, according to a simplified analysis by the IBGE[5]. The idea is strengthened that schooling can interfere with self-care, the higher the schooling, the greater the concern and attention to health and vice versa.

Regarding occupation, half of the women in the study (50.0%) are students and single (83.4%). It is inferred, therefore, that remaining in the single marital situation may be, in addition to an option/choice, the very difficulty of maintaining relationships different from their original civil registry or the way to protect themselves against prejudice and/or embarrassing situations in public spaces. The predominance of agnostic women was 33.3%. Religion is an important factor in coping with everyday situations. The author points out that it is common for beliefs and values to interfere with self-care actions. Furthermore, there may be an association between religiosity and the quality of life of these women, since it is used as a means of managing stress and adversities in life.

Half of the participants have an income of 1 to 2 minimum wages. A study showed a prevalence of 36.7% for this income. Purchasing power is directly proportional to self-care. It is inferred that socioeconomic conditions interfere in the process of taking care of oneself, the lower the purchasing power, the lower the care aimed at transforming the body and vice versa^[11]. There are several aesthetic and surgical procedures necessary to achieve feminine shapes, which result in clandestine performance, such as the application of industrial silicone, a dangerous and less financially expensive method^[12,13]. Regarding housing, half of the participants (50.0%) live with parents and relatives, although they can often be expelled from home, leaving family life and seeking friends, community organizations, among others, as a support network. their gender identity resulting in a strengthening of bonds of support and trust^[14].

The qualitative variables of self-care capacity will be presented below, according to the Appraisal of Self-care Agency Scale (ASA-A), Graph 1 reveals that the majority of respondents – 7 (58.3%) prioritize doing whatever is necessary to maintain their health.

Graph 1. Frequency of the variable “I first do whatever it takes to stay healthy”. Maranhao, Brazil, 2019 (Source: Prepared by the author, (2019)).

Transsexuals need specific care that requires the provision of multiprofessional health services, hormone therapies, including mental health, hormone therapies and various procedures^[15].

A study found that, for transvestites and transsexual women, producing health corresponds to the process of transforming the body. The author reports that body modifications to achieve the desired body – industrial silicone applications and indiscriminate use of hormones – are considered as producing health problems. It is in living with other transsexuals that care for the transformations in the body is given. There is an exchange of information between them, resulting in constant body modifications, which makes them commonly look for "bombadeiras", who are the most experienced in injecting industrial silicone. The authors emphasize the dangers and consequences arising from the use of hormones and silicone^[16].

It is important to emphasize that transgender people tend to look for ways to take care of themselves through Afro-Brazilian religions, such as “houses of Afro religion”, “casas de santo” or “batuque”. This fact was evidenced by a Brazilian survey, in which the interviewees reported that the following of these religions and the protection of religious entities bring health and progress, as well as relief and the cure of diseases^[17]. The relevance of the involvement of health professionals is highlighted in order to understand what permeates self-care, as well as the ways they use to maintain health, in order to provide adequate guidance to transform the body, producing independence for self-care.

Regarding the ability to protect themselves and their families (graph 2), the majority of transsexual women – 10 (83.3%) responded that they take action for this purpose.

Graph 2. Frequency of the variable “I am capable of taking action to protect myself and my family. Maranhao, Brazil, 2019

Orem has universal self-care requirements, also known as activities of daily living. Among the eight activities identified by the theory, the prevention of dangers to human life, functioning and well-being of the individual stands out^[7]. Thus, the participants of this study perform what is advocated by Orem, in which it was found, a prevalence of women who judge themselves capable of protecting themselves and their families.

According to the National Association of Transvestites and Transsexuals (ANTRA), Brazil is the world leader in murders of transvestites and transsexuals, with a prevalence of female victims – 94% and a higher incidence in the Northeast region. In terms of physical violence, there is a social exclusion of this group in the economic sphere, especially in the labor market, forcing them to enter informal work, resorting to street prostitution, causing vulnerability to different types of violence^[5].

Although it is not a specific problem in the health area, violence, however, directly affects health^[18]. therefore, subjected to a hidden existence and socially rooted prejudice. In this scope, as well as in other experiences experienced in everyday life, the concealment of affective relationships, avoiding exposure in places of great circulation, consists of a mechanism to protect life. There is a need to foster health care networks for this population with the aim of inserting them into social relations in a fair and harmless manner, favoring an interaction of respect and appreciation of sexual diversity, eradicating socially established norms and making the aforementioned population possess their own own decisions^[3].

Graph 3 reveals that more than half of the participants – 7 (58.3%) are able to carry out an assessment of what can be beneficial for their health.

Graph 3. Frequency of the variable “I am able to assess what is good for my health”. Maranhao, Brazil, 2019 (Source: Prepared by the author (2019)).

For some transsexual women, taking care of their health is, as a priority, having a beautiful and feminine body, using methods to achieve such goals, such as the exaggerated and unsupervised use of female hormones^[19].

A survey found that transsexual women are capable of mitigating injuries or complications arising from the use of hormones even empirically, that is, they demonstrate a partial capacity to judge what is good or not for their health. Many are unaware of the harmful effects of alcohol, tobacco, self-medication and hormones^[20]. The two aforementioned findings contrast with the presented result of being fully capable of evaluating what is positive to be healthy, consequently taking actions that maintain their physical and mental health.

It is observed, in graph 4, that half of the transsexual women – 6 (50.0%) do not have the necessary time for self-care, in view of their routine activities.

Graph 4. Frequency of the variable “Due to my daily occupations, it is difficult to find time to take care of myself”. Maranhao, Brazil, 2019

Popular knowledge prevails in self-care requirements. In this scope, transsexual women are inserted in situations of deficit in self-care with the intention of guaranteeing their right of expression in relation to health through their own convictions about being healthy. It becomes challenging for the nurse to add the ability to integrate ethics and science for a welcoming assistance in the entire network of comprehensive health care for the transsexual population.

People's quality of life involves several factors, such as well-being and self-esteem, socioeconomic level, social coexistence, leisure activities, emotions and feelings, health status, cultural, ethical and religious aspects. In this context, the factors mentioned above, as well as taking care of the physical and mental body, together, constitute basic requirements that are important to guarantee quality of life.

Orem, in his theory, defines the therapeutic demand for self-care as a set of actions that are related and that must be performed in favor of self-care requirements, in addition to being performed with a certain duration. Furthermore, this demand is executed from decision-making actions, that is, intentionally^[7]. Therefore, for health promotion, it is important to encourage the development of individual skills, with the purpose of facilitating decision-making in defense of quality of life and health. When it comes to promoting self-care, and consequently health, the responsibility must be shared, both by the person, family, lifestyles, and by the State and health systems.

Graph 5 shows that the participants – 7 (58.3%) obtain necessary information when their health is affected.

Graph 5. Frequency of the variable “If my health is affected, I can get the necessary information about what to do”. Maranhao, Brazil, 2019

The advent of normative barriers, in a social context marked for years by the macho culture, is responsible for placing transsexuals at the mercy of the rights and duties imposed on society. In the health-disease process, this exclusion favors distancing from health care and preventive services, which results in increased contamination by sexually transmitted infections, exposure to violence of various types and significant damage to mental health^[9].

Several times, transgender women have their rights of access to health violated and neglected, due to the inability of health professionals in reception and health, leaving them vulnerable to health problems. It is common for transsexual women, when it comes to the body transformation process, to follow the guidance of friends called “godmothers” – those more experienced transsexual women – and the latter prescribe amounts of hormones greater than the limits of the human body^[18]. Transgender women need care, such as: wounds that require dressings, sutures, radiographic examination to search for fractures and even the need to undergo minor surgery. However, they avoid health care for these demands^[21].

On the other hand, a study observed a more welcoming service when it comes to private services. There was a report of a participant who received quality health care, their social name being respected throughout the treatment^[9]. In this scope, there is a self-care deficit - a deficit between the person's ability to perform and what needs to be performed to ensure optimal body functioning^[7].

When unable to carry out their self-care, – 12 (100.0%) of the transsexual women, they can seek help (“almost always” and always”), as shown in graph 6.

Graph 6. Frequency of the variable “If I can't take care of myself, I can get help”. Maranhao, Brazil, 2019.

These professionals are required to be prepared to provide quality care based on ethics, respecting the sexual identity and other attributions of individuals, in addition to expanding their scientific and practical knowledge, essential skills to care for the transsexual population^[22].

It was mentioned by more than half of the interviewees that they have “always” - 4 (33.3%) and “almost always” - 4 (33.3%) time for themselves, shown in graph 7.

Graph 7. Frequency of the variable “I have time for myself”. Maranhao, Brazil, 2019 (Source: Prepared by the author (2019)).

It is common for a busy lifestyle to cause serious harm to health, especially in the absence of self-care practices, resulting in health problems^[21,23]. Through a daily routine, people end up not allocating adequate time for health care, which contrasts with the reality presented by the women in the present study. For Orem, the self-care activity is based on the person's performance in a conscious, intentional and effective way, achieving real autonomy. On the other hand, the capacity for self-care is not only a method that will guarantee the maintenance, rehabilitation and benefits to health and well-being, but it constitutes the development of a potential for self-care activity, being an integral element of every human being^[24].

Conclusion

Transsexual women were characterized as young, brown, single, students, agnostic, with good education, income of 1 to 2 minimum wages and living with their parents and other family members. In most situations, they have the ability to perform selfcare, that is, they manage to perform self-care deliberately. As limitations of this study, the reality of a specific group, transsexual women, is highlighted.

References

1. Morera JA, Padilha MI. Trans-formation: A review of the main concepts of transsexuality. Revista Eletrônica Estácio Saúde. 2015;4:33-44.

Google Scholar, Crossref

2. Maksoud FR, Passos XS, Pegoraro RF. Reflections on gender identity disorder in relation to health services: A bibliographical review. Revista Psicologia e Saúde. 2014.

Google Scholar, Crossref

3. Silva GW, et al. Situations of violence against transvestites and transsexuals in a municipality in northeastern Brazil. Revista Gaúcha de Enfermagem. 2016; 37.

Google Scholar, Crossref

4. Sturza JM, Schorr JS. Transsexuality and human rights: Legal protection of the right to identity. Rev Juríd Cesumar Mestr. 2015;15:265-283.

Google Scholar, Crossref, Indexed at

5. BRASIL. Ministry of Health. Secretariat for Strategic and Participatory Management. Take good care of everyone's health. Faz bem para todos, faz bem para o Brasil. Brasília, DF, 2016.

Crossref

6. Queirós PJ, dos Santos Vidinha TS, de Almeida Filho AJ. Self-Care: Orem's Theoretical Contribution to the Nursing Discipline and Profession. Rev Enferm. 2014;4:157-164.

Google Scholar, Crossref

7. Foster P, et al. Nursing theories: The fundamentals of professional practice. 4 ed. Porto Alegre: Artmed; 2000.

Google Scholar, Crossref

8. Ferreira BD, et al. Experiences of transvestites in accessing the SUS. Physis: Revista de Saúde Coletiva. 2017;27:1023-1038.

Google Scholar, Crossref, Indexed at

9. Ferreira DG, et al. My days, my health: A local study on the social reality and health care of transvestites and transsexuals in Mato Grosso. Connection line-revista eletrônica do univag. 2018;18: 69-88.

Google Scholar, Crossref, Indexed at

10. Carrara S, et al. Body construction and health itineraries: A survey among travestis and trans people in Rio de Janeiro, Brazil. Cad Saude Publica. 2019;35:e00110618.

Google Scholar, Crossref, Indexed at

11. Ferreira Jr S, Francisco PM, Nogueira PA. Profile of transvestites and transgenders: Tuberculosis and HIV/Aids in the city of São Paulo. Rev Panam Salud Publica. 2016;40:410-417.

Google Scholar, Crossref, Indexed at

12. Pinto TP, et al. Industrial liquid silicone to transform the body: Prevalence and factors associated with its use among transvestites and transgender women in São Paulo, Brazil. Cad Saude Publica. 2017;33:e00113316.

Google Scholar, Crossref

13. Santos AC. Self-care of pregnant women with sickle cell disease: Construction of a nursing protocol. 2018

Google Scholar, Crossref

14. Menezes LM. Transphobia and racism: Articulation of violence in trans experiences. BIS, Bol. Inst. Saúde (Impr). 2018:62-76.

Google Scholar, Crossref

15. De Andrade CA, et al. Self-care requirements of transgender women using sex hormones according to Orem's theory. Cogitare Enferm. 2018;23.

Google Scholar, Crossref

16. Zucchi EM, et al. Psychological well-being among transvestites and transgender women in the State of São Paulo, Brazil. Cad Saude Publica. 2019;35.

Google Scholar, Crossref, Indexed at

17. Lindroth M. Transgender people and sexual health–findings from a swedish interview study. J Sex Med. 2017;14:e270.

Google Scholar, Crossref, Indexed at

18. Sampaio JV, Germano IM. “Everything is always a lot!”: Health production among transvestites and transsexuals. Rev Estud Fem. 2017;25:453-472.

Google Scholar, Crossref, Indexed at

19. Souza MH, et al. Therapeutic itineraries of transvestites from the central region of Rio Grande do Sul, Brazil. Cien Saude Colet. 2014;19:2277-2286.

Google Scholar, Crossref

20. Souza MH, et al. Violence and social suffering in the itinerary of transvestites in Santa Maria, Rio Grande do Sul, Brazil. Cad Saude Publica. 2015;31:767-776.

Google Scholar, Crossref, Indexed at

21. Rosa DF, et al. Nursing care for the trans population: Genres from the perspective of professional practice. Rev Bras Enferm. 2019;72:299-306.

Google Scholar, Crossref

22. Araujo CB, et al. The practice of self-care by nursing workers in basic health units. Revista Eletrônica de Enfermagem. 2016;18.

Google Scholar, Crossref, Indexed at

23. Cruz TA, Carvalho AM, da Silva RD. Reflection on self-care among nursing professionals. Rev Enferm Contemp. 2016;5.

Google Scholar, Crossref, Indexed at

24. Söderhamn O. Self-care activity as a structure: A phenomenological approach. Scand J Occup. 2000;7:183-189.

Google Scholar, Crossref, Indexed at