Mental suffering, family support and empowerment of transgender people

Abstract

Objective

Identify the presence of mental suffering, family support and empowerment of transgender people living in the State of Alagoas, Brazil.

Methods

Cross-sectional, descriptive, quantitative study. Transgender people over 18 years old who lived in the State of Alagoas were included in the study. The interviews were carried out on the Google Meet platform, through telephone and WhatsApp. The following instruments were used: Identification Questionnaire, State-Trait Anxiety Inventory, Depression Scale, Perceived Family Support Inventory and Empowerment Scale. The data were entered into the Statistical Package for the Social Sciences 23 software, and analyzed by calculating frequencies, means, standard deviation and the Pearson Chi-Square test.

Results

37 transgender people were interviewed, with an average age of 27.35 years, self-reported black/brown color (91.8%), presenting suicidal ideation in the last year (48.6%), attempted suicide (35.1%), risk for depression (64.9%) and low family support (94.6%). Transgender and pansexual women presented a greater anxious personality trait and transgender and bisexual women experienced a greater anxious state. There was greater impairment in heterosexual people in the Affective-Consistent dimension; in pansexual people, in the Family Adaptation dimension; in bisexual people, in the Family Autonomy dimension. Community Activism was more committed to empowering transgender people.

Conclusion

The weaknesses in family relationships, combined with the conditions of violence and prejudice experienced in the face of the difficulty of many in living with diversity, may be contributing to the mental suffering of transgender people. Thoughts about actions aimed at promoting their empowerment are essential, in a support network that can be internal and external to their family.

Transgender persons; Mental health; Anxiety; Depression

Resumo

Objetivo

Identificar a presença de sofrimento mental, o suporte familiar e o empoderamento de pessoas transgênero residentes no Estado de Alagoas, Brasil.

Métodos

Estudo transversal, descritivo, quantitativo. Pessoas transgênero maiores de 18 anos que residiam no Estado de Alagoas foram incluídas no estudo. As entrevistas foram realizadas na plataforma Google Meet, mediante agendamento telefônico e WhatsApp. Foram utilizados: Questionário de identificação, Inventário de Ansiedade Traço-Estado, Escala de Depressão, Inventário de Percepção de Suporte Familiar e Escala de Empoderamento. Os dados foram inseridos no software Statistical Package For The Social Sciences 23, e analisados por meio de cálculo de frequências, médias, desvio-padrão e teste de Pearson Chi-Square.

Resultados

Foram entrevistadas 37 pessoas transgênero, com idade média de 27,35 anos, cor autorreferida preta/parda (91,8%), apresentando ideação suicida no último ano (48,6%), tentativa de suicídio (35,1%), risco para depressão (64,9%) e baixo suporte familiar (94,6%). Mulheres transgênero e pansexuais apresentaram maior traço de personalidade ansiosa e mulheres transgênero e bissexuais vivenciavam um maior estado ansioso. Houve maior comprometimento em pessoas heterossexuais na dimensão Afetivo-Consistente; em pessoas pansexuais, na dimensão Adaptação Familiar; em pessoas bissexuais, na dimensão Autonomia Familiar. O Ativismo Comunitário apresentou-se mais comprometido no empoderamento de pessoas transgênero.

Conclusão

As fragilidades nas relações familiares, aliado às condições de violência e preconceito vivenciados frente à dificuldade de muitos em conviver com a diversidade pode estar contribuindo para o sofrimento mental de pessoas transgênero. É preciso pensar em ações voltadas para a promoção do seu empoderamento, numa rede de apoio interna e externa à família.

Pessoas transgênero; Saúde mental; Ansiedade; Depressão

Resumen

Objetivo

Identificar la presencia de sufrimiento mental, apoyo familiar y empoderamiento de personas transgénero residentes en el estado de Alagoas, Brasil.

Métodos

Estudio transversal, descriptivo, cuantitativo. Se incluyeron en el estudio personas transgénero mayores de 18 años que residían en el estado de Alagoas. Las entrevistas se realizaron en la plataforma Google Meet, previamente programadas por teléfono y WhatsApp. Se utilizaron los siguientes instrumentos: Cuestionario de Identificación, Cuestionario de Ansiedad Estado Rasgo, Escala de Depresión, Cuestionario de Percepción de Apoyo Familiar y Escala de Empoderamiento. Los datos se ingresaron al software Statistical Package For The Social Sciences 23 y se analizaron mediante cálculo de frecuencias, promedios, desviación típica y prueba de Pearson Chi-Square.

Resultados

Se entrevistaron 37 personas transgénero, de 27,35 años de edad promedio, color autopercibido negro/pardo (91,8 %), que presentaron ideación suicida en último año (48,6 %), intento de suicidio (35,1 %), riesgo de depresión (64,9 %) y bajo apoyo familiar (94,6 %). Las mujeres transgénero y pansexuales presentaron mayor rasgo de personalidad ansiosa y las mujeres transgénero y bisexuales tuvieron más vivencias de estado ansioso. Hubo una mayor afectación en personas heterosexuales en la dimensión Afectivo-consistente; en personas pansexuales en la dimensión Adaptación familiar, y en personas bisexuales en la dimensión Autonomía familiar. El activismo comunitario se vio más comprometido en el empoderamiento de personas transgénero.

Conclusión

Las debilidades en las relaciones familiares, junto con las condiciones de violencia y prejuicio que enfrentan las personas transgénero ante la dificultad de muchos de convivir con la diversidad, puede contribuir con su sufrimiento mental. Es necesario pensar en acciones para promover su empoderamiento, mediante una red de apoyo interna y externa a la familia.

Personas transgénero; Salud mental; Ansiedad; Depresión

Introduction

This research aimed to study mental suffering, family support and empowerment of transgender people. In itself, transidentity is not a pathology.¹ Transgender people are those who cross gender boundaries, proposing new ways of thinking and experiencing it.²

Transgender people, especially young women, are more vulnerable to worse mental health conditions and suicidal behavior.³ A study carried out in the Federal District identified that transgender people who expressed masculine gender had a higher frequency of suicidal thoughts (80%). Regarding sexual orientation, 72.2% of heterosexual people and 87.5% of bisexual people had suicidal thoughts. In relation to family approval, the fact that the family disapproves or is unaware of the sexual orientation of these people showed that the frequency of suicidal ideation can reach approximately 90% of them.³ These people are more vulnerable to mental suffering due to having to deal with transphobia which is structuring in society. People belonging to the Lesbian, Gay, Bisexual and Transgender (LGBT+) movement continually report situations in which they are raped and marginalized by individuals who cannot live with diversity.⁴

A systematic review study indicates that transgender people have a higher prevalence of mental disorders than the general population or cisgender individuals.⁵

The adversities experienced by transgender people can contribute to the emergence of anxiety symptoms. This is characterized as a natural reaction that encourages human beings in stressful situations, but can become pathological and have negative repercussions if experienced excessively and for long periods.⁶ These people may also present symptoms of depression, characterized as a mood disorder that causes damage to personal life, tends to cause discouragement and pessimism in the person, affecting social interaction, self-esteem, sleep and appetite patterns, sad mood, feeling of emptiness or irritation, accompanied by somatic and cognitive changes that affect the functional capacity of the individual, clear changes in affect, deep sadness, significant weight gain or loss, changes in sleep quality, loss of interest in situations or things that were previously pleasurable.⁶

Mental disorders have a strong influence on suicidal behavior and, combined with factors such as transphobia, can end up strengthening suicidal ideation or attempts. Suicidal behavior encompasses the desire to hasten death, indirect self-destructive behavior, parasuicide, deliberate self-harm, attempted suicide, self-mutilation and suicide.⁷ A community survey carried out in Australia highlights the presence of higher rates of attempted suicide, self-mutilation and depression in the trans community. Suicide attempts occur due to a complex interaction between sociopolitical, environmental, interpersonal and structural risk factors.⁸

In this context, family support could be a buffer against various stressors in people’s lives, and could be associated with social competence, coping with problems, a sense of stability, self-concept, positive affect and psychological well-being in these people’s lives.⁹ An integrative review study points out that the family can be a cause or protective factor for psychological distress in transgender people.¹⁰ Study shows that even among transgender people with families that supported their transitions, parents see better well-being of them, when they have more support from family, peers and schools.¹¹

Furthermore, the search for empowerment is independent of gender, appearance or sexuality. It is part of a process that recognizes that transgender people have historically been on the margins of society, being excluded by sexist and transphobic discourse and practices.¹² In this way, the empowered person could better manage the use of health services, identifying complications more easily and making more assertive decisions. Therefore, measuring empowerment in people in vulnerable situations is an innovation in the field of health care.¹³

Nursing plays an important role with regard to health care, as these professionals work at the gateway to health demands and are a communication link between the population and the entire health network. Despite this, there are still gaps in the training of these professionals aimed at caring for transgender people.¹

In this scenario, the following guiding question was brought to this study: what does mental suffering, family support and empowerment look like for transgender people living in the State of Alagoas, in Brazil?

Thus, the present study aimed to identify the presence of mental suffering, family support and empowerment of transgender people living in the State of Alagoas, Brazil.

Methods

This is a cross-sectional, descriptive, quantitative study guided by the Verification Checklist for Reporting Results of Electronic Research on the Internet (CHERRIES).

According to data estimated by the Gay Group of Alagoas (GGAL), in 2021, 70 transgender people from Alagoas were being monitored to undergo sexual reassignment surgery.¹⁴ The interviews were carried out between August and December 2020, during the period of social isolation due to the COVID-19 pandemic. In this virtual context, the recruitment process was more challenging, considering that not everyone had access to the internet or a mobile or fixed device to respond to this survey.

The sample was intentional and non-probabilistic. Transgender people over 18 years old with internet access, as well as an electronic device, living in the State of Alagoas were included in the study.

The power analysis of the study was carried out using the G*power software, version 3.0, using the following parameters: Chi-square tests, goodness-of-fit tests: contingency tables and Post hoc. The post hoc power analysis in this study was 78% for a sample of 37 participants with an effect power of 0.50.

The interviews were carried out by a cisgender, bisexual person and through appointment scheduled via telephone and WhatsApp and were carried out remotely through the Google meet platform. After each interview, people interviewed were asked to nominate other transgender people who could participate in the research. This non-probabilistic snowball sampling technique emerged to assist us for the collection of data from populations that are difficult to access, so that the sample grows as the people interviewed indicate other people who will possibly be part of the research.¹⁵ A link was made available on social networks (Facebook, Instagram, WhatsApp and Twitter) as an invitation to participate in the research and to increase the reach of participants.

The following instruments were used: Identification Questionnaire, State-Trait Anxiety Inventory (STAI), Depression Scale - CES-D (Center for Epidemiologic Studies Depression Scale), Perception of family support inventory (IPSF) and Empowerment Scale (ES).

The Identification Questionnaire was prepared by the authors and served to collect information regarding age, sexual orientation, gender, education, race/color, whether they work, place of residence, who they live with, marital status, presence of suicidal ideation in the last year and if they have ever attempted suicide in their lives.

The STAI is composed of two distinct self-report scales to measure two distinct concepts: state anxiety and trait anxiety. The trait anxiety scale requires participants to describe how they generally feel. The State Anxiety Scale requires people to indicate how they feel at a given moment. The trait anxiety scale and the state anxiety scale contain 20 statements each. In the state scale, the 20 items are presented on a 4-point Likert scale: 1 – absolutely not; 2 – a little; 3 – quite a lot; 4 – very much. In the trait scale, the 20 items are presented on a 4-point Likert scale: 1- almost never; 2 – sometimes; 3 – frequently; 4 – almost always. The scores for positive questions are reversed. In other words, if the patient answers 4, a value of 1 is assigned in the coding; if you answer 3, a value of 2 is assigned; if you answer 2, a value of 3 is assigned; and if you answer 1, a value of 4 is assigned. The total score varies from 20 to 80 for each scale. For analysis purposes, these scales do not have defined cutoff points, even because the level may vary according to individual and sample characteristics, as it is an ordering of categorical scores.¹⁶ A study with a Brazilian sample indicates a high level of internal consistency in both scales that make up the STAI.¹⁷

The CES-D consists of 20 items. He questions depressive symptoms in the last seven days prior to the interview. Each response admits four gradations of intensity (never or rarely: 0, sometimes: 1, often: 2 and always: 3). Items 4, 8, 12 and 16 (positive) are scored with inverse gradation. The final score varies from 0 to 60 points and corresponds to the sum of the scores of all responses. A score greater than 15 points is the cutoff level that indicates the presence of significant depressive symptoms. This scale presents feasibility and validity, and was shown to be sensitive to variations in the intensity of depressive symptoms, and can be used in epidemiological studies.¹⁸

The IPSF is a test capable of evaluating the perception of family support. The instrument is a three-point Likert scale: almost never or never, sometimes and almost always or always. It consists of 42 items and three dimensions: Affective-Consistent, Family Adaptation, Family Autonomy. The IPSF results are obtained by calculating the scores for each dimension, in addition to the general score (Total Family Support). This general score refers to the sum of the scores of all dimensions, and the higher the number of this score, the greater the individual’s perception regarding family support. The IPSF construct and reliability results demonstrated very satisfactory indices and can be very useful in developing research on the characteristics of the Brazilian family.⁹

ES evaluates manifestations of empowerment that the person demonstrates at the time of its application. The ES is organized into 25 items and uses the Likert model to score five factors: a) Self-esteem and self-efficacy, b) Power and powerlessness, c) Community activism, d) Optimism and Control of the future, e) Anger or righteous anger. The Likert scale is made up of items where the subject expresses the degree of agreement according to the four response options: 1 – I completely agree - value 1; 2 – I agree - value 2; 3 – Disagree - value 3; 4 – Strongly disagree - value 4. The highest score corresponds to the greatest manifestations of empowerment, with a final score that can vary from 25 to 100. This scale has validity and reliability and can be applied to people in a scenario of greater vulnerability.¹³

The data resulting from the collection were entered into the Statistical Package for the Social Sciences (SPSS), version 23. The data were analyzed by calculating frequencies, means and standard deviations for sociodemographic variables, state-trait anxiety, perception of family support and empowerment. Pearson’s linear correlation coefficient test was used to evaluate the association between depression and suicidal behavior. Statistical significance was defined at p≤0.05 and a confidence level of 95%. No pre-test or pilot test was carried out to apply the collection instruments.

The study was approved by the Research Ethics Committee of the Federal University of Alagoas number 4.013.350, Certificate of Presentation of Ethical Appreciation (CAAE): 31120620.1.0000.5013. After approval, transgender people who agreed to participate in the study signed the Free and Informed Consent Form, in accordance with Resolution No. 466/12, Resolution No. 510/2016 of the National Health Council/Ministry of Health and Circular Letter Number 1/2021/CONEP/SECNS/MS providing guidelines for procedures in research in a virtual environment. People who required mental health care were referred to the psychosocial care network in the State of Alagoas.

Results

Sociodemographic profile of participants

37 transgender people were interviewed. Of these, 51.5% were female and 48.6% male, with an average age of 27.3 (±9.15) years. The average age between the genders was 26.6 (±11.6) years for males and 28 (±6.13) years for females. The average age varied when analyzed according to sexual orientation, being 28.7 (±11.4) years for heterosexual people, 33.5 (±7.77) years for homosexual people, 28 (±8.44) years for a bisexual person and 24.1 (±3.94) years for a pansexual person. The predominant self-reported color was black (45.9%) and mixed race (45.9%), 27% had completed high school and 24.3% had completed higher education (Table 1). It was observed that 62.1% of transgender people were unemployed or had an informal job, while 37.9% had a formal job. It was found that 75.7% live in Maceió, 48.6% said they lived with family and 24.3% lived alone. When people were asked about their marital status, 54.1% said they had never been married (Table 1).

Table 1
Sociodemographic characteristics of transgender people

	Mean(SD)
Age	27.35(9.15)
Age x gender
Male	26.67(11.6)
Female	28.0(6.13)
Age x sexual orientation
Heterossexual	28.58(11.4)
Homossexual	33.5(7.77)
Bissexual	28.0(8.44)
Pansexual	24.18(3.94)
Variables	n(%)
Sex
Female	19(51.4)
Male	18(48.6)
Education
Complete primary education	2(5.4)
Incomplete high school	6(16.2)
Complete high school	10(27.0)
Incomplete higher education	10(27.0)
Complete Higher Education	9(24.3)
Race/color
Yellow	1(2.7)
Black	17(45.9)
White	2(5.4)
Brown	17(45.9)
Working condition
I have a formal job	14(37.9)
I have an informal job	12(32.4)
I do not work	11(29.7)
Place where they live
Maceió city	28(75.7)
Others	9(24.3)
Currently living situation
Spouse	4(10.8)
Relatives	18(48.6)
Alone	9(24.3)
Other people	6(16.2)
Marital status
Married	6(16.2)
Has never married	20(54.1)
Separated/divorced	11(29.7)
Total	37(100.0)

• n - Number; % - Frequency; SD – Standard deviation

State-trait anxiety and risk for Depression

The mean state anxiety and trait anxiety were 47.65 (±13.35) and 48.30 (±14.65), respectively (Table 2). The values for state anxiety and trait anxiety were measured considering the sexual orientation of the transgender people in the study. A higher mean state anxiety was identified for bisexual people (60.0±15.6) and lower for homosexual people (34.5±6.37). In trait anxiety, the mean was lower for homosexual people (42.0±2.82) and higher for pansexual people (55.45±12.63) (Table 2). It was observed that 64.9% of transgender people were at risk for depression (Table 2). There was no statistically significant difference between sexual orientation and the risk of depression (p>0.05). Perception of Family Support was also measured according to sexual orientation. A higher mean was identified for bisexual people (22.25±4.64) in the “Affective-consistent” dimension and a lower mean (20.37±3.49) for heterosexual people. The “Family Adaptation” dimension had the highest mean (18.00±2.44) for bisexual people and the lowest for pansexual people (15.36±4.77). The “Family Autonomy” dimension presented a higher mean for homosexual people (9.00±5.65) and a lower mean for bisexual people (6.00±3.47) (Table 2).

Table 2
State-trait anxiety, risk for depression and perception of family support

State-trait anxiety
Sexual orientation	Anxiety state Mean (SD)		Anxiety trait Mean (SD)
Heterossexual	42.58(10.97)		43.32(15.74)
Homossexual	34.50(6.37)		42.00(2.82)
Bissexual	60.00(15.60)		55.25(10.88)
Pansexual	54.36(12.40)		55.45(12.63)
Overall average	47.65(13.35)		48.30(14.65)
Depression Risk
Sexual orientation	Without risk n(%)		With risk n(%)
Heterossexual	9(47.4)		10(52.6)
Homossexual	1(50.0)		1(50.0)
Bissexual	-(-)		4(100.0)
Pansexual	2(18.2)		9(81.8)
Total	13(35.1)		24(64.9)
Perception of family support
Sexual orientation	Affective-Consistent Mean (SD)	Family adaptation Mean (SD)	Family Autonomy Mean (SD)	Total family support Mean (SD)
Heterossexual	20.37(3.49)	17.32(3.84)	7.53(2.99)	45.16(3.68)
Homossexual	21.00(5.65)	17.50(4.95)	9.00(5.65)	47.50(6.37)
Bissexual	22.25(4.64)	18.00(2.44)	6.00(3.47)	46.25(6.55)
Pansexual	21.82(4.35)	15.36(4.77)	8.64(3.04)	45.82(6.28)
Overall average	20.86(4.00)	16.86(4.00)	7.73(3.11)	45.43(4.90)

• n - Number; % - Frequency; SD – Standard deviation

Suicide ideation and attempt

It was observed that 48.6% (n= 18) of transgender people had suicidal ideation in the last year. Of these, 83.3% (n= 15) were at risk of depression (p<0.05), particularly pansexual people (n= 9; 81.8%). Regarding attempted suicide, 35.1% (n= 13) responded that they had already attempted suicide at some point in their lives. Of these, 76.9% (n= 10) were at risk of depression (p>0.05), especially heterosexual people (n= 6; 31.6%).

Perception of family support and empowerment

It was identified that 94.6% of transgender people had low family support. The dimensions that presented the highest averages were: “Affective-consistent” (20.86±4.00) and “Family adaptation” (16.86±4.00) (Table 3). Transgender people obtained an overall average of 9.72 (±1.90) in the level of empowerment. The factors that contributed most to empowerment were “Power and impotence” (2.29±0.51) and “Optimism and control of the future” (2.14±0.68). The factor that contributed least to the empowerment of transgender people was “Community Activism” (1.54±0.44) (Table 3).

Table 3
Perception of family support and empowerment of transgender people

Family support	n(%)
Low	35(94.6)
Median to low	2(5.4)
Total	37(100)
Family support dimension	Mean(DP)
Affective-consistent	20.86(4.00)
Family adaptation	16.86(4.00)
Family autonomy	7.73(3.11)
Full family support	45.43(4.90)
Empowerment Factor	Média(DP)
Self-esteem and self-efficacy	1.93(0.67)
Power and powerlessness	2.29(0.51)
Community activism	1.54(0.44)
Optimism and control of the future	2.14(0.68)
Wrath or righteous anger	1.66(0.53)
Overall average	9.72(1.9)

• n - Number; % - Frequency; SD – Standard deviation

Discussion

The majority of transgender people in the present study have completed high school and incomplete higher education. This data agrees with a study on “basic education and the access of transgender and transvestite people to higher education”, which shows that they managed to complete secondary education. On the other hand, the same study highlights that the number of people who manage to enter higher education is very small. And, among those who have managed to enroll for an undergraduate course, a small number manage to complete it.¹⁹

Although some participants in the current study reported that they have a formal relationship (62.1%), this is generally not part of the reality of transgender people. The employability contexts for these people present a problem full of challenges that involve prejudice, transphobia, documents, such as civil registration, use of bathrooms, uniforms, education and body and verbal language.²⁰

Regarding self-reported color, the majority declared themselves black and brown. This data is in accordance with the survey of the “1^st Mapping of trans people in the city of São Paulo” which shows that the majority of people interviewed declared themselves black or mixed race (57%).²¹

Studies show that transgender people are at greater risk for developing mental disorders such as anxiety. In addition to the feeling of fear, tension or worry, transgender people experience some stressors that may be linked to anxiety, such as low self-esteem, body image, loneliness, family rejection, social isolation, shame, discrimination and lack of social and family support.²²-²⁴ The current study identified higher anxiety symptoms in transgender, bisexual, and pansexual people.

A study carried out in the United States with young transgender people states that they have higher levels of anxiety and depression than cisgender individuals, mainly because they face more challenges throughout their lives.²⁵ Another study carried out in China shows a high prevalence of mental illness , such as depression, anxiety and stress-related problems in transgender people.²⁶ A survey with 928 transgender people in Australia identified that 73% of people reported a diagnosis of depression throughout their lives.²⁷ A study carried out in Argentina identified the presence of depressive symptoms in transgender women (50.8%).²⁸ In the current study, it was identified that 64.9% of transgender people were at risk for depression. This reinforces the need for health professionals to focus on identifying the presence of mental suffering in these people.

As mental disorders influence suicidal behavior,⁷ assessing them specifically is essential for those who present mental suffering. Therefore, the presence of suicidal ideation in the last year was reported by 48.6% of the people participating in this study. This frequency is higher than that found in a survey carried out in Rio Grande do Norte, where 41.4% of transvestites and transgender people had suicidal ideation.²⁹ Another study with transgender people carried out in the Federal District identified that 73.7% of the people participating in the research had suicidal thoughts at some point in their lives and 29.9% had attempted suicide at least once in their lives. The study also states that suffering related to one’s own body and socioeconomic factors such as color/race, marital status and education may be related to suicide attempts.³

This study identified that 94.6% of transgender people had low family support. The most compromised dimensions of the Perceived Family Support Inventory were “Affective-consistent” and “Family Adaptation”. The first dimension has to do with family communication, assertiveness and attention from family members. The second is related to conflicts, disagreement between members and criticism that are generally associated with negative affect.⁹ A review study indicates that the qualities of family relationships influence the health and well-being results of transgender people.²⁵ Family rejection has become a strong aggravating factor for depression and attempted suicide. While family support is seen as a protective factor against these aggravating factors.²⁶,²⁷

It is important to understand that empowerment aims at strengthening and developing capabilities that can balance risk factors.³⁰ When seeking the empowerment of transgender people, it is recognized that they are on the margins of social processes, excluded by sexist and cissexist discourses and practices, also by transphobic people. There is an emerging movement regarding depathologization and the formulation of new discursive strategies by transgender people, as they consider the social imaginary linked to the notion of a rigid and immutable morphological division between sex and gender as a factor in the oppression of trans people, by regulating bodies that are not conform to the binary norm man/penis and woman/vagina.¹²

In the current study, the factors that most contributed to the empowerment of transgender people were: “Power and impotence” and “Optimism and control of the future”. The factor that contributed least to empowerment was “Community Activism”. This factor is related to the organization of communities to solve social problems and improve their economic conditions and is directly related to social participation.³⁰ The actions produced by social movements contributed to the construction of new life projects, presenting paths and perspectives for the future; supporting the transition process and promoting autonomy and empowerment to resist and react to aggression.³¹

Support from health professionals can be especially important for the empowerment of these people.³² An integrative review study has shown that transgender people have not found answers to their health demands, are victims of prejudice and violence in services and seek care in extreme cases of illness.³³ A study carried out with nursing professionals shows that there is a lack of knowledge on the subject, social representations that are impregnated with judgments and prejudices, biological discourses and a pathological vision involving these people.¹,¹⁰

A systematic review study identifies some clinical strategies for affirmative interventions: a) to provide psychoeducation; b) to allow space for families to express reactions to their children’s gender; c) to emphasize the protective power of family acceptance; d) to use multiple support modalities; e) to provide families with opportunities for alliance and advocacy; f) to connect families to community resources; and g) to centralize intersectoral approaches and concerns.³⁴

This study has shown there is a necessity for us to think about intersectoral actions aimed at promoting the empowerment of transgender people and a support network that can be internal and external to the family. Nursing professionals must carry out a family approach, so that they can receive guidance on the importance of family support for promoting the physical and mental health of transgender people.³⁰

There is a need for a partnership between health services, organized social groups aimed at this public and higher education institutions aiming to promote education and training of health professionals to welcome and meet the health demands of transgender people; In addition, health courses, especially nursing, should include gender and sexuality as a mandatory subject in their curricula, with emphasis on non-normative sexualities and gender identities; That nurses guarantee transgender people treatment according to the gender with which they identify, as a synonym for quality in health care and guaranteeing the implementation of existing policies, human rights and obedience to the principles of equity of the Unified Health System (SUS in Brazil).¹

It is essential to recognize the vulnerabilities faced by transgender people and ensure care that respects their uniqueness, providing comprehensive care centered on humanized and holistic care. In this context, nursing plays a crucial role in identifying and addressing the challenges faced by families of transgender people. By promoting effective communication within the family, it contributes to building more solid and understanding bonds.

The limitations of this study were: a) the lack of face-to-face contact with the transgender people in the research, due to the COVID-19 pandemic. b) Difficulties in accessing the internet for transgender people to participate in the interview. c) The majority of articles cited were written by cisgender authors. d) The considered universe of 70 people may be underestimated, as it is a survey by a local non-governmental organization. e) The sample was intentional and not probabilistic.

Conclusion

This study identified that the transgender people interviewed presented mental suffering by identifying the presence of suicidal ideation in the last year, lifetime suicide attempts, risk of depression and low family support. Pansexual transgender women had a greater anxious personality trait and bisexual transgender women experienced a greater anxiety state. Community Activism was more committed to empowering transgender people, indicating difficulties in the struggles of social collectives.

Referências

• ¹
  Albino MS, Garcia OR, Rodriguez AM, Wilhelm LA. Vivências de pessoas transgênero e equipe de enfermagem na atenção à saúde: encontros e desencontros. Cadernos Genero Diversidade. 2021;7(3):176-99.
• ²
  Ruiz MS. Histórias de vida e trabalho de pessoas transgêneras em Foz do Iguaçu/PR. Biblioteca Digital de Teses e Dissertações: Universidade Estadual do Oeste do Paraná; 2022. [citado 2022 Dez 12]. Disponível em: https://tede.unioeste.br/handle/tede/6020
  » https://tede.unioeste.br/handle/tede/6020
• ³
  Corrêa FH, Rodrigues BB, Mendonça JC, Cruz LR. Pensamento suicida entre a população transgênero: um estudo epidemiológico. J Bras Psiquiatr. 2020;69(1):13-22.
• ⁴
  Façanha C, da Silva EG, Meira JC, de Castro EH. Pessoas LGBTQUIA+ preconceito e superação: movimento para além da dor e do sofrimento sob o viés da fenomenologia. Rev EDUCAmazônia. 2021;13(2):384-408.
• ⁵
  Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, et al.; Italian Working Group on LGBTQI Mental Health. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. 2022;34(3-4):292-359.
• ⁶
  American Psychiatry Association (APA). Diagnostic and Statistical Manual of Mental disorders - DSM-5. 2014 [cited 2022 May 26]; 2-12. Available from: http://dislex.co.pt/images/pdfs/DSM_V.pdf
  » http://dislex.co.pt/images/pdfs/DSM_V.pdf
• ⁷
  Goodfellow B, Kõlves K, de Leo D. Contemporary Definitions of Suicidal Behavior: A Systematic Literature Review. Suicide Life Threat Behav. 2019;49(2):488-504.
• ⁸
  Zwickl S, Wong AF, Dowers E, Leemaqz SY, Bretherton I, Cook T, et al. Factors associated with suicide attempts among Australian transgender adults. BMC Psychiatry. 2021;21(81):81.
• ⁹
  Baptista MN. Desenvolvimento do Inventário de Percepção de Suporte Familiar (IPSF): estudos psicométricos preliminares. Psico-USF. 2005;10(1):11-9.
• ¹⁰
  Cortes HM, Arauo LM. Repercussões da exclusão social na saúde mental de pessoas transgêneras. In: Sequeira C, Carvalho JC, Sa L, Seabra P, Silva M, Araujo O., editores. XI Congresso Internacional da ASPESM: mais saúde mental (Ebook]. Porto: ASPESM, 2020. p. 40-9. Disponível em: https://issuu.com/spesm/docs/final_e-book_2020_congresso_online-3_2
  » https://issuu.com/spesm/docs/final_e-book_2020_congresso_online-3_2
• ¹¹
  Durwood L, Eisner L, Fladeboe K, Ji CG, Barney S, McLaughlin KA, et al. Social Support and Internalizing Psychopathology in Transgender Youth. J Youth Adolesc. 2021;50(5):841-54.
• ¹²
  Jesus JG, Alves H. Feminismo transgênero e movimentos de mulheres transexuais. Rev Cronos; 2010. 11(2). [citado 2024 Abr 29]. Disponível em https://periodicos.ufrn.br/cronos/article/view/2150/pdf
  » https://periodicos.ufrn.br/cronos/article/view/2150/pdf
• ¹³
  Pinto MS, Oliveira HX, Barbosa JC, Ramos AN. Guia de Aplicação da Escala de Empoderamento. Universidade Federal do Ceará. 2019 [citado 2021 Nov 12]. Disponível em: https://www.nhrbrasil.org.br/images/1-Guia_Escala_de_Empoderamento_2019.pdf
  » https://www.nhrbrasil.org.br/images/1-Guia_Escala_de_Empoderamento_2019.pdf
• ¹⁴
  Gomes T. Alagoas tem 70 transgêneros à espera de cirurgia de mudança de sexo. Gazeta de Alagoas. 2020 [citado 2021 Nov 15]. Disponível em: https://d.gazetadealagoas.com.br/cidades/247174/alagoas-tem-70-transgeneros-a-espera-de-cirurgia-de-mudanca-de-sexo
  » https://d.gazetadealagoas.com.br/cidades/247174/alagoas-tem-70-transgeneros-a-espera-de-cirurgia-de-mudanca-de-sexo
• ¹⁵
  Heckathorn DD, Cameron CJ. Network sampling: from snowball and multiplicity to respondent - driven sampling. Annu Rev Sociol. 2017;43(1):101-19.
• ¹⁶
  Fioravanti AC, Santos LF, Maissonette S, Cruz AP, Landeira-Fernandez J. Avaliação da estrutura fatorial da Escala de Ansiedade-Traço do IDATE. Aval Psicol. 2006;5(2):217-24.
• ¹⁷
  Andrade L, Gorenstein C, Vieira Filho AH, Tung TC, Artes R. Psychometric properties of the Portuguese version of the State-Trait Anxiety Inventory applied to college students: factor analysis and relation to the Beck Depression Inventory. Braz J Med Biol Res. 2001;34(3):367-74.
• ¹⁸
  Gonçalves B, Fagulha T. The Portuguese version of the center for epidemiologic studies depression scale (CES-D). Eur J Psychol Assess. 2004;20(4):339-48.
• ¹⁹
  Lima T. Educação básica e o acesso de transexuais e travestis à educação superior. Rev Inst Estud Bras. 2020;77(11):70-87.
• ²⁰
  Silva MA, Luppi CG, Veras MA. Work and health issues of the transgender population: factors associated with entering the labor market in the state of São Paulo, Brazil. Cien Saude Colet. 2020;25(5):1723-34.
• ²¹
  Diéguez CRMA, Rodrigues CCP, Venturi G, Bicev JT, Adamos RE. Mapeamento das Pessoas Trans na Cidade de São Paulo: relatório de pesquisa. Centro de Estudos de Cultura Contemporânea (CEDEC). Relatório n° de janeiro de 2021: TFM/074/2019/SMDCH/LGBTI. Processo administrativo n°: 6074.2019/0003541-3.
• ²²
  Fernández-Rouco N, Carcedo RJ, López F, Orgaz MB. Mental Health and Proximal Stressors in Transgender Men and Women. J Clin Med. 2019;8(3):413-27.
• ²³
  Francisco LC, Barro AC, Pacheco MS, Nardi AE, Alves VM. Anxiety in sexual and gender minorities: an integrative review. J Bras Psiquiatr. 2020;69(1):48-56.
• ²⁴
  Silva RR, Silva LA, Souza MV, Silva MV, Neves MP, Vargas D, et al. Minority gender stress and its effects on mental health as a risk factor for depression in transgender persons: literature review. Res Soc Dev. 2021;10(3):e51610313693.
• ²⁵
  Brown C, Porta CM, Eisenberg ME, McMorris BJ, Sieving RE. Family relationships and the health and well-being of transgender and gender-diverse youth: a critical review. LGBT Health. 2020;7(8):407-19.
• ²⁶
  Braz DG, Reis MB, Horta AL, Fernandes H. Vivências familiares no processo de transição de gênero. Acta Paul Enferm. 2020;33:eAPE20190251
• ²⁷
  Melo DS, Silva BL, Mello R. A sintomatologia depressiva entre lésbicas, gays, bissexuais e transexuais: um olhar para a saúde mental. Rev enferm UERJ. 2019;27:e41942.
• ²⁸
  Radusky PD, Zalazar V, Cardozo N, Fabian S, Duarte M, Frola C, et al. Reduction of gender identity stigma and improvements in mental health among transgender women initiating HIV treatment in a trans-sensitive clinic in Argentina. Transgend Health. 2020 Dec;5(4):216-24.
• ²⁹
  Silva GW, Meira KC, Azevedo DM, Sena RC, Lins SL, Dantas ES, et al. Factors associated with suicidal ideation among travestis and transsexuals receiving assistance from transgender organizations. Cien Saude Colet. 2021;26 Suppl 3:4955-66.
• ³⁰
  Bomtempo J, Mendes JA. Risco, Proteção e Empoderamento na Adolescência Transexual: reflexões a partir de um estudo de caso. In: Lima AO, Andrade TA, Cunha UC. Juventudes: pesquisas e campos de atuação. Editora CRV; 2020. p. 37-52.
• ³¹
  Selles BR, Almeida PF, Ahmad AF, Lemos A, Ribeiro CR. Redes sociais de apoio às pessoas trans: ampliando a produção de cuidado. Saúde Debate. 2022;46(Supl 6):148-61.
• ³²
  Pflugeisen CM, Boomgaarden A, Denaro AA, Konicek D, Robinson E. Patient Empowerment Among Transgender and Gender Diverse Youth. LGBT Health. 2023;10(6):429-38.
• ³³
  Rosa DF, Carvalho MV, Pereira NR, Rocha NT, Neves VR, Rosa AD. Nursing Care for the transgender population: genders from the perspective of professional practice. Rev Bras Enferm. 2019;72 suppl 1:299-306.
• ³⁴
  Malpas J, Pellicane MJ, Glaeser E. Family-Based Interventions with Transgender and Gender Expansive Youth: Systematic Review and Best Practice Recommendations. Transgend Health. 2022;7(1):7-29.

Edited by

Associate Editor

Thiago da Silva Domingos (https://orcid.org/0000-0002-1421-7468) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  23 Sept 2024
• Date of issue
  2024

History

• Received
  21 Oct 2023
• Accepted
  29 Apr 2024