ORIGINAL RESEARCH

The medicalization and pathologization in the perspective of transgender women: accessibility or social exclusion

Janaina Janini Pinto^I; Rosângela da Silva Santos^II; Octavio Muniz da Costa Vargens^III; Luciane Marques de Araújo^IV

^INurse. PhD in Nursing, State University of Rio de Janeiro. Brazil. E-mail: jjanini40@gmail.com
^IINurse. PhD in Nursing. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: rosangelaufrj@gmail.com
^IIINurse. PhD in Nursing. Full Professor, Nursing School, State University of Rio de Janeiro. Brazil. E-mail: omcvargens@uol.com.br
^IVNurse. PhD in Nursing. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: lmdearaujo@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.29009

ABSTRACT

Objectives: to describe the transsexual women's perception about access and treatment in the process of transsexualization, and to discuss their vision regarding pathologization and medicalization. Method: descriptive, qualitative research with 40 transsexual women, performed between December 2016 and April 2017, using semi-structured interviews. Data were submitted to content analysis. The Research Ethics Committee approved the project (CAAE 64975517.9.0000.5266). Results: a category emerged Identities, depathologization and demedicalization - interfaces and dissidences of the autonomy of transsexual women, with subtheme: Medicalization of identity: hindrance or guarantee of transsexual rights? The pathologized and medicalized view predominate in the assistance to transsexual women. They experience medical domination and do not participate in decisions about surgical time and other elements of treatment. Conclusion: transsexual women do not understand transsexuality as pathology. However, they perceive the pathological view of the professional as something naturalized and submit themselves to this condition in order to get access to the process of transexualization.

Keywords: Transgender persons; medicalization; power; gender identity

INTRODUCTION

The view on health has undergone significant changes regarding the pathological production of diseases related to the psychic suffering and the re-reading and configuration of new means for achieving well-being. This concept of well-being emerges as an idealized and naturalized goal for reaching the quality of life and active life of the individuals, as well as fuel for the social relations of sociability.¹

One of the strategies used to achieve this well-being is the medicalization, which is massively adopted in the health area.² With the transsexual women it was not different. There are reports on the contemporary ontological trajectory, highlighted in the nineteenth and twentieth centuries, about the discomfort of transsexual women and men regarding their physical inadequacy, mediated by surgical mechanisms of genitals castration^3,4 for the correction of anomalies that were present.

This physical inadequacy is studied and defined as an antagonism between the biological gender and the gender identity, determining behaviors and practices and feelings by the affinity for transsexual women and not by the biological gender.⁵

The divergence between this identity concept, which is distinct from the biological gender, contradicts the concept of normality determined by the most common state found in society⁶ and it raises social questioning with subsequent need for control by medicalization, leading transsexuality to be understood and classified as a pathology. There were some change movements in the scenario, but it still persists as pathology by the Diagnostic and Statistical Manual of Mental Disorders (DSM - V) and the International Classification of Diseases (ICD - 10).^7,8

In the pathologization logic, authors define the DSM - V as a classificatory method, which determines transsexuality as a mental disorder to be treated and, consequently, pathological^1,9, in addition, they end up imbricating and inferring about the transsexual person in the health environment. The public health policy called the transsexualization process (TP) was intended to promote the hormonal and surgical contribution to the resolution of the physical inconformity of the transsexual women, counting on multidisciplinary care to advise this process, considering the "[...] need to establish standardization of the indication criteria for performing the procedures provided for in the transsexualization process, the transformation of the male to the female phenotype [...]".^10:25

Following the same reasoning line, the ICD-10 defines as such criteria the manifestation of the desire to live and to be accepted as a member of the opposite gender, along with the need to use hormonal and surgical treatment for physical adequacy.^11,12

The construction/nosological definition of transsexuality serves to perpetuate the health-disease model according to a pattern and, thus, expropriating the identity singularities of each transsexual woman. In this sense, it is questioned: Is the transsexual woman's thinking about her identity needs disregarded by the medical judgment? Does the transsexual woman have dominion over her body and over the desire for bodily changes?

For further clarification on such questions, the objective is: to describe the perception of transsexual women about access and treatment in the TP and to discuss their views regarding the pathologization and medicalization of this process. It is emphasized that the term transsexual women is attributed to those who have male biological gender, but with the female gender identity.^3,4

LITERATURE REVIEW

The concept of medicalization in the 60s and 70s of the twentieth century was highlighted by Ivan Illich and Irving Zola, who offered strong criticism regarding the medical action on the society. They referred to the whole movement of articulation of non-medical problems to a condition in the scope of medicine, using it to implement and regulate the society.^13-15

Medicalization consists of a tool organized through an interpersonal network, based on organizations, laws, normative decisions, conceptions understood as scientific or philosophical that determine that "what is said and not said are the elements of the device."^16:244 Thus, the medicalization is a social network device that determines normality patterns and the place that each individual occupies in society, according to the practices and behaviors adopted.

From this context, the medicalization becomes a mediator of conflicts and transforms all social issues into a state of dependence on biomedicine. Thus, humanity was subjected to a process of pathologization of normality, and to it some labels were attributed, aimed at framing situations that escaped a normative ideology of social well-being.^2,17

In an antagonistic way, the demedicalization and depathologization are the result of a system of thoughts that values feelings and identities, which encourage the individual empowerment¹⁸ within the context of health.

METHODOLOGY

It is a descriptive, qualitative research that had as sample 40 transsexual women, enrolled in the Transsexual Process of a public institution of reference to endocrinological care, located in the city of Rio de Janeiro.

Although the interviewees have not performed the surgery of gender re-designation and the prename process in the civil register, they were referred to here as transsexual women, in respect and accreditation to their identity perception.

The data collection was performed between December 2016 and April 2017, through a semi-structured interview, with questions regarding the perception of the woman about the acceptance of the diagnosis for inclusion in the transsexualization process and their trajectory in this process.

The inclusion criteria adopted were: transsexual women in the age group between 18 and 59 years old, submitted to endocrinological and psychiatric medical care in the public health policy of the transsexualization process, not sexually reassigned. Transsexual women who were diagnosed with psychiatric disorders were excluded.

The narratives were transcribed and submitted to the material exploration, the data were treated according to the content analysis, organized by similarity, and analyzed in the thematic modality.¹⁹ As a result of this process, the following sub-themes arose: Identities, depathologization and demedicalization: interfaces and dissidences of the autonomy of the transsexual woman , from which a thematic subunit derived: Identity medicalization: hindrance or guarantee of the trans' right?

After the execution of the observed steps, the analysis of the thematic content based on the Foucaultian concept of medicalization and pathologization^2,3 about the transsexualization process and the perspective of demedicalization, depathologization and gender was carried out.

In compliance with the Resolution 466/12, all the interviews were appraised and authorized, through the application, reading and signing of a Free and Informed Consent Term (FICT), and the project was approved by the Research Ethics Committee, through the protocol CAAE 64975517.9.0000.5266.

RESULTS AND DISCUSSION

Identities, depathologization and demedicalization: interfaces and dissidences of the autonomy of the transsexual woman

The interviewees do not understand transsexuality as pathology, but they perceive the pathological view of the professional as something naturalized and submit to this condition to have access to the Transsexualization Process:

Although transsexual women do not perceive themselves to be ill, nor as disrupted, as stated in ICD-10,⁴ the pathological view/attitude of the professionals still persists, forcing the users to be called crazy to have access to health services. Thus, the medicalization of the trans identities denies the gender plurality, although it has enabled the recognition of the possible physical needs for reversion and access to technologies for the physical changes desired by the transgender women, provided by transgendering and hormone therapy.^8,13

The adjustment of the biological matrix of transsexual women in itself ends up reaffirming the hetero-normative concept, since these trans women perceive no other way of being and feeling as women than through the genital adjustment.

Thus, as an auto-poietic system, the hetero-normative model was foundational for the binary construction of transsexual women. From there, identities are defined that do not contradict, but reaffirm this binary male-female model and the search for access to technologies for physical adequacy.³

However, the fulfillment of this well-being, as well as all the expectations of the transsexual women, through the corporal changes, is dependent on the medical diagnosis.

Thus, while these transsexual women recognize the TP as an emancipatory process, they also see it as a prison, since they must pretend to recognize themselves as sick even though they disagree:

The medical field has played a collective control of the body in which all the situations of a natural order of the society come to be analyzed on a specific optics and sectioned within the health-disease binomial, fact that can imply the health care process.^12,20 The pathologization of social order works as a tool for social control of the body and criticizes the model of pathologization of madness, reporting to madness as a state of rational vegetation, and the doctor has the responsibility of sanitizing them.²¹

This rational vegetation reveals the condition of the intellectual disempowerment of transsexual women who must confess the unbelievable as an absolute truth to the health professional, to guarantee their access to the TP.^21,22 This practice reveals a relationship of domination between health professionals and transgender women,²¹ which is given less force by the users, since they must comply with the conditions stipulated to have access to TP policy.

In this sense, the idea of depathologization accompanies a series of purposes that begin in the untying of transsexuality to the disease, as well as in the imposition of medical power on the bodies of transsexual people. The depathologization also proposes to dismantle closed concepts of the transsexuality diagnoses, since transsexual people do not fit into the preconceived definitions of physical adjustment²³, in addition, it ends up hindering the access to health care for transgender people who do not wish to make all the interventions that are offered in the transsexualization process.

This is due to the need for a causal association of health-disease and failure to meet the stipulated pathological pattern of transsexuality can lead to the loss of the services earned and subsidized by the Unified Health System (SUS – Sistema Único de Saúde).²⁴ As a solution to this dilemma, there is a reinvention of the social understanding about diversity, in the perspective of its confrontation.²¹

In this sense, significant changes are needed in the care of transsexual people, focused on changing the current model of assessment based on an informed decision, so that the users do not need to be subordinated to the therapeutic facilitation that the pathologization of transsexuality provides.^4,24

Identity medicalization: hindrance or guarantee of the trans' right?

The pathologization, evidenced in the diagnostic manuals that define transsexuality, is nothing more than a strategy of domination used in the medicalization process. Although in a differentiated way, both decline social problems to the category of medical and interventionist domain. ²⁵

The process of domination exercised by medicalization begins when society gives the doctor the authority to determine rules and guide the ways of living in modernity.²¹ The medicalization is a social construct of ethnocentric cleaning, acting as an apparatus of domination over the transsexual users in health, with the accomplishment of medical and surgical procedures in specialized units,^11,20 in face of the diagnosis.

Transsexual women who reported self-medication had their practices reoriented for the use of medications registered by the TP's medical professional:

This reorientation of the self-medication by the healthcare professional in service is done through the use of estrogens¹⁸ to change the sexual and secondary characters of the transsexual women. There are risks arising from the use of these drugs that should be elucidated, as well as sharing the therapeutic possibilities of the drugs offered by SUS, which does not happen.²⁶

The State only consolidates such conduct by placing the decision-making power on the hands of the doctor who cares for transgender women. In this sense, the use of standard procedures can be harmful, since these women do not have the right to decide on their bodies. Thus, not only the process of depatholization, but also demedicalization, should promote greater autonomy, allowing the other to have power over their body, their health and their well-being, as well as provide an overview at new possibilities of living beyond of the normalized.^21,22

The proof of life has been an equally disempowering procedure for users. It refers to the time in which the transsexual person must dress and behave according to their gender identity, daily.²⁷ In this process, the execution time of identity practices and behaviors are legitimized by the current legislation, both as a diagnostic basis for transsexuality and, from there, the access to the transgenitalization surgery.

The need to prove the real form, the female identity, shows the absence of the transsexual women's rights over their bodies, and places the medical professional with complete regulatory and interventionist control over them and, consequently, criminal liability for any decision taken wrongly.²⁸

It is then perceived that the decision-making process on the bodies of transsexual women is under strong medical domination and their participation in decisions is not allowed, imposing on them a condition of protection. As a training process, bodies are built and authenticated from a social point of view.²¹

In this perspective, power ceases to be considered only as an action on a body to train it, and to make it docile, and freedom is seen as an essential condition for the exercise of power. There is the opening of a space for creating new and resilient actions, that is, for the struggle against forms of ethnic, social or religious domination; against the forms of exploitation that separate individuals from what they produce and against the forms of subjection that link the subject to himself. ²¹

As the contradictory access to health, permeated by the state, there is a pseudo empowerment of transsexual women over their bodies, which occurs in a manner consented by dominant individuals or groups,²⁵ properly represented by the psychiatrist, along with the multidisciplinary team that reiterates its conduct.

The term medicalization of life is used to emphasize the hierarchical power relations between the physician and the patient. Unlike other authors who approach the subject, Foucault's proposal was to improve the idea of medicalization, which uses the principle of bio-power, building medical knowledge as a social truth and a tool for disciplining and domesticating the subjects.²

Thus, power relations through the medicalization are constant in caring for transsexual women in the TP, permissively by transsexual women, in the desire to guarantee their access to hormonal and surgical treatment. It is necessary a remodeling in the way of thinking and in relating of the health professional towards the user, in order to assure more autonomy and empowerment of the decision-making process of the transsexuals.

CONCLUSION

It is concluded that the pathologization and medicalization process is present in the care of transsexual women. This process compromises the autonomy and the decision-making capacity of the users, as opposed to the control of the health professionals about their bodies.

The transsexual women undergo a pathological condition to access the TP, although they do not understand their transsexuality as pathology.

The interviewees revealed the existence of a feeling of domination regarding the access to the health policy, and they continue to be dominated throughout their therapeutic process. The decision making about their body and hormonal and surgical treatment is not informed in the therapeutic proposal, which generates a certain degree of abstraction about the interventions they are experiencing, as well as anxiety about the celerity of their physical changes, both hormonal and surgical ones.

It is urgent to remodel the view of the health professional who acts in the medicalization process, abandoning the pathological strategy and creating room for the expression of the transsexual users in their own care, in order to guarantee greater autonomy and their empowerment in the decision making related to their bodies.

It should be emphasized that the qualitative research does not allow generalization, and this is a limitation of the study.

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