INTRODUCTION

Gender identity is characterized by the individual's self-recognition of his or her own gender. Thus, transvestites possess gender identity that differs from the sex they were assigned at birth. "The ambiguity or sexual duplicity in the very identity affirmation" that transvestites possess are part of the context and social construction they experience and is conFigured as an ongoing process that relies on feminine performances and gender technologies that are constantly under construction. From this non-linearity between sex-gender-body there is the production of processes that will strain the binary logic of gender and make them victims of transphobia^1)(2)(3.

Transphobia is associated with the social context of stigma, discrimination, violence and denial of the exercise of their citizenship, which can result in physical and psychological damage and even death, corroborating the life expectancy of up to 35 years for transvestites and transsexual women. The precarious living conditions result from social exclusion and marginalization, directing as main inducers the weakened or broken support networks, and the exclusion/avoidance of the areas of education, health, and work. This context results in insufficient alternatives for formal employability and labor rights, placing sex work among them as one of the only forms of (over)living^4)(5)(6)(7. Nursing, as a profession aligned with social processes and the health-disease process, is expected to establish criticism when it essentializes the practices and experiences of transvestites and to understand the biosocial nature of their experiences and existence. In addition, it is necessary to rethink the very concept of the individual present in the nursing metaparadigm, observing the pitfalls and universalism present therein⁸.

Transvestite sex workers experience social processes resulting from the hierarchization of powers that legitimize which lives matter. Transvestite bodies are associated, in the social imaginary, with sexual fetishes and the relation of domination by clients, which added to the lack of health education actions and social protection programs, potentiates vulnerable processes, resulting in a greater exposure to sexually transmitted infections (STIs), physical, verbal, psychological, and sexual violence, discrimination, stigma, and psychosocial diseases that will impact their quality of life^{4)(5)(6)(7)(9}.

The Theory of Social Representations (TSR) provides a theoretical and scientific basis for understanding the daily experiences of people and social groups such as transvestites. Social representations are considered as systems of values, ideas, and practices with a double function - to know and intervene in reality, identifying them in order to understand socially constructed and shared phenomena that become familiar by satisfying the argumentative reasoning of common sense^10,11.

It is believed that by adopting this theoretical framework it will be possible to analyze the representations of transvestite sex workers about quality of life¹⁰, involving the sociocultural context and the value system in which the individual is inserted, taking into consideration expectations and concerns¹¹ and the way in which they are reproduced in the context in which they are inserted. The identification of such representations will make it possible to understand the phenomena constructed. These phenomena will present themselves as a fundamental resource for the interpretation of the quality of life of the social group in question, becoming a powerful instrument of reflection and a guiding axis for the practices of health professionals, in general, and nursing, specifically, enabling the articulation between reflection, social history, and criticality of social and scientific knowledge¹¹. Thus, the following research question was defined: what are the social representations of transvestite sex professionals about quality of life? And as an objective to identify the social representations of transvestite sex workers regarding quality of life.

MATERIAL AND METHOD

Ethical aspects

The study met the standards established by Resolution No. 466 of December 12, 2012 of the National Health Council of the Ministry of Health¹². Data production occurred after approval by the Ethics Committee on Research Involving Human Beings (REC) of the Federal University of Pernambuco. All participants who agreed to participate in the research were provided with the Free and Informed Consent Term.

To ensure the anonymity of the participants, the statements were identified by the codename "Participants" followed by the order in which the interviews were conducted: 1, 2, 3, etc.

Type of study

This is a qualitative, descriptive, exploratory research, anchored in the TSR, which seeks to explore common sense to characterize previously unknown concepts. It is noteworthy that this theory aims to explain the origin as well as the transformation of knowledge, which is in line with the interests of humanity¹⁰. In addition, this study met the Consolidation Criteria for Qualitative Research Reports (COREQ)¹³.

Study Scenario

This research took place in the city of Recife, Pernambuco, Brazil, using as initial reference a social space for exclusive care of LGBT people. The place was chosen for hosting and providing medical, legal and social assistance to the population of interest of the study.

Study participants

The participants were selected using the Snowball chain technique, in which an individual from the study population, called a seed, indicates other individuals from his or her own social network. The sampling was by convenience, not probabilistic, following the criteria of theoretical saturation¹⁴, Thus, it included seven transvestite sex professionals. We included transvestites of the female gender, over 18 years old, of any sexual orientation and who were sex professionals.

Collecting and organizing data

Data collection occurred in the first half of 2020, through a questionnaire with sociodemographic variables consisting of: age, marital status, who lives with, and how the demand for health services occurs; and interviews guided by a semi-structured script containing the following guiding questions: 1) Tell me about your life story; 2). Tell me what you understand by quality of life; 3). In your opinion, do you have quality of life? If yes, explain me. It is noteworthy that two interviews were conducted before the inclusion of the first participant, with the purpose of obtaining the internal validation of the data collection instrument and to ensure the methodological rigor of the study, thus avoiding dubious interpretations¹⁵. The tests applied, therefore, were not included in the final sample.

It is worth mentioning that the script was used more as a guide during the empirical data production journey¹⁴, due to the researchers' recognition of the dynamics present in the field and to consider subjective aspects of the study. The researcher was immersed in the social space for prior knowledge of the dynamics of operation and bond building with the team and target audience. After this moment, the research was explained to a key informant of the space, who indicated the first participant of the study.

Data collection started with the researcher approaching the first participant indicated by a key informant of the service established as a starting point. This was followed by the application of the questionnaire and an interview in a reserved place. At the end of the survey, a new participant was asked to be indicated. The participants that integrated the sample of this study had links with other NGOs located in the micro-region of the city of Recife, made possible by the access to an exclusive network of transgender people, identified from the indications. Despite the location and the access to an exclusive network of sociabilities of transgender people, there were, during the fieldwork, two refusals to participate in the study.

The saturation of the empirical data occurred after the 6th interview, with one more being conducted for confirmation, which totaled 7 interviews. To determine the reach of saturation, the following eight procedural steps were followed: I) Registration of raw data (primary source); II) Immersion in the data; III) Compilation of the individual analyses of each interview; IV) Grouping of themes and/or pre-categories; V) Naming the data; VI) Allocation of the themes in a Table; VII) Constructing the theoretical saturation for each pre-category and VIII) Visualization of theoretical saturation. For the recording of the reports, two voice recorders were used¹⁶. It is noteworthy that all steps to reach saturation were performed by three researchers. The interviews lasted an average of 35 minutes, and were later transcribed and validated by the participants, since these same interlocutors had access from the telephone contact previously made available.

Data analysis

Data analysis was performed using the Thematic Content Analysis technique. The same was systematized as follows: pre-analysis - a floating reading was performed, applying the principles of completeness, representativeness, homogeneity and relevance; exploration of the material - phase consisting of coding operations, performed from key terms and interrelated themes resulting in thematic categories; interpretation - treatment of results and interpretation in the light of the theoretical framework of SRs¹⁷. The following criteria were used for the validation and reliability of this research: methodological and researcher triangulation¹⁸.

RESULTS

This study composed the representational universe of seven professional sex transvestites, with an average age of 29.1 years. Regarding marital status, four were single and three were in a sTable relationship. Regarding schooling, four mentioned having studied up to elementary school, two completed high school, and only one completed higher education; all mentioned being heterosexual. Three of them live with their families, two alone, and two with their partners. When asked about the frequency in relation to seeking health services, five mentioned going often, and two occasionally. None of them have children.

All the participants of the study come from micro-regions of the State of Pernambuco, Brazil. Of the seven participants none has a formal job, excluding the gender profession. Six consider their economic situation bad, living in unfavorable economic conditions, and one participant considers average.

From the Content Analysis, three thematic categories emerged: "The access to health as a principle to quality of life"; "NGO support in the visibility and respect to the demands of trans people" and "Social bonds as a propositional tool in the meaning of quality of life".

The thematic class "Access to health as a basic principle for quality of life" is characterized by the importance of having access to health services in the context of being a sex worker, in addition to having health professionals who respect their gender identity in care. It is noteworthy that the barriers posed by the binary and heteronormative system is one of the reasons why participants do not seek health services, or when they do, they experience the assistance of health professionals that relativize and/or invisibilize their needs, besides having their demands managed from a care focused on the identification of STIs.

I have already stopped going to health services, because I felt affected by a doctor who denied me hormone treatment, claiming that no one at the clinic took care of that and that hormones were for women and not for men. (Participant 1)

Quality of life is to be healthy, first of all you have to have access to health, because without health there is no way to fight for a better life. (Participant 2)

I have stopped going to the health service several times because of prejudice, the health center itself, I never went, I got syphilis when I was 18, but I was afraid to go because the prejudice is huge, both from professionals and the people around me. (Participant 3)

In relation to access to health services today is very relative, prejudice will always exist, transphobia and homophobia. We always go through one or another embarrassment, because there are employees who are there, but don't want to help us and always find a way to make a "joke". (Participant 4)

"The support of NGOs in the visibility of respect and existence of trans lives" was another class unveiled in the thematic analysis. It is possible to observe how the support of NGOs has fundamental importance in the representation of a decent quality of life for the participants of this research and how these positively impacted the change in their lives, identifying the moral support, companionship, complicity, actions to raise awareness of the population and access to health issues promoted by NGOs, as it is highlighted:

Today I no longer have difficulties in accessing health services, but this is because of the NGO, because before we had, especially those who live in the periphery. (Participant 7)

The moral support of the NGO improved my situation a lot, mainly after we started to know each other better, self-knowledge is very important for people who live in prostitution. (Participant 4)

The NGO makes the health issue much easier, because first we didn't have an outpatient clinic for LGBT people and now it has one, so it makes it easier, so that when you arrive you won't be looked at with prejudice. Because no matter how many studies health professionals have, there will always be a look of prejudice, but here there is not. This NGO has a great positive impact, both for me and for the whole LGBT community. (Participant 2)

The NGO is wonderful, the service with us is much better, because the service is specific to our needs, we feel more welcomed, we are very well taken care of by the health professionals, it is such a nice warmth, you feel at home, the question of complicity, the companionship, the respect, the reciprocity of the professionals is very nice, I feel very good, very good here, because I have the privilege of making my appointments, exams, and explain everything right. After the NGO my health has improved a lot. (Participant 5)

Before the NGO, only jesus in the cause, it was an agony, a penance. The health professionals didn't want to help us, they always said that they ran out of records, they always had to take the mother as a companion, it was a difficulty; but with the NGO they were much calmer, we mark the records all right, we arrive and are well assisted by everyone, they welcome us, respect us with education. (Participant 6)

"Social ties as a propositional tool in the meaning of quality of life" was the last thematic class that emerged in the context of data production. The interpretation of this class goes through contexts of self-identification of participants as transvestites; the processes that weakened the support networks in the family and culminate in scenarios that will produce suffering and provide difficulties in adulthood, having, thus, the reception and support of networks established from neighbors, friends and even strangers, as described:

It's like I always say, you have spent your whole life in that suffering, when you meet friends who support you, for you this is very important, especially for so many bad moments that you have gone through in prostitution. (Participant 4)

When I was 16 I met a friend who was gay, and he helped me a lot, he saw that I needed some things, because I had called my mother from the phone booth crying, and she told me that she was not going to give me, that she had no responsibility for me, that I no longer lived with her, she threw a lot of things in my face. (Participant 1)

Sometimes we have more support from a stranger, from a neighbor, from a friend, but not from our own family. (Participant 7)

The process of acceptance with my family has always been difficult, they can stand it, right, because they are Christians, but they will never accept it. (Participant 2)

DISCUSSION

The widespread and socially constituted common sense integrates the reality of transvestites throughout their lives as the process of social exclusion and the conformation of these marginalized groups is established, especially in prostitution spaces. The forms of communication, thoughts and practices of the participants who are sex professionals are based on the historical process of meanings linked to the objectification of their bodies, expressions and experiences that break the concept of social normality and make them vulnerable.

It was possible to identify that the SR of transvestites on quality of life is associated with having health and access to services in a respectful and inclusive way, however, the objectification goes through the fear of prejudice and is expressed in repulsion and not seeking health care. The appropriation of reality by the interlocutors is expressed in reports about the difficulties faced for a respectful relationship with health professionals and their unpreparedness to implement care actions for this social group.

The representations about quality of life emerge in a social scenario resulting from the exclusion experienced daily and historically by the participants, in addition, the empirical data show the condition and multifactorial processes that make them vulnerable, showing that their daily lives are tied to practices and norms that reproduce discriminatory and transphobic processes. It is necessary to understand that having access to health is, first of all, to understand that this is an essential element in the structuring of health services, public or private, permeated from the entry of users to services, until the completion of treatment, or even, their participation in any action offered by the health service¹⁹.

The discussion about access to health care for transgender people is in vogue in the literature, demonstrating how it is permeated by exclusion, discrimination and violence^20,21. There is also evidence of an inequality in meeting the specific demands of the trans population when compared to other social groups²². It is important to point out that the participants' conception of quality of life is influenced and results, to some extent, from the various social structures that hierarchize lives, placing them in subordinate positions. Enabling the access to health for the participants demands articulations of actions that go beyond health promotion and disease prevention, but that allow spaces for dialogues, construction, and a continuous re-signification of knowledge generated from a vision that essentializes the potentialities, experiences, and narratives of the participants.

The class and power relations historically constituted in society relativize the lives of transvestites, since there are processes that go beyond reproducing mechanisms of oppression, designating which lives are considered important to society. The spaces and social relations are sometimes projected through images, languages, and by the binary logic for people who compose the cisheteronormativity. In this sense, the representations of transvestites are constituted between thinking and acting in ways of survival from the search for shelter spaces, even if clandestine, being prostitution one of the main reflections of their reality.

It is essential to think of services (social, and especially health services) and professionals who are able to meet the demands of the interlocutors in a comprehensive way, because it is known that the representation and meaning of certain concepts, such as quality of life, is a collective and individual construction that is permeated by conceptions that can be created and recreated from experiences, cultural and social values²³. And when discussing access to health, it means, first of all, that this is a fundamental right guaranteed by the State, however, what gains prominence is that this access is insufficient and weakened in the context of the participants of this research, limiting and significantly disrupting the experiences and quality of life of transvestites, after all, how to have quality of life without health? A right that, theoretically, is guaranteed by the 1988 Federal Constitution and by the organic laws of the Unified Health System (UHS).

In the daily life of transvestites in this study, the materialization of thought and language about quality of life is also expressed in the search for mutual support in social movements and non-governmental organizations (NGOs). This search is related as a way of confronting marginalization, which is present to all people who tense the binary logic and has been systematically combated in recent decades by social movements and NGOs that dialogue with the needs and specificities of the public in question. This movement has enabled a conception and construction of ideas and practices that have as one of their objectives the self-empowerment and self-recognition of the subjects (politically and socially) in all social spaces, fundamental aspects for the construction of processes that legitimize and are part of the daily life and quality of life experience of the interlocutors.

The representations that structure the symbolic and affective role of NGOs develop a function of extreme importance in the lives of the interlocutors, because from the bond established there is recognition of their demands, which go beyond the hegemonic, biomedical and biomechanistic model. From the health perspective, it is possible to place a series of socially elaborated and shared actions that aim to provide spaces that will contribute in a propositional way to the full exercise of their citizenship, having positive impacts on their quality of life. Such actions allow SR to situate the positive influence and importance of NGOs in their lives, for the support and relationships established in these spaces are centered on biopsychosocial behaviors that encompass biological, psychological, cultural, and social factors. It is thus seen as the representation of a collective construction of a propositional space for the full exercise of their citizenship, favoring respect and the establishment of affective, loving, and social bonds.

In the process of identifying the representations of the social role of NGOs, they attributed a new meaning to it, reconstituting it as a place that brings security and empathy, because there is, in some way, a safe haven that within the historical and sociopolitical context in which the interlocutors are immersed, is characterized by being one of the few institutions that recognizes them as citizens and powerful beings of other positive narratives. This is how NGOs have a unique social position in the outburst of voices that are systematically silenced by cisgender and heterosexual norms. The anchoring is performed by the interlocutors in the symbolic structuring of NGOs as the main articulator of assertive space for the guarantee of human rights and citizenship; support; respect; welcoming and warmth, which converge to fundamental elements when discussing quality of life.

NGOs are one of the main links that enable the sharing of experiences, conceptions and experiences in certain social groups, enhancing the support relationships that will contribute to empowerment and social activism. In the conception constructed by the interlocutors, the representations were based on the relationships (individual and collective) established between the positive interactions with the NGOs, generating possible meanings involved in cultural processes. As NGOs are a network of vital importance in the construction and recognition of subjectivities of being a transvestite and being a sex professional, it favors dialogues and critical reflections in the fight against oppressions operationalized by cis-heteronormative logic, instigating and instrumentalizing the interlocutors in the scope of empowerment and recognition of their rights. They play, therefore, a crucial role in the quality of their lives, because at the same time that they constitute powerful social spaces for socialization of groups and individuals who experience vulnerable processes, they are also considered as spaces that enable the construction of other narratives of life, in which the protagonism of the interlocutors is based on welcoming, qualified listening, respect, trust, and the promotion of life.

In what is discussed about the process of building bonds and ties linked to family, and coexistence, it was possible to identify how some processes occurred in the childhood of the interlocutors can establish relationships that will result in negative experiences of quality of life. The objectification of quality of life is expressed by the excess of meanings that such experiences have in the lives of the participants, materializing them and structuring their knowledge¹⁰. The bonds with neighbors and friends play an important role in the daily (over)experience of the participants, configuring themselves as the establishment and strengthening of bonds intertwined in trust, companionship, loyalty and belonging, thus enabling a type of concrete support, attributing a specific and influential meaning as to quality of life. It is possible to identify from the categorization that such ties, bonds, and relationships favor a role of affective and reciprocal exchanges, and that they enable the establishment of respect, care, and positive relationships that influence the SR of the quality of life of the interlocutors.

The establishment of social ties and relationships is a fundamental tool for the construction of affective bonds that will enhance the strengthening of self-esteem, confidence and security. For the interlocutors, the bonds, especially family ones, are weakened, which begins with the legitimization of a series of processes that will ground conservative and transphobic discourses. Transvestites are in constant contact and receive continuous influence from the social environment, thus, one should consider the importance of strengthening relationships that provide mutual well-being, self-esteem, comfort and security, which promote dynamics to a full experience of quality of life²⁴.

It was also observed that the insufficient support and the lack of the basic family nucleus, provided, at various levels, a relationship of dependence of the interlocutors in the establishment of ties with neighbors, friends and even strangers, who despite being built in a perspective of dependence, play important and singular roles in the great web of social relationships. Thus, the representations that the bonds play as a function of new conFigurations due to their individualities and their self-recognition as transvestites, operated as a singular and important role in the quality of life of the interlocutors, because there was an anchoring of the object of study among the participants from the communication and sharing of the processes already experienced. Based on Moscovici's considerations¹⁰ it was possible to identify that there was the objectification of possible "ties" that could act as welcoming and supportive forces in the face of the problems experienced socially.

The materialization and the meaning given to the bonds built from social relations with friends and neighbors constitute an important tool resulting from the representations built in everyday life and in the articulation between subject and society interlocutors and society, and that will enable, at various levels, the use of these affections as "solid webs" for living and experiencing in a minimally safe way in various social processes, such as health care and socialization.

FINAL CONSIDERATIONS

The social representations of transvestite sex workers about quality of life are constructed and intertwined from social processes that delegitimize their identities and existences, influencing their perceptions and constructions of what is conceived as quality of life. This elucidation is permeated by social relations that will show, in the vision and experience of the interlocutors, that the quality of life is linked to the access to health services free of prejudice, discrimination, and stigma to meet their demands, including the care and respect of health professionals; as well as the support and existence of NGOs in the recognition of their potentialities and singularities, being established affective bonds of support, loyalty, and trust; and the establishment of social ties produced from the bond with neighbors and friends for the confrontation of difficulties and obstacles experienced daily in a society permeated by the cis-heteronormative logic: the re-signification of bonds for the strengthening of trust and security.

Finally, the transvestite sex workers communicated their knowledge in a perspective of representation of what they conceive the quality of life, recognizing it in their daily contexts. They affirm, however, that such representations are mirrored to an understanding of ideal or even possible quality of life in society, recognizing, however, that these are not yet experienced by them.