“Experiences marked by prejudice(s)?”: nurses’ representations on ‘transvestite’ people

Objectives: to learn and analyze the structure of nurses’ social representations about transvestite people. Methods: a qualitative research based on the Theory of Social Representations, with 110 nurses enrolled in Graduate Nursing courses, who answered the Free-Association Test, with the stimulus ‘transvestite’. Data were processed by the software Ensemble de Programmes Permettant I’ Analysedes Évocations . Results: in the central nucleus, the term “prejudice” was the most evoked, followed by “homosexual”, “identity” and “female-make-up”. Social representation is anchored in the social organization in which transvestite people are still seen and/or associated with homosexuals who make up and assume an identity, without being seen and/or understood as they really are. Final Considerations: although prejudice is noteworthy as a central element, terms present in the peripheral system reveal that the group recognizes transvestites as a person with rights, which can translate into health care practices. Descriptors: Transvestism; Nurses; Prejudice; Sexual and Gender Minorities; Free Association. RESUMO Objetivos: apreender e analisar a estrutura das representações sociais de enfermeiras(os) sobre a pessoa travesti. Métodos: pesquisa qualitativa, fundamentada na Teoria das Representações Sociais, com 110 enfermeiras(os) matriculadas(os) cursos de Pós- Graduação Enfermagem, que responderam ao Teste de Associação Livre de Palavras, o estímulo ‘travesti’. dados foram processados pelo software Ensemble de Programmes Permettant Analysedes Évocations . Resultados: núcleo central, termo “preconceito” foi “homossexual”, “identidade” “maquiagem-feminino”.


INTRODUCTION
Brazilian society is marked by gender binarity, in which it is recognized as a man or woman, that is, people who diverge from this cis-heteronormative pattern are understood as abject beings, in Butlerian terms (1) . Heterosexuality is seen and/or considered as natural and compulsory. Among the diversity of identities that do not fit this binary model, there are people who affirm themselves as transvestites, transsexual women and men, "gender-divergent identities", who integrate the population segment of lesbian, gay, bisexual, transvestite and transsexual people (LGBTT). This population has occupied a marginalized position in contemporary western societies (2) , which demands a singular view, including nursing, to meet their care demands. However, a survey conducted with nurses revealed that, among the investigated group, there is an image of transvestites as men, of homosexual sexual orientation, who use props to live an identity based on/by the female (3) .
Among the gender-divergent identities, transvestite people were the focus of investigation in this study. It should be considered that the experiences demarcated in/by transvestites, of the demand for recognition based on transvestite gender identity, constitute itself as another viability for people who thus perceive themselves. The anatomical shape of the genitalia does not define and/or prescribe people's fate (4) . To that end, they can use socially sanctioned clothes and props as feminine and even resort to the use of hormones, industrial liquid silicone and surgical procedures to modify the body for personal fulfillment (5) .
In an attempt to minimize the effects of discrimination, institutional violence and exclusion related to the health-disease process of people with a "non-hegemonic" identity, and to ensure the constitutional principles of comprehensiveness and equity, the Brazilian government launched the Brazilian National Policy for Comprehensive Health for LGBT (Política Nacional de Saúde Integral de LGBT) in 2010 (6) . However, creating and implementing a policy aimed at transvestite and transsexual people is insufficient to promote changes in the practices and conceptions of health professionals; such changes require incorporating meanings that are beyond political-scientific aspects (7) .
The problem of caring for these people involves beliefs and opinions that are formed from hegemonic Social Representations (SR). SR are built and shared by individuals and groups, such as, which formed by nurses, in a dynamic process that can cover subjective aspects, cognitions and affects, constituting itself as a reflection of their practices, in a given social context. In this segment, the question arises: how are nurses' SRs structured about transvestite people?
In this study, the Theory of Social Representations (TSR) is a guiding axis for producing knowledge about transvestites, making it possible to understand how social subjects strive to understand and signify the world around them. In this way, in the professional field of nurses, knowing their imaginary about transvestites will make it possible to highlight nuances about values and practices from the symbolic space and social relations arising from social knowledge.
Addressing the structure of social representation consists of considering a socio-cognitive and subjective set contemplated by a central and peripheral system, resulting from the interpretation of the symbolic and social universe of the investigated group; in our case, nurses with the environment and the social environment, supported by attitudes, behaviors and practices.

OBJECTIVES
To learn and analyze the structure of nurses' SR about transvestite people.

Ethical aspects
This study met all parameters of Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde) (8) , in accordance with the ethical principles of research involving human beings. The Ethics Committee of the School of Nursing of Universidade Federal da Bahia (UFBA) approved this study, under Opinion 1,203,257. This is an excerpt from the dissertation entitled "Laços e Embaraços do Cotidiano: Representações Sociais de Enfermeiras sobre as Travestis", linked to the Graduate Program in Nursing at UFBA. To preserve anonymity, all participants were identified with letter "P", followed by the chronological sequence of the application of the Free-Association Test, age in years and the course in which they were enrolled.

Type of study
This is a qualitative research, focusing on SR in its structural approach -Central Nucleus Theory (CNT).

Theoretical-methodological framework
The structural approach in TSR is specific in the field of SR. It is considered as a theoretical-methodological proposition complementary to the study by Serge Moscovici that proposes to point out and analyze the processes that determine SR as socio-cognitive sets organized and structured in two subsystems: a central system and a peripheral system (9) .
CNT is conceived through the determination of two distinct, yet interconnected elements: the central and the peripheral nucleus. Central nucleus (CN) is characterized by its ability to connect to collective memory, consensual, stable, being resistant to changes and not accessible to the immediate context. The peripheral system allows integrating individual experiences and stories; tolerates the heterogeneity of the group; and is sensitive to the immediate context and subject to change (10) .

Study setting
It was developed with 110 of the 136 nurses enrolled in lato sensu (specialization and residency) and stricto sensu (master's and doctorate) courses of the Graduate Program in Nursing at the UFBA School of Nursing.

Data source
Students enrolled in the second term of 2015 and with at least one year of experience in care, teaching and/or management participated in the study. Special students or who were on sick leave and/or maternity leave and/or those who were in the process of defending their thesis, dissertation or monograph did not participate in the study.

Collection and organization of data
Data production took place by applying a form with identification data and the Free-Association Test (FAT), containing the inductive term "transvestite". They were asked to evoke up to five words, rank in order of importance and justify the choice of the chosen word as the most important. It is a projective technique widely used in SR studies (4,11) that allows identifying latent content in SR by configuring the elements that constitute the associative network of the terms evoked in relation to the inducing stimulus (10) .
FAT is a tool that is quick to apply and easy to understand, but that provides important recommendations for its application. Among them, criteria related to the participants' understanding of the technique, response time of participants and preference for not using long phrases or expressions stand out (12) . Collection took place from October 2015 to March 2016.

Analysis of data
Data regarding the profile of participants were analyzed using simple descriptive statistics, presenting the characteristics of the investigated group. All evocations were submitted to prototypical analysis. They were processed in the software Ensemble de Programmes Permettant I' Analysedes Évocations (EVOC), version 2005, which made it possible to build the Four-quadrant technique, consisting of central and peripheral elements. In this sense, it was possible to structurally characterize social representation by calculating frequency and Average Order of Evocation (AOE) (13) .

RESULTS
The group corresponding to 110 participants, composed mainly of women (98), predominantly the age group of 25-35 years. Of the total, 84 declared themselves to be black. Most attended specialization and/or residency (42), followed by master's (32) and doctoral students (24). In addition to developing student activities, 81 nurses reported having an employment relationship. Thirty-six worked in care; 17 worked in teaching; 11 worked in management; and 17 revealed to act simultaneously in care/teaching.
Regarding the content and structure of the analyzed SR, 528 evocations were identified by the participants in corpus processing, 49 of which were different. AOE was 2.9 (on a scale of 1 to 5). Considering that evocations whose frequency was equal to or less than 4 were neglected, AOE equal to 19 was found, with 92.7% of the corpus being used. Combined analysis resulted in a fourquadrant chart (Chart 1), containing a set of words distributed in four quadrants, forming two systems: central and peripheral. Such systems reveal the SR structure of the group investigated about transvestite people.
Furthermore, it is possible to observe that Chart 1 comprises elements considered central (upper left quadrant) and peripheral ones (other quadrants). The terms present in the upper left quadrant (CN) may have a higher frequency and lower AOE than those arranged in the other quadrants. Thus, it is implied that they were evoked by several people and presented themselves among the first positions, on a scale of 1 to 5. Such characteristics, according to the principles of CNT, attach importance to the terms and reveal the collective memory of socio-historical values and the homogeneity of the investigated group about the object under analysis (10) .
The other quadrants in Chart 1 represent the peripheral system, composed of elements that may present less frequency and greater AOE in relation to the elements of the CN. They have a subjective connotation, are related to the immediate context of the investigated subjects, being vulnerable to changes. The lower left quadrant, called the contrast zone, contains the terms that were enunciated by a smaller number of participants. Although they are less frequent, they are readily evoked terms, being considered very important in understanding the structure of SR (14) .

DISCUSSION
In Chart 1, the terms that make up the probable CN and structure the social representation about transvestite are "prejudice", "make-up-female", "identity" and "homosexual". Considering the frequency criterion as one of the most important components, the term "prejudice" organizes the other elements and is related to the terms "female-make-up" and "homosexual", whose structure can be considered as a descriptive principle of the represented object. In this aspect, each element of the CN maintains a relationship and implication with one or more peripheral elements, given that the CN is constituted by notions strongly connected (15) . The term "prejudice", in addition to being the most evoked (67 times) and having a low AOE, (2.687), was flagged as the most important by 13 participants. In general, the justifications for this term referred to situations experienced by transvestites in the different scenarios of their lives, as shown below: In this sense, it is possible to affirm that the understanding and deconstruction of prejudices are important elements for comprehensiveness and humanization of care to transvestite people. Thus, strengthening new notions about transvestites and transvestism, together with health professionals, especially nurses, is essential to open conditions of access to services for these people (16) .
The term "homosexual" (F=20), present in the CN, presents AOE (1.650), and that means that it was one of the terms most readily evoked by the participants. It is worth noting that the term "homosexual" was mentioned as the most important by six participants. The content of the justifications signals a direct association between gender identity and sexual orientation. However, one does not determine the other, as they occupy different dimensions in people's lives (4) . If, on the one hand, the investigated group recognizes confronting prejudice on the part of transvestites, on the other hand, they reveal their lack of knowledge regarding gender identity. The pejorative and stigma associated with the word "homosexual" is further strengthened. The justifications are below:

I believe that the transvestite people's image is very linked to homosexuality; non-acceptance of a physical and sexual condition. That's why dressing up! In an attempt to hide or mask an identity that does not want to show. (P8, 36 years old, doctorate)
When I hear the word transvestite, I immediately think of the man who is characterized in a feminine way by identifying more and, therefore, is attracted and wants to attract people of the same sex -homosexual. (P9, 30 years old, master's) Based on the evocations and their location in the CN of Chart 1, it is possible to infer that the social group, while reproducing prejudices and stereotypes with regard to transvestite people, evidenced by the terms "homosexual" and "make-up-female", evoke terms that refer to the idea of "identity". However, it seems that this identity is not necessarily related to gender identity, considering that in the representational field, 85 (15.79%) of the terms were associated with "man", "man who wants to be a woman", "homosexual" and "make-up-female", contrary to the understanding about gender identity. In this respect, among the terms that make up Chart 1, those that were more readily evoked and considered in the prototypical analysis were "homosexual", with AOE of 1,650, and "man", with AOE of 2.118.
Prejudice is a social construction that has roots in the symbolic universe of culture and in power relations, which permeate the various social instances, with implications for the daily experiences of the subject, in cognitive and affective terms (2) . Although prejudice is considered a social and theoretical construction, it should be considered that what people experience in everyday life is discrimination (17) . With regard to people with nonconforming and/or dissenting identities, they experience various forms and levels of transphobia, which trigger different modes of sufferings. Living in sociocultural contexts marked by a conception of a cisgender normality excludes other possibilities of experiences (18) .
The term "prejudice" exposes the intimate relationship between the elements present in the other quadrants and demarcates a recognition of nurses about iniquity/vulnerabilities experienced by transvestites. Thus, it is possible to notice that the representation of nurses refers to a context of their practices evidenced in the term "prejudice". This corroborates the fact that there is difficulty in accepting differences, and both health professionals and society still reinforce and potentiate attitudes that generate suffering, exclusion, barriers and social distancing (3)(4)18) . However, tensions were observed in the relationship between the terms present in the CN and the peripheral ones, such as "bravery", "right" and "respect", which reverberate as transvestite people, possibly, are welcomed in the various spaces of the health care network.
From this perspective, transvestites are resistant to seeking professional help when they need care, because they are constantly disrespected during care in health institutions or because their complaints are neglected. It reveals the absence of a link with health teams, which impairs the performance of preventive actions, promoting the prevalence of several preventable or treatable diseases for this group (19) .
Therefore, it is possible to infer that the social representation of nurses on transvestite people is anchored in the social organization that this person is still seen and/or associated with the "homosexual" who is made up and 'assumes' an 'identity' without being seen and/or understood as they really are. It is important to highlight that the representation elaborated here shows that nurses do not distinguish between sexual orientation and gender identities. However, it should be noted that sexual orientation and gender identity should not be seen and/ or considered synonymous, since they occupy distinct dimensions in the lives of people (4,20) . The lack of distinction between these terms may constitute a mode of prejudice that implies situations of discrimination against transvestites, who, in some way, do not fit this inflection and do not allow themselves to be labeled (3)(4)20) .
When discussing the composition of the first periphery, the terms "joy" and "bravery" connote apparently positive situations experienced by transvestites, in an allusion to the playful dimension and in opposition to the terms "prostitution" and "suffering", also present in this quadrant (Chart 1). Such terms report two dimensions, not necessarily excluding, to explain the contrast related to gender expression and identity. For nurses, transvestites, when expressing an identity, they claim for themselves, are "brave and joyful". On the other hand, this attitude can lead them to a life that has its emphasis directed to suffering, in the face of the judgments of a cisheteronormative society. The first periphery is composed of terms that reinforce the CN, evidenced in the term "prostitution", while providing terms such as "joy", "bravery", "suffering" and "woman", adding new dimensions to the representational field (10) , in addition to referring to the affection and recognition of transvestite people.
The term "prostitution" (F=19), in this composition, denotes the presence of hegemonic representations (21) that are produced by a collective of nurses who still associate the transvestite's image with sexual work. It demands to clarify that not every transvestite person acts as a sex worker and that involvement with prostitution may not be the only alternative. Sometimes it occurs by necessity and the fact that this activity is meant by transvestite people as a space where they can exercise power, since they display their body not only for sexual purposes, but a corporality based on desire. Faced with these issues, transvestite people find, at night, at the corner, a way to make themselves visible (22) .
Associating transvestite with the terms "man" and "man who wants to be a woman", present in the contrast zone, may reveal the non-recognition and legitimation of her expression and gender identity, expressing difficulties of nurses in understanding transvestite as distinct from other historically constructed identities. The elements allocated here, although they presented low frequency, were considered important for the participants and can reinforce notions listed in the first periphery, as is the case of bravery demanded to transition from the gender designated at birth, to the self-perceived gender, named by the group as "man who wants to be a woman".
Understanding and deconstruction of stereotypes/labels are important elements for comprehensiveness and humanization of care to transvestites. Challenges in creating and implementing public policies require involving not only of prepared and committed professionals, but also management support and commitment. Furthermore, strengthening relationships, together with organization of social movement, may contribute to the training and improvement of health professionals, especially nurses, to open conditions of access to services for this population segment (23) .
There are, in the social representation of nurses about transvestite people, some elements that demonstrate an indication of transformation, by (re)knowing rights that all people have to be in the world: "joy", "respect", "woman", "right", "different", and freedom". Therefore, transvestite people deserve respect considering their human, ethical and subjective dimension. In this sense, the cognitions "right", "different" and "freedom", present in the second periphery (Chart 1), signal and point out elements claimed by the organized social movement (20) .
There are concomitant weaknesses in whether there are transvestites who are unaware of their rights and therefore do not claim to be treated by their social name. There are also health professionals who neglect the right to provide treatment that supports the singularities and specificities of this group (21) .
The cognitions "different" and "extravagant", also present in the second periphery, reveal a representational structure permeated with stereotypes and prejudices, since they allude to transvestites as people who escape normality and border on 'exotification' . Moreover, they highlight the depreciation of transvestite people's image, considering them "extravagant and exotic", external to the category of human. These elements seem to find resonance from media disclosures about the transvestite person as someone who is always in the category of 'not being' and 'not belonging (3) .
In this context, the representations elaborated here can contribute to transvestite people facing barriers in access to health services. Thus, it is a challenge for nurses to develop technical, scientific and emotional skills, guided by ethics, to establish inclusive and welcoming care to this population segment throughout the health care network (24) .

Study limitations
The limitation of this study involves participation of nurses (students) from a single graduate program. The results allowed access to elements that can contribute to the (re) thinking and doing of nursing. Specialization, residency, master's and doctoral students from a school that is at the forefront of the history of Brazilian nursing were part of this study. Scarcity of studies on the subject and addressing care hinders the establishment of analogies between the research findings and the reality of professionals/students in different national contexts.

Contributions to nursing and public policies
Developing this research points to elements that can raise reflection about the modes of care and contribute to the quality of nursing care directed to transvestite people. The research process allowed integration between graduate students; awakened to issues of respect and to the ethical aspects that involve health care; emerged latent senses and meanings about the theme investigated, favoring elements for consideration and possibilities to influence changes in hegemonic SR. In addition, the results found provide elements for insertion and expansion of the debate on sexuality among nurses, a poignant theme that demands a sensitive and careful look.

FINAL CONSIDERATIONS
This study revealed that the elements socially shared by nurses (graduate students) about transvestites point to the reproduction of socially linked ideas about them, insofar as they represent them as men with homosexual sexual orientation. However, as they transition from the gender designated at birth to the gender they feel they belong to, with a view to personal fulfillment and recognition, they experience prejudice and discrimination.
There is a need for investments in training processes that can provide the reorientation of this attitude. Disregarding gender self-determination can reinforce prejudice, discrimination and exclusion. Transvestites are given a meaning that is inconsistent with their internal feeling of belonging, reiterating violence, violation of rights and erasure and/or annulment of their subjectivity.
It is important to note that this study highlights the need for reflection on the identity references that support the representations of nurses about transvestites. The evoked elements point to social, biological and ethical-moral aspects, which permeate transvestites and the silencing of health-care related cognitions.