Brazilian transgender children and adolescents: Attributes associated with quality of life*

Objective: to describe attributes associated with the Quality of Life of Brazilian transgender children and adolescents according to their own perception. Method: descriptive study conducted with 32 participants between eight and 18 years old, who were either interviewed or participated in focus groups. The statements were transcribed, grouped with the aid of the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software, version 0.7 alpha 2 and described according to the definition of Quality of Life by the World Health Organization concerning to the mental, physical, and social dimensions. Results: it was possible to identify the family nucleus as the main social support for transgender children and adolescents. However, the experience of prejudice and discrimination were negative attributes associated with Quality of Life. Conclusion: the statements indicate that lives of transgender children and adolescents are impacted by social, physical, and mental factors due to the stigma and discrimination experienced. It is expected to contribute to the formulation of public policies related to transgender children and adolescents and expand the discussion on the citizens’ duties and rights in relation to transsexuality.


Introduction
Transgender individuals are those whose gender identity differs from their biological sex (1) . The so-called transgender persons are those who socially claim to be recognized as women, men, or as non-binary gender (2) .
The diagnosis of transsexualism first appeared in 1975 (3) . In 1980, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-3), transsexualism is described as a psychosocial condition, defined as "gender identity disorder" (4) . In 1990, in the International Classification of Diseases (ICD-10), the terms "transsexualism" (F64.0) and "gender identity disorder of childhood" (F64.2) were used to diagnose individuals who have an incongruity with their biological sex (5) . After reviews in the DSM, in its 5 th edition (DSM-5), the term "gender dysphoria" is used to diagnose individuals who do not identify with their assigned gender (6) .
In the ICD-11 version, the diagnosis of transsexualism was removed from Chapter V (F00-F99) on mental and behavioral disorders. Chapter 17, concerning the conditions related to sexual health, the term "gender incongruence" was created and included (HA60, HA61, HA6Z) (7) .
The effort to depathologize trans-identities has been claimed by movements of political struggle of transgender individuals, being recognized by social studies of gender, of sexuality, and by the World Health Organization (WHO). This claim starts from the premise that transgenderity is not configured as a disease, but as another possibility of expression and experience of non-cisgender people (8)(9) .
Transgender individuals recognize their gender identity even in childhood, and often express this desire by adopting symbolic elements of this gender (10)(11) .
Children between 17 and 21 months of age learn to label themselves as boys or girls, this becoming more noticeable around 2 years old. Gender identity occurs gradually, starting between 2 and 3 years old. Between 6 and 7 years old, children are aware that their gender will remain for life (10)(11) .
Children who do not identify with their assigned gender confront difficulties of social oppression and experience feelings of preconception, social discrimination, and denial about their own gender identity, a fact that makes self-acceptance a suffered process (11) .
Feelings experienced during childhood and adolescence can cause psychosocial damage until adulthood, and they may last. These periods are marked by the beginning of the construction of identities, experiments, discoveries, social affirmation, and questions related to gender, having as main reference the way in which the body appears in society and behavioral patterns to be performed by boys and girls (12)(13) .
The socialization process begins in the family, in the so-called Primary Socialization. It is in the family that the individual learns rules, personal values, and to interact with the world, therefore being the primordial socialization for the formation of the individual.
Secondary Socialization is understood as the experience in the social world -school, work, group of friendsand this is constantly changing, since society is not immutable (14)(15) .
In the field of health, Quality of Life (QoL) represents a multidimensional construct, with applicability and relevance for people of all age groups, cultures, geographic location or socioeconomic situation (16) .
The relevance of studies that address the QoL of children and adolescents is highly recognized (17) , as there are numerous factors that can influence their perception (18) . Understanding and knowing the QoL perspective of healthy children and adolescents is important for the development of public policies that promote their health and well-being (19)(20) .
The WHO defines that "quality of life is the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" (18,(21)(22)(23) .  (27) .
The classes were defined by the words that were most associated with it due to the average frequency of occurrences. Since the adolescents had longer segments of speech, the values of statistical significance for the inclusion of words were α = 0.05 for children and α = 0.0001 for adolescents, respectively. The categories resulting from the statements were described according to the WHO definition concerning to the mental, physical, and social dimensions (21) and according to Primary and Secondary Socialization (14)(15) .

children and 20 adolescents participated in the
study. Three FGs were conducted, one with 10 children and two with 13 and 10 adolescents, respectively. In the second FG, three adolescents who had been in the first one participated, and two children were interviewed, as there were not enough participants for an FG (26) . Both FG of children lasted 60 minutes and those of adolescents lasted 90 minutes.
The children's average age was 9.9 years old, with an SD of 0.9 years old (values between eight and 11 years old). In the adolescents, the average age was 15.8 years old, with an SD of 1.6 years old (values between 13 and 18 years old). Regarding gender, 58.3% of the children identify themselves as females and, in the group of the adolescents, 80.0% identify themselves as males.
Due to the specificity of the groups studied and to the confidentiality of the children and adolescents, it was decided not to present the statements.
Regarding the children's corpus, it was composed of 111 numbers of texts (number of statements), which were divided into 149 text segments (TSs). No negative attributes were observed in this class.

Classes 2 and 3 (39.45%): Social Inclusion and Exclusion
The      There are also cases in which the mother contradicts the adolescents' wishes, making them wear clothes or accessories used by the gender that does not represent them, causing mental suffering and social isolation.

Class 2 (13.80%). Secondary socialization: Stigma and Preconception
This class complements the previous one, but transcends the difficulties and preconceptions questions about the body often bring discomfort to the adolescents, as they feel their intimacy exposed and invaded, making them feel strange or abnormal.

Class 4 (18.7%). Emotional Satisfaction with life
The speech in the text excerpts of this class is characterized by the predominance of statements that refer to happiness and well-being, with art, leisure activities, and sharing moments with family and friends being frequently cited.
Another fact to consider refers to the words happiness and happy, which are entirely linked to statements that portray the adolescents' joy when they feel the freedom to express themselves as they are, reflecting self-acceptance and respect of the other in relation to them. Furthermore, knowing that they are fighting for a cause reflects happiness, as they feel that Nascimento FK, Reis RA, Saadeh A, Demétrio F, Rodrigues ILA, Galera SAF, Santos CB.
they can transform the suffering they experience into joy for others in the future.

Discussion
In a study about QoL (16) conducted with children and adolescents were found significant differences in the dimensions studies when analyzing the two age groups, and, therefore, it was decided to use the analysis of the results separately for the two age groups: children (eight to 12 years old) and adolescents (13 to 18 years old).
For both children and adolescents, the results demonstrate that the family nucleus is the main social means of reference and coexistence.

Primary socialization and Satisfaction with life
Gender identity is built throughout life, according to sociocultural experiences and influences, being a complex and constantly changing event (14)(15) . When identity construction begins, family is the first social means of coexistence during childhood, characterized as primary socialization (14)(15) . In the family environment, the initial connections are formed that guarantee the child's ability to relate and develop affective bonds later in life.
In this way, family support is an important element for the healthy process of gender self-designation.
A study that used the FG technique to develop the KIDSCREEN questionnaire to measure the QoL of healthy children and adolescents concluded that the most important aspect in the QoL of the group of children was associated with family relationships. However, for the adolescents, the aspects considered most important for QoL raised in the FGs were social relationships (28) .  (14)(15) .
Positive relationships with family members, close friends, co-workers or the school function as a social support network for building the social identity of transgender individuals, with the family environment being the main source of this support (29)(30)(31) .
A survey conducted with transgender people in two Brazilian states, which investigated the impact of parental support on the risk factors in the process of selfdesignation of transgender people, of 421 respondents 29.45% (124) reported not having parental support during gender self-designation, 20.43% (86) received less support, and 20.43% (86) said they received support from their parents. When asked about the need to move away from the family because they are transsexuals, 40% answered that this was an experienced reality (30) .
Consistent with the results of previous studies, the authors claim that family support in childhood brings benefits to the lives of transgender people in adulthood, as the family is a direct support for children and adolescents during the growth and development period, in particular, in their sexuality and gender selfdesignation process (31)(32)(33) .
Accordingly, the authors portray the importance that family support represents in the lives of transsexual people and conclude that intrafamily discrimination, as the lack of emotional support, represent a risk to the mental health and QoL of these individuals. Therefore, family support is directly associated with the QoL of transgender people (34)(35) . Thus, the importance is justified of interventions in different social sectors, particularly in the family health care services, so that they can act as facilitators of the acceptance and understanding by parents and/or caregivers, in order not to reject or discriminate transgender children.

Secondary socialization: social inclusion and exclusion
For the adolescents, the assessments associated The school setting becomes an environment that increases the vulnerability of transgender students, since they feel insecure in these places due to their sexual orientation and/or gender expression and identity, being Rev. Latino-Am. Enfermagem 2020;28:e3351.
Another issue related to the children, in addition to the expectation of acceptance by peers for inclusion, is the desire to be recognized by the gender they identify themselves with. Considering the important role of the school in the socialization of children and adolescents, it is important that issues related to sexual and gender diversity are adequately addressed and discussed in these environments (42)(43)(44) . For this, it is necessary to prepare teachers and staff to deal with these issues, as there is a tendency towards the biologization of sexuality in the schools. In this sense, the potential of the present study is believed to contribute to such approaches and discussions in different care contexts, understanding that, from an expanded health perspective, the school is also configured as a care space. Such actions are reinforced because, due to the prejudice experienced by transgender students in the schools (36,46) , there is a high dropout rate and few of these students advance to higher education, compromising their academic performance and their exercise of citizenship (47) .
Therefore, positive supportive relationships allow transgender children and adolescents to deal effectively with discrimination and face a social system full of challenges (32,48) . However, when talking about transsexuality, support networks and social relationships are weakened and demarcated by prejudice and stigma (49) and by institutionalized transphobia (fear, aversion, and exclusion to trans-existence) (9) . When faced by these people, such situations lead to a low QoL, as they result in individual and social representations of negative (self) image, in a feeling of inferiority in relation to the other, in loneliness, psychological suffering, depression, and suicide attempts (or concretization) (34) .

Physical Attributes: the transsexual "being"
It appears that the physical aspects are more In adolescence, the increase in body dissatisfaction is common, since in this phase secondary sexual characteristics develop, making the transgender youths' non-identification with their own body more accentuated (50)(51)(52) .
For some transgender individuals, body changes are issues with specificities and relevance, since dissatisfaction with body image is differentiated due to the need for body-gender adjustments to be more evident (53) . Despite not appearing in the statements of this research, the literature review shows studies that point to this issue associated with eating disorders in young transgender people (51,(54)(55)(56)(57) .
In this way, transsexuality represents a significant internal anguish, due to the dissatisfaction resulting from the contradiction between the exterior body and gender identification (55) . In a research on body dissatisfaction and transsexuality, more than half of the participants (65%) were involved in diets, 25% reported binge eating, 25% stated purging, and 40% excessive exercise (55)(56) .
Transgenders have lower levels of satisfaction with body image compared to cisgender people. Both transgender women and men exhibit body dissatisfaction in all spheres, not being directly related to male or female genitalia (58) . Although in most cases hormonization or surgery can alleviate this discomfort with the body itself, this modification is not the central solution for the low body image satisfaction experienced by transgender individuals. Therefore, the health professionals have an important role in providing information, education, and support for transgender children and adolescents and their parents or caregivers, to provide support for mental health, nutritional, and well-being issues during the process of gender self-designation and body dissatisfaction (35,53) . Another axis to be discussed is associated with situations of discrimination and violence due to physical appearance that lead to an increased feeling of isolation and denied existence, which can affect the physical, emotional, and social well-being of transgender individuals (32,59) .
Transgender people are marginalized in society and face difficulties in accessing rights such as the recognition of their transgender identity within the family, in the schools, at work, and in social services/sectors, such as the health service/sector. Furthermore, it is known that opportunities in the job market are scarce when it comes to these people, as there is discrimination by society in relation to their expression and non-cisgender identity (32,34) .
Thus, for transgender people, it is essential to recognize their gender identity in society, so they can enjoy the rights and access to education, health, housing, citizenship, and job opportunities, among others, equally to others in the population, with respect and dignity (59) .
The non-return to the research scenario, in order to conduct new focus groups with the same children and adolescents with the objective of presenting the results of the analysis of their statements, constitutes a limitation of this study. It is understood that returning to the group of children/adolescents to validate their statements would not be recommended because it is a study that sought subjectivities on a theme considered arid, with a great emotional burden. Performing this validation would imply "sterilizing" this material and running the risk of removing a very important aspect from it, which is precisely spontaneity.

Conclusion
The results of this research indicated that the Rev. Latino-Am. Enfermagem 2020;28:e3351.