Biographical ruptures by the COVID-19 pandemic on adolescent and young trans men and transmasculine people: demands for nursing

Abstract Objective: to understand the biographical ruptures caused by the COVID-19 pandemic on adolescent and young trans men and transmasculine people in the Brazilian context. Method: qualitative study - multicenter, online survey. A total of 97 self-identified trans men and 22 transmasculine people participated and completed a semi-structured form in two stages. The data was subjected to Reflective Thematic Content Analysis. The interpretation was made on a sociological basis, based on the concept of biographical rupture. Results: five categories were derived: interruption of hormonization, surgeries and specialized follow-up; discomforts caused by the rupture of masculine characteristics, self-image, self-perception, and identity; vulnerability from the losses of family members and significant people, employment, and weakening of support networks; emergence of psycho-emotional problems, such as loss of meaning in life; demands for nursing care and valuing the life of transmasculine adolescents and young men in post-pandemic times. Conclusion: the biographical ruptures caused by the pandemic threatened the identities of trans and transmasculine people of adolescents and youth, degraded and interrupted biographies, leading them to the loss of meaning in life. Nursing professionals can be strategic and essential in overcoming threats by intervening early.


Introduction
During the COVID-19 pandemic, specific groups, such as trans population, have experienced multiple life and health impacts (1)(2)(3) that have not yet been considered in coping strategies. A Brazilian study estimated that approximately three million (1.9%) trans people live in the country and are, on average, younger than the cisgender population (32.8±14.2 years) (4) .
The voices of trans men -men who were assigned the female gender at birth -and of transmasculine peoplepeople whose gender identity is male, but who do not necessarily identify as men, which involves a masculinity dimension, in this case, transmasculinities (5)(6) -have been silenced in decision-making and the subjects invisibilized in the construction of public policies (7) . This structural and systemic violence has a patriarchal and gendernormative component, which has historically silenced vulnerable groups, a phenomenon that can be explained from the concept of biographical ruptures (BR) (8)(9)(10) .
Faced with biographical ruptures, people develop the processing of reality through three interrelated and distinct characteristics. Firstly, the onset of the illness experience, which we will define as the causal condition of BR (which can be an illness or threat to integrity), implies the cracking of assumptions and behaviors incorporated into everyday life, which leads the person to conceive life as a chaotic set of disconnected events (8) .
Secondly, one experiences "rethinking one's biography and self-concept." At this point, people are urged to consciously reflect on what they thought about their own futures and how they will have to manage the interruptions of those futures (8) . Finally, the mobilization of new resources to deal with the chaos arising from BR is observed (11) .
The scientific literature suggests the aggravation of health problems, precariousness of care, and overlapping barriers to comprehensive health care, which reiterates the justification for this study (12)(13) .
Also, considering the fact that trans people have different health needs and that existing health programs cannot address multifactorial problems and provide coverage for the trans population, the scenario becomes even more worrisome (14)(15) . Thus, this theoretical movement of practical and epistemological disobedience should prompt special attention to the adolescent life cycle (16) and signals the existence of a global health problem that is a priority on the public agenda. This justifies the usefulness and relevance of this study, as well as the gap in the production of scientific knowledge on this subject.
We start from the assumption that from the COVID-19 pandemic all humans experienced a biographical rupture or threat, and therefore we are interested in understanding the singularities of this phenomenon for adolescents and young people who were already experiencing a daily gender-affirming life. In this sense, this research was guided by the question: how did adolescent and

Study design
This is a qualitative, sociological study (17) , structured based on the recommendations of the Consolidated Criteria for Reporting Qualitative Studies -COREQ. An online (18) , national multicenter survey entitled: "Analysis of the health impacts of the COVID-19 pandemic on trans men and transmasculine people" was conducted.

Data collection site
The research addressed all regions of Brazil, using consecutive chain sampling, snowball sampling (19) .
Participants were recruited on digital social media: Facebook, Instagram, Twitter, Scruff, Grindr, Tinder, in groups of trans men and transmasculine people, and/or transgender and/or lesbian, gay, bisexual, travesti, transsexual, queer, intersex, asexual, or those with experiences of gender variability, represented by the "+" symbol (LGBTQIA+) in WhatsApp and Telegram apps (20) .
To determine the zero wave of recruitment, initially ten participants, trans men and transmasculine people, were included as "seeds" -a term adopted to designate the participants who initiated the reference chain sampling, chosen non-randomly (19) . They were encouraged to invite new participants, which made it possible to track the recruitment of five major seeds, one from each region of the country, as well as the respective chains of new informants, the "seed children" -individuals recruited by the seeds-and resulted in representation from 17 states (21) .

Data collection
Data were collected in three stages. The first was by the participants (23)(24) . The software has features for intelligent response validation, which allows text entry detection and correction. The application also adopts security and data protection measures, in convergence with the General Law of Data Protection (LGPD) in force in the country (25) . In possession of this data set, the research team: (1) extracted the data from the spreadsheet generated by the Google Forms; (2) checking the data for integrity, duplication, and incompleteness; (3) organizing and systematizing them in customized files using identification codes; (4) transcribing and linguistically correcting the interview data; (5) preparing the corpus; (6) transferring data to NVivo12 software, and (7) analyzing data (26) .
In the third stage, which took place in March 2022, the categories and subcategories found in the first stage Theoretical saturation of the data was considered from the empirical theoretical density presented in the findings (26) .

Data treatment and analysis
All empirical material was subjected to a Reflexive Thematic Content Analysis in all three stages of the research. To this end, several cyclical moments of data analysis were performed, in a spiral fashion, as a way to ensure greater theoretical abstraction and reflexivity.
The in-depth reading was carried out, along with the constitution of the corpus of analysis, followed by the attribution of labels, the adjustment of data homogeneity, the formulation of empirical indicators of analysis, the ordering, the naming of codes and the derivation of categories, subcategories and respective themes (27)(28)(29) . Finally, the research team internally validated the codes, through peer consensus, as criteria for achieving the quality of the analysis, and submitted the categories to the participants for corroboration (30) .
After the participants validated the categories and subcategories obtained in the steps, the research team reconfigured their presentation based on suggested adjustments. Furthermore, the questions asked in the third stage brought out two new categories. Then, the findings were interpreted from the theoretical concept of BR. Although this concept was inaugurated by medical sociology and considered the experience of illness as a referent, in this study we adopted the more extended concept that BR involves a rupture/fissure over the individual's ability to enact an embodied orientation toward the world. In this sense, it does not result from illness, but from the ways in which processes that threaten integrity affect a person's abilities to engage with everyday life (8)(9)(10)(11) . Thus, the concept has proven useful for analyzing the investigated phenomenon in the face of the set of threats caused by the COVID-19 pandemic, such as transphobia.

Ethical aspects
This study followed the ethical recommendations in all stages and met the Regulation 466 of 2012 of the National Health Council (31) , the guidelines for research in the virtual environment, the care of surveillance and protection of the data generated: use of passwords, codes and zipped folders, no use of collective emails, no storage of data in clouds, preservation of anonymity with identification of participants by means of the initial H and ordinal number, for example, H01, H02, H03… (32)(33) .
In addition, an informed consent form was used in the imaging modality, and its copy made available by email or other modality of the participant's choice.

Results
Most participants self-identified as trans men (97)  The nursing team's sensitive and technically qualified performance and the integration of the multiprofessional health team and of transdisciplinary areas are essential for the subjects to achieve their individual goals related to appearance and "passability" during this vital cycle (4) .
In addition, such actions may involve aspects such as the choice of a name, management of conflicting situations such as menstruation, breast volume and the need to hide them with the use of binders, difficulty in thickening the voice and vocal adequacy, hair growthconfiguration of the beard -, application of the first doses of testosterone and even the use/employment of objects for building "penile volume" (briefs with volume/filling), use of prosthesis (packers) in daily life and during intimate relations and/or pump for clitoral growth (34) .
This study evidenced the abrupt suspension of the care processes that ensured the corporeality and identity preservation of the participants. It is noteworthy that in addition to the suspension of specialized care for those in the transition process, many people who have recently sought gender-affirming health care have had to postpone their projects (3) .
By causing discontinuities in the ways of living and in the identity trajectories expressed by individuals, the pandemic as a critical situation may be responsible for the transformation of lives and the narrative reconstruction of biographies (8)(9)(10)(11) , which may reproduce narrative re-elaborations of the relations between future, past, and present (10) . Thus, we add the need to understand the overlapping and intersecting social markers -for example, being adolescent, trans and/or transmasculine, Black, poor, homosexual -that amplified the vulnerabilities in the pandemic in Latin America (35) .
Our findings indicate the complexity of deteriorating From these data, we reinforce the need to pay attention to the wishes and desires, often managed by the environmentalization of trans people in public spaces from the social and collective violence committed -bullying, rejection, discrimination, stigmatization, stereotyped social representations (36) . Thus, the population that was already stigmatized suffered the greatest impacts, triggering illnesses, such as depression and anxiety, related to prejudice in the workplace, which generated even more insecurity and uncertainty. For trans people, decreased income has resulted in less access to routine hormone treatments and, consequently, body changes affecting their gender identity, a significant stressor (37) , as verified in this study.
Economic instability and barriers to the right to human dignity, often related to the internalization of prejudice and doubts inherent to the period of youth, cause trans adolescents and young people to blame themselves, to lose the meaning and purpose of life, to diminish their power strength, joy, and hope. Following this path, often with no way out, they attempt suicide (38)(39)(40) .
The hopelessness in the lives of trans people arises from the first expressions of the gender identity with which they identify, at as early as adolescence.
For example, a study that assessed the prevalence of suicidal ideation in a northeastern trans population in Brazil noted that the sample had "come out" regarding their gender identity before the age of 18 (67.3%).
In the group studied, those who came out in adolescence had a higher prevalence of suicidal ideation (36.2%) (39) .
This phase of life is consonant with the beginning of expressions of violence and aggression in their lives (3,(41)(42) .
Not responding to the wishes and norms of the families is the first major obstacle experienced by these people (43) .
For these reasons, suicidal behavior becomes common in the trans community, especially during youth, associated with the vexatious and violent situations to which they are exposed, causing melancholy, egodystonia, and deep sadness (44) .
In the United States, economic inequities have been recorded in the LGBTQIA+ community. It was identified that 19% of transgender and gender-diverse people and 26% of transgender ethnic minorities and gender diverse people of color lost jobs compared to 12% of the general population (3,45) . Another investigation compared cisgender and trans people in the COVID-19 pandemic and pointed to significantly increased financial instability and life degradation in the transgender public (46) .
Decreased access to care and restricted participation in social connection groups have led to worsening mental health indicators, with increased rates of depression, anxiety, and suicide (47) . One study pointed out that  (51) and trans men in Canada (52) .
Even in the face of multiple difficulties, these results indicated that adolescents and young trans men and transmasculine people exercised self-perception and perception of health regarding the COVID-19 pandemic. Moreover, they indicated the weaknesses of the services that provide health care, which can be understood as a complaint, but also as a call for help.
In face of everything they experienced, the participants indicated ways to overcome the problems generated by the pandemic, which public managers from governmental and non-governmental organizations, as well as nursing professionals, can benefit from, by knowing and then intervening.
In this way, by facing the threats to identities and the ruptures imposed by the pandemic, the propositions made can ensure mastery over the chaos and the resumption of their unfinished projects, and thus ensure a future regaining of control over their daily lives (8)(9)(10)(11) . Balance after such ruptures will claim acceptance of the ever-changing trans body, for living implies relating to your body and putting it in continuous interaction with other bodies (49) .
Thus, specifically for the nursing field, this study pointed out several propositions that can contribute to the redefinition of nursing actions/interventions, competencies, and skills in men's health (53)(54) . This research also suggests the development of new proposals, people (55) , as the protection of male mental health and the improvement of living habits and post-pandemic care (56)(57) .
In this sense, the engagement of nursing professionals in the welcoming and the production of sensitive and inclusive care is urgent. In addition, one should advocate for the strengthening of already

Conclusion
This study understands that the COVID-19 pandemic Furthermore, the study shows results that will be useful to instrumentalize public agents, health professionals, and the organized civil society in the promotion and prevention of health problems, in a collective exercise of post-pandemic resilience.