Archives of Medical Research - (2020) -

ORIGINAL ARTICLE
Qualitative Study of the Processes of Transgender-Men Identity Development
Tania Real-Quintanar,a Rebeca Robles-Garc
ıa,a Mar
ıa Elena Medina-Mora,a Luc
ıa V
azquez-P
erez,b and
Martha Romero-Mendozab
a
Centro de Investigaci
on en Salud Mental Global, Instituto Nacional de Psiquiatr
ıa Ram
on de la Fuente Mu~niz, Ciudad de M
exico, Mexico
b
Direcci

on de Investigaciones Epidemiol
ogicas y Psicosociales, Instituto Nacional de Psiquiatr
ıa Ram
on de la Fuente Mu~niz, Ciudad de M
exico, Mexico
Received for publication January 14, 2020; accepted January 15, 2020 (ARCMED_2020_50).

Objective. Describe and analyze the mental health service and medical needs of a group
of transgender men from the point when they changed their gender identity to male.
Material and method. Transgender men volunteers who attended a specialized care cen-
ter in Mexico City answered a qualitative semi-structured interview to explore their needs
as well as the adversities they unnecessarily face due to the lack of information and care
for their condition. Interviews were audio-recorded and transcribed for thematic analysis.
Results. Respondents began to develop their transgender identity in childhood; however,
during that time, almost none of them had any helpful contact with a health professional.
Those who did receive some form of care received mistreatment rather than positive feed-
back. It was not until adulthood that they obtained facts about a specialized care center.
Conclusion. It is necessary for health professionals to have information about sexual di-
versity and be trained to meet the needs of transgender children, in order to have infor-
mation on places and professionals who accompany them and advise on available
treatments such as hormone blockers or treatments. The study includes a small but impor-
tant sample. However, the currently hostile, discriminatory environment, significantly ex-
poses transgender people to developing mental health problems. Ó 2020 IMSS.
Published by Elsevier Inc.
Key Words: Gender identity, Transgender, Development, Health care, Mental health.

Introduction the accompaniment and care of the person from childhood

onwards (1). As part of the series of ICD-11 field studies to
The World Health Organization’s International Classifica-
evaluate this proposal in several countries (2), two sub-
tion of Diseases, version 10 (ICD-10 has been thoroughly
samples of adults that recognized themselves as transgender
reviewed. One of the main proposals regarding the trans-
since childhood were collected in the main Mexican study
gender condition, is to move its diagnosis out of ICD-10-
(3). In the first sample, Vargas-Huicochea I, et al. (4) eval-
chapter V of Mental and Behavioral Disorders, (as Gender
uated the impact of a diagnosis related to gender identity in
Identity Disorder), to a new chapter on Sexually-related
childhood among transgender people, as well as the opinion
conditions in ICD-11, with a different name that excludes
of transgender adults on the Category of Gender Discor-
the term ‘‘Disorder’’ (Gender Discordance). These changes
dance in Childhood proposed for ICD-11 The second sam-
seek to reduce stigma (by not regarding the condition as a
ple sought to evaluate the process of transgender
mental disorder) and to ensure that the transgender condi-
development and the mental health service and medical
tion is found in the classification (in a non-pathologizing
needs they identified in the course of this process (in both
chapter), so as to be able to offer services oriented towards
transgender-women and transgender-men). In this article,
we present the results of the transgender men respondents.
Address reprint requests to: Martha Romero-Mendoza, Direction of
Epidemiological and Psychosocial Research, Instituto Nacional de Transgender Condition: Definition
Psiquiatr
ıa Ram

on de la Fuente Mu~niz, Camino a Xochimilco 101, Col.
San Lorenzo Huipulco, Ciudad de M
exico, Mexico; E-mail: martha. The concept of transgender is an umbrella term used to
promero2@gmail.com describe a wide range of identities that includes trans sexual

0188-4409/$ - see front matter. Copyright Ó 2020 IMSS. Published by Elsevier Inc.
https://doi.org/10.1016/j.arcmed.2020.01.003
2 Real-Quintanar et al./ Archives of Medical Research
people, cross-dressers, people who identify as third gender,
and others whose appearance and characteristics are
perceived as gender atypical. This term mainly includes
people whose gender identity does not match the sex they
were assigned at birth. A person who was assigned male
at birth but identifies as a woman is a transgender woman.
A person who was assigned female at birth but identifies as
a man is a transgender man. Some transgender people seek
surgery or take hormones to bring their body into alignment
with their gender identity while others do not. Others do not
identify fully with female or male in a binary way, who are
located in intermediate, undefined or mixed states, self-
identifying as genderqueer, binary gender, gender diverse
or other variety of identities (5e7).
For some authors, gender identity refers to an individ-
ual’s self-perception and private sense of being male, fe-
male, or neither. It is a constitutive element of an
individual’s culturally-formed gender as opposed to their
biological sex, and generally takes the binary division of
sexuality for granted. Given the growing awareness of
the difficulties of distinguishing between nature and cul-
ture within sexuality, and of defining the differences be-
tween masculinity and femininity, gender identity is
increasingly becoming a theoretically unstable category.
Its definitional uncertainties are exacerbated when gender
identityedespite its relatively recent coinageeoccupies
the semantic field previously reserved for sexual identity
or when both concepts are utilized as interchangeable syn-
onyms (8).
Gender identity incongruence generally begins in child-
hood (9e11). Between 6 and 23% will maintain these iden-
tities in adulthood, (12,13), although in some cases, this
process can begin later in life (9e11).
Development of Transgender Identity
There is currently no agreement on a psychological model
that accurately describes the development of transgender
identity (14). However, in discussing the development of
transgender identity, several authors consider it relevant to
distinguish between these concepts; sex (anatomical, phys-
iological and chromosomal characteristics) and gender (un-
derstood as a socially assigned construct of what it means
to be a man or a woman). Thus, a person’s gender identity
defines their outward behaviors, traits, and attitudes, and
may be the same as or different from their sex assigned
at birth and is distinct from their sexual orientation (15).
In order to explain the development of transgender iden-
tity, some authors have adopted traditional models such as
the social cognitive theory of gender development of Bus-
sey and Bandura (16) while Marcia’s (17) research on iden-
tity states provides a non-linear model of development of
gender identity, combined with certain aspects of the devel-
opment of the identity of homosexual persons. In line with
research results, Devor (18) describes 14 possible stages: a)
- (2020) -
Abiding anxiety, b) Identity confusion about originally as-
signed gender and sex, c) Identity comparisons about orig-
inally assigned gender and sex, d) Discovery of
transsexualism, e) Identity confusion about transsexualism,
f) Identity comparisons about transsexualism, g) Tolerance
of transsexual identity, h) Delay before acceptance of trans-
sexual identity, i) Acceptance of transsexualism identity, j)
Delay before transition, k) Transition, l) Acceptance of
post-transition gender and sex identities, m) Integration,
and n) Pride.
Bioldeau B, and Renn K, (19) studied the experiences
of young bisexuals, gays and lesbians, establishing six
stages: a) Having a traditional gender identity, b) Devel-
oping a personal transgender identity, c) Developing a
transgender social identity, d) Becoming a transgender
offspring, e) Developing a transgender intimacy status
and f) Entering a transgender community. Both ap-
proaches have limitations in that they fail to detail the pro-
cesses, not all subjects undergo the same stages, and it is
essential to consider social and cultural elements, and
changes over time. (15,18,20).
Transgender people experience numerous health dispar-
ities as well as stigma, discrimination, and lack of access to
quality care (21). Medically, some transgender adults
request hormone replacement therapy and/or sexual reaffir-
mation surgery. Some pubescents may realize they are
transgender before puberty and be treated with a
gonadotropin-releasing hormone (22). And children require
supportive, gender affirming care, which may contribute to
enhanced mental health and well-being (23). Moreover, this
gender minority develops high rates of psychiatric morbid-
ities such as anxiety, substance abuse, depression and suici-
dality, which must also be addressed (24e26).
The above refers to specialized care during childhood
and part of adolescence, when people are just beginning
to be aware of their process, when neither the individual
nor the family have information on transgender identity
and only observe manifestations such as the desire to wear
clothes, play games, adopt hair styles, or be called names of
the opposite sex.
The present article addresses the experiences of trans-
gender men, whose specific development characteristics
have been studied to a lesser extent. This article contributes
to explore experiences, meanings and history, identifying
some of the mental health service needs and medical con-
siderations of a small group of transgender men, during
the development of their identity in childhood and adoles-
cence, as well as the response of certain health profes-
sionals when they care for a transgender patient.
Method
This is a qualitative study, which is part of a larger project
approved by the Ethics Committee on Research of the
 Processes of Transgender-men Identity 3

Table 1. Sociodemographic characteristics

Age 39
Educational attainment Completed 9th grade
Marital status Single
Perception of socioeconomic Lower middle class
status (USD$100 per month)
Job Works in a cafeteria
People you are currently ‘‘Mother’’ (actually an aunt)
living with
Sex at birth Female
Gender Identity ‘‘Man’’
Family He has 1 older brother and
2 younger brothers, he has
lived with an aunt since
he was a baby ‘‘She is
like a mother’’ David, 39.
34 33 22
Completed 12th grade Studying college Studying college
Single Living together Living together
Middle class (USD$225 Middle class (USD$750 Lower middle class
per month) per month (USD$350 per month)
Works at clothes hanger factory Unemployed Civil society
He has lived with an aunt and Lives with a girlfriend Girlfriend and parents
a cousin
since he was a baby
Female Female Female
‘‘Male’’ ‘‘Male’’ ‘‘Male’’
He never has lived with He is the youngest He has a mother, father
his mother. ‘‘I have not of 3 brothers and and older sister and has
known anything about her 2 sisters. Mother been living near his
for many years.I have a and dad. grandparents and
brother and a half-brother, other relatives.
he now lives with his partner,
they have a daughter and live
in the house next door’’
Erik, 34, ‘‘.I haven’t seen
my half-brother for many years,
because he is with my mom,
he was always with my mom’’
Erick, 34.

Ram
on de la Fuente Mu~n
ız National Institute of Psychiatry
(named: Toward ICD-11 categories on gender incongru-
ence: evaluation of validity, reliability and utility among
transgender people; principal investigator: Dr. Rebeca Ro-
bles, registration number: EP4318.1).
Participants
Participants were four adult transgender men receiving
healthcare services and hormonal treatment at a specialized
clinic in Mexico City. None have undergone surgeries to
modify their bodies. In childhood, none received a diag-
nosis or appropriate psychological treatment for their
gender identity. Their mean age was 32, two of them had
incomplete university studies, one had incomplete high
school and while the fourth had completed elementary
school. At the time of the study, three of them were
formally employed, and unmarried and two of them were
in a relationship. Sexually, three of them were attracted to
women and one described himself as ‘‘bisexual’’ (Table 1).
Procedure
The Project from which the results are derived had a quan-
titative part that consisted of surveying 250 transgender
adults who received health services at the ‘‘Condesa
Specialized Clinic’’ in Mexico City. This group of subjects
responded to a structured interview focused on sociodemo-
graphic characteristics, medical history related to gender
identity and during a specific period of adolescence, key
concepts with gender identity on the proposed diagnosis
of ICD 11, of DSM-V and ICD 10 (27). This population
was asked if they had received any diagnosis in childhood
and if so, they were invited to participate in an interview to
discuss the diagnosis in childhood, obtaining a sample of 12
subjects in total, 8 trans women and 4 trans men. So, the
sample was constituted as a non-probabilistic sampling by
intensity approach (28).
Participants were informed and agreed to participate. Af-
ter the purpose of the study had been explained and written
informed consent to participate had been obtained, they
were interviewed in a private office. Interviews were con-
ducted by a female researcher with a master’s degree,
who previously received training from a trained psychiatrist
who is also an expert in qualitative methodology. The inter-
views, lasting approximately 90 minutes, were audio-
recorded and the content of the interviews analyzed by
two researchers.
An interview guide was drawn up, for which eight
themes were analyzed: sociodemographic data, age at onset
of process, dressing up games and favorite activities, diffi-
culties expressing the preferred gender, puberty, contact
with health and mental health professionals, the moment
when they found out about transgender people, current hor-
monal treatment, opinion about a mental health diagnosis,
couple relationships and sexuality.
In order to understand how these issues were explored,
the six phases through which the thematic analysis process
was scientifically implemented are explained below (29).
These phases are: familiarization with data information,
generation of initial categories or codes, search for themes,
review of topics, definition and denomination of topics, and
drafting a report.
4 Real-Quintanar et al./ Archives of Medical Research
Results
It was decided to present the results according to the most
relevant topics and testimonials were chosen to match the
themes. Regarding the age at which participants identify
the beginning of their transition, there is a consensus that
this is in kindergarten, between the ages of 4 and 5. Respon-
dents described their preferences and tastes in clothing,
games and activities, hairstyles and choice of playmates.
At this stage, the group of participants did not experience
discomfort about their bodies or genitals. The adverse con-
sequences they identified were the restrictions on perform-
ing these activities, prohibitions and scolding and even
physical abuse if they insisted on doing activities associated
with children of the opposite sex or attempted to resemble
them. On the other hand, if the adults responsible for them
forced them to wear a particular type of clothing, they felt
rejection, anger and shame. At this stage of life, adults,
whether family members, friends or teachers, began to
identify the respondents’ preference for the male gender,
but not their peers (Table 2).
‘‘I have felt like this ever since I can remember’’
Juan, 33.
‘‘I liked to play with boys and with boys’ toys, hors-
es, ponies, donkeys, marbles, and play soccer.’’ Erick,
34
‘‘Putting me in a dress was a battle, I felt awful’’
Gabriel, 22. ‘‘I felt ridiculous in girly clothes; I never
liked girls’ clothes’’ David, 39
As children, they do not pay attention to anatomical dif-
ferences or what is wrong; they simply want to do and be
what they like. The stage of puberty, which begins in
approximately 7th grade, is the time when they experienced
the greatest adversity, beginning with the emergence of sec-
ondary sexual characteristics, particularly the growth of
breasts and the onset of menstruation. Sanctions on the part
of adults persist while their peers begin to sanction and crit-
icize them, ridiculing and making fun of them. During this
stage, they begin to express their attraction for girls, which
elicits criticism and scolding. Two of the participants iden-
tified this as the main reason why they left school (Table 2).
‘‘At puberty, the growth of my breasts and not having
a penis was really difficult for me; I tell you, it’s pain-
ful’’ David, 39.
It was also during adolescence that three of the four par-
ticipants were sent to consult a specialist for their condi-
tion: two psychologists and a general practitioner. None
of them received a diagnosis because of their gender iden-
tity and instead, they experienced criticism, rejection and
suggestions to perform an intervention to ‘‘reverse’’ the
condition. The result was that young people experienced
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shame, rejection, judgment and even began taking medica-
tion (Table 2).
‘‘The doctor told me that people like us were scum,
that God had made a mistake in creating us, that
perhaps God had not created us and we were the
product of Satan’’ Gabriel, 22.
The point when respondents found out about the concept
of transgender men or sexual diversity and found people or
institutions that provided truthful information on trans peo-
ple was between the ages of 18 and 20. They did not receive
this information from health professionals but from the me-
dia or people who oriented or guided them.
As for receiving a diagnosis in childhood, they agreed
that it would have been extremely useful for their families
to obtain information. They said that this would have been
reflected in understanding and support, and enabled them to
know that they were not alone. They would have under-
stood what was happening and obtained timely medical
intervention, such as the use of hormones. Regarding the
need for care, for these four people, hormone treatment is
important and, in the future, they want mastectomies and
only one of them wants a phalloplasty. They believe that
the health personnel, with whom they have had contact,
lack the sensitivity and training to deal with them and that
administrative aspects should also change, such as updating
file formats in which sex and gender are specified (Table 2).
‘‘We just want to be treated properly’’ David,
39 years
Conclusions
From the information obtained, one can infer that the devel-
opment of the male gender identity of the participants con-
tains some elements of the models described. On the one
hand, male transgender identity was developed at a young
age; participants had the norms and behaviors of their as-
signed sex at birth, and suppressed and sanctioned those
that corresponded to their male identity, which created
discomfort. Another source of discomfort was puberty, with
the emergence of secondary sexual characteristics. Discov-
ery of the transgender concept and identification with the
process takes time.
Transgender individuals have reported negative experi-
ences in health care related to their gender identity (30).
It is therefore important to improve health services and
acknowledge the special needs of transgender people. Some
basic actions include: knowing the words and labels people
use to describe their identities, which encourages respect
and understanding (31). Other aspects include having
adequate clinical record form, which reflect a person’s sex-
ual background, including intersex states, regardless of the
legal status of the person’s gender identity, and gender di-
versity, which are relevant to care (6,25). It is also
 Processes of Transgender-men Identity 5

Table 2. Narrative themes in the process of masculine transgender identity

Theme 1. Age of beginning of the process

‘‘Since I was little, seriously, since I can remember, since kindergarten’’. ‘‘when I was 4 or 5’’ David, 39
‘‘I remember that since I was in kindergarten, I did not want to wear skirts’’ (4e5 years’ old) Erick, 34
‘‘Since I was in kindergarten’’ Juan, 33.
‘‘I thought all children were the same’’ Gabriel, 22.
Theme 2. Dressing up and favorite activities
‘‘I liked soccer, car, playing the role of mom and dad, I was always the dad or eldest son, playing with boys was what I liked.’’ David, 39
‘‘I wore pants and shorts, denim, boots, I hated skirts and dresses, it was ridiculous, I hid and did not go out’’ David, 39
‘‘Ever since I was a kid, I wanted to be a soldier. I wanted hair on my face, once I painted it with black shoe polish and I really liked seeing myself like
that.’’ Erick, 34
‘‘I liked the boys’ uniform, always, it was always like that.’’ Erick, 34
‘‘I liked boys’ shoes’’. ‘‘I did not like skirts, I hated my braids and my grandmother would comb my hair’’. Erick, 34
‘‘When I played, I asked to be the father, the uncle or the boyfriend, I liked soccer, I played with girls too, because I liked being with them, playing arm
wrestling, marbles, spinning tops, football. I liked being with my dad in the garage.’’ Juan, 33 years.
‘‘I stole my brother’s clothes, but I could not wear any other shoes and the ones I had were girls’ shoes.’’ Juan, 33.
‘‘I liked playing soccer, wrestling, rough games, bicycle, go karts, videogames, I also liked to be with my dad, who is a taxi driver, fixing the car and
helping him’’ Gabriel, 22 years.
‘‘I hated the girls’ uniform. As I had asthma as a child, I was dressed in pants and more comfortable clothes but at religious meetings my mom made me
wear a dress’’ Gabriel, 22.
Theme 3. Difficulties expressing the preferred gender
‘‘Being forced to wear a dress, the girl’s uniform’’. ‘‘Being forced to leave school’’ ‘‘Bullying at school’’. ‘‘Legal change of identity’’.’’ Scolding and
spanking’’ David, 39.
‘‘Putting on my dress was a battle’’. ‘‘Elementary school was the most difficult’’
‘‘I had a lot of problems at high school because I began to feel attracted by girls and the others called me a tomboy’’. ‘‘I stopped going to school because
another classmate rejected my advances. She told me it was wrong, that I was not normal, at that time I realized I was gay’’ Erick, 34.
‘‘I was about 9 years old and they forced me to wear a dress and I was crying in the photography’’. ‘‘Bullying at middle school’’ Juan, 33.
‘‘Some neighbors played a trick. They took my girlfriend from elementary school on the day of my 15th birthday party, she did not know anything about my
gender identity, and she looked at me with a disappointed expression’’ Juan, 33.
‘‘I started to drink alcohol and drugs, I was mad at the world’’ Juan, 33.
‘‘My mom used to dress me up to go to their religious meetings, I did not like it at all’’
‘‘When I started to develop physically as a girl, that’s when I started having more emotional conflict’’ Gabriel, 22.
Theme 4. Puberty. Emergence of secondary sexual characteristics
‘‘My first period and when I started to have breasts, I had a very strong conflict, I wanted to have male genitalia.’’ David, 39.
‘‘I recognized my genitals as a girl, they were not what I expected but they did not bother me. My body began to change when I was about 8, my breasts
grew and it was traumatic to wear a teenage bra, I did not understand much about menstruation but I found it annoying and uncomfortable.’’ Erick, 34.
‘‘Having my breasts develop was especially annoying and menstruation was also unpleasant and I wanted a deeper voice. When I was 25 years old I
became reconciled with my body and I no longer wanted to have men’s genitals because I did some research and found out they are not that functional and
are costly interventions’’ Juan, 33.
‘‘As a child, I did not have problems, when my body began to develop, I started to experience a conflict. When I had my period and my breasts started to
grow (10) I realized men and women had different genitals, I had never seen a naked body as a child, I looked for information and illustrations and it was
difficult, uncomfortable, annoying, I felt that it was not my body.’’ Gabriel, 22.
Theme 5. Experiences of mistreatment by health and mental health professionals during adolescence
‘‘You must see a psychologist’’ ethey said at school- ‘‘when my breasts began to grow, I used a bandage then that day the psychologist said etake that off
because you should not use that-he made me leave without the bandage, I was shocked, I left feeling very bad, instead of having received orientation and
support’’. David, 39
‘‘My diagnosis was that I had a mental problem’’ David, 39
He did not receive any type of care.
‘‘I went to therapy like two or three times but because of my anger against the world.’’ ‘‘The therapist told me: your parents have to come, so they can do
family therapy with you (about his gender identity) and my parents told me they didn’t want to go’’ Juan, 33
‘‘My parents took me to a doctor who was also a Jehovah’s witness to change my evil ideas’’ Gabriel, 22.
‘‘He told me I was going to get AIDS; something was going to happen to me, and that I would get cancer too’’ Gabriel, 22.
Theme 6. Epiphany. Moment when they discover the concept of male transgender identity
‘‘I was 19 or 20, a co-worker oriented me’’. ‘‘At approximately 26, somebody recommended a sexologist who helped me a lot’’ David, 39
‘‘In a TV show at 18 or 19’’ Erick, 34
‘‘At 20 at a conference on trans men’’ Juan, 33
‘‘At high school, I joined a sexual diversity group’’ 15e16
Theme 7. Medical care needs for male transgender identity process
‘‘I want the surgery’’ (breasts and genitalia). David, 39
‘‘Breast surgery’’. ‘‘Implement all health services, because at the Mexican Social Security Institute or ISSSTE there is an area I do not know that includes
everything from planning and contraceptives to Pap smears and so on’’ Erick, 34
‘‘Mastectomy’’ Juan, 33
‘‘In the health system, they are not prepared; if you are a transsexual, they put an F for female on your medical report’’ Gabriel, 22.
‘‘I have dealt more with psychiatrists, with psychologists on the issue of bipolarity, there are many.psychiatrists and psychologists who are still very
macho, or very feminist and do not have all the necessary information’’ Gabriel, 22.
6 Real-Quintanar et al./ Archives of Medical Research
‘‘Mastectomy and phalloplasty’’ Gabriel, 22.
Theme 8. Opinion about receiving a diagnosis in childhood
‘‘We are not mentally ill, however, having received a diagnosis in childhood would have helped’’ David, 39
‘‘Knowing that as a child, I might have done everything sooner, when I was younger’’ Erick, 34
‘‘If they had given me the diagnosis, I would not have wasted time in lots of places, I would have avoided some of the things I went through’’ Juan, 33
‘‘Having had a diagnosis in childhood would have made life easier for me, because to begin with I would not have had to deal with this pseudo-good
doctor, who made me grow up with the idea that it was wrong’’ Gabriel, 22.
important to have and provide information on the use of
hormonal blockers for children and adolescents to suppress
estrogen or testosterone production and consequently delay
the physical changes of puberty, and the use of hormone
treatment for gender affirmation (32,33).
From adolescence onwards, patients can receive guid-
ance on sexual and reproductive health, fertility consider-
ations and the implications of hormonal treatment and
surgeries, ovule and sperm preservation options; and uro-
genital and gynecological care, among others (32).
Mental health care for children and adolescents and sup-
port for parents and families in accepting them are also
required, as are assessment, accompaniment in decision
making, therapeutic assistance, drug use prevention, anxi-
ety, depression and suicide care (34,35).
Providing information on gender identity in health care
can be crucial for proper care (36). However, this informa-
tion is not shared with health personnel by users, either
because they do not trust them or feel uncomfortable
answering, due to previous bad experiences, or because
health personnel do not explore this issue due to lack of
training or because they experience irrational fear, hatred
or aversion towards transgender people (6,14,15).
In this respect, the present study complements evidence
found in the study from which the sample comes, to support
the retention of a category in ICD-11 in a chapter concep-
tualized as more ‘‘medical’’ (vs. ‘‘psychiatric’’) which
would allow proper information and counseling, while
reducing social and professional stigma towards the trans-
gender condition. Training and anti-stigma efforts based
on this new scientific reconceptualization of the transgender
condition are crucial to modifying current malpractices and
providing access to the high-quality health services this
population needs and deserves.
Limitations of the study include the small number of re-
spondents who assist to health service, which does not
allow for generalization and do not represent the population
of trans men in Mexico, either. However, the shortage of ar-
ticles addressing the issue of male transgender identity
means that it must be explored in greater depth and this
research explores the needs of this population. Results
confirm that the process begins in early childhood, the iden-
tity process is initially located in the psychological realm
and subsequently in the body. Transgender males are a hid-
den population that experiences undetected suffering. On
- (2020) -
the one hand, they experience social suffering due to the
lack of response to their needs. They do not talk about
the subject, feel awkward, and inhibit and sanction their
tastes and preferences, which creates stigma. At the same
time, they experience personal suffering due to being
different, are not accepted and are the victims of attacks
and abuse.
Although in various health services staff have learned to
respect and consider diversity, it is still necessary that they
expand their knowledge about the needs of populations of
sexual and gender diversity. Education is an important tool
in medical schools and postgraduate programs and it is
essential to put aside ideological, moral and religious
discourse that remains and replace it with a scientific one en-
compassing sexual and gender diversity. Practicing physi-
cians, social workers, psychologists and psychiatrists must
be taught how to care for transgender people or refer them
in a timely, appropriate manner. School staff must also be
trained, since classrooms and schoolyards can either be un-
safe and intimidating for transgender people or a welcoming
environment where everyone feels part of a community and
is encouraged to learn. Training must also be provided for
the media, which often portrays transgender people in a ste-
reotypical or negative way that does not accurately reflect the
real experiences of transgender people.
A person’s gender identity cannot be changed. What
must change are the negative social attitudes that stigmatize
people and contribute to the violence and discrimination
against them. (5).
Conflict of Interest
The authors have no conflicts of interest to declare.
Acknowledgments
The main study ‘‘Toward ICD-11 categories on gender incongru-
ence: evaluation of validity, reliability and utility among trans-
gender people’’ was funded by the National Institute of
Psychiatry Ram
on de la Fuente Mu~ niz, and additional in-kind sup-
port was provided by the Condesa Specialized Clinic, Mexico
City.
The author received a CONCAYT grant when pursuing a
doctorate in Social and Environmental Psychology at at the Na-
tional Autonomous University of Mexico Psychology Faculty.
 Processes of Transgender-men Identity
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