Modeling lines of ways of working, caring, and managing trans people’s health

In a meeting with the management, they said: - “You need to have a protocol of how many appointments you will do before referring for surgery if the patient will have a suicidal reaction and if he will regret it later or not”. That (laughs). Exactly. So the desire is to speak like this: - “It doesn't work”. Because that guy needs 30 [calls], the other needs 01 [calls], and if he is going to be sorry or not, I don't have a crystal ball (Worker 1).

Among women I feel a little more challenged, I realize that there is something like that, I feel more pressured about giving a report, a referral to surgery, what the surgery will be like; as if they were following that script thing for me to grant a report. When I try to get out of it a little bit, it seems that I'm not welcoming them (Worker 5).

She asked me if I had a relationship or not, or even if it was something frequent, about people, how things happened. Also, how it was like with the family, here at work, how it worked ... And, everything else. And, I think the next meetings were kind of based on what I was bringing, every time I went, which was bothering me somehow. So, I remember that my follow-up was much more in this sense, and concerning this issue of surgery, and to understand what I wanted, and why, and everything…. Kind of to justify, too, why you want a surgery (User 1).

These three reports show the effects of the training processes that discipline the health working process with the transsexual and transvestite population using transsexual services based on devices as protocols, therapeutic flows, diagnostic manuals, and legislation. We understand device as

An undoubtedly heterogeneous set that includes speeches, institutions, architectural organizations, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral, philanthropic propositions. In short, what was spoken and the unspoken are elements of the device. The device is the network that can be established between these elements (^{FOUCAULT, 2014}a, p. 364).

The aforementioned devices cross the daily lives of trans people, configuring “[...] relations of forces, whether to develop them in one direction, to block, to stabilize, or to use them” (^{FOUCAULT, 2014}b, p. 47), due to attempts to normalize the bodies. In this sense, they converge for the production of what ^{Bento (2006}; 2008) named the device of transsexuality, which seeks to produce knowledge amid power relationships that aim to fix genders to body structures, according to truths for genders presented as universal and before the existence of the bodies themselves.

Such facts, more specifically, present genders from a binary perspective, according to which “gender reflects, mirrors, sex” (^{BENTO, 2006}, p. 90), and sexualities, under the heteronormative norm: “heterosexuality [...] as the standard [...]. All other forms of sexuality are considered, at best, incomplete, accidental, and perverse; and, at worst, pathological, criminal, immoral and destructive of civilization” (^{BORRILLO, 2010}, p. 31). Hence, “In a society whose predominant norms for the intelligibility of bodies reside in the gender binary and heteronormativity, all bodies that do not fit this standard might be considered ill, as is the case with trans bodies.” (^{ROCON et al., 2016}, p. 2524).

Under such perspectives, the participants present how the devices in question, when producing a normalizing formation, model ways of working, of putting themselves at work and, then, possibly listening, seeing, speaking, and relating to users. We perceive that such devices also play an important role in surveillance over the working bodies, insofar as, through the quantification and surveillance of the attendances and/or events, they exercise a central determination on the practices and the organization of the work.

It is not too much to recall, as ^{Foucault (2014}c) pointed out, that health workers are the first object of normalization inside a hospital that operates as a clinic; thus, they can operate disciplinary processes and normalizers on the bodies made up of patients, users, etc. This way of operating can also be understood as the effect of training based on the perspective of scientification, protocolization, and technification of health practices. A perspective that Camargo Jr. calls biomedicine and, consequently, analyzes it through three of his propositions:

It addresses the production of speeches with universal validity, proposing models and laws of general application, not dealing with individual cases: generalizing character; the models mentioned above tend to naturalize the machines produced by human technology, turning the Universe into a gigantic machine, subordinated to principles of linear causality translatable into mechanisms: a mechanistic character; the theoretical and experimental approach adopted to elucidate the general laws of the functioning of the universal machine presupposes the isolation of parts, assuming that the functioning of the whole is necessarily given by the sum of its parts: analytical character (^{CAMARGO JR, 2005}, p. 178-179).

Biomedicine presents a pre-determined body and world to health workers in training, whose invariability is ensured by normality dictated by universal biological laws of operation. In this perspective of formation, knowledge and information transmission are preached, scientific truths about norms and universal laws that regulate the normal functioning of the body and the world to apply them when necessary, to combat the then conceived as pathological and social deviations.

The dialogue with ^{Camargo Jr (2005}) enables the possibility to think of the fourth proposition about biomedicine: inscribed in a discursive order, organized as a discipline, biomedicine will be involved in the production of truths about the functioning of bodies, from discourses on health and pathology, normality and anomaly, separating them from other teratologies referring to a so-called false knowledge. According to ^{Foucault (2014}d):

Within their limits, each discipline recognizes true and false propositions; but it repels, outside its margins, a whole teratology of knowledge [...] Discipline is a principle of control of discourse production. It sets the limits for the game of an identity that takes the form of a permanent updating of the rules (^{FOUCAULT, 2014}d, p. 31, 34).

The author problematizes, from a genealogical perspective, the production of speeches in power games and the constitution of a field defined as true. In this context, not every speech will be assumed to be true, as its speech will be organized by games of interdiction and normalization. Then, ^{Foucault (2014}e) speaks of a political economy of truth in which "[...] the truth is centered on the form of scientific discourse and the institutions that produce it [...]" (^{FOUCAULT, 2014}e, p. 33).

Therefore, not everyone will be able to say what is desired, when it is desired, and in the way in which it is intended to affirm something. Those classified by a medical power/knowledge as abnormal and crazy and, in the case of this text, transsexuals and transvestites will be under the aegis of a kind of logophobia, which according to ^{Foucault (2014}d, p. 48), presents itself as a fear of discourse that may be presented as possessing something "[...] violent, discontinuous, combative, disorderly [...]".

To the extent that “the speeches are elements or tactical blocks in the field of the correlation of forces” (^{FOUCAULT, 2013}, p. 112), the processes of normalizing training will imputate to the set of health practices of workers a search to unveil the truths behind the symptoms, the pathological manifestations, deviating from possible diagnostic and therapeutic mistakes through the use of protocol diagnostic devices. Devices that are presented in everyday health as guiding a practice called based on scientific evidence, which would be delimited in the real plane. In this plan, the truth, when proposed as a universal, invariable element and produced based on scientific neutrality, excludes a set of other propositions, conceived as teratologies of knowledge.

User 1, in her report, showed tiredness. Perhaps because we talked after she left work at the end of the day; but I also believe it was due to the fact of having to repeat and reiterate the truth to the workers who accompanied the report. Therefore, she told us that, to have the surgery, it was necessary to correspond to a real discourse on transsexuality. In her speech, it became necessary to select the elements that corresponded to an idea of true transsexuality, produced by the operation of the transsexuality device. In this truth produced for transsexuality, we seek to model the dissident experiences of the binary genre from discourses, powers, and knowledge, framing them in a regime of truth that preaches the impossibility of being, living, and existing in the world in perspectives not foreseen by gender binarisms and heteronormativity.

In a tone that mixed indignation and incomprehension, user 1 questioned why the service could not be differentiated for those who had document changes; that is, a recognition, by the legal power, of the veracity of their identities.

In this standardized way, a working process is configured in a way that sets back eventual possibilities of exercise of autonomy by the user population through discursive police. There is a demand for a correspondence between the users and the real transsexual identity thought by the workers. These seek a possible correspondence between the narratives of users and trans users about their experiences, in gender and sexuality, and the truths printed in legislation and diagnostic manuals, which present the measurement of the performance of the binary genre and heteronormativity, by the trans population, as a necessary component of the working process and as a condition of access to health services (^{ROCON et al., 2019}). In this context, a user tells us about the astonishment of a worker when reporting her affective experiences as gays: “But are you a trans man with a man? [...] That thing, like this: - “But, you... I thought you were with a woman, a trans man”. That facial expression. that when you see it, you imagine it, you know (User 2).

The user's talk takes us back to the analysis that ^{Bento (2008}, p. 87) carries out on the process of working with health services for the trans population, pointing out that “the only map that guides the eyes of the doctor and the team members are the socially established truths for genders ”. Another element to be highlighted is the interdiction of discourse that we can perceive in the narrative of user 1 as a transsexual woman. In the follow-up process, she was bombarded with questions to be answered, and these questions were repeated in other consultations to assess the veracity of the answers. Such an interdiction is perceived to the extent that the user cannot say what she might understand as important in her therapeutic follow-up process, or what she might simply like to say. A condition was placed on her to only manifest herself when required and through the words expected from a real transsexual.

In this scenario, researchers such as ^{Bento (2006}; 2008) and ^{Rocon et al. (2016}; 2019) show how the trans population organizes their discourses in line with the idea of true transsexuality expressed in the diagnostic manuals and the understandings that workers Transsexualizing services have gender, sexuality, and true transsexuality. The script, then, would be a resistance strategy in the face of attempts at discursive interdiction, from which a selection is made of what to say and what to omit about the experiences and experiences with genders and sexuality, to obtain the report which conditions access to hormone therapy services and sexual reassignment surgeries.

In this respect, in her speech, worker 5 envisions presenting her attempts not to make the report as a central element in her working process with the trans population. Nevertheless, she says she feels challenged, as, according to her, the users pressure her for the report, not allowing the decentralization of the issue of the report to occur in the therapeutic monitoring.

Her look, while speaking, seems to reflect doubts or even concern with what she is saying. Perhaps for her, at that moment, being in front of a gay researcher familiar to her, could put her at risk of being reprimanded by the others because of her speech about the collection in the report. Yet, what I thought during her narrative and what I analyze here is the strength with which the device of transsexuality operates, and not only in the production of true transsexuality and the related exclusion of transsexuals and transvestites from public health services. But, also, how such mechanisms ties, bars, and prevents attempts to create care devices that escape binary gender norms.

After years of interdiction by health services through the device of transsexuality, the discourse of the trans population about their experiences in genders and sexualities, the presence of practices that seek to overcome the normalizing, disciplining, medicalizing, and pathologizing form in which these services have been organized, it may eventually be perceived as new attempts to gain the presence, or not, of the so-called true transsexuality, sounding, as a result, as a search to surprise users in a discursive vacillation that would harm their access to health service.

It is not too much to expect such a response from the trans population. As user 1 narrated to us – and we can also verify in the literature –, the configuration of health workers as true inquirers about a truth produced for genders and sexes has been present in transsexual services since its creation in Brazil, in 1997, by the Federal Council of Medicine.

Such analysis helps us to understand that the requirement of making the working process standardized, as worker 1 tells us, not to mention the diagnostic process that goes through it – and that presents itself and/or becomes more evident in the statements of worker 5 and user 1 – configure a normalization. This normalization crosses the lives of the subjects that make up the existential setting of health services, as the truths that guide, like a map, the views of workers are those through which their bodies, genders, and sexuality have also been shaped.

It is from this set of processes in everyday health that ^{Rocon (2020}), in dialogue with Gilles Deleuze, Felix Guattari, and Michel Foucault, claims that the molar lines of a formation that normalizes gender, sexuality, and practices of health workers. According to Deleuze and Parnet (1998, p. 151), “[...] all the hard segmentarity, all the lines of hard segmentarity involve a certain plan that concerns, at the same time, the forms and their development, the subjects and their formation ”. From them, dichotomous machines (male/female, teacher/student, teacher/disciple, social classes, public/private) derive so that if you are not a or b, you will be c. (^{DELEUZE; GUATTARI, 2012}; DELEUZE; PARNET, 1998). Such lines produce an organization plan that seeks to establish identities under normative perspectives of the binary and heteronormative genre, modulating ways of living, being, and being in the world. The training strategies that these lines follow will be configured in a normalizing formation: the set of their practices tend to control a normalization of the bodies of the workers, for there is also a control and normalization of the trans bodies under supposedly neutral, universal, and invariant truths.

The strategies that make up a formation as a normalizer constitute a kind of orthopedics by standardization. Thus, they operate by transmitting information and representations to be applied by workers in health services, shaping health practices – managing and caring for health services –, guided by diagnostic manuals articulated by transsexuality as truth, and operated by the device of transsexuality.

The practices that emerge from this training restrict eventual autonomy exercises by the trans population over their bodies, genders, and sexuality; over their stories and experiences as they produce a hierarchical relationship between workers(s) and users. Such practices, permeated by relations of power/knowledge, operate the interdiction of discourses of the trans population considered untrue, discourses capable of enunciating/announcing possibilities of living with genders, bodies, and sexuality beyond the normative limits established by biomedical discourses, for transsexuals and transvestites. In these terms, there is a glimpse of the control and/or dissipation of emergencies that create possibilities of experiences with genders and sexualities, both in workers and in trans users, as well as in health practices that affirm the difference.

In resistance to the normalizing formation, on account of a disruptive transetopoiesis: escape through learning with trans signs.

I also learned to deconstruct my body. When you're in this job, it's not a one-way job, right? You are there to rescue also who you are, your existence as a gender, as a black, my sexuality, my libido. It all came into play, right? That's why I think working with transsexuality, in terms of gender diversity, is difficult. It involves you in several issues, it's not just getting there, doing your service, picking up your bag, and leaving. No, it goes with you! It accompanies you home, in your relationship with your partner, in your desires, and you also open your mind: "I can also do many other things" [...]. So I am also a woman built differently, but how much I had to repress it, even in front of my partner so that we could live better. And now, working with that, I find out, hello?! It’s not like that! [guffaws]. [...] So we need to be there all the time [observing ourselves]. And working with diversity, it does that to you, it makes you think about the world, and it seems that you can do it differently. [...]. As a black woman, in fact, I always say the opposite, right? How much I had to shape my body, my thinking, to be able to live better in society. When in reality, society had to try to be the opposite in this story, right? (Worker 4).

The worker tells us about her learnings in the meetings, conversations, looks, and listening in the daily health in which she works with users and trans users. According to ^{Dias, Barros and Rodrigues (2018}, p. 956), in a meeting, we have the opportunity to dive into a “relationship in which thought enters into connection with that which does not depend on it” . Such a formative process, unlike a normalizing formation, is established in a convergence of affections that result from the presence of the trans population, with their bodies and experiences, in the existential territory of health services.

In this process, the worker speaks of a dip in thinking about herself, about the relationships she establishes with her body, genders, sexualities, and skin color. In this return to self-care in Foucaultian terms (^{FOUCAULT, 2010}), in which thoughts, ways of conducting life and relating to others and the world are observed, the worker seems to perceive herself silencing and also shaping her color and the so-called male experiences to report to their partner and the world.

It is interesting to note that, among the workers, she is the only one who presents her color and experiences as a body that is often marginalized and charged for modeling of modes of existence – once again based on binary gender and heteronormativity. This circumstance calls us, even though this aspect is not further explored in this text, to analyze the norms for gender and sexuality linked to whiteness, which converges in an oppression “[...] white and European-based cishetropatriarcal [...] ”(^{RIBEIRO, 2020}, p. 14). The normalization processes that led worker 4 through self-techniques, to the production of a woman subjectivity corresponding to the dimensions of prescribed roles, both in the relationship with her partner and with society.

To look within, one own thought and way of living the relations with sex, gender, and sexuality, ^{Rocon (2020}) called lines of learning with trans signs – which, as lines of flight, can be “defined by decoding and deterritorialization (there is always something like a war machine working on these lines) ”(^{DELEUZE; GUATTARI, 2012}, p. 112). The idea of trans signs and of learning from such signs is produced in dialogue with ^{Deleuze (2003}, p. 29), for whom, more important than thinking is “what makes you think”. So that "thinking is always experimenting, not interpreting, but experimenting and the experimentation is always current, the spring, the new, which is about to be created" (DELEUZE, 2003, p. 136). For the author, we think and learn something through violence with which the signs, through an encounter, summons us to decipher them by their experimentation as catalysts of experiences. For the author:

The unity of all worlds is that they form systems of signs emitted by people, objects, materials; [...]. But the plurality of worlds consists in the fact that these signs are not of the same type, they do not appear in the same form, they cannot be deciphered in the same way, they do not maintain an identical relationship with their sense (^{DELEUZE, 2003}, p. 5).

We Interact with the world and the world with us by the signs emitted by people, objects, and materials. We invented, created worlds through the systems of signs immersed in the encounters we held: “The sign implies in itself heterogeneity as a relationship. You never learn by doing as someone else, but by doing it with someone, who has no similar relationship with what you learn “(^{DELEUZE, 2003}, p. 21). ^{Deleuze (2003}) discusses the existence of four groups of signs: the worldly signs, the signs of love, the sensitivity, and the signs of art. Signs force us to think because:

The sign is the object of an encounter, but it is precisely the contingency of the encounter that guarantees the need for what he makes us think. The act of thinking results from a simple natural possibility; on the contrary, it is the only true creation. Creation is the genesis of the act of thinking in thought itself. Now, this genesis implies something that violates thought, which takes it away from its natural stupor, from its only abstract possibilities. Thinking is always interpreting, that is, explaining, developing, deciphering, translating a sign. Translating, deciphering, developing is the form of pure creation. There are neither explicit meanings nor clear ideas, there are only meanings involved in signs. [...] Creation, as the genesis of the act of thinking, will always arise from signs (^{DELEUZE, 2003}, p. 91).

It is through the violence of a sign, as a catalyst for an experience that forces us to think, that we experience learning from something and/or someone. Very different from a learning process planned for the accumulation and transmission of information and representations, normalizing training in which we learn by effects of recognition, storing in memory for later application. Learning with signs is to experience a temporal formative process, in the order of the encounter, summoned by the malaise that moves the thought.

Among the trans signs, a category proposed for our analysis, we privilege the signs of art proposed by ^{Deleuze (2003}, p. 13), dematerialized signs to which the mundane, love, and the sensitive converge, is the world of art that “[...] integrates them, gives them the color of an aesthetic sense and penetrates what they still had as opaque”. The trans signs are signs of an art of making yourself trans, of active experimentation of life as a work of art, a work opened by the manipulation of bodies to live and exist in genres and sexualities not normatively limited.

In the encounter with transsexuals and transvestites we have the opportunity to learn from these signs. But this does not mean that they belong to the subjects who experience transsexuality and transvestism; they do not originate from a given identity. Hence, the search for an objective interpretation of trans signs, linking them to subjects or identities, will cause disappointment.

Disappointment is a fundamental moment of search or learning: in each field of signs, we are disappointed when the object does not reveal the secret we expected. [...] Few things are not disappointing the first time we see them, because the first time is the turn of inexperience, we are still not able to distinguish the sign and the object: the object interposes and confuses the signs (^{DELEUZE, 2003}, p. 32).

The disappointment of trying to objectify to understand – for instance, linking trans signs to trans identities – is the first moment in a line of learning. The second is “the attempt to remedy this disappointment by a subjective interpretation, in which we build associative sets” (^{DELEUZE, 2003}, p. 34). How do we learn, then, with trans signs? Experiencing an encounter with them. Accordingly, perhaps the disappointment of the workers in meeting with the trans signs is also the disappointment in meeting with the absence of the so-called universal truth about their bodies, genders, and sexuality.

Another account of learning with trans signs portrays the problem of the social name, which, despite being provided for in a set of laws, ordinances, and technical notes that guide work with trans health, remains neglected.

We had a place to assist the patients at the clinic, people went there, but I started to do things differently, I started to see them at the social service, because I wanted this population to enter the hospital. And then it started to cause problems and I started to be called even by the coordination of the ordinance. [They questioned] why I allowed people to come in even though I was not wearing appropriate clothes. But, what are these suits that are not appropriate? So, then, girls who wear short shorts can enter, why, here, a transvestite who wears short shorts cannot get in? [...] Something they didn’t do, they did not use to have access to this discussion, little by little it was brought up. Yes, it may not have been the complete acceptance of the person itself, but we promoted this discussion, she was taken there, they had to face it and they had to learn to deal with it: - “Is it a boy? It's a girl? What do I call it? ” So, these basic things, from the treatment, we managed to bring them inside, inside the social service that they didn't bother to discuss since the reception the staff asked: - "How do I call them?" [...] So, this discussion went to the meal table, [...] they [other workers] ended up being instigated to this because people were looking for me, looking for interns. So, how are you going to deal with it? So, I think this was one of the strategies that we started to bring to work, right? (Worker 4).

The use of the social name and the reception of transgender people in health services are configured as an important problem of access to health for this population. Worker 4 presents, in her narrative, the effects of the meeting with the other workers in the hospital community, many of them not involved in the transsexualizing process, with the trans bodies traversing the hospital corridors.

Then, there is a kind of public appearance of trans bodies at the Hospital, without the control of clinics, offices, outpatient clinics, surgical centers, wards, among other delimited hospital spaces, through which trans bodies should walk under control and surveillance. When circulating through hospital corridors, places that did not foresee their presence, the bodies appear as they are, with the clothes they wear, disturbing an environment that feels they can no longer control them by defining acceptable clothing and behaviors to walk through that territory.

The encounter with trans signs, by producing malaise for forcing to think about what had not been an object of concern until then, makes the social name and discrimination emerge as a concrete problem in the daily practice of health. No longer restricted to transsexualizing services and their structures within the hospital, they provoke workers with their violence to produce a new body to give way to new forms of existence, managing, and working.

A problem that forces them, in this case, to an experience, promoted by the change of posture; which forces the emergence of a way of working, listening, and looking at this population from a relationship that is not foreseen or possibly based on the transmission of information, concepts or representations about gender, sexuality, transvestite, transsexuality, etc.

Learning from the trans signs is to produce, in the order of the encounter with the trans experiences an etopoietic knowledge that, according to ^{Foucault (2010}) in his analysis of self-care and self-knowledge of the Greeks, enables the production, modification or transformation of an êthos – something quite different from the truth though as universal, invariable and before subjectivities, present in normalizing formation.

Learning from trans signs is to experience a disruptive transetopoiesis, a trans-etho-poi-ethical movement of subjective repositioning through the production of an ethos that experiences uncomfortably experiencing gender and sexuality relations in face of binary and heteronormative norms. Thus, the truth is not a priori granted to the subject, as they find it in the operations of trans-figuration and trans-production of an ethos that gives way to difference, “a discontinuous, non-universal, dispersed truth that is produced as an event” (^{CANDIOTTO, 2007}, p. 204).

The encounter with the trans signs produces the malaise of an encounter with what differs, with what is in the order of an event and causes truth to emerge which, in its violence, makes us think. A truth that, in its provisionality, breaks with an organized and established field of knowledge, enabling the emergence of “a field in thought that is the embodiment of the difference that worries us, making thought a work of art” (ROLNIK, 1995, p. 246). Also according to Rolnik:

What forces us is the malaise that invades us when forces from the environment in which we live, which are the very consistency of our subjectivity, form new combinations, promoting differences in the sensitive state concerning the states we knew and in which we were situated. At this moment it is as if we are out of focus, and regaining focus requires us to make an effort to constitute a new figure. This is where thought work comes in: with it, we cross these sensitive states which, despite being real, are invisible and unspeakable, for the visible and the saying. Thought, then, is at the service of life in its creative power. When this is the work of thought, what comes first is the ability to let ourselves be affected by the forces of our time and to withstand the strangeness we feel when we are pulled out of the contour through which we previously recognized and were recognized (ROLNIK, 1995, p. 245).

It is the power of the signs of life as an open work that forces workers to an ethical repositioning in their clinical practices. It is necessary more than previous readings on the knowledge to know that trans lives have been framed in an identity-diagnostic prison. In contrast, such learning takes place in an ethical and aesthetic dimension, of permanent creation of practices, of repositioning care, working and managing with health services; also from looking, listening, feeling and problematizing oneself and the world; and still with a political dimension, certainly, “because it is a struggle against the forces that obstruct the source of becoming in us: reactive forces, reactionary forces” (ROLNIK, 1995, p. 246).

The encounter with trans signs invites us for an ethical repositioning towards life, experiences with gender and sexuality; a disruptive transetopoietic movement, escaping the binary genre and heteronormativity, inviting ways of living, and working that affirm the difference.