Sample characteristics.

Characteristics of the study sample are presented in Table 1. Participants had a mean age of 24 years (range ages 18–48 years), reflecting a sample that was mostly young; 42% were current students, and most frequently reported their sources of primary income as 58% employment (full- or part-time) and 21% parents. The majority (87%) lived with family/extended family or 16% partner/boyfriend/girlfriend/spouse. Most participants reported residing in the Centro de Lima (central district of Lima).

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Table 1. Characteristics of the study sample of trans men in Lima, Peru (n = 46).

https://doi.org/10.1371/journal.pone.0254494.t001

Gender identity and transgender identity development and disclosure.

As shown in Table 1, trans men most commonly described their gender identity as 87% male/ man, 47% transgender man, and 8% transmasculine. Varying rates of transgender identity disclosure were reported and depended on who they were disclosing to (95% friends, 79% partner, 74% siblings, 69% parents). Participants reported first becoming aware they were transgender at a mean age of 12 (range ages 3–30 years). Four participants wrote-in a response: “forever”, “for as long as I can remember”, and “since I had the use of reason”. Trans men reported first telling another person about being transgender at a mean age of 18 years (range ages 8–30 years).

Avoidance and limited use of healthcare.

Participants described avoidance and limited use of healthcare due to previous experiences of maltreatment and associated high levels of mistrust toward health providers and the medical establishment. All participants (100%) reported discomfort with healthcare providers as a deterrent to accessing health services. More than half (55%) reported not feeling comfortable interacting with health personnel or talking about their gender identity with them (53%). Almost three quarters (72%) reported not trusting that providers could help them with medical gender affirmation processes. Only 11% reported having ever disclosed they were transgender to a healthcare provider. One participant described how the non-recognition of his gender identity on his National Identity Document (DNI, Document Nacional de Identidad) and discrimination experiences deterred him from accessing healthcare:

“Well, I´ve never liked going to the hospital because of those issues, the ID (DNI), the name your appearance and that stuff, right? I mean, I´ve been in the hospital and seen physicians or nurses making gestures or saying things that don´t make me feel good. So I´ve never liked seen a doctor”

(FG #1).

Discrimination in healthcare.

Overall, 69% of participants reported experiencing discrimination or mistreatment from health personnel in relation to their gender identity. One participant recounted his experience:

“Yes, then I went in and left, and they kept looking at me weird. Well, the doctor up to then (was) super polite and everything, but when they were going to check me, the nurse came and started talking: ‘Is she a woman or a man?’ and I (was) super uncomfortable, and until now I have an abscess there and I have not been (back) to be seen.”

(FG #2)

In addition to discrimination from healthcare personnel, participants reported experiences of discrimination and mistreatment from others in the healthcare environment, including from front desk and administrative staff (e.g., receptionists), security personnel, and fellow patients.

A common barrier that participants described to accessing care (and to accessing any official institution) was the need to present a DNI. Participants discussed how their DNI reflected the sex assigned at birth, drawing attention to the discrepancy between their current gender identity and assigned sex at birth. As one participant described: “I have never liked going to the hospital or a doctor because of my DNI… my name and my appearance.” (FG #1)

Lack of awareness and information among medical providers.

Participants reported a widespread lack of awareness and information regarding transgender identity and health needs among medical providers. One participant narrated an experience he had with an uninformed provider this way:

“Of course, I had already made my transition, I had my hair cut, I went with my mother, I remember and the doctor checked me. I had not menstruated for about 4 months and I was worried. The doctor took my mom out of the office and told me hija (daughter) you are pregnant. I told him that was impossible. What happened was that I had a tumor on my right ovary that I had to have removed and the tumor was so big it was the size of a ball. The doctor, like he did not have much understanding at the time (about transgender issues), did not have the required education in the subject of trans men.”

(FG #1)

Frequently trans men described the lack of clinical training and protocols in Peru for providing healthcare to transgender people, especially for trans men, as an unmet health need. Further, participants described that while transgender women had some visibility in Peruvian society and within medical institutions, trans men were erased. As described, “I would like to society to recognize us. We exist. We are people. We are not one, we are many… We need respect we need to our identity.” (Interview #6)

Unmet medical gender affirmation needs.

Nearly all participants described gender affirmation as a health priority. Medical gender affirmation characteristics of the sample are presented in Table 2. Participants most commonly expressed a desire for hormone therapy and chest reconstruction. However, they indicated that services for hormone therapy were difficult to locate, non-existent within public institutions, and very scarce and costly in the private sector. For example, the cost of hormones, around 200 soles per month ($60), was reported to be unaffordable for many participants.

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Table 2. Medical gender affirmation in the study sample of trans men in Lima, Peru (n = 46).

https://doi.org/10.1371/journal.pone.0254494.t002

Participants reported accessing information about hormone therapy through the Internet or peers. Approximately 30% reported having used male hormones, although the majority of participants (94%) reported wanting to use them. Of those using hormones, all reported using intramuscular injection. Pharmacy (83%), clinic or health center (33%), or private practice (8%) were the most commonly reported procurement sources for hormones.

Participants described the absence of public health services for medical gender affirmation and the importance of making medical gender affirmation accessible, particularly in the context of societal stigma:

“It’s important because if you physically look like a man, people will think you are a man, and they will treat as such. The problem if you still have feminine characteristics people will see you and think ‘here something is weird’.”

(FG #4)

Information regarding access to surgical procedures for trans men was described as rare relative to access to hormone therapy. Participants described both the high costs of surgery and the limited number of providers offering transgender surgical interventions as key barriers to accessing these types of gender-affirming services. The procedure participants mentioned most was chest surgery (e.g., mastectomy, chest reconstruction). Yet, only one participant reported having undergone chest surgery, although more than 90% reported the desire to have that type of surgery.

Due to unavailable medical gender affirmation policies and procedures within in public health institutions, participants described primarily accessing behavioral gender affirmation practices, such as, relying on binding, using constrictive materials to flatten the breast tissue and create a male-appearing chest, and packing, using a non-flesh penis or other material to give the appearance of having penis. Participants expressed a need for early gender-affirming interventions, wanting publicly available services for trans men in late adolescence.

Sexual and reproductive health needs.

Participants did not describe gynecological care as a health need. When asked if they had ever been screened for cervical cancer (e.g., had a Pap test), the overwhelming majority said they had not. As one participant reported: “I have never gone, ever. I’m 24 and I haven’t stepped into a gynecologist’s office. Not as a man, not as a woman. Ever.” (FG #1)

Anticipated stigma and associated anxiety deterred participants from accessing gynecological care, even when needed and/or among those who had accessed care reported evading follow-up care. Participants note the difficulty in seeking this type of “female” care as a man, which they viewed as exacerbated by the absence of trained healthcare providers:

“… I haven´t gone because I don´t know how, because I know it would be a problem. First, by saying your [legal] name and why you’re going to a gynecologist, if you look like a man; then, with the gynecologist. What am I going to say? Like, there is no one who is, let’s say, trained on these topics, that knows how to treat a trans person in a way that doesn’t make them feel all that anxiety when going to a doctor. That’s really needed.”

(FG #1)

To alleviate gender policing and stigma in communal waiting rooms, some participants described strategies they had used when accessing gynecological care. For example, one strategy was going with their female partners, sisters, or their mothers to avoid situational discomfort with front desk staff, nurses, and providers. As one participant reported:

“I took advantage when I was in a relationship to go and get checked together. then [my girlfriend] would say to me ’we are going to get checked. We are not going so that they will also check you’, and I would go and talked to the doctor. I would always look for a female doctor, for different reasons, and then we both got checked. But when I don’t have a girlfriend, I don’t go.”

(FG #2)

Mental health needs.

Daily experiences of psychological distress and anxiety were reported by all participants. Many described struggling with self-acceptance and reported feelings of self-blame, guilt, and shame about being transgender. One participant linked his transgender identity to feelings of guilt: “And then I said ‘I have something, something is going on with me, I mean, I don’t have to be like that [trans],’ I mean, I felt guilty, right?” (FG #4) In many cases, participants reported social isolation and feeling alone, as if they were the only person in the world who was transgender.

Participants commonly described the internal conflict resulting from the clash between their felt gender identity as men and the social expectations and gender norms associated with their female sex assigned at birth. One participant described experiencing this as a betrayal of his transgender identity because he felt he had been living a lie: “I felt like Pinocchio, I could never truly become myself, I felt as though I was always going to stay this way [in between two genders].” (Interview #1)

Several participants reported suicidal ideation and attempts associated with feelings of loneliness. One participant described social isolation due to bullying he experienced based on not conforming to gender norms in childhood and highlighted the toll this took on his mental health:

“I was isolated and ridiculed…. I only went between school and my room. As a result, I was super depressed and tried to kill myself two times.”

(Interview #1)

Participants described the lack of available mental health services, particularly the lack of publicly funded mental health services. Participants relayed difficulties finding mental health providers who were knowledgeable about the mental health concerns of transgender people and trained in working with trans men specifically.

Family.

Participants commonly described rigid and conservative gender norms in their family growing up as confining and stifling. They described frustration, anger, and ultimately sadness at not being able to express their masculinity visibly and outwardly in childhood, and the long-term negative mental health effects of this hiding. The act of “coming out” was recounted by many participants as an abrupt turning point in their lives. For most, the first disclosure of their transgender identity was to family members, in particular to their mothers. One participant shared:

“I felt I just couldn’t go on and I told my mother everything…My hair had been long since I had been 14 and I said, ‘No, I just can’t take any more’ and I grabbed and one day I left the house, I went to a party and got drunk and cut my hair [laughs]. And like that I went home, and my mother started to cry.”

(FG #2)

Participants narrated variable experiences with their families and familial acceptance of their being transgender. While some reported maintaining relationships with their family, others were no longer able to. Participants with conservative or religious families described the greatest family difficulties. Even in families that were accepting, participants reported common struggles, particularly the harms associated with being misgendered: “what is most difficult to change are the names when of calling us because, it’s been like, twenty years that they have called you one way, and to change overnight, I understand it can be confusing for them” (FG#1)

School.

Participants described educational institutions as challenging due to experiences of gender policing related to the sex-segregated dress code at school, as well as moments of resisting these: “My mom sent with me my nice little hairdo, with my little skirt, and in the middle of the street I took everything off and put on my track pants. -Yeah, I also had my track pants in my backpack.” (FG #4) Participants described how transgressing gender norms in school was generally not accepted by peers or school faculty and resulted in harassment and bullying victimization. Participants explained how others refer to them using pejorative terms such as “bicho raro” (literally, strange animal) (FG #4) and “la rara” (the strange one) (Interview #8). Others recounted harassment and bullying experiences beyond name-calling:

“They (my peers) would take photos of me on their cell phones while I was in the bathroom. They would mock me and talk about me as though I wasn’t there. I was isolated, never included.”

(Interview #10)

Participants explained that schools have little or no information on issues related to gender identity or gender diversity. Participants also reported varying experiences of acceptance or rejection and discrimination at the institutional level according to the type of school attended. Numerous participants reported attending a religious school and described how religious beliefs and teachings on “homosexuality as sin” fueled rejection by family and peers, as well as inhibited their own self-acceptance. As one participant described:

“I went to an evangelical school and in those years…We were taught that homosexuality was a sin and that homosexuals would go to hell, and at that age I believed it. Psychologically, I couldn’t accept myself because I thought I would go to hell… I tried to remind myself that I wanted God to love me and forced myself to dress like a woman and to try and forget how I felt.”

(Interview #1).

Trans men often reported that finishing school marked the turning point in their lives when they openly began to transition and express their “true selves.” However, participants reported that the challenging experiences they had in school settings remained with them, including resultant feelings of internalized shame and poor mental health.

Employment.

Participant narratives about employment were varied and differ according to job type. Approximately 70% reported some form of employment, yet participants pointed to difficulties finding employment. One participant described his challenges:

“…but unfortunately in questions of being able to apply my capabilities, I have applied, I have (submitted) more than 105 applications…they do not give me the option. And there are people who, I do not want to say that they are bad either, but (who are less capable)…they enter positions that I have been seeking for 3 years…”

(FG #4)

Participants also discussed difficulties of precarious employment: “I was working cleaning offices and they got rid of me in a month for being like this (trans)” (FG #2).

Trans men reported ongoing complications carrying out their workplace responsibilities because of their transgender identity. These challenges included threats of being “outed”, having their identity questioned, and being discriminated against because of it. Participants commonly alluded to limitations accessing and exercising their right to work due to the incongruence between their gender identity and their legal identity. Participants described how they were misrepresented on the DNI, which legally designates sex assigned at birth rather than current gender identity, and the ongoing difficulties that caused for employment.

Legal identity recognition.

All participants reported difficulty changing their name and gender markers on official forms of identification. They highlighted this lack of legal recognition as a chronic stressor affecting their health and as a structural barrier to everyday living. Participants viewed the DNI as the primary barrier to accessing healthcare services, employment, and other resources (e.g., banking, credit). All participants associated discrimination, fear, mental health distress and anxiety, and social exclusion with the need to present a DNI which was not concordant with their gender identity.

“It´s always tedious to do any procedure that involves the DNI.”

(FG#3)

“they call you by your name and stare at you like a weirdo (bicho raro), and they you- it´s that you? And you blush because its embarrasing, right?”

(FG#1)

Discrimination in public spaces.

Trans men reported widespread experiences of discrimination, often in public spaces (e.g., public restrooms), including in healthcare settings. These experiences were often attributed to their physical appearance (e.g., inability to “pass” as male) and/or to their transgression of gender norms (e.g., presenting as masculine). Participants reported public restroom use as an unavoidable and challenging situational context in their daily lives. As one participant described:

“I always have issues entering a bathroom. Honestly, I am scared to enter a public bathroom. Because in the women’s bathroom, I am not enough of a woman to enter and for the men’s bathroom, I am not masculine enough.”

(FG #4)

Participants perceived that medical gender affirmation (e.g., hormones) was not only important to their self-perception and self-actualization as men, but also necessary for easier day-to-day navigation of public spaces such as restrooms and public healthcare settings.

Conflation of sexual orientation and gender identity in Peruvian society.

Many participants reported being unaware of the concept of transgender identity until the late stages of adolescence or adulthood. However, they often described in their narratives an early identification with the masculine through their choices of clothing, toys, or identification with a male close to them such as a sibling or father. Participants recounted common questions of ‘who am I’ and ‘what am I’ when searching for “[their] true self” (“mi verdadero yo”, Interview #6) in late adolescence or young adulthood. They highlighted the need for social support during that process.

Trans men commonly recalled perceiving and naming themselves as butch lesbians (“activa”, “chito”) and confusing gender identity with sexual orientation. Participants emphasized the need for greater societal awareness of and access to information about the distinction between sexual orientation and gender identity and expression. Further, they described an absence of role models as transgender boys, and lack of cultural references (“invisibility”) in society as transgender men.

“And when I supposedly came out of the closet, I didn’t have the necessary information, and because I liked girls and I was woman, then I’m a lesbian, right? What other option did I have if I didn’t know about the topic.”

(FG#2)

Peer support.

Trans men reported resistance and self-care strategies rooted in peer social support, often obtained virtually online. Participants frequently described Facebook, chats, and other online platforms as crucial to circumnavigating feelings of isolation, learning about trans men identity, and understanding medical gender affirmation needs. One participant conveyed his experience:

“I started to find out about the meaning of the word [trans]. I started to look on the Internet and I began to see that there were other people. I started to see a group of more people who were trans and I felt identified and I said I am like that. And as I felt identified somewhere and started to find out, I started to inform myself, I found other trans people through the internet, who guided me and helped me.”

(FG #3)

Participants described the Internet as a resource for health, and a safe space to access needed information and seek social support. The Internet was described as enabling them to understand they were not alone and that trans manhood existed. They reported how the Internet was instrumental to becoming aware of peers, especially others living in their city, and how it boosted self-acceptance of their own transgender identity.