Transgender Identities, Pressures, and Social Policy: A Study Carried Out in Spain

ABSTRACT This article draws on a qualitative research project concerning the relationship between trans people’s mental health and wellbeing, pressures, social policy, and heteronormative gender norms in Spain. Drawing on interviews carried out with trans people from all regions and generations, we use an ecological framework to illustrate how a socially entrenched heteronormativity pressures trans people to comply with gender norms that impact negatively their mental health and wellbeing. The article argues that the legal changes in Spain are not enough in themselves to bring about social change, but, rather, Spanish social policy makers also need to challenge gender categorization and work toward transforming public discourses on gender issues if trans people are to gain full social recognition and equal social rights.

judicial process, and, second, it brought forth the formal recognition of a need to address social inequalities and support trans people's rights. One of the positive advances of this law was that trans people were not required to undergo genital surgery to legally change their gender status. However, with the introduction of this law there were two strict requirements. First, trans people were required to undergo a strict medical and psychological evaluation, and, second, they were required to gain a medical diagnosis of gender dysphoria, linked to trans trajectories understood as temporal transition and not as identity experience (Grau, 2015). Since the introduction of the 2007 law, social movements and political agents (especially LGTBI NGOs and PSOE-Spanish Socialist Worker's Party political party, opposite to other more conservative parties, which the main one is PP-Partido Popular) have supported the need for Lesbian, gay, transgender, bisexual and intersex (LGBTI) rights more broadly, and a range of protective legislation has been introduced (for example, Galicia, law 2/2014;Catalonia, law 11/2014, andEstremadura, law 12/2015). Some Spanish regions have also developed their own laws to protect transgender rights and to prevent transgender discrimination specifically (for example, Navarre, law 12/2009; Basque Country, law 14/2012; Andalucia, law 2/2014; Canary Islands, law 8/ 2014; and recently approved in Madrid; March 2016).
The 2014 Andalucia law has been particularly significant for trans people in Spain. While other laws were focused on the discrimination of trans people, the 2014 Andalucia law was the first to introduce the right for gender self-determination, and also to depathologize trans identities by removing the requirement for psychological treatment or medical procedures in the gender recognition process. After this law was approved in Andalucia, other regions in Spain developed similar laws (mentioned above). The main difference between the 2007 national Spanish law and the Andalucian 2014 law is that while the first attempted to solve a legal vacuum (avoiding the required judicial process to demonstrate the personal gender identity and, consequently, to change the name and sex on Spanish identification cards), the Andalucian law employed the notion of citizenship as a framework for both gender recognition and trans rights more broadly. While these legislative changes have led to some rights being acquired, the question of whether the needs of trans people are now being met has, however, yet to be explored. In this article, we argue that although legislative developments have been positive, socially entrenched norms of binary gender and heterosexuality underpinning the legislation remain problematic, causing many trans people to continue to face discrimination and social exclusion. Here, we illustrate the ways in which a socially entrenched heteronormativity creates pressures to comply with gender norms and how this can have a negative impact on trans people's mental health and wellbeing, where wellbeing is understood to occur when physical, emotional, social, and sexual needs are met (Lopez, 2008).

Ecological systems theory
It is well documented that trans people's experiences of being trans, accessing and using medical services, and establishing identities in everyday life are all influenced by sociocultural forces (Hines & Sanger, 2010;Westbrook & Schilt, 2014). Thus there is an interplay between the personal aspects of the individual and their specific environment (Monro, 2003). Bronfenbrenner's (1989) ecological systems theory, which postulates that development and wellbeing is an evolving function of person-environment interaction, offers a useful framework through which trans people's experiences can be explored. The socio-ecological framework distinguishes among proximal and distal influences, formulated in four systems that interact with each other: the micro-level of self and immediate relationships with family and peers; the meso-level, or connections between micro-level contexts; the exosystem of social contexts beyond an individual's direct contact; and the macro-level of a community's shared culture and values (1989). According to this model, people, relationships, community, and societal structures interact and influence each other, creating dynamics responsible for a variety of behaviors. In this article, we draw on the social-ecological framework to characterize the multiple and interacting levels of influence on trans people's experience and their mental health and wellbeing. The microsystem includes face-to-face environments such as the family, school or work context, partner, friends, and interactions within medical settings. The mesosystem consists of the interactions between these microsystems (e.g., relationship between family and school). The exosystems are indirect links to the person, such as the region of the country, neighborhood-community context, or the institutional systems (e.g., health system). Finally, the macrosystem constitutes institutional patterns of the culture and includes explicit manifestations, in laws and social policies, and implicit manifestations of ideology, which include societal norms such as heteronormative gender and sexuality. The interrelations among these are important insofar as people will spend time in several systems at the same moment.

Distal influences: The cultural pressure of heteronormativity
Questions concerning the relationship between gender, sexuality, and citizenship has emerged as an increasingly important area of debate (Lombardo & Bustelo, 2012;Platero, 2011). A central issue within current discussions is the role of heteronormativity: the cultural assumption that heterosexuality is the only valid social norm; that gender is binary (there are only two genders, male and female); and that there is a "natural" alignment between anatomical sex, gender identity, and (hetero) sexual orientation (Butler, 1990;Stryker, 2008). What is defined as "normal" sexuality and "appropriate" (heterosexual) gender expression is constructed and reinforced through culture (Butler, 1990;Schilt & Westbrook, 2009;Westbrook & Schilt, 2014). Thus men and women are expected to have male or female bodies that match their gender identities and engage in sexual practices with the "opposite" sex. This exerts significant distal influence on the social organization of sexuality and the construction of gender, where non-heterosexual sexualities and non-conforming expressions of gender are seen to be problematic and stigmatized (Butler, 1990;Hines & Sanger, 2010;Rich, 2003). For example, gender non-conforming and LGBT individuals may encounter homophobia and transphobia (Worthen, 2016) and also a range of barriers when seeking work or promotion (Johnson & Ghavami, 2011;Schilt & Wiswall, 2008;Whittle, Turner, Al-Alami, Rundall, & Thom, 2007). Heteronormative social expectations around sexuality and gender underpin this social inequality, where the rights of those who do not conform to the heteronormative narrative are also often undermined (Gil, 2008).

Proximal influences: Heteronormative interpersonal pressures and trans wellbeing
Trans people experience a number of cultural pressures regarding gender and sexual norms because they do not conform to the cultural and psychosocial expectations that gender identity is an immutable derivation of biology (Westbrook & Schilt, 2014). These pressures exert most influence psychosocially, for example, through interpersonal relationships where pressures related to gender or sexual exclusion have a direct effect on trans people's wellbeing. The social construction of gender and sexuality, operating through heteronormative social processes, generates an ideological master narrative of the naturalness of heteronormativity that permeates social life (Butler, 1990), where those around trans people may unwittingly or deliberately place pressure on them in a direct and personal way. For example, it is usual for trans people to encounter a variety of microaggressions from people around them in their daily lives (Nadal, Skolnik, & Wong, 2012;Nordmarken, 2014). These can include a lack of respect for and/or acceptance of their gender identity (Schilt & Westbrook, 2009), the use of denigrating language and/or deliberate use of incorrect gender pronouns; Nadal et al., 2012), an undermining of their sense of community belonging, such as being accused of not being "trans enough" (Galupo, Henise, & Davis, 2014;Leary, Tambor, Terdal, & Downs, 1995), a negation of their sexual needs (Davy & Steinbock, 2012), or, conversely, being exoticized (Nadal, Davidoff, Davis, & Wong, 2014). Thus regular experience of microaggressions and the pressure to engage with and/or conform to norms of gender and sexuality exposes trans individuals to various levels of psychosocial stress that have a negative impact on their psychological wellbeing (Mayock, Bryan, Carr, & Kitching, 2009).
Various international studies have demonstrated a direct relationship between cultural pressures concerning gender and sexuality and direct psychosocial pressure at the interpersonal level (Dysart-Gale, 2010;Fernández-Rouco, Fernández-Fuertes, Carcedo, Lázaro-Visa, & Gómez-Pérez, 2016;Schilt & Westbrook, 2009). For example, trans people have typically reported a distant relationship and a high fear of victimization from their parents (Floyd, Stein, Harter, Allison, & Nye, 1999). Further, it has been well documented that many trans people suffer from rejection, bullying, and lack of friendships (Griffen, Wilson, & Wren, 2005;Lombardi, 2009) and also a lack satisfactory and healthy romantic relationships (Dank, Lachman, Zweig, & Yahner, 2014). Finally, school and work contexts are often prime sites for discrimination, with many trans people leaving school to avoid violence or rejection by peers (Loutzenheiser, 2015;Williams, Connolly, Pepler, & Craig, 2003), thus putting future opportunities to develop a career or gain work at risk (Dietert & Dentice, 2009;Forman, 2003;Whittle et al., 2007). Discrimination is also present in institutions that are meant to defend and protect trans people's wellbeing. For example, a high level of discrimination is perceived by trans individuals in medical services (Burgess et al., 2008;Grant et al., 2010). This entire situation may lead trans people to have feelings of shame and stigmatization (Jupp, 2013).
In summary, heteronormative cultural pressures are associated with rejection and discrimination, a lack of support and the presence of stigmatization, isolation, transphobia, and violent behaviors toward trans people (Budge et al., 2013;Meyer, 2003). Poor mental health and wellbeing, and also a higher risk of risky sexual behavior have been identified as occurring largely as a consequence (Budge et al., 2013;Ryan, Huebner, Diaz, & Sanchez, 2009). Due to Spain's heteropatriarchal state, where gender inequality and sexism operate on both structural and cultural levels, trans women have been particularly stigmatized because by transitioning from male to female and deviating from their expected gender role, prior social status is lost (Sirin, McCreary, & Mahalik, 2004). Further, as in other European countries, there are cultural challenges to the legitimacy of their new social status. Within this context, trans women have reported higher levels of isolation, stigmatization, social exclusion, loneliness, more incidents of sexual risk-taking behaviors, and difficulties accessing education, cultural resources, and services and the labor market, compared to trans men and cisgender men and women (Hoffman, 2014;Sevelius, Reznick, Hart, & Schwarcz, 2009). Further, trans women have been found to be more likely to become involved in sex work (Baral et al., 2013, Clements-Nolle, Marx, Guzman, & Katz, 2001. As Bockting, Miner, Swinburne, Hamilton, and Coleman (2013) observed, the interaction of these factors are significant in decreasing overall health and wellbeing.

Methodology
To explore the above issues in the lives of trans people in Spain, a qualitative research approach was adopted where the research focused on firsthand experiential accounts of Spanish trans people regarding their everyday lives and relationships. The research sample was generated through the use of the snowball technique (Atkinson & Flint, 2001), which resulted in semistructured interviews being carried out with 120 trans people from different regions of Spain (e.g., Madrid, Canarias, Cataluña, Castilla, León). Of the participants, 60 were trans men and 60 were trans women, and ages ranged from 18 to 63 for women and 18 to 52 for men. The interviews were designed to explore different aspects of participants' biographies linked to human needs and wellbeing dimensions (López, 2008), and they were organized by a range of topics, including gender identity (e.g., "What situations make you feel bad regarding your gender identity?"), family, social, community, romantic and sexual relationships (e.g., "How is the relationship with your family/friends/partner regarding satisfaction?"), school or employment (e.g., "What was the reason you stopped studying?"), and psychosocial risks and mental health (e.g., "Have you ever been discriminated against by any professional?"). During the interviews, participants were also encouraged to reflect on the current political situation in Spain regarding trans equality (and also trans equality in the past, if applicable), their experiences and feelings associated with the current situation, and the support and barriers they encounter in everyday living. All the interviews lasted for approximately 90 minutes and were carried out in a private room in a location chosen by the participants (either in their own home or another venue, such as a university). As some participants did not want the interview to be recorded, notes were made by the interviewers throughout the interviews.
A high standard of ethical integrity was adhered to throughout the research. Participants were provided with a full outline of the aims and objectives of the study, and informed consent from each participant was gained before the interviews were carried out. Participants were also assured of confidentiality and anonymity and were informed of the right to withdraw from the study at any time. The data drawn from the interviews were analyzed using an inductive thematic analysis approach (Braun & Clarke, 2006, where similarities and differences of experience were systematically identified and clustered into relevant analytical themes. In the following sections, discussion of the data is ordered around two main issues: participants' experiences of gender and sexuality and how these were connected to cultural, social, and psychological pressures; and how these pressures interacted with participants' experiences of their mental health and wellbeing.

Family settings
Existing empirical research on trans people's lives has shown familial relationships to be particularly significant to the experience of being trans. For example, family relationships are often the most difficult to negotiate when coming out as trans and/or going through the transitioning process. While the family can provide much-needed support for some, others may face hostile reactions from family members and, ultimately, rejection (Hines, 2007;Sanger, 2010;Whitley, 2013). Participants within this study offered similar accounts, describing tensions with family members, or situations where they were rejected, as being caused by not fitting in with their families' expectations in relation to gender norms. As one transwoman we interviewed recalled, "When I told them at home, my father kicked me out" (Transwoman, 46 years old). Many reported how this generated the need for secrecy, such as attempting to "pass" as their desired gender only when away from the family and without them knowing, or hiding true feelings in order to avoid conflict and potential rejection. For example, one participant stated: I always knew I did not fit what they expected of me but it took me a long time to say so. Everything I heard at home about gender and about how boys and girls should be made me feel excluded and as I grew up it gradually got worse.
Transwoman, 44 years old Many participants described their family environments as unsupportive and intolerant and were unable to live as their desired gender until much later in life. One transman, for example, described how his family had added to the difficulties he faced when younger and also when transitioning: When I was 14 or 15, I, I didn't want to be called a lesbian, and I couldn't wear my hair the way I wanted, dress the way I wanted, or go by the name I wanted… I remained silent for too long […] My family always knew I didn't feel like a girl, but even when I told them I was transitioning, they never accepted it and they continued using my birth name. It was so embarrassing.
Transman, 28 years old Both accounts above illustrate how the attitudes of family members were affected by social expectations concerning the gender binary and heteronormative gender expression, and how this then led to the interviewees experiencing pressure to hide their identity and feelings and to be silent. However, for some participants, the need to keep their trans identity a secret was not only tied to a fear of rejection but a fear of homophobic and transphobic responses they would likely receive from family members. This also included violence, as one transwoman explained: My father abused my mother until he died and at home I always heard him talking about faggots, deviants … how could I say that I was a woman? … my father would have killed me.
Transwoman, 51 years old Similar to the experiences of the trans people in Brill and Pepper's (2008) research, the accounts of all the participants highlighted how their families could cause significant stress as they sought to understand, claim, and develop their gender identities. In many cases, while participants' families exhibited otherwise good relationships, these were often superficial. This was largely due to family members being in denial or refusing to accept participants' identities and lifestyles. As one participant remarked: I have my mother and my sister, but I never actually ask for their support. We meet to eat or something like that, but if something happens to me, I cannot expect their help, maybe in the case of money, but not with other problems, I don't feel understood.
Transwoman, 26 years old In these cases, family relationships were fragile where there were no feelings of acceptance or support. Participants often referred to not being entirely accepted by family members, and also reported how speaking with their families about the experience of being trans was taboo and unwanted. Thus instead of emotional support being provided by family members, the issue of gender identity was instead kept silent and hidden, leaving the participants to cope with their experiences alone (Factor & Rothblum, 2007). From the accounts given by the participants, this experience also led them to be misgendered on a regular basis, whereby they then become somewhat distant from their families: I'd rather not talk about this with my family. I speak very little with them because they don't stop using the masculine pronoun to refer to me, and I feel so humiliated. They are my family and although I ask them to change it, they ask me to understand them… it's a lot of pressure.
Transwoman, 48 years old Participants' accounts of their families highlighted how home and familial relationships were often far from being places of safety and support. Growing up as a young trans person involved various forms of gender identity rejection that, according to López (2008), should be considered a form of child abuse.
While heteronormativity operates in all countries, Spain is distinctive insofar as it is also Catholic and conservative in character, whereby heteronormativity is tied to faith as well as culture. For trans women the rejection of male privilege afforded them at birth leads to them being punished for being "weak men," and also for failing to meet the expectations of femininity (Serano, 2007). In addition, in this conservative context, children who do not conform to the gender norms are seen to shame the family, thus generating a pressure within families to deny the child's identity and ignore their needs. This suggests that although legislative changes have led to some improvements for trans people in terms of equality and citizenship, a number of cultural problems nonetheless remain.

Friendship and romantic relationships
As Maycock et al (2009) observed, friendship ties and a sense of belonging are crucial within LGBT communities to help manage minority stress (Mayock et al., 2009). Some studies have highlighted that networks emerge as a key component to LGBTI identity in a different way for young and older people, where the young are offered a level of insulation from the discriminative attitudes of family members and the larger culture, and the older experience a lack of LGBT community and higher stigma through the compartmentalization of their behavior. For some, this is associated with changes in traditional gender ideologies and religious-based moral values (Severson et al., 2013). In contrast, regardless of age, many of the participants in our study did not have a close friend with whom to talk to and share their emotions and experiences. As Hines (2007) observed, many trans people develop social relationships with other trans people to create support networks. Transgender groups and associations are often successful in facilitating such networks and, for some, may be the only place where their identity is fully accepted and recognized. As one participant remarked: I do not go out with friends, I have no friends, I just go to association meetings. Those Saturdays are my time, because that's when we all go out and have a drink together, and when I feel free. At the moment I cannot be myself anywhere else.
Transman, 25 years old It is well documented that some trans people may have difficulties obtaining social support and are left to themselves to deal with issues of segregation (Robles, 2000) and feelings of loneliness and isolation (Budge et al., 2013;Griffen et al., 2005). The accounts of these participants, however, revealed informal community resources such as associations and support groups to be important insofar as they provided understanding environments where social pressures were understood and they could "be themselves." Friendships forged within such settings thus played a crucial role as it was through these friendships that participants' social and emotional needs were met (Bockting et al., 2013). As Hines (2007, p. 483) observed, relationships developed within associations and support groups are also significant insofar as they "fill in the gaps in care left by professional organizations." For many participants, romantic relationships were the most difficult relationships to negotiate. Heteronormative cultural assumptions and expectations led many to feel that their gender would be considered invalid or fake by others, and that they would ultimately be rejected by potential sexual partners. As the following transwoman noted: It is very difficult to have a long and successful relationship, especially if you are heterosexual like me, because of course, he can love you very much but at the moment you introduce yourself to the family, especially the mother, he does not want to… and their friends, … and it makes you feel rejected and it doesn't really end well.
Transwoman, 38 years old This account highlights how social norms of gender can be powerful-that although establishing sexual contacts may not in themselves be difficult, they can become so once the relationship moves beyond the private sphere where there is a risk of "relationship stigma" (Gamarel, Reisner, Laurenceau, Nemoto, & Operario, 2014). All the participants recounted regular experiences of romantic loneliness and low levels of relationship satisfaction (see also Dank et al., 2014).

School and work contexts
Trans people are exposed to a broad range of stressors in social contexts such as school and work. Stigma and discrimination generates exclusion, making school experiences difficult and painful for young trans people, and causing difficulties in gaining employment or succeeding at work in the case of trans adults (Griffen et al., 2005). Due to the pressures trans people face as a direct result of discrimination and stigma, many avoid applying for jobs, stop attending work, or drop out of school (Bockting et al., 2013). In the following accounts, a trans man and transwoman both recount reasons for quitting school: As illustrated here, some trans people leave school because of difficulties being accepted during the transition process. This can then lead to poor job prospects with some, particularly trans women, moving into sex work out of necessity to survive.
For other participants, gaining employment and succeeding at work had been particularly problematic. One participant, for example, recounted how accessing work, even in lower-paid occupations, was difficult and that she had not been successful in gaining employment due to her gender nonconforming appearance: I have never worked in a store, they always tell me the same thing, I don't fit the profile, but of course, it's a lie. I know why I don't fit the profile, I have no physical traits of a biological woman… Transwoman, 31 years old For another participant, transitioning had been problematic during his training for work as a mechanic due to his gender identity being invalidated by colleagues. This experience then led him to hide his trans status when applying for work, due to a fear that this invalidation of his identity would continue: I always wanted to work as a mechanic, but when I looked for work, they told me that it was not a job for women. I enrolled in a course and they don't consider me as valid because I was a woman for my colleagues, it was very difficult for me to finish it. Now I've made the transition, but I never talk about it, and I work in a car shop.
Transman, 29 years old As highlighted in these extracts, being trans often means experiencing rejection by others and being excluded from fully participating in local communities and workplaces. Both participants discussed here recount their rights being violated and their identities being rejected. It is situations such as these that lead to feelings of loneliness, isolation, and rejection and also weaken everyday social networks necessary to gain access to certain relationships and social spaces, such as school and work settings. As described by one participant: I had a hard time at work, and generally in my life, so I stopped work to transition. I spent a long time without work and without leaving home, where I became depressed and anxious. I was, waiting for transition to change my life so that I could leave the house and look for work. I have spent almost 3 years alone. I still feel lonely because nobody knows my situation at work, but at least nobody discriminates me.
Transman, 25 years old As illustrated here, school and work settings are often discriminatory and unsatisfactory for trans people and significant sources of unhappiness and stress (Williams et al., 2003).

Wellbeing, mental health, and medical services
All the participants recounted how social and psychological pressures concerning their gender identities and gender expression and, in many cases, consequent victimization generated a high degree of psychological distress that had a significant effect on their mental health and general wellbeing regardless of their age. One transman, for example, described how he regularly experienced social exclusion, stating that: Being excluded affects everything, and makes you believe you are outside of everything, you feel bad, you feel helpless, and I do not want to complain all the time, but it's very difficult, it gets very difficult.
Transman, 26 years old Similarly, some of those interviewed referred to the discomfort they felt due to social and interpersonal pressures. These participants explained how social isolation and the lack of people to talk to, due to difficulties in gaining acceptance, had led to loneliness and feelings of helplessness: I'm single, I have no close friends, and I can't talk with my family, so I went to a psychologist, because I was feeling very badly and didn't know how to change it. That's why I am here, it's an opportunity to talk and feel better.
Transman, 34 years old I went to live in another city to start a new life and not have to tell anyone about my transition, I hoped to be happy, but it has been very hard, because I felt very lonely and if something happened to me, nobody really knew who I am.
Transwoman, 36 years old A significant issue that arose within the accounts of the transwomen participants was how psychological distress, as well as frequent experiences of violence and other forms of victimization, often contributed to engaging in sexually risky behavior. One participant, for example, recounted how the desire to be accepted by men as a heterosexual woman had resulted in her contracting HIV: I knew I had HIV a few years ago, but I think I'd been infected for a long time.
When I started to present as who I am, as a woman, I was so depressed and alone, and once I saw I could be with men as a woman, I just hoped that they would accept me and I didn't think about condoms or anything else.
Transwoman, 44 years old Psychosocial pressures can, then, lead to risky sexual behavior and sexual health care problems, particularly for trans women. For example, as shown in the above extract, sexual health risks and safe sex practices, such as using condoms, may not be considered and adopted when the main goal of their sexual relationships is to be loved by another person (Bockting, Robinson, & Rosser, 1998). Psychosocial and cultural pressures are, then, inextricably linked, affecting mental health and wellbeing, and sometimes causing health issues such as STDs. As the above extract also illustrates, this is also linked particularly strongly to pressures to conform to heteronormative binary gender norms in order to gain gender affirmation. There is a need, therefore, for social policy makers to consider the importance of social inclusion measures to support the current law, and to facilitate social tolerance and critical awareness around trans and gender issues (Gil, 2008).
The participants in this study all recounted experiences that suggest the need for the revision of current mental health and care services. The available resources intended to provide social, medical, and legal support to trans people were described as functioning from a heteronormative ideology and often inefficient, even negligent. One participant, for example, described how he had been treated "very badly" by one psychologist: It depends on the psychologist, but I went to one who treated me very badly, they told my family I had to be medicated and that we had to do therapy to resolve my identity conflict. I was young and went to several psychologists until finally I found a professional who made the process easier for me, but I had a hard time until then. During this time I lost hope of starting my transition.

Transman, 41 years old
Despite the recent legal regulation, the participants described how medical procedures are invariably linked to heteronormative binary norms of gender and sexuality. For the participants a high degree of psychological distress was generated in their engagement with medical processes and practitioners, as one transman explained: I had been waiting for years for the psychological report so that I could begin the hormone therapy. In his opinion I had not lived long enough as a man … I had lived all my life as a man! And now even longer with the hormone treatment and yet am unable to have surgery. I can't do it anymore. Everyday I go to work with this body, I go and I feel insecure and in a bad mood.

Transman, 27 years old
As in other studies (Norton & Herek, 2013), our research revealed that legal and formal rights did not guarantee social acceptance or prevent transphobia. Most of the participants described having been forced to manage bodies that belied their gender identities, often for years, due to rigid medical protocols. As well as exacerbating symptoms of gender dysphoria (Levine, 2009), this meant living with constant fear of hate crime (Hein et al., 2013) and dealing with ongoing discrimination in their daily lives, all of which had a severe impact on their mental health and wellbeing. As Budge et al. (2013) observed, transgender transitions are sometimes understood by health professionals as being the same experience for all trans persons, where stages and experiences are idealized. However, as discussed here, far from being ideal, these procedures are related to higher levels of loneliness, anxiety, and hopelessness for many trans people.
In summary, the accounts of participants reveal the necessity to work toward generating an inclusive social model of gender, requiring policy makers to take on the challenge of reconceptualizing gender categorization (Monro, 2003) and thus work toward transforming gender discourses more broadly. It is noteworthy to state that developments in legislation, cultural and psychosocial pressures, and trans people's health and wellbeing are influenced by each other. What can be concluded from the accounts discussed here is that although the legal framework has improved in Spain during the last decade, the influence of heteronormativity and its effects on individuals' social spheres has a greater influence on individuals' wellbeing than legislation. While law is a necessary instrument to ensure citizenship, changes in social norms and understandings are also required if the needs of trans people are to be fully met (Pichardo, Molinuevo, & Riley, 2009).

Conclusions
Heteronormativity has a direct influence on the quality of trans people's lives and their mental health and wellbeing. It exerts cultural pressure on trans people to meet and/or adjust to dominant norms of gender and sexuality. As trans people are often not able to meet these norms before obtaining gender confirming treatment and legal gender change (or, indeed, have no wish to meet such norms), they are considered to be "deviant outsiders" and, as a consequence, become stigmatized (Moolchaem, Liamputtong, O'Halloran, & Muhamad, 2015). This article drew on interviews with trans people to highlight the cultural and psychosocial pressures that trans people encounter in Spain due to deeply entrenched heteronormative social norms and expectations. The cultural pressure of heteronormativity on trans people has been seen to occur most poignantly through psychosocial pressures experienced in relation to family, friends, and romantic relationships, and also education, work, and mental health settings regardless of age and existing laws. The analysis presented here illustrates the significance of proximal and distal interactions in the lives of trans people, and how heteronormativity crosses the socio-ecological systems, as defined by Bronfenbrenner (1989). The discussion of participants' accounts also illustrate how exclusion can seriously affect the self-identities of trans people, leading to feelings of loneliness, helplessness, and, for some trans women, risky sexual behavior, all of which impact severely mental health and wellbeing. The accounts discussed further highlight the insufficient, inefficient (or even negligent) support that many receive from mental health resources. Transgender transitions are sometimes understood by health professionals as a defined process with defined steps, which excludes those experiences that do not fully fit, increasing levels of loneliness, anxiety, and hopelessness for many trans people. Contrary to previous studies in Spain, this study illustrates the multiple pressures that trans people face in different spheres of their lives and how these connect to the dominant social model of gender and also the Spanish legal context. Further, our heterogeneous sample enabled us to access polyphonic and multi-vocal stories where the personal narratives revealed the importance of talking about experience from particular identities (Peralta & Mérida, 2015).
To improve the situation of trans people in Spain there is a need for further legislative change. Although recent changes have certainly made a move toward improving the mental health and wellbeing of trans people, for example, enabling a change of name and sex on identification cards or revising the requirements for gender correction treatments, there are numerous strict requirements that exert pressure to demonstrate a fit with heteronormative binary gender ideals. Thus while legal changes are of paramount importance for the recognition of rights and citizenship, this does not guarantee changes in social attitudes toward gender norms. It is, then, crucial for policy makers to challenge gender categorization and work toward transforming public discourse on gender issues.
Although the data presented here provide new, current, and interesting information about the situation of trans people in Spain, it does have some limitations. The article did not, for example, adopt an intersectional approach and address the issues discussed across ethnic, social, racial, national, economic, and many other boundaries. An intersectional approach would be useful in extending the findings of this research. In addition, the snowball sampling method used placed limitations on the research sample. For example, the sample could not be controlled for diversity or representativeness. Nevertheless, the method does facilitate access to populations that are difficult to reach when using other sampling methods. Further, the research discussed here did not adopt a longitudinal approach and analyze the participants' accounts across time. As such, the ongoing impact of legislative change on the participants' lives and experiences over time has not been explored. The research does, however, provide more knowledge about the effect of heteronormativity and psychosocial pressure on the mental health and wellbeing of Spanish trans people, which, to date, remains largely under-researched. Finally, the research has further relevance insofar as it explores different human systems, both distal and proximal, and reflects how legal changes are not in themselves enough to bring about social change.

Disclosure statement
No potential conflict of interest was reported by the authors.