Social Determinants of Health

#### **Chapter 2**

## Transfeminine Bodies: Survival and Resilience Experiences in Brazil

*Silvana de Souza Nascimento and Luz Gonçalves Brito*

#### **Abstract**

This article aims to provide the results of anthropological research in Brazil regarding how trans and transvestites have survived in a country that is world-ranked in transfeminicide and how they find ways of resistance and resilience through support and care from networks to public health policies. The methodology used in the research was based on a multisited ethnography, through fieldwork and qualitative interviews, in two different regions: the metropolitan area of João Pessoa, in the state of Paraíba, in the Northeast, and the metropolis of São Paulo, in the Southeast. Using an intersectional perspective, the results show an increase in risks and vulnerabilities by black transfeminine people, mostly those who work in prostitution, because they do not have access to public health systems and have informally produced their care strategies based on local knowledge about the body, health, hormonal therapy, and so forth.

**Keywords:** transfeminine people, Brazil, care, vulnerability, ethnography

#### **1. Introduction**

Lilith went to the basic health unit near her home in a big city of Brazil. She thought she had HIV and she wanted to make sure. Lilith was a middle class trans woman in process of social and hormonal transition. She studied social science at the university. Although she was not a sex worker, she had had unsafe sex, due to her extreme emotional vulnerability. She arrived at the basic health unit, watching her steps, unsecure about her appearance, even though she wore a mask, which hid her sparse laser-removed facial hair. There was an enormous line, and she asked someone if she could use the stairs. "Are you going to the infectious disease department, sir?" said out loud the ugly men in the front desk. He disrespected her twofold, misgendering her and exposing a presumed health status. She reached the stairs, thorn inside. While she was waiting in the line to schedule her appointment with the doctor, a white man, who was working in the reform of the windows in the public health center, noticed she was trans. He looked at her with creepy eyes, approached her, almost touching her, invading her personal space. Without any words, he was suggesting sex. Lilith was feeling terrible with her silent social suffering. She left the place, heading to the bakery. While she was paying for the cheese bread, a Black woman who was homeless came into the place and asked her for money. She could not help at that moment. Angry, the woman said: "You are just a boy who sits on cocks," and left. When Lilith arrived home, with all the transphobic situations returning over and over in her head, she looked at the windows of her room on the 10th floor. She thought it would be a final solution for her social suffering. She took out her clothes of her heavy body, stepped to the rampart, with anxious breath. She could not even feel the air. She imagined her monstruous armor floating in the direction of the morning blue sky. But she returned to the basic health unit, talked to the manager, and decided to report the harasser to the police. The women's bureau was not prepared to register cases like hers, not only because she was trans (the cops subtly laughed at her and one female cop was not sure if her case should be investigated there), but also because sexual harassment is naturalized in Brazil, even by the police, whose scope of action usually prioritizes domestic violence.

Social suffering, as Kleinman *et al*. [1] defined, is an important category of analysis when it comes to the experience of trans women and transvestites in Brazil.1 The narrative above situates the evident and subtle social suffering, which is part of the lived experience of trans people in Brazil. The allegoric narrative contains some modalities of the structural violence experienced by a trans woman in process of social transition in the country. Such a structural violence involves misgendering, emotional and psychological abuse, sexual harassment, discrimination, misogyny, difficulties in accessing health services. The narrative is the composite picture that summarizes samples of oral information and written texts of transgender women gathered by means of ethnographic interviews during 15 years of research. Nevertheless, the situations experienced by a trans person are not merely personal problems, but rather social problems, which are experienced personally and aggravated by the different layers of intersectionality. A poor Black transvestite woman who does not have access to privileged spaces of knowledge production, such as a university, experiences other forms of oppression and violence, even though the main modalities of discrimination affect most trans women.

Along the narrative, the social problems are experienced as personal and intimate discomfort, anger and hate, leading to a sense of unease and bodily sensations of desperation, sadness, and hopelessness. Although such an experience could seem extremely particular, if we consider the wide set of research on the transgender experience in Euro-American societies, we will find that suicide ideation and trials are more common among trans people than among cisgender population [2]. We understand that such a prominent reality is a result of transphobia—the culturally shared hate discourses and structural violence by a certain society in detriment of trans people—and not a correlate fact relative to a supposedly inherently problematic identity [3].

We understand that most of the mental health issues experienced by transgender people are deep and intimate impacts of the sociological problem of transphobia. The core of transphobia is a naturalized, socially tolerated, and still unpunished violence against trans people (transgender men, transgender women, nonbinary people, and transvestites). In a country where transfeminicide exceeds all the rates in comparison to other nations [4–7], it is not surprising that trans people, and specifically transgender women and transvestites, need to face huge problems whose origins certainly are not a particular mental disease or an individual nonconformity.

<sup>1</sup> Alongside this text, we use trans women as an umbrella term that includes transgender women and Transexual women. Usually, the term trans is also used to encompass a set of diverse identities, such as non-binary and gender-non-confirming people.

In the context of this culturally shared hate, the cycles of violence faced by trans women and transvestites have been reiterated like a precise sociological pattern. The revelation of the transgender identity is frequently followed by parental alienation, abandonment, truancy, and—due to marginalization, exclusion, social hostility, and the lack of formation and social support—compulsory sex work, which often begins in the early adolescence. The dynamics of social vulnerabilities experienced by the population of trans women and transvestites in Brazil also impact their access to public health services.

In the face of adverse circumstances, trans women and transvestites create their own strategies of resilience through their own support and care networks. Interestingly, trans women and transvestites who work as sex workers declare that the experience of prostitution enables resilient ways of life, through which care networks and affective bonds are built [8–14].

This article will explore how trans women and transvestites have built their networks in order to survive in such a difficult social environment caused by the structural violence of transphobia. First, we delineate an overview of trans health in Brazil. The other two topics present ethnographic experience in the metropolitan area of João Pessoa, state of Paraíba, in the Northeast, and in the metropolis of São Paulo, situated in the Southeast. We conclude suggesting an analogy between the "Brazilian racism" explored by Lelia Gonzalez [15] and the "Brazilian transphobia." We also suggest that transvestites and trans women construct a lived knowledge on their own bodies as an important form of resistance.

#### **2. Methodology**

Since 2009, Professor Silvana de Souza Nascimento has coordinated ethnographic research regarding trans women and transvestites who work as sex workers in the Northeast and Southeast. First, in the Northeast region of the state of Paraíba, the fieldwork was done at one peripheral place, on the margins of a federal road, where transvestites from rural and Indigenous areas live, circulate, and work on the local sex markets. The aim of this primary research, between 2009 and 2012, was to understand how this population occupied and mobilized the territory. Two other circuits beyond prostitution were identified: the LGBTQIA+ movements and the beauty contests.2 We could observe that transvestites and trans women who were sex workers at the contryside of Paraíba have a lifestyle translated on the road as an interstitial space, in its metaphorical and literal meaning, constituted on the borders of metropolitan regions. They circulate in small and medium-sized cities, relatively close to the main centers, whose strategic locality allows for a great circulation of people, vehicles, information, and networks of relations [12].

Research conducted in Paraíba followed the ethnographic method, including fieldwork, 15 interviews, and production of photographs. The ethnographic perspective is the theoretical base of our reflections, which are drawn upon the experience and the lived knowledge of our interlocutors.

<sup>2</sup> The first research, "Variations of the feminine: dialogue between gender, city and transexualities", funded by CNPQ, included the participation of young undergraduate researchers at the Federal University of Paraíba: Lívia Freire, Verônica Guerra, Luzicleide Bernardo and Thiago Oliveira, who are currently Masters or Phd students of Anthropology at different universities. Paulo Rossi, a photographer and sociologist, also participated.

*The ethnographic theory aims to elaborate a model of comprehension of any social object (language, magic, politics) that, even though being produced in a particular context, may work as a matrix of intelligibility in other contexts (...) The ethnographic theory proceeds like the savage thought: takes the very much concrete elements collected in the fieldwork and articulates them in a little bit more abstract propositions, giving intelligibility to the happenings and the world. ([16], p. 460).*

In 2014, after her move to the University of São Paulo, Professor Silvana Nascimento began to research in São Paulo city. A new research project was developed, from 2015 to 2017.3 The aim of the project was to comprehend the forms of urbanity by means of the transits and mobilities of trans women and transvestites in three regions of the country: in the metropolitan region of João Pessoa, Northeast; in the city of São Paulo, Southeast, specifically, the Butantã area; and in the triple Amazonic frontier, in the region of Alto Solimões, at the North, between the cities of Letícia (Colombia), Tabatinga (Brazil), and Santa Rosa (Peru). This text concerns only the two first regions mentioned above because the ethnographic data are more structured.

In São Paulo, research was conducted, mainly, at the spaces of prostitution in the Butantã area, near Cidade Universitária, where the biggest campus of the University of São Paulo is situated. During our interviews, in partnership with the Defensoria Pública do Estado de São Paulo and the Service of Specialized Assistance STD/SIDA of Butantã, we dispensed informative leaflets on the rights of sex workers and gender violence, besides condoms.

By means of a multisited ethnography, drawing upon the notion of sharing as the condition for a certain anthropological project, this ethnography is informed by transfeminism, putafeminismo, by the demands of trans movements, and by the wide knowledge produced by trans researchers ([6, 17–24], among many others).

#### **3. Trans health in Brazil**

The recognition of "trans" as a socially visible identity is inherently tied to the public health policies that included the population of trans people. Hand in hand with those policies, the recognition of gender identity of trans people was widely divulgated for health providers in the context of SUS, the Brazilian national public health system. An important identity policy was the recognition of the social name. The main health policies are the processes of gender affirmation, such as sex reassignment surgery and other related body transformations, provided by a dozen hospitals in the country. The pioneers were Hospital de Clínicas (Porto Alegre-Rio Grande do Sul); Hospital das Clínicas (Goiânia-Goiás); Hospital de Clínicas

<sup>3</sup> The research entitled "Trans-cities: experiences among people, frontiers and places" was funded by Fundação de Amparo à Pesquisa do Estado de S. Paulo (Fapesp) and Pró-Reitoria de Pesquisa of the University of São Paulo (Edital Novos Docentes). The following undergraduate students at USP participated: Alexandre Martins, Beatriz Rossi, Maria Iachinski Natália Corazza, Sabrina Damaceno e Lucas Vechi. And included the participation of the following graduate students of Anthropology: Veronica Guerra (Universidade Federal da Pernambuco/UFPE), Thiago de Lima Oliveira (USP), Luiza Lima (USP) e Letizia Patriarca (USP). Flávia Melo, Professor of Anthropology of UFAM (Federal Universidade of Amazonas) and José Miguel Olivar Nieto, researcher of the Group of Gender Studies Pagu/UNICAMP (Universidade Estadual de Campinas).

#### *Transfeminine Bodies: Survival and Resilience Experiences in Brazil DOI: http://dx.doi.org/10.5772/intechopen.102849*

(Recife-Pernambuco); Hospital Universitário Pedro Ernesto (Rio de Janeiro-Rio de Janeiro); e Hospital das Clínicas (São Paulo-São Paulo).

"Transexualizer process" regards the set of specialized services offered to trans people as a public health service. It encompasses endocrinological follow-up, psychological and social support, and surgeries. The transexualizer process was first stablished in 2008 by the Ministry of Health by means of Portaria 1707 and Portaria 457.4 In 2013, the "transexualizer process" was expanded and included as part of the National Policy of LGBT Integral Health. According to Cardoso ([25]: 6), the main goal of the National Policy of LGBT Integral Health is "promoting the integral health of lesbians, gays, bisexual people, and trans people, and eliminating discrimination and institutional prejudice, as well as the reduction of inequalities and consolidation of SUS as universal, integral and equitable."

More recently, family health facilities began to offer basic assistance to trans people, regardless of their participation on the "transexualizer process" of SUS. This is remarkable because these "ambulatórios" propose another perspective on transgender health. On the one hand, they propose a non-pathologizing practice, avoiding the confinement of identities by the diagnosis of gender dysphoria.5 On the other hand, they do not prevent gender nonconforming people and nonbinary people to access services of hormone therapy or other relative therapeutic processes. The notion of a "true transsexual" is abandoned, favoring self-determination of identity and including people who would not fit the criteria of a psychiatric diagnosis.

Even though the "ambulatórios" are, indeed, more inclusive than the biggest hospitals of reference, there is a parcel of trans population who still face more difficulties in accessing health services: the poor Black transvestites. In fact, gender, class, and race as social markers of difference overlap, engendering forms of discrimination, which are increased and shifted depending on how these social markers are embodied and perceived in social relations. Rego [7] suggested that the state plays an important role in the extermination of the abject bodies, particularly trans, Black, and poor people. The difficulties of poor and Black trans people in being truly included and welcome at public health spaces are the extension of their marginalization of social life as a whole. According to Rego, "afronecrotransphobia is a politics of symbolic and actual extermination of Black trans people; politics that affect living and take away life" ([7], p. 179) Afronecrotransphobia is rooted in the social hierarchy of bodies who deserve to live and others who are not "grievable."

These different forms of violence, according to Snorton [26], clearly reveal the failures of the promise made by the state and its technique of production of a "racialized gender." In other words, it is necessary to investigate the articulation between gender and race in order to understand the specific form of violence against trans people and transvestites. Such a violence denunciates the grammar of a genocide state and demonstrates the construction of a continuous state of emergency for this population. "There is no absolute difference between the importance of Black lives and trans lives under the sign of the racialized gender" ([26], p. 13).

We understand that the visibility of trans identities in Brazil is largely tied to the institutionalization of public health services for trans people. Nevertheless, trans visibility in Brazil is due more to the social action of Black transvestites by means of the trans movement. Trans woman and transvestites, especially the Black ones, have always been very important for the activism in Brazil, likely Marsha P. Johnson and

<sup>4</sup> Portaria is an official document signed by a state leadership in Brazil.

<sup>5</sup> See International Classification of Deseases 11th: https://icd.who.int/en.

Sylvia Rivera during the sixties in the Gay Liberation Front. Fernanda Benvenutty, for example, a transvestite who became an important political leadership is well recognized, and her photograph can be seen in the posters of the campaign for the social name, which are affixed to the walls at the public hospitals all around the country.6

#### **4. The experience of the streets**

The activist Fernanda Benvenutty (1962–2020), one of our interlocutors who followed our work in Paraíba, was a Black transvestite. She was born in a small city of Paraíba and participated in the trans movement, locally and nationally. Fernanda had an important trajectory in the field of trans health, participating in national and regional councils. She also participated in the process of foundation of ABGLT and ANTRA (National Association of Transsexuals and Transvestites), with Keyla Sympson, another Black transvestite. When she was a member of CNS (National Health Council), which established the national politics of health at that time, she became a protagonist of the campaign for the social name of transvestites and transexuals in the realm of SUS. The campaign included, specially, the distribution of posters with images of transvestites and trans women to the health facilities and hospitals. It aimed to inform about the existence of the legitimacy of the social name, defending the guaranteed use of the social name as part of the citizenship for transexuals and transvestites.

Locally, in Paraíba, Fernanda was one of the founders of ASTRAPA (Association of Transvestites and Transexual of Paraíba). Together with Movimento do Espírito Lilás (gay movement) and Grupo de Mulheres Lésbicas e Bissexuais Maria Quitéria, Fernanda organized numberless seminars, debates, meetings and proposed public policies for the local and regional governments. In 2017, she collaborated with the creation of the Ambulatório de Saúde Integral Travestis e Transexuais da Paraíba.7

Fernanda was not only an activist of the LGBTQIA+ movement. She was a nurse technician who worked for more than 20 years at a public maternity hospital, where she participated in hundreds of childbirth processes. She also worked at a psychiatric hospital. Her experience in the field of public health made her well known and respected not only by the professionals, but also by the users of the hospitals. Thus, through her political and professional action, she built a network of care and affection beyond her biological and familiar circle. In the region she lived, she founded a *Samba School* (Unidos do Roger), which became a space of solidarity and possibilities for people who had dissident gender identities and sexual orientations. Consequently, her house was the main space for the *Samba School* and a gathering place for LGBTQIA+. Fernanda was the leader of the *Samba School*, and she took care of everybody as a family united by affection and care, with her attentive, rigid, and controlling maternity.

As the director of ASTRAPA, Fernanda contributed to the aforementioned research, participating in projects against transphobia at the University of Paraíba. She also participated in the photographic exhibition "Variations of the Feminine: poetics of the trans universe," in 2010 and 2011, whose aim was to create the visibility of non-exoticizing images of trans women, transvestites, and effeminate homosexuals that could reveal details, feeling, and gestures, which could touch the sensibility of

<sup>6</sup> https://bvsms.saude.gov.br/bvs/cartazes/nome\_social\_sus.pdf.

<sup>7</sup> The Ambulatório TT of Paraíba offers services for the specialized care of trans people by a multiprofissional team, including psychologist, psychiatrist, social worker, nurse, gynecologist, and urologist.

#### *Transfeminine Bodies: Survival and Resilience Experiences in Brazil DOI: http://dx.doi.org/10.5772/intechopen.102849*

the public. During the exhibition, one room excelled: a photographic essay created by the anthropologist Verônica Guerra [27], the register of a 19-year-old Black transvestite, Márcia, who had been killed recently. Márcia was born in the rural area of Paraíba and worked as a prostitute since early age, mainly on the federal road of the North Litoral region.8 Nevertheless, aiming to increase her income, invited by a more experienced transvestite, she decided to move to Recife, biggest city of the state of Pernambuco, where the levels of urban violence are very much higher. Thus, shortly after her moving to Recife, Márcia was brutally assassinated on the street. There are rumors that she was trying to help a colleague who was being violated, and Márcia was shot. Her case was not even reported officially as transfeminicide, and her social name was not respected in her death certification.

Unfortunately, this tragic history is a reality for trans women and transvestites raised by poor families in vulnerable situations, especially for those who work in the sex markets. They leave their original places, moving to bigger cities where they can achieve better conditions of life and income. The circulation by different cities in Brazil and abroad is part of the dynamics of the sex markets, but it also suggests a lifestyle: a constant movement of seeking for oneself, for one's own body and the desired gender, the scape from the violence of transphobia and racism, from cisheteronormativity. A mobility that brings financial support in order to survive and obtain the necessary body interventions (hormone therapy, surgeries, cosmetics, clothes, and so forth). It is a journey toward a possible and safe future, where one could live and guarantee the rights of citizenship.

*They move between cities and model themselves in the fabric of temporary experiences in places that offer them the possibilities for social and economic ascension and that, at the same time, are more likely to accept their ways of being, past and present, usually considered abject. ([28], p. 192)*

The death of Márcia adds to the statistics of transfeminicide. However, following the argument of Snorton, it is necessary to go beyond the obvious acknowledgement of the high rates of homicides of Black trans people, considering the loss of the subject, their memory, and their future.

*The recurring practice of enumerating the assassinated people on the press and social media seems to coadunate with the logic of accumulation that structurates the racial capitalism, where the quantified abstraction of trans and Black deaths reveals the calculated value of trans and Black lives by means of the grammar of a state of doubt and deficit ([26], p. 10)*

Transvestites like Márcia circulate constantly by different cities. The mobility is facilitated by the existence of a federal road (BR 101) that connects different big cities. In these areas, they attend clients who are, mainly, truckers, travelers, and workers of the sugarcane plants. They meet at strategic points, such as gas stations, where there is a great circulation of people and money. Those who live in João Pessoa, circulate by the beaches, on medium and high-class regions, but also Downtown, an impoverished region.

<sup>8</sup> The North Litoral of Paraíba is a microrregion encompassing 11 small municipalities, which are part of the Metropolitan Region of João Pessoa. This region also encompasses other contiguous areas, near the main city, João Pessoa, with small and medium scale cities (up to 70 hundred inhabitants).

The main work in the sex markets is street prostitution and work at websites that offer sexual services (presential or virtual meetings by means of live cams). The latter increased in the last years, especially during the COVID-19 pandemic in 2020. Most clients are cisgender men who identify as straights. Often, they are married or maintain stable relationships. They vary in age, class, and occupation. Nevertheless, depending on the city or territory where the prostitutes work, there are meaningful economic differences and the clients' profile and prices shift.

According to ANTRA, more than 90% of the transfeminine population in Brazil worked or has worked as sex workers, at least once in the lifetime. Besides being a source of income, the prostitution allows for the creation of networks of affection, support, and care. The prostitution is also a space—be it the streets, houses, or hostels—where a feminine identity is constructed. The prostitution houses are also places of sociability and, usually, are governed by older or more experienced transvestites and trans women, who are called "madrinhas" or "mothers" [9, 14, 29]. These entanglements of economic relations and affection relations [30] also recreate kinship and friendship relations.

According to Manuel Roberto Escobar [31], the trans body can be understood as a baroque body whose movements go beyond its own objectives, escaping from the homogeneity of the capitalist *ethos*. Escobar suggests that the trans body is pure excess of meaning, which is transformed by means of esthetic, surgical, and pharmacological interventions. The trans body is attentive to all details, ornaments, and gestures that are revealed or occulted. They overflow the frontiers, and their transformations affect their surrounding worlds, modifying the spaces through which they move.

In Paraíba, the interlocutors of research were young transvestites who were raised in the region and kept their relations, more or less hostile, with their families and places of origin. Most of them wanted to move to other city and obtain more income with sex work, in order to pursue their body transformations more adequately. In São Paulo, the biggest Brazilian metropolis, the reality is quite different.

With more than 12 million inhabitants, São Paulo receives hundreds of transvestites and trans women from different regions of Brazil and also from Latin America. The central region of the city is well known for the services of prostitution, consumption, and sociability. Besides Downtown, a place with touristic and national projection, other localities are important. Among them, the region of Butantã is remarkable. Situated in the West Zone of São Paulo, near USP main campus, Butantã is inhabited by 5400 people and, historically, is an area of great circulation of people, alternating commercial and residential streets.

During our fieldwork, we talked to more than 40 transvestites and trans women, whose age varied from 16 to 40 years old. They were born mainly in the North and Northeast of Brazil, in the cities such as Manaus (Amazonas), Belém (Pará), Natal (Rio Grande do Norte), Recife (Pernambuco), and Fortaleza (Ceará). Many tranvestites and trans women stay shortly, from 1 week up to 6 months, especially the young. The older ones, 25 years old or more, stay longer, from 5 to 15 years, but they also create intense mobility, moving to other cities and countries. These people rarely settle in a single territory, especially the young ones. Often, they live in collective residences, where they share their lives with other transvestites from the same region, their friends.

The daily reality of trans women and transvestites from North and Northeast is coming to São Paulo, where they work as prostitutes. Regardless of their origin, they have the same project of social mobility: making money through sex work, accessing a network of esthetic consumption, making their bodies more feminine by means

#### *Transfeminine Bodies: Survival and Resilience Experiences in Brazil DOI: http://dx.doi.org/10.5772/intechopen.102849*

of hormonal and surgical interventions. During our fieldwork, we collected many reports of body transformation, particularly hormonal therapy experiences, with or without medical follow-up, and use of industrial silicone for body feminization.

Industrial silicone, despite its risks to health, has still been used to modify the body because the prices are lower than surgeries. Due to the insufficiency of SUS in providing surgeries and a long line in which many trans people wait for their turn, many transvestites and trans women search for liquid silicone, in order to achieve shortly the desired ideal body. However, the substance is not indicated for human application. It is used for machine lubrication, automobiles, and civil construction, causing serious consequences in the human bodies [32]. According to the Muriel Project, in Brazil, there is a preference for the injection of SLI on the buttocks, hips, and thighs because the prosthesis for the breasts became more accessible in the private health systems where, often, these women pay for the plastic surgery instead of waiting for the slow process of SUS.

*The use of SLI can bring the fast body transformations, representing the valuing of a capital of the body. It means that an ideal body also brings more clients and value. On the other hand, some people who use SLI or undergo other procedures may increase their workload in the sexual market in order to enable for its payment, also increasing the risk for HIV infection because they have worse conditions of negotiation with clients, becoming more vulnerable to unprotected practices ([32], p. 10).*

Those trans women and transvestites who work as sex workers often need fast transformations and enhancements of their bodies. Therefore, they cannot wait for the long process of transformation enabled by the hormone therapy. Some medications such as estradiol enantate/algestone acetophenide (Perlutan®) are well known by the trans community for its quick effects of breasts and buttocks augmentation and general feminization of the body due to liquid retention. Trans women and transvestites who use this injection of estradiol anecdotally report the fast reversion of the augmentation when they stop its continuous use.

In the region of Butantã, there is a basic health center, binding to the University of São Paulo, where trans people are welcome to access some public health services. In the same region, there is also a center of reference for HIV,9 where prevention agents act. Nevertheless, the great challenge is to include sex workers in this health spaces. During our fieldwork, many trans women and transvestites told us that the opening hours are reduced, and they cannot go there early morning because they work all night long. They also reported a disrespect for their correct pronouns at different kinds of private and public services, even if they do have their new documents. They also distrust the treatment they will receive by health providers because their experiences of transphobia and racism are numberless.

Despite all difficulties, Fernanda, a white trans woman born in Fortaleza (Ceará, Northeast), works as prevention agent daily with the prostitutes. She dispenses condoms and lubrication gel, talking to them about forms of preventions and health care. Furthermore, she often hosts other transvestites and trans women who are experiencing situations of violence or working difficulties and sickness derived from the use

<sup>9</sup> Even though the official Brazilian statistics do not report the prevalence of HIV among trans women and transvestites, research suggests that they are the population most affected by the virus (ROCHA, ABM; BARROS, CRS; PRADO, I.; BASTOS, F. I.; VERAS, MA. HIV continuum of care among trans women and travestis living in São Paulo, Brazil. *Revista de Saúde Pública*, v. 54, 54:118, 2020).

of industrial silicone. Like Fernanda of Paraíba, the house of Fernanda of São Paulo is also a place where webs of affection, mutual help, and solidarity are weaved. Both work in the field of health, and through this experience, they also support others who need their care. After long years working as a prostitute, Fernanda of São Paulo became an autonomous entrepreneur. She owns a sewing atelier where she creates and sells clothes. The atelier is her main source of income. "Each day is a step we make onward."

Even though we have not done fieldwork during the COVID-19 pandemic, we visited twice the territory of Butantã. Transvestites and trans women reported that, despite the risks, they were unable to follow social distancing protocols because they needed to maintain their work, circulating by different regions and cities. They also needed to avoid face masks most of the time in order to attract their clients. At this territory of prostitution, it seems there was a private security control of their circulation, especially in front of business buildings where they cannot neither stay nor stop for their clients in the cars. Before the pandemic, there was a circulation of pedestrians and cars, but today the streets are desert. Only transvestites and trans women are present. The empty space also increased the vulnerability and risk of violence.

Thus, amid numberless situations of violence and transphobia, working as sex workers enables economic and social alternatives, even though trans women and transvestites are more vulnerable in the streets. However, many think the risks are worthy. Others think the streets engender circumstances of moral, sexual, physical, and gender violence.

#### **5. Conclusion**

An important question deeply explored by transfeminist intellectuals like Amara Moira and Megg Rayara Oliveira [23, 33] concerns the stereotypical image of transvestites always seen with a bias of sexualization, bodies subject to violation. This image is related to the sexualized figure of Brazilian Black women, the *mulata*. Lélia Gonzalez [15] discussed that the idea of *mulata* is a historic unfolding of the figure of *mucama*, the domestic enslaved woman who worked for the patriarchal white family and who suffered from numberless violations. During carnival, the image of the *mulata* is exalted at the samba parade by national and international mass media. *Mulata* is an emblematic figure on the postal cards of Brazilian tourism and on TV advertising. Thus, during the parades of *Samba Schools*, *mulatas* are recognized, demonstrating her artistic gifts through her dance and beautiful, shining bodies. However, according to Gonzalez [15], the day after the parade she returns to the world of the house, becoming again a maid who lives in precarious conditions and who are explored as cheap workforce and sexual object. This is what Gonzalez [15] calls "Brazilian racism."

Similarly, at the catwalk of the streets, transvestites parade their splendid wishful bodies and attract men looking for sex and affection. There, at the sidewalks, they weave webs of solidarity among friends and colleagues, strive for survival, and learn local knowledge on hormones, men, sexual relations, prevention, safety, and so forth. Nevertheless, the same territory presents serious risks because they are exposed to numberless forms of transphobic and racist violence. It is no coincidence that Brazil is ranked as the most dangerous place to trans people, with enormous rates of transfeminicide, but at the same time one of the countries where transvestite pornography is extremely consumed. Many narratives of violence at public spaces, perpetuated by men (cops, clients, partners, security guards) against trans women and transvestites,

#### *Transfeminine Bodies: Survival and Resilience Experiences in Brazil DOI: http://dx.doi.org/10.5772/intechopen.102849*

particularly the Black ones, reveal common situations where there is a clear trial of masculine domination, demonstration of authority and humiliation. Drawing inspiration upon the reflections of Lélia Gonzalez, we may call this process "Brazilian transphobia": the place of simultaneous desire and rejection of people who contest the patriarchal cisnormativities overlapped by the Whiteness.

Since the beginning of 2000, trans movements have claimed strongly for the construction of public policies on the realm of health, education, and work. Even though there are important milestones—such as the recognition of social name by public and private institutions, the right of changing birth documents, and the access to the transexualizer process of SUS—numberless events, situations, and practices of transphobia are still observed at public and private spaces, streets, schools, universities, workplaces, and so forth. The most vulnerable spaces for transvestites and trans women are the streets, where most of them work as sex workers. But paradoxically this occupation embraces them.

In this context of precarity, vulnerability, and gender violence, an important strategy of resistance is the lived knowledge regarding trans bodies, constructed by trans people. This lived knowledge is rooted in the experience of trans women and transvestites. The core tenet of such a knowledge is the experience with hormone therapies, a safe way to achieve body transformations. The exchange of this knowledge happens through different networks of care (forums on the Internet, collective residences, hostels, and streets).

Lived knowledge on their body transformations is a form of resistance because the structural transphobia implies subtle and open forms of discrimination against trans people. Therefore, trans women and transvestites share and apply this knowledge, in order to live fully and express their gender identities. The difficulties in accessing health services are counterbalanced by the lived knowledge on the transformations of the trans bodies. Although the medical community tends to validate academic knowledge, it is necessary to understand the experience of the lived body. If health providers are sufficiently humble to welcome their knowledge, trans people will probably feel more welcome. Evidently, trans women and transvestites, particularly the poorest ones, often trust on anecdotal and merely empirical reports of hormone use, shared by other trans people. There may be some incongruencies and disinformation, but scientific knowledge also fails sometimes. Nevertheless, it is important to recognize the relevance of the "savage thought"10 that trans people create to express their experiences of their lived bodies. The repetition and patterns of hormone use are nothing but experiments, which lead to a form of knowledge, a lived knowledge.

The body transformations of trans people are not pathological. They can be understood as a human search for self-acceptance. Even though trans identities are not dependent on bodily transformations, body transformations are very important to many trans women and transvestites. Body transformations guarantee minimal social acceptance. Nevertheless, trans bodies are still seen as unintelligible because the normal bodies, according to the historical categories of normal and abject, are referenced by cisheteronormativity. The trend is that, with time and trans visibility and representativity, society will accept and expand the cultural constructs regarding trans people. Trans existences are embodied in multiple corporalities, which are never homogenized or pasteurized because trans identities extrapolate and implode the possibilities that the century considers acceptable or natural.

<sup>10</sup> Here, we borrowed the idea of Lévi-Strauss on the construction of a science of the concrete. LÉVI-STRAUSS, Claude et al. *La pensée sauvage*. Paris: Plon, 1962.

#### **Acknowledgement**

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 and by CNPQ (Process 312677/2019-7).

### **Author details**

Silvana de Souza Nascimento and Luz Gonçalves Brito\* Department of Anthropology, FFLCH - University of São Paulo (USP), Brazil

\*Address all correspondence to: luzgoncalves@usp.br

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Transfeminine Bodies: Survival and Resilience Experiences in Brazil DOI: http://dx.doi.org/10.5772/intechopen.102849*

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#### **Chapter 3**

## Public Policies Advances on Transgender People in Portugal

*Dalia Costa and Miguel Miranda*

#### **Abstract**

When rights are guaranteed through public policy, the probability of becoming *de facto* rights rather than just *de jure* rights is greatly increased. On the one hand, the conditions and mechanisms for its implementation are created or, at least, foreseen, and the conditions for effective access by all people to the rights in question are reviewed. This is the case of Portugal in promoting the rights of trans people, following a consolidated public policy on equality and gender (since 2007). The countries in Europe (European Union) have adopted different perspectives and paths ahead regarding the definition and implementation of comprehensive public policies for trans people. Previous studies about Portuguese case reveal that health, work, but also rights in the family and sexuality, are fragile domains, which place trans people in a situation of great vulnerability. Adopting a participatory methodology, the chapter presents the diversity in political and ideological positions and debates the obstacles in the process of public policy formulation to promote the integral well-being of trans people. The evaluation of the Portuguese case is useful for other political and social contexts, while it reveals the cornerstones of public policies advances on transgender persons, namely stereotypes and gender biases.

**Keywords:** gender identity, trans, self-determination, public policy, Portugal

#### **1. Introduction**

This chapter describes the process of advances in public policy, applied to the recognition of the right to gender identity and the sexual characteristics of people, including transgender. Portugal is the case study.

The Portuguese case is interesting because it has a recent democratic regime (since 1976) consolidated with the State's accession to the European Union (EU) in 1986. This social and political path shows a slow development until the 1990s focusing on the country's economic growth. This explains why it was only in the late 1990s that society began to wake up to plurality, including the uniqueness of people due to their gender identity.

Another fact that makes the Portuguese case interesting is that this period coincided with the resurgence of equality issues in the European context. Throughout the chapter, we demonstrate how Portugal aligned itself with other social contexts at the turn of the century. In the 1990s, the concept of gender entered the scientific lexicon. In addition, the pressure groups have also helped to make it part of the political

agenda. These two elements are important for the process of construction of the right to gender self-determination, which culminated in the legislation of this right in 2018.

In an attempt to contribute to the in-depth knowledge of this process, we carried out a study with its main protagonists: deputies in the Portuguese parliament, who have the capacity and legitimacy for decision-making; social activists, with opportunities to emphasize the relevance of the right to self-determination of gender identity, specifically for transgender people; and social scientists who, in some cases, are also politicians or deputies and, in other cases, are also activists.

The study revealed the importance of external factors for deputies, such as voter expectations. It also revealed the importance of debate for the appropriation of concepts, questioning stereotypes in the public policies process production.

In the policy process analysis, we adopt the political pluralism, as the most suitable model for the analysis of a complex topic. This means that we are not going to analyze the content of the policy, but the policy production process, interviewing the main protagonists in that process.

In the first point of the chapter, we frame the theme. In the second, we describe the Portuguese context, to locate readers. We then present the study, highlighting its main results.

#### **2. New perspectives on trans people**

New perspectives on transgender people are relatively recent. The identification of transgender as an (autonomous) gender identity can be located in the paradigm shift generated from the conceptualization of gender. The ideological construction of a trans person began only after the appropriation of the gender concept. After that, the social problem construction process started, questioning how to deal with trans and how to answer to their expectations and needs, adapting public responses and their mechanisms. The next point follows this order.

#### **2.1 A paradigm shift towards essentialist determinism**

The concept of gender emerged from the feminist debate, chronologically identified with the second wave of this social, political and ideological movement, on the 1970s. Its operative dimension made it possible to deal with the 'anxieties of placing the issue of differences between the sexes on the social research agenda, removing it from the domain of biology'. At the same time that it was willing to 'orient its analysis to the historical and social conditions of production of beliefs and knowledge about the sexes and the legitimization of social divisions based on sex' [1].

In this way, the gender perspective allowed for an effective shift towards the differential Psychology of sexes approach, which explains differences between men and women, and towards Biology, which defines differences based on a nature determinism. Scientifically in the field of social sciences, and, later, politically, this can be considered 'an important transformation' [2] or, as the authors of this text consider it, a paradigmatic shift.

We consider this a paradigm shift for three main reasons. First, because it favored the emergence and subsequent imposition of another paradigm of interpretation of society and social relations in everyday life, replacing the paradigm of biology and psychology, both based on an interpretation of nature. Alternatively, the

#### *Public Policies Advances on Transgender People in Portugal DOI: http://dx.doi.org/10.5772/intechopen.102704*

interpretation of the environment, the context or the social, encourages considering more factors in explaining the complexity of social relations.

Secondly, for giving to the scientific community and to the political community as well, specific concepts with a new meaning. Thus, thinking, describing and interpreting differences become possible through a concept, that of gender. Having a concept available, in turn, raises questions and drives away determinism. Among the questions were the extent and depth of social norms and expectations in shaping masculinities and femininities. Another issue linked to this was the weight of social structures on individuals, constraining their self-determination. The questioning of patriarchal social norms and broad expectations of performance of a social role defined by the sex of individuals at birth became easier.

Being born a man or a woman makes a difference and accentuates a determinism that is difficult to change, especially by common sense. It is very different to admit that one is born with a reproductive physiological system, but that we become men or women, through the induction of social processes, as Simone de Beauvoir had stated in her famous book (published in 1949).

It is very different because it opens up the concept of identity and establishes the importance of culture and the action of social structures on subjects. Thirdly, we believe that this is a paradigm shift because it has transformed the way of interpreting people, their relationships and the ways in which societies are organized around the way they interpret people. Gender is not determined but socially constructed; therefore, societies have a transforming capacity to change the subordination of the feminine to the masculine [3]. Gender, by ceasing to be something biologically determined, also ceased to be seen as something static, natural and immutable.

Considering that gender 'is not just about identity, not just work, not just power, not just sexuality, but all of this at the same time' [4], the complexity thickens. In this text, this complexity is addressed in relation to trans people who biologically have a male or female mark but who have a gender identity that does not coincide with that mark and socially impose who they are.

Being trans is more than the affirmation of a gender identity because it involves social interactions, thus implying social structures and mechanisms to guarantee equality, rights and de facto, that is, in everyday life.

#### **2.2 New perspectives based on what means to be trans**

The interpretation of a trans person began by being based on the most available and dominant model: the biological. Thus, the dimension of sexuality became the most relevant.

Western scientific communities have developed two relevant conceptual approaches: the concept of transsexuality and the concept of transgender. Transsexuality suggests a biomedical model, popularized in part by the North American contributions of John Money in the 1970s [5], and basically seeks to understand a situation in which the individual's gender contrasts with the physiological identification of sex.

The concept of transgender gained prominence from the 1990s onwards with the expansion of gender studies and the post-structuralist trend within the social sciences, distancing themselves from biomedical contributions. Authors such as Butler place the emphasis of their critical analysis on the binary gender system [6] that manages to associate biological characteristics with the sphere of social phenomena, intertwining them and producing attributed identities that do not always correspond to the unique experience and identification of each person. Butler, in fact, identifies gender as an instrument for naturalizing sex, making use of discourse to produce the distinction between sexual bodies; making room for the attempt to rationalize, in a social context, allegedly natural relations of power, shaping institutional action and, simultaneously, other individual and collective practices and discourses [7].

In this text, the term trans is adopted in order to emphasize 'the history of the shift from a paradigm of pathology and medical appropriation on gender variability to a new approach that recognizes, and to a large extent through the hands of trans activism, the right of people to designate themselves' [5].

Instead, what we see most of the time is a process in which people identify, define and reframe, plus, attribute a resignification of trans and, after this process, allow themselves to enter into interaction with trans people.

#### **2.3 New perspectives from social relationships with trans people**

The Universal Declaration of Human Rights resulted from one of the most serious and heinous ways of selecting people and determining their extermination: the holocaust. Following World War II, in 1948, humanity explicitly states equality through that declaration. As further developed in another text by the first author [8], 'human rights are inherent rights of all human beings, regardless of the place where they are born, conferring nationality, the place where they live, defining cultural norms and the legal and legal norms to which obedience is owed (tacit or mandatory), of the sex with which one is born, of the religion professed and of any other belonging'. The main and distinctive argument is the principle of universality, emphasizing the common element worldwide: to be a human being.

The human rights framework is the broadest approach analyzing social relationships with trans. It is easier to let stereotypes domain in everyday life. In the same way, prejudices emerge unquestionably in social interactions. It is, also, where discrimination occurs and social exclusion takes place.

Seeing the issue from this perspective and knowing that trans persons have become the subject of increased research activity and everyday conversation [9], it is clear that promoting the rights and protection of trans people is a social concern and, therefore, also a political issue. Although it is not assumed that trans persons are a vulnerable population, it is assumed that they may be placed in a vulnerable situation, as they are confronted with stigmatization and transphobia, being sometimes exploited as a weirdo, and not accepted by others [10]. Heteronormative expectations conflict with the idea that a person could be trans. In youth, specifically, trans can be discriminated against and even victims of violence. Furthermore, their gender identity tends to be disrespected, as they are regarded by 'others' as being in the process of 'becoming' and also for being considered that someone only become fully gendered as adults [11]. Recent research dedicated to homophobic bullying, developed in a public school with young people (participating in several focus groups), suggests the acceptance of those who challenge heteronormative expectations—at least among peers, once the study did not involve teachers or other professionals in the school context [12]. In the adult phase of life, research is also being carried out on the acceptance of the labour market and the integration of trans people in the labour market by companies [13]. In fact, the process of building a trans identity is still to be understood in Portugal.

#### **3. The process of right recognition to gender self-determination in Portugal**

Internationally, the World Health Organization (WHO), on June 2018, published the 11th version of the Manual for the Classification of Diseases (ICD), where transgender experiences no longer appear as 'sexual identity disorder' (also referred to as 'transsexualism'). Even so, in the V edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) of the American Psychiatric Association (APA), trans people still appear as suffering from a 'gender dysphoria'. This interpretation, in fact, maintains a sexist perspective, when it uses a diagnosis rooted in gender stereotypes of what it is to be a woman or a man, thereby promoting an environment not inclusive of other gender expressions [5].

A few years earlier, in 2009, the International Network for Trans Depathologization, created an international initiative, called Stop Trans Pathologization, with the aim of removing non-normative gender identities from the categories of mental pathologies and disorders. In addition to this objective, it also aimed to revoke the mandatory medical and psychiatric diagnosis for hormonal and surgical treatments and for changing the name and gender in the civil registry.

The 'ideology of legal protection' [14] not always allows us to admit the inability to make an adequate response to sexism, transphobia or misogyny. What is at stake is more than discrimination against people. It is social rights, whether in the sense of access to their effective enjoyment by all people, or in the sense of their inability to cover all people globally, that is, universally. The plurality of gender identity and the diversity of gender intersectionality force us to re-locate the issue in the analysis of processes and not just in the analysis of the result or the impact generated by the result.

A process is a series of actions or steps taken in order to achieve a particular end, distinct, therefore, from a procedure, which is an established or official way of doing something. The process presupposes a duration, and meanwhile, it allows the external influence of other agents on the political position of an agent. Besides, it also allows the same agent to change its interpretation, to review and even change its opinion and/or to get involved in a more participatory way. Moreover, the same agent can distance himself from the debate—either because you lose interest or because you feel that your investment has an unsatisfactory return.

The biomedical model has imposed itself in the social field, expanding its space to areas of behavior previously seen as moral problems or as natural phenomena in the course of life [15]. Despite this, bio-politics, in the case of the regulation of the right to gender self-determination, in Portugal, did not succeed. The legislative framework seems to have favored the opening of space for debate, calling for different positions, including the claim of rights by activist groups inspired by feminism.

In Portugal, the process of building the right to gender self-determination began with a legal-legal perspective, which, in turn, is based on a medical position.

#### **3.1 The Portuguese socio-political context**

It is important to situate politically Portugal in the European context, specifically, in the context of Southern Europe. In this context, recent progressive legal transformation coexists with conservative cultural paradigms linked to previous right-wing dictatorships, colonial practices and a powerful Catholic influence, there is a deficit of visibility for lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ ) people throughout history [16].

The individual experiences of trans and non-binary people allow us to retain the importance of the socio-cultural transformation undergone at the micro level, in parallel with the macro-based legal and political advances already studied in the Southern European context [17].

Belgium and Spain show similarities regarding the matters of trans protective rights. In both countries, the regional level has been relevant in introducing trans protective policy. In Belgium, the federal level is responsible for the legislative framework regarding gender recognition. The regional government of Flanders has developed additional extensive policies in order to enhance the well-being, care and equal rights of trans individuals. Similarly, in Spain, a growing number of regions are developing nowadays both trans specific and LGTB antidiscrimination policies, filling the gap that exists at the central state level. In addition, when looking at Trans Rights Europe Map and Index 2017 of Transgender Europe, we see that both countries have developed protective trans legislation at about the same speed [18].

In both Belgium and Spain, additional medical pathways and legal requirements for trans care are demanded, as well as in Portugal.

In turn, the European Parliament in its 2016 Resolution on the application of Council Directive 2000/78/EC of 27 November 2000, establishing a general framework for equal treatment in employment and occupation (called the Employment Equality Directive), called on the Member States and the Commission to combat all forms of multiple discriminations and to ensure application of the principle of nondiscrimination and equal treatment in the labour market and in access to employment, increasing monitoring of the intersectionality between gender and other grounds in cases of discrimination and in practices.

The principle of equal treatment, expressed in Article 2 of the Treaty on the European Union and Article 21 of the Charter of Fundamental Rights of the European Union, is a fundamental value of the European Union. The Employment Equality Directive 2000/78/EC forbids discrimination based on sexual orientation only in the context of employment, occupation and training. However, most Member States have extended protection based on sexual orientation, and in some cases, gender identity, to cover some or all fields to which the Race Equality Directive (2000/43/EC) applies. These fields include social security and healthcare, education and access to and supply of goods and services, including housing.

EU law also prohibits sex discrimination in employment and access to goods and services (the Gender Equality Directive (Recast) 2006/54/ EC and the Goods and Services Directive 2004/113/ EC), partly covering trans people.

#### **3.2 Portuguese socio-cultural context**

Portugal went through several structural changes that led to the end of a dictatorship, lasting about 50 years. Thus, visibility and space for some themes that were already part of the agenda of other EU Member States were only achieved in Portugal at the end of the first decade of the twenty-first century [19].

It was during this period that the scientific literature began to draw attention to the discrimination and stigmatization of trans people, especially when the gender expression of some trans individuals did not follow traditional gender norms [20–23].

The various social actors place certain identities in a collective social imaginary, composed of social representations, in which trans people are pathologized through biomedical narratives, as they do not integrate the expectations of a binary model in which the genitalia, for a long time, was considered a predictor infallible of each person's gender identity [24].

In Portugal, one of the turning points was the decriminalization of homosexuality in the Penal Code in 1982. Progressively, gender plurality was accepted by society, although initially closely linked to differences between men and women [1]. The first time that the theme of the needs of trans people was on the agenda was through the creation of health responses, linked to surgical intervention aimed at the reassignment of sex. Regulation, once again, marked the process; this time not from a legal perspective, but linked to the ethics of the medical professional practice.

In 1995, the medical profession's regulatory body revoked the prohibition of sex reassignment surgeries in the Code of Ethics, which until then was considered an unethical and illegal practice [25]. The resolution approved on 19 May 1995, by the National Executive Council of the Medical profession's regulatory body, states in article 55, paragraph 1, that 'Surgery for sex reassignment in morphologically normal people is prohibited, except in clinical cases properly diagnosed as transsexualism or like dysphoria'. Following the last authors mentioned, the repeal of the ban on sex reassignment surgeries did not result from pressure exerted by LGBTI activists. In the mid-1990s of the twentieth century in Portugal, collective activist actions were still recent and dispersed. It was only from 2000 onwards that activism formally took over social and legal struggles.

In the process we describe here, this is another turning point, considering that the most organized and most prominent activisms were those on gay and lesbian issues, compared with issues related to bisexuality or specific themes of trans people and women intersex people. Despite the acronym identifying diversity, in reality, only the rights, expectations, needs and the political agenda of gays asserted themselves in Portugal. Even lesbian claims were and continue to be much more dispersed, discrete and with little influence on the political agenda.

It is interesting to know that in Portugal, the trans movement matured and consolidated only after the Gisberta Salce Júnior case, a trans woman victim of homicide, carried out by a group of teenagers, in the city of Porto in 2006 [26]. The attention given by *media* has catapulted a hidden reality marked by social vulnerabilities, which trans person can be targeted, in a way, exposing the fallacies of the Portuguese legal system. Following the social pressure exerted by LGBTI organizations, the small group of organizations specializing in trans issues has become more visible.

Following these events, in 2007, sexual orientation was included in the Penal Code as an aggravating factor in cases of hate crimes. Although this legal advance did not integrate gender identity issues, it represented an achievement for the social movement and reinforced a collective attitude of intolerance towards forms of violence against LGBTI citizens.

In fact, until 2011, the Portuguese legal framework did not contemplate the legal recognition of gender identity. Sex, a natural and birth attribute, continued to be legally considered as an objective, unambiguous factor. In practical terms, that is, in everyday life, a trans citizen had to sue the State to change his name and mention of sex in his civil identification. Only after the bodily transformations could the case lead to the recognition of that person's gender identity [27].

The law that regulated the procedure for changing the sex and changing the name in the civil registry (Law n.° 7/2011, of 15 March), known as the gender identity law, was approved by the Parliament, celebrated by activists and identified by *media* as one of the most progressive laws in the world, for allowing gender to be

changed in the personal documentation of each citizen regardless of bodily changes. Corroborating this fact, a report published by Action for Identity in 2015 also states that this was the first law in the world to comply with all Yogyakarta principles, protecting citizens from the obligation to undergo bodily modifications, hormonal treatments or sterilization, different than it was before.

However, from 2015 and 2016, trans and intersex activists began to question aspects they considered obsolete in the law. One of the heavily criticized aspects was the power attributed to medical diagnosis. Although bodily changes due to the use of hormones or surgical procedures are not an aspect taken into account by the Civil Registry in cases of gender recognition, the 2011 law considers a diagnosis to be necessary, carried out by a multidisciplinary team specialized in clinical and surgical sexology, signed by at least one physician and one psychologist, attesting to a gender identity dysphoria, also commonly referred to as transsexuality. Adding to the critique of the pathologized character, activists also point out a need to reduce the bureaucratic burden of this administrative procedure; gender self-determination from 16 years of age onwards; gender recognition for citizens from other countries living in Portugal; the end of any gender-based categories in identification forms and documents; access to other possibilities for gender neutral names; and the prohibition of medical intervention in new-born or intersex child without their consent.

This was the agenda of trans and intersex activists. The bills discussed in parliament included some of these demands, with greater boldness for change in the bills of parties located in the left wing of the Portuguese political party spectrum.

In March 2017, the government presented a final, more consensual version. In this version, changes were made in relation to themes in the health, legal and education areas. Specifically, the biomedical report is no longer mandatory and allows an individual (trans or intersex) aged 16 or over to choose their gender identity. In addition, younger children will be able to choose the name they want to be treated with in schools, regardless of the name on official documents. That is identified as your social name, different from your civil name, which appears in your documentation.

The two bills and the proposed law presented by the government were discussed in the first months of 2018, and the law was approved in April. This process was very intense, as shown in the text below, when we present the results of the study carried out with the main protagonists who participated in the process.

It is now important to bear in mind that in this process, the right to selfdetermination of gender identity seeks to change pathologized representations towards trans people. Thus, it also breaks with the idea of the existence of a binary gender system, recognizing the right to a plurality of expressions of masculinity and femininity [4, 7].

This very peculiar advance in Portuguese society, which tends to be conservative, was quite important to raise gender issues in the field of human rights. In the Portuguese constitutional system, which is semi-presidential, bills are sent to the president of the republic, who approves or vetoes them. It was precisely in the effective fulfillment of this requirement that, in Portugal, everything seemed to go backwards. Portuguese society in general, activists, social scientists, even a part of the doctors and a part of the deputies in parliament were disappointed.

Decree-Law n. ° 203/XIII, which defined the following: 'Right to self-determination of gender identity and gender expression and to the protection of each person's sexual characteristics', was vetoed (lead) by the President of the Republic in June 2018. The main argument was the prediction of access to self-determination for young people between 16 and 18 years old, without medical supervision. Self-determination turns out to be a critical point. In addition to this, the fact that the doctors did not lead the process was also revealed as a critical point.

The diploma has then returned to parliament. At its plenary meeting on 12 July 2018, the proposed law was approved, providing for the possibility for people aged between 16 and 18 years old to proceed with their process of changing their name and mentioning sex, since accompanied by their legal representatives, and with a medical report attesting to their decision-making capacity and informed will.

Public policies are the result of a negotiation process, with advances and concessions. And, once again, this is demonstrated in the process described here. In addition to this aspect, often referred to in the literature, public policies are always framed by a context. This context, which is external to the political decision process, but which imposes itself on the process, is part of a conservative tradition, a guaranteed way of legislating and an interpretation of the family as determinant, moving away from a perspective of the subject's autonomy. The subject, although he is the holder of rights, enjoys his rights as a member of a family unit. The welfare state has a strong familial bent in Portugal.

The diploma was promulgated (approved) on 31 July 2018, after being modified and resubmitted to the President of the Republic. On 7 August 2018, is published the Law n. ° 38/2018, which defines and regulates the 'Right to self-determination of gender identity and gender expression and to the protection of the sexual characteristics of each person'.

In 2018, Portugal approved a remarkable gender identity law that respects selfdetermination, because of the concerted work between political actors, academics and activists. The questions that deserved our attention and led us to develop an empirical study were the following: How did social actors interact with each other? What reciprocal influences have occurred?

This text aims to record and analyze the process of formulating the law that established the right to self-determination of gender identity and gender expression and to the protection of each person's sexual characteristics. The achievement of this objective was sought through a qualitative study, using interviews carried out with leaders of the parliamentary groups of political parties represented in Parliament; to activists defending the rights of LGBT people; and to researchers who study the subject scientifically. We have carried out 14 in-depth interviews. The interviews allowed us to identify the reciprocal influence between these social agents and characterize the modes of political pressure most used in the legislative process.

#### **4. The study of public policies advances on trans rights in Portugal**

This chapter describes the process of recognizing people's rights through legislative action. In this way, it assumes a critical trans politics perspective instead of a critical approach to resistance. That is, a trans politics demands more than legal recognition and inclusion, seeking to transform current logics of state and social equality. A critical approach does not recognize as useful national stories about social change that actually continues to operate. Besides, a critical approach assumes that public policies and laws are mechanisms used by those with (more) power in society to maintain conditions of suffering and disparity for some—the disempowered ones. Instead, a critical tans politics recognizes legal change in the form of rights as a way of deep transformation [28].

As we said before, the focus of the study and this text is the analysis of the process and not the result or impact of the law. Nor is the focus on analyzing the content of the law. In view of this objective, we explain in more detail the policy analysis process.

#### **4.1 Policy analysis**

This text deals with the process of producing a policy (policy process) that refers to the set of methods, strategies and techniques employed in the political resolution of a problem and not the content of that policy (policy content), that is, the essence of matter dealt with [29] —which is analyzed elsewhere.

The analysis of the political process is carried out from the definition of the political agenda in Portugal, including the theme of gender equality in a comprehensive way, to include in the debate the right to gender self-determination.

The agenda is a set of themes that, at a given moment, are perceived by certain political actors as deserving of the State's attention, most of the time in order to correct a situation. In a pragmatic sense, the agenda is a tool that allows organizing problems, favoring an effort to understand their causes and defining possible solutions [30, 31]. The definition of the agenda establishes an order of priorities between themes that do not always follow clear criteria known to others.

The systemic agenda includes issues that gather consensus among the political community as problems that must be resolved, and whose resolution may depend on the Governments. Political decision-makers transfer a part of these issues to the institutional agenda, through pressure, generated by the aggravation of problems or carried out by activists [30]. This internal pressure sometimes coincides with external pressures, which, in the case of Portugal, assume greater importance when they come from the EU and when they result from commitments made by the State [32]. Furthermore, in the virtual space, influence is also exerted on political agendas, which can, in a negative sense, generate some entropy in the collective perceptions that form around a social problem [33].

The political process model, inspired by the contributions of Easton [34], moves away from perspectives that consider the needs, the impulses for social policies. Impulses are factors external to a political system that influence the process of producing social policies, such as public opinion and pressure groups. These present demands or requirements, the demands and keep them continuously in their action. At the same time, they gather support, which assumes different expressions of political support.

The most recent proposal, by Jenkins [29], takes this as a starting point, but it is more useful because it allows integrating the competition between groups and key actors, in a dynamic sense based on a systemic perspective. Thus, the various proposals of a diversity of social actors are considered, in addition to the proposal initially presented [35].

Policy decisions are decisions authorized by political authorities and constitute the pressure for government action that arises both within and outside the political system.

One of the main tools used by interest groups to disseminate their beliefs and views about social reality, whether supported or not by scientific arguments, is the creation of narratives [36, 37].

Narratives are attempts to bring order to a set of complex information. Especially when it comes to information that raises uncertainties, narratives reduce complexity

#### *Public Policies Advances on Transgender People in Portugal DOI: http://dx.doi.org/10.5772/intechopen.102704*

through the creation of stories or scenarios, which can neutralize complex phenomena [2]. One of the main effects that narratives produce on social policies is the reduction of room for negotiation, by conditioning the possibility of new approaches to the problem and by prescribing a set of solutions that tend to be rudimentary [37]. Despite recognizing these biases, the narratives do in fact influence the development of policy-making. They continue to be used because they are instrumental and intrinsic to institutional structures [38]. Therefore, we chose to use the Narrative Policy Framework [39] since it centrally locates the role of policy narratives in the policy process.

#### **4.2 Methodological options in the study of public policies advances on trans rights in Portugal**

The Linear Model assumes that policy-makers approach the issues rationally. If we followed a linear model, the flaws would be blamed on a lack of political will, poor management or shortage of resources [37]. In this study, we opted for an analysis of the policy process, as influenced by a range of interest groups that exert power and authority over policy-making. This option makes it clear that we assume a pluralist model that presents policy as primarily reflecting the interests of groups within society.

For the study, we chose as protagonists those most evidently connected and interested in the political process: deputies in parliament; activists, who act as political pressure groups; and the agents who study and, at the same time, define and offer to the other concepts, contribute to marking the barriers to the discussion and to identifying the lines of debate, in a rational and rigorous way. Those names legitimize the debate in the field of science, while the first ones carry out the debate on the political stage of the parliament.

*Media* were not included in this study, although their power to reinforce and construct alternative narratives is recognized.

The interview was chosen as a data collection technique as it allows the interviewees to elaborate their reasoning only with the orientation of the interviewer (the same in the 14 interviews carried out). The interviews were carried out after the invitation and signing of the informed consent form by each of the interviewees. All interviews were in person and carried out according to the same script and by the same interviewer. The shortest interview lasted about 30 minutes and the longest, about 90 minutes. The transcript, which constituted the corpus of analysis, was subjected to theoretically thematic analysis.

#### **4.3 Main results**

This section presents the results of the empirical study, involving different social actors (parliamentary groups, activists and researchers), who were interviewed, individually and separately. One of the objectives is to understand the reciprocal influence between them, despite operating in different stages: the leaders of the parliamentary groups are linked to the *stictu sensu* political process, with the parliament having legislative powers; activists play a fundamental role in a mixed political system and in a democratic regime in which social movements and organized activism can influence the political and legislative process; and researchers produce knowledge about the object of the law and its process as well, analyzing it from a scientific perspective, which is not to be confused with politics or the activist.

All the people interviewed reveal great knowledge and familiarity with the Law, resulting from their involvement with the political process, as deputies or researchers and/or activists heard in parliamentary hearings. In some cases, the people interviewed revealed more than one form of involvement, for example, some deputies simultaneously presented themselves as citizens concerned with the social rights of the trans, and others were simultaneously deputies and activists and/or also experts in area of gender studies.

Five of the 14 interviewees support the designation of trans person as a doctrinal reference used by activists in the trans community, and that they recognize themselves as trans people, coming closer to the conceptual logic of the transgender person, which emphasizes the individual construction of the identity, blurring the experiences of gender as strictly related to the sphere of biology most perceived as a central element in the concept of transsexuality and in pathologize trans people.

It is interesting to point out the opportunity created for social actors to reflect and increase their specific knowledge regarding a proposed law. For example, in one of the interviews it is stated that, 'Regarding the conception I have, it was always a conception that I didn't even question, I didn't know that to say trans instead of saying transgender or transsexual was a political statement'.

Other interviewees look for security in the construction of their political position in international bodies and mechanisms, saying: 'I particularly anchored myself in these guidelines, some of them with the participation of WHO, as you know, WHO on this issue of change It took a long time, but finally it removed issues related to gender change and gender identity from the category of disease'.

The interviewees create, on their own, an association between the conceptual identification and the ideology and political belonging to the party. As one respondent mentioned: 'In political terms, I think there is a tendency for right-wing parties to anchor themselves more to the concept of transsexuality and left-wing parties to the concept of transgender'.

The biomedical model, in turn, emerges as being instrumentalized by conservative political forces. The existence of conceptual tensions that separate ideological-party wings. Specifically, in the narrative of three interviewees, ideological cleavages are an influencing factor on the definition and conceptual references of sex, gender and even on the integration of self-determination for people under 18 years of age.

In this association spontaneously made by the interviewees, one of them refers to the capacity of empathic understanding of certain deputies, from parties more to the right, who internally did not see themselves in the party's position. In an expressive way, an interviewed deputy states that: 'there are positions already taken and it is not exactly scientific knowledge and what we are told changes positions, this was noted in this case'.

Another respondent admits that there are overlapping political commitments, namely the need to maintain the electorate, for example, by constraining a party position aligned with a human rights framework. Thus, there are only three interviewees who place the social rights of trans people within the framework of human rights, adopting it as their reference.

From the interviewees' point of view, among the main triggers for public and political discussion is political intention or will. The government's programme has been an essential factor, because it contained the intention to legislate on this topic—specifically in the chapter entitled 'Building a more equal society', in which it is explained that the intention is to 'improve the regime of gender identity, namely in the which concerns the need to provide for the civil recognition of intersex people and to improve the legislative framework for transsexual and transgender people' [40].

Another trigger that drives the legislative process itself is activist work and scientific investigation. These emerge in the interviewees' speeches as the main tools for integrating the theme in the public space of debate and in the political agenda. The penetration into the institutional agenda of the right to gender self-determination, gender expression and protection of sexual characteristics may have been the culmination of a path guided mainly by social actors outside the political arena, in the strictest sense, such as activists and researchers.

Immediately afterwards, the individual perception of the availability of political decision-makers to incorporate scientific contributions and associations in the decision-making process emerges in their speeches. The majority of interviewees, 11 out of 14, believe that scientific contributions and/or those arising from the pressure of movements or associative processes may have calibrated the discussion in light of the initial opposition to the idea of gender self-determination by some political forces.

Nevertheless, the remaining respondents believe that the valuation exists, but up to a point. One of the interviewees mentions that scientific contributions should be even more valued in the decision-making process of some parliamentary groups, which sometimes have positions previously taken even before scientific considerations.

#### **5. Final remarks**

The study of policy process on advances on rights of trans persons in Portugal confirms that when rights are guaranteed through public policy, the probability of becoming 'de facto' rights rather than just 'de jure' rights is greatly increased.

The interviews reveal that when reflecting on gender identity in the political sphere, it is not always clear that gender is also a discursive medium that situates certain identities in a collective social imaginary, composed of social representations, in which trans people have been pathologized by the biomedical model, for not integrating the expectations of a binary model in which the genitalia, for a long time, was considered an infallible predictor of gender identity.

The study also revealed that the interaction between activists and some political decision makers is productive, namely in the assimilation of some concepts and in the appropriation of reflexive logics. This interaction is also seen as productive because it is instrumental, improving parliamentary contributions and interactions with the *media*. Even so, some policy-makers are selective about what they listen to and what they integrate into their political agendas, especially concerning structural issues.

Lastly, it emphasizes the importance of analyzing the political process from theoretical models that invite us to observe each of the interveners and the interaction between them, admitting also that the interpretation of a theme as a problem influences the outcome of this political process.

#### **Acknowledgments**

This work was funded by national funds through FCT - Fundação para a Ciência e Tecnologia, I.P., under project UIDP/04304/2020.

*Transgender Health - Advances and New Perspectives*

#### **Author details**

Dalia Costa1 and Miguel Miranda<sup>2</sup> \*

1 Interdisciplinary Centre for Gender Studies, Research Centers of the Institute of Social and Political Sciences, University of Lisbon (ISCSP-ULisboa), Lisbon, Portugal

2 Higher Institute of Social and Political Sciences (ISCSP) of University of Lisbon, Lisbon, Portugal

\*Address all correspondence to: miguelmiranda001@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 4**

### Perspective Chapter: Transitioning to Transgender – How Can We Help?

*Phaedra E. Cress*

#### **Abstract**

Change is not easy in a professional environment and it is even more challenging in our personal lives. In this chapter, I explore how we can all become champions of the transgender population. My interest in the transgender population started 3 years ago when my child came out as transgender. My daughter is now a son and I have become an ally of the LGBTQ+ community. I have learned to embrace the journey and am continuously learning how I can support and elevate the transgender community in myriad ways. I share the experiences that have shaped my life recently with the hope it might help others, particularly parents of transgender children, understand one simple idea: "you are not alone".

**Keywords:** transgender, LGBTQ+, diversity, inclusion, microaggression, survivor, pronouns, anxiety, depression

#### **1. Introduction**

"You deserve the best, the very best, because you are one of the few people in this lousy world who are honest to themselves, and that is the only thing that really counts."

—Frida Kahlo

You are not alone. That phrase resonates with me as the parent of a transgender son. We live in a new era that welcomes changes in gender, identity, and sexual orientation. Unlike past generations who chastised and criminalized those who were different, we now have an established vernacular that continues to evolve toward inclusivity and equality. Among this community is the transgender population comprised of trans men who were assigned as females at birth and trans women who were assigned as men at birth. The transgender population deserves to not only be understood but embraced for their important contributions and authenticity. They deserve our attention and the empathy and sympathy of the personal and professional communities in which they work [1]. They deserve to be their authentic selves without fear of microaggressions and discrimination.

#### **2. Discussion**

In this chapter, I explore the following key points to help put these concepts into perspective; (1) How can everyone champion the transgender population and understand their unique population? (2) How should the transgender be cared for, communicated with, and psychologically related to as is done so naturally for cisgender men and women? (3) What society's obligation in this context and what resources exist? The author also discusses her personal experiences relative to her transgender son and their journey together with the hopes it will guide those on a similar path now or in the future.

My impressions and personal interest in the transgender population began 3 years ago when my child expressed that his contrary to his biological gender, he believed his true gender was male. To illuminate my journey, I offer readers a view into the experiences that have shaped my life in the years since I became mother to a transgender son with the hopes that it might help others understand one simple idea: you are not alone.

There are myriad resources for parents of transgender children and while every transgender person may be on their own path to discovery and personal enlightenment, we cannot discount the ripple effect of the parents, families, friends, and by extension all those with whom a transgender person interacts.

There is a strong connection between the psychological, emotional, and physical feelings of dysphoria and confusion, especially when trans men and women begin their transition. There is beauty in a name especially when chosen as the first step of a brand-new journey in discovering oneself. Imagine the satisfaction that must come with re-branding oneself in a movement toward transitioning to a new gender. What's in a name? Simply put: everything. Hearing your chosen name used for the very first time by those around you is one of the first steps toward social acceptance and self-awareness. My son chose to use his initials (A. J.) as an interim name while he selected Drew as his formal new name. Retraining myself after 13 years to call my child by these new names wasn't easy but it was critically important, so he understood immediately that I was by his side, his lifelong champion, and that my love was unconditional. Surprisingly, it was my younger son who was faster at adapting and remember to use the new name, an unexpected resilience that helped our family in so many ways.

Another valuable lesson learned was the huge impact of using preferred pronouns to help the transgender immediately begin to feel more like themselves and more accepted by their family, friends, and community. I've known many parents of trans men and women who've expressed their own discomfort and inability to bring themselves to make this change or to call their child by their new name. I cannot judge them any more than I'd want them to judge me. However, it quickly became apparent to me that in my situation, the significance of names and pronouns and the power they held for my child could not be overstated. In this sense, I realized I had to quickly adopt both as the first steps in his transition.

Consider how long some transgender people wait to share their true feelings and how by accommodating this request you can illustrate your support for them. I have known transgender men and women who were married for decades and then finally shared their true gender with their spouse. Some were accepted and are living harmoniously and for others it destroyed their relationship. Many trans men use the pronouns he/him and many trans women use the pronouns she/her. Some who identify as nonbinary may prefer they/their pronouns. Using the appropriate and

#### *Perspective Chapter: Transitioning to Transgender – How Can We Help? DOI: http://dx.doi.org/10.5772/intechopen.104599*

preferred pronouns shows respect and care for those with whom you interact and is one important way to champion the transgender community [2]. Making gender assumptions based on appearance could send a harmful message or be interpreted as offensive. Leadership by example, set by someone who uses pronouns, may be the paradigm to make your coworkers feel more connected, inspired, or empowered to bring their "true self" to work every day and contribute in a more passionate and meaningful way. Leaders and peers should all be encouraged to express their authenticity freely and without fear of judgement. It may be a very small gesture for the cisgender but can have a life-changing effect for the transgender. Using the incorrect pronouns, whether intentionally or not, is known as "misgendering." This show of disrespect can trigger dysphoria and embarrassment for some individuals because it forces them to have painful conversations and reveal identity information about themselves they may not be comfortable sharing publicly. The sharing of preferred pronouns in business, among both cisgender and the transgender community, has become more popular. But are all the ramifications positive? I include my personal pronouns in the signature of every email I send plus a descriptive informational link as: Pronouns: She/Her/Hers Why pronouns? As the mother of a transgender, I feel ownership about the need to help educate others about the importance of pronouns, which I hope will lead to broader understanding, acceptance, and usage. International Pronouns Day began in 2019 on the third Wednesday in October as an effort to create a more inclusive environment for everyone to "make respecting, sharing, and educating about personal pronouns commonplace" [3]. I appreciated this quote from the International Pronouns Day website:

"Trans and nonbinary people often have to share their pronouns to be identified correctly. As a cisgender person, sharing pronouns costs nothing and naturalizes this process."

A more generalized set of personal pronouns that evolved from the transgender community and are becoming more widely adopted as gender-neutral are: xe/xir/ xem/xeir and ze/zir/zirs [4]. Using the correct pronouns may be particularly challenging in a work environment but as the movement toward better diversity and inclusivity continues to evolve, the conversation has become more important than ever. A McKinsey and Company survey shows that 39% of potential job candidates turned down an offer because they perceived the organization to lack inclusivity in their workplace and 84% of respondents experienced microaggressions in the workplace, everyday slights or biases against them, such as negative remarks about their identity or how they dress, being asked to speak for or represent "people like them" or to correct assumptions of colleagues about their personal lives. Thirty-nine percent of LGBTQ+ respondents were uncomfortable sharing their LGBTQ+ identity with colleagues, or "coming out" to them and 37% responded the interactions were slightly or very uncomfortable [5]. My main motivation is to empower my child and contribute to a world where his path is easier if even in some small way, so he and others are spared unnecessary bias and judgement.

In addition to selecting a new name and surrounding oneself with those willing to help them transition by using their pronouns, for the female to male (FTM) transgender population there is another crucial stage of the transition process: chest binding [6]. Binding affords them another tool in the FTM armamentarium: to look and feel more cisgender. I have witnessed firsthand how binding can help alleviate dysphoria and enable an FTM to present as a cisgender male whose identity pairs more naturally with how they feel authentically. Wearing a compression binder helps flatten the breast and can avoid the embarrassment of looking like a woman or being judged by

peers. It is important for parents to monitor their children's use of binders because wearing sizes that are too small in an effort to "look more flat" can make it difficult to breathe, especially when playing sports, in gym class, or on hot and humid days. It's also important to know that trans men do not have to bind for the rest of their lives. Once a decision is made to begin a testosterone regimen, eventually the breast will become smaller and menses will stop, both of which are huge developmental and emotional improvements during a transition. Using kinetic tape is another binding method with which I am less familiar, but it could also be effective if care it taken to avoid sensitive skin irritation. According to WebMD finding the right size binder is crucial because failure to do so can cause overheating and rib bruising or even fracture and it's especially challenging for anyone with asthma, scoliosis, Lupus, or Fibromyalgia [5]. It is also important to monitor those who bind because sleeping with a binder on is not recommended. Like everything, the body needs time to rest and recuperate and more than 8 h of binding can cause longer-term health issues.

Once a transgender person has conquered the beginning stages of their transition and are supported by their family, friends, and co-workers with the use of their new name, preferred pronouns, and they have begun dressing and feeling more like their authentic identity, it may be time to consider puberty blockers or hormone therapy. Puberty blockers will help reduce the growth of breast tissue and block menses and are an accepted and universal first step in the transition process. They are, however, very costly, and sometimes unaffordable. The use of puberty blockers is understood to be reversible—meaning if there was a desire to return to one's biological gender, there would be no adverse long-term effects. The use of hormone therapy offers no guarantee about reversibility, and in fact it is generally understood that using them is *not* reversible and *may* contribute to long-term effects such as an increase/reduction in hair growth, changes to the voice, and more masculinized or feminized body features that result from hormone therapy. The process involves an initial consultation with a pediatrician and referral to an endocrinologist (typically one who specializes in transgender patients). It is also important to seek out a therapist, psychiatrist, or psychologist with transgender experience who can help guide those transitioning during or throughout the process to ensure their mental and emotional wellbeing.

The World Professional Association for Transgender Health (WPATH) and the Endocrine Society created guidelines for doctors to help care for the transgender community and to ensure all decisions are as evidence-based as possible and appropriate for the age and stage of the transition. According to Unger, hormone therapy for trans men is based on treatment of hypogonadal natal men whereas estrogen therapy for trans women is based on the treatment of postmenopausal women. The hormones are most typically administered intramuscularly on a regular basis by needle injection [7]. A study by Korpaisarn et al. applied the 2017 Endocrine Society Clinical Practice Guideline for the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons and found that within the first 6 months of testosterone treatment, the study participants developed skin oiliness, acne, cessation of menses, increased facial hair, deepening of the voice. After 6 months, they observed an increased muscle mass, body hair [8]. According to Cirrincione and Huang there are 25 million transgender people 15 years or older yet clinical pharmacology for transgender medicine has fallen behind [9]. Grant et al. found that 70% of transgender adults reported taking hormone therapy [10].

Some in the transgender community talk about being survivors because they are faced with the challenge of chronic misgendering in addition to things we take for granted such as using public restrooms (or in the case of school-aged children, locker

#### *Perspective Chapter: Transitioning to Transgender – How Can We Help? DOI: http://dx.doi.org/10.5772/intechopen.104599*

rooms), public showers at the gym, and swimming in pools and at beaches. I have observed this in my own child, a complete reticence to wear a bathing suit because of his dysphoria. But do they identify as being survivors because of their identity change or are they survivors of their past identity (or "dead name" as many call their birth name)? Budge et al. looked at anxiety and depression in the transgender population and found it was higher than in the general population. They found that symptoms of depression were present 51.4% of transgender women and 48.3% for transgender men and symptoms of anxiety were found in 40.4% of transgender women and 47.5% for transgender men [11].

How else can the world at large help offset the psychological turmoil felt by this population? A new study in the *Journal of Adolescent Health* by Turban et al. [12] looked at the timing of transition, harassment during elementary, middle school, and high school, and mental health outcomes in adults. The study reports on more than 27,000 transgender men and women who transitioned at different times (ages 3–9; ages 10–17; or 18 and older). They found those who transitioned in adulthood (18 or older) experienced higher use of marijuana and lifetime suicide attempts but an equally important factor was having a safe and affirming social environment that avoids harassment between grades K and 12. In an aptly named article by Andrzejewski et al., "Perspectives of Transgender Youth on Parental Support: Qualitative Findings From the Resilience and Transgender Youth Study," [13] the authors looked at the intervention of parental support on outcomes in this population. While there is a general paucity of information and data to address this data point, they interviewed 33 parents of transgender youth, looking at these forms of support: (1) emotional; (2) instrumental; (3) appraisal; (4) informational. While they found a general support for their child's transition, it was more limited than expected, indicating parents could benefit from help and information to help gender-affirming behaviors and transitions.

One of the most dynamic and useful resources I have found is this one: https:// pflag.org/. Nine days after my son told me he was transgender I was referred to this group, which meets locally throughout the country. It is a diverse group of transgender boys, girls, men, women and their parents. Prior to COVID, we met monthly and the support, guidance, and knowledge I gained has been invaluable throughout my journey with my son. During some of the most challenging times, the group has provided support and perspective and I often left feeling humbled by the experiences of others and grateful to know they understood what my son and I were going through from personal experience.

#### **3. Conclusions**

Whether you are considering a transition or are guiding a loved one through the journey, there are a few simple steps you can take to be a champion and to be a survivor and to help someone navigate their own journey. The easiest first step is to begin using pronouns in the workplace in their email signatures, on video conference calls, and referring to colleagues with their preferred pronouns [14, 15]. This helps support the transgender community and allows the freedom of expression among their cisgender peers [14, 15]. I encourage you to learn all that you can to help the transgender population because it will have exponentially positive ripple effects as we all work toward improvements in diversity and inclusion. I never suspected that I would become a tangential part of the LGBTQ+ community, but now that I am, I feel it is a unique honor to participate in any

way I can to help educate, guide, and counsel those around me who need support. Issues of diversity, epidemiology, and mental health are interrelated and must be carefully observed in the transgender population, especially by parents and close associates to ensure their mental and physical stability [16–20]. This population is more prone to mental health issues and suicidal ideation as a result of the social issues and physical dysphoria they face. It is critical that public policy, laws, and social practices be improved to avoid transgender discrimination and marginalization because even plastic surgery procedures such as gender-affirming facial procedures and top surgery are not effective without such reform because mental health issues will persist [21].

Sharing what I've learned and helping those who I can has been one of the most rewarding experiences of my life. Where I initially felt I was not capable of managing all the emotions and challenges and questions, I now impart to others that it will be OK, you can survive. It is critical to remember that gender does not define who your child is; they will always be your child. Being their champion and ultimate supporter will help them become the incredible individual they were meant to be. We all go through the experience at a different pace and there is no right or wrong in this regard. The best advice I can offer is to love your child unconditionally so they will love themselves unconditionally. Everything begins with knowing they are supported, loved, and understood so the lessons they've learned can be taken forward with positivity and creativity to help them evolve into a strong and confident person who knows their value and is proud of themselves. We parents may not have all the answers and may sometimes feel as if we have nothing but questions, but you're now raising a survivor and that means you, too, are a survivor. Good luck, and Godspeed my friends!

#### **Author details**

Phaedra E. Cress Aesthetic Surgery Journal, Garden Grove, USA

\*Address all correspondence to: pecress@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Spirgel C. It's about basic respectmaking pronoun sharing the standard. Includr. 2021. Available from: https:// includr.org/practice/its-about-basicrespect-making-pronoun-sharing-the-sta ndard/?gclid=Cj0KCQiA2NaNBhDvARIs AEw55hjEczvE498X82nWBJNL5P0Oz\_ fu27AarrIVlXXjddUSqezJ 8atobHoaApnPEALw\_wcB. [Accessed: 02 December 2 2021]

[3] International pronouns day. Available from: https://pronounsday.org/. [Accessed: 12 December 2021]

[4] My pronouns are. Pronouns.page. Available from: https://en.pronouns.page/ ze/zir [Accessed: 11 December 2021]

[5] Understanding Organizational Barriers to a More Inclusive Workplace. McKinsey and Company. 2020. Available from: https://www.mckinsey. com/business-functions/peopleand-organizational-performance/ our-insights/understandingorganizational-barriers-to-a-moreinclusive-workplace [Accessed: 09 December 2021]

[6] Brennan D. What is chest binding? WebMD. April 9, 2021. Available from: https://www.webmd.com/a-to-z-guides/ what-is-chest-binding#:~:text=Chest%20 binding%20has%20become%20 a,female%2Dto%2Dmale%20transition. [Accessed: 05 December 2021]

[7] Unger CA. Hormone therapy for transgender patients. Translational Andrology and Urology. 2016;**5**(6): 877-884. DOI: 10.21037/tau.2016.09.04 [8] Korpaisarn S et al. Effects of testosterone treatment on transgender males: A single-institution study. SAGE Open Medicine. 2021;**9**:1-9. DOI: 10.1177/20503121211051546

[9] Cirrincione LR, Huang KH. Sex and gender differences in clinical pharmacology: Implications for transgender medicine. Clinical Pharmacology & Therapeutics. 2021;**110**(4):897-908. DOI: 10.1002/ cpt.2234

[10] Grant JM, et al. Injustice at every turn: A report of the national transgender discrimination survey. Available from: https://transequality. org/sites/default/files/docs/resources/ NTDS\_Report.pdf. [Accessed: 07 December 2021]

[11] Budge S, Adelson JL, Howard KAS. Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology. 2013;**81**(3):545-557. DOI: 10.1037/ a0031774

[12] Turban JL et al. Timing of social transition for transgender and gender diverse youth, K-12 harassment, and adult mental health outcomes. Journal of Adolescent Health. 2021;**69**(6):991-998

[13] Andrzejewski J et al. Perspectives of transgender youth on parental support: Qualitative findings from the resilience and transgender youth study. Health Education and Behavior. 2021;**48**(1):74-81

[14] Cress P. The power of personal pronouns to encourage diversity and inclusion. Aesthetic Surgery Journal 2022. DOI: 10.1093/asj/sjac087. [Epub ahead of print]

[15] Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, Swan J, et al. Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review. Journal of Gay & Lesbian Mental Health. pp. 1-44. DOI: 10.1080/19359705.2021.2016537

[16] Koehler A, Motmans J, Mulió Alvarez L, Azul D, Badalyan K, Basar K, et al. How the COVID-19 pandemic affects transgender health care—A cross-sectional online survey in 63 upper-middle-income and high-income countries. International Journal of Transgender Health. 2021:1-14

[17] Ghassabian A, Suleri A, Blok E, Franch B, Hillegers MHJ, White T. Adolescent gender diversity: Sociodemographic correlates and mental health outcomes in the general population. Journal of Child Psychology & Psychiatry. 2022;**20**. DOI: 10.1111/ jcpp.13588

[18] Stryker SD, Palleria H, Yockey RA, Berdad-Thomas J, Pickle S. Training mental health professionals in genderaffirming care: A survey of experienced clinicians. Transgender Health. 2022;**7**(1):68-77

[19] Rutnin S, Suchonwanit P, Kositkulijorn C, Pomsoong C, Korpaisarn S, Arunakul J, et al. Characterizing dermatological conditions in the transgender population: A crosssectional study. Transgender Health. 2022;**13**. DOI: 10.1089/trgh.2021.0105 [Epub ahead of print]

[20] Lett E, Everhart A. Considerations for transgender population health research based on US national surveys. Annals of Epidemiology. 2022;**65**:65-71

[21] Swan J, Phillips TM, Sanders T, Mullens AB, Debattista J, Brömdal A. Mental health and quality of life

outcomes of gender-affirming surgery: A systematic literature review. Journal of Gay & Lesbian Mental Health. 2022. DOI: 10.1080/19359705.2021.2016537

### **Chapter 5** Health of Trans People in Paraguay

*Carlos Miguel Rios-González*

#### **Abstract**

Trans care is not taught in conventional medical education programs, and very few doctors have the knowledge and comfort level to do so. A theoretical design study was carried out using the bibliographic review method, which allowed to provide a systematic framework of products in terms of scientific publications and official publications on the health of transgender people. In the Paraguayan context, it is recognized that sex work is the main economic activity of 86% of trans people, which although it is a job that is not punished in Paraguay, but neither is it recognized or regulated by law, although in Paraguay, numerous international instruments for the protection of human rights have been ratified, by which it is obliged to adopt measures to guarantee the sexual and reproductive health of all people and nondiscrimination based on sex, sexual orientation, and gender identity.

**Keywords:** transgender, health, LGTB+ collective, trans people, Paraguay

#### **1. Introduction**

The LGTB+ collective (lesbians, gays, transsexuals, and bisexuals) has acquired in recent years greater recognition of its affective-sexual diversity and with it, greater visibility in society [1]. Although the policies for the representation of this group at the community level have been updated, numerous studies continue to show the discrimination suffered by LGTB individuals, particularly the group of trans people, who are more frequently victimized even through the use of powers in public in each country [2].

Gender identity is one of the determining aspects in a person's life. Likewise, biological sex is a condition that is assigned to us at birth based on primary sexual characteristics, a corporality that will later constitute both a legally and socially binding factor [3]. Both concepts are in interaction in the person and may or may not coincide according to what is culturally established [4].

By trans people, we will understand all those who do not recognize themselves in the sex assigned at birth and build, assume, and identify themselves and others as trans men or women; consequently, it is usual for them to want to change their names, do some medical or surgical intervention, or position themselves from another place of gender different from the normative one according to their sexual assignment [5].

The foregoing is based especially on the fact that their identity constructions go beyond the binary conception of gender, according to which there is a natural relationship and full correspondence between sex and gender [6, 7]. This sustains a system of oppression, under which "everyone" must identify and recognize themselves as they were assigned at birth, and becomes the most legitimized by society, generating as a consequence segregation, discrimination, and violence against anyone who identifies in a different way to those established and that are not normative [1].

The scenario that trans people face, with respect to the development and expression of their experiences and the construction of their gender identities, in Colombian society at the time of receiving medical care, makes it necessary to specify the definitions of the key concepts that make up these processes and that allow us to understand that they are different for each individual [3]. They are constantly nurtured from diverse identity experiences and therefore deserve that the whole of society and health providers respect and recognize their diversity [5].

The transgender population faces a social and historical problem, since the establishment of the so-called "sexual dimorphism" established in the eighteenth century, from which a whole culture arises to name the anatomical variations of the bodies, and the supposed correspondence of this with gender, whether feminine or masculine [1, 6]. All this has been implanted as an ideal for many centuries in people, causing a marginalization of everything that is outside these terms, which can also be expressed as limits.

In the field of health, there is a misunderstanding due to the differences that make up their identities, corporalities, and gender expressions, in the same way that happens in other areas of society, making it necessary for there to be an adequate provision for their needs and particularities. A situation that has given rise to discrimination, artisanal medical practices, apathy toward the health system, among others; hindering the free development of the personality of these people and the right to a life in conditions of dignity and equality [7]. The foregoing has meant that they direct their struggles so that the State and health providers guarantee adequate and continuous care, which has been materialized in different normative instruments at the international and national levels, as explained below.

#### **2. Methodology**

A theoretical design study was carried out using the bibliographic review method, which allowed to provide a systematic framework of products in terms of scientific publications and official publications on the health of transgender people.

The units of analysis were scientific articles of primary type, located through seven databases recognized for their scientific rigor. In addition, the official web pages of activist and/or related groups were searched.

The search equation used in the keywords field (KW) was: "Health" AND "Transgender," "Trans" OR "LGBT" AND "Paraguay." These keywords do not necessarily correspond to thesauri, since they were chosen to ensure the widest possible number of articles published on the subject.

The search for documents included the Spanish, English, and Portuguese languages, no time period restriction was applied, and that they had been published and/or carried out in scientific journals and official web pages of activist and/or related groups.

A database of bibliographic records was generated to describe each unit of analysis with the following inductive categories: (a) bibliographic data: author and year of publication; (b) study objective and most important findings; (c) contextual variables: country where the study was conducted; (d) methodological variables: instruments and data collection techniques used. From the analysis of the bibliographic records, the deductive categories emerged: application method, study method, models, and evaluation.

### **3. Key concepts**

Currently, the demand for health care from trans people is more frequent, so it is necessary for the doctor, even if he is not a specialist, to know general aspects regarding terminology, health needs, legal medical treatment, and considerations regarding possible effects of medical treatments to which these patients are subjected in their transition to felt gender identity [8].

To analyze this topic, it is necessary to define the terms: sex, gender, sexual determination, sexual orientation [9].


The expression of gender that encompasses aspects of behavior in which men and women are different according to culture and historical stage (male or female gender behavior according to cultural patterns). In recent decades, it is more common to see expressions of gender behaviors other than those classically known as masculine or feminine, including people who are androgynous, bigenders, or who do not identify with either of the two genders (non-binary).

• Sexual orientation refers to whom the sexual desire is directed toward, existing people with homo, hetero, bisexual, pansexual, demisexual orientation, none (asexual), etc., depending on where the individual's erotic-affective attraction is directed, which it is not necessarily defined by the sex assigned at birth [9].

In short, we will have individuals with:


Thus, we can see that sex, gender, and sexual orientation are not synonyms.


#### **Table 1.**

*Definitions.*

There is scarce and inaccurate information on the prevalence of transgender people in the general population; This is because population statistics reports exclude them, because trans people identify more with the denominations "man" or "woman" than with the identity of "trans," or because of the lack of inclusion of the "nonbinary" category (neither masculine nor feminine) in the studies (**Table 1**) [11].

#### **4. Social determinants for trans health**

Social determinants of health are social and economic factors that influence people's lives and circumstances in ways that predispose them to certain healthrelated behaviors and health outcomes [12].

According to the WHO Commission on Determinants of Health, these determinants *" … are largely responsible for inequities in health—the unfair and avoidable health condition observed within and between countries*" and include factors such as social position, education, occupation, income, gender, and ethnicity/race.

The distribution of these factors has been empirically shown to correlate with how health problems are distributed across populations and within subpopulations. Addressing inequity in these factors would have multiple potential benefits in terms of better health and better life experiences and opportunities in general [13].

Increasingly, sexual orientation is recognized as a social determinant of health. Research has shown that sexual minorities are disproportionately affected by mental health problems, substance use problems, and HIV, compared with heterosexual populations globally [14].

A fundamental driver of health disparities for sexual minorities is sexual stigma, defined as "*negative regard, inferior status, and relative powerlessness that society collectively assigns to any non-heterosexual behavior, identity, relationship, or community.*" Sexual stigma influences health by causing unequal access to health services, psychological stress, and internal feelings of shame that influence health-related behavior [15].

The stigma associated with sexual orientation can also influence the social conditions and life opportunities available to sexual minorities. Access to these resources by sexual minorities is restricted because sexual stigma devalues people who are homosexual, bisexual, or who hold gender identities that do not conform to heterosexual norms [8, 9].

Restricted access to these resources can, in turn, influence "livelihood strategies," or the activities that people carry out and the decisions they make, in order to meet basic life needs such as food and shelter.

Transphobia plays a fundamental role as the determinant that conditions the health of people in this group.

#### **5. Transphobia**

Transphobia is "*the specific discrimination suffered by trans people since they put in question the prevailing sex/gender system from its roots, since they challenge the identity of gender assigned at birth"* [16].

Transphobia is etymologically a term of recent appearance, not yet included in the most current edition (2014) of the Dictionary of the Spanish Language of the Royal Spanish Academy (RAE). Despite this, the absence of an official description of a term does not imply its nonexistence. Continuing with the etymology, the word is made up of the particle "trans," which according to the RAE means "on the other side," and the word "phobia," which means "distressing and uncontrollable fear of certain acts, ideas, objects or situations, which it is known absurd and approaches the obsession" [17, 18].

Although according to this definition, we are faced with a fear that is supposed to be personal, arbitrary, and irrational, it is far from being so. This considered "phobia" has a much deeper root than a simple irrational fear, since it is anchored to a series of values and prejudices that we internalize when socializing in a certain culture [18].

Transphobia can manifest itself from subtle forms such as fear or negative beliefs, to much more explicit and aggressive forms such as intimidation, abuse, and even violence. There are two types of transphobia, direct and indirect. Indirect occurs when a supposedly neutral practice, rule, or criterion excludes or causes disadvantages either for reasons of gender identity, sexual orientation, or belonging to the LGTB group.

Direct transphobia consists of, for the reasons mentioned above, receiving less favorable treatment than another person who does not meet these characteristics and is in the same or equivalent situation [17].

Some noteworthy aspects in the activist and academic depathologizing discourses are the demand for recognition of both legal and health trans rights, the review of the healthcare model, and the questioning of the labels in the diagnostic classification manuals (ICD-10 and DSM) [18].

The controversy that is formed around this definition is wide, as well as the existing one about the psychiatric classification systems. This is due to the fact that, as we have commented and some authors explain, the deviation from the mean is considered abnormal, but frequently what is abnormal does not imply what is pathological. A clear example is homosexuality, excluded from the DSM in 1973 [19–21].

Thanks to activists and campaigns such as *Stop Trans Pathologization* (STP), these diagnostic manuals have adapted labels in order to abandon the psychopathological model that characterizes trans care.

The changes introduced in the DSM-V are still insufficient according to the STP, since the change of the title to "Gender Dysphoria" tries to reduce the stigma, but it is still debatable. For STP, this term associates the transition these people go through with a state of discomfort [9].

Although the terminological differences can be seen in the diagnostic criteria of last DSM speaks of "incongruence," which implies a "congruence" based on the normativity and pathologizes both transit and previous experiences. In addition, the criteria in the DSM-V require for their fulfillment that the person shows at least two of those described in the figure, during a period of 6 months or more [19].

As for ICD-10, the term "Transsexualism" is found within Mental and Behavioral Disorders, while in ICD-11 we find a new chapter called "Conditions related to sexual health", where the "Discordance of gender" in adults, adolescents. and infants.

Other barriers include: financial barriers (lack of insurance, lack of income), discrimination, lack of cultural competency by healthcare providers, health systems barriers (electronic records, forms, lab referrals, inappropriate clinical facilities), and socioeconomic barriers (transportation, housing, mental health). While other minority groups face some of these healthcare barriers, many are unique, and many are significantly magnified for transgender people [22].

#### **6. Situation of the trans population in Paraguay**

Paraguay has ratified numerous international instruments for the protection of human rights, by which it is obliged to adopt measures to guarantee the sexual and reproductive health of all people and nondiscrimination based on sex, sexual orientation, and gender identity.

The amount of information referring to this situation in the country is scarce. Regarding the development of guarantees and rights in the matter, our legal framework is manifested in the following ways:

The National Constitution of Paraguay (1992) states [23]:

#### • **ARTICLE 24 - RELIGIOUS AND IDEOLOGICAL FREEDOM**

Religious freedom, worship and ideology are recognized, with no other limitations than those established in this Constitution and in the law. No confession will have an official character.

The independence and autonomy of churches and religious denominations are guaranteed, with no other limitations than those imposed in this Constitution and the laws.

Nobody can be bothered, investigated or forced to testify because of their beliefs or their ideology.

#### • **ARTICLE 25 - EXPRESSION OF PERSONALITY**

Every person has the right to free expression of their personality, creativity and the formation of their own identity and image.

Ideological pluralism is guaranteed.

#### • **ARTICLE 46 - EQUALITY OF PEOPLE**

All the inhabitants of the Republic are equal in dignity and rights. Discrimination is not allowed. The State will remove the obstacles and prevent the factors that maintain or promote them.

The protections that are established on unfair inequalities will not be considered as discriminatory factors but rather as egalitarian.

#### • **ARTICLE 68 - RIGHT TO HEALTH**

The State shall protect and promote health as a fundamental right of the person and in the interest of the community.

No one shall be deprived of public assistance to prevent or treat diseases, pests or plagues, and relief in the event of catastrophes and accidents.

Every person is obliged to submit to the sanitary measures established by law, while respecting human dignity.

It is recognized that sex work is the main economic activity of 86% of trans people, although it is work that is not punished in Paraguay, but it is also not recognized or regulated by law. Access to jobs is impeded by discrimination due to the fact of assuming a different sexual identity, since transgender people are not hired in private entities, except in hairdressing salons or volunteering in the field of health [24].

Working life is further complicated by the fact that more than half (52%) of transgender people did not complete primary school and ended up dropping out of school due to the "*teasing, harassment, physical punishment and degrading treatment*" they received from other students and teachers [25].

Transgender encounter the same degrading treatment when they go to health services, where they are subjected to psychological aggression and humiliation when they require health care in general, and especially when they go to obtain treatment and care for HIV and AIDS.

According to the Ministry of Public Health and Social Welfare of Paraguay (MSPyBS), in the general population, the prevalence of HIV infection (2017) was 23% in this population. The cascade of the continuum of HIV care in 2019 in the population of trans women shows that, for the period cited, there are 187 (96.4%) people alive who know their diagnosis, are on ART 114 (58.8%).

Lastly, 63 (32.5%) of people living with HIV have their viral load suppressed, representing a gap of 67.5%. In this case, the pillar of diagnosed trans women is practically saturated, and the main difficulty is observed in the low percentage of trans women who maintain a suppressed viral load. It can be concluded that some type of barrier must exist to ensure that this population group maintains adherence to antiretroviral treatment [26].

#### **6.1 Paraguayan health regulations for the trans population**

Regarding the Regulations, in Paraguay Resolution No. 72/2012, of the General Directorate of Penitentiary Establishments and Criminal Enforcement of the Ministry of Justice, "*Which establishes new regulations for the operation of the benefit of private visits in penitentiaries and correctional facilities for women of the Republic.*" Among these, neither the sex nor the gender of the visiting partner of the person deprived of liberty is determined [27].

In addition to this, in 2015, the Protocol for Attention to Trans Persons Deprived of Liberty was established. On the part of the MSPyBS, through Resolution No. 695/2016, the use of the social name for trans people is recommended [28].

This is why determining the knowledge and biases of the existing medical workforce should be included: medical students, physicians in training, practicing physicians, and other health workers across the spectrum of training; the adequacy of enough providers for the care required, and the state of a framework for paying for adequate care.

There is a specific need to determine if providers receive adequate training in transgender medicine and, if not, determine the gap. There is also a specific need to determine the current state of discrimination against transgender people in the healthcare system. Additionally, studies should determine possible solutions to address gaps (including training for knowledge gaps and policy changes for financial gaps) along with mechanisms to validate such solutions.

#### **7. Discussion**

This population faces a series of problems to access health services in their countries, and Paraguay is no exception, many of the situations are linked to stigmatization, lack of medical care protocols, and lack of information on how to act in certain situations, which is determined by the lack of inclusion in the training curricula of health professionals [12, 25, 26].

Although the health problems that affect transgender people are similar to those that affect the rest of the population, some conditions are more widespread within these groups because they face situations that increase their vulnerability or risk of exposure to pathogens [1, 6].

#### *Health of Trans People in Paraguay DOI: http://dx.doi.org/10.5772/intechopen.106488*

Different studies indicate that they are mostly affected by infectious diseases such as HIV, syphilis, gonorrhea, hepatitis, or genital herpes, to mention a few examples [7].

The first challenge that trans people face, and the one that permeates almost all the other challenges, is the one that has to do with the adequate recognition of their identities, and the fight for the reduction of transphobia, for the purposes of offering comprehensive and quality care [8].

There is also a great lack of education in all the staff, about their realities and rights; as well as the appropriate care protocols since there are women with a penis and men with a vulva, who require different treatments and accompaniments to achieve the full enjoyment of their identities, these points must be discussed by decision-makers in order to help the inclusion of all groups within the health service. Although, in Paraguay, the use of the social name can be found, discrimination and stigmatization continue to be an important problem [10–13].

In the development of trans identities, acceptance is an aspect that perhaps has the most serious consequences for the health and full development of all the rights of these people. Although the medicalization of their bodies and sexualities has existed since the nineteenth century, due to the fact that all their diverse expressions were marginalized and cataloged by scientific discourse as abnormal and disturbed, requiring medical intervention to undo everything that does not fit into the imposed ideal dichotomy [14, 26].

An important point to note is also that 39% of the transgender population suffers from serious psychological distress (compared with 5% of the general population) that they have a nine times higher risk of suicide attempts and a five times higher frequency of infection for HIV (mostly transgender women), 25% did not seek medical care for fear of mistreatment in care services, which is striking due to the constant increase [25–27].

Violence motivated by sexual orientation or gender in sexual minorities indicates the presence of 68% of physical violence inflicted and 49% of sexual violence [15], in Paraguay there is a lack of studies that can demonstrate the real impact of transphobia in services of health and in addition to this study on the burden of diseases and disorders.

The limitations of this review are based on the scarcity of studies to carry out the study, so it is suggested to carry out a study to provide evidence on the health of trans people in Paraguay.

#### **8. Conclusions**

In conclusion, it is highlighted that although Paraguay has ratified numerous international instruments for the protection of human rights, there is still a lack of measures to guarantee the sexual and reproductive health of all people and nondiscrimination based on sex, sexual orientation, and gender identity.

In addition to public policies aimed at this group, it is necessary to establish gender regulations or laws that allow the population to develop in an integral manner.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Transgender Health - Advances and New Perspectives*

#### **Author details**

Carlos Miguel Rios-González1,2,3

1 Faculty of Medical Sciences, National University of Caaguazu, Paraguay

2 Ministry of Public Health and Social Welfare, National Institute of Health, Asunción, Paraguay

3 South American University, Pedro Juan Caballero, Paraguay

\*Address all correspondence to: carlosmigue\_rios@live.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 3
