JOURNAL OF HOMOSEXUALITY

2016, VOL. 63, NO. 11, 15561572

http://dx.doi.org/10.1080/00918369.2016.1223359

Trans-Specific Health Care: Challenges in the Context of

New Policies for Transgender People
Grazielle Tagliamento, PhDa and Vera Paiva, PhDb
a
Department of Community Social Psychology, Tuiuti University of Paran, Brazil; bDepartment of
Social Psychology, University of So Paulo, So Paulo, Brazil

ABSTRACT KEYWORDS
This study aims to understand transgender peoples access to the Health care; human rights;
Brazilian public health care system in light of the new public transgender; trans men;
policies for this group in Brazil. Our ethnographic study involved trans women
interviews with transgender women at a nongovernmental orga-
nization and a direct participant-observation study conducted
2 years later to observe how a new specialized service was
providing health care for transgender people. Transgender peo-
ple reported difficult personal life trajectories, marked by discri-
mination and binary standards, in their struggle to become
recognized as women/men. At the specialized service, gender
norms and stereotyping were observed being put into operation
by untrained service providers. This dominance of pathologizing
models ended up not decreasing transgender patients access to
unsafe care outside of the public sector. The promotion and
protection of the right to health thus depends on cultural
changes. This may well include changes in technical-scientific
discourse regarding the transgender experience to account for
the depathologization and gender fluidity recognition.

Introduction
In the process of constructing new bodily and gender identities, transgender
people feel encouraged to constantly seek out affirmation of their feminin-
ity or masculinity. The queer multitudes (Preciado, 2011) often modify
their bodies to achieve a social intelligibility that eliminates their diversity,
complexity, and differences. They also search out and use silicone implants,
mastectomies, and hormone therapy, among other biomedical technologies.
In Brazilian terms, transgender people attempt to be socially acknowledged
as men or women, looking to construct themselves and being recognized as
person deserving rights and escape a more dangerous ambiguous
positioning. In this direction, the Brazilian transgender social movement
demanded that public policies should adopt the prefix trans to refer to
transgender peopleconceptualized as persons whose gender identity is
different from their gender attributed at birth.

CONTACT Grazielle Tagliamento grazielle.tagliamento@utp.br Department of Community Social Psychology,

Tuiuti University of Paran, Monsenhor Ivo Zanlorenzi Street, 4400, ap. 86, Bl. 2B, Curitiba, Paran, Brazil.
2016 Taylor & Francis
 JOURNAL OF HOMOSEXUALITY 1557

According to the Pan-American Health Organization (2013), the health risks

resulting from taking hormones without medical prescription is one significant
issue for both trans men and trans women in Latin America and Caribbean. These
include increases in cardiovascular death, kidney failure, and hepatic diseases
(Asscheman, Giltay, Megens, Ronde, van Trotsenburg, & Gooren, 2011;
Feldman & Safer, 2009). In Brazil, the majority of trans women who cannot afford
costly procedures to undergo plastic surgery in medical clinics commonly inject
silicone to reshape their bodies. Bombadeiras, older and more experienced trans
women, inject younger transitioning women, oftentimes without proper steriliza-
tion, risking infections and other complications, or even sudden death (Peres,
2008). Serious reactions to back-alley silicone injections can even compromise the
lungs and the central nervous system of trans women who search for bombadeiras
(Macedo et al., 2013; Visnyei, Samuel, Heacock, & Cortes, 2014).
These are salient issues that should inform comprehensive and effective
health care services for trans communities. The World Professional
Association for Transgender Health (WPATH) goes far beyond hormonal
and surgical treatments, emphasizing the need for holistic care, including
access to primary care, gynecologic and urologic care, reproductive
options, voice and communication therapy, and mental health services,
such as counseling and psychotherapy (WPATH, 2012).
In this same direction, very early on in the 1990s in response to the
disproportional number of AIDS cases among trans people, the National
AIDS Program (NAP) became the first Brazilian governmental body to
include initiatives directed toward the health of trans people. A decade
later (2008), responding to social mobilization and inspired by NAPs
human rightsbased approach, the Ministry of Health enacted public
policies allowing trans people access to health care, as described in the
Background section.
This article discusses the results of a study conducted at a critical historical
moment, when government programs were responding to social mobilization
by trans people. It documents the perspectives of trans women, trans men,
and community stakeholders regarding the implementation of a specialized
health care service for trans people in a southern Brazilian city. Would the
implementation of a seemingly equitable health care service respect the rights
and the daily life choices of the people who sought out these services?

Background
The government program Brazil Without Homophobia was launched in 2004
(Special Human Rights Secretariat, 2004). Its aim was to foster full citizenship
for LGBTs (lesbians, gays, bisexuals, travestis, and transsexuals), equity, the
promotion of rights, and the mitigation of violence and homophobic, lesbopho-
bic, and transphobic discrimination. In 2008, the National Policy for LGBT
1558 G. TAGLIAMENTO AND V. PAIVA

Integral Health was launched to implement actions that would identify and
eradicate inequities in health care access for neglected population groups such as
lesbians, gays, bisexuals, travestis, and transsexuals (Health Ministry, 2010). In
the same year, the Campaign for the Inter-American Convention on Sexual and
Reproductive Rights (2008, p. 25) defined travestis as people who were assigned
the male gender at birth, but whose self-expression defines them as female. They
can choose to modify their bodies, or not, using surgical procedures or hormo-
nal treatments. In Brazil, travestis want a feminine gender identity, reinforcing
a binary gender system. What normally has them more or less closer to feminine
body patterns is their ability to pay for the necessary treatments and procedures.
This often results in bodies that show a mixture of traits of both genders.. . . Any
other transgender identity should have the power to live outside this binary
division. (Garcia, 2009, p. 598).
The structural and political context for these initiatives is the 1988 Brazilian
Constitution, which defines health as a right for all and an obligation of the State.
Regardless of sexual orientation, race/ethnicity, age, or economic condition, all
Brazilians are entitled to integral health services. All users of the system should be
welcome and treated without prejudice or discrimination. This principle of free
and universal health care for all Brazilians has resulted in the creation of the
countrys Unified Health System (SUS). The principle of integrality seeks to
broaden health cares focus from the treatment of disease to include health
promotion, prevention, and the stimulation of inter-sectorial dialogue regarding
health resolutions and other public policies that take into account the Brazilian
populations social and economic contexts (Vasconcelos & Pasche, 2006).
Concerning trans people, treaties and international agreements adopted by
Brazil have pointed the way forward. Documents inspired by the 1994
International Conference for Population and Development and the 4th
World Conference on Women (in 1995) have expanded understandings of
sexual and health rights, although without mentioning gender diversity.
Following these documents, the Yogyakarta Principles (2006) mention gender
identity as a fundamental axis of diversity, requiring protection as part of a
broad spectrum of human rights standards and their application in issues of
sexual orientation and gender identity (p. 8).
Responding to needs and rights of trans people, as included in both
national and international public policy documents, in 2008, the Brazilian
Ministry of Health instituted specialized health care services for trans people
within SUS. Initially, only trans women (male-to-female) with a diagnosis of
transsexuality and who were willing to undergo sex reassignment surgery had
access to comprehensive and specific care, as foreseen by the 1997 Federal
Council of Medicines (FCM) resolution on sex reassignment surgery. This
resolution has since been modified, and, since 2010, male-to-female sex
reassignment surgery as well as bilateral mastectomies and hysterectomies
are no longer considered to be experimental. In 2013, the Ministry of
 JOURNAL OF HOMOSEXUALITY 1559

Healths programs also included trans men (female-to-male) and trans

women not wishing to undergo sex reassignment surgery. Accordingly,
accredited specialized ambulatory services were authorized, offering health
care and including psychologists, social workers, nurses, endocrinologists,
and speech therapists among their staff. Hospital services were ordered to
include mastectomies, hysterectomies, thyroid surgery, and breast surgery
(including implanting silicon breast prostheses), among their other services.
Issues not related to trans-specific health care were to be referred to the
regular SUS services, therefore being carried out free from charge and with-
out discrimination.
In the state where our study was conducted, a specialized trans ambu-
latory service was inaugurated to offer access to hormone therapy and
other special treatments. This state does not have hospitals with specia-
lized services, and its trans residents thus need to travel to other Brazilian
states for sex reassignment surgery. Only five other state capitals have
authorized hospitals. Their waiting list includes people from all the other
21 Brazilian states, and access to surgery is often quite delayed. Moreover,
to be recognized in their rights to SUS special care, trans people need to
be diagnosed with sexual identity disorder as defined by the Medical
Association Resolution (CFM, 2010): F64.0 (transsexualism) and F64.9
(nonspecific gender disturbance) in the International Disease
Classification System. Diagnosis is carried out by a multidisciplinary
professional team. It is a requirement for surgeries, hormone therapy,
and officially changing ones nameand the latter is offered only by
some specialized services.
When the trans health service was inaugurated in this state capital in
2013, the health professionals attached to it had undergone very little
training, as was the case elsewhere in the country (Federal Psychology
Council, 2016). Sexuality and gender are largely understood as synon-
ymous in most Brazilian cultural contexts and communities. When a
cisgender mana cisgender person who assumes the gender identity
attributed on their birth certificateexpresses stereotyped femininity, he
is interpreted as being a homosexual (Tagliamento & Toneli, 2010), and
the same happens when a cisgender womans gender performance reflects
normative masculinity. As observed in other countries, many trans people
adhere to stereotyped masculine and feminine performances also to avoid
questions about their gender identity (Iantaffi & Bockting, 2011;
Stroumsa, 2014). Would trans people who did not correspond to conven-
tional binary gender patterns be guaranteed care by the new health
service? How would the service recognize and address those people with
masculinities and femininities that do did not fit into the traditional
gender binary?
1560 G. TAGLIAMENTO AND V. PAIVA

Method
In this ethnographic study, we aimed to understand the obstacles that trans
people face when accessing specialized health care through SUS. From March to
December 2011, we conducted participant observation during indoor and out-
reach activities of the nongovernment organization (NGO) trans people use to
organize for social mobilization. During this period, 23 trans people were
approached through snowball methodology and invited to participate in the
study. Sixteen of these people did not openly refuse to be interviewed but did not
show up for their interview appointment; most of these cases were sex workers.
Seven participants agreed to in-depth interviews, and all of these people were
White. The city where the study took place has a population that is 20% Black
and mixed (as opposed to 52% for Brazil in general). Except for skin color
(which is used in Brazil to designate race/ethnicity), study participants reflected
the diversity of the NGOs clients. Participants were asked to describe real-life
scenes that reflected obstacles or successful access to good-quality health care
and the urgent need to access a specialized health care service within the SUS, as
well as other themes from their life trajectories. The interviewer openly stated
that the aim of the study was to identify ways of addressing negligence in service
provision, as well as improving the protection of the right to universal and
equitable health services. All interviews were recorded, after signing an informed
consent form. The study was supported by the NGO and approved by the
University of So Paulo ethics committee.
The interview questions explored participants life trajectories, the obsta-
cles they and other trans people faced in accessing health care, and their
experiences with enablers as well as barriers in the regular SUS service to
specific trans health needs.
Ethnographic observation was also conducted at the newly inaugurated trans
specialized service 2 years later (20132014). This was a follow-up study that
observed how this service was providing health care access for trans people. Direct
participant-observation at the institution focused on social dynamics and the
quality of the services. The study included conversations with five key
informantsall of them patients and staff of the serviceand with the seven
same earlier interviewees who described their experiences as clients of the recently
inaugurated service. The service was located in a large health care facility that
offered other types of specialized health care services such as vaccination, derma-
tology, and other specialties for the general population. Observations sessions
were carried out at the trans people health service for 10 months, every other day
at least twice a week. Observation focused on describing processes of accessing the
service and contrasting the demands of transgender clients with health profes-
sionals practices. Table 1 resumes the characteristics of the interviewees and key
informants. All names are fictional, with the exception of Carla, who specifically
requested that her name not be changed.
 JOURNAL OF HOMOSEXUALITY 1561

Table 1. Interviewees characteristics.

Fictional name Gender Age Education Profession
Interviewed in 2011, 2013, 2014
Jessica Transsexual* 29 Graduate studies Teacher
Veronica Transsexual* 29 Incomplete high school Sex worker
Luiza Transsexual* 23 High school Sex worker
Luciana Transsexual* 21 Undergrad student Call center sales supervisor
Aline Travesti* 23 Incomplete high school Sex worker
Leticia Travesti* 26 Basic education Sex worker
Carla Transsexual* 38 Incomplete high school NGO staff
Key Informants at the specialized service in 20132014
Andr Transsexual* 18 Undergrad student
Jos Transsexual* 19 Incomplete high school Salesperson at a call center
Priscila Travesti* 33 High school Sex worker
Sheila Transsexual* 22 Incomplete high school Sex worker
Alice Cisgender Woman 43 Higher education Psychologist
*Self-defined.

To guide the research paths and interpretation, a human rightsbased health

framework was productive; human rights violations at the level of programs can
increase social and individual vulnerability to morbidity and mortality (Ayres,
Paiva, & Frana Jr., 2010; Mann & Tarantola, 1996). Considering mortality, for
example, a global ranking of deaths resulting from transphobia puts Brazil in
the first place802 trans people were killed from 20082015; Mexico is second
(Transgender Europe, 2015). The social and cultural organization of sexuality
and sexual rights in Latin America should be better understood to face this
terrible data, in each territory. Still, access to quality health care and health
promotion is such a key social determinant of health and illness that is
conceived as a distinctive dimension of social vulnerability to mortality and
morbiditythe programmatic vulnerability dimensionexpressed as the right
to health. As discussed by Ayres et al. (2010), the analysis of accessibility,
technical organization, and the moral orientation of prevention and treatment
programs can indicate where programs might be negligent or might even create
a set of conditions that make people and communities more susceptible to
disease or disability. This framework therefore assumes that there is not only a
natural history of disease but also a social history of disease and mortality.
This is definitely the case of health issues involving trans people.

Results
Gender norms and the impact of stereotypes on untrained service
providers
The trans people who participated in this study found themselves asking
several questions before they began searching for health care in the public
unified health system (SUS): Will the health professionals welcome me?
Will the doctor examine me with care? Will the people in the waiting
1562 G. TAGLIAMENTO AND V. PAIVA

room look at me in a peculiar way? Will other clients think that I have
sexually transmitted diseases (STDs) or HIV/AIDS because I am seeking
health care? Will I be called by the name I chose, my social name, or by
the name on my birth certificate? Since 2006, the Charter of Rights for
SUS Users guarantees the use of the social namethe name that a person
is commonly known by, which most frequently is not their name on the
birth certificate. All these questions revealed their previous experiences
with stigmatization.
Both the interviewees and trans people observed during visits to the NGO
described different forms of discrimination within the health system. Barriers
to health care arose immediately upon arrival at the service when reception-
ists requested trans peoples names and identity documents to complete their
patient intake sheets.
The [receptionist] said: Give me your documents. She took my documents,
looked at them and said: This document belongs to John Doe, who is a man.
Upon which I said: Yes, that is me. The person said: No, no it is not you.. . . To
finally embarrass me she said: All right then John Doe, very loudly and clearly, so
everyone looked up, Go to that room. (Luciana)

Although the social name can substitute the birth name on the National
Health Card without any reference to the original birth name, many health
professionals do not know this, as reported by Leticias experience listening
to a receptionist: No, there is no law that approves this sort of thing, so you
cant put it there. So you can only be called by your [civil] name.
Previous situations relating to her social name had led Luiza to seek out a
health service only after she had a serious accident. She was stigmatized and
discriminated against, could not use her social name, and was aware that all
the trans persons she knew had the right to be known by their social name
scoffed at and disrespected. All interviewees agreed that health professionals
lacked preparation in dealing with trans peoples bodies. Carla, who has this
female name on her official ID documents, was identified and treated as a
woman by the centers receptionist, as if she had a female sex designation on
her birth certificate. As long as the female doctor identified her as a cisgender
woman, care proceeded normally. When the doctor understood that Carla
was a trans woman, care was interrupted.
I lay down on the stretcher and she [the doctor] began to examine me. She poked
me, saw that it was swollen, and she began asking some questions about some
things she wanted to diagnose, in principle, before she carried out the exam. . .. She
pressed the part of my pubis that was swollen. She asked Are your periods
regular? To which I responded: I do not menstruate. She then said What do
you mean you do not have periods? I said No, I am a transsexual woman. It
became very clear from then onwards that she would not know how to examine
me. She stopped the examination and asked me to carry out several exams [with
other health providers]. (Carla)
 JOURNAL OF HOMOSEXUALITY 1563

In addition to difficulties in gaining access to holistic health care,

trans women were always assumed to be sex workers. Stigmatization
continued as they were seen as promiscuous, and their vulnerabilities
were reduced to those related to STDs and HIV/AIDS. Like Carla,
several felt that if a trans person like myself comes to a medical office
with a tooth ache or pain in their kidneys, the first thing they ask for is
an HIV and STD exam.
According to participants, before being examined or welcomed at a
primary health care service, they are referred to an HIV/AIDS specialized
center: . . .go there, as the AIDS people will know what to do with you, as
Priscila was told. In the specialized HIV/AIDS centers, there is indeed a
greater probability that health care professionals will have had access to
continuing education in sexuality, gender identities, and humanized treat-
mentacceptance and understanding human diversity, to guarantee peoples
autonomy throughout health actions (American Psychological Association,
2015; Ayres et al., 2010).
Faced with all these obstacles, the participants who had more financial
resources therefore preferred to seek out private medical insurance plans or
pay for private medical visits.

As of that moment, I gave up on the public health program, which is what many
travestis and transsexuals do. It seems as if you are taking something, you are still
entitled to something more. (Luciana)

The in-depth interviews also investigated if trans people felt that their
right to health was respected in the private sector, but not in the public
sector? According to the interviewees, because one pays, specific care is
made according to what the payer demands and needs: you buy it. In the
public health services on the other hand, as professionals have to work in
a variety of places and have a higher workload, they have no time to
receive adequate training to meet the demands of trans people. Most
private health insurance providers demand a nondiscriminatory stance
from their health care professionals, ensuring that they adapt to company
demands. In private care, being able to choose ones doctor is understood
to be something of great worth.
According to the interviewees perspective, the quality of services also
varied according to individual professionals. Public services were better if
the health center had a history of dealing with trans clients. Care rendered at
health units in central neighborhoods was better than at neighborhoods in
the urban peripheries, where services are more precarious and clients are
poorer. Participants also confirmed key limitations in the range of services
rendered at HIV/AIDS specialized centers, however, where professionals had
been trained for decades to welcome and serve trans people.
1564 G. TAGLIAMENTO AND V. PAIVA

The dominance of pathologizing models

With the creation of the specialized outpatient service at the end of 2013,
many trans persons mobilized by the NGO believed the care provided would
be nondiscriminatory and welcoming.
However, we observed psychologists dilemmas before issuing their
diagnoses at the specialized service. One female-to-male trans person
sought to change their civil name but was not recognized as being
male by health professionals. Throughout our conversation with Alice,
the psychologist, she argued that even when this young person stated he
was a man, he was seen as delicate, romantic. . . not enjoy[ing] having
body hair and [thus] shaving. Observation at the specialized health
service showed that several questions crossed health professionals
minds. Some of Alices dilemmas were: Does one have to have body
hair to be a man? Are sensitivity and romanticism necessarily aspects of
femininity? What makes a person a man or a woman? Her undergraduate
training never touched on these issues, and Alice did not think outside of
the limits of these binaries in her professional practice.
According to interviewees narratives, trans women who do not corre-
sponded to normative femininity and trans men who do not correspond to
normative masculinitythe normal oneshad their rights neglected and
did not gain access to the necessary technical judgments regarding their
gender precisely because they did not conform to gender binaries.
I spent a year and a half being followed-up by a psychologist and when I told her I
used my penis in my sexual practices. . . while I was prostituting myself, she said I
was not a real woman and that she would exclude me from the service. (Carla)

In these professionals minds, gender should correspond to traditional

norms, to classical biological discourse and not to new public health or
human rightsbased discourses. To be a female, Carla had to deny her
penis and remove it. Participants agree that health professionals are con-
stantly seeking clues that will discern gender performance binaries to clarify
the identification of a trans person:
I have no doubts whatsoever: he says he is a man, but he has relations with another
man; he is passive in his sexual practices and is still the one supporting the house
and the boyfriend. That is why I am hesitant about issuing an opinion. My
professional reputation is at stake. (Alice)

In this context, at all times trans people sought to correspond to what was
expected of them by health care professionals. Some even stated that there was a
set of rules regarding what they could and could not say to professionals at
specialized health care services, especially to psychologists and psychiatrists. I
am going to end up creating a manual on how to be a woman and how to be a
man in order to obtain the necessary technical opinions (Priscila).
 JOURNAL OF HOMOSEXUALITY 1565

The need to correspond to regulatory standards regarding genders repro-

duces a set of rules in medical clinics that reproduce the socialized binary of
masculinities and femininities.

The necessity to access care outside the public sector

When asked about the masculine traits that she still had, Jessica referred to her
narrow hips, her large stomach/belly, and small breasts. The quest for the ideal
female body (according to Brazilian standards) is reinforced by the specialized
services: having large breasts, a large behind, and a flat tummy is considered
appropriate for trans women.
This is a quest which I deem to be endless. . . even though you go through all of the
transition processes. . .. I still think I have some masculine traits. . . Plastic surgery is
always good. (Jessica)

Trans women seek to literally shape themselves and thus resort to silicone
implants. Given that medically approved silicone implants are a financial impos-
sibility for many trans women, they put their health and lives at risk when using
bombadeiras. Even when trans people navigate the bureaucracy successfully and
get authorization to medical procedures at specialized services, mastectomies and
hysterectomies as well as other body-shaping interventions are unavailable at SUS
units in most states. The confusing paths to access these services stimulate the
search for private-sector professionals who feel entitled to charge more. Our
informants relate this to the scarcity of these professionals in this market.
According to Carla, a breast prosthesis for a regular woman costs around 5, 6
thousand reais; for a trans, on the other hand, it costs between 10 and 15
thousand. Furthermore, the private clinics mentioned by the participants were
semi-clandestine and have no supervision or public health oversight.
All interviewees reported that despite knowing the risks of industrial
silicone, they had already used it, as it was the only available and affordable
resource that could make me feel like a real woman and to get the perfect
and idealized body they so desired. In addition to being exposed to infection,
trans women who have industrial silicone injected into their bodies did not
receive the necessary treatment for the noxious effects of the silicone, or to
treat diseases resulting from the clandestine injections.
I have often heard reports of young girls coming to public hospitals for silicon
problems, dying of thrombi-embolism or similar things, and people not giving
them assistance: they do not want to touch them. Because we are going to touch
them and do not know how. (Leticia)

In the case of trans men, prices also hinder access to qualified surgical
procedures. They use bands to secure their breasts and hide them. Often, this
leads to necrosis because of excessive band tightening: It hurts a lot. Everything
1566 G. TAGLIAMENTO AND V. PAIVA

has necrotized, but even that is better than looking like some kind of woman.
Theres no way out (Andre).
Hormones are also used without medical guidance, leading to serious health
risks. According to participants, hormones are prescribed by other trans persons
who have already taken them with positive results. I met a person who had begun
this process. I asked her how to do it. Then I went out and bought some, and I
have started taking them (Carla). The search for rapid results also leads to trans
people ingesting amounts of hormones that are well above what is recommended.
I take a Perlutan injection [an injectable contraceptive for monthly use] every
week, in addition to some Estradiol tablets (Sheila).
Searching for recognition, trans men adopt social practices deemed to be
those of real men: promiscuity, for example, or being strong in crisis
situations. They take risks, buying supplements and hormones they have
no legal access to without medical supervision: Ah, I use a lot of anabolic
substances or steroids. I buy everything through the Internet (Jose).

Discussion
The trans people in our study sought access to biomedical technologies to
manufacture a body in accordance with dominant gender ideals, demanding
that these technologies become available at specialized trans health services. For
trans women, an aesthetic search for femininity has been part of their need for
recognition as a woman, a citizen, and (most probably) a socially intelligible
gender (Butler, 2002; Pelcio, 2005; Peres, 2008). This quest is not merely about
being beautiful, but about being a real woman. Trans women thus often
express the dominant cultural model of women that values certain attributes
at the expense of others.
Nevertheless, professionals lack of knowledge on issues of gender diversity
as well as their refusal to render clinical or surgical assistance to trans women
that have used industrial silicone (for example) may affect trans peoples
access to care, even at specialized services. Professional training does not
include these topics, perhaps expressing the scant scientific production on
the effects of clandestine health services and procedures. We also observed
professionals use traditional categorizations based on male/female dichoto-
mies as strong/delicate. As Butler (2003) put it, repeated inculcation follows
the naming of male/female frontiers, and this in turn produces the gender
standard while ignoring or diminishing dissimilar experiences. This is how
contours and restrictions are established and maintained. Therefore, if a
trans man does not like body hair, what is he? A woman? If a trans
woman speaks loudly or is not delicate, how can she truly be a woman?
When trans people do not correspond to the normalized attributes for men
and women, can they really be considered to be trans?
 JOURNAL OF HOMOSEXUALITY 1567

Trans people seek out private-sector services or, in the absence of these,
clandestine services, avoiding discrimination while increasing their vulner-
ability to health problems. Rachlin, Green, and Lombardi (2008) found a
high satisfaction index among trans men in their study of private-care
services in the United States but remarked that the sampling might have
skewed their results: If it had been made up of people who did not have
health insurance, perhaps the results would have been different.
Although official documents and policies aim to guarantee trans people
equitable access to health care, in daily life trans people face programmatic
barriers because of hard-to-change cultural standards. All participants declared
that they had met discrimination in their trajectories through the health services,
and we directly observed gender discrimination ourselves. The barriers to health
care access found in this study, such as the negative stereotypes and stigmas
associated with trans identity, may result in the interruption of ongoing clinical
care, as also described in other countries, including the United States (Stroumsa,
2014) and Argentina (Socas et al., 2014). These also include AIDS-related
stigmatization and discrimination and the reduction of trans people to STDs
and AIDS patients, as observed in Guatemala by Boyce, Barrington, Bolanos,
Arandi, and Paz-Bailey (2012)related to the high prevalence of STD/AIDS
among trans people (Faras et al., 2011).
Pelcio (2006), Garcia (2009), and Kulick (1998) have conducted studies
about travestis in Brazil, describing other sources of discrimination that
express a synergy of race, social class, and sex worker stigma in travesti life
trajectories. We observed the salience of the gender binary discrimination
over other factors in the newly inaugurated service. Sex worker stigma and
discrimination and class differences or class-based discrimination were not
observedthe service is a free and a public health system unit. Before the
center was inaugurated, class was an issue, and the poorest trans people
would look for bombadeiras and other clandestine services. Black people
were also well represented among the users, and we did not observe scenes
of racial discrimination. We were unable to interview Black trans people to
understand better.
Normative gender standards structure daily life and the socialization of trans
people and their families, as well as that of professionals designated to treat trans
people in the public services (Tagliamento, 2013). In the implementation of the
new specialized services, the production and reproduction of fixed identities
confront resistance and break down. On the one hand, one may agree with the
authors who adopt a more structural stance, such as Bourdieu (1995) and Faria
(1998), that the reported and observed scenes express the fact that, historically in
Brazil, men belong to the public and professional sphere and should be strong,
whereas being a woman meant being a domestic housewife: passive, maternal,
affective, and focused on details as well as fitting into a specific aesthetic model.
The Brazilian Society for Plastic Surgery (2013) has stated that Brazil is the
1568 G. TAGLIAMENTO AND V. PAIVA

second country in the world in terms of the number of plastic surgeries

performed, with stomach liposuction and silicone breast implants being the
surgeries most often carried out among Brazilian women
Most trans people seek to change their bodies as dictated by normalized
binary standards, which may indeed well respect their desires and choices.
When they produce more unique gender identity and performances, however,
professional practices may not respect their rights. In these cases, trans people
may not be allowed to occupy the normal category because of the current
technologies for the production of bodies or gender normalization (Preciado,
2011, p. 14). Although they self-identify as trans people, they are under social
pressure to occupy one specific normal field of gender performance to receive
a diagnosis of sexual identity disorder and adequate treatment through the
public health services. In other words, they need to be a normal holder of a
disorderclassified as F64.0 (transsexualism) or F64.9 (nonspecific gender
disturbance)to have access to a specialized trans service and to guarantee
their right to health. O avesso, do avesso, do avesso. . . (the opposite of the
opposite of the opposite), as in Caetano Velosos song.
As Tenrio and Prado (2015) pointed out, the diagnosis bureaucracy
makes trans people dependent on psychologists and psychiatrics who strip
away trans peoples autonomy over their own bodies and their ability to
decide what they want to change. This limit is imposed by the health
resolution (CFM, 2010) that informed the 2013 Ministry of Health policy
on trans people. Not every person wants or needs a 2-year therapeutic
process. Based on human rights perspectives, the Federal Psychology
Council has called for a public debate on depathologizing trans lives and
decision making, taking into account a general lack of understanding about
gender transitioning, which is laden with compulsory gender norms and
control of the body (Tenrio & Prado, 2015, p. 45).
Rights are the product of political struggles (Murray, 2006), but the
automatic hegemony of tradition ends up prevailing, to the detriment of
different cultures and diverse lifestyles (Santos, 1997). Regulatory gender
standards keep producing inequality and vulnerability to disease in the
programs responsible for decision making in legislation, public policies,
and health services, which are made instrumental and are embodied by
people (Tagliamento, 2013).
To thus mitigate social and individual vulnerabilities to the different
illnesses that trans people face, programs should guarantee a quality of care
that depends on health professional training regarding social and physical
issues that specifically affect trans peoples health. As observed in other
countries, poorly trained professionals and discrimination further exacerbate
mental suffering (Grossman & DAugelli, 2006).
Trans people encounter innumerous obstacles and rights violations
along their path into the education system and in the labor market
 JOURNAL OF HOMOSEXUALITY 1569

(Garcia & Parker, 2006; Tagliamento, 2013). This study confirms

negligence in the promotion of the right to health care. This negligence
is caused by stigmatization of and discrimination against trans peoples
personal production of gender identityit is present in the health system
and even in the new specialized service. This study also confirms that
guaranteeing the freedom to change ones civil name as well as social
recognition of this change is an important asset in mitigating the
embarrassment caused by stigmatization and discrimination against trans
identity. As Parker and Garcia (2006) put it, recognition of sexual rights
and gender identity may guarantee citizenship within the health system. A
trans women can indeed still be using her penis in sexual encounters
(particularly as a means of economically reproducing her existence) and
still understand herself as a trans person: medical professionals, trained in
understanding trans culture, should and would recognize this.
One limit of our study indicates that new research is needed to describe
health professionals perspectives in greater depth and in different national
contexts to document the current limitations of training. Not having the
professional perspective was a limit of our study; another was the inclusion
into in-depth conversation efforts different segments of trans people, as Black
people and more trans men.

Conclusion
Acknowledging programming efforts in the federal sphere to produce public
policies and regulatory norms, this study found that the access of trans
people to specialized health care is not guaranteed and depends on the
provision, by state and municipal governments, of quality and holistic
human rightsbased professional training.
The suggestions we have offered up in this debate regarding interventions
in Brazil may be valuable in other national contexts: (1) to include topics
related to the healthdisease dynamics of trans people in graduate training
curricula, especially in medicine, nursing, and psychology; (2) to stimulate
continuing education regarding the social and singular/personal construction
of gender identities and the diversity and fluidity of identities and sexual
orientation; (3) to promote clear guidelines for collaboration with councils or
associations of medicine, endocrinology, psychology, and social services on
how professionals should conduct care services; (4) to strengthen sexuality
education and health promotion in schools with teaching about different
gender identities and sexual orientations to protect young trans people from
bullying that undermine them as rights holders; and (5) to foster debate on
the use of human rights frameworks for health equity, with the inclusion of
gender diversity and sexual rights as a key issue. Workshops held by trans
people with the collaboration of NGOs in a variety of sectors of society have
1570 G. TAGLIAMENTO AND V. PAIVA

been very productive, an interpretation supported by this study. As human

rights frameworks have pointed out, the most affected people should be part
of the solution.
The promotion and protection of trans peoples right to health depends on
cultural changes and actions by both government and civil society. These
actions need to actively monitor the protection of this right and must include
the newly inaugurated specialized health services in this monitoring. This
process may also well include changes in the technical scientific discourse
regarding the transgender experience to account for gender fluidity recogni-
tion and depathologization.

References
American Psychological Association. (2015). Guidelines for psychological practice with
transgender and gender nonconforming people. American Psychologist, 70, 832864.
doi:10.1037/a0039906
Asscheman, H., Giltay, E. J., Megens, J. A., De Ronde, W. P., Van Trotsenburg, M. A., &
Gooren, L. J. (2011). A long-term follow-up study of mortality in transsexuals receiving
treatment with cross-sex hormones. European Journal of Endocrinology, 164, 635642.
doi:10.1530/EJE-10-1038
Ayres, J. R. C. M., Paiva, V., & Franca Junior, I. (2010). From natural history of disease to
vulnerability: Changing concepts and practices in contemporary public health. In R. Parker
& M. Sommers (Eds.), Routledge handbook of global public health (pp. 98107). London,
UK: Routledge.
Bourdieu, P. (1995). A dominao masculina [Male dominance]. Rio de Janeiro, Brazil:
Bertrand do Brasil.
Boyce, S., Barrington, C., Bolanos, H., Arandi, C. G., & Paz-Bailey, G. (2012). Facilitating
Access to sexual health services for men who have sex with me and male-to-female
transgender persons in Guatemala City. Culture, Health, & Sexuality, 14, 313327.
doi:10.1080/13691058.2011.639393
Butler, J. (2002). Cuerpos que importan: Sobre los lmites materiales y discursivos del sexo
[Bodies that matter: On materials and discursive limits of sex]. Barcelona, Spain: Paids.
Butler, J. (2003). Problemas de gnero: Feminismo e subverso da identidade [Gender trouble:
Feminism and the subversion of identity]. Rio de Janeiro, Brazil: Civilizao Brasileira.
Campaign for the Inter-American Convention on Sexual and Reproductive Rights. (2008).
Manifesto [Manifest]. So Paulo, Brazil: CCIDSDR.
Faria, N. (1998). Sexualidade e gnero: Uma abordagem feminista [Sexuality and gender: a
feminist approach]. So Paulo, Brazil: SOF.
Faras, M. S. R., Garcia, M. N., Reynaga, E., Romero, M., Vaulet, M. L. G., Fermepn, M. R.,
. . . vila, M. M. (2011). First report on sexually transmitted infections among trans (male
to female transvestites, transsexuals, or transgender) and male sex workers in Argentina:
High HIV, HPV, HBV, and syphilis prevalence. International Journal of Infectious Diseases,
15, e635e640. doi:10.1016/j.ijid.2011.05.007
Federal Medicine Council (CFM). (2010). Resolution CFM n 1.955. DOU, Braslia, DF.
Federal Psychology Council. (2016). A despatologizao das transexualidades e travestilidades
pelo olhar da Psicologia Parte II [The depathologization of transsexualities and
 JOURNAL OF HOMOSEXUALITY 1571

travestilidades by the look of Psychology part II] [video on-line]. Braslia, DF, Brazil:
CFP. Retrieved from https://www.youtube.com/watch?v=RL4M_Msl-eA
Feldman, J., & Safer, J. (2009). Hormone therapy in adults: Suggested revisions to the sixth
version of the standards of care. International Journal of Transgenderism, 11, 146182.
doi:10.1080/15532730903383757
Garcia, J., & Parker, R. (2006). From global discourse to local action: The makings of a sexual
rights movement? Horizontes Antropolgicos, 12(26), 1341. doi:10.1590/S0104-
71832006000200002
Garcia, M. R. V. (2009). Alguns aspectos da construo do gnero entre travestis de baixa
renda [Some aspects of gender construction amongst low-income travestis]. Psicologia
USP, 20, 597618. doi:10.1590/S0103-65642009000400007
Grossman, A. H., & DAugelli, A. R. (2006). Transgender youth: Invisible and vulnerable.
Journal of Homosexuality, 51(1), 111128. doi:10.1300/J082v51n01_06
Iantaffi, A., & Bockting, W. O. (2011). Views from both sides of the bridge? Gender, sexual
legitimacy, and transgender peoples experiences of relationships. Culture, Health &
Sexuality, 13, 355370. doi:10.1080/13691058.2010.537770
Kulick, D. (1998). Travesti: Sex, gender, and culture among Brazilian transgendered prosti-
tutes. Chicago, IL: University of Chicago Press.
Macedo, R. F., Lobo, R. A., Capitani, E. M., Zanovello, M. E. P., Caruso, P. C., Leme, M. S. T., . . .
Zambon, L. (2013). Alveolar hemorrhage after parenteral injection of industrial silicon. Jornal
Brasileiro de Pneumologia, 39, 387389. doi:10.1590/S1806-37132013000300018
Mann, J., & Tarantola, D. (1996). AIDS in the world II. New York, NY: Oxford.
Ministrio da Sade [Health Ministry]. (2010). Poltica nacional de sade integral de lsbicas,
gays, bissexuais, travestis e transexuais LGBT [National policy of integral health of lesbian,
gay, bisexual and transgender LGBT]. Braslia, DF, Brazil: MS.
Murray, D. A. B. (2006). Whos right? Human rights, sexual rights and social change in
Barbados. Culture, Health & Sexuality, 8, 267281. doi:10.1080/13691050600765145
Pan-American Health Organization. (2013). Por la salud de las personas trans. Elementos para
el desarrollo de la atencin integral de personas trans y sus comunidades en Latinoamrica y
el Caribe. Retrieved from http://www.paho.org/arg/images/gallery/Blueprint%20Trans%
20Espaol.pdf
Pelcio, L. (2005). Toda quebrada na plsticacorporalidade e construo de gnero entre
travestis paulistas [Every broken in plasticcorporeality and construction of gender
between So Paulo travestis]. Campos, 6, 97112. doi:10.5380/cam.v6i0.4509
Pelcio, L. (2006). Abjeo e desejo: Uma etnografia travesti sobre o modelo preventivo de aids
[Abject and desire: A travesti ethnography of the preventive model of AIDS]. So Paulo,
Brazil: Annablume.
Peres, W. S. (2008). Travestis: Corpo, cuidado de si e cidadania [Travestis: Body, self care and
citizenship]. In Fazendo Gnero (ed.), Anais do Fazendo Gnero 8 Corpo, Violncia e
Poder. Florianpolis, Brazil.
Preciado, B. (2011). Multides queer: Notas para uma poltica dos anormais [Multitudes
queer. Notes for a politics of abnormality]. Estudos Feministas, 19, 1120.
Princpios de Yogyakarta. (2006). Princpios de Yogyakarta [Yogyakarta principles]. Rio de
Janeiro, Brazil: CLAM.
Rachlin, K., Green, J., & Lombardi, E. (2008). Utilization of healthcare among female-to-male
transgender individuals in the United States. Journal of Homosexuality, 54, 243258.
doi:10.1080/00918360801982124
Santos, B. S. (1997). Por uma concepo multicultural dos direitos humanos [For a multi-
cultural conception of human rights]. Revista Crtica das Cincias Sociais, 48, 1132.
1572 G. TAGLIAMENTO AND V. PAIVA

Secretaria Especial dos Direitos Humanos [Special Human Rights Secretariat]. (2004). Brasil
sem homofobia: programa de combate violncia e discriminao contra GLBT e
promoo da cidadania homossexual [Brazil without homophobia: program to combat
violence and discrimination against GLBT and promotion of the homosexual citizenship].
Braslia, DF, Brazil: SEDH.
Socas, M. E., Marshall, B. D. L., Arstegui, I., Romero, M., Cahn, P., Kerr, T., & Sued, O.
(2014). Factors associated with healthcare avoidance among transgender women in
Argentina. International Journal for Equity in Health, 13, 18. doi:10.1186/s12939-014-
0081-7
Sociedade Brasileira de Cirurgia Plstica [Brazilian Society for Plastic Surgery]. (2013).
Nmero de cirurgias plsticas entre adolescentes aumenta 141% em 4 anos [Number of
plastic surgeries among adolescents increased 141% in 4 years]. Retrieved from http://
www2.cirurgiaplastica.org.br/numero-de-cirurgias-plasticas-entre-adolescentes-aumenta-
141-em-4-anos/
Stroumsa, D. (2014). The state of transgender healthcare: Policy, law, and medical frame-
works. American Journal of Public Health, 104(3), e31e38. doi:10.2105/AJPH.2013.301789
Tagliamento, G. (2013). A arte dos (des)encontros: Mulheres trans e a sade integral [The art
of the (un)meetings: Trans women and the integral health]. Rio de Janeiro, Brazil:
Multifoco.
Tagliamento, G., & Toneli, M. J. F. (2010). (No)Trabalho e masculinidades produzidas em
contextos familiares de camadas mdias [(No)work and masculinity produced in family
contexts of middle class]. Psicologia & Sociedade, 22, 345354. doi:10.1590/S0102-
71822010000200015
Tenrio, L. F. P., & Prado, M. A. M. (2015). Patologizao das identidades trans e a violncia
na ateno sade: Das normativas s prticas psicolgicas. In A. P. Uziel et al. (Eds.),
Transdiversidades: Prticas e dilogos em trnsito [Trans diversity: Practices and dialogs in
transit]. Rio de Janeiro, Brazil: Eduerj.
Transgender Europe. (2015). 2,016 reported deaths of trans and gender diverse persons
murdered between January 2008 and December 2015. Transrespect. Retrieved from
http://transrespect.org/wp-content/uploads/2016/03/TvT_TMM_TDoV2016_Tables_EN.
pdf
Vasconcelos, C. M., & Pasche, D. F. (2006). O sistema nico de sade. In G. W. Campos, M.
C. S. Minayo, M. Akerman, M. Drumond Jnior, & Y. M. Carvalho (Eds.), Tratado de
sade coletiva [Treaty of collective health] (pp. 531562). So Paulo, Brazil: HUCITEC.
Visnyei, K., Samuel, M., Heacock, L., & Cortes, J. A. (2014). Hypercalcemia in a male-to-
female transgender patient after body contouring injections: A case report. Journal of
Medical Case Reports, 8, 71. doi:10.1186/1752-1947-8-71
World Professional Association for Transgender Health (WPATH). (2012). Standards of care
for the health of transsexual, transgender and gender nonconforming people. Retrieved from
http://www.wpath.org