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Texto & Contexto - Enfermagem

versão impressa ISSN 0104-0707

Texto contexto - enferm. vol.24 no.1 Florianópolis jan./mar. 2015

https://doi.org/10.1590/0104-07072015001920013 

Original Article

Health care: the transvestites of Santa Maria, Rio Grande do Sul, Brazil

Cuidado con la salud: travestis de Santa Maria, Rio Grande do Sul, Brasil

Martha Helena Teixeira de Souza 1  

Pedro Paulo Gomes Pereira 2  

1Ph.D. in Sciences. Professor at Centro Universitário Franciscano. Santa Maria, Rio Grande do Sul, Brazil. E-mail: marthahts@gmail.com

2Ph.D. in Anthropology. Professor in Preventive Medicine at Universidade Federal de São Paulo. São Paulo, São Paulo, Brasil. E-mail: pedropgpereira@gmail.com


ABSTRACT

The general purpose of this paper is to present the health care of transvestites from Santa Maria, central region of Rio Grande do Sul, Brazil. Field research was conducted in 2012, between January and November, with transvestites originated from different cities of this State, who were living in Santa Maria at that time. Qualitative methodology was adopted through ethnographic research. The results showed that the interlocutors avoid the institutionalized health services, choosing other forms of care. The interlocutors indicated their choice for "houses of african religion" by identifying them as places that, without questioning the bodily changes and sexual orientation, were able to afford forms of care and protection. Therefore, this article can help to provide some visibility to care transvestites looking for health.

Key words: Health services for transgendered persons; Anthropology, cultural; Patient-centered care; Religion and medicine

RESUMEN

Este trabajo tiene como objetivo general presentar el cuidado a la salud de travestis en el municipio de Santa María, región central de Rio Grande do Sul, Brasil. El trabajo de campo se llevó a cabo en el período de enero a noviembre de 2012, con travestis procedentes de municipios del Rio Grande do Sul, que vivían en Santa María en el momento del estudio. Se trata de un estudio cualitativo a través de investigación etnográfica. Los resultados mostraron que las interlocutoras evitan los servicios de salud institucionales existentes, eligiendo otras formas de atención. Las interlocutoras indicaron su preferencia para asistir a las "casas de religión africana" identificándolas como espacios que, sin cuestionar los cambios corporales y la orientación sexual, ofrecían formas de cuidado y protección. Este artículo puede contribuir con las discusiones de las diversas dimensiones de cuidado, tema central de enfermería.

Palabras-clave: Servicios de salud para las personas transgénero; Antropología cultural; Atención dirigida al paciente; Religión y medicina

RESUMO

O objetivo desta pesquisa foi apresentar os cuidados com a saúde de travestis do município de Santa Maria, Rio Grande do Sul, Brasil. A pesquisa de campo realizou-se no período de janeiro a novembro de 2012, com travestis de diversos municípios do Rio Grande do Sul, que residiam em Santa Maria durante a pesquisa. O estudo foi de metodologia qualitativa, por meio de investigação etnográfica. Durante o trabalho de campo, acompanhamos a trajetória de 49 travestis em busca de cuidados com a saúde. As falas foram gravadas e, logo após, transcritas para a reflexão crítica dos dados. Os resultados demonstraram que as interlocutoras evitam os serviços institucionalizados de saúde, optando por outras formas de cuidado. As travestis indicaram sua opção em frequentar as "casas de religião afro", identificando-as como espaços que, sem questionar as modificações corporais e sua orientação sexual, proporcionam formas de cuidado e proteção. Este artigo pode contribuir com as discussões sobre as várias dimensões do cuidado, tema central para enfermagem.

Palavras-Chave: Serviços de saúde para pessoas transgênero; Antropologia cultural; Cuidado centrado no paciente; Religião e medicina

INTRODUCTION

Some authors have studied transvestites.1 - 8 These studies have granted a broader understanding of countless aspects in these people's universe, enhancing reflections on gender issues, public policies and spatial dimensions. Nevertheless, gaps and questions remain. One of the gaps relates to how the transvestites seek health care.

By destabilizing the traditionally constructed gender frontiers, the transvestites face difficulties in multiple scenarios, one of which refers to public health services. The influence of gender on health/disease issues is perceptible in many dimensions, including the service access and public policies.9 Researchers10 have suggested a reflection on the freezing and stunning of the gender concept, aiming to break with a binary grammar, reducing the different forms of producing differences and inequalities and their intercessions. This freezing could be pointing towards a presupposed universality of the subjects, as an anchor for universalizing policies, without translating the complex relations established, involving sexual orientation, bodily performance, among others.

In the course of this study, distinct and complex itineraries were perceived, related to the routes the transvestites take. An itinerary that represents a movement of life, which simultaneously involves time and spaces. This trajectory constantly reconfigures the body and life of the transvestites, who live in spaces that are continuously altered. When outlining the courses that will be followed in search of care, they generally share strategies with the group, always aiming to deviate from prejudice.

The general proposal in this study was to present health care for transvestites in the city of Santa Maria, central region of Rio Grande do Sul (RS), along their itineraries.

METHOD

This research was based on a qualitative study method, through an ethnographic research, in which participant observation procedures were adopted, as well as in-depth interviews and observation of the interlocutors' daily life. The choice for an ethnographic research was partially due to its relevance and timeliness in health research.9 , 11 Ethnography is not defined by the techniques it applies, such as participant observation and interviews, but by a particular kind of intellectual effort, which the author describes as a 'dense description'.12

The field research was undertaken between January and November 2012. Data were collected through daily observations and the interviews were written down in a field diary. The data, registered in the field notebook, permit capturing information the interviews and cameras do not reach.13

Access to the transvestites was possible as a result of previous knowledge of this group, through the researcher's aids prevention actions. The data were collected in different spaces, such as: boarding houses for transvestites, prostitution areas, holy houses, carnival parades and parades of lesbians, gays, bisexual and transsexual individuals (LGBT).

During the fieldwork, we accompanied the transvestites' complex trajectories in search of health care, in different spaces and instances. Their statements were recorded and later transcribed to enhance a critical reflection on the collected data. In the course of the research, 49 transvestites were contacted, who lived in the city of Santa Maria-RS. After exhaustive reading of the transcriptions, the data were grouped in categories for thematic analysis, according to the study objectives. The anthropologic analysis resulted from all knowledge production phases. Looking (observation), listening (interviews) and writing (data analysis and interpretation), as cognitive acts, are disciplined within the horizon of Anthropology.14

The project received approval from the Research Ethics Committee at Universidade Federal de São Paulo (UNIFESP), under number 1937/11. The voluntary decision to participate in the research or not was respected and anonymity was guaranteed, through the use of pseudonyms to identify the participants.

RESULTS AND DISCUSSION

The interlocutors' age ranged between 18 and 53 years. The predominant education level was unfinished primary education. As regards the professional activity, three research participants serve as mothers of saints, two are domestic servants, one is a general maintenance worker at the bus station, one chairs the Non-Governmental Organization Igualdade, and the remainder are sex workers. Although 84% of the research participants work as sex professionals, the mistaken association between the term transvestite and prostitution should be highlighted, as if they were synonyms,7 as a transvestite is not always a sex professional as well. This picture is due to different reasons. During the fieldwork, we repeatedly heard that the bond with prostitution was due to the difficulties faced, the prejudice, the negative reaction towards their biased bodies. Nevertheless, it should be emphasized that other factors also emerged, all of which involved the forms of accepting their bodies.

The initial idea in this study was to follow the transvestites during their care in official health services. During the research, however, the ethnographic experience led towards another course, also followed in search of care, including health care: the "batuque" or, as they call it, the "Afro religion". Studies15 - 24 have demonstrated that the Afro-Brazilian religions have particularities across the Brazilian territory, but the research participants generically referred to the "Afro religion".

The transvestites' care option suggests that, although biomedicine holds the legitimized monopoly of curative solutions for disease issues in the contemporary western societies, it is not the only form of considering the health-disease process. This dimension found in this research was also mentioned in another study,25 in which the populations living in conditions of great social inequalities look for alternative care, like in the case of Afro-indigenous religions for example.

Considering the understanding of the transvestites' search for care from the biomedical perspective, in the sense of disease or health, means a partial perception of the results. These research data, however, demonstrated that the care the interlocutors sought went beyond the official health services. We visited the places they attended most together, such as: prostitution areas, gay clubs, police precincts, homes of transvestites' family members, LGBT parades, excursions to participate in LGBT events in the region, the week of diversity in the city and carnival parades. One surprising aspect in the search for care was that they rarely sought the public health services.

To clarify the transvestites' search for health care, the text was organized as follows: first, the care in the spaces the transvestites attend will be described. Then, the care in public health services will be discussed. Finally, considerations will be presented on what the participants expressed about care in the "batuque".

The transvestites' care in the spaces they attend

The transvestites elaborate care tactics in the spaces through which they circulate. They reveal care forms that represent a set of performances that gain flexibility along the way. The notion of space goes beyond the conception of distances and of the identification of functional and social characteristics. This refers to an intrinsic relation between the space and their own body, which sets limits and possibilities for existence and sociality. This intimate social perception takes the form of shared learning in the group. It is important to highlight that the notion of space is expanded, including the own body, which is molded and modified along the way, as Katy's experience suggests.

When mentioning the places where the transvestites can freely move, Katy, 25 years old, mother of saint, highlights that in life, the transvestite knows she can choose to live among three parlors: the beauty parlor, the orixás' parlor or the street parlor, which is prostitution. When she reveals this, she explains that, like other orientations, this diktat is learned from the more experienced transvestites, as soon as they start their bodily transformations. The start of taking female hormones, the use of silicon, care with the growth of the hair and the removal of the body hair gradually transforms the transvestites' body and, at the same time, limits the course they follow or not. In some spaces, they can exhibit their full glamour (clubs, bars, carnival parades). In others, they need to move discretely or even avoid them.

It is common for the transvestites to avoid moving in public spaces during the day: the street, the pharmacist's, the market, the bakery and, often, institutionalized health services. Therefore, they use tele-delivery services for pharmaceutical products, home visits by beauty product vendors, taxis with an indicated driver for any transportation they need, and so forth.

Care involves multiple dimensions, such as precaution with the housing spaces, the prostitution areas, the public places less subject to violence, bars, clubs and samba schools. They rarely live with family members, mainly when working as sex professionals. Most of the research participants share the rent with other transvestites.

The group always comments on drug addiction and, when some use crack, they do not stay at the places of residents. The care taken with crack is explained in statements like crack users always end up stealing and living together becomes a problem. The alert on the effects of crack always comes from the older transvestites, who have already witnessed or even experienced situations involving drug use, producing situations of violence or criminalization. The most sensitizing aspect to avoid drug use is probably that it causes bodily neglect, affecting the lack of clients for those working as sex professionals. Another important factor relates to reports of histories of difficulty to "quit the addiction", causing serious health problems. Anyway, the body is the main concern.

In case they need to visit places where they now in advance that they will be rejected, they modify their attitude, using discrete clothing to circulate with less obstacles and violence. The initial situations of rejections and violence frequently happen in the biological family. As a strategy, they transform the family concept. When they constitute "homes" with other transvestites, they create new bonds, often expanding the family notion: there they build affective relations, being identifies as "sisters". Jeny's statement, 20 years old, clarifies this new family relation when she expresses that we are sisters now, we take care of one another, like family really.

The use of terms of parenthood emerges in contrast with the experiences of the core family, in accordance with Jessye's report, 18 years old, who mentioned a situation of violence most of the group experiences: my father used to hit my head against the wall a lot. When I was about five years old, he used to punch my head and throw my body on top of things. Because he wouldn't accept me being a homosexual! It was very bad and I used to cry a lot. Then he accepted it more. He said I could even be gay, but not use women's clothes, I'd rather be dead! Some time later, I forgot to take off my mother's clothes I was wearing. He almost killed me because he hit me that much. Then I left home and went to live with other transvestites, because I couldn't take it anymore!

Reports of suicide attempts at times of suffering are frequent in this contact with other transvestites, as observed in Ashley's statement, 29 years old: before telling my family I'd be a transvestite, I used to have headaches. I tried to commit suicide twice. It's horrible. When I was able to tell my family I felt relieved. Suicide is a complex phenomenon with diverse causes. It is an important indicator of the populations' quality of life and one of the challenges to rethink the knowledge and practices related to the population's health.26

In this contact with other transvestites, the trajectories to take care of their bodily changes are expanded. The mutual information exchange leads to the accomplishment of constant changes in their physical appearance. For these changes, there is an intense movement in the region in search of "bombadeiras". In general, these are older transvestites who gained experience in the injection of industrial silicone. The use of hormones and silicon is widely discussed and all of them know its "problems" and "risks". The first option is the use of industrial silicon. This whole movement and displacements serve to produce transformations in their own body. The use of hormones, silicon, surgeries, increasingly sophisticated makeup, removal of body hair, ways of hiding the penis represent gender and sexuality shifts.

As a result of the situations of violence they experienced, wounds that need care commonly appear. These situations are common and part of the transvestites' daily life. During the fieldwork, for example, a homicide attempt occurred, involving two twin transvestites. The report by Whitney, 22 years, displayed below, identifies excerpts of this episode: we left from a club with two guys. When they perceived that we were transvestites, they locked us in the car and attacked us a lot, with pliers and a screwdriver. Natallye was able to break the glass and escape first. She ran and asked for help. The security guard at the club called the police. We all went to the precinct. Despite the witness, however, we ended up as bandits. Nobody believes a transvestite. Then, we had to go to the health service. They just put some gauze on the injuries. Even explaining that it was hurting a lot, they didn't give us any medicine.

Despite the histories of inappropriate public health care, the situations of violence they are confronted with make the transvestites turn to these places for care, even when these services expand the violence.

The care for the transvestites in the public health services

In the city of Santa Maria-RS, there is no specialized service to attend to people with diverse sexual options, like in the city of Uberlândia, state of Minas Gerais, and in São Paulo. When they visit the public health services, they usually go to the municipal emergency service for wound care, or to the Test and Counseling Center for the diagnosis and treatment of sexually transmitted diseases (STD). Attending to the population's demand in the services, with difficulties aggravated by social problems, has been a great challenge for public health. These difficulties favor the reorientation of the users' trajectory in search of alternative care.

In the course of the research, observations about difficulties to get satisfactory care at the public health services were frequent, as observed in the statement by Kelly, 30 years: in health it is no different from daily life. They treat us as non humans, that's why I don't go to the SUS, no way. If I need care, I go where I can pay for it. They always respect you more when you pay. SUS, no way.

Authors3 - 4 indicate that the transvestites' health is relegated to self-medication or the action of "bombadeiras". The participants' statements sustain a search to redirect the trajectories whenever possible, often seeking the response for their health care in private services. Since the first attempt, they perceive a care barrier, which starts with their identification.

The other day, I went for my HIV test and the room was full of people. Everyone already looks at you oddly, it's as if you already had it [aids], you know? They left the door open during care. I got up embarrassed and tried to close the door. They said I should leave it open. I asked them to put my female name on the file. No way! It was really embarrassing when they called me by my male name. I pretended that it wasn't me and left in disguise. But it's no use. The people there perceive that it's you. In addition, it's the neglect, they don't solve the problem. Imagine, if my HIV test had been positive I wouldn't return there. That are some of the reasons, among others, why people don't get treatment (Ashley).

Ashley's report shows that her experience points towards health professionals who do not consider these subjects' particularities, ignoring public initiatives to respect the users' diversity. One important action to promote universal access to the health system was the introduction of the right to the social name in the Bill of Rights of Health Users, in any services available in the public health network.27 To structure a national health policy for the LGBT population, the federal government launched the "Program Brazil without Homophobia". Other actions within this program relate to knowledge production on the LGBT population and the training of health professionals.28 Aiming to comply with the SUS guiding principles of universality, equity and integrality, in 2008, the Ministry of Health presented the National Integral Health Policy for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals.29 In this study, however, a gap is observed between the text of the policies and the service practice. The statement by Jhesyka, 25 years, pictures this problem: when we are working in the prostitution area and are assaulted on the street, we turn to the health service for stitches, medication or anything else. But sometimes, it's better to go home and cure it alone. No matter the health service we go to they call us by our male name. They hardly look at us and even mock us. It seems as if we are not people. So it's better to stand the pain at home.

The situation Jhesyka appoints demonstrates the distancing from the health service. The bodily transformations, the inappropriateness between the name on the documents and the physical appearance also seem to transform these strange, biased bodies that do not constitute precarious bodies. By avoiding the health service, the transvestites mobilize care to protect themselves for a transvestite life, thus building a marginal, foreclosed life. Lacan's concept of foreclosure was borrowed to consider the social, violence and gender relations, signaling those who "failed" to be sexed and genderized in line with the heterosexual matrix.30 Foreclosed people, in precarious living conditions, experience lives on hostile grounds, whose socialization is marked by social rejection.31 These precarious lives would be of all women and men who learned to understand themselves based on the injury of the experience of being offended, as they are suspected of or proven subjects who do not comply with the heterosexual standard.31

These precarious bodies, however, build new spaces and new forms of circulation for themselves. When accompanying the transvestites on these complex routes towards care, we are confronted with spaces that lie beyond the official health services. The place the transvestites attend most in search of care are the "holy houses", an aspect that will be explored in further detail ahead.

The care for the transvestites in the Afro religions

The ethnography showed that the transvestites choose other forms of care: the "houses of afro religion", "holy houses" or "batuque". In the course of the fieldwork, our interlocutors systematically argued that the protection of the orixás, caboclos, pretos velhos, Pombagiras and Exus is fundamental in their lives. Questioned about the theme, Nicky, 32 years old, considered that they bring health, protection and progress.

To provide a panorama of what is called "Afro-Brazilian religion", researchers19 - 20 have divided these religions in models of three ritualistic expressions: a) The first worships the orixás and privileges the mythological, symbolic, linguistic, doctrinarian and ritualistic elements of the banto and nagô traditions. This group includes the candomblé in Bahia, the xangô do Recife, the batuque in Rio Grande do Sul and the casa de mina in Maranhão; b) The second seems to have emerged based on the candomblé, mixing traditions and adapting to the urban life in Brazil. This group includes the macumba and, according to the regional variations, it is also called quimbanda, black line, black magic, crossed umbanda and crossed line; and c) The third is the umbanda, composed of elements from the Catholic, African, indigenous, Kardecist, oriental religious traditions. Important studies have been developed about the Afro-Brazilian religions in Rio Grande do Sul.16 , 19 , 32 And the particularities of the batuque in Rio Grande do Sul have been outlined well.17

One point that has been considered fundamental to choose the "batuque" as a care form is the way they are not only received, but also accepted, respected and valued, as Kathy highlighted. They explain that, on the fields of fathers and mothers of saints, they do not question our way of being, we are accepted like that, in our way and that makes all of the difference, as Lolla, 22 years old highlighted.

The religious therapy is one of the care alternatives. Its followers' adherence is influenced by individual or collective experiences of its effectiveness and/or by the fidelity to a religion that regulates life in general, including the conducts related to bodily and health care.33 Like most religions, the Afro-Brazilian religions offer formulations to cope with afflictions. One of the main sources of suffering that take people closer to these religions is the search for relief or cure for diseases.34Religion, more than anything, offers a set of notions that constitute reference points in view of the unpredictability of daily life.35

The adversities faced in the transvestites' life can induce the transvestites' search for safety, protection and care in the "Afro religion". It is at the heart of a troubled and dense context, at the mercy of uncertain arrangements of sociability and the lack of institutions like family, school, work that, mainly in urban midst, the "Afro religions" operate as structuring sources of identification models, in which the orixás emerged in the role of the person's tutor.24 But the transvestites attend the "batuque" fields not only to solve their problems. This is a complex picture that involves at the same time: characters, which manage sophisticated mythical knowledge and construct a grammar of gender and sexuality that is greatly distanced from the compulsory heterosexuality; bodily reconstructions by means of technologies; and ritual performances, in which the bodies are at the center, attaining a process of evoking and producing these same bodies.36

In Santa Maria-RS, the fathers and mothers of saints say that they consider the three sides: nation, umbanda and quimbanda. The research showed that the transvestites prefer to participate in the quimbanda rituals, in which Exu reigns, as it is the place that allows them incorporate Pombagira and dance to the sound of the "batuque", and also execute body performances. According to one father of saint, the transvestites come more for Exu really. They like it much more, because they can receive the Pombagiras. They come dressed as a woman, wearing a hoop skirt, using earrings, necklaces. The father of saint justifies the transvestites' desire by their desire for identification with the female, as Pombagiras are the spirits of women, who were lovers and prostitutes, they are messengers between this world and the world of the spirits, they are the spirit of luxury, linked to the sexual pleasure. During the nights of umbanda sessions, the transvestites wear very feminine clothes and go out at night, dismissing their paid activity which is usually prostitution, and go to the "holy houses", going straight to the quimbanda fields. At the sound of a "batuque"that shudders the walls, they get into a trance, incorporating the Pombagira, the spirit of a woman (and not orixá), who is supposed to have been a prostitute during her lifetime, a woman capable of dominating men with her sexual feats, who loved luxury, money and pleasure.36

The explanation of one father of saint underlines the care the religion offers: the transvestites chest down this part of care really. As they don't have the protection they imagine, they turn to the Entities to protect them. So she'll say: I have the Pombagira who protects me. Religion takes care, and a lot!

Pombagira lives not only of spells and works and goes to Exu's parties to have fun, be appreciated and honored.37 In these spaces, the transvestites - strange bodies, precarious lives, who find themselves in the condition of having to reinvent the "family", who develop care tactics at the new homes, who face difficulties to freely circulate in public spaces and do not feel welcomed in the public health services - have their bodies, with the changes and contours constructed with great efforts, at the center of events, in experiences in which they feel accepted.

The "houses of saints" then turn into outstanding spaces in the interlocutors' care, as they are spaces that permit experiences that escape from the normalization processes of the bodies. The care offered in the fields allows the transvestites to escape from the heteronormative model, traditionally imposed in the spaces they pass through, turning into a place where they can arrange themselves in the female form without being criminalized and judged for this.

FINAL CONSIDERATIONS

To present the health care for transvestites in the city of Santa Maria, in the central region of the state of Rio Grande do Sul, we perceive that they avoid the public health services. Therefore, for them, taking care of one's health is not a movement in circles, in search of solutions to their problems, as it involves other scenarios and health practices.

The transvestites understand that health is something built in the housing spaces, in the prostitution areas, in the public spaces, in the "holy houses". What they define as health goes far beyond the view of health that is merely linked to the illness processes, and even to the health services.

In fact, in the rare situations in which they turned to the health services for care, these did not attend to their expectations and demands, and were therefore considered inappropriate. One of the harrowing issues was the way they were named at the health services. Although some transvestites are familiar with specific legislation, which grants them the right to be identified by their social name, the services do not comply with that right. The health services' lack of knowledge about the transvestites' care trajectories makes the situation more complex for care, as they report that the health professionals are surprised by the transvestites' care with the silicon, with the use of hormones and the desire for femininity.

Based on this field experience, it is observed that the transvestites' form of health care goes beyond the notions of health and disease that are exclusively linked to the biological, and also goes beyond the institutionalized and bureaucratic apparatus of the Unified Health System (SUS). To consider this group's health care, a broader perspective on the health-disease process is needed, incorporating elements characteristic of these subjects, such as the social determinants involved, the bodily modifications, the group life and the influence of the Afro-Brazilian religions on their health, protection and wellbeing. This study can contribute to the discussions about the various dimensions of care, a central theme for nursing.

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Received: June 26, 2013; Accepted: December 05, 2013

Correspondence: Martha Souza Rua dos Andradas, 1614 97010-032 - Santa Maria, RS, Brasil E-mail: marthahts@gmail.com

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