Political action in the health of transgender people in Manaus, Amazonas,

This article describes the political action repertoire mobilized in the construction of public health policy for trans persons in the Manaus, capital city of the state of Amazonas, in northern Brazil. It is based on ethnographic research combining participant observation in the multiple sites where these policies are constructed and interviews with members of two transgender rights organizations in Manaus, between January 2016 and July 2018. Four modes of political action were reconstructed, as ideal types, named after native categories: those of confrontation, others of “articulation”, the ones seeking visibility and others collaboration. Each mode has the local society as public and agents of the municipal and state Judiciary, Legislative and Executive bodies sometimes as adversaries, sometimes as allies.


Introduction
With the advent of AIDS in the 1990's, the health of trans people became "relevant" for the Brazilian Ministry of health.Initially marked by contradictory discourse, impregnated with stigma and guided by the need to moralize and control "uncontrolled sexualities", the response to AIDS became a landmark in the construction of the sexual diversity and gender diversity movements 1 , for which the demand for the right to health was fundamental.
In the period which began with the first AIDS epidemic, the categories of "transvestite" in 1980 and "transexual" in the 1990s emerged as political identities 2 .Until the 1950s, men were referred to as "transvestite" only in Carnaval and parties, gay clubs, and transvestite shows.In the 1970s, transvestites wandered around the prostitution areas in large cities of Brazil, such as Rio de Janeiro and São Paulo 3 .For Mário Carvalho and Sérgio Carrara 2 , the category "transvestite" as a political identity, by the end of the 1970s, was gradually reconfigured as an identity category with new social visibility 4 .
In 1992, the first transvestite association was created in Brazil, the Association of Transvestites and the Liberated (ASTRAL, in Portuguese) in Rio de Janeiro, with its initial focus on the fight against police violence towards sex professional transvestites and on the prevention of AIDS.ASTRAL was organized by the transvestites who worked as prostitutes in the Mauá Square, with the support of the "Health in Prostitution" project, from the Instituto Superior of Estudos da Religião 2 .
In 1993, the success in fighting police violence motivated the ASTRAL members to organize the First National Meeting of Transvestites and the Liberated (I Encontro Nacional de Travestis e Liberados -ENTLAIDS, in Portuguese), which followed the motto of: "Citizenship does not require the right clothes" 2 .However, Alessandro Soares Silva and Renato Barboza 5 point to other factors that inspired the organization of the meeting.According to these authors, the motivation was the insatisfaction of the ASTRAL members, who on one hand did not feel contemplated by the discussions, such as that regarding hormonal therapy, and on the other hand, had to improve the organization of the groups that represented them as well as improve the discussion concerning health policies to combat aids promoted by the coordination of the National Program of Sexually Transmitted Diseases and AIDS from the Ministry of Health, in such a way as to construct responses against the AIDS virus, specifically for Brazilian transvestites.
At the time, the event had the support of the National Commission to combat AIDS from the Ministry of Health, and the ENTLAIDS became, over time, the main deliberative forum for the movement and the main responsible forum for the movement's organization on a national level 2 .If on the one hand the period showed a greater participation of the public powers in the several initiatives to combat the epidemic, on the other hand the social movements began to take a more centralized stance on the collective actions against AIDS, involving demands and, at the same time, acting as policy executors.This movement occurred cross-sectionally through the elaboration and development of projects, as well as by proposing solutions, plans, and strategic responses, having the Brazilian State as the main financier in the process.In this configuration of health policies, transvestites and transsexuals became political actors, and the transvestite became a political category and the subject of rights.
In face of Trans activism in the national public sphere, health policies, as the agenda of the social movement, contributed to legitimize specificities and demands 2,6 .Some of the landmarks in those demands were the instruments on which official commitments are based, such as the "Transsexualizing Process in the Unified Health System (SUS)" and the "National Policy for Integral Care Provided to the Health of Lesbians, Gays, Bissexuals, Transvestites and Transseuals (LGBT)".The regulamentation of the Transsexualizing Process as a landmark in the Unified Health System (SUS) began in August 2008 by means of Legal Decisions No. 1,707 7 and 457 8 , implemented by the Ministry of Health, regulating the outpatient and surgical procedures for genital procedures for trans women.
In 2011, the National Policy for the Integral Health of the LGBT population was officialized by Decision no.2,836, from December 1, 2011, guaranteeing access to health services established in the transsexualization process.That policy's core objective was: "[...] the promotion of integral health for the LGBT community, thereby eliminating discrimination and institutional prejudice, and contributing to the decrease in inequalities and the consolidation of SUS as a universal, integral, and equitable system" 9 (p.18).Here, we call attention to the fact that the legal decision is from 2011, but it was only published and officialized effectively in 2013, in the con-text of the approval of health equity policies.The scope of the Transsexualization Process was expanded by Decision No. 2,803, from November 19th, 2014, which considered embracement and access to SUS services, including the use of social names, the access to hormonal therapy, and surgeries of gender identity adequation 10 .
The expansion of governmental healthcare structures also occurred in the context of the Trans movement.New organizations of transvestites and transsexual people were created, which articulated several achievements, together with the Ministry of Health, with emphasis on the recognition of their specificities.For Keila Simpson 11 , the public policy which had the greatest impact for trans people was the National Integral LGBT Health Policy and the Transsexualization Process by SUS, which were old demands from trans people in Brazil.
As normative measures by the Federal Government were officialized and executed, other initiatives for the promotion of health for Trans people were implemented at the state level.In the North region of Brazil, for example, the first Trans outpatient clinic was created in Belém, Pará, in 2016, nine years after the Transsexualization Process was instituted at SUS.The state of Pará was the fifth to implement the process, with the sixth Transsexualization Process Outpatient Clinic in Brazil, financed by the state government.Such an accomplishment was possible thanks to mobilization by the LGBT Movement in the state of Pará and pressure on the Ministry of Health, especially on the State Secretary for Public Health from Pará 6 .
In the state of Amazonas, which is the location of this study, specific health policies are even more incipient.When this study began in 2016, one of the demands from the XVI LGBT Pride Parade of Manaus was the creation of public LGBT policies in Amazonas.During the celebration of the Trans Visibility Day on January 29th, that same year, Trans health was discussed for the first time beyond the scope of sexually transmitted diseases (STDs) and HIV/AIDS.The current health policies for Trans people in Manaus include, besides actions for the prevention of AIDS and other STDs, orientation regarding hormonal therapy offered at the outpatient clinic, which is linked to the State University of Manaus (Universidade do Estado do Amazonas -UEA).
There are significant bureaucratic challenges and subjective material difficulties for access to health care through the path of the regulation of the Transsexualization Process in Brazil, espe-cially in the state of Amazonas.After our analysis of the national and local landmarks, the main core of this article was the observation of the process of construction of public health policies for transvestite and transsexual people in terms of primary health care (PHC) and of specialized care in Manaus, Amazonas, Brazil.
Therefore, the present study aims to describe the contexts and conditions of the advent of demands that allow us to contemplate Trans health in the state of Amazonas.To accomplish this, it was necessary to identify the repertoire of different forms of political actions used by the Trans movement in Manaus, from 2016 to 2018, considering its interaction with other social sectors.

Methodology Ethnographic process and specificities in the field
The empirical research of an ethnographic cohort that backed this study combined participant observation in the multiple spaces where those policies were created, along with interviews conducted with members of two Trans organizations from Manaus: the Association of Transvestites, Transsexuals and Transgender of the Amazon Region (ASSOTRAM) and the "The Gender" group, during the period when the field work was conducted, from January 2016 to July 2018.ASSOTRAM is run by transvestites and Trans women.Before its creation, all of them had some sort of experience in activism and in LGBT movements in Manaus.The "The Gender" group, run by Trans men, was created in 2016; however, before the creation of this group, none of the members had had any experience in activism and social movements.
Our field work gave priority to the follow-up of the organization and the promotion of events and meetings in which these movements were involved.The process of "approaching" in different places and prostitution areas was also included in our follow-up procedures.To "approach" is a field category, put in action by the activists of ASSOTRAM, which refers to practices of the distribution of condoms, guidance to prevent STDs, and the distribution of informative pamphlets that discuss the rights of Trans people.
Such actions were, to a great extent, organized in partnership with key institutions, such as the Amazonas State Secretary of Health (SUSAM), the Secretary of Citizenship and Jus-tice (SEJUSC), or the UEA.We also participated in academic seminars on the theme, promoted by public education institutions, meetings with the SUSAM, and the Amazonas State Secretary for Social Assistance (SEAS), as well as Facebook pages related to the events promoted by the two social organizations.
In the interface between university and health services, we had the opportunity of taking part in the implementation of the Codajás Polyclinic Outpatient Clinic, and we observed the first appointment and the first meeting called by SUSAM to discuss its creation with ASSOTRAM, "The Gender", and the UEA.We participated in appointments and held meetings with the UEA professors responsible for the appointments, and took part in discussions in the outpatient clinic's WhatsApp group and in several other movements of field immersion.
To understand the contexts and the conditions of the emergency of the demands that allow us to think about Trans health in Manaus, it was relevant for us to know other political and social actors -activists from other state level LGBT movements, from the medical area, and from the academic area, who promoted the actions, in other words, to understand how Trans people and those other actors participated in the construction of demands formulated by State policies.
We took on an empirical approach to the public performance of ASSOTRAM and of the "The Gender" group in relation to different public and administrative instances with different actors, with the explicit purpose of demanding and building public health policies for Trans people in Manaus.Our analysis of that performance allowed us to identify four means of strategic mobilization in search of recognition: confrontation, articulation, production of visibility, and collaboration with other agents.These are described here below, together with the definition of some of their main aspects.
Although those forms of political action have interaction scripts, formal characteristics, and differentiated emotional grammar, and they mobilize different resources, actors, and institutions, they often combine with each other, and their logics are profoundly intertwined.Therefore, they are classified according to Weberian ideal types 12 , in terms of their heuristic production.This variation (as well as each type's own variation), its strategic mobilization, and its level of efficiency (not only in terms of its specific purpose, but also in terms of building Trans people as po-litical subjects) enabled us to appreciate the creativity of the Trans activists in the development of responses to the adversities which they face and the prejudice to which they are submitted, as well as the trajectory and the specific conditions of the Trans movement and the health policies for Trans people in Manaus.
This study was approved by the Research Ethics Committee from the Instituto de Medicina Social da Universidade do Estado do Rio de Janeiro, Decision no.2,392,189, Certificate of Presentation for Ethical Appreciation (CAAE) 79369317.5.0000.5260.

Results and discussions
In this section, we describe forms of political action, seeking to understand how the State and the social movement produce a series of somewhat defined formats that determine a distinctive set of practices that explain how things are "done by the State".Those forms of action may appear as support, resources, and a commitment in the fight for visibility and public legitimacy, as well as in the fight for the rights of transvestite and transsexual people.

Confronting powers and seeking influential allies
We include here a quote from an activist from a group of professionals from the Sexual and Gender Diversity Outpatient Clinic, professors from UEA and from the Universidade Federal do Amazonas (UFAM in Portuguese), who denounced the lack of public policies for Trans Health in Manaus.Besides their accusations, they also sought to attract influential allies in two contexts: at the Public Defenders Office of the state of Amazonas (DPE/AM, in Portuguese) and at the Amazonas State Health Council (CES/ AM, in Portuguese).The acceptance of demands by these influential allies would have the purpose of "putting pressure" on the structure of the State and facilitate the implementation of the necessary policies, working from the inside.To demonstrate this point, we describe two actions.the first is the "process" at DPE/AM: We started a suit at the Public Defenders Office.We are there, trying to get an appointment with the public defender to see how the suit is going, to know if he really got the action going (Interview with the activist Joyce with a researcher, 03/28/2018).
In May 2017, during the III Regional Congress of Transvestites, Transsexuals, and Trans Men, the Amazon Association of Transvestites, Transsexuals and Transgender People was created, which became known by the acronym AS-SOTRAM.That event had the participation of the public defender "Curupira" (fictitious name, after the mythological defender of living things in the forest), who, when speaking during the round table held on human rights, indicated his "involvement in the fight for the guarantee of basic rights for the LGBT population" (field diary 05/17/2017).
Remembering this episode, in the beginning of 2018, the ASSOTRAM activists decided to contact "Dr.Curupira".In the morning of January 9th, after scheduling the meeting by phone, we joined the ASSOTRAM activists Joyce, Flor do Dia, and Rebecca, and headed off to Dr. Curupira's office to participate in the meeting.During that meeting, which lasted little more than 20 minutes, they requested "public health policies that were appropriate for the caring for transvestites, transsexuals and transgender people from the state of Amazonas" (Field diary, 01/09/2018).The meeting "enabled", according to Flor do Dia, the scheduling of another appointment with "Dr.Caiçara" (another mythological creature who defends life in the forests), at the Public Defenders Office Specialized in the Promotion and Defense of Health Related Rights (DPE/AM).
The health group in the Public Defenders Office acts primarily on the extrajudicial solutions to promote access to health and performs the mediation in order to receive the services in the state and municipal public health networks.As a rule, before commencing a judicial demand, settlement attempts are made to ensure the right of the population to health care.
Joyce, an ASSOTRAM activist, mentioned the regulation for the Transsexualization Process that is currently in effect at the Federal level according to Legal Decision no.2,803/2013 10 , from the Ministry of Health, which obliges (in the activist's words) the Public Powers to provide all of the required treatment, including the Transexualization Process.She mentioned that the Decision defines the offer of hormonal therapy, psychological follow-up, social assistants, and gender reassignment surgery.However, in reality, none of those services had been implemented by the State.
The request for "mediation" (according to Joyce's words) to Dr. Caiçara was done under the assumption that the defender could become an ally capable of exerting influence in order to put the law into effect (in this case, a regulated health policy, which according to the official discourse, was "agreed upon" at the municipal, state, and federal levels).The tone in Joyce's speech was marked by a combination of confrontational strategies with other strategies that had a propositional and collaborative tone.On the one hand, she denounced the fact that the law is not being followed, while on the other hand, she adopted the administrative logic of the State when bringing up the service of Out of the Domestic Sphere treatment (TFD, in Portuguese), officialized by Legal Decision No. 55 13 from the Secretary for Health Assistance from the Ministry of Health, to argue that the implementation of the Transsexualization Process would minimize costs for the State.The TFD is a program which seeks to guarantee, through SUS, medical treatment for patients who have diseases that are not treatable in the patient's home town for lack of technical conditions.That service consists of financial aid to cover costs for the person who seeks it as well as for an accompanying person.The seeker is then directed by medical indication to receive care at other health services in different towns or States of the Federation, when there are no resources available in the location of residence, as long as there is a possibility of total or partial cure, limited to the period of time strictly necessary for the treatment and within the existing budgetary conditions 13 .
When proposing that the SUSAM, in that hypothesis, would not have to pay the TFD for the Transsexualization Process in other states, Joyce is proposing to the Defender, in some manner, that he could "think together with us" about SUSAM's ability to interfere, thus expanding the structure of human and physical resources for transvestites and transsexual people in the State.
Nonetheless, the denouncing tone prevails when the activists referred to several health risks and life-threatening conditions for Trans people if the health policy is not implemented.Flor do Dia mentioned the serious risks due to the lack of availability of a Transsexualization Process: It is common, since childhood, to use hormones.If there is no continuity, the Trans person may have side effects for one's entire life, with irreversible problems.We have acquaintances who got to the point of self-mutilating.The lack of this policy generates serious health risks to all of us.I myself had to prostitute and travel to Europe to do my procedure, but not all of us are so lucky.People start at a very young age, and this brings us psychological problems, because there is no specific medical care for us.We need this as soon as possible, the Trans people are in depression, committing suicide, mutilating themselves, we urgently need SUSAM to structure this service (Words by Flor do Dia, during the meeting with the public defender in 01/11/2018).
The narrative by Flor do Dia uses the grammar of convincing, as described in other studies [14][15][16] .Such studies reveal the relation of physical and especially mental grievances with the needmarked by a pathological psychiatric discourseto fit into what is defined as a "true transsexual" 17 , in this case, being cared for in the sense of undergoing surgery.Next, we quote the second action in this confrontation: The "denouncement" in the meeting at CES/AM.
Informed by social media (WhatsApp groups and by email), the group from the outpatient clinic mobilized, together with ASSOTRAM and representatives from the "The Gender" group, to "denounce" the absence of the process of the licensing of the outpatient clinic to the State Council and to present the argument used by SUSAM, justifying that one of the hurdles for this licensing was the extinction of the CES/AM.
We arrived on the day and time of the meeting, together with the activists Joyce, Thiago, Flor do Dia, Dária, and Denison at the auditorium of the Vasco Vasquez Convention Center of Amazonas.
After the arrival of enough council members to reach the required quórum (minimal number of council members in order for "the approved decisions to become legitimate") the president of the Council, Francisco Deodato Guimarães, the Secretary of Health at the time, opened the session mentioning the seven themes to be discussed in the meeting: approving the agenda of the meeting, presentation and approval of the reports, communication, information from the council members, presentation, discussion and decisions by the plenary, presentation of a request for examination by one of the council members, among other matters.This last item provided the opportunity for ASSOTRAM and "The Gender" to include the denouncement against SUSAM.The word "denouncement" was used by the activists and the outpatient clinic group during the preparation of the arguments which would be mentioned in the meeting and the production of the "dossier", which is described as follows.
On that morning, the council members were simply greeting each other and having low voice conversations while they waited for the others.
We noticed that the configuration of the council members' chairs followed the partnerships among them.However, after each presentation of the several sub-items which composed the seven main themes in the meeting, we noticed that dealing with administrative matters and putting together and consolidating relationship networks had given place to an atmosphere of shouting, arguments, and accusations that would continue until the end of the meeting.The rupture among the council members was evident.
Besides our group, which was present at that meeting as a movement, other representatives from the Manaus society were present: the legal advisor from the Regional Medical Council (CRM, in Portuguese); the nurse from the Hepatitis department of the Tropical Hospital; a director and a physician from the Amazonas Hematology and Hemotherapy Hospital Foundation (Fundação Hospitalar de Hematologia e Hemoterapia do Amazonas); and technicians from the Amazonas Care and Medication Center.All of them sought to resolve specific demands with CES/AM.
It was past lunchtime, and the council members meeting at the Vasque Vasquez Convention Center were on the edge.A generalized argument could be heard involving two of the council members.They accused each other of being, at that moment, defending their own political segment instead of "representing society".Sometime around one in the afternoon, the president of the council managed to bring the situation under control, and the arguments and the shouting ceased.At that time, Joyce, representing ASSOTRAM, and Thiago, representing the "The Gender" group, managed to gain space in the "other matters" part of the agenda of the State Health Council (CES/AM) meeting.In an awkward speech due to the widespread arguing among the council members, Joyce spoke: "The state of Amazonas" did little or nothing in order to have "this policy regulated, so we as an association have been to SUSAM' several times, you understand?We put ourselves in the defense of this project, and SUSAM has done nothing; in fact, the creation of this outpatient clinic was not proposed."In the last meeting, SUSAM claimed that the Council was not having meetings".The policy is quite clear; it is the responsibility of the state, but also of this Council, to inspect."Where do we stand?How does the state of Amazonas stand?"Myself, being a Trans woman, have no right to basic health, because basic health is not guaranteed, even though the policy guarantees that, basic attention and interdisciplinary care be provided as well.Since 2011, we have information about a budget which was provided for the state, but the LGBT policies were not implemented."There is nothing to show for it, nothing that the State took responsibility for.All there is, is occasional care and volunteers, and we have to settle for that.Meanwhile", the population needs several specific healthcare services, which we never see, not for gays, nor for lesbians or bisexuals, and especially nothing for transsexuals.Thank you! (Joyce's speech at the 310th meeting of CES/AM -05/20/2018.Highlights by the author).
The reiterated statement regarding the right of access to a policy of integral health for the LGBT population, with a consistent emphasis on the transsexualization process, indicates, in the speeches, a very evident area of conflict in terms of rights for the Trans people to access and use public health services.

About visibility: event from the "T" agenda
We are here on our visibility day seeking inclusion, value, and dignity as humans, right?For that, we from ASSOTRAM joined with the Trans Network and The Gender, to provoke a discussion which is not only amongst ourselves, but also with representatives of the government and society, to debate themes such as education, safety, labor market, among others.We are here, we exist, resist, and want a dignified life.We will fight for public policies!Today, our fight is to make them [government representatives] come to us! (Quote from Joyce's opening speech at the workshop, 01/29/2018).
On January 29th, 2018, the day in which Trans Visibility is celebrated nationwide, ASSOTRAM, in a partnership with the Trans Network of Brazil organized a workshop to discuss "the T Agenda".It was the first event organized by ASSOTRAM since its foundation.Above the entrance to the place where the event was being held, there was an orange banner, approximately two meters in length, with the phrase "TRANS VISIBILITY IN AMAZONAS -RESISTANCE FOR DIGNI-TY AND HUMAN RIGHTS", written in white letters.The phrase was centralized between two drawings of human figures without traces like eyes, nose, and mouth; the one on the right wearing pink pants and a blue shirt with sleeves down to the biceps, and the one on the left, wearing a pink skirt and a blue shirt with sleeves down to the forearm.In the drawing, the figures looked like they were jumping.When paying attention to such details, we were able to notice other similar figures mixed amongst the lateral figures and the letters.
Although mostly contemporary to other homosexual identities, the Trans categories achieved distinctive political identity in Brazil in the end of the 20th century and reached undeniable visibility in the 21st century, becoming part of the scenario of the most important social struggles 2 .This visibility is constructed in instances including the LGBT Pride Parades and the ENTLAIDS.Their political activism is structured around agendas, such as the fight against violence, respect for the social name, and access to health care.
Still with the words from the catch phrase fresh in our minds, we entered the theater and were received at the door of the Les Artistes Cafe and Theater by Fifi, the receptionist of the event.Fifi was wearing a long dress, tight fit, which revealed her curves, and with a cleavage highlighting her breasts.She wore a blue, pink, and white scarf around her neck, the colors which symbolize Trans pride.She told us: "we exist, resist and will be noticed", translating into words the meaning given by the organizers of the celebration.Fifi's statement evoked the constant search and negotiation for spaces of visibility by the Trans activists from Manaus, and respectability by the State and society, regardless of which side of the boundary they were on, sometimes the prostitution side, sometimes the downtown trading side.
Moreover, the Trans workshop, as a political action, sought to problematize their main demands in the sectors of health, justice, social assistance, public safety, education, and religion, so that they can accomplish and guarantee what they demanded in the banner at the entrance of the Les Artistes Cafe Theater: "Dignity and human rights".

Trans activists and the State: reciprocity as the organizing principle of the forms of collaboration
Of all the different forms of political action identified in the process of construction of public health policies for the Trans -practices which, in the Brazilian political jargon, especially at the level of government and social movements, are called "articulation", which are defined by collaboration mainly between activists and government managers -seem to be the practices which currently prevail in the relationship between the Trans organizations and the municipal secretar-ies of health: there is a reciprocity between the Trans movement and the State.During the period of our field work, ASSOTRAM and "The Gender" group routinely participated in meetings with representatives of those secretaries, discussing the licensing of the outpatient clinic and the execution of "prevention practices" to control STD/HIV/AIDS.
The exchanges established in those spaces and by those activities generated understanding, but also disputes and tension, at various levels.For instance, although academics participated in some of the meetings, the secretaries of health preferred to listen to the Movement rather than the health professionals who had already worked at the outpatient clinic.That caused the relationship between university professors who led the outpatient clinic project and the government departments to become fragile in face of the disputes and tension about who should coordinate the outpatient clinic after its licensing.
The main result of the effort to articulate SUSAM and the Municipal Secretary of Health (SEMSA), together with ASSOTRAM and "The Gender", is the definition of the movements, materialized in the demands for hormonal therapy; for sexual reassignment surgeries; for avoiding damage resulting in the use of industrial silicone and the use instead of silicone prosthetics; and for the respect of the social name, considered essential for access to and use of the primary health units.Even though those meetings have no immediate efficiency in terms of making the issue a priority for the government, the meetings have become a strategy for the adoption of the Transsexualization Process and for the creation of a health policy for the LGBT in Amazonas, as the activist Thiago explained: Even though it does not seem to be the priority, the meeting with the state and municipal secretaries is a chance to make things happen, to implement the state policy agendas for LGBT integral health and to implement the transsexualization process (Interview with the researcher on 11/13/2017).
Besides the form of reception mentioned in relation to the transsexualization process and to the LGBT integral health policy, which corresponds to SUSAM and SEMSA, another form of interlocution found by ASSOTRAM and by "The Gender" is the "pact making" to enable them to act in the prevention of HIV/AIDS and STD.It is a reciprocate way of acting between the secretaries and the social movements, especially those connected to the Forum of the Organiza-tion of Civilian Society (OSC) STD/AIDS, which included the distribution of inputs (condoms, leaflets, lubricating gel, among others), and the financing of travel, hotel fees, and even coffee breaks at the events."Pact Making" generates reciprocal obligations.
Therefore, SUSAM and SEMSA act as "donors" of prevention inputs and as supporters of the events.Meanwhile, the movements reciprocate by promoting their activities as a "partnership" with the secretaries, contributing in a reciprocal manner with the legitimation of both actors for their public.
ASSOTRAM and "The Gender" provide "approaches" aimed at prevention in the prostitution districts and in large events in Manaus.According to the activists, the actions began in February 2018, during Carnaval.Five activists were present in the "Carnaval bands" and in the Sambódromo, handing out condoms and lubricating gel, with the support of the secretaries of health.After Carnaval, until the conclusion of the field work for this study, the "approaches" were limited to the "places of prostitution".Although the main argument for the approaches had been the prevention of AIDS and STDs, in the organization meetings for those activities, ASSOTRAM was heard and participated in the process of construction when the agenda of the Transsexualization Process was promoted.The prestige acquired through participation in those activities was evident, since the "The Gender" group began to participate in meetings and workshops for the prevention of STD and HIV.
Marcel Mauss 18 , in his classic Essay on the Gift, describes relationships and situations of reciprocity.When exploring those exchanges, the author unveils fundamental principles in the organization and in the economic and social logic of reciprocity between members of a society.In order to give, one must produce, and such production is subordinated to the donation, generating an economy which follows different guidelines than those concerning the utilitarian value of the objects; there is a symbolic value in terms of the social position of the donor and of the receiver, and in relation to the obligations generated between them.The gifts are reciprocated and mandatorily retributed.In the exchanges with the health secretaries, the Trans organizations, when placing themselves as receivers, are themselves candidates to act by retribution.As the two sides become and remain partners, each one acquires and expands knowledge which constitutes prestige and political authority.

Final considerations
Four forms of activism were considered in the political scenario in the process of the politicization of Trans health in the state of Amazonas, which were classified in this study by means of categories and native notions as: confrontation, articulation, visibility, and collaboration.These are differentiated interaction resources, present as hues in the performance of several social movements with the State.Different political contexts enable the use of different resources (knowledge, emotions, moral appeal, etc.) with the purpose of achieving the recognition that is sought, in terms of disposition (solidarity, antagonism, etc.) between the parts and the effects of the interaction expected by the different agents involved in terms of the public impact of their actions.
"Confrontation" actions were among the first executed by the Trans people in Brazil as the protagonists of political action, especially when fighting against police violence.With the political organization of the Trans identities, confrontation as a modality of political action takes place together with the broader process of the judicialization of social demands.
The second form of action corresponds to what is called, at several instances of formal politics, "articulation".It is defined by alliances with other actors considered to be influential, among those, the University which is relevant because of its role, its institutional prestige, expertise, experience, political capital, as well as the specific character of a professor or a group of professors.An articulation with the UEA was what enabled the creation of the first outpatient clinic with specific health care for Trans people in Manaus.
The third form of action, visibility strategies, has to do with how politics and entertainment are related.We observed that such a relation seeks to promote the idea of respecting differences and valuing "LGBT culture" and Amazonas culture.In addition to the movement being set up at the workshop to discuss their specific demands with different sectors of society, there were also musical performances by Amazonian artists; an exhibition of documentaries by Trans people who live in Amazonas; and the presentation of a typical Amazon dance called "Ciranda", all coordinated by an activist from ASSOTRAM.
Acting together with the health secretaries constitutes the fourth form of activism, defined as "collaboration".The establishment of collaborative interactions of the movement with SUSAM and SEMSA varies according to the demand and the sector of public policy defended by the movement and the State's permeability to such policies.We conclude that the two movements defend the revindication that the lack of the Transsexualization Process is not negotiable.In the meetings, it was clearly defined that the lack of such policy constitutes a threat for the health of the Trans population.It is also extremely expensive for the State not to have the transsexualization process, since when the state is legally sued, one can gain access to the lawsuit by means of the TFD.
The current study sought to improve the discussions regarding the history of the protagonism of transvestites and transsexual people, through political participation and organization as a social movement, as well as through their involvement in the implementation of health policies, in changing their own realities, and in expanding the recognition of their rights.We, therefore, expect to contribute to broadening the dialogue, the reflections and studies regarding public gender policies and sexuality in Brazil, especially in terms of the access, demand, and use of public health services, as well as in terms of the political organization of transvestites and Trans people in regional contexts.

ALM
Neves worked on the design, research, writing and final review of the article.HF Sívori worked on research orientation, writing and final review of the article.