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Public policy

Fluid identities

A new study estimates the number of transgender and nonbinary people in Brazil at 3 million

Juliana Freire

A recent survey by the Botucatu School of Medicine at São Paulo State University (FMB-UNESP) is the first academic study to assess the proportion of people who identify as transgender or nonbinary in Brazil. Their research, published in Nature Scientific Reports in 2021, found that 3 million individuals are included in these groups, corresponding to about 2% of the adult population. Another analysis completed last year focused on the city of São Paulo. Conducted as a partnership between the Center for Contemporary Culture Studies (CEDEC) and the São Paulo Municipal Human Rights Department, researchers investigated the living conditions of transgender individuals, finding that in the city of São Paulo the average lifespan for trans people is only 35 years. Based on the ongoing dialogue between researchers in the fields of medical and human sciences, the study seeks to fill certain research gaps regarding sexual and gender diversity (see glossary) and provide support in developing public policy, especially in the area of public health.

“One significant finding of our work is that these individuals are distributed homogeneously throughout the country, which reinforces the urgency of developing public policy for the entire country,” stresses psychiatrist Giancarlo Spizzirri, of the Hospital das Clínicas at the University of São Paulo (HC-USP) and lead author of the article published in Nature. The data gathered resulted from interviews with about 6,000 people in 129 municipalities throughout Brazil. Through interviews conducted over two years with more than 1,700 trans women, cross-dressers, trans men, and nonbinary individuals, the CEDEC survey revealed that, on average, 58% of these individuals are unregistered or self-employed, short-term workers without formal employment. Considering the cross-dressing group by itself, the percentage rises to 72%.

In the CEDEC survey, cross-dressers and trans women (70%) made up the majority of interviewees, who as a whole were mostly single (70%), black (57%), and had high school educations (51%). “The study also identified that, as a result of the prejudice many trans subjects commonly suffer, they tend to drop out of school before completing basic education. This affects their entire life trajectories,” says sociologist Carla Diéguez, from the Sociology and Politics Foundation School of São Paulo (FESPSP) and one of the study coordinators. She points out that the survey shows that 88% of respondents undergo hormone therapy treatments through the Unified Health System (SUS). The issue of sexual and gender diversity has never been addressed by censuses conducted in Brazil. In 2016 Uruguay was a pioneer in South America in conducting the first national count of this group, identifying 853 trans individuals in the country, within a population of 3.4 million inhabitants.


Biological category that differentiates men and women based on chromosomes, hormones, reproductive organs, and genitals

Personal and social classification of individuals as men or women, regardless of biological sex

Gender identity
Gender that a person self-identifies with independently of their biological characteristics

People who identify with the gender assigned to them at birth

Epidemiologist Maria Amélia Veras, from the School of Medical Sciences of Santa Casa de São Paulo (FCM-SCSP) considers demographic studies on the trans population to be one of the main research gaps in her field. She recalls that during the 1990s, her first studies involving sexual and gender diversity pertained to the AIDS epidemic among homosexuals. “Initially, in the area of public health the focus of studies on this cohort were analyses of how sexual behaviors affected health,” she says. Over time, the investigations began to encompass identity issues and demonstrate that the vulnerabilities of the LGBTQIA+ population (lesbian, gay, bisexual, transsexual, queer, intersex, asexual and other sexual and gender identities) were related more to economic and societal factors, such as social stigma and discrimination, than individual attitudes. Anthropologist Regina Facchini, a researcher at the Pagu Gender Studies Center at the University of Campinas (PAGU-UNICAMP), says that in the beginning, in addition to the AIDS epidemic, other themes that mobilized researchers to the trans issue were prostitution and body changes. “In the last 20 years, researchers have begun to change their approach and today include several other subjects and theoretical perspectives. There has also been an emerging movement of research carried out by openly trans people who entered higher education once there were policies for affirmative action and respecting their chosen names,” the researcher observes. In a survey carried out in 2021, the Affirmative Action Multidisciplinary Studies Group at the Institute of Social and Political Studies of the State University of Rio de Janeiro (GEEMA-IESP-UERJ) identified 2,900 openly trans students attending Brazil’s federal universities. The number represents less than 0.5% of the total number of enrolled students.

Over the last five years, institutions of higher education have also recorded the doctorates of the first openly transgender and cross-dressing individuals in their history. Individuals from this group have also begun to teach at universities, as is the case with Professor Letícia Carolina Nascimento, the first openly trans person awarded a teaching position at the Federal University of Piauí (UFPI), in 2019. “I know of only 15 actual trans teachers working in public universities in Brazil,” she says. Nascimento is author of the book Transfeminismo (Editora Jandaíra, 2021), which addresses the concepts of gender, transgenderism, and feminism, in language aimed at a general audience.

Physicist Gabrielle Weber has been teaching at USP’s Lorena campus since 2014. “I entered the USP Institute of Physics in São Paulo in 2002 as an undergraduate student and didn’t leave until 2013, after completing my postdoc studies. During all those years, I heard jokes about the transvestites who work in prostitution around the university. I looked at those women and worried about my future,” she recalls, explaining her decision not to come out as transgender until 2019. Currently, in addition to trying to connect concepts of gender studies with the teaching of mathematics, Weber is coordinating the first survey on the existence and scientific production of LGBTQIA+ researchers in Brazil.

Reflecting a similar story, Lucy Gomes de Souza, coordinator of the Systematic Biology Center (NUBIS) at the Museum of the Amazon (MUSA), has known she is transgender since 2014, but only made the transition to the female gender in 2019, at age 27, while finishing her doctorate at the National Museum of the Federal University of Rio de Janeiro (UFRJ). “I was afraid of being subjected to prejudice, not being able to get my degree, and being unemployed. I decided to begin the process when my career was more established.” Souza and Weber say they received institutional support regarding their decisions, including support for changing their names within the academic systems and assistance in communicating their gender transitions to students and coworkers.

Alexandre Affonso

Methodological obstacles
“The trans issue has challenged scientific methods,” says Veras, from Santa Casa. She believes this is because the field of epidemiology characteristically uses precise analytical methods, which are often incapable of capturing the complexities involved in gender identities. “Epidemiological research, for example, uses quantitative methods, which establish well-defined categories suitable for statistical analyses. How can one represent limits and demarcations in a population whose gender identity is characterized by its fluidity?” she asks. One way to circumvent such difficulties is through closer dialogue with researchers in the human sciences, especially anthropology. Such dialogue has made it possible to integrate different theoretical and methodological perspectives, allowing data common to the analyzed populations to be captured simultaneously, along with specifics regarding minority groups. “The exchange between qualitative and quantitative methods makes it possible to incorporate different variables into epidemiological analyses and has produced instruments for data collection that allow an intersectional approach to the trans issue,” the epidemiologist states.

Sociologist Gustavo Gomes da Costa, from the Federal University of Pernambuco (UFPE), faced a similar methodological challenge when researching LGBTQIA+ individuals within political parties (see Pesquisa FAPESP issue nº 264). “In this study, I had to create categories to be able to map who identified as nonbinary or asexual. We need to develop methodologies to deal with these complexities.” Costa notes that during the last three years it has been difficult to obtain funding for research on these topics, and points to the fundamental role FAPESP has played by supporting projects in areas such as public health and anthropology.

In contending that there are more than just two biological sexes, psychiatrist Saulo Vito Ciasca, coordinator of the health sector of the organization Aliança Nacional LGBTI+, also recognizes the existence of multiple categories involved in sexual and gender diversities. Based on this premise, the book Saúde LGBTQIA+ – Práticas de cuidado transdisciplinar (LGBTQIA+ Health: Transdisciplinary care practices) (Manole, 2021) presents research results to support the work of health professionals working with this cohort. As one of the book’s editors, Ciasca says that someone typically characterized as belonging to the male sex has a penis, testicles, XY chromosomes, and a predominance of testosterone in the body. “However, there are situations in which the genital sex does not correspond to the chromosomal or hormonal sex, so that an individual may have a vulva, but his chromosomes are XY or he has a beard and a deep voice,” he explains. Ciasca also cites the existence of people with atypical genitalia, for example, those who have both a penis and vulva. “According to our cultural perspective, people need to have a penis to be a man or a vulva to be a woman. Any other possibility is seen as a biological malformation or a genetic error that needs to be corrected, which I consider unethical,” observes Ciasca, noting that there are cultures that recognize other genders. In the Isthmus of Tehuantepec region in the Mexican state of Oaxaca, there are three genders: female, male, and those known as muxes. These are nonbinary persons of female gender expression, that is, people who socially manifest feminine characteristics, but do not identify as male or female.

Transgender or transsexual
Designates those who identify with a different gender than the one they were assigned at birth

Nonbinary individual
A person who does not self-identify as belonging exclusively to the female or male gender

A person who assumes characteristics of their biologically opposite gender and does not self-identify as either male or female, but as belonging to a third gender

Acronym for lesbian, gay, bisexual, transsexual, queer, intersex, asexual and other types of sex and gender diversity

SOURCE Jesus, J. G. Orientações sobre identidade de gênero: conceitos e termos. Brasília, 2012

Considering the specific health issues of the trans population, endocrinologist Karen Seidel, director of the Department of Female Endocrinology, Andrology, and Transgenderism at the Brazilian Society of Endocrinology and Metabolic Research (SBEM), points out other challenges involving laboratory analyses. “As one example, laboratories often use female reference values to analyze test results from trans men, which can be harmful to their hormone treatment. In situations where the individual is taking testosterone replacement therapy, male reference values must be taken into consideration,” she warns. Seidel is also coordinator of the Multidisciplinary Gender Identity Outpatient Clinic at the Luiz Capriglione State Institute of Diabetes and Endocrinology (IEDE) of the State Health Department (SES) of Rio de Janeiro. She notes that in order to alleviate such analytical problems, in 2019 SBEM prepared a guidelines document for both public and private diagnostic medical labs to use in caring for the trans public.

Endocrinologist Magnus R. Dias da Silva, coordinator of the Roberto Farina Center for Studies, Research, Outreach, and Assistance to Trans Persons at the Federal University of São Paulo (TRANSUNIFESP Center), has a similar perspective, recognizing, for example, that “there are women with a vagina and without a vagina, and women with and without a prostate.” Roberto Farina, from whom the center takes its name, was a professor of plastic surgery at the UNIFESP São Paulo School of Medicine, who performed the first sex reassignment surgery in Brazil, during the 1970s. Today, Dias da Silva researches the effect of hormone therapy in animal models, evaluating the safety of types and doses of hormones most commonly used by the transgender population. Three years ago, another UNIFESP doctor, gynecologist Marair Gracio Ferreira Sartori and her team became pioneers in performing the removal of the uterus and freezing the gametes removed from a trans man. “This individual had already undergone surgical extraction of the breasts, but was bothered by the menstrual bleeding,” Sartori says, noting that removing the uterus has consequences on reproductive capacity. With this issue in mind, researchers from TRANSUNIFESP Center, coordinated by Dias da Silva and others from the UNIFESP departments of human reproduction, gynecology, and urology, coordinated by Renato Fraietta, came together in search of a solution to the problem. “From this dialogue, we developed a technique by which it was possible to remove the patient’s uterus, while preserving the ovarian tissue. We were surprised to find that there were viable cells in the ovaries, even after years of testosterone treatment,” Sartori says, explaining that the eggs were frozen for future fertilization. Currently, Dias da Silva, Fraietta, and Sartori are researching techniques to preserve trans patients’ fertility when undergoing hormone therapy or opting for sex reassignment surgery.

Endocrinologist Berenice Bilharinho Mendonça from the USP School of Medicine (FM-USP) reports that the estimated proportion of trans women in Brazil is 1 per 100,000 individuals, and for trans men, 1 per 30,000. Mendonça explains that transgender subjects develop from multifactorial influences, which includes their genetic, hormonal, and environmental circumstances. “A person becomes aware of their gender identity very early, at the age of five or six. I’ve heard reports from patients who remember getting their dresses dirty at two or three years old, because they didn’t consider themselves to be girls,” she says. She clarifies that the clinical recognition of transgenderism is done through a psychological assessment carried out by professionals trained in the field, a process that takes at least six months. As for cases of atypical genitalia, the vast majority derive from a genetic mutation involving the formation of the gonads and genitals (see Pesquisa FAPESP issue nº 170). In an ongoing project funded by FAPESP, Mendonça is studying the genetic and epigenetic alterations related to this phenomenon. “One of the project’s objectives is to disseminate knowledge about these clinical conditions, simplifying their diagnoses and reducing biases,” she observes, mentioning her book, still in press, which will publicize the issues analyzed in the project.

Alexandre Affonso

Alexandre Saadeh is the coordinator of the Transdisciplinary Outpatient Clinic for Gender Identity and Sexual Orientation of the Psychiatry Institute of the Hospital das Clínicas at the USP School of Medicine. He notes that for cases in which transgenderism is detected in childhood, Resolution No. 254/2019 of the Federal Council of Medicine determines that a hormone-based treatment is permitted only through the establishment of research protocols. “This means that scientific evidence is needed to validate the relevance of any interventions, insofar as some of them are irreversible,” he adds. The outpatient clinic under his coordination currently serves 80 children and 180 adolescents. “We receive children from three to five years old, the stage at which gender identity begins to be defined by a profound association with a certain gender, although some cases are fluid and are defined during the consultations. A minority, on the other hand, don’t define themselves, so we discuss with the families what protocol is to be adopted,” he explains, bearing in mind that suicide attempts are ten times more prevalent among transgender people. “Because of the pandemic, which forced us to suspend services for a few months, we have a pent-up demand. At this moment, there are more than 180 families waiting for an appointment.”

Carmita Abdo, founder and coordinator of the Studies in Sexuality Program at HC-USP and president of the Brazilian Association of Psychiatry, emphasizes that concepts of sex and gender are rapidly changing. “Until 20 years ago, individuals were thought of as being male or female. Today we know that there are people with multiple conditions, which has changed the medical understanding of gender and identity issues,” she explains. This new understanding impacts on the composition of medical school curricula. For over 10 years, Abdo has been coordinating an elective course on sexual and gender diversity at USP. Currently, UNIFESP offers a similar course, whose syllabus is being updated so that the subject can be handled in a more comprehensive manner across the various disciplines. Two years ago, Santa Casa de São Paulo also created an outpatient clinic for transgender people. Medical students from the institution can work at the clinic from their fifth year onwards. “Although it’s not yet mandatory content, we are taking the first steps to change how our doctors are trained,” Veras concludes.

Resistance strategies
Analyses of individual trajectories and places of socialization reveal aspects of the history of gender diversity

Official documents and periodicals from different eras have allowed the history of the LGBTQIA+ population in various places in Latin America to be uncovered, highlighting the group’s relationship with spheres of power and the strategies individuals created to survive, even under adverse conditions. In a postdoctoral study developed at Rio de Janeiro State University (UERJ), educator Amaral Arévalo reconstructed the history of this group in El Salvador from the colonial period forward, by examining police files, newspaper articles, and documents stored in the country’s National Library. “In the historical archives, the most distant point in time that I found any reference to dissident sexual practices was the year 1765,” he says.

Arévalo says reading the material produced in the early years of the twentieth century confirmed the efforts of those in power to combat and censor homosexual practices. “The documents show, for example, that at that time there was a preoccupation with preventing public restrooms from functioning as meeting and relationship sites among the male population,” he observes.

Later, starting in the late 1940s, the documents began to indicate the discriminatory views of society. At the same time, they record movements of resistance and insubordination against local authorities. “In El Salvador’s public archives, official documents involving cases against LGBTQIA+ people are stored in unmarked boxes, which makes research difficult. What’s more, access to official files on the internal conflict, from 1980 to 1992, continues to be prohibited,” he adds. Arévalo says there are rumors about massacres of trans sex workers that were carried out by the Salvadoran army during this period, but access to documentation would be necessary for confirmation.

Meticulous work
Independent researcher Luiz Morando, a PhD in comparative literature from the Federal University of Minas Gerais (UFMG) is committed to reconstructing LGBTQIA+ history in Belo Horizonte. He has for 20 years been reviving the stories of individuals who lived in Minas Gerais’ capital city from 1917 on, searching for records and information in police files, court cases, periodicals, and oral reports. His research has resulted in the publication of two books, one of which is a biography of cross-dresser Cintura Fina (1933–1995), considered a central character in the LGBTQIA+ history of Brazil.

During his investigation, Morando came across news published in a 1952 edition of Diário de Minas, about the appearance of a man and two women at a police station in Belo Horizonte. According to the news story, the man asked the deputy to speak with one of the women, who was his wife, but who had left him to live with the other woman. “His wife’s then companion, named Feliciana Campos de Oliveira, was a person in transition to the masculine gender and shortly thereafter became Edmundo de Oliveira,” Morando says. The researcher found another series of news articles related to the trans world in a newspaper from 1981. It regarded a night watchman who, after dying of a heart attack, was discovered to be a “woman who dressed like a man.” “This person was, in fact, Edmundo de Oliveira, who made the transition process at a time when hormonal treatments were not available. The finding was uncovered at the Forensic Medicine Institute,” he reports. For Morando, the incident shows that throughout history trans people have invented strategies to move around the city, work, and get married in accordance with their gender identity.

This report was made with the support of a journalistic production grant to Christina Queiroz by Fundación Gabo and Instituto Serrapilheira, with support from the UNESCO Regional Science Office for Latin America and the Caribbean.

1. Molecular diagnosis of sexual differentiation disorders (nº 97/01196-1); Grant Mechanism Thematic Project; Principal Investigator Berenice Bilharinho Mendonça (USP); Investment R$608,743.81.
2. Is there a university in Pajubá?: Disputes and tensions in the production of trans people as subjects of knowledge (nº 19/06630-2); Grant Mechanism Master’s (Msc) Fellowship; Supervisor Regina Facchini (UNICAMP); Grant Beneficiary Brume December Iazzetti; Investment R$20,006.78.

Scientific articles
LICHTENECKER, D. C. K. et al. Cross-sex testosterone therapy modifies the renal morphology and function in female rats and might underlie increased systolic pressure. Clinical and Experimental Pharmacology and Physiology. Vol. 48, no. 7, pp. 978–86. 2021.
SPIZZIRRI, G. et al. Proportion of people identified as transgender and nonbinary gender in Brazil. Nature – Scientific Reports. 11, 2240. Jan. 2021.

CIASCA, S. V. et al. (orgs). Saúde LGBTQIA+ – Práticas de cuidado transdisciplinar. Sao Paulo: Manole, 2021.
NASCIMENTO, L. C. Transfeminismo. São Paulo: Editora Jandaíra, 2021.
AREVALO, A. Dialogando con el silencio: Disidencias sexuales y de género en la historia salvadoreña 1765–2020. San Salvador: Editorial Universitaria. In press.
MORANDO, L. Enverga mas não quebra – Cintura Fina em Belo Horizonte. Uberlândia: O sexo da palavra, 2021.

Mapping of trans people in the city of São Paulo. Center for the Study of Contemporary Culture (CEDEC). Jan. 2021.