Health of Trans People in Paraguay

Abstract

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

1. Introduction

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

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

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

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

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

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

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

2. Methodology

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

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

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

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

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

3. Key concepts

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

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

• Sex is defined according to the biological determinants of the individual; In most cases, newborns are assigned as male or female according to their anatomical sex, which, for the social context, should seek to be consistent with a “masculine” (as a child) or “feminine” gender identity and expression (of girl). In the event that the newborn does not have a defined anatomical sex, the term intersex is used (previously called hermaphrodites) [10].

• Gender refers to the internal personal experience of feeling masculine, feminine, or androgynous, depending on the cultural context (gender identity). The World Health Organization (WHO) defines it as “characteristics of men and women that are based on social factors, while sex refers to characteristics that are biologically determined.” If the person identifies with the sex assigned at birth, they are considered a “cisgender” person, if they do not, they are considered “transgender” [9].

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

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

In short, we will have individuals with:

• Chromosomal sex XX, XY and its variants.

• Male, female, or intersex genital sex.

• heterosexual, bisexual, asexual, demisexual, or pansexual sexual orientation.

• Sexual appearance determined by the phenotypic aspect and by the expression of masculine, feminine, or androgynous gender identity or expression, depending on the cultural context of the individual [10].

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

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

Finished	Definition
Gender	Cultural construction that assigns, in the public and private sphere, forms of behavior and roles to women and men based on their sexual differentiation (WHO definition)
Gender identity	Internal feeling of the individual (not visible to others), of being male or female
Gender variants	Individual with gender expression that differs from social expectations related to the assigned gender
Transgender	Gender identity, expression and behavior differs from the gender assigned at birth
Cisgender	Gender identity, expression and behavior concordant with the gender assigned at birth
Non-binary gender	Disagreement with any of the two classic forms of gender (male-female)
Transgender man	Person with female sexual characteristics, identified as female at birth, who now feels like a man
Transgender woman	Person with masculine sexual characteristics, identified as male at birth, who now feels like a woman
Gender Dysphoria/Gender Identity Disorder	Term used in DSM-V and ICD-10, respectively, to describe conditions by which gender nonconformity causes clinically significant distress or discomfort.
Transition	Time through which the person begins to live with a gender with which they identify, rather than with the gender assigned at birth
Real life experience	Full adoption of the gender role to which the person fits. This phase is necessary before the hormonalization processes and subsequent surgical body readjustment.
Drag queen	A man who dresses as a woman, usually for the purpose of entertainment or performance
Drag- king	A woman who dresses as a man, usually for the purpose of entertainment or performance
Shemale	Commonly used as a synonym for transgender. However, in some publications it is used to differentiate transgender people who have already undergone sexual readjustment processes.
Transvestism	Temporary foray into the clothing or accessories of the opposite sex for the purpose of sexual arousal and pleasure. It is considered a paraphilia

Table 1.

Definitions.

4. Social determinants for trans health

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

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

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

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

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

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

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

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

5. Transphobia

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

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

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

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

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

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

The controversy that is formed around this definition is wide, as well as the existing one about the psychiatric classification systems. This is due to the fact that, as we have commented and some authors explain, the deviation from the mean is considered abnormal, but frequently what is abnormal does not imply what is pathological. A clear example is homosexuality, excluded from the DSM in 1973 [19, 20, 21].

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

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

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

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

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

6. Situation of the trans population in Paraguay

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

The amount of information referring to this situation in the country is scarce.

Regarding the development of guarantees and rights in the matter, our legal framework is manifested in the following ways:

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

• ARTICLE 24 - RELIGIOUS AND IDEOLOGICAL FREEDOM

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

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

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

• ARTICLE 25 - EXPRESSION OF PERSONALITY

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

Ideological pluralism is guaranteed.

• ARTICLE 46 - EQUALITY OF PEOPLE

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

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

• ARTICLE 68 - RIGHT TO HEALTH

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

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

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

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

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

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

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

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

6.1 Paraguayan health regulations for the trans population

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

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

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

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

7. Discussion

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

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

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

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

There is also a great lack of education in all the staff, about their realities and rights; as well as the appropriate care protocols since there are women with a penis and men with a vulva, who require different treatments and accompaniments to achieve the full enjoyment of their identities, these points must be discussed by decision-makers in order to help the inclusion of all groups within the health service. Although, in Paraguay, the use of the social name can be found, discrimination and stigmatization continue to be an important problem [10, 11, 12, 13].

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

An important point to note is also that 39% of the transgender population suffers from serious psychological distress (compared with 5% of the general population) that they have a nine times higher risk of suicide attempts and a five times higher frequency of infection for HIV (mostly transgender women), 25% did not seek medical care for fear of mistreatment in care services, which is striking due to the constant increase [25, 26, 27].

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

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

8. Conclusions

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

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

Conflict of interest

The authors declare no conflict of interest.