Trans Women’s Health Conditions in Sex Work

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This entry is adapted from the peer-reviewed paper 10.3390/socsci12040219

Because of employment segregation, which leads to economic and social constraints, some trans women engage in sex work to satisfy basic needs and to achieve financial autonomy. In general, trans women sex workers, broadly known as women who exchange sex for money or other goods, experience widespread violations of their human rights due to the intersection of transgender stigma, sex work stigma, and other marginalized identities facing personal struggles related to their bodies and health.

trans women sex work gender embodiment health

1. Discrimination against Trans Women and Its Intersection with Sex Work

Transgender or trans and/or non-binary people are, according to the American Psychological Association (APA 2015), those who experience a gender identity, expression, or behavior that typically does not conform to the sex assigned to them at birth. In below, following the practices of trans organizations such as TGEU (Transgender Europe), the term trans will be used as an open-ended social umbrella term to denote people who present themselves differently to the expectations of the gender role assigned to them at birth. Among many others, this can include transsexual and transgender people, transvestites, cross-dressers, agender, multigender, and genderqueer people, and intersex, and gender variant people (TGEU 2016). Trans women are defined as individuals who were assigned male at birth and self-identify as female or transgender women (Bettcher 2014; Ferreira et al. 2022).

Although Portugal has already achieved significant progress regarding the recognition of Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) populations (ILGA Portugal 2018), trans people are one of the most socially marginalized groups due to persistently hegemonizing hetero- and cis-normative systems (Wirtz et al. 2020).

Despite Portugal being the first European country to prohibit discrimination based on sexual orientation in its Constitution (Santos 2013), until 2011, the identity of trans people in Portugal was not legally recognized, and the right to their gender identity was recurrently denied, thus constituting a violation of human rights (ILGA Portugal 2016). In the last 12 years, however, several changes in legal and social contexts have occurred regarding sexual and gender diversity acknowledgement and respect. In 2011, Portugal approved a gender identity law which aimed to facilitate legal sex and name changes, and no longer required a previous sex change (Pinto and Moleiro 2015). This law was considered pioneering in Europe, as it was the first to fully comply with the Yogyakarta Principles, allowing trans people to change their birth certificate by presenting the diagnosis of gender dysphoria in the Portuguese civil registry. For the first time, Portugal currently has an action plan to combat discrimination based on sexual orientation, gender identity and expression, and sexual characteristics that is integrated into the National Strategy for Equality and Non-Discrimination 2018–2030 (ENIND).

Even if it is true that significant progress has been made in Portugal to recognize the rights and social protection of trans people (ILGA Europe 2022), from a young age, trans people often face stigma, discrimination, and social rejection in their families and communities for expressing their gender identity (Rodrigues et al. 2020; Winter et al. 2016). Transphobia fuels a lack of access to education and work, is usually found in lower social classes, and implies less access to healthcare and shorter lifespans (Safer et al. 2016; Wilkinson et al. 2018). These life experiences of discrimination, abuse, harassment, and violence on systemic, institutional, and interpersonal levels are distressingly common experiences for trans people and negatively influence their psychological health and quality of life (Blosnich et al. 2015; Connolly et al. 2016; Meyer 2003; Nadal et al. 2014; Neves et al. 2023; SAHM 2020). There is a clear impact on the decision to seek specialized help (Spizzirri et al. 2021) and access support (e.g., accessing medical care, seeking police assistance, or reporting violence) due to fear of being discriminated against based on their gender identity or other groups of belonging and identities (e.g., being a person of color) (Sausa et al. 2007).

Multiple identity belongings can contribute to greater vulnerability and oppression in the different spheres of trans people’s lives. The heterogeneity of trans people’s lives demands an intersectional approach that captures how vulnerabilities traverse. As Wesp et al. (2019) advocated, trans people are involved in intersecting forms of social marginalization, disproportionately affecting their health. Thus, as evidence suggests, trans people generally have worse health indicators than cis people, which are predictors of future disability and morbidity (Griffin et al. 2019).

In the workplace, when trans people can find employment, they often experience many forms of interpersonal discrimination (e.g., transphobic jokes or language, harassment) occurring at all phases of the employment process, including recruitment, training opportunities, employee benefits, and access to job advancement, making it challenging to obtain or maintain a job. This may discourage them from applying for jobs, and many start to apply for jobs that have limited potential for growth and development, for example, in the entertainment industry or in sex work (Oliveira 2018). Especially for transgender women of color, who face even more discrimination in the labor market because of an intersection of different oppression systems (sexism, heterosexism as well as racism), engagement in the sex industry is estimated to be high (Nuttbrock and Hwahng 2017; Sausa et al. 2007). The added complication of inadequate workplace policies and legislation that fail to protect transgender people makes securing gainful employment difficult. Individuals undergoing gender-affirming transition processes while maintaining the same job (at workplaces without policies protecting against transgender discrimination) encounter even more obstacles (Schilt and Connell 2007).

The numerical under-representation of trans people in the workplace leaves them without a voice and under-considered by many organizations. All these obstacles to employment put trans people at greater risk of living in poverty or even becoming homeless; they often choose to engage in sex work as a means of survival (Nadal et al. 2014; Oliveira 2011; Sausa et al. 2007), which puts them in danger of adverse (and potentially fatal) outcomes, including violence, poor sexual health, and incarceration.

2. Trans Women Sex Workers, Health, and Body Expectations

Sex work can be defined as a range of activities in which sexuality is explicitly being sold in exchange for material compensation (Cohen et al. 2013; Nadal et al. 2014) between consenting adults (Oliveira 2018, p. 13). It includes acts of direct sexual services (e.g., prostitution in a flat, brothel, or street work), erotic dance (e.g., stripping, lap dancing, and peepshows), pornography, webcam work, erotic phone calls, and live sex shows, among others (Cohen et al. 2013; Weitzer 2023).

In Portugal, over the last 25 years, the contexts in which sex is sold are very diverse, including brothels, apartments, massage parlors, hotels, bars, clubs/brothels, saunas, and the streets (Oliveira 2018, p. 13). However, the dominant social and institutional discourses on prostitution in Portugal often associate the activity with the imbalance of power and control, conceptualizing it as a form of violence against women and a form of women’s oppression (Oliveira 2013, p. 20), not taking male or trans sex workers into account. Sex work is seen as an activity performed by women who are depicted as victims without agency, or as having a pimp; it is never portrayed as a free choice (Oliveira 2018, p. 13) or an empowering activity. Nowadays, sex work is very fluid. Some sex workers have adopted hybrid work practices, fluctuating between street solicitation and connecting with clients by phone or the Internet and then meeting them at a motel, for example.

Sex work is a highly risky work sector for many reasons: the lack of legal frameworks that offer protection from violence; the lack of political will to create programs to support sex workers; and the nonexistence of religious and cultural approaches that foster sex work legislation and policies. Other factors that enhance stigma and marginalization also make it a risky activity (Platt et al. 2018).

Sex work also entails dangers such as exposure to situations of abuse (Gamboa et al. 2018), greater vulnerability to the consumption of alcohol and other drugs, and exposure to sexually transmitted diseases (Panopoulou and Gonzalez-Pier 2019).

The proportion of trans people among sex workers is context-specific. TAMPEP’s mapping report from 2009 states that six percent of all sex workers in Europe are transgender. However, this figure could be higher, as there are very few projects working with trans sex workers.

Trans sex workers are among the most marginalized and vulnerable sex workers due to widespread social stigmatization, generally attributable to transphobic prejudice in almost all countries (Nadal et al. 2014; Van Schuylenbergh et al. 2019).

The research data (Glick et al. 2018) suggest that trans women who engage in sex work are particularly prone to high levels of psychological, physical, and sexual violence, HIV infection, and even homicide. According to the TAMPEP report (TAMPEP 2009), trans and gender-diverse murder victims are often migrants in Western and Southern Europe, as in Germany, Italy, Portugal, and Spain, or sex workers, as in Albania, France, Germany, Italy, Portugal, Spain, Turkey, and the UK (and often both).

Stigma affects these sex workers in various aspects of their lives and can lead them to “isolation, loss of social ties, lack of well-being, low self-esteem, the restriction of freedom, exploitation and violence, including symbolic violence” (Oliveira 2018, p. 16). Trans sex workers are very diverse. They have different sexual orientations, different ages, nationalities, and diverse ethnic characteristics (Oliveira 2018), which can mean their experiences are affected by other factors, including but not limited to poverty, ethnic and religious background, disability, HIV status, and residency status. This intersectionality of oppression can serve to increase the impact of transphobic discrimination. However, some groups of trans persons have more difficulty claiming their rights, as language and citizenship status can be additional barriers to accessing healthcare and employment (Pinto and Moleiro 2021; Van Schuylenbergh et al. 2019).

For years, trans people’s experiences of breaking with a normative assumption have thus been influenced by the medical establishment, including controlled access to gender-affirming medical procedures (Davis et al. 2016; Hilário 2017). Many health practitioners had limited the attribution of a gender dysphoria diagnosis to trans people who conform to the ideal of the ‘true transsexual’ (Ferreira et al. 2022; McQueen 2016). This idea is based on the notion that one’s assigned gender at birth, one’s gender identity, and biological sex characteristics should be aligned. Therefore, the proof of ‘authenticity’ draws on the desire of an individual to rid themselves of their existing genitalia through gender-affirming surgery (Davis et al. 2016). Assuming that gender identity follows from genitalia and that gender is something fixed and stable across the course of life (McQueen 2016), some trans people may wish to display their gendered selves within the framework of gender binaries (Marques 2019), while others may feel pressured to conform to dominant gender normativity, that is, to align their bodies in accordance with the ideal of the female-bodied woman and male-bodied man (Davis et al. 2016).

Although trans people try to live in accordance with their gender identity, expression, or behavior, and the body assumes capital importance in this process, they do not always undergo clinical procedures for body alteration (Pinto and Moleiro 2021). The proportion of individuals identifying as gender-diverse could exceed the estimated number of people who receive gender-affirming medical assistance. On the other hand, for trans sex workers, their bodies and sexuality are not only implicated in all labor, but their body is the central instrument of sex work.

Trans people often feel obliged to resort to clandestine procedures of body alteration to be more profitable (Ramos et al. 2014). For trans women, this requirement translates into a more significant concern with acquiring body capital that is as close as possible to the feminine ideal (Pessoa 2020). The public scrutiny to which trans people are subjected tends to be substantially associated with their physical appearance (Lagos 2019). Discrimination can become even more pronounced when physical appearance does not correspond to gender expectations seen as normative for each of the sexes (McLemore 2018). Those who do so, seeking to increase their personal well-being and greater social recognition of their identity (Canella Filho and Rocha-Coutinho 2013), often face multiple challenges in accessing and using health services (Oliveira and Fernandes 2017).

Delays in scheduling appointments and treatments, inconsistency in the availability of treatments, a lack of money, bureaucracy, distance, or the difficulty in accessing health services, as well as the disrespect and insensitivity of professionals who have gender binary and cis heteronormative attitudes, contribute to keeping trans people away from health services (Hughto et al. 2015; Pinto and Moleiro 2021; Roche and Keith 2014; Rodrigues et al. 2020).

This makes them more vulnerable to offers from the underground market (Mazaro and Cardin 2017), which tend to be fraudulent and harmful to physical and psychological integrity. In addition, these offers are usually expensive, requiring trans people to have economic resources that allow them to pay for the treatment.

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1. Discrimination against Trans Women and Its Intersection with Sex Work

2. Trans Women Sex Workers, Health, and Body Expectations

References