Sex, Drugs, and the Culture of Transvestimo in Rio De Janeiro

by James A. Inciardi (1), Hilary L. Surratt (2), Paulo R. Telles (3) and Binh H. Pok (2)

(1) Center for Drug and Alcohol Studies, University of Delaware
(2) Comprehensive Drug Research Center, University of Miami School of Medicine
(3) Nucleo de estudos e pesquisas em atencao ao uso de drogas, State University of Rio de Janeiro 

Citation: Inciardi J.A., Surrant H.L., Telles P.R., Pok B.H.. (1999) Sex, Drugs, and the Culture of Transvestimo in Rio De Janeiro. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/inciardi.htm

Correspondence and requests for materials should be sent to:
James A. Inciardi, Center for Drug and Alcohol Studies, University of Delaware, 77 East Main Street, Newark, DE 19716.
Tel: (302)831-6286; Fax (302)831-1275; E-mail: JaiNYC@aol.com

• Abstract
• Methods
• Findings
• Discussion
• References Cited

Abstract
Transvestites in Brazil are members of an intricate and distinct subculture whose marginalization uniquely impacts the effectiveness of HIV prevention/intervention programs. As such, the purpose of this research was to assess the drug using and sexual behaviors, and prevalence of HIV-1 infection among a sample of 100 male transvestite sex workers, and to develop appropriate intervention strategies. AIDS risk behaviors were common among the transvestites studied, and almost half tested positive for HIV infection. Recommendations for prevention efforts include the incorporation of condom negotiation and empowerment techniques. Female condom demonstration and distribution (for anal sex) should also be included since the findings show it was well-received by transvestites. Finally, nearly all of the clients reported non-hygienic use of needles for silicone injections, suggesting that needle cleaning techniques also should be included in future prevention initiatives targeting transvestite sex workers.

In Brazil, transvestism is a specific social and cultural construct in which both gender and sexuality are mapped out and performed in highly particular ways (1). Moreover, it has a long history, both as an integral theme during Carnaval, and as a gender variation with its own distinct culture (2,3,4). At Carnaval, best described as an enthusiastically celebrated street festival and parade during the five days prior to Ash Wednesday, many males - both gay and heterosexual - participate dressed as women, not only to glorify and venerate women, but also as a projection of male sexual fantasies (4).

In contrast to Carnaval cross-dressing, the travestis of Brazil view transvestism as an identity and a designation that pervades every aspect of their lives. Although the clinical literature emphasizes that transvestites do not live continuously in the cross-gender role, and that their cross-dressing is periodic and fetishistic (6,7), for the travestis of Brazil, transvestism appears to be enduring - typically life long.

Transvestites in Brazil, as in other cultures, are marked by an exaggerated femininity in both dress and makeup. They come almost exclusively from the poorest segments of Brazilian society, but there is little toleration for them in either the favelas (shantytowns) or the traditional, low income suburban areas. Thus, as they begin to cross the lines of gender, most leave behind family and friends, emigrating to Rio de Janeiro, Sao Paulo, and other large cities into districts where: . . . a mixture of socially marginal and often illegal activities creates not only a kind of moral region but a moral anonymity in which the traditional values of Brazilian society cease to function. Within this world (which is also the world of female prostitution, drug trafficking, homosexuality, and the more sporadic prostitution of the miches [male prostitutes]), given pervasive prejudice and discrimination, almost no options other than prostitution are open to the travesti for earning a living; as a result, almost all travestis quickly become involved in prostitution as their primary activity (8).

Most transvestites live in close proximity to each other, and they always dress as women. Many use drugs, and because of their involvement in street prostitution, they are regularly exposed to both violence and a full range of sexually transmitted diseases, including HIV and AIDS. For example, among 57 drug-using transvestites engaging in prostitution in Rome (the great majority of whom had emigrated from Brazil), the overall prevalence of HIV was 74% (9). Studies conducted in various parts of Brazil over the past ten years also reflect high rates of HIV seropositivity among transvestite sex workers. Among 37 transvestites tested in Sao Paulo during 1988, 62% were found to be HIV positive (10), and among 112 transvestites contacted four years later, 60.7% tested positive (11).

In Rio de Janeiro, it is estimated that there are at least 2,000 transvestites, (and they prefer the term "transvestite," or travesti in Brazilian Portuguese, as opposed to transsexual or transgender), 80% of whom support themselves through prostitution. Within this context, the following discussion examines aspects of the subculture of male transvestite sex workers in Rio de Janeiro, with a particular focus on their drug-using and sexual risk behaviors.
 

Methods
The data reported here were collected as part of a larger HIV/AIDS prevention initiative funded by the National Institute of Drug Abuse. Known as "PROVIVA" (Projeto Venha Informar-se sobre o Virus da AIDS), the project operated between 1993 and 1997 as a collaborative effort between the University of Miami School of Medicine and the State University of Rio de Janeiro. Its general purposes were to establish a community-based HIV/AIDS surveillance and monitoring system, and to develop and evaluate a culturally appropriate prevention/intervention program for cocaine users in Rio's favelas and "red light" districts. A total of 1,643 individuals were recruited into the project, of whom 100 were male transvestite sex workers.

Data collection on these travestis occurred in two phases: 1) street recruitment as part of the overall project outreach and intervention effort; and 2) focus groups.

Two cohorts of male transvestite prostitutes were sampled for this study. The first (N=52) were recruited from the "Lapa" and "Copacabana" neighborhoods of Rio de Janeiro. Lapa is a downtown section of the city described in the guide books as an inner residential area, with some sections having numerous strip clubs and cheap hotels, many of which are considered "hot pillow establishments" (12,13). It is an old Bohemian area, famous in the past for its night life. However, as drug users, prostitutes, and transvestites began moving into Lapa and establishing themselves, the area began to deteriorate. Late at night, along such thoroughfares as Mem de S and Riachuelo, transvestite prostitutes in various states of undress can be observed soliciting their clientele.

Copacabana, famous since the 1920s as a flamboyant ocean resort, is a narrow, curving expanse covering just over 4 square kilometers. It is the most populous community in Rio de Janeiro, and its 250,000 residents make it one of the most densely inhabited areas of the world. High-rise apartments and hotels line the elite and expensive beach-front Avenida Atlantica, but behind it are 109 narrow streets and alleyways that mark a neighborhood in which as many as ten people are often crammed into small, 2-bedroom apartments. Although prostitutes are active on many streets in Copacabana, including "Posto 6" and Rua Rainha Elizabeth, late at night transvestites can be found concentrated on an easterly segment of Avenida Atlantica, not too distant from the world-renowned, five-star Hotel Meridien.

The second cohort (N=48) was sampled from a distant suburb of Rio de Janeiro known as Baixada fluminense, an area containing more than 2.6 million persons, the majority of whom were living in abject poverty. The baixada is considered one of the poorest areas of Brazil, with infant mortality rates and the incidence of infectious diseases five times higher than in Rio de Janeiro. Lacking a sewerage disposal system and potable drinking water, and awash in garbage, Baixada fluminense is considered a public health disaster where tetanus, typhoid, meningitis, and a variety of intestinal infections are commonplace, especially among children (14). Yet surprisingly, rates of HIV infection tend to be lower in the baixada than in the downtown sections of Rio de Janeiro (15).

Initially, the recruitment of male transvestite sex workers for PROVIVA was conducted by outreach workers, on a one-night-a-week basis. Because transvestites are highly reviled in Rio de Janeiro and are frequently the targets of violence, outreach workers typically operated in pairs for the sake of their own personal safety. Contacts were made on the street, and in the bars, strip clubs, hotels, and rooming houses frequented by transvestites. Success at recruitment was limited, however, for a variety of reasons. First, the great majority of the transvestites contacted began "working" quite late in the night, and slept most of the day, and as such were unwilling to visit PROVIVA during the project's operating hours. Second, the travel stipend paid to PROVIVA clients was R$10 in Brazilian currency (about U.S.$10), for each visit and was considered too low to entice many transvestite sex workers to make the trip. For those coming from Baixada fluminense, the commute was nearly two hours by bus. Third, many were either afraid of being tested for HIV, or already knew their HIV status. Finally, because of widespread discrimination against transvestites, many were suspicious of any university-based project, including PROVIVA.

As an alternative to traditional outreach techniques, two additional procedures were implemented. Since the latex condoms available in Rio de Janeiro are expensive and sometimes of low quality, transvestite recruits were promised 40 U.S.-made condoms in addition to the regular travel stipend when they appeared at the PROVIVA office. Moreover, transvestite key informants from local organizations were retained as part-time outreach workers in order to increase the rapport between the project and the client population. These key informants were enthusiastic about working for the project because it targeted members of their peer group who were in great need of HIV prevention information. The new strategies resulted in the recruitment of 52 transvestite sex workers from Lapa and Copacabana, and 48 from Baixada fluminense.

Once contacted in the field, all project clients were either transported to, or given directions to, the PROVIVA assessment center, located in the Sao Cristovao section of Rio de Janeiro. All interviewing, drawing of blood for HIV testing, pre- and post-test counseling, and AIDS prevention training were conducted at this center. Intake included informed consent, drug testing, and administration of a standardized "Risk Behavior Assessment" (RBA) interview instrument. Individual pre-test HIV prevention counseling was provided, covering such topics as HIV disease, transmission routes, risky behaviors, risks associated with crack or cocaine use, rehearsal of male and female condom use, stopping unsafe sex practices, communication with partners, cleaning and disinfection of injection equipment, rehearsal of needle and syringe cleaning, disposal of hazardous waste material, stopping unsafe drug use, and the benefits of drug treatment. Voluntary HIV testing, and distribution of relevant literature and referrals were also done at intake. An effort was made to reassess all participants at a follow-up session 3-5 months later, with a standardized Risk Behavior Follow-Up Assessment (RBFA) interview instrument, followed by HIV re-testing and counseling for previously seronegative clients.

Descriptive statistics were compiled on demographic characteristics, drug use and sexual behaviors of the participants. Multivariate logistic regression analyses were then conducted to examine the relationship between HIV seropositivity and its predictors. The independent variables entered into the model included: age, race/ethnicity, level of education, income, sample, history of cocaine use, history of injection drug use, history of trading sex for drugs, STD history, number of sexual partners in the past thirty days, unprotected receptive anal sex in the past thirty days, unprotected insertive anal sex in the past thirty days, cocaine use during sex, and previous access to risk reduction information.
  

Findings
Because the lifestyles and patterns of sexual behavior appear to be similar among both samples of the male transvestite sex workers recruited into this study, the data for each of the two cohorts are presented aggregately. As illustrated in Table 1, the transvestites sampled were young, with a median age of 26 years. The overwhelming majority had minimal education, with only 22% completing more than eight years of school. Further, white, black (Afro-Brazilian), and multi-racial (mulato, pardo, and moreno) individuals were evenly represented in the sample. The data in Table 1 also suggest that the earnings of these transvestites were not high. The median monthly income of the sample was U.S. $450.00, which is equivalent to the salary of a part-time secretary or interviewer in Brazil. And although the data are not delineated in Table 1, four-fifths of the sample reported earnings through prostitution during the 30-day period prior to interview, with the remaining 20% having income from other illegal activities, selling/trading goods, odd jobs, and/or friends and relatives.

Table 2 indicates that almost all of the transvestites had histories of alcohol use (91%), and that the majority had some experience with both marijuana (61%) and cocaine (76%). Other drugs, such as heroin, amphetamines, and hallucinogens are not listed because they are generally unavailable in Rio de Janeiro. In terms of sequential patterns of drug use onset, the first drug used was alcohol at a median age of 15 years, followed by cocaine and marijuana. During the 30-day period prior to being enrolled into the project, 68% reported alcohol use, 26% reported marijuana use, and 55% reported cocaine use. Finally, only 12% reported any injection drug use, and even fewer (5%) had had any treatment for substance abuse.

Because the male transvestites contacted as part of this project were active sex workers, sexual risk behaviors were not uncommon. As illustrated in Table 3, most had numerous sex partners in the month prior to interview, and 50% reported engaging in sex with at least thirty different partners. Significant proportions also reported histories of sexually transmitted diseases, participation in both receptive and insertive anal sex, sex for drug exchanges, and sex while under the influence of cocaine.

Of the 100 male transvestite sex workers studies in this prevention/intervention program, 48% tested positive for antibodies to HIV. As indicated in Table 4, multivariate logistic regression analyses found that the risk factors significantly related to HIV seropositivity included older age, lower education, having ever injected drugs, and having had unprotected insertive anal sex. Surprisingly, none of the other variables in the model, including unprotected receptive anal sex, appeared to relate to serostatus.

Because this project counted among its aims the re-assessment of HIV risk behaviors levels among clients who participated in the intervention, an attempt was made to re-contact the 100 participants at three months after the baseline interview. Because the recruitment difficulties noted earlier in this paper persisted in the follow-up phase of the project, only 39 of the participants who were re-located agreed to be re-interviewed. When examining risk behaviors at follow-up, no changes were apparent on any of the sexual behavior dimensions. In other words, participants neither decreased the number of sexual partners, modified the types of sexual activities engaged in, nor increased condom use in response to the intervention.

Given that the male transvestites contacted as part of the PROVIVA project were active sex workers, exchanged sex for drugs and/or money, had numerous sex partners, histories of sexually transmitted diseases, and participated in both receptive and insertive anal sex, it is not surprising that almost half tested positive for antibodies to HIV. However, because the RBA was a standardized instrument designed primarily for injection drug users, few questions related to historical sexual risks, and none of the questions targeted the special risks associated with male transvestite sex work. Furthermore, the RBA had not been designed to elicit information about cultural and lifestyle issues. As a result, the investigators conducted seven focus groups, each containing five to eight transvestites. Topics included their views of prostitution and transvestism, employment patterns, sexual activities, condom use, drug use, and mechanisms of feminization.

During these sessions participants described the feminization process using silicone, a virtually unstudied potential risk factor for HIV transmission among male transvestites (16). The focus group data suggested that the use of silicone was widespread among the 100 clients recruited into the project. It was reported that the great majority of the transvestites in Rio undergo silicone injections to shape their bodies. These "beauty treatments," as the clients refer to them, are done by other "experienced" transvestites who are too old to support themselves as street prostitutes. The injection equipment was typically shared by several transvestites, with less than adequate cleaning between each use. Industrial quality silicone was most commonly used because it could be purchased by the gallon at a relatively cheap price. Numerous injections, sometimes more than 70 punctures, were required to accomplish each individual body shape. Since this was a painful process, it was common for transvestites to be under the influence of alcohol and/or drugs during the process. The injected liquid silicone had a tendency to dislodge after a few months, and thus, new injections were required periodically to reshape certain parts of body. Moreover, infections were common after such procedures and often, plastic surgery was the only recourse to remove the dislodged silicone.

The general lack of insight into the role of the travestis as they define it further attests to the marginalization of the population. For example, focus group data indicate that the travestis of Rio de Janeiro, contrary to much of the literature on transvestism, do not consider themselves to be heterosexual. Although they report feeling sexually attracted to men, they do not identify themselves as either women or male homosexuals. Rather, they view themselves as having a separate gender identity which they designate as "transvestite." Furthermore, unlike gay men, transvestites do not have a sexual interest in male homosexuals, but to men "who are normally attracted to women."

Ideally, the travestis wish their sex partners to look at them as women, to take the active role in anal intercourse, and to ignore the transvestite's masculine genitalia during sex. A transvestite typically keeps "her" penis hidden from her insertive partners during sexual intercourse through special clothes or posture. However, this act of "hiding" is more apt to take place when a transvestite sex worker is engaging in sexual activity with clients as opposed to their steady partners. Playing the active role in a sexual encounter is considered by many participants to be a violation of their "ideal sexuality," although many engaged in this behavior in order to satisfy their clientele.

Although transvestites dress and make themselves up as women, it is not their intent to "pass" as women. The ideal expressed by transvestites is to perform the traditional gender roles of women -- being a wife, a homemaker, and cooking for the partner -- without physically becoming a woman. In fact, many voiced a special repugnance for the vagina and considered transsexual surgery to be nonsensical. These attitudes were a reflection of two convictions held strongly by this group of transvestites. On the one hand, they tended to devalue women as a group, and the vagina was a symbol of being biologically female. At the same time, the transvestites considered themselves to possess a separate, special kind of sexual identity in which the ideal of the feminine role is achieved without requiring the full female anatomy.
  

Discussion
The high rate of HIV infection observed among male transvestite sex workers demonstrates the need to include this population in both outreach and intervention efforts. Yet this Rio-based initiative failed to demonstrate any significant behavioral changes subsequent to the intervention. This, however, was not surprising to the investigators, since the standardized intervention utilized had been designed for primarily drug-using populations. In fact, the purpose of the pilot study among the travestis was to better understand the unique HIV/AIDS and special needs of Brazilian transvestite sex workers.

An effective AIDS prevention initiative targeting this population must take these notions of gender identity and sexuality into account, and include the following strategies. First, although transvestite sex workers are aware of the importance of condoms during anal sex, few actually use them. Not only are condoms expensive, but the transvestites' clients are often unwilling to use them. As such, not only must there be greater availability of condoms, but mechanisms to teach transvestites how to negotiate condom use with clients. Condom negotiation and empowerment techniques have long since been a part of risk reduction initiatives for women, but because transvestites are typically looked upon as "men," this aspect of prevention programming is typically forgotten.

Second, the investigators were the first to introduce the female condom to Brazilian transvestites (17,18). Pilot work determined that not only did transvestite sex workers consider the female condom to be an acceptable method of HIV risk reduction during anal sex, but also that they liked it and were willing and eager to use it. As such, female condom distribution and instruction in its use would appear to be a crucial part of AIDS prevention for this population.

Third, there is the problem of the repeated use of contaminated needles and syringes during silicone injections. This is not a topic that is addressed in contemporary AIDS prevention programs. Although the cleaning of injection paraphernalia is discussed with drug users, more general HIV prevention discussions bypass the topic. In this regard, information about the hazards associated with using potentially infected needles must be provided not only to transvestite sex workers, but also to the other members of their subculture who actually administer the injections.
  

References Cited

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