Together we celebrate twenty years of transgender visibility in Brazil. Visibility can empower transgender people and their allies and encourage them to advocate for rights and protections, including legal recognition of gender identity, access to healthcare, and protection against discrimination.¹1 Simpson K, Benevides B. 20 Years of Trans Visibility, from Mourning to Fighting! Epidemiol Serv Saude. 2024 Jan 26;33(spe1):e2024034. Unfortunately, much work remains to be done in these areas. Globally, transgender women face extreme vulnerability and marginalization, including in Brazil.²2 Luna CP, Barros DF. An ANTi-History about Transgender Inclusion in the Brazilian Labor Market. Emerald Publishing Limited; 2023. Violence and Resistance: Understanding Issues Situated (Not Limited) to Brazil; p.11-20. Experiences of stigma and discrimination lead to social isolation and violence; regrettably, the country is often cited as having some of the highest rates of transphobic violence in the world.³3 TvT research project TvTW. Trans Murder Monitoring, Global Update. http://transrespect.org/en/research/trans-murder-monitoring/2023. Accessed 20 February, 2024.
http://transrespect.org/en/research/tran...

Experiences of discrimination and violence increase susceptibility to negative health outcomes, including HIV and poor mental health.⁴4 Brezing C, Ferrara M, Freudenreich O. The Syndemic Illness of HIV and Trauma: Implications for a Trauma-Informed Model of Care. Psychosomatics. 20150119 2015(1545-7206 (Electronic)).–⁶6 Magno L, Silva LAVD, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saude Publica. 2019;35(4):e00112718. Rates of depression, anxiety, substance use, trauma symptoms, and suicidal ideation are higher among trans women compared to the general population.⁷7 Almeida MM, Silva LAVD, Bastos FI, et al. Factors associated with symptoms of major depression disorder among transgender women in Northeast Brazil. PLoS One. 2022 Sep 1;17(9):e0267795.,⁸8 Lefevor GT, Boyd-Rogers CC, Sprague BM, Janis RA. Health disparities between genderqueer, transgender, and cisgender individuals: An extension of minority stress theory. J Couns Psychol. 2019 Jul;66(4):385-395. Thus, the demand for healthcare services is consistently high; however this population often avoid health services due to anticipated and experienced stigma and discrimination.⁹9 Sevelius J, Murray LR, Martinez Fernandes N, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019 May;21(5):543-558. Experiences of stigma, discrimination, and violence are even more common among transgender women facing additional oppressions, such as racism and classism.

In Brazil, the Psychosocial Care Network (Rede de Atenção Psicossocial – RAPS), which includes Psychosocial Care Centers, aims to provide free mental health services to individuals suffering intensely from psychological disorders, substance abuse and experiencing various crises. RAPS often fails to adequately serve individuals with non-acute mental health symptoms – such as mild to moderate depression and anxiety,¹⁰10 Sampaio ML, Bispo Junior JP. Towards comprehensive mental health care: experiences and challenges of psychosocial care in Brazil. BMC Public Health. 2021 Jul 8;21(1):1352. which are common among transgender people – associated with unmeet gender affirming needs and chronic invalidation of their identities.

The shortage of human resources, particularly in mental health, demands alternative strategies to bridge existing gaps in care for others. Peer support interventions have proven invaluable across many health domains, including mental health, cancer, substance use, and HIV treatment and prevention, demonstrating success in addressing support and care needs among vulnerable populations.¹¹11 Corradi-Webster CM, Reis G, Brisola EBV, et al. Peer support in Brazil: experiences and strategies of inclusion, empowerment and citizenship. Journal of Public Mental Health. 2023;22(3):98-108.

12 Berg RC, Page S, Øgård-Repål A. The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis. PLoS One. 2021 Jun 17;16(6):e0252623.-¹³13 Kia H, MacKinnon KR, Abramovich A, Bonato S. Peer support as a protective factor against suicide in trans populations: A scoping review. Soc Sci Med. 2021 Jun;279:114026. These interventions are crucial in building relationships that promote behavior change and can effectively address trauma symptoms and develop coping and resilience skills in the face of stigma, improve social gender affirmation, and help prevent the internalization of stigmatizing experiences.¹⁴14 Kia H, Kenney K, MacKinnon KR, et al. “It saves lives”: Peer support and resilience in transgender and gender diverse communities. SSM - Qualitative Research in Health. 2023;3.

Our team has collectively worked in Brazil for many years developing and testing peer support interventions for travestis and transgender women. These interventions have shown feasibility, acceptability, and effectiveness in reducing symptoms of trauma, depression, anxiety, and stress, while enhancing coping skills, and increasing acceptance of HIV prevention and treatment.¹⁵15 Lippman SA, Sevelius JM, Saggese GSR, et al. Peer Navigation to Support Transgender Women’s Engagement in HIV Care: Findings from the Trans Amigas Pilot Trial in São Paulo, Brazil. AIDS Behav. 2022 Aug;26(8):2588-2599.

16 Steward WT, Sumitani J, Moran ME, et al. Engaging HIV-positive clients in care: acceptability and mechanisms of action of a peer navigation program in South Africa. AIDS Care. 2018 Mar;30(3):330-337.

17 Sevelius JM, Neilands TB, Reback CJ, et al. An Intervention by and for Transgender Women Living With HIV: Study Protocol for a Two-Arm Randomized Controlled Trial Testing the Efficacy of “Healthy Divas” to Improve HIV Care Outcomes. Front Reprod Health. 2021 Oct 27;3:665723.-¹⁸18 Sevelius JM, Neilands TB, Dilworth S, Castro D, Johnson MO. Sheroes: Feasibility and Acceptability of a Community-Driven, Group-Level HIV Intervention Program for Transgender Women. AIDS Behav. 2020 May;24(5):1551-1559. This approach is gaining popularity because it can provide health benefits to both participants and peers; promote empowerment; maximize acceptability; increase access for marginalized groups; facilitate dissemination of these actions; and reduce intervention costs.¹¹11 Corradi-Webster CM, Reis G, Brisola EBV, et al. Peer support in Brazil: experiences and strategies of inclusion, empowerment and citizenship. Journal of Public Mental Health. 2023;22(3):98-108.

Peer support can increase individuals’ feelings of being seen and understood, which can positively impact mental health and well-being among transgender people by reducing feelings of isolation and stigma.¹⁴14 Kia H, Kenney K, MacKinnon KR, et al. “It saves lives”: Peer support and resilience in transgender and gender diverse communities. SSM - Qualitative Research in Health. 2023;3. Peer support increases resilience to stigma and reduces internalized stigma, and people who receive it often report less psychological distress caused by stigma experiences. They are also more likely to engage in health care and increase self-care behaviors, leading to better health outcomes.¹⁹19 Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PLoS One. 2019 Jan 25;14(1):e0211298.

REPORT OF OUR EXPERIENCE

In our studies conducted in São Paulo and the United States, transgender people enthusiastically expressed a desire for peer support (referred to as peer navigation) from those who understand their experiences and the challenges of engaging in health care. Peer navigators provide practical assistance within healthcare systems – including how to handle experiences of stigma and discrimination – as well as urgently needed emotional support informed by shared experiences and that foster mutual understanding, respect, and empowerment. Unlike professional power dynamics, peer support is a “give-and-receive system,” guided by core principles such as shared responsibility and mutual agreement on what is considered helpful.²⁰20 Burke EM, Pyle M, Machin K, Morrison AP. Providing mental health peer support 1: A Delphi study to develop consensus on the essential components, costs, benefits, barriers and facilitators. International Journal of Social Psychiatry. 2018;64(8):799-812. These type of support differs from friendship as the focus of the relationship is to help the recipient obtain and understand relevant information to set goals and make the best choices for themselves. It also differs from health care provision: once goals are collaboratively established, hierarchies are avoided and shared lived experience is encouraged.

In the interventions we have developed in collaboration with travestis and transgender women, peer navigators engage in various activities. Important tasks include familiarizing themselves with healthcare and social assistance networks, and legal aid resources, providing referrals or accompanying individuals to access these services. Peer navigators also offer basic information, share personal experiences, strengthen and expand support networks, facilitate groups, develop skills, provide individual guidance, and help set personalized goals with practical steps. To effectively perform these activities, peer workers require ongoing training and supervision to ensure they engage with participants carefully and collaboratively, maintaining personal and professional boundaries, which can be challenging within community settings.

Peer support workers share many lived experiences with those they support, making the transition into this role potentially challenging.²¹21 Shalaby RAH, Agyapong VIO. Peer Support in Mental Health: Literature Review. JMIR Ment Health. 2020 Jun 9;7(6):e15572 These workers require compassionate guidance from trained supervisors to monitor and maintain their own mental health, avoiding secondary traumatic stress – emotional distress resulting from exposure to the trauma experienced by the participants they support.. In Brazil, we found it essential to provide regular supervision to these workers to ensure they have the guidance needed to navigate the challenging situations that inevitably arise and to succeed in their role.

In addition to the direct benefits to peers and recipients, the visibility of peer support workers in the healthcare system can lead to greater social inclusion and awareness, as well as a better understanding of the issues faced by transgender people, including the need for inclusive policies and practices. Seeing transgender people various roles and positions in society helps diversify their representations and challenges stereotypes and misconceptions. The visibility of transgender people serving as peer support workers in the healthcare system can validate their experiences and identities, affirming that they are valued members of society with unique needs, perspectives, and contributions.

Despite the benefits, introducing peer support services into the Brazilian health system can pose challenges, as systemic change can be slow and resources are often scarce.¹¹11 Corradi-Webster CM, Reis G, Brisola EBV, et al. Peer support in Brazil: experiences and strategies of inclusion, empowerment and citizenship. Journal of Public Mental Health. 2023;22(3):98-108. In healthcare settings, barriers to integrating peer support workers often include confusion about their role, resistance from other team members, and unequal treatment of peer support workers, including stigmatization.²¹21 Shalaby RAH, Agyapong VIO. Peer Support in Mental Health: Literature Review. JMIR Ment Health. 2020 Jun 9;7(6):e15572 Clear definition of the role, personal and supervisory training, and sufficient ongoing support should be carefully considered and provided.

FUTURE PERSPECTIVES

Although there is extensive empirical evidence supporting the benefits of peer support in improving health and well-being among transgender people, research on the successful implementation and scaling of peer support remains in its infancy and urgently needed. Many scholars have advocated for systematic research on the processes involved in the implementation of peer-led health promotion programs and the conductive conditions for effectively integrating this workforce into health systems, including the necessary systematic changes to accommodate such programming.¹¹11 Corradi-Webster CM, Reis G, Brisola EBV, et al. Peer support in Brazil: experiences and strategies of inclusion, empowerment and citizenship. Journal of Public Mental Health. 2023;22(3):98-108.,¹⁴14 Kia H, Kenney K, MacKinnon KR, et al. “It saves lives”: Peer support and resilience in transgender and gender diverse communities. SSM - Qualitative Research in Health. 2023;3.,¹⁵15 Lippman SA, Sevelius JM, Saggese GSR, et al. Peer Navigation to Support Transgender Women’s Engagement in HIV Care: Findings from the Trans Amigas Pilot Trial in São Paulo, Brazil. AIDS Behav. 2022 Aug;26(8):2588-2599.,²²22 Zamudio-Haas S, Koester K, Venegas L, et al. “Entre Nosotras:” a qualitative study of a peer-led PrEP project for transgender latinas. BMC Health Serv Res. 2023 Sep 20;23(1):1013. Understanding the conditions for implementation is crucial to determining the facilitators and barriers to effective peer support services in Brazil, as well as to identifying the optimal contexts where these programs can yield the greatest benefits and the policies needed to ensure sustainability of these programs.

Peer support workers can play a critical role in serving transgender people in Brazil, where stigma and discrimination often lead to poor-quality care, avoidance of seeking care, and many unmet health needs within transgender communities, especially among those facing intersectional oppressions, such as Black travestis and transgender women and those living with HIV. Peer support aligns well with the principles of making public health services more human-centered, a stated commitment of the Brazilian National Health System.²³23 Ministério da Saúde B. Política Nacional de Humanização - HumanizaSUS. https://www.gov.br/saude/pt-br/acesso-a-informacao/acoes-e-programas/humanizasus. Accessed 24 February 2024.
https://www.gov.br/saude/pt-br/acesso-a-... Using peer support helps identify and address health needs from social, collective, and personal perspectives. This form of support also respects people from different communities involved in healthcare and encourages their independence and active participation. We believe that by working with the community, we can drive the systemic changes needed to create conditions where we can thrive and lead healthier lives.

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