Abstract

The transgender population encounters several barriers in entering the labor market, whichfurther impacts their health. In this cross-sectional study, the factors associated with their insertion in the formal job market were analyzed. Participants were recruited in seven municipalities of the state of São Paulo between 2014 and 2015. Logistic regression was used to estimate the odds ratios (OR) of the association between formal insertion and selected characteristics. We included 672 individuals, of which 82.3% were working, 13.1% were not employed, and 4.6% were not in the labor market. Among those working, only 16.7% were in the formal labor market. Factors independently associated with formal employment were: being atrans man, having 12 years or more of education, being under follow-up for gender transition procedures in the healthcare services, having private health insurance, and never having been arrested. Our results highlightpart of the obstacles the transgender population has toovercome to enter the labor market, and point to the need for public policies specifically designed for the transgender population aiming to reduce school dropout and expand access to comprehensive health care, thereby reducing theirvulnerability.

Key words
Transgender people; Labor market; Stigma; Discrimination

Introduction

The transgender population faces barriers to access formal social institutions such as health and work¹1 Maranhão filho AM. Inclusão de travestis e transexuais através do nome social e mudanças de prenome: Diálogos iniciais com Karen Schawach e outras fontes. Rev Oralidades [internet]. 2012 [acessado 2019 Abr 20]; 11:90-106. Disponível em: http://diversitas.fflch.usp.br/files/5.%20MARANH%C3%83O%20FILHO,%20E.M.A.%20Inclus%C3%A3o%20de%20travestis%20e%20tran00sexuais%20atrav%C3%A9s%20do%20nome%20social%20e%20mudan%C3%A7a%20de%20prenome%20-%20di%C3%A1logos%20iniciais%20com%20Karen%20Schwach%20e%20outras%20fontes_0.pdf.
http://diversitas.fflch.usp.br/files/5.%...

2 Sampaio LLP, Coelho MTAD. Transexualidade: aspectos psicológicos e novas demandas ao setor saúde. Rev Comunicação, Saúde, Educ 2012; 16(42):637-649.

3 Socías ME, Marshall BD, Arístegui I, Romero M, Cahn P, Kerr T. Factors associated with healthcare avoidance among transgender women in Argentina. Int J Equity Health 2014; 13(1):81.

4 Organização Internacional do Trabalho (OIT), Programa das Nações Unidas para o Desenvolvimento (PNUD), Programa Conjunto das Nações Unidas sobre HIV/AIDS (UNAIDS). Promoção dos direitos humanos de pessoas LGBT no mundo do trabalho: construindo a igualdade de oportunidades no mundo do trabalho, combatendo a homo-lesbo-transfobia [internet]. 2015 [acessado 2019 Abr 20]. Disponível em: https://issuu.com/pnudbrasil/docs/manual_promocao_direitos_lgbt_mun.
https://issuu.com/pnudbrasil/docs/manual...

5 Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a review. Lancet 2016; 388(10042):412-436.^-66 White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015; 147:222-231.. At the structural level, public policies aimed at the inclusion of transgender people in educational and healthcare systems, as well as the labor market, are lacking. Unemployment and difficulty to enter the labor market are also associated with the stigma and discrimination experienced by this population⁷7 Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender Health in Massachusetts: Results From a Household Probability Sample of Adults. Am J Public Health 2012; 102(1):118-122.^,88 Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey, executive summary. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011..

In addition to being recognized as a fundamental human right⁹9 Organização das Nações Unidas (ONU). Declaração Universal dos Direitos Humanos. Resolução 217 da Assembléia Geral das Nações Unidas. Paris: ONU; 1948. [acessado 2019 Abr 20]. Disponível em: http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf
http://www.ohchr.org/EN/UDHR/Documents/U... , working allows the individual the means to afford basic necessities and it has direct repercussions on the living and health conditions of any population¹⁰10 Giatti l, Barreto SM. Situação do indivíduo no mercado de trabalho e iniquidade em saúde no brasil. Rev Saude Publica 2006; 40(1):99-106.

11 Ulyssea G. Informalidade no mercado de trabalho brasileiro: uma resenha da literatura. Rev de Economia Política 2006; 26(4):596-618.^-1212 Miquilin IOC, León LM, Monteiro MI, Filho HRC. Desigualdades no acesso e uso dos serviços de saúde entre trabalhadores informais e desempregados: análise da PNAD 2008, Brasil. Cad Saude Publica 2013; 29(7):1392-1406.. Work status is also considered an important social determinant of health¹³13 Whitehead M. The concepts and principles of equity in health. Copenhagen: World Health Organization Regional Office for Europe ( [internet]. 1990; (document number EUR/ICP/RPD 414) [acessado 2018 Abr 20]. Disponível em: http://www.humanitarianweb.org/wp-content/uploads/2017/11/The-concepts-andprinciples-of-equity-and-health.pdf
http://www.humanitarianweb.org/wp-conten... .

The economic, social, and political context of Brazil, combined with changes in the productive structure, does not guarantee the employment protection legislation to be applied to all workers¹⁴14 Teodoro M. Características do mercado de trabalho e origem do informal. In: Jaccoud L, Silva FB, Delgado GC, Castro JA, Cardoso-Júnior JC, Theodoro M, Beghin N. Questão Social e Políticas Sociais no Brasil Contemporâneo. Brasília: IPEA; 2005. p. 91-126. [acessado 2018 Abr 20]. Disponível em: http://www.en.ipea.gov.br/agencia/images/stories/PDFs/livros/Cap_3-10.pdf
http://www.en.ipea.gov.br/agencia/images...

15 Oliveira HC, Santos JSP, Cruz EFC. O mundo do trabalho: concepções e historicidade. in III Jornada internacional de políticas públicas; 28 a 30 agosto de 2007. São Luiz: Universidade Federal do Maranhão. [acessado 2018 Abr 20]. Disponível em: http://www.joinpp.ufma.br/jornadas/joinppIII/html/Trabalhos/EixoTematicoB/178d5144a74686f5b7ffHILDERLINE%20C%C3%82MARA_JOSENEIDE%20SANTOS_EDUARDO%20CRUZ.pdf
http://www.joinpp.ufma.br/jornadas/joinp... ^-1616 Lameiras MAP, Sandro SC. Mercado de trabalho. Conjuntura e Análise. Brasília: IPEA; 2017. [acessado 2018 Abr 20]. Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/conjuntura/170418_cc34_mercado-de-trabalho.pdf
http://www.ipea.gov.br/portal/images/sto... , resulting in two types of work conditions: a formal and an informal labor market. The formal labor market is composed byworkers with salaries, who are supported by a set of labor laws and protection benefits. The informal labor market includes activities carried out without the support of the labor legislation¹¹11 Ulyssea G. Informalidade no mercado de trabalho brasileiro: uma resenha da literatura. Rev de Economia Política 2006; 26(4):596-618.^,1414 Teodoro M. Características do mercado de trabalho e origem do informal. In: Jaccoud L, Silva FB, Delgado GC, Castro JA, Cardoso-Júnior JC, Theodoro M, Beghin N. Questão Social e Políticas Sociais no Brasil Contemporâneo. Brasília: IPEA; 2005. p. 91-126. [acessado 2018 Abr 20]. Disponível em: http://www.en.ipea.gov.br/agencia/images/stories/PDFs/livros/Cap_3-10.pdf
http://www.en.ipea.gov.br/agencia/images...

15 Oliveira HC, Santos JSP, Cruz EFC. O mundo do trabalho: concepções e historicidade. in III Jornada internacional de políticas públicas; 28 a 30 agosto de 2007. São Luiz: Universidade Federal do Maranhão. [acessado 2018 Abr 20]. Disponível em: http://www.joinpp.ufma.br/jornadas/joinppIII/html/Trabalhos/EixoTematicoB/178d5144a74686f5b7ffHILDERLINE%20C%C3%82MARA_JOSENEIDE%20SANTOS_EDUARDO%20CRUZ.pdf
http://www.joinpp.ufma.br/jornadas/joinp...

16 Lameiras MAP, Sandro SC. Mercado de trabalho. Conjuntura e Análise. Brasília: IPEA; 2017. [acessado 2018 Abr 20]. Disponível em: http://www.ipea.gov.br/portal/images/stories/PDFs/conjuntura/170418_cc34_mercado-de-trabalho.pdf
http://www.ipea.gov.br/portal/images/sto... ^-1717 Campos AG. Breve histórico das mudanças na regulação do trabalho no Brasil. [internet]. Brasília: IPEA; 2015. [acessado 2019 Abr 20]. Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/3513/1/td_ 2024.pdf
http://repositorio.ipea.gov.br/bitstream... .

Few studies have investigated the insertion in the labor market of transgender people in Brazil and the world. In general, such studies are exploratory and restricted to the Sexually Transmitted Infections (STIs) context, especially HIV infection⁵5 Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a review. Lancet 2016; 388(10042):412-436.^,1818 Rondas LO, Machado LRS. Inserção profissional de travestis no mundo do trabalho: das estratégias pessoais às políticas de inclusão. Rev Pesquisas e Práticas Psicossociais 2015; 10(1):194-207.

19 Bonassi BC, Amaral MS, Toneli MJF, Queiroz MA. Vulnerabilidades mapeadas, Violências localizadas: Experiências de pessoas travestis e transexuais no Brasil. Quad Psicol 2015; 17(3):83-98.

20 Rocha RMG, Pereira DL, Dias TM. O contexto do uso de drogas entre travestis profissionais do sexo. Rev Saúde e Sociedade 2013; 22(2):554-565.^-2121 Roche K, Keith C. Como o estigma afeta o acesso à saúde para profissionais do sexo transgêneros. Rev British Journal of Nursing 2014; 23:1147-1152..

A better knowledge of the travesti and transsexual population conditions in relation to the labor market in the state of São Paulo could highlight the magnitude of the issue and help the developing public policies. The aim of this study was to identify the factors associated with formal employment of transgender people in the state of São Paulo.

Methods

This study analyzed data from the cross-sectional study “Vulnerabilities, health demands, and access to services of the travestis and transsexuals population in the State of São Paulo” - “the Muriel Project”²²22 Núcleo de Pesquisa em Direitos Humanos e Saúde da População LGBT (NUDHES). Projeto Muriel. [acessado 2018 Dez 28]. Disponível em: https://www.nudhes.com/projeto-muriel
https://www.nudhes.com/projeto-muriel... .

The project included 673 transsexuals who accessed healthcare and social assistance services in seven municipalities in the state of São Paulo (São Paulo, Campinas, São Bernardo do Campo, Santo André, Santos, São José do Rio Preto, and Piracicaba). The sample size was calculated by mapping travestis and transgender people enrolled or attending some activity developed by the healthcare and social assistance services in 2012, in the abovementioned cities.

Participants were selected by consecutively sampling travestis and transsexuals using the above services, and by the snowball technique, which is based on social networks. The inclusion criteria were: being 16 years old or older at the time of the interview, being a travestis, transsexual or transgender, and living in the state of São Paulo for at least six months.

The data collection instrument included questions on seven subjects: sociodemographic, professional background, health conditions, sexual and reproductive health, violation of human rights and discrimination, social context, and transgender transition path. The questionnaire was applied in a face-to-face interviewby a trained interviewerusing a tablet. Data collection occurred from mid-2014 to January 2015. For the present study, data from the questions related to work status were used.

Participants’ profession was investigated through the following questions: “Do you currently work?”, and if yes, “What is the employment relationship”, if not, “How do you live?”, “Has it been difficult for you to find a job?” Participants who reported that they were currently working wereconsidered workers. Workers were classified as formal or informal,adapted from categories used by the IBGE in the Continued National Survey of Household Samples (PNAD)²³23 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Notas metodológicas: Pesquisa Nacional por Amostra de Domicílios Contínua: Notas Metodológicas. [internet] 2014. [acessado 2019 Abr 20]. Disponível em: ftp://ftp.ibge.gov.br/Trabalho_e_Rendimento/Pesquisa_Nacional_por_Amostra_de_Domicilios_continua/Notas_metodologicas/notas_metodologicas.pdf
ftp://ftp.ibge.gov.br/Trabalho_e_Rendime... (Figure 1). Formal workers were those formally employed, municipal, state or military civil servants, paid interns, and employers with CNPJ (Brazilian legal person). Informal workers were those without a contract, who reported working for themselvesor for employers without CNPJ.

The dependent variable was being in the formal labor market (yes or no). The independent variables were: gender identity (transsexual woman /travestis or transsexual man), years of education (8 or less, 9 to 11, and 12 or more), age group in years (16 to 24, 25 to 39, 40 and over), race / skin color (white, black, brown, yellow, indigenous, ignored), having ever moved from the city of birth (yes or no), having a name change in documents (yes, no, or ignored), having a technical / vocational training or course (yes or no), having ever felt discriminated (yes or no), havingever been arrested (yes or no), type of medical follow-up (not on follow-up, follow-up for AIDS or sexually transmitted infections (STIs), or follow-up forgender transition process and others), being under medical follow-up (yes or no); being under follow-up for a transsexual process (yes or no), having a private health insurance (yes, no).

A descriptive analysis of the variables was performed. Bivariate and multivariate analysis was used to assess factors related to formal employment. The crude and adjusted odds ratios (OR) were calculated for each independent variable, with the respective 95% confidence intervals (95% CI), using the logistic regression model. Variables with a p <= 0.20 in the bivariate analysis were tested in the multivariate model, in ascending order (forward stepwise selection). Variables with a 95% confidence interval that did not include nullity (OR = 1.00) remained in the model, using the maximum likelihood ratio. The fit of the model was verified with the Hosmer and Lemeshow test (goodness-of-fit). All statistical analyzes were performed in the STATA^® software, version 13.0.

The project was designed and conducted according to the ethical standards in research with human beings in Brazil and was approved by the CRT/DST AIDS ethics committee, of the SMS-SP and SMS-Santo André. Participants signed the Informed Consent Form. People diagnosed with a health problem were referred to public health services or social assistance for treatment and follow-up.

Results

From a total sample of 673 interviews, 672 had valid information and were analyzed. Of those, 82.3% were from employed people, 13.1% not employed, and 4.6% were out of the labor market (Table 1). Regarding thetype of occupation, 53.9% were self-employed and 27.2% were employees, but only 14% of them had contracts protected by the labor law. About 40% of respondents were sex workers (Table 1).

The gender identities reported were: transsexual man (7%), transsexual woman or travestis (90.4%), and in 2.5% of the sample (n = 17) this information was ignored.

The average age of the sample was 32 years, 50.4% were in the age group from 25 to 39 years, 62% self-reported being of white race / skin color, 16.2% had 12 years or more of study, and 60.5% owned or rented their home. The current place of residence of most participants (49.5%) was the municipality of São Paulo. As for the other characteristics, 56.8% had some technical / vocational education, 37.9% contributed to the National Institute of Social Security (INSS), 25.4% had been previously imprisoned, 13% were undergoing medical follow-up for the sex reassignment procedures, and 16.3% had medical insurance. The distribution of the sample characteristics is shown in Table 2.

For the bivariate analysis of factors associated with entering the formal labor market, only the 528 workingparticipantswere included, excluding 119 persons that were not working and 25 others for whom the variables of interest were blank or had an unknown response (Table 3). The proportion of formal employment was 16.7%. Formal employment was 59.4% among transsexual men and 13.9 among transsexual women; transsexual men had nine times higher chance of entering the formal labor market than transsexual women (Table 3).

Among participants with 12 years or more of education, the chance of entering the formal labor market was almost 19 times higher compared to those with 8 years or less of study. In the bivariate analysis, being under follow-up for thegendertransition process was associated with a formal job compared with those who were not being followed up medically (Table 3).

In the final model, the following characteristics were independently associated with having a formal job: being a transsexual man (OR = 2.7; 95%CI = 1.7-6.5), having 12 years or more of study (OR = 7.5; 95%CI 2.7-20.1), receiving some type of medical follow-up (OR = 1.8; 95% CI 1.0-4.4), being followed up for gendertransition process (OR = 2.1; 95%CI 1.0-3.4), having private health insurance (OR = 2.8; 95%CI 1.5-5.1), and never having been arrested (OR = 3.3; 95%CI 1.2-8.9) (Table 4).

Discussion

The percentage of participants in our study that were in the formal labor market was extremely low: 16.7%. The factors associated with having a formal employment were being a trans man, having at least 12 years of education, receiving some medical follow-up, being followed up for the gender transition process, having a private medical insurance, and never having been arrested.

Data from the Monthly Employment Survey (PME) of the Brazilian Institute of Geography and Statistics (IBGE)²⁴24 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... show that, compared to our findings, the percentage of the general population in the metropolitan region of São Paulo with a formal job was much higher in 2014 and 2015 (55.3% and 54.9%, respectively).

The percentage of the transsexual population in informal jobswas much higher than that of the general population (25.9% in 2015)²⁵25 Organização internacional do Trabalho (OIT). A OIT no Brasil, trabalho descente para uma vida Digna - Escritório do Brasil [internet]. 2012 [acessado 2018 Abr 20]. Disponível em: http://www.oitbrasil.org.br/sites/default/files/topic/gender/pub/oit_no_brasil_folder_809.pdf.
http://www.oitbrasil.org.br/sites/defaul... . This difference is not an exclusively Brazilian phenomenon. In a study with 6,450 transgender people in the United States in 2011,the frequency of non-employed persons was double that found in the general population⁸8 Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey, executive summary. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.. In addition, our data probably also reflect the socioeconomic situation in Brazil in recent years, in which an increase in informal employmentoccurred, aggravating the inequality regarding transsexual people, who were already victims of stigma and discrimination and hadmore difficulty getting a formal employment¹⁸18 Rondas LO, Machado LRS. Inserção profissional de travestis no mundo do trabalho: das estratégias pessoais às políticas de inclusão. Rev Pesquisas e Práticas Psicossociais 2015; 10(1):194-207.^,1919 Bonassi BC, Amaral MS, Toneli MJF, Queiroz MA. Vulnerabilidades mapeadas, Violências localizadas: Experiências de pessoas travestis e transexuais no Brasil. Quad Psicol 2015; 17(3):83-98..

Although work informality can take place by choice, the lack of contributions to the social security system makes an informal worker more vulnerable¹¹11 Ulyssea G. Informalidade no mercado de trabalho brasileiro: uma resenha da literatura. Rev de Economia Política 2006; 26(4):596-618.^,2525 Organização internacional do Trabalho (OIT). A OIT no Brasil, trabalho descente para uma vida Digna - Escritório do Brasil [internet]. 2012 [acessado 2018 Abr 20]. Disponível em: http://www.oitbrasil.org.br/sites/default/files/topic/gender/pub/oit_no_brasil_folder_809.pdf.
http://www.oitbrasil.org.br/sites/defaul... . Contributing to the social security system guarantees income in case of leaving work, whether due to retirement, illness, disability, or unemployment. In Brazil, workers with a formal contract automatically make contributions and are entitled to the benefits, which is much less frequent among the unemployed and informal workers¹¹11 Ulyssea G. Informalidade no mercado de trabalho brasileiro: uma resenha da literatura. Rev de Economia Política 2006; 26(4):596-618.^,1717 Campos AG. Breve histórico das mudanças na regulação do trabalho no Brasil. [internet]. Brasília: IPEA; 2015. [acessado 2019 Abr 20]. Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/3513/1/td_ 2024.pdf
http://repositorio.ipea.gov.br/bitstream... . In the present study, close to 80% of informal workersdid not contribute to the social security system, while in the general populationthe annual average was 22.0% in 2014 and 2015²⁴24 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... . Values similar to ours were found by Bonassi in Santa Catarina: 74% of transsexuals or travestis reported not contributing to the social security system¹⁹19 Bonassi BC, Amaral MS, Toneli MJF, Queiroz MA. Vulnerabilidades mapeadas, Violências localizadas: Experiências de pessoas travestis e transexuais no Brasil. Quad Psicol 2015; 17(3):83-98.^,2424 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... .

The unemployed transsexual population in our study had financial difficulties: 37.8% lived in temporary homes and more than half reported living with a monthly income of less than two minimum wages. The average income in the general population in 2014 and 2015 in the metropolitan region of São Paulo was slightly more than three minimum wages²⁴24 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... .

The occupation reported by 40% of the interviewees in this study was sex work, which corroborates the findings of other studies¹⁸18 Rondas LO, Machado LRS. Inserção profissional de travestis no mundo do trabalho: das estratégias pessoais às políticas de inclusão. Rev Pesquisas e Práticas Psicossociais 2015; 10(1):194-207.^,2626 Organização internacional do Trabalho (OIT). Discrimination at work on the basis of sexual orientation and gender identity: Results of the ILO's PRIDE Project [internet]. 2015. [acessado 2019 Abr 20]. Disponível em: http://www.ilo.org/wcmsp5/groups/public/---dgreports/---gender/documents/briefingnote/wcms_368962.pdf
http://www.ilo.org/wcmsp5/groups/public/... . Although sex work is included in the Brazilian Classification of Occupations - CBO²⁷27 Brasil. Classificação Brasileira de Ocupações: CBO [internet]. Brasília: MTE; 2010. [acessado 2018 Abr 22]. Disponível em: http://www.mtecbo.gov.br/cbosite/pages/download?tipoDownload=3
http://www.mtecbo.gov.br/cbosite/pages/d... , its activities are not regulated in Braziland carried out entirely informally. Entering the labor market as a sex worker is probably one of the results of the stigma suffered by transsexual people, which also motivates early school drop-out that leads to low rates of professional training. In addition, transsexual sex workers are extremely vulnerable to sexually transmitted infections, being one of the groups most affected globally by HIV infection²⁸28 Soma T, Underhill K. Sex Work and HIV Status Among Transgender Women: Systematic Review and Meta-Analysis. J Acquir Immune Defic Syndr 2008; 48(1):97-103.

29 Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, Sherman SG, Kerrigan D. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis 2012; 12(7):538-549.^-3030 Programa Conjunto das Nações Unidas (UNAIDS). The Gap Report 2014. [acessado 2019 Mar 9]. Disponível em: http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf
http://www.unaids.org/sites/default/file... .

Transsexual men were more likely to have a formal job than transsexual women or travesti. The finding could be due to the influence of the generalappearance being in agreement with the gender identity of transsexual men after the use of hormones, which would protect them from being identified as transsexual, and, consequently, be less discriminated.

Studies also indicate that the gender inequality in the work environment of cisgender people is reproduced in the transsexual population²⁴24 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... . Corroborating this hypothesis, a study carried out in the USA showed that after gender transition, the probability of transsexual women finding a job is lower than men⁸8 Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey, executive summary. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.. According to reports by transsexual women interviewed in Salvador, the difficulties entering the formal job market were much greater after gender transition³¹31 Magno L, Dourado I, Silva LAV. Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saude Publica 2018; 34(5): e00135917.. In contrast, transsexual men had a greater chance offinding formal work or improving their incomeafter gender transition³²32 Schilt K, Wiswall M. Before and After: Gender Transitions, Human Capital, and Workplace Experiences. The B.E. Journal of Economic Analysis & Policy Contributions 2008; 8(1). [acessado 2018 Abr 20]. Disponível em: https://www.ilga-europe.org/sites/default/files/before_and_after_-_gender_transitions_human_capital_and_workplace.pdf
https://www.ilga-europe.org/sites/defaul...

33 Davidson S. Gender inequality: Nonbinary transgender people in the workplace. Rev Cogent Social Sciences [internet]. 2016 [acessado 2019 Abr 20]; 2:1-12. Disponível em: https://scholarworks.umass.edu/cgi/viewcontent.cgi?referer
https://scholarworks.umass.edu/cgi/viewc... ^-3434 Geijtenbeek L, Plug E. Is there a penalty for becoming a woman? Is there a premium for becoming a man? Evidence from a sample of transsexual workers. Rev IZA [internet]. 2015 [acessado 2019 Abr 20]; 9077. Disponível em: http://ftp.iza.org/dp9077.pdf
http://ftp.iza.org/dp9077.pdf... . The study by Davidson³³33 Davidson S. Gender inequality: Nonbinary transgender people in the workplace. Rev Cogent Social Sciences [internet]. 2016 [acessado 2019 Abr 20]; 2:1-12. Disponível em: https://scholarworks.umass.edu/cgi/viewcontent.cgi?referer
https://scholarworks.umass.edu/cgi/viewc... demonstrated that transsexual women are more discriminated at hiring, as their job applications get more refusals than those of transsexual men. This differentiation was observed in other categories of the analysis, showing that transsexual women have worse jobs and lower wages³³33 Davidson S. Gender inequality: Nonbinary transgender people in the workplace. Rev Cogent Social Sciences [internet]. 2016 [acessado 2019 Abr 20]; 2:1-12. Disponível em: https://scholarworks.umass.edu/cgi/viewcontent.cgi?referer
https://scholarworks.umass.edu/cgi/viewc... .

The percentage of transsexuals with higher education in our study was 16.2%, while in the general population of the metropolitan region of São Paulo this percentage was 66%²⁴24 Instituto Brasileiro de Geografia e Estatísticas (IBGE). Indicadores IBGE: Principais destaques da evolução do mercado de trabalho nas regiões metropolitanas abrangidas pela pesquisa - Ano 2003 a 2015, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre. [internet] 2015. [acessado 2019 Abr 20]. Disponível em: https://ww2.ibge.gov.br/home/estatistica/indicadores/trabalhoerendimento/pme_nova/retrospectiva2003_2015.pdf
https://ww2.ibge.gov.br/home/estatistica... . Similar results were found in other regions of Brazil. Bonassi et al.¹⁹19 Bonassi BC, Amaral MS, Toneli MJF, Queiroz MA. Vulnerabilidades mapeadas, Violências localizadas: Experiências de pessoas travestis e transexuais no Brasil. Quad Psicol 2015; 17(3):83-98., in a study carried out in Santa Catarina,reported that 33.9% (N = 100) of transsexuals and travestis dropped out of school at between 16 and 19 years of age. In the metropolitan region of Recife, of 100 travestis interviewed between 2008 and 2009, 17.4% had less than four years of education and 44.9% did not complete elementary school³⁵35 Sousa PJ, Ferreira LOC, Sá JB. Estudo descritivo da homofobia e vulnerabilidade ao HIV/Aids das travestis da Região Metropolitana do Recife. Cien Saude Colet 2013; 18(8):2239-2251..

Our data showed that having 12 years or more of study is a factor positively associated with entering the formal job market. However, this finding is not consistent in the literature. Bauer³⁶36 Bauer GR, Scheim AI. Trans PULSE Project Team. Transgender People in Ontario, Canada: Statistics to Inform Human Rights Policy [internet]. London: ON; 2015. [acessado 2019 Abr 20]. Disponível em: https://www.rainbowhealthontario.ca/wp-content/uploads/woocommerce_uploads/2015/09/Trans-PULSE-Statistics-Relevant-for-Human-Rights-Policy-June-2015.pdf
https://www.rainbowhealthontario.ca/wp-c... , studying discrimination and prejudice against transsexuals in Canada, found a high frequency of highlyeducatedtranssexuals who were not in the labor market or had employment levels below their degree of qualification. In Brazil, Rondas and Machado mention that, although recommended, achieving high education does not guarantee this population will enter the labor market¹⁸18 Rondas LO, Machado LRS. Inserção profissional de travestis no mundo do trabalho: das estratégias pessoais às políticas de inclusão. Rev Pesquisas e Práticas Psicossociais 2015; 10(1):194-207.. The low education level of the transgender population can be explained, among other factors, by thehostile environment of schools for those people. In the USA in 2011, transsexuals reported having suffered harassment (78%), physical aggression (35%), and sexual violence (12%) at schooldue to their gender identity⁸8 Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey, executive summary. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011..

An association was found between access to healthcare,such as being monitored for the gender transition process and having a private medical insurance,and having a formal job. The reasons that allowed having one of the scarcespots in the healthcare services for transition procedures might be similarto the reasons for which other barriers were broken, such as education and access to the formal labor market. In Brazil, between 2008 and 2015, data from the Hospital Information System of the Unified Health System (SIH-SUS)indicate that only 320 surgeries were performed for sex reassignment, and there are long waiting lines for the procedure³⁷37 Popadiuk GS, Oliveira DC, Signorelli MC. A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros (LGBT) e o acesso ao Processo Transexualizador no Sistema Único de Saúde (SUS):avanços e desafios. Cien Saude Colet 2017; 22(5):1509-1520. [acessado 2019 Mar 10]. Disponível em: https://doi.org/10.1590/1413-81232017225.32782016
https://doi.org/10.1590/1413-81232017225... . Other studies also report relationships between access to the labor market and the gender transition procedures.

The International Labor Organization PRIDE study²⁶26 Organização internacional do Trabalho (OIT). Discrimination at work on the basis of sexual orientation and gender identity: Results of the ILO's PRIDE Project [internet]. 2015. [acessado 2019 Abr 20]. Disponível em: http://www.ilo.org/wcmsp5/groups/public/---dgreports/---gender/documents/briefingnote/wcms_368962.pdf
http://www.ilo.org/wcmsp5/groups/public/... reported that among the difficulties transsexual people faceentering the labor market were: having a gender expression incompatible with the name in official identification documents and presenting an incomplete gender transition due to difficulties in accessing the necessary services²⁶26 Organização internacional do Trabalho (OIT). Discrimination at work on the basis of sexual orientation and gender identity: Results of the ILO's PRIDE Project [internet]. 2015. [acessado 2019 Abr 20]. Disponível em: http://www.ilo.org/wcmsp5/groups/public/---dgreports/---gender/documents/briefingnote/wcms_368962.pdf
http://www.ilo.org/wcmsp5/groups/public/... . In Brazil, a 2012 study found that among the various reasons for not undergoing transgender transition were: disadvantages of finding a formal job due to discrimination and insufficient financial resources to fund the process²2 Sampaio LLP, Coelho MTAD. Transexualidade: aspectos psicológicos e novas demandas ao setor saúde. Rev Comunicação, Saúde, Educ 2012; 16(42):637-649.. Gender transition procedures might also interfere with professional insertion due to the long period required for recovery and special careafter a sexual reassignment surgery³⁸38 Petry AR. Mulheres transexuais e o Processo Transexualizador: experiências de sujeição, padecimento e prazer na adequação do corpo. Revista Gaúcha de Enfermagem 2015; 36(2):70-75. [acessado 2019 Jun 15]. Disponível em: www.scielo.br/rgenf www.seer.ufrgs.br/revistagauchadeenfermagem
www.scielo.br/rgenf www.seer.ufrgs.br/re... . For formally employed people, the required leave of absence is covered by income from the social security system, which is rarely the case with informalworkers.

Our findings corroborate the considerations of Almeida et al.³⁹39 Almeida GS, Ribeiro ACP, Gebrath Z. As relações de trabalho como um aspecto da assistência à saúde de pessoas trans. In: Coelho MTAD, Sampaio LLP, organizadoras. Transexualidades: um olhar multidisciplinar. Salvador: EDUFBA; 2014. p. 187-200., who emphasize the need to consider all the factors involved in the complex health status and health determinants of the transsexual population, and that interventions should not be focused on body manipulations only.

As for study limitations, participants were selected in specialized health services –including a comprehensive healthcare clinic for travestis and transsexuals – and social assistance centers, which could result in selection bias. In addition, the original study was not designedwith the objective of investigating insertion in the labor market. However, it wasa population-based study with a large sample that included people from different regions of the state of São Paulo. Therefore,our findings provide new information onthe access to the labor market of transsexual people.

The low percentage of transsexual people in formal jobswas a highlight, which shows their increased vulnerability. Public policies for inclusive actions in educational institutions, promoting tolerance and respect for the diversities of gender identity are key to reverse the school dropout scenario and consequently the low educational level of this population. Another important aspect to reduce the inequalities experienced by transsexuals in the labor market is the need to increase access to gender transition process in the Unified Health System.

In summary, our results indicate the need for public policies aiming at reducing stigma and discrimination and improving access to education and professional qualification for transgender people, making the competition for a position in the formal job market more equitable.

Acknowledgments

To FAPESP, fort he financial support of the Muriel project.

To the Health Secretariat of the State of São Paulo and to the Reference and Training Center for Sexually Transmitted Diseases - CRT / DST-AIDS of the São Paulo State Program - PESP.

To the professional team involved in the Muriel Project, without whom the study would not be possible.

To Márcia Giovanetti (in memoriam) for her work in promoting the visibility, dignity and human rights of transsexual and travestis women, contributing to the development of public policies against prejudice and discrimination and expanding access to health services.

To all transsexual people who participated in the Muriel Project.

References

Publication Dates

History