Trans Women’s Body Self-Image and Health: Meanings and Impacts of Sex Work

Abstract

This paper aims to present and discuss the results of a qualitative study conducted in the city of Porto, Portugal, aiming to understand the self-determination process and the meanings and impacts of sex work on trans women’s body self-image and health. Between January and July 2019, six individual interviews were performed with participants aged between 23 and 57 and then analyzed using thematic analysis. The results suggest that the participants were subjected to several experiences of discrimination and violence since childhood, negatively impacting their health and social integration. In their narratives, a conflict between the idea of an idealized body, congruent with gender identity, and the idea of a profitable body, compatible with the requirements of sex work clients, emerged. As a consequence, several tensions are experienced, both in personal and professional domains. Additionally, the difficulties felt in accessing the National Health System, to receive specialized support and treatment, increase the risk of being exposed to clandestine procedures, which exacerbates their vulnerability. The findings point to the importance of comprehending trans women sex workers’ needs and reanalyzing how their health conditions might be improved.

1. Introduction

Trans individuals have gained more attention in recent years, and Portugal has taken up the responsibility for reinforcing the protection of trans rights (ILGA Portugal 2020). Despite the steps taken, transgender people still face structural barriers in their lives due to bias, stigma, and discrimination (European Union Agency for Fundamental Rights (FRA) 2020; ILGA Portugal 2020; Saleiro et al. 2022).

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 (Zoli et al. 2022). 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.

1.1. 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 this paper, 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 the year 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 acknowledgment 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.

1.2. 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).

Recent 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.

1.3. The Current Research

As research on trans people in sex work in Portugal and elsewhere is still scarce (Oliveira 2018; Weitzer 2023), this exploratory study aims to understand the self-determination process and the meanings and impacts of sex work on trans women’s body self-image and health.

Starting from a constructionist and critical social paradigm (Marecek et al. 2004) and seeking to privilege the subjectivities and idiosyncrasies of the participants, the qualitative methodological design gains a central character in the development of this investigation.

2. Methods

2.1. Participants

A total of six individual interviews were carried out with trans women that were engaged in sex work when the interviews were conducted, except for one. Participants ages ranged from 23 to 57 years (M = 35; SD = 13.431). Four participants were Portuguese nationals and two were Brazilian immigrants. One of the Portuguese participants was Roma. All resided in Portugal and were single. Concerning educational qualifications, they vary between the fourth grade and a bachelor’s degree (Cf.

Table 1. Sociodemographic characteristics of the participants.

Participants	Age	Nationality	Education	Marital Status
P1	46	Portuguese	4th grade	Single
P2	26	Portuguese	7th grade	Single
P3	29	Portuguese	6th grade	Single
P4	57	Brazilian	Bachelor’s	Single
P5	23	Portuguese	12th grade	Single
P6	29	Brazilian	12th grade	Single

).

2.2. Procedure

To recruit participants, Portuguese non-governmental social organizations that work with trans sex workers in the north of the country were contacted to disseminate the study among their users. Participants were eligible to participate in the study if they identified themselves as trans women; were more than 18 years of age; had been or were sex workers and understood Portuguese. A non-probabilistic, intentional, and convenience sample to access experiential experts was intended (Denzin and Lincoln 2011).

The request for the interviews was made through direct contact with the participants by telephone, after their consent. At the beginning of each interview, the study objectives were explained, safeguarding anonymity and confidentiality. Participants were informed about the anonymous nature of the study and gave their written informed consent to participate.

The process of selection was carried out by using the snowball technique, i.e., the contribution of some participants by suggesting other possible candidates be part of the study, facilitating access to the six interviewees. Although more trans women were identified as potential participants, they did not accept being interviewed. The interviews were conducted in places of their preference.

This process of data collection took place between January and July 2019. Each interview lasted an average of 40 min. The study was conducted in accordance with the Declaration of Helsinki and respected all the ethical standards of scientific research, especially those concerned with confidentiality and human care (APA 2017), respecting the Code of Ethics of the Order of Portuguese Psychologists, and the General Data Protection Regulation.

2.3. Instrument

A sociodemographic form and an individual semi-structured interview script were used to collect data. The interview script, built by a literature review, was composed of five sections: (1) life and gender identity paths (e.g., How was your gender identity development?), (2) characterization of healthcare services in Portugal (e.g., How do you characterize and what is your personal experience with health services in Portugal being a sex worker?), (3) social support networks during gender identity development (e.g., Did you have any support (financial, affective) during the transition process?), (4) sex work paths and experiences (e.g., Describe the beginning of your professional activity. Have you ever felt discriminated against? If yes, in which contexts?) and (5) sex work and interference in their transition trajectories (e.g., Does sex work impact your body image? Does it have consequences for your health? Do you consider that body changes can influence/influence the performance of your work?).

2.4. Data Analyses

Interviews were fully transcribed and analyzed following Braun and Clarke’s (2006) proposal of thematic analysis. This qualitative descriptive approach constitutes a useful tool to identify, analyze and describe patterns within data (Braun and Clarke 2006). The thematic analyses made were informed by the constructionist perspective. This perspective does not focus on essentialisms reporting only life experiences, but on understanding events, realities, meanings, and experiences that are both reflections and effects of existing social discourses (Braun and Clarke 2006).

Braun and Clarke’s (2006) recommendations were followed, namely, by featuring the six steps that a thematic analysis must include: (i) become familiar with the data (close and repeated reading of the material, allowing in-depth knowledge of the data and drawing first insights); (ii) generate initial codes; (iii) search for the themes (identification of a certain level of standardization of data about the research questions posed and the purposes of the study) (iv) review the themes; (v) define and name the themes; (vi) produce the report. Using the data obtained from the semantic content and the latent constructs present in participants’ discourses, an inductive thematic analysis was conducted (Braun and Clarke 2006). This comprehensive examination of the data and the coding and categorization processes were developed following the intersubjective consensus of the research team members. In an earlier phase, both the codification and the categorization were carried out by each researcher autonomously, and several meetings were organized to reach a final consensus.

The whole analysis was informed by an intersectional grid, considering that the formation of these discourses is conditioned by this context but also by people’s different identity belonging.

3. Findings and Discussion

Thematic analysis resulted in the identification of two themes and seven subthemes contained in the discourses of the six interviewees (Cf.

Table 2. Themes and subthemes.

Themes	Subthemes
Identity experiences	Identity self-questioning
	(Re)constructions of the body
	Experiences in healthcare
	Violence
Sex work experiences	Drivers
	Meanings of experiences and health consequences
	Sex work’s impact on body changes

).

We will describe, analyze and discuss each one of the themes and subthemes in further detail, and to characterize each participant, we will use quotations.

3.1. Identity Experiences

This theme reflected participants’ gender development trajectories in different social contexts.

There were four subthemes identified in this theme: (i) identity self-questioning; (ii) (re)constructions of the body, (iii) experiences in healthcare, and (iv) violence.

The first subtheme includes the prospective experiences of participants regarding gender identity since childhood, and how they deal with them. Although the interviewees’ life trajectories encompass a diversity of experiences, participants focused on their personal experiences when describing their struggle with self-identity. Throughout their development, these women soon realized the non-conformity between the sex designated in the birth record and the gender to which they felt they belonged.

[…] it all started at school. I remember that a person of 4/5 already has an idea. I remember that I liked going outside as a girl with toys then …

(P1, Portuguese)

Since being children, they have known their gender identity to be feminine, expressing it through clothes, toys, or adornments (Monteiro and Brigeiro 2019). They also report an early occurrence of confrontation with the persistent pathologizing of transgender or non-binary experiences (Rodrigues et al. 2014, 2020). Participants described the development of female gender identity and expression as a complex process, sometimes confused by third parties with issues of sexual orientation.

People sometimes turned to my mother and said does your son have homosexual tendencies?

(P1, Portuguese)

Thus, the perceived incongruity generated discomfort concerning self-image and self-conceptualization, as expressed in the statement transcribed below.

[…] from a young age, I always knew, I always knew, since I was little, that something was not right with me. (P3) For as long as I can remember. Because I actually always felt different from other kids.

(P4)

Therefore, the self-questioning of gender identity since childhood seems to have been accompanied by a feeling of disruption reinforced by the environment, which may be indicative of psychological suffering. The life of a trans is a struggle to always conform to the standard. It’s not an obligation, but it’s bliss. So, a lot of people stop wanting to know me just because I’m trans, and that hurts. That hurts a lot.

(P6, Brazilian)

Since childhood, these women conceptualize themselves as different from the heteronormative norm, feeling that they do not fit into the imposed cis heteronormative system (Wirtz et al. 2020). The social transphobic reactions they experience create a sense of having a “wrong body”, impacting not only the way they see themselves, but also the way they want to be, and the way they move socially (Rodrigues et al. 2020; Winter et al. 2016).

Regarding the development of their gender expression, some participants assume it to be a difficult process, due to the lack of courage in assuming a “new identity”. Others expressed that was a harder process for other people than for themselves.

“I always dealt well with it, it was people who did not deal well with it (…) I went in front of the mirror, with a little bit of makeup that I used. A little bit of mascara on the eyelashes and just a gloss”.

(P4, Brazilian)

However, the female body, its built-in context, and functions as a projection of themselves are quite important for the interviewees, demarcated by changes in appearance, namely in the way they dress, their use of make-up, and having long hair.

The second subtheme, (Re)constructions of the body, conveys how these women incorporate the need to affirm their identity with body changes. From the analysis of the data collected, it was noted that the interviewees agreed with the existence of a multiplicity of ways of being women.

The affirming process may resort to different social, hormonal, and/or surgical means. All participants described adherence to gender affirmation to achieve psychological well-being, or the desire to do so. Thus, bodily (re)constructions are seen as a process that can be carried out throughout their lives, as they have the economic capacity to do so. All mentioned, however, that it was not in the genitalia that they expected to find femininity and/or masculinity. Thus, sex reassignment surgery was not a mandatory goal to be achieved for some of the participants. However, the construction of a feminine appearance, the consumption of hormones, breast implants, rhinoplasty, and the readjustment of the thighs are procedures that all the participants desire.

I started by working as a crossdresser, crossdresser. I was just a boy dressed for services, in nightclubs, in private events, and even on the street at night. Then, I started the transvestite phase, which was still unwilling to have surgeries, but I wanted a breast to have a completely feminine look. It was later that I started the treatments and medical consultations with specialists.

(P3, Portuguese)

“In my case, the first thing was to increase my breasts because breasts increase a woman’s self-esteem”.

(P6, Brazilian)

Breast implants seem to have special prominence since they are acknowledged as an aspect that significantly contributes to increased self-esteem and increasing a sense of belonging. The breast assumes an expression and social recognition of the feminine body, according to the norms and stereotypes of normativity (Davis et al. 2016; Pinto and Moleiro 2021; Stowell et al. 2020), allowing the performative construction of bodies). Thus, gender affirmation is to them much more than the genitalia (Canella Filho and Rocha-Coutinho 2013).

Participants considered these gender-affirming interventions and procedures very expensive.

I paid three thousand euros at the time […]

(P1, Portuguese)

Despite free support from the National Health Service (SNS) for carrying out some procedures, not all are covered, and financial support is practically non-existent.

I even went to CUF to pay out of my pocket; consultations are very expensive.

(P3, Portuguese)

On the other hand, there is a great delay in care, which leads some trans women to opt for using private health services when they have the financial means, or through clandestine ways.

I took a high dosage, and it started; in my breast, it came out; how can I tell you, it’s a white liquid like milk? I had too much-altered prolactin …

(P6, Brazilian)

Interviewees assumed that these were risk decisions with clear implications for their health.

I made a butt and injected it at home with silicone. Wow, I almost died … Oh, I almost died. I still feel it today; today, I have to take medicine, and sometimes my leg gets stuck; it swells a lot.

(P1, Portuguese)

I used ten different hormones … Always looking for perfection, but without medical control. Always on my own.

(P6, Brazilian)

Sometimes, access to the SNS occurs late (Monteiro and Brigeiro 2019), when damage caused by harmful practices has already occurred. Although these women have the full mental capacity for their self-determination, they face some risks because in many cases, they do not have access to specialized medical support (Spizzirri et al. 2021). The participants, being aware of the risks and considering them in their decisions, still tend to focus on the expectations of the result (Monteiro and Brigeiro 2019). Not infrequently, and motivated by the expectations generated by their profession, they are subjected to invasive procedures that compromise their health and well-being. The consequences of using clandestine routes are often harmful to health and can leave a medium to long-term sequelae. In the case of trans women, the use of contraceptive pills is particularly prominent (Arán and Murta 2006) due to the ease of acquisition. Body (re)construction appears as an end in interviewees’ speeches, but also as an end to achieve that is worthy, contributing significantly to their physical and emotional well-being.

However, after seeing the changes, oh, it’s worth it. It pays off, indeed! It pays off! Much better.

(P3, Portuguese)

The process of self-realization that the transformation of the body seems to provide is, however, not without risks.

The third subtheme includes the experiences of the participants within health services: one regarding health support during the self-identity process and another regarding gender-affirming interventions.

Participants were advised from an early age to have psychological and psychiatric help:

At school, they began to realize what I was and told my mother that they had advised her to take me to a psychologist or psychiatrist. […] He called my mother crazy.

(P1, Portuguese)

Contexts and social actors assume that a trans person has a mental problem. As previously mentioned, the trans population presents higher health risks than the rest of the population at physical, psychological, and social levels (Pinto and Moleiro 2015), but not all trans people need support.

However, healthcare professionals are sometimes the first and only support available, as discrimination and stigmatization often come from families.

Contact with the health system is described as demanding, and, in some cases, evidence of discrimination is pointed out, as we can see in the following excerpts,

One negative aspect highlighted about the gender-affirming procedures was the slowness of medical procedures over time and bureaucracies. At first, it was tiring; it was an industrial dose of treatments, consultations, and evaluations, and we went through several evaluations. There were years of treatment, consultations, and evaluations […] I think sometimes they take a long time.

(P3, Portuguese)

Maybe in the bureaucratic part, of course, there has to be bureaucracy, but for health, I think it didn’t need to be that much.

(P6, Brazilian)

Another aspect was the discrimination felt in health services with the use of pronouns based on the sex assigned at birth. One participant said,

People are humiliated. They carry out terrorism, take advantage of the fact you are vulnerable, and begin to gloat over your vulnerability.

(P4, Brazilian)

[…] Sometimes I drove to the hospital, you know? Because I go to the hospital for an appointment, and if I had the man’s name, I would say, “oh my god,” but look what comes out on the computer, and they call me by the name that appears.

(P1, Portuguese)

Indeed, many of the principles established by entities such as the World Professional Association for Transgender Health (Coleman et al. 2012), which advocate the application of a gender-affirming perspective, are not adopted by the services, which not infrequently act as an extension of the prejudice and violence that trans people are subjected to in other contexts (Goldenberg et al. 2020; Pampati et al. 2021; Winter et al. 2016). Inadequate care practices often compound the constraints of a lagging public healthcare system that seems ill prepared to respond to the needs of trans people (Pinto and Moleiro 2021; Rodrigues et al. 2020). Such practices contribute to increased stigma and are perceived by the participants as violating their fundamental rights (Hughto et al. 2015). In this sense, the health context is identified as one that most accentuates the structural inequalities experienced by trans people.

The fourth subtheme, violence, describes episodes of violence due to trans people’s gender identity. When asked if they had been victims, all participants responded affirmatively, saying that most of the time, transphobia and violence start within the family. While it is true that for some of these women, their families are an essential source of support, for others, they are the source of rejection, which also happens with friends.

My mother knew what I was, and woe to anyone who said anything to her, woe to anyone. I had a great mother. I lost many friends. When I was gay, they weren’t ashamed; when they saw me with my breasts, they said the same thing, but it’s you there and me here.

(P1, Portuguese)

Participants 2 and 3 had a persistent experience of violence in their families up to an expulsion from home.

It wasn’t easy to deal with because my family is Roma. It wasn’t easy; my mother packed my things “goodbye, see you tomorrow” when I was 15.

(P2, Portuguese)

Because I was thrown out at 14 … my family put me out. In my family, I was super mistreated and insulted; they humiliated me a lot and beat me.

(P3 Portuguese)

In some cases, romantic relationships are characterized by victimization processes, in which context trans people may have their gender identity questioned. Participants reported being blamed for not yet having a vagina or for being an imitation of a woman (Rocon et al. 2020) when they have not yet performed the sex reassignment procedures.

[…] when I was attacked by my partner, he stepped on my head, and I got a loose tooth.

(P5, Portuguese)

Additionally, school and work contexts, particularly sex work, emerge as those in which violence is most felt. Sex work, as evidenced in the participants’ speeches, is especially violent.

Regarding school, I was mocked … I was already a transvestite or a gay; it was this, it was that.

(P5, Portuguese)

There is no job for you in the formal market. It’s not a choice. I would not choose to go through psychological suffering all my life to adapt my appearance to the female gender, family suffering, suffering in the job market, and love suffering. It’s tough.

(P6, Brazilian)

[…] I suffered a lot, I suffered … sometimes at night I went out into the street, and they pulled out a pistol, they threw stones at me, fire extinguishers, they treated me badly, they kicked my door, broke windows […]

(P1, Portuguese)

I got beat up by five transvestites. Because they didn’t want me on the street … I was prone to be beaten, robbed, and stabbed; I’d already been stabbed.

(P2, Portuguese)

I’ve been to the hospital, beaten and violated. People stoned me during the day; I was even unconscious on the floor, with my head all open, a huge pool of blood.

(P3, Portuguese)

In the case of the participants, the victimization they suffer tends to be characterized as chronic over time, manifesting itself in multiple contexts and implying different typologies. This reality is reflected in the dramatic experience of stories marked by insecurity and trauma.

Stigma, discrimination, and violence against trans people seem to be a constant in the different spheres in which they move, with these experiences translating into serious consequences for physical and psychological health (Connolly et al. 2016; Meyer 2003; Nadal et al. 2014; Neves et al. 2023; Oliveira 2011; Ramalho et al. 2013; Stotzer 2009). Even routine activities pose significant challenges for the participants, since social norms limit their freedom.

3.2. Sex Work Experiences

This theme exposed the sex work experiences of the participants and is composed of three subthemes; (i) drivers; (ii) meaning of experiences and health consequences; (iii) sex work’s impacts on body changes.

The first subtheme identified spans interviewee experiences linked to the beginning of sex work. Most participants entered the sex industry to survive, as the alternatives placed them in a situation of particular social vulnerability. Some of them were homeless, without any family support.

My family put me out on the street, but I met a girl who lived in an abandoned house where several young people lived, who also lived on the streets, and that girl led me to prostitution, heroin, and cocaine.

(P3, Portuguese)

I started sleeping under a boat, always looking for new ideas and knowing what I would do until I got a proposal from a 50-something man who said that my life was not under a boat and that I could make a lot of money. I had to pay a commission of 250 euros per month. That is, of the money I earned, 250 was for him. Regardless of earning more or less.

(P2, Portuguese)

Others had difficulties accessing job opportunities. One participant said,

There is no work for you in the formal market. Because there is prejudice.

(P6, Brazilian)

Indeed, resistance to their insertion in the so-called conventional professional market does not seem to come from them but from the employers themselves. This gave them no chance of another career path.

He got me a job at a wire factory; he gave me the documentation, and I went. The man at the factory actually said, “they’re playing with us, aren’t they? I look at you, and you’re a woman, and I’m going to put you to work among men; this won’t turn into work. People don’t look at what I know how to do; they look at what I am … I had two options: I stole or prostituted myself.

(P1, Portuguese)

The stigma and discrimination faced by trans women as a result of their gender identity are pervasive in many contexts. The participants face interpersonal discrimination not only in their families but also in the workplace (Nadal et al. 2014; Winter et al. 2016). As a result, trans women experience a high prevalence of adverse outcomes, including homelessness, poverty, lack of employment opportunities, and violence. This interpersonal discrimination and the lack of opportunities push them into sex work (Oliveira 2018). Sex work emerges as a context of survival, but also as a context that allows participants’ gender to be affirmed more quickly,

I used to work, but with my salary, I would never in my life get a breast, never, never, never. I earned it to survive, didn’t I?

(P1, Portuguese)

The money raised for this activity is more than the options found in the formal labor market (Ramalho et al. 2013). In this sense, the gender affirmation goal also contributed to involvement in sex work, as is widely documented in other studies (Pessoa 2020).

Despite being aware of the difficulties they will face in future, one participant commented

I can’t imagine the future. Because it’s like that, I won’t have work; I won’t have retirement. It’s all very unstable.

(P1, Portuguese)

Their life projects contemplate achieving stability at the individual, labor and relational level, as we can see in the following speeches:

In 10 years, I hope to have my process completed; I hope I already have my vagina, my pair of breasts, and my hair long, and I already look like a woman. To be already working in my chain of stores and already married.

(P5, Portuguese)

Have my house, and a potential husband, full of animals; I love animals, let it be my children, or possibly adopt a child as, unfortunately, there are many children for adoption … have a decent job.

(P2, Portuguese)

Although, they doubt that this is possible:

I would like not to go back to prostitution, but I don’t think that will happen. However, I would like to marry R.

(P3, Portuguese)

The body as a work tool is an argument easily recognized in the participants’ voices; the participants seem to have started to exercise it because they did not have other options available. The inevitability of sex work during these women’s lives invites us to reflect on the additional pressure they are subjected to concerning their bodies and the uses they make of them.

The second subtheme identifies participants experiences in sex work and its health consequences. All participants considered that the only inherent advantage of sex work is the speed with which money is earned,

The only advantage is money, nothing more.

(P6, Brazilian)

Being aware that sex work is an activity that is devalued and socially reproached, facing situations of stigmatization and exclusion, interviewees mention that it entails numerous other disadvantages. Some examples are exposure to sexual practices considered inappropriate (such as fetishes), violence, and health problems, including emotional ones.

The downside is getting sick. If we don’t have our heads on straight, we die early. One who is a doctor here […] stopped coming here because he wanted to use me without a condom. And I never wanted to. He always came with many. Many. And it’s true what I’m saying. He was “ah, just a little bit, tell me how much it is,” and I was “No, doctor, you should be ashamed to be asking for such a thing.” […] there’s everything, there is the good and evil. There are rich; there are poor. I’ve been with a policeman, I’ve been with lawyers, with judges, I’ve been with ball players.

(P1, Portuguese)

[…] they want you to pee on them, spit on them, etc. The world of sex is like that. They come and unload their most disgusting desires on you.

(P6, Brazilian)

For some participants, this activity was not a choice that made them comfortable, and it had physical and psychological consequences.

When I started prostituting myself in the beginning, I used to go to a hostel in Lisbon, and I would shower there about 50 times. Because it was the smell, it was the memory of the old, the old people, less young, touching me. It was difficult and even today, it’s not something I like to do […] you feel like chewing gum, disgusted.

(P2, Portuguese)

There is, on the other hand, one participant who claims to enjoy being a sex worker and all the experiences that sex work gives her, considering it an empowering activity. For this participant, her work goes beyond just sexual intercourse.

“(…) I think that actually, I think I have a great talent for doing this job. Because not all the men who come with me necessarily come to have sex. Some come to dress up as women (…). Some pay to sit here in the room. Some want to be in stockings, in a corset, in high heels, talking. Fulfill fantasies that you cannot achieve elsewhere”.

(P4, Brazilian)

It therefore seems that in sex work, her identity is recognized and valued (Ramalho et al. 2013).

Most participants mentioned having health care in the exercise of the profession, often encouraged by non-governmental organizations (NGOs).

I always check for HIV, hepatitis, that sort of thing.

(P4, Brazilian)

There are some NGOs in Portugal that take care of sex workers, regardless of being a trans woman, regardless of being a man who works with sex, […] and I have already tried to do tests to see if my health is fine, know about sexually transmitted diseases, and ask for guidance on how to have a user card so that I can access health care here and get condoms from these NGOs.

(P6, Brazilian)

Sex work can manifest as a context of recognition and appreciation of the identities and bodies of these women (Pessoa 2020). However, it also presents challenges due to its framework, the relationships established in it, and its potential effects on health (Hughto et al. 2015).

Finally, the third subtheme identified reveals that during sex work there are some specific body demands. The interviewees made somebody changes to optimize not only their gender-affirming process, but also demand, satisfaction, and customer loyalty.

The more the female body has, the more it attracts men (…) what attracts them is the female side …

(P1, Portuguese)

There is no consensus, however, on the idea that sex reassignment surgery benefits all trans women sex workers. Thus, some consider that altering the genitalia can negatively influence sex work.

“(…) clients asked if I had already been operated on, or if I already had breasts and I said no and they said “okay, then I’ll come by later” and they ended up never coming back”.

(P5, Portuguese)

(…) we are considered the third sex. It’s what they like. I won’t say 100%, but 99% of men like it. All of them.

(P1, Portuguese)

After the surgery, there come disadvantages. I will deal with another market.

(P6, Brazilian)

The body image socially considered feminine is essential for the participants. This body is sometimes built through sex work, although the construction of what it means to be a woman manifests itself beyond genitalia and a body. As Vartabedian (2019) concluded, for trans women sex workers, beauty matters in the sense that it represents a strategic position to succeed in the sex industry. The context of sex work seems to recognize different identities due to the diversity of possible, legitimate, and desirable bodies. Accordingly, the concept of a shared “trans body” is questionable (Edelman 2011).

4. Conclusions

The present research corroborates that those trans women who engage in sex work, even if freely, face several constraints and difficulties, not only because their gender identity is still being considered socially deviant, but mainly due to the stigma associated with sex work. As is well documented in the literature, trans women face, in general, multiple forms of discrimination and violence, starting in childhood, with sex workers experiencing additional types of segregation and exclusion.

Although scientific research on transgender issues and sex work has been expanding in recent years, including in Portugal, studies concerning the meanings and impacts of sex work on trans women’s body self-image and health are still scarce, making this piece of research innovative. By pursuing this goal, it was also possible to explore how participants construct their gender identity development within a social organization marked by prejudice, discrimination, and violence. Thus, to better comprehend the singularities of sex work performed by trans women, it is also important to analyze how their life experiences, both personal and professional, have shaped their body image and their sense of social adjustment. As has been evidenced in other studies (e.g., Goldenberg et al. 2020), the diversity of people’s experiences, even when belonging to the same community, calls for the adoption of a culturally informed and situated perspective that simultaneously does not ignore individual specificities. To do so, the intersectionality approach might because it creates the possibility of observing how different axes of oppression traverse. In our sample, the axes of age, cultural background, ethnic origin, and education seem to influence participants’ experiences and how they interpret them.

The relationship that the participants establish with their bodies refers to the dialectic between the physical–organic and the cultural and social context in which bodily practices are established (Pessoa 2020); while on the one hand, the body symbolizes the affirmation of female gender identity and has an emotional function, strengthening self-esteem and consolidating self-conceptualization, on the other hand, it is a working instrument that serves itself. For some of the participants, the profitable body appears to reach the idealized body imposed by the cissexist and cis-hetero normative system and desired by it (Rodrigues et al. 2014), while for others, the idealized body is not always aligned with the presupposition of gender binarism.

In romantic relationships, trans women tend to be blamed for not being true women, i.e., for not having a vagina, whereas the context of sex work emerges as a privileged space for the construction of female identity inscribed in the body. Yet, this is further complicated by the fact that different identities and different bodies seem to be attractive to customers, and imply possibility.

The persistent rejection of cis-hetero normative society is especially noticeable regarding gender identity issues, which are often confused with sexual orientation, and to which other identities are added, for example, ethnic characteristics, or being a migrant. In fact, discrimination and violence permeate all areas of these women’s lives from a very early age. The family, school, so-called conventional labor market, and the broader social context are foci of oppression. Sex work, often the only alternative seen as possible, is yet another extension of this oppression.

The (re)construction of their feminine ideals faces different challenges. Access to the SNS is time-consuming; they experience urgency in their desire to undergo bodily changes, and they fear a discriminatory approach from healthcare professionals. Thus, many trans women sex workers choose to resort to clandestine markets, even knowing the risks to which they may be exposed. Concerning health management, this seems in the case of body alteration procedures to be associated with clandestine and/or private clinical practice, and in the case of sex work, with the use of NGOs to avoid physical illnesses, above all. From the participants’ reports, there seems to be resistance to seeking psychological support.

Thus, specialized services for trans people performing sex work must be provided to prevent and combat processes of stigmatization, discrimination, and violence, and to promote physical, mental, and social health. As a complement to this, the training of health professionals must include knowledge and skills focused on LGBTI issues, in-keeping with national and international standards of care. Manifestations of transphobia are still present within public services; they affect the quality of interventions and, as a consequence, their efficacy.

4.1. Limitations

This study presents some limitations that should be considered in its interpretation. First, the small number of participants (e.g., gender, nationality, race, age, education, geographical location, citizenship, and immigration status) did not allow us to capture the diversity of trans people and their experiences. A deeper comprehension of the processes underlining both self-determination and the meanings and impacts of sex work on the body’s self-image and health would benefit from a larger sample. In fact, accessing trans women who are involved in sex work to be part of the research was particularly difficult. The resistance to adhering to scientific studies could be explained by the sensitive nature of the subject, as well as by the number of requests trans people receive to be interviewed or inquired after by researchers. The participation of trans people in scientific studies, especially sex workers in contexts other than street prostitution, is tendentially low, making it difficult to study larger samples. Thus, in future research, a diversity of sex work participants should be considered in order to understand the other contextual specifics that could impact their body image and health.

4.2. Future Directions

In future research, a more extensive study would be pertinent for trans women sex workers, allowing a better understanding of the connections between class, nationality, gender identity, and other axes of discrimination. An intersectional perspective that accounts for issues such as class, ethnicity, religious background, HIV status, migration status, gender, gender identity and sex work is clearly necessary to build better awareness of the lives of trans sex workers in Portugal. On the other hand, it is urgent that we undertake an assessment, with healthcare professionals and NGOs, of the perceptions and difficulties inherent in the care and follow-up of these women in order to increase their adherence to the SNS. Additionally, considering the impact of questions on the body and on sex work practices, mental health screening should be provided to trans women to prevent any risk of developing psychopathology. Finally, it is essential to invest in specialized training for those who work with this population.