Securing the Body: Transgender Contraceptive Access and the Limitations of Sistema Único de Saúde (SUS) in Brazil
by Mary Martin

A note on the inclusivity of language– In this paper, I use the terms “transgender” or “trans” as an inclusive umbrella term encompassing the diverse identities, expressions, and lived experiences that exist beyond or across binary constructions of gender. My intention is not to fix or define anyone’s identity within rigid categories, but rather to speak with recognition of the multiplicity, fluidity, and self-determination that characterize trans and gender-diverse lives. This note reflects my commitment to write about trans experiences without reproducing the hierarchies or exclusions that propose boundaries upon them. 

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       Introduction

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          In this paper, the research question I intend to approach is: How does Brazil’s approach to contraception access for transgender individuals highlight the exclusion of marginalized groups within traditional security frameworks? What does this reveal about the limitations of international human rights norms in promoting reproductive security for Queer people? The following pages will discuss transgender individuals’ access to contraception in Brazil as a human security issue rather than a typical healthcare problem. By employing a critical human security framework, this paper redefines security through the lens of bodily autonomy and exposes how institutionalized forms of neglect and exclusion sustain structural violence that denies transgender people equitable access to reproductive care. In the field of International Relations, specifically the sector of security studies, traditional security presents a state-centric, realist view of security, emphasizing the protection of sovereignty and survival through military strength, deterrence, and alliance formation, institutionalized during the Cold War era[1]. In response to traditional realist frameworks, critical security studies stem from post-modernism and post-Marxist critical theory and view security through the lens of “emancipation” rather than the “state-centric” focus of power[2]. Beyond that, human security expands the concept of traditional security, focusing not only on the preservation of states, borders, and territories but also on the survival and dignity of individuals. It emphasizes protection from structural violence caused by factors such as poverty, inequality, and marginalization, in addition to traditional security threats like war[3]. Access to contraception for transgender individuals is best viewed as a human security issue, as it highlights the importance of access to care and bodily autonomy to protect individuals’ health, thus ensuring security. A critical framework is essential here because it helps eliminate heteronormative binary frameworks that are built into traditional security, which often erase transgender and nonbinary individuals from the narrative. Contraception access, denial of quality services, and insufficient research on Queer health are widespread issues worldwide, now more than ever, as transgender identities are being weaponized and stigmatized by far-right politics. By focusing specifically on Brazil, I will closely analyze a compelling case study that could assist future policymakers in addressing policies related to transgender access to reproductive services without overlooking important needs and requirements. Brazil’s case shows that, despite progressive policies, transgender individuals face structural insecurities in contraception access, revealing the limits of traditional security and international human rights frameworks.        

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       Brief historical overview of transgender rights and security in Brazil 

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          In April 1964, the Brazilian Armed Forces, with assistance from the United States, orchestrated a coup d’état that led to a 21-year military dictatorship that restricted democratic rights and suppressed political and cultural organizations not aligned with the military leadership[4]. A few years after the coup and the establishment of the military dictatorship in Brazil, Queer recognition and “sexual liberation” were pushed underground as the Brazilian dictatorship targeted Queer people as “criminals” and “moral deviants,” viewing them as immediate threats to the country’s “national morality” and values[5]. State-led repression legitimized civilian violence and normalized persecution, encouraging neighbors to out Queer civilians and call for their arrest, detention, torture, and loss of employment[6]. In 1980, the “Operação Limpeza” or “Operation Cleanup” marked a mass arrest of queer people, “travestis,” a Latin American term for an individual assigned male at birth who adopts a stereotypically feminine presentation and identity, and sex workers, all under the guise of “cleansing” the city center in São Paulo[7]. In Brazil's military dictatorship, traditional notions of national morality and order framed Queer existence as a threat to national security, showing how traditional security frameworks justified the marginalization and exclusion of a specific population. 

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        However, driven by the Stonewall Riots in the 1970s amid the military dictatorship, the LGBTQIA+ movement began to find its footing in Brazil. When Queer people were forced underground during the reign of the dictatorship, the “parts of the queer community that could afford it started to create coded spaces to exist out of the public eye”[8]. These spaces, such as bars, clubs, and saunas, became sanctuaries where Queer people could gather and express themselves without fear. Additionally, the creation of independent media outlets like Lampião da Esquina and ChanacomChana provided platforms for Queer people to express their voices and reject the state-imposed public isolation[9]. Lampião da Esquina, Brazil’s first openly Queer newspaper, “represented a class that had no voice in society, proving to be important for the construction of a pluralist national identity”[10]. ChanacomChana, a lesbian magazine created by the Lesbian Feminist Group of Action (LFGA), circulated from 1981 to 1987, and was primarily distributed at a bar in São Paulo called Ferro’s[11]. However, in 1983, the owner of the bar expelled the women who sold the magazine, which later led to a political protest organized by the same women and other members of the Queer community. This protest ended the ban on independent newspaper sales and was later called the “Brazilian Stonewall”[12]. 

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          Established in 1985, the Triângulo Rosa Group advocated for the inclusion of “sexual orientation” as a category of protection during the 1987 Constitutional Assembly[13]. The proposed article sought to prohibit discrimination based on “origin, race, sex, color, and age,” and to prevent salary disparities driven by “gender, age, color, and marital status”[14]. These concessions were not included in the national constitution but influenced provisions later written into municipal laws and several state constitutions[15]. In the 1980s, the momentum of HIV/AIDS activism worldwide prompted a shift in recognizing health as a human right, ultimately paving the way for Brazil’s universal healthcare system, Sistema Único de Saúde (SUS), which will be discussed later in the paper. Despite these advancements, queer Brazilians, especially transgender people, still faced systemic discrimination and social exclusion, revealing how the dictatorship’s legacy of moral control continued to shape the boundaries of gender and sexuality in Brazil’s emerging democracy.

          In Brazil, transgender identities have long been criminalized and considered a mental disorder, leading to widespread targeted violence. Transgender men are referred to in Portuguese as “travestis,” a direct translation of the word “transvestite,” which I choose not to use in this paper to refer to trans men, as it reinforces a cis-heteronormative system that detests trans individuals[16]. Compared to other Queer identities, trans individuals face disproportionately higher victimization by state violence, and after the 2016 coup, “violence has become the main mechanism of control and power over trans bodies,” framing trans people as opponents to cisgender rights[17]. Although heightened after the latest coup, this violence is rooted in historical state repression and moral policing. The “Dossiê Trans” is a comprehensive report produced by the Associação Nacional de Travestis y Transexuais (ANTRA) that documents and analyzes the realities of violence, discrimination, and policy gaps affecting trans people in Brazil. The 2022 report states that Brazil has led the world in murders of trans people for 15 consecutive years, with most of the victims being young, Black, impoverished trans women or men, often engaged in sex work[18]. In 2022, 131 trans individuals were murdered in Brazil, and 20 trans people died by suicide, bringing the total to 151 deaths[19]. The paradox is striking; Brazil is the world's largest consumer of trans pornography on adult content platforms while also being the country that has killed the most trans people for the 14th consecutive year[20]. It is also important to note that the report emphasizes that there remains a lack of information about the profiles and personal details of the subjects, and this is hindered by a state policy of underreporting anti-LBGTQIA+ violence, as authorities resist collecting this information, especially when it involves homicides. The report confirms that out of 131 homicide cases, only 94 of the victims’ ages were identified, of which: 

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• 5 victims were between 13 and 17 years old;

• 49 victims were between 18 and 29 years old;

• 30 victims were between 30 and 39 years old;

• 7 victims were between 40 and 49 years old;

• 2 victims were between 50 and 59 years old; and

• 1 victim was 60 years old

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          Thus, among the trans individuals murdered in 2022, 89% were between 15 and 39 years old, and the average age of the victims was 29.2 years[21]. These killings are not isolated incidents but part of a systemic pattern of structural violence that exposes the state’s complicity through negligence and institutional silence, where police often misgender victims, refuse to acknowledge hate crime motives, and erase gender identity from reports. These homicide incidents reveal how the Brazilian state security apparatus continues to exercise necropolitical power–deciding whose lives are protected and whose are rendered expendable–while its public institutions, including SUS, reproduce preexisting hierarchies through structural neglect disguised as “public order”[22].   

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       Background on the Brazilian Healthcare System

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          The SUS was established in 1993 following the adoption of the 1988 Constitution, which declared healthcare to be a “fundamental right” and a “duty of the state”[23]. The system was created to offer universal, equitable, and decentralized care, focusing on primary and preventative health after years of stratified access under the military dictatorship. However, it coexists within a private supplementary healthcare system that serves wealthier Brazilians who can afford private insurance plans and out-of-pocket care, creating a tiered structure within what is supposed to be an equal playing field framework[24]. Given this context, SUS theoretically covers 100 percent of Brazil’s population, but 75 percent rely solely on SUS, while about 25 percent, predominantly middle and upper income groups, use private healthcare plans to avoid bottlenecks in care access[25]. This dual model reinforces hierarchies and excludes marginalized populations, as wealthy groups with access to private hospitals offering high-tech interventionist care are in stark contrast to those relying on underfunded facilities, long wait times, limited specialists, and inconsistent treatments in SUS facilities, especially in rural areas outside major cities. Similarly, specialty resources and physician services remain concentrated in wealthier, urban areas, leaving rural and poorer regions medically underserved compared to their more privileged counterparts. The coexistence of SUS and a private healthcare market allows the Brazilian state to maintain a façade of inclusivity, while predominantly white and wealthier Brazilians can opt out of the public system. Additionally, while the federal government covers 33% of primary healthcare expenditures, OECD data from 2019 reports that Brazil’s 5,570 municipalities finance 61% of total primary healthcare costs[26]. The same data reports that Brazil dedicated about 16.3% of its total health expenditure to primary healthcare, which falls slightly below the OECD average of 16.6%, yet wide regional disparities persist, with wealthier areas like the Southeast maintaining far higher doctor-to-population ratios of 2.81 per 1,000 compared to only 1.16 in the North and 1.41 in the Northeast[27]. Overall, these divisions transform healthcare into an example of biopolitical differentiation, where one’s access to medical care, their quality of treatment, and even their likelihood of survival are shaped by their position within their state’s intersecting structures of race, class, and gender[28]. 

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       Reproductive Frameworks within SUS 

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          Before SUS was established in 1993, the military dictatorship promoted conservative reproductive policies by expanding contraception and family planning initiatives with a eugenic perspective[29]. I want to highlight that these are racially motivated structures designed primarily to promote “development” and ensure women have fewer children. The initiatives operated as a form of state-led biopolitical control, involving the government in health decisions targeting fertility among poor, Northeastern Brazilian populations, whose fertility was considered “excessive” and “unproductive” for a developing society[30]. Oral contraceptives were circulated as early as 1962, with state and church officials promoting and legitimizing their use through Catholic-influenced narratives of “responsible parenthood” that reflect the biopolitical narrative mentioned above[31]. Founded in 1965 and officially affiliated with the Brazilian state by 1971, Sociedade Civil de Bem-Estar Familiar no Brasil (BENFAM) was a network of semi-private, state-aligned organizations that distributed contraceptive and family planning services in predominantly Afro-Brazilian communities in the Northeast, under the pretext of fertility regulation as a modernization and national security priority[32]. These programs received significant funding from donors such as the International Planned Parenthood Federation and USAID and embodied eugenic ideologies aimed at decreasing fertility rates among marginalized, rural, and impoverished communities[33]. With the implementation of the constitution and SUS in 1993, reproductive health was consequently institutionalized as part of the public health conversation, although services like abortions still remained criminalized, and the structural inequalities discussed above persisted throughout reproductive services. Today, similar structural inefficiencies persist with reproductive health care services as they do with the entire SUS system. Digital integration (e-SUS) and local-level family health teams aim to enhance reproductive care coordination and access; however, uneven municipal funding and physician shortages hinder equitable implementation[34]. Additionally, reproductive health frameworks within SUS continue to reflect heteronormative and cisgender assumptions, often equating reproductive health solely with motherhood and heterosexual family structures. This framing excludes trans, nonbinary, and queer people whose reproductive and contraceptive needs don't fit the traditional maternal-infant model that still shapes reproductive health policies in Brazil.  

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       Reproductive Frameworks Regarding Transgender Individuals in SUS

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          As discussed above, the SUS framework’s universalist premise that health is a right for all remains complicated by cisnormative reproductive models that focus on heterosexual relations and biologically female reproduction. The Saúde Integral da Mulher, or integral women’s health framework, which was inherited from Programa Atenção Integral à Saúde da Mulher, or the National Policy of Comprehensive Women's Health Care, does not account for trans, nonbinary, and gender-diverse reproductive needs, leading to systemic gaps in contraceptive policy and care delivery[35]. Because contraceptive policy is centered around cisgender female fertility control that excludes individuals whose reproductive experiences do not align with “biological womanhood,” trans men and nonbinary individuals seeking contraception face bureaucratic and cultural barriers[36]. Many SUS healthcare professionals lack training in trans-specific reproductive care, resulting in inconsistent contraceptive counseling and the pathologization of trans bodies[37]. Health teams often focus exclusively on gender-affirming hormone therapy, overlooking contraceptive counseling or risk of pregnancy among transmasculine patients who retain reproductive capacity[38]. The lack of protocols that incorporate contraception into trans healthcare pathways forces individuals to rely on informal networks or private care options, which are often inaccessible to low-income, marginalized populations[39]. For trans men using testosterone, access to contraception is often limited and based on misinformation. Many providers promote the idea that testosterone is a form of contraception; however, it is not, leading to unintended pregnancies[40]. Additionally, obstacles to hormonal and intrauterine contraceptives remain due to stigma, provider discomfort, and a lack of evidence-based guidelines regarding interactions between gender-affirming hormones and contraceptives[41]. These structural omissions demonstrate how SUS’s contraceptive framework, although designed to be universal, still reproduces biopolitical hierarchies by determining who is considered a reproductive subject. In the next section, I critique these frameworks further and suggest policy interventions to incorporate trans-inclusive contraceptive care into SUS practices.

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          The 2006 Health Users’ Rights Charter established the right of trans individuals to use their social name across all SUS services, marking an early step toward recognition[42]. In 2008, SUS introduced the Processo Transsexualizador, or the Transsexualization Process, which ensured access to hormone therapy, body modification surgeries, and multidisciplinary care for trans people—a milestone achieved through years of activism by social movements[43]. Despite these advances, ANTRA highlights that SUS discrepancies persist, with specialized services remaining concentrated in a few hospitals, and waiting lists for surgeries exceeding ten years, severely limiting access for most trans Brazilians[44]. The SUS framework continues to emphasize hormone therapy and HIV prevention while neglecting the full spectrum of trans health needs, especially reproductive and contraceptive care[45]. The Ministry of Health has yet to update its guidelines to align with the World Health Organization’s 2019 reclassification of transsexuality as “gender incongruence,” creating a gap between global standards and national practice[46]. ANTRA stresses that the consistent use of social names and pronouns across healthcare settings is not just symbolic but essential to trust, safety, and inclusion in medical environments[47]. Yet, persistent misgendering and bureaucratic refusals to respect social names reflect institutional transphobia that discourages many from seeking care, undermining the right to health guaranteed by the SUS.

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       Shortfalls of Transgender Reproductive Policies within SUS

          After reviewing the historical and current framework context in detail, here are some of my perceived shortfalls of Brazil’s approach to reproductive policies and contraception access for transgender individuals: 

• Rampant institutional invisibility– The reproductive health system defines “the reproductive subject” as a cis woman of childbearing age, which structures the marginalization of trans and nonbinary people into the foundation of the system.

• Moralized health discourse– State-encouraged narratives that emerged during the military dictatorship emphasize the idea of “responsible parenthood,” which frames reproduction as a moral obligation rather than bodily autonomy, and polices the fertility of marginalized populations who historically give birth to more children under the guise of modernization and development.

• Racial and class disparities– Black, Indigenous, and impoverished women experience disproportionate sterilization, unsafe abortion, and maternal mortality, showing that “universal” access masks deep structural inequality.

• Policy stagnation– Reforms such as Rede Cegonha, which states that “every woman has the right to reproductive planning and to receive humanized care during pregnancy, childbirth and the puerperium (postpartum), just as children have the right to a safe birth and healthy growth and development,” improved maternal care but failed to expand the conceptual frame of reproductive health to encompass intersectional identities.

• Data and training deficits– The lack of inclusive medical education, which leads to inequality in hospital services—especially between rural and urban systems—along with the absence of standardized national data and honest reporting on gender identity, and systemic training deficiencies in trans-affirming care, perpetuate exclusion.
  
  Critiques of Transgender Reproductive Policies within SUS

          After reviewing the historical and current framework context in detail, here are some of my critiques of Brazil’s approach to reproductive policies and contraception access for transgender individuals: 

• Cis-heteronormative paradigm– Contraception is framed almost exclusively as a “women’s health” service offered to cisbirth females of reproductive age, which erases the identities of trans, nonbinary, and gender non-conforming individuals from the design and messaging of healthcare services.

• Lack of inclusive counselling protocols– Health services rarely provide guidance for trans individuals. For instance, they often do not address potential interactions between hormones and contraceptives, fertility preservation options, and pregnancy risks in trans men taking testosterone. This lack of guidance leaves trans people dealing with misinformation, confusion, or no guidance at all.

• Provider bias and knowledge gaps– Many healthcare providers lack training in trans-affirming contraceptive care; some may hold discriminatory attitudes, misgender patients, or simply omit discussing contraception with trans clients, thereby reinforcing exclusion.

• Data invisibility– Health information systems and contraceptive uptake statistics do not systematically capture gender identity or sexual orientation, which means marginalized populations’ needs are invisible in planning and resource allocation.

• Access disparities– Even where contraceptive services are available, marginalized populations, including those based on race, region, class, and gender identity, face additional barriers such as geographic, financial, and informational hurdles that prevent full access; this undermines the “universal” promise of SUS.

• Biopolitical logic– Contraceptive policy has historically targeted impoverished, racialized, and rural populations to control their fertility, while other groups’ reproductive choices and mobility remain unquestioned. This perpetuates state-supported structural violence through contraceptive practices like sterilization.

• Fragmented implementation and coordination– Contraceptive services are often organized into separate vertical programs like family planning and maternal health. They are not usually integrated into trans health, hormone clinics, or primary care settings. This creates access gaps for trans people who may need personalized contraceptive options.

• Failure to consider changing fertility desires– Frameworks still assume binary outcomes that either prevent pregnancy or achieve pregnancy and do not consider the diverse desires of trans individuals, which might include delaying childbearing, chest-feeding, or fertility preservation before hormone therapy.

• Quality and counselling deficiencies: There is emphasis on the supply of contraceptive methods but less focus on the quality of interactions and informed choice, especially for marginalized groups who may have had coercive histories or face distrust in health systems.

• Moralizing rhetoric and stigma– Contraceptive services are often built around cisheteronormative assumptions that define reproductive health through heterosexual and maternal norms, which stigmatize trans people who don't fit traditional reproductive roles or result in their contraceptive needs being overlooked.
  
  Suggestions for Transgender Reproductive Policies within SUS

          After reviewing the historical and current framework context in detail, here are some of my suggestions for Brazil’s approach to reproductive policies and contraception access for transgender individuals: 

• Reframe policy to encompass reproductive human security– Shift the focus to highlighting bodily autonomy, informed choice, and protection from coercion or neglect instead of just fertility control that reflects biopolitical control. Prioritize the served individual’s needs, approach their medical situation from a humanistic perspective, and see them as a whole person rather than just a metric. 

• Integrate gender-inclusive rhetoric– Revise the language used in SUS documents and statements to make the rhetoric more gender-inclusive and move away from a binary and cisheteronormative approach to healthcare policies. Instead of focusing solely on male/female or on women’s fertile/maternal health, include sections for individuals who do not identify within the confines of those categories. 

• Adopt intersectional data collection– Instead of collecting and presenting data from a single perspective, such as race, economic status, or geography, gather and present intersectional data to identify the effects of ongoing structural inequalities. As outlined in the intersectional data framework, this means capturing “context, relationships, and lived experiences” rather than isolated variables, and disaggregating data to reflect the complexity of social identities. Viewing data through this lens exposes how structural inequities operate across multiple dimensions and allows policymakers to design more targeted and equitable interventions. 

• Provider education– Within SUS medical education institutions and public health curricula, develop mandatory training courses and information sessions that educate current and future providers about gender-affirming and trauma-informed reproductive care for transgender individuals. This will help build a more diverse knowledge base regarding trans existences and experiences within healthcare. By including these topics in mandatory curricula, SUS can reduce disparities between hospitals, increasing the chances that a trans patient will speak with a provider who understands and respects their unique situation. 

• Digital inclusion– Utilize telemedicine to connect rural communities and underserved populations with knowledgeable specialists. Additionally, update and integrate health records to include intersectional identities, enabling trans individuals to select the appropriate identifying information in healthcare portals and administrative paperwork.

• Policy collaboration– When revising and drafting policy proposals and implementations, amplify the voices of feminist, Black, Indigenous, rural, trans, and other marginalized activists and organizations. This inclusion encourages a shift from state paternalism to participatory governance that values the voices and opinions of those most affected by policies. (maybe mention networks like ANTRA-human rights report and queer news/media sources)

• Cultural transformation– Finally, rewrite the previous narrative about reproductive healthcare to go beyond moralized discourses of “responsibility” and recognize diverse reproductive desires such as parenthood, non-parenthood, fertility preservation, and body autonomy as equally valid. Reproductive health does not only involve women and traditional maternal frameworks of motherhood; it encompasses a wide range of needs that serve a diverse group of people who do not identify as female. Healthcare structures should reflect this diversity of needs and serve people to the best of their ability, ensuring human and societal security.  
  
  Conclusion
   

          Brazil’s approach to transgender contraception access reveals that even within a system constitutionally committed to universality and equity, biosecurity remains unevenly distributed. Upon closer examination, what begins as a healthcare issue becomes a question of whose bodies are made visible, valued, and secure within both domestic and international contexts. Despite the progressive intentions of the SUS, structural inequalities that are rooted in race, class, gender, and geography continue to influence whose reproductive autonomy is protected and whose is overlooked. 

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          From a critical human security perspective, the Brazilian case shows that state and international institutions often perpetuate insecurity by pathologizing or invisibilizing trans and queer lives. The lack of comprehensive contraceptive frameworks for trans people, along with bureaucratic and cultural barriers to care, exposes the biopolitical limits of human rights discourse: rights may be universal in language but conditional in practice. Traditional notions of security, rooted in sovereignty and order, overlook the fact that safety is closely tied to bodily autonomy and the ability to access affirming healthcare. 

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          To wholly improve reproductive security, policymakers and scholars must broaden the concept of protection beyond the state and toward the individual, particularly those whose existence challenges traditional views of gender and sexuality. Emphasizing trans experiences reveals how human rights and security are not fixed ideals but evolving practices that demand ongoing critique and revision. In this way, Brazil’s contradictions do not merely show policy failures; they prompt a reexamination of security itself. One rooted in recognition, action, and the right to live free from structural violence. ​​​​​​​​