Peer‑Led Harm Reduction in Brazil: Gender‑Based Violence, Intersectionality, and Decolonial Perspectives of Community-based care

Peer‑Led Harm Reduction in Brazil: Gender‑Based Violence, Intersectionality, and Decolonial Perspectives of Community-based care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Peer‑Led Harm Reduction in Brazil: Gender‑Based Violence, Intersectionality, and Decolonial Perspectives of Community-based care Delia Da Mosto, Ueslei Solaterrar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8042292/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract This article examines how gender‑based violence (GBV) and substance use intersect in the lives of trans women and travestis in Brazil, and how community harm reduction practices emerge in response. It also analyzes harm reduction as a technology of care and life‑sustaining practice. Two ethnographic studies were conducted in Brazil between 2019 and 2023, combining life histories, interviews, and participant observation with trans women, sex workers, activists, health professionals, and NGOs. Data from both studies were intersected and analyzed to identify common themes, resulting in four categories: (1) gender‑based violence and trajectories of marginalisation; (2) substance use as coping and as risk; (3) harm reduction from the margins through community practices of care; and (4) agency, resistance, and re‑signification of marginality. Findings indicate that the suffering experienced by trans women can be conceptualized as a form of “crossroads suffering,” produced at the intersection of trajectories of vulnerabilisation and encruzilhamento that challenge binary logics. The study also demonstrates that self‑care and community care practices within solidarity networks play a crucial role in everyday survival, emphasizing the importance of situated knowledges in contexts of care. Central to these practices was the role of lived experience: trans women and travestis drew on their own histories of violence, exclusion, and survival to generate harm reduction strategies that were credible, culturally resonant, and effective in reaching peers. Their experiential expertise functioned as a counter‑hegemonic form of health knowledge, challenging biomedical authority and reshaping harm reduction from the margins. Experiences of violence and exclusion generated both vulnerability and innovative strategies of resistance and harm reduction, contributing to the construction of alternative pathways and possibilities. By centering these practices, the article expands the conceptual and practical horizons of harm reduction through an intersectional and decolonial perspective. It argues for broadening the notion of harm reduction from Global South contexts, such as Brazil, where the harms to be reduced are not limited to drug‑related risks but include those produced by colonialism, racism, patriarchy, and neoliberal capitalism. Harm reduction is thus understood as a technology of care that extends beyond health, sustaining more dignified and less precarious lives. Harm reduction Gender‑based violence Trans health Community care Decolonial public health Situated knowledges Sex work Introduction Harm reduction has long been recognised as a pragmatic and rights‑based response to substance use and its associated risks. Yet mainstream harm reduction frameworks, reflecting hegemonic health perspectives, have often been criticised for neglecting the ways gender, sexuality, race, and other intersecting inequalities shape experiences of harm [ 1 , 2 ]. Gender‑based violence (GBV) is both a driver and a consequence of substance use: women and LGBTQ + people who experience violence are more likely to use substances as coping mechanisms, while substance use can in turn increase exposure to further violence [ 3 ]. From a public health perspective, these vulnerabilities are not evenly distributed but are structured by broader systems of power. Hegemonic models rooted in capitalism, patriarchy, racism, and colonialism have historically defined humanity through the figure of the “first‑class citizen: European, male, rational, white, heterosexual, cisgender, and Christian” [ 4 , 5 ]. Gonzaga [ 6 ] emphasises that racism—and, by extension, gender‑based violence—should not be treated merely as theoretical constructs but as fundamental ethical concerns within the civilizational framework of coloniality. This framework ordered the hierarchisation of people by skin colour [ 7 ] and by the anatomy of the genitalia [ 8 ]. Those with non‑conforming bodies and genders [ 9 ], or who engage in stigmatised sexualities and sex work [ 10 ], are relegated to zones of abjection, where their intelligibility is constantly questioned [ 11 ]. Yet, as hooks [ 12 ] reminds us, marginality is not only a site of exclusion but also a potential space of resistance and radical possibility. Intersectionality, originally theorised by Crenshaw [ 13 ], provides an essential framework for understanding these dynamics. Rather than treating gender, race, sexuality, or class as separate categories, an intersectional lens highlights how overlapping systems of oppression shape both vulnerabilities and forms of resilience [ 14 ]. As Ussher et al. [ 15 ] demonstrate in their study racism, transphobia, misogyny, class, and migration status intersect in what they describe as a “matrix of domination,” producing unique vulnerabilities that cannot be understood through a single axis of identity. Recent calls for intersectional harm reduction emphasise the need to address stigma, discrimination, and structural violence [ 16 ] in ways that move beyond biomedical models [ 17 , 18 ]. In Brazil, sex workers, trans women and travesti are disproportionately exposed to GBV, social exclusion, and substance‑related harms. According to ANTRA’s 2025 report, at least 60% of murders of trans people worldwide occur in Brazil, with 78% of victims being Black travesti and trans women, and over 90% engaged in sex work [ 19 ]. Multiple studies further show that healthcare services often reproduce broader social inequalities, limiting access for sex workers and trans people despite policy reforms [ 20 – 25 ]. Although punitive and abstinence‑focused drug policies remain a constant threat—particularly under right‑wing and far‑right governments, as between 2015 and 2022 [ 26 ]—Brazil has also been shaped by the process of Psychiatric Reform movement, initiated through psychiatric deinstitutionalization. This process sought to dismantle the asylum model and replace it with community‑based mental health care, aligning with harm reduction principles. Within this context, Brazilian trans communities, together with workers and activists in the anti‑asylum movement, have developed situated practices of solidarity and harm reduction. These include peer‑led outreach in sex work zones, informal networks of knowledge sharing, and community self‑care initiatives. Such practices resist biomedical hegemony and generate new forms of autonomy, emerging as vital strategies for survival and resistance [ 27 – 29 ]. This article contributes to these debates by examining how GBV and substance use intersect in the lives of trans women and travesti in Brazil, and how community‑based formal and informal harm reduction practices emerge in response. It analyses their role as technologies of care and life sustenance. Drawing on ethnographic research with sex workers, activists, and health professionals, we highlight how lived experiences of violence and exclusion generate both vulnerability and innovative strategies of harm reduction. By centring these practices, we aim to expand the conceptual and practical horizons of harm reduction through an intersectional and decolonial perspective. Methodology Study Design This article draws on two qualitative ethnographic studies conducted in Brazilbetween 2019 and 2023. Both studies followed a collaborative approach [ 30 ] and a multi‑sited ethnographic design [ 31 ], privileging situated knowledges [ 32 ] and engaging participants as co‑producers of knowledge. The studies were designed to capture the intersections of gender‑based violence (GBV), substance use, sex work, and harm reduction practices through an intersectional lens, specifically trans identity and race. Researchers’ choice of methods was guided not only by epistemological and theoretical considerations but also by moral and ethical commitments [ 33 ]. Building on the assumption that social justice is a “politics of doing,” applicable both in political life and in research practice [ 34 ], our methodological orientation treated research itself as a form of praxis, we adopting qualitative and participatory strategies that could adapt to the needs of participants and foreground their experiential expertise. Participants and recruitment Participants included trans women and travesti engaged in sex work, peer educators, harm reduction workers with and without lived experience, health professionals, and activists. Recruitment was guided by an intersectional approach, ensuring that participants reflected diverse racial, class, and gendered positions within Rio’s trans and sex worker communities. This approach stems from an understanding of the limitations of biomedical framings of suffering [ 35 ] and the need to construct counter‑hegemonic readings. Recruitment was carried out through snowball sampling involving community networks, health services, NGOs and activist groups. This ensured the inclusion of both individuals with lived experience of GBV and substance use, and those directly involved in harm reduction practices. Data Collection Data were generated through multiple qualitative and participatory techniques, designed to capture the intersections of GBV, substance use, sex work, and harm reduction practices. The following activities were conducted: Network mapping: 10 interviews with key actors in formal and informal networks of care and activism, documenting the “trans care network in (de)construction.” Life history interviews: 4 in‑depth biographical interviews with trans women and travesti who work and/or use mental health services, focusing on experiences of GBV, substance use, access to health services, harm reduction, and coping strategies. Participant observation in sex work zones: sustained ethnographic observation in 2 street‑based sex work areas of a big city in Brazil, documenting everyday practices of survival, harm reduction, and exposure to violence. Participant observation with CAPSAD outreach service: shadowing a Psychosocial Care Center for Alcohol and Other Drugs (CAPSAD ) night outreach team, with attention to peer‑led harm reduction practices with sex workers. Semi‑structured interviews: 18 interviews with sex workers, activists, and health workers, exploring GBV, substance use, community‑based care, and harm reduction strategies. Collective conversation circles: 3 group discussions involving a total of 20 participants, designed as participatory spaces for dialogue and co‑analysis of experiences. Creative and participatory approaches (e.g., conversation circles, visual mapping of care networks, and photovoice‑inspired strategies) were incorporated to allow participants to express experiences that might not be easily captured through conventional interviews. This design was informed by an intersectionality lens, ensuring that data collection foregrounded the ways race, gender identity, class, and sexuality intersect in shaping vulnerability and resilience. Data Analysis All interviews and fieldnotes were transcribed and coded using thematic analysis [ 36 ]. The analysis focused on three intersecting domains: (1) experiences of GBV and structural violence, (2) substance use and harm, and (3) community-based harm reduction practices. An intersectional and socio‑anthropological perspective informed the analysis. In addition, we drew on the Framework Method [ 37 ], which provided a systematic yet flexible structure for managing and comparing qualitative data across cases and themes. This approach was particularly useful for working collaboratively with community partners and ensuring transparency in the analytic process. Reflexivity was central to this process: the research team engaged in reflexive journaling, private field diaries, and co‑analysis with community collaborators to enhance validity and ensure alignment with participants’ perspectives [ 38 ]. Reflexivity was understood as a continuous practice of critical self‑awareness, recognising both the influence of the researcher on the research process and the reciprocal impact of the research on the researcher [33; 38]. Ethical considerations Both studies were approved by institutional review boards (Universidade do Estado do Braziland Universitat Rovira i Virgili). Written informed consent was obtained from all participants. To protect anonymity, pseudonyms are used, and potentially identifying details have been removed. Special care was taken to ensure safety and confidentiality given the participants’ exposure to violence, stigma, and criminalisation. Results The ethnographic material revealed four interrelated themes that illuminate how GBV, substance use, and harm reduction intersect in the lives of trans women and travesti in Brazil. The results are divided in: Gender-based violence and trajectories of marginalisation: Substance use as coping and as risk: Harm reduction from the margins: community practices of care: Agency, resistance, and re-signification of marginality: 1. Gender-based violence and trajectories of marginalisation Participants’ life histories underscored the pervasive role of gender‑based violence (GBV) in shaping trajectories of exclusion. Violence was experienced across multiple domains — within families, schools, institutional settings (particularly health services), and intimate relationships — and was described as both physical and symbolic. “ I am a woman who never bled every month. I bled for a long time, every day, every hour, and every minute for years. For almost 20 years of my life [...] I knew that the way I bled was not synonymous with femininity, but rather synonymous with a lot of pain that no one but me could perceive how much I bled. At 14, I was already a woman, I had hair, breasts, my body... This woman had to face the streets at 14, she had to face difficulties [...] at 14, I experienced my first rape [...] and that rape by four men led to many others, unspeakable, I can't even count them... And violence isn't just physical aggression, it's also verbal or visual.[...] But I think it's crazy: a drug dealer who walks down the street, kills, destroys families, and does a lot of things is idolized, but I walk down the street and haven't hurt anyone, and I get booed, and many of us die." (Bruna , 35 years old, white, former sex-worker, heterosexual, trans woman) Many participants recounted being expelled from their homes as adolescents when their gender identity became visible, or being forced out of school due to harassment. “When my family found out I was transitioning, they kicked me out of the house. They told me I was a filthy, ragged lunatic who deserved nothing and deserved to die. At first, I decided to stop transitioning and stay with them, but even though I started dressing like a man again, my brothers and father beat me every night.” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) “The house pushed me to the street… when the family doesn’t expel you directly, the hostility makes you leave anyway.”(Jessica, 39 years old, Black, advertising student, heterosexual, trans woman…). Healthcare settings were also described as sites of violence and exclusion, where transphobia and institutional fragility undermined access to care. “The SUS (National Health System) can be sexualizing and discriminating. [...] Some professionals, whether due to transphobia or lack of knowledge, are unable to provide this treatment to trans women at the clinic... She suffers transphobia there, she cannot access care." (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) Participants also recounted violence within sex work itself, due to the impossibility of self-organising of sex workers correlated to the current legal framework and the struggle to denounce violence due to stigma. “One day I accepted a job with a client I didn't know [...] after some time I told him I had to leave... [...] At that moment, he took out a gun, pointed it at my head, and told me I wasn't going anywhere until he decided... [...] I kept quiet because in my head I was wrong [...] in my mind... what I suffered was part of the risk. I thought, "I'm here doing a job that is wrong, that no one can know I do this, so I suffered this violence and I'll have to bear it alone in silence…” (Cleide, 29 years old, black, former sex-worker, activist, heterosexual, trans woman) Furthermore some participants highlighted how also the sex work industry could be discriminating against trans people: “In brothels, transvestites stay hidden. When a client arrives, the manager says that there are also transvestites there... But there are no brothels exclusively for trans women.” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) “They [cis prostitutes] always had a distant relationship with travestis. [...] They never mixed in the places where they work. Usually, travestis are prohibited from entering, so only one or two are allowed in. There is a lot of transphobia in prostitution, right? So it's very complicated.” (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman) Taken together, these accounts reveal GBV not simply as a series of personal experiences but as a pervasive structure that organises the life chances of trans women and travestis in Brazil. Violence was embedded in families, schools, health services, labour markets, policing, and even within sex work spaces, producing cumulative layers of exclusion. This underscores the need to understand GBV intersectionally — as entangled with racism, class inequality, and cisnormativity — and as a structural force that shapes trajectories of marginalisation. 2. Substance use as coping and as risk Experiences of trauma, sexual violence, and loss were closely linked to substance use in participants’ narratives. Drugs and alcohol were described not only as substances but as tools for managing pain, loneliness, and exclusion. “How not to use? People are poor, Black, rejected by family… drugs make the suffering a little lighter.” (Serena, 37 years old, Black, harm reduction worker, heterosexual, trans woman) For many, substance use was a way to endure the weight of systemic violence and to create fleeting moments of connection. “The money I got today was to eat tonight, not for the future… so drugs made me feel less alone”. (Bruna, 35 years old, white, former sex-worker, heterosexual, trans woman) “I felt alone. Do you know what it's like for people to be close to you because of what you can provide? Working on the street, earning money, and using drugs brought people closer to me. It was a way to have people around, to escape loneliness.” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) At the same time, participants recognised that substance use could generate new risks, including health complications, heightened exposure to policing, and intensified stigma. This ambivalence — substances as both survival strategies and sources of harm — was a recurring theme. Substances were often introduced in the context of sex work encounters, with clients offering higher payments in exchange for use. While biomedical frameworks tended to pathologise these practices, participants framed them as inseparable from the broader social suffering generated by GBV and exclusion. “sex workers use a lot of drugs to keep herself alert and awake, because the more sex she has, the more... well... the more sex, the more money, and as I told you, we get into a vicious cycle, our consciousness changes, we become another person. [...] I only slept three hours a night for five years of my life when I was a prostitute, it was a lot of work. I had to work, I had to work out, I had to do prostitution, and I knew it would be for a short time, but that it would be worth it later…” (Cleide, 29 years old, black, former sex-worker, activist, heterosexual, trans woman) Alcohol consumption, in particular, was embedded in the economic logic of prostitution, the illegal framework and the lack of policies to safeguard sex workers, as brothel owners pressured sex workers to drink with clients to generate profit. “Another point that comes up [when I think about health issues] is the labor issue, health doesn't stand alone, right? It has to be political, it has to be incisive, it has to be all policies together, because this problem is now going to be physical? For me, the physical aspect has to do with the lack of legislation, because you are not recognized as a worker. So, to work in certain places there are rules, you work where you want, of course, but in most brothels you have to drink drinks. You can't drink beer. Because every drink you have... Then you have to make the client pay. To boost income, and make them pay for the drink, which is expensive, which is how they make money. So we drink a lot. Prostitutes drink a lot, they drink a lot. [...] So for me, I think it's the high consumption of alcohol and drugs, because afterwards I had liver problems, right? Liver. And I'm sure it has a lot to do with the amount of drinking... [...] You know? Because many age quickly, because you sleep little, drink a lot, use drugs... for the client. And that's where the problems come in…” (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman) Field observations confirmed this dynamic. In one of the sex worker areas, the smell of alcohol mixed with sewage, while during night outreach, sex workers staggered in high heels after long hours of drinking with clients. Many explained that drugs entered their lives through clients, who offered more money for encounters involving substances. “When I discovered prostitution, I thought it would be the only way to survive and get out of the life I was living there. Until I got to the point of discovering drugs. [...] But that's what often leads sex workers to drugs, because the price doubles when you have a client who uses drugs. The price doubles. Then that tempts you, tempts the person, right? It tempts you. Then when you realize it, you're already in that situation [drug abuse].” (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti) For some, alcohol and drugs were also tied to grief and despair, blurring the line between coping and self‑destruction. “It took me a long time to understand, when I lost my mother, my father... [...] Then I discovered alcohol abuse. I would go out to work, but before leaving I would cry and drink...” (Bruna, 35 years old, white, former sex-worker, heterosexual, trans woman) Participants also challenged the stigma that associates sex work uniquely with drug use, pointing out that substance use is widespread across society. “People like to say that many people in prostitution use alcohol or drugs to cope with their work. But not at universities. Guys! I'm here all the time, I have several friends who are academics. I don't use cocaine, for example. All my drugs are legal: beer, whiskey, caipirinhas, coffee, sugar. All my drugs are legal. But how many university professors, students, and administrators use cocaine? An addiction is when you lose control, and that's when something becomes an addiction. [...] But looking at prostitution through that lens [of addiction], when it's already a stigmatized, marginalized, and dangerous occupation, “most people in prostitution use drugs,” that's also a lie. Because the vast majority of society uses drugs. And most of the drugs that prostitutes use? Most of the time, it's the clients who bring the drugs. It is the clients who bring them or ask if they know someone from whom they can buy drugs. It is their clients…” (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman) In sum, substance use emerged as a deeply ambivalent practice: a means of survival, connection, and economic gain, but also a site of exploitation, stigma, and health risk. Rather than reducing these practices to pathology, participants framed them as embedded in the structural conditions of marginalisation and in the economic logics of sex work. This perspective highlights substance use as both a strategy of endurance and a terrain of vulnerability, shaped by capitalism’s commodification of bodies and by the intersecting oppressions of gender, race, and class. In the next section, we turn to harm reduction practices, examining how trans women, travestis and sex workers develop community‑based strategies to navigate these ambivalences and reclaim care on their own terms. 3. Harm reduction from the margins: community practices of care Despite structural barriers and exclusion from formal health systems, participants generated situated harm reduction practices that mitigated risk and fostered solidarity. These practices were rooted in lived experience, collective knowledge, and everyday improvisation. They echoed harm reduction principles but emerged from within the community, shaped by intersectional experiences of gender violence, racism, poverty, and transphobia. Peer‑led outreach grounded in lived experience. CAPSAD night teams, often staffed by trans women, travestis and sex workers with lived experience, were described as more accessible and trustworthy than traditional clinical care. Their presence not only encouraged trust but also shaped therapeutic decisions: psychiatrists and social workers frequently reconsidered treatment plans after peer educators highlighted forms of oppression invisible to biomedical frameworks, highlighting for example how specific therapies could not be followed in such marginalized contexts. In multiple occasions the psychiatrist reconsidered the therapy after talking to the harm reduction person with lived experience which highlighted oppressions which were not visible to the psychiatrist that would have generated some complications for the psychiatric/substance substitution therapy. Furthermore the role of people with lived experience as well as the presence of trans women and travestis was perceived as more accessible and trustworthy than traditional clinical care. “With all respect to the health professionals at the centre, which I think they all do a good job, I do feel a special connection with Gloria… And I trust her… She was on the streets with me, she knows what it’s like, she is not a privileged white girl that learnt from the books… She will never force me to do something that I don’t want to do and she know exactly what I need…” (Sofia, 49 years old, white, sex worker, heterosexual, trans woman) This credibility was central to engagement, and according to participants was also determined by the embodiment of a “street code” and laguage. “When you come from the streets you learn a certain type of language, a certain type of attitude, which you can’t learn in University…” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) Informal knowledge networks and self-harm reduction. WhatsApp groups functioned as spaces where trans women and travestis exchanged advice on hormone use and it’s interactions with PREP and drugs, silicone injections, and safer practices — knowledge otherwise unavailable in formal services. “We have a WhatsApp group. And there's the girls' health chat [trans women and travesti]... this group is ours [trans women and transvestites], right? Here, we're done with the psychiatrist who knows everything, right? No way! It becomes a means of communication between LGBTQIA + people and health... We work hard on this issue of putting the doctor in the background... In the group, the conversation flows between us. [...] Access to the group is free, everyone is an administrator...[...] We only speak as health workers when something is necessary. To guide or intervene... They are the ones who say how to take hormones, what dosage and which hormone is good for what (breasts, penis, muscles...), the professionals who are there are only there to provide information regarding opportunities, access to services or if there are issues for which they are directly requested…” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) Beyond hormones, sex workers also shared “tricks of the trade” related to substance use and safety. While some of these practices remained deliberately undisclosed, participants emphasised that they were passed down from more experienced colleagues. Others stressed the importance of sharing information about dangerous clients: ““It’s important that we tell at least one of our closest colleagues: ‘Look, that guy stole my money!’… so that other people don’t go through what you went through.” (Nina, 30 years old, sex worker, activist, lesbian, trans woman) Others described private self‑care strategies to manage substance use. “ When I was using drugs and my father was alive, I was able to reconcile it with harm reduction, you know? Without visiting any mental health centers, I would lock myself in my room at home and no one could tell…” (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti) Collective care and safe spaces In the absence or impossibility to access healthcare services due to transphobia or other barriers, participants often reported taking care of one another and improvising harm reduction techniques which could however be impacted by external factors. “ My friend who brought me into the world of sex work had developed a serious substance abuse problem... Gradually, crack had consumed every part of her life, and one day I found her in one of the rooms vomiting blood, and she begged me to help her... I took her to my mother's house for six days and we took care of her... She got clean, but after a while her ex-boyfriend took her back to the drug tunnel..." (Sonia, 35 years old, black, sex worker, heterosexual, trans woman) Harm reduction also took the form of collective defence and vigilance in sex work zones. Participants described intervening when colleagues were attacked or cheated by clients. “If a customer doesn't pay or hits one of our colleagues, of course we all take action... it's in everyone's interest to have decent working conditions…” (Carla, 25 years old, white, sex worker, bisexual, trans woman) On the street, women often worked in pairs, watching over each other during encounters. “On the street... I liked to be with a colleague... I would tell her when I got in the car, “Look closely at the client's face... look at the license plate... the color of the car...” It may not solve everything, but it discourages the man from doing something bad." (Raffaela, 33, black, sex worker, trans woman) This collective protection extended even into hostile institutions. When one of them faced transphobic treatment in a health service, others would accompany her to “armar um caos” “make a mess” and demand accountability. Yet these networks were deeply ambivalent. While they offered solidarity and strategies of survival, they were also marked by rivalry, competition for clients, and capitalist pressures. As Erica, puts it: “On the track you are alone… today’s client may find my colleague prettier tomorrow”. (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman) Care was thus simultaneously a resource and a fragile practice, constantly undermined by structural and economic violence. 4. Agency, resistance, and re-signification of marginality While violence and exclusion structured participants’ lives, the margins were also described as spaces of possibility. Sex work, for many, was not only a survival strategy but also a way to affirm gender identity, exercise autonomy, and access income otherwise denied in the formal labour market. “So when I was 19, I left home, and since there weren't many services that could support me at the time, I decided to enter the world of prostitution. There I found a new world, not only did men not beat me, but they also paid me to be who I was!” (Sonia, 35 years old, black, sex worker, heterosexual, trans woman) Several participants framed sex work as a deliberate choice among limited but real options, highlighting the agency involved in deciding how to inhabit their gender identities and sustain themselves. "When you socialize as a trans woman or travesti, you have two job options: either be a hairdresser or be a prostitute, there isn't much choice! As I had already tried being a hairdresser and didn't like it, I opted for prostitution." (Fabiane, 45 years old, white, sex worker, bisexual, trans woman) Others emphasised that sex work offered a space of affirmation compared to the discrimination they faced in formal labour markets. “Before entering prostitution, I worked as a domestic worker, but I wore men's clothes. When my boss found out I was undergoing hormone treatment, he tried to fire me... I'm already black, poor, and transgender. Things are even tougher for me, right? I don't have a great resume, I already lived in a place that was frowned upon, so it's already difficult for you to enter the job market. So how are you going to pay your bills? That's when you get into prostitution, right?” (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti) Sex work was also narrated as a profession that aligned with political values, offering freedom from the rigidities of formal labour markets. “I have always seen prostitution as one of the professions that has freed me most from capitalism. It has also given me total freedom to live my life as I want. Prostitution gave me total freedom to travel, to do things at my own pace, to use my time as I saw fit. So it was a profession where I chose when I was going to work, I chose the client I was going to see, I had the advantages, the power, the advantage of always being able to choose, not least because I had a certain body type.” (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman) Several participants emphasised that prostitution provided freedom and even the basis for chosen families. “ For a travesti in prostitution, the word ‘family’ has a special meaning… the brothel mother, the sisters, the daughters. For those expelled from home or who preferred to leave rather than continue suffering abuse, prostitution represents a space of freedom — a place where you can begin your life, exist as you want, start your transition, and claim your place in the world.” (Gabriela, 53 years old, white, sex worker, activist, lesbian, trans woman) Importantly, agency was also expressed through trajectories of recovery and professional transformation. Some participants who had been sex workers and substance users described how being cared for in CAPSAD services opened the possibility of imagining recovery. Through these experiences, they later became harm reduction agents themselves, using their lived experience as a source of credibility and political strength. “I was once on the other side, using and surviving. But CAPSAD didn’t just treat me — they involved me. They showed me I could be part of the team. Today I am a harm reduction agent, and when I talk to someone on the street, they believe me because I’ve been there too.” (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti) These trajectories illustrate how marginality can be re‑signified into professional and activist roles, where lived experience becomes a form of expertise. By moving from being “cared for” to becoming carers themselves, participants challenged biomedical hierarchies and embodied the principle that recovery is possible. Taken together, these narratives illustrate how participants re‑signified marginality: transforming spaces marked by stigma into sites of agency, solidarity, and political affirmation. Sex work, while shaped by structural violence, was also narrated as a practice of freedom, a source of chosen kinship, and a pathway into activism and harm reduction work. In this sense, the margins were not only places of exclusion but also terrains of resistance and re‑existence, where participants challenged dominant narratives of abjection and created alternative ways of living. Discussion This study demonstrates how gender‑based violence, substance use, and harm reduction intersect in the lives of trans women and travestis in Brazil. By foregrounding participants’ narratives, the analysis reveals GBV not as isolated incidents but as a structural force embedded in families, schools, health services, labour markets, policing, and sex work. At the same time, the findings highlight how women actively navigated these conditions, developing situated harm reduction practices, re‑signifying sex work as a space of affirmation, and transforming lived experience into professional expertise as harm reduction agents. In doing so, the study contributes to scholarship on intersectionality, social suffering, and community‑based health by showing that the margins are not only sites of exclusion but also of creativity, solidarity, and political imagination. Intersectionality and structural violence The life histories of trans women and travestis in this study illustrate what Solaterrar (2020) terms an itinerário de vulnerabilização — an itinerary of vulnerabilisation — where structural processes continually generate situations of social humiliation and exclusion. Drawing on Breilh’s concept of the social determination of health [39], these trajectories can be understood not as the outcome of isolated “risk factors” but as the historical and political production of health and illness through intersecting systems of exploitation, patriarchy, racism, and cisnormativity. Participants’ narratives made visible how gender‑based violence was institutionalised: expulsion from families, harassment in schools, and denial of care in health services were recurrent. Gloria’s testimony of being beaten nightly by her brothers after being forced to “de‑transition,” or her account of transphobic treatment in the SUS, exemplify how violence is embedded in the very institutions meant to provide protection and care. These experiences resonate with the notion of structural violence [16], where systemic inequalities reproduce vulnerability while simultaneously obscuring responsibility. The illegality of sex work in Brazil further intensified these dynamics. Because sex work is not recognised as formal labour, participants described how the criminalisation of collective organising left them exposed to violence and exploitation. Cleide’s account of being held at gunpoint by a client, and her sense that she had to “bear it alone in silence” because her work was criminalised and stigmatised, illustrates how the legal framework itself produces risk. Similarly, participants highlighted how transphobia within the sex industry compounded exclusion: brothel managers hiding travestis from clients, or limiting their presence to “one or two,” reinforced hierarchies even within marginalised economies. These experiences cannot be reduced to single axes of oppression but emerge from the convergence of gender identity, race, class, territory, and sexuality [13]. This corroborates Brazilian public health scholarship that highlights how Blackness, poverty, and drug use intersect to shape vulnerability [5; 26]. At the same time, the findings invite a revisiting of the concept of vulnerability itself. As Delor and Hubert argue, vulnerability is not a fixed attribute but a dynamic process operating across three levels: individual trajectories, the intersections where trajectories converge, and the broader social context [40]. The participants’ narratives demonstrate precisely how differences — of gender identity, race, class, and territory — are transformed into health inequalities through institutional practices of exclusion. These dynamics also speak to Mbembe’s concept of necropolitics [41], increasingly mobilised in public health to interrogate how states and institutions decide “who may live and who must die.” Participants’ testimonies of being denied care in health services, exposed to police violence, or left unprotected in sex work zones illustrate how trans women and travestis are positioned as populations whose suffering is normalised and whose deaths are rendered socially acceptable, as also documented in the increased number of dead trans women, travestis and sex workers [19]. Their itineraries of vulnerabilization and marginalization are thus not accidental but reflect necropolitical logics that regulate life and death along lines of gender, race, and class. By situating participants’ experiences within the frameworks of intersectionality, social determination of health, and necropolitics, this study underscores that GBV is not only a matter of interpersonal violence but also a structural determinant of health inequities and premature death. It highlights the urgent need for health systems and public policy to move beyond biomedical framings of “risk” and to address the political and economic conditions — including the illegality of sex work and pervasive transphobia — that produce vulnerability in the first place Substance use beyond pathology Our results question biomedical approaches that pathologise substance use among trans women, travestis and sex workers. While drug use was linked to health risks, participants interpreted it as inseparable from trauma, loneliness, and survival under conditions of GBV. As one woman explained, “drugs made me feel less alone,” while others described how clients introduced substances into sex work encounters, often doubling the payment but increasing risk. Recognising substance use as embedded within broader histories of violence and exclusion, dynamics is essential for designing harm reduction interventions that are responsive rather than punitive. The life stories collected here also show how easily participants’ experiences were read through the grammar of psychopathology, with psychiatric diagnoses used to name and contain their relationship with drugs. Yet such categories often failed to capture the complexity of their suffering. As Favero argues, nosological discourses historically claimed stability and authority while relying on sexist stereotypes to define trans populations [42]. In our study, psychiatric labels reduced substance use to “psychic suffering,” obscuring the structural and colonial dimensions of trauma. Kilomba reminds us that colonial projects have always relied on the dehumanisation of certain bodies [43], while Fanon describes how these bodies are relegated to the “zone of non‑being” [44]. In this light, categories such as “prostitution” and “drug use,” historically attached to street populations and travestis , appeared not only as markers of stigma but also as acts of agency — resources for managing precarity, pain, and abandonment. This suffering was not merely additive but relational: the intersection of multiple oppressions produced unique vulnerabilities, while also creating conditions for innovative harm reduction practices. Participants described WhatsApp groups where they exchanged information on hormones and safer drug use, peer‑led outreach that drew credibility from lived experience, and improvised clinics that filled gaps left by the SUS. These practices exemplify the principles of popular education, where experiential knowledge circulated and solidarity was enacted [45]. What Clarindo et al. call saberes da putaria — sex‑work knowledges blending humour, improvisation, and embodied expertise — were not informal curiosities but counter‑hegemonic forms of health knowledge [46]. At the same time, care was deeply ambivalent. Solidarity was constantly undermined by rivalry, competition for clients, and capitalist pressures, resonating with Mol’s distinction between the logic of care (relational, collective, situated) and the logic of choice (individualised, market‑driven) [47]. In the sex work economy, care practices were simultaneously protective and fragile. Still, they can be read as forms of mutual aid in precarity [28]: sex workers watching each other’s backs on the street, sharing information about violent clients, or collectively confronting transphobic health professionals. Harm reduction here was not only about safer substance use but about reclaiming dignity and survival in hostile environments. Marginality as possibility At the same time, our data underline that marginality is not only a site of harm but also of possibility. In line with hooks, participants re‑signified their positions of abjection, developing alternative forms of knowledge and practice [12]. Peer‑led harm reduction initiatives, WhatsApp groups, and the saberes da putaria are examples of what Haraway terms situated knowledges [32]: experiential expertise that challenges biomedical authority. These practices allowed participants to mitigate risks, share resources, and build chosen families in contexts of exclusion. For the women who collaborated in this research, survival required negotiating their own policies of survival. “Being on the street” was often experienced as violence and fear, but also as another way of inhabiting the world [48], a form of agency [49] when the home represented abuse and exclusion. Agency here was not simply opposition to norms, but the invention of alternative spaces and subjectivities. Kilomba reminds us that resisting colonial, patriarchal, and racist projects requires not only opposition but also the creation of new places for those pushed to the margins [43]. As Mombaça writes, “the world is my trauma,” underscoring the need to escape the paths that push trans and travestis toward death [50]. This reinvention was visible in participants’ trajectories from sex work and substance use into harm reduction work. Becoming professionals in the public health system, while drawing on lived experience, exemplifies the paradox of subjectivation: the same conditions that subordinate subjects also provide the means for self‑conscious agency [51–52]. Favero calls for “de‑cisgendering” mental health care, and the de‑patriarchalisation and de‑colonisation of health knowledge [42]. These critiques resonate with participants’ efforts to name their own histories and claim authority as harm reduction agents. Sex work itself was rarely narrated as a “last resort” [53]. Instead, it appeared as a resource for self‑determination when the state failed or responded violently. Women described prostitution as a profession that allowed them to “work for themselves,” accumulate capital for personal projects, and counter economic and cultural injustices of a patriarchal system that excluded them from formal labour. By inhabiting these “limit situations,” participants re‑subjected themselves from the margins, liberating themselves from structural violence and reconstructing new forms of existence. Here, contradictions became visible, dominant orders were challenged, and possibilities for counter‑attack emerged. Marginality, in this sense, was re‑signified as a site of agency, solidarity, and re‑existence — a place where stigma was transformed into freedom, chosen kinship, and political imagination. Implications for harm reduction and policy These findings have several implications for the future of harm reduction and public health policy. First, harm reduction must explicitly integrate gender‑based violence (GBV) as a central concern, recognising its role in shaping substance use trajectories and health outcomes. Critical public health scholarship has long argued that violence is not peripheral but a structural determinant of health [16; 39]]. Trauma‑informed and survivor‑centred approaches are therefore essential to ensure that harm reduction services respond to the realities of trans women, travestis and sex workers rather than reproducing exclusions. Second, policies should support and integrate and recognise people with lived experience and community‑led harm reduction practices without undermining their autonomy. Evidence from harm reduction research shows that peer‑driven initiatives are more effective in reaching criminalised populations and building trust [26]. Institutional recognition must be accompanied by funding and protection of these practices, while safeguarding their independence from biomedical co‑optation. Third, services must adopt intersectional approaches that address not only substance use but also the overlapping effects of gender identity, racism, poverty, and stigma. Intersectionality has been increasingly mobilised in public health to highlight how health inequities emerge from converging systems of oppression. In practice, this means integrating anti‑racist strategies into health services, connecting with Black and Indigenous heritage groups, and ensuring trans‑affirming care that includes access to hormones, PrEP, and broader sexual health services. Fourth, decriminalisation of sex work is a critical step. As demonstrated, criminalisation increases vulnerability to violence, limits access to health services, and undermines collective organising [1; 54; 55]. Decriminalisation, combined with labour protections, would allow sex workers to negotiate safer conditions, reduce client‑driven coercion into substance use, and strengthen solidarity networks. Finally, harm reduction must be reframed as a political practice of resistance to patriarchy and coloniality. This includes comprehensive gender and sexuality education in schools, destigmatisation campaigns for dissident genders and sexualities, and the inclusion of people with lived experience in the design, delivery, and evaluation of services. As Spade argues, mutual aid and community‑based care are not supplements to formal health systems but essential strategies for survival in contexts of precarity [28]. Taken together, these implications call for a shift from narrow biomedical framings of harm reduction toward a critical public health agenda that recognises GBV, racism, transphobia, and criminalisation as structural determinants of health. Only by addressing these intersecting forms of exclusion can harm reduction fulfill its promise of dignity, safety, and self‑determination for trans women and travestis . Strengths and limitations This research offers a deep and intersectional perspective on harm reduction in dialogue with gender‑based violence. It contributes to strengthening locally situated perspectives on violence, gender, care, and health, moving against medicalising, transphobic, and exclusionary approaches that pathologise trans identities. The article is innovative in three ways: it integrates GBV into harm reduction frameworks, foregrounds trans women and travestis as producers of health knowledge, and redefines harm reduction as a practice of survival and dignity rather than solely a biomedical intervention. However, this study has limitations. Firstly, it focuses exclusively on trans women and travestis , which highlights the need for future research that includes other subjectivities. Seconldy, while ethnographic depth was achieved, the absence of a fully co‑participatory writing process limited the extent to which interlocutors could shape the final text. Finally, the findings are situated in Brazil and may not be generalisable to other contexts. These constraints underscore the importance of further participatory and comparative studies to expand the scope of harm reduction research. Conclusion The objective of this study was to examine how gender‑based violence and substance use intersect in the lives of trans women and travestis in Brazil, Brazil, and how community harm reduction practices emerge in response. To do so, we placed two ethnographic inquiries in dialogue. Through an intersectional, socio‑anthropological, and decolonial lens, the analysis showed that gender‑based violence and psychoactive substance use are inseparable from interpersonal, institutional, and structural violence. These dynamics generate itineraries of vulnerabilisation, often limiting participants to precarious survival strategies. At the same time, the findings demonstrate that marginality is not only a site of harm but also of possibility. Amid violence, suffering, and pain, women mobilised formal and informal solidarity networks, community care, and shared resources to enact harm reduction practices that we describe as itinerários de encruzilhamento [ 24 ]. Situated knowledges — from WhatsApp groups to peer‑led outreach and the saberes da putaria — became fundamental strategies for empowering dissident subjectivities and responding to complex health needs [ 29 – 38 ]. These practices illustrate how trans women and travestis transform spaces of exclusion into arenas of resistance, care, and re‑existence. By centering GBV within harm reduction, this research advances critical public health debates that often overlook violence as a determinant of health. It also expands the conceptual horizons of harm reduction beyond the mitigation of drug‑related risks, framing it as a political and ethical technology of care against the damages produced by colonialism, racism, patriarchy, and neoliberal precarity. In doing so, the study contributes to global harm reduction scholarship by offering a perspective rooted in the Global South, where the harms to be reduced are inseparable from histories of structural violence. Ultimately, the study underscores the role of harm reduction in constructing alternative pathways for trans women and travestis , who often face sex work as a compulsory livelihood and substance use as a means of managing suffering, loneliness, and fear. Experiences of exclusion generate both vulnerability and innovative strategies of care. By centering these practices, we expand the conceptual and practical horizons of harm reduction through an intersectional, locally grounded, and contracolonial perspective. In contexts of the Global South, harm reduction must be understood not only as a response to drug‑related risks but as a technology of care against the damages produced by colonialism, racism, patriarchy, and neoliberal capitalism. From this vantage point, harm reduction is redefined as a practice for sustaining more dignified and less precarious lives. By situating harm reduction within the lived experiences of trans women and travestis , this study underscores its potential to sustain more dignified and less precarious lives, and to open new pathways for re‑existence in contexts marked by violence and exclusion. Declarations Author Contribution DDM and US jointly conceptualized the study and designed the methodological approach. Both authors contributed to data collection, analysis, and interpretation of findings. DDM prepared the first draft of the manuscript. US provided critical revisions and substantive feedback. DDM then revised the manuscript again, incorporating additional refinements. Both authors approved the final version and agree to be accountable for all aspects of the work. 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The word carries a decolonial perspective that cannot be adequately rendered in English: it refers to subjectivities that disrupt binary gender categories, resist the reductionist and pathologizing gaze of biomedicine, and challenge capitalist, patriarchal, and colonial forms of violence. Beyond describing gender variance, travesti names a political identity and a collective practice of survival and resistance, rooted in Latin American histories of marginalization and activism. Indigenous trans and travesti activists emphasize that the term revives plural, non‑binary identities embedded in ancestral traditions and knowledges that were erased by the gender binary imposed through Catholicism during colonization. To translate it would risk erasing these specific genealogies and struggles; leaving it in its original form acknowledges its epistemic and political force. For further discussion, see Puta Librino (Da Mosto et al., 2023), available at: https://www.edizioniminoritarie.it/acquista/p/puta-librino We use the term trans to encompass all subjectivities who define themselves as such, not in the sense of reifying biomedical categories or the biomedical management of subjectivities (Aran, 2012), but rather to refer to those who transgress the binary sex–gender system (Pelúcio, 2011; Santos, 2013). In the Brazilian context, we also recognise the category of travesti , which does not map neatly onto English understandings of “trans woman.” Travesti historically and politically articulate a gendered existence that challenges both cisnormativity and biomedical classifications, rooted in specific cultural, racial, and classed experiences (Pelúcio, 2009; Vergueiro, 2016). By including both trans and travesti , we aim to foreground local epistemologies and resist the universalisation of biomedical or Western categories of gender. A service that is part of the Psychosocial Care Network within the Brazilian public health system, aimed at people with "serious, severe, and persistent suffering" resulting, in this case, from the "abusive and harmful use of alcohol and other drugs". Regulated, in the context of the Brazilian Psychiatric Reform, by Law 10.216/2001 and Ordinances 336/2002 and 3088/2011. This is a fictitious name chosen by this woman to present herself in this work. The self-definitions of race, gender, sexuality, and generation have been kept as they were spoken by the people themselves. Ellipses are used to indicate that these are multiple people/existences, far beyond any classificatory categories. To date, although prostitution is recognized as a profession and therefore not considered illegal, the involvement of third parties—as well as pimping—is illegal, and their definition in the Penal Code is deliberately ambiguous, effectively making it illegal to create organized spaces dedicated to prostitution such as brothels or other workplaces. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers invited by journal 02 Feb, 2026 Editor assigned by journal 06 Jan, 2026 Submission checks completed at journal 10 Nov, 2025 First submitted to journal 05 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8042292","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":584502332,"identity":"f06c67cf-e37a-4986-94c5-deffdf6c66d5","order_by":0,"name":"Delia Da Mosto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYDCCA8wNBxgYmKG8igQGPggrAY8WRrgWxgaGMwkMbMRoYYBrYWwjQgvf8cbGAz8YrOV129ufP/g4L02ejYH54QfGtjScWiTPHGw42MOQbrjtzBnDxpnbcgzbGNiMJRjbcnBqMbiR2HCAh+Ew47YbOYzNvNsqEoAOM2NgbKvAreX+w4aDfxgO22+7kf6wmXcOSAv7N/xabjA2HAbakrjtRoJhM29DDlALD8gW3A6TPJPYcFjGID0Z5JeZM46lGbYx8xRLJJzD7X2+44cPf3xTYW277Xj7gw8fapLl+dnbN374UJaMUwvUecgcUBwlENAwCkbBKBgFowA/AACsXVlrPI7dIQAAAABJRU5ErkJggg==","orcid":"","institution":"King’s College London","correspondingAuthor":true,"prefix":"","firstName":"Delia","middleName":"Da","lastName":"Mosto","suffix":""},{"id":584502333,"identity":"a1e9fe6e-7ab2-439f-b305-e2457e8e4912","order_by":1,"name":"Ueslei Solaterrar","email":"","orcid":"","institution":"Universidade do Estado do Rio de Janeiro","correspondingAuthor":false,"prefix":"","firstName":"Ueslei","middleName":"","lastName":"Solaterrar","suffix":""}],"badges":[],"createdAt":"2025-11-06 00:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8042292/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8042292/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101943063,"identity":"ff11eb62-f639-4790-ade6-84a6f3d5079e","added_by":"auto","created_at":"2026-02-05 09:40:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":715385,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8042292/v1/84675d4c-59a7-44ca-a483-f8a1bbf55ca4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Peer‑Led Harm Reduction in Brazil: Gender‑Based Violence, Intersectionality, and Decolonial Perspectives of Community-based care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHarm reduction has long been recognised as a pragmatic and rights‑based response to substance use and its associated risks. Yet mainstream harm reduction frameworks, reflecting hegemonic health perspectives, have often been criticised for neglecting the ways gender, sexuality, race, and other intersecting inequalities shape experiences of harm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Gender‑based violence (GBV) is both a driver and a consequence of substance use: women and LGBTQ\u0026thinsp;+\u0026thinsp;people who experience violence are more likely to use substances as coping mechanisms, while substance use can in turn increase exposure to further violence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a public health perspective, these vulnerabilities are not evenly distributed but are structured by broader systems of power. Hegemonic models rooted in capitalism, patriarchy, racism, and colonialism have historically defined humanity through the figure of the \u0026ldquo;first‑class citizen: European, male, rational, white, heterosexual, cisgender, and Christian\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Gonzaga [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] emphasises that racism\u0026mdash;and, by extension, gender‑based violence\u0026mdash;should not be treated merely as theoretical constructs but as fundamental ethical concerns within the civilizational framework of coloniality. This framework ordered the hierarchisation of people by skin colour [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and by the anatomy of the genitalia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Those with non‑conforming bodies and genders [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], or who engage in stigmatised sexualities and sex work [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], are relegated to zones of abjection, where their intelligibility is constantly questioned [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Yet, as hooks [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reminds us, marginality is not only a site of exclusion but also a potential space of resistance and radical possibility.\u003c/p\u003e \u003cp\u003eIntersectionality, originally theorised by Crenshaw [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], provides an essential framework for understanding these dynamics. Rather than treating gender, race, sexuality, or class as separate categories, an intersectional lens highlights how overlapping systems of oppression shape both vulnerabilities and forms of resilience [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. As Ussher et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] demonstrate in their study racism, transphobia, misogyny, class, and migration status intersect in what they describe as a \u0026ldquo;matrix of domination,\u0026rdquo; producing unique vulnerabilities that cannot be understood through a single axis of identity. Recent calls for intersectional harm reduction emphasise the need to address stigma, discrimination, and structural violence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] in ways that move beyond biomedical models [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Brazil, sex workers, trans women and \u003cem\u003etravesti\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e are disproportionately exposed to GBV, social exclusion, and substance‑related harms. According to ANTRA\u0026rsquo;s 2025 report, at least 60% of murders of trans people worldwide occur in Brazil, with 78% of victims being Black \u003cem\u003etravesti\u003c/em\u003e and trans women, and over 90% engaged in sex work [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Multiple studies further show that healthcare services often reproduce broader social inequalities, limiting access for sex workers and trans people despite policy reforms [\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Although punitive and abstinence‑focused drug policies remain a constant threat\u0026mdash;particularly under right‑wing and far‑right governments, as between 2015 and 2022 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u0026mdash;Brazil has also been shaped by the process of Psychiatric Reform movement, initiated through psychiatric deinstitutionalization. This process sought to dismantle the asylum model and replace it with community‑based mental health care, aligning with harm reduction principles. Within this context, Brazilian trans communities, together with workers and activists in the anti‑asylum movement, have developed situated practices of solidarity and harm reduction. These include peer‑led outreach in sex work zones, informal networks of knowledge sharing, and community self‑care initiatives. Such practices resist biomedical hegemony and generate new forms of autonomy, emerging as vital strategies for survival and resistance [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis article contributes to these debates by examining how GBV and substance use intersect in the lives of trans women\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e and \u003cem\u003etravesti\u003c/em\u003e in Brazil, and how community‑based formal and informal harm reduction practices emerge in response. It analyses their role as technologies of care and life sustenance. Drawing on ethnographic research with sex workers, activists, and health professionals, we highlight how lived experiences of violence and exclusion generate both vulnerability and innovative strategies of harm reduction. By centring these practices, we aim to expand the conceptual and practical horizons of harm reduction through an intersectional and decolonial perspective.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis article draws on two qualitative ethnographic studies conducted in Brazilbetween 2019 and 2023. Both studies followed a collaborative approach [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and a multi‑sited ethnographic design [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], privileging situated knowledges [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and engaging participants as co‑producers of knowledge. The studies were designed to capture the intersections of gender‑based violence (GBV), substance use, sex work, and harm reduction practices through an intersectional lens, specifically trans identity and race. Researchers\u0026rsquo; choice of methods was guided not only by epistemological and theoretical considerations but also by moral and ethical commitments [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Building on the assumption that social justice is a \u0026ldquo;politics of doing,\u0026rdquo; applicable both in political life and in research practice [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], our methodological orientation treated research itself as a form of praxis, we adopting qualitative and participatory strategies that could adapt to the needs of participants and foreground their experiential expertise.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants included trans women and \u003cem\u003etravesti\u003c/em\u003e engaged in sex work, peer educators, harm reduction workers with and without lived experience, health professionals, and activists. Recruitment was guided by an intersectional approach, ensuring that participants reflected diverse racial, class, and gendered positions within Rio\u0026rsquo;s trans and sex worker communities. This approach stems from an understanding of the limitations of biomedical framings of suffering [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and the need to construct counter‑hegemonic readings. Recruitment was carried out through snowball sampling involving community networks, health services, NGOs and activist groups. This ensured the inclusion of both individuals with lived experience of GBV and substance use, and those directly involved in harm reduction practices.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were generated through multiple qualitative and participatory techniques, designed to capture the intersections of GBV, substance use, sex work, and harm reduction practices. The following activities were conducted:\u003c/p\u003e \u003cp\u003e Network mapping: 10 interviews with key actors in formal and informal networks of care and activism, documenting the \u0026ldquo;trans care network in (de)construction.\u0026rdquo;\u003c/p\u003e \u003cp\u003eLife history interviews: 4 in‑depth biographical interviews with trans women and \u003cem\u003etravesti\u003c/em\u003e who work and/or use mental health services, focusing on experiences of GBV, substance use, access to health services, harm reduction, and coping strategies.\u003c/p\u003e \u003cp\u003eParticipant observation in sex work zones: sustained ethnographic observation in 2 street‑based sex work areas of a big city in Brazil, documenting everyday practices of survival, harm reduction, and exposure to violence.\u003c/p\u003e \u003cp\u003eParticipant observation with CAPSAD outreach service: shadowing a Psychosocial Care Center for Alcohol and Other Drugs (CAPSAD\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e) night outreach team, with attention to peer‑led harm reduction practices with sex workers.\u003c/p\u003e \u003cp\u003e Semi‑structured interviews: 18 interviews with sex workers, activists, and health workers, exploring GBV, substance use, community‑based care, and harm reduction strategies.\u003c/p\u003e \u003cp\u003e Collective conversation circles: 3 group discussions involving a total of 20 participants, designed as participatory spaces for dialogue and co‑analysis of experiences.\u003c/p\u003e \u003cp\u003e Creative and participatory approaches (e.g., conversation circles, visual mapping of care networks, and photovoice‑inspired strategies) were incorporated to allow participants to express experiences that might not be easily captured through conventional interviews. This design was informed by an intersectionality lens, ensuring that data collection foregrounded the ways race, gender identity, class, and sexuality intersect in shaping vulnerability and resilience.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll interviews and fieldnotes were transcribed and coded using thematic analysis [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The analysis focused on three intersecting domains: (1) experiences of GBV and structural violence, (2) substance use and harm, and (3) community-based harm reduction practices. An intersectional and socio‑anthropological perspective informed the analysis. In addition, we drew on the Framework Method [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which provided a systematic yet flexible structure for managing and comparing qualitative data across cases and themes. This approach was particularly useful for working collaboratively with community partners and ensuring transparency in the analytic process. Reflexivity was central to this process: the research team engaged in reflexive journaling, private field diaries, and co‑analysis with community collaborators to enhance validity and ensure alignment with participants\u0026rsquo; perspectives [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Reflexivity was understood as a continuous practice of critical self‑awareness, recognising both the influence of the researcher on the research process and the reciprocal impact of the research on the researcher [33; 38].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e Both studies were approved by institutional review boards (Universidade do Estado do Braziland Universitat Rovira i Virgili). Written informed consent was obtained from all participants. To protect anonymity, pseudonyms are used, and potentially identifying details have been removed. Special care was taken to ensure safety and confidentiality given the participants\u0026rsquo; exposure to violence, stigma, and criminalisation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe ethnographic material revealed four interrelated themes that illuminate how GBV, substance use, and harm reduction intersect in the lives of trans women and \u003cem\u003etravesti\u003c/em\u003e in Brazil. The results are divided in:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eGender-based violence and trajectories of marginalisation:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSubstance use as coping and as risk:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHarm reduction from the margins: community practices of care:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAgency, resistance, and re-signification of marginality:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003e1. Gender-based violence and trajectories of marginalisation\u003c/h3\u003e\n\u003cp\u003eParticipants\u0026rsquo; life histories underscored the pervasive role of gender‑based violence (GBV) in shaping trajectories of exclusion. Violence was experienced across multiple domains \u0026mdash; within families, schools, institutional settings (particularly health services), and intimate relationships \u0026mdash; and was described as both physical and symbolic.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI am a woman who never bled every month. I bled for a long time, every day, every hour, and every minute for years. For almost 20 years of my life [...] I knew that the way I bled was not synonymous with femininity, but rather synonymous with a lot of pain that no one but me could perceive how much I bled. At 14, I was already a woman, I had hair, breasts, my body... This woman had to face the streets at 14, she had to face difficulties [...] at 14, I experienced my first rape [...] and that rape by four men led to many others, unspeakable, I can't even count them... And violence isn't just physical aggression, it's also verbal or visual.[...] But I think it's crazy: a drug dealer who walks down the street, kills, destroys families, and does a lot of things is idolized, but I walk down the street and haven't hurt anyone, and I get booed, and many of us die.\" (Bruna\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e, \u003cem\u003e35 years old, white, former sex-worker, heterosexual, trans woman)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMany participants recounted being expelled from their homes as adolescents when their gender identity became visible, or being forced out of school due to harassment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When my family found out I was transitioning, they kicked me out of the house. They told me I was a filthy, ragged lunatic who deserved nothing and deserved to die. At first, I decided to stop transitioning and stay with them, but even though I started dressing like a man again, my brothers and father beat me every night.\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The house pushed me to the street\u0026hellip; when the family doesn\u0026rsquo;t expel you directly, the hostility makes you leave anyway.\u0026rdquo;(Jessica, 39 years old, Black, advertising student, heterosexual, trans woman\u0026hellip;).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHealthcare settings were also described as sites of violence and exclusion, where transphobia and institutional fragility undermined access to care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The SUS (National Health System) can be sexualizing and discriminating. [...] Some professionals, whether due to transphobia or lack of knowledge, are unable to provide this treatment to trans women at the clinic... She suffers transphobia there, she cannot access care.\" (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants also recounted violence within sex work itself, due to the impossibility of self-organising of sex workers correlated to the current legal framework\u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e and the struggle to denounce violence due to stigma.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;One day I accepted a job with a client I didn't know [...] after some time I told him I had to leave... [...] At that moment, he took out a gun, pointed it at my head, and told me I wasn't going anywhere until he decided... [...] I kept quiet because in my head I was wrong [...] in my mind... what I suffered was part of the risk. I thought, \"I'm here doing a job that is wrong, that no one can know I do this, so I suffered this violence and I'll have to bear it alone in silence\u0026hellip;\u0026rdquo; (Cleide, 29 years old, black, former sex-worker, activist, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFurthermore some participants highlighted how also the sex work industry could be discriminating against trans people:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In brothels, transvestites stay hidden. When a client arrives, the manager says that there are also transvestites there... But there are no brothels exclusively for trans women.\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They [cis prostitutes] always had a distant relationship with travestis. [...] They never mixed in the places where they work. Usually, travestis are prohibited from entering, so only one or two are allowed in. There is a lot of transphobia in prostitution, right? So it's very complicated.\u0026rdquo; (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTaken together, these accounts reveal GBV not simply as a series of personal experiences but as a pervasive structure that organises the life chances of trans women and \u003cem\u003etravestis\u003c/em\u003e in Brazil. Violence was embedded in families, schools, health services, labour markets, policing, and even within sex work spaces, producing cumulative layers of exclusion. This underscores the need to understand GBV intersectionally \u0026mdash; as entangled with racism, class inequality, and cisnormativity \u0026mdash; and as a structural force that shapes trajectories of marginalisation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2. Substance use as coping and as risk\u003c/span\u003e \u003c/p\u003e \u003cp\u003e Experiences of trauma, sexual violence, and loss were closely linked to substance use in participants\u0026rsquo; narratives. Drugs and alcohol were described not only as substances but as tools for managing pain, loneliness, and exclusion.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;How not to use? People are poor, Black, rejected by family\u0026hellip; drugs make the suffering a little lighter.\u0026rdquo; (Serena, 37 years old, Black, harm reduction worker, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor many, substance use was a way to endure the weight of systemic violence and to create fleeting moments of connection.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The money I got today was to eat tonight, not for the future\u0026hellip; so drugs made me feel less alone\u0026rdquo;. (Bruna, 35 years old, white, former sex-worker, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I felt alone. Do you know what it's like for people to be close to you because of what you can provide? Working on the street, earning money, and using drugs brought people closer to me. It was a way to have people around, to escape loneliness.\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAt the same time, participants recognised that substance use could generate new risks, including health complications, heightened exposure to policing, and intensified stigma. This ambivalence \u0026mdash; substances as both survival strategies and sources of harm \u0026mdash; was a recurring theme.\u003c/p\u003e \u003cp\u003eSubstances were often introduced in the context of sex work encounters, with clients offering higher payments in exchange for use. While biomedical frameworks tended to pathologise these practices, participants framed them as inseparable from the broader social suffering generated by GBV and exclusion.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;sex workers use a lot of drugs to keep herself alert and awake, because the more sex she has, the more... well... the more sex, the more money, and as I told you, we get into a vicious cycle, our consciousness changes, we become another person. [...] I only slept three hours a night for five years of my life when I was a prostitute, it was a lot of work. I had to work, I had to work out, I had to do prostitution, and I knew it would be for a short time, but that it would be worth it later\u0026hellip;\u0026rdquo; (Cleide, 29 years old, black, former sex-worker, activist, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlcohol consumption, in particular, was embedded in the economic logic of prostitution, the illegal framework and the lack of policies to safeguard sex workers, as brothel owners pressured sex workers to drink with clients to generate profit.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Another point that comes up [when I think about health issues] is the labor issue, health doesn't stand alone, right? It has to be political, it has to be incisive, it has to be all policies together, because this problem is now going to be physical? For me, the physical aspect has to do with the lack of legislation, because you are not recognized as a worker. So, to work in certain places there are rules, you work where you want, of course, but in most brothels you have to drink drinks. You can't drink beer. Because every drink you have... Then you have to make the client pay. To boost income, and make them pay for the drink, which is expensive, which is how they make money. So we drink a lot. Prostitutes drink a lot, they drink a lot. [...] So for me, I think it's the high consumption of alcohol and drugs, because afterwards I had liver problems, right? Liver. And I'm sure it has a lot to do with the amount of drinking... [...] You know? Because many age quickly, because you sleep little, drink a lot, use drugs... for the client. And that's where the problems come in\u0026hellip;\u0026rdquo; (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eField observations confirmed this dynamic. In one of the sex worker areas, the smell of alcohol mixed with sewage, while during night outreach, sex workers staggered in high heels after long hours of drinking with clients. Many explained that drugs entered their lives through clients, who offered more money for encounters involving substances.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I discovered prostitution, I thought it would be the only way to survive and get out of the life I was living there. Until I got to the point of discovering drugs. [...] But that's what often leads sex workers to drugs, because the price doubles when you have a client who uses drugs. The price doubles. Then that tempts you, tempts the person, right? It tempts you. Then when you realize it, you're already in that situation [drug abuse].\u0026rdquo; (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor some, alcohol and drugs were also tied to grief and despair, blurring the line between coping and self‑destruction.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It took me a long time to understand, when I lost my mother, my father... [...] Then I discovered alcohol abuse. I would go out to work, but before leaving I would cry and drink...\u0026rdquo; (Bruna, 35 years old, white, former sex-worker, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Participants also challenged the stigma that associates sex work uniquely with drug use, pointing out that substance use is widespread across society.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;People like to say that many people in prostitution use alcohol or drugs to cope with their work. But not at universities. Guys! I'm here all the time, I have several friends who are academics. I don't use cocaine, for example. All my drugs are legal: beer, whiskey, caipirinhas, coffee, sugar. All my drugs are legal. But how many university professors, students, and administrators use cocaine? An addiction is when you lose control, and that's when something becomes an addiction. [...] But looking at prostitution through that lens [of addiction], when it's already a stigmatized, marginalized, and dangerous occupation, \u0026ldquo;most people in prostitution use drugs,\u0026rdquo; that's also a lie. Because the vast majority of society uses drugs. And most of the drugs that prostitutes use? Most of the time, it's the clients who bring the drugs. It is the clients who bring them or ask if they know someone from whom they can buy drugs. It is their clients\u0026hellip;\u0026rdquo; (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn sum, substance use emerged as a deeply ambivalent practice: a means of survival, connection, and economic gain, but also a site of exploitation, stigma, and health risk. Rather than reducing these practices to pathology, participants framed them as embedded in the structural conditions of marginalisation and in the economic logics of sex work. This perspective highlights substance use as both a strategy of endurance and a terrain of vulnerability, shaped by capitalism\u0026rsquo;s commodification of bodies and by the intersecting oppressions of gender, race, and class. In the next section, we turn to harm reduction practices, examining how trans women, \u003cem\u003etravestis\u003c/em\u003e and sex workers develop community‑based strategies to navigate these ambivalences and reclaim care on their own terms.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e3. Harm reduction from the margins: community practices of care\u003c/span\u003e \u003c/p\u003e \u003cp\u003eDespite structural barriers and exclusion from formal health systems, participants generated situated harm reduction practices that mitigated risk and fostered solidarity. These practices were rooted in lived experience, collective knowledge, and everyday improvisation. They echoed harm reduction principles but emerged from within the community, shaped by intersectional experiences of gender violence, racism, poverty, and transphobia.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePeer‑led outreach grounded in lived experience.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCAPSAD night teams, often staffed by trans women, \u003cem\u003etravestis\u003c/em\u003e and sex workers with lived experience, were described as more accessible and trustworthy than traditional clinical care. Their presence not only encouraged trust but also shaped therapeutic decisions: psychiatrists and social workers frequently reconsidered treatment plans after peer educators highlighted forms of oppression invisible to biomedical frameworks, highlighting for example how specific therapies could not be followed in such marginalized contexts. In multiple occasions the psychiatrist reconsidered the therapy after talking to the harm reduction person with lived experience which highlighted oppressions which were not visible to the psychiatrist that would have generated some complications for the psychiatric/substance substitution therapy.\u003c/p\u003e \u003cp\u003eFurthermore the role of people with lived experience as well as the presence of trans women and \u003cem\u003etravestis\u003c/em\u003e was perceived as more accessible and trustworthy than traditional clinical care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;With all respect to the health professionals at the centre, which I think they all do a good job, I do feel a special connection with Gloria\u0026hellip; And I trust her\u0026hellip; She was on the streets with me, she knows what it\u0026rsquo;s like, she is not a privileged white girl that learnt from the books\u0026hellip; She will never force me to do something that I don\u0026rsquo;t want to do and she know exactly what I need\u0026hellip;\u0026rdquo; (Sofia, 49 years old, white, sex worker, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e This credibility was central to engagement, and according to participants was also determined by the embodiment of a \u0026ldquo;street code\u0026rdquo; and laguage.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When you come from the streets you learn a certain type of language, a certain type of attitude, which you can\u0026rsquo;t learn in University\u0026hellip;\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInformal knowledge networks and self-harm reduction.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhatsApp groups functioned as spaces where trans women and \u003cem\u003etravestis\u003c/em\u003e exchanged advice on hormone use and it\u0026rsquo;s interactions with PREP and drugs, silicone injections, and safer practices \u0026mdash; knowledge otherwise unavailable in formal services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have a WhatsApp group. And there's the girls' health chat [trans women and travesti]... this group is ours [trans women and transvestites], right? Here, we're done with the psychiatrist who knows everything, right? No way! It becomes a means of communication between LGBTQIA\u0026thinsp;+\u0026thinsp;people and health... We work hard on this issue of putting the doctor in the background... In the group, the conversation flows between us. [...] Access to the group is free, everyone is an administrator...[...] We only speak as health workers when something is necessary. To guide or intervene... They are the ones who say how to take hormones, what dosage and which hormone is good for what (breasts, penis, muscles...), the professionals who are there are only there to provide information regarding opportunities, access to services or if there are issues for which they are directly requested\u0026hellip;\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBeyond hormones, sex workers also shared \u0026ldquo;tricks of the trade\u0026rdquo; related to substance use and safety. While some of these practices remained deliberately undisclosed, participants emphasised that they were passed down from more experienced colleagues.\u003c/p\u003e \u003cp\u003eOthers stressed the importance of sharing information about dangerous clients:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026ldquo;It\u0026rsquo;s important that we tell at least one of our closest colleagues: \u0026lsquo;Look, that guy stole my money!\u0026rsquo;\u0026hellip; so that other people don\u0026rsquo;t go through what you went through.\u0026rdquo; (Nina, 30 years old, sex worker, activist, lesbian, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOthers described private self‑care strategies to manage substance use.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen I was using drugs and my father was alive, I was able to reconcile it with harm reduction, you know? Without visiting any mental health centers, I would lock myself in my room at home and no one could tell\u0026hellip;\u0026rdquo; (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eCollective care and safe spaces\u003c/h3\u003e\n\u003cp\u003eIn the absence or impossibility to access healthcare services due to transphobia or other barriers, participants often reported taking care of one another and improvising harm reduction techniques which could however be impacted by external factors.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy friend who brought me into the world of sex work had developed a serious substance abuse problem... Gradually, crack had consumed every part of her life, and one day I found her in one of the rooms vomiting blood, and she begged me to help her... I took her to my mother's house for six days and we took care of her... She got clean, but after a while her ex-boyfriend took her back to the drug tunnel...\" (Sonia, 35 years old, black, sex worker, heterosexual, trans woman)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eHarm reduction also took the form of collective defence and vigilance in sex work zones. Participants described intervening when colleagues were attacked or cheated by clients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If a customer doesn't pay or hits one of our colleagues, of course we all take action... it's in everyone's interest to have decent working conditions\u0026hellip;\u0026rdquo; (Carla, 25 years old, white, sex worker, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOn the street, women often worked in pairs, watching over each other during encounters.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;On the street... I liked to be with a colleague... I would tell her when I got in the car, \u0026ldquo;Look closely at the client's face... look at the license plate... the color of the car...\u0026rdquo; It may not solve everything, but it discourages the man from doing something bad.\" (Raffaela, 33, black, sex worker, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis collective protection extended even into hostile institutions. When one of them faced transphobic treatment in a health service, others would accompany her to \u0026ldquo;armar um caos\u0026rdquo; \u0026ldquo;make a mess\u0026rdquo; and demand accountability.\u003c/p\u003e \u003cp\u003eYet these networks were deeply ambivalent. While they offered solidarity and strategies of survival, they were also marked by rivalry, competition for clients, and capitalist pressures. As Erica, puts it:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;On the track you are alone\u0026hellip; today\u0026rsquo;s client may find my colleague prettier tomorrow\u0026rdquo;. (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eCare was thus simultaneously a resource and a fragile practice, constantly undermined by structural and economic violence.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e4. Agency, resistance, and re-signification of marginality\u003c/span\u003e \u003c/p\u003e \u003cp\u003eWhile violence and exclusion structured participants\u0026rsquo; lives, the margins were also described as spaces of possibility. Sex work, for many, was not only a survival strategy but also a way to affirm gender identity, exercise autonomy, and access income otherwise denied in the formal labour market.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So when I was 19, I left home, and since there weren't many services that could support me at the time, I decided to enter the world of prostitution. There I found a new world, not only did men not beat me, but they also paid me to be who I was!\u0026rdquo; (Sonia, 35 years old, black, sex worker, heterosexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSeveral participants framed sex work as a deliberate choice among limited but real options, highlighting the agency involved in deciding how to inhabit their gender identities and sustain themselves.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"When you socialize as a trans woman or travesti, you have two job options: either be a hairdresser or be a prostitute, there isn't much choice! As I had already tried being a hairdresser and didn't like it, I opted for prostitution.\" (Fabiane, 45 years old, white, sex worker, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOthers emphasised that sex work offered a space of affirmation compared to the discrimination they faced in formal labour markets.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before entering prostitution, I worked as a domestic worker, but I wore men's clothes. When my boss found out I was undergoing hormone treatment, he tried to fire me... I'm already black, poor, and transgender. Things are even tougher for me, right? I don't have a great resume, I already lived in a place that was frowned upon, so it's already difficult for you to enter the job market. So how are you going to pay your bills? That's when you get into prostitution, right?\u0026rdquo; (Gloria, 42 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSex work was also narrated as a profession that aligned with political values, offering freedom from the rigidities of formal labour markets.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have always seen prostitution as one of the professions that has freed me most from capitalism. It has also given me total freedom to live my life as I want. Prostitution gave me total freedom to travel, to do things at my own pace, to use my time as I saw fit. So it was a profession where I chose when I was going to work, I chose the client I was going to see, I had the advantages, the power, the advantage of always being able to choose, not least because I had a certain body type.\u0026rdquo; (Erica, 45 years old, indigenous, sex worker, activist, bisexual, trans woman)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Several participants emphasised that prostitution provided freedom and even the basis for chosen families.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eFor a travesti in prostitution, the word \u0026lsquo;family\u0026rsquo; has a special meaning\u0026hellip; the brothel mother, the sisters, the daughters. For those expelled from home or who preferred to leave rather than continue suffering abuse, prostitution represents a space of freedom \u0026mdash; a place where you can begin your life, exist as you want, start your transition, and claim your place in the world.\u0026rdquo; (Gabriela, 53 years old, white, sex worker, activist, lesbian, trans woman)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eImportantly, agency was also expressed through trajectories of recovery and professional transformation. Some participants who had been sex workers and substance users described how being cared for in CAPSAD services opened the possibility of imagining recovery. Through these experiences, they later became harm reduction agents themselves, using their lived experience as a source of credibility and political strength.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I was once on the other side, using and surviving. But CAPSAD didn\u0026rsquo;t just treat me \u0026mdash; they involved me. They showed me I could be part of the team. Today I am a harm reduction agent, and when I talk to someone on the street, they believe me because I\u0026rsquo;ve been there too.\u0026rdquo; (Sandra, 49 years old, black, harm reduction agent with lived experience, heterosexual, travesti)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese trajectories illustrate how marginality can be re‑signified into professional and activist roles, where lived experience becomes a form of expertise. By moving from being \u0026ldquo;cared for\u0026rdquo; to becoming carers themselves, participants challenged biomedical hierarchies and embodied the principle that recovery is possible.\u003c/p\u003e \u003cp\u003eTaken together, these narratives illustrate how participants re‑signified marginality: transforming spaces marked by stigma into sites of agency, solidarity, and political affirmation. Sex work, while shaped by structural violence, was also narrated as a practice of freedom, a source of chosen kinship, and a pathway into activism and harm reduction work. In this sense, the margins were not only places of exclusion but also terrains of resistance and re‑existence, where participants challenged dominant narratives of abjection and created alternative ways of living.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates how gender‑based violence, substance use, and harm reduction intersect in the lives of trans women and \u003cem\u003etravestis\u003c/em\u003e in Brazil. By foregrounding participants\u0026rsquo; narratives, the analysis reveals GBV not as isolated incidents but as a structural force embedded in families, schools, health services, labour markets, policing, and sex work. At the same time, the findings highlight how women actively navigated these conditions, developing situated harm reduction practices, re‑signifying sex work as a space of affirmation, and transforming lived experience into professional expertise as harm reduction agents. In doing so, the study contributes to scholarship on intersectionality, social suffering, and community‑based health by showing that the margins are not only sites of exclusion but also of creativity, solidarity, and political imagination.\u003c/p\u003e\n\u003cp\u003eIntersectionality and structural violence\u003c/p\u003e\n\u003cp\u003eThe life histories of trans women and \u003cem\u003etravestis\u003c/em\u003e in this study illustrate what Solaterrar (2020) terms an \u003cem\u003eitiner\u0026aacute;rio de vulnerabiliza\u0026ccedil;\u0026atilde;o\u003c/em\u003e \u0026mdash; an itinerary of vulnerabilisation \u0026mdash; where structural processes continually generate situations of social humiliation and exclusion. Drawing on Breilh\u0026rsquo;s concept of the social determination of health [39], these trajectories can be understood not as the outcome of isolated \u0026ldquo;risk factors\u0026rdquo; but as the historical and political production of health and illness through intersecting systems of exploitation, patriarchy, racism, and cisnormativity.\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; narratives made visible how gender‑based violence was institutionalised: expulsion from families, harassment in schools, and denial of care in health services were recurrent. Gloria\u0026rsquo;s testimony of being beaten nightly by her brothers after being forced to \u0026ldquo;de‑transition,\u0026rdquo; or her account of transphobic treatment in the SUS, exemplify how violence is embedded in the very institutions meant to provide protection and care. These experiences resonate with the notion of structural violence [16], where systemic inequalities reproduce vulnerability while simultaneously obscuring responsibility.\u003c/p\u003e\n\u003cp\u003eThe illegality of sex work in Brazil further intensified these dynamics. Because sex work is not recognised as formal labour, participants described how the criminalisation of collective organising left them exposed to violence and exploitation. Cleide\u0026rsquo;s account of being held at gunpoint by a client, and her sense that she had to \u0026ldquo;bear it alone in silence\u0026rdquo; because her work was criminalised and stigmatised, illustrates how the legal framework itself produces risk. Similarly, participants highlighted how transphobia within the sex industry compounded exclusion: brothel managers hiding \u003cem\u003etravestis\u003c/em\u003e from clients, or limiting their presence to \u0026ldquo;one or two,\u0026rdquo; reinforced hierarchies even within marginalised economies.\u003c/p\u003e\n\u003cp\u003eThese experiences cannot be reduced to single axes of oppression but emerge from the convergence of gender identity, race, class, territory, and sexuality [13]. This corroborates Brazilian public health scholarship that highlights how Blackness, poverty, and drug use intersect to shape vulnerability [5; 26]. At the same time, the findings invite a revisiting of the concept of vulnerability itself. As Delor and Hubert argue, vulnerability is not a fixed attribute but a dynamic process operating across three levels: individual trajectories, the intersections where trajectories converge, and the broader social context [40]. The participants\u0026rsquo; narratives demonstrate precisely how differences \u0026mdash; of gender identity, race, class, and territory \u0026mdash; are transformed into health inequalities through institutional practices of exclusion.\u003c/p\u003e\n\u003cp\u003eThese dynamics also speak to Mbembe\u0026rsquo;s concept of necropolitics [41], increasingly mobilised in public health to interrogate how states and institutions decide \u0026ldquo;who may live and who must die.\u0026rdquo; Participants\u0026rsquo; testimonies of being denied care in health services, exposed to police violence, or left unprotected in sex work zones illustrate how trans women and \u003cem\u003etravestis\u003c/em\u003e are positioned as populations whose suffering is normalised and whose deaths are rendered socially acceptable, as also documented in the increased number of dead trans women, \u003cem\u003etravestis\u003c/em\u003e and sex workers [19]. Their itineraries of vulnerabilization and marginalization are thus not accidental but reflect necropolitical logics that regulate life and death along lines of gender, race, and class.\u003c/p\u003e\n\u003cp\u003eBy situating participants\u0026rsquo; experiences within the frameworks of intersectionality, social determination of health, and necropolitics, this study underscores that GBV is not only a matter of interpersonal violence but also a structural determinant of health inequities and premature death. It highlights the urgent need for health systems and public policy to move beyond biomedical framings of \u0026ldquo;risk\u0026rdquo; and to address the political and economic conditions \u0026mdash; including the illegality of sex work and pervasive transphobia \u0026mdash; that produce vulnerability in the first place\u003c/p\u003e\n\u003cp\u003eSubstance use beyond pathology\u003c/p\u003e\n\u003cp\u003eOur results question biomedical approaches that pathologise substance use among trans women, \u003cem\u003etravestis\u003c/em\u003e and sex workers. While drug use was linked to health risks, participants interpreted it as inseparable from trauma, loneliness, and survival under conditions of GBV. As one woman explained, \u0026ldquo;drugs made me feel less alone,\u0026rdquo; while others described how clients introduced substances into sex work encounters, often doubling the payment but increasing risk. Recognising substance use as embedded within broader histories of violence and exclusion, dynamics is essential for designing harm reduction interventions that are responsive rather than punitive.\u003c/p\u003e\n\u003cp\u003eThe life stories collected here also show how easily participants\u0026rsquo; experiences were read through the grammar of psychopathology, with psychiatric diagnoses used to name and contain their relationship with drugs. Yet such categories often failed to capture the complexity of their suffering. As Favero argues, nosological discourses historically claimed stability and authority while relying on sexist stereotypes to define trans populations [42]. In our study, psychiatric labels reduced substance use to \u0026ldquo;psychic suffering,\u0026rdquo; obscuring the structural and colonial dimensions of trauma. Kilomba reminds us that colonial projects have always relied on the dehumanisation of certain bodies [43], while Fanon describes how these bodies are relegated to the \u0026ldquo;zone of non‑being\u0026rdquo; [44]. In this light, categories such as \u0026ldquo;prostitution\u0026rdquo; and \u0026ldquo;drug use,\u0026rdquo; historically attached to street populations and \u003cem\u003etravestis\u003c/em\u003e, appeared not only as markers of stigma but also as acts of agency \u0026mdash; resources for managing precarity, pain, and abandonment.\u003c/p\u003e\n\u003cp\u003eThis suffering was not merely additive but relational: the intersection of multiple oppressions produced unique vulnerabilities, while also creating conditions for innovative harm reduction practices. Participants described WhatsApp groups where they exchanged information on hormones and safer drug use, peer‑led outreach that drew credibility from lived experience, and improvised clinics that filled gaps left by the SUS. These practices exemplify the principles of popular education, where experiential knowledge circulated and solidarity was enacted [45]. What Clarindo et al. call saberes da putaria \u0026mdash; sex‑work knowledges blending humour, improvisation, and embodied expertise \u0026mdash; were not informal curiosities but counter‑hegemonic forms of health knowledge [46].\u003c/p\u003e\n\u003cp\u003eAt the same time, care was deeply ambivalent. Solidarity was constantly undermined by rivalry, competition for clients, and capitalist pressures, resonating with Mol\u0026rsquo;s distinction between the logic of care (relational, collective, situated) and the logic of choice (individualised, market‑driven) [47]. In the sex work economy, care practices were simultaneously protective and fragile. Still, they can be read as forms of mutual aid in precarity [28]: sex workers watching each other\u0026rsquo;s backs on the street, sharing information about violent clients, or collectively confronting transphobic health professionals. Harm reduction here was not only about safer substance use but about reclaiming dignity and survival in hostile environments.\u003c/p\u003e\n\u003cp\u003eMarginality as possibility\u003c/p\u003e\n\u003cp\u003eAt the same time, our data underline that marginality is not only a site of harm but also of possibility. In line with hooks, participants re‑signified their positions of abjection, developing alternative forms of knowledge and practice [12]. Peer‑led harm reduction initiatives, WhatsApp groups, and the saberes da putaria are examples of what Haraway terms situated knowledges [32]: experiential expertise that challenges biomedical authority. These practices allowed participants to mitigate risks, share resources, and build chosen families in contexts of exclusion.\u003c/p\u003e\n\u003cp\u003eFor the women who collaborated in this research, survival required negotiating their own policies of survival. \u0026ldquo;Being on the street\u0026rdquo; was often experienced as violence and fear, but also as another way of inhabiting the world [48], a form of agency [49] when the home represented abuse and exclusion. Agency here was not simply opposition to norms, but the invention of alternative spaces and subjectivities. Kilomba reminds us that resisting colonial, patriarchal, and racist projects requires not only opposition but also the creation of new places for those pushed to the margins [43]. As Momba\u0026ccedil;a writes, \u0026ldquo;the world is my trauma,\u0026rdquo; underscoring the need to escape the paths that push trans and \u003cem\u003etravestis\u003c/em\u003e toward death [50].\u003c/p\u003e\n\u003cp\u003eThis reinvention was visible in participants\u0026rsquo; trajectories from sex work and substance use into harm reduction work. Becoming professionals in the public health system, while drawing on lived experience, exemplifies the paradox of subjectivation: the same conditions that subordinate subjects also provide the means for self‑conscious agency [51\u0026ndash;52]. Favero calls for \u0026ldquo;de‑cisgendering\u0026rdquo; mental health care, and the de‑patriarchalisation and de‑colonisation of health knowledge [42]. These critiques resonate with participants\u0026rsquo; efforts to name their own histories and claim authority as harm reduction agents.\u003c/p\u003e\n\u003cp\u003eSex work itself was rarely narrated as a \u0026ldquo;last resort\u0026rdquo; [53]. Instead, it appeared as a resource for self‑determination when the state failed or responded violently. Women described prostitution as a profession that allowed them to \u0026ldquo;work for themselves,\u0026rdquo; accumulate capital for personal projects, and counter economic and cultural injustices of a patriarchal system that excluded them from formal labour.\u003c/p\u003e\n\u003cp\u003eBy inhabiting these \u0026ldquo;limit situations,\u0026rdquo; participants re‑subjected themselves from the margins, liberating themselves from structural violence and reconstructing new forms of existence. Here, contradictions became visible, dominant orders were challenged, and possibilities for counter‑attack emerged. Marginality, in this sense, was re‑signified as a site of agency, solidarity, and re‑existence \u0026mdash; a place where stigma was transformed into freedom, chosen kinship, and political imagination.\u003c/p\u003e\n\u003cp\u003eImplications for harm reduction and policy\u003c/p\u003e\n\u003cp\u003eThese findings have several implications for the future of harm reduction and public health policy. First, harm reduction must explicitly integrate gender‑based violence (GBV) as a central concern, recognising its role in shaping substance use trajectories and health outcomes. Critical public health scholarship has long argued that violence is not peripheral but a structural determinant of health [16; 39]]. Trauma‑informed and survivor‑centred approaches are therefore essential to ensure that harm reduction services respond to the realities of trans women, \u003cem\u003etravestis\u003c/em\u003e and sex workers rather than reproducing exclusions.\u003c/p\u003e\n\u003cp\u003eSecond, policies should support and integrate and recognise people with lived experience and community‑led harm reduction practices without undermining their autonomy. Evidence from harm reduction research shows that peer‑driven initiatives are more effective in reaching criminalised populations and building trust [26]. Institutional recognition must be accompanied by funding and protection of these practices, while safeguarding their independence from biomedical co‑optation.\u003c/p\u003e\n\u003cp\u003eThird, services must adopt intersectional approaches that address not only substance use but also the overlapping effects of gender identity, racism, poverty, and stigma. Intersectionality has been increasingly mobilised in public health to highlight how health inequities emerge from converging systems of oppression. In practice, this means integrating anti‑racist strategies into health services, connecting with Black and Indigenous heritage groups, and ensuring trans‑affirming care that includes access to hormones, PrEP, and broader sexual health services.\u003c/p\u003e\n\u003cp\u003eFourth, decriminalisation of sex work is a critical step. As demonstrated, criminalisation increases vulnerability to violence, limits access to health services, and undermines collective organising [1; 54; 55]. Decriminalisation, combined with labour protections, would allow sex workers to negotiate safer conditions, reduce client‑driven coercion into substance use, and strengthen solidarity networks.\u003c/p\u003e\n\u003cp\u003eFinally, harm reduction must be reframed as a political practice of resistance to patriarchy and coloniality. This includes comprehensive gender and sexuality education in schools, destigmatisation campaigns for dissident genders and sexualities, and the inclusion of people with lived experience in the design, delivery, and evaluation of services. As Spade argues, mutual aid and community‑based care are not supplements to formal health systems but essential strategies for survival in contexts of precarity [28].\u003c/p\u003e\n\u003cp\u003eTaken together, these implications call for a shift from narrow biomedical framings of harm reduction toward a critical public health agenda that recognises GBV, racism, transphobia, and criminalisation as structural determinants of health. Only by addressing these intersecting forms of exclusion can harm reduction fulfill its promise of dignity, safety, and self‑determination for trans women and \u003cem\u003etravestis\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eStrengths and limitations\u003c/p\u003e\n\u003cp\u003eThis research offers a deep and intersectional perspective on harm reduction in dialogue with gender‑based violence. It contributes to strengthening locally situated perspectives on violence, gender, care, and health, moving against medicalising, transphobic, and exclusionary approaches that pathologise trans identities. The article is innovative in three ways: it integrates GBV into harm reduction frameworks, foregrounds trans women and \u003cem\u003etravestis\u003c/em\u003e as producers of health knowledge, and redefines harm reduction as a practice of survival and dignity rather than solely a biomedical intervention.\u003c/p\u003e\n\u003cp\u003eHowever, this study has limitations. Firstly, it focuses exclusively on trans women and \u003cem\u003etravestis\u003c/em\u003e, which highlights the need for future research that includes other subjectivities. Seconldy, while ethnographic depth was achieved, the absence of a fully co‑participatory writing process limited the extent to which interlocutors could shape the final text. Finally, the findings are situated in Brazil and may not be generalisable to other contexts. These constraints underscore the importance of further participatory and comparative studies to expand the scope of harm reduction research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe objective of this study was to examine how gender‑based violence and substance use intersect in the lives of trans women and \u003cem\u003etravestis\u003c/em\u003e in Brazil, Brazil, and how community harm reduction practices emerge in response. To do so, we placed two ethnographic inquiries in dialogue. Through an intersectional, socio‑anthropological, and decolonial lens, the analysis showed that gender‑based violence and psychoactive substance use are inseparable from interpersonal, institutional, and structural violence. These dynamics generate itineraries of vulnerabilisation, often limiting participants to precarious survival strategies.\u003c/p\u003e \u003cp\u003eAt the same time, the findings demonstrate that marginality is not only a site of harm but also of possibility. Amid violence, suffering, and pain, women mobilised formal and informal solidarity networks, community care, and shared resources to enact harm reduction practices that we describe as \u003cem\u003eitiner\u0026aacute;rios de encruzilhamento\u003c/em\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Situated knowledges \u0026mdash; from WhatsApp groups to peer‑led outreach and the saberes da putaria \u0026mdash; became fundamental strategies for empowering dissident subjectivities and responding to complex health needs [\u003cspan additionalcitationids=\"CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These practices illustrate how trans women and \u003cem\u003etravestis\u003c/em\u003e transform spaces of exclusion into arenas of resistance, care, and re‑existence.\u003c/p\u003e \u003cp\u003eBy centering GBV within harm reduction, this research advances critical public health debates that often overlook violence as a determinant of health. It also expands the conceptual horizons of harm reduction beyond the mitigation of drug‑related risks, framing it as a political and ethical technology of care against the damages produced by colonialism, racism, patriarchy, and neoliberal precarity. In doing so, the study contributes to global harm reduction scholarship by offering a perspective rooted in the Global South, where the harms to be reduced are inseparable from histories of structural violence.\u003c/p\u003e \u003cp\u003eUltimately, the study underscores the role of harm reduction in constructing alternative pathways for trans women and \u003cem\u003etravestis\u003c/em\u003e, who often face sex work as a compulsory livelihood and substance use as a means of managing suffering, loneliness, and fear. Experiences of exclusion generate both vulnerability and innovative strategies of care. By centering these practices, we expand the conceptual and practical horizons of harm reduction through an intersectional, locally grounded, and contracolonial perspective. In contexts of the Global South, harm reduction must be understood not only as a response to drug‑related risks but as a technology of care against the damages produced by colonialism, racism, patriarchy, and neoliberal capitalism. From this vantage point, harm reduction is redefined as a practice for sustaining more dignified and less precarious lives. By situating harm reduction within the lived experiences of trans women and \u003cem\u003etravestis\u003c/em\u003e, this study underscores its potential to sustain more dignified and less precarious lives, and to open new pathways for re‑existence in contexts marked by violence and exclusion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDDM and US jointly conceptualized the study and designed the methodological approach. Both authors contributed to data collection, analysis, and interpretation of findings. DDM prepared the first draft of the manuscript. US provided critical revisions and substantive feedback. DDM then revised the manuscript again, incorporating additional refinements. Both authors approved the final version and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our deepest gratitude to all those who contributed to the development of this study. We thank the participants who generously shared their time, experiences, and perspectives, without whom this research would not have been possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and environmental barriers to condom use negotiation with clients among female sex workers: implications for HIV-prevention strategies and policy. 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PMID: 30532209; PMCID: PMC6289426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParker R, Garcia G, editors. The Routledge handbook on the politics of global public health. New York: Routledge; 2017.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e In the present article, the authors have chosen not to translate the term \u003cem\u003etravesti\u003c/em\u003e. The word carries a decolonial perspective that cannot be adequately rendered in English: it refers to subjectivities that disrupt binary gender categories, resist the reductionist and pathologizing gaze of biomedicine, and challenge capitalist, patriarchal, and colonial forms of violence. Beyond describing gender variance, \u003cem\u003etravesti\u003c/em\u003e names a political identity and a collective practice of survival and resistance, rooted in Latin American histories of marginalization and activism. Indigenous trans and \u003cem\u003etravesti\u003c/em\u003e activists emphasize that the term revives plural, non‑binary identities embedded in ancestral traditions and knowledges that were erased by the gender binary imposed through Catholicism during colonization. To translate it would risk erasing these specific genealogies and struggles; leaving it in its original form acknowledges its epistemic and political force. For further discussion, see \u003cem\u003ePuta Librino\u003c/em\u003e (Da Mosto et al., 2023), available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.edizioniminoritarie.it/acquista/p/puta-librino\u003c/span\u003e\u003cspan address=\"https://www.edizioniminoritarie.it/acquista/p/puta-librino\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e We use the term trans to encompass all subjectivities who define themselves as such, not in the sense of reifying biomedical categories or the biomedical management of subjectivities (Aran, 2012), but rather to refer to those who transgress the binary sex\u0026ndash;gender system (Pel\u0026uacute;cio, 2011; Santos, 2013). In the Brazilian context, we also recognise the category of \u003cem\u003etravesti\u003c/em\u003e, which does not map neatly onto English understandings of \u0026ldquo;trans woman.\u0026rdquo; \u003cem\u003eTravesti\u003c/em\u003e historically and politically articulate a gendered existence that challenges both cisnormativity and biomedical classifications, rooted in specific cultural, racial, and classed experiences (Pel\u0026uacute;cio, 2009; Vergueiro, 2016). By including both trans and \u003cem\u003etravesti\u003c/em\u003e, we aim to foreground local epistemologies and resist the universalisation of biomedical or Western categories of gender.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e A service that is part of the Psychosocial Care Network within the Brazilian public health system, aimed at people with \"serious, severe, and persistent suffering\" resulting, in this case, from the \"abusive and harmful use of alcohol and other drugs\". Regulated, in the context of the Brazilian Psychiatric Reform, by Law 10.216/2001 and Ordinances 336/2002 and 3088/2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e \u003cb\u003eThis is a fictitious name chosen by this woman to present herself in this work. The self-definitions of race, gender, sexuality, and generation have been kept as they were spoken by the people themselves. Ellipses are used to indicate that these are multiple people/existences, far beyond any classificatory categories.\u003c/b\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e To date, although prostitution is recognized as a profession and therefore not considered illegal, the involvement of third parties\u0026mdash;as well as pimping\u0026mdash;is illegal, and their definition in the Penal Code is deliberately ambiguous, effectively making it illegal to create organized spaces dedicated to prostitution such as brothels or other workplaces.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Harm reduction, Gender‑based violence, Trans health, Community care, Decolonial public health, Situated knowledges, Sex work","lastPublishedDoi":"10.21203/rs.3.rs-8042292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8042292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis article examines how gender‑based violence (GBV) and substance use intersect in the lives of trans women and \u003cem\u003etravestis\u003c/em\u003e in Brazil, and how community harm reduction practices emerge in response. It also analyzes harm reduction as a technology of care and life‑sustaining practice. Two ethnographic studies were conducted in Brazil between 2019 and 2023, combining life histories, interviews, and participant observation with trans women, sex workers, activists, health professionals, and NGOs. Data from both studies were intersected and analyzed to identify common themes, resulting in four categories: (1) gender‑based violence and trajectories of marginalisation; (2) substance use as coping and as risk; (3) harm reduction from the margins through community practices of care; and (4) agency, resistance, and re‑signification of marginality.\u003c/p\u003e \u003cp\u003eFindings indicate that the suffering experienced by trans women can be conceptualized as a form of \u0026ldquo;crossroads suffering,\u0026rdquo; produced at the intersection of trajectories of vulnerabilisation and encruzilhamento that challenge binary logics. The study also demonstrates that self‑care and community care practices within solidarity networks play a crucial role in everyday survival, emphasizing the importance of situated knowledges in contexts of care. Central to these practices was the role of lived experience: trans women and \u003cem\u003etravestis\u003c/em\u003e drew on their own histories of violence, exclusion, and survival to generate harm reduction strategies that were credible, culturally resonant, and effective in reaching peers. Their experiential expertise functioned as a counter‑hegemonic form of health knowledge, challenging biomedical authority and reshaping harm reduction from the margins.\u003c/p\u003e \u003cp\u003eExperiences of violence and exclusion generated both vulnerability and innovative strategies of resistance and harm reduction, contributing to the construction of alternative pathways and possibilities. By centering these practices, the article expands the conceptual and practical horizons of harm reduction through an intersectional and decolonial perspective. It argues for broadening the notion of harm reduction from Global South contexts, such as Brazil, where the harms to be reduced are not limited to drug‑related risks but include those produced by colonialism, racism, patriarchy, and neoliberal capitalism. Harm reduction is thus understood as a technology of care that extends beyond health, sustaining more dignified and less precarious lives.\u003c/p\u003e","manuscriptTitle":"Peer‑Led Harm Reduction in Brazil: Gender‑Based Violence, Intersectionality, and Decolonial Perspectives of Community-based care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 18:10:53","doi":"10.21203/rs.3.rs-8042292/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-15T23:25:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51569106581023923501354612577826994128","date":"2026-03-04T15:55:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324250228721186021129843193734873856011","date":"2026-03-02T20:52:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-02T11:38:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-06T20:20:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T10:40:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-11-06T00:33:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8134ce4d-accf-4d5c-a0a5-bd60b808fe1c","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T18:10:54+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-04 18:10:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8042292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8042292","identity":"rs-8042292","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}