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Toward an Intersectional Approach to Sexual and Reproductive Health Policies in Brazil

By guest contributor Mariana Rodrigues

Brazil faces critical challenges in sexual and reproductive health, including high rates of unplanned pregnancies, maternal morbidity and mortality, increasing prevalence of unsafe abortions, and significantly low usage and adherence to pre-exposure prophylaxis (PrEP).  Despite recent progress in public health initiatives, including expanded family planning services and efforts to address menstrual poverty, significant gaps persist in addressing the complex structural factors that impact access to sexual and reproductive healthcare.

Individuals at the intersection of multiple minoritized identities face disproportionate health impacts and barriers to healthcare access. For instance, Sexual and Gender Minority (SGM) individuals are significantly affected by the lack of societal awareness surrounding their unique needs, perpetuating their invisibility and hindering access to essential services. Challenges in ensuring access to Brazil’s Unified Health System (SUS) for transgender individuals include discrimination in healthcare services, the pathologizing of transgender identities, and the requirement of gender-reassignment surgery as a criterion for access.These barriers, coupled with the absence of specific primary care policies and insufficient resources for promoting sexual and reproductive health, further compound the challenges faced by SGM individuals.

Similarly, Black women encounter barriers at every stage of their healthcare journey, from the initial search for services to the actual care provision. Structural racism and limited accessibility contribute to limited opportunities for reproductive planning, higher risks of unintended pregnancies, and difficulties in accessing contraceptives. Although a discussion of Brazil’s abortion laws and conservative agenda is beyond the scope of this commentary, it is crucial to highlight that abortion legislations in Brazil significantly exacerbate existing health disparities. Due to such barriers, women are forced to look for unsafe alternatives for abortion and only seek health care when complications arise. These barriers disproportionately affect young, Black, and low-income women, highlighting systemic issues of racism and discrimination within Brazil’s sexual and reproductive healthcare. Overall, the challenges faced by marginalized communities in Brazil’s sexual and reproductive healthcare system reveal deep-rooted systemic issues that call for an intersectional approach to research and policy.

Coined by Kimberlé Crenshaw, intersectionality is a theoretical framework that acknowledges how multiple identities (i.e., race/ethnicity, gender identity, sexual orientation) intersect and interact with systems of oppression leading to unique experiences and barriers. Adopting an intersectional approach involves recognizing how these intersecting identities and their interactions with power structures, influence individuals’ access to resources, opportunities, healthcare, and sexual and reproductive health outcomes, especially for those with multiple minoritized identities.

While progress has been made in analyzing health disparities in Brazil with a holistic approach, intersectionality remains underutilized in research and policy. Brazilian researchers have historically focused on social class when examining healthcare issues, neglecting invisible processes affecting those at the intersection of multiple minoritized identities, such as socioeconomic backgrounds, race, sexual orientation, and gender identity. Indeed, there is a critical need for research that prioritizes Young (18-29) SGM of color, who face disproportionate challenges yet lack comprehensive studies and policies addressing their unique needs and challenges in sexual and reproductive health.

Notably, a few studies have examined the sexual and reproductive health needs of SGM individuals in Brazil. For instance, the “PrEParadas” study found that Black transgender women with lower education levels had lower PrEP adherence, emphasizing the importance of considering intersecting identities and the impact of multiple axes of oppression. Additionally, a qualitative study highlighted significant challenges faced by transgender women in Brazil related to PrEP use and adherence, including stigma, discrimination in the public health system (SUS), and lack of trans-specific healthcare services. These findings underscore the need for research that holistically addresses these barriers and informs the development of tailored interventions to improve the sexual and reproductive health of individuals at the intersection of multiple minoritized identities.

Overall, adopting an intersectional approach allows for an inclusive analysis and consideration of the unique needs of marginalized communities, leading to more targeted interventions and solutions. It involves developing culturally competent services, community-based outreach programs, comprehensive sexual education, and strategies to reduce systemic barriers that not only center the discussions around marginalized groups but make them key actors in societal change. In addition, a critical need exists for disaggregated, nationally-wide data collection that allows for a more comprehensive understanding of the unique needs of individuals with multiple marginalized identities. By addressing the barriers and challenges in sexual and reproductive health with an intersectionality approach, we can effectively prioritize tailored solutions rather than a “one-size-fits-all” approach.

About the author:

Mariana Rodrigues is a licensed Clinical Psychologist in Brazil and holds a Master’s degree in Clinical Psychology from Columbia University. Currently, she is a Ph.D. student in Social & Behavioral Sciences at the New York University School of Global Public Health, working under the supervision of Dr. Stephanie Cook. Mariana’s primary research interests include exploring the structural and environmental factors that impact the health and well-being of individuals at the intersection of multiple minoritized identities, as well as the protective (e.g., perceived social support, community connectedness) that might mitigate such impacts. Her ultimate goal is to inform the development and optimization of culturally-sensitive interventions to reduce health and healthcare disparities.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

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