Care and Demedicalization in Colombia

CONVERSATION WITH LA LIGA DE SALUD TRANS
TRANSLATED FROM SPANISH BY VALENTINA SARMIENTO CRUZ

This discussion with La Liga de Salud Trans (Trans Health League) hints at a collective effort to make the demedicalization and collectivization of healthcare a field of resistance and agency for trans people in Colombia. Advocating for alternative health protocols, redress for violence, and exchanges with anti-racist and feminist movements are all actions to counter a health system that reproduces the social hierarchy necessary for the functioning of the patriarchal capitalist system based on cisnormativity.

Daniela Páez Delvasto & Léopold Lambert: We would like to ask how trans struggles (which encompass broader demands from intersex and non-binary bodies) understand health as a space for questioning power regimes? (We can discuss Colombia specifically.)

Juli Salamanca: Historically, health has been a field where hierarchies and exclusions that sustain the cisheteropatriarchal system—which is racist, ableist, and classist—have crystallized. The pathologization of our identities and bodies has been one of the most effective control mechanisms for keeping that system in place. However, and precisely for this reason, trans struggles in Colombia have identified health as a field of resistance and agency. At La Liga de Salud Trans, we think of “health” not only as the possibility of accessing medical services or a medical transition, but as a comprehensive right that encompasses emotional, social, affective, spiritual, and community life. This implies that access to dignified and discrimination-free services must be coordinated with the construction of sustainable ecosystems of care, where trans people can exercise autonomy over our bodies and our decisions. Resistance occurs on several levels. First, in the fight against pathologization and institutional violence, by promoting the implementation of evidence-based protocols and international standards that recognize affirmative health care as a duty, not a favor. Second, through active participation, which means that we seek recognition of trans people as political subjects who influence the definition of health policies, programs, and practices. And third, through the creation of community models of sensitive support, led by peers, which give people back the possibility of living their gender transitions in a safe, loving manner, and with respect towards their own pace. In this sense, our commitment to integral public health becomes a strategy to fight against power structures that try to reduce us to diagnoses or exclude us from care. Committing to autonomy, self-care, harm reduction, mental health, the collectivization of care, and dignity means challenging the very meaning of what it means to “be healthy” and “live well.”

Thus, “health” ceases to be a space of domination and becomes a space of resistance, agency, and future-building, where trans and non-binary lives in Colombia can be affirmed through dignity and care, rather than exclusion and violence.

Fernande Álvarez Molina: We, at La Liga de Salud Trans, take an epistemic justice approach because we understand that this health system has pathologized us, singled us out as bodies that need to be corrected, healed, or discarded, bodies that need to be marginalized, right? But, with this approach, we seek to challenge medical discourses by listening to trans voices by recognizing that we are subjects of knowledge. This means that not only do we contribute with our lived experiences of the disastrous procedures in the healthcare system, but we also build knowledge and advocate for the healthcare system in Colombia to adopt the WHO measures and to implement the WPAD and the ICD-11 recommendations.

DPD & LL: You describe one of your goals as being able to build community health and care ecosystems through pluralistic conversations with different actors to offer support that is sensitive to the life experiences of trans and non-binary people in Colombia, promoting a collectivization of care. Could you share more?

FAM: At La Liga, we understand care as those everyday and relational actions that seek the well-being of transgender people. We consider care to be that which sustains life. We identify the need for our transitions to be accompanied and to develop a model of accompaniment that recognizes that these are not one-sided processes. The State generates some protocols and pathways, and it is understood that this is a procedure, perhaps linear. Still, each gender transition is very specific to the person, and it does not always align with these protocols. So, we build a model of accompaniment that is sensitive to these particularities. This model comprises three types of support: initially, we have peer support, which is provided by people we call “trans health navigators,” who are trans people and caregivers (friends, family) of trans people, who receive training from us. These people are part of a care ecosystem in which, through concrete actions, they accompany trans people in accessing their right to health, particularly those in precarious and marginalized situations, which is the case, for example, of trans people who are racialized and/or have disabilities.

We believe this peer support is necessary because it challenges the medical system that reduces our well-being to hormones or gender affirmation measures. Here at La Liga, although there is a basic pathway in our support model, the steps are built by trans people as consultants, and they are the ones who make the decisions and steer their own course. The consultant will make decisions about their identity construction and their life with experiential recommendations that will help them have a more bearable journey. That is why the notion of health in our model starts from something as simple but as important as being listened to by a person who has gone through a similar experience. That is our starting point, and there are a lot of experiences we could share with you about what it has meant to be accompanied by peers. Things as basic but as necessary as, for example, the use of makeup, which, for some women, can offer satisfaction and affirmation of their own process and to inhabit this world more peacefully; or the mothers of trans children who can meet and talk to other people who are going through a similar situation. So, the accompaniment is based on actively listening to each person’s needs and desires. Additionally, in avoiding a pathologizing or psychiatrizing interpretation, we also recognize the need for many people to have psychological support, which is requested by our users, and we also see the need for legal support because, as we have said before, the right to health here is a right that must be exercised, and trans people with different levels of education and literacy have had to fight legal battles to access their rights, and what we seek here is to accompany those struggles.

JS: Yes, we are convinced that this support strengthens their well-being, affirms their identity, and reduces mental health risks and unsafe practices. And here it’s important to talk about the State’s vision of trans health because it reduces the health of trans people to packages consisting of hormones and surgeries, and this compartmentalizes everything. That is why we have thought about health integrally, from a holistic perspective. But it is very important to recognize that we do not want to take responsibility away from the State, because we do not have the capacity to do so. Although we have accompanied more than 900 trans people in Colombia, this shows us that the health system remains a space where a continuum of violence is normalized and, therefore, trans people prefer to turn to us. That is why we have focused on connecting with institutions through various strategies: political advocacy that challenges decision-makers and renegotiates care protocols; strategic litigation that forces the system to respond to the exclusion of people; the production and translation of knowledge through educational tools so that health centers, universities, and public entities can approach trans life experiences from a non-pathologizing perspective; and community education processes that raise awareness and sensibility among health professionals. Besides the peer support, led by navigators that not only guide others in their transition or in accessing healthcare, but who also participate in academic, private, and public spaces, bringing their voice directly to the table. Together, these strategies allow La Liga to transform its relationship with institutions: not as a passive recipient of services, but as a political actor that proposes, debates, and builds a health system that is more just and sensitive to trans realities.

FAM: When we talk about the collectivization of care, we are referring to the way in which care is no longer understood as an individual responsibility—which falls solely on the trans person—and becomes a shared task, built by the community and through support networks. This means that care is not limited to the relationship between a healthcare professional and a user, nor to the notion of “self-care” in solitude, but rather expands to collective practices where peers, families, friends, sensitive professionals, and organizations are involved in the sustainability of trans life. Collectivizing care means recognizing that gender transition and identity affirmation processes do not occur in isolation, but rather within social and emotional networks that can either enhance or limit well-being. That is why our model creates spaces where care circulates and is redistributed: health navigators support other trans people; community networks provide emotional support; professionals trained in affirmative practices ensure dignified treatment; and the person being accompanied contributes with their own agency and knowledge. This conception breaks away from the idea that care is an individual act and redefines it as a shared ethical and political responsibility rooted in solidarity and empathy. Collectivizing care is also a form of resistance: in the face of a system that isolates, pathologizes, and precarizes us, we are committed to building bonds that sustain trans life, dignity, and autonomy.

JS: On this subject, I would like to mention a study we conducted called “The State Does Not Take Care of Me, My [Female] Friends Take Care of Me: Care Practices Created by Transgender People in the Absence of the State.” We traveled throughout Colombia seeking to understand what care was, how trans people experience it, and what strategies they have created in the face of violence and State absence. We intended to find each other, generate dialogue around this issue, and develop recommendations for public policy at a crucial moment when the National Care System was being built and trans people were being left out because they were not and are not seen as caregivers. There, we encountered figures such as the trans mother and the trans father, who have done community care work, and we realized that care practices are not homogeneous: they are deeply determined by territorial, cultural, and social hierarchies.

The care practices adopted by an Afro-trans person in Quibdó, for example, are marked by gender, racial, and territorial discrimination and are constructed from knowledge rooted in the experiences of their bodies-territories.

That is why it was important to have navigators in different territories of Colombia who understood this complexity and could provide better support for people. It is not the same thing to travel in major or medium-sized cities, where, although barriers persist, there is greater access to information, support networks, specialized services, and more visible institutional frameworks, as it is to do so in the outskirts of those cities or in municipalities where racism, socioeconomic precariousness, State absence, and violence complicate care processes and access to the health system, particularly for trans people.

DPD & LL: Through social media, we followed the #YoMarchoTrans demonstration on July 5, which has been held for ten years now, and we noticed how the speeches fostered an intergenerational dialogue, which we have also been able to identify in the conversations on your podcast. This dialogue counters fascist discourses that homogenize social reality, in which trans and non-binary identities are presented as “contemporary phenomena.” Examples of this dialogue include slogans such as “As a child I exist, as an oldie I resist”; “trans old age is sacred”; and “travestis and old women,” which pays tribute to the figure of the trans mother as a community leader who embodies the evidence that there is a future for dissident children and adolescents. How do you think this intergenerational dialogue is shaping the struggle at this moment, particularly in Colombia or in the region?

FAM: As part of the Integral Trans Law platform, together with other organizations, we have decided not to leave anyone behind and to uphold a few non-negotiables, such as not building said initiative without trans children and adolescents. The push for the law is a complex one because of the epistemic, institutional, and social violence that is directed towards life courses—an approach we adopted that recognizes the needs, rights, and violence that trans people experience at all stages of life. Each life course presents specific challenges that must be addressed in public policy, from early recognition of gender identity in childhood, access to affirmation measures in adolescence, to the guarantee of dignified conditions in old age. Attacks from antiderechos (anti-rights) groups are concentrated here, especially in relation to childhood and adolescence, where they seek to misinform through fear. This has not only been difficult in Colombia, but also in the region, and, in turn, it has been influenced by what is happening in the United States, where there are attempts to ban affirmative measures for minors. These discourses have sought to misinform on two points: the progressive autonomy of children and adolescents and the parental authority of fathers, mothers, and caregivers of minors. As a response, it’s worth mentioning that the bill understands progressive autonomy as a principle recognized by the Convention on the Rights of the Child and by the Constitutional Court, which establishes that children and adolescents are subjects of law with progressive capacities. This principle recognizes their dignity, their role in the legal field, and the continuous development of their capacities, which implies that they can exercise their rights to an increasing degree as they mature. Second, we seek to reinforce the attention given to the violence suffered by children and adolescents, often from their own families, who have been expelling and denying their experiences. Not addressing or turning a blind eye to these situations generates very alarming cases of suicide, as has been particularly the case here with transmasculine adolescents.

JS: Yes, I think we also need to look at what is happening in the world in terms of attacks on health programs for trans people and specifically attacks on health care programs for trans minors. There is a setback in trans health care for minors, which has been the main weapon used to attack the trans movement. Here in Colombia, in September 2024, the Superintendency of Health issued a bulletin stating they guarantee the right to health for trans people, but as in other parts of the world, political, religious, and media actors used a fear tactic by arguing that the they were instead seeking to mutilate children, impose sex changes, and remove parental rights. This led to a massive mobilization to generate pressure to have the bulletin withdrawn, and there is currently a bill called “Don’t mess with my children” that is part of a regional offensive strategy promoted by ultra-conservative sectors that seeks to curb the recognition of sexual and gender dissidence rights, using children as a tool. Their narrative is that they are countering a “gender ideology” by spreading fear because it threatens the hegemonic image of the family.

What this has done is take away agency from trans children and adolescents by imposing the idea that they can only be trans when they reach the age of majority. I believe that we are currently facing the same situation we encountered during the 2016 peace referendum in Colombia. One of the reasons why the referendum, which sought to legitimize a negotiated peace agreement between the former FARC guerrilla group and the State, lost, among many others, was the appeal to misogynistic, transphobic, and homophobic discourses that argued that the gender perspective included in the agreement was a “gender ideology.” This fed fears derived from what the word “gender” could represent: the recognition of the existence of bodies that dissent from the social mandate. It mobilized the idea that children were going to become transgender and that the “homosexualizing ray” was coming. With these narratives of naturalized violence and repudiation of our bodies, the referendum was lost. This scenario is no different. I see it as a second plebiscite, because we already see how in different territories they are sending out flyers showing bodies with scars, warning that “if the bill is passed, this is what your child will end up like.” It is the same strategy used by the right wing. So, despite all these risks we face, the integral bill said “children are non-negotiable.” Although it’s been an issue that has historically been rejected, “no, let’s not talk about that,” and we have seen that in other countries—when gender identity laws have advanced, they have had to remove the component of children and adolescents to avoid backlash—we are not leaving this component in the closet.

FAM: The bill also takes into account the historical debt owed to trans elders. Because our trans mothers, fathers, and older adults are, in many cases, subjects of reparation. We seek, for example, to prioritize the cases of those who are victims of the armed conflict, who suffered specific and aggravated violence because of their gender identity. The Truth Commission’s report Mi cuerpo es la verdad (My Body is the Truth) documents how they were victims of systematic sexual violence, forced displacement, torture, and murder, often justified in discourses of “social cleansing” or control over morals and customs. This violence perpetrated by guerrillas, paramilitaries, and State forces sought not only to physically eliminate these people, but also to curb or punish their gender transitions and expressions of freedom. In addition to armed violence, there was a strong network of social and institutional stigma that exacerbated this violence. In territories such as Arauca [near the Venezuelan border], a hotspot for clashes, there were documented cases in which communities asked armed actors to “punish” or forcibly recruit sexual and gender dissidents, and even families requested these actions against their own children out of prejudice. These experiences show how violence was supported by social dynamics of exclusion and discrimination.

Despite this historical debt of recognition and dignity, many trans people have been invisible victims in the processes of reparation and memory.

On the other hand, trans elders have also been victims of the lack of support in the health system, which is the case of victims of biopolymers or, more broadly, of “medical malpractice” or body shaping practices with unsafe substances such as oils, silicones, and/or elements with which trans women in particular have shaped their bodies in artisanal practices without the necessary medical support, often due to a limited access to the healthcare system.alta de garantías en el acceso al sistema de salud.

DPD & LL: Currently in Colombia, the Sara Millerey Law has passed its first debate in Congress. Also known as the Integral Trans Law, promoted by the “Ley Integral Trans Ya” (Integral Trans Law Now), the bill brings together more than 100 organizations. What makes it integral? What was the path of this collective effort? What partnerships and exchanges with other struggles in the region were created?

JS: This discussion has been ongoing for years. Many trans people who dedicated their lives to fighting for this law are no longer with us. We believe that this process is different from all the others, not only because of the recognition of the existence of the armed conflict and the much-needed reparations, but also because of the participatory construction process that took place—that is why the goal was to leave no one behind. We managed to survey more than 1,300 people throughout Colombia with a community strategy that allowed us to identify that trans people have experienced differential violence: forced displacement, corrective sexual violence, murders, recruitment, and silencing of their identities. Many people expressed their anxieties: fear of mobility in territories controlled by armed actors, fear of experiencing violence, of being expelled from their communities because of their identity, and despair at the absence of the State in the health and justice systems. But hopes also emerged: the Integral Trans Law could become a tool to name and redress these forms of violence, to guarantee rights to health and care, and to ensure that new generations do not have to live with the same fear. We also conducted an international mapping exercise to identify which countries already have a gender identity law and which are developing an integral trans law. We met with many trans organizations in the region to understand what had worked for them and what had not. The conversations we held with RedLactrans and trans community organizations that supported the bill’s progress in different territories were very important. But the conversations we had with feminist organizations and activists were also very important. At the same time, this process was a space for difficult conversations within the trans movement: recognizing racist and ableist practices and the historical exclusion of sex workers in some spaces. It was also a dialogue exercise with other social movements. With the anti-racism movement, we talked about how to ensure that Afro-descendant and Indigenous voices were at the forefront. Discussions with feminists were particularly significant because certain segments have positioned themselves as antagonists in other countries. In Colombia, however, we managed to open dialogues on two crucial points: on the one hand, dismantling the false idea that the advancement of trans rights implies an “erasure” of cis women; and on the other, embracing the importance of raising awareness of the issues faced by trans men in terms of sexual and reproductive health, specifically on access to abortion and obstetric violence, which have been invisible historically. For these issues, it was very significant to have conversations with groups in Argentina that are experts in sexual and reproductive rights. So, I would say that it was the conversations with the anti-racism movement, feminist groups, and trans community organizations in the region that provided us with a very interesting perspective on the development of the bill. Through these exchanges, we built alliances and now maintain a common agenda, showing that the Integral Trans Law also contributes to broadening the horizon of social and gender justice.

FAM: These conversations are ongoing, and we need to strengthen them. I think one thing this process has made us understand is that although we have already found tools to be able to talk among ourselves first, because we were very isolated due to urban-rural gaps, for example, we have now managed to talk to other movements and learn from experiences in other countries. All of this has allowed us to affirm an ethical and political principle: that no one is left behind and that the Integral Trans Law is born from specific experiences, collective care, and the certainty that trans lives deserve dignity, reparation, and a future. ■