Original Research

Journal of Interpersonal Violence

1­–14
Interpersonal Violence © The Author(s) 2021
Article reuse guidelines:
and Passing: Results from sagepub.com/journals-permissions
DOI: 10.1177/08862605211005152
https://doi.org/10.1177/08862605211005152
a Brazilian Trans-specific journals.sagepub.com/home/jiv

Cross-sectional Study

Eduardo Mesquita Peixoto,1 Virginia Maria

de Azevedo Oliveira Knupp,1,2
Jesilaine Resende Teixeira Soares,1
Davi Gomes Depret,3 Cleo de Oliveira Souza,4
Maria Eduarda Dantas Messina,3,5
Lívia Machado de Mello Andrade,1
Luciana Catarina Santos de Melo,1
Damiana de Figueiredo Bezerra,3
Cristiane Regina Viníssius de Castro,4
Laylla monteiro Tavares da Silva,4
Biancka Fernandes,4 Emilia Moreira Jalil,4
Ruth Khalili Friedman,4 Cláudia de Moura Silva,4
Edson José Abas Filho,1
Beatriz Gilda Jegerhorn Grinsztejn,4
Ronaldo Ismério Moreira,4
Ricardo de Mattos Russo Rafael,3 and
Luciane de Souza Velasque1,4

1Federal University of the State of Rio de Janeiro, Brazil

2Federal Fluminense University, Rio de Janeiro, Brazil
3University of the State of Rio de Janeiro, Brazil
4Evandro Chagas National Institute of Infectious Diseases (Oswaldo Cruz Foundation), Rio de

Janeiro, Brazil
5National Council for Scientific and Technological Development (CNPq), Brasília, Brazil.

Corresponding Author:
Eduardo Mesquita Peixoto, RN, Federal University of Rio de Janeiro State. Rua Dr Xavier Sigaud,
290, Sala do Programa de Pós-graduação em Enfermagem. Urca, Rio de Janeiro (RJ), Brazil.
Email: teachereduardo@outlook.com
2 Journal of Interpersonal Violence

Abstract
Trans women are specifically vulnerable to interpersonal violence. Being
perceived as the gender that a transgender person identifies with, defined in
some contexts as passing, may influence violence ratings. The EVAS (Violence
and Health Self-Evaluation) study was a cross-sectional study that enrolled
121 trans women between 2019 and 2020 in Rio de Janeiro, Brazil, aiming to
investigate the association between self-reported passing and different types
of interpersonal violence. We enrolled 121 participants who had a median
age of 36.3 (interquartile range [IQR] 13.7). Most of them were Black/mixed
(78.5%) and had at least a high school education (63%). Most participants
considered themselves as trans women (71.9%). Their median monthly
income was $252.50 (IQR $302.50). Only 40 (33.1%) trans women had a
main partner. Trans women with high passing had a higher prevalence of
family violence and lower prevalence of observed police violence, violence
in open and closed public spaces. Participants that reported a high passing
had higher prevalence of family violence (p = .016); moreover, they reported
observing less frequently police violence in the neighborhood they lived in
for the last 12 months (p = .012) as well as having lower rates of suffering
violence. Trans women who reported high passing had 81% (56%-92%)
lower chance of suffering violence in open public places more than once,
while prior racism experience had a positive association with violence in an
open public place (aOR = 3.93, 95% CI [.48, 15.40]). There is an urgent need
to better understand the complex relationships around violence and foster
its prevention.

Keywords
community violence, domestic violence, cultural contexts, GLBT, hate
crimes Background

The disproportionately high rates of violence among trans women worldwide

may echo the noncompliance with the standards of cisnormativity and het-
eronormativity, seen as dangerous and immoral. Violence is articulated in an
interconnected way that prevents the recognition of the other based on indi-
vidual characteristics, such as gender or race/ethnicity, by use of physical
and/or symbolic force. This context undermines the possibilities of dialogue
and creates other codes, interactions, and social performances. One category
Peixoto et al. 3

of violence according to the victim-perpetrator relationship, namely interper-

sonal violence, relates to violence between individuals and is usually divided
into family and intimate partner violence, and community violence (World
Health Organization [WHO], 2002). The latter includes violence by acquain-
tances and strangers (Dahlberg & Krug, 2006; World Health Organization
[WHO], 2002).
Verbal, psychological, and physical aggression toward trans women is
highly common in western societies (Flentje et al., 2016). They are also five
times more likely of being sexually abused when compared to cisgender
women (Smith et al., 2017). Community violence most frequently occurs on
the streets, at school, and in health services. A qualitative research in the
Brazilian Northeast pointed out the diverse settings that increase transgender
vulnerability and exclusion: the family as the first group that excludes trans
people, the school as a setting that replicates transphobia and discrimination,
and the street as the place that welcomes them but worryingly increases their
vulnerability (Da Silva et al., 2015). In addition, Brazil is the country with the
highest rate of trans homicides worldwide, and Rio de Janeiro surpasses the
country median homicides rate (Benevides & Nogueira, 2019).
Young trans women may be extremely susceptible to sexual violence in
intimate relationships, which may also be related to child abuse and experi-
ences of “minority stress” as many trans women suffer violence based on
intersectional categories of race, gender presentation, and wealth (Johns et
al., 2018).
The various types of violence have deleterious effects on mental health,
including drug use, violent behavior, suicide, and depressive or traumatic
symptoms (Johns et al., 2018).
Passing is an expression related to the social evaluation on whether a trans
person’s gender is perceived as deviant or not, attributing validity to it
(Duque, 2017). The term is controversial and debated since that alignment,
defined by social norms and expectations, may be related to an attempt by
trans people to fit into heterocisnormative and binary standards. On the other
hand, being perceived as transgender may lead to increased stigmatization
and discrimination (Lucca & Passamani, 2018). Misgendered trans women
may have worse adverse experiences, such as health care discrimination,
social and work discrimination, and increased concern with their personal
safety (Clark, 2019).
Although a worrisome aspect of trans women’s daily life, especially in
low- and middle-income countries, there is little data on interpersonal vio-
lence and its associated factors in the trans community. As of the writing of
this article, we could not locate any data that linked interpersonal violence to
passing among trans women. We aimed to evaluate passing as it relates to
4 Journal of Interpersonal Violence

interpersonal violence (specifically family and community violence) against

trans women in Rio de Janeiro, Brazil.

Methods
Study Design and Population
The EVAS (Violence and Health Self-Evaluation study) was a cross-sectional
study conducted in a specialized center, in Rio de Janeiro, Brazil, between
July 2019 and March 2020. Eligible participants were aged 18 or older, self-
identified as trans women or as women who fit under the trans umbrella but
rejected the term “trans woman”, had no previous risk of suicide, depression,
or self-harm registered into their Electronical Medical Record, and were
capable of consenting with the participation. Individuals could participate
only once and could not be enrolled in another study that hindered co-enroll-
ment. Interviewers trained in sensitive and gender issues collected data on
demographics and violent experiences in a private and safe environment
using digitally structured questionnaires. Both institutional review boards of
the INI-FIOCRUZ and the Federal University of the State of Rio de Janeiro
approved the study. All participants provided written consent prior to any
study procedure.

Measures
Ordinal variables were categorized into dichotomous. We collected age as a
continuous variable and further categorized using the mean age of Brazilian
trans women that were murdered as cut-off (Benevides & Nogueira, 2019).
The equivalent to the Brazilian minimal wage served as the cut-off for
monthly income (considering the R$1 = USD 0.25 conversion rate).
Trans women self-rated their passing in response to item “Understanding
that passing is when the transgender person is seen by society as being a cis-
gender person, in this case as a cisgender woman; how often would you say
that you pass?,” with the potential answers: never, rarely, sometimes, very
frequently. In addition, we categorize high passing responses “very fre-
quently”, and low passing when responses were “never”, “rarely,” and
“sometimes.” The option to categorize responses in a dichotomous variable
occurred due to the high concentration of responses in the answer option;
also, all possible cuts and combinations were tested but it did not result in
usable models.
Peixoto et al. 5

Outcome
Interpersonal violence was assessed by using the JuviPool questionnaire
(Ramos & Musumeci, 2009), adapted for trans women during meetings with
trans collaborators between January and April of 2019, which included spe-
cific questions on family, police, acquaintance, and stranger violence, and in
open and closed spaces. Potential answers were never, once, sometimes, and
frequently. For each kind of violence, we tested all potential combinations of
answers using logistic regression. Only the combination comparing once or
less violent experience (0) and more than once (1) fit all the assumptions and
was selected. We also tested the outcome as an ordinal variable, but it did not
comply with its assumptions; we also tried all combination of cut-offs for the
outcome. All other cut-offs than the ones presented possibilities did not fit the
assumptions and could not be used, and thus were suppressed.

Statistical Analysis
Descriptive analysis included absolute and relative frequencies for categori-
cal variables and median and interquartile range (IQR) for numeric variables.
The Shapiro-Wilk normality test evaluated normality for the inferential anal-
ysis. We compared participants with and without violence report by using t
test, Wilcoxon test, Fisher or Chi-square accordingly. We performed linear
binary logistical models using the stepwise method, with a 5% level of sig-
nificance. The verification of the logistic models’ assumptions used the fol-
lowing criteria: (a) Harvey-Collier test in the binary models to evaluate
linearity, (b) Breusch-Pagan test to evaluate the homogeneity of variance, (c)
the variance inflation factor (VIF) to evaluate independence (using <5 as
adequate), and (d) the Hosmer and Lemeshow statistic to assess the fit quality
for binary logistic models. Initial models included age, monthly income, edu-
cation level, and race as effect modifiers for logistic regressions. Final mod-
els passed the assumptions verification. We used R software version 4.0 to
perform all analysis.

Results
We enrolled 121 participants who had a median age of 36.3 (IQR 13.7). Most
of them identified as Black/mixed (78.5%) and most reported at least a high
school education (63%). Most participants self-identified as trans women
(71.9%). Their median monthly income was $252.50 (IQR $ 302.50). Only
40 (33.1%) trans women had a main partner.
6 Journal of Interpersonal Violence

Table 1 presents participants characteristics according to their self-rated

passing. Participants that reported passing very frequently had higher preva-
lence of family violence (p = .016); moreover, they reported observing less
frequently police violence in the neighborhood they lived in for the last 12
months (p = .012) as well as having lower rates of suffering violence both in
open (p < .001) and closed public spaces (p = 0.010). Passing very fre-
quently also showed borderline univariate association with having white
ethnicity (p = .050).
Multivariate models for violence by family, police, acquaintances, and
strangers, as well as violence in closed public spaces did not fit the assump-
tions and thus are not presented. Table 2 presents the multivariate model on
violence in open public spaces. Trans women who reported passing very fre-
quently had an 81% lower chance of violence in open public places as com-
pared to those with low passing. Participants with more than one prior racism
experience were four times more likely to have also experienced violence in
an open public place.
Table 1. Demographics and Violence Experiences According to Self-rated Passing
Among Trans women in a Specialized Care Unit in Rio de Janeiro, Brazil, 2019-
2020.
Low High Univariate
Characteristic Passing Passing p-value OR
Age (years) .125 .77
<35 11 (61.11%) 7 (38.99%)
35+ 69 (66.99%) 34 (33.01%)
Monthly income .926 1.04
Higher than $250 28 (66.66%) 14 (33.33%)
Equal or less than $250 52 (65.82%) 27 (34.17%)
Race/color .05 .42
White 13 (50.00%) 13 (50.00%)
Nonwhite 67 (67.37%) 28 (32.63%)
Education .922 1.04
Less than high school 30 (66.66%) 15 (33.33%)
Equal or higher to high 50 (65.79%) 26 (34.21%)
school
Prior racism .100 .42
experiences
Once or less 60 (62.50%) 36 (37.50%)
More than once 20 (80.00%) 5 (20.00%)
(continued)
Peixoto et al. 7

Table 1. continued
Low High Univariate
Characteristic Passing Passing p-value OR
Prior transphobia .108 .53
experiences
Once or less 27 (57.45%) 20 (42.55%)
More than once 53 (71.62%) 21 (38.38%)
Discrimination .240 .77
due to physical
characteristics
Once or less 50 (62.50%) 30 (37.50%)
More than once 30 (73.17%) 11 (26.83%)
Observed police .012 .25
violence in the last 12
months
Once or less 56 (60.21%) 37 (39.79%)
More than once 24 (85.71%) 4 (24.29%)
Observed police .283 .55
corruption in the last
12 months
Once or less 64 (64.00%) 36 (36.00%)
More than once 16 (76.19%) 5 (23.81%)
Physical violence by .469 .68
known person
Once or less 64 (61.54%) 35 (35.36%)
More than once 16 (72.72%) 6 (27.28%)
Physical violence by .109 .49
unknown person
Once or less 51 (61.44%) 32 (38.56%)
More than once 29 (76.31%) 9 (23.69%)
Physical violence by .016 2.77
family
Once or less 65 (72.22%) 25 (27.78%)
More than once 15 (48.38%) 16 (21.62%)
Physical violence in <.001 .18
open public spaces
Once or less 24 (45.28%) 29 (54.72%)
More than once 56 (82.36%) 12 (27.64%)
(continued)
8 Journal of Interpersonal Violence

Table 1. continued
Low High Univariate
Characteristic Passing Passing p-value OR
Physical violence in .010 .36
close public spaces
Once or less 31 (54.39%) 26 (45.61%)
More than once 49 (76.56%) 15 (23.44%)
* p<0.05 in bold, indicating significance.

Table 2. Predictors of Suffering Violence in Open Public Spaces Against More

Than Once Trans Women in Care in a Specialized Care Unit in Rio de Janeiro,
Brazil, 2019-2020.
Univariate Adjusted
Predictors OR CI P aOR CI P
(Intercept) - - - 1.74 [1.04, .035
2.91]
High .18 [.08, .40] <.001 .19 [.08, <.001
passing 0.44]
More than 5.47 [1.91, .004 4.93 [1.48, .009
one prior 19.83] 16.40]
racism
experience
Note. *Assumptions Tests: Homoscedasticity (studentized Breusch-Pagan test), p = .065;
independence (variance inflation factor), VIF = 1.00; linearity (Harvey-Collier test), p =
.330; goodness of fit (Hosmer and Lemeshow test), p = .9433. * p<0.05 in bold, indicating
significance.

Discussion
The current analysis identified the influence passing has on violence rates
experienced by Brazilian trans women. Passing very frequently had higher
rates of family violence as well as lower rates of observed police violence and
violence in open and closed public spaces. Our multivariate analysis showed
that passing very frequently reduced in 81% the chance of suffering violence
in open public spaces more than once in the lifetime. This analysis is the first
to address interpersonal violence among trans women in low- and middle-
income settings. Trans women are a highly stigmatized and marginalized
group, especially in transphobic settings. Brazil is the leading country in trans
homicides worldwide (Benevides & Nogueira, 2019). Being female and trans
synergistically interacts leading to exclusion (Lucca & Passamani, 2018).
There is a process of dehumanization, in which society considers trans people
as unhealthy and immoral. Violence against trans people is usually underre-
ported and often justified by conservative groups (Leal & Mendonça, 2019).
Peixoto et al. 9

The risk of aggression is daily, and most perpetrators are unknown

bystanders. According to a trans-specific research paper, among the violence
trans people suffer throughout their life, physical violence ranks second
(31.3%). As far as violent acts are concerned, pushing (21.8%) and punching
(17.4%) prevail. The most common target for attacks was the face (84.4%)
and most of the aggressors are unknown people (13.6%). (Parente et al.,
2018). Among the homicides against Brazilian trans women in 2018, 82% of
the cases were identified as black and brown people. A total of 52% of the
murders against transgender women in 2018 were committed by firearms,
18% by cold weapons, and 17% by beatings, asphyxiation, and/or strangula-
tion (Benevides & Nogueira, 2019). Participants of another trans-specific
research frequently reported feeling unlikely to seek help from public health
services for fear of suffering discrimination, mainly because they do not yet
have documents with their chosen name. Health practitioners often address
patients publicly in the waiting rooms using the names registered in official
documents, such as an ID or driver’s license, which may lead to embarrass-
ment and discrimination for trans women that were not able to change their
legal name (Portela, 2018). The exclusion of this group is more accentuated
for being female and for being trans. In addition to the violence against
LGBTTQIA+ people in general, which also affects this group, they also suf-
fer misogyny. There is a process of dehumanization, in which trans people are
unhealthy and immoral in the eyes of society.
There is selective impunity on crimes against trans women that makes the
feeling of insecurity a daily occurrence in this group of the population (Leal
& Mendonça, 2019). There are basically two mechanisms described that
explain passing as a protector from violence in general, but as a risk factor for
family violence in transgender women through the trans-panic mechanism
(Blondeel et al., 2018; Clark, 2019; Duque, 2017; Lee, 2019; Lucca &
Passamani, 2018; Lyons et al., 2019; Rodriguez et al., 2018).
Recent developments within the Brazilian federal government since the
2018 presidential campaign have marked a shift on policies regarding
LGBTTQIA+ people away from protective measures and contributed to fur-
ther violence and stigmatization of marginalized groups, not only socially but
also as a form of institutional violence. Culture and politics have a symbiotic
relationship, and such a shift has culminated in an environment that is overall
hostile to trans women’s very existence (Medeiros, 2019).
The current study has several limitations. First, the Cronbach’s alpha coef-
ficient for the subset prevenient by the data collection instrument prior to the
categorization of the variables was 0.58 (95% CI [.53, .63]). Our analysis did
not include all types of interpersonal violence, such as child abuse, sexual
abuse, suicide, and elderly abuse.
10 Journal of Interpersonal Violence

Although trans women are a hard-to-reach population and we successfully

enrolled 121 participants, the limited sample size and absence of probabilistic
sampling process restricted some inferences and the findings generalization.
The cross-sectional design hinders causality inferences, although temporarily
bias was reduced by time specification in the asked questions.
Our study corroborated the empirical association between interpersonal
violence and passing. Despite being a controversial expression, passing (as
related to a more socially acceptable gender expression) interplays a role
sometimes increasing and other times decreasing specific violence types.
More and better data summed to further analysis are needed to dwell on the
complex and tangled relationships related to interpersonal violence against
trans women. At this juncture, cisnormativity emerges as an important factor
in this relationship. Understanding anti-trans violence and making it visible
is the initial path to develop preventive measures and to protect this extremely
vulnerable population.

Acknowledgments
We acknowledge all the EVAS team and participants.

Author Contribution
All authors contributed equally to this work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Damiana de Figueiredo Bezerra was
granted the Community-extension Program of the University of the State of Rio de
Janeiro, Brazil. Eduardo M. Peixoto received the Graduate Social Demand grant from
Coordination for the Improvement of Higher Education Personnel, Brazil. Lívia
Machado de Mello Andrade received a scientific initiation grant from National
Council for Scientific and Technological Development, Brazil. Luciana Catarina
Santos de Melo Received a Scientific Initiation Grant from National Council for
Scientific and Technological Development, Brazil. Luciane de Souza Velasque
received a post-doctorate grant from National Council for Scientific and Technological
Development, Brazil. Ricardo de Mattos Russo Rafael was supported by funding
from the Carlos Chagas Filho Research Support Foundation of the state of Rio de
Janeiro and from the Program for Incentives to Scientific, Technical and Artistic
Production of the University of the State of Rio de Janeiro, Brazil. (PROCIENCIA/
Peixoto et al. 11

UERJ). Maria Eduarda Dantas Messina received a Scientific Initiation Grant from
National Council for Scientific and Technological Development (CNPq).

ORCID iD
Eduardo Mesquita Peixoto https://orcid.org/0000-0001-5699-7290

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Author Biographies
Eduardo Mesquita Peixoto, RN, is a graduate student at the Federal University of
the State of Rio de Janeiro, Nursing Post-graduation Program.

Virginia Maria de Azevedo Oliveira Knupp, RN, PhD, is a post-doctoral student at

Federal University of the State of Rio de Janeiro and an adjunct professor at
Fluminense Federal University, Nursing and Public Health Department.

Jesilaine Resende Teixeira Soares, RN, is a graduate student at the Federal

University of the State of Rio de Janeiro, Nursing Post-graduation Program, worker
health specialist, pediatrics and neonatology specialist.
Peixoto et al. 13

Davi Gomes Depret, RN, MSc, is a gender and sexuality specialist and Family
Health specialist, assistant professor in Public Health Nursing Department, University
of the State of Rio de Janeiro.

Cleo de Oliveira Souza is a clinical research assistant at Evandro Chagas National

Institute of Infectious Diseases (Oswaldo Cruz Foundation) and has a bachelor’s
degree in social work.

Lívia Machado de Mello Andrade is a medical student at the Federal University of

the State of Rio de Janeiro (UNIRIO), Scientific Initiation, National Council for
Scientific and Technological Development (CNPq).

Luciana Catarina Santos de Melo is a nutritionist, medical student at the Federal

University of the State of Rio de Janeiro (UNIRIO), Scientific Initiation, National
Council for Scientific and Technological Development (CNPq).

Damiana de Figueiredo Bezerra is a nursing student at Community-extension

Program of the University of the State of Rio de Janeiro.

Cristiane Regina Viníssius de Castro, BS, is a psychologist/research coordinator at

Evandro Chagas National Institute of Infectious Diseases (Oswaldo Cruz Foundation)
and holds a Bachelor of Arts degree in Psychology.

Laylla monteiro Tavares da Silva, BPd, is a research assistant at Evandro Chagas

National Institute of Infectious Diseases (Oswaldo Cruz Foundation) and Community
educator.

Maria Eduarda Dantas Messina is a nursing student, University of the State of Rio
de Janeiro (UERJ), Scientific Initiation, National Council for Scientific and
Technological Development (CNPq).

Biancka Fernandes is a research assistant at Evandro Chagas National Institute of

Infectious Diseases (Oswaldo Cruz Foundation).

Emilia Moreira Jalil, MD, PhD, is a public health researcher at Evandro Chagas
National Institute of Infectious Diseases (Oswaldo Cruz Foundation).

Ruth Khalili Friedman, MD, PhD, is a researcher at Evandro Chagas National

Institute of Infectious Diseases (Oswaldo Cruz Foundation).

Cláudia de Moura Silva is a flux coordinator for Clinical Research, Chagas National
Institute of Infectious Diseases (Oswaldo Cruz Foundation) and holds a bachelor’s
degree in Social Work.
14 Journal of Interpersonal Violence

Edson José Abas Filho is a library sciences undergraduate student at the Federal
University of the State of Rio de Janeiro and has an Associate degree in Audio/Visual
Production.

Beatriz Gilda Jegerhorn Grinsztejn, MD, PhD, is a senior researcher at Evandro

Chagas National Institute of Infectious Diseases (Oswaldo Cruz Foundation).

Ronaldo Ismério Moreira is at Evandro Chagas National Institute of Infectious

Diseases (Oswaldo Cruz Foundation).

Ricardo de Mattos Russo Rafael, RN, PhD, is an adjunct professor in the Public
Health Nursing Department, University of the State of Rio de Janeiro.

Luciane de Souza Velasque is an adjunct professor at Federal University of the State

of Rio de Janeiro, Department of Quantitative Methods and is at Evandro Chagas
National Institute of Infectious Diseases (Oswaldo Cruz Foundation).