Peer‑led harm reduction in Brazil: gender‑based violence, intersectionality, and decolonial perspectives of community-based care

Harm Reduct J. 2026 Jul 18. doi: 10.1186/s12954-026-01499-7. Online ahead of print.

ABSTRACT

BACKGROUND: Gender-based violence (GBV) and substance use are closely linked in the lives of trans women and travestis. However, mainstream harm reduction frameworks rarely address these issues or focus on community-based practices that emerge in response. In Brazil, trans women and travestis-who are disproportionately Black, engaged in sex work and exposed to lethal violence-navigate health systems marked by transphobia, racism, and the dismantling of harm reduction policies. This study examines how GBV and substance use intersect in their lives, and the role of peer-led harm reduction practices as technologies of care and life-sustaining strategies.

METHODS: This article draws on two multisited ethnographic studies conducted in Brazil between 2018 and 2023. The first (2018-2020) examined suffering, self-care, and community-based support among trans women and travestis in Rio de Janeiro, combining life history and semi-structured interviews. The second (2022-2023) explored sex work, violence, resistance, and practices of care among cis and trans women sex workers, through participant observation, semi-structured interviews, and rodas de conversa (collective conversation circles). The two studies were placed in dialogue and analysed using thematic analysis supported by the Framework Method, through an intersectional and socio-anthropological lens.

RESULTS: Four interrelated themes emerged: (1) GBV was enacted across families, schools, health services, labour markets, and sex work spaces, producing cumulative trajectories of exclusion shaped by racism, cisnormativity, and class inequality; (2) substance use was inseparable from trauma, social suffering, and the labour conditions of sex work-embedded in an economy of survival rather than reducible to individual pathology; (3) despite structural exclusion, participants generated situated harm reduction practices-peer-led outreach, informal knowledge networks, collective care, and mutual protection-functioning as counter-hegemonic forms of health knowledge; (4) participants re-signified marginality as a site of agency, transforming exclusion into professional expertise, chosen kinship, and political activism.

CONCLUSIONS: This study advances a conception of harm reduction that is intersectional, decolonial, and politically grounded. It demonstrates that GBV is not peripheral to substance use but constitutive of it, and that lived experience-generated knowledge, forged in structural oppression, is a legitimate foundation for harm reduction practices. These findings call for frameworks that move beyond individual risk reduction toward a social determination of health perspective-locating harm in intersecting systems of racism, transphobia, patriarchy, and criminalisation of sex work. Trans women and travestis must be recognised not only as populations exposed to harm, but as producers of care, knowledge, and political claims whose expertise is indispensable to advancing harm reduction theory and practice.

PMID:42471695 | DOI:10.1186/s12954-026-01499-7