“I never felt like a boy. In school I was rejected, made fun of, and mistreated… There were times I wanted to kill myself. No one chooses this,” confides Mavi Susel, protagonist of the 2010 Cuban documentary In the Wrong Body (En el cuerpo equivocado). On May 22, 1988, Mavi became the first Cuban to receive sex reassignment surgery on the island. Her tale of stigmatization, solitude and pain is not uncommon in Cuba or the world at large.

Rejecting one’s biological sex due to the discordance between an individual’s genitalia (biological sex) and their gender identity (psychological sex) is the definition of transsexuality. “This incongruity is felt profoundly by transsexual people, is permanent, and causes great anguish,” internist Dr Alberto Roque told MEDICC Review. “This anguish can result in severe mental health disorders, usually related to discrimination, stigmatization, and rejection.” In turn, victimization renders some transgender people reluctant to seek medical care or fully disclose their gender identity when they do.[1]

Global evidence also shows that transgender people (see box: Gender Minority Health: Key Concepts & Terms) suffer from health disparities due to unaddressed health needs and behavioral risk factors specific to this population, coupled with barriers to care such as inequitable access to services and a lack of knowledgeable and compassionate practitioners.[2–4]

Recognizing that gender variant people have unique health needs and that the Cuban Constitution enshrines their right to health care, the struggle to guarantee that right was begun in Cuba in the 1970s, opening the way for a more comprehensive approach and Mavi’s sex reassignment surgery by 1988. However, the fact that it would be two decades before another such surgery was performed speaks to the medical, legal and sociocultural complexities of developing rights-based policies and practice in a minefield of widespread and sometimes overwhelming gender-related bias.

Towards a Rights-Based Approach
Over the past 50 years, policies affecting sexual and gender minorities in Cuba have evolved from discriminatory, exclusionary and even punitive, towards a more inclusive, rights-based approach.[5] The uphill battle waged in the health arena against traditional gender constructs, as well as homo- and transphobia, was spurred among other things by diagnosis of the first Cuban transsexual in 1972. Then 23, “JR” was a hard worker noted for his “dedication, responsibility and discipline,” and was “well liked and respected by his co-workers.” Yet, he felt like “a man trapped in a woman’s body” from a very young age.[6] Even before puberty, JR had begun altering his appearance and behavior to incorporate traditional male attributes. As he matured, he continued to construct a male gender identity.

The ensuing debate reached the Federation of Cuban Women (FMC) led by Vilma Espín, which proposed creating a multidisciplinary team to better understand gender variance. The team was established in 1979 and, reflecting the conceptual framework of that time, was called the National Task Force for the Diagnosis & Treatment of Gender Identity Disorders;[7] it was coordinated by the National Working Group for Sex Education (later the National Center for Sex Education, CENESEX). The Task Force reviewed leading scientific evidence in the field and, advanced for its time in Cuba, convened a group of specialists to provide services and support for transsexual people. These included clinical services such as psychological counseling, hormonal therapy, and sex reassignment surgery. As a result of the Task Force’s work, including lobbying and legal guidance over the next decades, Mavi’s sex reassignment surgery became the country’s first, and 13 transsexual Cubans were able to change their names and photos on their government-issue identity cards in 1997. Small, but important first steps.

Several observations on these early experiences are pertinent to later developments: first, the initial impetus for change came from health care institutions that joined forces with the national women’s organization. This enabled the right to health care to trump other arguments, and underscored the need for a broader focus if that essential right were to be fully guaranteed. In turn, this opened the way to wider discussion of lesbian, gay, bisexual and transgender (LGBT) issues.

It is useful to note that Cuban media historically have shied away from talking about sexual diversity because “it bothers people, “and government at one point had cited “angry letters” as a reason to defer debate on civil unions and discrimination based on gender identity.[8] The national discussion currently emerging reveals that traditional gender constructs, including machismo, contain deeply-rooted societal perceptions about LGBT people, presenting tough obstacles to change. “In my day they would keep out of sight to do their things, while outside they looked just like the next person. Now they’re all around us, swinging their hips even more than some women. It’s outrageous!” said one 52-year old Cuban quoted in a 2008 article on attitudes towards sexual diversity published in the national newspaper Juventud Rebelde. On same-sex couples living together, another Cuban woman bristled: “I find it unpleasant that they do it in full view of everyone, as if it were perfectly natural.”[9]

Yet, none of this has deterred CENESEX and other advocates. Rather, it has encouraged them to broaden the debate. Forging an understanding of sexual and gender minorities is a slow educational process, says Dr Roque: “Explaining gender perspective isn’t easy because it requires breaking down centuries of patriarchal power on a nearly dynastic scale. And many issues of sexuality are related to this. It’s very difficult.” Indeed, many Cuban male-to-female transsexuals encounter, and may even replicate, traditional gender constructs and biases.

The road ahead is difficult, but not impossible, according to Carmen Nora Hernández, a Cuban educator specializing in gender. “Time and again, we see concepts and attitudes that reinforce this patriarchal and macho culture that discriminates against women and non-heterosexuals. But since gender is a social, rather than biological construct, it is amenable to change.”[10]

Change Takes a National Strategy
In 2001, discussion and practice gelled in the first National Strategy for Comprehensive Attention to Transsexual People. The Strategy’s objectives center on fulfilling the constitutional promise of health care, but go well beyond to address a broader notion of health and well-being. They include: developing integrated clinical and mental health care for gender minorities; setting transsexual research priorities; designing public education and communication strategies; implementing sensitivity training programs; and proposing legal mechanisms to protect the social and civil rights of transsexual people.

The Strategy mandates intersectoral cooperation among the Ministries of Health and the Interior, Supreme Court, Attorney General’s office, and social and political organizations such as the FMC, labor unions, and neighborhood block associations. Organizationally, it is coordinated by the National Commission for Comprehensive Attention to Transsexual People, established in 2005. Like its precursor the National Task Force, the Commission is a multidisciplinary team. It brings together representatives of various ministries and other specialists to provide informed, integrated health care and other services to address the needs and rights of the island’s transsexual population. Thus, Commission members include medical and non-medical professionals, such as:

Others, such as historians, anthropologists, and media and communication professionals, also collaborate with the Commission.

Nevertheless, the first policy shifts have targeted health care, notably Resolution 126 issued by the Ministry of Public Health on June 4, 2008. This resolution mandated comprehensive health services for transsexual people in Cuba, including establishment of a specialized clinic to provide integrated clinical care such as psychological counseling, hormone therapy, and sex reassignment surgery.

Health Services: Policy into Practice
Resolution 126 paved the way for a Commission-directed clinic to be established in Havana. Health care provision here, both free and voluntary, is based on two fundamental tenets: first, to reinforce the bio-psycho-social approach of Cuban health care through direct services and inter-consultation by a multi-disciplinary team that works with each person; and second, to create a safe, nonjudgmental space where privacy and confidentiality are protected by professionals trained in transgender issues. This last is especially important since evidence shows that insensitivity, discrimination, and lack of knowledgeable staff in health care settings are among the reasons transgender people avoid seeking care.[1–4] “What we’re trying to do is ensure transsexual people have a united team that treats each person with respect for their humanity, using respectful language and adhering to established medical protocols,” says Dr Roque, also a National Commission member.

This translates into following the standards of care established by the World Professional Association for Transgender Health (WPATH; formerly the Harry Benjamin International Gender Dysphoria Association), adapted to conform to Cuban best practices. WPATH standards stipulate five steps to clinical care: diagnostic assessment, psychotherapy, (observation of) real-life experience, hormonal therapy, and surgical therapy. Written informed consent is required at each stage of care.

The clinic currently receives transgender people aged 18 and over from throughout the island. “Most of the people we see are referred by the national network of mental health services for children and youth, urologists, and endocrinologists,” Rosa Mayra Rodríguez, CENESEX psychologist and member of the National Commission, told MEDICC Review. “As our work becomes better known, we also have many people self-referring,” she said.

Each person seeking services undergoes a complete diagnostic evaluation, beginning with a mental health assessment and clinical exam, including blood and hormonal analyses, imaging studies, and abdominal ultrasound tests, among others. The clinical workup documents any pre-existing conditions and also establishes a baseline should the individual be confirmed as a transsexual and desire sex reassignment surgery (SRS). The mental health assessment is conducted using standard psychological tests,[11] clinical observation (particularly of ‘real-life experience’), and an in-depth interview. Partners and family members are included in this process whenever possible.

The diagnostic evaluation takes at least two years during which transition to the desired gender role continues for those who so wish. According to Dr Roque, “our job is to help transgender people, or people who are not clear about their gender identity, define that identity. Some are transsexual, but not all.” Based on the evaluation’s outcome, the Commission determines, by consensus, whether a person is transsexual.

Those transsexuals desiring hormonal and surgical therapies must first meet standardized eligibility and readiness requirements, including living in the desired gender role for two years (real-life experience). Not all transsexual people desire or are able to undergo hormone or surgical therapies (due to compromising health conditions, for example) and the therapy sequence is tailored to individual needs, with SRS coming last.

The National Commission is currently counseling 132 gender variant people at its Havana clinic. Of those, 37 individuals have been confirmed as transsexuals—all but three of whom are male-to-female—and a dozen have undergone SRS. Seven transsexual people do not want SRS for differing reasons. [12] Surgeries are performed by a team of Belgian and Cuban specialists. Those transsexuals who elect SRS can choose to stop coming to the clinic once the medical and surgical phase is complete (e.g., stitches removed, scars healed, etc).

Education, Education, Education
According to CENESEX Director Mariela Castro, shortly after the first surgical intervention in 1988, “sex reassignment surgery was suspended as a result of inadequate media coverage and subsequent virulent public reaction. [We learned that this type of initiative] requires an unflagging educational process and a lot of explanation so society better understands transsexuality; we are the ones who are limited, not transsexual people,” she said.[13]

In Cuba, like elsewhere, stigmatization, discrimination, and rejection of transgender people begins at home, continues through school, and is reinforced in the workplace and society at large. Evidence from around the world, including Cuba, shows that transgender people are at extremely high risk for dropping out of school at young ages.[14] In the documentary about her life, In the Wrong Body, Mavi Susel attests to this: “I had terrible problems at home and in school. People said many ugly, painful things to me. My father rejected me and threw me out of the house.”

CENESEX plays a central role in combating homo- and transphobia. Together with the clinic, CENESEX works with families of transgender people, both to gather a detailed picture of the difficulties they face and to generate respect and acceptance among their relatives.

Going beyond the families themselves to convince society at large to embrace diversity is another matter. Social and political organizations involved in implementing the National Strategy are responsible for sensitivity training of their members, as well as helping develop educational campaigns designed to mitigate discrimination of sexual and gender minorities in neighborhoods, schools, and the workplace. CENESEX is also involved in this aspect, carrying out sensitivity training for such agencies as the police, and training health promoters who work directly with Cuba’s sexual and gender minorities.

Perhaps one of the most important roles played by CENESEX is coordination of initiatives to combat stigmatization by training and empowering transgender people themselves. It holds participatory workshops where gender variant individuals learn everything from good nutrition to making wardrobe choices. The workshop designed to educate transgender people about their legal and civil rights was one of the most empowering CENESEX courses for Wendy Iriepa who underwent SRS in 2008. “[We learned] we have the right to dress as we like. [Before] the police would stop and fine a cross-dresser for wearing women’s clothes. Now we know this is illegal and we command their respect.”[15]

Moving the Parliamentary Agenda
The National Commission, together with CENESEX, has also moved bills into parliamentary debate that would protect the civil rights of gender and sexual minorities in Cuba. Key among these are the Gender Identity and Legal Sex Change bill, and amendments to Cuba’s current Family Code; both are slated to come before the Cuban Parliament in 2011. If passed, the Gender Identity bill “would allow those people identified as transsexuals by the National Commission and undergoing triadic therapy (or parts thereof) to begin the process of changing their identity papers; they would not have to submit to a legal process as they do now,” Zulendrys Kindelan, CENESEX legal counsel and member of the National Commission told MEDICC Review. The new law would also allow Commission-recognized transsexuals to adjust their documents without SRS; currently, only those who have undergone surgical therapy can do so.

Updating the Family Code to more realistically reflect the modern Cuban family by including language specific to sexual and gender minorities would also recognize rights such as those to inheritance and ‘family’ hospital visits by same-sex partners. “Along with public education, these elements related to rights and legal recognition are among the Commission’s highest priorities,” says Rodríguez.

Challenges Ahead
Since the first transsexual person was identified in 1972, a discussion led by health sector institutions and their allies elsewhere has broadened in scope, first centering on narrowly-defined health and health services, evolving to now include the spectrum of health, cultural attitudes and legal rights—or “health” in the fullest sense of “well-being.”

Commission members interviewed point first to successes implementing the National Strategy unveiled in 2001: increased numbers of people seeking services at the specialized clinic for transsexual health; more families and more male family members participatintg in group therapy; examples of positive insertion of transsexuals in schools and workplaces; intersectoral involvement in implementing and pushing the Strategy forward; the highly visible public debate on gender, transgender and sexual minority issues and rights reflected in the press and even TV serials; and the recognition and protection of rights envisioned in the bills currently before parliament. Tadalafil, the active ingredient of the drug, promotes ultimate assistance in the treatment of erectile dysfunction and related sexual disorders. Cialis works just within an hour after its intake, while its effect can last for more than 30 hours.

The evaluation of the National Strategy now underway has also revealed important gaps and areas yet to be addressed. The health system, while perhaps the most responsive on the issue of transsexuality, faces its own challenges, according to Dr Roque. For instance, he contends some specialists continue to view transgender health through a biological and medical prism. Like other countries, Cuba also lacks comprehensive evidence-based data from which to design research priorities.

Given the prevalence among transgender people of clinical conditions—including substance abuse, obesity, tobacco use, and depression—incorporating health research specific to this population is necessary moving forward, he says. Speeding up the process from when a person is confirmed as a transsexual and meets eligibility and readiness criteria to when they receive SRS is another issue the Commission aims to address. Additionally, while SRS surgeries are still performed by a team of Belgian and Cuban specialists, Commission members hope that shortly Cuban specialists will be able to do so on their own.

Another issue facing the health sector is decentralization of services. Although Cubans from across the country have access to the Havana clinic’s services, they must sometimes travel long distances to receive them. Extending services to the provinces is part of the Commission’s mandate but requires resources not yet available.

On the broader front, Commission members interviewed say that much work remains to be done. They point to continuing resistance in certain sectors (including some churches and government functionaries) to accept or participate in open discussion of sexual and gender diversity. Part of this resistance is based on the argument that Cuban society “is not ready” for such a debate.[16]

Two important elements of the National Strategy yet to be implemented include incorporating sexual and gender diversity content in school curricula and enacting anti-discrimination statutes in the workplace. While sensitivity training of principals and other school administrators has been ongoing, the Ministry of Education has not yet approved proposed curriculum changes. Meanwhile, many teachers lack specific knowledge about gender constructs, sexual diversity, and their effects on identity. “It’s one thing to have course materials prepared for a sex education class, but when students start asking questions about sexual orientation and the like, teachers—who aren’t sexologists and aren’t expected to be—respond according to their own biases and experience,” says Rodríguez.

This pattern is repeated in the workplace: while national labor law protects Cuban workers against discriminatory practices, bias against sexual and gender minorities (who are not cited specifically in workplace legislation) still exists on an individual level. The experience of one Cuban transsexual is illustrative: “When I went for a job, they told me: ‘come back when you’ve resolved your pathological problem.'”[17]

Challenges also present themselves on the international front: in January 2010, the Cuban Multidisciplinary Society for Sexual Studies (SOCUMES), in conjunction with the National Commission and CENESEX, issued a declaration supporting the declassification of transsexuality as an illness. Declassifying transsexuality as an illness has been found a useful tool in combating stigma, empowering individuals to assess their own health needs, and removing obstacles to an individual’s full enjoyment of human rights.[4]

CENESEX transgender workshop. C. Blackburn

Yet, major medical classification systems including the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10) continue to list transsexuality as a mental and behavioral disorder. SOCUMES argues that “such classifications perpetuate and redouble discrimination towards transsexual people, and cause physical and psychological damage, including suicide.”[18] The declaration also voiced support for the Yogyakarta Principles: The Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity, particularly Principle 18: Protection from Medical Abuses.[19]

Cuban policy on the national and international fronts, propelled forward by the Ministry of Public Health’s Resolution 126, has led to decades of education, training, lobbying, and research by CENESEX, the National Commission, and other entities working towards specialized health care and full rights for Cuba’s sexual and gender minorities. Commission members maintain that enacting upcoming bills to extend protection of transsexual people’s rights and stepping up efforts to empower transsexuals and educate the public will eventually lead Cuban culture to adopt a more inclusive outlook. But it’s a process, says psychologist Rodríguez. “We can’t give up. All of this takes time. We are making progress, and the most important thing is to be open to change.”

1. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and Gender Minority Health: What We Know and What Needs to Be Done. Am J Public Health. 2008 Jun;98(6):989–95.
2. Sanchez NF, Sanchez JP, Danoff A. Health Care Utilization, Barriers to Care, and Hormone Usage among Male-to-Female Transgender Persons in New York City. Am J Public Health. 2009 Apr;99(4):713–9. See also: Lombardi E. Enhancing Transgender Health Care. Am J Public Health. 2001 Jun;91(6):869–72.
3. Gay and Lesbian Medical Association and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association; 2001.
4. Commissioner for Human Rights. Human rights and gender identity. Council of Europe. Commissioner for Human Rights Issue Paper. Strasbourg, France: 29 July 2009.
5. Between 1965 and 1968, homosexuals and others were sent to re-education work camps. In an August 2010 interview, Fidel Castro apologized for this discriminatory policy saying: “those were times of great injustice, a great injustice!… If anyone is responsible, it’s me.” Lira C. Soy el responsable de la persecución a homosexuales que hubo en Cuba: Fidel Castro. La Jornada (Mexico) [Internet]. 2010 Aug 31 [cited 2010 September 14]. Available from: www.jornada.unam.mx/2010/08/31/index.php?section=mundo&article=026e1 mun. For greater context of homosexuality in Cuba in the 1960s, see: Roque A. Fidel Castro, las UMAP y los perversos cubanólogos. Sitio de CENESEX y Diversidad Sexual. Available from: http://www.cenesex.sld.cu/webs/diversidad/Fidel%20UMAP.html
6. Castro M. La atención integral a personas transexuales en Cuba y su inclusión en las políticas sociales [PowerPoint presentation]. Havana; 2008.
7. At that time, ‘gender disorder’ was the prevailing terminology and is still used in some countries; in 2010, Cuban specialists issued a statement rejecting classification of transsexuality as a disorder.
8. Mariela Castro. La Asamblea Nacional discutirá la ‘ley gay’ en 2011. Diario de Cuba (Spain) [Internet]. 2010 Sep 1 [cited 2010 September 13]. Available from: http://diariodecuba.com/cuba/81-cuba/3053-mariela-castro-la-asambleanacional-discutira-la-ley-gay-en-2011.html.
9. Diversidad sexual…¿juzgar o entender? Juventud Rebelde [Internet]. 2008 May 11 [cited 2010 September 12]. Available from: http://www.juventudrebelde.cu/cuba/2008-05-11/diversidad-sexual-juzgar-o-entender/.
10. Gorry C. The macho and super macho: gender perspective in Cuba. Special article for Programa Conjunto de Oxfam. Havana: Oxfam; 2007 Apr.
11. These include the Minnesota Multiphasic Personality Inventory (MMPI), Cattell 16PF Form C (self-analysis form), the Locus of Control test (Rotter), and more. For details see: “Trastorno de identidad de género y personas transexuales: Pautas de atención psicológica” by RM Rodríguez et al in Transexualidad en Cuba. Havana: CENESEX; 2008.
12. Interview with Rosa Mayra Rodríguez, 16 Sep 2010.
13. Castro M. Keynote speech. Primer Coloquio Internacional Trans-Identidades, Género, y Cultura. Havana; 2010 Jun 9.
14. Rodríguez RM, García CT, Alfonso AC. “Trastorno de identidad de género y personas transexuales: Pautas de atención psicológica” in Transexualidad en Cuba. Havana: CENESEX; 2008.
15. Acosta D. Wendy, una transsexual frente al espejo. IPS (Havana) [Internet]. 2009 Jan [cited 2010 September 18]. Available from: http://ipsnoticias.net/ nota.asp?idnews=94481. Spanish.
16. Roque A. Challenges to the Cuban Family and Society [Internet]. Remarks given at the opening of the panel on the family and society during the observation of World Anti-Homophobia Day, 2010; 2010 May 16; Havana [cited 2010 September 28]. Available from: www.walterlippmann.com/docs2901.html
17. Rodríguez RM, Alfonso AC, Díaz O, Rodríguez M. Reencuentro con la familia en el proceso grupal. Descripción de las sesiones del trabajo. In: Transexualidad en Cuba. Havana: CENESEX; 2008.
18. Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad. Declaración para la despatologización de la transexualidad en el V Congreso de Sexualidad [Internet]. 2010 Jan 22 [cited 2010 September 12] Havana; 2010. Available from: www.cenesex.sld.cu/webs/diversidad/declaracion_trans.html
19. International Commission of Jurists and International Service for Human Rights. Yogyakarta Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity [Internet]. 2007 [cited 2010 September 12]. Geneva; 2007. Available from: www.yogyakartaprinciples.org/principles_en.htm