Silueta X: Lobbying to establish a LGBTI counseling and medical Center in Ecuador

Diane Maria Zambrano Rodríguez

Published Online: November 15, 2014

Full Text: HTML, PDF


In this article, I describe Asociación Silueta X and highlight three of it current virtual campaigns: BESOS LGBTI (Kisses LGBTI), Tiempo de Iqualdad (Time for Equality), and Campana Mi Genero en Mi Cedula (My Gender Identity in my ID Card). I specifically outline how Asociación Silueta X uses information, communication technologies ICTs to support advocacy for the lesbian, gay, bisexual, transgender, and intersex (LGBTI) communities in Ecuador. I also outline and describe how Asociación Silueta X engaged in research and advocacy to lobby the Ecuadorian Government to establish the country’s first LGBTI counseling and medical center in Guayaquil, Ecuador. This medical center was created not only to meet the needs of LGBTI individuals, but also to improve access to healthcare among Ecuadorian transgender individuals specifically, due to data showing that this population has particularly low levels of access to services.

Keywords: Transgender, LGBTI, Ecuador, social inclusion, transgender friendly medical center

Asociación Silueta X

I established Asociación Silueta X when I was 28 years old. It is a grassroots organisation that was created on May 12, 2008 and legally established on May 5, 2010 by Presidential Decree MIES # 9989 of Ecuador. It is a nonprofit association whose mission is to fight for lesbian, gay bisexual, transgender, and intersex (LGBTI) rights in Ecuador.  Asociación Silueta X specifically works to create accessible living conditions for LGBTI individuals with an emphasis on the transgender and intersex population. These conditions encompass health, education, employment, and social justice programs for sexual diversity.  After nearly four years of working for the LGBTI people of Ecuador, Asociación Silueta X has transformed from a small grassroots organisation reaching people through face-to-face interactions into a highly visible grassroots association with a virtual presence that has helped the LGBTI population experience unprecedented visibility and access to information important to its diverse communities. This critical step not only highlights Silueta X’s innovative methodological process to successfully execute our advocacy plans, projects, and campaigns and celebrate the impact achieved nationwide, but also reflects Silueta X’s innovative and successful use of information communication technologies (ICTs). Asociación Silueta X runs numerous campaigns that focuses on holistic health and sexual and reproductive rights for LGBTI individuals, including:

  • Capacitaciones a Voluntarios (Training Volunteers)
  • Capacitaciones a Instituciones Públicas  (Training for Public Institutions)
  • Salud Integral  (Integral Health)
  • Juventud GLBTI (LGBTI Youth)
  • Incidencia Política  (Political Advocacy)
  • Arte y Cultura  (Arts and Culture)
  • Derechos Humanos (Human Rights)
  • Comunicaciones (Communications)

Importantly, as an LGBTI organisation, we are able to use ICTs to communicate widely and effectively with all of our members across Ecuador.


Figure 1: Facebook of Asociación Silueta X

From its founding until the present day, Silueta X has experienced a dramatic increase in coverage by the mass media coverage, which now covers more of its activities than those of  LGBTI organisations in Ecuador that were founded earlier. Silueta X leverages the power of social media via social networking sites and apps, especially Facebook (with more the 5,800 members), using it to provide  updates about its organisational and advocacy activities (Figure 1). Asociación Silueta X clearly understands the powerful role of social media and has created multiple  sites that cover specific activities.  In part, Silueta X measures its impact by the tremendous amount of mass media coverage that grows out of social media strategies.

To date, ICTs have allowed Silueta X (Figure 2) to reach a diverse population of LGBTI individuals, especially those who are targeted through distinct approaches, such as the trans or intersex populations. The use of technology has not only brought the trans and intersex populations closer to organisational activities, but has also allowed the organisation to save time.  Previously, as a grassroots organisation, we working primarily thorough field work, which of course is still carried out, but has been made easier thanks to ICTs.

Technology has also been involved in legal matters, such as the recognition of name changes on ID cards (Campana Mi Genero en Mi Cedula/My Gender Identity in My ID Card), collecting data for trans-focused studies, and addressing proposed laws that include sexual diversity. Primarily though using ICTs, Silueta X has created paradigm shifts regarding the safety of trans sex workers; has engaged and trained national police officers (Capacitaciones a Instituciones Públicas/Training for Public Institutions); and has created several promotional and preventative programs with emphasis on the trans population regarding STDs and HIV using videos on YouTube as part of the Tiempo de Iqualdad (Time for Equality) campaign, among other activities.


Figure 2. Silueta X’s website

We also have the three virtual campaigns we are very proud of:

  • Tiempo de Iqualdad (Time for Equality); and
  • Campana Mi Genero en Mi Cedula (My Gender Identity in My ID Card)


Beso Gay Les Bi Trans is Asociación Silueta X’s campaign that confronts homophobia.  It uses Facebook and YouTube videos.  It promotes a public kiss between the participating LGBTI partners. Besos LGBTI has had three massive public “kiss ins” in Guayaquil,  Ecuador that have been replicated across Latin America.


Figure 3. Asociación Silueta X’s BESOS LGBTI campaign

Tiempo de Iqualdad (Time for Equality)

Asociación Silueta X’s campaign Tiempo de Iqualdad (Time for Equality) is focused on the structural and paradigmatic changes for LGBTI populations that resulted from the conservative and fundamentalist mentality in Ecuador that often denies LGBTI individuals their human and sexual rights. The campaign has five poignant videos that address the following topics:

  1. Centros de Tortura/Torture Centers
  2. Acceso a Salud/Access to Health
  3. Acceso a Empleo/Access to Employment
  4. Acoso/Bullying
  5. Educación Laica/Secular Education

Silueta X is using these videos, which are posted on YouTube,  to promote structural changes through advocacy and agreements with various state institutions. By collaborating with a number of LGBTI organisations, the films explore various topics from issues of sexuality to fighting for justice and rights. This national campaign would not have been possible without the support of Silueta X’s sponsors, including Mama Cash, amfAR, and Hivos.


Figure 4.  Tiempo de Iqualdad’s  (Time for Equality) video, ‘Discriminación a transexuales en centros de Salud’ (Discrimination of transsexuals in medical centers)

Campana Mi Genero en Mi Cedula (My Gender Identity in My ID Card)

On June 6, 2012, the Ecuadorian Confederation of Trans and Intersex Communities (CONFETRANS), which is part of Asociación Silueta X’s Transgender Project “Building Equality,” presented a draft amendment to the Civil Registration Act of Ecuador that would remove the gender/sex on the Ecuadorian citizenship identity card. The campaign My Gender Identity in My ID Card  accompanied the amendment and was presented to the Rule Governments and Decentralization Commission of the National Assembly of Ecuador on July 23, 2012.  The campaign includes a YouTube video (Figure 5.).


Figure 5.  Asociación Silueta X’s Campana Mi Genero en Mi Cedula (My Gender Identity in My ID Card) YouTube video


Social inclusion for lesbian, gay, bisexual, transgender, and intersex (LGBTI) persons regarding public health policies in Ecuador is still challenged, despite the fact that sexual orientation and gender identity are included in the constitution of the Republic of Ecuador (Constitution of the Republic of Ecuador, 2008).  In fact, this recognition of gender identity and/or expression is one the first trans-inclusive constitutional provisions in the world (Martínez Dalmau, 2008).  However, the enforcement of and/or adherence to this ‘said’ recognition is complex in a conservative and exclusionary culture, such as the one in Ecuador.

In addition, in 2012 Ecuador’s Secretary of Health, Carina Vance Mafla, was the first openly lesbian secretary to be appointed in Ecuador (Garcia, 2012).  The inclusion of a lesbian Secretary would make most people believe that Ecuador is progressing on social acceptance of LGBTI human rights, even with regards to gender identity in the public or government sphere.  Nevertheless, accessing the right to gender identity or expression in public services is still complicated.  To address this glaring issue, as part of its social responsibility, Asociación Silueta X has requested countless dialogues with the authorities in order to be able to come to an adequate agreement.

Using ICTs to support advocacy

Depathologization of Transsexuality

Starting in 2012, Silueta X successfully engaged in dialogue with academia and the Department of Health to incentivise those who would appear before the WHO to advocate for the Depathologization of trans sexuality in a forum entitled “Psychology and the Department of Health on the Depathologization of Transsexuality.” This advocacy resulted in success. Gabriela Rivadeneira from the Department of Health’s Division of Standardization and Silueta X drafted a statement and appeared at a hearing on the subject.  All of the planning and community mobilisation activities for this event were done through contact via ICTs, including Silueta X’s website, Facebook, and Twitter. This allowed Silueta X to elicit constant feedback from members that was used to develop the document that was presented to the Department of Health.  With this statement Secretary Rivadeneira was prepared to appear before the WHO in

Screen Shot 2014-11-14 at 07.06.49

Figure 6. Silueta X’s social networking mobilisation activities for the Depathologization of Transsexuality

December and advocate for the depathologization of transsexuality publicly in March of 2013. An official Letter was sent to the WHO from the Department of Health on the depathologization of transsexuality thanks to Silueta X’s work engaging in dialogue with the Department of Health. This is not only important because of Silueta X’s commitment, but also because Silueta X’s activities successfully influenced the political sphere to support the transsexual population, in this case by advocating for depathologization. Moreover, it is vitally important to emphasise that the organisation’s success lies in the use of information technology to mobilise LGBTI individuals and the general public.

Silueta X lobbying to establish the first trans friendly medical office

Asociación Silueta X has also sought to work more effectively with the Secretary of Health and educate the entire ministry about transsexuals and hormone therapy. This led to Asociación Silueta X successfully hosting a formal meeting to inform the Secretary about  the difficulties that transsexual and intersex populations face regarding gender identity. Silueta X also asked for support to establish the first LGBTI counseling and medical center in Ecuador.  After the meeting, the Department of Health verbally agreed to take on this task. Division 7 from the Department of Health was present to support the the LGBTI medical center, along with state authorities such as the Secretary’s Advisor Patricio Aguirre and representatives from multilateral organisations such as UNAIDS, among other high ranking key players (Salazar, 2013).

This medical center was specifically created due to statistical data recognising the low level of access to healthcare services among Ecuadorian trans individuals (Figure 7). A bio-behavioral survey of the HIV epidemic carried out in 2012 by the Department of Health of Ecuador shows that the trans population has an HIV incidence of 31.9%, followed by 11% among men who have sex with men (MSM) (Pan American Health Organization, 2012).  These results truly show that the trans population is the most exposed to HIV.  To compliment this study, Silueta X conducted another study in 2012 (in partnership with the University of Guayaquil and financially supported by amfAR) that indicated that 55% of female trans have been discriminated against while seeking public healthcare services (Asociación Silutea X, 2012). Close to one hundred surveys from this study were collected online through Facebook.


Figure 7. The inauguration of the first LGBTI health center (El Telegrafo, 2014)

Silueta X also used its online community to help recruit clients for a study called “Report on LGBTI Access to Justice and Human Rights 2010 to 2013.” In the study, Silueta X gathered concrete data proving that the trans population is exposed to violence on multiple levels. For example, data indicated of 20 murders where victims were from the LGBTI community, two were gay men, three lesbian women, and 15 trans individuals (Asociación Silueta X, 2013). The report also made recommendations for Ecuadorian public policies paying greater attention to the needs and rights of trans individuals, including a call for research to estimate the size of the trans population, a call for gender- affirming healthcare, and a call for programsaddressing simple quality of life issues that are free from stigma and discrimination based on gender identity and expression.  The key goal of the study was to obtain a realistic picture of the lived realities of trans individuals and inform policies to match those needs, thus having greater impact on the health and rights of this population.

This study added to data from a study conducted by the National Institute of Statistics and Censuses, which used a sample of almost 1000 trans individuals. This study also showed major deficits in social services—58% of trans participants did not have access to basic services including, social health insurance (INEC, 2013).

A private medical consult for trans individuals typically costs USD $35 to $50, without the cost of medication, which is often quite expensive.  Additionally, the hormone therapy needed by the trans and intersex populations is not often covered by social insurance and has exorbitant costs. In fact, Ecuador does not regularly stock specific varieties of masculine and feminine hormones.  With the new Comprehensive Organic Penal Code, access to a medical consult for hormone therapy is almost impossible to obtain, due to the fact that there is no protocol for such services in Ecuador, and the Department of Health is not aware of established international norms, such as the guidelines developed by the Center of Excellence for Transgender Health in San Francisco.

In additional to collecting this data and supporting these meetings held with the Department of Health, Silueta X has continued operating its own counseling and medical center , while dealing with countless difficulties—namely lack of financial resources. Silueta X also held the first meeting between several governmental and mainstream non-governmental sexual diversity organisations to offer greater support for and achieve a greater impact on the trans population by discussing the common needs felt by all of the groups of Ecuador. In other words, Silueta X wanted to stop creating methodological processes that intend to solve social issues without having the key effected populations present during the design. Thus, the first meeting was held during which sexual diversity groups talked about health, education, employment, and justice for the LGBTI population. It was entitled, “Four Oversights Will be Created for the LGBTI Community in Ecuador” (2013).

The group proposed establishing a department of health oversight and a pilot program focusing on the topic of health.  The results of the oversight only reaffirm the study done by Asociación Silueta X in 2012 (supported by amfAR) and the survey data from the Department of Health’s study done by the National Institute of Statistics and Censuses, which for the 4th time has reaffirmed the need for separate health processes for LGBTI populations.

Although Asociación Silueta X carried out this study as a relatively small community-based organisation, the impact of the study has had a very significant effect. Asociación Silueta X worked with the National Institute of Statistics and Census to incorporate their methodology to implement a national study.  Due simply to the complexity of the trans population, the study was based on the popular “snowball” sampling methodology, which seeks additional participants for the study through interviewees’ friends and acquaintances.

Silueta X’s “Descriptive Study of the Influential Factors of HIV Rates and Discrimination of Female Trans on the Coast of Ecuador in 2012” surveyed 767 transsexuals on the coast of Ecuador. In order to carry out the survey and administer the questionnaires, Asociación Silueta X hired Ramón Aranguren, a Spanish Neuropsychologist specialising in scientific research who traveled from his home country of Spain to make a commitment to work with the organisation. An agreement was also reached with the State University of Guayaquil department of Psychology and its scientific ethics committee to constantly monitor the development of the proposed methodology.

In order to collect both the physical and digital data for the study, a questionnaire was developed that included questions focuseing on lived realities, such as socio-economic status, legal issues regarding gender identification, and sexual and reproductive health issues specific to trans individuals.  The questionnaire was created by the research team and was reviewed and approved by the Scientific Ethics Committee of the Department of Psychology of the University of Guayaquil.  The questionnaire was distributed in person to a sample of 621 transsexuals and transgendered people.  An additional 146 trans people were reached online. Awealth of information was obtained regarding the transsexual community in Ecuador, because a trans-led organisation—Silueta X—was the implementer.

The study confirmed that trans individuals have needs and demands that are not met by the department of health, such as hormone therapy and the use of aesthetic surgeries without risk of silicone use, to name a few.  All in all, Silueta X recognises that a process that provides healthcare under a gender affirming doctor in order to achieve an adequate transition without much risk to one’s health is vital for transgender individuals.

The Asociación Silueta X study also revealed that 55% of the trans population does not have access to healthcare in Ecuador.  This is a very troubling figure if we review the needs of the trans population that have not been adequately met due to the lack of access to healthcare in the country.  Moreover, 47% reported to be engaging in risky sexual behaviours, such as not using a condom on one or two occasions over several encounters.  Condom use must be consistent, and this results in a greater risk of exposure to HIV for the transsexual population, according to the data reported by Silueta X’s study.

Another health issue is that there is high mortality among trans individuals improperly using silicone (Salazar, 2013).  Silueta X, troubled by this issue, worked to create a protocol for better “gender affirming” services to meet the needs of the transgender population, given that the Department of Health, in spite of these deaths, has not paid much enough attention to this issue (“Death: The price to pay for beauty,” 2011).

Another issue specific to HIV and trans individuals is the lack of care being taken with regards to condom use, based on certain prejudices and religious beliefs.  Rejection by medical personnel due to the anatomy of trans populations does not allow service providers to adequately serve different gender identities and offer them all the necessary information in order to use adequate prevention regarding condom care and use.  These factors therefore become complimentary factors to the lack of adequate health services.

The first LGBTI-specific counseling and medical center in Ecuador

Recognising these challenges, Silueta X developed a sexual health strategy thatincludes a medical center and a gender-affirming sexual health handbook.  “Incentive to Make Your Femininity a Reality” is now available at the first LGBTI Counseling/Medical Center in Ecuador that opened its doors in May of 2013 (Figure 8). In launching the medical center, Silueta X engaged numerous media outlets, announcing the launch using technology and social networks.

Supported by amfAR, Asociación Silueta X responded to the the trans population’s need for a place where they can have access to healthcare without being mistreated by healthcare personnel or even other patients.  These findings were based on the qualitative study mentioned above, in which 20 focus groups were held throughout the country.  Each discussion resoundingly suggested a specific healthcare space for the trans population was vital.

The medical center was launched as a clinic for all LGBTI individuals to be as inclusive as possible; however, the clinic primarily services trans individuals, simply due to the turnout of the organisation’s community members and social networks.


Figure 8. Facebook page of the first LGBTI-specific counseling and medical center in Ecuador

Therefore, in spite of its name, the clinic specialises in trans health.  To date, the clinic has been successful in serving trans clients because of the focus on the health issues that matter to the population, including supporting positive body images for trans people and helping them claim their sexual lives.  By addressing structural issues, Silueta X is more likely to see greater enrollment in such health services.

It is undeniable that identifying these challenges and finding solutions for them has not been easy.  Nevertheless, Silueta X recognises the power of social networks and communication technology to increase the organisation’s reach and effectiveness.  In addition, Silueta X has been able to offer comprehensive services, including both physical and mental health, and to collect patients’ medical data.   HIV testing is required for individuals before they receive hormone therapy.  Thus, the number of community members seen at the clinic is growing due to the trans- specific healthcare that is provided.  Silueta X provides effective and healthy hormone therapy provided by specialised doctors, and promotes this service to draw clients in on both a fieldwork level and through technologies such as social networks, e-mails, and even phone apps like Whatsapp.  During hormone therapy, the staff speaks to patients about the importance of caring for their sexual health by using support from the Department of Public Health. At the same time and as part of the process (with their consent), Silueta X asks them to undergo HIV testing.

It is worth mentioning that coming up with this process has not been easy.  In 2013, Silueta X did empirical work in implementing proposals for hormone therapy follow-ups.  Afterwards, staff was offered financial resources to develop a formal protocol for appropriate use of hormone therapy as administered by a doctor.

It should be noted that the process of hormone therapy is important in identifying people who are living with HIV.  In fact, we have considered all necessary factors in order to protect the confidentiality of those who have been tested.  This has given the population confidence in us, and caused them to promote the services that we offer.

Of the nearly 271 female trans individuals who have a chart at our medical center, 135 have been tested.  Twenty-eight of these trans individuals have tested positive for HIV.  It should be pointed out that the center uses rapid tests and therefore these data should be verified atpublic medical centers that administer micro-ELISA and western blot tests.  In this aspect we are still working out an agreement with the Department of Health so that we can access data that we have sent regarding these 28 individuals who tested HIV positive.

The first signs of satisfaction have been seen in our very own members.  In spite of not having yet been formally documented, they have made their satisfaction publicly known.  Below is a local news piece on the care provided at our medical center and a statement by one of our trans members:


Figure 9: Local news piece on the care provided at the LGBTI medical center at

The whole program has been based on the experience and goodwill of the doctor and psychologist currently working at our medical center.  Due to the fact that the classification and behaviour of the trans population does not vary for the most part, our model that is under development could be implemented in other places in Ecuador and across Central and South America


In our experience, we estimate that Silueta X’s innovative ‘gender affirming’ sexual healthcare and HIV prevention methodology, complimented by both advocacy and demand creation activities through the use of communication technology, has affected the trans population in positive ways.  Even with the lack of support received by the Department of Health, which has only passed legislation but not acted to implement it.  Based on several meetings, including one held at the university hospital during which we thoroughly discussed the issue of hormone therapy, we recognised that other centers could not meet the demand for hormone therapy at this time. Thus, we created our own center as a pilot project to entice the government to implement their legislation.  Additionally, through our program, Silueta X is able to collect and store medical outcomes of trans clients, which could benefit researchers, advocates, and government.  We even hope to increase the capacity of our services to expand on a national level since there are many trans individuals who want to have access to our services, but unfortunately are from other provinces where access is difficult. Our pilot project is becoming a comprehensive HIV care model for the trans population, and we have decided that it is useful to share our experience so that it can possibly be replicated in other contexts.

ICTs have been the cornerstone of our successful efforts to advocate for and serve trans individuals.  With our daily e-blasts, Silueta X is recognised as a regional leader on trans rights and GLBTI health.  We consistently are looking for new technologies that would further our cause.  Clearly, in this day and age, these technologies make it easier to help trans individuals and allies get involved in demanding their rights.

Our next challenge is signing a formal agreement with the Department of Health, so that we can link our medical database to the national one (especially in cases of HIV diagnosis).  Unfortunately, this issue is a major challenge due to the fact that the new Comprehensive Organic Penal Code penalises the divulging of medical data.  The Department of Health will not come to an agreement on the confidentiality of the data of people who have had a seropositive test result since there is a new penal law, and many public healthcare officials do not want to provide public information on statistical data regarding HIV prevalence unless they divulge it themselves whenever they see fit.  So the information becomes monopolised using the new law as justification when the statistical data do not have anything at all to do with the new law.

Of our 28 trans members living with HIV, close to 13 have come back to our offices and continued therapy with the psychologist.  Nevertheless, we have 12 that are not participating, and we can identify those who have quit.  Our goal is not only to identify HIV prevalence, but also to give follow-up to trans individuals living with HIV.  Above all, we understand that individuals living with HIV are still discriminated against in Ecuador, and it is necessary to consider that an HIV-positive trans individual is dually discriminated against.

We will continue researching how ICTs can help Silueta X attract and educate the LGBTI population, provide outreach, and pressure state institutions to take action.  While we have been taking full advantage of ICTs, we believe that perhaps there are means that we have not identified to improve the productivity of our outreach.


I want to thank the team of individuals who worked with me to write this manuscript, first in Spanish and then to translate it into English.


Asociación Silueta X (2012).  Estudio descriptivo de los factores influyentes, en la incidencia del vih y discriminación de las trans femeninas en la costa ecuatoriana, durante el 2012.  Retrieved from

Asociación Silueta X (2013). Libro del Informe de Acceso a la Justicia y Derechos

Humanos de los TILGB en el Ecuador 2010 al 2013. Retrieved from:

Constitution of the Republic of Ecuador (Vol. 2, p. Articule 11). (2008).

El Telegrafo (2013). ‘Hoy se inaugura el primer centro de salud trans-lésbico’. 2013, May 8). Retrieved from:

Forum, Psychology and the Department of Health on the depathologization of transsexuality. (2012, October 15). Retrieved October 15, 2014.

Four oversights will be created for the GLBTI community in Ecuador. (2013, January 1). Retrieved October 15, 2014.

Garcia, M. (2012). Ecuador: Lesbian Activist Appointed to Presidential Cabinet.  The

Advocate, January 24, 2012. Retrieved from

National Institute of Statistics and Censuses. (2013). Retrieved from: Programa Nacional de Estadística. Retrieved from:

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Pan American Health Organization  (2012). Respuesta Nacional a la Epidemia del VIH. Retrieved from:

Salazr, G, (201). ¡La muerte, el precio a pagar por la belleza! (2011, August 11). Retrieved from:–el-precio-a-pagar-por-la-belleza/

Salazr, G, (2013). ¡Primer consultorio médico trans! (2013, May 1). Retrieved from:

Salazr, G, (2013). ¡“Cristina” murió por querer ser hermosa!. (2013, May 3). Retrieved from:–querer-ser-hermosa/

Biographical Statement

Diane Marie Zambrano Rodríguez was born on March 16, 1982 in Guayaquil – Ecuador.  She is a male to female transgender activist working for human rights and LGBT issues. Diane is currently the president of Silueta X, a trans specific health and advocacy organisation as well as the representative of the “LGBTI Observatory of Ecuador”. In 2009 she successfully advocated for the Ecuadorian government to legally allow transgender people to change their names. During the elections of February 2013, Diane became the first openly transgender candidate to run for public office in Ecuador. Through Diane’s intense advocacy, she was able to obtain funding from multiple donors for a trans-specific health care center in Guayaquil that specialises in hormone replacement therapy.

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