ORIGINAL RESEARCH

Orders and disorders: the complexity of adolescence and sexual health – contributions to nursing

Ítalo Rodolfo Silva^I; Joséte Luzia Leite^II; Sílvia Maria de Sá Basílio Lins^III; Thiago Privado da Silva^IV; Maria José Carvalho Santos^V

^I Nurse. MSc in Nursing, PhD student in Nursing. Anna Nery School of Nursing, Federal University of Rio de Janeiro. Brazil. E-mail: enf.italo@hotmail.com
^II Nurse. PhD in Nursing by the Graduate Program of the Anna Nery School of Nursing, Federal University of Rio de Janeiro. Brazil. E-mail: joluzia@gmail.com
^III MSc in Nursing, PhD student in Nursing, Anna Nery School of Nursing, Federal University of Rio de Janeiro. Brazil. E-mail: silviamarialins@gmail.com
^IV Nurse. Master and PhD in Nursing, School of Nursing Anna Nery, Federal University of Rio de Janeiro. Brazil. E-mail: thiagopsilva87@gmail.com
^V Nurse. MSc student in Nursing, Anna Nery School of Nursing, Federal University of Rio de Janeiro. Brazil. E-mail: maria.jcarvalho@live.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.14569

ABSTRACT

Objective: to discuss nursing care strategies, from the perspective of complexity, for promoting adolescent sexual health in view of factors intervening in exercising sexuality. Method: the participants in this qualitative study were 15 nurses from an adolescent health study nucleus located in Rio de Janeiro City, Brazil. Data were collected by semi-structured interviews conducted between January and August 2012. The methodological framework was given by Grounded Theory. Results: this revealed the category pluralities and singularities in the processes of becoming adolescent and of health, underpinned by the subcategories: the gender factor and its implications for adolescent nursing care; care for sexually abused adolescents; breaking with health services' institutional hetero-normativity: and emerging challenges. Conclusion: taken together, these discuss strategies for adolescents' healthy sexual development amid the complexity of this process.

Keywords: Nursing; adolescent; sexual health; sexually transmitted diseases.

INTRODUCTION

The development of the human being is based on interactions between individual/collectivity/context in an interdependent and complementary relationship¹. Intervening factors to healthy development pervade the process, factors that, in turn, imply in the harmony of the bio-psycho-socio-spiritual dimensions^1,2. Indeed, adolescence covers the set of connections that are established within the multidimensional singularities of be-adolescent,³ which, in a broad sense, involves the need to know oneself, to consolidate an identity and be accepted by others^3,4.

Among the natural demands of the adolescence is the awakening to the exercise of sexuality^5,6 where the factors related to the assurance safe sexual practice have a programmatic, contextual and individual nature, comprising the plural conception for vulnerabilities ^7,8. Thus, strategies to promote sexual health must pervade the mechanical dimension of biologizing practices of health systems, because in addition to the negative consequences of unprotected sexual practice is the crumbling conception of sexuality, gender and health^9-11. Therefore, public policies that are intended to adolescent health, with emphasis on sexual health, must include the dimensions imbued with the polysemy of these three aspects, which, in common, have their social conformation founded by the systems of meanings and values for relations between masculinity and femininity, highlighting gender inequalities and heteronormativity exclusionary of individuals that break the paradigm of men-bodies/women-bodies^9,12.

Besides the heteronormative cultural aspects, gender inequalities represent major challenges for health systems¹³, beginning with the need to break the conception of gender as a category fundamentally nosological and, therefore, susceptible to medication⁹. Thus, the modification of this situation is fundamental in order that the universality, integrality and equity of care practices be guaranteed, especially regarding the access and accessibility of different segments of the population to health services.

Given the above, the following question is posed: how do nurses include the specificities and pluralities involved in the exercise of sexuality in their care practices to promote adolescent sexual health? Therefore, the objective is to discuss nursing care strategies from the perspective of complexity, for the promotion of adolescent sexual health in face of the factors that intervene in the exercise of sexuality.

THEORETICAL FRAMEWORK

The Science of Complexity¹ was used as theoretical framework because the phenomenon of adolescence and care systems are configured in non-linear processes permeated by interactions and retroactions of human dimensions. Because it means all that is woven together - the complexity aims to encompass existing connections between the elements of a phenomenon and the relationship of this phenomenon with its context, involving the whole and the parts that compose it.

Thus, it unites and searches the necessary and interdependent relationships of the aspects of life, since the phenomena themselves can only be thought correctly in their contexts¹. Therefore, the Science of Complexity may favor decisive intervention mechanisms to the problem of sexually transmitted diseases (STDs) and AIDS in adolescence, and other related mechanisms.

Nevertheless, science and humanity insist on denying the complexity, while seeking the explanation of reality from the simplification/reduction of complex systems. This is an illusion because the complexus is in everything, from microscopic particles and the atom to the macroscopic dimensions as the universe, which, in common to the atom, lie their characteristics of dynamicity, heterogeneity, order, disorder, interaction and organization.

METHODOLOGY

Qualitative study using the Grounded Theory (GT) as the methodological framework, a method developed from a set of analytical resources that when systematically conducted may generate a theoretical matrix¹⁴.

The research was conducted on a center of studies on adolescent health, inserted in a university hospital in the capital of Rio de Janeiro - Brazil. Activities under this scenario include the three health care levels: primary, secondary and tertiary, according to the Unified Health System (SUS).

Research subjects were 15 nurses who composed three sample groups. This is because the definition of new sample groups is related to the need for explanatory conformation of the phenomena that emerge in the analytical course of data. The main hypothesis that guided the delimitation of the three sample groups was: the connections of the process of becoming adolescent are inherent to adolescents, regardless of the care setting in which they are inserted. Therefore, how does the nurse perceive the transversality of this process at different levels of health care? Thus, the subjects were distributed as follows: six nurses from primary care representing the 1st group; five from secondary care representing the 2nd group and four from tertiary care representing the 3rd group.

Subjects were selected intentionally and the theoretical sampling followed the assumptions of GT, which consists in maximizing comparative opportunities for facts, incidents or events to determine how a category varies in terms of its properties and dimensions¹⁴.

Were established as inclusion criteria: be a nurse and develop actions of care for adolescents involving approaches of prevention against STD and the Acquired Immunodeficiency Syndrome (AIDS). Nurses who were entered in these activities in less than one year before the study were excluded.

The average of working experience of participants in the care of adolescents was 2.5 years. Three nurses had academic master degree and their research subjects involved adolescents/adolescence and 10 nurses had attended or were enrolled in graduate courses latu Sensu in adolescent health, in the residence modality.

Semi-structured interviews were used as data collection technique and these were carried out from January to August 2012 and were recorded in digital media. Data analysis was performed based on the encoding process which in GT consists of a comparative analysis process in three levels - open, axial and selective¹⁴.

In the open coding, concepts are identified from the comparisons between properties and dimensions of data. In this step, preliminary codes emerge from the titles assigned to each incident, idea or event. With the primary codes in hands, the movement of comparison between them to group them into conceptual codes is started.

In the axial level, the grouping of conceptual codes to form categories and subcategories happens¹⁴. The purpose is, then, to start the process of reunification of data that were separated in the open coding aiming at a dense explanation of the phenomenon.

Selective coding consists in the comparison and analysis of categories and subcategories, a process carried out continuously that aims to develop categories, integrate and refine the theoretical matrix giving rise to the central phenomenon¹⁴.

The categories were sorted according to the paradigmatic model¹⁴ , a scheme that makes interactive consistency between the dimensions that underpin the phenomenon investigated possible. Its structure comes from the following components: phenomenon, causal conditions, intervening conditions, context, strategies of action/interaction and consequences.

The project was approved by the Ethics Committee in Research of the Anna Nery School of Nursing/UFRJ, under protocol nº 082/2011 and the Ethics Committee of the Pedro Ernesto University Hospital, under protocol nº 3149/2011. Researchers complied Resolution nº 466/12 of the National Health Council. The participation of subjects was voluntary after clarified about the project and after they signed the Informed Consent - IC. In order to assure the anonymity of subjects, they are identified by the letter "I" followed by the corresponding number of the interview.

It is important to mention that the research presented here is an excerpt of the academic master's thesis entitled: Managing nursing care on the complexity of adolescence in the context of STD/AIDS, and obtained financial support from the Foundation Carlos Chagas Filho of Support to the Research of the State of Rio de Janeiro (FAPERJ).

RESULTS AND DISCUSSION

The central phenomenon of theoretical matrix was so named - Glimpsing the management of nursing care in the face of the complexity of adolescence in the context of STD/AIDS. However, only one category is discussed in this article. This, in the use of paradigmatic scheme, figures as a set of intervening conditions that reveal plural relationships and specificities of the adolescent. They influence the promotion and guarantee of their health and sexual development, as well as the implications of this process for the nursing care practices and, consequently, for the strategies of intervention to the adolescent and in the context at hand.

Thus, the study raised the category Pluralities and singularities of the process of becoming adolescent and of health , based on the sub-categories: The gender factor and its implications for the nursing care to the adolescent; Providing care for the adolescent victim of sexual abuse; Glimpsing the break of institutional heteronormativity in health services: emerging challenges.

The gender factor and its implications for the nursing care to the adolescent in the context of sexuality

Thinking on gender inequities, from the perspective of adolescence, implies the possibility of formulating strategies to intervene with these clients, so as to favor the rupture of the hegemonic model that ignores the relational dimension of gender¹³ that reasons that the man's health leads to thinking in the women's health in a complementary relationship¹⁵. In this regard, to intervene in the promotion of sexual health, nurses recognize the behavioral specificities of the gender of the adolescents for their health and the health of others.

There are different ways of working with adolescents, mainly because boys are more childish (I2) ;

Girls have the issue of gynecology, prenatal care, family planning, all about them. And what about boys? (I11)

Armed with this understanding, they develop strategies to reach the adolescent based on the identified needs and understood in the scenarios of health care, as can be seen in the following excerpt:

[...] we know that male adolescents are somehow away from health services. [...] We are still as an experimental laboratory when working specifically with male teenagers (I8).

Although the studies related to men's health and the public policies that are intended for them have gained expressiveness in the scientific and practical fields,¹⁵ adherence of male individuals to health services still represents a challenge to managers, to health professionals and to society^15,16. On the other hand, in heteronormative relationships, gender inequalities affect mostly women^9,13,17, a reality that can be attributed to sociocultural constructions for the meanings of man-being and woman-being, given they present remnants of a society that seeks to centralize power around males⁹. This phenomenon also takes place among the reality of the research subjects, as highlighted below:

[...] I tell them that it is important to trust in the relationship, and that proposing the use of condoms does not interfere in this confidence, because they many say that they do not use it because they trust the partner, like a proof of love. But boys, sometimes they say that they don't use because their friends also do not use, they do not want to be different (I10).

The unequal relationship of power and roles in relation to care of themselves and the promotion of sexual and reproductive health strengthens the influence of culture on the paradigmatic fragmentation that distorts the rights and duties of man to the detriment of women's rights. In this respect, to the woman is entrusted the responsibility of parental care and the maintenance of the home, while the man takes primarily the role of provider, virile, competitive and professionally active^9,17. This reality has an effect on the promotion of health and prevention of diseases and/or injuries.

However, nurses recognize that the socio-cultural construction of these conceptions begins even before the individual enters into the adult stage of life, since the teenager, to fulfil gender roles, may perform harmful sexual practices to the self and to the other, especially the manifestation of violence against women through the deprivation of their right to promotion and maintenance of sexual and reproductive health, as occurs when, for example, the adolescent male refuses to use a condom during sexual intercourse¹⁸.

Because of these consequences, an important measure to address gender inequities may be in the eradication of the game of power between the social roles of being-man and being-woman during the adolescence. This may make possible the right to disease prevention and promotion of sexual health¹⁹, a strategy used by nurses in this study, as highlighted at the beginning of the previous statement. Therefore, it is necessary to recognize the gender perspective as an explanatory matrix of conditions and determinants of health-disease and care process, individually and collectively¹⁵.

Providing care for the adolescent victim of sexual abuse

Violence in youth is a major public health problem because it is the leading cause of morbidity and mortality in this phase of life. Added to this is the problem of underreporting the high rate of cases²⁰. However, as any complex phenomenon that affects society, violence is not restricted to an isolated causal factor²⁰. There are multiple triggering and/or aggravating mechanisms, among which are the programmatic inefficiency for identification of cases and intervention, social inequalities and restraining deficiencies and corrective policies of this reality which, added to the structural and functional imbalance of the economy and legislative shortcomings, raise the multifaceted vulnerability of violence²¹.

In adolescence, when considering the issue of STD/AIDS, attention focus on the sexual dimension, although this type of violence is not dissociated from the psychological and physic aspects, among others. However, it is important to note that the context of violence may be associated with the inequities of gender, as this is a non-linear phenomenon, in order to connect in a cause-effect relationship to other factors, as scored in the previous subcategory. This situation is independent of the stability or of the existence of a loving relationship of mutual intentions, whereas may occur in the family context, where the offender has or not blood relationship with the victim²⁰.

The consequences of this kind of violence may be increased in view of the spread of STDs, expressing reactions in the biological/psychological/behavioral fields which may vary from silence to revolt, besides favoring the manifestation of functional pain, that is, pain without pathological etiology ^20,22. This reality can be thought from the following obtained speeches:

We meet many adolescents who have been victims of sexual abuse. They are more closed. To be able to reach them, we have some difficulty. Therefore, to carry out prevention, first of all, is trust (I2) ;

Sexually abused adolescents are more revolted. In one case - there was a teenager who did not accept treatment because of the revolt of having contracted HIV by the sexual abuse suffered [...] it is important to know how to reach this teenager (I10).

Besides the importance of knowing how to deal with situations involving different forms of violence with teenagers, and in this particular, situations of sexual character, the nurse must also develop skills to identify them, which, in turn, involves the set of relational skills, attitudes and knowledge²⁰ to know and be able to intervene with resoluteness. At this scenario, communication is indispensable for establishment of trust between the professional and the adolescent ^20,23particularly, the ability to interpret nonverbal communication, so as to turn the understanding of silence possible, which when sustained by fear, aims to break barriers of impunity.

Glimpsing the rupture of institutional heteronormativity in health services: emerging challenges

The connections of the process of becoming adolescent, from a complex perspective, place the adolescent between orders, disorders, interactions and organization necessary for their healthy development. In this scope is the identification of sexuality and, consequently, the libido for sexual practices, whether homo- or hetero-affective. However, it is worth to point out that sexual identity involves aspects related to the individual conception of gender, social roles, biological dimension and sexual orientation²⁴. However, for conceptual sake, the term sexual practices are used considering adolescence as a period in which the affective-sexual interactions are being formed. Therefore, the thinking that sexual orientation may suggest the consolidated understanding of identity is comfirmed²⁵.

Thus, thinking on interventive mechanisms for the promotion of adolescent health that establishes homo-afective sexual practices, especially regarding access and accessibility to health services and care, it is necessary to consider the stigma arising from the socio-cultural-historical conceptions about homo-affectivity, namely, sin in the context of theology, crime in the legal sense, illness and psychological deviation for medicine ²⁶.

Therefore, although currently there are public policies and constitutional developments aimed at ensuring the health and rights of the LGBT (lesbian, gays, bisexuals, transgenders)^9,16,27one can not disregard the biologizing paradigm and the social stigma of homo-affectivity, especially in complex systems of human interaction such as family and health and care settings. In these circumstances, the understanding on the threshold between the normal and the pathological states may dictate standards and behaviors that must be accepted or restrained by society. Such reality can be seen in the statement that follows.

[...] she began to reveal that she was discovering herself as homosexual and that for mother was a disease [...] It was clear that the mother was bringing her daughter in an attempt of curing her, that we cured her (I5).

The commitment of the dynamics and functionality of the family may interfere with the healthy development of its members²⁸, what probably includes the crises generated in their context of interactions when faced with phenomena that standards pre-established by society exclude. In fact, the fragility of affective bonds between family members enhances the detachment between the family's social matrix and the adolescent and, at the same time, strengthens his/her approximation to the peer group²⁹ as basal support network. This phenomenon can trigger contextual and individual vulnerabilities as the peer group figures as the primary source of information for the prevention of risks and/or health problems.

On the other hand, health and care scenarios contribute to this reality when the professional value systems, imbricated in the process, reinforce through exclusive attitudes the gaps of access and accessibility of LGBT to public health care services,¹²even though they are under the aegis of the Citizen Constitution regarding the realization of the underlying principles of universality, integrity and equity of SUS. These issues and other related to them are present in the speeches of the research, as punctuate:

The homosexual adolescent feels too inhibited to talk about his/her sexuality to the health professional, because the professional already has a lot of preconceived ideas and may judge him/her (I8) ;

This is a reality, and I began to think about who is the homosexual adolescent, who is he? Where is he? Why he was not in the health service? He did not come here! But it turns out that the service, somehow, did not allow him to come in (I9) ;

I emphasize to the team - we have to treat him well! Because that that one had the courage to face the barrier of the service, this is because he is in need of help, if he is mistreated he will not come back [...] Here, he is welcomed (I11).

In addition to the issues that involve the value systems of health professionals, the programmatic weaknesses for adolescent care in the health and care services, regardless of sexual orientation that the adolescent is developing, contributes to the distancing of him/her from the public health service. Similarly, the formulation of strategies for the teenager freely enter these spaces, if they exist at all, are still slow.

In the complex dimension of the phenomenon, the strategies to improve the access and affordability of that to public health services should be guided by the capacity of connection between the different facets that influence it. Indeed, it is necessary to invest efforts in intersectoral and interdisciplinary practices and in the relationships with family and with other support networks for that adolescent.

CONCLUSION

The complexity involved in factors intervening to the exercise of sexuality of the adolescent points to the importance of strategies guided by in contextual and unique dynamicity of each case. The nurse in this context recognizes the gender inequities in their practices of providing care for adolescents, especially in terms of sexuality. Thus, it seeks to intervene based in the acknowledgement of specificities imbued in the construction of being-man and being-woman in a complementary relationship.

The research also demonstrated the importance of nurses to develop skills to intervene with the adolescent victim of sexual violence, dealing with the subtleties of contextual and individual characteristics to better intervene. In this same direction, it demonstrated the urgency of developing strategies for welcoming the adolescent who breaks the heteronormative paradigm, in order to assure the constitutional right of access and accessibility of this public to health services.

The connections between the gender perspective during adolescence, sexual violence and the exclusion of homo-affective adolescents in health services denoted the problem as a complex phenomenon, whereas one dimension may reflect on the other, provoking and/or enhancing it . Thus, it is urgent to understand the development of sexual health of adolescents as a multidimensional phenomenon and, therefore, requires the involvement not only from the perspective of nursing, but also in the interdisciplinary and intersectoral strategies. For this reason, it is recommended as future lines the development of research involving the different facets imbricated in the phenomenon in question, given that the research here presented is limited to the context of perception of nurses.

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