RESEARCH ARTICLES

Sexuality of adolescent girls in foster care: context of vulnerability to STD

Lucia Helena Garcia Penna^I; Raquel Fonseca Rodrigues^II; Liana Viana Ribeiro^III; Mírian Verdeno Paes^IV; Claudia Rosane Guedes^V

^IObstetric Nurse; PhD in Children and Women Health; Adjunct Professor of Maternal and Child Department and of Graduate Program in Nursing at the Nursing School of the State University of Rio de Janeiro. E-mail: luciapenna@terra.com.br
^IIObstetric Nurse; Women's Nurse, Gynecology Sector of the Fernandes Figueira National Institute of Women, Child and Adolescent's Health. Master in Nursing (Nursing School of the State University of Rio de Janeiro).E-mail: quelfr@gmail.com
^IIIObstetric Nurse; Master in Nursing at the Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: liana_vian@hotmail.com
^IVNursing Student at the Nursing School of the State University of Rio de Janeiro; Scholarship by the Institutional Scholarship Program for Scientific Initiation/National Council for Scientific and Technological Development - Project: Vulnerability sexual and reproductive health of adolescents in foster homes. E-mail: mirian_vrm1993@hotmail.com
^VObstetric Nurse; Professor at the Celso Lisboa University Center; Master in Nursing at the Nursing School of the State University of Rio de Janeiro. E-mail: docente.rosane@outlook.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.18402

ABSTRACT

Adolescent girls in care are no exception to the labels commonly applied to teenagers, but because of their context are more vulnerable to STDs. This qualitative, descriptive, exploratory study examined situations of vulnerability in the sexual health of adolescents in care. The scenarios were two reception units in Rio de Janeiro city. The sample comprised 10 adolescents from 13 to 18 years old. Data were collected between June and September 2014 using narrative interviews, and treated by thematic analysis. Two categories emerged: violence in dating as vulnerability in adolescents' sexual health; and the teenager's body and her sexuality: low self-esteem as a factor in vulnerability. The girls' difficulty in pointing to strategies for credibility and empowerment portrayed a context of submission, subjugation and deprivation. Adolescent girls need to be identified as subjects of rights and capable of deciding on their own lives.

Keywords: Adolescent health; institutionalized adolescents; vulnerability; sexual health.

INTRODUCTION

Adolescence is a stage of life that hosts important biological, psychological and social changes. At this stage of life, sexuality is a personal, family and social manifestation of greater impact. It involves not only biological and psycho-affective characteristics, but also aspects directly influenced by the social precepts and values¹. It is a significant element in adolescent identity formation, being manifested by different identifications, among them sexual conduct.

The main health problems of adolescents derive from genital sexual exercise, including: unplanned pregnancy, complications of pregnancy, childbirth and postpartum, sexual violence, sexually transmitted diseases (STDs)². From 2000 to 2006, 19,793 cases of Acquired Immunodeficiency Syndrome (AIDS) in the group of 13 to 24 years old were officially notified, corresponding to 80% of cases identified in Brazil³. In 2009, 41% of new infections by human immunodeficiency virus (HIV) occurred in people between 15 and 24 years old. Currently, it is estimated that 2,500 young people are infected daily with HIV ⁴.

With regard to adolescents living in foster homes, they are not exempt from labels common to any teenager. However, they have added to their social characteristics the institutionalization that throughout history has segregated and excluded this population. Teenagers living in foster homes due to family breakdown, low self-esteem, unprotected sex, exposure to violence, trading of sex for survival, use of legal and illegal drugs are exposed to numerous vulnerabilities, among them vulnerability to sexual and reproductive health^5-9.

Given that background, this study aimed to analyze the vulnerabilities in the sexual health of adolescents living in foster homes.

THEORETICAL-METHODOLOGICAL FRAMEWORK

This is a qualitative study of descriptive exploratory type that used as theoretical framework the narrative of life, which seeks to understand the fact occurred and has the mark of the narrator in the life story ¹⁰.

The setting of the study were two foster units in the city of Rio de Janeiro that house children and adolescents, one in the North and another in the South of the city. The sample consisted of 10 adolescents aged between 13 and 18 years old. Inclusion criteria were: being institutionalized in the study settings in the period of data collection; belonging to any ethnicity, religion and education level; being aged between 12 and 18 years old; self-declaring practicing genital sexual activities; being or not pregnant; being or not mother; and having the permission of the foster unit to participate. Adolescents signed the Informed Consent Form, along with the heads of foster units. After the ambiance, data collection began through a narrative interview, which took place from June to September 2014. The interviews were recorded and later transcribed. Anonymity was guaranteed through the use of the letter A for adolescent followed by the number corresponding to the order of collection of interviews (1-10). The thematic analysis was used as an analytical process, which aims to discover the core meanings of communication whose frequencies mean something else to the desired analytical objective¹¹. This article is an excerpt of the doctoral thesis: The vulnerability of adolescents living in foster homes for STD, which is part of research funded by the National Council for Scientific and Technological Development entitled Reproductive and sexual health of adolescents in psychosocial vulnerability.

RESULT AND DISCUSSION

Violence in dating as vulnerability to sexual health of adolescents

In adolescence, sexuality has a peculiar sense, in which to understand sexual behavior is to understand the contexts in which they are produced ¹².

Adolescents who spoke about their love relationships mentioned experiencing and practicing physical and verbal abuse (reciprocity), but did not identify it as a problem.

Because I put that hair for the first time, and my boyfriend he worked in a drug den, then he pulled all my hair in a fight I had with him. (A2)

I spent little time with him, because he started to use drugs again and started hitting me. He kicked my stomach [she was pregnant]. (A9)

Violence against and among young people in dating relationships has been a pointed reality. Studies indicate that 20-50% of teenagers have already experienced a situation of violence in intimate relationships¹³.

The reciprocity of violence among young people in dating relationships has been also identified in other studies, where at least 30% of girls physically have assaulted their boyfriends and 17% of boys have also attacked their girlfriends¹⁴. These data suggest that aggression is the instrument of communication between partners. And that control behaviors are considered as a way of showing love and jealousy is presented as an important ingredient in a dating relationship^15,16. Thus, if the social and cultural norms where young people are embedded support violence, this kind of behavior becomes acceptable for many situations.

It should be noted that female adolescents living in foster homes often have a history of violence in their family context and in interpersonal relationships they establish (physical, sexual, psychological and social violence)^17-19. There may be relationship between these realities of violence experienced previously, which influences how they conduct their romantic relationships, as a naturalized social continuity. This relationship has its explanation in the notion of social learning, where the behavior of each person is determined by the environment in which they are inserted through observation, reinforcement, modeling or coercion²⁰. The family or the place where one lived their childhood (personality building period) is identified not only as an environment that can enable aggressive behavior, but also as a location that can cause the individual to internalize values that promote violent behavior²¹.

He [stepfather] hits her [the mother]. It seems she likes. He still hits her. (A4)

They argued, but he's a womanizer ... So my stepfather has already hit my mother. I saw. [...] Then he [stepfather] punched my mother. That was when I went between them. (A5)

Adolescents voiced that respond to these situations by fighting back the attacks with other attacks. With this, vicious and pernicious circle is build up, in which as these teenagers do not have other role models, they "end up repeating what they have learned at home when they begin to have romantic relationships"²².

So we discussed a lot. Then I stuck the knife in him. He went to the hospital, then he hit me. Then I hit him back (A1).

[...] I ran to the bathroom and did not let him enter. By the time he managed to break down the door, I started to tear his leg with razor (A6).

These situations, even being a response to aggression, are nonetheless violence with injury risk to integrity. The naturalization and banalization of violence in intimate partner relationships has been a major cause of violence against women. In societies marked by gender inequality, the perpetrator's responsibility is trivialized and their opportunistic, exploitative and destructive behavior is forgotten. Society mostly values the image of women as being provocative and guilty. Shame that should affect the aggressor "is directed against women and silences them, integrating them to the network that keeps domination happening"^23-27.

The initiation in adolescence of an intimate loving relationship (dating) for most adolescents in this study is the idealization of building a family and establishing a home. Thus, the pressure to be in a relationship can lead adolescents to ignore and excuse the violence they are subjected to. The lack of identification of a better life and of a network of social support contributes to the normalization of violence and to blaming themselves for the violent acts, making it difficult to recognize and to end this abusive relationship²⁴.

Although some studies ^25,26 claim that this type of violence (in dating) men and women are victims and aggressors equally, we must, in our patriarchal culture, increase knowledge about gender differences. In societies marked by gender inequality, the perpetrator's responsibility is trivialized and their opportunistic, exploitative and destructive behavior is forgotten. Society mostly values the image of women as being provocative and guilty.

I used to tease him. It would go, without anyone seeing, and stepped on. Then, none of us could go without punishment, and we discussed. Ah! We kept on discussing. (A1)

He's nice, he's affectionate. He is [...] As I was very jealous of him, I came to attack him, so he hit me too. But only in this situation, otherwise, he would never hit me, no, only when I assaulted him. (A2)

Women who experience the violence perpetrated by the partner usually tend to blame themselves, thinking that their actions are solely and exclusively responsible for the partner's violent reactions.

Still on the characteristics of relationships with partners, adolescents said they had relationships with other women in the period they were apart often, according to them, to cause jealousy. In this case, the betrayal came to be interpreted as blackmail and even coercion.

Then we would stop talking to each other, sometimes. One day, two days. Then, he would go out with a woman, then I would tease him. (A1)

So once we had broken up, [...] he came to ask me, just to try to put me jealous, then he asked me whether ... he came to me for advice, came to ask me whether he would go out or not with this girl, because she had a boyfriend. (A4)

In the case of female adolescents, they did not cogitate separation for many reasons, among them, the fact that in these relationships, there was, besides emotional linkages, social interest, both as status within the community or at the foster institution of being with a mighty man (dealer or a popular teenager), and an option of having somewhere to live, since adolescents who had boyfriends out of the host institutions moved in with them on the first day who made out.

Another reason for staying in the relationship is that, since the teenagers do not have a bond with the family, they saw in the partner the possibility of building a different life, where personal desires were idealized and the desires and needs could be met and matched by the partner. A third reason is due to the very context of exclusion in which they live, where countless losses or even absences are part of their history: family exclusion, social exclusion, economic exclusion and cultural exclusion. Losing the partner brings insecurity and fear of other exclusion, as they cease to be part of the life of another person.

Thus, in situations where they felt threatened of losing the partner and gains from the relationship, the female adolescents justified their fears claiming that their partners wanted to cause jealousy by having other relationships. These manifestations of jealousy cited by teens are valued in our society as synonyms for love or investment strategy in the relation²⁸.

In fact, this social understanding widespread among young people has sustained the increased incidence of HIV infection, especially its feminization ²⁹. Women become more exposed to contamination, since they have difficulty and embarrassment in using a condom or in asking their partner to use it due to fear of losing their confidence and thus experiencing the separation or even some kind of violence³⁰. Women, historically and culturally, live in conditions of greater vulnerability because of their submission to the partner. Men tend to be more exposed because they believe in a false immunity because their infidelity is accepted naturally by society and because they are responsible for using or not using condoms. In contrast, women become impaired in starting a conversation with their partner about safer sexual practice and forgo the use of condoms in the belief of romantic love ^31-33.

The body of the female teenager and her sexuality: low self-esteem as a vulnerability factor

Female adolescents, in addressing the perception they had on their body, pointed being ashamed to expose it to the partner or that were not satisfied with their own body.

I'm getting too fat. I think I'm awful. I think I'm fat. I think I'm horrible! (A1)

I am ashamed even of being naked in front of him, I do not know why, but I feel ashamed to be naked in front of him. So in the first few times I did not let, because I was ashamed. Then it happened (oral sex) because it was dark, then I let him do it, since he was not seeing me at all. (A6)

Adolescence is characterized by physical, behavioral, emotional, sexual and social changes and is marked by individuals' effort to satisfactorily match cultural expectations of society in which they live.

In a society where the body plays an important social value, adolescents who do not meet the required stereotypes suffer or behave as naturally excluded. Studies show that this high prevalence of dissatisfaction with body image interferes directly in self-esteem^34,35.

Thus, the construction and perception of the body by female teenagers transcend private matters and is influenced by social spaces mediated by interrelationships. Friends, the host institution and the family, although unstructured, as well as cultural influences contribute to the construction of the identity of the body of female adolescents in the context in which they live. Added to this, there is the media and social networks. In today's society, these types of media are an important intervention in the attitudes and behaviors of adolescents, including among adolescents in foster homes.

The culture of thinness, of the voluptuous body, of clothes that shape the bodies end up dictating the ideal and desired body image by these adolescents. A culture too focused on thinness and the media as a vehicle of wide spreading this ideal turns the body into an projection object of desires to reach the female model of beauty³⁶.

Parallel to these bodily changes, the psycho-emotional changes occur, i.e., the search for identity, the trend of groups, the singular experience and the evolution of sexuality ³⁷. Sexuality here should be understood as the way that adolescents come into contact with the world and how they perceive themselves, using the body as an instrument of connection and communication. Thus, sexuality has as much to do with the beliefs, ideologies and imaginations of this group as with the physical body³⁸.

Therefore, the context found in the narratives of female teenagers who took part in the study regarding shame, lack of confidence, fear and low self-esteem associated with lack of family support, the use of drugs and the experience of violence, increase the vulnerability of these adolescents to STD because the use of condoms during sexual intercourse remains non-existent and of difficult negotiation and the prevention and promotion of their sexual and reproductive health are not understood as important and priority.

Also in the context of the experience of sexuality by adolescents in foster homes who participated in the study, issues regarding the loss of virginity emerged in the narrative of a female adolescent. She spoke about the right time to have her first sexual intercourse and how she will handle the matter with her daughter. The idea of maintaining virginity in the narrative below shows that the teenager associates sexuality to love, as opposed to the pleasure of men. She refers the loss of virginity in a loving relationship based on feelings of respect and affection complicity.

Others say that there is an age to lose virginity, but 10 years old is too much ... too soon. But if you love a person, you see that guy is right for you to lose your virginity, you can lose. [...] But I do not want it for my daughter. I want her to lose her virginity at 20, 30 years old. Because men hurt women. Sometimes she makes out with that boy, loses her virginity and that guy was not the one. (A1)

[...] But I do not want it for my daughter. I want her to lose her virginity at 20, 30 years old. Because men hurt women. Sometimes she makes out with that boy, loses her virginity and that guy was not the one. (A1)

Currently, female adolescents experience their sexuality in a more liberal way, where dating and the age for first intercourse have undergone great changes. This freedom for women to experience sexuality occurred from the sexual revolution and the advent of the contraceptive pill, which gave them the right to feel pleasure during sexual intercourse unrelated to procreation³⁹. However, the loss of virginity is still considered a rite of passage in which the girl passes from childhood world for womanhood, and is seen by them as a special time, still linked to romantic love. Unlike the man, who is socially encouraged to start their sexual life as early as possible regardless of the interest or relationship with the partner, showing and marking their virility⁴⁰. Thus, different values between men and women assigned to first intercourse, which are social, historical and culturally defined, are based on gender relations, in which the traditional model of virginity has not suffered equality modifications. Even with the female conquests with regard to sexual practices, motivations continue responding to the roles socially and culturally assigned to women, where love, romance and commitments become motivators for the first relationship. Such practices show that the double sexual standard is still in force, strengthening the power asymmetries in sexual practices and in which the methods of protection against STD can be difficult to negotiate.

The life stories of some teenagers also pointed to the experience of homosexual relationship.

And so [laughs] ... I had only gone out with boys, but here I am dating a girl. And so... [laughs] it is different. I do not know ... it's different. But we still have not have sexual relations, no. (A8)

So when I was in another foster home, I end up kissing a girl. But I have only kissed. I did not have sexual relation, no. I have dated her for a little more than one month. (A9)

As it has been discussed, it is in adolescence that sexuality assumes an important role in the identity of teenagers. They get to know and experience their own bodies and the body of others. They begin to have sexual desires and attractions. Therefore, in adolescence, it is common that more intimate approaches happen among adolescents, including among adolescents of the same sex. In the narratives of the participating teenagers, it was identifies that the emotional relationships established with other girls were resulting from an identification and an approximation by someone who shares the same stories of loss, exclusions, difficulties and rejections. Physical attraction and involvement emerged from the fellowship, the hearing and established conversations, from the comfort cuddles offered one to other. There is presence and share of cultural scenarios of constant neediness, deprivation and absence, in which the peer groups play a key role in meeting the answers and discoveries, not offered by their households.

Female adolescents tend seek closer ties with other girls, with which they exchange confidences, talk about the losses and rejections, share the games of seduction, flirt and dating, and it is in this context that often the physical attraction occurs⁴¹.

CONCLUSION

Adolescents living in foster homes narrated culturally constructed behaviors, where gender issues, violence, social, family, economic and cultural exclusion were naturally diluted in their speech and showed strong interference in their worldview and in the relationship with themselves, with the other and with society. The difficulty of pointing credibility and empowerment strategies portrayed a context of submission, subjugation and deprivation, where sexual health preventive and promoting care became scarce and dialogue and negotiation on condom use by have become absent, which placed them more vulnerable to STDs.

This unfavorable context, added to the characteristics of adolescents in general to experience the new, to challenge the limits and to have a thought of invulnerability and omnipotence, puts teenagers living in foster homes in a position of constant vulnerability to STDs.

It is therefore necessary in health care to identify and understand the contexts of vulnerability that adolescents in care situation are inserted. They should consider these teenagers also as subjects of rights and able to decide about their own lives. Simply informing and prescribing the condom use and the right sexual behaviors to teenagers are not sufficient measures for the experience of a full sexuality and a safe sex.

Sexual health policies should be constructed and oriented with an emphasis on transmission of information and on responsibility and empowerment of the female adolescent through embracement, sensitive listening, assistance and conditions for decisions to be made by the very empowered teenagers.

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