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Empowerment of female adolescents at shelters: sexual health in terms of the Theoretical Model of Nola Pender


Lucia Helena Garcia PennaI; Liana Viana RibeiroII; Iraci dos SantosIII; Kézia Áurea de Almeida RamosIV; Fábio de Oliveira FélixV; Claudia Rosane GuedesVI

I Nurse. PhD in Nursing. Professor, Rio de Janeiro State University. Brazil. E-mail:
II Nurse. Master and PhD student, Graduate Nursing Program, State University of Rio de Janeiro. Brazil. E-mail:
III Nurse. PhD in Nursing. Professor, Rio de Janeiro State University. Brazil. E-mail:
IV Nurse. PhD student, Graduate Nursing Program, Rio de Janeiro State University. Brazil. E-mail:
V Nurse-midwife. PhD student, Graduate Nursing Program, Rio de Janeiro State University. Brazil. E-mail:
VI Nurse-midwife. Master in Nursing. Rio de Janeiro, Brazil. E-mail:





Objectives: to describe the sexual attitudes and behavior of adolescent girls in shelters, and to analyze the repercussions of these attitudes on their sexual health, in view of the theoretical model of Nola Pender. Methods: after approval by the Research Ethics Committee (number 279A/2013), this exploratory, qualitative, descriptive study interviewed eight girls, from 12 to 18 years old, at shelters in Rio de Janeiro City, using a structured interview script based on Nola Pender's Health Promotion Diagram. Content analysis indicated the category Sexual Health Promotion: gender perspective and empowerment of adolescent women at shelters. Results: sexual health promotion behavior and attitudes observed among these adolescents at shelters included: increased use of condoms, and perception of sexual vulnerability. Conclusion: the adolescents' attitudes and sexual practices demonstrated a certain autonomy, assertive participation and consequently empowerment, thus contributing to promotion of their sexual and reproductive health.

Keywords: Adolescent; sexual health; nursing theory; health promotion.




Adolescence corresponds the ages from 10 to 19 years1 and can be understood as the individual's structuring process towards emancipation. This stage is established from experiences acquired through life and is bounded by social, economic and institutional structures, which are marked by gender, social class and ethnic group categories2.

Among the peculiarities of this stage of life is the process of love and sexual experimentation, until formation of opinion and decision making regarding sexuality. Sexual health involves sexuality, practices and desires related to satisfaction, affection, pleasure, feelings, the exercise of freedom, sex, gender identity and roles, sexual orientation, eroticism, intimacy and reproduction. Thus, the exercise of sexuality involves gender issues and the socio-cultural context of adolescents, directly influencing sexual attitudes and behaviors responsible for the maintenance of sexual health3,4.

Institutionalized female adolescents have peculiarities about sexual health, mainly because of their double vulnerability - gender asymmetry and institutionalization during adolescence (away from family life)5 .

Given this context, the following question stands out: how do the sexual behavior dynamics of institutionalized adolescents take place regarding promotion of sexual health? In order to answer this question, the following objectives were set: to describe the sexual attitudes and behaviors of institutionalized adolescents; and to analyze the impact of these attitudes over their sexual health, according to the Nola Pender theoretical model.



Health promotion is based in the generation of health and quality of life to individuals. These individuals are seen in a comprehensive manner as the main agents of their own health, able to participate, intervene and choose the best conditions for enjoy full health and to cope and resolve problems, acquiring healthy habits and lifestyles6,7.

The term empowerment is discussed in this context of self-care. This can be understood as an extension of the freedom to choose and act, i.e. the increase of authority and power of individuals over resources and decisions that affect their own lives8. Thus, women's empowerment means a change in gender relations in society, whose traditional dominance of men over women disappears and women are assured of their autonomy with regard to the control of their bodies, sexuality, the right to come and go as well such as to strengthen the feeling of abhorrence against violence and unilateral decisions of males that affect the whole family

The health of adolescents is directly related to the promotion of youth participation and exercise of citizenship, disease prevention and comprehensive health care, including attention to sexual health. Thus, adolescence can be considered a unique opportunity to ensure the full expression of potential growth and development of each individual. To get this objective, it is necessary to know their behavior and attitudes.

In the search for recognition of the empowerment of institutionalized female adolescents and the promotion of sexual health, we elected the Theoretical Health Promotion Model of Nola Pender9 to describe this reality.

The first of the three key components of the Nola Pender's Health Promotion Model9, namely, individual characteristics and experiences, provides basis for interesting sexual health systematization, becoming a useful tool for the implementation and evaluation of future health promotion actions.



This study has qualitative, descriptive and exploratory approach and is the result of a master's thesis of the Graduate Nursing Program, Rio de Janeiro State University10. Eight participants were selected. Inclusion criteria were: adolescent (12-18 years old), female, sexually active, experiencing the process of care in an institute for social inclusion.

The setting was a public care institution located in the municipality of Rio de Janeiro and linked to the municipal system of the Municipal Secretariat of Social Assistance of Rio de Janeiro (SMAS/RJ)

This study met the ethical precepts11. After learning the purpose of the research, adolescents signed the Informed Consent and as they were underage, one professional of the institute responsible for the adolescent was also asked to sign the Informed Consent.

Structured interviews took place in the period March-May 2014 after approval by the Research Ethics Committee (nº 279A/2013). The interview followed a script of questions based on the diagram of Nola Pender, addressing issues on promotion of sexual health, and this was recorded in electronic audio device.

We adopted systematic content analysis for treatment and interpretation of data12. The following category emerged: Sexual health promotion: gender perspective and empowerment of female adolescents under situation of institutionalization based on the Health Promotion Model designed by Nola Pender9.



Sexual health promotion: gender perspective and empowerment of female adolescents under institutionalization

In this study, behaviors such as buying/having a male condom and its consequent use denoted important actions of the young women regarding their sexual life. The choice of using condom in a shared manner, through dialogue with the partner, displays shared responsibility during sexual practice.

Look, before dating this guy I bought a lot of mint condoms, there, then I stopped buying and I would only go to the medical post to get them. I also had a condom pouch. (I2)

I have a lot of condoms. [...] The two of us [would choose the contraceptive method]. He would use that. But when we said, we said 'no... I want condom today', then he would use it! (I3)

Men's resistance to use condoms and negotiation methods to prevent Sexually Transmitted Infections (STI) between the couple it reflect gender inequalities in society, with the worst situations found among the less favored economic social classes. Gender issues reveal the synergistic effect of multiple determinants of vulnerability to which women are subjected13.

The data showed that equal powers to men and women contribute to a healthy relationship and this equality promotes safer sexual behaviors, especially among adolescents. Situational influences as families, spouses and health professionals are important sources to strengthen or weaken the commitment to maintain health promotion.

In the case of these young women, it is likely that they pledged to adopt and maintain sexual health promotion conducts when the individuals who are important to them, their partners, offered help and support to the safer sexual behavior9.

Also, it is necessary to ponder that the sexual behavior of adolescents and the importance given to their sexual health cannot fully ensure a safe sexual practice solely by dialogue or by buying/having condoms. Yet, these behaviors are strategies to increase the use of contraceptive methods and offer, therefore, protection during the sexual practice. Thus, these small gestures indicate attempts of this group to perform self-care in their sexual health, seeking to practice safe sexual practices and to ensure prevention against STIs.

During the experience at the care institution, new behaviors full of authenticity and safety during sexual practice were detected. This reaffirmed the empowerment of adolescents, such as the denial of sexual practice when the partner did not want to use condom, as well as the onset of sexual practice only when the affective relationship was further deepened or if affective feelings for the partner existed.

I ask him to use really [use condom during sexual practice]. Are you going to put it or not? If not, get off. (I6)

Because I'm not..., the kind that start dating, and have sex. Not me! I prefer to know the person well. I'm serious, I really prefer to know the well the guy first. I prefer to have that interaction with the person really, to know what he really wants from me, what is his interest, you know? Some men take advantage and bye! But then, it is so. [...] I will first know the person, and then I have sex. And then I give myself to the person, you know? (I7)

When it comes to sex, issues of prevention and condom use stand out. Although this is a problem to be faced by most women, since they need the partner's cooperation, they create strategies to overcome these obstacles and ensure their health14.

Some teenagers feel the need of to get protected when they do not know the sexual health history of partners. In one of the cases, the denial to use condoms from the part of the partner caused a concern in the young woman who sought, as alternative, female condom to protect her sexual health.

But if one day, it happens, I'll have a condom with me, because I served as bait. I also know that if he was involved like this with some girl there, I'll use condom really. I was already thinking about it [...]. I use the female condom, as he does not want to put, I'll use a condom for women. (I2)

Condoms are the only methods during sexual activities that offer dual protection, to prevent STIs and to avoid pregnancy. When condom is not used, this is an indicator of risk sexual behavior. The use of female condom indicates knowledge about the body and health, as well as authenticity and confidence to expose choices, denoting the female empowerment, and even strategies to promote sexual health.

Therefore, female empowerment allows the adolescents believe in their true potential to make changes in relation to their own health. This empowerment encourages and facilitates the emergence of alternatives to modify the risky sexual behavior among young woman9.

Opposed to sexual conventions culturally and historically imposed by gender roles, by adopting the use of female condom, these adolescents symbolically break the cultural duty that is imposed on them to satisfy the sexual needs of males. The popularization of the female condom can make changes in the symbolic field of sexual negotiation between partners possible, because the possibility of a new feminine attitude, by handling the product and by the knowledge of the female body arising from its use, represents a dual alternative of protection besides the male condom14.

Thus, this behavior can be seen as a strategy of sexual promotion able to generate changes considered liberating in a social context, breaking the cultural paradigms of woman/passivity and man/activity in the sexual act.

Unprotected sexual activities during institutionalization, from the knowledge of the partner's sexual history, were also detected. When six young women learnt that the partner did not have STIs led them to unprotected sexual practice.

I think ... like this, if I am with someone else, of course I will use, because I do not know what the person has, but this is not his case, I know him, because I saw his medical tests too. (I4)

With him, I do not use any protection during sexual practice, but rather with others I do [...] Because I know he does not have any kind of disease ... with the other was different, I did not know him well and then I started using condoms with him. Then I was using a condom with him. But with him, no, I know him, I know all of him really. Then I use no condom. (I6)

In affective relationships, there is a tendency of not using condoms during sex in the case of women with steady partners because preventive actions are linked to loyalty15. The concern of women with the assurance of the partner's sexual satisfaction is considered ordinary and natural condition, as they assume the role that they should serve men during sexual relations14.

Thus, it appears that the female body is imbued in context of culture and relationships, the channel through which the links are constructed and lived14. This comes to reinforce the idea of ​​submission of women to the opposite sex and the constant need to satisfy it. Thus, the influence of people, beliefs, feelings and even the reproduction of views on sexual health common in society contribute to determining attitudes of promotion of sexual health9.

Other points identified were the knowledge and tightening of emotional ties with the partner that arise as a justification for non-use of condoms. Thus, these adolescents tend to leave the protected sexual practice when they feel there is stability in the relationship with the partner 16. This fact shows that the control of women's sexuality is still concentrated in the hands of the male figure.

In this sense, the greater independence and sexual autonomy seems to be located only in the plan of idealization. It is noteworthy that strong ties of vulnerabilities and gender intensify the real and imaginary difficulties to the negotiation process of condom use and, thus, weaken the possibilities for combating unprotected sexual practice among adolescents.

The possibility of acquiring condoms was a reality indicated by the institutionalized young women. However, the difficulty of dealing with gender issues in which there is a predominance of male power over women set up the paradox of not using condoms despite having them at hand. This internal conflict of young women resulted in their choice for unprotected sexual practice and abandonment of the use of condoms.

The sexual behavior and practices are objects of normative control, and gender relations culturally imposed define what is allowed for both sexes. This contradiction, receiving and storing condoms but not using them exposes the difficulty that adolescents have in recognizing their sexuality and exercising it.

Thus, in the sexuality aspect, gender relations impose to men the role of active subject and to women, passive object. Women must be attracted and dominated by men, and women must be responsible for ensuring that only the partner reaches sexual pleasure. In this sense, the speeches show an often weakened sexual empowerment, plagued by gender violence, full of flaws in the promotion of sexual health, where women are prevented from owning their own bodies, their self-esteem, their pleasure, sexual satisfaction, and their right of get protected against STIs, but getting exposed to live at risk instead.

Thus, the recognition of their true potential in the exercise of their own sexual health minimizes the perceived barriers and increases the likelihood of a commitment to action and performance of real autonomy towards a specific health conduct9,17. When they realize they have skills, adolescents may begin adopting strategies against sexual risk, implying autonomy and empowerment in sexual health.

Among the real situations of difficult dialogue and negotiation about condom use, episodes of physical violence or threats of breaking up the relationship happen. The imaginary include, among various issues, personal exposure to other people's suspicion with all the consequences resulting from this situation, such as defamation, humiliation and loss of privacy5,18.

Another situation was the difficulty of teenagers to think that they are autonomous persons.

This fact reinforces the difficulty of negotiating condom use with their partners. Women generally tend to be more involved with the consequences of their actions in the field of sexuality, while men experience their sexuality in a more carefree way. Men also show less knowledge about the various possible strategies to be used, in order to take care of sexual and reproductive health16.

There were changes in sexual behavior in the periods before and during institutionalization. The possibility of dialogue and negotiation about condoms were previously non-existent, leading (three) adolescents to not use condoms during sex. Then, after institutionalization, more reports (seven) of dialogue and negotiation of protection in sexual relations with partners were observed.

It is likely that the teenagers commit themselves to adopting sexual health promotion conduct when individuals who are important to them, their partners, remodel their conduct themselves, supporting girls in the search for safer sexual behavior. This change of thinking of partners helps adolescents to believe in their true potential for achieving changes in their health and to create alternatives to modify their sexual behavior9.

Adolescents showed actions that highlight a certain measure of autonomy, as well as strategies that promote a sexual practice free of harm. They often reported their concerns regarding future sexual and reproductive health, especially on issues such as pregnancy and STI prevention.

We also found that the adolescents commit more easily with behaviors from which they clearly see benefits and give them greater security. Consequently, the behaviors that concern sexual activities work in specific situations that involve relations of gain and lowest possible losses in their lives9.

The healthy exercise of sexuality is a right and a desirable goal in the promotion of sexual health. Certain behaviors such as sexual abstinence, the decision to have sexual activity with wanted partners and the attempt to dialogue with partners contribute to reducing risks and gender inequalities and to further strengthen the image of persons who are completely capable of deciding their own future.



Attitudes of sexual empowerment of adolescents presented a duality of sexual practices. They oscillate between attitudes of using or not using protection during sexual intercourse, and taking or not taking a greater risk on the face of STIs.

Behaviors, such as requiring protection during sexual practices, the choice and use of contraceptive methods, identification of risk situations in sexual practices and attitudes full of empowerment and resilience, highlight strategies to promote sexual health adopted by the young women.

While we observed in reports the presence of greater sexual autonomy, it was clear in this study that gender inequality relations and historical and socio-cultural integration are present, as revealed by these adolescents. The use of the method can generate only the illusion of greater power and control of the sexual act, which may interfere with the adoption of condom use, negotiation strategies in sexual relations and exercise of one's own sexuality.

In this sense, we must produce well thought out education strategies to adolescents in situation of institutionalization, under a dialogical practice of care, valuing their personal and social, gender and ethnic characteristics.



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Direitos autorais 2016 Lucia Helena Garcia Penna, Liana Viana Ribeiro, Kézia Áurea de Almeida Ramos, Fábio de Oliveira Félix, Claudia Rosane Guedes

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