Perceived Experiences of Community Violence Among Adolescents: A School Survey From Rio de Janeiro, Brazil.

Community violence (CV) is a global public health problem due to its high frequency and severe consequences. Although CV is one of the leading causes of death among adolescents, little is known about the everyday CV situations that do not lead to death. This study aimed to estimate the frequency of exposure to and involvement in CV situations among adolescent students from public and private schools in the city of Rio de Janeiro, Brazil. This was a cross-sectional study of 693 individuals in their second year of high school selected through stratified multistage random sampling. Information about their exposure to and involvement in CV was collected through a self-completed multidimensional questionnaire in the classrooms. For approximately 30% of the adolescents, someone close to them had been murdered, and 40% had already seen the corpse of a victim of homicide. Seventeen percent reported having been directly involved in CV situations. Approximately 38%, 13%, and 25% had been victims of robberies, interpersonal aggression, and death threats to either themselves or their relatives, respectively. Many of these situations occurred more than once. In general, CV was more frequently reported by boys and by those who did not live with both parents. Adolescents from higher economic classes experienced more interpersonal aggression and felt a greater need to carry a gun. Those who belonged to the lower economic classes and studied in public schools were more exposed to lethal violence than other students. The results call attention to the very high percentage of adolescent students that are involved in CV situations as well as to the differences in violence rates among population subgroups. Such findings should be considered when planning CV prevention and management actions in schools and other socialization spaces for adolescents.

Contradictions in relation to sexual violence in the eyes of adolescents and the disconnect with the law defining "rape of vulnerable individuals". / Contradições acerca da violência sexual na percepção de adolescentes e sua desconexão da lei que tipifica o "estupro de vulnerável".

Article 217-A of Brazilian Law n. 12,015/2009 defines carnal knowledge or any other libidinous act with an individual under 14 years of age as "rape of a vulnerable individual" (statutory rape). Given the young average age at sexual initiation in current society, the study aimed to understand the adolescents' views of sexual initiation, sexual assault, and the law that defines sex at this age as "rape of a vulnerable individual". The authors used a qualitative approach with 13 focus groups totaling 132 secondary students from public and private schools in the city of Rio de Janeiro, Brazil. Data analysis used the webQDA software with a hermeneutic-dialectic approach that yielded three categories: feeling ready to initiate sexual activity, (in)vulnerability to sexual assault, and protective mechanisms. Girls associated sexual initiation with a romantic vision and feeling safe with and trusting the partner. Boys associated it with opportunity, regardless of other factors. Most of the students felt that when consent to the sexual act is mutual, regardless of age, there is no violence involved. At the same time, they wondered about the possibility of younger girls' discernment to consent to having sex. Most of these adolescents disagreed with the protective measures established by the law, arguing that it is the family's duty to provide this care. The contradictions in the adolescents' views concerning vulnerability to sexual assault and rape of vulnerable individuals as defined by the law lead us to conclude that it is necessary to expand and improve sex education in general for Brazilian adolescents, besides creating spaces for discussion that can help improve these legal provisions.

O Art. 217-A da Lei nº 12.015/2009 definiu como crime de estupro de vulnerável a conjunção carnal ou outro ato libidinoso praticados com menor de 14 anos. Diante da baixa idade de início da atividade sexual observada na atualidade, objetivamos neste estudo compreender a concepção de adolescentes acerca da iniciação sexual, da violência sexual e da lei que a tipifica como "estupro de vulnerável". Utilizamos método qualitativo por meio de 13 grupos focais com 132 estudantes do Ensino Médio de escolas públicas e privadas do Município do Rio de Janeiro, Brasil. A análise dos dados foi realizada com apoio do software webQDA, em uma abordagem hermenêutico-dialética que deu origem a três categorias: sentir-se apto a iniciar o sexo, (in)vulnerabilidade à violência sexual e mecanismos de proteção. A iniciação sexual para as moças está relacionada a uma visão romântica, a se sentirem seguras e terem confiança no parceiro, ao passo que, para os rapazes, está associada a oportunidade, livre de outros fatores. Para a maioria dos estudantes, quando o consentimento para a prática sexual é mútuo, independente da idade, não há violência. Ao mesmo tempo, questionam-se quanto à capacidade de discernimento das mais jovens para permitir o sexo. A maior parte discorda das medidas protetivas previstas na lei, por entender que é dever da família prover esse cuidado. As contradições na percepção dos adolescentes sobre a vulnerabilidade à violência sexual e o estupro de vulnerável previsto em lei nos levam a concluir que é necessário ampliar e qualificar a educação sexual de forma abrangente para adolescentes, assim como criar espaços de discussão que possam proporcionar aperfeiçoamento desse dispositivo legal.

El Art. 217-A de la Ley nº 12.015/2009 definió como delito la violación de personas vulnerables, la unión carnal, u otro acto libidinoso practicado con un menor de 14 años. Ante la baja edad para la iniciación sexual observada en la actualidad, el objetivo de este estudio fue comprender la concepción de los adolescentes sobre: iniciación sexual, violencia sexual y la ley que la tipifica la "violación de una persona vulnerable". Utilizamos el método cualitativo mediante 13 grupos focales con 132 estudiantes de enseñanza media de escuelas públicas y privadas del municipio de Río de Janeiro, Brasil. El análisis de datos se realizó con el apoyo del software webQDA, desde un enfoque hermenéutico-dialéctico que dio origen a 3 categorías: sentirse apto para iniciarse en el sexo, (in)vulnerabilidad ante la violencia sexual y mecanismos de protección. La iniciación sexual en el caso de las chicas está relacionada con la visión romántica, sentirse seguras y tener confianza en la pareja, mientras que, para los chicos, está asociada a la oportunidad, aparte de otros factores. Para la mayoría de los estudiantes, cuando el consentimiento para la práctica sexual es mutuo, independientemente de la edad, no hay violencia. Al mismo tiempo, se cuestionan respecto a la capacidad de discernimiento de las más jóvenes para permitir el sexo. La mayor parte está en desacuerdo con las medidas protectoras previstas en la ley, por entender que es un deber de la familia proporcionar ese cuidado. Las contradicciones en la percepción de los adolescentes sobre la vulnerabilidad a la violencia sexual y la violación de personas de vulnerables prevista en la ley nos llevan a la conclusión de que es necesario ampliar y mejorar la educación sexual de manera que abarque a los adolescentes, así como crear espacios de discusión que puedan perfeccionar este recurso legal.

Teen-dating violence: conception of adolescents in a Brazilian metropolis.

BACKGROUND: Teen-dating violence (TDV) can lead to health problems for those involved, especially females, including homicides and is predictive of intimate partner violence in adulthood. METHODS: To analyze the adolescents' perception of definitions, justifications and consequences of TDV, a qualitative study through 13 focus groups with 132 high school students from public and private schools of Rio de Janeiro city, including 70 girls and 62 boys was conducted. We followed a guide with questions about interpersonal violence and participants completed a self-administered questionnaire on socio-demographic data. The data analysis included reading and comprehension of the textual data; coding of the reports according to the emerged categories; identification of the meanings attributed by the subjects to the questions raised; comparative dialogue with literature; and elaboration of interpretative synthesis. RESULTS: Most adolescents affirmed that TDV is not justifiable. However, in practice, they found it acceptable in certain situations. The narratives of the boys were based on the role of the perpetrator and the girls on that of the victim. Violence occurs when the man feels his power challenged and is influenced by situations of violence experienced in his own family as victims or witnesses. The TDV consequences are for the women and include, in addition to physical and psychological damage, relational problems in other spheres such as family, friends and school. The experience of violence was more common among public school students. CONCLUSIONS: The adolescents' narratives reflect the gender patterns of society in which violence results from inequality of power. The data of this study offer subsidies to policies on TDV prevention and its consequences. They can contribute to training primary care professionals to identify on clinical consultations signs and symptoms of violence and to develop interventions to reduce the health problems of victims.

Contradições acerca da violência sexual na percepção de adolescentes e sua desconexão da lei que tipifica o "estupro de vulnerável" / Contradicciones acerca de la violencia sexual en la percepción de adolescentes y su desconexión de la ley que tipifica la "violación de personas vulnerables" / Contradictions in relation to sexual violence in the eyes of adolescents and the disconnect with the law defining "rape of vulnerable individuals"

Resumo: O Art. 217-A da Lei nº 12.015/2009 definiu como crime de estupro de vulnerável a conjunção carnal ou outro ato libidinoso praticados com menor de 14 anos. Diante da baixa idade de início da atividade sexual observada na atualidade, objetivamos neste estudo compreender a concepção de adolescentes acerca da iniciação sexual, da violência sexual e da lei que a tipifica como "estupro de vulnerável". Utilizamos método qualitativo por meio de 13 grupos focais com 132 estudantes do Ensino Médio de escolas públicas e privadas do Município do Rio de Janeiro, Brasil. A análise dos dados foi realizada com apoio do software webQDA, em uma abordagem hermenêutico-dialética que deu origem a três categorias: sentir-se apto a iniciar o sexo, (in)vulnerabilidade à violência sexual e mecanismos de proteção. A iniciação sexual para as moças está relacionada a uma visão romântica, a se sentirem seguras e terem confiança no parceiro, ao passo que, para os rapazes, está associada a oportunidade, livre de outros fatores. Para a maioria dos estudantes, quando o consentimento para a prática sexual é mútuo, independente da idade, não há violência. Ao mesmo tempo, questionam-se quanto à capacidade de discernimento das mais jovens para permitir o sexo. A maior parte discorda das medidas protetivas previstas na lei, por entender que é dever da família prover esse cuidado. As contradições na percepção dos adolescentes sobre a vulnerabilidade à violência sexual e o estupro de vulnerável previsto em lei nos levam a concluir que é necessário ampliar e qualificar a educação sexual de forma abrangente para adolescentes, assim como criar espaços de discussão que possam proporcionar aperfeiçoamento desse dispositivo legal.

Resumen: El Art. 217-A de la Ley nº 12.015/2009 definió como delito la violación de personas vulnerables, la unión carnal, u otro acto libidinoso practicado con un menor de 14 años. Ante la baja edad para la iniciación sexual observada en la actualidad, el objetivo de este estudio fue comprender la concepción de los adolescentes sobre: iniciación sexual, violencia sexual y la ley que la tipifica la "violación de una persona vulnerable". Utilizamos el método cualitativo mediante 13 grupos focales con 132 estudiantes de enseñanza media de escuelas públicas y privadas del municipio de Río de Janeiro, Brasil. El análisis de datos se realizó con el apoyo del software webQDA, desde un enfoque hermenéutico-dialéctico que dio origen a 3 categorías: sentirse apto para iniciarse en el sexo, (in)vulnerabilidad ante la violencia sexual y mecanismos de protección. La iniciación sexual en el caso de las chicas está relacionada con la visión romántica, sentirse seguras y tener confianza en la pareja, mientras que, para los chicos, está asociada a la oportunidad, aparte de otros factores. Para la mayoría de los estudiantes, cuando el consentimiento para la práctica sexual es mutuo, independientemente de la edad, no hay violencia. Al mismo tiempo, se cuestionan respecto a la capacidad de discernimiento de las más jóvenes para permitir el sexo. La mayor parte está en desacuerdo con las medidas protectoras previstas en la ley, por entender que es un deber de la familia proporcionar ese cuidado. Las contradicciones en la percepción de los adolescentes sobre la vulnerabilidad a la violencia sexual y la violación de personas de vulnerables prevista en la ley nos llevan a la conclusión de que es necesario ampliar y mejorar la educación sexual de manera que abarque a los adolescentes, así como crear espacios de discusión que puedan perfeccionar este recurso legal.

Abstract: Article 217-A of Brazilian Law n. 12,015/2009 defines carnal knowledge or any other libidinous act with an individual under 14 years of age as "rape of a vulnerable individual" (statutory rape). Given the young average age at sexual initiation in current society, the study aimed to understand the adolescents' views of sexual initiation, sexual assault, and the law that defines sex at this age as "rape of a vulnerable individual". The authors used a qualitative approach with 13 focus groups totaling 132 secondary students from public and private schools in the city of Rio de Janeiro, Brazil. Data analysis used the webQDA software with a hermeneutic-dialectic approach that yielded three categories: feeling ready to initiate sexual activity, (in)vulnerability to sexual assault, and protective mechanisms. Girls associated sexual initiation with a romantic vision and feeling safe with and trusting the partner. Boys associated it with opportunity, regardless of other factors. Most of the students felt that when consent to the sexual act is mutual, regardless of age, there is no violence involved. At the same time, they wondered about the possibility of younger girls' discernment to consent to having sex. Most of these adolescents disagreed with the protective measures established by the law, arguing that it is the family's duty to provide this care. The contradictions in the adolescents' views concerning vulnerability to sexual assault and rape of vulnerable individuals as defined by the law lead us to conclude that it is necessary to expand and improve sex education in general for Brazilian adolescents, besides creating spaces for discussion that can help improve these legal provisions.

Causes and consequences of adolescent dating violence: a systematic review.

BACKGROUND: Adolescent dating violence (ADV) is highly prevalent and can have serious health consequences, including homicides, and be a predictor of intimate partner violence in adulthood. This review aims to systematize the knowledge produced in recent empirical investigations in health that focus on the causes and consequences of ADV to subsidize new research and prevention programs. METHODS: Review of studies published in PubMed over the last five years through MeSH Database: "Intimate Partner Violence" AND "Adolescent" NOT "prevention and control" NOT "Adult". RESULTS: We analyzed 35 papers, of which 71.4% were developed in the USA. Some studies have shown prevalence greater than 50% in both genders, both as victims and perpetrators, with more serious consequences for females. Three main thematic cores were identified in the studies: ADV-related vulnerabilities, circularity of violence and ADV-associated health problems. Data indicate that ADV is deep-seated in the patriarchal culture and is more frequent in connection with racism, heterosexism and poverty. It occurs in a circular way and is linked to other forms of violence in different contexts (family, school, community and social media). It is associated with health problems such as depression, anxiety, low self-esteem, alcohol and drugs abuse and unprotected sex. CONCLUSIONS: The knowledge produced in the studies reviewed reveals the urgency and importance of implementing early preventive actions in schools, involving families and the community. These should focus on the deconstruction of current cultural gender patterns, based on their historical origin, in order to support emancipatory and liberating pedagogical approaches.

Violence and sexually transmitted infections in pregnancy.

OBJECTIVE: To synthesize the knowledge produced in studies about the association between violence and STI during pregnancy. METHODS: In this systematic review, we conducted basic activities of identification, compilation, and registration of the trials. The instruments of data collection were studies that investigated, explicitly, relationships between violence, gestation, and STI, from July 2012 to July 2017, using PubMed, Cochrane Library, SciELO, and LILACS. RESULTS: In all, 26 articles were chosen to form the basis of the analysis of this study. The relationship between violence and STI was observed in 22 of the 26 studies, and in eight of them, the violence was practiced during the gestation period. In two studies, there was no evidence of this relationship. In one study, the lack of care for STI was attributed to the unpreparedness of health professionals. Mental disorders were cited as resulting from STI in three articles and in another as a result of violence. One study found more frequent violence against adolescents, while two others cited gestation as a protective factor. CONCLUSIONS: IPV combines characteristics that have a different expression when the woman is in the gestational period. The literature points to a relationship between IPV against women and the presence of STI. The monitoring of pregnancy, whether in the prenatal or postpartum period, offers unique opportunities for the health professional to identify situations of violence and thus provide assistance.

Violence and sexually transmitted infections in pregnancy

SUMMARY OBJECTIVE: To synthesize the knowledge produced in studies about the association between violence and STI during pregnancy. METHODS: In this systematic review, we conducted basic activities of identification, compilation, and registration of the trials. The instruments of data collection were studies that investigated, explicitly, relationships between violence, gestation, and STI, from July 2012 to July 2017, using PubMed, Cochrane Library, SciELO, and LILACS. RESULTS: In all, 26 articles were chosen to form the basis of the analysis of this study. The relationship between violence and STI was observed in 22 of the 26 studies, and in eight of them, the violence was practiced during the gestation period. In two studies, there was no evidence of this relationship. In one study, the lack of care for STI was attributed to the unpreparedness of health professionals. Mental disorders were cited as resulting from STI in three articles and in another as a result of violence. One study found more frequent violence against adolescents, while two others cited gestation as a protective factor. CONCLUSIONS: IPV combines characteristics that have a different expression when the woman is in the gestational period. The literature points to a relationship between IPV against women and the presence of STI. The monitoring of pregnancy, whether in the prenatal or postpartum period, offers unique opportunities for the health professional to identify situations of violence and thus provide assistance.

RESUMO OBJETIVO: Sintetizar o conhecimento produzido em estudos sobre a associação entre violência e IST na gestação. MÉTODOS: Nesta revisão sistemática, envolvemos as atividades básicas de identificação, compilação e registro dos ensaios. Os instrumentos de coleta de dados foram os estudos que investigaram, explicitamente, as relações entre violência e gestação e IST, no período de julho de 2012 a julho de 2017, utilizando PubMed, Biblioteca Cochrane, SciELO e Lilacs. RESULTADOS: Ao todo, 26 artigos foram escolhidos para formar a base da análise deste estudo. A relação entre violência e IST foi observada em 22 dos 26 estudos, sendo que em oito deles a violência foi praticada durante o período de gestação. Em dois estudos, não houve evidências dessa relação. Em um estudo, a falta de cuidados com a IST foi atribuída ao despreparo dos profissionais de saúde. Transtornos mentais foram citados como resultantes de IST em três artigos e em outro como resultado de violência. Um estudo encontrou violência mais frequente contra adolescentes, enquanto outros dois citaram a gestação como um fator de proteção. CONCLUSÕES: A VPI combina características que possuem uma expressão diferenciada quando a mulher está no período gestacional. A literatura aponta para uma relação entre a VPI contra as mulheres e a presença de IST. O acompanhamento da gravidez, seja no pré-parto, seja no pós-parto, oferece oportunidades únicas para o profissional de saúde identificar situações de violência e, assim, prestar assistência.

The magnitude of syphilis: from prevalence to vertical transmission.

INTRODUCTION: In 2013, the World Health Organization (WHO) reported that 1.9 million pregnant women were infected with syphilis worldwide, of which 66.5% had adverse fetal effects in cases of untreated syphilis. Congenital syphilis contributes significantly to infant mortality, accounting for 305,000 perinatal deaths worldwide annually. AIM: To estimate the prevalence of syphilis in parturients, the incidence of congenital syphilis and the vertical transmission rate. MATERIAL AND METHODS: a cross-sectional study with data collected from 2041 parturients who had undergone treatment between 2012 and 2014 in the maternity section of the Pedro Ernesto Hospital of the State University of Rio de Janeiro, in the metropolitan area of Rio de Janeiro. The inclusion criterion was positive VDRL and treponemal test in a hospital environment. RESULTS: the prevalence of syphilis in pregnant women was 4.1% in 2012, 3.1% in 2013 and 5% in 2014, with official reporting of 15.6%, 25.0% and 48.1%, respectively. The incidence of congenital syphilis (CS) was 22/1,000 in live births (LB) in 2012; 17/1,000 LB in 2013 and 44.8/1,000 LB in 2014. CS underreporting during the period was 6.7%. Vertical transmission occurred in 65.8% of infants from infected mothers. It was concluded that, in 34.6% of the CS cases, maternal VDRL titers were = 1/4. CONCLUSION: Results demonstrate the magnitude of the disease, fragility of the reporting system in the assessment of the actual prevalence, impact on perinatal outcomes, and they are a warning about the real situation of syphilis, which is still underestimated in the State.

Postnatal and postabortion care during adolescence in the National Health System in Rio de Janeiro, Brazil.

OBJECTIVE: To study postnatal and postabortion outpatient care for adolescents in relation to the guidelines of the Brazilian Ministry of Health. METHODS: The present cross-sectional study was conducted between 2011 and 2012 via interviews with coordinators from 147 of 148 (99.3%) National Health System facilities providing sexual and reproductive healthcare for adolescents in the city of Rio de Janeiro, Brazil. The χ(2) test or Fisher exact test was used to compare ratios, and t test to compare means, with a significance level of 5% (P<0.05). RESULTS: Postnatal care was provided by 141 (95.9%) facilities; however, only 95 (67.4%) facilities complied with the guidelines of the Ministry of Health by providing two consultations: one in the first week and one between the 30th and 42nd day postpartum. In 32 (22.7%) facilities, a consultation was not scheduled in the first week; and in 25 (17.7%), a consultation between the 30th and 42nd day postpartum was not scheduled. Furthermore, only 11 (7.8%) facilities provided care in the age bracket recommended by WHO and the Brazilian Ministry of Health. CONCLUSION: The provision of puerperal care in the Brazilian National Health System is currently far from the recommendations in government guidelines.

Study of the sexuality and demand for gynecologic services by high school students in the city of Rio de Janeiro.

OBJECTIVE: To identify the sexual and reproductive profile and demand for gynecologic services by high school girls in the city of Rio de Janeiro. DESIGN: Cross-sectional study carried out by administration of a questionnaire filled in by the respondents on their own, given to students at 3 high schools with different socioeconomic profiles: private, state, and federal. The questions covered socio-demographic characteristics, sexual behavior, and demand for gynecologic services. The data were analyzed by the Yates chi-square test and Student t-test, with P < .05. SETTING: Three high schools in the city of Rio de Janeiro. INTERVENTIONS: None. PARTICIPANTS: Female high school students. MAIN OUTCOME MEASURE: Age, race, socioeconomic level, parents' schooling, and sexual activity. RESULTS: A total of 418 students participated, 122 from a private school, 165 from a state public school, and 131 from a federal public school. The state school students were predominantly black and had the lowest socioeconomic level, with their parents having the fewest average years of schooling. They also reported the most sexual partners, pregnancies, and abortions. Their characteristics differed significantly from those of the private and federal school students, which were similar to each other. The average age of first sexual activity was similar for all the respondents and the first visit to a gynecologist occurred significantly later among the state school students. CONCLUSIONS: The more frequent pregnancies and abortions by the state school students can be a consequence of the lower demand for or insufficient access to gynecologic services, depriving these students of the necessary care to promote sexual and reproductive health. This demonstrates the need for public policies that promote and facilitate access to routine preventive gynecologic care by low-income adolescent girls.

Epidemia de HIV/Aids em adolescentes no Brasil e na França: semelhanças e diferenças / HIV/ Aids among adolescents in Brazil and France: similarities and differences

Com objetivo de analisar a epidemia de Aids na França e no Brasil, especialmente entre adolescentes, realizou-se revisão crítica de literatura, documentos oficiais e verificação in loco de serviços de saúde sexual e reprodutiva para adolescentes. Utilizaram-se as categorias que compõem o conceito de vulnerabilidade como base teórica da análise. O Brasil em relação à França tem o triplo do número de casos de Aids, proporcionalmente à sua população. Na França houve declínio ininterrupto da incidência a partir de 1998 e, no Brasil, a redução iniciou somente em 2002, voltando a aumentar em 2008. O acesso universal ao tratamento antirretroviral (ARV) e a tendência de pauperização, feminização e heterossexualização da epidemia está presente em ambos os países. Entre adolescentes brasileiros, o número de casos é proporcionalmente 3,5 vezes mais elevado e estes vivem em contextos de maior vulnerabilidade: têm iniciação sexual mais precoce, usam menos preservativos e a escolaridade é menor. Na França a educação sexual nas escolas é prevista em lei, a notificação da Aids e do HIV são obrigatórias, o acesso a serviços para adolescentes com confidencialidade é facilitado, e há disponibilidade de exames para DST e interrupção voluntária da gravidez oportunizando prevenção e tratamento de agravos sexuais.

Discriminação racial e vulnerabilidade às dst/aids: um estudo com adolescentes negras / Racial discrimination and vulnerability to std/aids: a study of black teenage girls in Rio de Janeiro

O estudo teve como objetivo verificar a discriminação racial vivenciada por adolescentes negras moradoras em favelas da cidade do Rio de Janeiro e sua possível influência no processo de vulnerabilização ao HIV/Aids. Utilizou-se uma combinação de métodos, quantitativo e qualitativo. Este artigo se refere a um recorte da etapa qualitativa desenvolvida por meio de dez grupos focais com a participação de 139 adolescentes. Seguiu-se um roteiro para o debate contendo dois grupos temáticos: sexualidade/DST/Aids/gênero e raça/cor/discriminação. Os relatos foram gravados e o material transcrito organizado conforme os temas tratados e analisados criticamente por equipe multidisciplinar. Os dados coletados foram classificados em categorias específicas articuladas aos pressupostos teóricos, a fim de responder às questões formuladas, tendo por base os objetivos da pesquisa. Os resultados revelaram que as adolescentes negras sofrem discriminação racial no seu cotidiano, que é manifestada nas expressões de suas falas, referindo-se ao aspecto físico, ao caráter e à capacidade intelectual. Tais condutas discriminatórias dificultam o acesso aos serviços de saúde e induzem um atendimento de baixa qualidade. Concluiu-se que a discriminação racial vivida por estas adolescentes negras, na cidade do Rio de Janeiro, influencia o desenvolvimento da autoestima e contribui para a construção de uma identidade negativa que, aliada ao racismo e à pobreza, se configura num contexto de vulnerabilidade às DST/Aids. Sugere-se que estes dados sejam levados em consideração na elaboração de políticas públicas para que ofereçam atenção diferenciada àqueles que estão inseridos de forma desigual na sociedade.

This study aimed to verify the racial discrimination experienced by black teenage girls living in shantytowns in Rio de Janeiro city and its possible influence on their vulnerability to HIV/AIDS. We used a combination of quantitative and qualitative methods, based on data collected from focus groups composed of 139 teenage girls. Group discussions followed a script of subjects involving two thematic areas: sexuality/STDs/AIDS/gender and race/color/discrimination. The discussions were recorded and the transcribed texts were critically analyzed by a multidisciplinary team. The data collected were classified in specific categories associated with the theoretical assumptions, to respond to the research questions. The results reveal that the girls suffer racial discrimination in their daily lives, manifested in disparaging remarks and attitudes toward their way of speaking, physical appearance, character and intellectual capacity. This discriminatory behavior hinders their access to health services and also reduces the quality of the services received. The conclusion is that the racial discrimination experienced by these black teenage girls influences their development of self-esteem and contributes to the construction of a negative identity, which allied with poverty creates a context of vulnerability to DSTs/AIDS. We suggest these findings be taken into consideration in the formulation of public policies to offer better health care services to those who suffer from inequality and discrimination.

Desafios da consulta ginecológica na adolescência: questões éticas e conflitos / Challenges in adolescent gynecology care: ethical issues and conflicts

As pacientes adolescentes apresentam características particulares por estarem em uma etapa da vida de crescimento e desenvolvimento. Os serviços de saúde precisam estar preparados para as demandas dessa clientela que requer ações específicas no atendimento médico. Este artigo aborda as situações eticamente conflituosas que mais frequentemente ocorrem na consulta ginecológica deste público. Tem como objetivo contribuir com informações para auxiliar profissionais de saúde a melhor avaliar e solucionar os problemas éticos que se apresentam no dia-a-dia de seu trabalho, garantindo maior proteção à paciente nesta faixa etária.

La consulta ginecológica en la adolescencia bajo la óptica de médicos ginecólogos de la ciudad de Río de Janeiro / Attitudes and procedures of gynecologists who attend teenagers in the city of Río de Janeiro

Objetivo: Conocer actitudes y conductas de los ginecólogos en la atención de adolescentes y evaluar las dificultades/facilidades que encuentran. Metodología: Estudio de corte transversal realizado mediante un cuestionario estructurado, con muestra significativa de médicos asociados a la Associação de Ginecologia e Obstetrícia do Estado do Rio de Janeiro. Los participantes respondieron preguntas sobre datos personales, ubicación del ejercicio de la profesión, procedimientos médicos, experiencias y actitudes en la consulta ginecológica y también brindaron su opinión sobre la necesidad de un entrenamiento específico para la atención de este grupo de usuarios. Se ha utilizado el test Chicuadrado para la comparación entre proporciones. Resultados: Hubo predominancia de los participantes del sexo femenino (62,3 por ciento), edades entre los 25 y 35 años (39,3 por ciento) y con más de 20 años de conclusión de curso académico (38,2 por ciento). La contracepción fue la razón más frecuente de la consulta de las adolescentes. Se observó, cierto temor de algunos en cuanto a la indicación del método hormonal a esta población. El principal obstáculo a la atención de las adolescentes señalado por los entrevistados fue el mayor tiempo de duración de la consulta. Los participantes pusieron de relieve la importancia de la capacitación profesional específica hacia la atención de adolescentes y de la realización del examen colpocitológico rutinariamente. Conclusión: Los médicos ginecólogos estiman que la asistencia ginecológica de calidad para adolescente incluye entrenamiento profesional específico, pues la consulta ginecológica es un espacio privilegiado para la promoción de la salud y prevención de agravios derivados de la práctica sexual sin protección.

Objectives: To know the attitudes and procedures of gynecologists who attend teenagers and to evaluate the difficulties/facilities found in the work with this sort of patients. Methodology: A study of transverse cut achieved through a structured list of questions, with prominent sample of doctors associated to the Gynecology and Obstetrics Association of Rio de Janeiro. The participants answered questions about personal data, working place, medical procedures, previous experience and location in gynecological attendance. They also gave their opinion about the necessity of specific treatment to teenagers. The Chisquare test was also utilized to make comparisons of proportions. Results: There was a predominance of female participants (62,3 percent), ages between 25 to 35 (39,3 percent), and with over 20 year graduates (38,2 percent). Contraceptive methods were the biggest reason for gynecological consultation among adolescents. Younger and female gynecologists as well as the ones recently graduated adopted a less conservative posture during the consultation. The main obstacle to the attendance pointed by the doctors was the biggest duration time of the consultation. The participants highlighted the importance of specific professional training to the attendance of adolescents and the importance of more frequently colpocytologic exams. Conclusion: In gynecologists' point of view, a good gynecological care towards adolescents includes specific professional training, since the gynecological consultation is a privileged area to promote health and prevention of problems originated from unprotected sexual habits.

Interseccionalidade de gênero, classe e raça e vulnerabilidade de adolescentes negras às DST/aids / Intersectionality of gender, class and race, and vulnerability of black female adolescents to STD/AIDS

OBJETIVO: verificar a vulnerabilidade ao HIV/aids de adolescentes femininas moradoras de favelas da cidade do Rio de Janeiro. MÉTODO: foi utilizada uma combinação de métodos, quantitativo e qualitativo. Na etapa quantitativa, realizou-se um estudo observacional de corte transversal por meio de entrevistas e exames clínico/laboratoriais para diagnóstico de DST, e, na qualitativa, desenvolveram-se grupos focais sobre os temas sexualidade, gênero e raça. RESULTADOS: foram entrevistadas 816 adolescentes de 10 diferentes comunidades, com um grupo focal em cada favela: 74 por cento eram negras, 39 por cento eram sexualmente ativas e destas 24,4 por cento eram portadoras de DST. Houve uma relação estatisticamente significativa entre a variável raça/cor negra e a atividade sexual. Na fase qualitativa, evidenciou-se que a discriminação racial sofrida é cotidiana e contribui para a construção de autoimagem negativa que aliada a pobreza, violência de gênero e dificuldade de acesso aos serviços de saúde ampliam a vulnerabilidade às DST/aids. CONCLUSÃO: o estudo sugere a criação de políticas que proporcionem o aumento da oferta de serviços de atendimento ginecológico a esse público, com ações que favoreçam a utilização de preservativo feminino e contribuam para reduzir a desigualdade social, de gênero e de raça.

OBJECTIVE: To verify the vulnerability to HIV/AIDS of female adolescents that live in poor communities of the city of Rio de Janeiro. METHODS: It was carried out with quantitative and qualitative analyses. The quantitative phase was a cross-sectional study, through interviews of 816 adolescents and clinical/laboratory tests in ten different slums, and the qualitative phase was done on one focus group about sexuality of gender and race in each community. RESULTS: 74 percent of the adolescents were black, 39 percent had sexual activity and 24.4 percent of those had STD. A statistical significant association occurred between the black color/race and sexual activity. In the qualitative stage, it became evident that racial discrimination occurs every day and contribute to a negative self-concept. This, in addition to poverty, violence based in gender and bad access to health services, creates a vulnerability context to STD/AIDS. CONCLUSION: This study suggests policies that offer more gynecologic services to this public, with actions that favor the use of feminine condom and contribute to the reduction of social, gender, and race inequality.

Mulher adolescente / jovem em situação de violência: propostas de intervenção para o setor saúde: módulo de auto-aprendizagem / Adolescent women / young victims of violence: a proposed intervention for the health sector: module self-learning

O presente manual apresenta onze casos emblemáticos de violência contra mulheres adolescentes e jovens, e através de metodologia de auto-aprendizagem visa contribuir para o desenvolvimento de uma abordagem específica e adequada a estas faixas etárias qualificando a intervenção profissional nestas situações.

Factores asociados al abandono de la anticoncepción hormonal oral: un estudio con los adolescentes de la ciudad de Rio de Janeiro / Factors associated with the abandonment of oral hormonal contraception: a study with adolescents from the city of Rio de Janeiro

ANTECEDENTES: El anticonceptivo hormonal oral es el método más usado por las adolescentes. OBJETIVO: Teniendo como objetivo contribuir con la reducción de las tasas de embarazos no previstos y sus riesgos médicos y sociales, estudiamos los factores que llevan al abandono de esta técnica. MÉTODO: Estudio experimental no controlado, con el uso de anticonceptivo oral, por seis meses, en adolescentes de 15 a 19 años, que concurren al Hospital Geral de Bonsucesso (Rio de Janeiro, Brasil) desde noviembre de 2004 a agosto de 2005. Las participantes fueron entrevistadas y se sometieron a los exámenes clínicos y de laboratorio, antes y después del uso de la medicación. RESULTADOS: En el análisis de los datos fue utilizada la prueba Chi cuadrado con nivel de significación menor al 5%. Se constató que la edad precoz (15 a 16 años), la baja escolaridad y la relación conflictiva de la adolescente con la familia, son factores que están significativamente asociados a la no adhesión al método. CONCLUSIONES: Para reducir la ocurrencia de embarazos no planeados son necesarios programas de salud reproductiva para adolescentes que incluyan la participación de sus familias, e inversiones que proporcionen el acceso universal y la valorización de la educación.

BACKGROUND: The oral hormonal contraceptive is the most adopted method among adolescents. OBJECTIVE: Seeking to reduce the rates of undesired pregnancy and all the medical and social risks, we studied the causing factors of the abandonment of this method. METHODS: A non-controlled experimental study of the use of oral contraceptive was accomplished, for six months, with adolescents from 15 to 19 years old attended in the Hospital Geral de Bonsucesso (Rio de Janeiro, Brazil) between November 2004 and August 20005. The participants were interviewed and submitted to clinical and laboratorial tests before and after using the medication. In the data analysis the chi-square test was used with 5% level of significance. RESULTS: It was verified that the precocious age (of 15 to 16 years old), the low education and the adolescent's conflicting relationship with their family are significant factors to the non-adhesion to the contraceptive method in question. CONCLUSIONS: We concluded that in order to reduce the occurrence of undesired pregnancies it will be necessary the adoption of programs of reproductive health for adolescents which include the participation of their families, as well as investments to provide the universal access and the valorization of the education.

Conflitos éticos no atendimento à saúde de adolescentes / Ethical conflicts in health care for adolescents

O objetivo desta pesquisa foi identificar situações eticamente conflituosas, vivenciadas por profissionais de saúde no atendimento de adolescentes, para se criar diretrizes mínimas de atuação que auxiliem os primeiros na tomada de decisões que protejam essa clientela. Utilizou-se um método observacional, transversal através de entrevistas com profissionais do Núcleo de Estudos de Saúde do Adolescente, Universidade do Estado do Rio de Janeiro, para se colher dados sobre casos atendidos em que foram identificados conflitos bioéticos, éticos ou legais. Setenta e quatro profissionais relataram 149 casos, nos quais, através de análise qualitativa posterior, identificou-se 250 conflitos. Estes amiúde se articulavam entre si, mas, por motivos didáticos, foram ordenados em separado e dizem respeito a: sigilo e confidencialidade, prática de atividades ilícitas, violência, contracepção em menores de 15 anos, negligência, autonomia e registro de informações confidenciais no prontuário. Concluímos que os conflitos éticos no atendimento de adolescentes são constantes e para solucioná-los a bioética se apresenta como um útil instrumento. Além disso, é preciso conhecer leis e códigos, consultar os órgãos competentes e avaliar situações em particular, não seguindo prescrições absolutas.

[Comparative study between female adolescents with and without sexually transmitted diseases]. / A relação entre as características sociais e comportamentais da adolescente e as doenças sexualmente transmissíveis.

OBJECTIVES: To learn about some social and behavioral characteristics of female adolescents with Sexually Transmitted Diseases (STD), to compare them with adolescents without STD attended at NESA-UERJ (Adolescent Health Study Center of the State University of Rio de Janeiro) and to identify possible risk factors related to STD. METHODS: A cross-sectional study was performed by interviewing adolescents that sought care at NESA between August/2001 and July/2003. For data analysis, we computed the frequency of variables and compared the two groups of adolescents, with and without STD, performing chi-square test, with a 5% level of significance. RESULTS: We interviewed a group of 251 adolescents of which 78 (31.1%) were sexually active and had STD, 83 (33.1%) were sexually active and did not have STD and 90 (35.8%) had never experienced sexual intercourse. The mean age of the first sexual intercourse of the sexually active adolescents was of 15 years. Vulvovaginitis was the most frequent diagnosis. Comparing girls with STD to those without STD we found respectively, school setback in 41% and 23.1% (p<0.05), alcohol use in the last month in 43.6% and 25.4% (p<0.05), drug abuse in 15.4% and 2.9% (p<0.05), live away from both parents 73.1% and 46.8% (p<0.05), family violence in 52.6% and 38.1% (p<0.05), sexual abuse in 33.3% and 11.6% (p<0.05) and failure to use a condom during sexual intercourse in 80.3% and 59% (p<0.05). CONCLUSIONS: Results indicate that there are multiple STD risk factors in both groups. We believe that intervention of the health services for the purpose of reducing incidence of STD in adolescents should be concentrated on the continued encouragement for the use of a condom at each sexual intercourse, as the decrease of other risk factors seems to rest upon actions that are beyond the health ambit.