Sexuality Workshop for Adolescents : Participative Strategy for Collective Knowledge Construction

Results: The representations about sexuality were related to sexual relationships and showed erroneous information concerning sexually transmitted infections, which makes the adolescents vulnerable. Many of them reported not to know anything about infections or contraceptive methods, to know about contraceptive pills and condoms and to have doubts about condom use, and when experiencing sexuality, gender manifestation was present in the adolescents’ descriptions.


Introduction
Adolescence is complex and more than a just transition process.However, it has been described, in a limiting fashion, as a phase of human development or transition between childhood and adulthood that is marked by the biological changes of puberty related to psychosocial maturity [1].
It comprehends the age range from 10 to 19 years and is characterized by rapid physical changes that are different from the steady development occurring in childhood.Such alterations are influenced by hereditary, environmental, nutritional and psychological factors (WHO, 1965) [2].
Due to their emotional and behavioral specificities, adolescents may be more vulnerable to the risks occurring in sexual and reproductive life.
Hence, thinking about pregnancy in adolescence or about young people's vulnerability to HIV requires an individual reflection about the practice of sexuality at this phase of life by people whose only common characteristic may be the fact that they were born in the same period of time.Being "young" goes beyond an age delimitation: it means being new and innovative, projected to the future; youth is beauty, lightness, good humor, responsibility, courage, boldness and sex.Between the vulnerability of elements that guide the research, it was possible to see the inclusion of an element not previously defined, which was lack of prospects of a promising future [1].The study confirms our findings... because it believes that adolescence is a greater vulnerability to HIV infection stage not only by the biopsychosocial changes that occur, but also by the need that the adolescent has to explore the new and experience risks [4].
Although women's health programs contemplate orientation for them to experience their sexuality, it is observed that actions targeted at teenage girls and aiming at meeting the demands and peculiar needs of such population still lack.

Objective
To investigate the knowledge, practices and attitudes related to female adolescents' sexuality.

Methods
This is a qualitative study, considering that such investigation modality can incorporate meaning and intentionality as inherent to actions, relationships and social structures.Social and collective-health research takes into account individuals' subjective and objective aspects [5].
Action-research was the methodology used to develop the activities because it has a participative nature.Action-research makes it possible to contemplate the objective by bonding with adolescents in the attempt to understand the reality and cultural and socio-economic context in which they live.The action-research process consists of four main phases: exploration, principal phase, action and evaluation [6].
Exploratory Phase -The researcher identifies and defines the problem, makes a diagnosis of the current situation and establishes the possibilities of and producer market.It is important to reflect about the inclusion of sexual diversity in order to act in this reality by understanding sexuality in the perspective of human rights.
various actions to solve it.In this phase, the researcher determines the epistemological principles that will guide his action and must understand how knowledge is produced as well as the studied subjects' position.This phase is developed by holding a meeting with the adolescents participating in the workshop in order to identify their needs concerning sexuality.
In the planning phase, which is referred to as principal phase, the researcher takes the role of coordinating the group in discussions with the purpose to think, act, reflect and evaluate.
The action phase encompasses practical measures based on the previous phases, such as the dissemination of results, setting goals that can be achieved by means of concrete action, presentation of proposals to be negotiated between the interested parties and implementation of pilot actions, which, after evaluation, can be taken by the players without participation by the researchers [6].
Following the dissemination of information, the phase of presentation of proposals began with the purpose to improve the studied aspects.Thus, an action plan was designed, and its implementation in the unit where the study was developed was suggested.
The evaluation phase then followed.Such phase is the final step of the action-research process and shows the essential purposes, such as observing the outcomes of the actions in the organization context of the study and its consequences in the short and medium term as well as drawing lessons that will be useful to continue the experience and apply it in future studies [6].
Aiming at collecting data for the action plan, the workshop strategy was used as a work instrument, which is understood as an opportunity for shared learning by means of face-to-face group activities with the objective of collectively constructing knowledge.The search action is alternative for searching, in that in their assumptions include the dynamic and complex character, as well as cultural and political, of social processes, such as education and communication, the inseparability of subject and object of research.At the same time, it allows the researcher to engage and interact with the research universe in order to make the search experience an exercise in citizenship, social learning and content flow between the university and the school.Rescues accordingly and essential form the inseparability of teaching, research and extension university [7].
The workshop is an opportunity for ideas and values to be shared openly and without restrictions, thus allowing for discussion on autonomy, responsibility and sexual issues, which is necessary to break away from the alienation produced by the social world about sexuality [7].
It is an opportunity for reflection, intervention and empowerment of participants as well as a technique for collecting data for the study [8].
The workshop was implemented in the participative methodology, according to Villela [9].It was based on ludic techniques, experiences and group dynamics.Also, it was structured in two modules.The first module dealt with dating, "staying" and sexual initiation, and the second addressed contraceptive methods, sexually transmitted infections/ the Human Immunodeficiency Virus (STI/HIV), and teenage pregnancy.
The questionnaire consisted of 24 closed questions and one open question as well as of two steps, one for sexually active adolescents and another for those who had not begun sexual activity.The common variables to both groups were: chronological age, education, marital status, ethnicity, religion, professional activity, who participants lived and talked about sex with, knowledge about sexuality, STIs and contraceptive methods.Variables related to sexual practices were addressed in the questionnaire for the group of adolescents who reported having initiated their sexual life, such as age, gynecological consultation before and after initiation and the use of contraceptives in the first sexual intercour-se.It also addressed active sexual life, contraceptive method currently used, and number of children and the performance of preventive screening for cervical cancer.
The post workshop questionnaire was applied in order to meet the assessment phase of action research through the same questions used in the diagnostic step: What is sexuality?;What do you know about STIs?; Which contraceptive methods you know?; and plus workshop evaluation: What did it mean for you to participate this workshop?
The participants' comments allowed for capturing actions and emotions expressed by the subjects' verbal and body manifestations.The themes that were worked on encouraged questions, favoring external determinants such as social class, gender and age, among others.By participating in the discussions, the adolescents expand resources to protect themselves.
The reflection on this real learning episode led us to understand the action-research methodology as the best methodological design to apprehend the reality in the experience of adolescents' sexuality.

Study subjects and methodological procedures
The study was conducted at a Primary Care Health Care Unit from June to October 2009.It consisted of 29 female adolescents aged 10 to 19 years who agreed to participate.The adolescents were asked to sign a Free-Consent Form with agreement from their parents for their participation in the study [as most of the participants were younger than 18 years old].The research project was approved by the Research Ethics Committee of the Botucatu School of Medicine, and its approval process was recorded as CEP 3189-2009

Data analysis
The action research facilitated the analysis of the adolescents' experience as it was observed that they showed prior knowledge about sexuality, sexually transmitted infections and contraceptive methods.Such knowledge was brought to discussion within the group, but there was also a need to review concepts from the theoretical, social, ethical and political viewpoints.Hence, a proposal was made to analyze the implications of action research in practice by taking the exchange of experiences as reference

Results and Discussion
Of the 29 participants, 14 adolescents were 11 years old.Six were 12 to 13, four were 14 and one was 15.Three adolescents were from 16 to 17, and one was 19.According to chronological age, the adolescents were classified into groups based on the categories: Early, Middle and Late [3].
As to education, the majority of participants were attending elementary school (25 adolescents); one was attending secondary school, one had graduated from secondary, one was attending vocational school, and one was not currently attending school.
As regards marital status, most of them were single (27 adolescents), and of these, twenty did not have a boyfriend.Four reported to be "staying" with a boy, and three reported to have a boyfriend."Staying" with someone refers to an emotional relationship that is more expressive in the adolescent culture at present.The expression has been often used, has become notorious and is now considered to be a typical type of relationship among young individuals [9].The behavior of "staying" refers to a short-lived feeling due to the absence of interaction; it is a bond that does not bind [10].
There was a predominance of Caucasians, followed by pardos and blacks.The prevailing religions were Catholic and Evangelical.A smaller number of participants were spiritualists or followed no religion.As to participation in the work market, only one adolescent reported to be working at the moment, and most of them [27] lived with their parents or relatives, and two lived a partner.
Among the persons responsible for providing sex information, the mother was the most often mentioned (12 times), followed by friends.As regards contraceptive methods, condoms and oral contraceptives prevailed, followed by female condoms, the morning-after pill and the injectable method.
Among the adolescents, six reported to have already initiated their sexual life, and four of them did it at age 13, one at 14 and one at 16. Four adolescents reported they had used contraceptive methods at the first time.Those were condoms and the contraceptive pill, used separately or in combination.Two reported to have had gynecological consultations before their first relationship, and four had seen a gynecologist after the beginning of their sexual activities.
As regards contraceptive methods, four adolescents reported to always use the pill; one reported the use of condoms in all sexual relations; two always used the pill and sometimes a condom.One of the adolescents reported not to use any contraceptive methods due to her desire for a planned pregnancy.Concerning maternity, five adolescents had no children, and one was pregnant.Regarding disease prevention, three had undergone preventive cervical cancer tests.
By means of the participative dynamics, the subjects 'staying", dating and sexual initiation were discussed, thus enabling the construction of new knowledge.
Sexual initiation was related to the condition of not losing the person one was staying with/boyfriend as well as to the promise of eternal love.Sex-pleasure, social outcomes of sexual activity initiation, sexual relationships and gender difference were also addressed.Decision making about sexual initiation with influence from the social group, individuality, "the right moment" for each woman, considering one's life history and the representation of this moment as special were issues that were seriously discussed by the adolescents.However, sexuality is experienced by young people, either in their times of trial, sexual initiation, the emotional investment made in choosing partners, and social areas that allow them, as asymmetrical.Boys and girls do not experience it the same way, they have different areas of operation and different moral pressures that fall on them [11].
The ignorance about sexuality and reproduction both in parents, teachers and adolescents increases the early initiation of coital relations and of unwanted pregnancies [12].
The way the adolescent experiences his sexuality is guided by male or female, a factor attitudes generator, establishing a public area of your choice and sexual choice when single when married.Corresponds, in this way, social and sexual script of their condition.[13].
The group dynamics allowed for the adolescents to talk about life decisions that follow the orders of a certain social group so as to be accepted in it in a relaxed form.It also enabled a reflection about the influence on decision making as regards the moment "to stay", date or have one's first sexual relation.
Two analytical categories were designed for the open question: The adolescents' knowledge about sexuality and about Sexually Transmitted Infections (STI).

Category I. The adolescents' knowledge about sexuality
Sexuality can be defined as a person's sexual quality and orientation, the set of sexual-life phenomena, or also as an individual psycho-affective and sexual manifestation that transcends the basic biological base [sex], whose expression is normalized by current social values [14].Adolescents are sexual beings, whether engaged in sexual intercourse or not.They seek for their spaces and identity in the world.Hence, sexuality must be understood in context [15].
And in this understanding, it is fundamental to incorporate dialectics in order to perform the analy-sis, in which cultural aspects and juvenile sociability are taken into account.The dialectics concept is constructed historically, and it is constituted by elements that are characterized by human reason, which, while understanding, clarifies and gathers, questions and dissociates by the meaning present in language [16].
Once the cultural aspects associated with individual and collective factors determine an individual's position at a certain moment, contradictions permeate the whole construction of being in the world, making part of human beings, who are part of a historical and social context.And the expressions of these contradictions constitute the social reality [17].In association with the cultural aspect, another dimension is juvenile sociability, whose centrality is developed in peer groups and located in places and times of leisure as well as in institutional sites such as schools and workplaces [18].It is in peer groups that individuals exchange ideas and seek for ways to assure themselves in the adult world, with the clarity of the construction of one's self and the idea of being us [19].This group meets the need for communication, solidarity, autonomy, exchanges, reciprocal acknowledgement and identity.The attractive power of the first peer groups fosters the construction of autonomy in relation to the adult world [18].

Love relationships and the construction of a family
To me, sexuality means sex with love A17.

Something good to construct a family and to have a lot with one's husband"
A23.
Having a very good relationship.

Having a life of union between couples
To me, sexuality is making a family.

A20.
A relationship between two people with love.

A12.
The adolescents' representations about sexuality were almost totally limited to the sexual relationship and to the biological aspect.Considering the dynamic contradictions in time and space, these representations interpret sexuality for that specific moment because they are fed by new contradictions, influencing people's conducts, choices and their very way to live [17].
Sex is the biological basis of sexuality, but sexuality is not restricted to sex.It involves femininity and masculinity.It manifests psychologically and affectively to both individuals and the social milieu, and it does not refer only to one's genitals or reproduction, but also to body-related activities, such the sexual intercourse and masturbation, which foster inter-and intrapersonal contact, the purpose of which is, in general, the search for pleasure with another person [19][20].
Adolescents give the ideology of a love experience to the meaning of sexuality, with feelings of desire to encounter a possible partner for exercising sexuality.
For a long time, sexuality was addressed according to its biological and reproductive aspects; however, in the present scenario, the importance of the affective component in young people's attitudes must not be disregarded.Differently from adolescent boys, girls are not attached only to sexual impulses, as they associate them with other feelings.They consider love and sex to be a single feeling [13].
To female adolescents, the definition of sexuality transcends the sexual act; however, they cannot define it clearly: To me, sexuality is not only sex, but it means any physical relationship, or not, which is kept with someone else.

A29.
These results reflect the need to include, in the work action plan for adolescents, activities that involve the conceptualization of sexuality so that they can understand themselves as integral beings in the biological, psychic and social dimensions.
If there is reflection when trying to understand one's feelings, behaviors and knowledge about human sexuality, there may be a revaluation of dialogue, self-knowledge and a better integration between feeling, thinking and acting.
In implementing actions, a dialogical relationship enables reflection on the experiences of sexuality and openness for change in behavior to occur based on the knowledge and understanding of sexuality in all dimensions of human beings.
Guidance understanding should contemplate the informative character in the biological sphere, but it is also necessary to contemplate the psychic and social dimensions.
The concept of sexuality has changed over time, as the term was defined in the nineteenth century from the intermingling of knowledge fields, such as medicine, education and demography [21].
To anthropology, the biological dimension of the human species is not taken as an important explanatory factor, but cultural training is viewed as essential for survival.It is culture that humanizes the species, and it does it in very different senses.
Culture is largely responsible for the transformation of sexed bodies into socialized bodies, embedded in networks of meanings that are responsible for sexual orientation and choice of partners.It is through values that desires are shaped and guided and that people are not commonly considered to be potential sex objects.
Educational practices often take the view that knowledge [information transmission] is sufficient to change behavior.However, culture simultaneously implicates both a conscious and an unconscious level [for individuals] which determine their actions [22].

Sexuality associated or not with prevention of diseases and pregnancy
I think it has to do with sex, like diseases, prevention, etc.

A12.
It is that 13-or 14-year-old girls are becoming pregnant.This is sexuality to me.

20.
To me, sexuality is when a woman becomes pregnant too early, when she is 12, 13 or 14 years old.A14.
To adolescents, the initiation of sexual activity and body and life changes are may be associated with unwanted pregnancy, sexually transmitted diseases and abortion, among other things.In study one of results were positively linked to their acceptance of stereotyped gender roles and power imbalance in sexual relationships, permissiveness of premarital sex, sexual compulsion, and sexual daydreaming [23,24].
In study of Ethier, Harper, Hoo and Dittus (2016) [25] adolescents who in eighth grade reported greater parental knowledge and more family rules about dating were less likely to initiate sex between eighth and 10 th grade.They also concluded that there were no gender differences in the impact of dating rules and parental knowledge on sexual initiation, but the paths to acquiring knowledge did differ by gender.
A study revealed in its conclusions an awakening to the fact that the myths and taboos are an issue on the agenda that deserves investment in research and prevention programs for sexual and reproductive health [23].
Statistical data illustrate this situation: 14% of young people aged 11-14 years are sexually active; this number increases to 43% in those aged 15-17; 4.5 million adolescents become pregnant every year in Brazil, and 3.5 million adolescents have abortions.The reasons for teenage pregnancy can be different, and most often what happens is a mixture of these factors, such as passion, need for acceptance and interest in forging stronger ties, and lowered self-esteem [24].During the workshop, reports that confirm this reality were heard.

Sexuality related to gender and sexual orientation
It also means a person's gender: female or male (...).

A25.
It is the sex difference, with males and females.

A15.
It is the sex difference, like: male and female, and it is also a word that derives from sex (...) love.

A12.
The gender manifestations in the experience of sexuality were present in the adolescents' descrip-tions, thus reinforcing the existence of the social and cultural construction of the different roles assigned to men and women, as in the statement of one of the adolescents: "Women must be careful because they may lose their "reputation", men can do anything ..." The fact that a girl initiates her sex life with a certain boy does not "morally oblige" him to stay with her, as it once was, and pregnancy may appear as an alternative in this case [24].
The statement above brings us to the socialization of adolescents targeted at a particular gender role.It is, therefore, evident that, despite all the discourses about equality by some segments of the society we live in, what prevails in our children's education is inequality and inequity in the distribution of power between men and women.The differences between different genders exist, but what must not exist is inequality [25].
Its articulation with the concept of gender is essential, since it is a system of social classification that contrastingly organizes the masculine and feminine attributes in different societies.Thus, the particular experiences of men and women with regard to sexuality and reproduction can only be considered in light of gender differences that shape the male and female representations and practices in each culture [26].

Category II -Adolescents' knowledge about Sexually Transmitted Infections ) (STI)
An STI is a disease transmitted in sexual relationships.
These are diseases that usually come with sex.

A11.
They are infections transmitted by sexual intercourse.

A28.
It is a disease that is transmitted in one's sexual life, such as AIDS and Herpes.If you have a sexually transmitted disease and have sex with someone, you will pass the disease.

InternatIonal archIves of MedIcIne
A13.
The adolescents' statements showed that they conceptualized sexually transmitted infections as diseases that are transmitted through sexual intercourse.However, they also showed misconceptions about the subject, which makes them vulnerable to such infections.
This vulnerability decreases with orientation; however, it is noticed that there are many factors in the relationship between parents and adolescents that prevent or hinder conversation about sexuality, such as lack of education, parents' unpreparedness, shame and freedom about the subject with their children, or also the belief that a conversation about sexuality could anticipate their children's sexual practice [27,28].
Information on methods to prevent pregnancy and sexually transmitted infections should seek greater understanding about healthy sexuality, in a committed fashion and according to moral and ethical values, because what is often seen is that only technical information is not enough.According to statistical data, approximately 50% of sexually active young people have had sex with people that they had just met and did not use condoms, and 95% of these had information on how to avoid pregnancy and STIs.These data confirm the figures released by WHO that 10 million people infected with HIV are adolescents [13].
The fragmented and repetitive teaching of concepts does not bring satisfactory results to students because, from this method, students fail to activate their knowledge, basing on misunderstood information that leads to mere reproductions.Then, it can be argued then that the lack of a critical approach by students and teachers to the concepts of gender and sexuality presented by the media, by schools and other sources tends to crystallize values and reproduce hegemonic knowledge that contributes to the increase social inequalities [29].

STIs are diseases transmitted in unsafe sexual relations
If we do not wear condoms, we get AIDS. A19.

If you have sex (sexual intercourse) without condoms, you can get diseases.
A25.
It's not really good to have it, because you need to be treated and take care of yourself; you get it from sexual relations.

A12.
If you don't wear condoms, you get several diseases, like AIDS.

A12.
When questioned, the adolescents acknowledged the importance of safe sex in order to prevent sexually transmitted infections.In study aimed to investigate the attitudes and perceptions of Youths Regarding adolescent pregnancy, in order to appraise their understanding of sexuality, contraception and why adolescents failed to use contraceptives the condom was reported as the most common method youths/adolescents used in attempting to prevent pregnancy (38.1%) [21].
However, the use of condoms in this population is low, and intercourse, in most cases, is not planned.Studies have shown that only one third of adolescents always wear a condom.According to the Ministry of Health, rates are even lower at the age range of 15 to 19 years.One of the main factors for this low utilization rate is that men find it unnecessary to wear condoms because they do not feel threatened by the AIDS epidemic and do not consider themselves to be in the risk group.Adolescent girls are unable to negotiate condom use despite the fact that they cannot be sure about their partners' faithfulness [21].They fear that asking for a condom cause a situation of embarrassment in the relationship and lead to the loss of their partners [22].

I do not know anything about STI
I don't know anything about that subject.
Whereas early sexual initiation has occurred, that is, from 14.5 to 16.4 years for boys, and from 15.2 to 20.6 years for girls, the lack of knowledge about STI is a worrying factor, because the current heath care provision policy for the sexual and reproductive health of adolescents does not prioritize practical actions in health services, thus increasing the incidence of pregnancy and new AIDS cases.
This picture is a result of the combination of several factors, such as the liberalization of sexuality, misinformation on the subject, family breakdown, influence from the media, among others [24].Taking steps to ensure that young people can apprehend the knowledge and adopt safe sex practices is viewed as a possibility of change.To that end, it is important to work on values and feelings about sexuality and not only on technical orientation [26].

Conclusion
The adolescents' experiences were reported so that they could understand that it is necessary to think about sexuality and vulnerability to the risks to which they are exposed as well as about action taking.
The gender issues and age range related to the topic of sexuality can create conflicts and tension and expose young people to greater vulnerabilities.
Rigid gender roles and a patriarchal and sexist social structure determine behavior in adolescents that make them believe that there are two worlds, the male and female worlds, and that they are antagonistic.With this regard, identities are constructed in multiple institutions that produce and reproduce differences.Among these institutions, schools, families and the media are noteworthy, which, despite social and individual resistance movements, impose conduct models according to the dominant social practices and oriented to the consumer and producer market.
It is important to reflect about the inclusion of sexual diversity in order to change this reality by means of sexuality understood in the perspective of human rights.