Primary Health Care and the Third Sector in the face of violence between intimate adolescent partners*

Objective: to identify and analyze the perceptions and practices of health professionals and of the third sector regarding adolescence and violence between intimate adolescent partners. Method: an exploratory and descriptive study. Data was collected in two sessions of a Critical-Emancipatory Work Workshop carried out with 55 professionals who work in Primary Health Care services and services related to the third sector. Data was submitted to content analysis with the support of the WebQDA software. The categories of analysis used were gender and generation. Results: the perceptions and practices in the face of violence between intimate adolescent partners are based on common sense and subjugate female adolescents in particular. In the health services, violence is perceived during consultations for other demands, under the biomedical paradigm. Third sector professionals understand the confrontation of violence as a responsibility of the health area. Conclusion: negative and stereotyped conceptions of violence between intimate adolescent partners are marked by gender and generation biases. The study highlights the need to promote networking actions in the professional practices that consider the historical and social understanding of adolescence to cope with the problem.


Introduction
Violence, in its structural, communitarian, extra or intra-family involvement, affects the adolescent population in practically all geopolitical spaces. An important form of violence, which generates destructive consequences for the lives of adolescents in situations of violence and perpetrators, is that which occurs in affective or sexual relationships, called Violence between Intimate Partners (Violência entre Parceiros Íntimos, VPI) in adolescence (1) .
A study conducted with 3,200 Brazilian adolescents revealed that 86.9% of those interviewed had suffered some form of violence during an affective or sexual relationship. The forms of violence most observed were verbal violence (85.0%), followed by sexual violence (43.8%), threats (24.2%), and physical violence (19.6%). In addition, more than 90% of these adolescents consider the different manifestations of the VPI as a serious phenomenon (2) . On the international scene, other studies (3)(4) corroborate the importance of the VPI approach in adolescence in different political, economic, and social contexts.
VPI in adolescence is determined by generational, historical, economic issues and, above all, by the experience of gender roles that polarize different tensions for the genders, such as the production and reproduction of socially accepted models (5) . Also, further difficulties are driven by generational issues that adolescents encounter in accessing the health services (6)(7) .
In Brazil, with the expansion of the neoliberal trend that has also struck the Public Policies aimed at the adolescent population, since 1980, the Third Sector's participation grew up in the implementation of projects executed mostly by Non-Governmental Organizations (NGOs) that congregate these characteristics: they are private, non-profit entities, able to manage their activities on a voluntary basis (8) .
In this context, research shows the potential of third sector institutions, in partnership with PHC, to act as spaces for promoting health and social inclusion, with a view to providing adolescents with autonomy and improving their health-disease process (9)(10) ; therefore, being characterized as an alteration to the network confrontation of the adolescent VPI. Despite this possibility, there is a knowledge gap in research identifying actions aimed at adolescent VPI established between PHC and Third Sector services (6) .
In order to understand the possibilities of confronting adolescent VPI, it is necessary to know how this problem is perceived and faced by the professionals from the various institutions in the territories where they operate. With this in view, we wonder: What is the perception of health and third sector professionals about violence in affective and sexual relationships among adolescents? What are the practices of these professionals regarding adolescent VPI? To answer these questions, this study had as objectives to identify and analyze the perceptions and practices of health and third sector professionals regarding adolescence and violence between intimate partners in adolescence, in the light of gender and generation categories. This study considers that the gender category is inherent to social relationships, and it is also primordial for the construction of meanings about the power relations between men and women, men and men, and women and women (11) . In turn, the generation category establishes the space occupied by the different generations, which suffer the impact of society's events.
More than an age concept, the generation marks the groups' social statutes by the political and ideological similarities that differentiate them from others, in time and space (12) . These categories, as a social construct, determine the social place and the experience of affective and sexual relationships between adolescents.

Method
An exploratory and descriptive study with a qualitative approach, whose theoretical framework is reality. This study met the two first stages of the TIPESC (13) , dedicated, mostly, to the recognition and understanding of the social phenomena.
The study was carried out in the municipalities of Curitiba and São Paulo. In the municipality of Curitiba, the scenarios were in PHC services with and without Family Health Strategy (FHS) of two administrative regions, besides a service linked to the third sector in one of these regions. In São Paulo, the research scenarios were a health service linked to the FHS's PHC and a service linked to the third sector in the same territory. In both cities, the third sector's services surveyed were NGOs that developed activities of social assistance, education, sports, theater, music, digital inclusion, and professional training courses with adolescents from 12 to 18 years old.  (14) . Each session took place based on a script developed and tested by the researchers to understand the perceptions and practices of health professionals and of the third sector on violence between intimate adolescent partners. They occurred in the investigated services, in private rooms, and during the working hours of the participants.
The participants for the OTCs were indicated by key informants (15) of the territories (health service managers and coordinators of third sector institutions) for their relevance in serving adolescents in the investigated service. There was no refusal to participate in the study from the invited individuals.
The following were defined as inclusion criteria: The data produced in the workshops were recorded, transcribed in full, and analyzed according to Bardin's proposition (16) to identify the empirical categories, which were discussed in the light of the gender and generation analysis categories. In this study it was decided to transcribe all the moments of the OTC sessions developed, making a total of 32 hours of recording.
The WebQDA software was used to support qualitative data analysis due to its relevance to the organization and analysis of non-numeric and unstructured data (17) . The participants' speeches were identified by their name's first letters, followed by the service and scenario in which they served.
Besides the speeches, images composing a collage panel were analyzed, which was built by the participants as a result of an OTC activity to understand the participants' perception of the adolescent. These images were public, as they were taken from two national journals.
The study complied with the legal provisions of

Results
In the Curitiba scenario, 34 professionals participated; of these, 25 were from the health team (eight nurses, three dentists, one nurse assistant, two nursing technicians, one oral health assistant, three physical educators, two physiotherapists, three physicians, and two psychologists) and nine from the third sector (one social worker, three social projectors, one pedagogical coordinator and three teachers). In São Paulo, 21 professionals participated, 10 of whom were from the health team (three nurses, one dentist, one nurse technician, one physician, two Community Health Agents (CHAs), one social worker and one pharmacy technician) and 11 from the third sector (one social worker, two pedagogical coordinators, four teachers, and four management assistants).
The data from the group speeches and panels produced in the OTCs guided the coding process through the WebQDA software. Ten data sources were created out of the transcript files from each of the OTC sessions carried out and the images of the produced panels, using the internal sources import tool. In all, 182 images were inserted in the panels and 131 were analyzed since the 51 excluded images did not concern the concepts indicated in the proposed activity.
After exhaustive reading of the transcripts and analysis of the images, the information that highlighted the core meaning of the communications were coded in 52 free codes, i.e., codes that bind ideas without a hierarchical system, which housed 528 excerpts of speeches and images. After successive readings of the data coded in free codes, it was possible to establish a www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3341.
new coding process, in a hierarchical way and with links between the information, using the tree codes tool.
Thus, the excerpts from the speeches and also the images were organized with the desired depth into three tree codes, which represent the three empirical categories of this study: 1-The perception of the professionals about adolescence, its relationships, and violence between intimate adolescent partners; 2-The reality and limits of the health practices related to adolescent VPI and 3-The place of the Third Sector in confronting adolescent VPI. The tree codes also housed 10 tree sub-codes, i.e., the sub-topics that emerged from the data analyzed in the study.
In the "professionals' perception of adolescence, its relationships and violence between intimate partners" category, it was identified that the images most used The representation of the adolescent through images and speech has brought specific elements from the territories to which these subjects belong. Adolescent VPI has been described as common in the investigated scenarios, and even the use of appropriate terminology stands out to describe physical violence with terms such as: "a slap in the face", "push", "pinch", and "beating".

Discussion
The participants portrayed adolescence based on stereotypes. This result is in line with that identified by another study which states that, among professionals who develop actions aimed at the adolescent population, the vision that associates adolescence with circumstances of crisis and rebellion prevails. In this construction, the adolescent is not considered an autonomous subject, on the contrary, there are growing visions of a regulatory nature that stigmatize and subjugate these subjects (10) , as verified in the study in question.
The territory was perceived for containing important wear potentials for adolescents, expressed by vulnerabilities. Whereas social relations are power relations, it is possible to assume that, because they hold less power than adults, adolescents become more vulnerable to processes of social exclusion that degrade their health (18) , among them, VPI.
Most of the speeches have referred to gender relations from the classical hegemonic approach, which seeks to explain such relations based on femininity and masculinity as biological, innate and therefore naturalized characteristics (12) .
The professionals attributed to the girls more severe moral judgments than to the boys regarding the adolescents and adults impossible (6) .
In this study, physical violence was the most cited, which contradicts findings of another research, in which professionals from different departments who work with adolescents perceive psychological violence as the main expression of VPI in adolescence (19) . This data may be related to the invisibility and naturalization of VPI in the territory, implying greater perception of those situations that are socially typified as more serious expressions of violence.
Another important result of this study was that the participants identified the presence and impact of violence that occurs in the digital space, the so-called cyberviolence. This manifestation of violence can be considered as or more severe than that experienced personally. More spaces and formats for the perpetration of violence can be created virtually, as it is difficult to distance oneself from the permanent recording of an offensive message and, in addition, fear prevails that the content of virtual violence, for example, an intimate photo, will become public (20)(21) .
The social devaluation of affective and/or sexual relationships among adolescents was highlighted by the participants from both professional groups and used as an element to blame the girls for VPI. The fact that they are not inserted in socially accepted relationships, such as marriage, may erroneously translate that they can easily get rid of the situation, which does not always happen. This perception denotes the social weight of the marriage institution, understood as a scenario of acceptance and submission of women (22) .
The participants also attributed accountability on the adolescents' mothers for the VPI situation suffered.
It must be taken into account that, by attributing responsibility for violence to the mother, the gender yoke on these women is revealed, from whom one expects www.eerp.usp.br/rlae 7 Lourenço RG, Fonseca RMGS.
dedication to raising children, even if she is the head of the family and has other obligations and responsibilities related to their subsistence (23) .
The statements of the health professionals showed that the situations of adolescent VPI identified in these services are those that have been aggravated due to social processes and, therefore, are detected in routine services, such as prenatal consultations. This condition may be related to the incipient way in which the adolescent is inserted into the health services, especially in PHC (24) .
The results regarding the health practices revealed that they are based on a fragmented and medicalizing perspective, reproduced by the biomedical model. The State and society can act as driving forces in the process of medicalization. The existence of a network of power that crosses the entire social structure, allied to the economic order of the capitalist market, determines the weakening of society to resist medicalization. This process is as much driven by the potential for technology and innovation in health, as it is by the consumer society, also induced by the health services themselves to consume more and more pharmaceutical products (25) .
PHC professionals feel unprepared to act in adolescent VPI situations. However, we found differences Concerning the professionals from the Third Sector, the fact that there is a gap of links with the health services prevailed. The labels that stand out in both researched scenarios are those of a health service distant from confronting the problem. A similar reality was exposed in a study which identified that, among 11 NGOs that maintained projects with the adolescent population, there was no monitoring process by inspection bodies or inter-sectoral proposals between these institutions and other public services (9) . The issues identified by this study revealed limitations to the formalization of inter-sectoral proposals between Third Sector institutions and the health field.
For example, the poor visibility that the health service interventions have assumed in the territory and the lack of recognition of available resources for addressing adolescent VPI. This may reflect the relative invisibility of the Third Sector regarding the other State structures (9,26) .

Conclusion
The perceptions about adolescence, the experience they do not have adequate programs or services to deal with the problem.
As a challenge, the need is evidenced to promote actions that consider the understanding of adolescents as socially and historically determined subjects, from their insertion in society. Indeed, to reveal the specificities of a social phenomenon such as adolescent VPI implies to visualize and advance scientific knowledge on the subject in the health field in order to strengthen alternatives that can modify health and inter-sectoral work practices and processes directed to the adolescent population, a necessary condition for the protection of this group in a context of gender equality and generational respect.