Young men in juvenile detention centers in Rio de Janeiro , Brazil : gender , sexuality , masculinity and health implications

This article presents results for young men’s health based on an interventionstudy on gender, sexuality, and health of adolescents and young men in conflict with the law, deprived of their freedom, and subject to socio-educational confinement in Rio de Janeiro, Brazil. The themes addressed included questions on overall health, mental health, and sexual and reproductive health, analyzed from a relational gender perspective and social construction of masculinities. The majority of these young men are black, from low-income communities, with low schooling levels, and ranging in age from 14 to 21 years of age; some of them are fathers. The study showed that these young men have been exposed to police and social violence from a very early age and have been deprived of their freedom due to involvement with the drug traffic, homicides, or episodes of sexual violence. The male and female health professionals that work with them report that the most common health problems are skin conditions, mental disorders, and sexually transmissible infections. Male chauvinism and rigid notions of gender and sexuality are important factors in the views of these young men on health (especially sexual and reproductive). Their discourse takes violence and paternity for granted as important signs in the public demonstration of masculinity. There is an urgent need to include discussions on gender and sexuality in health professionals’ training and activities with these young men. It is also necessary to call attention to the strong influence of gender concepts, social group, and sexual orientation in practices, interpersonal relations, and health promotion.


Introduction
The health of young males has been the object of studies and public policies in many countries throughout the world 1,2 .Taking a relational perspective on gender, we can see that themes associated with the health of young males include the promotion of gender equality by seeking male involvement in sexuality issues, more specifically reproductive planning (use of condoms and other contraceptive methods), sexual and reproductive rights, prevention of violence against women and girls, and participation in parental care 2 .In addition, the literature points out that one should take into consideration specific features of young males gender socialization, especially the way it influences help-seeking and health-seeking behaviors 3,4 .
However, it is important to emphasize that young males cannot be seen as a homogeneous group.The inter-relation between gender, race and ethnicity, social class, age, sexual orientation and geography is fundamental for a more comprehensive approach in the field of health, especially in the case of socially vulnerable young males 5 .
In Brazil, around 96% of the population in juvenile centers are young males 6 .Adolescent women represent only 4% 7 , a slightly smaller proportion than incarcerated adult women, which is around 7% according to the DEPEN (Brazilian National Penitentiary Department) 8 .
The Brazilian legislation (ECA -Child and Adolescent Statute) defines an adolescent as someone aged between 10 and 18 years old.In the case of those in conflict with the law, the so-called "socioeducational measures" target adolescents aged between 12 and 18 years (or 21, when they enter before 18).These adolescents in conflict with the law are sent to DEGASE (Brazilian General Department of Socio-Educational Actions), an educational institution that regulates and implements socio-educational actions aimed at this population.These actions include access to education, health, culture, sport and, in some cases, vocational courses.Nevertheless, depending on funds available, the number of adolescents and young adults held in detention facilities, and theirmanagement perspective, these actions may not occur.News from February 2016 highlighted that four of the biggest male detention facilities -with only 602 places available -received 1,341 young adults, just before the Olympic Games in Rio de Janeiro started 9 .
The majority of young adults are black and from low-income communities, with low levels of education and exposed to the violence of drug dealers and policemen in their communities, usually located in the working-class suburbs and/or without access to precarious urban services.The most common infractions are related to drug trafficking, armed robbery, sexual violence and homicide.
These young adults, whether or not linked to the different organized gangs that control the sale of drugs and weapons in the city, are considered as belonging to such "factions".In Brazil, different groups called "factions" are hierarchical and solid organizations that sell illicit drugs since the 1970s, albeit in a bolder fashion in some big cities from the mid-1980s onwards.In Rio de Janeiro, the most important ones are Comando Vermelho, Terceiro Comando, and ADA (Amigos dos Amigos).This recognition of belonging is achieved due to social norms they need to fulfill, such as those related to clothing, hair styles, tattoos, verbal and body language.In addition, there are other stricter norms of loyalty among specific groups and ways of relating to the police, to women, to people who live in their communities, and to acquaintances, and these groups use violent methods of punishment.

Objectives and methodology
Our main goal is to explore how social and gender norms affect the management of sexuality and the implications in sexual, reproductive, mental and general health of young men held in detention.
The study uses an intervention research model 10 .We sought to include activities that favour participatory knowledge construction methods, trying thus to contribute to the social transformation of the reality in which youth in conflict with the law live, focusing on the effects of rigid notions of gender and sexuality on the institution's daily routine and in a general way on young adults' experiences.
The study used qualitative techniques, such as focus groups, in-depth interviews, field diaries, and participant observation, in addition to photographs, videos and dramatizations to facilitate discussion and reflection of study participants 11 .The sample for this study comprised adolescents and young Cad.Saúde Pública 2018; 34(2):e00177916 adults deprived of their freedom and employees of DEGASE, such as psychologists, social workers, pedagogues, doctors, security staff, directors, managers and teachers.Data were analyzed using the inspired cartography approach 12 .
Data collection took place in 2015 and 2016, in two male detention facilities for adolescents in conflict with the law, in the metropolitan region of Rio de Janeiro, Brazil, with the participation of 61 young males.The study also included 64 professionals, including educators, health and education professionals, and managers.The Institutional Review Board of the State University of Rio de Janeiro approved the study under CAAE 50686215.7.0000.5282and it was funded by Rio de Janeiro State Research Foundation (FAPERJ).

Sexual and reproductive health
The period of detention provides a new scenario for sexual practices.The first of them refers to masturbation, which is regulated inside the facilities by strict codes of honor among the boys themselves.Young men report, for example, that on days immediately before and after family visits -who are mostly women -, masturbation is forbidden because it is assumed that a youth may fantasize sexually with the woman who is a relative or a partner of a dormitory mate.In order to protect the honor of women in the family, masturbation is banned under penalty of use of physical violence by peers 13 .Young men express that this rule was established by their "factions".They argue that it is a symbol of "respect", and they regulate it intensely, applying harsh penalties to those who break it.
Not all educators, service providers and managers of DEGASE agree with the recent decision to allow intimate visits for adolescents in conflict with the law.The SINASE (Brazilian National Socio-Educational Care System) regulates the execution of what is called "socio-educational measures" targeting young adults for committing offences.As regards detention facilities, the SINASE, in article 68, establishes the right of an adolescent who is married or in a civil union to an intimate visit.An interdisciplinary work group was formed to fulfill what the new guideline prescribes.They chose the term "affective/affectionate visit" and defined certain requirements, considering age and marital ties.Adolescents will be able to receive visits from only one person while they are fulfilling socioeducational measures.Until 2016, this policy had not been implemented in Rio de Janeiro 14 .
One of the biggest concerns among these professionals is that a young female visitor may become pregnant because of unprotected sexual practices inside the facilities.In addition, some professionals consider that the right to sexuality and pleasure is incompatible with the "bandit" identity.On the other hand, almost all youngsters want to have access to this right, although they criticize the requirements that will regulate it, such as having to prove marriage or civil union to be eligible for the visit.
The possibility of having intimate visits makes it necessary to have a broad discussion of the theme of sexuality throughout DEGASE, regarding sexual rights of people deprived of freedom, especially in a situation involving underage people.
It should be highlighted that intimate visits encompass same-sex partners.Even though homosexuality is a taboo in DEGASE, one cannot deny that sexual relationships exist between boys inside the facilities.As regards health, the practices lead to other concerns related, for example, to STI and HIV.There is not permanent distribution of condoms in the facilities.According to some professionals and educators, this decision is justified by the argument that sex between youngsters should not be "encouraged".There is also an impossibility of thinking about sexual practice detached from sexual identity, that is, young men who do not declare themselves as homosexuals would not have sex with each other.In addition, issues related to security are used as a justification, arguing that young adults can use condoms to strangle a mate, or, may clog the toilets when discarded.In addition, health professionals warn about the high prevalence of STI, especially syphilis, among young men.Most young men deny the possibility of sexual relationships between them.However, some of them report knowing that they actually happen and find it reasonable to have access to condoms.It is important to note that the provision of condoms alone is not a solution for the prevention of STIs.The literature and our research show that condom use is inconsistent among both homo-and heterosexual young Cad.Saúde Pública 2018; 34(2):e00177916 men, and it depends on various factors beyond information.It is necessary to associate the offer of condoms with a gender sensitive educational approach 2,3 .
Data from our study reveal the existence of traditional values regarding sexuality.Social norms around masculinity include the idea that men need sex more than women do; the desire to have children as a way of leaving "one's mark in the world"; a competition to be socially recognized as being more virile and, thus, a "real man" among their peers and in their communities, is exhibited in the discourses of young males interviewed.
There is a naturalization of paternity, which can be dissociated from childcare or economic support.It represents an important sign of masculinity, as it constitutes public evidence of their potency and virility.According to these young males, having a large number of children with different women demonstrates their virility and enhances their social prestige.However, one should point out that, despite the context of unequal gender relations, some young men do not correspond to this traditional profile and value their participation in private world relations, sharing reproductive and childcare concerns.For some of them this means considering the possibility of leaving the drug trade, despite the difficulty of finding another activity that generates income, due to their passage through DEGASE and low level of education.Very often, the absence of a father whom they had no contact with, strengthens the intention or desire to do something different.

General health
Many of these young adults are black, come from low-income communities, and have had little access to formal education and health services.There are numerous accounts of school absenteeism in their trajectories and little use of health services.As reported by young men and professionals, entry into DEGASE, especially before the crisis in the state of Rio de Janeiro, enabled many of them to have access, for the first time, to dental treatment, blood tests and the possibility of obtaining vaccines for immunization against a series of preventable diseases, in addition to daily meals.They often enter the world of crime because their basic rights have been violated but, paradoxically, this same violation guarantees their access, through the socio-educational system, albeit precariously, to health services.However, this access causes some tension in the daily routine of health units.In one of the units surveyed, there were reports of the general population's reaction against these young adults -identified due to their uniforms, shaved heads and accompanying socio-educational agents -in health clinics or hospitals.These young adults are seen by the population in general as delinquents who have privileges in health services, in precarious public health contexts.
DEGASE aims at guaranteeing certain rights, including psychological, dental and medical care, among others.When young adults enter an institution, they receive a booklet with information on health, body and hygiene.However, the same institution also exposes them to serious health risks, especially due to overcrowding, which is exacerbated by events like the World Cup and Olympic Games, and the financial crisis that Rio de Janeiro faces nowadays.The young adults and the staff report insalubrious conditions in the dormitories, classrooms and yards, including leaks that cause mildew and open sewers that lead to the proliferation of mosquitos, responsible for diseases like dengue fever and Zika, in addition to dirty toilets.Dermatological problems such as lice are common in the facilities and are confused with STI symptoms.In addition, health monitoring and vaccination practices have been increasingly hampered by the precarious state of local government finances.

Mental health
Each detention facility has a "mental health" sector.This sector provides care for young adults with proven mental problems, who are on some kind of psychiatric medication, have had a psychotic break in the facility, are in drug abuse rehabilitation or who have begun to take controlled medicine, especially to sleep.A recent study 15 points to medicalization issues in the socio-educational system, highlighting the fact that youths undergo psychiatric examinations aimed at revealing associations between personality disorders and some degree of dangerousness, exposing thus the attempt to pathologize their conduct.In 2006, an inspection undertaken by the Federal Psychology Council in DEGASE detention facilities all over Brazil had already identified many young adults with psychiatric Cad.Saúde Pública 2018; 34(2):e00177916 disorders that were not receiving appropriate treatment or were being over medicated, which was clearly an attempt to control them 16 .

Discussion
There is a consensus in the international literature regarding the relationship between the experience of young adults, the hegemonic production of masculinity and violence 2,5,17 .In Brazil, various studies show that concepts of masculinity, based on social gender norms that naturalize and banalize the use of violence, end up legitimizing such practices in different social contexts 5,17,18 .
Cecchetto 18 calls attention to the existence of a "warrior ethos" in which the use of violence is seen as a statement of masculinity among men and, thus, of social distinction among their peers and in their communities.This warrior ethos is activated through codes of honor and conduct, shaping the relations between young people, and between them and the remainder of the team of professionals.
The levels of mortality among men due to violent acts in Brazil are impressive.Homicides and traffic accidents are among the most frequent external causes of mortality in the male population, especially among black people.Statistics reveal the vulnerability of the population of young adults, who are black, poor have low levels of education and are the main victims of homicide throughout the country 19 .However, only more recently one can detect a preoccupation in the health field with the theme of violence due to the severity of injuries and death of a considerable number of young males 20 .
Literature shows that seeking help for health problems is strongly marked by gender conceptions 3,4,21 .However, if men, including young and adult males, on the one hand tend to use health services less so as not to demonstrate fragility, on the other hand, the health system and its professionals are not adequately prepared for this group's inclusion.Studies carried out in Brazil show that it is necessary to adopt a more comprehensive approach to health and the contexts of social exclusion in which the majority of young people live.This may have positive consequences for the organization of services and actions towards the promotion of health, including the youth in conflict with the law 19 .
In line with other global studies, one can detect a strong relationship between sexuality, masculinity and virility in the boys' reports 3,21,22 .Having an active sex life with many partners is an important sign in the social construction of the masculinity of young men.Most of them say they started their active sexual life at age 12 or before, mostly with older girls or women.They speak proudly of maintaining relationships with various women at the same time and that they "got a girl pregnant".Many of these sexual practices may involve the use of physical and psychological violence against young women, revealing a high degree of sexual coercion 23 .Some of them also report having participated in gang rapes.They also regulate women's bodies, reporting cases of physical punishment to women who cheated on them (even when they are deprived of liberty), and express they would not permit their partner to have an abortion.
Studies show that the use of condoms in sexual relations among young people is usually irregular.There is a greater tendency to use condoms in casual relations than in those considered stable.The decision whether or not to use condoms is usually taken by the man, revealing a power asymmetry in decisions regarding sexual practices 23 .The discussion of gender asymmetry in relations with women is vital for fostering greater gender stereotype flexibility.
It is important to stress that the prevailing conception of masculinity presupposes and encompasses heterosexuality.For those young men who do not identify themselves as heterosexualswithin a binary homosexual-heterosexual logic -life can be marked by countless experiences of discrimination and violence, increasing their vulnerability to different health issues, such as suicidal ideation and making them victims of physical and psychological violence within family, school and community contexts, or exposing them to HIV infection 24 .In the socio-educational system environment, this can be seen in the isolation to which declaredly homosexual boys are submitted, with specific dormitories and separate plates and cutlery, etc., once again revealing the subordination of masculinities that are dissident relative to the hegemonic heterosexual type 25 .The institution argues that it is the only way to ensure the protection of these young men, who may suffer physical violence and blackmail because of their sexual orientation.
Cad. Saúde Pública 2018; 34(2):e00177916 However, the relationship between people of the same sex is not necessarily associated with a homosexual or gay identity.In Brazilian culture the person who has the active role in sexual relations (the one who penetrates) may be seen socially as being masculine to the detriment of the person who assumes the passive role (the one who is penetrated), who is considered to be socially inferior and non-masculine 20,26 .This appears in the daily routine of the socio-educational institution, given that many young adults have sexual relations with each other, including those who exhibit a more legitimized virility.It should be emphasized that in contexts of confinement, reports of sexual relations between people of the same sex are common, without configuring an identity and/or that is repeated in other situations, appearing rather as desire or coercion.In terms of reproductive health, studies show that the domain of reproduction is still seen as a female function/concern.In low-income contexts, there is still a lack of information about sexuality and reproduction, couched in an attractive language to young males, taking into account gender specificities 2 .
Young men report that it is difficult to communicate with the technical staff (especially women) when they discover symptoms of sexually transmitted diseases.First of all, because they do not have enough information to identify them, and, secondly, because of the rigid codes governing relations, in which a young male cannot talk about his own body, even less about genitalia with women who have authority over them.
Therefore, sexuality remains a taboo, involving serious consequences for health vulnerability due to the denial of sexual relations, often through violent coercion; the maintenance of rigid norms of sexuality, which reproduce models of masculinity with strong gender asymmetries.

Conclusion
DEGASE in Brazil, despite the ECA and the SINASE, aimed at regulating the ECA's provisions regarding socio-educational issues, remains far from achieving its objectives.The service, mirroring what is happening in other public institutions, is increasingly precarious, and this is followed by a lack of political will to develop a policy that could effectively ensure alternatives for young people who have committed offenses.These factors, together with constant overcrowding, do not offer minimum conditions necessary for catering to this part of the population, which enters the system already marked by institutional racism, and the lack of economic, cultural and educational resources.
Men in general make little use of the few health services available and these youths even less so, and they do not even when the most basic services are available.Thus, as we mentioned in this study, in detention facilities it is common to find respiratory, dermatological and sexually transmitted diseases, in addition to a lack of information in the fields of sexual and reproductive health, and basic care.
Lack of knowledge of one's own body, as well as of the female body is very common and certainly affects sexual -whether between people of the same sex, gender or opposites -and reproductive life.In addition, crystallized notions of gender hinder the institution from offering these young people new kinds of relationships with their own bodies and with their family, limiting thus the socio-educational system's ability to contribute to an integral approach to sexual education.