MALE ADOLESCENTS' EARLY SEXUAL INITIATION IN THE CONTEXT OF GENDER DIVERSITY

INICIACIÓN SEXUAL TEMPRANA DE ADOLESCENTES VARONES EN EL CONTEXTO DE LA DIVERSIDAD DE GÉNERO

ABSTRACT

Objective:

to understand the early sexual initiation process among male adolescents attending school in the context of gender diversity, in the light of Madeleine Leininger's Theory.

Method:

a descriptive and exploratory research study with a qualitative approach, conducted with 18 adolescents attending school in the city of Recife-Pernambuco, Brazil. The individual interviews were conducted from June to December 2018 and a semi-structured interview script was used to produce the empirical material. As analytical resource, the IRAMuTeQ® software was resorted to in order to categorize the data in the thematic modality.

Results:

four thematic axes emerged from the interviews, namely: Influencing factors in early sexual initiation; Experience in early sexual initiation; Gender identity in the context of multiple masculinities; and Cultural aspects related to early sexual initiation. Sexual initiation emerges as a requirement for male adolescents to be respected and accepted in a group. It is understood that early sexual initiation is mainly characterized by emotional immaturity and by lack of knowledge, exposing adolescents to situations of vulnerabilities.

Conclusion:

taboos inhibit the establishment of dialogical relations in the family context and in the school setting, configuring situations of vulnerability for early sexual initiation, given the findings of sexuality in the context of gender diversity. Interdisciplinary and intersectoral actions, with emphasis on nurses' articulating role, become essential to foster dialogical spaces of congruent care for adolescents aiming at constructing knowledge about gender diversity and safe sexual initiation.

DESCRIPTORS:
Adolescent; Sexuality; Sexual behavior; Gender diversity; Masculinity; Education in health

RESUMEN

Objetivo:

comprender el proceso de iniciación sexual temprana de adolescentes varones que asisten a la escuela en el contexto de la diversidad de género, a la luz de la Teoría de Madeleine Leininger.

Método:

investigación descriptiva y exploratoria con enfoque cualitativo, realizada con 18 adolescentes que asisten a la escuela en la ciudad de Recife-Pernambuco, Brasil. Las entrevistas individualizadas tuvieron lugar en los meses de junio a diciembre de 2019, y para producir el material empírico se empleó un guion de entrevista semiestructurado. Como recurso analítico, se recurrió al programa de software IRAMuTeQ® para categorizar los dados en la modalidad temática.

Resultados:

surgieron cuatro ejes temáticos a partir de las entrevistas, a saber: Factores que ejercen influencia en la iniciación sexual temprana; Experiencia en la iniciación sexual temprana; Identidad de género en el contexto de múltiples masculinidades; y Aspectos culturales relacionados con la iniciación sexual temprana. La iniciación sexual emerge como requisito para que los adolescentes varones sean respetados y aceptados en un grupo. Se entiende la iniciación sexual temprana está principalmente caracterizada por inmadurez emocional y carencia de conocimientos, exponiendo a los adolescentes a situaciones de vulnerabilidad.

Conclusión:

los tabús inhiben la posibilidad de establecer relaciones de diálogo en el contexto familiar y en el ambiente escolar, configurando situaciones de vulnerabilidad para la iniciación sexual temprana, frente a lo descubierto sobre la sexualidad en el contexto de la diversidad de género. Es esencial implementar acciones interdisciplinarias e intersectoriales, con énfasis el rol articulador de los enfermeros, a fin de fomentar espacios dialógicos de atención congruentes con los adolescentes y con el objetivo de construir conocimientos sobre diversidad de género e iniciación sexual segura.

DESCRIPTORES:
Adolescente; Sexualidad; Conducta sexual; Diversidad de género; Masculinidad; Educación en salud

RESUMO

Objetivo:

compreender o processo de iniciação sexual precoce de adolescentes escolares masculinos em contexto de diversidade de gênero, à luz da Teoria de Madeleine Leininger.

Método:

pesquisa descritiva, exploratória de abordagem qualitativa, realizada com 18 adolescentes escolares na cidade do Recife-Pernambuco, Brasil. As entrevistas individualizadas ocorreram nos meses de junho a dezembro de 2019 e, para produção do material empírico, empregou-se um roteiro de entrevista semiestruturado. Como recurso analítico, recorreu-se ao software IRAMuTeQ® para categorização dos dados na modalidade temática.

Resultados:

a partir das entrevistas, emergiram quatro eixos temáticos: Fatores influenciadores na iniciação sexual precoce; Vivência na iniciação sexual precoce; Identidade de gênero em contexto de múltiplas masculinidades e aspectos culturais relacionados à iniciação sexual precoce. A iniciação sexual constitui-se como um requisito para o adolescente masculino ser respeitado e aceito em um grupo. Compreende-se que a sexarca precoce delimita-se principalmente pela imaturidade emocional e carência de conhecimentos, expondo-os a situações de vulnerabilidades.

Conclusão:

os tabus inibem o estabelecimento de relações dialógicas no contexto familiar e no cenário escolar, configurando situações de vulnerabilidades para a iniciação sexual precoce, diante das descobertas da sexualidade em contexto de diversidade de gênero. Torna-se essenciais ações interdisciplinares e intersetoriais, com ênfase no papel articulador do enfermeiro, para fomentar espaços dialógicos de cuidado congruente para com o adolescente visando a construção de conhecimentos sobre a diversidade de gênero e a iniciação sexual segura.

DESCRITORES:
Adolescente; Sexualidade; Comportamento sexual; Diversidade de gênero; Masculinidade; Educação em saúde

INTRODUCTION

Sexuality is built from the experiences underwent through a continuous process in the life of a human being, through constant learning and permeated by historical, social and cultural conceptions 1. Understanding of sexuality emerges as an integral part of an individual identity, being influenced by social attitudes that affect both sexual behavior and the totality of human functioning 2.

The social and cultural context exerts significant influences on the integration of each person.2 Therefore, in the contemporary world, sexuality and gender relations can influence each other, reverberating in the adolescents' sexual choices and practices3. Countless behavioral and attitudinal requirements are socially established for adolescents in the construction of their masculinity, contributing to situations of vulnerability such as violence, internalization of emotions and sexual harassment4.

The gender approach is anchored in the circumstances experienced throughout life in a non-binary conception, as it considers a context of gender diversity characterized by constituting multiple possibilities of a self-perception not restricted to biological issues, and that do not fit into cisheteronormativity standards5.

It is worth mentioning that the invisibility of social demands, the denial of subjectivation and the construction of male identity, considering gender diversities, is capable of providing conditions correlated with patterns of vulnerability to health, especially the Early Sexual Initiation (ESI) of this minority group6.

ESI is defined as sexual initiation before the age of 157. Studies carried out in Brazil,8 in the Caribbean Countries 9 and in the United Kingdom10 show that the main factors associated with ESI are as follows: sociodemographic issues (gender identity, age, skin color, religion, onset of puberty, years of studies); interpersonal and behavioral relationships, consumption of psychoactive substances (alcohol, cigarettes and illicit drugs): and exposure to situations of vulnerability.

It is noted that the occurrence of early initiation exerts influences on the construction of personality and sexual life in male adolescents, reinforcing the need for access to guidelines for Sexual Health promotion11. Sexual and reproductive health education, targeted at male adolescents who are subjected to aspects related to the experience and intrinsic perception of gender diversity, requires a theoretical framework that supports Nursing care actions.

Nurses' role emerges as articulators of intersectoral actions between education and health, in various global contexts, expanding the dialogical scenarios on the theme in articulation with the family context12.

In this research, it was decided to resort to Madeleine Leininger's Theory of Culture Care Diversity and Universality (TCCDU), which proposes a connection between Nursing and Education, based on the adolescents' health needs, and expresses the importance of cultural phenomena in health-disease processes13. Given the above, the objective of this study was to understand the early sexual initiation process among male adolescents attending school in the context of gender diversity, in the light of Madeleine Leininger's Theory.

METHOD

A descriptive and exploratory study with a qualitative approach, grounded on the Theory of Culture Care Diversity and Universality (TCCDU)13. Choice of such theory is justified by the purpose of achieving understanding about the construction and experience of ESI among adolescents in a context of gender diversity, in which values and beliefs are determinants of the culture of this minority group and which can contribute to the provision of Nursing care.

The research was conducted in a state public school offering Basic Education, in the city of Recife/PE. The institution offers education from 5^th year and does not have the Saúde na Escola (Health at School) program. The pedagogical and management team reported the existence of health vulnerability factors among the students, such as alcohol and drug consumption, bullying, teenage pregnancy and ESI.

The subjects included were male adolescents aged between 15 and 19 years old in the context of gender diversity and who had already initiated their sexual practices. Adolescents with a medical report, who presented cognitive repercussions with the need for special education, and those who were participating in another study focusing on sexuality during data collection were excluded. This age group was chosen to provide an opportunity for a discourse on the theme with greater maturity, enabling the report of early sexual initiation experiences with greater accuracy of the reports.

The “snowball”14 method was applied to recruit the participants. The first participant was invited by indication of the school's Board, during a meeting with the professors. This participant, called “seed”, initiated the sequence to indicate new candidates for the study. Thus, each candidate indicated another individual.

The theoretical saturation criterion15 was used to determine the number of participants. It was verified that data saturation occurred in the 14^thinterview, where no new information was identified or considered relevant for the research. It was decided to conduct another 4 interviews to ensure that saturation was confirmed, defining sample size at 18 adolescents.

Data collection was initiated by the lead author prior inclusion into the school environment, in order to recognize the participants' context. The school routines were explored and the meetings favored the researchers' approaches to the group of students who were invited to participate in the research, with the support of the school manager and teachers.

The study was presented in the classrooms to invite the students that expressed interest. They were taken to a private room to provide them with guidance on how to fill in and sign the formal consent forms, namely: Free and Informed Assent Form for those minors 18 years old; Free and Informed Consent Form for parents or guardians of adolescents under 18 years of age and Free and Informed Consent Form for adolescents over 18 years old.

To produce the data, a semi-structured interview script validated based on the literature was used, as well as by three specialists in the area of sexuality: a nurse, a pedagogue and a psychologist. The first part of the form had characterization data of the participants, including sexual orientation, age, age at first sexual intercourse, religion, ethnicity and family income, followed by the second part, which included an interview script.

At the beginning of the collection phase, in order to verify adequacy of the script regarding clarity of the questions and correlation with the study objectives, a pilot test was carried out with three adolescents, who were not part of the sample, subsidizing necessary modifications in the presentation of the interview script applied. It included the following questions: 1) Which factors do you identify as having contributed to your sexual initiation? 2) How do you describe your sexual initiation experience? 3) How do you perceive your own gender identity? 4) Which knowledge and conditions do you consider necessary for male adolescents to feel prepared to initiate their sex life?

The interviews took place from June to December 2019 in a reserved school environment, lasted a mean of 40 minutes, recorded through recording and double transcribed in full. The data were validated by the adolescents in the school setting by reading and consenting to the transcriptions made, via telephone scheduling.

For data analysis, a database was constituted with the answers from the interviews, or text corpus, which was subsequently subjected to a lexicographical statistical analysis using the IRAMuTeQ^® (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) software, which generated the Descending Hierarchical Classification (DHC). Data organization for analysis in the software followed the recommended procedures,16 namely: organization of the text content in the Libre Office software; definition of the command line for each interview by means of markers in asterisks; construction of the content in a monothematic way with removal of questions and paragraphs, standardization of acronyms or words composed by the underline symbol; inclusion of numbers in the form of an algorithm and exclusion of symbols such as quotation marks, apostrophe, hyphen, dollar sign, percentage, ellipses and asterisk in the text corpus. This organization resulted in a text corpus with 70 pages. The software analyzed the vocabulary repetitions contained in the text corpus and performed thematic groupings between the text segments (TSs) that were constituted in classes, resulting in the graphic formation by the Reinert method16.

Data interpretation was based on the TCCDU “Sunrise Model”, to understand the cultural and social structure dimensions in the health care complexity, given the influences of human life conditions, analyzed from the participants' point of view. Thus, it was possible to obtain diverse information on the meanings related to health care and direct the nurses' attention to the knowledge that involves the experience in ESI from the perspective of male adolescents in the context of gender diversity13.

Both secrecy of the participants' personal information and their anonymity were ensured. The participants were assigned code names from Greek Mythology. Elaboration of the manuscript followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) recommendations, translated and validated into Portuguese, meeting the scientific requirements for qualitative studies 17.

This study met the ethical precepts set forth in Resolution N^o.466/12 of the National Health Council, obtaining approval from the Research Ethics Committee.

RESULTS

The research participants were 18 male adolescents in the context of gender diversity, aged between 15 and 19 years old and with a mean of 18.3. The youngest and oldest ages reported for the first sexual relation were 10 and 17 years old, respectively, with a mean of 13.6. Regarding sexual orientation, thirteen adolescents recognize themselves as heterosexual, four as homosexuals and one as transsexual; fourteen adolescents declared themselves black- or brown-skinned; and most of them have family incomes of up to two minimum wages. Regarding the religious aspects, five stated being Evangelicals; four Catholics; one Candomblecist; and eight adolescents said that they professed no religion, but claimed to believe in God.

The data collected through eighteen interviews made up the Text Corpus called “ESI among male adolescents in gender diversity”, which generated 432 Text Segments (TSs), relating 2,112 words that occurred 15,138 times. Of these TSs, 346 were considered as statistically valid by the software, which corresponds to 80.09% leverage of all the material, generating four classes. In the reading of the dendogram (Figure 1) performed from left to right, as recommended by IRAMUTEQ^®0.7, the corpus was divided into two subcorpus: the one on the left underwent two subdivisions with the emergence of classes 3, 2 and 1; and the one on the right underwent a subdivision originating class 4, where it is possible to see the association of predetermined words in response to the study object, with p-values<0.005 and p<0.0001 considered as with significance and as with high statistical significance, respectively, after applying the Chi-square test.

Figure 1 -
Descending Hierarchical Classification (DHC) dendogram of the corpus on early sexual initiation among male adolescents in the context of gender diversity. Recife, PE, Brazil, 2020.

In the analysis of the dendogram from the DHC, it is observed by the connection keys that Class 1 contains a topic that supports the others. Classes 2 and 3 are closer to each other, separated from Class 4. This allowed formulating the first thematic axis (Class 3), entitled “Influencing factors in ESI.” This class is characterized by the highest percentage level, expressing the factors that were the possible triggers for the early sexual initiation among the adolescents surveyed. This fact marks a new stage in the life of this population group, as it constitutes a moment of (re)discovery of their sexuality, experienced in the interrelationship with their peers and that encompasses the integrality of being an adolescent, marked by intersubjective and symbolic issues, with the possibility of negatively interfering in the emergence of sexual health.

[…] desire, curiosity [...] I suffered psychological pressure from my friends [...] I watched erotic films to learn more (Hephaestus). […] I was under psychological pressure by my friends. I decided to have sex because I was afraid of being excluded from my social group (Helios).

[…] I was always talking about sex with friends, watched erotic videos on the Internet and social media. My friends would talk about my age and say it was time to have sex(Eros). […] in my first time, I was drunk and had used marijuana (Dionysus).

The desire to start my sex life was increasing and aroused in me curiosity about what it would be like [...] so I decided to start of my own free will (Hymenaeus). […] I suffered psychological pressure from my cousin, I had no feelings for her [...] she forced the bar until the sexual act happened (Éos).

With 27.5% of the TSs, the second thematic axis (Class 2) was called “Experience in ESI”; a class that is directly related to the challenges socially imposed by the discoveries arising from the first experiences of early sexual practice. Feelings of momentary pleasure with the outbreak of sexuality are subordinated to those recognized as absence of concern, tranquility, strangeness, indifference and frustration, portraying different perceptions associated with gender, religion and health issues.

[…] in my sexual initiation I felt a unique sensation [...] I didn't use a condom [...] in my head I just wanted to have sex. I wasn't worried about pregnancy, AIDS, syphilis, so I didn't even think (Helios). […] my first time was with a man [...] at the time I felt pleasure, but it was something that added nothing to my life [Aphrodite].

[…] we were Evangelicals and having sex before marriage is a tricky thing. I felt strange at the time of the sexual act (Hades). […] my sexual initiation happened with a call girl [...] it was very bad and I never went back to that place (Dionysus).

[…] this experience was strange, it had never happened to me [...] during the sexual act, she wasn't rude to me, but she asked me to hit her [...] it was good at the time. And only then did I think about the situation (Anteros). […] I met a friend's cousin at a party [...] we were drunk and ended up having sex [...] it wasn't like the erotic videos show. At the end of sexual intercourse, I felt worried, because I'm afraid of getting some woman pregnant (Ares).

The third thematic axis (Class 4), presented as “Gender Identity in the context of multiple masculinities”, refers to the adolescents' perception of gender identity in a context of diversity. This class contained 22.8% of the TSs. In the male social construction, the determination of sexist cultural values can also be seen, which tend to reproduce conflicting relationships in the face of intolerance with the different. In the family setting, some adolescents who declare themselves homosexual and assert exposure to situations of oppression and intolerance, through homophobic discourses, may involve psychological and physical aggression, in order to “readapt” the male adolescent to cisheteronormative norms.

[…] my gender identity generated conflict. When my friends discovered my sexual condition, they excluded me from social life (Zeus). […] I'm attracted to people of my same sex. I've known it since childhood, I already felt different from other people. My father won't accept me. I've experienced verbal aggression at school [...] they use low-level words [...] coarse attitudes such as pushing (Apollo).

[…] I’m attracted to men. I found out in my first sexual relationship. My gender identity caused several conflicts at school, I suffered physical aggression from my classmates. Family conflicts happened through verbal aggression, even from my mother (Poseidon).

[…] I'm attracted to women. I figured out because it came from blood. I had counseling from my father and my grandparents, talking about women. So I followed the blessed path. I loved myself when I discovered that I liked women, because there's a period in adolescence that we're in doubt (Dionysus). […] I only like women. My father taught me in childhood that it was better to stay with a woman, because society discriminates and attacks those who are homosexual (Priapus). […] I'm attracted to women [...] it's already man's instinct. We were born to like only women (Himeros).

Class 1 represents the fourth thematic axis, called “Cultural aspects related to ESI”, with 21.4% of the TSs, and refers to the cultural influences experienced by male adolescents during the sexual discovery phase. Adolescence is marked by a phase that yearns for interaction with peers, in search of new discoveries, generating emotional clashes in the face of transgenerational constructions of beliefs, values and cultural customs.

[…] today's songs encourage teenagers to start their sexual activity, because they only talk about sex (Hermes). […] adolescents need to have the orgasm and the will, to understand that it’s simply some fun […]’it's necessary to be popular in society [...] that they know how to dance, because girls already think about staying with us (Pothos).

[…] dance and some musical rhythms favor a better interaction between individuals(Helios). […] my relatives are Evangelicals and exerted pressure on me [...] they said that it was wrong to be homosexual and have sex before marriage (Apollo). […] free access to the Internet and erotic content sites end up encouraging teenagers to want to practice sex as soon as possible (Dionysus). […] using chat apps stimulates adolescents' sexual initiation a lot, mainly in groups of friends, as many things are said about sex (Demeter).

DISCUSSION

The study participants presented low socioeconomic status, most of them did not report any religious practice and there was prevalence of adolescents who declared themselves black- and brown-skinned. The literature indicates that this profile is strongly related to early sexual practices and, consequently, to behaviors considered vulnerable to health19^-20.

To understand vulnerability issues related to the ESI process among male adolescents attending school in a context of gender diversity, anchorage in Leininger's Transcultural Theory emerges. This theory considers the historical, political and sociocultural aspects as essential to consolidate an integral health care proposal with this population group,12 the bio-psycho-socio-cultural development is under construction in this population segment18.

According to the theorist, the representativities of the world view and social systems take into account the perception of aspects and ways of living, habits and behaviors that are represented as an integral part of the culture, relating the influences of the patterns of comprehensive care in health and well-being, which have repercussions on the experiences underwent throughout an adolescent's life13.

The mean of 13.6 years old for sexual initiation among the adolescents in this study corroborates the data found in a survey conducted with public school students in Pouso Alegre, Minas Gerais, who presented a mean of 13.8 years old18. In addition, male adolescents initiate sexual activities earlier and present more relationships experienced, when compared to the female gender9. How ESI is understood is also influenced by emotional immaturity and by lack of pertinent knowledge, exposing adolescents to situations of vulnerability19.

Class 3 of the DHC originated words referring to the factors influencing on ESI among male adolescents in gender diversity, being a phenomenon that transcends the aspects related to sexual determinism, capable of increasing vulnerability to health, such as exposure to STIs and occurrence of unplanned pregnancies21.

The ESI tendency in the male gender is detected in different cases, noticing a higher number of sex partners18. In these circumstances, ESI distances adolescents from a sex life based on safe and responsible actions, contravening their full development22.

Throughout the reports, it is noted that the outbreak of adolescents' sexuality is aroused by interest and curiosity for sexual initiation, influenced by physical changes and feelings of libido and sexual attraction, in addition to the interference exerted by extrinsic factors, which can contribute to anticipating or delaying sexual initiation. It is elucidated in the literature that the transitory process of sexuality, associated with the precocity of sexual relations, shows that adolescents are developing behaviors of vulnerability to health, such as unprotected sexual intercourse19.

The health-disease process of male adolescents permeates human sexuality and originates from individual and collective interactions, established through sociocultural dimensions. According to Leininger, knowledge of the sociocultural context for the characterization of life conditions and experiences should be considered in order to recognize the customs not favorable to the integral well-being of male adolescents and strengthen satisfactory behaviors and habits13.

Proximity to their peers in adolescence culminates in the participants' report on the pressure for sexual initiation, with the stimulation of access to materials and virtual environments with erotic content. The media appeal to the sexual act has an expanded space, being able to anticipate sexual initiation and potentiate vulnerable practices, in the search for sexual sensations with multiple partners and in inconsistent condom use22.

In this study, it is noted that decision-making for the beginning of sexual relations, in addition to suffering interference from gender issues, is influenced and stimulated by peers, mainly when the network of friends is comprised by adolescents who already maintain an active sex life23.

ESI even constitutes a requirement for male adolescents to be respected and accepted in the group. On the other hand, it was reported that, when feeling pressured to fulfill this ritual, adolescents may resort to consumption of alcohol and other drugs to break shyness and insecurity, culminating in situations of greater vulnerability. It should be noted that Leininger recognizes the influence of the socio-environmental and cultural context in which adolescents are inserted, by reverberating in social interactions and health demands13.

A study carried out at a public school in the North of Portugal corroborates this fact, by emphasizing that ESI can occur through the dissemination of behavioral sexual models dictated by friends who, in turn, are subjected to social impositions that shape and integrate ethical, moral and sexual behaviors devoid of awareness and responsibility21.

Class 2 of the DHC is related to the experience in ESI, consolidating the understanding and complexity that involves the influence of intrinsic and extrinsic factors in adolescents' sexual initiation, without the instrumentalization of adequate knowledge and guidelines for decision-making with autonomy. A study that diagnosed lack of knowledge about the first sexual intercourse and pregnancy prevention converges with this understanding, highlighting the need for counseling and care in sexual and reproductive health, with recommendations for educational actions, considering the cultural influences specific to the gender context21.

The reports of male adolescents in the face of the outbreak of sexuality, as a component of human development, contribute to an impulsive and uncompromising attitude towards sexual practices. The family constitutes a social support network, capable of enhancing situations of resilience or vulnerability, when it can or cannot play a role of guidance and acceptance of concerns and needs in relation to adolescents' sexual health.

A study carried out in the inland of São Paulo showed that the family reproduces cisheteronormative cultural discourses and practices, discriminating dissent, with violent stances and imposition of a male hegemonic sexual pattern on the children24. The resistance to deal with and respect the reality of sexual and gender diversity of each individual in its entirety corroborates the exacerbation of situations of exclusion and even violence24.

In this study, with the advent of gender diversity, it is verified that the ESI of cisheterosexual male adolescents demand recognition among peers, family members and society. However, homosexual adolescents' sexual initiation is still marked by intolerance and exclusion stances, sometimes coming from the family itself.

According to Leininger's theory,13 it is indispensable to consolidate the importance of understanding male adolescents in their cross-cultural dimension, taking into account the plurality of individuals living and being healthy. Leininger reinforces that care requires an approach to the individuals in their sociocultural context, breaking the barriers of impersonality, and valuing each person's specificities and needs, in order to expand the look at the multiple existing masculinities.

Class 4 refers to gender identity in the context of multiple masculinities. The adolescents reported an experience marked by psychosocial conflicts arising from the formation process of their personal, social and sexual identities, revealing indicators of new masculinities. However, the adolescents' expressions reveal the influence of a cisheteronormative social organization, which endorses hegemonic masculinity. Certain male social construction also prevails, in which boys are stimulated to sexual experiences with the opposite sex early in time, with repercussions of complex dimensions when the adolescents do not perceive themselves represented by these patterns.

The gender representations in the face of cisheteronormative masculinity refer to male sexual activity, understood as a ritual for the constitution of virility, contributing to a stance of intolerance in the face of the possibilities for multiple masculinities25. Leininger points out that the cultural dimensions comprise the world view, each boy’s knowledge and experiences, whether individually or collectively, built during adolescence, and that they will designate the choices and meanings in the course of their existence;13 as it is the case in the conceptions about the body and gender differentiation, considered as cultural discursive idealizations regulated by internalized rules and knowledge26.

For Leininger, the approach to people in their sociocultural context provides recognition and appreciation of specificities proper to the integral development of adolescents. When approaching the reality of the adolescents' habits, values and beliefs, nurses and other professionals are instrumentalized to establish harmonious and welcoming relationships, based on gender differentiation, in order to expand the look at the multiple existing masculinities13.

A study that corroborates the findings and addresses the way in which the family reacts in relation to the revelation of the adolescent's gender orientation is dissonant from the cisheteronormative standards, generating often violent experiences with behavioral repression, persecution and even expulsion from the family. Situations of psychological violence were reported as a modality adopted by the family, in order to “readapt” male adolescents to hegemonic sexual norms, generating situations of psychological distress, uncertainties and fears, with harmful repercussions for the integral development of adolescents27.

Leininger evidences that each person perceives the world based on their own beliefs and values, a reality that can limit or enhance their life13. Situations of discrimination experienced by adolescents regarding their gender identity have harmful repercussions on emotional development, as they trigger feelings of fear, insecurity and a sensation of isolation to deal with sexuality issues.

The words from Class 1 contribute to resignifying the conceptual understanding of culture proposed by Leininger, which comprises beliefs, values, behavioral norms and practices related to lifestyle, learned, shared and transmitted by specific groups, which focus on the thinking, decisions and actions of the adolescents that belong to the groups.

Thus, ESI is permeated by the ways of life, values and cultural relationships that underlie male sexuality, considering the bio-psycho-socio-cultural influences of this age group. The adolescents presented religious issues and beliefs as factors repressing the ways of experiencing human sexuality.

It is important to recognize that beliefs and customs, aligned with cultural differences in the way male adolescents express their sexuality, are related to gender norms that correlate with personal, family, social and religious ways of life28.

Regarding the culture of accessing online content, the study carried out in Chicago stands out, which shows that communication in the virtual environment is an important factor to boost sexual initiation. In this context, the recommendation for health professionals, educators and parents is to monitor the adolescents that show chances of becoming sexually active22.

Cultural factors related to ESI exert influences on expressions related to health, disease, well-being or coping with the vulnerability issues of the adolescent population. The TCCDU addresses the need to establish care measures in line with beliefs, practices and cultural values, both individual and collective, contributing to culturally congruent care13.

The dimensions of some religious practices propagate that the perception of sex and sexuality should only be practiced after marriage, considering sinful such occurrence outside this context29. The study conducted at the Oklahoma State University evaluated the relationships between sexual anxiety, family communication and the emphasis on religion during childhood, verifying among adolescents and young adults that current religious beliefs do not interfere with the variation in sexual anxiety29. With this perspective, religious practices in the family arrangement can assume an oppressive or liberating factor of the male body, depending on the coherence posed by the appreciation of Christian principles.

The fundamentals of the TCCDU highlight the recognition of cultural diversities for the development of educational actions in health, proposing care sensitive to the subjective issues involving male adolescents' integral sexual development process13.

Hence the necessary integration of public policies, universities, schools, families and young people in the elaboration of dialogical interactions to promote respect and self-care. In order to foster actions promoting sexual health, with emphasis on safe sexual initiation, cultural care is considered important, articulating the educational role of nurses and other health professionals, teachers and family members. Thus, the challenge is to encourage and subsidize the social actors involved for the construction of dialogical spaces and listening to adolescents, stripping themselves of prescriptive and normative guidelines in relation to young people's behaviors.

The need to address the sexuality issues as an important intervention in the Public Health field is evident,30 involving the family and school contexts, by informing and sensitizing adolescents in relation to care issues related to sexually transmitted infections, HIV/AIDS and unplanned pregnancies, as well as to intersubjective issues, which have repercussions throughout the life cycles. To this end, it is important to ensure an environment conducive to dialogical relationships involving the theme of sexuality, in order to promote autonomy and responsibility in people's emancipatory process, in line with policies that contemplate sexual and reproductive rights20.

The study showed the need to understand the ESI process among male adolescents attending school, in their own historical and sociocultural context. When considering the reality of these adolescents, the research provided a situational diagnosis of the adolescents' individual, social and programmatic vulnerabilities, which are essential to support the creation of new actions and health policies.

For Nursing, apprehending the factors that contribute to ESI among adolescents in the context of multiple masculinities comes to sensitize and redefine the complexity of the Nursing service in school health. By provoking concerns regarding the commitment to systematically offer health education strategies, based on participatory approaches, promoting the adolescents' leading role, it is essential to encourage critical and reflective construction of knowledge and health behaviors, to ensure possibilities in the construction of an individual identity purposeful in their life path.

The limitations of this study are related to the approach to issues related to gender identity, which involve taboos and resistance. Acknowledging these limitations required the researcher to value intersubjective aspects to safeguard the establishment of relationships of trust and acceptance between him and the adolescents in the context of multiple masculinities.

CONCLUSION

Understanding the ESI process of male adolescents in the context of gender diversity, anchored in the Theory of Culture Care Diversity and Universality, allowed considering the possibilities of re-dimensioning the understanding of the influence exerted by the environmental and cultural context in the production of attitudes and behaviors that will safeguard cultural care, considering the complexity of ESI and its perspectives on life, when understanding adolescents as influential and experiencing beings, who undergo certain plurality of psychosocial conflicts arising from the process of coping with biological changes and the orientation of the gender, social and sexual identities.

The adolescents' experience in the context of gender diversity is marked by attitudes of intolerance and prejudice, within the family, at school and in society, contributing to self-blame, when realizing that their gender identity transits between multiple masculinities, not conforming to cisheteronormative standards.

The discussion on the theme still involves taboos, which inhibit establishing dialogical relationships in the family context, reverberating in the school scenario, weakening the composition of the support network and contributing to a sexual initiation experience with negative repercussions for the full development of male adolescents.

It becomes necessary to consider the development of certain awareness of the challenges imposed by erroneous and fragmented perceptions of human sexuality, as an element inherent to the development of individuals in their entirety, considering the care processes in ethnic-humanistic contexts, which safeguard their life perspectives.

Faced with the ESI complexity dimension, interdisciplinary and intersectoral actions are required, with emphasis on nurses' articulating role to foster dialogical spaces, integrating the school and family contexts, conducive to care in line with cultural the issues and the needs and specificities of the adolescent population, in the construction of knowledge about gender diversity and safe sexual initiation, as integrating elements to their leading role and bio-psycho-socio-cultural development.

As contributions to the Health and Nursing areas, the study presents dissemination and consolidation of scientific knowledge about the identification of vulnerability factors to health, experienced from ESI among male adolescents who do not fit into the cisheteronormative standards;

In order to provide a situational analysis of the violent discriminatory experience, which denies the sexual and reproductive rights of this population segment, which makes them face situations of prejudice on a daily basis, contributing to the minimization of opportunities, school evasion, restraints regarding sexuality and rupture of family ties. Thus, this study aims at encouraging the planning of sexual health actions for this population segment, in addition to favoring the understanding of the breadth of Nursing activities in the health education field.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the dissertation - Male adolescents' sexual initiation in the context of gender diversity, in the light of Leninger's theory, presented to the Graduate Program in Nursing of Universidade Federal de Pernambuco. in 2020

• APPROVAL OF RESEARCH ETHICS COMMITTEE

  Approved in the Research Ethics Committee of Universidade Federal de Pernambuco, under opinion No. 3,314,889/2019 and Certificate of Presentation for Ethical Appraisal No. 11322119.9.0000.5208.

Edited by

EDITORS

Associated Editor: Francielly Zilli, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  02 June 2023
• Date of issue
  2023

History

• Received
  08 Nov 2022
• Accepted
  29 Mar 2023