The (im)possibilities in contraceptive management of young women in Rio de Janeiro, Brazil: challenges to reproductive justice

Abstract

This article analyzes narratives of young women from lower and middle socioeconomic backgrounds regarding their intentions (not) to become pregnant and reproductive experiences, considering gender, class, race, and generation. This socioanthropological study is based on an intersectional framework. The empirical material consists of eight in-depth interviews, conducted in 2021 and 2022, with cisgender women, aged 17 to 24 years, from Rio de Janeiro. Women from lower socioeconomic backgrounds reported difficulties accessing copper IUDs or tubal ligation through the Brazilian Unified Health System (SUS) and dissatisfaction with contraceptive methods, leading to unintended pregnancies. Middle-class women did not face access issues but did encounter challenges in communicating with gynecologists. One experienced an unintended pregnancy. All expressed a desire not to become pregnant, but only one did not feel at risk. Suffering, discomfort, and fear of hormonal contraceptive side effects were common. Coercion, reproductive abuse, and sexual violence appeared in some narratives. The (im)possibilities of contraceptive management intersect with social contexts marked by multiple oppressions. Given social health inequities, challenges to reproductive justice are heightened.

Key words:
Youth; Contraception; Pregnancy; Reproductive Health; Intersectional Framework

Resumo

O artigo analisa narrativas de jovens mulheres, de camadas populares e médias, sobre suas intenções de (não)engravidar e vivências reprodutivas, considerando as dimensões de gênero, condição socioeconômica, raça e geração. Trata-se de pesquisa socioantropológica, cuja análise inspirou-se na matriz interseccional. O material empírico reúne oito entrevistas em profundidade, realizadas em 2021 e 2022, com mulheres cisgêneros, de 17 a 24 anos, do Rio de Janeiro. As jovens de camadas populares relataram dificuldades em acessar o DIU de cobre ou a laqueadura pelo Sistema Único de Saúde e estavam insatisfeitas com seus métodos anticoncepcionais, engravidando de modo não intencional. As de camadas médias não têm dificuldades de acesso aos mesmos, mas problemas no diálogo com ginecologistas. Uma delas engravidou sem intenção. Todas as jovens não desejavam engravidar, mas apenas uma não se sentia em risco. Há sofrimento, desconforto e receio dos efeitos colaterais dos métodos hormonais. Coerção, abuso reprodutivo e violência sexual integram algumas trajetórias. Destacam-se as (im)possibilidades no manejo contraceptivo nos contextos sociais atravessados por opressões interseccionais. Diante das iniquidades sociais em saúde, os desafios à justiça reprodutiva se intensificam.

Palavras-chave:
Juventude; Anticoncepção; Gravidez; Saúde Reprodutiva; Enquadramento Interseccional

Resumen

El artículo analiza narrativas de mujeres jóvenes, de clases populares y medias, sobre sus intenciones de (no)embarazarse y experiencias reproductivas, considerando género, clase, raza y generación. Investigación socioantropológica basada en marco interseccional. El material empírico reúne ocho entrevistas en profundidad, realizadas en 2021 y 2022, con mujeres cisgénero, de entre 17 y 24 años, en Río de Janeiro. Las jóvenes de clases populares relataron dificultades para acceder al DIU de cobre o a la ligadura de trompas por el Sistema Único de Salud y estaban insatisfechas con sus métodos anticonceptivos, quedando embarazadas de forma no intencional. Las de clases medias no tienen problemas de acceso, pero sí dificultades en el diálogo con ginecólogos. Una de ellas quedó embarazada sin intención. Ninguna deseaba embarazarse, pero solo una no se sentía en riesgo. Se reportan sufrimiento, incomodidad y temor a efectos secundarios de métodos hormonales. Coerción, abuso reproductivo y violencia sexual están presentes en algunas trayectorias. Se destacan las (im)posibilidades en el manejo anticonceptivo en contextos sociales atravesados por opresiones interseccionales. Frente a inequidades sociales en salud, los desafíos para la justicia reproductiva se intensifican.

Palabras clave:
Juventud; Anticoncepción; Embarazo; Salud Reproductiva; Marco Interseccional

Introduction

This article analyzes the “narratives” of young women from working-class and middle-class backgrounds about their intentions (not) to become pregnant and their reproductive “experiences”¹, considering the intersectional dimensions of gender, class, race, and generation. In contrast to approaches that limit themselves to measuring contraceptive (non)use as a central aspect of fertility regulation policies, this study adopts the “reproductive activism matrix”² as its analytical framework, which articulates different dimensions of reproductive phenomena from a critical and intersectional perspective.

The so-called “reproductive activism matrix” brings together knowledge and practices that analyze reproductive phenomena in an integrated and situated manner. It consists of three pillars: reproductive health, reproductive rights, and reproductive justice. The first pillar refers to the needs for health, care, information, and access to services; the second, the struggle for recognition and legal protection of reproductive possibilities, especially for women. The third, reproductive justice, constitutes an analytical and political framework developed in the 1990s by Black feminist women in the United States - such as Loretta Ross, who proposed this concept as a criticism and a means through which to overcome the limitations of biomedical and liberal approaches centered on access to services/inputs or individual rights.

As an expression of intersectional Black feminisms, reproductive justice denounces “reproductive oppression” as a result of the simultaneous and complex interaction of various structures of domination - racism, patriarchy, heteronormativity, and class inequality - that restrict or hinder the full exercise of bodily and sexual autonomy for historically vulnerable populations. This approach is anchored in three fundamental values: “(1) the right not to have children; (2) the right to have a child; and (3) the right to raise children in safe and healthy environments”². In addition to reproductive issues, sexual autonomy and gender freedom for all are also advocated. According to Ross and Solinger² (p.79): “reproductive justice is the application of the concept of intersectionality to reproductive policy to achieve human rights”.

Intersectionality, formulated by Kimberlé Crenshaw and expanded upon by such authors as Patricia Hill Collins and Carla Akotirene^3-5, constitutes a fundamental theoretical and methodological framework for Black feminism. It reveals how social markers of difference, such as gender, race, class, and generation, interact with one another in the production of structural inequalities. This perspective highlights the fact that the effects of oppression are not merely cumulative, but they are also integrated, simultaneous, and interdependent, constituting what Akotirene calls the “matrix of colonialist oppression”⁴, structured especially by racism, cisheteropatriarchy, and capitalism.

In this context, reproductive justice broadens the understanding of inequalities by incorporating the material, historical, and structural conditions that limit the exercise of bodily and reproductive autonomy for certain social groups. According to Johnston and Zacharias⁶, for many women, the “distance” between their daily reality and access to resources that would allow them to exercise reproductive autonomy is significant. To bridge this gap and enable what the authors call a reproductive autonomy “worth having,” it is necessary to link reproductive rights to a critique of structural inequalities and the pursuit of social justice. In this sense, the concept of reproductive autonomy is critically incorporated into the framework of reproductive activism, reaffirming its commitment to the principles of intersectional Black feminism and the transformation of concrete conditions of existence.

Thus, by linking reproductive rights to the criticism of structural inequalities, it becomes clear that reproductive decisions go beyond the individual dimension and are shaped by broader relational and social contexts. The emphasis on the figure of the “woman” who “chooses” a particular contraceptive method reinforces a logic that individualizes and moralizes reproductive responsibility, tending to blame her for any failure in this process. Therefore, it is more pertinent to reflect in terms of contraceptive/reproductive “possibility” or (im)possibility, rather than purely voluntary choices. Reproductive autonomy and women’s agency, in this sense, are always “relative,” conditioned by the constraints and opportunities embedded in specific social and structural contexts⁷.

In this sense, it is essential to situate Brazilian reproductive public policies in a context marked by advances strained by setbacks. Rosa’s analysis⁸ reveals how the National Policy for Comprehensive Women’s Health Care (PNAISM) represented an effort to broaden the concept of women’s health by incorporating such topics as mental health and aging, and by engaging with various feminist movements. However, its formulation still maintained the centrality of reproduction as an organizing axis, reproducing an essentialist and universal notion of “woman” centered on fertility. The launch of the Stork Network (Rede Cegonha) in 2011 signaled a setback, recentralizing the agenda on the pregnancy-postpartum cycle and weakening the PNAISM, without the active participation of social movements. This policy reaffirmed the maternal-infant paradigm, neglecting the ethnic-racial dimension and multiple female identities. As Rosa points out, such regulations operate as technologies of government that reiterate hierarchies of gender and sexuality, excluding subordinated women, such as transvestites, lesbians, Black women, and Indigenous women, from full citizenship in health care.

According to Carvalho⁹, despite incorporating relevant guidelines, the Stork Network maintained structural gaps by ignoring inequalities based on race, region, and generation. The lack of an intersectional approach compromised its effectiveness, especially in caring for Black women, who are often marked not by good practices, but by the neglect of care. In 2022, under a conservative government, the creation of the Maternal and Child Welfare Network (RAMI) reinforced the focus on the pregnancy-postpartum cycle and introduced the notion of “responsible sexuality,” which was absent from previous guidelines and indicated a moralization of sexual behavior. Although linked to the UN 2030 Agenda, RAMI further undermined the agenda for reproductive justice and diversity, consolidating a selective and exclusionary reproductive policy.

Maternal mortality remains high in Brazil and worsened during the COVID-19 pandemic, with a 94% increase in the maternal mortality ratio, reaching 107.4 deaths per 100,000 live births in 2021¹⁰. In response to this scenario, in 2024, the Ministry of Health established the Alyne Network¹¹, which updates and expands the guidelines of the Stork Network to promote humane and comprehensive health care for pregnant women, women in labor, postpartum women, and children. The initiative seeks to address ethnic, racial, and regional inequalities by strengthening primary care, fostering coordination between levels of care, and expanding access to reproductive health services, with a focus on reducing maternal and child morbidity and mortality.

Another key dimension of reproductive policies, with a direct impact on unplanned pregnancies, is the limited availability of legal abortion services, crippled by institutional and moral barriers that highlight the disconnect between current legislation and effective access to health services. This restriction poses especially serious obstacles in cases of pregnancies resulting from the rape of children and adolescents¹².

Aiken et al.¹³ propose a critical reflection on the binaries widely used in reproductive planning, primarily (un)planned, (un)intentional, and (un)wanted. These categories, although hegemonic in policy and research, do not capture the complexity of reproductive experiences, nor do they help to assess the nuances involved in pregnancy at different stages of life. For many women, reproduction can be perceived as something natural and spontaneous, without the lack of planning in itself, thus implying health risks. The authors suggest, rather than dichotomies, the adoption of a continuum between the “intentional” and “unintentional” poles, recognizing that a woman may simultaneously desire pregnancy to some degree, prefer to avoid it in other contexts, or simply be indifferent to the issue at the time.

These reproductive ambiguities reveal that, for many women, these are “choices without a choice”², limited by the structural conditions of their life contexts. Therefore, it is urgent to break with the paradigm of individual female autonomy as the sole reference for public policies, promoting approaches that incorporate intersectionality⁷. This discussion should not be captured by neoliberal logic, centered on individual decisions and private healthcare funding. Ensuring improvements in sexual and reproductive health requires that sexual and reproductive rights be treated as a state responsibility and a public policy priority².

This connection between oppressive structures and youth contraceptive practices is empirically supported by the National School-Based Health Survey (PeNSE-2019)¹⁴, which investigated sexual initiation and contraceptive use among 125,123 Brazilian students, aged 13 to 17 years - a representative population of approximately 12 million students. Among those who reported having already initiated their sexual life, 63.3% reported using a condom during their first sexual encounter, a percentage similar to that observed in 2015. In the age range of 13 to 15 years, condom use was slightly lower (61.8%) than among those aged 16 to 17 years (64.5%), a group that showed a 3.7% decrease compared to the previous survey. The highest percentages were observed among girls (66.1%) and students in private schools (66%). Condom use in the last sexual encounter fell to 59.1%, with a significant reduction among girls (54.3%). Most young people purchased condoms at pharmacies, markets, or stores (40%). The state of Rio de Janeiro recorded the lowest rate of condom use in the last sexual encounter (50.8%). Other most common contraceptive methods include the birth control pill (52.6%), emergency contraception (17.3%), and injectables (9.8%). Considering the last sexual encounter, almost 80% of young people used at least one of these three methods.

Given this context, the article deepens the understanding of the reproductive experiences of young women, highlighting how the intersections of gender, race, class, and generation restrict their contraceptive choices. By overcoming the notion of individual autonomy, the article adopts the framework of reproductive justice, which recognizes multiple structural oppressions and demands public policies committed to universal and equitable access to reproductive health. In this context, the article investigates the dilemmas of contraceptive management and the suffering associated with it, highlighting the limits faced by young people seeking non-hormonal methods in the SUS, where alternatives are still limited.

Methods

This article is part of a broader multicenter socioanthropological study, “Young People in the Digital Age: Sexuality, Reproduction, Social Networks, and STI/HIV/AIDS Prevention.” This study interviewed 197 young men and women, aged 16 to 24 years, from four urban Brazilian capitals (Rio de Janeiro-RJ; São Paulo-SP; Porto Alegre-RS; and Salvador-BA), along with two rural cities (Conceição do Mato Dentro-MG, and São Gabriel da Cachoeira-AM). Our study is based in Rio de Janeiro. The research was approved by the Research Ethics Committees (CEP), CAAE: 46977021.3.3005.5286 and 46977021.3.3004.5257.

This work is a qualitative study of the biographical trajectories of young people, from a retrospective perspective, based on the collection of personal narratives about the experiences lived by the interlocutors themselves^1,15. The stories told present material concerning demands for social justice, as they reveal human rights violations or guarantees, as well as forms of resistance to oppression².

The selection of interlocutors followed intentional quotas - or “diversification criteria”¹⁵ - based on sex/gender, race/color, social inclusion, reproductive experience, and sexuality, aiming to encompass a greater diversity of social contexts. Convenience sampling was also used, based on contacts established by the researchers and study participants. Thus, eight individual in-depth interviews were selected, conducted between 2021 and 2022, with cisgender women, aged 17 to 24 years, residing in the city of Rio de Janeiro, using a semi-structured interview guide. Seven took place in person and one in a hybrid format (part in person and part remote), lasting an average of three hours.

Regarding the profile of the eight young women, their ages ranged from 17 to 24 years. The working-class (WC) young women were predominantly Black, while the middle-class (MC) young women were mostly white. Most lived with their families of origin, and the distribution varied between the North, South, and West zones of the city, including poorer areas. Approximate monthly family income ranged from R$ 1,900 to R$ 2,600 (WC) and R$ 5,100 to R$ 16,500 (MC). There was religious diversity: they were evangelical, Christian, and without religion (WC), and Spiritist, Candomblecist, Jewish, and Umbanda practitioner (MC). Regarding education, three were pursuing higher education (MC; 19, 20, and 24 years of age), three had completed high school (WC; 18, 20, and 24 years of age), one was currently attending high school (MC; 17 years of age), and one had not completed high school (WC; 24 years of age). All of the young women from MC had some type of paid work - teaching scholarship holders, micro-entrepreneurs, and school interns - and only one young woman from WC worked as a home baker, yet without earning a profit.

The age of sexual initiation ranged from 14 to 18 years. The young WC women had a sexual orientation more aligned with heteronormativity, while among the young MC women, only one identified herself as heterosexual. Half were dating, three were single with varying partnerships, and one was married. Three young WC women and one MC woman had had reproductive experience (one to two pregnancies, all carried to term). The age of their first pregnancy ranged from 16 to 20 years, and they had one to two children. All of the young women’s names are fictitious (code names).

We conducted a reflective thematic analysis^1,16 of the empirical material in light of approaches inspired by intersectional critical social theories, derived from Black feminist thought^2-5,17,18. The possibility of framing the experiences of young women within the theoretical framework of intersectionality, derived from Black feminist authors, allows us to integrate social markers of difference (class, gender, race, territory, etc.) in the problematization of their daily experiences regarding sexuality, contraception, and reproduction. We emphasize the active role of researchers, both subjective and political, as an important resource in the reflective process of knowledge construction. Their theoretical assumptions, ideological commitments, and intellectual background are considered in the discussion of the results.

Results and discussion

What’s behind the (non)use of contraceptive methods? Uncovering the complexity of contraceptive management and the suffering of young women

None of the young women wanted to get pregnant, although they all felt at risk. Only Joana (24, white, mother, MC) didn’t consider changing her contraceptive method - condoms and calendar method - because it was “working very well” in her relationship. She reported feeling more aware of her cycle and identifying ovulation. Before that, she had used different hormonal contraceptive methods, but she felt “very uncomfortable” - it was “terrible.” After trying pills and injectables that caused “severe side effects,” such as continuous bleeding, she decided to stop them because she couldn’t “take it” anymore. A medical “report” contraindicated hormones in her case.

The other young women expressed a desire to change methods, associating dissatisfaction with practical obstacles and adverse effects. Among the middle-class young women, Vanessa (17, brown) combined the pill and condom use, the latter only when available, and considered a copper intra-uterine device (IUD) because it eliminated “daily medication” and “a lot of hormones.” Renata (19, white), single, also used the pill and condoms, but was looking into “other methods,” such as the implant, because she would forget to take her pill “at night.” Despite the initial “swelling,” she reported that the medication “slowed down.” Hianka (20, white) only used condoms, which helped her “lose the mood.” She wanted another contraceptive method, as long as it was non-hormonal. She refused IUDs and implants, and feared that the pill would cause a lack of lubrication and a risk of thrombosis, as had happened with her cousin. She mentioned tubal ligation as an alternative because she wanted a method that would “prevent her from getting pregnant.”

Among young women from WC backgrounds, the use of contraceptive pills was also fraught with discomfort, dissatisfaction, and difficulty accessing them. Suzana (18, brown), single, used the pill as prescribed by her doctor, along with condoms. Despite this, she wanted to avoid “loading up” on “hormones” because she experienced “bloating,” “headaches,” and changes in “discharge.” Ana Maria (24, white), with her boyfriend, combined the rhythm method, withdrawal, and condoms, the latter of which she stopped using around the time of her period. She intended to pay “out of pocket” for a tubal ligation, as she was unable to access a copper IUD through SUS and considered the surgery “even more difficult.” She didn’t use the pill for fear of “forgetting,” and reported feeling “really bad” about the “side effects” of the injectable, which made her “really sick.” She admitted that the methods she used weren’t “completely safe,” but it was what she could “try to do.”

Tatiana (20, brown), in a stable relationship, used only condoms. She planned to have a copper IUD inserted through the SUS system the week after the interview, but explained that she had to wait until her period to undergo the procedure, as required by the service, which highlighted limited access. She preferred the injectable to the pill, although she found the quarterly version “horrible,” which “makes you swell and gain weight,” and reported difficulties with the pill because she frequently forgot to take it. Patrícia (24, black), pregnant with her husband, was not currently using contraceptive pills. Before pregnancy, she used withdrawal and wanted to use a copper IUD, but she had been “on the waiting list” for about seven months in two municipalities. She described her “search” for a contraceptive as “very difficult”. She reported not adapting to condoms, associated with a “trauma” of painful penetration with a former partner; nor to the pill, which her mother advised against when she was younger, nor to the injectable, which caused severe effects, such as bleeding “for the entire month”, “beginning of thrombosis” and “migraines”.

The young women’s accounts reveal the persistence of contexts marked by the denial of women’s and girls’ bodily and reproductive autonomy, often deprived of decision-making power and with human rights neglected¹⁹. Gender hierarchies that subordinate female agency directly influence the difficulties in contraceptive negotiations among peers. In this context of inequality and oppression, access to emergency contraception becomes essential, expanding the range of methods available to ensure sexual and reproductive rights^20,21. The sexual and reproductive trajectories of young women, especially those of Black and poor women, reveal a path riddled with difficulties arising from their material and symbolic conditions of existence, as several studies have shown^2,18,22-25.

PeNSE-2019 highlighted the increase in the use of emergency contraception among sexually experienced Brazilian school youth. The majority obtained the method in pharmacies (68.2%), while only 11% obtained it through a healthcare provider¹⁴. Among the 13-15 and 16-17 age ranges, use was higher among older girls. It is important to note that 45.5% of the girls have used this method at some point - 37.2% in the younger group and 51.1% among the older groups. Despite an increase in use, access to emergency contraception remains predominantly through direct purchase, as there are no public policies that integrate pharmacies into free distribution or effectively expand its availability in public services^20,21.

Three accounts from young people from WC backgrounds highlight the importance of using emergency contraception (EC) in adverse situations. Patrícia (Black) used EC after suffering abuse and sexual violence from a partner. She reported feeling “very afraid” of getting pregnant because she was in her “fertile period” and took “four” pills on the same day in an attempt to “take effect.” She stated it was her only way out: “I... had to take it.” Despite feeling “very ill,” she did not mention seeking medical attention. Tatiana (Brown) stated she would use EC whenever a condom failed. Ana Maria (White) reported using EC for “clearance,” at times when she felt “afraid” of getting pregnant. She purchased the medication directly from the pharmacy, with home delivery.

Oppressive social structures produce inequities in sexual and reproductive health, manifesting in situations of “reproductive coercion and abuse”²⁶, a phenomenon present in the experiences of most of these young women from diverse social backgrounds. They suffered reproductive coercion and abuse, including sexual violence. The concept encompasses practices designed to influence or control another person’s reproductive choices and autonomy, often perpetrated by intimate partners, but also by family members. Risk factors include being a woman of color, young, single, or in an abusive relationship. The three main forms identified are: 1) contraceptive sabotage (damaging, hiding, or interfering with the chosen method); 2) coercive/forced pregnancy (pressuring or forcing a pregnancy against the will of the other person who becomes pregnant); and 3) controlling the outcome of the pregnancy (forcing the termination or continuation of the pregnancy). Furthermore, this type of violence is also associated with other phenomena, such as intimate partner violence (which can include sexual violence), sexual violence by casual partners, and unintended pregnancy.

The experiences of contraceptive sabotage reported by the young interlocutors, across different backgrounds of class, race/color, and age, highlight forms of “reproductive coercion and abuse” linked to partners’ failure to use contraceptive methods, even when explicitly requested. Three types of contraceptive sabotage reports were identified, some associated with violence. The first occurred when men refused to use a condom or perform coitus interruptus, even when their partners requested it. Patrícia, Ana Maria, and Hianka experienced these situations, and in the cases of Patrícia and Ana Maria, the coercion came from intimate partners. Ana Maria became pregnant unintentionally after giving in to pressure. Patrícia and Hianka, on the other hand, reported coitus interruptus as an imposed practice. Such experiences reveal reproductive oppressions aggravated by sexual abuse. Renata was a victim of stealthing, having a condom removed without consent by a casual partner. Patrícia also reported a similar episode: by asking her partner “not to ejaculate inside”, he disrespected her wishes, constituting another form of transgression of reproductive autonomy.

These experiences, when analyzed in their relational and intersectional dimensions, reveal how the contemporary macrosocial context, marked by sexual, gender, and racial oppression, favors the reproduction of asymmetrical power dynamics. In this scenario, people who can become pregnant, especially “women”, have their choices, needs, and reproductive autonomy systematically suppressed. The experiences reported highlight the interdependence of axes of oppression at the societal, relational, and individual levels, generating suffering and anguish. Given so many complications, it becomes clear that the adoption of contraceptive methods during adolescence is not a simple yes or no equation, but a process intertwined with multiple social determinations of class, gender, and race²⁷.

Non-hormonal contraceptive methods that “don’t exist”? Barriers and difficulties in accessing desired non-hormonal methods

All the young women interviewed reported some form of suffering, discomfort, or fear due to the side effects of hormonal contraceptives, which led most to abandon them. Only Suzana and Vanessa continued using them, although they expressed a desire to avoid them. Renata (MC) was the only one who demonstrated some adaptation to hormones, despite the initial side effects, and was considering replacing the pill with a hormonal implant.

According to Le Guen et al.’s typology²⁸ of reasons for rejecting hormonal contraceptives, the young women interviewed in this study cited five reasons, from most to least frequent: physical side effects, discourse related to “nature,” bleeding disorders (but only related to menstruation), fear/anxiety, and impact on sexuality. Adverse physical effects were the most common justification in the narratives, highlighting experiences marked by discomfort and a rejection of hormonal methods.

Women’s struggles to deal with the side effects of hormonal contraceptive methods remain largely “invisible”, even to healthcare professionals. Among the physical effects, “bleeding disorders” were highlighted as significant menstrual changes. Hianka expressed fear and anxiety about possible adverse reactions, such as thrombosis, attributing her concern to a lack of adequate information. She also mentioned a negative impact on sexuality due to vaginal dryness. The perception that synthetic hormones destabilize the “natural balance of their bodies” connects to a discourse that values “nature”²⁸. According to the literature, this generational trend is linked both to ecological concerns and to the influence of feminist movements - since the “second wave” - that have denounced the adverse effects of contraceptive methods²⁸. In this sense, reports of dissatisfaction can be interpreted as forms of resistance to the medicalization of reproduction and pressure from the pharmaceutical industry.

Paradoxically, with the valorization of “naturalness” and the spontaneous menstrual cycle, there is a growing use of hormones, with generational biopolitical implications. This manifests itself both in fertility control and in the use of hormones to enhance bodily performance, the so-called “lifestyle drugs”^28-30. It is important to emphasize that the idea of a “hormonal body” is less a natural given and more a social construct of scientific medicine³¹.

Three young mothers from lower-income backgrounds, living in precarious areas, reported difficulties in gaining access to sexual and reproductive health care, especially through SUS. Patrícia had been waiting for a gynecological appointment for six months, and Ana Maria faced obstacles in getting a tubal ligation, considering turning to the private sector due to a lack of doctors. Tatiana, on the other hand, reported regular access to gynecology services but is awaiting insertion of a copper IUD. Among the young women from MC backgrounds, having health insurance did not prevent negative experiences with care. Vanessa was criticized by a doctor for seeking care only after becoming sexually active. Hianka, in turn, reported misinformation about the pill and the need to resort to emergency contraception, which she considered a “horrible” experience. Later, she was discouraged by another doctor from using it and, when requesting a non-hormonal contraceptive pill, was told that it “didn’t exist”, leaving her disillusioned: “I wanted something non-hormonal, but it doesn’t exist, right?”

These experiences highlight gaps in both access and quality of sexual and reproductive health services. From the perspective of reproductive justice, problematized by Black feminist authors who address this issue^2,17,18, access to these services is an essential condition for guaranteeing human rights, which implies economic and physical availability and non-discriminatory care². However, access alone is not enough: services must respond to young women’s demands by listening to them with qualified attention and respecting their needs. In contraceptive counseling, it is essential to consider women’s concerns about hormonal contraceptives and value their informed choices²⁸. Hianka’s case illustrates how inadequate, contradictory, and unwelcoming medical advice can create barriers, leading young women to seek information online, risking misinformation. Her complaint was delegitimized, and the options offered were limited, denying her the right to emergency contraception.

Young women reported seeking information about contraception online, while lacking access to comprehensive sex education³² at the educational or health institutions they attended. This scenario reveals a serious lack of qualified information, compromising their ability to make informed and autonomous decisions regarding sexual and reproductive health.

Young women from WC backgrounds faced severely limited contraceptive options, awaiting copper IUD insertion through SUS without viable alternatives in other services. At the same time, studies point to a hegemonic trend of approaches focused exclusively on the effectiveness of methods, such as LARC (long-acting reversible contraception), to the detriment of users’ experiences. A “patient-centered approach” is essential to recognize that contraceptive choices are complex, individual, and intertwined with multiple factors²⁸. In this scenario, external and internal barriers to health services deepen the disconnect between choices and access²³, further limiting options when hormonal contraceptives are rejected.

Amid the difficulties of contraceptive management, pregnancies “simply happened”³³, unintentionally. There were six in total, experienced by four young women - three from WC backgrounds and one from an MC background. According to the National Abortion Survey (PNA-2021), which interviewed women, aged 18 to 39 years, 66% of pregnancies in Brazil were unintentional, affecting two out of every three pregnant women. Although abortion is a reality in the lives of many young Brazilian women^34,35, the issue remains invisible and surrounded by gaps in research regarding its conditions³⁶. Although all pregnant young women have considered or attempted to terminate their pregnancies, their sexual and reproductive rights - especially the right to decide not to continue an unintended pregnancy to term - are still not fully guaranteed. Social neglect pushes these young women into a “dead end,” even in the face of public policies, like SUS, which fail to guarantee adequate and universal access to sexual and reproductive health supplies, services, and information.

Conclusion

The scarcity of non-hormonal options and the complexity of using methods like condoms, which depend on the partner’s cooperation, have led many young women to seek the copper IUD or tubal ligation to eliminate the risk (temporary or permanent) of pregnancy. It is worrisome that these methods, although recognized as rights guaranteed under SUS, are not readily available. The delay in offering them compromises equity and reinforces inequalities in access to sexual and reproductive health.

In addition to concerns about hormonal contraceptive methods, it was observed that reproductive counseling provided by health professionals is often insufficient²⁸. Communication gaps, omission of information about side effects, disregard of complaints, and exclusion of young women from the decision-making process compromise their reproductive autonomy. It is imperative that sexual and reproductive health care assess the level of autonomy of users; identify barriers to access; and provide technical, non-discriminatory information aligned with their needs. Counseling should be focused on the user, seeking informed decisions that are consistent with their values and life projects.

Therefore, care for reproductive life should not fall exclusively on young women, but rather it should be assumed as a collective responsibility - social, political, and state - guided by public policies committed to universal human rights. Social inequities produce unfavorable outcomes for sexual and reproductive health, demanding effective state action^2,17,18,22. Beyond health, it is crucial to integrate educational policies that promote contraceptive socialization among young people and ensure a broad and inclusive approach to sexual education³⁷.

It has been widely recommended that future research incorporate the perspective of reproductive justice, derived from the intersectional framework, to investigate structural barriers that shape individual attitudes and behaviors regarding sexual and reproductive health^{6,25,35,38,39}. Producing knowledge based on this approach is essential to inform policies that promote structural and institutional transformations focused on reproductive autonomy and dignity. By articulating social justice and autonomy, reproductive justice offers a powerful theoretical and methodological framework for understanding how multiple, intersecting oppressions unequally impact young women’s experiences. Connecting macrostructural dimensions to everyday experiences allows for a critical analysis of contraceptive practices in contexts marked by cisheteropatriarchy, racism, and capitalism⁴. Moving forward in this direction requires addressing historical inequalities and recognizing the diversity of bodies, subjectivities, and trajectories.

Acknowledgements

The research project “Youth in the Digital Age: Sexuality, Reproduction, Social Networks, and STI/HIV/AIDS Prevention” was coordinated by Cristiane da Silva Cabral (general and São Paulo coordinator/University of São Paulo), Ana Paula dos Reis (Salvador/Federal University of Bahia); Daniela Riva Knauth (Porto Alegre/Federal University of Rio Grande do Sul); Elaine Reis Brandão (Rio de Janeiro/Federal University of Rio de Janeiro), Flávia Bulegon Pilecco (Conceição do Mato Dentro/Federal University of Minas Gerais); José Miguel Nieto Olivar (São Gabriel da Cachoeira/University of São Paulo). The study received financial support from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq; processes 442878/2019-2 and 431393/2018-4). We also appreciate the support received by the first author, as a Master’s degree scholarship holder financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ; process SEI-260003/001958/2022).

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• Data availability statement
  The data sources adopted in the research are indicated in the article’s body.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

• Publication in this collection
  28 Nov 2025
• Date of issue
  Nov 2025

History

• Received
  25 July 2024
• Accepted
  11 June 2025
• Published
  13 June 2025