Enfermería y sexualidad : revisión integradora de artículos publicados en la Revista Latino Americana de Enfermería y en la Revista Brasileña de Enfermería

Correspondencia: Lúcia Helena Rodrigues Costa Universidade Estadual de Montes Claros Centro de Ciências Biológicas e da Saúde Prédio 6 Departamento de Enfermagem Rua: Dr. Rui Braga S/N Vila Mauricéia CEP: 39401-089, Montes Claros, MG, Brasil E-mail: luhecosta13@yahoo.com.br Enfermería y sexualidad: revisión integradora de artículos publicados en la Revista Latino Americana de Enfermería y en la Revista Brasileña de Enfermería


Introduction
Sexuality has been a subject discussed in many fields of knowledge and has achieved great visibility through psychology and psychoanalysis, especially since Freud's studies (1) .Studies addressing sexuality in the fields of the human and social sciences became more evident and frequent in the second part of the 20 th century, as more emphasis was placed on the studies of Michel Foucault (2) , who through his genealogy of sexuality, identifies it as a capable dispositive to sustain power mechanisms.
Sexologists have especially addressed sexuality in the health field, which gives it a normative character mainly marked by biological aspects.In studies addressing sexology and views of feminism, feminist researchers call attention to the fact that the medical discourse on sexuality seems not to have been observed by the feminists themselves (3) .www.eerp.usp.br/rlaeCosta LHR, Coelho ECA.
Particularly in the second half of the 1990s, international entities focused on public policies directed to women's health incorporated the concepts of reproductive rights and especially sexual rights as human rights, through the force of feminist movements.
The discussion of sexuality from this perspective was brought up mainly because of the feminization of the Acquired Immunodeficiency Syndrome (AIDS), which led the World Health Organization (WHO) to adopt the term 'sexual health'.In the context of issues related to women, gay and lesbian movements were also organized seeking to reflect upon and deconstruct sexuality considered just from the heterosexual point of view, which does not take into account homoerotic relationships.
Brazilian nursing has historically maintained professional education based on the biomedical model and has for a long time emphasized nursing care focused on technical procedures developed for the biological body, somewhat denying human multidimensionality.
A movement seeking to enlarge care actions beyond techniques and eminently biological aspects is apparent.
From this perspective, sexuality has been a subject present especially in the fields of women's health and sexual education directed to adolescents.
Sexuality is a theme that directly involves nursing, since care practices refer to the contact of bodies, with intimacy and the erotic.In the domains of health promotion and education, one cannot disregard the importance of discussions addressing sexual and reproductive rights as unalienable human rights of men and women.Despite this fact, sexuality in recent studies, especially those in the nursing field, is concealed in the interface with care in the education of nurses (4) .
Our professional experience has shown that focus and care practices are still based on the traditional, instrumental and normative model both in schools and health care networks, which hinders a critical approach to sexuality.In this context, this study is justified because it seeks knowledge produced and disseminated in the nursing field in Brazilian periodicals with international circulation that enables the problematization of the context of education and health care provided in the sphere of sexuality.
This study assumes that studies addressing sexuality in the Brazilian nursing field present changes and enlarge the scope of discussion to include gender and sexual rights, though a strong tendency to link sexuality to its biological aspects still persists.Hence, this study seeks to identify the state-of-the-art of studies addressing sexuality in the nursing field through papers published by two Brazilian periodicals of international circulation, with the belief that such periodicals will enable us to find responses to the study's assumptions.

Method
This integrative literature review (5) identifies the state-of-the-art of studies addressing sexuality in two periodicals with international circulation: Latin American Journal of Nursing (RLAE) and Brazilian Journal of Nursing (REBEn).The concept of 'state-of-the-art' is considered to encompass the mapping of trends and dimensions of studies of relevant subjects to the advancement of scientific research in the most diverse fields of human knowledge (6) .The sources used included scientific papers

Results
The obtained results are presented in Figure 1: authors, titles of papers and year of publication.For that, studies point to the need to adopt new methodologies to approach and get nurses closer to fathers, mothers and educators.They also suggest that spaces where nurses provide health education should be increased since these break out of the limits of health institutions (7)(8)(9)(10)(11)(12)(13)(14)(15) .
It is important to highlight that even though these studies were published in a decade characterized by studies carried out by nurses addressing gender issues, most of them do not refer to this analytical category even when identity issues of boys and girls and their sexual experiences are discussed (12) .
Only two experience reports based on the participative methodology of Paulo Freire effectively include the category 'gender' when addressing sexuality issues among adolescents.Experiential workshops were conducted (8)(9) in both studies seeking a broadened perspective of sexuality that transcended sex involving "values, feelings, culture and gender" (8) .These reports show the importance of identity constitutions of masculinity and femininity in the determination of social behavior in relation to the exercise of sexuality.
Three papers problematize the issue of sexuality without however specifically addressing the interface with adolescence as the previous studies did.Of the three papers, two contribute to proposals in the field of primary health care, especially focused on sexual health (16)(17) .
Of the latter two papers, the one discussing methodological fundamentals for nursing consultation in the sexual health of adults and adolescents presents a broader proposal of the concept of sexuality and also a conceptual framework of sexual rights.The author (16) emphasizes the concept of sexual rights and proposes the inclusion of nursing consultations to promote sexual health respecting socio-cultural and geographical diversity and the demands of users in each region.
In another paper (17) , which originated from a doctoral dissertation, the author addresses political-ethical aspects in primary health care regarding sexual health.She stresses one aspect, among other important ones, that we consider essential: the education of nurses, because for one "to comprehensively deal with sexuality one needs to recover it as an object of professional training, going beyond a privileged biomedical perspective" (17) .This requires assuming and thereby overcoming a technical education toward an approach focused on inter-relations.
The third group of papers (18) addressing 'Sexuality, education, adolescence and nursing practices', which does not specifically address the sexuality of adolescents, contributes to a critical reflection.This paper presents a theoretical approach of the cultural construction that permeates Brazilian sexuality, the role of the media, and how nurses should contribute to sexual education, though it questions the lack of education in nursing programs that is specifically in the field of sexuality.It was published in January 2007 and discusses movements considered "deviant" such as the feminist movement, the gay and lesbian movements, which alter the configuration of the hegemonic sexuality.The authors operate with the category 'gender' concluding that gender relations "are based on categorizations that permeate social order and these categorizations determine a symbolic dominance.
Even though Western societies have developed a certain tolerance in relation to issues involving sexuality, their symbolic systems remain unaltered and continue to be focused on the assumption of male dominance according to "nature" as an instrument to keep social order" (18) .

Sexuality and STI/AIDS
Six papers (19)(20)(21)(22)(23)(24) were identified in this thematic group and even though they were published in a time when a sweeping debate was taking place on the feminization of AIDS, only one addresses the issue of gender vulnerability (20) .The authors indicate the need for new approaches in nursing in relation to AIDS, in which gender and sexuality are present.They suggest that nursing care should seek a more contextualized perspective identifying the nuances of unequal relationships of power between sexes as one of the strong determinants of female vulnerability to AIDS.
In studies that included both men and women in the studied population (22)(23) , it was difficult to identify to what "subjects" the authors were referring, men or women.
The authors defend the need to care for serodiscordant partners (22) , envisioning a less biologicistic, and more humanized and integral approach.However, while the authors contemplate in small excerpts of analysis the Rev. Latino-Am.Enfermagem 2011 May-Jun;19(3):631-9.
differences of "gender" roles, the authors used the masculine in the universalist meaning to classify all human beings as men, which denies the gender approach and moves away from integrality.The extensive scientific literature has confirmed that hierarchies and inequalities of power are socially established from differences of gender, broadening gender vulnerability and favoring the feminization of AIDS.
One of the papers points in this direction since it was developed with military police in Natal, RN, Brazil through focal groups (24) .From a Foucaultian perspective, the results showed very evident signs of unequal power between men and women.Gender asymmetry results in sexuality reproducing inequalities through socially acceptable behavioral rules.The study shows that STI and AIDS exist in this tangle of inequalities between sexual partners and from the collective health point of view, individual behavior arises from social conditions that determine vulnerability.

Sexuality and chronic-degenerative diseases and/or surgeries
In the thematic group 'Sexuality and Chronicdegenerative diseases and/or surgeries', five papers were found, all published by RLAE.These papers show a concern with aspects of sexuality that go beyond a biologistic view, however, a physiopathological approach to diseases is the dominant view, while sexuality is reduced to the sexual act per se (25)(26)(27)(28) .These two papers do not present a theoretical discussion and in some there is no reference to the concept of sexuality that guides the view of researchers.Even though sexuality is one of the key words used, it is not a central issue in the studies described by these two papers (25)(26) .
What we often found as a conclusion of these studies demonstrates a very idealized level of care.An example is the study (28) that proposes an understanding of the sexuality of partners of individuals with colostomies.At the end, the authors state "the client's sexual integrity needs to be seen and understood by health professionals in order to plan care actions that contemplates the Integral Being" (28) .The 'Integral Being' of sexuality cannot be a universal client: s/he is a subject of differences marked by gender, ethnicity, class, and generation, among others that we come into contact with in a complex society as ours.S/he is the singular human being whose sexuality is affected by multiple sociocultural factors.
Only one paper (29) in this group discusses sex and sexuality beyond the viewpoint of a pathology and includes the category 'gender' in the analysis of results.Departing from the assumption that Hansen's disease or what is commonly called leprosy causes distinct effects on men and women and that sexuality determines behavioral changes, the authors concluded that "knowing to capture the differences that are socially constructed between the masculine and feminine roles is essential to promoting educational actions in the health field, including those directed to Hansen's disease" (29) .

Sexuality and nurse education and/or socioprofessional profile
Despite the fact these studies are of different natures, all converge on the point of intersection between sexuality and care in which education and socio-professional profile are determinants in routine practices.
The first of them, published in 1998 (30) , does not focus on sexuality per se but refers to it as it discusses gender and morality in professional nursing practice.It focuses on the particularities of the care act and the power relationships established in health facilities that go beyond the asymmetries more easily identified in the relationships between physicians and nurses.
According to the authors, these power relationships are marked by two perspectives that are opposed to each other: the rationalizing and scientific perspective represented by medicine and the interpersonal dimension, which "does not exclude a scientific logic but is based on an affective, supportive relationship" represented by nursing (30) .Scientific rationality is based on the principle of masculinity and relational logic is a feminine principle.From this perspective, the authors argue that the introduction of subjectivity as an analytical category "breaks up the male hegemony and enables one to reconceptualize coded and hierarchical social relations, especially in the health field and labor relations.
[…] In the health field for instance, the dimensions of affectivity, feeling, language in the work concept, virility, femininity and sexuality are incorporated" (30) .
The second paper (31) in this thematic group presents the results of a study carried out with 40 students in the 8 th semester of an undergraduate nursing program.This paper discusses the concept of sex and sexuality and presents several studies addressing this subject in the nursing field in its literature review.The authors concluded that nursing students have incorrect information concerning sex and sexuality and that schools should provide an education that includes sexuality because "men could be treated as holistic beings with

Figure 1 -
Figure 1 -List of the identified papers between 1998 and 2007.
read, which is the total number of published articles.The abstracts and full papers were easily accessed because all the issues from the chosen period (1998 to 2007) are available online.Once it was decided to read all the abstracts published in the period selected for the study, those not mentioning the word sexuality were excluded.Of the 1,894 read abstracts, 29 met the inclusion criteria: being a study addressing the subject with a focus on nursing and including the word sexuality in the title, abstract or key words or descriptors.After the abstracts were selected, the second stage consisted of reading all the selected papers, whether they were trials, research results, experience reports, or literature reviews.The analysis of the material was performed through a critical and qualitative reading, which enabled us to identify convergences and group them into thematic Rev. Latino-Am.Enfermagem 2011 May-Jun;19(3):631-9.www.eerp.usp.br/rlaeaxes: 'Sexuality, nursing education and practice'; 'Sexuality and Sexually Transmitted Infections/Acquired Immunodeficiency Syndrome (STI/AIDS)'; 'Sexuality and chronic-degenerative diseases and/or surgeries'; 'Sexuality and women's health'; and 'Sexuality, nurse education and/or socio-professional profile'.