Challenges for adolescents’ health: reflections on diversity, dignity, and human rights

ABSTRACT

The study examines the socio-educational system as a means of addressing violence, reflecting on its challenges, and highlighting the importance of public policies that promote diversity and respect the dignity of adolescents The right to express their sexuality was also added and re-evaluated. The data was collected using experience reports, participant observation and informal dialogues. What emerged were prejudiced treatments, denial, and neglect of rights as well as the maintenance of a system with outdated actions that perpetuate themselves. These findings highlight the need to overcome access barriers quickly by strengthening education, investing in human resources, government and inter-institutional partnerships. The study identifies gaps in the knowledge about the socio-educational system and proposes more humanized and inclusive approaches to dealing with the difficulties faced by adolescents undergoing socio-educational measures. It also suggests concrete recommendations for raising social awareness with ethical, political, social and citizenship values, thus improving the quality of care and protecting the human rights of these young people.

KEYWORDS
Adolescents; Socio-education; Socio-educational measure; Reproductive health; Public policies

RESUMO

O estudo analisa o sistema socioeducativo como um meio de enfrentar violências, refletindo sobre seus desafios e destacando a importância de políticas públicas que promovam a diversidade e respeitem a dignidade dos adolescentes. Adiciona-se e reavalia-se o direito à expressão da sexualidade desses sujeitos. Para coletar dados, utilizaram-se técnicas de relato de experiência, observação participante e diálogos informais. Os resultados revelam tratamentos preconceituosos, negação e negligência de direitos, além da manutenção de um sistema com ações ultrapassadas que se perpetuam. Essas descobertas ressaltam a celeridade em superar as barreiras de acesso por meio do fortalecimento da educação, de investimentos em recursos humanos, parcerias governamentais e interinstitucionais. O estudo identifica lacunas no conhecimento sobre o sistema socioeducativo e propõe abordagens mais humanizadas e inclusivas para lidar com as adversidades dos adolescentes em cumprimento de medidas socioeducativas. Além disso, sugerem-se recomendações concretas visando a uma consciência social com valores éticos, políticos, sociais e de cidadania, melhorando assim a qualidade do cuidado e promovendo os direitos humanos desses jovens.

PALAVRAS-CHAVE
Adolescentes; Socioeducação; Medida socioeducativa; Saúde reprodutiva; Políticas públicas

Introduction

Comprehensive care, based on the National Policy for Comprehensive Healthcare for Adolescents in Conflict with the Law in Internment and Provisional Internment (PNAISARI) ds, healthcare defined as welcoming, giving attention, treating and respecting human beings, permeating ethical, political, social, and citizenship values². Ayres³ talks about healthcare as an effective strategy for dealing with crises and building possibilities for conducting healthcare practices: humanized approaches, reflection on the notion of care, based on theoretical principles; integrality of potentially transformative care with shared and practical knowledge; ethical, political and healthcare reparation, professionals and users in links as key points.

The coverage and provision of health services for adolescents in Brazil pose significant challenges for both managers and civil society, given the complexities arising from the diversity in the structure of Brazilian states in terms of health management. Ensuring comprehensive health care for adolescents is a challenging issue, taking into account aspects such as the extent of coverage and effective access to health services. Despite the public policies in place, this population still faces significant limitations. Although there have been remarkable advances, such as the implementation of actions to protect adolescents from exploitation and the promotion of national programs for nutrition, health and vaccination, it is clear that there is an urgent need for additional proposals to meet the needs of this population⁴.

To create a socially just country, free of inequalities and prejudices, we have the Universal Declaration of Human Rights, which recognizes and protects the dignity of all human beings, paying attention to not subjecting children and adolescents to cruel or degrading treatment or torture⁴. Likewise, the Federal Constitution determines social responsibility in guaranteeing the right to life and health, also providing for protection against forms of neglect, discrimination, exploitation, violence, cruelty and oppression⁵.

The entire legal apparatus within the Rights Guarantee System is equally affected by and involved in the National Socio-Educational Care System (SINASE), in the Education System, the Unified Social Assistance System (SUAS), the Justice and Public Security System, and the Unified Health System (SUS) with co-responsibility. According to Julião et al.⁶, in order to achieve compensation, we are currently in a context in which the Federal Constitution guarantees the participation and control of society in relation to public policies. This historical, legal and regulatory framework has standardized the understanding of guaranteed rights and full protection for children and adolescents. Additionally, in the case of adolescents serving time, it exposes them to a condition of great vulnerability?⁷.

Strengthening SINASE and guaranteeing the validation of the Statute of the Child and Adolescent (ECA) are essential instruments for protecting these adolescents, ensuring that they comply with measures in a system that ensure their rights. They enable the effectiveness of socio-education and these young people’s inclusion in society. However, over the years there has been a lack of continuity in guaranteeing the legal rights of these individuals, from primary healthcare to issues related to respect for individuality, subjectivity, and sexuality. Overcoming these barriers is the greatest challenge to be faced by entities in society⁸.

It is worth pointing out that these individuals are in the period of adolescence, a transitional phase marked by various changes and conflicts during which they strive to build an adult identity⁹. The meaning of adolescence goes beyond the mere definition ‘adolescere’, which comes from the Latin verb denoting growth and maturation. This stage is also characterized by phenomena of a biological nature, such as puberty, which are crucial for these young people’s transition to adulthood. During this period, there is a hormonal reorganization followed by anatomical and physiological changes that result in fully functional male and female bodies full of sensations¹⁰.

The full development of these bodies is directly linked to the culture in which they are inserted and the way in which they experience the transformations occurring in their bodies. Both the recognition of this new body and the reorganization of formative identities as a social person will have a significant impact not only on the individual, but also on the society in which they are inserted¹¹.

Human development raises fundamental points about adolescence, which includes a reflection on sexuality¹². For Ribeiro¹³, sexuality is a broad concept that encompasses the sexual impulse, the emergence of desire, the search for sexual purposes, the manifestation of desire, the mental elaboration to make desire a reality, all of which is influenced by cultural, social, family, moral, and religious aspects as well as processes of sublimation and repression. In his view, ‘in its essence, sexuality is biological and its primary objective is the perpetuation of the species’¹³.

Regarding the approach to sexuality among imprisoned adolescents, the emphasis is on promoting sexual and reproductive health, since there is an urgent need to address health issues related to the epidemic of Sexually Transmitted Infections (STIs)¹¹. These circumstances reveal the scarcity of healthcare during sexual practices among young people, which often take place without proper guidance.

This experience report aims to share strategies used to deal with challenges found in the face of various conservative stances in an institution dedicated to the care of male adolescents subjected to socio-educational measures of deprivation of liberty. Furthermore, it seeks to emphasize the right to the expression of sexuality and to contribute to legal alignment within the true purpose of socio-education, which is to make the re-socialization of young people in socio-education effective, preparing them for the inclusion or re-inclusion in social life after completing their socio-educational measure.

It is fundamental to emphasize sexuality as a fundamental human right guaranteed by the Federal Constitution and Human Rights. In the context of health, the perspective of sexuality is understood as an essential right providing individuals with the possibility of acquiring autonomy, freedom, pleasure, and fully exercising their rights and citizenship¹².

Figure 1 illustrates the configuration of adolescent monitoring in the Brazilian socio-educational system.

Figure 1
Design of adolescent ofender monitoring in Brazil

Material e methods

The method used to collect data in this study involved the use of experience reporting techniques, participant observation, and informal dialogues. These techniques were used to understand how adolescents being deprived of their liberty perceive their daily social relationships, starting within the context of imprisonment. Through the continuous observation of professionals, we sought to understand how these young people deal with health-related dilemmas, especially with regard to the exercise of their sexuality, which is often obscured and controversial within an institution permeated by devices of control, discipline, and power.

Data collection and analysis instruments

To analyze adolescent healthcare, previous surveys, published between 2015 and 2020, were used which provided demographic information such as age, gender, race/color, socioeconomic factors and schooling. There were also document searches on socio-ed-ucation to compile historical data, between January 2015 and December 2020, by using collections of relevant publications, including the collections ‘Ações Socioeducativas: Formação e Saberes Profissionais’ and ‘Dicionário do Sistema Socioeducativo do Estado do Rio de Janeiro’¹⁴.

The work of prevention and health promotion with adolescents is integrated into the Individual Care Plan (PIA), which is discussed and defined during the monitoring of compliance with the socio-educational measure¹⁵. Health interventions are carried out through group meetings and individual consultations, addressing topics aligned with the health axes of the PNAISARI¹.

To disseminate health information, we chose to raise awareness and share it among employees through informal conversations, lasting up to 15 minutes each, held weekly to avoid impact on the institutional routine. We recorded notes to monitor the extent and content of what was discussed, as well as the challenges faced by them, all of which were documented in files. This study was approved by the Research Ethics Committee of the National School of Public Health Sergio Arouca of the Oswaldo Cruz Foundation (ENSP/FIOCRUZ), CAAE: 54769221.0.0000.5240. Opinion No. 5,765,910.

Experience reports

Work routine

The day begins with a shift change at around 6.30am, when the coordinator in charge hands over the duty to the next coordinator. The professional agents report the incidents in a book, counting the number of adolescents, handcuffs, radios, pepper spray, and checking the incident book. In addition, the physical space is inspected to identify possible damages. It is worth mentioning that there are standard procedures for conflict situations such as escape attempts, damage to property or any other event relevant to general security. In these cases, the adolescents are taken to the police station and an incident report is generated. The police officers are assigned to specific posts within the unit working in shifts and taking turns throughout the day.

The unit is monitored with real-time camera surveillance available in the management room at the security coordinators’ desk and in the reception guardhouse. Institutional protocols are routinely communicated by radio to agents at posts. Real-time monitoring is carried out simultaneously by the intelligence center in Ilha do Governador, a small island located in the north zone of the state Rio de Janeiro. In cases of emergency, this center requests help, activating police officers and a security support team to the unit.

During the day, the agents circulate around the accommodations to check on the adolescents in activities such as family visits, technical assistance, school, courses, sports courts, worship services, among others. At night, they carry out security rounds at times set according to a security plan. Until 2019, socio-educational security professionals were called socio-educational agents. However, Law No. 4,802/2017 was amended, and the new nomenclature coming into force which then changed to Socio-Educational Security Agents, in the state of Rio de Janeiro¹⁶. They are distributed in shifts with a specific coordinator and his team for shifts A, B, C or D, for 24 hours.

Reception of the socio-educational adolescent

The adolescent is admitted by a technical professional who fills out a detailed reception form with full name, age, reason for admission, nickname/alias, previous records in the socio-educational system, address, names of parents and/or guardians, and telephone contact. A physical injury assessment is carried out, alongside the presence of comorbidities, the use of controlled prescriptions, a history of alcohol and other drug use, level of education, employment, etc. During this initial assessment, possible health demands, physical injuries or sequelae are identified together with signs of psychological distress, which may indicate the need for mental health monitoring. It is also assessed whether there are any risks in remaining with the other adolescents, which may require protective measures for the newcomer, in order to avoid negligence. The institutional rules are presented to the adolescent as well as the sanctions for non-compliance.

It is emphasized that the teenager will always be treated as such, not as an offender, and will be given a registration number. They are instructed on the importance of peaceful coexistence in the institutional environment, school obligations, participation in workshops, courses, technical assistance and health care, among other things. They are informed of the times and places for meals, visiting days and hours, with the automatic inclusion of parents, siblings and grandparents on the list of visitors. Other people must request judicial authorization or submit the request to the technical team accompanying the adolescent. More precisely, those adolescents who commit offenses similar to rape must stay in a ‘secure accommodation’. This environment is isolated from social life, with separate meals and individualized service. However, due to the lack of architectural structure to meet the individual needs of each adolescent, paradoxical situations can arise. From 2015 to 2020, few adolescents declared their gender identity and sexuality that differed from common sense. During this period, the unit received openly gay adolescents, and to protect them from possible violence from their inmates, they continued to be housed in the same ‘secure accommodation’ used by adolescents whose offenses were not accepted by the group.

Accommodation and coexistence

Moreover, the practice of making tattoos using the aluminum from meal packaging and the plastic from shaving razors is common, which increases the risk of STIs. At one point, clothes and objects were washed with water from the toilet, resulting in recurring infections which were hard to eradicate. In 2015, the security team notified the unit’s direction that at night, some adolescents were involved in affectionate relationships with exchanges of cuddles escalating to sexual acts and that this also occurred during the day. This situation was associated with an increase in reports of violence on the part of the adolescents leading to more frequent application of punitive measures and sanctions for those found in situations not consistent with male gender norms.

Healthcare intervention: applying care

The unit has safety regulations that all workers must strictly follow. The technical personnel, in particular, are given specific guidelines, such as keeping the doors of the rooms open when attending to the adolescents and avoiding being left alone with them when no security agent is present. It’s vital to note that, over the years, technical assistance in the rooms has never taken place with the doors closed, and there have been no conflictive incidents to date. These moments of technical assistance are considered among the most empathetic and humanized in the resocialization process, and are recognized and valued by the adolescents and their families.

Health issues are raised as soon as the adolescent arrives at the unit. Just as there is a professional from the technical team at reception, there is also a health professional. The adolescent is weighed, vital signs checked, health and illness history, possible comor-bidities, physical injuries, mental disorders, etc. When an adolescent presents a health complaint, there is a medical evaluation, and if there is a need for specialized care, complementary tests or other assistance from the health network, these should be undertaken.

Faced with the discomfort expressed by the security agents when dealing with ways of proceeding, especially the sexual ones within the accommodation, there was a significant mobilization. The unit’s management called in the technical assessment team and the health team to collaborate in proposing interventions and formulating strategies to address and discourage displays of affection among adolescents.

The unit’s management chose to designate employees with a profile more aligned with the sexual and reproductive rights of adolescents to act as a reference in the daily management of these matters. These employees would be more involved in the health team’s interventions, receiving information to share with other colleagues in each shift and sector of the unit.

The content of the health team’s work was shared during informal conversations in the courtyard, the place of greatest concentration, to avoid interruptions in the flow of communication, correct misunderstandings, and prevent sabotage of work strategies.

The individual uncertainties that arose among the security agents were addressed in conversations separate from the group, aiming to provide answers and clarifications. In a second stage, individualized meetings were held and, if necessary, more intimate conversations were carried out with the aim of demystifying concepts and exploring possibilities for dealing with adolescents on a daily basis.

Initially, the appeal made by the security agents to the management seemed unsolvable, especially from a security perspective. However, it turned out that these controversies involved more complex health problems than previously thought. As a result, the entire unit turned to a more careful approach to the teenagers’ demands.

To this end, a constant technical presence was adopted in the living environments and at school, as well as joint health promotion and prevention actions in collaboration with the municipal health network and the school. These actions addressed both school curriculum topics and general health issues at the institution. The purpose was to contribute to epidemiological surveillance and prevent avoidable diseases.

The adolescents with health complaints had the option of receiving care from a health professional, including counseling and, if required, rapid testing for STIs such as HIV/AIDS, hepatitis (B, C) and syphilis. The results of these tests guided other health actions and interventions, aimed at improving health indicators and preventing diseases.

Discussion

The Universal Declaration of Human Rights, in Article 3, emphasizes the right to life, and in Article 5, prohibits cruel, degrading treatment and torture against children and adolescents¹⁷. Furthermore, the lack of specific provisions in the Statute of the Child and Adolescent (ECA) that guarantee the exercise of sexuality for these adolescents generates numerous discussions about what truly constitutes rights or privileges for these individuals¹⁸.

The actions developed to assist adolescents in compliance with a socio-educational measure of deprivation of liberty, as outlined in policies, reflect important legal frameworks in full protection, in the ECA, SINASE, and PNAISARI, within the Rights Guarantee System. For health monitoring, we rely on GM Ordinances No. 1,082 and No. 1,083 of 2014, which guarantee and expand access to healthcare for these adolescents from the perspective of Comprehensive Healthcare for Adolescents in Conflict with the Law, in Regime of Hospitalization and Provisional Hospitalization¹.

Following the principle of institutional incompleteness, in accordance with the guidelines of Art. 60 of Law¹⁹, healthcare for adolescents under socio-educational measures in open and closed settings is guaranteed, including health promotion, prevention, care, and recovery in the SUS. This strengthens support networks with the active participation of the state and the municipal departments, subsidizing care and services in socio-educational units. The first welcome is strategic, as it is essential to preserve the peaceful coexistence and physical and mental integrity of the adolescents, avoiding the generation of further conflicts, especially considering that many of them identify with factional groups.

For Goffman²⁰, the concept of the total institution, in which everything is resolved internally, refers to the world of internment as a closed, controlled social barrier for and withdrawal of the subject’s right to expression. Foucault²¹ stresses the emphasis on the production of the discourse of knowledge, rather than simple repression, which represents a break with traditional views on power and institutions. For him²¹, the focus is on the production of the discourse of knowledge, rather than repression, breaking with traditional views on power and institutions. The author analyzes how spaces of discipline and disciplining have evolved throughout the history of the West, with special emphasis on modernity and its transformations over time. He argues that, starting from an imaginary that involves the suppression of discussions about sex and sexuality, the prohibition of discourse would have the effect of repression, influencing and shaping the ways of demonstrating truth and regulating what can be said²¹.

Regardless of the breach of the social contract, no entity in society should deprive a human being of their rights. Health management includes strategic visits to the accommodations of adolescents to identify the organization of the collective space, check for unhealthy conditions, and observe behaviors and habits of personal and collective hygiene.

It is worth pointing out that the right to sexual and reproductive health is provided for, and the application of the law must be adapted to institutional requirements, the profile of the unit and the capacity to provide for that²². The adolescents in the unit that behave differently from the standard recognized by the officer are subjected to hostile and differentiated treatment for their permanence in internment. Despite the efforts made in terms of capacity building and continuous training, the structural obstacles persist and change over the years.

Gender differences are socially and culturally constructed over time, and because they are part of a historical process, they are considered to be essentially masculine or feminine²³. Typically, the approach to adolescent sexuality is limited to topics such as pregnancy and the prevention of STIs/AIDS, although these issues are undeniably relevant. The exclusive association of sexuality with pregnancy and STI/AIDS prevention leads to a relative restriction of the possibilities of experiencing pluralities, reducing them to specific scientific knowledge¹¹. Sexuality reveals its differences in historical and cultural contexts, emphasizing dominant discourses²¹. Louro et al.²⁴ highlight the significance of sexuality in culture, with sex being valued in life and relationships, pleasure, identity, obligations, responsibilities, and freedom of choice.

An experience report describing an experience in a field of professional activity can make a significant contribution, especially for the socio-educational sector, broadening the perspectives of critical evaluation and providing knowledge about the complexities of the subject as well as proposing possible paradigm shifts in the future. The dimension of sexuality emerges as a controversial topic and as a major obstacle to progress due to the taboos and prejudices that permeate the discussion. The way institutions and health procedures are organized reflects this context, offering fragmented and low-resolutive care²⁵. The exercise of sexuality, understood as part of human development, involves concepts such as affectivity, pleasure, exchange, decision-making autonomy, and respect, thus constituting a fundamental right²⁶.

These incidences highlight the need for healthcare during sexual activity among young people, which often occurs without proper guidance. Specifically in relation to sexual activities in socio-educational spaces, it is important to note that there is no direct correlation with sexual orientation. Some misconceptions on the part of socio-educational professionals can arise due to the naturalization of the sexual instinct, the sexual deprivation of adolescents, and the environment of confinement. However, it is crucial to emphasize that such behaviors should be recognized solely as expressions of pleasure and that scenarios of violence must not be tolerated¹¹.

Final considerations

The proposal for this experience report on healthcare for adolescents from the perspective of comprehensive care emerges from the analysis of the right to access healthcare and, especially, the right to exercise sexuality considered fundamental for human beings.

Reflecting on socio-education involves considering the setbacks in the construction and implementation of public policies for assistance with an emphasis on diversity and respect for the dignity of adolescents undergoing socio-educational measures.

We have sought to contribute to the discussion on adolescent health and sexuality in the socio-educational system as a right reflecting on the practices of the system’s operators based on the principles of human rights, the Rights Guarantee System, and current public policies.

Collective action promotes innovation, generates driving forces, breaks down paradigms and facilitates the representation of minority groups, helping to think about and achieve joint solutions. A society engaged in the common good is powerful, capable of transforming people’s realities, helping to build more equitable public policies, reducing inequalities, and providing growth by opening up spaces of opportunity.

It is the responsibility of society to get involved in proposing laws, monitoring and denouncing them. It is essential to be part of the assistance, pedagogical and educational process so that these young people can be reintegrated into society, abandoning illicit practices, and being guided towards the making of citizenship, contributing to the development of a project for the future.

• Financial support: non-existent

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  » http://periodicos.unb.br/index.php/SER_Social/article/view/12921

Edited by

Responsible editor: Vania Reis Girianelli

Publication Dates

• Publication in this collection
  17 June 2024
• Date of issue
  Dec 2023

History

• Received
  16 Oct 2023
• Accepted
  03 Dec 2023