In January 2020, the issue of adolescent sexuality sparked intense debate in Brazil over a proposal for abstinence (or postponement of sexual initiation) as a public policy to deal with adolescent pregnancy.

To discuss adolescent pregnancy in a context of profound social, racial/ethnic, and gender inequalities such as in Brazil requires skill, theoretical and technical expertise, and especially respect for the lives of millions of adolescents. Adolescents are bearers of rights that are learning autonomy, care, and control of themselves and their sexuality as an inherent dimension of social relations.

The theme appeared on the agenda after an announcement by the Brazilian Ministry for Women, Family, and Human Rights (MMFDH, acronym in Portuguese) on the elaboration of a National Policy for Prevention of Risk of Early Sexual Activity. On December 6, 2019, a seminar in the Brazilian National Congress promoted by the MMFDH discussed the postponement of adolescents’ sexual initiation, taking inspiration from initiatives by religious groups (Eu Escolhi Esperar. https://www.euescolhiesperar.com/, accessed on Mar/2020) and groups from the United States, featuring guest speaker Mary Anne Mosack, CEO of Ascend (https://weascend.org/about-us/, accessed on Feb/2020), a social organization working in the area of Sexual Risk Avoidance Education Programs.

With the creation of the National Week for the Prevention of Adolescent Pregnancy by the Brazilian Federal government under Law n. 13,798¹1. Brasil. Lei nº 13.798, de 3 de janeiro de 2019. Acrescenta art. 8º-A à Lei nº 8.069, de 13 de julho de 1990 (Estatuto da Criança e do Adolescente), para instituir a Semana Nacional de Prevenção da Gravidez na Adolescência. Diário Oficial da União 2019; 4 jan., in January 2019, to be celebrated annually in the first week of February, the MMFDH, in partnership with the Ministry of Health, launched a national teenage awareness-raising campaign on the unwanted effects of “early pregnancy”. Although the term “sexual abstinence” was not used, possibly due to widespread rejection and criticism ²2. Sociedade Brasileira de Pediatria. Abstinência sexual na adolescência: o que a ciência evidencia como método de escolha para prevenção de gravidez na adolescência. https://www.sbp.com.br/imprensa/detalhe/nid/abstinencia-sexual-na-adolescencia-o-que-a-ciencia-evidencia-como-metodo-de-escolha-para-prevencao-de-gravidez-na-adolescencia/ (acessado em Mar/2020).
https://www.sbp.com.br/imprensa/detalhe/... , there is an underlying appeal to delaying sexual initiation through the slogan Adolescence First, Pregnancy Later: All in Due Time³3. Ministério da Mulher, da Família e dos Direitos Humanos. Campanha visa reduzir altos índices de gravidez precoce no Brasil https://www.mdh.gov.br/todas-as-noticias/2020-2/fevereiro/campanha-visa-reduzir-altos-indices-de-gravidez-precoce-no-brasil (acessado em Mar/2020).
https://www.mdh.gov.br/todas-as-noticias... . The campaign’s choice to not address the exercise of sexuality in this phase of life and to not publicly confront the sexual violence that mostly affects girls during childhood and adolescence eliminates an important possibility for debate on gender inequality.

Sexual abstinence or postponement of sexual initiation may be a legitimate intimate and personal choice by any man or women of any age, regardless of religious belief. Still, public policies in a democracy should be based on a human rights perspective that draws on the best available scientific evidence and with respect for the premise of a lay State ⁴4. Paiva V. Facing negative reactions to sexuality education through a Multicultural Human Rights framework. Reprod Health Matters 2015; 23:96-106..

In recent decades, researchers from various fields have exhaustively analyzed policies for pregnancy prevention in the United States and have not recommended the sexual abstinence strategy as the only solution for counseling adolescents and young adults ⁵5. Luker K. Dubious conceptions: the politics of teenage pregnancy. Cambridge: Harvard University Press; 1997.^,66. Schalet AT. Beyond abstinence and risk: a new paradigm for adolescent sexual health. Womens Health Issues 2011; 21(3 Suppl):S5-7.^,77. Harper C, Henderson JT, Schalet AT, Becker D, Stratton L, Raine TR. Abstinence and Teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States. Perspect Sex Reprod Health 2010; 42:125-32.. The Society for Adolescent Health and Medicine of the United States has taken an official stance ⁸8. Society for Adolescent Health and Medicine. Abstinence-only-until-marriage policies and programs: an updated position paper of the Society for Adolescent Health and Medicine. J Adolesc Health 2017; 61:400-3. on the need to adopt a comprehensive approach to adolescent sexuality that includes respect for cultural, sexual, and gender diversity, the right to receive accurate information on sex, sensitivity on the part of health professionals and educators, and opportunities for knowledge on methods to protect their health and prevent pregnancy ⁶6. Schalet AT. Beyond abstinence and risk: a new paradigm for adolescent sexual health. Womens Health Issues 2011; 21(3 Suppl):S5-7..

Systematic reviews on the theme ⁹9. Santelli JS, Kantor LM, Grilo SA, Speizer IS, Lindberg LD, Heitel J, et al. Abstinence-only-until-marriage: an updated review of US policies and programs and their impact. J Adolesc Health 2017; 61:273-80.^,1010. Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. Am J Sociol 2001; 106:859-912.^,1111. Brückner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health 2005; 36:271-8. have reiterated the inefficacy and waste of public resources applied to educational programs premised on sexual abstinence. One of the strategy’s actual effects is a relative delay of sexual initiation (average of two years), but higher odds of non-use of contraceptive methods when individuals begin exercising their sexuality ¹⁰10. Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. Am J Sociol 2001; 106:859-912.^,1111. Brückner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health 2005; 36:271-8..

Another mistake is to assume a linear association or direct causal relationship between sexual initiation and unwanted pregnancy. The mistake overlooks the mediations and variables present in the context of a sexual relationship and a possible pregnancy, such as peer violence, the meanders of contraception, social negotiations, spousal hierarchical differences, and sexual consent as a gift. It also highlights the perspective of sex as “danger”. If sexual initiation alone accounted for adolescent pregnancy, how does one explain such disparate rates between countries? Numerous studies have identified the importance of socioeconomic, political, and cultural factors in higher versus lower incidence of sexual transmitted infections (STIs) and unwanted pregnancies, regardless of age at sexual initiation ⁶6. Schalet AT. Beyond abstinence and risk: a new paradigm for adolescent sexual health. Womens Health Issues 2011; 21(3 Suppl):S5-7.^,1212. Schalet A. Must we fear adolescent sexuality? MedGenMed 2004; 6:44.^,1313. Bozon M. A quel âge les femmes et les hommes commencent-ils leur vie sexuelle? Comparaisons et évolutions réecentes. Popul Soc (Paris) 2003; (391):1-4.^,1414. Bozon M. Novas normas de entrada na sexualidade no Brasil e na América Latina. In: Heilborn ML, Duarte LFD, Peixoto C, Barros ML, organizadores. Sexualidade, família e ethos religioso. Religião e sexualidade: uma relação íntima. Rio de Janeiro: Garamond; 2005. p. 301-14.. The difference lies in the existence of public policies encouraging sexual education, which involves talking about sex, having the necessary resources available for prevention, high-quality information, health professionals and educators trained in the issues and that know how to address young people’s doubts by opening a dialogue without conceptual or religious morals, and counting on support from people that the young people can trust ¹⁵15. United Nations Educational, Scientific and Cultural Organization. International technical guidance on sexuality education: an evidence-informed approach. Paris: United Nations Educational, Scientific and Cultural Organization; 2018..

The prevention of a pregnancy also depends on knowledge and the possibility of exercising various forms of safe sex. This concept was originally developed by the gay movement in confronting the HIV/AIDS epidemic and has slowly been reinvented ¹⁶16. Parker R. O fim da AIDS? Rio de Janeiro: Associação Brasileira Interdisciplinar de AIDS; 2015.. It should also be included in pregnancy prevention. Safe sex is not limited to the use of technical inputs and devices for prevention (contraceptive methods like condoms, besides emergency contraception), but requires the development of relational and affective skills in the process of building youth’s autonomy, fundamental dimensions that allow young women and men to know and express sexual desires and limits and to learn how to anticipate and prepare for sexual acts ⁶6. Schalet AT. Beyond abstinence and risk: a new paradigm for adolescent sexual health. Womens Health Issues 2011; 21(3 Suppl):S5-7..

The inclusion of adolescent men in approaches to reduce pregnancy is still a challenge if males are not urged to reflect on manhood, virility, and gender inequality and violence. The slogan “adolescence first, pregnancy later” may easily go unnoticed by those who do not feel responsible for the pregnancy.

High rates of unwanted pregnancies ¹⁷17. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher. PNDS 2006: relatório final. Brasília: Ministério da Saúde; 2008.^,1818. Theme-Filha MT, Baldisserotto ML, Fraga ACSA, Ayers S, Gama SGN, Leal MC. Factors associated with unintended pregnancy in Brazil: cross-sectional results from the Birth in Brazil National Survey 2011/2012. Reprod Health 2016; 13 Suppl 3:118. are not limited to Brazil’s young population, but also affect adult women and men. These rates signal other dimensions besides the lack of qualified information or access to contraceptive methods. The rates reveal the lack of public policies focused on the complexity of practicing contraception, regardless of the individual’s life stage.

Sexual initiation tends to occur mostly during adolescence and is closely dependent on conceptions of gender and sexuality. There are countries in which female sexual initiation precedes male initiation (as in some African countries) and others in which boys initiate sexual activity earlier than girls (Latin America). On average, the event occurs between 15 and 19 years of age ¹⁹19. World Health Organization. The changing world of adolescent sexual and reproductive health and rights. https://www.who.int/news-room/detail/03-02-2020-the-changing-world-of-adolescent-sexual-and-reproductive-health-and-rights (acessado em Mar/2020).
https://www.who.int/news-room/detail/03-... . In Brazil, a population-based study with nearly five thousand young people in three state capitals showed that median age at sexual initiation was 16 years for boys and 17 years for girls ²⁰20. Heilborn ML, Aquino EML, Bozon M, Kanuth DR. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Editora Fiocruz/Garamond Universitária; 2006.. A study in 9th-grade students 13 to 17 years of age also showed different behavior between male and female adolescents: 36% of boys reported any sexual intercourse in the past, compared to 19.5% of girls ²¹21. Felisbino-Mendes MS, Paula TF, Machado IE, Oliveira-Campos M, Malta DC. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol 2018; 21 Suppl 1:e180013..

Another challenge for understanding and addressing adolescent pregnancy is this age group’s sociocultural heterogeneity. Another mistake is to analyze all pregnancies between 10 and 19 years of age with the same criteria. The 10 to 14-year group requires a different approach. On the one hand, the fertility rates in girls 10 to 14 years of age have remained constant in Brazil in recent years, unlike the decreasing rates in adolescents 15 to 19 years of age. On the other, there is strong evidence that a considerable share of sexual relations in 10 to 14-year-olds are not consensual, and the magnitude of the association between sexual abuse and pregnancy in this age bracket is not negligible ²²22. Finer LB, Philbin JM. Trends in ages at key reproductive transitions in the United States, 1951-2010. Womens Health Issues 2014; 24:e271-9.^,2323. Madigan S, Wade M, Tarabulsy G, Jenkins J, Shouldice M. Association between abuse history and adolescent pregnancy: a meta-analysis. J Adolesc Health 2014; 55:151-9.^,2424. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Estupro e gravidez de adolescentes no Brasil: características e implicações na saúde gestacional, parto e nascimento. In: Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde, organizador. Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: Ministério da Saúde; 2018. p. 237-58..

Another complex issue is that not all adolescent pregnancies are unwanted. To take this for granted means to ignore multiple youth contexts and the meanings assigned to reproduction between social classes. The problem lies in the impossibility of terminating an unplanned pregnancy in Brazil, making motherhood compulsory for a large share of Brazilian women, who fear risking the unsafe and illegal conditions of abortion ²⁵25. Domingues R, Fonseca S, Leal MC, Aquino EML, Menezes GMS. Aborto inseguro no Brasil: revisão sistemática da produção científica 2008-2018. Cad Saúde Pública 2020; 36 Suppl 1:e00190418.^,2626. Heilborn ML, Cabral CS, Brandão ER, Faro L, Cordeiro F, Azize RL. Itinerários abortivos em contextos de clandestinidade na cidade do Rio de Janeiro - Brasil. Ciênc Saúde Colet 2012; 17:1699-708..

The State needs first and foremost to offer alternatives for Brazilian teenagers and young adults to build life projects that include other important dimensions such as professional, scholastic, artistic, and athletic fulfillment. What are the odds of children and adolescents growing up happy and fulfilling their dreams in the midst of such poverty, social inequality, urban, gender, and sexual violence, unemployment in the family, and government abandonment of cultural, recreational, sports, and educational opportunities and health and sanitation? The misguided shortcut of counseling adolescents to practice sexual abstinence cannot hide the fact that the problem is not limited to “early pregnancies”, but involves what such pregnancies reveal as symptoms of the abandonment and social indifference towards excluded segments of the Brazilian population.

It is unthinkable to disregard an existing public policy and guidelines for the health of adolescents and young people in the Ministry of Health, the drafting of which convened researchers, health professionals, educators, activists, youth representatives, and public administrators with vast technical expertise in the international frameworks for sexual and reproductive rights ²⁷27. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção em Saúde, Ministério da Saúde. Cuidando de adolescentes: orientações básicas para a saúde sexual e a saúde reprodutiva. Brasília: Ministério da Saúde; 2015.^,2828. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção em Saúde, Ministério da Saúde. Diretrizes nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília: Ministério da Saúde; 2010.^,2929. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção em Saúde, Ministério da Saúde. Marco teórico e referencial: saúde sexual e saúde reprodutiva de adolescentes e jovens. Brasília: Ministério da Saúde; 2006..

In any government department, a public policy focused on the responsible exercise of sexuality in adolescence and that addresses gender inequality should include strengthening of schooling, personal autonomy, and adolescents’ capacity to reflect on their affective and sexual choices and to know and take measures to protect their health, including condom use, regular or long-acting contraceptive methods, emergency contraception, access to legal abortion, and measures to combat gender discrimination, racism, male chauvinism, homophobia, and transphobia. These elements are indispensable for building youth’s autonomy and for exercising sexuality from the perspective of acknowledging alterity and human rights.

Acknowledgments

To Brazilian National Research Council (CNPq: 431393/2018-4) for the financial support.

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