Abstract:

This article presents the results of a qualitative study based on semi-structured in-depth interviews with ten adolescents, aged between 15 and 17 years, who live in a favela in the South Zone of Rio de Janeiro, Brazil, and who had experienced an illegal abortion between the ages of 12 and 17. We sought to examine more effectively the issue of abortion in adolescence and the strategies employed by adolescents in order to have an abortion within an illegal context. We unveiled the methods that were used, the locations where abortions took place and the manner in which the process of having an abortion happened. The abortions took place at clandestine clinics; at the apartment of a partner’s friend; and using the medication “Cytotec” (misoprostol). The values paid for the abortion ranged between BRL 500.00 and BRL 2,500.00 and all took place without the knowledge or participation of the adolescents’ legal guardians. One adolescent had to seek out a health service due to complications from the abortion. Informants relied on friends and/or partners and almost all were alone when they had their abortions, which should motivate a reflection regarding the risks taken and the solitude experienced by these adolescents in order to undergo an unsafe and illegal act. We conclude that the study of abortion at this life stage makes an important contribution to understanding sexuality and reproduction in adolescence.

Keywords:
Abortion; Adolescent; Pregnancy in Adolescence; Sexuality; Reproductive Rights

Introduction

In Brazil, the crux of studies about abortion remains its illegality. Studies are still scarce and usually refer to hospital admissions in the public health network, based on data from the Brazilian Hospital Information System (SIH, in Portuguese), and to maternal mortality, based on data from the Brazilian Mortality Information System (SIM, in Portuguese), a fact that hinders our ability to ascertain the dimension of the problem on a national scale ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60..

Therefore, studies are restricted to particular empirical universes, due to the obstacles imposed by illegality. Thus, in order to consider abortion and its intersections with subjects such as sexuality and contraception, or the multidimensional issues linked to it in Brazil, one must acknowledge that most works have a partial perspective on the problem given the limitations imposed by its illegality ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,33. Luna N. A polêmica do aborto e o 3º Programa Nacional de Direitos Humanos. Dados 2014; 57:237-75.^,44. Silva RS, Fusco CLB. Aborto provocado: uma realidade ilegal. In: Associação Brasileira de Estudos Populacionais, organizador. Qualificando os números: estudos sobre saúde sexual e reprodutiva no Brasil. 2009. http://www.abep.org.br/publicacoes/index.php/ebook/article/view/49/47 (acessado em 19/Mar/2019).
http://www.abep.org.br/publicacoes/index... .

When it comes to the specificities of adolescent women, data are even more scarce ⁵5. Menezes GMS. Aborto e juventude: um estudo em três capitais brasileiras [Tese de Doutorado]. Salvador: Universidade Federal da Bahia; 2006.^,66. Berquó E, Garcia S, Lima L. Reprodução na juventude: perfis sociodemográficos, comportamentais e reprodutivos na PNDS 2006. Rev Saúde Pública 2012; 46:685-93.. The demand for authorization from legal guardians, given through Signed Consent Forms, amplifies the difficulties of carrying out studies on induced abortion in this period of the life cycle ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,77. Peres SO, Heilborn ML. Cogitação e prática do aborto entre jovens em contexto de interdição legal: o avesso da gravidez na adolescência. Cad Saúde Pública 2006; 22:1411-20..

According to broader studies ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60., the experience of induced abortion is concentrated (between 72% and 78%) among older adolescents, aged between 17 and 19 years, with these data referring to the age at which they experienced their last abortion. However, these studies show the need to broaden the age range included in traditional studies, including girls aged between 10 and 14 years, possibly by establishing the beginning of sexual life. We emphasize that 17% of abortions in Brazil were carried out by adolescents aged between 12 and 18 years, with 26% between 12 and 15 years and 74% between 16 and 17 years ²2. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60..

When these studies focus on adolescence, they follow social pregnancy trends, showing adolescents who are not in school or in the job market, who are financially dependent on family members and/or partners ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. Therefore, there are important indicators in Brazil which reinforce the concern with the practice of clandestine and unsafe abortions, despite the many obstacles, among adolescents. We emphasize that, for example, girls aged up to 15 years have a greater participation in mortality from abortion than from other causes ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde)..

With this background, recent studies reinforce the gaps in the literature on the subject ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.^,44. Silva RS, Fusco CLB. Aborto provocado: uma realidade ilegal. In: Associação Brasileira de Estudos Populacionais, organizador. Qualificando os números: estudos sobre saúde sexual e reprodutiva no Brasil. 2009. http://www.abep.org.br/publicacoes/index.php/ebook/article/view/49/47 (acessado em 19/Mar/2019).
http://www.abep.org.br/publicacoes/index... ^,55. Menezes GMS. Aborto e juventude: um estudo em três capitais brasileiras [Tese de Doutorado]. Salvador: Universidade Federal da Bahia; 2006.^,66. Berquó E, Garcia S, Lima L. Reprodução na juventude: perfis sociodemográficos, comportamentais e reprodutivos na PNDS 2006. Rev Saúde Pública 2012; 46:685-93.^,77. Peres SO, Heilborn ML. Cogitação e prática do aborto entre jovens em contexto de interdição legal: o avesso da gravidez na adolescência. Cad Saúde Pública 2006; 22:1411-20.^,88. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido por faixa etária e grandes regiões: Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.. Thus, the lack of knowledge on how adolescents decide to have an abortion, how they have access to abortive instruments and how they buy and receive abortifacient drugs becomes clear ⁹9. Silveira P, McCallum C, Menezes G. Experiências de abortos provocados em clínicas privadas no Nordeste brasileiro. Cad Saúde Pública 2016; 32:e00004815.. We also know little about the social inequality indicators associated with abortion, such as class, generation and race ¹⁰10. Menezes GMS, Aquino EML, Silva DO. Induced abortion during youth: social inequalities in the outcome of the first pregnancy. Cad Saúde Pública 2006; 22:1431-46.. Further, we still have scarce knowledge on the abortion itineraries undertaken by adolescents, on the symbolic universe and moral, physical, psychological and reproductive impact of abortion on their biographical trajectories ⁷7. Peres SO, Heilborn ML. Cogitação e prática do aborto entre jovens em contexto de interdição legal: o avesso da gravidez na adolescência. Cad Saúde Pública 2006; 22:1411-20.^,1111. Ferrari W, Peres S, Nascimento M. Experimentação e aprendizagem na trajetória afetiva e sexual de jovens de uma favela do Rio de Janeiro, Brasil, com experiência de aborto clandestino. Ciênc Saúde Colet 2018; 23:2937-50..

Therefore, this work shares with other authors ¹²12. Aquino EML, Almeida MC, Araújo MJ, Menezes G. Gravidez na adolescência: a heterogeneidade revelada. In: Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Editora Fiocruz; 2006. p. 309-60.^,1313. Área Técnica de Saúde da Mulher, Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Magnitude do aborto no Brasil: aspectos epidemiológicos e sócio-culturais. Abortamento Previsto em lei em situações de violência sexual. Brasília: Ministério da Saúde; 2008. the critique of the invisibility of illegal abortions among adolescents, seeking to discuss the specificities of the practice in this life cycle stage. In order to supply as-of-yet scarce data on illegal abortion itineraries and decision-making process involving adolescents, this study focuses on the empirical reality of 10 adolescents aged 15-17 years who had undergone an illegal abortion between 12 and 17 years of age.

Methods

This is a qualitative study based on social health research principles. Because this is a sensitive subject within a complex social reality, we chose to carry out individual in-depth interviews with adolescents in order to describe and understand in detail the meanings they hold regarding the abortion decision-making process and itineraries.

The study was registered in Plataforma Brasil and was approved by the Ethics Research Committee of the Center for Philosophy and Humanities of the Federal University of Rio de Janeiro (CEP-CFCH-UFRJ), under number 1.359.048 (CAAE: 51609315.1.0000.5582). We met all requirements in order to guarantee subjects’ confidentiality, ethics and safety. Interviews followed a semi-structured outline, for which we used the GRAVAD ¹²12. Aquino EML, Almeida MC, Araújo MJ, Menezes G. Gravidez na adolescência: a heterogeneidade revelada. In: Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Editora Fiocruz; 2006. p. 309-60. study as a reference. The interview outline included subjects such as sexual and romantic initiation, contraception, pregnancy and abortion itinerary, decision-making process, choice of method, partner’s participation (or lack thereof), financial resources and support networks.

In order to select participants, we used the “snowball” method ¹⁴14. Turato ER. Tratado da metodologia da pesquisa clínico-qualitativa. Petrópolis: Editora Vozes; 2003., in which one participant nominates others from the same sociability network, and so on. They were contacted by an adolescent from the same network and were informed of the prior need of parental consent before they could participate in the study. The selection criteria was being aged 12-18 (incomplete) years, an age range that was in line with the Child and Adolescent Statute ¹⁵15. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul. and with the National Health Council Resolution n. 466/2012 ¹⁶16. Ministério da Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 jun..

Interviews were only carried out after guardians and adolescents read and signed informed consent forms, in which all subjects that were to be discussed in the interview were included, with emphasis on the investigation of the meaning that young women aged between 12 and 18 assign to romantic and/or sexual initiation, sexuality, pregnancy, abortion and contraception.

We informed parents of the need for the adolescents to sign a Term of Assent, after they had signed an informed consent form. Additionally, we provided information regarding the study to guardians over the phone. Of the 10 signatures we required, 9 were given by mothers and one by a grandmother. We only established contact with a prospective participant after the key-informant obtained her authorization. Thus, we avoided any kind of coercion or confidentiality breach ¹⁷17. Diniz D. Ética na pesquisa em ciências humanas: novos desafios. Ciênc Saúde Colet 2008; 13:417-26., guaranteeing the adolescents the freedom to accept or refuse to participate in the study, which would require that they discuss sexuality and their “secrets” with the researcher.

The first contact with potential participants was mediated by a 15-year-old adolescent who frequented a non-governmental organization where the first author worked as a psychologist. The adolescent nominated acquaintances/friends from her social circle, who each nominated at least one young woman from the same network. There were no refusals or failures to appear for scheduled interviews.

The interviews lasted on average one hour and took place in locations chosen by the adolescents. Eight interviews took place at the non-governmental organization (NGO), one took place at a diner “on the asphalt”, and another at a public space in the favela, at a time when few people were around. In these two cases, adolescents remarked that they “did not wish to be seen” by NGO workers or by the favela inhabitants when they entered the institution, so as to preserve their “secret”. The study’s data were archived with no identifying information, protected by a password, in a protected device at UFRJ, and all names used in this article are fictitious. The answers were observed based on thematic and categorical content analysis ¹⁸18. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011..

Results and discussion

Participant, family and partner profiles

As shown in Box 1, the adolescents were aged between 15 and 17 years at the time of the interview and had had an abortion between the ages of 12 and 17 years. Half of them stated they had “no religion”. Nine declared themselves to be “black” or “brown” and only one declared herself to be “white”. This is in line with the literature ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60. on illegal abortion in Brazil, which shows a higher frequency among women with lower educational levels and those who are black and brown, and also that young black women resort more frequently to unsafe abortions due to their financial conditions.

All adolescents lived with their mothers, who became pregnant during adolescence or early adulthood, between the ages of 15 and 24. Three adolescents (1, 2, 3) did not live with their fathers and four (1, 2, 3 and 6) also lived with their grandmothers. Seven adolescents (1, 2, 3, 4, 5, 7 and 10) stated that their mothers were “extremely Catholic” and three (6, 8 and 9) stated that their mothers were “extremely Evangelical”. All guardians had jobs/occupations that required low qualification and little schooling, as house cleaners, hairdressers, bus drivers and doormen. Of the participants, nine were students at the time of the abortion abortion, and they were attending between the 7^th and 11^th grades, which was compatible with their ages. Only one adolescent (10) was not a student, due to having started working as a salesperson after her first pregnancy, at age 15, which she carried to term.

As for the relationships at the time of the abortions, half stated that their partners were “boyfriends”. In some cases (2, 3, 5, 8 and 9), there was a large age gap between partners at the time of the pregnancy which resulted in an abortion. This age gap is considered more representative when it exceeds five years ¹²12. Aquino EML, Almeida MC, Araújo MJ, Menezes G. Gravidez na adolescência: a heterogeneidade revelada. In: Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Editora Fiocruz; 2006. p. 309-60..

In effect, large age gaps may be associated with risk factors among adolescents: different forms of violence, gender inequality and discrimination, exposure to infections/drugs, attitudes related to condom and contraception use, as well as to the occurrence of sexually transmitted infections, pregnancy and unsafe abortions, in addition to conflicts with the law and forms of violence ¹⁹19. Tronco CB, Dell'Aglio DD. Caracterização do comportamento sexual de adolescentes: iniciação sexual e gênero. Gerais: Revista Interinstitucional de Psicologia 2012; 5:254-69..

In these cases, when the age gap is too unequal, often male domination is internalized as natural, so that neither girls nor their mothers question the legitimacy or illegality of relationships with much older and more experienced men, or the reason for adolescents’ choice for older men with whom they establish and maintain hidden relationships marked by violence and abuse ²⁰20. Cordeiro F. Negociando significados: coerção sexual em narrativas de jovens brasileiros [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Federal do Estado do Rio de Janeiro; 2008..

Decision-making process

Sharing the pregnancy news and choosing to have an abortion

An itinerary is the set of actions up to undergoing an abortion ²¹21. 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.^,2222. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81., which involved the decision-making process (network of interlocutors and material support, information in order to make an abortion possible, justifications mobilized), methods, procedures and ramifications of the abortion ²2. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.^,2121. 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.^,2222. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81..

Mothers excluded from the decision-making process

After confirming the pregnancy, the adolescents shared the news with their friends, who were also adolescents, and some (2, 3, 4, 5, 8 and 9) also had conversations with their partners. None of them shared the news with their mothers. The argument most often used by participants not to tell their mothers about the pregnancy was related to religion, given the mothers’ likely religious morality with regard to abortion, which is perceived as a “sin”.

Afraid to involve their mothers in the decision-making process, adolescents used strategies that relied on friends, some partners, or young men involved with drug trafficking. The highly “unusual” strategy employed by the adolescents, of not telling their families, goes against some studies on pregnancy and abortion during adolescence ⁷7. Peres SO, Heilborn ML. Cogitação e prática do aborto entre jovens em contexto de interdição legal: o avesso da gravidez na adolescência. Cad Saúde Pública 2006; 22:1411-20.^,1212. Aquino EML, Almeida MC, Araújo MJ, Menezes G. Gravidez na adolescência: a heterogeneidade revelada. In: Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Editora Fiocruz; 2006. p. 309-60.^,2121. 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., because in most studies the mother or the partner’s family are frequently called upon due to the adolescents’ limitations for taking responsibility for and carrying out a decision that depends on financial autonomy.

“I don’t think my mother would have let me get an abortion. She’s extremely Catholic. She says it’s wrong for teenagers to have sex, let alone get pregnant and have an abortion, she thinks it’s a sin. I think I would end up having the baby if I told her” (Flávia, 16 years old, abortion at 15, casual dating partner aged 17)

In fact, the fear expressed in the previous quote corroborates the preservation of a culture of silence surrounding abortion ²³23. Souza ZCSN, Diniz NMF. Aborto provocado: o discurso das mulheres sobre suas relações familiares. Texto & Contexto Enferm 2011; 20:742-50., as does the acknowledgment that adolescents learn from an early age the importance of keeping secrets when they are faced with the decision to have an abortion, so as not to succumb to adversities, oppositions, conflicts and hostilities originating in the family context. For adolescents, this means a distancing and the tendency to stay silent because, in general, of a fear of not being understood in their realities, a situation that may require a difficult and failed negotiation process, forcing them to have a child ²⁴24. Aberastury A, Knobel M. Adolescência normal: um enfoque psicanalítico. Porto Alegre: Artes Médicas; 1990..

Friends: source of “protection” and solidarity

If mothers and fathers were excluded from the decision-making process and from the abortion itinerary, the participants were incisive with regard to the participation of their friends, also adolescents, who emerge as the great confidants and companions in the young women’s abortion itinerary (1, 2 and 3). Always present, they provided financial assistance, information on websites and places where they could have an abortion, as well as advice and words of support and comfort in the post-abortion moment. Friends are mentioned as “angels”, “doctors”, and “psychologists”. In terms of an adolescent’s central needs, the bonds with these peers are the most important ²¹21. 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.. Additionally, the words and gestures directed at the friends, which indicate intimacy and mutual recognition, are essential to living together in this moment filled with challenges ²⁵25. Mattos P. O reconhecimento na esfera do amor: para uma discussão sobre os paradoxos da transformação da intimidade. Síntese 2016; 43:421-42. in which vulnerability increases due to the young age and lack of experience for identifying some of the risks ²⁴24. Aberastury A, Knobel M. Adolescência normal: um enfoque psicanalítico. Porto Alegre: Artes Médicas; 1990..

“The conversation with them was great. They gave me a ton of tips on how to do it, they showed me some websites and told me they were going to help me with everything! They told me not to go to the beach and not to have sex too soon. Many of them had had one and told me it was no big deal, so I wouldn’t be afraid! They were my psychologists!” (Ana, 16 years old, abortion at 15, casual dating partner aged 19).

What distinguishes them is how much each becomes an important source of “self-experience” ²⁵25. Mattos P. O reconhecimento na esfera do amor: para uma discussão sobre os paradoxos da transformação da intimidade. Síntese 2016; 43:421-42.. We highlight the young age of participants’ friends (between 14 and 23) and the fact that many had had an abortion, in addition to the fact that all knew at least one other adolescent who had had an illegal abortion. In several interviews, we observed that they knew some adolescent who had gone through the same experience as them: “I know a lot of friends I can nominate! Abortion is very common in the favela”. Thus, for these young women, the bonds with friends are a strategy for affective and financial support, a source of information and guidance.

Relationship status and pressure from partners

One issue was a determining factor in the decision regarding the outcome of an unplanned pregnancy during adolescence: the status of the relationship and the pressure from partners in favor of an abortion ⁷7. Peres SO, Heilborn ML. Cogitação e prática do aborto entre jovens em contexto de interdição legal: o avesso da gravidez na adolescência. Cad Saúde Pública 2006; 22:1411-20.^,1111. Ferrari W, Peres S, Nascimento M. Experimentação e aprendizagem na trajetória afetiva e sexual de jovens de uma favela do Rio de Janeiro, Brasil, com experiência de aborto clandestino. Ciênc Saúde Colet 2018; 23:2937-50..

Few participants discussed their non-acceptance of the pregnancy without resorting to the “partner argument”, which denotes the difficulty and the social and moral limits imposed on abortion. The decisions on whether or not to share the pregnancy with their partners, as well as the age gap between them, are important factors when understanding the itineraries, methods and locations of clandestine abortion. The ten cases are emblematic of the subordination of the reproductive project to the type of involvement with male partners, and reveal once again that the choice for abortion is always conditioned by the dynamic of affective relationships. Thus, the termination of a pregnancy is not necessarily connected with the lack of desire for motherhood, but with the affective-sexual context ²⁶26. Bajos N, Ferrand M. Introduction. In: Bajos N, Ferrand M, editors. De la contraception à l'avortement: sociologie des grossesses non prévues. Paris: Inserm; 2002. p. 1-17.. The description of the four adolescents (1, 6, 7 and 10) who did not share the news of the pregnancy with their partners show how this happened:

“Oh, I didn’t tell him. I preferred to get my money and not tell him. I didn’t even need him for that, so I thought it was best not to tell! I don’t even know if he would want this child! Men just get in the way” (Mara, 17 years, abortion at 17, 23-year-old partner, pregnancy from an episodic sexual relationship).

The importance of the type of romantic and/or sexual relationship is highlighted in studies with different social groups ⁵5. Menezes GMS. Aborto e juventude: um estudo em três capitais brasileiras [Tese de Doutorado]. Salvador: Universidade Federal da Bahia; 2006.^,99. Silveira P, McCallum C, Menezes G. Experiências de abortos provocados em clínicas privadas no Nordeste brasileiro. Cad Saúde Pública 2016; 32:e00004815.^,2727. Cecatti JG, Guerra GVQL, Sousa MH, Menezes GMS. Aborto no Brasil: um enfoque demográfico. Rev Bras Ginecol Obstet 2010; 32:105-11., which show the extent to which not feeling secure in the relationship is determinant for having an abortion. In the case of our study’s participants, we assume that the decision to have an abortion without the partner’s participation is a result of the fact that it was an “occasional”, casual relationship.

Six other participants (2, 3, 4, 5, 8 and 9) told their partners about the pregnancy. Once again, the adolescents who became pregnant by a much older man portrayed a kind of asymmetrical arrangement in terms of gender power, which must be taken into account:

“I went to him in desperation. I hoped he was going to support me. He already had two daughters and said that I would ruin his life. He called me stupid and that I didn’t take the pill right. He put pressure on me saying it would be better for me, having an abortion. Since I trusted him, I was very scared, I accepted” (Deise, 16, abortion at 12, 42-year-old partner, “boyfriend”).

There is a tendency for adolescents to share the news of a pregnancy with a partner defined as a “boyfriend”, and his reaction to the pregnancy is a determining factor in the choice to have an abortion, showing that male disapproval is crucial for adolescents to choose to terminate pregnancies. In this case, the man bears the financial costs and does not support the adolescent, in person or emotionally, as other studies that have analyzed male participation in the abortion decision-making process have shown ²⁸28. Brito RS, Tavares MSG. Quatro fases do homem no contexto da reprodução. Natal: Observatório RH Nesc/Universidade Federal do Rio Grande do Norte; 2011.^,2929. Venturi G. Homens falam sobre aborto: uma pesquisa em São Paulo e Recife. Católicas pelo Direito de Decidir 2013. http://catolicas.org.br/wp-content/uploads/2014/07/Pesquisa-HomensFalamSobreAborto.pdf (acessado em 19/Mar/2019).
http://catolicas.org.br/wp-content/uploa... . Studies also reveal that the prevailing perspective is that of female responsibility over reproduction, leaving deeper discussions regarding gender asymmetries in the shadows in investigations of reproduction, pregnancy and abortion at that life stage.

The male experience in the process is permeated by stereotypes that must be understood based on the relational view of gender and on the cultural standards experienced by both, because these are determining factors for men’s involvement in reproduction ²⁸28. Brito RS, Tavares MSG. Quatro fases do homem no contexto da reprodução. Natal: Observatório RH Nesc/Universidade Federal do Rio Grande do Norte; 2011..

Itineraries

The itineraries were divided into three sub-items, according to the location or methods of the abortions: Itinerary 1 - abortions carried out at the “clinic in the favela”; Itinerary 2 - abortions carried out “in clinics outside the favela”; Itinerary 3 - abortions through use of misoprostol. We related the itineraries to the following variables: participant’s age, partner’s age, sharing the pregnancy (with family members, partners or friends), relationship type (“boyfriend”, “casual dating partner” or “episodic sexual relationship”) and means for acquiring the needed funds (friends, partners, drug dealers or family members).

In the analysis of itineraries, the study showed that, in most cases, the age gap between partners was associated with the method/location chosen for the abortion, since this was related with the availability of the necessary financial resources.

In Itinerary 1 (Figure 1), we find participants 1, 6, 7 and 10, who had an abortion at the “clinic in the favela” where they lived. They did not share the abortion with family members or partners, only with friends. They went alone to the clinic nicknamed the “witch’s house” and had no complications. The price they paid varied between BRL 500.00 and BRL 650.00, always in cash.

“The clinic is very small, filthy! It seems like a place where dogs sleep, it’s horrible! There was blood on the sheets too, everything was dark, it looked like a horror film. I went under anesthesia and I ‘went out’ right away. Then she had a big ax, like a sickle, so I closed my eyes and I didn’t feel anything else. I slept at a friend’s house that day, I didn’t know what it would be like. I bled a little overnight, but there was nothing left in there, she got everything out! I slept a lot and later I went back home, then I went to school as usual” (Evelin, 17 years of age, abortion at age 15, partner aged 20, pregnancy from an episodic sexual relationship).

Evelin illustrates how she was able to get the money for the abortion:

“My friends loaned me some. I remember I also asked 200 BRL from my dad, I said it’s what I wanted for my birthday, but it was a lie, right, my birthday was still a month away. I said I was going to get a really large tattoo! So he gave it to me, that was nearly all of it, right? So then I asked my brother for 50 reais because I wanted to go to a party and he gave it to me! At the time, I already had around 50 reais saved. Then some friends loaned me the rest and I managed to get all the money. Then my dad asked me about the tattoo, I lied and said I had been robbed, I couldn’t tell him the truth!” (Evelin, 17 years of age, abortion at age 15, partner aged 20, pregnancy from an episodic sexual relationship).

We highlight that the adolescents borrowed money from friends and from drug dealers, who charged monthly interest rates. In order to pay the drug dealers, the participants “did small jobs” at the beach, borrowed more money from friends, and some lied to their parents in order to get the entire sum. Between threats and risks, the narratives show the need for a greater reflection regarding the vulnerability of these adolescents’ coming closer to drug trafficking, as well as their submission/subjection to their partners, who, for the most part, were older or had to a different social status.

In Itinerary 2 (Figure 2) are the three adolescents who had abortions in “clinics outside the favela”, the first at a “clinic in the West Zone” (2), the second at the “apartment of a doctor friend” (5) and the third at a “first-rate clinic” located in a middle-class neighborhood in Rio de Janeiro (9). None of the adolescents in this group shared their abortions with their families, but they all told their partners and friends. The key point is that the financial resources were obtained from partners (2 and 5) or from friends and from drug dealers from the favela (9). Renata’s (9) narrative illustrates this example:

“The clinic was ‘first-rate’ , it wasn’t just any clinic! I was super well cared-for. I talked to the doctor first, with the nurse. She really calmed me down. I have no complaints. I was really scared of doing it at just any place, you know? So I talked to a friend who told me that a friend of hers,who was a total princess, had an abortion at this place and told me to go there. I was really welcomed! It was like I had gotten a haircut!” (Renata, 17, abortion at 15, “first-rate ” clinic at a middle-class neighborhood, 28-year-old casual dating partner).

Two adolescents (2 and 5) had their abortions paid for by their partners. Renata (9), who did not receive financial support from her partner, said she started to work at a bookstore located in the South Zone in order to pay back the BRL 2,500.00 loan she had gotten from drug dealers from the favela where she lived. The adolescent, who earned minimum wage at the bookstore, paid the drug dealers BRL 3,200.00, due to interest rates. She also recounted the constant death threats she received during the six months that it took her to repay the debt because, to the drug dealers, she was “taking too long to pay the full amount”.

Renata’s account is the most emblematic. As seen in Itineraries 1 and 2, the lack of financial resources ends up becoming one more vulnerability for the young women who, lacking family support, seek out drug dealers in order to have an abortion. The difficulty in amassing the financial resources is also a factor shown by many studies on abortion ¹1. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,22. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.^,2121. 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.. However, we can affirm that the lack of financial resources is even more delicate for women with low educational levels, who are poor and black, as the ones in this study.

The three adolescents who used misoprostol are in Itinerary 3 (Figure 3). Two took the medication at home and alone, while the third was with her boyfriend when she took it. There are obstacles to acquiring Misoprostol in the favela, because it cannot be sold directly to women.

“It used to be very cheap, Cytotec. You could easily get a pack. But the drug dealers realized that only girls bought it. Then one time a girl who dated a drug dealer bought it. Then the guys told the drug dealer. The guy was pissed because she was getting rid of his child. The girl even ran away, he said he was going to kill her! Then they stopped selling it. Then they started selling it again, but that’s when they stopped selling to women. Only men can buy it. Not even older women can buy it!” (Deise, 16, abortion at 12, 42-year-old partner, “boyfriend”).

This surprising reality is due, in part, to the prohibition imposed by the drug dealers as a way of exercising control over the decision to have an abortion. Only men are “authorized” to buy misoprostol, which signals a profound control over reproduction. The medication used in three of the abortions in this study was bought and paid for by the participants’ partners, symbolizing a subtle and efficient form of recurring male domination ³⁰30. Bourdieu P. A dominação masculina. Educação & Realidade 1995; 20:133-84.. Based on the narratives, we may conclude that the availability of misoprostol sales and purchases is embedded in a vulnerable and dangerous network, which brings them close and subjects them to drug trafficking ³¹31. Diniz D, Madeiro A. Cytotec e aborto: a polícia, os vendedores e as mulheres. Ciênc Saúde Colet 2012; 17:1795-804., making them hostage and exposing them not only to the risk of adulterated products, but also to the illegal commercialization of misoprostol and to a greater subordination to their partners and to the laws in the favela.

Post-abortion complications: more fear and discrimination

Joice was the only participant to experience post-abortion complications. She felt strong pains and lost “a lot” of blood. She called her younger sister, who took her to the Brazilian Unified National Health System (SUS):

“I went to his home, and he had the pills. He made a point of putting it ‘in there’ to make sure I was using it. It was at his place, after lunch. I’ll never forget it. Then he went to work, he left me bleeding the whole day alone, crying. I started to feel really ill, I began to bleed a lot, I was certain I was going to die. I was desperate! I was suffering, I was in a lot of pain, and then I started freaking out that I was going to be caught and arrested, that my secret was going to end up with the police. I called my sister in tears, I was losing blood and in a lot of pain. So she went to pick me up. God, that was the worst part! My sister went with me and she told me to say that I had miscarried. When I told the nurse, she gave me a dirty look and told me to wait. I waited forever, when I started screaming, saying I was going to die, that’s when they took me to the room with the doctor. He asked what had happened, I said it was a miscarriage. He asked me if that was really it and I said yes. Then, after a while, he told me to wait in a room where there were two pregnant women, I’m sure he did it on purpose. Then I kept looking at those two mothers sitting there, I was crying and bleeding. Once more, I was alone. Then the doctor came in with a dirty look on his face and said that I was going to evacuate the rest of the baby. Then he removed the rest of the baby and told me to leave and not to come back even if I was dying. He said it with those words, judging me” (Joice, 16, abortion at 15, using misoprostol, at her 20-year-old boyfriend’s house, in his absence).

In the adolescents’ narratives, their fear of being arrested, dying or having their “secret” discovered due to some complication stands out. In Joice’s case, this fear is more emblematic, because she was the only one who finalized her abortion at a SUS health unit. Her account shows health teams’ difficulty in dealing with this illegal issue, because there are still moral and ethical judgments, on the part of health professionals, negligence in the provision of care and subjective penalization of women, configuring a grave institutional violence that must be faced ³²32. Wiese IRB, Saldanha AAW. Aborto induzido na interface da saúde e do direito. Saúde Soc 2014; 23:536-47.^,3333. Ministério da Saúde. Atenção humanizada ao abortamento: norma técnica. Brasília: Ministério da Saúde; 2011..

Feelings after it is all over: “relief”

None of the adolescents regretted having had an abortion (Itineraries 1, 2 and 3). The most cited feelings were “relief” and “no regrets”. The uncertainty with regard to complications also appeared in all narratives:

“I have no regrets! It was a relief! And, like, I went there on a Thursday and had the abortion on a Friday, Monday I had to work. You just hope that everything works out so you won’t die and will show up at home and at work on Monday safe and sound” (Mara, 17, abortion at 17, 23-year-old partner, pregnancy resulting from an episodic sexual relationship).

When asked to speak, none of the participants mentioned any regrets after having had an abortion. One of the most common ways of “victimizing” women over having had abortions is moral guilt. This rationalization is often used to mark the existence of the sacredness of life and to impute women, morally and legally ³⁴34. Mori M. A moralidade do aborto: sacralidade da vida e o novo papel da mulher. Brasília: Editora Universidade de Brasília; 1997.. Still, it is crucial that we consider that the young women who took part in this study, despite being subjected to many vulnerabilities, were in a position to say that they did not regret having had an abortion, even at high costs and risks to their lives.

Final thoughts

At a life stage in which adolescents are beginning their affective and sexual lives, the identification with the friend group is intensified and the control exercised by family members or guardians is reduced ³⁵35. Ferraz E, Ferreira IQ. Início da atividade sexual e características da população adolescente que engravida. In: Vieira EM, Fernandes MEL, Bailey P, McKay A, organizadores. Seminário gravidez na adolescência. Rio de Janeiro: Associação Saúde da Família; 1998. p. 47-54.. Therefore, the possibility of responding to affective and sexual appeals supports the hypothesis of not sharing the decision to have an abortion with family and with some partners. On the one hand, abortions are a result of the “autonomy” gained with regard to reproduction ³⁶36. Chatel MM. Não ter filhos: uma revolução. In: Chatel MM, organizador. Mal-estar na procriação: as mulheres e a medicina da reprodução. Rio de Janeiro: Campo Matêmico; 1995. and, on the other, of the ethical nature of the emotions and feelings ³⁷37. Solomon RC. Fiéis às nossas emoções: o que elas realmente dizem. Rio de Janeiro: Civilização Brasileira; 2015. involved in the decisions in the face of ongoing changes in biographical trajectories.

All participants found means to have an abortion, with or without support from partners or as a result of being pressured by them, and without their parents’ knowledge. We must especially mention the difficulties they faced in order to obtain financial resources for an abortion, through loans and deals made with friends and drug dealers, given their context of different social vulnerabilities, such as the lack of resources of their own, absence of family participation, solitude when reaching their goals, inexperience with regard to pregnancy, which exposes them to moral, psychological and physical risks ³⁸38. Castel R. A discriminação negativa: cidadãos ou autóctones? Petrópolis: Editora Vozes; 2008.^,3939. Adesse L, Jannott CB, Silva KT. Aborto e estigma: uma análise da produção científica sobre a temática. Ciênc Saúde Colet 2016; 21:3819-32..

Different forms of gender and age discrimination, and also violence, were present and reproduced in each of the ten trajectories and itineraries of clandestine and unsafe abortions we analyzed. The age gap between partners can be considered substantial, considering the adolescents’ time of life and relationship experience.

We face a universe of very young adolescents who made an illegal abortion possible, in a solitary manner and within risky contexts. Beyond advancing in the discussion of the legalization of abortion, we must also consider abortions as a legitimate event with regard to adolescents’ reproduction, a subject little addressed in its specificities, so as to protect rights and confront processes of social exclusion, gender oppression and social injustices in the realm of sexuality and reproduction at the beginning of the reproductive trajectory, as observed in this study.

Acknowledgment

We thank the ten adolescents who participated in the study. We thank them for the trust, reciprocity, sincerity and courage to share their secrets in this study.

References

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