Abstract

Introduction

As the Aids pandemic enters its fifth decade, globally the number of cases of the disease among young people has begun to grow again ¹1. Idele P , Gillespie A , Porth T , Suzuki C , Mahy M , Kasedde S , et al . Epidemiology of HIV and Aids among adolescents: current status, inequities, and data gaps . J Acquir Immune Defic Syndr . 2014 ; 66 Suppl 2 : 144 - 53 . . In Brazil, where policies have been developed to ensure universal access to treatment, condoms, and HIV testing through an approach known as “combination prevention”, there are approximately 40,000 new cases of Aids per year – including a worrying number of cases among young people, men, and people living in large urban centers ²2. Grangeiro A , Castanheira ER , Nemes MIB . A re-emergência da epidemia de Aids no Brasil: desafios e perspectivas para o seu enfrentamento . Interface (Botucatu) . 2015 ; 19 ( 52 ): 5 - 8 . . This paper discusses the challenges in preventing new HIV infections among young people in Brazil at a time when the country’s new government reverts to a discourse reminiscent of that of the military dictatorship that ruled from 1964 to 1985.

A similar moral-sexual discourse was widely used to validate military rule and the repression imposed on its opponents by the regime ³3. Cowan AB . Securing sex: morality and repression in the making of the cold war in Brazil . North Carolina : The University of North Carolina Press ; 2016 . , which was still in power when the first cases of Aids appeared in the country in 1981. Sex education was limited to “moral and civic education”, which was introduced as a compulsory subject in all levels of education, from primary schools to universities, and remained so up to the 1990s. Fúlvia Rosemberg ⁴4. Rosemberg F . A educação sexual na escola . Cad Pesqui . 1985 ; ( 53 ): 11 - 9 . describes how educators who dared to address the topic in the classroom were often persecuted and prosecuted under the laws of exception. The military regime assigned joint responsibility for sex education to Air Force brigadiers and the parts of the Catholic Church that had adhered to the government. They defended that sex education should not be a “collective activity” in schools and that “innocence was the best defense for purity and chastity”, while the Federal Council of Education claimed that it was “a task of the family”.

Reverting back to this discourse in 2019, president Bolsonaro publicly tore up a government sex education booklet designed for teenagers, claiming that the illustrations of the human reproductive system were “unacceptable” ⁵5. Cancian N . Ignorar saúde sexual não protege jovem, diz criadora de caderneta vetada por Bolsonaro . Folha de São Paulo, Equilíbrio e saúde [ Internet ]. 9 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2019/03/ignorar-saude-sexual-nao-protege-jovem-diz-criadora-de-caderneta-vetada-por-bolsonaro.shtml
https://www1.folha.uol.com.br/equilibrio... . This moral-sexual discourse was adopted by various ministries during the first months of the new government, with the administration defending that only the family should talk to teenagers about sexuality ⁶6. Cancian N . Bolsonaro diz que vai recolher caderneta de saúde do adolescente . Folha de São Paulo, Equilíbrio e Saúde [ Internet ]. 7 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2019/03/caderneta-para-saude-da-adolescente-sera-revista-diz-ministro-apos-criticas-de-bolsonaro.shtml
https://www1.folha.uol.com.br/equilibrio... , ⁷7. Prazeres L . A escolhida. Polêmica, ministra Damares Alves ri do uso de fala sobre abuso no Carnaval e critica ensino sexual nas escolas . UOL, Notícias [ Internet ]. 11 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://noticias.uol.com.br/reportagens-especiais/entrevista-com-damares-alves-ministra-da-familia-mulher-e-direitos-humanos/index.htm
https://noticias.uol.com.br/reportagens-... .

Successful government programs that support sex education in schools and have helped tackle the spread of Aids are now under threat. What impact might the dismantling of these programs have on the prevention of Aids among young people initiating sexual activity? Is it feasible, or indeed desirable, to stifle the technical-scientific discourse on prevention that has supported decades of successful responses to Aids and the promotion of contraceptive use among younger and older women? How can we ignore the increased access young people have to various, often unreliable, sources of information on sexuality on social media ⁸8. Comitê Gestor de Internet no Brasil . TIC Kids Online Brazil 2012. Pesquisa sobre o uso da internet por crianças e adolescentes no Brasil [ Internet ]. São Paulo : Comitê Gestor de Internet no Brasil ; 2012 [ citado 10 Ago 2018 ]. Disponível em: https://www.cetic.br/media/docs/publicacoes/2/tic-kids-online-2012.pdf
https://www.cetic.br/media/docs/publicac... ?

Ruptures and continuities

During the dictatorship, the prohibition of the discussion of sexuality in schools made the topic a taboo ⁹9. Barroso C , Bruschini MC . Educação sexual, debate aberto . Petrópolis : Vozes ; 1982 . . With the introduction of prior censorship in December 1968, the regime, which sought to uphold “morality and good customs”, allocated the task to the Federal Police and Ministry of Justice. With the introduction of prior censorship in December 1968, the regime, which sought to uphold “morality and good customs”, allocated this task to the Federal Police and Ministry of Justice. Fear of punishment and self-censorship, which mark intersubjectivity in times of authoritarianism, intimidated the opposition, and imposed silence on sex education.

As the outbreak of HIV swept across Brazil, the end of the military regime at the end of the 1980s created a new context for health promotion and the universal right to health, from prevention to rehabilitation, was enshrined in the 1988 Constitution. Researchers and health professionals dedicated themselves to planning program-based prevention tailored to the specific needs of different sexualities and underpinned by new constitution. However, sexual health promotion faced a number of obstacles: Brazilian libraries were recovering from the censorship imposed by the dictatorship, there was no access to the internet, and research on the cultural and social dimensions of sexualities was still in its early stages.

Brazilian feminist researchers ⁹9. Barroso C , Bruschini MC . Educação sexual, debate aberto . Petrópolis : Vozes ; 1982 . , ¹⁰10. Bruschini MCA , Barroso C , Simonetti C , Vieira EM . Caminhando juntas: uma experiência em educação sexual na periferia de São Paulo . Cad Pesqui . 1983 ; 41 : 43 - 9 . , still exiled from universities, dedicated themselves to pondering upon and coming up with an alternative to “birth control”, which impinged on women’s autonomy and participationd. They resisted the instrumentalization of a single “responsible” model of family or paternity/maternity and discussed the “acceptance of differences and respect for minorities”. In the 1970s and throughout the reconstruction of democracy, dedicated to learning by doing and inspired by Brazilian authors such as Paulo Freire, they experimented with feminist emancipatory methodologies. They coproduced sex education resources with women from the periphery, learning about the everyday reality of their sexuality. They introduced “gender” (still often synonymous with “woman”) ¹⁰10. Bruschini MCA , Barroso C , Simonetti C , Vieira EM . Caminhando juntas: uma experiência em educação sexual na periferia de São Paulo . Cad Pesqui . 1983 ; 41 : 43 - 9 . as a category in the debate about rights and public policy throughout the redemocratization process.

With the emergence of Aids, the homosexual movement and other social movements fighting for universal access to public health ¹¹11. Nunn A , Dickman S , Nattrass N , Cornwall A , Gruskin S . The impact of Aids movements on the policy responses to HIV/Aids in Brazil and South Africa: a comparative analysis . Glob Public Health . 2012 ; 7 ( 10 ): 1031 - 44 . , ¹²12. MacRae E . A construção da igualdade. Política e identidade homossexual no Brasil da “abertura” . Salvador : EDUFBA ; 2018 . promoted the involvement of people directly affected by HIV/Aids as “the solution rather than the problem” ¹³13. Paiva V . Em tempos de Aids . São Paulo : Summus ; 1991 . . Such as the feminism who thought about women’s sex education, other social and psychosocial researchers had described peripheral cultural scenarios and sexual practices in the first decade of the social response to Aids ¹⁴14. Clastres PV . A sociedade contra o estado: pesquisas de Antropologia Política . Rio de Janeiro : Francisco Alves ; 1986 .

15. Trevisan JS . Devassos no paraíso. A homossexualidade no Brasil . 4a ed. Rio de Janeiro : Objetiva ; 2018 . - ¹⁶16. Paiva V . A psicologia redescobrirá a sexualidade . Psicol Estud . 2008 ; 13 ( 4 ): 641 - 51 . . In the second decade of the epidemic, Aids programs were organized and, parallel to prevention projects, this decade gave rise to a Brazilian strand of social constructionist thought about sexualities that showed, for example, how gender power and gender identities structured sexual scenes ¹⁷17. Parker R , Barbosa R . Sexualidades Brasileiras . Rio de Janeiro : Relume-Dumará ; 1996 . .

Researchers, nongovernmental organizations, and health professionals joined forces through various experiences to improve access to HIV/Aids prevention, care, and treatment as a right ¹⁸18. Gavigan K , Ramirez A , Milnor J , Perez-Brumer A , Terto Jr V , Parker R . Pedagogia da prevenção: reinventando a prevenção do HIV no século XXI . Rio de Janeiro : ABIA ; 2015 . . Learning occurred in an apparently inescapable context of Aids-related mortality and morbidity, leading to the consolidation of evidenced-based programs underpinned by constitutional principles. State secularism and the right to nondiscrimination and comprehensive healthcare validated the dissemination of complete information and the tools that were part of the right to prevention, which also included teenagers ¹⁹19. Organização das Nações Unidas para a Educação, a Ciência e a Cultura . Orientações técnicas de educação em sexualidade para o cenário brasileiro: tópicos e objetivos de aprendizagem [ Internet ]. Brasília : UNESCO ; 2013 [ citado 10 Ago 2018 ]. Disponível em: http://www.unesco.org/new/fileadmin/MULTIMEDIA/FIELD/Brasilia/pdf/Orientacoes_educacao_sexualidade_Brasil_preliminar_pt_2013.pdf
http://www.unesco.org/new/fileadmin/MULT...

20. De Jesus N , Soares Jr JM , Moraes SDTA , organizadores . Adolescência e saúde 4. Construindo saberes, unindo forças, consolidando direitos . São Paulo : Instituto de Saúde ; 2018 . - ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . .

To effectively plan prevention, Aids programs required a comprehensive synthesis of the dynamics of Brazilian sexualities at the time and their unique cultural and historical traits. These traits contrasted with Foucault’s account of power and knowledge in “The History of Sexuality” and those thematized (without context and history) by psychoanalysts, behaviorists, and epidemiologists ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . , ²²22. Parker R . Corpos, prazeres e paixões . São Paulo : Best Seller ; 1991 . . In response to the Aids social movement, Parker ²²22. Parker R . Corpos, prazeres e paixões . São Paulo : Best Seller ; 1991 . , ²³23. Daniel H , Parker R . Sexuality, Politics and Aids in Brazil . London : Falmer Press ; 1993 . described five subsystems that shaped Brazilian sexualities: (1) the Catholic religious discourse preaching marriage, monogamy, and reproductive sex; (2) the often racist social hygiene discourse defending sexual normality as opposed to promiscuous abnormality; (3) patriarchal ideology that molds sexuality (masculine/active and feminine/passive roles); (4) the notion that Brazilians are an “erotic people”, which sees Brazilian women as “export goods”; (5) the scientific discourse on the “normal”, desirable sexuality, disseminated by the media as “natural sexuality”.

The 1990s also saw the emergence of Aids prevention and reproductive health programs developed by local and state governments and incorporated into Brazil’s national health system. Aids prevention projects ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . , ²⁴24. Antunes MC , Peres CA , Paiva V , Stall R , Hearst N . Diferenças na prevenção da Aids entre homens e mulheres jovens de escolas públicas em São Paulo, SP . Rev Saude Publica . 2002 ; 36 Supp 4 : 88 - 95 . and comprehensive sex education programs ²⁵25. Nardi HC , Quartiero E . Educando para a diversidade: desafiando a moral sexual e construindo estratégias de combate à discriminação no cotidiano escolar . Sex Salud Soc . 2012 ; ( 11 ): 59 - 87 . valuing sexual diversity and equality between men and women were also introduced to the school curriculum and implemented in around 600 cities across the country’s 27 states ²⁶26. Brasil . Ministério da Educação . Projeto Saúde e Prevenção nas Escolas (SPE) [ Internet ]. Brasília : Ministério da Educação ; 2018 [ citado 10 Abr 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?Itemid=578
http://portal.mec.gov.br/index.php?Itemi... .

The moral, religious and technical-scientific discourses of previous decades coexisted with these initiatives, coproducing the socialization of young people. However, the celebrated control of the spread of Aids in Brazil was dependent on these government and nongovernmental initiatives with young people and schools. In this respect, comprehensive programs led to an increase in condom use among young people aged 14 to 19 years, from almost zero at the end of the 1980s to 48% in 1998, 54.5% in 2003, and 65% in 2005, and a reduction in differences between girls and boys over these two decades ²⁷27. Calazans G , Venturi G , Dias R . Grupo de Estudos em População, Sexualidade e Aids. Age and condom use at first sexual intercourse of Brazilian adolescentes . Rev Saude Publica . 2008 ; 42 Suppl 1 : 45 - 53 . .

Anticipating policy reversals

Aids prevention in Brazil has taken major backward steps since 2012 ²⁸28. Basthi A , Parker R , Terto Jr V , organizadores . Myth and reality: evaluating the response to Brazilian HIV/Aids response in 2016 . Rio de Janeiro : ABIA, Global Aids Police Watch ; 2016 . . The number of cases of the disease among young people (15 to 24 years) has risen and people born in the 1990s are 3.2 times more likely to be HIV-positive than those born in the 1970s and who initiated sexual activity at the beginning of the 1990s, while young men (15 to 23 years) who have sex with men are 6.6 times more likely to be HIV-positive than those who initiated sexual activity at the at the peak of the epidemic ²⁹29. Grangeiro A . Da estabilização à reemergência: os desafios para o enfrentamento da epidemia de HIV/Aids no brasil . In: Basthi A , Parker R , Terto Jr V . Mito vs realidade: sobre a resposta brasileira à epidemia de hiv e aids em 2016 . Rio de Janeiro : ABIA, Observatótio de Políticas de AIDS ; 2016 . p. 18 - 23 . . The political scenario has taken a drastic turn away from the “Brazilian formula for success”: ultraconservative Christians have questioned sex education in schools and legislative proposals have accused successful approaches of “propagating gender ideology” ³⁰30. Correa S . A política de gênero: um comentário genealógico . Cad Pagu . 2018 ; ( 53 ): e185301 . doi: http://dx.doi.org/10.1590/18094449201800530001 .
http://dx.doi.org/10.1590/18094449201800... . Reminiscent of the dictatorship and cold war ³3. Cowan AB . Securing sex: morality and repression in the making of the cold war in Brazil . North Carolina : The University of North Carolina Press ; 2016 . , a mixture of discourses prevails that fails to recognize the constitutional right of religious freedom and safeguard the secular state, disregarding that more than half of families are outside the “desirable” traditional model ³¹31. Almeida C . “Pai, mãe e filhos” já não reinam mais nos lares . O Globo [ Internet ]. 2012 [ citado 10 Ago 2018 ]. Disponível em: https://oglobo.globo.com/economia/pai-mae-filhos-ja-nao-reinam-mais-nos-lares-5898477
https://oglobo.globo.com/economia/pai-ma... . Once again, self-censorship is stimulated in schools and access to evidence-based prevention education validated by the United Nations has shrunk ³²32. Organização das Nações Unidas para a Educação, a Ciência e a Cultura . Orientação Técnica Internacional sobre Educação em Sexualidade: uma abordagem baseada em evidências para escolas, professores e educadores em saúde . Paris : UNESCO ; 2010 . .

Anticipating an increase in the vulnerability of young people to STI/Aids in this new conjuncture, the projecte that gave rise to this paper provided valuable insights into changes and continuities in the dynamics of the sexuality discourse. Below we present unpublished baseline data that help rethink sexuality subsystems and discourses.

A detailed description of the project is beyond the scope of this paper ^, . As previously described, the data analyzed below ³³33. Paiva V , Silva VN . Facing negative reactions to sexuality to sexuality education through a Multicultural Human Rights framework . Reprod Health Matters . 2015 ; 23 ( 46 ): 96 - 106 . , ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). was debated in the schools when the baseline was presented. It represents the key elements of young people’s discourses on sexual initiation and the range of opinions and behaviors influenced (or not) by religion and religiosity, where the latter is a central theme of the debate initiated by the government elected in 2019.

Method

Using the multicultural human rights-based approach (summarized in box 1 ) as a frame of reference, the first stage of the project consisted of a collaboration with the school community to explore sexual behavior among students and the meaning they assign to sexuality.

In the midst of Aids policy reversals, the debate about the results (moments 1 and 2, box 1 ) demonstrated the range of opinions and behaviors in the school community and played a crucial role in obtaining consent and sustaining permanent dialogue with parents and teachers ³³33. Paiva V , Silva VN . Facing negative reactions to sexuality to sexuality education through a Multicultural Human Rights framework . Reprod Health Matters . 2015 ; 23 ( 46 ): 96 - 106 . , ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). . This debate ensured adherence to and support for the prevention education project developed between 2013 and 2017. In one of the regions covered, the project is still maintained by schools even after the end of the research project.

The project was conducted in 2013 with students from six state schools in the Metropolitan Region of Brasília and Vale do Ribeira in São Paulo who signed an informed assent form and provided a parent/guardian informed consent form. Using palmtops, the students individually responded a questionnaire with the help of two previously trained monitors. An identification number was used for each student to ensure participant anonymity. The questionnaire contained a series of questions designed to gather the following information: (a) sex, age, family income, neighborhood of residence, grade, religion, religiosity; (b) perception of risk of HIV infection and prevention knowledge; (c) places where students get condoms and attitude towards prevention; (e) sexual practices; (f) contraception and pregnancy prevention. The questionnaire was based on instruments validated for use in Brazil to allow for national and international comparisons ³⁵35. Berquó E , Gomes MD , Ferreira MP , Correa M , Souza MR , Bussab W , et al . Comportamento sexual da população brasileira e percepções do HIV/Aids . Brasília : Ministério da Saúde ; 1998 . ( Série Avaliações 4 ). , ³⁶36. Berquó E , Barbosa RM , Lima LP . Grupo de Estudos em População, Sexualidade e Aids. Uso do preservativo: tendências entre 1998 e 2005 na população brasileira . Rev Saude Publica . 2008 ; 42 Suppl 1 : 34 - 44 . .

To allow for comparison with the literature, we selected responses from 925 students aged between 15 and 19 years and established a baseline for the intervention. The opinions of students from different religions regarding prevention and sexuality were analyzed using the chi-squared test. The analysis was performed using the statistical software package SPSS, version 23 ( Table 1 ). For the purposes of the analysis, Baptist, Presbyterian, Methodist, and neo-Pentecostal students were put into the same category.

Binomial regression was conducted for three sexual behavior-related outcomes: has had sexual relations (not a virgin), condom use during first vaginal intercourse, and condom use during last vaginal intercourse. The independent variables (potential predictors) for these outcomes were age, sex, skin color, religion, and beliefs and attitudes towards sexuality.

In addition to the above variables, the following predictors were used for condom use: age of first sexual intercourse and beliefs regarding condom use. The association between independent variables and outcomes was tested individually. Noncollinear variables with a p-value of < 0.20 were included in the multivariate model (Tables 2 to 4). The presence of collinearity was tested using Pearson’s correlation coefficient for the scale variables 1 to 4 (totally disagree to totally agree) and the chi-squared test for other variables. Binomial regression was performed using forward selection (likelihood ratio), obtaining the likelihood ratio, confidence interval, and respective p-value. A significance level of 0.05 was adopted.

Results

For the purposes of this article, we chose questions and themes synthesizing discourses on sexuality, sexual behavior, and religious practices among young people relevant to the debate with a government opposed to sex education in schools.

The average age of the students was 16.8 years and the majority of the students were female (59%) and self-declared brown (51.9%). The majority of students were practicing Christians (42% Catholic, 36.9% Evangelicals/Protestants), with 14.5% having no religion. Seventy percent of students reported that religion was very important and 40.2% attended church at least once a week.

Table 1 shows that the opinion of young people regarding sexuality varied according to religion. The proportion of students who agreed with delaying the initiation of sexual activity until marriage was greatest among Evangelicals/Protestants. This proportion was significantly lower among Catholics and other religions/those without religion. There was no statistically significant difference between girls and boys (84% and 82%, respectively) ^ffData discussed in detail in a book published by UNESCO .

The proportion of students who agreed with the statement “sex only with love” and disagreed with the statement “love without fidelity” was greatest among Protestants/Evangelicals. The proportion of girls and boys who agreed with the statement “love without fidelity” differed (38% in boys, compared to 30% in girls across all religions) ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). . Table 2 shows that approval of nonreproductive sex (masturbation and sexual activities between people of the same sex) was much lower among Protestants/Evangelicals.

The results ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). showed that 53.5% of students engaged in sexual activity. As expected, the likelihood of engaging in sexual activity increased with age. It is interesting to note that the average age of first sexual intercourse among students who engaged in sexual activity did not differ between Catholics, Protestants/Evangelicals, those with other religions, and those without a religion. The average age of first sexual intercourse among girls and boys was 14.9 and 14.2 years, respectively. This difference was statistically significant (p = 0.000). The majority of students who engaged in sexual activity (69.2%) used a condom during the first sexual intercourse.

Multivariate regression ( Table 2 ) was performed to answer the following question: what factors or characteristics are associated with and can explain the fact that these teenagers have already had sexual intercourse?

As expected, the more progressive students – those who agreed with the statement that all forms of consensual sex are valid – were more likely to have engaged in sexual activity. Evangelicals/Protestants were more likely to be virgins than Catholics and those without religion.

The strongest indicator of support for sex education in schools was the extremely high rate of agreement with access to condoms at school among all students, regardless of whether they engaged in sexual activity or not: 90.3% of students overall (86.9% of Evangelicals/Protestants). As expected, agreement with access to condoms at school was greater among students who engaged in sexual activity.

No statistically significant association was found between skin color and the outcomes in the final model.

Table 3 shows that students who agreed that information about condoms should be provided at school and that condoms increase sexual pleasure were more likely to have used a condom during first sexual intercourse. The results also show that the likelihood of using a condom during first sexual intercourse increased with age of first sexual intercourse. On the other hand, the greater the frequency of participation in religious activities, the lower the likelihood of condom use.

No statistically significant association was found between opinions regarding women having sex outside of marriage and love without fidelity and the outcomes in the final model.

Table 4 shows the results of the analysis of predictors for condom use during the last sexual encounter, revealing that 84.2% of students who had already engaged in sexual activity had had sex in the last 12 months. The most frequent sexual practice in the last sexual encounter was vaginal sex (90%), with 71.7% of those who reported having vaginal sex in the last sexual encounter using a condom.

No statistically significant association was found between religion, the importance of religion, and frequency of participation in religious activities and condom use during the last sexual encounter.

Ease of access to condoms, confidence in condom use for Aids prevention, and the association between condom use and promiscuous sexual behavior – important obstacles to prevention at the beginning of the epidemic – were included in the analysis. However, no statistically significant association was found in the final model (p < 0.20).

Finally, we identified four variables that are particularly relevant to the discussion of the challenge of sustaining school sex education programs in order to guarantee the right to prevention: (1) age of first sexual intercourse was a predictor of condom use in the last sexual encounter, meaning that delaying sexual initiation increased the likelihood of condom use in the last sexual encounter; (2) condom use during first sexual intercourse also increased the likelihood of condom use in the last sexual encounter; (3) those who agreed that condoms take the romance out of sex are less likely to use a condom in the last sexual encounter; and (4) boys were almost four times more likely (OR = 3.8) to use a condom than girls. These factors suggest that, contrary to the desires of conservative Christian political factions, the discussion of prevention and gender inequality in schools is essential to ensure effective protection against HIV infection/STIs and unwanted pregnancies among adolescents, particularly girls.

Discussion: will religious discourse and the prohibition of sex education have an impact?

The pedagogy of Aids prevention ¹⁸18. Gavigan K , Ramirez A , Milnor J , Perez-Brumer A , Terto Jr V , Parker R . Pedagogia da prevenção: reinventando a prevenção do HIV no século XXI . Rio de Janeiro : ABIA ; 2015 . depends on understanding – in all segments of the population and at any time – the cultural scene associated with the different sexualities that need to be targeted. Parker, among others, attributed the defense of more traditional values in the construction of Brazilian sexuality in the 1980s/1990s to Catholics. Our findings show that Evangelicals/Protestants were the most conservative group among those who had not initiated sexual activity, corroborating trends observed by other studies conducted in Brazil ³⁷37. Coutinho RZ , Miranda-Ribeiro P . Religião, religiosidade e iniciação sexual na adolescência e juventude: lições de uma revisão bibliográfica sistemática de mais de meio século de pesquisas . Rev Bras Estud Popul . 2014 ; 31 ( 2 ): 333 - 65 . . With respect to sexual behavior, Evangelicals/Protestants were much less likely to initiate sexual activity at high school.

On the other hand, among students who had initiated sexual activity – when access to STI/Aids prevention education and the right to access all available prevention tools is crucial – religion or having more conservative opinions was not shown to influence the adoption of safe sex practices.

Other studies using different methodologies show that having a religion influences opinions and experiences with sexuality ³⁸38. Agha S , Hutchinson P , Kusanthan T . The effects of religious affiliation on sexual initiation and condom use in Zambia . J Adolesc Health . 2006 ; 38 ( 5 ): 550 - 5 .

39. Cooksey EC , Rindfuss RR , Guilkey DK . The initiation of adolescent sexual and contraceptive behavior during changing times . J Health Soc Behav . 1996 ; 38 ( 1 ): 59 - 74 .

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47. Paul C , Fitzjohn J , Herbinson P , Dickson N . The determinants of sexual intercourse before age 16 . J Adolesc Health . 2000 ; 27 ( 2 ): 136 - 47 .

48. Stulhofer A , Soh D , Jelaska N , Bacak V , Landripet I . Religiosity and sexual risk behavior among Croatian college students 1998-2008 . J Sex Res . 2011 ; 48 ( 4 ): 360 - 71 .

49. Whitaker DJ , Miller KS , Clark LF . Reconceptualizing adolescent sexual behavior: beyond did they or didn’t they? Fam Plann Perspect . 2000 ; 32 ( 3 ): 111 - 7 - ⁵⁰50. Sambiza W , Curtis SL , Stokes CS . Ethnics differences in sexual behavior among unmarried adolescents and young adults in Zimbabwe . J Biosoc Sci . 2010 ; 42 ( 4 ): 531 . . Studies conducted in Africa have shown the opposite – that religiosity may actually increase the likelihood of sexual initiation at high school ⁵¹51. Agardh A , Emmelin M , Muriisa R , Ostergreen P . Social capital and sexual behavior among Ugandan university students . Glob Health Action . 2010 ; 3 : 1 - 13 . , ⁵²52. Hallett TB , Lewis JJ , Lopman BA , Myamukapa CA , Mushati P , Wambe M . Age at first sex and HIV infection in rural Zimbabwe . Stud Fam Plann . 2007 ; 38 ( 1 ): 1 - 10 . – or that there was no association between religion and sexual initiation ⁵³53. Broman CL . Sexual risk behavior among black adolescentes . J Afr Am Stud . 2007 ; 11 ( 3-4 ): 180 - 8 . , ⁵⁴54. Mnyika KS , Klepp K , Kvale G , Ole-King’ori N . Risk factors for HIV-1 infection among women in the Arusha region of Tanzania . J Health Soc Behav . 1996 ; 37 ( 1 ): 59 - 74 . .

Studies conducted in Brazil ³⁷37. Coutinho RZ , Miranda-Ribeiro P . Religião, religiosidade e iniciação sexual na adolescência e juventude: lições de uma revisão bibliográfica sistemática de mais de meio século de pesquisas . Rev Bras Estud Popul . 2014 ; 31 ( 2 ): 333 - 65 . have also shown that premarital sex is less likely among people with a greater frequency of participation in religious activities, regardless of religion. The influence of different religions depends not only on religion as it is actually lived and the meaning it assigns to sex, but also the interplay between religious discourse and other discourses that young people have access to during sexualization, as can be observed in studies conducted in the 1990s ¹⁷17. Parker R , Barbosa R . Sexualidades Brasileiras . Rio de Janeiro : Relume-Dumará ; 1996 . , ¹⁸18. Gavigan K , Ramirez A , Milnor J , Perez-Brumer A , Terto Jr V , Parker R . Pedagogia da prevenção: reinventando a prevenção do HIV no século XXI . Rio de Janeiro : ABIA ; 2015 . , ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . , ²⁴24. Antunes MC , Peres CA , Paiva V , Stall R , Hearst N . Diferenças na prevenção da Aids entre homens e mulheres jovens de escolas públicas em São Paulo, SP . Rev Saude Publica . 2002 ; 36 Supp 4 : 88 - 95 . and research with young people in the 2000s ³⁷37. Coutinho RZ , Miranda-Ribeiro P . Religião, religiosidade e iniciação sexual na adolescência e juventude: lições de uma revisão bibliográfica sistemática de mais de meio século de pesquisas . Rev Bras Estud Popul . 2014 ; 31 ( 2 ): 333 - 65 . , ⁵⁵55. Silva CG , Santos AO , Licciardi DC , Paiva V . Religiosidade, juventude e sexualidade entre a autonomia e a rigidez . Psicol Estud . 2008 ; 13 ( 4 ): 683 - 92 . .

Furthermore, international studies dating back to the 1990s have shown that, contrary to the fears of conservative Christians, there is an association between delaying the initiation of sexual activity and comprehensive sex education in schools ⁵⁶56. Kirby D , Obasi A , Larisa BA . The effectiveness of sex education and HIV education interventions in schools in developing countries . World Health Organ Tech Rep Ser . 2006 ; 938 : 103 - 50 . . Of particular relevance to the pedagogy of rights-based combination prevention ¹⁸18. Gavigan K , Ramirez A , Milnor J , Perez-Brumer A , Terto Jr V , Parker R . Pedagogia da prevenção: reinventando a prevenção do HIV no século XXI . Rio de Janeiro : ABIA ; 2015 . , scientific discourse has normalized condom use, making it desirable. At the same time, the media, which previously disseminated the notion of “natural sexuality” (male and female) ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . , ²²22. Parker R . Corpos, prazeres e paixões . São Paulo : Best Seller ; 1991 . – a concept that is pleasing to some of those in the government – has incorporated the new scientific discourse of socially constructed sex, challenging the imperative of “instinct” or adolescent “hormonal fever”. Most media sources have also normalized prevention discourses, assuming that boys are able to protect themselves and control their violent instincts, and that girls have sexual desires and the right both to pleasure without reproduction and consent. In other words, the media has supported the feasibility of prevention. This begs the question, why is this technical and scientific discourse desirable in the media but not in schools?

On the other hand, access to sexual content on social media and the internet is a novelty in the production of discourses on sexuality, contrasting considerably with the information sources available in the 1980s/1990s when the Aids epidemic exploded. A household survey conducted in Brazil in 2012 showed that 85% of children aged between nine and 17 years had access to the internet - 93% via cellphone ⁸8. Comitê Gestor de Internet no Brasil . TIC Kids Online Brazil 2012. Pesquisa sobre o uso da internet por crianças e adolescentes no Brasil [ Internet ]. São Paulo : Comitê Gestor de Internet no Brasil ; 2012 [ citado 10 Ago 2018 ]. Disponível em: https://www.cetic.br/media/docs/publicacoes/2/tic-kids-online-2012.pdf
https://www.cetic.br/media/docs/publicac... (70% in the socioeconomic classes C/D) – while half reported that their parents/guardians were totally unaware of their activities on the internet. Almost a quarter (23%) of teenagers aged between 15 and 17 years and 5% of children aged between nine and 14 years had accessed sexual content in videos and images. A large proportion (42%) of teenagers aged between 15 and 17 years had contacted people unknown to them and a significant percentage had exchanged sex messages (16% among 11 to 17-year-olds) on the internet. Although such information was not covered by the questionnaires in the present study ³³33. Paiva V , Silva VN . Facing negative reactions to sexuality to sexuality education through a Multicultural Human Rights framework . Reprod Health Matters . 2015 ; 23 ( 46 ): 96 - 106 . , ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). , the consumption of online pornography was observed by the ethnographic study and future research should address this issue ⁵⁷57. Poulin R . La pornographie, les jeunes, l’adocentrism . Les Cahiers Dynamiques . 2011 ; 50 ( 1 ): 31 - 9 . doi: https://doi.org/10.3917/lcd.050.0031 .
https://doi.org/10.3917/lcd.050.0031... .

While we agree with Heilborn ⁵⁸58. Heilborn ML . Entre as tramas da sexualidade brasileira . Estud Fem . 2006 ; 14 ( 1 ): 43 - 59 . that not all young people adhere to eroticized Brazilianness, one might ask whether this same eroticization explains why the influence of religious leaders on their followers is less than they might expect, especially on those who have initiated sexual activity? Might this also explain the ambiguities between the discourse and practices of conservative Christian political factions? At the beginning of his presidency, the same president who tore up the sex education booklet ⁶6. Cancian N . Bolsonaro diz que vai recolher caderneta de saúde do adolescente . Folha de São Paulo, Equilíbrio e Saúde [ Internet ]. 7 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2019/03/caderneta-para-saude-da-adolescente-sera-revista-diz-ministro-apos-criticas-de-bolsonaro.shtml
https://www1.folha.uol.com.br/equilibrio... surprisingly published images taken from pornographic sites ⁵⁹59. Fernandes T . ‘O que é golden shower’, pergunta Bolsonaro após publicar vídeo polêmico . Folha de São Paulo, Cotidiano [ Internet ]. 6 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2019/03/o-que-e-golden-shower-pergunta-bolsonaro-apos-publicar-video-polemico.shtml
https://www1.folha.uol.com.br/cotidiano/... . In other words, it is not only among the young people of this study that religiosity influences opinions about sexuality, but not their actual practices.

What will be the impact of social media on socialization for genders and sexuality and how will this impact contrast with that of the discourse of the current government? The patriarchal ideology adopted by the new government (blue is for boys and pink is for girls ⁶⁰60. Pains C . ‘Menino veste azul e menina veste rosa’, diz Damares Alves em vídeo . O Globo, Sociedade [ Internet ]. 3 Jan 2019 [ citado 10 Abr 2019 ]. Disponível em: https://oglobo.globo.com/sociedade/menino-veste-azul-menina-veste-rosa-diz-damares-alves-em-video-23343024
https://oglobo.globo.com/sociedade/menin... ), which supports the abolition of cartilhas ⁶6. Cancian N . Bolsonaro diz que vai recolher caderneta de saúde do adolescente . Folha de São Paulo, Equilíbrio e Saúde [ Internet ]. 7 Mar 2019 [ citado 10 Abr 2019 ]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2019/03/caderneta-para-saude-da-adolescente-sera-revista-diz-ministro-apos-criticas-de-bolsonaro.shtml
https://www1.folha.uol.com.br/equilibrio... about the reproductive and sexual body, still influences opinions and practices; however, as to be expected two decades later, differently to the way discussed by Parker ²¹21. Paiva V . Fazendo arte com camisinha . São Paulo : Summus ; 2000 . , ²²22. Parker R . Corpos, prazeres e paixões . São Paulo : Best Seller ; 1991 . . A comparison of our results with those of previous national studies ²⁷27. Calazans G , Venturi G , Dias R . Grupo de Estudos em População, Sexualidade e Aids. Age and condom use at first sexual intercourse of Brazilian adolescentes . Rev Saude Publica . 2008 ; 42 Suppl 1 : 45 - 53 . , ³⁵35. Berquó E , Gomes MD , Ferreira MP , Correa M , Souza MR , Bussab W , et al . Comportamento sexual da população brasileira e percepções do HIV/Aids . Brasília : Ministério da Saúde ; 1998 . ( Série Avaliações 4 ). , ³⁶36. Berquó E , Barbosa RM , Lima LP . Grupo de Estudos em População, Sexualidade e Aids. Uso do preservativo: tendências entre 1998 e 2005 na população brasileira . Rev Saude Publica . 2008 ; 42 Suppl 1 : 34 - 44 . shows that the differences of opinion between boys and girls regarding what is desirable for each sex are less pronounced. Support for homosexual sex has also grown – especially among young people who are not Evangelicals/Protestants ³³33. Paiva V , Silva VN . Facing negative reactions to sexuality to sexuality education through a Multicultural Human Rights framework . Reprod Health Matters . 2015 ; 23 ( 46 ): 96 - 106 . , ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). . However, condom use was greater among boys and girls were less likely to receive condoms from parents/guardians, who, as shown in another paper about this project, are more concerned with their daughter’s virginity than their son’s ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). .

If moral and religious preaching failed to avoid the explosion of the Aids epidemic at the end of the military dictatorship and to control the diversity of experiences and beliefs among young Brazilians in subsequent decades, it will also fail to protect against HIV infection and unwanted pregnancies. Its effectiveness has been contested not only in the realm of ideas, but also by programs that, in another direction, occupied prevention researchers and professionals and were successful over a period of two decades ¹⁸18. Gavigan K , Ramirez A , Milnor J , Perez-Brumer A , Terto Jr V , Parker R . Pedagogia da prevenção: reinventando a prevenção do HIV no século XXI . Rio de Janeiro : ABIA ; 2015 . . It is important to highlight that the debate about the preliminary study results in each school community guaranteed consent for the school prevention programs, indicating that parents and teachers value not only religious beliefs, but also scientific evidence related to sexuality and prevention ³⁴34. Paiva V , Bermúdez XP , Merchan-Hamann E , Tagliamento G , Antunes MC , Brito I , et al . Cenas escolares e sexualidade: saúde e prevenção nas escolas na perspectiva dos direitos humanos . Brasília : UNESCO ; 2019 ( no prelo ). .

Governments still have a constitutional obligation – enshrined in the universal right to health without discrimination – to promote Aids prevention for those who are unable or unwilling to take on the role proclaimed by political-religious discourse as “good behavior”. Access to information about all modes of prevention, and therefore combination prevention – including condom and contraceptives, emergency contraception, testing, and antiretrovirals (PrEP, pre-exposure, and PEP, post-exposure) – depends on the popular and pedagogically efficient dissemination of technical and scientific discourse and respect for religious freedom and individual autonomy.

It remains to be seen whether the government will be able to manipulate the prohibition of the discussion of sexuality in schools, making the topic a taboo as it did during the military dictatorship, or whether two decades of successful prevention strategies directed at two generations of young people will be wiped from the experiences of the generation who are now young adults, parents and teachers.

Acknowledgements

We are grateful to the participating schools and all the research assistants involved in this project. We would also like to thank the following organizations for generously funding the project: Ministry of Health/STI/Aids Department; United Nations Educational, Scientific and Cultural Organization; World Health Organization; United Nations Population Fund; National Council for Scientific and Technological Development (CNPq), which granted a research productivity grant to the project coordinator (312717/2013-0) and research support grant (Universal 2012487648/2012-9); and Coordination of Improvement of Higher Education Personnel (CAPES), which provided a PNPD scholarship for the Social Psychology Program offered by the University São Paulo over a period of 48 months and two doctoral scholarships for the São Paulo team.

References

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