Abstract

This study presents the findings of the social anthropological research project “Jovens da era digital: Sexualidade, reprodução, redes sociais e prevenção às IST/HIV/AIDS” [Young people in the digital age: Sexuality, reproduction, social media, and prevention of STI/HIV/AIDS], which was conducted with interlocutors between the ages of 16 and 24 years old from six Brazilian cities. This study focuses on contraceptive management among heterosexual adolescents and young adults, with particular emphasis on women, given their prominent role in family planning within hierarchical gender contexts. We describe the typical script for youth contraception, which involves the use of condoms at the onset of sexual activity, followed by the incorporation of hormonal methods or the withdrawal method. We also find that adolescents frequently resort to the use of emergency contraception. Women frequently report experiencing side effects from hormonal contraceptives, which results in high rates of discontinuation and an increased interest in copper IUDs, which are scarce resources within the Brazilian National Health System. It can be concluded that, despite gender constraints and social, ethnic, and racial inequalities, the interviewees value contraception, offering insights for the review and improvement of public policies concerning young people.

Keywords:
Contraception; Youth; Gender; Sexuality; Sexual and Reproductive Rights

Introduction

Researchers from a variety of academic disciplines, public policy makers, educators, healthcare providers, and other professionals have frequently addressed adolescent pregnancy. A moralistic discourse is typically employed, wherein the phenomenon is regarded as a cause or aggravating factor of social problems. Nevertheless, certain exceptions to this rule do exist, with some analyses seeking to uncover the heterogeneity of adolescent pregnancy experiences in light of socio-anthropological contributions, employing human rights-related concepts (Brandão; Cabral, 2017CABRAL, C. S. Articulações entre contracepção, sexualidade e relações de gênero. Saúde e Sociedade, São Paulo, v. 26, n. 4, p. 1093-1104, 2017.; Cabral; Brandão, 2021; Heilborn et al., 2006HEILBORN, M. L. et al(Orgs). O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Fiocruz; 2006.).

A study utilizing data from the Brazilian Live Birth Information System (SINASC) found that the proportion of adolescents aged 10-14 years who become mothers is decreasing, while the proportion of adolescents aged 15-19 years who become mothers is stable, despite differences across racial groups (Goes et al., 2023GOES, E. F. et al. Desigualdades raciais nas tendências da maternidade adolescente e no acesso ao pré-natal no Brasil, 2008-2019. Research, Society and Development, Vargem Grande Paulista, v. 12, n. 1, e8312139404, 2023.). Moreover, Brazil has witnessed a substantial decline in total fertility rates over recent decades, with an average of 1.76 children per woman in 2021 (IBGE, 2024IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Panorama. Rio de Janeiro: IBGE , 2024. Disponível em < Disponível em https://cidades.ibge.gov.br/brasil/panorama >. Acessado em: 20 jan. 2024.
https://cidades.ibge.gov.br/brasil/panor... ). Moreover, the most recent Brazilian census data indicated that the country’s average annual population growth rate was the lowest on record, at 0.52%. This further substantiates the rapid demographic changes currently underway in Brazil (IBGE, 2023IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Censo Demográfico 2022: População e domicílios - Primeiros Resultados. Rio de Janeiro: IBGE , 2023.).

Notwithstanding these shifts, Brazil exhibits considerable socioeconomic and demographic contrasts in family planning. The 2019 National Health Survey revealed that white women aged 15 to 49 years from southern and southeastern Brazil were more likely to use oral contraceptives (40.6%) than black/mixed-race women from northern and northeastern Brazil with low educational levels, who were the most likely to undergo tubal ligation (17.3%). Despite the decreasing prevalence of this permanent method, it is noteworthy that the groups were the most likely to resort to it (Brazil, 2021aBRASIL. Pesquisa Nacional de Saúde 2019: ciclos de vida. Rio de Janeiro: IBGE, 2021a.; Trindade et al., 2021TRINDADE, R. E. et al. Uso de contracepção e desigualdades do planejamento reprodutivo das mulheres brasileiras. Ciência & Saúde Coletiva , Rio de Janeiro, v. 26, sup. 2, p. 3493-3504, 2021.).

It can be reasonably inferred from the findings of Diniz, Medeiros, and Madeiro (2023DINIZ, D.; MEDEIROS, M.; MADEIRO, A. National Abortion Survey - Brazil, 2021. Ciência e Saúde Coletiva, Rio de Janeiro, v. 28, n. 6, p. 1601-1606, 2023.) that the use of contraceptive methods (CM) in Brazil has likely contributed to a reduction in the incidence of abortions. In Latin America, the use of long-acting reversible contraceptives — which have not yet been made fully available in the Brazilian National Health System (NHS) — has grown, although with significant social disparities (Bearak et al., 2018BEARAK, J. et al. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. The Lancet Global Health, London, v. 6, n. 4, e380-e389, 2018.; Ponce De Leon et al., 2019PONCE DE LEON, R. G. et al. Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries. The Lancet Global Health , London, v. 7, n. 2, e227-e235, 2019.). This study is concerned with the narratives of adolescents and young adults regarding their contraceptive experiences. Our analysis is informed by previous reflections that have highlighted the impossibility of understanding youth contraceptive practices as dissociated from gender and sexuality. Furthermore, contraceptive methods (CM) are biomedical technologies that can facilitate the exercise of a pleasurable sexual life (Cabral, 2017CABRAL, C. S. Articulações entre contracepção, sexualidade e relações de gênero. Saúde e Sociedade, São Paulo, v. 26, n. 4, p. 1093-1104, 2017.).

The practice of contraception is deeply enmeshed with power and hierarchical relations and is expressed and enhanced at the intersection of axes of inequality, such as gender, race, class, sexuality, ethnicity, and generation. The multiplicity of discourses, including those from medicine, education, religion, the media, and social networks, among others, shape the experiences of individuals regarding contraception. The findings of this study demonstrate that, despite social constraints, young people employ various strategies to access and use contraceptive methods (CM) beginning with their sexual initiation and throughout their affective-sexual trajectories. These strategies are indicative of a valuing of contraceptive practices. This study is part of a larger, multifaceted socio-anthropological research project entitled “Jovens da era digital: Sexualidade, reprodução, redes sociais e prevenção às IST/HIV/AIDS” [Young people in the digital age: Sexuality, reproduction, social media, and STI/HIV/AIDS prevention]. The research delves into the sociability, sexuality, and reproductive experiences of adolescents and young adults to gain a deeper understanding of the forms of affective-sexual intimacy that emerge in the context of relationships mediated by social media.

This study presents an overview of the empirical findings based on our experiences working with the topic and team discussions about the analytical insights that have caught our attention and warrant further discussion.

Methodological aspects

A socio-anthropological perspective was employed in the conduct of 194 in-depth individual interviews with young people aged 16 to 24 years. The objective was to analyze their affective, sexual, and reproductive trajectories and the intertwined nature of these trajectories. The field research was conducted in four distinct locations: one in the northeastern region (Salvador), one in the southern region (Porto Alegre), two in the southeastern region (Rio de Janeiro and São Paulo), and two smaller cities in the states of Minas Gerais (Conceição do Mato Dentro) and Amazonas (São Gabriel da Cachoeira).

The interviews followed a semi-structured script, with the assistance of young researchers, the majority of whom were affiliated with the academic institutions involved in this research. The research team underwent training in fieldwork and interview techniques, based on the theoretical and methodological assumptions of this study. Most interviews were conducted in person at a location selected by the participants, in accordance with the preventive recommendations against SARS-CoV-2. The interviewers recorded, transcribed, and reviewed the interviews, after which they created analytical summaries and tables utilizing the interlocutors’ biographical information. Furthermore, NVIVO was employed as a storage, organization, and coding tool.

The local research teams employed a variety of recruitment strategies, including leveraging the personal networks of study coordinators and interviewers, disseminating study materials on social media, and utilizing snowball sampling. The fieldwork was conducted between October 2021 and July 2022, a period during which Brazil experienced a decline in the incidence of COVID-19 and associated mortality, in conjunction with an increase in vaccination, including among adolescents and young people.

The study’s heterogeneous sample included primarily cisgender women and men, in addition to transgender and non-binary individuals. The study’s findings were derived from interviews with young people from diverse social classes and racial groups, who provided information on their reproductive experiences (or lack thereof) and sexual orientations. Additionally, researchers’ fieldwork notes were utilized. The objective was to create a diverse set of narratives that would facilitate an understanding of contemporary youth trajectories, with a particular focus on affective-sexual issues.

Most respondents (n=194) identified as cisgender women (n=100) or men (n=87). Seven participants identified as transgender, non-binary, or gender-fluid. The largest group in this study was that of self-declared Black or mixed-race individuals (n=120). Approximately one-third of the participants identified as members of the LGBTQIA+ community (n=58), with a significant proportion identifying as bisexual (n=37). A significant proportion of participants had completed or were still pursuing a secondary education. Approximately half of the sample (n=96) indicated that they did not adhere to any religion. The study analyzed the narratives of boys and girls, given the pivotal role they play in making contraceptive decisions within hierarchical gender contexts. Finally, this study focused on cisgender, heterosexual, and sexually initiated individuals.

This study was approved by the Brazilian National Research Ethics Commission and the research ethics committees of the co-participating institutions. In accordance with the ethical standards of the research community, parental consent was waived for participants under the age of 18, who signed free and informed assent forms. Participants aged between 18 and 24 years of age signed informed consent forms. To maintain the confidentiality of the participants, fictitious names were used in their stories and testimonials.

Exploring contraceptive possibilities

Sunna, aged 19, is a cisgender, White, female college student. She resides with her parents and younger sister in a middle- to upper-middle-class neighborhood of Salvador. Like her peers, Sunna espouses a progressive worldview on gender attributes and expectations, as well as on sexuality. She self-identifies as bisexual, although her affective-sexual trajectory has been characterized by heterosexual partnerships.

Sunna initiated sexual activity at the age of 16. Prior to engaging in sexual intercourse for the first time, Sunna and her partner discussed contraception and opted to utilize a condom. Subsequently, Sunna began to combine the use of condoms with the administration of birth control pills, which were prescribed by a private gynecologist. She purchased these pills from pharmacies after medical appointments, which were attended by her mother. The couple continued to employ a combination of contraceptive methods for a period of four years until the relationship came to an end. She did not become pregnant. She stated that she rejected the contraceptive pill on the grounds that “a healthy individual should not regularly take medication” and due to the unpleasant side effects. Sunna reported a condom breakage incident during sexual intercourse at a time when she was unusually abstaining from the pill. The subject of this study, a woman who had previously rejected the contraceptive pill, nevertheless opted for emergency contraception (EC) without hesitation. She stated that she had felt violated by the prospect of inserting a foreign substance into her body, despite her awareness that it would have adverse effects “I knew it was going to hurt me, it would to be a hormone bomb”.

Sunna’s trajectory aligns with the social expectations commonly held by healthcare providers (McCallum; Reis, 2008MCCALLUM, C. A.; REIS, A. P. Users’ and carers’ perspectives on technological procedures for ‘normal’ childbirth in a public maternity hospital in Salvador, Brazil. Salud Pública de México, Cuernavaca, v. 50, n. 1, p. 40-48, 2008.), who prioritize postponing childbearing in favor of pursuing other life projects, including education and entering the labor market, which are considered significant milestones in the transition to adulthood. Sunna’s social class and racial background afforded her convenient and informed access to CM, including EC, family support, and open communication with her partner. In contrast, Ana, a young woman residing in the state of Amazonas, lacked these resources.

Ana is a 19-year-old Indigenous girl belonging to the Baré ethnic group. She has seven siblings and resides with her grandmother, daughter, and other relatives. She completed nine years of formal education but was compelled to interrupt her studies due to the global pandemic caused by the novel coronavirus, SARS-CoV-2. She mentions difficulties with her mother and asserts that she is unsure of her father’s identity. As in the case of Sunna, she initiated sexual intercourse at the age of 16 with an Indigenous male of a different ethnic group, who was 17 years old and a friend of her friends. The two individuals first engaged in discourse via the WhatsApp application. Subsequently, they commenced a romantic relationship that endured for approximately one year. The couple utilized a condom during their first sexual encounter. Subsequently, Ana commenced the daily use of contraceptive pills, which she procured from a public health clinic or purchased from a pharmacy. Furthermore, she has also resorted to EC in certain instances. Ana notes that she and her initial partner frequently discussed the potential for sexual intercourse. According to Ana, “prior to our first sexual encounter, we engaged in extensive discourse. I found him attractive, and we engaged in sexual intercourse. I said yes, so I consented to this act.”

Ana’s second romantic partner was also an Indigenous young man of a different ethnic background. The duration of their affective-sexual relationship was 10 months. Both met at Ana’s aunt’s residence. In this relationship, the interlocutor did not employ continuous hormonal contraceptives, relying primarily on condoms and, in other instances, the morning-after pill. With this partner, at the age of 18, Ana became pregnant and considered terminating the pregnancy, but her aunts, with whom she discussed the pregnancy, dissuaded her from doing so. One month after the birth of her daughter, Ana terminated the relationship and has not engaged in any further affective-sexual relationships. She indicated that she had not participated in any educational programs about pregnancy prevention and that she had not discussed the topic with her partners. The health information that they possessed had been obtained through social project lectures.

As with the other young people who comprise our study group, Sunna and Ana have disparate life trajectories and social and ethnic-racial origins. However, they exhibit similarities in their contraceptive practices, which were characterized using condoms during sexual initiation, followed by daily use of the birth control pill and EC. In the group of sexually active cisgender women (86), more than half (48) had used contraceptive pills at some point in their lives, corroborating the findings of previous studies (Olsen et al., 2018OLSEN, J. M. et al. Práticas contraceptivas de mulheres jovens: Inquérito domiciliar no município de São Paulo, Brasil. Cadernos de Saúde Pública , Rio de Janeiro, v. 34, n. 2, e00019617, 2018.).

The 2019 Brazilian National School Health Survey, conducted with students aged 13 to 17 years, revealed that among sexually initiated adolescents (35.4%), 79.7% utilized hormonal CM during their most recent sexual intercourse. Of these, 52.6% utilized the birth control pill, 17.3% employed EC, and 9.8% engaged in injectable contraception (Brasil, 2021bBRASIL. Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE ; 2021b.). Lago et al. conducted an analysis of a population survey in the city of São Paulo, which estimated that 84.8% of women aged 15 to 44 years old use contraception. The CM most frequently cited was the pill (27%), followed by condoms (19%) and injectables (10.4%) (Lago et al., 2020LAGO, T. G. et al. Diferenciais da prática contraceptiva no Município de São Paulo, Brasil: resultados do inquérito populacional Ouvindo Mulheres. Cadernos de Saúde Pública , Rio de Janeiro, v. 36, n. 10, e00096919, 2020.). Lago et al.’s survey observed an 81% prevalence of contraceptive practices among young people aged 15 to 19 years, with male condoms (28.2%) and oral contraceptive pills (23%) being the most reported methods. This finding is consistent with Olsen et al.’s (2018OLSEN, J. M. et al. Práticas contraceptivas de mulheres jovens: Inquérito domiciliar no município de São Paulo, Brasil. Cadernos de Saúde Pública , Rio de Janeiro, v. 34, n. 2, e00019617, 2018.) observation that male condoms and oral contraceptive pills were the most frequently used CM among young people aged 15 to 19 years.

Hormonal contraceptives, particularly daily pills, were the most prevalent CM (n=48) among the study participants. In addition, 22 respondents selected injectables administered every three months, while 18 participants received injectable contraceptives monthly. At the time of the interview, 28 study members were using some form of hormonal CM, with a higher prevalence among lower-class youths (n=15). Moreover, 54 individuals had utilized the morning-after pill at least once in their lives.

Another method frequently utilized was the use of condoms, either independently or in conjunction with other CM. Most study participants (n=93) reported using male condoms during the initial stages of sexual initiation, a finding that is line with other studies (Marinho; Aquino; Almeida, 2006; Cabral; Brandão, 2021CABRAL, C. S.; BRANDÃO, E. R. Uma bricolagem de experiências contraceptivas: desafios impostos à gestão da potencialidade reprodutiva. Teoria e Cultura, Juiz de Fora, v. 16, n. 1, p. 21-31, 2021.). Moreover, our findings indicated that a substantial proportion of cisgender young women who had initiated sexual activity (67%) had utilized condoms at some point in their lives. When considering both cisgender young men and young women, more than half (n=57) indicated that condoms are currently their predominant CM.

This phenomenon is exemplified by the case of Nicolas, an 18-year-old, White, heterosexual, middle-class resident of São Paulo, whose sexual initiation occurred at the age of 16 with a casual partner who was three years older than him on New Year’s Eve 2019. In his own words, Nicolas recounts the circumstances of his sexual initiation: The incident in question occurred at a social gathering held in a condominium complex. As the two of them conversed, the woman proceeded to the women’s restroom. “I accompanied her; we secured the door and proceeded to engage in sexual intercourse within the bathroom.” The individual in question had procured a prophylactic from a pharmacy and utilized it. The couple proceeded to engage in sexual intercourse after his initial orgasm, yet without the use of a condom. This information was provided by Nicolas. “I purchased [... ] and was a virgin, so I said, ‘It’s going to be at the end of the year.’ “I was exerting my utmost effort.” The initial encounter involved the use of a condom, but the male partner was compelled to remove it following completion of the act. Consequently, the couple proceeded to engage in a second sexual intercourse without the use of a contraceptive.

Nicolas’s inaugural romantic partner was 16 years of age. The couple’s relationship lasted for a period of two years. Initially, they engaged in sexual intercourse without the use of a condom. This led to the partner utilizing EC that she had purchased from a pharmacy. He states that the young woman consulted a private gynecologist and began taking daily contraceptive pills. During this period, the young man engaged in a casual relationship with another girl, during which they used condoms.

In principle, male condoms represent the simplest, easiest, and most accessible CM. They are widely used by young people, although often discontinuously. This resource appears to be linked to the type of relationship or to the non-adoption of other CM by partners (Cabral; Brandão, 2021CABRAL, C. S.; BRANDÃO, E. R. Uma bricolagem de experiências contraceptivas: desafios impostos à gestão da potencialidade reprodutiva. Teoria e Cultura, Juiz de Fora, v. 16, n. 1, p. 21-31, 2021.; Marinho; Aquino; Almeida, 2006). This is analogous to the case of Joaquim, a lower-class, single, 23-year-old male from Rio de Janeiro who has two children. When queried about his condom usage, Joaquim responded: “I utilize them. However, this is not the case if one is married. Consequently, I carry condoms in my wallet and other protective measures in case the situation arises. Plus, before entering a relationship with someone, I inquire about their contraceptive practices. While some may be reluctant to disclose this information, I believe it is important to know if they are using contraceptives, including the use of intrauterine devices (IUD). I have had a relationship with a person who had an IUD in the past. Subsequently, I did not utilize any form of contraceptive protection. Instead, I undergo a series of tests every six months to ensure I am fine. Thank God I have never had anything [bad happened to me]”.

Joaquim’s response shows that condom use depends on the nature of the affective-sexual relationship. When he got married, contraception became the responsibility of his partner, who used various hormonal methods before discontinuing them due to side effects. The young man points out that he tried to convince his wife not to stop taking hormonal contraceptives: “No, keep taking it, it will keep you from having children[... ] ‘No, let’s protect ourselves in another way, I’ll get harmed, I’ll get fat’, women and aesthetics, you know...” So, I said ‘Oh, it’s okay,’ and it turned out that with that came, you know, another child. Because she did not take the injections, I now have two children. The story above illustrates the interplay between the inclusion and exclusion of men from the contraceptive burden. The responsibility for using regular contraceptive methods often falls on women, with men bearing contraceptive responsibility only in casual relationships.

Couples also often use the withdrawal method, a male control method that is an alternative to contraception. In our survey, seven young men and five women said they often used the withdrawal method, although they understood its low effectiveness, as did other young men and women. During their lives, 26 women and 46 men said they had used this method. In general, the use of this method of contraception is part of strategies in the absence or temporary discontinuation of other contraceptive methods.

Our data suggest a typical contraceptive regimen for adolescents, which includes the initial use of condoms, followed by, or combined with, the pill or another hormonal contraceptive method, or combined with the withdrawal method. This study highlights two noteworthy findings, namely the recurrent use of emergency contraception and the frequent complaints of young women about the adverse effects of hormonal contraceptives, which will be discussed in more detail in the next section.

Emergency contraception’s strategic place in current generation

As in the cases of Sunna, Ana, and Nicolas’ partner, 54 women reported having used the morning-after pill during their reproductive lives. The 2019 Brazilian National School Health Survey (Brasil, 2021bBRASIL. Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE ; 2021b.) showed that 45.5% of sexually active girls aged 13-17 had used emergency contraception at some point. Furthermore, the population survey by Olsen et al. (conducted in São Paulo) supports these findings, confirming that 60% of young women aged 15 to 19 years who had had heterosexual intercourse had used emergency contraception at least once in their lives (Olsen et al., 2018OLSEN, J. M. et al. Práticas contraceptivas de mulheres jovens: Inquérito domiciliar no município de São Paulo, Brasil. Cadernos de Saúde Pública , Rio de Janeiro, v. 34, n. 2, e00019617, 2018.).

Camila is 23 years old, working class and lives in São Paulo. She defines herself as a cisgender, Black, heterosexual woman. Although pregnancy was not discussed, she insisted that her partner use a condom the first time they had sex. Her partner agreed, but she brought a condom to their date anyway. According to Camila, “when the time comes, they will pretend to have forgotten, so I feel like I’m always the one who has to remind them that they’re going to put on the condom, right?” After starting a new relationship, Camila saw an NHS gynecologist to start using the pill but was unable to get the tests her gynecologist requested due to the onset of the COVID-19 pandemic and the resulting restrictions on access to non-essential health services.

Hence this young woman did not start using oral contraceptives, but she told us that she insists that all her sexual partners use condoms and that she always carries one with her as a precaution. She has been using condoms with her current partner but is planning to switch to CM because she finds that condom use has negatively affected his sexual performance.

Camila also used emergency contraception after a male condom broke during intercourse. Our interviewee provides more information about the situation that led her to use EC:

As in her reported experience, Camila believes in the constant risk of pregnancy. “See, the condom can break, and I do not take the pill. There is always the morning-after pill, of course, but anyway, I do not know if something can happen, and it won’t be effective. So, I know there is [risk], and I always have that little fear.” Male condom breakage or the withdrawal method and its unsafe consequences are the most common reasons for EC use. Many respondents mentioned using EC in other situations, as in the case of Amanda, a young resident of Conceição do Mato Dentro, Minas Gerais.

Amanda is a 24-year-old, lower-class, cisgender, heterosexual woman who grew up in a quilombo and identifies as Black. Her first sexual relationship was at the age of 18 years with a 21-year-old man who became her boyfriend. Before sexual initiation, they discussed about what CM they would use to avoid pregnancy and decided on condoms purchased from a pharmacy, which they have used “almost always” since the beginning of their six-year relationship. In addition to condoms, Amanda has also used EC: “I have used it once, the morning-after pill, because we thought the condom had not worked and, just to be safe [… ], he bought it. [… ] Because it was the first medicine I had ever taken, it affects your body, you know, so I had a headache. Anyway, my menstrual flow was irregular, but I knew that this could be because of the pill, right [… ]”.

Our interviewee stated that she never wanted to use another method of contraception, such as the pill. She and her partner agreed that the pill was not an ideal method because it could harm her health or affect her future fertility. Although she wanted to use another type of contraception, Amanda said she was not aware of any that did not have negative health effects. Like many of our respondents, Amanda was concerned about hormonal contraceptives. These methods are often discontinued because of their unpleasant side effects and fears about their long-term effects on users’ health and fertility.

Our findings show that EC was generally obtained from commercial pharmacies, rather than through the NHS. In some cases, young people use this strategy to escape the social control they face when they seek help at their local public health clinics (UBS). Luciano, a 22-year-old Black man living in a lower-class neighborhood in Salvador, recounts a situation in which his partner resorted to the morning-after pill:

Another aspect that deserves further attention is that EC is often used incorrectly, both in terms of frequency and administration. We have seen stories of young people using EC repeatedly, in combination with other hormonal contraceptives. Maria, a 23-year-old lower-class Black mother from Salvador, said she had used the method several times, even unnecessarily: “It was really weird... At that time, if he came on my leg, I would take a morning-after pill because I was very afraid of that happening.”

Men also frequently used EC. Commercial pharmacies allow its purchase and immediate use after unprotected intercourse or when male condoms break, remain in the vagina of the female partner, or when semen leaks. Many interviewees have full confidence in the effectiveness of EC, even buying them repeatedly to give to their partners in “risky” situations.

When Iago, 23 years old, Black, lower class, married, father of one child and resident of Conceição do Mato Dentro, is asked about his concerns about pregnancy, he expresses his confidence in EC: “See, I had it, but the morning-after pill solves everything, you know?!” He explains that he has repeatedly purchased the method for his current and former partners. His testimony stands out for the way he handles risky situations. Iago explains: “I bought [EC] and gave it to her, right? Yes, then just send me the picture, right?! After you take it. Show me that you took it.” When asked about possible negotiations with his partner regarding the use of EC, Iago denies any prior agreements. For him, the use of EC after unprotected sex seems implicit: “No, because it is the right method, right? [... ] Everyone knows that.”

In conclusion, the diffusion of EC as an alternative contraceptive is clear, especially as a resource in cases of non-use or failure of another CM, uncertainty about the efficacy of the used CM, possible failure of the withdrawal method, delays in the timing of injectable contraceptive use, or forgetting to take the pill, among other situations. The popularity of EC is since it is available behind the counter, without a prescription, and that it can be used sporadically in emergencies, avoiding the need to take pills continuously. Nevertheless, there is a widespread perception that EC is a "hormonal bomb", which may hinder the effective management of contraceptive risks (Brandão et al, 2016BRANDÃO, E. R. et al. “Bomba hormonal”: Os riscos da contracepção de emergência na perspectiva dos balconistas de farmácias no Rio de Janeiro, Brasil. Cadernos de Saúde Pública , Rio de Janeiro, v. 32, n. 9, e00136615, 2016.).

Beyond the benefits: use of hormonal methods and experience with adverse effects

As mentioned above, most of the young women in our study use hormonal CM. Young people’s experiences of learning how to use these methods refer to a generation that is very concerned and anxious about their side effects, a phenomenon that has attracted interest in different countries (Bajos et. al., 2014BAJOS, N. et al. La crise de la pilule en France : vers un nouveau modèle contraceptif ?. Population & Sociétés, Aubervilliers, v. 511, n. 5, p. 1-4, 2014.; Gubrium, 2011GUBRIUM, A. “I’ve lost my mojo, baby”: a narrative perspective on the effect of depo-provera on libido. Sexuality Research and Social Policy, v. 8, n. 4, p. 321-334, 2011.). There were several narratives about the side effects of hormonal contraception, such as headaches, excessive bleeding, vascular problems, weight gain, decreased libido, fatigue, mood swings, swelling/edema, irritation, and malaise, among others. However, reports of adverse effects associated with the pill are not new. Since the introduction of the pill in Brazil in the 1970s, women have expressed discomfort due to its adverse effects (Pedro, 2003PEDRO, J. M. A experiência com contraceptivos no Brasil: uma questão de geração. Revista Brasileira de História, São Paulo, v. 23, n. 45, p. 239-260, 2003.).

As a result of these problems, many young women often change or stop using hormonal methods. Clarice is a 23-year-old, cisgender, Black, bisexual woman from Rio de Janeiro. Unemployed and with no income of her own, she interrupted her degree at a public university. Unlike most women, she reported regular visits to the gynecologist because she uses a copper IUD. She decided to get an IUD after a long period of using hormonal contraception. Although she used the pill for five years in addition to condoms in certain scenarios, the negative effects of the pill forced her to look for alternatives, as Clarice tells us:

When Clarice went to a local public health clinic, the doctor was not receptive to her request to change her CM: “The doctor said, ‘Ah, if it ain’t broke, don’t fix it...’ I said, ‘Man, I am not okay, I am not okay.’” She goes on to explain how the doctor underestimated the reported side effects of hormonal contraception and recommended that she stick with that method. Dissatisfied, Clarice went to another NHS gynecologist, who referred her for a copper IUD.

Like Clarice, many young women (n=28) wanted to use a non-hormonal contraceptive method, especially copper IUD, which were used by only five lower-class and five middle-class respondents, respectively. Overall, these devices were inserted postpartum through the UHS or in private health clinics for those who could afford it. Of the women who had children (n=45), 13 lower-class and two middle-class women expressed interest in using copper IUD but believed that they were difficult to obtain free of charge. Although the NHS has had the device for decades, studies highlight how organizational barriers, such as a lack of IUD or trained professionals to insert them, and moral barriers, such as health professionals’ reluctance to recommend IUD for adolescents or women without children, hinder access to IUD (Gonzaga et al., 2017GONZAGA, V. A. S. et al. Barreiras organizacionais para disponibilização e inserção do dispositivo intrauterino nos serviços de atenção básica à saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 51, e03270 , 2017.).

To advance on adolescent and teen pregnancy prevention, public policymakers and health care providers often neglect or silence reports of adverse effects of hormonal contraceptives. Ignoring young women’s complaints can be understood as a form of “medical gaslighting” (Sebring, 2021SEBRING, J. C. H. Towards a sociological understanding of medical gaslighting in western health care. Sociology of Health and Illness, Massachusetts, v. 43, n. 9, p. 1951-1964, 2021.), a term used to describe forms of psychological violence by health care providers who express disbelief in their patients’ symptoms or suffering. The normalization of the side effects of hormonal contraception in the context of sexual and reproductive care/counseling may significantly influence women’s contraceptive choices, including those of adolescents and young adults.

Sources of information, access to contraception and non-comprehensive approach of healthcare providers

Official documents from the Ministries of Health (Brasil, 2009) and Education (Cassiavillan; Albrecht, 2023CASSIAVILLANI, T. P; ALBRECHT, M. P .S. Educação sexual: uma análise sobre legislação e documentos oficiais brasileiros em diferentes contextos políticos. Educação em Revista, Belo Horizonte, v. 39, e39794, 2023.) emphasize the importance of providing quality reproductive and sexual health information as a basic strategy for sexuality education for adolescents in health services and schools.

However, the main sources of information cited by our respondents were Google, health websites, blogs, and social media. On the one hand, the willingness of the study participants’ generation to seek new knowledge in the digital world expands their access to multiple sources of information. On the other hand, these sources often do not guarantee access to reliable information, as many websites provide misleading or even harmful information that is used as a reference when making contraceptive decisions.

The second most frequently mentioned sources of information were schools, NGO, or social projects. Schools provide information that is considered inadequate, in the form of sporadic lectures on sexual and reproductive health that focus on the physiological aspects of reproduction.

Their men were largely misinformed about the types and function of female contraceptives. Many cited their sisters or partners as their main sources of information about CM. Among young women, many sought information from blogs or support groups on social media, viewing other women’s contraceptive experiences as reliable information. A significant proportion of women in our study follow digital influencers on social media (Instagram, Tik Tok, YouTube), some of whom are doctors. Paradoxically, despite this myriad of available information (often of uneven quality), young women feel helpless when making contraceptive decisions, sometimes using contraceptives used by their friends, cousins, or sisters, or in certain situations receiving misguided advice from relatives or pharmacists, among others. Unfortunately, it is often difficult to find health care providers capable of providing negotiated and non-authoritarian counseling, both essential components of sexuality education for the adolescent population (Guimarães; Cabral, 2022GUIMARÃES, J.; CABRAL, C. S. Pedagogias da sexualidade: discursos, práticas e (des)encontros na atenção integral à saúde de adolescentes. Pro-Posições, Campinas, v. 33, e20200043, 2022.).

The dialogue about sexual initiation remains unspoken in many families, especially in lower-class families. As for their middle-class counterparts, some young women have been referred to gynecological appointments through private health insurance, which may or may not result in adequate counseling. On the other hand, some lower-class mothers, upon learning of their daughters’ sexual initiation, tried to take their daughters to local public health clinics in search of an immediate solution, such as a hormone injection, without any prior dialogue with these young women about the use of this contraceptive method or its possible side effects.

The lack of information provided by schools, health services and families silences any questions or uncertainties related to young people’s exercise of sexuality and use of contraception. This worrying trend is exacerbated by the barriers to care that exist in many health services, which are often difficult for young people to navigate or understand.

Final remarks

This study outlined how adolescents and young people have used a variety of strategies to access and use contraceptive methods. The narratives examined illustrate how contraceptive management processes - beginning with sexual initiation and continuing throughout their sexual lives - are mediated directly by young people and, in some cases, through dialogue with their partners.

Based on our empirical findings, we argue that despite the limited focus on sexuality and gender issues in schools (Cassiavillani; Albrecht, 2023CASSIAVILLANI, T. P; ALBRECHT, M. P .S. Educação sexual: uma análise sobre legislação e documentos oficiais brasileiros em diferentes contextos políticos. Educação em Revista, Belo Horizonte, v. 39, e39794, 2023.), limited family support in affective-sexual decision-making, and the relative absence of health services, particularly in terms of their ability to provide attentive and involved listening, reception, monitoring, and regular and discussed provision of contraceptive methods, young people use different strategies to obtain and use available CM. Hormonal methods, such as emergency contraception, are notable for their widespread use and distribution, often outside of the NHS.

Our interviewees report being immersed in learning processes related to the exercise of their sexuality and contraceptive strategies, in addition to valuing non-reproduction at this stage of life. This is where contraception comes into play. In our study, adolescents do not exhibit fully internalized contraceptive norms, as found by Bajos and Ferrand (2002BAJOS N., FERRAND M. (Org.) De la contraception à l’avortement: sociologie des grossesses non prévues. Paris: Éditions INSERM, 2002.). However, an incorporated disposition (Bourdieu, 1983BOURDIEU, P. Esboço de uma teoria da prática. In: ORTIZ, R. (Org.). Pierre Bourdieu: Sociologia. São Paulo: Ática, 1983. p. 46-81.) guides contraceptive practices and strategies, valuing contraception. Thus, in the context of our study, young people view contraception positively, considering it good, right, and socially desirable.

However, gender hierarchies and the social, racial, ethnic, and other inequalities that characterize Brazilian society often constrain young women’s agency. These hierarchies and inequalities, coupled with setbacks in the organization of education and sexual and reproductive health services, are barriers to women’s family planning autonomy (Cabral, 2017CABRAL, C. S. Articulações entre contracepção, sexualidade e relações de gênero. Saúde e Sociedade, São Paulo, v. 26, n. 4, p. 1093-1104, 2017.).

Although our study shows that adolescents and young adults use contraception frequently, we cannot conclude that they are always successful or satisfied with the contraceptives available or used. On the contrary, many study participants report almost impossible difficulties in avoiding pregnancy or managing their contraceptive use in a stable, continuous, and regular way without harming their bodies. As shown in previous studies, our research also found reports of frequent contraceptive changes, discontinuations, and failures in contraceptive use patterns (Borges et al., 2021BORGES, A. L. V. et al. Descontinuidades contraceptivas no uso do contraceptivo hormonal oral, injetável e do preservativo masculino. Cadernos de Saúde Pública, Rio de Janeiro, v. 37, n. 2, e00014220, 2021.; Chofakian et al., 2019CHOFAKIAN, C. B. et al. Contraceptive discontinuation: frequency and associated factors among undergraduate women in Brazil. Reproductive Health, London, v. 16, n. 1, p. 131, 2019.).

This finding illustrates that learning to use contraception requires many skills. These skills are not innate, but rather procedural and require dialogue and support from peers, educators, family members, and health care providers, underscoring the need for contraceptive socialization before sexual initiation (Brandão, 2009BRANDÃO, E. R. Desafios da contracepção juvenil: interseções entre gênero, sexualidade e saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 4, p. 1063-1071 2009.; Heilborn et al., 2006HEILBORN, M. L. et al(Orgs). O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond/Fiocruz; 2006.).

Broad and complex social processes surround contraception as a value, including public health and education policies, new configurations of gender relations and sexuality, and the role of social movements, among others. As the scope of this study allowed for sufficient exploration of these processes, future research will explore them in greater depth.

Finally, the inclusion of contraception as a value can provide insights for updating and redefining public policies aimed at young people. Recognition of young people’s sexual and reproductive rights requires that schools and health services act to ensure access to reliable information on sexual and reproductive health. There is an urgent need for the NHS to offer a wider range of contraceptives, prescribed and monitored by competent, welcoming, and attentive health professionals who take into account the specific needs of the current generation of young people.

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