ABSTRACT

Contemporary studies explain how sexuality is a contextual and relational dimension of human life. This reading of sexuality has gradually posed new challenges to notions relating to health but has also, by extension, put tension in the field of the guarantee of fundamental human rights. It is no coincidence that international and national entities have highlighted the need for psychosocial interventions in an educational context, as a strategic space for guaranteeing rights at the interface with sexuality. Given the need, verified in international literature, for longitudinal, contextual interventions that are not restrictive to a physicalist reading of sexuality, the present study aims to present the adaptation of the intervention protocol South Africa and Tanzania (SATZ) for Brazil. In view of the adjustments made in this adaptation, including greater openness to gender and sexuality dissent, greater emphasis on dialogic aspects, and participation of the school community, SATZ-BR is in line with human rights, with the 2030 Agenda for Development Sustainable and with the guidelines of the Brazilian national curricular plan.

KEYWORDS
Sexuality; Human rights; Sexual health; Sex education; Psychosocial intervention

Introduction

Sexuality is understood, in many fields of study, as a visceral dimension of human experience. As a historical construct, it makes clear that eroticism, desires, affections and uses of the body are always contextual exchanges related to the social plane. This reading of sexuality, derived especially from studies such as those of a critical, constructionist, Foucaultian and/or feminist nature, has gradually posed new challenges to notions related to health, reproduction, the use of technologies and their relations with the exercise of power in society¹1 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. Brasília, DF: Unesco; 2014.,²2 Franco-Assis GA, Souza EEF, Barbosa AG. Sexualidade na escola: desafios e possibilidades para além dos PCNS e da BNCC. Braz J Develop. 2021;7(2):13662-13680. DOI: https://doi.org/10.34117/bjdv7n2-130
https://doi.org/10.34117/bjdv7n2-130... , but also, by extension, has put pressure on the field of guaranteeing fundamental human rights. It is no coincidence that in many geopolitical contexts we experience the contrast between readings of sexuality as a multidimensional aspect – physical, psychological, spiritual, economic, political, socio-cultural³3 Soares ZP, Monteiro SS. Formação de professores/ as em gênero e sexualidade: possibilidades e desafios. Educ Rev. 2019;35(73):287-305. DOI: https://doi.org/10.1590/0104-4060.61432
https://doi.org/10.1590/0104-4060.61432... ,⁴4 Furlanetto MF, Marin AH, Gonçalves TR. Acesso e qualidade da informação recebida sobre sexo e sexualidade na perspectiva adolescente. Estud Pesqui Psicol [Internet]. 2019 [acesso em 2023 nov 10];19(3):644-664. Disponível em: http://pepsic.bv-salud.org/scielo.php?script=sci_arttext&pid=S1808-42812019000300006&lng=pt&nrm=iso&tlng=pt
http://pepsic.bv-salud.org/scielo.php?sc... – but also reactionary movements that interpret desires, emotions, experiences and behaviors considered dissident through prohibition and imposition⁴4 Furlanetto MF, Marin AH, Gonçalves TR. Acesso e qualidade da informação recebida sobre sexo e sexualidade na perspectiva adolescente. Estud Pesqui Psicol [Internet]. 2019 [acesso em 2023 nov 10];19(3):644-664. Disponível em: http://pepsic.bv-salud.org/scielo.php?script=sci_arttext&pid=S1808-42812019000300006&lng=pt&nrm=iso&tlng=pt
http://pepsic.bv-salud.org/scielo.php?sc... .

Considering this tension, and in favor of an emancipated reading of sexuality, the United Nations Educational, Scientific and Cultural Organization (UNESCO)⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura. Orientações técnicas internacionais de educação em sexualidade: uma abordagem baseada em evidências. Brasília, DF: UNESCO; 2019. establishes the school context as a strategic field of intervention, especially with regard to sexual education measures. According to UNESCO⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura. Orientações técnicas internacionais de educação em sexualidade: uma abordagem baseada em evidências. Brasília, DF: UNESCO; 2019., sexual education is a teaching and learning process that aims to build knowledge, skills, attitudes and values for children and young people in order to produce autonomy, well-being and dignity; develop respectful sexual relationships; develop ethical implications for themselves and others; and affirm the protection of their rights throughout life⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura. Orientações técnicas internacionais de educação em sexualidade: uma abordagem baseada em evidências. Brasília, DF: UNESCO; 2019..

It therefore shares the perspective of the 2030 Agenda for Sustainable Development⁶6 Organização das Nações Unidas. Agenda 2030 [Internet]. [local desconhecido]: ONU; 2015 [acesso em 2023 nov 10]. Disponível em: https://nacoesunidas.org/pos2015/agenda2030/
https://nacoesunidas.org/pos2015/agenda2... , which aims to address different contexts of inequality using human rights and the search for more equitable relationships as a framework. In this regard, the Agenda establishes among its objectives the end of the HIV/AIDS epidemics and other communicable infections and

In fact, the 2030 Agenda – the United Nations’ development plan to combat inequities and sustainable development – in addition to highlighting the need to expand access to sexual health services, also emphasizes the need to achieve gender equality and to empower all women and girls, in order to eliminate violence, discrimination, human trafficking, sexual exploitation, early and/or forced marriages and the lack of autonomy in decisions about sexual and reproductive health⁶6 Organização das Nações Unidas. Agenda 2030 [Internet]. [local desconhecido]: ONU; 2015 [acesso em 2023 nov 10]. Disponível em: https://nacoesunidas.org/pos2015/agenda2030/
https://nacoesunidas.org/pos2015/agenda2... .

In the wake of these international documentary landmarks, some basic measures were developed for the Brazilian context. In the interface with education, for example, in 1996, we see the third Law of Guidelines and Bases of National Education (LDB), which originated the National Curricular Parameters (PCN) and which comprise nodal points for the present discussion. The PCN constitute a reference for qualifying education in the country and ensuring coherence of investments in the educational system and, among the ten volumes of the PCN, there is one dedicated to addressing sexuality in the school environment⁷7 Ministério da Educação e do Desporto (BR), Secretaria de Educação Fundamental. Parâmetros Curriculares Nacionais: terceiro e quarto ciclos: orientação sexual. Brasília, DF: MEC/SEF; 1998.. According to this volume, the objective is to contribute to making the school an environment where young people are capable of, for example: respecting the diversity of values, beliefs and behaviors related to sexuality; understanding the search for pleasure as healthy; knowing their body, valuing and taking care of their health as a condition for enjoying sexual pleasure; critically recognizing characteristics socially attributed to the masculine and feminine, positioning themselves against discrimination; identifying and expressing their feelings and desires, respecting those of others; protect oneself from coercive or exploitative sexual relationships; act in solidarity towards people with HIV and in a proactive manner in the implementation of public policies aimed at sexually transmitted diseases/AIDS; know and adopt safe sex practices; and develop critical awareness and make responsible decisions regarding one’s sexuality⁷7 Ministério da Educação e do Desporto (BR), Secretaria de Educação Fundamental. Parâmetros Curriculares Nacionais: terceiro e quarto ciclos: orientação sexual. Brasília, DF: MEC/SEF; 1998..

These guidelines point to the fact that, although young people learn about sexuality and sexual health from many sources, schools play a central role. In this sense, and in line with international guidelines on human rights, the role of education – and especially its formal institutions – is key to the shift towards greater guarantees of sexual and reproductive rights.

Sexual rights are an expression that seeks to articulate multiple demands related to sexuality and gender identity, encompassing them under the grammar and general legal framework of fundamental and human rights. It aims to protect and legitimize identities, practices and behaviors that are not necessarily linked to health or reproduction, reaching individuals and groups traditionally disregarded as subjects of rights⁸8 Gomes JCA. Direitos sexuais e reprodutivos ou direitos sexuais e direitos reprodutivos? Dilemas e contradições nos marcos normativos nacionais e internacionais. Rev direito GV. 2021;17(3):e2136. DOI: https://doi.org/10.1590/2317-6172202136
https://doi.org/10.1590/2317-6172202136... . Despite efforts to build and consolidate an autonomous field, sexual rights are often mobilized based on the joint treatment of ‘sexual and reproductive rights’, an undifferentiated approach that has negatively impacted the advancement of themes related to sexuality, marginalizing non-hegemonic practices, identities and agendas⁸8 Gomes JCA. Direitos sexuais e reprodutivos ou direitos sexuais e direitos reprodutivos? Dilemas e contradições nos marcos normativos nacionais e internacionais. Rev direito GV. 2021;17(3):e2136. DOI: https://doi.org/10.1590/2317-6172202136
https://doi.org/10.1590/2317-6172202136... .

Seeking to advance the agendas for guaranteeing sexual rights, despite the difficulties of the processes of moralizing ideologization experienced in the country in recent years⁵5 Organização das Nações Unidas para a Educação, a Ciência e a Cultura. Orientações técnicas internacionais de educação em sexualidade: uma abordagem baseada em evidências. Brasília, DF: UNESCO; 2019., educational institutions and, particularly, schools, present more effective possibilities of operating objectively against the reduction of sexuality to the physiological field, falsely related only to sexual relations, diseases and reproduction. Sexual education that follows the prerogatives of human rights and an emancipatory school, therefore, must explore the field of sexuality in a comprehensive way, considering the articulation between dimensions of the subject, such as self-esteem, not dissociated from sociocultural issues, such as gender relations and prejudice⁹9 Ew RDAS, Conz J, Farias ADGO, et al. Diálogos sobre sexualidade na escola: uma intervenção possível. Psicol Pesqui. 2017;11(2):51-60. DOI: https://doi.org/10.24879/2017001100200155
https://doi.org/10.24879/201700110020015... ,¹⁰10 Sehnem GD, Crespo BTT, Lipinski JM, et al. Saúde sexual e reprodutiva dos adolescentes: percepções dos profissionais em enfermagem. Av Enferm. 2019;37(3):343-352. DOI: https://doi.org/10.15446/av.enferm.v37n1.72008
https://doi.org/10.15446/av.enferm.v37n1... .

Several systematic reviews on psychosocial interventions aimed at sexual education indicate that there is sufficient scientific evidence showing that these actions contribute to promoting safer sexual practices¹¹11 Kirby D, Laris BA. Effective curriculum-based sex and STD/HIV education programs for adolescents. Child Dev Perspect. 2009;3(1):21-29. DOI: https://doi.org/10.1111/j.1750-8606.2008.00071.x
https://doi.org/10.1111/j.1750-8606.2008... ,¹²12 Montgomery P, Knerr W. Review of the evidence on sexuality education: report to inform the update of the UNESCO International technical guidance on sexuality education [Internet]. Paris: Unesco; 2018 [acesso em 2023 nov 10]. Disponível em: https://unesdoc.unesco.org/ark:/48223/pf0000264649
https://unesdoc.unesco.org/ark:/48223/pf... ,¹³13 Schooler D. Early adolescent body image predicts subsequent condom use behavior among girls. Sex Res Soc Policy. 2013;10:52-61. DOI: https://doi.org/10.1007/s13178-012-0099-9
https://doi.org/10.1007/s13178-012-0099-... . Furlanetto et al.¹⁴14 Furlanetto MF, Lauermann F, Costa CB, et al. Educação sexual em escolas brasileiras: revisão sistemática da literatura. Cad Pesqui. 2018;48(168):550-571. DOI: https://doi.org/10.1590/198053145084
https://doi.org/10.1590/198053145084... , based on a systematic review of sexual education in schools, identified studies that indicate: a majority of specific, non-longitudinal interventions; carried out by professionals who are not part of the school staff; only one study, out of 24 interventions, included adolescents, family members and teachers; with a predominance of themes that responded to the medical-informative approach, strictly related to the prevention of sexually transmitted infections and pregnancy. Other studies addressed diverse themes, involving discussions on gender and identity norms, prejudice, diversity and cultural and family aspects – but they represented the minority of the mapped interventions.

These aspects indicate that there is a need to carry out longer-lasting, structured interventions that encompass different subjects in the school context and that list the ethical and political prerogatives for an emancipatory reading of sexuality – especially in populations such as Brazil, marked by groups that have a high prevalence of the HIV virus and that present data of early onset of sexual life¹⁵15 Harrison A, Cleland J, Gouws E, et al. Early sexual debut among young men in rural South Africa: heightened vulnerability to sexual risk? Sex Transm Infect. 2005;81(3):259-261. DOI: https://doi.org/10.1136/sti.2004.011486
https://doi.org/10.1136/sti.2004.011486... . Based on these assumptions, the present study seeks to describe the process of cross-cultural adaptation of the South Africa and Tanzania (SATZ) intervention, which is described as an effective intervention¹²12 Montgomery P, Knerr W. Review of the evidence on sexuality education: report to inform the update of the UNESCO International technical guidance on sexuality education [Internet]. Paris: Unesco; 2018 [acesso em 2023 nov 10]. Disponível em: https://unesdoc.unesco.org/ark:/48223/pf0000264649
https://unesdoc.unesco.org/ark:/48223/pf... ,¹⁶16 Levy E, Kaufman MR, Gidron Y, et al. Interventions targeting social cognitive determinants of condom use in the general Sub-Saharan population: A systematic review. Cogent Psychol. 2019;6(1):1-17. DOI: https://doi.org/10.1080/23311908.2019.1637167
https://doi.org/10.1080/23311908.2019.16... ,¹⁷17 Aarø LE, Flisher AJ, Kaaya S, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory-and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150-158. DOI: https://doi.org/10.1080/14034940510032356
https://doi.org/10.1080/1403494051003235... ,¹⁸18 Mathews C, Aarø LE, Grimsrud A, et al. Effects of the SATZ teacher-led school HIV prevention programmes on adolescent sexual behaviour: cluster randomised controlled trials in three sub-Saharan African sites. Int Health. 2012;4(2):111-122. DOI: https://doi.org/10.1016/j.inhe.2012.02.001
https://doi.org/10.1016/j.inhe.2012.02.0... and is highlighted in the UNESCO report ‘Review of the Evidence on Sexuality Education Report – International Technical Guidance on Sexuality Education’ as one of the most complete, as well as to discuss the strategic aspects of this intervention in view of sexual education aligned with human rights.

Material and methods

The adaptation is developed systematically with two objectives: the preservation of the core components of the original intervention and the cultural sensitivity in which the intervention will be developed, in order to respect the identity, values and needs of a given population¹⁹19 Menezes JCLD, Murta SG. Adaptação cultural de intervenções preventivas em saúde mental baseadas em evidências. Psico-USF. 2018;23:681-691. DOI: https://doi.org/10.1590/1413-82712018230408
https://doi.org/10.1590/1413-82712018230... . These aspects point to the fact that, in the process of adapting interventions, there is a significant dilemma between maintaining fidelity to the original intervention and adapting it to the aspects of the target population. The quality of adaptations will be strongly associated with the influence of contextual factors, such as the characteristics of the community, the quality of training provided to carry out the intervention, supervision and organizational capacity for implementation¹⁹19 Menezes JCLD, Murta SG. Adaptação cultural de intervenções preventivas em saúde mental baseadas em evidências. Psico-USF. 2018;23:681-691. DOI: https://doi.org/10.1590/1413-82712018230408
https://doi.org/10.1590/1413-82712018230... . Thus, adaptation should be done with careful consideration and with some understanding of the core components of the program or curriculum, as described by the program developers or in subsequent research¹²12 Montgomery P, Knerr W. Review of the evidence on sexuality education: report to inform the update of the UNESCO International technical guidance on sexuality education [Internet]. Paris: Unesco; 2018 [acesso em 2023 nov 10]. Disponível em: https://unesdoc.unesco.org/ark:/48223/pf0000264649
https://unesdoc.unesco.org/ark:/48223/pf... .

For this purpose, Adapt-IT, an instrument created for the adaptation of HIV preventive interventions that is divided into phases²⁰20 Wingood GM, DiClemente RJ. The ADAPT-ITT Model: A Novel Method of Adapting Evidence-Based HIV Interventions. J Acquir Immune Defic Syndr. 2008;47(supl1):S40-46. DOI: https://doi.org/10.1097/qai.0b013e3181605df1
https://doi.org/10.1097/qai.0b013e318160... , was used as a basis for the adaptation of SATZ. This study focused on the following steps: 1) Selection of the intervention; 2) Translation of the intervention; 3) Adaptation of the modules to the Brazilian context; 4) Training of the team; 5) Presentation of the intervention to education professionals; 6) Pilot study. The pilot study, specifically, was carried out in two public schools in the city of Porto Alegre and its metropolitan region. The participants were 30 adolescents with an average age of 15.2 years, students in the 9th grade of elementary school and the first year of high school. For the qualitative monitoring of the pilot study, field diaries were prepared after each intervention meeting, aiming to describe the empirical experiences of the researchers and comments on the meetings. Subsequently, a thematic analysis was carried out, which consisted of analyzing and categorizing the themes that emerged, making it possible to identify analytical axes²¹21 Boyatzis RE. Transforming qualitative information: Thematic analysis and code development. California: Sage; 1998..

This research was approved by the Research Ethics Committee of the Pontifical Catholic University of Rio Grande do Sul, registered by the Certificate of Presentation of Ethical Appreciation (CAAE) No. 55413622.2.0000.5336, under opinion No. 5,750,981, as well as by the Education Department of the State of Rio Grande do Sul, through the Coordination of Specific Policies for Education/Human Rights Advisory and the Coordination of the School Health Program, in accordance with the guidelines and regulatory standards for research involving human beings established by Resolutions No. 466/2012²²22 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos e revoga as Resoluções CNS nos. 196/96, 303/2000 e 404/2008. Diário Oficial da União, Brasília, DF. 2013 jun 13; Seção I:549. and No. 510/2016²³23 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana. Diário Oficial da União, Brasília, DF. 2016 maio 24; Seção I:44. of the National Health Council (CNS). Because this is a study that involved the participation of minors, informed consent and the signing of the Free and Informed Consent Form (FICF) were performed by their guardians.

Results

The processes related to the steps used in Adapt-IT will be described below. An analytical discussion of the data will then be presented.

Intervention selection

The UNESCO report by Montgomery and Knerr12 analyzed 22 systematic reviews, 70 randomized controlled trials, and 65 publications and online resources evaluating sexuality education interventions aimed at children and young people aged 5 to 18. After the analyses, three protocols were described as most effective. Among them is the STAZ protocol, developed by researchers from Europe and Africa¹⁷17 Aarø LE, Flisher AJ, Kaaya S, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory-and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150-158. DOI: https://doi.org/10.1080/14034940510032356
https://doi.org/10.1080/1403494051003235... ,¹⁸18 Mathews C, Aarø LE, Grimsrud A, et al. Effects of the SATZ teacher-led school HIV prevention programmes on adolescent sexual behaviour: cluster randomised controlled trials in three sub-Saharan African sites. Int Health. 2012;4(2):111-122. DOI: https://doi.org/10.1016/j.inhe.2012.02.001
https://doi.org/10.1016/j.inhe.2012.02.0... . This is an intervention for young people aged 12 to 14, originally focused on preventing HIV infection and measuring the impact on condom use. The intervention is based on a model called Attitude–Social Influence–Efficacy (ASE), from which it is understood that behaviors occur based on personal attitudes/beliefs, social norms, and self-efficacy.

The SATZ was developed in the municipalities of Mankweng and Cape Town (South Africa) and Dar es Salaam (Tanzania), where randomized clinical trials were conducted, with thirty secondary schools in South Africa and twenty-four primary schools in Tanzania being selected. The schools were randomly allocated to an experimental or control group, and the school selection process was also random¹⁷17 Aarø LE, Flisher AJ, Kaaya S, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory-and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150-158. DOI: https://doi.org/10.1080/14034940510032356
https://doi.org/10.1080/1403494051003235... . In these school organizations, the SATZ was administered by teachers who received 4 to 5 days of prior training, including at least one reinforcement meeting per school, and the intervention moments lasted 11 to 17 hours. Supporting material included a manual for the interventionist (the person responsible for conducting the intervention) and a student manual, each culturally adapted to the reality of each city where the intervention took place – containing the same basic topics.

The themes were divided into 16 learning experiences¹⁷17 Aarø LE, Flisher AJ, Kaaya S, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory-and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150-158. DOI: https://doi.org/10.1080/14034940510032356
https://doi.org/10.1080/1403494051003235... , namely: self-image and values; personal, social and physical development; sexuality and reproduction; HIV, AIDS,

Sexually Transmitted Infections (STIs) and substance use; condom use; gender roles; skills for protection and safety; intimate partner violence; contraception; sexual decision-making and risky sexual behavior; sexual risk assessment; myths and misconceptions; healthy living; and reproductive rights. The methods used to achieve their objectives were: presentations; skills training; discussions in large and small groups; role-plays; various activities in small groups; questionnaires for students to interview their family members; homework and tasks to involve guardians in these lessons.

It was observed that the way the intervention was conducted, in a dialogical manner, was the reason for its high levels of effectiveness. Since it was organized in an experiential and participatory manner, seeking to improve the capacity for assertive communication and self-care, as well as the fact that it addressed information that was not restricted to the physicalist field of sexuality (addressing it in a more comprehensive way), the intervention enabled engagement and production of meaning in the activities. Table 1 systematizes the main elements of the original intervention.

Translation of the intervention

The translation stage of the intervention occurred in four phases and was carried out by researchers fluent in English and Portuguese. The entire translation was reviewed by a team of researchers composed of two PhD professors, one PhD student, two master’s students, and one undergraduate research fellow. Each member individually performed a literal translation of the learning experiences (phase 1). The translations were shared and analyzed, identifying opportunities to improve and unify the terminology used (phase 2). Substitutions were made in support materials as necessary, such as vignettes that could be replaced by more current material with the same content or adjustments to better understand the texts guiding the proposed activities (phase 3). Finally, the notebooks used by the interventionist and the students were unified (phase 4).

Adaptation of the protocol to the Brazilian context

Changes occurred in the following dimensions: planned duration (number of meetings, length of each meeting and total intervention time); materials (teachers’ manual, activity book for young people, worksheet for homework); learning topics (personal, social and physical development; myths and misconceptions; healthy lifestyle); educational methods (questionnaire for students to interview their parents, role-play and poster making); and teacher training (at least two counselors or trained science teachers per school).

Originally, the 16 learning experiences were organized into weekly 2-hour meetings and an intervention period of approximately 5 months. However, considering the demands of the schools, both in terms of curriculum and their specificities, it was decided to modify the intervention to 11 experiences, with an approximate time of 1h30min (16h30min in total) and an average of 3 months of process. This reduction was important so as not to converge with the schools’ evaluation period and to be carried out continuously, without interruptions. These changes were made based on contact with the Municipal Department of Education of Porto Alegre and interviews with the management teams of the participating schools.

Regarding the themes, these were adapted by unifying some learning experiences. The original intervention had 47 activities in total, of which 21 (44.7%) remained unchanged in the pilot. However, due to the needs of the school context and cultural issues, 11 (23.4%) activities were removed, 10 (21.3%) adapted and 01 (2%) replaced. These adaptations were made to suit the time of the intervention, such as removing the activities of looking up the meanings of concepts in the dictionary, starting instead from the students’ beliefs and values. The activities of searching for reports on the internet about coercive situations and role-playing were reduced, but their reflexive thoughts on them were maintained.

Furthermore, the original intervention presented vignettes only with cisgender and heterosexual couples. In contrast to this perspective, activities were included throughout the protocol that considered sexual and gender diversity, which also proved relevant since schools requested additional meetings on issues of gender dissidence and sexuality. One of the main resources added was the Gender Unicorn, which addresses gender identity, sexual orientation, gender expression/presentation, sex assigned at birth, and sexual/ emotional attraction²⁴24 Trans Student Educational Resources. The Gender Unicorn [Internet]. [local desconhecido]: TSER; 2015 [acesso em 2023 nov 10]. Disponível em: http://www.transstudent.org/gender
http://www.transstudent.org/gender... .

Another important change in the adaptation process to the Brazilian context was the reduced emphasis on sexual abstinence (which made more sense in the original intervention due to the cultural demands of the original context), and greater emphasis on responsible decision-making, assertive communication and identification of situations of violence. Sexual abstinence has been identified in several studies as a limited strategy for adolescent sexual health²⁵25 Cabral CS, Brandão ER. Gravidez na adolescência, iniciação sexual e gênero: perspectivas em disputa. Cad Saúde Pública. 2020;36(8):e00029420. DOI: https://doi.org/10.1590/0102-311X00029420
https://doi.org/10.1590/0102-311X0002942... .

In an effort to make learning more inclusive and to invest in more informative aspects according to the population’s needs, the pilot intervention added the example of the internal condom during the demonstration and practice of how to use it correctly. Other prevention methods were also addressed, such as PrEP, PEP and HPV vaccines.

Table 2 systematizes the meetings proposed for the pilot of the adapted intervention, considering its themes, activities developed, as well as the knowledge, skills and attitudes proposed to be worked on:

Team training

The team that carried out the pilot project received training and, on a weekly basis, members met for two hours to review how the previous meeting had gone in terms of difficulties, challenges or tensions. In addition, this weekly time was dedicated to preparing materials for subsequent meetings, based on the joint study of the adapted application manual. In addition, they were also instructed on how to keep field diaries, which contributed to the evaluation of the intervention’s progress and results, in addition to increasing the quality of the protocol. In the two schools where the intervention pilots were carried out, at least one member of the intervention group was involved in all stages of translation and adaptation of the original protocol.

Presentation of the intervention for education professionals

Prior to the pilot project, meetings were held with the Municipal Department of Education of Porto Alegre and with all the management teams of the participating schools, presenting the project and allowing for questions and suggestions. After the presentation, it was requested that the topic of sexual and gender diversity be addressed in greater depth, compared to the original intervention. In addition, it was identified that it was difficult to fit the intervention into the school calendar, which resulted in the original intervention process being reduced to a 3-month version.

Pilot Study

Aspects related to the development of the Pilot Study will be explained in more detail in the Discussion of this article, however, some basic points are important to be mentioned beforehand. The team’s reports in the diaries demonstrated that the students had more difficulty in self-reflective and self-esteem activities, such as the task of listing positive characteristics about themselves; greater engagement in practical and dynamic activities between small or large groups, such as role-plays, poster making and demonstrations of how to use external and internal condoms; the need to make homework tasks more flexible, since they had little adherence and engagement from the students; the importance of relaxation and connection for openness to experience; the importance of addressing cisheteronormative dissidences.

Discussion

We found that SATZ-BR is an intervention that advances in several aspects in relation to other interventions in the field, since it does not focus solely on topics related to STIs and unwanted pregnancies, going beyond more biological content that is sometimes anchored in a prohibitionist and negative message about sexuality. In this sense, we can consider that the main elements of advancement are in the field of content covered and the methodologies used. Regarding content, the intervention has several modules focused on self-knowledge, self-esteem, gender attributions, sexual rights, violence and assertive communication, among other themes that are crucial to thinking about sexual education connected with the perspective of rights. Regarding methodologies, we see the importance of the diversity of techniques and the format of the intervention, which is participatory, even though it is a protocolized strategy.

Intervention axes and the Brazilian context

Although students evaluated the 11 modules positively, there was less participation in topics with impractical activities or that involved individual self-reflective exercises and/or self-esteem. In addition, the meetings on ‘Substance use and sexual decision-making’ and ‘Abstinence and responsible decisions for a safe sex life’ had little engagement. It is worth noting that in the version adapted to the Brazilian context, the space occupied by the topic of abstinence was significantly reduced and addressed together with responsible decision-making in relation to sexual health.

In meetings where students performed practical or group tasks, the activities seemed to flow more smoothly. Currently, several studies advocate the use of active methodologies to encourage student participation in the learning process. This means encouraging a more investigative and active stance from those involved, putting pressure on the place of expository activities²⁶26 Piffero EDLF, Soares RG, Coelho CP, et al. Metodologias Ativas e o ensino de Biologia: desafios e possibilidades no novo Ensino Médio. Ens Pesq. 2020;18(2):48-63. DOI: https://doi.org/10.33871/23594381.2020.18.2.48-63
https://doi.org/10.33871/23594381.2020.1... . The use of groups can also facilitate the production of different meanings based on experiences among its members, challenging already crystallized ways of thinking about certain topics.

It is worth highlighting the relevance of individual activities carried out in the modules, together with others in groups, even if they present less engagement. When talking about gender and sexuality, the members will not always feel comfortable sharing their experiences or opinions. The dialogue between individual and group activities contributes to self-reflective processes and, even though they do not present an immediate benefit, they create a space for this. From there, it is also possible to encourage a look at self-esteem. In the activities related to this, the students often had difficulty describing positive characteristics of themselves and, despite the difficulty of the activity, in general the group of students helped all the students to identify potentialities in themselves. This was reinforced in the speech of the students during the last meetings, who reported experiencing few moments of exchange like those in their school activities, despite wishing to. To this end, the bond and the affections experienced in each meeting are crucial, as they produce reflections, reverberations and actions among its participants²⁷27 Carvalho MSD, Merhy EE, Sousa MFD. Repensando as políticas de Saúde no Brasil: Educação Permanente em Saúde centrada no encontro e no saber da experiência. Interface (Botucatu). 2019;23:e190211. DOI: https://doi.org/10.1590/Interface.190211
https://doi.org/10.1590/Interface.190211... .

Regarding substance use, students had greater difficulty sharing their thoughts on the subject, even when there were no reference teachers present during the intervention or when the intervention happened after a stage in which they already had a stronger connection with the intervention team (which occurred during the final meetings). It can be assumed that this difficulty is due to the stigma associated with illicit substances, even when their use is present. The prevalence of the prohibitionist paradigm can shape beliefs, values and laws, as well as foster exclusionary actions regarding the topic²⁸28 Gomes-Medeiros D, Faria PHD, Campos GWDS, et al. Política de drogas e Saúde Coletiva: diálogos necessários. Cad Saúde Pública. 2019;35(7):e00242618. DOI: https://doi.org/10.1590/0102-311X00242618
https://doi.org/10.1590/0102-311X0024261... . Prohibitionist anti-drug campaigns, for example, corroborate discourses of social exclusion and stigma, articulating with issues such as the lack of dialogue in the family context and fostering barriers to access to health care. Thus, even with less participation of young people in the module, it continues to be relevant as a topic of discussion when articulated with sexual health, since substance abuse is considered one of the risk factors for exposure to STIs/ AIDS. Furthermore, formulating strategies that encourage a critical, autonomous and preventive stance among students proves to be more effective than uncritical conduct²⁹29 Oliveira MPCA, Gontijo DT, Schneider DR, et al. Avaliabilidade do Programa Descolado na prevenção do uso de drogas no contexto escolar. Saúde debate. 2023;47(136):68-82. DOI: https://doi.org/10.1590/0103-1104202313604
https://doi.org/10.1590/0103-11042023136... .

Regarding the axis ‘Abstinence and responsible decisions for a safe sex life’, it was observed that students were less connected to the activities carried out, an aspect expected by the research team, but placed on the agenda for analysis and adaptation of the intervention in Brazil. The vast majority had little interaction in the meeting, which indicates that the focus on abstinence does not yield good results as a care strategy, reiterating what the literature in the Brazilian context already indicates, that is, that abstinence as a central resource is not sustainable²⁵25 Cabral CS, Brandão ER. Gravidez na adolescência, iniciação sexual e gênero: perspectivas em disputa. Cad Saúde Pública. 2020;36(8):e00029420. DOI: https://doi.org/10.1590/0102-311X00029420
https://doi.org/10.1590/0102-311X0002942... . In this sense, the choice of whether or not to have sexual relations necessarily involves an openness to dialogue about sexual practices as a possibility. Thus, the reflection on when one chooses to have sexual relations can be inserted within several axes, considering that it also addresses consent, assertive communication, decision-making, self-esteem, values, beliefs, prevention, sexual and reproductive rights, etc. In the wake of these aspects, it is understood that abstinence as a prominent theme differs from the Brazilian context and the evidence mapped to date.

Gender, sexuality and human rights: addressing new themes

The original intervention did not address issues related to sexual and gender dissidence, providing guidelines and examples from a cisheteronormative perspective, which was a lack of diversity that weakened the intervention and its potential to promote human rights. Therefore, a detailed adaptation was made throughout the protocol, including themes in the activities, in a transversal manner, but especially with regard to issues of the body and gender identity.

In the module ‘Human Body and Sexual Organs’, specifically in the Rapport of activities for students, it was discussed that having a body characterized by certain sexual organs does not delimit the gender identity of the subjects, with the existence of cis and trans people within a broad spectrum of self-representations. It is important to emphasize the importance of this understanding, since it is known that the school environment can contribute to discrimination against gender identity, as it has several devices mediated by the biological paradigm³⁰30 Bonfim M, Mesquita MR. ‘Nunca falaram disso na escola…’: um debate com jovens sobre gênero e diversidade. Psicol Soc. 2020;32:1-16. DOI: https://doi.org/10.1590/1807-0310/2020v32192744
https://doi.org/10.1590/1807-0310/2020v3... . However, despite the openness to dialogue about the body, the topic still needs to advance in intervention, covering aspects such as intersexuality, which, for example, was not discussed in this module.

The ‘Sex, Sexuality and Gender’ axis also underwent reformulations, especially in the aforementioned context of cisheternormative dissidences. This emphasis was chosen due to the classic invisibility of these topics in the school context, using more diverse vignettes, not only with heterosexual couples. It is worth noting that, in this module, students engaged a lot in discussions about coercive situations and other violence between men and women. Due to the interest, it was decided to give special attention to intimate partner violence, promoting reflections on consent and coping strategies. The original intervention already covered this axis, but adapting it to the Brazilian context contributed to more effective actions, being able to discuss public policies and legislation specific to the country, such as the Maria da Penha Law³¹31 Marques BOM, Erthal RMC, Girianelli VR. Lei Maria da Penha: uma análise crítica à luz da criminologia feminista. Saúde debate. 2019;43(4):140-153. DOI: https://doi.org/10.1590/0103-11042019S412
https://doi.org/10.1590/0103-11042019S41... .

The criticism leveled at SATZ regarding sexual diversity and gender identity can also be supported by the Sustainable Development Goals (SDGs). The SDGs focus on inequalities between men and women, but do not openly address sexual diversity and gender identity as a challenge that must be faced in order to build a more egalitarian society. According to the United Nations Development Program (UNDP)³²32 Defensoria Pública da União (BR); Programa das Nações Unidas para o Desenvolvimento – PNUD BRASIL. Direitos da População LGBTQIA+: cartilha de orientação jurídica [Internet]. Brasília, DF: DPU; PNUD; 2023 [acesso em 2023 nov 10]. Disponível em: https://www.undp.org/pt/brazil/publications/direitos-da-populacao-lgbtqia-cartilha-de-orientacao-juridica#:~:text=17%20de%20May%20de%202023,na%20vida%20de%20pessoas%20LGBTQIA%2B
https://www.undp.org/pt/brazil/publicati... , issues related to these groups would be covered by SDG 10 (Reduction of Inequalities); however, even in light of epidemiological data, they do not appear explicitly, since their goals state that actions should be taken “regardless of age, gender, disability, race, ethnicity, origin, religion, economic or other status”⁶6 Organização das Nações Unidas. Agenda 2030 [Internet]. [local desconhecido]: ONU; 2015 [acesso em 2023 nov 10]. Disponível em: https://nacoesunidas.org/pos2015/agenda2030/
https://nacoesunidas.org/pos2015/agenda2... .

School community participation and human rights

The participating schools showed interest in the intervention protocol and the team encountered few barriers to addressing the topics of discussion. However, issues arose regarding the organization of the activities. Since the intervention took place during class time, the activities needed to be carried out during the periods when students were in class, while at the same time not taking up time for certain activities in the subjects. During exam periods, events and school holidays, for example, the intervention was rescheduled.

In addition to the necessary organization of the schools’ schedule, as mentioned above, one of the biggest challenges faced by the team with the institutions was getting their professionals to be more involved in the process. The managers and teachers at the schools expressed that they would like to better understand the stages of the pilot and the activities that were being carried out, so that they could discuss the topics. As a strategy for this monitoring, one of the schools asked the teacher responsible for the class to monitor the SATZ-BR process. However, in the meetings in which she was present, the class was less open to dialogue, an aspect related to the fact that the professional expressed her dissatisfaction with some students during the intervention, as well as downplaying some topics discussed. In this regard, SATZ provides training for educators, making them aware of the application of their activities¹⁷17 Aarø LE, Flisher AJ, Kaaya S, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory-and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150-158. DOI: https://doi.org/10.1080/14034940510032356
https://doi.org/10.1080/1403494051003235... . This can be a strategy for handling situations like this, training professionals and generating autonomy so that they can apply the activities without the presence of researchers. In addition, it can promote the development of skills that help deal with demands regarding sexuality that generate anxiety in professionals.

Some activities proposed in the intervention for family members and to be carried out at home did not have good adherence. Most of the time, the young people reported not feeling comfortable talking to family members about the topic. Furthermore, because it was a research project, only families who signed the informed consent form could participate in the intervention. One of the principals of the participating schools pointed out that, with this strategy, perhaps the adolescents who most needed to participate were excluded. In view of this, it is important to highlight that sexual education is present in the PCN and in line with the modules presented by SATZ-BR (version adapted to Brazil). SATZ-BR is designed so that it can be carried out by teachers, working on the themes within the disciplines and transversally in the classroom and not as a specific research activity, which could encourage teachers to address the topic. In any case, carrying out activities of this nature has institutional potential, reverberating in the community as a whole and encompassing psychosocial aspects already demonstrated in the literature as strategic for interventions involving education and health³³33 Hamann C, Dipp RP. Psicologia institucional e escolar: (des)enlaces para uma prática efetiva. In: Guilherme AA, editor. Psicologia escolar e educacional: um guia didático. Porto Alegre: EDIPUCRS; 2021. p. 9-372..

Final considerations

The SATZ-BR protocol covers a series of axes relevant to the field of sexuality and appears to be in line with the guidelines found in the PCN and the SDGs. It is an intervention that offers reflections and coping strategies that go beyond the biomedical paradigm, promoting a focus on comprehensive care, as well as sexual and reproductive rights. Its protocol, with the appropriate modifications referenced in this adaptation study, presents characteristics that are favorable to social justice and health, education, and assistance policies, as it considers sexuality as interdisciplinary and as a right. Furthermore, by taking into account personal attitudes/beliefs, social norms, and self-efficacy, it tends to enable complex care strategies that are appropriate to different school and personal contexts.

This study has some methodological limitations. For future stages, it is important to collect data from a larger number of participants. The use of control and experimental groups, with schools randomly selected, may also be important to assess its efficacy and effectiveness. In addition, adapting the training for professionals is also necessary, with a view to better approaching and disseminating SATZ-BR in the school community. These demands correspond to the next stages of the study and are being developed by the research team. Despite the limitations described, the adaptations made to the Brazilian context contributed to a greater adaptation of SATZ-BR to elements considered in the scientific literature. In addition, the formulation of an intervention protocol that facilitates the participation of students and professionals in critical reflection on sexuality, as well as encouraging the acceptance of their experiences, contributes to a greater response in prevention and health promotion.

References

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