Educação em Saúde segundo os preceitos do Movimento Feminista: estratégias inovadoras para promoção da saúde sexual e reprodutiva

Objective: To present a reflection on the educational practice in sexual and reproductive health, according to the feminist movement. Methods: A theoretical and reflective study was performed, based on the literature and perception of the authors, aiming to foster discussion about the possibilities and potential of educational practice to promote sexual and reproductive health. Results: The promotion of sexual and reproductive health can be enriched with the teachings, methodologies and approaches coming from the feminist movement, considering comprehensiveness as the guiding principle for educational activities. Conclusion: Approaches and the concept of comprehensiveness should be recovered through the appreciation of participants and their experiences, as performed by the Movement feminist, so that new ways to intervene in the context of sexual and reproductive health through educational practice can be developed.


INTRODUCTION
Seeking to understand the themes covered by Sexual and Reproductive Health groups, an integrative review was performed between July and August 2014 in the Biblioteca Virtual de Saúde (Online Health Library) database.A gap was found between what had been proposed by the Programa de Assistência Integral à Saúde da Mulher (PAISM -Women's Comprehensive Health Care Program) and what is actually being offered, as this review showed that the majority of educational activities are limited to the transmission of information about contraception and sexually transmitted diseases.Thus, apart from themes such as sexuality, conceptive methods and gender issues not being included, participants' reality and needs have been ignored 1 .
Therefore, some health education principles defended and promoted by the Feminist Movement should be emphasized, seeking to highlight the actual relevance of the educational practice in the promotion of equality of rights, citizenship and respect regarding sexual and reproductive health, whereas such principles are currently being neglected 2 .
The use of educational actions and the acknowledgement of their essence and value, as advocated by the Feminist Movement in the 1970s and 1980s, can be a successful strategy to turn this challenge into reality.This movement defended the idea that health promotion should be considered as a way to guarantee the participation of the population, so that they could in fact obtain an improvement in quality of life and health.
Thus, Health Education as a strategy based on comprehensiveness must emphasize and promote an individual's participation as an active, responsible and independent subject with regard to their body, health and well-being, free to make choices and seek support for their needs 3 .
In the context of the educational approach, comprehensiveness corresponds to individual or group health care founded on active and empathic listening that values user subjectivity and seeks to grasp and meet their needs in an empathetic and solution-oriented way 4 .It is in this context that questions inherent to sexual and reproductive health will be approached, according to the women's comprehensive health care proposal promoted by the Feminist Movement and emphasized by the PAISM, in whose dimensions the concept of "reproductive health" alludes to the principle of reproduction as a right, rather than a duty.In contrast, "sexual health" aims to guarantee the free exercise of sexuality as a key element of female autonomy, so as to change perspective and the way women are viewed, who as a result begin to be regarded as physical and social subjects 5 .
Despite the policies that have guided principles of educational practice in sexual and reproductive health, some studies indicate that this approach is "being neglected in the planning and organization of services, in the execution of health care actions and in health management itself" 2:848 .Thus, we agree with the scientific literature when it states that there is indeed a challenge to be overcome, that of changing the concept of traditional education 6 , as many of these practices are currently based on the biological model, which prevents the purpose of Health Education from being achieved.As indicated by the Feminist Movement, this purpose is to guarantee the autonomy, emancipation and empowerment of those involved, aiming to enable them to make choices and decisions suitable for health promotion, maintenance and recovery.
Consequently, the act or process of health education is characterized by a set of practices that promote individuals' autonomy in their care and the debate with professionals and governmental spheres, aimed at achieving health care compatible with the needs of health system users 7 .
Sexual and reproductive health is one of the health themes included in the educational strategy since the Feminist Movement and PAISM.It is considered to be essential to promote women's empowerment when caring for their health and life.The Brazilian Ministry of Health instructs that family planning should provide educational activities, counseling and clinical activities, considering sexual and reproductive health as a right of any citizen 8 in the sphere of primary health care, through the Programa Saúde da Família (PSF -Family Health Program) created in 1994 and aimed at reorganizing this level of health care to understand the needs of users and to give new directions to health practices, emphasizing its promotion 9 .
The scientific literature consulted 10 instructs on the development of themes included in family planning, also recommending the inclusion of themes aimed at family development such as: health care planning, budget and reproductive issues, gender equality and affective aspects.Furthermore, it shows that the educational practice is key to make family planning effective.As a result, it emphasizes the importance of the use of participative methods with psychoeducational techniques, as it is believed that this activity can help to promote and maintain the quality of sexual and reproductive health 10 .
The present study on the integrative literature review 11 of knowledge about health promotion and practice of nurses working in Primary Health Care (PHC) showed that among the eight publications analyzed, only one recognized educational activities as a strategy to be used to achieve health promotion, a fact that draws attention and allows one to infer that this theme and others connected to it may have been neglected or inadequately dealt with when implementing such practice.
Thus, it is possible to infer that, in some contexts, educational practices provided in the sphere of sexual and reproductive health diverged from that which had been proposed by the Feminist Movement.This is because such problem emphasizes the need to develop cross-sectional health education activities through contextualized actions according to participants' needs, including knowledge and practices that are founded on respect, dignity, humanization and comprehensiveness 11 .
Based on what has described here, the present article aims to provide a reflection on the true ideal of this practice in sexual and reproductive health, following the action strategies recommended by the Feminist Movement.This is because the Education on sexual and reproductive health Paiva CCN, Villar ASE, Souza MD, Lemos A need to restructure these practices can be currently perceived, so that they can be effectively prioritized in actions that promote sexual and reproductive health, strictly observing principles of comprehensiveness.Thus, it is believed that the educational practice can help to strengthen individuals' ability to make choices, respecting their autonomy and guaranteeing their emancipation in this process 6 .

METHODS
A theoretical-reflective study was performed, based on the literature and authors' perception, seeking to discuss about the possibilities of sexual and reproductive health promotion through an educational practice.This is in accordance with the perspective of the PAISM and Feminist Movement, which have already indicated the effectiveness of participative methods and approaches, among other strategies that must be considered in the sphere of the educational practice.
The theoretical framework provided by the publications on educational actions performed by the Feminist Movement and on PAISM proposals for women's sexual and reproductive health promotion was used, through sources such as publications from the Ministry of Health, books and articles from scientific periodicals made available in the SciELO online library, using the following descriptors: Women's Health, Feminist Movement, Health Education, and Sexual and Reproductive Health.Sources published between 2005 and 2014 were used in this study.The reflection made emphasized aspects related to the following themes: Education for autonomy and freedom: History of the influences from the Feminist Movement; and Experiences of educational groups in the Feminist Movement: contributions to the innovation of the approach to sexual and reproductive health.

Education for autonomy and freedom: History of the influences from the Feminist Movement
Women's groups reflecting on the daily routine of "being a woman" spread throughout the United States and were incorporated into the international Feminist Movement in 1966.At that time, such groups were considered to be autonomous and had members who held weekly meetings in their participants' own homes, approximately ten women per meeting.They used the technique of the Chinese revolutionaries -"Speak Pain to Recall Pain" (thus overcoming it) -in this way, discussions about the experiences related to their themes of interest, such as sexuality, maternity, affective relationships and work, became possible 12 .
The first group of feminists in Rio de Janeiro was formed slowly and tentatively in 1975, as a specific political movement that was named Centro da Mulher Brasileira (CMB -Brazilian Women's Center), opposing the historical, political and capitalist oppression to which women were submitted.This group gave rise to actions, reflections and studies that dealt with the problems faced by women in Brazil, such as the right of experiencing maternity as an option.As a result, they fought for the government to propose reproductive health actions 13 .
In 1981, in the city of São Paulo, Elisabeth Souza Lobo, Maria José de Oliveira Araújo and Maria Tereza Verardo founded the Sexuality and Health Feminist Group, aimed at improving health as a women's right and discussing political and personal questions experienced at that time.The first actions of this group were performed in unions, district associations and other institutions situated in poor districts located outside downtown São Paulo and in the neighboring cities, where courses were held to sensitize people to questions related to women's health, aiming to enable them to reflect on their body, health, contraception and maternity, in addition to encouraging the participation of other women in the policy for better living conditions for them all 13 .
With the development of courses provided by this group in São Paulo, another group was formed to work on women's qualification to become multipliers of the movement's ideals and proposal.One of the results of this activity is the preparation of a booklet entitled "O Prazer é Revolucionário" (Pleasure is Revolutionary) and other educational materials related to the themes dealt with in the courses 14 .
It is worth remembering that in the PAISM's proposal, women's comprehensive health was promoted by the Feminist Movement and, in this way, apart from being founded on the principles of social determination of the health-disease process, it also includes the perspective of gender as a social organizer that supports inequality between women and men.In this sense, great emphasis was given on the educational practices aimed at self-knowledge and mental health questions, based on the recognition that the majority of women's psychological suffering is associated with the pressure from gender culture imposed on them 15 .However, this proposal is incomplete in the sense that it did not include the recognition of the impact of subordination on health and the search for ways to overcome this situation.
Since 1985, the Sexuality and Health Feminist Group sought to develop a service to care for women, known as "soft medicine".According to this health care model, natural treatments sought to prepare women to know their own body and, as a result, considered their autonomy when caring for them.This experience brought women and health services closer together, a fact that revealed social and family problems (sexual coercion, rape, unwanted pregnancy, disrespect for labor and human rights and emotional violence, among others) faced by them in their daily routine.Thus, in addition to the treatment of clear health problems such as vaginal infections and contraceptive problems, the Feminist Movement created reflection and mental health care groups to meet such needs 16 .
The strength of the Feminist Movement allowed women to speak up and begin sharing their reflections in newspapers.Consequently, the Jornal da Cidade de São Paulo published a story entitled "Us, Women" which covered women's rights and the "relationship of women and men in the family context" 13:62 .These actions enabled the development of other reflection groups, also comprised of European women who "studied health, law, education and sexuality" 13:63 .

Education on sexual and reproductive health
Paiva CCN, Villar ASE, Souza MD, Lemos A Reflection groups created by the Feminist Movement became a space for solidarity and care, where women shared physical experiences such as "menarche, menstruation, sexuality, pregnancy and birth, contraception and abortion" 16:84 .These reflections and knowledge caused them to reclaim "control of their body through contraception and the right to legal abortion" 16:84 .The experience in these reflection groups helped the development of educational actions to promote sexual and reproductive health proposed by the PAISM in 1983, as idealized and influenced by the Feminist Movement.The comprehensiveness defended by this Movement represents the social, psychological and emotional context of women who will be cared for 17 .
It should be emphasized that the program actions on which the PAISM is founded were influenced by the Feminist Movement and public health movements, in terms of the adoption of the concept of comprehensiveness.Therefore, this Program is viewed as the result of the process of fighting for democracy in Brazil and respect for individual and civil freedom 13 .
In this context, aiming to provide comprehensiveness under the perspective of the PAISM, health promotion, protection and recovery actions must be performed to meet the health requirements of women in general 18 .Consequently, the PAISM redirected women's health from a model on the gestational-puerperal period to a proposed clinicalgynecological-educational comprehensive health care model that focuses on prenatal care control improvement; on birth and puerperium; on the approach to problems found from adolescence to old age; on the control of sexually transmitted diseases; on cervical-uterine and breast cancer and on conception and contraception health care 17,19,20 .
The PAISM emphasized the importance of actions related to basic health care and, as a result, "educational actions".The Feminist Movement required sexualeducation actions 21 to be included as this would prevent this program from being influenced by birth-oriented policies, which mainly emphasize the importance of family planning as a way to provide women and men with autonomy and freedom in their sexual and reproductive life 20 .
Consequently, this program promoted several educational materials that covered themes on sexual and reproductive health.In practice, the educational aspects of the discussions were based on the same ones used by the feminists, named "feminist work methodology applied to the educational process".This process regarded comprehensiveness as its basis, because knowledge is connected to experience in a dialogue-based way, in this perspective of education.Thus, in a flexible manner, health themes that ranged from knowledge about one's body and sexuality to reproduction, diseases, gender issues and family relationships were dealt with, among other questions that were revealed according to participants' needs and their views about these themes, enabling changes as a result 20 .

Experiences of educational groups in the Feminist Movement: contributions to the innovation of the educational approach in sexual and reproductive health
The Feminist Movement caused the educational practice to advance as it enabled the health requirements of participants of educational groups promoted by this movement to be known 5 .In these groups that share experiences, reproduction or sex were found to be a social practice that expands in different dynamic contexts and with several meanings that, in their turn, are transformed according to the time, culture, society, politics and customs of a certain population.
Thus, the educational practice must be valued as a space to exchange experiences, following the principle of empowerment and encouragement of transformations experienced with health and autonomy.The exchange of experiences among users enables the development of the awareness of being human as one who is free, informed and worthy of rights 22 .
In this line of thought, educational groups and individual consultations were performed by the Feminist Group under different formats, such as seminars and workshops, aiming to value personal experiences.These actions recognized that participants have experiences and a unique reality of life, principles that guaranteed the group's success 22 .In this way, they valued health education as a whole, rather than the transmission of knowledge exclusively.Therefore, participants were instructed about their choices and encouraged to reflect on their convictions, without ideas and/or values being imposed at all.This space was used by them as a group to build knowledge about the body, healthy eating, disease prevention and sexual and reproductive options.In this way, they became active participants in the health promotion and autonomy process 22 .
The reflection used as group work methodology, considering the reality of life of each woman, enabled the exchange of teachings about health treatments and their effects, and the advantages and disadvantages, among other aspects that helped to promote participants' health.In this way, the group mission went beyond that of supporting women in matters of health and their rights, it enabled their potential to be revealed and encouraged them to overcome their limitations.Thus, the group not only provided sexual and reproductive health care, but also empowerment and how to value citizenship, human rights and respect for diversity and individuality 22 .Another Feminist Movement group, known as SOS-Corpo, based in the city of Recife, Pernambuco, northeastern Brazil, and created in 1980, also promoted educational actions in the sphere of women's comprehensive health.Similarly to the other groups previously described, this one promoted women's debate on their physical experiences.

Education on sexual and reproductive health
Paiva CCN, Villar ASE, Souza MD, Lemos A As a result, they developed educational and informative materials that pointed to the importance of knowledge about the body so as to reveal one's identity.Physical experiences during childhood, menstruation, pregnancies, births and sexuality were shared and discussed 22 .The documents that depict this group show that lack of knowledge about one's body, apart from causing anguish, leads to negative feelings experienced during pregnancy, puerperium and breastfeeding.
The SOS-Corpo meetings mainly aimed at the sharing of experiences, when members discussed knowledge about the body, the diseases affecting women, their fears, taboos and the embarrassment of gynecological consultations.When selfexams were approached, participants were divided into pairs to learn how to perform it.Through the preventive exam known as Papanicolaou test, women had the opportunity to see that their cervix and vagina are pink and beautiful.Themes were dealt with according to group requirements, including topics such as rights, politics, violence, family relationships, sexuality and work 22 .
This experience revealed that, after the educational process, women became more aware of their health, as knowing and looking at themselves without prejudice enable them to seek health services with greater awareness.
The feminist educational practice accepts the principle of "nobody teaches nobody else, nobody learns alone, people teach each other mediated by the world" 2:39 .As a result, it is believed that an educational process aimed at health comprehensiveness must consider the physical, mental, physiological and health changes that take place 23 .
Thus, the feminist pedagogy, using constructive and participatory methods that value equality, is understood as the principle and practice that aims to enable individuals to become aware by constructing and sharing knowledge, so as to guarantee equality and the right to citizenship between women and men in society.
The feminist pedagogy can significantly help to strengthen educational groups that are currently provided by PHC services, as its methodology considers an educational action as an instrument for policies on inequality reduction.This instrument functions according to population requirements; thus, it values the knowledge, reality and experience of group participants through methods that enable their active participation, such as group dynamics to promote team work, workshops, seminars and participatory activities, including events that encourage participation and dialogue, develop self-esteem, autonomy and empowerment, and prepare interactive manuals and booklets, among other educational resources 24 .
Consequently, as education is understood as a knowledge sharing process resulting from reflection, questioning and selfknowledge, it is possible to use its results to transform a certain reality, whether it is in society, one's professional life and/or personal life.
In order to strengthen the educational space, the feminist movement's way of teaching suggests the preparation of guidelines to plan and perform workshops and other educational activities.Additionally, this planning should include the following: moments when the work objectives of the group and participants are presented, role play of themes, dialogue to know the experiences of each participant with these themes; critical/political group reflection; discussion of group actions; assessment and referrals; record of testimonies and, in the end, the preparation of a workshop report 25 .
Regarding the approach of the group coordinators and facilitators, trained for such situations, the feminist pedagogy instructs that activities must have clear objectives, so that group interaction rules, the times and other relevant instructions are also emphasized.Another suggestion is that the techniques and dynamics applied should be participatory, so that the interaction among participants is encouraged.Additionally, it is pointed out that the beginning of group work should include the guarantee of anonymity of all personal information, aiming to establish respect and ethics and to assure the privacy of all those involved 25 .
Furthermore, the feminist pedagogy clarifies that, for group activities to function well and for this time to be used effectively, it is important that health professionals keep their word with all those involved, without expressing their personal opinions, judgments and other types of authoritarian behavior 25 .
Another recommendation is to follow the sequence of activities scheduled for the period of time proposed for the groups, according to the existing needs, in addition to promoting the exchange of experiences and maintaining the order of activities, so that participants can assess them in the end with the purpose of preparing a report 25 .
Thus, based on the experiences of educational spaces, it could be observed that guaranteeing the participation of all women in the group activities enabled enriching debates, dialogues and trust, thus valuing direct interactions.In this way, in the selfawareness workshops, it was possible to know participants' inner and intuitive world and to follow the development of critical thinking in the analyses of the conceptions discussed in the groups 25 .Thus, certain myths, preconceptions and cultural concepts that had been socially imposed were deconstructed, enabling all participants to express themselves freely 25 .
Therefore, it is possible to infer that the previously mentioned groups coordinated by the Feminist Movement had the use of the space for knowledge sharing and interactions to construct further knowledge as a common characteristic and, consequently, its objectives of valuing every woman's citizenship, rights, empowerment, respect and dignity could come true, as a unique Being with limitations and potentials that deserves respect and attention.Thus, each participant was awakened to their social rights and gender issues.

Education on sexual and reproductive health
Paiva CCN, Villar ASE, Souza MD, Lemos A The Feminist Movement, by using different methodologies, strategies and group dynamics, among other ways to develop educational activities, indicates somewhat innovative potentials, as certain concepts currently identified in old practices are being forgotten.
In this way, using educational actions from the Feminist Movement as a model, nurses can improve and restructure this practice in the field of sexual and reproductive health.The purpose is to guarantee and meet the needs of men and women, using simple educational resources, which in essence value the human Being and their experiences, apart from assuring the right to live a safe, healthy, free and satisfactory sexual and reproductive life.

FINAL CONSIDERATIONS
In summary, based on what was described here, the educational practice provided in accordance with the Feminist Movement showed that it is possible to promote the sexual and reproductive health of the population.However, health professionals, especially nurses, must be open to build this space that guarantees citizenship, autonomy, empowerment and knowledge sharing.Therefore, to value the educational practice as something that promotes sexual and reproductive rights, in addition to health and well-being, requires the work performed by the group of professionals involved in this activity.
Consequently, it is essential to remember the concepts and the way in which such educational practice was provided by the Feminist Movement.This is because the reports and knowledge promoted in the interactions among participants, which point to methods, educational techniques, themes and knowledge about this activity, reveal that it is possible to identify and meet the needs of participants seeking this type of health service.
In view of the gap between the old practice and the current offer, it is worth reflecting on the possible causes of such change, such as the work process, absence of participation in the social movement of health services, individualistic ideologies, and the valuing of the technique and technology to the detriment of the investment in human relationships.These are only some of the questions that may be answered by future studies.One of the reasons is that the development of educational actions in a planned, dynamic and contextualized way, which recognizes and values participants' experiences and understands and respects human Beings as a whole, will contribute to strengthen the link between women and health services and to bring them closer together, enabling social participation and the strengthening of the social and professional role of nurses.