Condom use among participants of the Carnival-gender perspective

Objective: This study has the purpose of identifying the use of condoms among men and women who participate in Carnival. Methods: Descriptive research with a quantitative nature using a sample according to convenience. The subjects were spectators, partygoers and workers present in the carnival parade at Sambadrome, in Rio de Janeiro, Brazil. Data were collected in February of 2013, with 1067 respondents, by using a form. The analysis was performed using EpiInfo program. Results: Men use and have in-hand condoms in their day by day more often than women, they agree with the statements that the condom interferes in the sexual relation, they are more impulsive and tend to be expose themselves to risk situations. Conclusion: Inequality between the sexes and the hegemonic normative of male gender prevails in our society and contributes to the vulnerability of men and women.


INTRODUCTION
The pandemic caused by the Human Immunodeficiency Virus (HIV) is one of the biggest problems of public health in Brazil and all over the world.Its infection occurs through contaminated blood, unprotected sex relations and by vertical transmission.The first cases were recorded in the 1980's, in homosexual men, injecting drug users and sex professionals.The hypothetical selectivity of the disease in certain population groups generated the term "risk group", which marked the history of acquired immune deficiency syndrome (AIDS), better known by its abbreviation coming from English, AIDS 1 .
This labeling terminology generated stigma and discrimination around the affected groups, and a false sense of immunity to the rest of the population.Those who did not adopt preventive measures eventually change the epidemiological profile of the disease that is currently characterized by feminization, pauperization, heterosexual and internalization.In the 1990's the creation of the concept of vulnerability appears to reinforce that each and any individual is exposed, and can become infected with HIV, but even with this change, the stigma towards people living with HIV remains 2 .
In 1985, the ratio of sexes in Brazil was 26.5 cases of AIDS reported in men to one case in women; in 2005, this ratio was reduced to 1.5 cases in men to one in women.In the population aged between 13 and 29 years has been identified reversal from 1998 3,4 .This change is due to increased transmission of the virus through heterosexual contact, and this has been a worldwide phenomenon, but nowhere it happened as quickly as occurred in Brazil 3 .
The multiple facets of the epidemic contributed to paradigmatic rupture of moralism and social buildings, with the understanding that everyone was susceptible and that the answer to the problem involved the political, economic and cultural factors that impact on individuals, regardless of their wishes 2 .Among the various phenomena that focuses on the dynamics of infection, the vulnerability of men and women has been attributed to the construction of gender role in society 5 .
Differently form sex, biologically understood as the anatomical and physiological differences between men and women, the term gender is used to describe the social conditions in which we are identified.The conception of masculinity and femininity is seen in opposite ways.Men are the providers, strong and virile and therefore are responsible for "keeping" the family and the home.Women are weak, responsible for taking care of this house and family.Concerning health, men deny the presence of diseases, by considering that the care is associated with the feminine.This male perspective, where the man must be strong, can make him vulnerable in several situations 6 .Lack of information geared exclusively to men is also an aggravating factor.Women have many public policies geared specifically to them, while men had their first health policy launched in 2008.This reinforces the idea that men are invulnerable because his own health agencies do not see them as an important group to be served 7 .
Even with the entry of women into the labor market, a predominantly male field, there were no major changes about it.Women are still underemployed, there are difference between salaries and social inferiority.Even today, women are not totally included on family decisions.It is known that women have less decision-making and negotiation power about her sexual life, being submissive to the wishes of her partner, should he be fixed or eventual 8 .
Socioeconomic levels aggravate gender relations even further.Its visible, through the phenomenon of impoverishment, that individuals most affected by HIV are those who are the poorest class of our society.This phenomenon is evident not only in Brazil, it can be found all over the world.The poorest individuals have less access to health and education, thereby increasing their vulnerability.Crossing references to gender issues, poor women are subordinate to their husbands because of their socioeconomic status 5,9 .
International data also demonstrate that women who suffer gender violence have increased chances of being infected by the HIV virus.Study 10 conducted in Uganda and South Africa, showed that women who have experienced gender violence by their partners are more susceptible to acquiring HIV at 50%.Data also show that every hour another 50 young women acquire the virus 10 .
Analyzing the problem by this way, men can aggravate this situation when not accepting the use condoms, which can expose women to greater risks in the same way that a man who is conscious of his role in the mutual protection of the couple can increase the chances of protection in the relationship.On the other hand, women who did not empower are more submissive on the negotiation of condom use 5 .
Considering the dynamism of gender relations in condom use and consequently, in the conduction of epidemiological HIV and AIDS, it was defined as a problem to be studied: condom use among men and women.
Therefore, the study aims to identify the use of condom among men and women participating in the Carnival.
The dissemination process of HIV/AIDS has different impacts on populations.This study seeks to bring contributions regarding gender issues, so that strategies are designed to increase the use of condoms by sexually active people, minimizing the factors that hinder this practice, especially when associated with cultural issues and gender inequity.

METHODS
This research is linked to the extension project "Only happiness will infect -the samba prevention will catch on Carnival", conducted by the Universidade do Estado do Rio de Gender perspectives among condom's Users Francisco MTR, Fonte VRF, Pinheiro CDP, Silva MES, Spindola T, Lima DVM Janeiro for over 20 years.The project aims to promote prevention and research about sexually transmitted infections (STIs) and AIDS in the Rio's Carnival.This is a descriptive and quantitative research.The field of study was the "Passarela do Samba Professor Darcy Ribeiro", popularly known as the Sambadrome in Rio de Janeiro.During the four festive days, it is estimated that approximately 600,000 people attend the Sambadrome among spectators, partygoers and workers 11 .
The participants were workers, partygoers and spectators of carnival present in four days of collection.Were considered eligible for the study those aged over 18 years and who have declared performing sexual practices over the last 12 months.As an exclusion criteria were rejected those who presented intellectual and sensory disabilities (aphonic and deafness).This study used the convenience sampling, having totaled 1067 persons investigated.
Data collection was performed by 10 scholars of the Extension Project already mentioned who participated in a theoretical and practical education course for training multipliers on the subject STI/HIV/AIDS.This course was organized by the coordinator of the project, having as target public academics in many different professional areas, and had the purpose to raise awareness and to recruit human resources regarding the IST, through changes in values and attitudes, making them capable of disseminating the contents within their expertise fields.
The data collection instrument used was a form containing 22 closed questions.It took into account the objectives of the study, data from previous research carried out by the project coordinator, and the social and epidemiological dynamics of STI/HIV/AIDS.Participated in the drafting process of the instrument the whole team involved in the project.The instrument has been tested by applying a pre-test in the technical trials prior to the carnival.The research was conducted on 08 th , 09 th , 10 th and 11 th of February 2013, with the researchers positioned in sectors 1, 12 and 13 (popular bleachers), circulation area of the even and odd sectors and "Balança, mas não cai" and "Correios" concentrations, in order to capture all eligible participants for the study.
Whereas the research takes place in a festive atmosphere, competitive and wrapped in assessment costs for enjoyment of the show, the researchers' position aimed to ensure the involvement and participation of respondents without disturbing the event.So, the search began at 4:00 p.m., one hour before opening of the gates for access to stands (time required to collect information from workers), and ended at 9:00p.m., due to the beginning of the parades.
To compose the study were selected variables related to socioeconomic profile, condom use and behaviors and attitudes towards condom use among men and women.The data was tabulated using EpiInfo software and analyzed with simple descriptive statistics in absolute and percentage frequencies.
To develop this research all the recommendations of the National Health Council, Resolution 466/2012, have been complied.The study was approved by the opinion 223.405/2012 of the Research Ethics Committee of Universidade Veiga de Almeida.

Sexual behavior
The data show that among the women interviewed, 542 (93.9%) had sex more often with men, 29 (5%) with other women and 6 (1%) with men and women.Among men the results show that 426 (86.9%) had sexual relations with greater frequency with women, 49 (10%) with men, and 15 (3.1%) with men and women.When asked if they had ever had sexual relations with people of the same sex 531 (92%) women said "no" and 46 (8%) said "yes".Among men, 420 (85.7%) answered "no", and 70 (14.3%) said "yes".

Behaviors and attitudes towards condom use
Asked about the habit of having condoms for use, if necessary, 279 (48.4%) of women never have, 155 (26.9%) sometimes have available for use and 143 (24.8%) always carry it.Concerning the men, 179 (36.5%) always have, 169 (34.5%) never have to use and 142 (29%) sometimes.
In Table 2 are described four fictitious situations about condom use.The results show that if a friend says that condoms disturbs in sexual relations, most women (42.5%) did not agree with this statement; before an imminent situation of sexual intercourse, 57.7% of respondents reported that they would not have sexual relation if she or her partner would not have the condom; if the partner refuses to use a condom, 60.1% of respondents would not have sex; 80.8% of participants said that they would never let to use condoms in order to please their

Gender perspectives among condom's Users
Francisco MTR, Fonte VRF, Pinheiro CDP, Silva MES, Spindola T, Lima DVM Regarding the power relations about the condom use, data show that 285 (49.4%) women never had partners who refused to use a condom, 251 (43.5%) had partners who already refused and 41 (7.1%) do not remember a partner refusing.Compared to men, 299 (61%) have never been partners which refused to use a condom, 150 (30.6%) already had partners which refused and 41 (8.4%) do not remember refusing the use of condoms for any partner.
In Table 3 are presented the data about the purchase of condoms.Most participants reported that they buy the condom.

Socioeconomic profile
Is consensus in several studies that social determinants are fundamental characteristics for the vulnerability to HIV/AIDS, being a worldwide phenomenon of susceptibility to infection black individuals, residents of rural areas, with low income and education level 3,5,9,12 .Cultural characteristics assigned to gender serve as pillars in maintaining the dynamics of sexual infections.Women are still subjugated to the male hegemonic normative, have less social prestige, reduced autonomy and sexual power, suffer gender violence, have lower wages and suffer moral judgments when they seek to counteract the social norms 5,12 .Meanwhile, men are induced by the culture to assert their hegemony, built and designed in the figure of the white male, heterosexual, rich, strong, brave, active, potent, resistant and invulnerable 13 .
Regarding to religion, a study has shown that religious dogma has not been a relevant criterion for abandoning the condom and even their religious leaders have encouraged the use.In despite of contrary beliefs and taboos involved in the theme, it is noticed that the main Western religious construction that focuses on the use of condoms is seated in monogamous relationships, where love, fidelity and trust are the foundations that underpin the non-recognition of condom 3 .
The stable partnership has been one of the factors associated to abandonment of condom use due to the belief in fidelity and confidence-building in the partner.The study 3 shows that as much as there is suspicion about possible extramarital relationships, the condom remains ignored in stable relations due to the belief of its being associated with casual partnerships.However, the same study found in men statements, that in longterm extramarital affairs and considered stable by them, the condom was not used.
A good anamnesis, listening to the individual and knowing their social construct, helped in the identification of vulnerability situations.It is understood that population groups may be more susceptible to infections due to historical, political and social constructions, but that the assessment should be based on the uniqueness of the subject.The research identified that rich men have increased susceptibility to infection when associated with the higher consumption of alcohol, drugs and parties 14 .

Sexual behavior
The evolution of the HIV/AIDS was marked by the strong association with risk groups, including homosexual men.Currently in Brazil, we experienced an epidemiological dynamic based on heterosexuality, with consequent increase of cases among women due to biological, social and programmatic issues that reinforce vulnerability to HIV.It is known that the vagina and anus are suitable to infection, especially when not properly lubricated, as penetrative sexual act causes micro cracks that raise the biological risk 5,12 .Compared to men who have heterosexual relationships, women have double chance of infection 5 .Situations of sexual violence, coinfection with other sexually transmitted infections (STIs), drugs use, multiple partners, power imbalances between men and women, youth and prostitution, are pointed to increase vulnerability to HIV 5,12,15,16 .
Study shows that homo and bisexuality male was associated with higher prevalence of STIs and that respondents had sometimes sexual behavior motivated by a situational question 17 .

Gender perspectives among condom's Users
Francisco MTR, Fonte VRF, Pinheiro CDP, Silva MES, Spindola T, Lima DVM Another study 18 , points the weaknesses of the health services related to the homo and bisexuality, in particular the female situations, when this group needs more specific support.This situation at health services reinforces the distance and silence on the part of the individuals in the search for preventive interventions 18 .
Regarding to biological issues aimed to men, researches have been shown that penile circumcision has contributed in reducing HIV infection in African countries 5 .

Condom use
In this study, it was observed that women tend to abandon the use of condoms.Research involving 8000 people found that women have less sexual activity than men, start their sex life later, have fewer casual partners and more stable partners, but tend to use condoms less frequently 19 .
As previously mentioned, the consistent use of condoms is associated with the type of partnership, being abandoned as soon as intimacy and trust are constituted.When the method is maintained during the stable relationships, usually is associated to the control of reproduction, especially when women do not adapt to other types of contraceptive techniques 3 .
Studies have found that the abandonment of condom use by women is due to the desire and imposition of the partner, especially in the case of young women or in situations of inferiority for not have bargaining, negotiation and decision power 12,20 .However, other results show that women also refuse to use condoms for considering that affects pleasure and in cases where there is no adaptation 5,21 .
It is understood that women should be empowered through interventions that encourage self-efficacy for negotiating safe sex, which may be the women protagonists and holders of knowledge about their own bodies, wishes and desires, in addition to being stimulated to participate in social movements to combat gender inequalities.Broader spectrum actions should include changes in legislation and social policies in order to promote the rise of women in prestigious careers and incomegenerating initiatives.Scientific actions must seek to propose new preventive technologies that have women as a protagonist in the handling and use of methods 5 .
Nevertheless, the actions of prevention that question the constructs of gender should give greater visibility on campaigns that included men, to understand that these are the main agents responsible for women's vulnerability to infection.The prevailing gender model considers that women should position themselves safe and protected from the bad behavior of the men, named as the main problem 5 .
Study 22 reports that in the current model of vulnerability, men are "punished" for their behavior, but there are not offered mechanisms, tools and incentives for them to change and protect the sexual partners.In this sense, interventions have been used to rethink measures aimed at gender equality in order to reduce violence against women.Data from educational workshops with men has been demonstrated reduction in the number of partnerships, increased condom use, reduction of extramarital sex, drug use and violence against women 22,23 .

Behaviors and attitudes towards condom use
The data presented reaffirm women's vulnerability in negotiating condom use.Most of women do not have in-hand the preservative in their day by day, as the majority of men do.The cultural and moral foundations consider that women who carry condoms in their purse would be in a proactive position for sex, this behavior that is assigned to men in the male hegemonic normative.Nevertheless, moral judgments are made , condemning and suppressing this attitude among women to understand that they should have a position of passivity and domain 24 .Low diffusion and costs wrapped in the use of the female condom may difficult even more the women's empowerment.
Studies show that condoms are considered uncomfortable and limit sensitivity, erection and pleasure.Although most complaints about condom use come from men, women also report that the use is uncomfortable 5,21 .The phenomenon wrapped in condom use encompasses a multitude of factors, such as biological, psychosocial, social, religious or programmatic.Physical complaints (loss of sensation or erection), in general, are more valued, however other interpretations can be linked to the use of condoms, as the breach of confidence, the non-acceptance by religion, difficulty of acquisition at the price and lack of access to health units 3 .
A more attentive listening from health professionals is necessary to reframe the use of condoms as something related to love, affection and pleasure.Workshops and techniques to enhance the sensuality of the condom in the relationship may result in effective strategies in the deconstruction of the social imaginary 25 .
The majority of respondents reported that in hypothetical situations, they probably would use the condom in despite of the imminent sexual intercourse context or their partner's desire.However, it is observed that women are the gender to search more condom use and men tend to avoid.Studies indicate that among the various reasons declared by women for not using condoms the partner's negative is the main reason 3,19,21 .The low bargaining power and the fear of the partner's judgment constitutes limitation factors.The study describes that women understand that use of the condom in stable relationships, would mean saying to their partners to be careful and protect themselves for her.In this sense, social culture tends to blame the woman 3,5 .
Although male condoms be distributed for free in public health units, it is observed that the main form of acquisition is by purchasing.To ensure gender equality and women's empowerment, female condoms are also distributed in public Gender perspectives among condom's Users Francisco MTR, Fonte VRF, Pinheiro CDP, Silva MES, Spindola T, Lima DVM health services, but in very small quantity.The Ministry of Health claims that there is only one worldwide producer and that 80% of its production is purchased by the Brazilian government 3 .
Understanding the factors associated with the acquisition of condoms becomes an important tool in understanding the dynamics of prevention.Several factors may be associated with the prevalence of the acquisition by purchase, whether by convenience, facility, preference for brands, textures and flavors, through ignorance or being ashamed to acquiring them in public agencies.

CONCLUSION
Men use and have in-hand condoms in their day by day more often than women.Men agree with the statements that the condom interferes in the sexual relation and they are more impulsive and tend to expose themselves to risk situations.The results demonstrate situations of vulnerability, especially for women.The differences between the roles of men and women are a historical reflection of the social construction that echoes in a disharmonious way between the genders.
Nursing as a science that takes care of the human being must be engaged in the creation and execution of contingency plans to ensure gender equality, women's empowerment and cognitive and behavioral changes of men towards women, and about the hegemonic structure of gender power.
The completion of the study in a dynamical space, as the Sambadrome, put a limit to conducting an investigation with other features, such as an in-depth interview, which could favor the immersion of the subject and further discussion.However, the study can reaffirm that gender inequality and the male hegemonic normative prevail in our society, and contributes to the vulnerability of women and men to sexually transmitted infections.

Table 1 .
Socioeconomic profile of the participants of the carnival in the Sambadrome in Rio de Janeiro according to sex.Rio de Janeiro, 2013 (N = 1067)

Table 2 .
Attitudes towards condom use before fictitious situations among the participants of the carnival in the Sambadrome in Rio de Janeiro according to sex.Rio de Janeiro, 2013.(N = 1067) Source: Prepared by the authors.

Table 3 .
Locations for acquisition of condoms mentioned by the participants of Carnival in Sambodrome, Rio de Janeiro, according to the gender, in 2013.(N = 1067) * The findings do not add up to 100% for allowing several response options.Source: Prepared by the authors.