Ethical conflicts and limitations of medical care for women victims of gender violence

Domestic violence is the most common type of violence against women, resulting in sequelae in the physical, emotional, family, and economic domains, constituting a public health problem. However, the issue is treated negligently by health professionals, which contributes to its invisibility. Based on a review of the literature, the objective of this study was to identify the main difficulties, including ethical conflicts, found by physicians in the approach to patients who are victims of this type of violence. The basic obstacles are grouped in 3 main axes: issues related to the health professional, to the structure of the health system and to the victims of violence. It is concluded that the greatest obstacle comes from the health professionals themselves, and involves factors ranging from inadequate training to the occurrence of moral and ethical conflicts that culminate in blaming and accountability of the victims for the situation of violence in which they were found.


Ethical conflicts and limitations of medical care for women victims of gender violence
Gender inequality perpetuates throughout history and is reflected in male hierarchical discourses about women, which falls particularly upon the female body 1 .It is known that one of the most brutal externalizations of this inequality is violence against women (VAW), which generates great repercussions in their life and especially in their health 2 .Since violence is an act of disrespect for human dignity, it is an issue that must be reflected in the light of bioethical principles 3 .
According to the United Nations Declaration on the Elimination of Violence against Women 4 , this form of violence is defined as any act of genderbased violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life 5 .
The most common type of violence against women is domestic and family violence [6][7][8] .According to the "Maria da Penha" Law 9 , this includes any action or omission based on gender that causes death, injury, physical, sexual or psychological suffering and moral or property damage in the household or domestic (with or without family bond) domain, or when perpetrated by an intimate partner.According to the "WHO Multi-country study on women's health and domestic violence against women" 10 , undertaken in ten countries between 2000 and 2003, from 15% to 71% of women were victims of some type of physical and/or sexual violence perpetrated by intimate partners in some period of their lives.
In the last three decades, violence against women has been gradually recognized as a public health problem by the international community 4,6,[10][11][12] .According to a report issued by the World Health Organization 13 , violence generates great repercussions on health, not only because of its direct effect on the victims, but also on the health services themselves, demanding actions to attempt to minimize their consequences from the public sector and professionals in the area.
The consequences of VAW reach significant dimensions in both the physical, emotional, family, and economic realms.Women in situations of violence resort to health units with various complaints about the resulting injuries, such as injuries from beating, chronic pain, depression and low self-esteem.However, health professionals, for the most part, do not perceive or do not document the occurrence of such violent episodes 10,[14][15][16][17] .The study by Schraiber and D'Oliveira 18 , carried out in São Paulo, Brazil, identified that 57% of the women treated in a primary care unit reported some cases of physical violence in their lives.However, only 10% of the events had been registered in medical records.
A study indicates that the majority of women victims of domestic violence resort to health services with physical symptoms and hide the occurrence of violence from the health professionals 19 .In this way, the woman does not report the aggression, and so the professionals do not question her, evidencing the poor communication in the doctor-patient relationship, which contributes to the invisibility of the issue 2,20 .
In addition, one of the main problems about the difficulty that health professionals, particularly physicians, have in dealing with victims of gender violence is the fact that the issue is not adequately addressed during their training.These issues, when discussed at undergraduate level, are usually not politically and socially contextualized, being traditionally approached in the fragmented biologistic model, in which there is no correlation between health and social reality.Thus, professionals feel paralyzed by subjective issues such as emotional frailty and lack of protection, common in victims of domestic violence 2,16,21 .
Some studies have pointed out other factors that also contribute to the inefficiency of the medical practice in relation to violence.3][24][25] .In addition, the brutal dissimilarity that normally exists between the reality of the physician and the situation of risk of the users makes it difficult for the professional to understand violence as a real health problem 21,24 .
In addition, other obstacles block the perception and direction of VAW cases.These are: the lack of knowledge by physicians about appropriate places for referral of women victims of violence 16,25 , fear of affecting personal safety, refusal to engage with judicial bureaucracy, and disbelief that domestic violence is within the scope of health facilities 25 .
In view of this situation, the objectives of this research were to identify the main difficulties and limitations encountered by health professionals in approaching women victims of domestic violence, as well as to detect possible ethical conflicts associated with the care of these patients.

Methods
This is a descriptive narrative review whose survey was carried out between March and July of 2016 in the following databases: Latin American and Caribbean Literature in Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde -Lilacs), PubMed and Scientific Electronic Library Online (SciELO).All the descriptors used in the search of the articles were searched in the Descriptors in Health Sciences.
Inclusion criteria considered publications in Portuguese, English and Spanish; either original or review articles, master's dissertations and doctoral theses.Articles that did not discuss health professionals' actions regarding violence against women and those that only deal with other types of intrafamily violence were excluded.After applying these criteria, we obtained a total of 16 articles, which were read and grouped according to the theme involved.During the analysis of these articles, it was also verified which bioethical principles could not be respected during the health services.

Results and discussion
The articles were selected by means of an exploratory reading, and a table containing the main difficulties encountered by health professionals in the care of women victims of violence was elaborated for the organization and recording of the material obtained.The publications were systematized in Table 1 (annex), including title and method employed.
The sample of this research comprises 16 articles.The period of publication of the texts analyzed was between 1997 and 2014, with the majority of articles published in the last five years, which indicates the growing concern about the subject.Regarding the type of study, one is a dissertation, another one is a thesis, and all others are original articles.
With regard to the method chosen, eleven articles were qualitative, two were qualitative and quantitative, one was descriptive, one was analytical and another one was quantitative and descriptive.Qualitative analysis was perceived as a preference, which can be explained by the fact that it deals with an interdisciplinary theme, such as social, scientific and bioethical spheres, as well as the description of subjective aspects such as emotions and feelings.
The analysis of the articles allowed to define three main axes in relation to the obstacles encountered by professionals in the care of women in situation of violence.The first one concerns health professionals: personal perceptions, attitudes, training and capacity building, personal barriers and feelings generated by violence.The second addresses the situation of the health system and its articulation with other available services to treat and welcome women in situations of violence.Finally, the third axis contains aspects related to users of the health system victims of violence.The elements pointed out on each axis will be discussed in detail below.

Health professionals in cases of violence against women
It was observed that 14 articles listed aspects within this axis, suggesting that much of the difficulty found in dealing with VAW cases is centered on the health professional himself.
One of the main obstacles to dealing with VAW is the lack of preparation and inadequate training of these professionals, as evidenced in eight articles, including in this aspect both academic training and professional qualification.It was identified that the professional training pattern is predominantly based on the fragmented biological model, incompatible with adequate assistance in VAW cases.In addition, there was a precarious knowledge of the professionals about services available for referral of the victims, which indicates the lack of care of the health services in enabling professionals to deal with the issue 22,[26][27][28][29][30][31][32] .
The invisibility of VAW, whether true or apparent, is also evident for health professionals.In general, women do not complain of violence and seek care, most of the time, due to physical injuries.Thus, professionals usually treat clinical lesions without identifying women as victims of gender violence 31,32 .When the violence is perceived by the professionals, by the appearance, location or type of Ethical conflicts and limitations of medical care for women victims of gender violence injury, it is common for them to ignore the fact, not addressing the issue during the consultation.This can be interpreted as institutional violence, since professionals do not work to break the cycle of violence to which the patient is subject.By placing themselves as unaware of the situation, they contribute further to the continuity of female oppression 21,24,27,30 .In addition, the omission of health professionals regarding the problem demonstrates the non-fulfillment of their moral duty to act for the benefit of the victim, described by the principle of beneficence.Some studies 29,30,[33][34][35][36] call attention to the judgment of health professionals towards the victims, justifying and naturalizing the violence with the strategy of blaming the patients.Similarly, other authors 22 observed the imposition of the values of health professionals on their patients.Other moral and ethical issues were also pointed out in a study 34 that discussed abortion in rape victims, in which great difficulty as observed in accepting the termination of the pregnancy by health professionals, who blamed the victims for the violence suffered.In this sense, professionals disregard the patients' autonomy, since this principle recommends the prioritization of the individual's values and preferences in the making of diagnostic and therapeutic decisions.
Another issue in this axis is the fear and insecurity that plagues health professionals, this being a personal barrier to face the VAW.In the studies surveyed, the respondents reported, mainly, fear of suffering retaliation from aggressors 24,28 .Many of the professionals who participated in the studies showed that they feel powerless and frustrated in such situations, since the clinical treatment of the lesions can not able to solve this multi-factorial problem 21,24,26,28,34 .In addition, they said that one of the greatest difficulties is dealing with associated factors, which in many cases are the triggers of violence, such as drug use and drug trafficking 36 .
As for the professional class (physicians and nurses), there were significant differences regarding the representations about violence and actions between the two groups 24,31,35,37 .It was also identified that most of the professionals are unaware of the epidemiological aspects of VAW, which contributes to the invisibility of the issue; however, nurses had greater capacity to deal with the cases 32 .
Regarding VAW identification only as a public safety problem, most participating physicians thought that this issue should not be addressed by the health services and declared they were able to identify these cases from clinical signs and symptoms associated with family issues and mental issues of patients 24,35 .On the other hand, the nurses participating in this study understood this violence as a "private" problem, believing that they should not intervene directly to resolve the issue.
A similar result was found among nurses participating in another study, who stated that VAW should not be directly addressed 37 .To another author 28 , some physicians reported not knowing the resources available to victims of violence, and affirmed that they entrusted the task to nursing.
On the other hand, the power and efficiency of the Family Health Strategy ("Estratégia de Saúde de Família", ESF) were highlighted in the identification and management of cases of domestic violence 36,38 .
In both studies the role of community health agents (CHAs) was pointed out as fundamental to the success of case management, which can be attributed to the opportunity the CHAs have to detect signs of violence, since they come into direct contact with the environment in which patients live.
However, the first study 36 also highlighted the work of social assistants and psychologists and identified a lesser participative relevance of physicians, nurses and nursing technicians in the approach and solution of cases.In the second study 38 , nurses were protagonists in the identification, conduct and prevention activities in the issue of VAW.Fonseca et al. 34 found contrasting results to the ones mentioned previously, pointing out the naturalization of violence by the CHAs and also their fragility.This is because these professionals are part of the same community of the victims and perpetrators and are not supported by institutions that could protect them to actively interfere in situations of VAW.
One of the studies 35 identified a greater understanding of ESF physicians and nurses about the social dynamics of violence, associating their etiology with external factors such as drug and alcohol use and their respective consequences the health and social status of the woman, who tends to become submissive, dependent and have diminished self-esteem.Similar results were observed by another author 37 .

The health system and support services to women
In this axis, there was a notable convergence of most articles, which point to the precariousness of the health system, making it even more difficult to solve VAW cases.Four studies 21,31,32,35 pointed out that the model of vertical and fragmented medical http://dx.doi.org/10.1590/1983-80422018261228

Research
Ethical conflicts and limitations of medical care for women victims of gender violence care is inadequate to care for women in situations of violence.Carried out without biopsychosocial contextualization of the patient, care becomes an obstacle to the humanized and welcoming care.
Moreover, several studies 21,24,29,30,32,35,38 point out other gaps in the functioning of the health system, such as an absence of the counter-referral of the cases, which causes a false sense of resolution after referrals.In the same way, the inapplicability of the principle of integrality of the service and the absence of specific protocols standardized to help the professionals to conduct the cases are also factors associated with the malfunction of the system in relation to the VAW.
There is also a need to maintain multidisciplinary teams available to serve these women and to create an inter-sectoral network that articulates public safety, women's health and psychological care services, thus enabling decentralization and effective response to the problem.
Regarding the physical structure of the health services received by women victims of violence, among other cases 21,26,29,30,32 , have found that health units are physically inadequate for the dynamics of care.
Small rooms, lack of privacy, and the lack of space reserved to address the issues of these patients, since many women feel ashamed to share the situation, make it difficult to talk frankly.In addition, these authors pointed out the lack of time of the professionals as a limiting factor of the adequate and more humanized care to these patients.
In general, it is observed that these findings violate the concept of Justice, since the studies surveyed pointed to the low demand to meet the needs of the victims in order to respect their peculiarities, freedom of expression and interests.

Perceptions of female victims of violence
In the studies that discussed the perception of women about gender representations and the issue of violence 32,35,38 , the phenomenon of naturalization and banalizing of violence by the patients was identified.It is important to note that this fact was also identified in the perception of some professionals.It can be assumed that this perception shared by the two groups stems from the trivialization of violence against women in Brazilian society, as portrayed in an abundant way by the media.
Concerning the search for help by patients in situations of violence, it was noticed that the majority of women do not see the health units as a place to which they can resort 29 , and when they seek them due to physical injuries, it hides the occurrence of violence 27,32 .In another study 38 , it was identified that the majority of women believe that domestic violence is a serious health problem and that it would be up to physicians to actively screen for care.About 70% of the women who participated in the study stated that they would tell the physician about the occurrence of violence if they were asked.However, only 12% of the total of 406 women have been questioned by doctors or nurses about the occurrence of aggression.Regarding the prevalence of violence between different social levels and ethnicities, this same study did not find significant differences 38 .

Final considerations
The present review of the literature allowed to systematize the difficulties found by health professionals in the care of women victims of gender violence, which contribute to the invisibility of this problem.In this sense, it can be stated that the greatest obstacle is in the health professional itself and involves issues ranging from inadequate training to the occurrence of moral and ethical conflicts that culminate in the blaming of the victims for the situation of violence that they suffered.This was the greatest conflict raised, since violence disrupts the state of health of those who suffer it, indirectly affecting health professionals who must guarantee the welfare state of patients, according to the bioethical principle of beneficence 39 .
It was also possible to note the violation of the principles of justice and autonomy, since the victims are deprived of care that is consistent with their particularities and, in many cases, have their preferences and moral values judged and, above all, placed in the background by professionals who care for them.In addition, the precarious structure of the health system and the social representations of violence by the victims were outlined as other aspects that make the approach to this issue more difficult.
Considering the relevance of the problem, it is concluded that there are few studies in the literature that relate the health issue to violence, thus limiting further reflection on the issue.In this sense, the importance of more studies on the subject is emphasized and it is expected that the present study may contribute to the knowledge from the findings presented.

Participation of the authors
Angela Alves Correia de Souza was responsible for the sample survey, critical reading of the publications and final version of the article.Raquel Barbosa Cintra supervised the project and collaborated with suggestions and correction of the article.