Gender and violence against women in nursing literature : a review

In the scientifi c production on inequalities in relationships between men and women, studies on violence against women and the urgency to recognize it as a public health problem stand out. Objective: considering the potential of nursing to expand understanding on this theme, this study aims to learn what is being published on gender and violence against women in the main Brazilian nursing journals. Method: an integrative review of online publications between 2000 and 2012 was conducted. Of the 138 articles selected, 25 addressed gender and violence against women as social constructs. Results: there was a predominance of qualitative approaches (60%), empirical research (60%), academic (100%), authors who were nurses (96%), spousal violence (32%) and domestic violence (20%). Violence against women in the light of gender was associated in only 32% of the articles. Conclusion: there is a need for increased studies in partnership with the public health care service, and to expand discussions on the dynamics of power and resistance, which are the basis of the concept of gender.


INTRODUCTION
The concept of gender has undergone several transformations throughout history, notably in the 1970s (1) , when the biological perspective of gender, based on distinction between the sexes, was disputed, and new theories that consider gender to be permeated by cultural, historical, and social meanings related to race, ethnicity and generation emerged.In this perspective, gender is not knowledge of fixed and natural sexual differences, but knowledge that has been used in Western societies to establish rules and configure the social place that each subject or group occupies in the current productive and reproductive system.Since then, with different proportions and understandings, gender studies have expanded, especially in the areas of human sciences and health, in a significant effort to understand and transform gender inequalities.
Historically, women have occupied subaltern positions in society, the result of an evident social differentiation of the sexes (2)(3) .This differentiation feeds and is fed primarily by the sexual division of labor, structured on the separation of labor of men and women, and the valorization of activities regarded as male (4) .An example of these inequalities can be seen in the Pesquisa Nacional por Amostra de Domicílios [National Research by Home Sampling] of 2011 (5) , in which 57.4% of men were economically active, in comparison to 42.6% of women.This data may point to the predominance of domestic work by women and its undervaluation, taking into account that this activity is not included in calculation of social wealth produced, despite being directly responsible for the production of life (4) .Furthermore, this study (5) identified that although women have higher levels of education, at the time, men earned a mean monthly income of R$1,129.00 (about US$350), while women earned R$650.00 (about US$200).Such devaluations can result in less access to goods and services by women, and greater exposure to wears that directly interfere in the process of getting sick and dying (6) .
Gender studies have sought to expand and diversify knowledge on the dynamics of relations between men and women, and demonstrate the various life conditions of women that result in inequalities of power, and create a grave scenario associated with violence -predominant in domestic and affective spaces.In the World Health Organization's 2002 World Report on Violence and Health (7) , the percentage of women who reported having experienced at least one physical assault by an intimate partner ranged from 10% to 34.4%, according to data obtained from statements of victims of violence.Such findings underscore the urgent need for recognition of gender inequalities as a public health problem (7) .
From a feminist perspective, understanding the dynamics of gender means seeking to deconstruct these inequalities in the field of health.In this sense, healthcare professionals must be qualified both to identify situations of violence against women, and to build critical reflection on gender inequalities, legitimized in our society, together with these women.Within healthcare teams, nursing, a predominantly female and social profession, has the potential to bring to healthcare practice reflections on gender, and to broaden perspective on the problem of violence against women.Regardless, studies have revealed that healthcare practices are degendered, and do not take into account the social processes that construct differences between women and men, and thereby are predominantly based on a biological perspective (2,6) .
Understanding the importance of the knowledge of gender as a guiding tool for an expanded view of nursing, and the potential of nursing professionals to assist in constructing autonomy of women in regard to gender-based violence, were the inspiration of this study.This study aimed to know what is being produced and published on gender and violence against women in the main Brazilian nursing journals.The purpose was to understand the gaps in this kind of knowledge, and indicate challenges and potentialities in this area.

METHOD
This was an integrative review study based on the following guiding question: What has been published in the main national nursing journals on gender and violence against young and adolescent girls and adult women?
Research was conducted in the LILACS database.Inclusion criteria were: publications in national nursing journals with Qualis classification of A1, A2, B1 or B2, according to the Coordination for Higher Education Staff Development (CAPES); the term gender in the title, abstract or keywords, as well as derivations of the terms gender identity and gender-based violence; articles published between 2000 and 2012; and availability online.Exclusion criteria were journals not accessible online; abstracts wherein the term gender was used as a synonym for sex and not as a category; and articles in which gender was not treated as a social construction.When used as a synonym for sex, the term gender does not broach the dynamics of social and power relations, fundamental for a study that aims to examine gender inequalities and violence against women.
The articles were initially classified according to the journal, year of publication, key words and authors.In a second screening, articles that addressed gender and violence against young and adolescent girls and adult women were selected, and a table was constructed with all of the descriptors from the selected articles.References to violence were selected from among the descriptors such as: violence, violence with women, violence against women, gender-based violence, enriquecer los estudios en asociación con el servicio y de la expansión de las discusiones que involucran dinámicas de poder y resistencia, que son la base del concepto de género.Palabras clave: Género; Violencia de Género; Violencia Contra la Mujer; Revisión.domestic violence, sexual violence and symbolic violence.Several descriptors that could indicate treatment of gender and violence against women were also selected, such as vulnerability, social vulnerability, sexism, gender relations, racism, prostitution and power.Finally, articles that addressed gender and violence against young and adolescent girls and adult women were selected.
Selection of texts was carried out by reading the abstracts and the entire article when the information in the abstract was not sufficient.The articles were arranged in a summary table consisting of the name of the journal; Qualis classification; year of publication; descriptors; author(s); education of the author(s); type of study; data sources; scenario; subjects; research instrument or data collection technique; form of information processing; and types of violence addressed.

RESULTS
According to CAPES, there are 18 national nursing journals with Qualis classification of A1, A2, B1 and B2, 16 of which were available online in the LILACS database.From these 16 journals, 309 articles were selected that used the descriptor gender, of which 138 (44.7%) treated gender as a social construction.
In these 138 articles, 210 descriptors were identified, some of which were found in more than one article.From these, only descriptors with references to violence were selected: violence, violence with women, violence against women, gender-based violence, domestic violence, sexual violence and symbolic violence.The 39 descriptors that indicated a treatment of the relationship between gender and violence against women, identified in the methodology, were also selected.
From reading the abstracts and, when necessary, the full text, 38 articles were selected.Of these, 25 composed this study because they specifically treat the topic of violence against young and adolescent girls and adult women.
The journals with the highest number of publications on gender and violence against women (40%) were Revista Latino Americana de Enfermagem and Revista da Escola de Enfermagem da USP, each with 20% of the publications.These were followed by the Acta Paulista de Enfermagem and Revista de Enfermagem da UERJ, both with 12% of the publications.Then came the journals Texto & Contexto Enfermagem (8%) and Escola Anna Nery Revista de Enfermagem (8%).As regards Qualis classification, 64% of the articles were from journals with A1 and A2 classification, and 36% were from journals with B1 and B2 classification.In terms of year of publication, two articles were published in Regarding type of study, most were the result of empirical research (60%), followed by review (20%), theoretical and reflective (16%) and reporting experience (4%).60% of the articles had a qualitative approach.Among the instruments and techniques used for data collection, the interview predominated (32%).In 76.5% of the articles, the theoretical framework of gender as a social construct was explicit.In the other 23.4%, the approaches pointed in this direction, although gender as a social construct was not explained as the theoretical basis for the studies.
All of the articles were academic, and 96% of the articles had at least one author that was a nurse.Of the 25 articles, 19 (76%) had exclusively female authors, while the others had men and women as authors, with a predominance of the latter.Of the 71 authors, 65 (91.5%) were women and 6 (8.45%) were men.
Considering only the 15 studies classified as empirical (60%), in seven of these the investigations were conducted with women who experienced violence (46.7%), followed by five (33.3%) with professionals of the Family Health Care teams (FHC) of the Brazilian Unified Health System.The remaining four included a combined study on women and FHC professionals; on male perpetrators; and on police reports, making up 6.7% each.
In the articles on the perception of health care professionals on prevention and care of cases of violence against women, it was found that they recognize this situation as a problem to be faced, although they share feelings of helplessness, inability, discomfort and anxiety when faced with these cases (8)(9)(10)(11) .These professionals also demonstrated that they recognize the idealized social roles for men and women, although this recognition was not always associated with gender inequalities, for example, when they considered that women should take the initiative to break with the situation of violence in the relationship (9)(10)(11)(12)(13) .In these cases, the consequences are several lapses in care, such as absence of records on patient charts, thereby contributing to the invisibility of violence against women (13) .The type of violence addressed in the articles was mainly spousal (32%): that practiced by intimate partners, characterized as physical in 87.5% of the articles, moral in 37.5%, and sexual and psychological in 75%, respectively.Spousal violence was also identified in three studies as responsible for the emergence of an ambiguous feeling marked by both submission, humiliation and affection for the person who dominates the victim (12,(14)(15) .
The second form of violence most identified in the articles was domestic (20%), and spousal and domestic violence were associated in 16% of studies.Sexual violence was the subject of 16% of the articles.Psychological or emotional violence materialized as rejection of affection, threats of beating women and children, and prohibiting women to work, have friends or leave the home (14)(15)(16)(17)(18) .
Violence against women was associated with gender violence in only 32% of the articles, and in most of the studies this term was not used or defined (68%).The Maria da Penha Law, enacted on August 7, 2006 and created to prevent domestic and family violence against women, was cited in only five of the articles (20%).In one of these, it was explained that the rigorous treatment of this Law for the aggressor can somehow result in the woman's hesitation to resort to public authorities in cases where the attacks are characterized by threats or by behavior deemed inappropriate by the woman herself (19) .In some cases, complaint to the authorities may mean separation from the attacker, when in fact it was intended to prevent new outbreaks of violence (19) without disrupting the relationship, which for women may mean having to assume a space that is not socially recognized (8,(10)(11)19) .

DISCUSSION
The research revealed that the most respected journals according to the CAPES criteria had the most articles on gender and violence against women.This leads to questioning and a research proposal, considering that these journals may be more open to issues of greater complexity, both from a theoretical, political and social point of view, as well as investigative.
Such complexity, inherent to studies on gender and violence, can also justify the prevalence of qualitative methods observed in this study, since these issues require a depth of knowledge and closer relationship with the subject, which is difficult to achieve in quantitative studies.This idea is also supported by many feminist researchers who believe that "quantitative methods are unable to capture the complexity of gender relations and their effects on different spheres of social life [...]" (20) .
Without ignoring the importance of qualitative studies in this area, the results of this research also portray the need to invest in studies that translate into numbers the extent of violence against women, thereby contributing to greater visibility and better planning of actions to confront this problem.In this regard, researchers (21) have faced the challenge of translating into numbers a situation arising from a social construct, establishing statistical indicators that enable detection of and make visible situations of violence against women.In this sense, the difficulty of advancement frequently stems from problems encountered in information systems combined with the number of complaints that are not made, making the measurement of violence against women and girls a complex task (22) .
The fact that gender was treated as a social construct in less than 50% of the 309 articles in this study that used this descriptor demonstrates how this approach still needs to be consolidated, to the detriment of the biological view that ignores power relations.This is essential for any research that focuses on gender and violence.
It is also worth mentioning that almost all authors of the articles are professionals with nursing degrees, pointing to the importance of the topic of gender and violence against women in their research processes.In some articles, the data also pointed to the contribution of these professionals for reflection and construction of a context that encourages the emancipation of women living in situations of violence (10)(11)13) . Thiscontribution can also be embodied in the participation of nurses in different spaces of formulation and implementation of public policies.
Also regarding the authors of the articles, there was an overwhelming predominance of women who investigated these issues.This fact may indicate that efforts to build a health science that it is more critical and feminist are also constituted in and by gender relations.At the same time, it is important to consider the possibility that this study worked with predominantly female authors because the investigation was carried out on nursing journals, in which most of the articles were written by nurses, most of which are women.But even taking into account that the female predominance in the investigations may have been influenced by this trend, the questions remain: are women researchers more sensitive to the problem of violence against women?Are male researchers more resistant to investigations in this area?Is gender a major factor both to the perception and practice of professional health care with regard to violence against women?
The fact that all of the articles were academic also points to the need for investment in shared production between health care services and academia, also considering that of the 60% of the empirical articles investigated, more than half corresponded to research on the work of health care professionals who were members of Family Health Strategy teams.The importance of involvement of such professionals in the investigative process becomes even more important given possibility of a theoretical and practical deepening of the limits and potential for prevention and care of cases of violence.
The complexity involved in this practice is demonstrated in this study by the contradictions identified in the statements of these professionals who, while recognizing the importance of seeking strategies to cope with violence against women, at the same time reveal an androcentric vision in which men are represented by the figure holding the power in relation to women, considered weak and submissive (9)(10)(11)(12)(13) .This misperception may cause a lot of nursing professionals to feel that they are not accountable or powerless in the face of violence perpetrated against women.At the same time, it may contribute to uncritical listening in the care process, and to placement of responsibility on the abused woman both for the existence of the situation of violence and ending it (9)(10)(11)(12)(13) .
This understanding, often naturalized and reproduced in care for women who suffer violence, needs to be overcome, making way for partnership in the investigative and intervention processes as a promising path in this direction.The possibility of a critical and reflective position on situations of violence against women has potential for greater involvement of researchers, professionals and society, for greater visibility and accountability for the violence carried out against child and adolescent girls and adult women.Thus, the need for recognition and deepening on the idealized social roles for women and men, and the consequences of such social constructs, including gender inequalities that are reflected in all areas of life, especially health.
In the articles investigated, it was noted that most of the studies refer to women who suffered violence and also have a low level of education.The rest were concerning the male perpetrators and those that jointly examined women and the FHS, as well as women and male perpetrators.In only two studies the subjects were children (23)(24) , which may indicate an important gap in the studies on this subject, especially considering that this age group has the greatest number of victims of violence in almost all regions of the country, according to the 2012 national report on the situation of violence against women in Brazil (25) .
Regarding the forms of violence addressed in the articles, spousal violence predominated.This type of violence was defined by the authors as that in which there is an exercise of power over women by their intimate partners.Despite the concept of spousal violence having been used in a similar way, the nature of the violence was not always discussed in all its forms (16,26) .Spousal abuse can manifest itself in various ways, such as sexual, moral and psychological, and is not always associated with physical violence, and thereby demands even more skill on the part of health care professionals to recognize, treat and preserve the health of battered women.The greater appearance of physical spousal violence in the studies may be related to greater ease in identifying this type of aggression, both for battered women and professional health care services.Sexual violence, for example, was indicated in only four articles, despite its significant presence associated with other types of violence, particularly spousal (9,23,(27)(28) .The fact that sexual violence often does not leave visible marks, and may therefore not be associated with physical violence, may cause the battered woman to be perceived with mistrust or suspicion when she seeks help in health care services (29) .Sexual violence is also subjective in nature, with different meanings and weights depending on the culture (30) .Although sexual violence often does not leave physical marks and is not easily detected, it is equally as or more responsible than other types of violence for consequences which may be reflected in various forms of illness.In the articles, the main consequences of sexual violence included diseases of the urinary tract and sexually-transmitted diseases (9,22,(26)(27) .
The second most prevalent form of violence in the articles was domestic.The domestic environment is the stage for reproduction of unequal relations between the sexes, given that the family is one of the most important institutions for reproducing social inequalities between men and women (26) .
The construction of domestic violence is historically linked to the positions that men and women must assume in society.In andocentric cultures, still legitimized by Western society today, men assume the place of highest authority as father and husband.This scenario was observed in both the articles that addressed violence against girls, in which the main perpetrator was the paternal figure (23)(24) .
Post traumatic stress syndrome is one result of the various forms of violence against women, and is characterized by an acute phase of disorganization in the lifestyle of the person assaulted and her family, requiring a prolonged process of behavioral reorganization (28) .The signs and symptoms camouflage a silence which shows feelings of humiliation, shame and anger.The fact that women have difficulty leaving this condition, and do not believe in the legal system to resolve the problem, make it so that these situations are often not reported (9,14,18,23,(26)(27)(28)(29) .
For example, it was expected that the Maria da Penha Law, because it is relevant and current, would be cited more, yet it was only referenced in 20% of the articles.In one of the publications, the authors also claimed, based on observations in routine services, that after the Law was enacted, the number of cases of women with demand for examination of corpus delicti in the Legal Medical Institute (LMI) decreased considerably.Thus, these authors questioned whether the law was strong enough to inhibit the aggressors or had contributed to increased silencing of battered women (31) .Another hypothesis is associated with the fact that many women have been educated to silently bear the abuse in an attempt to maintain the idealized model of relationship, or to ensure balance, support and maintenance of the family (12,14,28,32) .
An important correlation which can also be related to the Maria da Penha Law, and which deserves to be deepened, is the longer period of publishing of the articles -between 2007 and 2009.Considering that the law was enacted on August 7, 2006 and entered into force on September 22 of the same year, the increase of publications in the following year could mean greater attention by researchers on violence against women, with later stabilization of articles produced starting in 2010.
Although most of the articles consider gender as a social construct, violence against women was linked to gender violence in only 32% of the publications.In this sense, the authors understand the importance that the studies make this association, since thinking about violence against women as an integral part of gender relations means going beyond the findings of violence, to discuss the dynamics of power and forms of resistance to it.

CONCLUSION
This study revealed more similarities than differences among the articles, in addition to signaling the need for increased nursing publications involving discussions about gender inequalities for different social groups.Its results enabled greater knowledge of the gaps, difficulties and potential of both practice and research focusing on violence against women.Its limitations are due to the fact that this integrative review was developed only in national nursing journals, and it is important to continue research on this topic in journals from other areas, and to seek answers to the many questions arising from their results and that were not possible to consider at this time.
Gender-based violence was recognized as a concept that is still used in a limited way by some authors, even in some cases in which it was treated as arising from a historical and social construction.Violence against women was shown to be an important issue, with greater weight in private spaces, where the woman seems to find it difficult to deconstruct violent relations due to both affective and cultural reasons.This situation, added to the feeling of disbelief in the services that could help her, make cases of violence an immeasurable problem that is still not sufficiently confronted by the health care sector.
Health care professionals were identified as key to recognizing cases of violence, as women who experience it tend to seek services due to the physical and psychological consequences that they suffer.The poor preparation of many health care professionals also revealed their responsibility in reproducing gender inequalities.In addition to recognizing cases, the professionals should be trained to work on issues of gender and the construction of autonomy, aiding in the prevention of new cases of violence, and in disseminating the results of their daily practice.The scarcity of studies from professionals in the service or in partnership with academia points to a needed change in this framework.The increase of scientific articles derived from partnership between academia and the public health care service, and the expansion of means of dissemination of publications resulting from experiential reports and other modalities, can contribute to the unveiling of strategies, limitations and potential to reduce gender inequalities and violence against women.In this sense, it is also necessary to incorporate the category of gender by health care institutions, towards an expanded perspective of women's health in situations of violence, constituting a privileged space for overcoming violence against girl children and adolescents and adult women.
2004, and only one in 2000, 2005 and 2006.Fourteen articles were published between 2007 and 2009, four in 2007 and 2008, and six in 2009.From 2010 to 2012, the number of publications remained at two per year, respectively.

Table 1 -
Articles that addressed gender and violence against young and adolescent girls and adult women, by national nursing journal,Brazil, 2000-2012