Interface between conjugal violence and alcohol consumption by the partner Interface

Objective: to analyze the discourse of women on the interface between marital violence and alcohol use by the partner. Method: qualitative exploratory research, based on the methodological reference of oral history. We interviewed 19 women with a history of marital violence and involvement with drugs. The data were analyzed through discourse of the collective subject. Results: the participants’ discourse points to consumption of alcohol by partners as a potentiating element of violent episodes, also experienced by their parents, signaling to its transgenerational character; it also calls attention to the danger of marital violence resulting from men’s reactions to having their alcohol consumption questioned by their partners. Final considerations: the study identifi es alcohol as a precipitating and/or potentiating factor of conjugal violence, as well as the intergenerational character of violence based on male domination and intolerance. Descriptors: Violence Against Women; Intimate Partner Violence; Drug Users; Nursing; Health Promotion. RESUMO Objetivo: analisar o discurso de mulheres sobre a interface entre violência conjugal e uso de álcool pelo companheiro. Método: pesquisa exploratória, qualitativa, fundamentada no referencial metodológico da história oral. Foram entrevistadas 19 mulheres com história de violência conjugal e envolvimento com drogas. Os dados foram analisados através do discurso do sujeito coletivo. Resultados: o discurso das participantes aponta o consumo do álcool pelo companheiro como elemento potencializador dos episódios violentos, evento também experienciado pelos pais, sinalizando para seu caráter transgeracional; alerta ainda para a violência conjugal decorrente da reação do homem ao ser questionado pela companheira quanto ao consumo do álcool. Considerações fi nais: o estudo identifi ca o álcool como fator precipitador e/ou potencializador da violência conjugal, bem como o caráter intergeracional da violência alicerçada na concepção de dominação e intolerância masculina. Descritores: Violência Contra a Mulher; Violência por Parceiro Íntimo; Usuários de Drogas; Enfermagem; Promoção da Saúde. RESUMEN Objetivo: analizar el discurso de las mujeres sobre la interfaz entre la violencia conyugal y el uso de alcohol por el compañero. Método: investigación exploratoria, cualitativa, basada en el referencial metodológico de la historia oral. Se entrevistaron a 19 mujeres con antecedentes de violencia conyugal e implicación con drogas. Los datos fueron analizados a través del discurso del sujeto colectivo. Resultados: el discurso de las participantes apunta el consumo del alcohol por el compañero como elemento impulsor de los episodios violentos, evento también experimentado por los padres, señalando para su carácter transgeneracional; advierte también a la violencia conyugal derivada de la reacción del hombre al ser cuestionado por la compañera en cuanto al consumo del alcohol. Consideraciones fi nales: el estudio identifi ca el alcohol como factor precipitador Interface between conjugal violence and alcohol consumption by the partner Interface entre a violência conjugal e o consumo de álcool pelo companheiro Interfaz entre violencia conyugal y el consumo de alcohol por el compañero


INTRODUCTION
Violence against women represents a major challenge in the area of public health and safety, resulting in sickness and having repercussions on economic productivity.Confronting this issue requires professional preparation, so it can be identified early, especially when it is interfaced with consumption of alcohol and other drugs.
Several studies point out the damages to the physical and psychological health of women, generating costs for the health sector (1)(2)(3)(4)(5) .This issue has been severely affecting families and society due to high numbers of morbidity and mortality.The Map of Violence (2014) identified the occurrence of 2.4 times more female homicides in Brazil than the international average, making it the world's fifth-highest in the number of women killed by aggression.As for morbidity, in the same year, 147.691 women needed medical attention as a result of violence, a burden on public finances (6) .
Considering the magnitude and implications of violence against women, certain mechanisms were built with the aim of preventing and confronting the phenomenon.Law No. 11.340 (7) created devices to curb domestic and family violence, typifying expressions of violence into five forms: physical, which corresponds to any conduct that affects the integrity of the body; sexual, characterized by impositions that nullify the exercise of women's sexual and reproductive rights; patrimonial, identified as subtraction or destruction of objects or economic resources as a strategy of domination; moral, associated with slander, defamation and insults; and, finally, psychological, related to actions aiming to degrade or control the actions of women.
Regardless of its form of expression, the experience of violence triggers physical and mental illness resulting from direct injuries, presented through bruising, lacerations and fractures caused by physical aggression, or even from somatization, characterized as mental and physical symptoms of emotional origin, such as insomnia, low self-esteem, panic disorder, gastric ulcers and hypertension (1) .Observation of damages to the physical integrity of victims is corroborated by a study made in France, which also refers to cuts and avulsions, warning that these injuries can lead to death (4) .
While all these health hazards are already typified, practitioners find it difficult to recognize and address the situation.This is due to professionals' insufficient training and also the social construction of gender, which makes it difficult for hospitalized women to admit the situation of domestic violence (8) .A research developed in Israel also reveals that primary carefocused health professionals do not commonly recognize cases of domestic violence.Consequently, injuries go without being notified, and physical and psychological repercussions are not perceived: when it comes to health care professionals, these elements remain invisible (9) .In Turkey, a research with nursing students addressed the non-recognition of cases of violence, suggesting integration of courses on the subject into the nursing curriculum to help detect signs of violence against women (10) .
The difficulty of addressing marital violence in the healthcare network is also a reflection of the multiplicity and complexity of elements associated with the phenomenon, such as low levels of education and involvement with alcohol and other drugs.The latter stands out in the literature as an important component of conjugal violence.However, studies rarely point out which aspects of drug involvement are related to the occurrence of domestic aggravation (11)(12)(13) .Authors from the US and India emphasize that there is no clear understanding of the relationship between alcohol and increased risk of violence, which attest to the importance of future studies examining this association (14)(15) .Faced with such a gap, we outline the following research question: what is the discourse of women on the interface between conjugal violence and their partners' consumption of alcohol?

OBJECTIVE
To analyze the discourse of women on the interface between conjugal violence and the consumption of alcohol by the partner.

Ethical aspects
The scope of this study was developed in the thesis Vivências, vulnerabilidades e enfrentamentos da violência conjugal: discurso de mulheres envolvidas com drogas, approved by the Research Ethics Committee of the State University of Bahia, and complies with the ethical and legal provisions contained in Resolution 466/12 of the National Health Council (16) .Data collection was initiated only after the signing of an Informed Consent Term by the women, who chose to perform the interview in their own homes or residences of people close to them.In these residences, a space was chosen that would guarantee privacy during the collection of data.

Type of study and methodological reference
This research had a qualitative approach, based on the semistructured interview, a technique that allows the exploration of sensitive subjects, providing rich information and detailed perceptions and experiences, broadening the knowledge on investigated social objects (17) .

Scenario of the study
The research was carried out in the coverage area of two family health units (USFs), located in the urban zone of a municipality in the interior of Bahia (Brazil).According to data from Ipea (18) (2016), the municipality is one of the most violent in the country, a situation evidenced by the 1136.9%increase in the homicide rate during the assessed period, due to deterioration of security conditions and high social vulnerability.

Data source
The study was carried out with 19 women residing in the referred municipality.Inclusion criteria were the following: to reside in the area covered by one of the two family health units, to have a history of marital violence and involvement with drugs, and an age equal to or greater than 18 years.Exclusion criteria were: signs of emotional instability, expressed by the greater tendency for panic disorders, states of negativity and depression, and to be using drugs or suffering from substance withdrawal syndrome.Evaluation of emotional instability was carried out by the researcher, in some cases with the support of a psychologist from the local Psychosocial Care Center for Alcohol and Drugs and also from the Family Health Support Center.The number of collaborators was limited due to the difficulty of identifying women who experience the phenomena of conjugal violence and involvement with drugs.
Approach to the community was supported by community health agents, who made visits in the coverage area of the health units possible.Several home visits were considered necessary in order to promote a bond between researcher and interviewee, developing a trustworthiness for the sharing of experiences.

Data collection and organization
Data collection was performed between October 2016 and February 2017.Recovery of memories of women involved with alcohol and situations of conjugal violence occurred through an in-depth interview.Individual interviews were recorded, with their narrative organization being performed only after transcription, textualization, and transcreation.Transcription consists in the faithful conversion of the recorded content to written form.During the textualization stage, after incorporation of answers, the first-person narrative is organized chronologically, facilitating the comprehension of the person's experience.The last phase corresponded to transcreation, meaning the elaboration of a complete textual registry, enriched with extratextual elements from the field diaries.

Data Analysis
Data were analyzed through comparison between interviews, in view of the opinions, perspectives and facts reported.This analysis was guided by discourse of the collective subject, a method for grouping individual expressions that have similar senses, so as to establish general semantic categories (19) .Thus, the content of the interviews was converted into a synthesis-statement, written in the first-person singular, as a kind of synthetical expression of the collective.Results were anchored in the produced knowledge on marital violence and drugs, and in the analytical category of gender.

RESULTS
The 19 collaborators, women in situations of conjugal violence and involved with drugs, were between 20 and 69 years old.They were mostly black, Catholic, married or in stable union and had one to three children, little schooling and monthly incomes of less than a minimum wage.In respect to drug involvement, most reported frequent abuse of alcoholic beverages and cigarettes, in addition to use of benzodiazepines.The women also reported frequent abuse of alcohol and cigarettes by their companions.
The interface between partners' alcohol consumption and marital violence was revealed by collective discourses organized in the following categories: "Alcohol potentiates partner's violent behavior," "Partner reacts violently to being questioned about his alcohol consumption," and "Intra-family violence permeated by partner's use of alcohol is transgenerational." Idea-synthesis 1: Alcohol potentiates partner's violent behavior In this discourse, women point to effects of alcohol on the daily habits of their peers, including potentiating violent episodes, expressed in various ways.
The problem of drinking is that it makes you more violent.He drank before he met me, but at the beginning of the wedding, he always came home quiet.Time passed, and he started drinking more and more.He left the house to drink on Saturday and only came back on Monday.Nowadays, he drinks all week!He is already an ignorant person, not good at having conversations, and he likes to fight, but it is drinking that gets him worse, constantly angry, nervous; even then, every day he keeps drinking more and more.He was always very good on the money side of things, … a good man, father, husband, and homeowner.But every time he drinks, he spends all his money, stays on the street for days, becomes a womanizer, even more ignorant, and when he gets home he gets rougher with everybody, disturbs us, curses, calls me a slut, breaks things inside the house, punches and kicks the windows frames, the door, the window.He throws the food away, refuses to accept me not wanting to be near him, pulls the machete and threatens to fire a gun to my head.(E2, E3, E4, E5, E7, E8, E9, E18, E19)

Idea-synthesis 2: Partner reacts violently to being questioned about his alcohol consumption
The discourses also reveal that when asked about alcohol consumption the husbands react violently, which demonstrates the interface between conjugal violence and men being questioned about their drug use.
The fight starts because I do not want him to drink.When I met him, he already drank a bit, but over time he started to drink a lot.Now he drinks every day, starting Monday, and drinking more every day.I hate it so much to see him drink that when he comes home, I get nervous, I question, I complain, I threaten, I say I will not stay with him and his drinks … and so the discussions begin.He thinks it is bad and starts breaking things in the house.With the same fury, he leaves me, attacks me by pulling my hair, kicking me and trying to suffocate me.To conclude, he always says that because of my daring to contradict him, eventually he will cut my neck.(E1, E2, E3, E5, E6, E7, E8, E9, E13, E16, E15, E18, E19) Idea-synthesis 3: Intra-family violence permeated by partner's use of alcohol is transgenerational In their discourse, women reveal that their own family follows the same patterns as their parents' family: the partner uses alcohol and harasses his wife and children; and the woman naturalizes this condition.This transgenerationality of intrafamily abuse predisposes women to experience conjugal violence.
Interface between conjugal violence and alcohol consumption by the partner Carvalho MRS, Oliveira JF, Gomes NP, Santos MM, Estrela FM, Duarte HMS.
My father drank a lot, and when he got home, he would fight, curse, break everything in the house, say that he did not like people, and beat us.When he drank, he would assault everyone, get very jealous, and beat my mother a lot more.She just did not get even more beaten because the rest of the family members intervened.My brother learned from my father and got into drugs early.Today he is an alcoholic and cannot stay with any woman because he is very aggressive.He would hit them all.What happened to my mother nowadays also happens to me.When my husband drinks, I already know that he will again break everything in the house, start mistreating the kids, argue, curse, scream to me loudly so the neighbors can hear, show distrust of me, attack me, suffocate me and push me.I see myself in the same life as my mother and I cannot get out of it either.I already know that this is my life and there is nothing I can do about it … It will not change!(E1, E3, E4, E9, E10, E11, E12, E13, E16)

DISCUSSION
The discourse of women in situations of conjugal violence and involvement with drugs reveals the relationship between alcohol consumption by the partner and the triggering of conjugal violence.From this perspective, men that are socially perceived as non-aggressive begin to behave violently, and those with already violent behaviors manifest them in potentialized way.This is corroborated by national and international studies showing how male partners' use of alcohol plays an important role in domestic violence: drinking behavior is demonstrably not only a direct cause of disagreement between couples, but also a factor of violence (3,14,(20)(21) .
Although this study does not establish a cause and effect relationship between use of psychoactive substances and occurrence of violent acts, the former's role as a violence enhancer can be explained by the effects of the substance on the body.Neurotransmitter stimulation triggered by the drug inhibits several neural regions and, consequently, generates structural and behavioral changes in the individual (22) .These neurological disorders alter the integrative control of the functions of the organism and affect the neural processes that determine behavior, generating inability to make rational decisions, mood inconstancy, euphoria, and intolerance to certain situations (23) .
With loss of critical sense and control of actions, the inability to make rational decisions and intolerance in the face of certain situations become mainly responsible for inhibiting self-control.This inhibition deprives the person of the ability to discern morally accepted behaviors, contributing to the adoption of violent behaviors (24) .This effect of alcohol on the behavior of the individual explains the relationship between aggressions experienced by women and abuse of alcohol and other drugs by their partners, as well as the fact that men demonstrate more peaceful behaviors when free from the effect of psychoactive substances (11) .Corroborating this idea, a study conducted in India, with 272 couples, and in South Africa, with 1388 women, revealed that alcohol use by the partners represented an increased risk factor for aggression (15,25) .A similar reality was confirmed in a study of 422 pregnant women in Ethiopia, which investigated the prevalence of conjugal violence during pregnancy and its associated factors (26) .By revealing the abuse to which women are exposed in a context of conjugal violence permeated by the consumption of alcohol by the companion, the discourses make it possible to identify all the forms of expressions typified in the Maria da Penha Law, which have also been pointed out in other studies developed nationally and internationally (21,27) .Regarding physical violence, for example, while discourses pointed to the experience of hair pulling, kicking and suffocation, a study conducted with Pernambuco women also revealed the relationship between alcohol consumption and aggressive behavior of the partner, referring to other forms of violence such as punching and stabbing, resulting in lacerations and bone fractures (21) .
Regarding the patrimonial form of expression, it is worth emphasizing that in the discourses this is considered to occur when the companion, under the effect of alcohol, breaks household items and deprives the family of food by throwing it in the trash.In a study carried out in Minas Gerais with 27 women, alcohol consumption by partners was observed as part of the daily life of women affected by conjugal violence, related to the retention and subtraction of economic resources, especially those used to support the family (28) .This reality is also pointed out in other literature, even acknowledging the influence of dependence on the redirection of resources previously destined for the provision of the home, with these resources being used to purchase alcohol, compromising the family's livelihood (11,13) .
The discourses also allowed us to identify the manifestation of violence in psychological form, expressed through threats involving weapons and firearms, and in moral form, evidenced by the dishonorable curses that women were subjected to, in acts of slander and defamation.The presence of the psychological and moral forms of expression was also pointed out in a study carried out from records of a police station in the southern region of Brazil, in which occurrences of violence against women associated with alcohol use were significantly moral and psychological, expressed in threats, humiliation and cursing, triggering reports of fear, impotence, guilt, low self-esteem and submission (29) .
Sexual violence, also present in discourses, is corroborated by a study carried out in the interior of Rio Grande do Sul; its findings revealed that women were forced to maintain sexual practices through intimidation, threat, and coercion, even during the gestational period (11) .This is confirmed in a study carried out in the USA which recognizes conjugal rape as a common occurrence (27) .This occurrence is better understood from the current perspective on gender, which, by reinforcing inequality in the roles and conducts of men and women, corroborates sex in marriage as a man's right and a woman's obligation.This condition makes it difficult to recognize conjugal acts of violence and, consequently, contributes to the scarcity of reports of sexual violence.
Besides the understanding that the partner's consumption of alcohol precipitates violence, expressed in different ways, another element that favored its occurrence was related to instances where the female questioned the partner's use of alcohol.Men's violent reactions when questioned are explained by a historical and sociocultural process which naturalizes and reproduces submission and passivity as attributes inherent to the feminine gender.A Brazilian study of women victims of violence, when investigating the factors that triggered or intensified conflicts in the marital Interface between conjugal violence and alcohol consumption by the partner Carvalho MRS, Oliveira JF, Gomes NP, Santos MM, Estrela FM, Duarte HMS.
relationship, identified an idealization of man as the sole owner of knowledge, reason and power-one who should not, therefore be questioned-and of woman as a person who owes allegiance and obedience, having no right to self-expression, disagreement or decision in respect to partner (30) .Other studies, conducted in Cuba, Nigeria, and East Africa, also have data on male control and female subservience as factors in violence against women (31)(32)(33) .
The social reassertion of men's expectations of women is the basis for the socially legitimized domination of the male.A context in which men's supposed rights are imputed to the feminine gender reinforces a relationship of power wherein there is no tolerance to any kind of questioning by women, and not only in relation to alcohol consumption.In this environment, the naturalization of female domestication through violence is also replicated, associating and strengthening the idea of the power of a dominator who obtains a right to aggression.Thus, preestablished roles are performed by each gender.These roles are socially agreed and, naturally, reaffirmed in marital relations (30) .Such conduct of domination, which justifies acts of violence as manifestations of masculinity and female subordination, is based on the construction of patriarchy, and cannot be ignored in the face of conjugal violence, even though it is naturalized even by the professionals of the healthcare system (34)(35) .For example, an international study carried out with Angolan health professionals on their perceptions of violence against women in the marital relationship, identified the cultural construction of the social role of women in the family as a pillar of support for the naturalization of this type of violence, marked by the belief in male superiority and female frailty (36) .
Another relevant piece of data identified in the oral history of the participants was the report of involvement with alcohol as a precipitator of domestic and intrafamily violence being a transgenerational experience.This finding is corroborated by other studies conducted in Brazil, which point out that children of couples in violent relationships are more likely to repeat the same experience in their future relationships (12,(37)(38) .A survey conducted in Sri Lanka with multiple generations of families also pointed to the transgenerationality of violence when children witness and/or experience violence in childhood and adolescence and reproduce it in marital life (39) .
Reaffirming this reality, research in Bangladesh showed that women who witnessed or experienced involvement with alcohol and violence in childhood were more likely to be involved in marital violence as adults (40) .A study conducted in Brazil to investigate transgenerational patterns of family violence associated with alcohol use also confirmed transgenerational reproduction, as well as the reiteration of patterns of consumption, types of violence and reactions of the victims (41) .Thus, by witnessing violent relationships between parents since childhood, women can naturalize and reproduce the same model in their marital bonds.Naturalization of experiences of intrafamily violence associated with alcohol use, as a relational model, favors the construction and permanence of women in disrespectful marital relationships.
Contributions to nursing, health and public policy Although this study was limited to the individual context of women from an urban area of the Northeast, understanding the expectations created by the social construction of gender allows results to be extrapolated to other realities, even outside Brazil.By unveiling the interface between the experience of conjugal violence and the consumption of alcohol by partners, the study offers elements that may support interventions enabling prevention and coping with these phenomena.

FINAL CONSIDERATIONS
The discourse of women in situations of conjugal violence and drug involvement indicates the consumption of alcohol by the companion as a precipitating and potentiating element of the violent episodes, something also experienced by the parents, pointing to its transgenerational character.It also calls attention to marital violence resulting from the man's reaction, which does not admit having his alcohol consumption questioned by the female partner.
Considering that the discourse reveals women's understanding that their partners' use of alcohol makes them vulnerable to violence, educational actions are necessary in order to stimulate reflections about this issue and its relation to alcohol, as well as its transgenerational character, anchored in the social construction of gender.We hope that the various spaces for women's care will promote women's empowerment, providing a recognition of the experience of violence and strategies for a life free of violence.
In this context, nurses are essential references.They are able to carry out an educational process with actions not only in healthcare spaces but also in the education and social security scenarios, preventing and confronting the phenomenon.In the school context, these actions are essential, since they can discourage the early use of drugs in the child and youth public, as well as contribute to the social deconstruction of gender inequality, perhaps allowing the construction of more symmetrical relationships between men and women.It is also believed that early intervention will avoid the reproduction of the conjugal context witnessed in the relationship between parents, a way of minimizing the transgenerational character of violence in future marital relationships.