Considerations on domestic violence, gender and the activities of family health teams

Abstracts

Este trabalho apresenta considerações sobre a violência doméstica contra as mulheres. Partindo do pressuposto que o fenômeno é baseado nas relações sociais de gênero, enfatiza a categoria analítica gênero como apropriada para uma abordagem aprofundada e consistente da questão. Considerando a promoção da saúde e a integralidade como eixos norteadores das ações, pretende fazer uma reflexão sobre a possibilidade do enfrentamento da violência doméstica a partir do trabalho das equipes do Programa de Saúde da Família. Aponta elementos que dificultam a abordagem da violência doméstica contra as mulheres, evidenciando a necessidade de reorganizar as práticas assistenciais, de capacitação dos profissionais de saúde e da realização de parcerias com instituições públicas e privadas, grupos de mulheres e famílias.

Saúde da mulher; Violência doméstica; Identidade de gênero; Promoção da saúde

CRITICAL REVIEW

Considerations on domestic violence, gender and the activities of family health teams

Consideraciones sobre la violencia doméstica, género y el trabajo de los equipos de salud de la familia

Clara de Jesus Marques Andrade^I; Rosa Maria Godoy Serpa da Fonseca^II

^IDoctoral Student of the Inter-units Graduate Nursing Program of São Paulo and Ribeirão Preto of University of São Paulo (USP) campi. Professor at the Federal University of Minas Gerais (UFMG) Nursing School. Belo Horizonte, MG, Brazil. [e-mail]

^IIPh.D. Professor at the Inter-units Graduate Nursing Program of São Paulo and Ribeirão Preto of Universidade de São Paulo (USP) campi. Professor at the Nursing Department of Collective Health of the Nursing School, Universidade de São Paulo (EEUSP). São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This work presents considerations on domestic violence against women. Based on the assumption that this kind of violence is based on gender-based social relations, it emphasizes the analytical category of gender as appropriate for a consistent methodological approach of the problem. Considering health promotion and the person's integrality, as the guiding foundations of behavior and actions, this work intends to ponder on the possibility of confronting domestic violence from the work perspective of the Family Health Program teams. It points out factors that make it difficult to approach domestic violence against women to domestic violence against women. Thus, it evidences the need for reorganize healthcare practices, health professionals' qualification and building partnerships between public and private institutions, and women and family groups.

Keywords: Women's health; Domestic violence; Gender identity; Health promotion.

RESUMEN

Este trabajo presenta consideraciones acerca de la violencia doméstica contra las mujeres. Partiendo del presupuesto que el fenómeno se basa en las relaciones de género, enfatiza la categoría analítica de género como apropiada para un abordaje profundo y consistente de este tema. Considerando la promoción de la salud y la integralidad como ejes guías de las accionnes, pretende hacer una reflexión respecto a la posibilidad del enfrentamiento de la violencia doméstica a partir del trabajo de los equipos del Programa de Salud de la Familia. Señala elementos que dificultan el estudio de la violencia doméstica contra las mujeres, evidenciando la necesidad de reoganización de las prácticas asistenciales, de capacitación de los profesionales de salud y de la realización de un trabajo conjunto de instituiciones públicas y privadas, grupos de mujeres y familias.

Descriptores: Salud de las mujeres; Violencia doméstica; Identidad de género; Promoción de la salud.

THE PHENOMENON OF DOMESTIC VIOLENCE AGAINST WOMEN

Violence is considered as a complex phenomenon of difficult conception by researchers, and it may be understood as all the events represented by relationships, actions, negligence, and omissions performed by individuals, groups, classes and nations that result on physical, emotional, moral and/or spiritual damages to another. The roots of violence are found within social, economic and political structures, as well as individual consciences⁽¹⁾.

It is not related to a recent phenomenon, exclusive to contemporary world. History presents examples of violence against the different, such as minorities, black people, women, children, elderly, etc. This difference, when translated into dissimilarities, have propitiated and justified situations of violence that have been perpetuated by humans. The interest in the phenomenon as an area of social research studies is recent.

For approximately three decades, violence has been considered an issue of human rights and justice, being reported and investigated as a result of public policies and the work of non-governmental organizations, and also women's groups, which, apart from reporting, seek for interventions, mainly when relating to violence against women⁽¹⁾. Starting in the 1990s, domestic violence has been conceived as a gender-based healthcare issue⁽²⁾.

The National Activist Campaign, which has been performed for sixteen years, proposes an end to violence against women. It is promoted and articulated by feminist entities, women's and human rights associations, governmental organs, public and private companies. Focusing on the entire society's responsibility and not only women's, when dealing with domestic violence, the campaign represents an advance in the sense of creation of public policies aiming at the reduction of domestic violence⁽³⁾.

In Brazil, on August 7^th, 2006, the Maria da Penha Law was approved, which alters the Brazilian Penal Code and foresees penalties for domestic aggressors. It represents a significant step to assure the right to physical, sexual and moral integrity to women⁽⁴⁾, and may be considered as an important advance dealing with the issue. However, since the penalties are restrained only to guilty parties, it reaches only part of the issue. There is a risk that it may stop encouraging reflections and the alternative search for the transformation of situations of violence experienced by women. Initiatives like this one, even though fundamental, may be articulated with others that will guarantee information and reflections about domestic violence in locations where women are present. That happens because domestic violence is still invisible for a large share of society, despite the space it has occupied, including in the media, for some time now.

Domestic violence features for its aggressiveness and coercion, which correspond to physical, sexual and psychological attacks, as well as the economic coercion that adults and adolescents use against their family members, practiced, above all, by husbands, partners, fathers and stepfathers, and considered to be taboos until a few years ago. Nothing was spoken about the subject, and, above all, nothing was done to stop it⁽⁵⁾.

In the aggressions, serious physical assault is caused by punches, slaps, kicks, tying and corporal punishment, burnings to sexual organs and breasts, strangulation and piercing/slashing wounds, where strikes are aimed at the victims' face, arms and legs^(5-6).

Most times, victims of domestic violence are women. According to IBGE's data from the late 1980s, the aggressor is her own partner, stating that 63% of the victims of physical aggression occurring in the domestic space are women⁽⁷⁾. Adult physical violence reaches between 20 and 50% of women, presenting a domestic violence centered pattern, where the partner or former partner is the aggressor, in approximately 77.6% of the registered cases⁽⁸⁾.

Sexual violence is also considered as domestic violence when performed by the partner. The National Feminist Health and Reproductive Rights Network defines sexual violence as an action that forces a person to perform sexual, verbal or physical contact or to participate on other sexual relation by force, intimidation, coercion, blackmail, bribery, manipulation, threat or any other mechanism that denies or limits personal will⁽⁷⁾.

The authors⁽⁸⁾ affirm that studies reveal that sexual violence is common. However, they highlight the existence of a relative invisibility of this type of violence in the reports presented in specialized police departments. A possible explanation for this situation might be the socio-cultural barriers present in the life of women, which make the elaboration and sharing of their violent life experiences difficult. Allied to these barriers, healthcare services action is still limited in cases of domestic violence^(2,8).

Domestic violence affects women's health and their quality of life, and it is associated to depression, suicide, drug and alcohol abuse, vague complaints such as headaches, gastrointestinal disorders and general psychic suffering. In these cases, women seek, more frequently, for healthcare services; however, in a paradox, violence is not counted in the performed diagnoses^(9-10).

International studies point to a high prevalence of domestic violence in healthcare services, since the episodes are repetitive and tend to become progressively more severe. However, despite this situation, domestic violence is not always recognized by healthcare services⁽²⁾.

Considering reproductive health, domestic violence against women is associated to chronic pelvic aches, sexually transmitted diseases, AIDS, inflammatory pelvic diseases and unwanted pregnancy^(2,10).

Domestic violence against women is also frequent during pregnancy. Literature shows that between 4 and 25% of pregnant women are victims of some type of violence. This percentage varies according to the population studied, definitions of violence and the methods used for identification^(5,11). In this case, physical violence is featured by strikes, and kicks aimed, mostly, against the women's abdomens⁽¹²⁾.

Pregnancy may function as an aggravator or protective factor against domestic violence⁽¹¹⁾. These studies also point that domestic violence during pregnancy is highly associated to childhood abuse and previous pregnancies. These data demonstrate the complexity and cyclic character of domestic violence in the life of women.

Studies done in Mexico^(11-12) and Brazil⁽¹³⁾ agree on pointing the magnitude of the seriousness of domestic violence during pregnancy and the consequences to women, fetus and newborns. They also confirm domestic violence during pregnancy as a psychosocial factor related to pregnancy hypertension syndrome, premature dislocation of the placenta, depression, suicide attempts, women's low self-esteem, and, regarding the newborn, premature birth and low weight.

Apart from contributing to high morbidity, domestic violence is a not a recognized component of maternal mortality, and some researchers propose a concept enhancement of maternal mortality incorporating domestic violence as one of its determiners⁽¹⁴⁾.

Basic health services are important to detect violence, since its broad covering of pre-natal assistance may work as an important space for its identification⁽²⁾, representing the doorway to approach violence, establishing a link with women and encouraging them to report⁽¹⁰⁾.

However, in order for domestic violence visibility to occur in the basic health network, organizational changes in services and changes in approach by professionals are necessary, so as to not simply prioritize the accomplishment of objectives and executing the techniques proposed by the programs. It means that dialogues and more symmetric relations between professionals and users must be established.

These more symmetric relations within the healthcare services enable women to seek refuge and attempt to solve the situations of violence. That requires a re-work of assistance programs, exploring distinct female conceptions, different findings and several strategies for combat and accommodation, seeking more efficient alternatives for the work⁽⁹⁾. Therefore, only a professional position that is not technically correct, but also based on dialogue and on the relationship with the other, as a subject, will be able to create this type of relation in the healthcare services.

Reports on the experience of midwives on identifying women mistreated during pregnancy confirm that an attentive listener, the refuge and the establishment of a relation of trust with women will enable them to talk about the situation and seek help⁽¹²⁾.

In group work situations, when they started feeling welcomed, women spontaneously spoke about their violence experience. The speech of one of them has propitiated other reports on violence, working as a snow ball. It proves that women are ready to talk about the situation, provided that they feel the possibility of an attentive listener and of refuge from her problems, even with no guarantees of solution⁽⁹⁾.

GENDER AS A CATEGORY OF ANALYSIS OF DOMESTIC VIOLENCE

In order to be understood, within its whole complexity, violence against women must be understood as gender violence, and its analysis must be performed not only in individual terms, but also because it is, primordially,

a social, economic and political reflex of inequality, which is perpetuated by the social apparatus that reinforces sexist, racist and classicist ideologies⁽⁵⁾.

The roots of violence in gender relations are settled in the relationships between men and women themselves, where violence is a perverse aspect of these relations, since it revokes a relation between two subjects and reduces one of the poles to the condition of an object. Therefore, gender issues and violence often converge, and are treated with the same conceptual definition⁽⁹⁾.

Gender is a category of analysis that, under the lights of power, explains biologically and socially constructed differences between men and women. The analysis of this situation demonstrates that the exercise of power is performed under an unequal format between genders, where women occupy subaltern and secondary positions⁽¹⁵⁾.

The theoretical gender referential, considering the established relations between subjects,

emphasizes plurality and conflict of process by which culture builds and distinguishes female and male bodies and subjects, and it is expressed by gender articulation with other social marks as class, race/ethnicity, sexuality, generation, religion, nationality⁽¹⁶⁾.

Since it is incorporated into the issue of violence against women, the gender referential enables a deep understanding of the phenomenon, since it implies the consideration that relations between men and women are not only based on Biology, but male and female genders are socially built and vary according to the culture in which they are inserted⁽⁵⁾.

This subaltern situation that features and aggravates violence against women is related to the capability of sexually and socially self- determination. Women become more vulnerable to physical and emotional male abuse, since they are not the subjects of their own lives.

THE WORK OF FAMILY HEALTH TEAMS AS A SPACE FOR REFLECTION ON DEALING WITH DOMESTIC VIOLENCE

The researched literature presents domestic violence against women as a complex invisible problem; However, it present and recurrent in healthcare services, and difficult to be approached. On the one hand, there are services that generally present no technical or organizational conditions to serve this specific demand, and health professionals feeling impotent to deal with such a complex problem, while, on the other hand, there is the difficulty of women in talking about their experiences of violence.

Research about the professional practices of family healthcare teams aimed at women subjected to situations of sexual violence point the need of discussing the issue of domestic violence inside the routine activities of health services⁽¹⁷⁾, improving the capacity of the professionals and establishing partnerships with other services. That is why domestic violence, given its complexity and contradictions, requires an interdisciplinary and inter-sectorial interventions and approaches. While discussing the difficulties on approaching domestic violence, this research also points to the need of reorganizing healthcare practices, considering that domestic violence must be approached in an inter-institutional structural, singular and private-dimensioned format.

The Family Health Program (FHP) may be understood as a reorientation strategy of the current Brazilian healthcare model, provided that multi-professional teams are implemented into basic health units, which are responsible for the follow-up of a certain number of families, residing in a delimited geographical area. The teams should perform health, prevention, recovery, and actions promoting the rehabilitation of the most frequent diseases and aggravations. Among other aspects, they are characterized as such because they establish commitment links and co-responsibility with the population by sectorial actions, through partnerships established with different social and institutional segments, intervening in transcendent situations according to the specificity of the sector and through determining effects over the conditions of health and life of the family⁽¹⁸⁾.

When they learn about the situation violence in the life of the women, the professionals may initiate health promotion actions. For that, a good partnership with several sectors of society is needed, since the solution may not be sought only within the family or health teams. Dealing with domestic violence against women requires, beyond the definition of the State, public policies, articulated actions and partnerships between healthcare services and other social services, such as schools, churches, police, specialized police departments, neighborhood associations and women's groups⁽¹⁷⁾.

Health promotion, understood as one of the axes that guides basic healthcare, demands a coordinated action among the government, health and other social and economic sectors, volunteer and non-government organizations, local authorities, industry and media. Health promotion, as understood in the last 25 years, is part of a broad conception of the health-disease process and their determining factors. It proposes the articulation of technical and popular knowledge and the mobilization of institutional and community, public and private resources for dealing with the resolution of various health aggravations⁽¹⁹⁾. Under this perspective, being characterized as a space for health promotion, the FHP has issues of domestic violence against women under its responsibility, intended to work as a resource for the reflection and articulation of strategies for coping with it.

Family health professionals have, as their greatest challenge within everyday practice, the need to overcome the monopoly of diagnosis of necessities, and also the need of integrating with the voice of the other, changing the technician-user relationship of power, evidencing the social being, with a full and dignified life as the expression of their rights. It represents a transformation in the position of the professionals in family health teams, a transformation featured as a potential link building, bringing those who offer or provide services closer to those who receive it ⁽²⁰⁾.

FINAL CONSIDERATIONS

The theoretical proposal of the Family Health Programs presents conditions for coping with domestic violence against women, considering health promotion and inter-sectorial ability as action-conducing axes. However, during routine practices, elements as lack of preparation and insufficient professional qualification to act in the FHP and the difficulty for interacting with the new knowledge and practices for collective actions, make it difficult to implement FHP and consequently team actions that guarantee linking and refuge⁽²⁰⁾.

Despite the noted difficulties and the limitations that they represent, there is the possibility of creating, within the acting space of the family health team, local strategies for coping with domestic violence against women. In order to perform that, a new professional attitude is needed, based on reflections about social gender relations and the complexity of domestic violence against women. With this reflection, it is also necessary to building, with the women themselves, alternatives for coping with violence.

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Correspondência:

Clara de Jesus Marques Andrade

Av. Alfredo Balena, 190 - Campus Saúde

CEP 30130-100 - Belo Horizonte, MG, Brasil

Publication Dates

• Publication in this collection
  19 Sept 2008
• Date of issue
  Sept 2008

History

• Received
  09 Apr 2007
• Accepted
  20 June 2007