Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.43 no.spe2 São Paulo Dec. 2009
El cuerpo y la salud de la mujer
Dulce Maria Rosa GualdaI; Neide de Souza PraçaII; Miriam Aparecida Barbosa MerighiIII; Luiza Akiko Komura HogaIV; Roselena Bazilli BergamascoV; Natália Rejane SalimVI; Fabiana de Souza OrlandiVII; Sebastião CaldeiraVIII
IMidwife. Full Professor of the Department
Maternal-Infant and Psychiatric Nursing at School of Nursing, University of
São Paulo. São Paulo, SP, Brazil. firstname.lastname@example.org
IINurse-Midwife. Associate Professor of the Department Maternal-Infant and Psychiatric Nursing at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. email@example.com
IIINurse-Midwife. Full Professor of the Department Maternal-Infant and Psychiatric Nursing at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. firstname.lastname@example.org
IVNurse-Midwife. Associate Professor of the Department Maternal-Infant and Psychiatric Nursing at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. email@example.com
VNurse-Midwife. Assistant Professor of the Department Maternal-Infant and Psychiatric Nursing at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. firstname.lastname@example.org
VIMidwife. Doctorate student in the Interunit Doctoral Program in Nursing at School of Nursing and Ribeirão Preto College of Nursing. University of São Paulo. São Paulo, SP, Brazil. email@example.com
VIINurse. Doctorate student in the Graduate Program at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. firstname.lastname@example.org
VIIINurse. Doctorate student in the Graduate Program at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. email@example.com
The study aimed to develop a theoretical reflection on the thematic "body" during woman's life course events in the phenomenological perspective and the research methods used in their approach, led by faculty of Women's Health area at the School of Nursing, University of São Paulo. This theme was chosen due to the centrality acquired by the body in contemporary society and the relevance of the topic. In this paper we show its applicability in the field of Women's Health, the results of some studies using different methods, focusing on the body on woman's life course events.
Key words: Human body. Women's health. Qualitative research.
El estudio tuvo como objetivo hacer una reflexión teórica sobre la temática del cuerpo durante los eventos del curso de la vida de la mujer en la perspectiva fenomenológica y los métodos de investigación utilizados en su enfoque, dirigidos por profesores del area de Salud de la Mujer en la Escuela de Enfermería de la Universidad de São Paulo. Este tema fue elegido debido a la centralización adquirida por el cuerpo en la sociedad contemporánea y la importancia del tema. En este trabajo se presenta su aplicabilidad en el ámbito de la salud de la mujer, los resultados de algunos estudios sobre los diferentes métodos, centrados en el cuerpo acerca de los acontecimientos del curso de la vida de la mujer.
Descriptores: Cuerpo humano. Salud de la mujer. Investigación cualitativa.
Studying the social appropriation of the body has become extremely important because it is the first and most concrete asset of a human being once it takes a place of its own when we try to understand the human experience and the care provided to it. It is in the body that unique phenomena take place, to which the organic and social nature of a human being contributes. It is the society that indicates what individuals should do with their bodies in daily life and when facing the modifications experienced in their existential process.
Recently, the body has stopped being an exclusive subject of the Natural Sciences and has become object of study in several human disciplines, such as History, Philosophy and Social Sciences. It is worth adding that the valuation of the body came up in the social movements of the sixties with highlight of feminism, movements for racial equality and contra-culture, which have transformed it into an object of study. The body offers several possibilities and leads to the analysis of themes discussed in the nursing area, particularly those related to women's health once it is its object of care.
In the societies the body has been highly valued, mainly due to aspects that draw the attention, such as aesthetics, sexuality and social relations between genders, which are closely linked. Although, as a result of a body model socially adopted that is close to perfection, many women have problems related to libido and are not able to live their lives in full.
Some events are crucial for women's development because they involve complex physical, emotional and social modifications which interfere with personal dynamics. This aspect, associated to the core importance acquired by the body in the current society and considering the relevance of several possible approaches, has become the focus of researchers linked to the area of Women's Health at the School of Nursing of University of São Paulo. Thus, in this article are discussed some conceptual approaches and study methodologies focused on body-related themes, either treated in a cross-sectional way or actually focused on the body.
To make a theoretical reflection on the body in events during women's life course under a theoretical phenomenological perspective and to present research methods used in the approaches of researches conducted by faculty members in the area of Women's Health at the School of Nursing of the University of São Paulo.
Theoretical perspective should be understood here as the philosophical stance supporting a methodology. Different ways of seeing the world condition the choice of different methodologies. Methodology here stands for the design of an investigation that conditions the choice of a method to obtain the results expected. In the research methods are included the techniques or procedures used to collect and/or analyze the data related to the question of the research. In this text, the body is the theme of choice.
THEORETICAL PHENOMENOLOGICAL APPROACH
In this paper the unifying element is the concept that considers mind and body aspects of an organic process where meaning, thought and language are dimensions of the activity incarnated.
We assumed that a person is not only body and mind once there are not two dimensions mysteriously combined. What we call a person is an organism that has a cerebrum that operate in a body and which is permanently interacting with the material and social context, in a continuous process of construction of the experience. Under this perspective, mind and body are just abstract aspects of the interactions with the environment that constitute the experience.
The body is the origin of our way of being, of reacting to the world; it represents the way we relate with the world. It is deemed an object whose story is the result of the relations it has with the world. It is, therefore, an object of the world whose origin is in the heart of the experience lived. The philosopher says: I do not have a body. I am my body; through this body I understand the other and perceive the things(1).
The body's objective is to meet man's biological and social needs, which is reflected in his bodily conscience (self-image) and in the search for his identity (self-concept). From its relations with the society result behaviors and life styles, which also depend on his notion of time and space related to the environment(2).
The body is temporary, mutable and transitory.
The body changes as time goes by, with diseases, which changes in eating and living habits, with different possibilities of pleasure or with new ways of medical and technological interventions(3).
In the health-illness process, the relation between body and risk should take into account a broad diversity of paths involved in a person's behavior. The perception of risks by segments of the population depends on their assimilation of information about health problems, stressing here bodily characteristics and their relation with being ill or being healthy. Another aspect suggests that people may become more reflexive about their body and, thus, they will emphasize situations they think to be under control, even when they keep high-risk behaviors related to a certain disease.
Phenomenology-based researches may use the ethnographical methodology, typical of anthropology and medical anthropology, or the phenomenological methodology itself, whose roots can be found in several areas of psychology. The phenomenological perspective opens a broad spectrum allowing various conceptual approaches.
Under an anthropological perspective we have conducted researches in an attempt to understand women during their life course, both in significant experiences such as birth and menopause and in processes of getting ill. The theoretical reference guiding some of our investigations is that developed by the followers of the American anthropologist Clifford Geertz. In this field of study the central focus is people in different cultures and social groups and how they explain things related to health and illness, their beliefs about treatments and the people they would seek to solve a health problem. We have to highlight here the practices related to the body, both in health and in illness. Meaning and knowledge always hold as reference the world constituted in the human experience, formulated and apprehended through symbolical shapes and different interpretative practices. The body is a mirror of the society, and it would not be possible to conceive exclusively biological processes.
The body is a construction where different marks are made within different cultural contexts: times, spaces and social groups. The idea of health or illness is a social construction. Someone is ill according to a classification of their society based on the criteria it has established. In this sense, a symptom refers to the sick person and the sign is the search conducted by a physician in the sick body. Similarly, disease refers to physical-pathological processes and illness refers to the person's experience(4).
Under a phenomenological perspective, papers have been written using the philosophical reference of Maurice Merleau-Ponty to study the relations of the body with the lived, the experienced. To that philosopher, the body is a way of being human; the world is an extension of our body. The body lived is the one experienced in the existential daily life. This body allows sensations at every moment which enable expanding our human existence. Man, when getting in contact with an object, with things, makes contact with himself; therefore, it is then considered corporeity because it is the source of senses and of a network of existential meanings(1).
Body and embodiment are interwoven concepts once they are interdependent in the existential experience of the human being. There is no body without embodiment and, similarly, embodiment demands a body to make itself concrete while a human phenomenon. Embodimentis composed of our attitudes, our way of interacting, our values and emotions within different social contexts from birth to death. It is constituted by the way we present ourselves before other people, the society and in daily-life events, everything we build while existential beings. Through embodiment we build our existence and our story.
Under a Post-Modernity anthropological perspective, the body has in its physical condition a relation with the illness phenomenon and the way it is understood takes us beyond a personal (individual) approach to a relation of the body within the socio-cultural context, which results in people's responsibility for keeping their own health(4).
Methodology of the studies
The reproductive period is characterized by significant changes, both at physiological and psychosocial levels in a woman's life. Bodily changes in this period are often linked to the transformations in the way a woman sees herself which, on its turn, can affect her self-esteem, self-image and social relations. The way every woman deals with those changes is related to the subjectivity and perception of her own body and of herself. Sexuality is part of this whole new process a woman experiences.
By considering the aspects previously mentioned, a study about the body and sexuality during the puerperium(5) was conducted. The objective of this study was to understand how a group of women deals with the changes and their sexuality during the puerperal period. The methods chosen to collect data were observation and interview. The sample was composed of six women who had given birth about fifty five days before the study. Some women reported that they were not comfortable with their body, which had affected their self-image and self-esteem, as much as their family life and social behavior, their relationship and sexual activity with their partners, although their partners had said that they were not concerned about the women's body at that moment. Feelings of dissatisfaction with the body were expressed through shame and the fact that they did not feel comfortable before their partners, which had caused them to feel jealous of other women and insecure about their relationship. As to the changes in the perineum, the women reported concerns about recovery and care.
The partners, relatives and friends who had already faced that experience were a source of help at that moment. The women said that the changes in their lives had been intense and meaningful, but that time had helped them adjust. With these results we can say that motherhood is a daily construction in the lives of those women and in their families and it implies transformations in behavior and in the family organization, which take place according to the experiences and relationships in those women's lives during that period.
Next we present the results of a research with a phenomenological approach holding Maurice Merleau-Ponty as theoretical-philosophical reference to interpret the experience lived by women experiencing menopause. We highlight the theme unveiled in Become aware of the world through your body in time and space(6).
The statements of the women leading to this theme allow us to say that each organism has its own way of communicating with the world. Every conscious perception a woman has of herself means that she experiences what is happening. Many women have lost this ability of being present and tuned in to her own body and they see it as an unspecified body of a woman.
The experience of this phase in life brings to a woman the awareness of her reproductive incapacity, i.e.: with the menopause the possibility of procreating is ended or made difficult; that woman cannot perpetuate herself any longer in the next generations. After all, procreating is laying roots in the world, i.e., to continue to be in the world.
The women reported both their daily life and the physical-emotional blockages arising from menopause. This process permeates the whole organism, interfering with the practice of daily activities, creating a new way of being and an existence in pain.
A woman during menopause, when she perceives her appearance, she perceives her body in the world, it is in the world, and there it remains being-with-the-other. A woman is a Being with relations and through them she perceives her body co-existing with others in a social context, in inter-corporeity, in a movement that makes the body come close and go far from itself, of ourselves and of the world where we live. This whole movement deserves to be understood so that space and time can be better inhabited. When experiencing menopause, a woman becomes aware of her new body through her perceptions and experiences until they are transformed into knowledge, and only then is she able to set priorities and choose news ways of living. Actually, there is no end, just a process of experiences linked to each other and all of them in one sole conscience.
On the other hand, when we study the health-illness process, we should highlight Post-Modernity which, in addition to the advancements it has brought to technology, economy and to the societies worldwide, is also characterized by a moment of deconstruction of the social organization, and within this context of transformations AIDS has come up which, since the beginning of its thirty-year path, has been killing and interfering with socio-cultural and economical relations at global level.
Under this perspective we should highlight the relation among body, risk and life style. In this position, we are interested in studying people's behavior, their beliefs related to health and health promotion by taking into account their acts before certain aspects of life styles and their correspondence with specific diseases(7).
Thus, the relation between body and disease, particularly AIDS, refers us to relevant aspects because even considering that a person has enough knowledge of how HIV is transmitted, there are individuals who underestimate the risks they are exposed once they understand that this situation may be deemed a cultural variability. On the other hand, a clearer view focused on the body would explain certain differences in replies about risks found in the literature(7).
The relation between risk and AIDS, when analyzed considering the various academic opinions related to risk, shows that people's behavior can mirror their views on the matter and guide their acts in situations of risk in order to keep the integrity of their body (health), but the components of their culture also influence their decision. When someone acts, they weigh the losses and benefits that a certain situation will bring to the health of their body, and they act according to their way of facing the environment, their relations and life style, considering their beliefs and cultural values. From that we can deduce that when someone takes a stance before a situation of risk, they are not deciding without reflection, nor are they isolated from their context(8).
The idea of risk within the area of interest of this text means danger and when it involves damaging the health, it is associated to prevention. As to AIDS, the objective of prevention is to promote changes in behavior and life styles; however, changing behavior targeting on preventing diseases is difficult due to their cultural limitations(9).
Within this approach, when we consider the outline of the situation of women who are 50 years old or older, as much as the shortage of studies directed to this age range in the country, we have conducted studies focused on the perception of risks to get AIDS by this segment of the population, particularly oriented towards AIDS and its reflexes in the body. The results gotten allow us to say that the significant majority of the interviewees acknowledged AIDS as a condition that debilitates the body, makes it slimmer and vulnerable to other diseases (10-11).
The same studies showed that when we compare the benefits women would obtain by adopting measures to prevent them from being infected by HIV with the barriers they would have to face to have safe sex, they reported that men not always agree to wear a condom and, so, they have difficulty asking them to wear it. It drew researchers' attention the low percentage of women who perceived themselves at risk of being infected by HIV due to their sex life; however, most of them tell the young members of their families to take measures to prevent the infection, which they do not follow, in an attempt to keep their children and grandchildren, particularly men, free from the risk of being infected by HIV.
The references chosen in the studies presented here and in others we have conducted have guided the path to obtain the results. In this path, several innovative methods of data collection have been used to approach issues related to the body.
Among them we would like to mention: focal group, which was used to allow the emergence of different views and to understand in depth people's behavior related to the body and to their sexuality in their relation with nursing. The dissertation Experiencing sexuality in nursing care: a study under a cultural perspective(12) held as fundamental concept the sexuality as a progressive, unique, historical-social-cultural construction, with a flexible and contextualized process. The objective was not to change behaviors, once it was a cultural analysis, but to disclose the differences and diversities existing within the same context.
The workshops stood for a new possibility of conducting a research, not only because they use techniques different from those usually used in qualitative studies, but also because they are a different way of structuring knowledge, reflection and action. They were used in the dissertation The Consecration of the Flowers: a ritual to enchant the woman's body when providing care(13) whose starting point was the restlessness before the silence about nurses' conceptions and beliefs related to women's body to which care is provided within the context of Brazilian nursing. The workshops were different from the other techniques because the subjects researched collectively build, take over and validate the knowledge, and artistic creativity is incorporated into the construction of knowledge, allowing putting together science and art.
The narrative, a research modality that is composed of a report of a set of individual experiences, individuals' propositions and truths, allows showing a version of the facts according to a person's view of the world, which is sovereign to disclose or hide cases, situations and identities. A subject is deemed a primordial subject, who is free to talk about his or her personal experience and to participate in every process, and he is called a collaborator(14). It was used in the study It is life as usual: body and sexuality in the birth process(5), whose objective was to understand the meaning of the body for a group of pregnant women, how those women experienced their body's physiological processes during pregnancy and the repercussions in sexuality, and also to learn the perception related to normal birth and its implications in sex life.
Photoethnography was used in the dissertation Experiences and expressions of pregnant women in their interactions with the healthcare system: a photoethnographic approach(15), which is an attempt to understand women's experience in their contact with the healthcare system at the time of childbirth. Photography was the visual aid chosen because it was believed that it could create alternatives to the collaborators' expression by helping them build their narratives in questions related to cultural topics and broaden their interpretative universes once it stimulates the memory and gives the interview a character of proximity to the objects.
In this article we have discussed the approach to the body while an object of study in nursing in the area of Women's Health. We started with the assumption that the body is not an object, but an agent. It is a biological organism that perceives, moves, responds to and transforms the environment. Its various systems work in a coordinated way, which allows subjects to express their attributes, to watch images, express feelings and ways of thinking. It is the body what lives and experiences, while social life and intersubjective relations coordinate the experience. People are able to be who they are due to their intersubjective capacity of communicating the meanings shared. Cultural artifacts, practices, institutions, rituals, ways of interacting transcend and model the body and the actions it takes. Therefore, we can talk about multiple bodies, and their number depends on how many aspects one is willing to disclose.
This way of conceiving the body determines different methods of investigation. No method on its own is able to capture all phenomena of the body and their meanings. Events of manifestation and maintenance of the health and those resulting from getting ill have unique meanings for each one, for their families and for each society at each moment.
In this article some ways of approaching women's body during the health/illness process during their lives have been presented. None is better than the others; actually, they are different ways of responding to certain concerns. Getting the proper answer requires articulating private interests and the methodology and methods of searching and analyzing data.
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