Violence as a research object and intervention in the health field: an analysis from the production of the Research Group on Gender, Health and Nursingi^{* **}

La violencia como un tema de investigación e intervención en salud: un análisis de la producción del Grupo de Investigación de Género, Salud y Enfermagem

Abstracts

The study aimed to describe how violence is revealed in the production of the Research Group on Gender, Health and Nursing. This is a historical research of qualitative approach, which evaluated the production of the Research Group, through content analysis. The results show gender as a central category in determining violence and health practices. This aspect determines limitations on professional practices of coping, such as the invisibility of the problem. The female autonomy, the use of alcohol and drugs and social vulnerability play an important relation with the phenomenon and the bond is revealed as potentiality of health practices to address the problem. Conclusion: The gender perspective in nursing research is an innovative field and counter-hegemonic, a possibility to assume a meaning of praxis by transforming potential of understanding and modes of intervention in the phenomenon of gender violence.

Research; Nursing; violence against women; Feminism health knowledge

El estudio tiene como objetivo describir cómo la violencia se manifiesta en la producción del Grupo de Investigación de Género, Salud y Enfermería. Se trata de investigación histórica, enfoque cualitativo, que evaluó la producción del grupo de investigación, mediante análisis de contenido. Los resultados indican el género como una categoría central en la determinación de las prácticas de salud y violencia. Este aspecto determina limitaciones en las prácticas de afrontamiento profesionales, como la invisibilidad del problema. La autonomía de la mujer, el uso de alcohol y drogas y la vulnerabilidad social desempeñan una importante relación con el fenómeno y el enlace se revela como una potencialidad de las prácticas de salud para abordar el problema. La perspectiva de género en la investigación en enfermería es un campo innovador y contra-hegemónica, con la posibilidad de asumir una práxis con potencial transformador de la comprensión y modos de intervención en el fenómeno de la violencia de género.

Investigación; Enfermería; violencia contra la mujer; Feminismo

O estudo tem como objetivo descrever como a violência se revela na produção do Grupo de Pesquisa Gênero, Saúde e Enfermagem. Trata-se de pesquisa histórica, de abordagem qualitativa, que avaliou a produção do Grupo de Pesquisa, por meio de análise de conteúdo. Os resultados apontam gênero como categoria central na determinação da violência e das práticas em saúde. Esse aspecto determina limitações nas práticas profissionais de enfrentamento, a exemplo da invisibilidade do problema. A autonomia feminina, o uso de álcool e drogas e a vulnerabilidade social assumem importante relação com o fenômeno e o vínculo é revelado enquanto potencialidade das práticas em saúde para o enfrentamento do problema. Conclusão: A perspectiva de gênero na pesquisa em Enfermagem constitui um campo inovador e contra-hegemônico, com possibilidade assumir um significado práxico pelo potencial transformador da compreensão e dos modos de intervenção no fenômeno da violência de gênero.

Pesquisa; Enfermagem; Gênero; violência contra a mulher; Feminismo

Introduction

In the construction process of a theoretical basis for research and interventions in the field of violence prevention, we highlight the scientific production of the research group on Gender, Health and Nursing, School of Nursing from the University of São Paulo on determining gender in the phenomena of violence.

From the 1990s, the category gender was appropriated by the health care field and has been used as an important tool for analyzing the determination of the phenomena of life of women and men. As a proposed category by feminism, then aggregate to the scientific field, this category carries intrinsically the political nature and the commitment to social transformations related to women, as well as a new view at the power relations established between women and men, men and men and women and women.

The discussion about the relevance of gender as a central category for understanding and intervening on violence against women is based on the assumption that in the hierarchy of power in this society, woman has always been inferior to men social position due to built inequalities, which are historically naturalized. Thus, although power relations have become modified, throughout history, in the social and State spheres, the structural reality is still far from equality between genders, what concerns the private space, inequalities remain reproduced, as small practices of power in everyday life remains, such as domestic violence.

Gender inequality has greatly compromised the quality of life for girls and women, presenting across all aspects of reality, empowering and legitimizing the oppression that manifests itself in different gender violence translated into physical, emotional and social violence, materialized in different ways. In opposition to this reality, equal rights between genders is a very recent possibility, being constant presence in the struggles for emancipation and the recognition of women´s rights as human rights, aspirations that, even today, is still largely utopia.

The dominant mode of explaining gender relations is based on the historicity of institutions and modes of social life that allowed the explanation of the feminine universe by addressing primarily a biological approach, in an interpretation that satisfies dominant social interests. This discourse is opposed to the one that says that humanity of the human being is socially constructed in social relations. Such understanding of the world assumes that all social phenomena are products of human action and can be transformed by it.

The gender perspective has allowed researchers to face the challenge of rethinking the inequalities produced in relations between genders in the light of production and reproduction of different social and historical contexts in which submission and inequality contribute to establishment and maintenance of gender violence. The research group on Gender, Health and Nursing from the University of São Paulo, is the first of the field of nursing and, perhaps, health, to take gender as specific field of studies to analyze the phenomena of women’s lives.

The work of nursing, the health-disease process of women and gender-based violence against women and adolescents are themes that have outlined the research history of the group, especially from the year 2005, when gender violence became the specific object of research studies.

The production of new research projects and intervention has allowed the researchers to observe a panorama of the studies regarding the phenomenon of violence in the light of gender. It is time to ask whether the conceptual field built and consolidated by the research group open to researchers and society important elements to an established theoretical base that actually subsidize the intervention for the prevention and facing gender-based violence against girls and women.

Thus, this research paper aims to reflect, from the scientific production of this Research Group on a Gender perspective in the search for understanding and intervening in the phenomenon of violence; and describing how the phenomenon of violence reveals the realities studied.

Method

This is a historical research, conducted through production review of the research group on Gender, Health and Nursing, registered at CNPq. The data consisted of the theses and dissertations produced by the research group, defended since the time of our research group formation until the present day. As inclusion criteria, we considered all theses and dissertations produced by professors and students of the Graduate Program (masters and doctorate) participants of the Research Group, from the period 1990 to 2014, which had the phenomenon of violence as a specific research object.

As exclusion criteria: studies that mentioned violence as one of the findings of the research (which is not uncommon in research on the phenomena of women’s lives), but whose object of research was another.

Information was obtained from reading the material and organizing into instrument containing: general data (author, type, date of defense), abstract (type of study, object of study and objectives, methodological framework, data collection technique, source of data, data analysis, type of analysis, consistency between objectives, results and keywords). We searched for the original volumes available in the Library Wanda de Aguiar Horta at EEUSP. In order to enable a qualitative analysis in depth, studies were accessed in full and submitted to content analysis(¹).

Results

In 25 years of existence, the production of the group was 17 doctoral theses, one of Full professor and 9 masters’ dissertations. All of these were produced in the context of Graduate Program, in the two existing Graduate Programs at School of Nursing, University of Sao Paulo, namely: Interunits Graduate Program in Nursing of the campuses of Sao Paulo and Ribeirao Preto (existing since 1982) and Nursing Graduate Program, area of concentration in Community Health Nursing (established in 1973 and the area started in 1992).

Among the 27 studies produced by the research group, only since 2005, gender-based violence has become the specific object of research studies, so that, by 2014, 10 studies on the subject have been completed as specified in Table 1. However, since the first thesis produced in the group, violence against women was presented as a recurring phenomenon, even when not constituted the object of specific research.

The same occurred in other paper works until the first specific study of violence against women was completed in 2005(²).

The analysis of studies on violence(²-¹¹) revealed a predominance of studies on gender-based violence against women, and two studies was under investigation of violence in adolescence. Most research chose the qualitative approach, data analysis from the standpoint of content analysis and Critical-emancipatory Workshops (CEW) as data production strategy. Regarding research settings, there was a predominance of studies in Primary Health Care, more specifically in the Family Health Strategy (FHS), as shown in Table 1

Table 1
CHARACTERIZATION OF VIOLENCE STUDIES FROM THE RESEARCH GROUP ON GENDER, HEALTH AND NURSING (UNIVERSITYTY OF SAO PAULO, BRAZIL)

Discussion

Empirical categories

1. Violence is never alone: the determination and experience of violence as a complex and multifaceted two-way street.

   In all studies, the findings confirm that violence is a phenomenon that involves, in its determination, coping and complexity, the social construction of male and female and the relations of domination-subordination established.

   With regard to the definition of violence revealed in several studies, it is noteworthy that gender violence may manifest in various ways and in varying degrees of severity. Having the family institution as its privileged locus, violence affects women in its various manifestations, being, in most cases, overlapped. Being the private sphere the one which predominantly expresses gender violence, in the public sphere, gender violence also takes various forms of expression, such as workplace and society violence. Thus, gender violence are presented in studies as a phenomenon that “is never alone”(⁸), as it is manifested in contexts listed by problems, related to structural violence and social exclusion.

   Furthermore, studies have revealed gender violence experienced in adulthood, most often in the marital relationship, accompanied by a prior history of violence in childhood or adolescence. A study on violence against adolescents, seen by adolescents’ themselves(²), is overwhelming by the combination of various types and intensities of violence on marginalized groups and the awareness that this is a serious problem for their life. Girls, as one might expect, are more affected by sexual violence than boys.

   Sexual violence was revealed in all studies, even though only one of them(²) specifically addresses this classification. When practiced against women who are married, sexual violence takes the meaning of “consensual violence” because it is legitimized by marriage. Few studies reveal findings of sexual violence committed by an unknown aggressor, so that, in most cases, violence is revealed as a phenomenon in the marital or family relationship, committed by partner or male relative, which makes it socially legitimized, naturalized and invisibly.

   Gender violence is a phenomenon that also occurs in relationships permeated with affection, in which are deposited expectations that revolve around the ideal of family and marriage. Being the aggressor, in general, a person with whom the victim shares her life, divides and constitutes home, it makes the violence a contradictory phenomenon even more important, since it involves feelings of helplessness, disappointment, disaffection and hopelessness. This aspect was a common finding in all studies.

   Studies found(²-¹¹) idealization of meanings related to the family in society, as they relate to the construction of the home as an institutional space where values of different types of society are internalized, providing the basis for the reproduction of learned cultural and social model. Thus, violence appears in the social imaginary, but it is in fact a consequence of an ideological mechanism to the ideological maintenance and reproduction of male power and its hegemony as direct consequences of gender relations.

   The social production materialized in a paid work was revealed in this study as an important determinant of potential for facing violence. However, entry into the labor market has not decreased, for example, the social responsibility of women for the care of the home and with family, which results in double or triple shifts, generating overload and constituting more potential stress for the health-disease process of women(²,⁹), making them subaltern and vulnerable.

   Studies revealed consequences of violence experienced in various aspects of life and health of women. Stress resulting from gender-based violence, such as high blood pressure, epilepsy, diffuse pain, aggravation of mental order and vulnerability to sexually transmitted diseases are presented in the studies(⁴,⁷,⁸).

   Among the repercussions of violence in women’s lives, several studies(⁴,⁷,⁸) revealed the reproduction of violence by women as a result determined by their experience, showing women as perpetrators of violence against the spouse, children and other people in their social relations. Nevertheless, the interviewees understand this behavior as arising from an emotional state given by experienced violence.

2. Silenced and invisibilized: gender violence is concrete in health services and in the lives of women

   The spaces searched for care by women are also spaces to capture the implicit violence that comes between the demands they bring, since care and gender violence are brought and experienced constructs which are, historically, much more experienced by women.

   In studies(²,⁴,⁶-⁷,⁹), violence is presented in health services always implicitly, that is, it is not the specific situation the reason that led women to seek health services. There are spontaneous expressions of women about experiences, but these hardly are placed in terms of demands for health care or by professionals. These manifestations are understood as both the presence of possible communication channels identified by women in relation to the service that represents the understanding of users and professionals about the possibility of caring and facing gender violence by the health service. Although they have the knowledge for compulsory notification of violence(¹²), studies reveal that services often do not notify nor registry(⁷,⁹), confusing notification with police complaint(⁹). This finding reveals the production of invisibility of violence as a health problem in the investigated scenarios. Far from being the exception, this reflects a common gap to most health services(²,⁴,⁶-⁷,⁹).

   Health professionals are able to identify users who experience violence, by marks or physical symptoms or associated symptoms such as somatization, unfounded complaints and diffuse discomfort, anxiety, depression, not located pain, among other manifestations. Another element that contributes to the identification of violence is a report produced by women, when asked about the theme(²,⁴,⁶-⁷).

   We talk about invisibility, but the findings reveal that gender violence is visible in health services, is part of reality, however, because it appears submerged in the complaints that women bring, it is invisibilized, or even not recognized by services as an inherent problem to their attention. As potential aspect of invisibility, studies(²,⁴,⁶-⁷,⁹) identified significant construction marks of gender identity practices and concepts of health professionals, men and women. At the same time, some women, health professionals also experience violence and pointed to this aspect as influencing their attitude towards its problematic(²,⁴,⁶-⁷,⁹).

   It is observed that, under the FHS, on one hand, women do not speak, on the other hand, the professionals do not ask about violence. The medicalization logic limits the development of tools that enhance the uptake of violence, which makes women also unaware of the health services as a possibility for support.

3. Autonomy of women as a possibility for overcoming violence

   The achievement of financial independence and work in the public world proved in studies of women as a necessity for its transformation and liberation from oppression and violence. This was a converging point for all studies. The social production, translated by paid work, appears as a necessity intrinsically related to autonomy and facing the situation of oppression that marks their social reproduction.

   The achievement of greater autonomy presupposes the liberation of women from the shackles determined by gender, and that include gender violence, the overload for exclusivity in reproductive responsibilities and care, and have been excluded from productive activities and therefore financially dependent.

   Social inequality is a concrete reality of excluded individuals from work and when added to gender inequality that pervades the relationship of conjugal violence, compromises social reproduction through the intercession of inequities produced by two categories: class and gender, both producing barriers to autonomy, to health and to the existence of women.

   Understanding that individuals are responsible for their choices and living conditions permeates health services, also being the focus found in many programs. This aspect is a strategy that denies the construction of a collective project of social transformation. The ability of subjects to make their choices has the fundamental assumption to guarantee the autonomy and equality, needs that could not be fulfilled without a transformation of the existing social structure(⁷).

   Nonetheless, the recovery of possible autonomy is an urgent need, critical to health and puts into question both the way it medicates and institutionalizes the lives of individuals, as the disregard of this dimension for the services. It is impossible to speak in absolute autonomy, since it is not possible to deny the difficult driving forces to control and the spaces of freedom are nearly privileges. However, it is important to rescue this need to restore a degree of human autonomy, since disease and related destructive processes are also determined by the alienation of men(¹³).

   The achievement of autonomy, understood as control over ones own life and body and the right to an independent identity and self-respect, is preceded by two conditions: one is the consideration of the needs and interests of men and women by policies and programs to achieve gender equality; the other is to support strategies that aim to female strengthening and empowerment(¹⁴).

   Facing the challenge for the achievement of gender equality and autonomy of women requires an overview, with care and caution, of the situation of thousands of women who suffer inequities in daily life, being indignant with it and moving to transformation rather than the unattainable idealization of individual and collective happiness, decontextualized and ahistorical. Women citizen-workers should be attended according to the needs of their health and disease profile, understanding them in the light of their gender, class status, generation profile and other analytical approaches(¹²).

4. Limitations of professional practices on violence: impotence and medicalization

   Studies reveal the impotence that health professionals refer to when they verbalize their coping with violence. Pointed out by professionals in all studies of which were subject(2-4,6-7,9), impotence is called in one study(⁸) as “paralyzing” and fueled by misinformation and lack of specific professional qualification.

   The issues identified in the studies that composes this category reflect the medicalization of health care for victimized women and girls, which is related to the technical impossibilities of professionals towards the problem and also with service limitations, referred by professionals as overload of demands and responsibilities. It seems like medicalization logic prevails in services, even when addressing situations of violence, with predetermined prioritization of needs.

   With regard to victimized women, they also seek health services from physical demands, since they transform the violence experienced in demands for health care in an attempt to be cared by the service. Regarding professionals, violence is not understood as a problem that is related to health when there is not physical visibility in their body.

   Studies(⁴,⁷,⁸) point for a reduced recognition of women’s needs to reproductive health, in an individual cutout and limited to reproductive and biological aspects of the female body. When not reduced to the body, attention is translated into actions related to referrals to psychiatric or psychological attention, even revealing the fragmented and factorial public health approach, in the perspective of health services.

   Although violence has an intrinsic relationship with physical and mental health, that is, with all aspects that make women’s health, the criticism that is made is related to the limitation of attention to aggravation, disregarding its determination that involves oppression, violence, gender relations and all relations that permeate their way of life. It is important to take care of health problems and we do not intend here dismiss the health area of this assignment as it shall. But should go far beyond them.

   Health services should be constituted as local care and support and no longer a barrier in an attempt undertaken by women to transform their situation of oppression. The studies, in general, point to the need that violence is recognized as a problem and as a demand whose attention is inherent to health services, considering the subordination of gender as a determinant of this process. This recognition is essential for the creation of practical possibilities to overcome the limitation to the dominant logic of medicalization.

   Furthermore, violence appears in a gender free and naturalized understanding. This reality is the result of a complete historical process of construction of health care in our society and therefore a further scientific training in biomedical and androcentric molds.

5. Potentialities: hearing and the bond as possibilities of care

   Studies(²,⁴,⁷) pointed to the hearing in the relationship between professionals and users, mediated by creating bonds, such powerful aspect of care given in experience related to gender violence. This theme seems related to the recognition of both health professionals, as the victimized women, when referring to confront violence and the support of health services. Nevertheless, it is important that the listener does not translate practice into a simple dialogue that permeates the assistance. A qualified hearing implies full attention, the close look, in the care for women who experience violence, it must be mediated by a gendered instrumental, which learn the needs of users, recognized as subjects of their existence and inserted into a society that determines subordination and violence. Hearing must stimulate talks not being limited to it, paying attention to details also omitted beneath the discourse.

   Considering the importance of the relational aspects and the conversations network that permeate FHS practices, the phenomenon of gender violence needs specific conditions to be spoken from the perspective of strength and emancipation. The limits should overcome a personal conversation and advices that the personal friendship or sympathy would conduct, those aspects that were identified in the discourses.

   From the bonds established between professionals and users, as determined by continuous service and the proximity that enables FHS, possibilities emerge to capture the violence. The dialogue and hearing established in this relationship enclose power to overcome trauma and women’s strength.

   The possibility of an expanded health care for women implies considering the health-disease dynamic process related to different universes of meaning, in addition to its gendering and valuing of qualities such as solidarity, trust, transformation of hegemonically defended, values, egalitarian social relations and recognition of differences, so that professional practices are instruments with potential to contribute to social emancipation.

6. Violence and the abuse of alcohol and drugs: a complex relationship

   All studies analised(²-¹¹) indicated a significant relationship among the abuse of alcohol and drugs and violence. The problem appears both in the meanings produced by health professionals, as the experiences reported by women. The problematic use of alcohol by aggressors in the studies seems as a phenomenon that precedes violent behavior. The use of alcohol and other drugs by victimized women is shown in studies as an escape mechanism to escape the physical and emotional effects caused by violence.

   Several national and international studies have investigated the association between domestic violence and the abuse of alcohol, however, a direct causal relationship has not been established. Excessive alcohol consumption is still one of the biggest controversies between the theories that try to explain violence. It is not yet consensus that there is a causal relationship between alcohol and violência(¹³).

   With regard to gender violence, domestic aggression associated with alcohol use remains mostly perpetrated by men against women. Consequently, assuming that the problematic use of psychoactive substances as a cause of social and complex phenomena as violence would fall into the same unicausal positivist reductionism that has, for a long time, understood the determinism of health-disease process. The use of alcohol and drugs, as violence is a complex social phenomena that have an important relationship, observed in several studies mentioned, assuming a complex association whose determination involves several other social, psychological and biological aspects.

7. Critical-emancipatory Workshops as a possibility of professional qualification for facing violence

   In researches, in general, there is a significant use of WCE (50% of studies) as a methodological strategy. The method development was an important contribution of the group to use the workshops to collect and analyze data, concomitant to reflection and empowerment of participants. It was shown that these techniques came to the scientific area as a pedagogical and knowledge production instrument, being adapted to objects of research in the social area, seeking qualitative transformation of learning spaces(²-⁴,⁷,⁹).

   Studies revealed the fertility of this methodological process that enables the integration of research and social intervention. It can be stated that, in gender studies, workshops constitute a method of feminist episteme, based on the theoretical foundations of critical-emancipatory education and in the emotions as constructions of knowledge(²-⁴,⁶,⁹).

Conclusion

Violence is a perverse form of power relations based on gender, which translates into domination where women are often disadvantaged. The analyzed studies bring violence as an object of research in the field of public health practice, more specifically in the Family Health Strategy. This strategy enables the bond and the approach of professionals with social reality, revealing problems before they are invisible and not considered amenable to health intervention and research. In general, violence is seen as a problem less of health care than others (education, security) and professionals consider themselves powerless and unprepared to deal with it. The concepts are based on the knowledge of common sense and do not take into account the historicity of the imbalance in power relations between men and women in determining the gender violence. This area has received a large concentration of studies nowadays, driven by increasing contribution of women’s movements in uncovering problems which were naturalized before and of little interest to the scientific production. It has gradually being constituted an important item in health area, which has also stimulated the emergence of research.

The production of the Research Group on “Gender, health and nursing” reveals that deepening understanding of social phenomena, among them, violence, under the view of gender, has brought advances not only in the field of research but also for interventions. The field of health practices have been shown to reveal the limits and potential that it permeates.

The use of gender perspective can be seen as guiding praxis of health care, transforming the view on realities and interventions to overcome its contradictions. The analysis of the scientific production on gender and violence of the Research Group on Gender, Health and Nursing revealed categories that evidence, even among studies with very different methodological designs, common findings that enable the consolidation of a powerful conceptual framework to support further research on interventions and policies to prevent and combat gender violence. This finding opens a new phase in the scenario of studies interventions in reality, aimed at focusing on preventing and facing violence.

It is these advances that have strengthened the constitution of a field of innovative studies, which are counter-hegemonic and sometimes contradictory to others. At the same time, this field is a fertile soil to produce studies that support Nursing and women’s place in the sun that both seek and deserve.

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• *
  Research Group of the Department of Community Health Nursing, School of Nursing, University of São Paulo (EEUSP). Registered in the National Directory of Research Groups of the National Center for Scientific and Technological Development (CNPq)
• **
  Research based in the work of: Fonseca RMGSF, Oliveira RNG. Gender as fertile ground for research in violence. Oral presentation. 3o Congresso Ibero Americano em investigação Qualitativa. 15-17 July, 2014. Badajoz(ES).

Publication Dates

• Publication in this collection
  Dec 2014

History

• Received
  30 Apr 2014
• Accepted
  16 July 2014