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Rev. Latino-Am. Enfermagem vol.20 no.2 Ribeirão Preto May/Apr. 2012
Maíra Rosa ApostólicoI; Caroline Rife NóbregaII; Rebeca Nunes GuedesI; Rosa Maria Godoy Serpa da FonsecaIII; Emiko Yoshikawa EgryIII
IDoctoral Student Programa Interunidades de Pós-graduação em Enfermagem, Escola de Enfermagem, Universidade de São Paulo and Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil. Scholarship holder of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)
IIUndergraduate student, Escola de Enfermagem, Universidade de São Paulo, Brazil. Scholarship holder of the Scientific Initiation Program at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)
IIIPhD, Full Professor, Escola de Enfermagem, Universidade de São Paulo, Brazil
The purpose of this exploratory, descriptive and retrospective study with a quantitative approach was to characterize violence against children in Curitiba. Reports of 2004 through 2008 about compulsory denouncements of violence cases were analyzed. The results showed an increase in violence, with home violence as the most frequent type and five to nine-year-olds as the most affected group, and negligence and physical violence as the most denounced forms of violence. Almost 81% of the sexual violence is performed against girls and the father is the main aggressor, showing inequality in gender relations and between generations. The importance of notification as a visibility instrument is highlighted. Other confrontation measures are necessary though, such as the promotion of equitable relationships of gender and generation, and cross-sectional policies that involve the social segments in a praxis that transforms reality.
Descriptors: Child Abuse; Public Policies; Violence.
At present, violence against children is a serious concern, as it has become one of the main causes of death at this age, due to external factors. The World Health Organization (WHO) acknowledges that violence is growing in a frightening way all over the world and that women and children are the main victims. Estimates for the year 2002 appoint 31,000 homicide cases of children who were up to 15 years old. It might be possible that these data are underestimated and they represent only part of the problem. The age level from zero to four years is almost five times more exposed to violence than children between 5 and 14 years old(1).
Violence consists of the "intentional use of physical force or power, in an actual way or as a threat, against himself-herself, against another person, or against a group or a community, which results or has a high possibility of resulting in lesion, death, psychological harm, deficiency of development or privation", linking intentionality with the self-committed act, regardless of the result(2).
This is a complex phenomenon, as it involves social and mainly family relations, and requires approaches with different theoretical and professional focuses. With a view to comprehensive health care, as recommended by the Brazilian Unified Health System, actions to confront it should aim for the social and community development of the assisted population. Thus, the phenomenon is an important matter for Public Health, which is not concerned with studying pathological events, but with sociological readings about the phenomena, also considering their psychological, anthropological and environmental aspects. This occurs because Collective Health considers man as a social and dynamic being, closely related to the geopolitical and cultural territory in which he expresses himself(3).
For any intervention to be effective, the collective aspects need to be considered, that is to say, the environment the child is involved in, the characteristics and individualities of each population group. This will lead to a clearer and broader understanding of the health-disease process.
When the violence focuses on children, the seriousness of these actions affects the whole childhood, and the physical, sexual and emotional lesions the children suffers, although not always fatal, entail significant eroding effects, not just at that time but along the whole life. The experience of maltreatments in the childhood is linked to the practice and experience of other types of violence, such as the conjugal, sexual and self-focused types. Prevention strategies for maltreatments in childhood can reduce involvement with violence in all stages of life(4).
Interventions in the phenomenon require multidisciplinary and interdisciplinary actions, combining health, legal, social, judicial, psychological, anthropological and religious areas, among others. Moreover, themes like violence, prevention and citizenship promotion should be included in professional training(5).
Regarding Collective Health, health care needs are socially and historically determined, and they result from social relationships(6). Seen as the (non-exclusive) subject of Collective Health Care, violence may be considered as one of the health care needs individuals and social groups manifest. Thus, the historical and dialectical vision of the world should be adopted, aimed to conceptualize health care needs and, as a consequence, broadening the analysis field of the phenomenon related to violence against children(7).
This work aimed to characterize violence against children in Curitiba, in the period from 2004 to 2008, based on the analysis of compulsory denouncements of violence or suspected violence against children and adolescents.
This study aimed to call attention to the phenomenon of violence, a hidden problem in many children's reality. Although there are laws to protect children in Brazil, the organization of the services does not fully meet the needs. Thus, identifying and expressing issues related to the phenomenon and calling attention to it will help to enhance public policies and organize children's health care services, besides promoting society's reflection on the magnitude and importance of combating violence against children. For nurses who represent the first qualified contact with patients in a health institution, this study emphasizes the need for an accurate reading of reality, as well as the improvement of actions and instruments that equip the work process.
Although it was a documentary research, the project received approval from the Research Ethics Committee at the University of Sao Paulo School of Nursing and the Ethics Committee of the Municipal Health Secretariat (MHS) of Curitiba, as per protocols 819/2009 and 69/2009, respectively.
It is an exploratory, descriptive and retrospective study with a quantitative approach, methodologically supported by the Theory of Practical Nursing Intervention in Collective Health TIPESC. The TIPESC can systematize the collection and interpretation of phenomena, which articulate with the social production and reproduction processes of a group, considering its social and historically determined environment and also proposing an intervention as from the dialectical contradictions that emerge from the phenomenon, in the form of vulnerable points that can be transformed and overcome(8).
The study setting was the city of Curitiba, capital of the state of Paraná, Brazil. The actions of the Municipal Health Secretariat (MHS) include the Network for Protection of Children and Adolescents at Risk of Violence, responsible for the report and monitoring of cases of violence against children from 0 to 18 years of age, in its various manifestations. The Network comprises social facilities (schools, hospitals, health services and others) that report and follow-up the cases. The report is done by professionals trained to recognize and refer cases of violence and occurs through a specific form made available by the MHS. The form includes information on the victim, aggressor and characteristics of the occurrence. After reporting the suspected or confirmed case, referrals are done according to the Protocol that regulates the actions of the Network and information from the forms is registered in a MHS database. Annually, these data are grouped and compose reports with general information about violence in the city. These reports enabled longitudinal observations, seeking to understand different characteristics of violence over the analyzed period.
This study analyzed reports from 2004 to 2008, provided by the MHS. The analysis was done using Epi info® software, and descriptive statistics was used to present the results.
In Curitiba, child health receives special attention in municipal political projects, in the set of diverse programs and projects that aim at confronting the health-disease process of the child population.
The Protocol of the Network for Protection of Children and Adolescents at Risk of Violence consists of a set of integrated and inter-sectorial actions taken by the Curitiba City Government to prevent violence, particularly the home/intra-family and sexual types, and to protect children and adolescents at risk of violence. Its general purpose is to provide integrated contributions to the reduction of violence cases. It classifies violence as follows regarding the type (intra-family or home violence, extra-family violence, self-aggression and fetal violence) and nature of the violence (physical, psychological, sexual and negligence)(9).
The analysis of the reports for the years 2004 through 2008, which focus on the violence that affects children and adolescents, appointed an increase in the number of denouncements, representing a growth of almost 125% in four years, growing from 2,231 denunciations in 2004 to 5,003 denunciations in 2008.
The most frequent type of violence, in all years, was home or intra-family violence. From 2004 to 2006, self-aggression was included in the others and not known categories. As from 2007, with the reformulation of the denouncement tool, those types of violence appear; fetal violence stands out, reaching 3.5% in the year 2008, which represents 157 cases.
Regarding the age of the home violence victims, in all years, the affected children are between five and nine years old, the age level that is most affected by violence according to WHO(1). The group of 10 to 14-year-olds follows.
Between 2004 and 2008, the highest number of denouncements was for negligence; the year 2008 stands out, when the cases represented 71.4%. Physical violence ranked second showing, from 2005 to 2008, a mild decrease in the percentage of those cases. Although percentages of sexual and psychological violence and abandonment were lower, they should not be disregarded, as they are serious form of violence that, for sure, will harm the children's lives. Abandonment, as the most serious form of negligence, showed considerably significant numbers, particularly in 2006, when 101 children were abandoned.
As regards the gender of intra-family violence victims, male victims prevailed, corresponding to negligence, physical and psychological violence. In 2007, they represented 54.9% of the total and, in 2008, 54.2%. The female gender appears as the most frequent victim of sexual violence; in 2008, considering the total number of cases, 81.2% involved girls.
Regarding sexual violence, in 2004, the stepfather was the most frequent offender of this type of violence. The father was the most known aggressor in 2005, 2006 and 2008. In 2007, fathers ranked second, followed by a large number of cases in which uncles were responsible.
In the five years analyzed, sexual extra-family violence was the most frequent in all years, followed by negligence and psychological violence. As regards the author of the extra-family physical violence, unknown people were most frequently mentioned, except in 2008, and public streets are the places where the highest numbers of cases of this violence type occur. Consequently, extra-family violence is mostly of a sexual nature and it occurs on the streets, by aggressors whom the victim does not know.
Aggressors whom the victim knows, but who do not belong to the family, appear as the second and first aggressors in 2007 and 2008, respectively. Neighbors and friends of the victim are shown in all years as aggressors in cases of extra-family violence, except in 2008, when friends were replaced by fiancés or former fiancés. In many denunciations, however, aggressors and mainly the place of aggression is not informed for that violence type.
The analyzed reality converges with the theoretical framework that defines violence as a way to dismiss, coerce, embarrass, torture, brutalize, harass and trespass against the fair and right. As a consequence, "violence is an act of brutality, ill-treatment and physical and/or psychological abuse against someone and characterizes interpersonal and social relations defined by oppression, intimidation, fear and terror"(10).
Violence can be analyzed in three dimensions that configure the social phenomena(8). In the structural dimension, there are (national and international) health care policies that address violence. In the private dimension, local programs and protocols seek to train professionals and inform the population about the importance and urgency of action towards the issue. In the singular dimension, related to individual or homogeneous group processes, it is verified that violence alters the family structure, changing relationships and transforming the development of children and adolescents in a reality of social inequality, lack of access to rights and little or no exercise of citizenship. In each of the dimensions and intra the three of them, it is possible to find major contradictions and perceive the weak points for intervention and change of reality. Public policies that seek to confront violence are conflicting with other policies generated by the same legal and administrative apparatus that intensify inequalities and perpetuate the lack of social rights, ignoring the fact that coping with complex social problems requires an interdisciplinary and intersectoral approach to be effective and efficient. In the singular dimension, within the family environment where violence occurs, the consequence of the contradictions in the other dimensions can be verified, as reflected in the abuse of paternal power, lack of resources to deal with everyday situations, oppression, stress and poor living conditions, rather than a friendly environment, favorable to the healthy development of relations. Based on this, several other aspects can be verified that involve the theme and support the identified contradictions.
This study disclosed the family environment as the privileged aggression locus involving children, similar to what occurs with women, but different from extra-family violence, generally perpetrated by a person the victim knows. The unequal power relationships in the family might be considered as determinants of intra-family violence. Violence against children is a phenomenon caused by unequal gender and generation relationships.
In those categories, the basic biological elements, gender and age, are frequently appointed to ideologically justify and naturalize power and domination. They have in common that they are natural attributes with social meanings, organized as per privileges and inequalities(11).
Teams involved with denouncements have worked to make violence cases visible, recording them and informing them to society. What influences these denouncements, however, are structural issues and the difficulties of health care professionals, in their daily professional practice, to identify and assist the people involved in violence cases, due to several reasons, including lack of visibility of the problem and non-qualification for the task. It is a generally accepted point that nurses' work is essential for the detection, treatment and prevention of new cases. But, when the violence cases are confronted, aspects like the life history, posture and professional attitudes affect the assistance and retroactively act on the professionals' lives. Therefore, there is an urgent need to discuss with the nursing teams the ethical-legal dilemmas involved, also regarding the compulsory nature of denouncements(12).
Schools can be a great tool for the detection of violence cases, as they have significant access to the children. When they confront violence cases, educators and teachers do not adopt a formative posture, and consider cases personally. There is not a critical analysis about the consequences of specific behaviors that just aim at temporarily stopping children's aggressive behaviors, attributing them to the impacts of the daily life manifested in the school environment. Consequently, according to the perception of female teachers and educators, the relationship among female teachers, caregivers and children is not violent(13).
Global studies reinforce the importance of violence prevention programs in childhood, with strategies that propose interventions to support the children regarding the development of potential skills for adult life, as well as the promotion of non-violent relationships among parents, caregivers and children. Those programs may represent significant positive impacts on social life at the educational level and on the perspectives of work with young people. They may even increase the levels of violence prevention in adult life, particularly the reproduction of violence against children in the future, considering that violent relationships among parents and children increase the risk of developing violent behaviors in childhood and adult life(4).
Cultural aspects should also be taken into account. There are cases where the child is considered as the parents' property and physical punishment is thought of as a pedagogical resource. In these cases, the home is no longer the safe place it should be. Physical violence as a form of education, according to the viewpoint of the aggressor/caregiver, is explained as the action of beating or spanking due to: social difficulties, daily difficulties in family relationships and with the child, emotional lack of control and blaming the child for the problems. In these cases, the conceptions, that embody such justifications, can be summarized by the understanding that: beating is not serious, beating educates and it causes pain to the person who beats(14).
Negligence is a type of violence that is difficult to define, as it involves cultural, social and economic aspects of each family or social group. The detection is easier when contact with the family and understanding of family dynamics increase. Abandonment, as a more severe form of negligence, cannot be disregarded. On the opposite, the mapping of the families and their children is needed to verify what has caused the problem. When they are compared with other forms of violence, perhaps abandonment cases may not be that representative in numerical terms, but the severity of the fact entails significant and worrying proportions.
According to the present study, the mother was the most frequent responsible person for negligence, physical violence and abandonment cases in all years that were analyzed. That fact can be related to the status of postmodern society, which has shown a significant increase in the number of female family head, with the respective degradation of quality of life and growing poverty.
The qualitative analysis of the violence phenomenon has shown that unequal gender relationships exacerbate the inequalities related to social classes, and they contribute to the precariousness of women's social status. Within this environment, it can be expected that such living conditions could cause, in addition to negligence regarding children, negligence and social violence against women (mothers), who have no individual, particular and structural conditions for a life with dignity for themselves and, consequently, for their children(11).
Women have historically been attributed the role of caregivers. Even when they assume work in the public environment, homework and care of the children do not cease to be female tasks. This status can explain the fact that the mother is the main aggressor of physical violence and negligence against children and adolescents. We are far from attempting to justify or naturalize the problem when we try to analyze it from a gender perspective. What we do intend is to understand its social determination beyond primary visible signs. The basis of this thinking has to do with the idealistic vision of the family as an environment where conflicts do not exist, and with the segregation of the public and private spheres, placing the men first, the women second and determining different social roles for men.
The signs of the socialization process are found in the task of caring, which the family performs as a priority. This process encompasses the teaching of the behavior patterns that are accepted by society and the punishment of unacceptable behaviors. Within the asymmetric environment of social relationships and, in this case, more specifically the adult-child relationship, the repression adults (mothers) exert on their children often extrapolates the necessary limits to characterize intergenerational violence. Taking into account that the women also reproduce behaviors they have experienced, violence is the measure they use, many times, to educate and impose limits on their children, facilitated by the scheme that permits the reproduction of dominance relationships, as determined by the inequality of the generational power.
The studies also show that the experience of violence cases during childhood, inclusively when there was violence between the parents, or the experience of physical and sexual abuses, may determine significant risks for the children's lives. After getting the experience of such behavior patterns, the children may reproduce them, conceiving violence as a way to solve conflicts. Children may reproduce the behaviors they learned and can take them along to adult life as stereotypes, being considered as socially acceptable and natural(15-16) .
As regards sexual violence, disclosed as a predominant mode in this study, the data show that, in most of the denounced cases, the abuses were perpetrated against girls. The data corroborate comparable studies that show similar percentages in Brazil (in Salvador and Porto Alegre: 86.36% and 80.9% respectively(17-18).
According to these studies, stepfathers or uncles perpetrated most of these abuses. When violence is committed against children and adolescents, sexual violence generally has an intra-family and incestuous nature, in which the aggressors are considered as the victims' caregivers. As they occur in the private environment and are a socially unacceptable relationship, this type of violence is permeated by fear, shame and dependence relationships. Despite the high number of denunciations submitted in these cases, the actual magnitude of this phenomenon is still under-denounced.
Sexual violence against girls is understood as a phenomenon determined by a double subalternity of gender and generation. In this type of relationship, gender violence is exacerbated by intergenerational violence, so that the social place where age and gender locate this violence disqualify the child of any autonomy.
In the context of violence, childhood takes on another meaning for subjects, referring to a concrete childhood of early relations with the world, different from the ideal understanding of the stage of life or play experience, of games and absence of obligations, the happy phase of life of a child protected by his/her parents(5).
Thus, the phenomenon of violence "is not a fatality, neither an abstraction. It occurs in micro-relations and in the context of life [...] No positivist proposal that represents dazzling plans to end violence in a magic trick or with authoritarianism has any theoretical reliability. It must be understood and analyzed as a phenomenon of expression and as part of the complex historical processes, in which it is possible to intervene [...] It is much more useful, for analysis purposes, to work with the proposal that there are violences instead of violence. They present specific manifestations and, usually, are articulated, each making others more potent"(19).
In addition, home violence during pregnancy is strongly linked with childhood violence and former pregnancies, demonstrating the complexity and the circularity of the life of women and children.(20) Considering the child as an individual who translates the start and continuity of the life, it can be stated that violence, in this stage, constitutes a phenomenon whose consequences follow a two-way course: they can determine and be determined by other manners of violence, generating destructive processes for human life and society as a whole.
The City of Curitiba attempted to discover the status of violence its children experienced, through projects that emphasize the importance of denouncing and monitoring violence cases. The Protection Network for the Child and the Adolescent at Risk of Violence, which aims to provide integrated contributions to reduce those violence cases, is helping the city in the fight against this problem, which affects children's health as a whole.
The analyzed reality revealed that, although power relations have changed throughout history, in the social and state areas, small power practices in the private sphere of family relations remain, as manifestations of domination, still justified by the private nature of the family relationship. This reality is contradictory to policies and children's rights. Violence hardly manifests itself alone, usually coming with other poor living conditions, such as unemployment, urban violence, alcohol and drug use, gender violence and other problems. The contradictions arising from the production of the categories generation, gender, ethnicity and social class are a reality ruled by an equally contradictory logic that maintains itself through similarly established social interests. This discourse is opposed to the one that claims that humanity is socially constructed in social relations. This understanding of the world assumes that all social phenomena are the product of human action and can be changed by it, through intervention projects based on recognizing and overcoming these contradictions.
In order to overcome the relationships determined by a male and adult culture, cross-sectional policies are needed, which modify the culture of subordination, encompassing the health care segment, articulated with other social segments through a transforming praxis of social relationships.
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Emiko Yoshikawa Egry
Av. Dr Eneas de Carvalho Aguiar, 419
Bairro: Cerqueira César
CEP: 05403-000, São Paulo, SP, Brasil
Received: Jan. 11th 2011
Accepted: Ago. 10th 2011