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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.25 no.12 Rio de Janeiro Dec. 2020  Epub Dec 04, 2020

https://doi.org/10.1590/1413-812320202512.15582020 

ARTICLE

The contribution of Journal Ciência & Saúde Coletiva to gender and health studies

Wilza Vieira Villela1 
http://orcid.org/0000-0002-6246-2716

Simone Souza Monteiro2 
http://orcid.org/0000-0003-2009-1790

Regina Maria Barbosa3 
http://orcid.org/0000-0002-3390-2137

1Departamento de Medicina Preventiva, Universidade Federal de São Paulo. R. Borges Lagoa 1341, Vila Clementino. 04038-034 São Paulo SP Brasil. wilza.villela@gmail.com

2Instituto Oswaldo Cruz, Fiocruz. Rio de Janeiro RJ Brasil.

3Núcleo de Estudos de População “Elza Berquó”, Universidade Estadual de Campinas. Campinas SP Brasil.


Abstract

This paper aims to explore Journal Ciência & Saúde Coletiva’s contributions to gender and health studies. Therefore, mapping was carried out through the SciELO platform, using the terms gender, man/men, woman/women, youth/youths, adolescent/adolescents. A total of 164 papers were selected, categorized by year of publication, type of study, population, topics addressed, and method. The analysis of the material shows the journal’s contribution to proposing themes that favor analyses from the gender perspective. Some productions reflect the most current discussions. However, the paucity of works on gender in life cycles and the intersectional approach suggests that the journal’s proactive posture should be maintained to encourage gender analysis in other topics than sexual and reproductive health, masculinities, and gender violence against women.

Key words: Gender; Collective health; Women; Men

Resumo

Este artigo tem como finalidade explorar as contribuições da C&SC para os estudos sobre gênero e saúde. Para tanto, foi realizado um mapeamento por meio da plataforma da revista no SciELO, utilizando os unitermos gênero, homem/homens, mulher/mulheres, jovem/jovens, adolescente/adolescentes. Foram selecionados 164 artigos, categorizados em função do ano de publicação, tipo de estudo, população estudada, temas abordados e método. A análise do material aponta a contribuição da revista ao propor temas que favorecem análises na perspectiva de gênero. Algumas produções traduzem discussões atuais. Entretanto, o pequeno número de artigos sobre gênero nos ciclos de vida e desde uma abordagem interseccional sugere que a postura proativa da revista deve ser mantida para estimular análises de gênero em outros temas que não a saúde sexual e reprodutiva, as masculinidades e a violência de gênero contra mulheres.

Palavras-chave: Gênero; Saúde coletiva; Mulheres; Homens

Introduction

The term gender appears in academic literature from feminist studies as an analytical tool to explain the social dynamics that produce and naturalize women’s oppression and domination. One of the benchmarks is the work of the anthropologist Gayle Rubin (1975). He coined the expression “sex-gender system” to refer to “the arrangements through which a society transforms biological sexuality into a product of human activity”1.

The sex-gender system divides human beings into two categories: women and men, distinguished not only by their reproductive anatomy-physiology but also by social, behavioral, and psychological attributes. Constructed as opposed and hierarchical, the ideas of femininity and masculinity organize everyday practices at the individual and collective level, including love and sexual relationships, since the sex-gender system presupposes heterosexuality as the norm2.

In 1986, historian Joan Scott affirmed that the relationships built from the differentiated valorization of feminine or masculine characteristics to the detriment of the former are necessarily power relationships3. The author adds that the power dynamics underlying gender relationships do not refer exclusively to interpersonal exchanges but are produced and reproduced historically and culturally through signs, symbols, and social practices. Thus, gender marks women’s and men’s subjectivities, determining ways of thinking, feeling, and acting in a given society that are somehow reflected in institutions and policies3. While it ultimately concerns the oppression of women, gender operates within women-men relationships, in the relationships among women, men, and in the relationships of all with the various social institutions. How each one takes part in a given society and experiences their own body, sex, feelings, identity, and social inclusion are marked by gender. Gender gives meaning to bodies and individuals and should be considered when analyzing social and political processes3.

In 1990, philosopher Judith Butler questioned the use of the term gender as a univocal category that unveils women’s oppression. She believes that distinctions of social class, ethnicity, sexuality, and cultural inscriptions confer a degree of heterogeneity among women that must be considered4. In dialogue with analyses that approach gender as “the social elaboration of sexual difference” - an expression that popularized the concept of gender, regarding the meanings of sex in each culture -, Butler suggests an inverse logic. Instead, the social processes of attributing meanings to bodies, bodily practices, and sexual practices, that is to say, gender, would establish sexual difference5. Furthermore, she argues about the relative independence between the sexual body, gender, and desire. Since corporeality and desire are experienced by the subject, they are not entirely subject to gender. That is, even if the ways of experiencing body and sexuality are informed by gender, they also challenge it, and can affirm and transform it from individual performances5. Gender does not determine sex or desire, nor does sex determine gender, although both are interwoven dimensions.

Anthropologist Adriana Piscitelli affirms that the acquisition of new meanings for the term gender does not diminish its political character. On the contrary, it requires:

Thinking not only about the distinctions between men and women, between male and female, but about how the constructions of masculinity and femininity are created in conjunction with other differences, of race, social class, nationality, and age; and how these concepts scramble and mix in everyone’s body6.

From this viewpoint, gender studies should broaden their focus, seeking to identify how women’s domination processes are linked to other social markers of difference. Moreover, in this way, they produce hierarchies and inequalities not only between women and men but between groups of women and groups of men, by race/ethnicity, social class, sexual orientation, religiosity, age group, and other social attributes. Initially coined by Crenshaw7, such perspective of seeking intersectionality between different social markers in the production of inequalities has been gaining importance in academic studies8, contributing to differentiate gender studies from those that take on women and men as their objects uncritically.

The potential of gender for the analysis of the processes of producing social inequalities and their consequences for health justifies the relevance of its inclusion in Public Health, committed both in Brazil and internationally9 to the right of all to health10. There has been increasing evidence about the differences in the morbimortality profiles between women and men over the years, in their behaviors vis-à-vis health and illness, and the demand and use of health services11. At the same time, these differences can be explained in part by analyzing the behaviors and practices appropriate for women and men, during the life stages12, which means that gender beliefs and norms collaborate to expose women and men to unnecessary risks, and can hinder the adoption of preventive and self-care practices and access to health services. Furthermore, they can interfere with decision-making processes that favor health13.

The recognition by the World Health Organization (WHO) that gender is one of the social determinants of health, and that gender inequalities promote health inequalities follows the historical position taken at the Fourth International Conference on Population and Development (Cairo, 1984) that these inequalities adversely affect sustainable development at the global level14,15. In this direction, the Fourth World Conference on Women (Beijing, 1995)16 reaffirms women’s right to health, especially the provision of sexual and reproductive health services and a life without violence. Thus, in 1997, the WHO recommended that all policies and practices developed by its entities be marked by a gender perspective17, including actions to prevent and mitigate the consequences of violence against women.

This WHO guideline was translated into stimulating the development of public policies aimed at reducing gender inequalities in health and the development of studies that could support them. There is a recommendation towards the disaggregation of data by gender in population-based surveys and the construction of theoretical frameworks that consider the analysis of the impact of gender on the daily lives of women and men18. It is also considered that the inclusion of the gender perspective in health requires initiatives at different levels, from the systematic analysis of possible gender biases in health laws, policies, programs, and services, to the identification of windows of opportunities provided by these instruments and the implementation and evaluation of responses. Furthermore, this effort seeks to define research priorities and resource allocation in order to identify how gender relationships shape social practices and their effects on health11.

In Brazil, driven by the women’s movement, public health (governmental and non-governmental) actions aimed at addressing the effects of gender inequalities on women’s health started in 1984, with the Comprehensive Women’s Health Care Program (PAISM). This program sought to break with the maternal and child perspective that guided the organization of primary health services to claim a care model that could consider the different needs of women throughout life19. The implementation of PAISM faced many difficulties, but its proposals were strengthened with the already mentioned Cairo and Beijing Conference Platforms. As a signatory to both, the Brazilian government produced several instruments - plans, policies, and programs - so that international agreements and the demands of civil society for equity could have an institutional translation.

The activism of segments of civil society, such as NGOs, researchers and academics, and the dialogue of these actors with government sectors, encouraged the creation of instruments to comply with the established agreements. Thus, the Health Policy for the LGBT Population was elaborated in 2004, and is included in the Brazil Without Homophobia Program. The Maria da Penha Law was signed in 2006 and establishes flows and lines of care for women victims of gender violence. The Comprehensive Health Care Policy for the Black Population is established in 2009. The Comprehensive Men’s Health Care Policy was established in that same year, driven by doctors from analyses of male morbimortality profiles20. These initiatives have been materialized through practices in services, illustrated by the expanded provision of sexual and reproductive health and fight against violence against women and its consequences for health21. Academic production on gender and health has also intensified, covering different themes, approaches and theoretical perspectives22.

Because of its interdisciplinary and political characteristics23, Collective Health is privileged to articulate reflections whose object are aspects of the daily lives of women and men and practices of services and institutions, and will discuss how gender determines the social production of life and health. In Brazil, the Brazilian Association of Collective Health (Abrasco) has played an essential role in the establishment and consolidation of this field, with Journal Ciência & Saúde Coletiva (C&SC), one of its leading spokespeople. Its publications have enabled its participation in the debates that shape Brazilian Collective Health. On the 25th anniversary of the foundation of the Journal, this paper aims to appreciate its contribution to gender studies in health.

Methods

Mapping and analysis of papers focused on the relationship between gender and health published by C&SC were carried out over these 25 years. Faced with the polysemic term “gender” and its political nature and perspective of denaturalizing the gaps between women and men, the proposed mapping favored manuscripts with a design, theoretical framework, or discussion that recognized that the subjects or studied processes are traversed by this social determinant. Studies that considered sexual identities without a discussion about gender or that took events related to women’s and men’s health without considering the gender dimension in the production or dynamics of the investigated event were not included.

A survey was carried out from this definition through the SciELO platform, searching papers with the term “gender” in any index (title, author, and subject) of the Journal C&SC, right from the first volume, which resulted in the identification of 271 papers. An additional search using the keywords woman/women, man/men youth/youths, and adolescent/adolescents, identified 22 more works meeting the inclusion criteria.

After reading the titles and abstracts, editorials and debate comments, and papers in which the term gender was not referred to sexual difference, or when this reference was restricted to biological aspects without addressing the cultural inscription of female or male bodies concerning the studied event were excluded. A total of 164 works that explicitly used the term gender as a theoretical device or analyzed its data based on gender determinations were retrieved. These manuscripts were categorized by type of publication, methodological approach, year of publication, central theme, and population studied. For the analysis of the material, we sought to identify possible relationships between the categories and emerging issues in public health.

The entire selection and classification, mainly when guided by a fluid category such as gender, can be questioned. The option of not including keywords “child” or “children” in the search criteria, not exhausting all the possibilities of keywords, and excluding works on sexual identity that did not assume the gender selection as an assumption or perspective of analysis, may have left out some relevant work. The independent selection and analysis of papers by the authors sought to minimize these possible biases. Respect for the authors’ choice of keywords or use of the term “gender” was another precaution, given that the definition of a study as “gender-related” is primarily linked to the researcher’s view. We believe that eventual gaps did not interfere in the proposed analysis of an eminently qualitative nature.

Another challenge is the thematic classification, considering the intersecting subjects covered in the works. Sexuality, for example, is an essential part of the construction of masculinities, practices in Reproductive Health, and the Prevention of STIs/AIDS. Likewise, public policies permeate the practices of services and subjects. However, the reductionism of classificatory processes is inexorable. Once again, respect for the thematic classification chosen by the author was a useful criterion. Finally, a reductionism is applied to the analysis, given that a broad set of papers hinders dialogue with the authors’ theoretical foundations. Furthermore, the option for analysis, favoring emerging themes in the field of public health from a gender perspective, may have overshadowed other possible contributions.

Results

The first paper included in the selected dates from 1999. In the following period, the distribution of publications is irregular, ranging from none between 2000 and 2002, and 2007, to 26 in 2012. The gender approach is present in issues on violence, suicide, and aging, alongside free theme papers. However, the years with the most significant volume of work with a gender perspective coincide with the publication of thematic issues on subjects more permeable to this view, such as the emergence of men as a focus of public health, the inclusion of gender in public health, abortion and the National Comprehensive Men’s Health Care Policy. Graph 1 shows the number of papers with a gender selection published each year.

Graph 1 Number of articles with a gender cut published each year in the Journal C&SC

Regarding the type of publication, empirical studies with primary data production (89/164) predominate, followed by essays, opinion texts, debate papers, and interviews (29/164). Secondary data analyses (21/164) were also identified using, in general, databases of information systems (SIM, SINAM, AIH hospital records, police reports, and others) or national surveys (PNAD, PENSE, and others). Twelve manuscripts (12/164) were based on documentary analysis (files, technical standards, newspaper news, and media pieces). Review studies (09), reviews (04) complete the set of publications.

The most studied population (in the 134 manuscripts to which this applies) is that of women (37/134), including women from the general population and those with some specificity, such as sex workers, women involved in trafficking, females with disabilities or health problems and who suffer violence. Most works address women of reproductive age, and only two focus on older women, and another two female adolescents/young women. Among the manuscripts that address men (33/134), seven focus on adolescents or young people, and one the elderly. Thirty (30/134) jobs include women and men, of which four are with older adults and twelve with adolescents or young people. Professionals or managers are also the subject of thirty papers (30/134). One study addresses the sexual orientation of the informants, analyzing their results from a gender perspective, and another uses the gender category to discuss empirical data on transsexual people. Six manuscripts contain an explicit intention to articulate gender determinations and other inequality markers, such as race/skin color/ethnicity or poverty from an intersectional perspective.

The themes vary, with a predominance of those related to Sexual and Reproductive Health, such as contraception, HIV/AIDS prevention, obstetric violence (35/164), and, mainly, abortion (16/35). Gender-based violence against women (Gender-Based Violence, GBV) is addressed in 32 papers; masculinities and their repercussions for men’s health also add up to 32 productions. Sexuality is a central theme in 15 manuscripts, and health issues, in general, analyzed from a gender perspective, total 10 papers. Work (10), public policies (07), mental health, and substance use (07) are addressed and, less frequently, violence (04) power issues (04) and aging (03).

The methodological diversity reflects the breadth of themes and objects, but there is a greater number of studies with qualitative approaches, which are ethnographic or not and are supported by different theoretical and methodological references. Works carried out in the five regions of the country are recorded, with a greater concentration of those from the southeastern and southern regions. There is also a contribution from international studies. Chart 1 summarizes the main results of this mapping, based on a classification developed by the authors taking into account type of study, subjects, themes, and methodological approach:

Table 1 Summary of results of the review of articles with a gender focus published between 1999 and 2020 in the Journal C&SC

Type of study N
Empirical 89
Theoretical (essay/opinion/debate, interviews) 29
Secondary data analysis 21
Document analysis 12
Review 9
Critique 4
Total 164*
Subjects
Women 37
Men 33
Women and men 30
Professionals/managers 30
Trans people/MSM 4
Total 134*
Themes
Gender-based violence (GBV) 32
Masculinities/Men’s Health/PNAISH 32
Sexual and reproductive health (contraception, childbirth care, obstetric violence, HIV/AIDS and others) 19
Abortion 16
Sexuality 15
Gender and Health 13
Work 10
Public policy 7
Mental health/substance use 7
Gender and violence 4
Gender and power 4
Aging 3
Others 2
Total 164*
Methodological approach N
Qualitative 64
Quantitative 46
Total 110*

* The totals include only the studies to which this classification applies.

Discussion

The use of the gender category as a device for analyzing human processes refers to a shift from the biological to the social. Thus, the presence of empirical and theoretical works from this perspective in the Journal C&SC is not surprising, given that this broadened human understanding is similar to the expanded focus of health studies to include disease and production of life24, a movement that marks the establishment of the Brazilian Collective Health.

As shown in Graph 1, manuscripts produced from a gender perspective are found in several volumes, especially those that refer to themes located at the interface with social and human sciences25, such as violence, suicide, and life cycles. However, the importance of thematic numbers to highlight issues whose debate is recent, such as men’s health and masculinities, the object of pioneering publication in 2005 (vol 10, n 1), or incorporation of the gender category in the analysis health-disease processes in 2009 (v14, n 4) is undeniable. However, the pioneering spirit of C&SC in addressing the theme of gender and health has been present since 1999 with the publication of a review on policies to combat domestic violence against women26, in an issue on violence (vol 4, n1). This theme was highlighted on the Human Rights Platform of the United Nations (Vienna, 1993)27 and preceded the statements about the right to sexual and reproductive health present on the Platform of Cairo and Beijing.

Taking the UN conferences as beacons for public policies and academic productions, it is clear that the GBV assumes a specific character vis-à-vis other forms of violence and health problems marked by gender inequalities. This specificity is reflected in the intense production on the subject and the repeated debate on GBV in health services. While there is consensus about the negative repercussions of GBV on women’s health, it has not necessarily translated into effective responses28. As one of the worst manifestations of gender inequality, violence seems to resist prevention or coping actions. Publishing texts that address the issue from different angles contributes to its greater visibility, breaking the pact of silence around the subject, and contributing to the search for solutions.

The first two works with the term “gender” date from 2002 and were published in a thematic issue on information and health29,30. Centered on an analysis of PNAD data, they aim to give visibility to gender inequalities in health to support the implementation of public policies to achieved equity.

The publication of the volume “Men as a focus for public health” (Free translation from the Portuguese) (2005, vol. 10, no1) assumes that men’s social inclusion is also marked by gender. Thus, it is necessary to investigate how gender norms affect men’s health. Announcing this position, a reflection was published in 2003 on the prevention of prostate cancer and the “genderized” imaginary about male sexuality31. Men’s health is again discussed in an issue on the National Comprehensive Men’s Health Care Policy (2012, vol.17, no10), in which the set of papers illustrates the reproduction of gender norms in social institutions and representations and practices. Discussions about the challenges of including men in primary health care actions, traditionally aimed at women and children, are resumed in subsequent volumes.

The deconstruction of the gender norms responsible for increasing the risks to men’s health is highly controversial, given that the supposed attributes that put men at risk are the same ones that empower them32. The analysis of existing hierarchies among men, by social class, race/ethnicity, sexual orientation, for example, is the key to deconstructing the idea of immanent “power”33. Thus, it is necessary to understand men and their masculinities based on gender norms, and not only from the angle of women’s domination. In other words, the study of masculinities and their repercussions for health are legitimized in collective health and in the study of the repercussions of the norms that establish femininities for women’s health34.

As for the thematic numbers, it is worth mentioning the volume on the incorporation of gender in public health (2009, vol. 14, no 4), which points out the potential of using this category in the field of public health and updates a published review study21. This issue was organized by the Gender and Health Thematic Group of the Brazilian Association of Public Health, ABRASCO, publisher of C&SC. The WG was created in 1995 “to contribute to education and the production of knowledge about the health impacts of social inequalities between men and women”35. The thematic issue on abortion (2012, vol. 17, n° 7) reiterates this sensitivity and commitment. As it is a criminalized and strongly stigmatized practice, the publication of data, experiences, and analyses on abortion is essential to dispel myths and prejudice that prevent women, especially the poorest, from accessing safe methods of terminating an unwanted or untimely pregnancy. The importance of this thematic issue is underlined when it appears that 14 of the 16 articles on abortion published in C&SC were included in this volume.

Even taking into account the edition of thematic volumes on themes permeable to gender analysis, the profile of the themes is similar to that pointed out in other reviews36. The multiplicity of themes and population groups investigated reflects the semantic developments acquired by the gender category as a result of its incorporation into academic studies. Thus, we can identify echoes of the different theoretical matrices that mark the construction and use of this category, such as the privileged focus on women and the male domination processes, the unraveling of the webs of power that subdues men and women, by creating antagonisms, analyses of overlap between body, sexuality, and subjectivity in the (re) production and transformation of gender norms.

Reflecting this theoretical multiplicity, the analyzed production reaffirms that gender does not refer only to women and that it is not only in the scope of sexual and reproductive health, the exercise of sexuality, and exposure to violence that it affects health. All dimensions of life, including work, mental health, lifestyles, and substance use, are affected by gender. While negligible, the production of manuscripts on these themes expresses other possibilities for using the gender category in public health.

Regarding gaps, despite the Journal’s effort to give visibility to the experiences of the subjects throughout their life cycles, few studies delve into this issue, whether concerning older adults or young people, and adolescents. Many studies with groups in the non-reproductive life stages do not distinguish female, male, or trans subjects’ experiences. Papers aimed at the teen or young population, in general, refer to sexuality or reproduction, as if gender inequalities reverberate only in these spheres.

The scarcity of works that explored the intersectionality among the social markers of inequality was also observed. While some papers refer to the social, occupational, or ethnic/racial inclusion of the subjects, there is a lack of an in-depth reflection on the synergy between different situations of inequality, or even their potential in the production of forms of coping or resilience. Such absence, in part, can be attributed to the theoretical, methodological challenge brought by this perspective37.

Final comments

What is published in a journal, among other aspects, depends on what is submitted. Thus, the gaps identified point to the appropriations of authors concerning the gender category than instead of a journal stance. It should be noted that C&SC has been active in proposing innovative themes over time, especially by publishing thematic gender-related issues. The researchers’ response to the thematic numbers shows the opportunity of the initiative. The existence of a gender editorial board and the present publication within the scope of the 25 years of the Journal, reinforce this position.

Global political reflections and guidelines9,11-13 point out the pertinence and relevance of the gender perspective, increasingly permeating the analysis of research data on different topics. In this sense, C&SC should maintain its commitment to the vitality of the gender approach and the inquiry of new objects and theoretical contributions that illuminate the understanding and coping with health inequalities. This perspective is illustrated by the highlight of UN Women38 on the impact of the recent COVID-19 pandemic on the female population. The international agency stresses that, despite the severe socioeconomic implications of the pandemic for all population segments, we should recognize that it affects men and women differently. Such differences must be considered in the control, prevention, and care actions, analyzed and published in wide-scope journals such as C&SC.

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Received: May 19, 2020; Accepted: May 27, 2020; Published: May 29, 2020

Collaborations

WV Villela and SS Monteiro also participated in the conception of the work, selection and analysis of material and preparation of the manuscript. RM Barbosa participated in the preparation of the manuscript and final review.

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