Ethical conflicts and limitations of medical care for women victims of gender violence

Abstract

Domestic violence is the most common type of violence against women, resulting in sequelae in the physical, emotional, family, and economic domains, constituting a public health problem. However, the issue is treated negligently by health professionals, which contributes to its invisibility. Based on a review of the literature, the objective of this study was to identify the main difficulties, including ethical conflicts, found by physicians in the approach to patients who are victims of this type of violence. The basic obstacles are grouped in 3 main axes: issues related to the health professional, to the structure of the health system and to the victims of violence. It is concluded that the greatest obstacle comes from the health professionals themselves, and involves factors ranging from inadequate training to the occurrence of moral and ethical conflicts that culminate in blaming and accountability of the victims for the situation of violence in which they were found.

Violence against women; Domestic violence; Health personnel; Physicians; Gender and health; Public health

Resumo

Violência doméstica é o tipo mais comum de violência contra a mulher e resulta em sequelas nas esferas física, emocional, familiar e econômica, constituindo problema de saúde pública. Porém, a questão é tratada de maneira negligente pelos profissionais de saúde, o que contribui para sua invisibilidade. Baseado em revisão da literatura, este estudo objetivou identificar as principais dificuldades, incluindo conflitos éticos, encontradas pelos médicos na abordagem de pacientes vítimas desse tipo de violência. Os obstáculos elementares foram agrupados em três grandes eixos: questões relacionadas ao profissional de saúde; estrutura do sistema de saúde; e aspectos das vítimas de violência. Concluiu-se que o maior entrave advém do próprio profissional de saúde e envolve fatores que variam desde formação inadequada até a ocorrência de conflitos morais e éticos que culminam na culpabilização e responsabilização das vítimas pela situação de violência em que se encontram.

Violência contra a mulher; Violência doméstica; Pessoal de saúde; Médicos; Gênero e saúde; Saúde pública

Resumen

La violencia doméstica es el tipo de violencia más común contra la mujer y da lugar a secuelas en la esfera física, emocional, familiar y económica, constituyéndose en un problema de salud pública. Sin embargo, la cuestión es tratada de manera descuidada por parte de los profesionales de la salud, lo que contribuye a su invisibilidad. Basado en una revisión bibliográfica, este estudio tuvo como objetivo identificar las principales dificultades, incluyendo los conflictos éticos, encontradas por los médicos en el abordaje de pacientes víctimas de este tipo de violencia. Los obstáculos principales fueron agrupados en tres grandes ejes: cuestiones relacionadas con el profesional de la salud; estructura del sistema de salud; y aspectos de las víctimas de violencia. Se concluye que el mayor obstáculo adviene del propio profesional de salud e involucra factores que van desde la formación inadecuada hasta la presencia de conflictos morales y éticos que culminan en la culpabilización y la responsabilización de las víctimas por la situación de violencia en la que se encuentran.

Violencia contra la mujer; Violencia doméstica; Personal de salud; Médicos; Género y salud; Salud Pública

Gender inequality perpetuates throughout history and is reflected in male hierarchical discourses about women, which falls particularly upon the female body ¹. It is known that one of the most brutal externalizations of this inequality is violence against women (VAW), which generates great repercussions in their life and especially in their health ². Since violence is an act of disrespect for human dignity, it is an issue that must be reflected in the light of bioethical principles ³.

According to the United Nations Declaration on the Elimination of Violence against Women⁴, this form of violence is defined as any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life⁵.

The most common type of violence against women is domestic and family violence ^6-8. According to the “Maria da Penha” Law ⁹, this includes any action or omission based on gender that causes death, injury, physical, sexual or psychological suffering and moral or property damage in the household or domestic (with or without family bond) domain, or when perpetrated by an intimate partner. According to the “WHO Multi-country study on women’s health and domestic violence against women” ¹⁰, undertaken in ten countries between 2000 and 2003, from 15% to 71% of women were victims of some type of physical and/or sexual violence perpetrated by intimate partners in some period of their lives.

In the last three decades, violence against women has been gradually recognized as a public health problem by the international community ^4,6,10-12. According to a report issued by the World Health Organization ¹³, violence generates great repercussions on health, not only because of its direct effect on the victims, but also on the health services themselves, demanding actions to attempt to minimize their consequences from the public sector and professionals in the area.

The consequences of VAW reach significant dimensions in both the physical, emotional, family, and economic realms. Women in situations of violence resort to health units with various complaints about the resulting injuries, such as injuries from beating, chronic pain, depression and low self-esteem.

However, health professionals, for the most part, do not perceive or do not document the occurrence of such violent episodes ^10,14-17. The study by Schraiber and D’Oliveira ¹⁸, carried out in São Paulo, Brazil, identified that 57% of the women treated in a primary care unit reported some cases of physical violence in their lives. However, only 10% of the events had been registered in medical records.

A study indicates that the majority of women victims of domestic violence resort to health services with physical symptoms and hide the occurrence of violence from the health professionals ¹⁹. In this way, the woman does not report the aggression, and so the professionals do not question her, evidencing the poor communication in the doctor-patient relationship, which contributes to the invisibility of the issue ^2,20.

In addition, one of the main problems about the difficulty that health professionals, particularly physicians, have in dealing with victims of gender violence is the fact that the issue is not adequately addressed during their training. These issues, when discussed at undergraduate level, are usually not politically and socially contextualized, being traditionally approached in the fragmented biologistic model, in which there is no correlation between health and social reality. Thus, professionals feel paralyzed by subjective issues such as emotional frailty and lack of protection, common in victims of domestic violence ^2,16,21.

Some studies have pointed out other factors that also contribute to the inefficiency of the medical practice in relation to violence. For example, a shortage of time, fear of insulting the victim, since it is a “private matter”, and a feeling of powerlessness in the face of a situation in which it is impossible to control the attitudes of patients. ^22-25. In addition, the brutal dissimilarity that normally exists between the reality of the physician and the situation of risk of the users makes it difficult for the professional to understand violence as a real health problem ^21,24.

In addition, other obstacles block the perception and direction of VAW cases. These are: the lack of knowledge by physicians about appropriate places for referral of women victims of violence ^16,25, fear of affecting personal safety, refusal to engage with judicial bureaucracy, and disbelief that domestic violence is within the scope of health facilities ²⁵.

In view of this situation, the objectives of this research were to identify the main difficulties and limitations encountered by health professionals in approaching women victims of domestic violence, as well as to detect possible ethical conflicts associated with the care of these patients.

Methods

This is a descriptive narrative review whose survey was carried out between March and July of 2016 in the following databases: Latin American and Caribbean Literature in Health Sciences (Literatura Latino-Americana e do Caribe em Ciências da Saúde - Lilacs), PubMed and Scientific Electronic Library Online (SciELO). All the descriptors used in the search of the articles were searched in the Descriptors in Health Sciences.

The search strategy consisted in combining all the primary descriptors “profissionais de saúde” (“health professionals”), “médicos” (“physicians”), “gênero e saúde” (“gender and health”), “saúde da mulher” (“women’s health”) and “serviços de saúde da mulher” (“women’s health services”), using the “and” filter, with one of the secondary descriptors “violência contra a mulher” (“violence against women”), “violência doméstica” (“domestic violence”), “maus-tratos conjugais” (“marital abuse”) and “mulheres maltratadas” (“abused women”). Thus, in each database, four searches were performed.

Inclusion criteria considered publications in Portuguese, English and Spanish; either original or review articles, master’s dissertations and doctoral theses. Articles that did not discuss health professionals’ actions regarding violence against women and those that only deal with other types of intrafamily violence were excluded. After applying these criteria, we obtained a total of 16 articles, which were read and grouped according to the theme involved. During the analysis of these articles, it was also verified which bioethical principles could not be respected during the health services.

Results and discussion

The articles were selected by means of an exploratory reading, and a table containing the main difficulties encountered by health professionals in the care of women victims of violence was elaborated for the organization and recording of the material obtained. The publications were systematized in Table 1 (annex), including title and method employed.

The sample of this research comprises 16 articles. The period of publication of the texts analyzed was between 1997 and 2014, with the majority of articles published in the last five years, which indicates the growing concern about the subject. Regarding the type of study, one is a dissertation, another one is a thesis, and all others are original articles.

With regard to the method chosen, eleven articles were qualitative, two were qualitative and quantitative, one was descriptive, one was analytical and another one was quantitative and descriptive. Qualitative analysis was perceived as a preference, which can be explained by the fact that it deals with an interdisciplinary theme, such as social, scientific and bioethical spheres, as well as the description of subjective aspects such as emotions and feelings.

The analysis of the articles allowed to define three main axes in relation to the obstacles encountered by professionals in the care of women in situation of violence. The first one concerns health professionals: personal perceptions, attitudes, training and capacity building, personal barriers and feelings generated by violence. The second addresses the situation of the health system and its articulation with other available services to treat and welcome women in situations of violence. Finally, the third axis contains aspects related to users of the health system victims of violence. The elements pointed out on each axis will be discussed in detail below.

Health professionals in cases of violence against women

It was observed that 14 articles listed aspects within this axis, suggesting that much of the difficulty found in dealing with VAW cases is centered on the health professional himself.

One of the main obstacles to dealing with VAW is the lack of preparation and inadequate training of these professionals, as evidenced in eight articles, including in this aspect both academic training and professional qualification. It was identified that the professional training pattern is predominantly based on the fragmented biological model, incompatible with adequate assistance in VAW cases. In addition, there was a precarious knowledge of the professionals about services available for referral of the victims, which indicates the lack of care of the health services in enabling professionals to deal with the issue ^22,26-32.

The invisibility of VAW, whether true or apparent, is also evident for health professionals. In general, women do not complain of violence and seek care, most of the time, due to physical injuries. Thus, professionals usually treat clinical lesions without identifying women as victims of gender violence ^31,32. When the violence is perceived by the professionals, by the appearance, location or type of injury, it is common for them to ignore the fact, not addressing the issue during the consultation.

This can be interpreted as institutional violence, since professionals do not work to break the cycle of violence to which the patient is subject. By placing themselves as unaware of the situation, they contribute further to the continuity of female oppression ^21,24,27,30. In addition, the omission of health professionals regarding the problem demonstrates the non-fulfillment of their moral duty to act for the benefit of the victim, described by the principle of beneficence.

Some studies ^29,30,33-36 call attention to the judgment of health professionals towards the victims, justifying and naturalizing the violence with the strategy of blaming the patients. Similarly, other authors ²² observed the imposition of the values of health professionals on their patients. Other moral and ethical issues were also pointed out in a study ³⁴ that discussed abortion in rape victims, in which great difficulty as observed in accepting the termination of the pregnancy by health professionals, who blamed the victims for the violence suffered. In this sense, professionals disregard the patients’ autonomy, since this principle recommends the prioritization of the individual’s values and preferences in the making of diagnostic and therapeutic decisions.

Another issue in this axis is the fear and insecurity that plagues health professionals, this being a personal barrier to face the VAW. In the studies surveyed, the respondents reported, mainly, fear of suffering retaliation from aggressors ^24,28. Many of the professionals who participated in the studies showed that they feel powerless and frustrated in such situations, since the clinical treatment of the lesions can not able to solve this multi-factorial problem ^{21,24,26,28,34}. In addition, they said that one of the greatest difficulties is dealing with associated factors, which in many cases are the triggers of violence, such as drug use and drug trafficking ³⁶.

As for the professional class (physicians and nurses), there were significant differences regarding the representations about violence and actions between the two groups ^24,31,35,37. It was also identified that most of the professionals are unaware of the epidemiological aspects of VAW, which contributes to the invisibility of the issue; however, nurses had greater capacity to deal with the cases ³².

Regarding VAW identification only as a public safety problem, most participating physicians thought that this issue should not be addressed by the health services and declared they were able to identify these cases from clinical signs and symptoms associated with family issues and mental issues of patients ^24,35. On the other hand, the nurses participating in this study understood this violence as a “private” problem, believing that they should not intervene directly to resolve the issue.

A similar result was found among nurses participating in another study, who stated that VAW should not be directly addressed ³⁷. To another author ²⁸, some physicians reported not knowing the resources available to victims of violence, and affirmed that they entrusted the task to nursing.

On the other hand, the power and efficiency of the Family Health Strategy (“Estratégia de Saúde de Família”, ESF) were highlighted in the identification and management of cases of domestic violence ^36,38. In both studies the role of community health agents (CHAs) was pointed out as fundamental to the success of case management, which can be attributed to the opportunity the CHAs have to detect signs of violence, since they come into direct contact with the environment in which patients live.

However, the first study ³⁶ also highlighted the work of social assistants and psychologists and identified a lesser participative relevance of physicians, nurses and nursing technicians in the approach and solution of cases. In the second study ³⁸, nurses were protagonists in the identification, conduct and prevention activities in the issue of VAW.

Fonseca et al. ³⁴ found contrasting results to the ones mentioned previously, pointing out the naturalization of violence by the CHAs and also their fragility. This is because these professionals are part of the same community of the victims and perpetrators and are not supported by institutions that could protect them to actively interfere in situations of VAW.

One of the studies ³⁵ identified a greater understanding of ESF physicians and nurses about the social dynamics of violence, associating their etiology with external factors such as drug and alcohol use and their respective consequences the health and social status of the woman, who tends to become submissive, dependent and have diminished self-esteem. Similar results were observed by another author ³⁷.

The health system and support services to women

In this axis, there was a notable convergence of most articles, which point to the precariousness of the health system, making it even more difficult to solve VAW cases. Four studies ^21,31,32,35 pointed out that the model of vertical and fragmented medical care is inadequate to care for women in situations of violence. Carried out without biopsychosocial contextualization of the patient, care becomes an obstacle to the humanized and welcoming care.

Moreover, several studies ^{21,24,29,30,32,35,38} point out other gaps in the functioning of the health system, such as an absence of the counter-referral of the cases, which causes a false sense of resolution after referrals. In the same way, the inapplicability of the principle of integrality of the service and the absence of specific protocols standardized to help the professionals to conduct the cases are also factors associated with the malfunction of the system in relation to the VAW.

There is also a need to maintain multidisciplinary teams available to serve these women and to create an inter-sectoral network that articulates public safety, women’s health and psychological care services, thus enabling decentralization and effective response to the problem.

Regarding the physical structure of the health services received by women victims of violence, among other cases ^{21,26,29,30,32}, have found that health units are physically inadequate for the dynamics of care.

Small rooms, lack of privacy, and the lack of space reserved to address the issues of these patients, since many women feel ashamed to share the situation, make it difficult to talk frankly. In addition, these authors pointed out the lack of time of the professionals as a limiting factor of the adequate and more humanized care to these patients.

In general, it is observed that these findings violate the concept of Justice, since the studies surveyed pointed to the low demand to meet the needs of the victims in order to respect their peculiarities, freedom of expression and interests.

Perceptions of female victims of violence

In the studies that discussed the perception of women about gender representations and the issue of violence ^32,35,38, the phenomenon of naturalization and banalizing of violence by the patients was identified. It is important to note that this fact was also identified in the perception of some professionals. It can be assumed that this perception shared by the two groups stems from the trivialization of violence against women in Brazilian society, as portrayed in an abundant way by the media.

Concerning the search for help by patients in situations of violence, it was noticed that the majority of women do not see the health units as a place to which they can resort ²⁹, and when they seek them due to physical injuries, it hides the occurrence of violence ^27,32. In another study ³⁸, it was identified that the majority of women believe that domestic violence is a serious health problem and that it would be up to physicians to actively screen for care.

About 70% of the women who participated in the study stated that they would tell the physician about the occurrence of violence if they were asked. However, only 12% of the total of 406 women have been questioned by doctors or nurses about the occurrence of aggression. Regarding the prevalence of violence between different social levels and ethnicities, this same study did not find significant differences ³⁸.

Final considerations

The present review of the literature allowed to systematize the difficulties found by health professionals in the care of women victims of gender violence, which contribute to the invisibility of this problem. In this sense, it can be stated that the greatest obstacle is in the health professional itself and involves issues ranging from inadequate training to the occurrence of moral and ethical conflicts that culminate in the blaming of the victims for the situation of violence that they suffered. This was the greatest conflict raised, since violence disrupts the state of health of those who suffer it, indirectly affecting health professionals who must guarantee the welfare state of patients, according to the bioethical principle of beneficence ³⁹.

It was also possible to note the violation of the principles of justice and autonomy, since the victims are deprived of care that is consistent with their particularities and, in many cases, have their preferences and moral values judged and, above all, placed in the background by professionals who care for them. In addition, the precarious structure of the health system and the social representations of violence by the victims were outlined as other aspects that make the approach to this issue more difficult.

Considering the relevance of the problem, it is concluded that there are few studies in the literature that relate the health issue to violence, thus limiting further reflection on the issue. In this sense, the importance of more studies on the subject is emphasized and it is expected that the present study may contribute to the knowledge from the findings presented.

Annex

Author(s) (year)	Title	Type of publication	Method of analysis	Main difficulties
Pedrosa, Spink (2011) 20	A violência contra mulher no cotidiano dos serviços de saúde: desafios para a formação médica (“Violence against women in daily health services: challenges for medical training”)	Original	Qualitative	Inadequate academic training Apparent invisibility of violence against women (VAW) Distancing and distress of professionals in VAW cases Absence of interdisciplinary institutional networks Lack of institutional resources Institutional Violence Lack of time
Vieira et al. (2013) 23	The response to gender violence among Brazilian health care professionals	Original	Qualitative	Epidemiological knowledge of professionals about VAW Apparent invisibility of VAW Doctors do not recognize VAW as a public health issue Professionals report feelings of impotence, revolt and fear Absence of integrality in health services
Büken, Sahinoglu (2006) 25	Violence against women in Turkey and the role of women physicians	Original	Qualitative	Educational deficiency in the training of health professionals Insecurity and lack of motivation Unsuitable physical environments Lack of time
Bispo, Almeida, Diniz (2007) 26	Violência conjugal: desafio para os profissionais de saúde (“Marital violence: a challenge for health professionals”)	Original	Qualitative	Identification of violence through physical injuries Lack of biopsychosocial contextualization Lack of time Professionals do not recognize violence as a public health issue Inadequate training of professionals Users do not report the situation of violence
De Ferrante, Santos, Vieira (2009) 27	Violência contra a mulher: percepção dos médicos das unidades básicas de saúde da cidade de Ribeirão Preto, São Paulo (“Violence against women: the perception of physicians of the basic health units of the city of Ribeirão Preto, São Paulo”)	Original	Qualitative	Blaming of victims by professionals Physicians’ lack of appropriate places to which refer patients Professionals belittle VAW identification Professionals feel insecure to approach VAW
Villela et al. (2011) 28	Ambiguidades e contradições no atendimento de mulheres que sofrem violência (“Ambiguities and contradictions in the care of women who suffer violence”)	Original	Qualitative	Blaming of victims Unprepared professionals Inadequate hospital structure Absence of integrality of health services Overcrowding of shelters
Osis, Duarte, Faúndes (2012) 39	Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais (“Violence among users of health units: prevalence, perspective and conduct of managers and professionals”)	Original	Descriptive	Professionals do not recognize VAW as a public health issue Unprepared professionals Lack of institutional resources Lack of specific protocols to address the issue Health service is not seen by general users as a place to get help
Hasse, Vieira (2014) 30	Como os profissionais de saúde atendem mulheres em situação de violência? Uma análise triangulada de dados (“How do health professionals treat women in situations of violence? A triangulated data analysis”)	Original	Qualitative and quantitative	Lack of biopsychosocial contextualization in care Most interviewees do not recognize VAW as a public health problem Epidemiological knowledge of professionals about VAW
Nascimento (2011) 31	Percepções dos profissionais de saúde de Angola sobre a violência contra a mulher na relação conjugal (“Perceptions of Angolan health professionals about violence against women in the marital relationship”)	Master’s Dissertation	Qualitative	Lack of biopsychosocial contextualization in care Blaming of victims by professionals Absence of counter-referral in health services Need to extend multidisciplinary care to victims Professionals see the problem as being private of the couple Judgment and discrimination of victims by professionals Others (prejudice, lack of training and overwork of professionals, absence of institutional support and protocols of conduct, lack of health policies, small physical spaces in health units) Women hide and naturalize violence
Soares (2003) 32	Profissionais de saúde frente ao aborto legal no Brasil: desafios, conflitos e significados (“Health professionals facing legal abortion in Brazil: challenges, conflicts and meanings”)	Original	Qualitative	Moral and ethical dilemmas involved in abortion (right to abortion × religious value) Prosecutors blame VAW victims for abortion due to rape
Fonseca et al. (2009) 33	Violência doméstica contra a mulher na visão do agente comunitário de saúde (“Domestic violence against women in the view of the community health agent”)	Original	Qualitative	Blaming of the victims by the Community Health Agents Feeling of powerlessness in the face of the situation Unawareness of the apparatus available to refer victims Naturalization of female oppression
Leal (2010) 34	Lugares de (não) ver? As representações sociais da violência contra a mulher na atenção básica de saúde	Doctoral Thesis	Qualitative	Lack of biopsychosocial contextualization in care Non-recognition of VAW as a public health problem Epidemiological knowledge of professionals about VAW Absence of counter-reference and integrality in health services Naturalization and banalizing of VAW by professionals and users
Moreira et al. (2014) 35	A construção do cuidado: o atendimento às situações de violência doméstica por equipes de Saúde da Família (“The construction of care: the attendance to situations of domestic violence by Family Health teams”)	Original	Qualitative	Dilemma: respect of users’ autonomy × intervention in life-threatening situations. Address factors associated with violence, such as drug use and drug trafficking. Unprepared professionals
Baraldi et al. (2012) 36	Violência contra a mulher na rede de atenção básica: o que os enfermeiros sabem sobre o problema? (“Violence against women in the primary care network: what do nurses know about the problem?”)	Original	Quantitative, descriptive	Invisibility of VAW in prenatal care Directly approaching VAW
Hesler et al. (2013) 37	Violência contra as mulheres na perspectiva dos agentes comunitários de saúde (“Violence against women from the perspective of community health workers”)	Original	Qualitative	Absence of an intersectoral network guaranteeing the citizenship rights of women Absence of interdisciplinary institutional networks Naturalization of VAW by victims and perpetrators
Caralis, Musialowski (1997) 39	Women’s experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims	Original	Qualitative and quantitative	Professional ignorance Adequate care for the VAW victim requires a lot of time and resources Physicians believe that this is a private problem for the couple Physicians believe that the woman is responsible for the violence she is experiencing. Lack of resources in support services for these victims Physicians fear for their own safety

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Publication Dates

• Publication in this collection
  Jan-Apr 2018

History

• Received
  24 Apr 2017
• Reviewed
  4 Oct 2017
• Accepted
  18 Nov 2017