fatherhood and parenting as health issues facing the rearrangements of gender

In this theoretical essay we aim to discuss paternity as a health issue in the context of contemporary gender roles by considering two lines of argument: (a) paternity, parenting and rearrangements of gender roles; and (b) paternity and parenting as a mutual relationship based on care. In our discussion, we highlight the inclusion of men in the health system from the point of view of paternity. At present this appears to be operating in an instrumental manner, with the mother-infant dyad still a major concern and men not being viewed as individuals with rights to health. Thus, we seek to question the system itself, in relation to its perceptions of the current state of paternity, by taking into consideration recent discussions about gender and sexuality as well as and new family arrangements that may challenge beliefs about the roles of families, fathers and mothers, which have impacts on care. Among other aspects, we conclude that we need to reinvent ourselves because we were not raised under the aegis of diversity and we were also not trained as professionals with a basis in the current problematic divisions that exist between father/mother and sex/gender, among many other previous certainties, all of which does not always help us to promote actions in the area of health.


Introduction
From the twentieth century onwards, family life has been redesigned because of social changes such as integrating women into the labor market, the absence of fathers in some cases, or, conversely in other cases, greater male participation in family life.These changes have become increasing trends in the twenty-first century and they have influenced the formation of different family structures, as well as creating different expectations and beliefs about parental roles 1 .
It can be argued that the issue of paternity has been highlighted in the fields of social sciences and the humanities since the 1980s.According to Valente 2 , between 1987 and 1990 discussions about paternity became a feature in the areas of law and psychology and this was expanded in the 1990s when the issue became a theme of research in the areas of public health, anthropology, education, nursing and sociology.In the 2000s the issue was taken up in other areas such as communications, women's and children's health, philosophy, neuroscience, public health and the social sciences.
However, there is uncertainty in these various fields as to the exact meaning of paternity, except for the legal field, which has had to respond to issues such as the demands brought about by DNA testing, assisted reproductive technologies, and new family and affiliation arrangements, among other matters related to paternity [3][4][5][6][7][8] .
In this scenario, with emphasis on the health field, there exists the same uncertainty about what constitutes paternity, which opens up the opportunity to think of it in multiple forms.For Keijzer 9 , there is a similarity to the idea of multiple forms of masculinity; the most appropriate manner to discuss paternity is to refer to 'paternities' in the plural because it exists in several forms and there is no universally given approach to the issue.Keijzer also recommends that reflections about paternity should focus not only on men's involvement in the process but also on the possibility of men deriving enjoyment from factors such as pregnancy, childbirth and more democratic and equitable relationships in the domestic sphere.However, Keijzer also draws attention to the need to articulate issues such as reproduction and paternity because this constitutes the main, or only, way for men to participate in reproduction.
In terms of health policies, the theme in question has been considered of great importance in Brazil.For example, the National Policy for In-tegral Attention to Men's Health (PNAISH) 10 explains the need to value paternity as an important aspect in the promotion of men's sexual and reproductive health, without, however, defining paternity or indicating ways to promote it.The Stork Network strategy 11 , which prioritizes the health care of women, targets the improvement of prenatal, birth and postpartum care.It also mentions the sexual and reproductive rights of men and women and refers to the father's presence at such times.However, it does not define or provide guidelines for the promotion of paternity; the father's role in this context is still considered to be in relation to the promotion of the health of the mother and baby.
In her reflection on the uncertainty or the plurality of paternity, Fonseca notes that there is currently a questioning of the basic principles of procreation, the exclusivity of heterosexual couples, the inevitable sequence of generations, and the sexual complementarity of parents 12 .According to Fonseca, these aspects go beyond the field of biology and impact on areas connected with the legal system, bioethics, health, social sciences and the humanities.But have these new possibilities linked with paternity and family arrangements been perceived and addressed by the health system?
Together with these aspects, we would raise other questions such as whether perceptions of paternity have taken into account the most recent discussions on gender, which encourage us to consider the erasure of certainties and boundaries between sex and gender.How can we understand paternity and parenting not as being simply reduced to an instrumental role in health actions, but as spaces of pleasure and the redesigning of identities?These and other questions lead to the need to not only discuss paternity (or maternity) but to also explore the dimensions of parenting as a concept.
Barreto 13 uses the theoretical references of Erick Erikson to argue that parenting is a powerful strategy to care for someone (a child or someone else), which contributes to the future of society.In other words, from the theoretical perspective of Erikson's psychology, adapted by Barreto, the concept of parenting is linked to generativity i.e. the possibility of linking individuals to social reproduction and future generations.These perspectives were developed in the 1950s, and they referred to the idea of a productive society and parenting that would sustain the bourgeois nuclear family.However, the commitments or developments of this definition end up naturalizing a vision of happiness or productive satisfaction that is closely related to the generation of parental care, and it is this aspect that we wish to question because adopting this theoretical perspective means foregoing reflection and criticism of the power hierarchies involved in expectations about the roles of men and women in society.According to Erikson's theory, parenting does not dialogue with gender roles and thus this psychological categorization of human beings loses the structural specificities between men and women; the differences and requirements that fall upon them.
As Corsaro 14 argues , the fact that this definition of parenting does not highlight the difference between genders ultimately generates a supposed horizontality between parental care and what is expected of men and women in child care, thereby hiding the fact that when we talk about hegemonic femininity the expectation of motherhood still dominates, which does not correspond to what happens in relation to hegemonic masculinity.In short, paternity is not so directly connected to the field of male performance as maternity connects women to reproductive events and childcare.
Starting from all these initial considerations, this study aims to discuss paternity as a health issue in relation to contemporary gender roles by considering the following two lines of argument: (a) paternity, parenting and rearrangements of gender roles; (b) paternity and parenting as as a mutual relationship based on care.
For this, we use a theoretical essay as our methodological approach, which is understood in this context as a critical, exploratory search related to a subject or object of meditation, seeking a new way of approaching it 15 .According to Meneghetti, using this approach means that, unlike the division and logic advocated by traditional scientific methodologies, guidance is given not by the search for true answers and statements, but by questions that guide individuals towards deeper reflections 16 .
Using this approach, and our professional experience, we used specific literature to anchor our reflections about an issue that still demands greater theoretical and conceptual attention.

Paternity, parenting and rearrangements of gender roles
In their study of pregnancy, Freitas et al. 17 point out that "men and women go from being simply sons and daughters to become fathers and mothers, both experiencing this transition with expectations, desires and fears.Men also suffer the impact of changing roles" 17 .Fundamental to this claim, although it is not conceptualized, is that it is a perspective that recognizes the role of men in childcare.In addition, according to the aforementioned authors so-called fathering and mothering deserve to be understood as constructions of shared responsibilities within the man-woman dyad.We would add that this responsibility also falls within the scope of homoaffective relationships.
Paternity has long been conceived as fundamental to a certain idea of masculinity i.e. married and heterosexual because the masculinity of single men can be based on a lack of responsibility, sexual freedom and access to several women.On the other hand, the masculinity of homosexuals is still not entirely socially legitimate.Thus, marriage (heterosexual and monogamous) recreates the notion of hegemonic masculinity -which has heterosexuality as its main marker -by incorporating paternity, with its attendant responsibilities, and turns heterosexual sexual orientation into an attribute of paternity 18 .In the same way that male sterility is associated with impotence, having a child appears to confirm heterosexual virility.However, paternity is not understood as simply being the ability to "make babies", it is also related to the ability to support and educate children.These attributes mean that men's paid work is a fundamental reference in the conceptions of paternity and masculinity, especially in the hegemonic concept.Consequently, if "making babies" can be used to prove the physical attribute of paternity, being able to support and educate children proves moral attributes 19 .But we would also argue that the concept of paternity has changed, or been associated with other attributes, throughout the history of contemporary Western societies.From the 1970s onwards, factors such as the rise of new industrial and economic models, the consolidation of the feminist movement, the questioning of gender inequalities, the advancement of contraceptive methods, and the massive entry of women into the labor market have all made evident the need for fathers to be more involved with their children 19 , as well as the fact that many women no longer dedicate themselves exclusively to their home and family 20,21 .However, we are still talking about a heterosexual father who is a member of a nuclear family.
It is worth remembering that the importance given to the nuclear family consisting of father, mother and children, and the offspring that derive from heterosexual couples has a historical basis and is founded on an "irreducible biological reality until the present day: a man and a woman are required to produce a child" 22 .In the opinion of Zambrano 22 , for this family model to be socially in accordance with biology it became the legitimate and "natural" space for sexuality and procreation, imposing itself as an indisputable truth and overshadowing the idea that it was a fairly recent construction.Similarly, this is not a universal model and there are many different possibilities for family arrangements.The naturalization of the traditional family model brings with it the commonly accepted belief that a child can only have one father and one mother, who are responsible for the biological make-up, filiation and care of that child.It is a relationship that seems so natural that we are often not aware that it reflects a social order derived from nature.
With regards to filiation, this model still suffers from a strong religious influence and the boundaries of the legal system, as well as the impact of psychoanalysis, which emphasizes the fundamental importance in the formation of subjectivity and humanization of children of the presence of a father/man and a mother/woman.This is because of the so-called Oedipus complex, a psychic process that requires the presence of both sexes and obedience to the "name of the father", as Lacan defined it, to deal with the construction of human individuals and their entry into the "symbolic order ".
For a deeper discussion of this issue, it is important to bear in mind that adult-child relationships involve at least four dimensions, which are not necessarily concomitant and can be combined in various ways: 1) the biological bond, which is given by conception and genetic origin; 2) the bond of kinship, which links two individuals in relation to a genealogy, determining their belonging to a group; 3) filiation, or the legal recognition of belonging according to the social laws of the group in question; 4) parenthood, the exercise of parental function, implying care regarding food, clothing, education, health, etc., which are woven into daily life around kinship 22 .
Using this concept it is easier to think of homoparental families who do not have procreative possibilities within the couple.Parenting by transvestites and transsexuals cannot be conceptualized as homoparental because the term "homoparenthood" only refers to sexual orientation, "alluding to those whose sexual desire is oriented to others of the same sex, which excludes people who have changed sex (transsexuals) and gender (transvestites)" 22 .Zambrano 22 outlines four main forms of homoparental upbringing: care of children born in a previous heterosexual relationship; by legal or informal adoption; through new reproductive technologies that allow the birth of biological children; and by co-parenting in which childcare is jointly and equally exercised by the partners.
In recent years, some commentators have questioned the naturalization of the traditional family formation.For example, within her discussions about gender, Butler 23,24 raises important questions about family, kinship and homoparenthood.Butler also continued this theme in an article 24 about the debates that occurred in France and the United States at the end of the last century regarding the legitimization or otherwise of gay marriage by the State.Such discussions had as their backdrop the question of the symbolic order mentioned above, as well as issues related to political and social rights.
With respect to the last two issues, Butler considers that discussions about this legitimacy are based on a type of arrangement that, even if it not yet considered legitimate, belongs to a group who could claim its legitimacy, i.e. samesex marriage.This occurred because it was a sexual practice that was considered to be coherent in legitimizing the lexicon that was available at that time.The problem is that such a definition excluded other sexual possibilities and desires "that do not appear immediately to be coherent in the available lexicon of legitimization" 24 .Thus, there are individuals who densely populate an area that is not socially recognized, an area that is "empty" of social life because their sexuality and/ or desires do not match that imperative 23 .It was, at that time, a political choice which, on the one hand brought these couples legitimacy conferred by the State, and on the other hand excluded a range of other possibilities of sexual practices and desires.
By bringing the contributions of Zambrano 22 and Butler 24 into our discussion, we would argue that the fact that the health system considers the inclusion of a father as necessary to provide care for a mother and child means that the traditional idea of paternity within the limits of heteronormativity, or heterosexual imperative as defined by Butler 23 , still prevails, as does the nuclear family.Or, at least within the possibilities of the lexicon of legitimacy, even with its limitations: gay couples that have been legitimized by the Brazil-ian State and recognized by the Unified Health System (SUS).
For example, the issue of sexual diversity is set out in the PNAISH 10 , where it is treated as an issue related to sexual and reproductive health and parenthood, stressing that the rights of all citizens must be assured and that the plurality of sexual experiences should be respected.Such an approach can also be noticed in some health strategies concerned with broader ideas of paternity, such as the "Partner of the Father Health Unit Guide" produced by the Municipal Health Secretary of Rio de Janeiro 25 , which outlines the rights of homosexual fathers.Nevertheless, considering that homoparenthood is accepted by the health system, there are many experiences of sexuality and desire that cannot be understood as "easily", which are ignored or made invisible, thereby depriving those individuals of the exercise of parental function within the sphere of care-giving.As Butler 24 argues, failing to address the implications of the non-recognition of civil unions for homosexuals can result in such couples feeling a sense of "illegitimacy".The process of "deleting" such relationships can make life, and maintaining parental bonds, much harder: "after all it is not real; it is a bond that does not "exist", which was never intended to exist" 24 .
Yet if the incorporation of these individuals within the health service is closely related to the promotion of childcare and women's health, as noted by some 25,26 , its removal would lead to the opposite.Thus, in the case of care arrangements there would be no reason to deny the desire to exercise paternity, in fact the opposite would be the case.But are these sufficient reasons to accept it?What is the "role of the father" that public services recognize as legitimate?What if a lesbian is recognized as a parent and does things that are considered in Brazil to be under the remit of the "role of the father", such as wanting to accompany their child on visits to the pediatrician?And what if a transsexual wishes to do the same?Will these desires and these roles related to paternity be accepted, respected and welcomed?There are many questions related to these issues; the intention of this essay is not to answer them, but to raise them.
We believe that in order to advance the discussions on parenting it is necessary to follow the example of Butler 24 and look at advances in a critical manner, questioning whether certain advances are possible, what else could be done, who is excluded and who is included regarding the way that the issue of paternity is viewed within the health system.
Returning to the specialist literature on this issue, Sarti 27 makes the point that looking at families as a unit can compromise one's view of the world of relationships 27 .This proposition does not highlight an a priori definition of the family, but it is rather a notion that is native and rooted in the practices of the actors within the family.This discussion can support a shift in the concept of paternity, making it possible to discuss it as a function that can be attributed relationally to an element that constitutes a couple, whether male or female.
Changes related to the family and social environment, which have an impact on the construction of parenting and the role of the father, should be valued 28 .A father could be recognized as someone who reconciles models of femininity and masculinity, as constitutive attributes of human care 29 .According to these authors, a socalled "reconciled man" would be the result of such a large paternal revolution.
Marsiglia 30 and Sarti 27 note that when the family becomes a prime target of service policies there is a supposed displacement and a review of trends in healthcare, which gives priority to the individual as the natural unit of attention.However, when looking at the family as a unit one loses the idea of it being a space for parental relationships and care in which stimulus can be provided to revise traditional roles regarding gender and childcare.In other words, it is important to think about the extent to which health institutions and the professional health culture are prepared to incorporate the idea of a family which is understood as a network of connections that is made in the relationships between men and women and their various combinations.
In this sense it is worthwhile to define parenting as being focused on childcare practices, highlighting parental skills and competence 31 .Parenthood appears as a transversal concept in the construction of the responsibilities of men and women, combinations thereof, and family arrangements.Its functions are directed to produce facilitating effects of development, autonomy and a sense of security for children.In this sense, there is a dialogue between generations and the reproduction of social mechanisms in order to ensure generativity 31 .In other words, the generation of parents preparing the second generation, i.e. that of their children.So-called "sufficient" parenting is built upon cultural references, context, and socialization objectives.The ecological model is central in order to contextualize beliefs and cultural heritages in parental relationships.
From the review undertaken by the authors, it is possible to reflect on commitments to the centrality of childcare.With the predominance of universes that do not incorporate homoaffective relationships and non-biological children, among other contemporary realities, it is worth considering these interactions.
When discussing parenting it is necessary, in criticizing and updating the concept, to incorporate a discussion of gender.Here we would refer to Costa 18 , for whom gender, as a category of differentiation, refers to men and women but also to objects, behaviors and events.In other words, this category can also include events such as the generation of a family network, as well as providing care and education for children, where adults are a reference and provide parenting functions at home.In this sense, in the contemporary scenario it is necessary to review polarities and to incorporate flexibility, changeability and contradictions in the roles of men and women, thereby incorporating diversity in the forms and meanings of participation in parenting 32 .
As previously stated, there are many questions that indicate the need for a greater discussion of parenting, shifting and renewing the axes of maternity and paternity, given that this is a necessary perspective in terms of the field of public policy and the integration of health care for men, women, children and adolescents.This integration is built on a dialogue between parenting, which is a concept that needs to be renovated and located within the socio-anthropological environment through a critical and situated perspective, and the idea that families are not only built up through blood ties but are the result of many multifaceted combinations.

Paternity and parenting as a mutual relationship based on care
In order to promote paternity, it is necessary to be clear about what is to be a father.The literature on the subject has indicated the emergence of idealizations of a "new" type of father in the light of social change.Accordingly, in addition to providing for the family, a father is now expected to provide childcare that is more flexible, affectionate and equal in conjunction with their partner 28,33 .
In the area of health, new strategies linked with the health of women and children have been focusing on the notion of father/caregiver as a partner in promoting the health of this dyad.However, it is known that health care is not something that is generally part of the repertoire of male concerns.Similarly, care for others is also not something inscribed within men's concerns, or at least not in the perspective that has been proposed.The denial of fear, exposure to risk, and silence in the face of physical and emotional pain are all considered to be traits of hegemonic masculinity, which should be valued, as opposed to hegemonic female fragility and emotionality.Such beliefs and values have been seen as important evidence of the lack of male demand for primary health care services, and for high mortality and morbidity rates, either from preventable diseases or by involvement in violent situations 10,34,35 .This is linked to the need for health care strategies designed specifically for men within the SUS, especially in primary care.This type of care cannot be separated from gender issues because the conceptions of what it is to be female and male overlap, not only in personal relationships, but in all social relations, including institutional ones.Furthermore, these strategies should not only take into account gender issues.International studies [36][37][38] have underlined the need to link gender issues with other aspects such as age groups, race/ ethnicity, socioeconomic status and cultural models in general.
With regard to reproductive health, international studies 36,39 have drawn attention to the need for strategies, such as family planning campaigns, to also target men.Although this area might traditionally be considered as a female space, women do not have total control of decisions related to contraception; men also have a strong influence on these issues.
In the case of Brazil, it is important to note that awareness about care does not only refer to men, but also to health professionals who frequently do not realize the presence of men in basic health units or who ignore and forbid the participation of fathers in prenatal care, delivery, and pediatric visits, often preventing their presence at these moments [33][34][35][40][41][42][43] . The chllenge is to also raise awareness and prepare health teams -including all workers in the health units -to recognize, receive, accept and care for men in all their many needs, thereby reducing the gap between the good intentions of the PNAISH and what men still encounter (or fail to encounter) in basic health units 42,[44][45][46] .
In the health field, or in other areas, it is important to share the idea that strategies should be flexible, adapting to different contexts and to dif-ferent situations.As with other positions of identity, becoming a father is a continual, plural and open process, which involves tensions between the individual and culture 33 .One of the ways to match strategies to the dialectic of life is through an understanding of everyday life, where the experiential dimension occurs.Thus, the experiences of men who (either through desire or contingency) become parents can provide a greater understanding of the cultural meanings of paternity, as well as the individual meanings assigned to it.In part, these experiences are influenced by other experiences that were previously constructed, which Schutz 47,48 refers to as biographical situations (the sedimentation of previous experiences).In other words, being a father can arise from reproduction or through a reframing of the experience of being a son.However, neither previous experiences nor contemporary ones are simply the products of the individual experiences of these actors.As Schutz 48 notes, daily life is a cultural and inter-subjective world because it is made up of a universe of cultural meanings and because people live in a world of personal interrelationships.
In the inter-subjectively constructed world, it may be that rather than promoting paternity or maternity, advances might be made by promoting parenting.In this case, according to Schutz, in the same way that inter-subjectivity is not simply the sum of individual subjective expressions but resides in the unforeseen and unexpected elements that appear in human encounters, parenting is not limited to the expression of maternity or paternity, or the roles expected of mothers and fathers.Parenting is the expression of the encounters that bring together the many combinations between men and women in the formation of family networks, and it is not restricted to the nuclear, blood-linked, heteronormative model.The inter-subjective dimension refers to encounters that may lead to the construction of social bonds.
When referring to the idea of the construction of social bonds, it is necessary to mention Marcel Mauss 49 and his Gift theory, which states that relationships are not merely constructed of economic and material elements, or utilititarian and instrumental interests.Symbols, words, feelings, expressions and gestures circulate, which can result in circular signifiers that promote health.These signifiers guarantee rights, but they also mark and reinforce prejudices and rigid hierarchies that are based on parental relationships and functions.We would argue that parental relationships need to guarantee safety and the possibility of exchange between care functions.Consequently, when maternity and paternity are reduced to elements of supporting social reproduction, with specific reference to a man and a woman and without considering gender inequalities, then the possibilities of parenting are limited.Parental care must embrace symbolic elements that address the inequalities and hierarchies related to gender, which, within the numerous combinations of family networks, protect expressions of parenting that are based on the exchange of care, promoting life and the expression of differences.
If we focus on the specifics of men's health, we cannot simply focus on the involvement of men in an instrumental manner, helping to ensure the health of the woman/mother and child.Nor can this simply be reduced to persuading men to have routine health tests.We need to go beyond these two foci, ensuring actions that can contribute to the preparation of parenting.In other words, it is necessary to create opportunities for actions that do not only create links between adults and children, but that also create or rebuild identities that are articulated towards self-realization.
In this sense, exchange occurs within the following triads: (1) gender/social class/race-ethnicity; (2) materiality/idealization/change; (3) mother/father/son; (4) caring for oneself/ caring for others/ being cared for and (5) bonds/ autonomy/pleasure.Numerous and complex challenges exist, both in the promotion and the experience of these exchanges.For those reasons, we advocate a project that is both individual and institutional in nature.In that way health actions can be planned with input from not only health professionals but also from all of those to whom these actions are directed.

final considerations
In keeping with the rest of this paper, our final considerations are much more starting points for further discussion than words to end this discussion.Thus, we do not intend to respond to the questions raised during our paper.Our reflection is a response to the challenges that present themselves to us as health professionals who deal with gender issues and who observe little progress in the discussion of paternity and parenting in the field of health.
To move forward, and to deepen the discussion of this issue, we would stress the need to listen more and to look more at the experiential dimension of individuals, whether they are men, women, service users or professionals.It is also important to reject the reification of existing models and the static nature of identities.To achieve this it may be better to envision the relativization or the erasure of boundaries between sex and gender, men and women, masculine and feminine, and father and mother.
It is not enough to simply consider differences based on class, ethnicities/races, education levels, location, age, among other factors; it is also necessary to relativize heteronormativity in order to understand other types of parenting arrangements.
All of the literature that we have referred to brings us to the need to reinvent ourselves because we were not raised under the aegis of diversity and we were not trained as professionals with a basis in the current problematic divisions that exist between father/mother, sex/gender, among many other previous certainties, all of which does not always help us promote actions in the area of health.

Collaborations
CR Ribeiro, R Gomes and MCN Moreira shared the writing and critical review.They also approved the final version of the article.R Gomes was responsible for the methodological design and analytical orientation.