Ana Flávia Pires Lucas d'Oliveira

Violence against women in health-care institutions: an emerging problem

Maternal morbidity and mortality in childbirth is a matter of utmost importance in public health. In this article, we argue that part of the problem lies in violence committed by health workers in childbearing or abortion services, which affects health-service access, compliance, quality, and effectiveness. We analysed rigorous research from the past decade and discuss four forms of violent abuse by doctors and nurses: neglect and verbal, physical, and sexual abuse. These forms of violence recur, are often deliberate, are a serious violation of human rights, and are related to poor quality and effectiveness of health-care services. This abuse is a means of controlling patients that is learnt during training and reinforced in health facilities. Abuse occurs mainly in situations in which the legitimacy of health services is questionable or can be the result of prejudice against certain population groups. We discuss ways to prevent violent abuse.

The health-systems response to violence against women

Health systems have a crucial role in a multisector response to violence against women. Some countries have guidelines or protocols articulating this role and health-care workers are trained in some settings, but generally system development and implementation have been slow to progress. Substantial system and behavioural barriers exist, especially in low-income and middle-income countries. Violence against women was identified as a health priority in 2013 guidelines published by WHO and the 67th World Health Assembly resolution on strengthening the role of the health system in addressing violence, particularly against women and girls. In this Series paper, we review the evidence for clinical interventions and discuss components of a comprehensive health-system approach that helps health-care providers to identify and support women subjected to intimate partner or sexual violence. Five country case studies show the diversity of contexts and pathways for development of a health system response to violence against women. Although additional research is needed, strengthening of health systems can enable providers to address violence against women, including protocols, capacity building, effective coordination between agencies, and referral networks.

Violence against women by their intimate partner and common mental disorders.

The World Health Organization considers gender violence a cause of anxiety, depression and suicidal thoughts among women. This study investigated the association between violence committed against women by their intimate partners, defined by psychologically, physically and sexually abusive acts, and common mental disorders, assessed by using the Self Reporting Questionnaire (SRQ-20). A population-based household survey was carried out among women aged 15-49 years in two sites: São Paulo, the largest Brazilian city, and Zona da Mata of Pernambuco, a region with both urban and rural areas in the Northeast of the country. A large proportion of women reported violence (50.7%). The most frequent forms were psychological violence alone (18.8%) or accompanied by physical violence (16.0%). The prevalence of mental disorders was 49.0% among women who reported any type of violence and 19.6% among those who did not report violence (p<0.0001). After adjustment for demographic and socioeconomic characteristics, the nature of the relationship, stressful life events and social support, all the forms of violence studied, with the exception of sexual violence alone or accompanied by either physical or psychological violence (p=0.09), were significantly associated with mental disorders: physical violence alone (OR1.91; CI 95%1.2-3.0), psychological violence alone (OR 2.00; CI 95% 1.5-2.6), sexual violence alone or accompanied by either physical or psychological violence (OR1.80; CI95% 0.9-3.6), both psychological and physical violence (OR 2.56; CI 95% 1.9-3.5) and all three forms of violence (OR 2.68; CI 95% 1.8-4.0). This is the first population-based study on the association between intimate partner violence and mental health in Brazil. It contributes to the existing body of research and confirms that violence, frequently experienced by women in the country, is associated with mental disorders. Policies and strategies aimed at reducing gender-based violence are necessary for preventing and reducing anxiety and depression among women.

Violência e saúde: estudos científicos recentes

An outline and critical analysis of scientific studies on Violence and Health is presented. On the basis of a non-exhaustive review, the construction of violence as a national and international field of knowledge and intervention is broached. Outbreaks of violence are shown to occupy a broad domain of social life that reaches practically everyone, in situations of both war and supposed peace. The unity of violence as an ethical-political question is highlighted and its extreme diversity as concrete situations for study and intervention is demonstrated. Through situating violence as related to collective, interpersonal and self-reported individual dimensions, and taking it to be intentional acts of physical force or power, resulting in physical, sexual or psychological abuse, and in negligence or deprivation, the studies examined mostly demonstrate a concern to respond to the widespread sense that violence is invisible, naturalized and inevitable. In order to do it, the studies show the high magnitude of violence, and the possibilities for controlling violence and attending to the multiplicity of harm to health. The initial approaches flow from a theoretical-methodological point of view related to social inequalities, family maladjustment, gender inequalities and, less frequently, race or ethnic inequalities. These imply reconstruction of the classical concepts of family, generation and social class. In conclusion, this problem is considered to be interdisciplinary and, returning to the notion of social-medical matters within Social Medicine, updating of this notion is recommended for topics that are as complex and sensitive as violence.

Fatores associados à violência por parceiro íntimo em mulheres brasileiras

OBJETIVO: Estimar a prevalencia e os fatores associados a violencia fisica e/ou sexual por parceiro intimo em diferentes contextos socioculturais. METODOS: Estudo transversal, participante do WHO Multi-country Study on Womens Health and Domestic Violence against women, com amostra representativa de mulheres no municipio de Sao Paulo e Zona da Mata de Pernambuco, regiao com normas mais tradicionais de genero. Foram entrevistadas no domicilio 940 mulheres de Sao Paulo e 1.188 da Zona da Mata, entre 2000-1, com idade entre 15 a 49 anos que tiveram parceria afetivo-sexual com homens alguma vez na vida. Foram construidos tres conjuntos de fatores, correspondentes a blocos hierarquicamente ordenados: caracteristicas sociodemograficas, familiares e aspectos referentes a autonomia/submissao feminina. Utilizou-se regressao logistica hierarquica na analise dos fatores associados a violencia por parceiro intimo em cada local. RESULTADOS: Encontrou-se prevalencia de 28,9% em Sao Paulo (IC 95% 26,0;31,8) e 36,9% (IC 95% 34,1;39,6) na Zona da Mata. Escolaridade ate oito anos, violencia fisica conjugal entre os pais da mulher, abuso sexual na infância, cinco ou mais gestacoes e problemas com a bebida mostraram-se associados a violencia por parceiro intimo em ambos locais. Autonomia financeira da mulher, uniao informal, idade e consentimento na primeira relacao sexual mostraram-se associadas a maiores taxas apenas na Zona da Mata. As caracteristicas socioeconomicas associadas no primeiro bloco foram mediadas por outros fatores no modelo final. CONCLUSOES: Os achados mostram a relativizacao dos fatores socioeconomicos diante de outros, em especial os representantes de atributos de genero. Nas duas localidades estudadas foram encontradas diferencas socioculturais que se refletiram nos fatores associados.

Violência contra mulheres entre usuárias de serviços públicos de saúde da Grande São Paulo

OBJECTIVE To estimate the prevalence of (physical, psychological, and sexual) violence against women by an intimate partner and non-partner perpetrators among users of public health services and to compare these womens perception of having ever experienced violence with reports of violence in their medical records in the different services studied. METHODS The study was conducted in 19 health services, selected as a convenience sample and grouped into nine research sites, in metropolitan area of São Paulo from 2001 to 2002. Questionnaires on having ever experienced violence in their lifetime and in the last 12 months and perpetrators were applied to a sample of 3,193 users aged 15 to 49. A total of 3,051 medical records were reviewed to verify the notification of violence. Comparative analyses were performed by Anova with multiple comparisons and Chi-square test followed by its partition. RESULTS The following prevalences were found: any type of violence 76% (95% CI: 74.2; 77.8); psychological 68.9% (95% CI: 66.4; 71.4); physical 49.6% (95% CI: 47.7; 51.4); physical and/or sexual 54.8% (95% CI: 53.1; 56.6), and sexual 26% (95% CI: 24.4; 28.0). The prevalence of physical and/or sexual violence by an intimate partner in their lifetime was 45.3% (95% CI: 43.5; 47.1), and by non-partners was 25.7% (95% CI: 25.0; 26.5). Only 39.1% of women reporting any episode of violence perceived they had ever experienced violence in their lifetime and 3.8% of them had any reports of violence in their medical records. The prevalences were significantly different between sites as well as the proportion of perception and reports of violence in medical records. CONCLUSIONS The expected high magnitude of the event and its invisibility was confirmed by low rate of reports in the medical records. Few perceived abuses as violence. Further studies are recommended taking into account the diversity of service users.

Cobertura e motivos para a realização ou não do teste de Papanicolaou no Município de São Paulo

Investigou-se a prevalencia da realizacao do teste de Papanicolaou alguma vez na vida e nos ultimos tres anos entre mulheres de 15 a 49 anos, o recebimento do resultado do ultimo teste realizado e os motivos relatados para a realizacao ou nao do exame. Um inquerito domiciliar foi realizado no Municipio de Sao Paulo em 2000, com uma amostra representativa de 1.172 mulheres selecionadas aleatoriamente em seus domicilios. Das mulheres que ja tinham iniciado a vida sexual (n = 1.050), 86,1% (932) realizaram o teste alguma vez na vida e 77,3 % (839) nos ultimos tres anos. Das que ja realizaram o teste, 806 (87,0%) receberam o resultado do ultimo exame. Os principais motivos para a realizacao do ultimo teste foram: demanda espontânea (55,5%), recomendacao medica (25%) e presenca de queixas ginecologicas (18,2%). As principais razoes para a nao realizacao do exame foram: ausencia de problemas ginecologicos, vergonha ou medo e dificuldades de acesso. A despeito do relativo aumento na cobertura do teste de Papanicolaou e de mais da metade das mulheres demandarem espontaneamente pelo exame, sua realizacao foi menor entre aquelas com as piores condicoes socio-economicas e, portanto, de maior risco para o câncer cervical.This study estimated Pap smear coverage (at least one test in the lifetime and one in the last three years) among women aged 15 to 49 years old. The study also discusses whether the women received the results of their last test, as well as self-reported reasons for and against submitting to the test. A population-based survey was conducted in the city of Sao Paulo in 2000 with a randomly selected representative sample of 1,172 women. Among the women who were already sexually active (n = 1,050), 86.1% reported having had at least one Pap smear during their lifetime, and 77.3% had undergone the test in the previous 3 years. Among those who reported having had at least one Pap smear, 87.0% had received the result of the last test. The main reasons reported for having had the last test were: spontaneous demand (55.5%), medical referral (25%), and gynecological complaints (18.2%). The main reasons for never having had a Pap test were: no gynecological problems, embarrassment or fear, and difficulties in accessing health services. Despite high coverage of the Pap test and the fact that the majority of the women had self-reported a spontaneous demand, use of the Pap test was less prevalent among women with the lowest socioeconomic level (and consequently at greater risk of cervical cancer).This study estimated Pap smear coverage (at least one test in the lifetime and one in the last three years) among women aged 15 to 49 years old. The study also discusses whether the women received the results of their last test, as well as self-reported reasons for and against submitting to the test. A population-based survey was conducted in the city of Sao Paulo in 2000 with a randomly selected representative sample of 1,172 women. Among the women who were already sexually active (n = 1,050), 86.1% reported having had at least one Pap smear during their lifetime, and 77.3% had undergone the test in the previous 3 years. Among those who reported having had at least one Pap smear, 87.0% had received the result of the last test. The main reasons reported for having had the last test were: spontaneous demand (55.5%), medical referral (25%), and gynecological complaints (18.2%). The main reasons for never having had a Pap test were: no gynecological problems, embarrassment or fear, and difficulties in accessing health services. Despite high coverage of the Pap test and the fact that the majority of the women had self-reported a spontaneous demand, use of the Pap test was less prevalent among women with the lowest socioeconomic level (and consequently at greater risk of cervical cancer).

Validade do instrumento WHO VAW STUDY para estimar violência de gênero contra a mulher

OBJECTIVE To validate the instrument of the World Health Organization Violence Against Women (WHO VAW) study on psychological, physical and sexual violence against women perpetrated by intimate partners. METHODS This was a cross-sectional study conducted in several countries between 2000 and 2003, including Brazil. Representative random samples of women aged 15-49 years with intimate partners were selected, living in the city of São Paulo (n = 940) and in the Zona da Mata, Pernambuco (n = 1,188), southeastern and northeastern regions, respectively. Exploratory factor analysis on questions relating to violence was performed (four psychological, six physical and three sexual questions), with varimax rotation and creation of three factors. Cronbachs alpha was calculated to analyze the internal consistency. To validate through extreme groups, mean scores (0 to 13 points) for violence were tested in relation to the following outcomes: self-rated health, daily activities, presence of discomfort or pain, suicidal ideation or attempts, heavy alcohol consumption and presence of common mental disorders. RESULTS Three factors were defined, with similar accumulated variance (0.6092 in São Paulo and 0.6350 in the Zona da Mata). For São Paulo, the first factor was determined by physical violence, the second by sexual violence and the third by psychological violence. For the Zona da Mata, the first factor was formed by psychological violence, the second by physical violence and the third by sexual violence. Cronbachs alpha coefficients were 0.88 in São Paulo and 0.89 in the Zona da Mata. The mean scores for violence were significantly higher for less favorable outcomes, with the exception of suicide attempts in São Paulo. CONCLUSIONS The instrument was shown to be adequate for estimating gender-based violence against women perpetrated by intimate partners and can be used in studies on this subject. It has high internal consistency and a capacity to discriminate between different forms of violence (psychological, physical and sexual) perpetrated in different social contexts. The instrument also characterizes the female victim and her relationship with the aggressor, thereby facilitating gender analysis.OBJETIVO: Validar preguntas sobre violencia psicologica, fisica y sexual por parejas intimas contra mujeres. METODOS: Estudio transversal, coordinado por la Organizacion Mundial de la Salud, realizado en varios paises (2000-2003), inclusive Brasil. Se seleccionaron muestras aleatorias y representativas de mujeres de 15-49 anos con parejas intimas, residentes, en la ciudad de Sao Paulo (en Sureste de Brasil, n=940) y en la Zona de Mata de Pernambuco (en Noreste de Brasil, n=1188). Se realizo analisis factorial exploratorio de las preguntas sobre violencias (cuatro psicologicas, seis fisicas y tres sexuales), con rotacion varimax y elaboracion de tres factores. Se calculo alfa de Cronbach para analisis de la consistencia interna. Para la validacion por grupos extremos, promedios de escores (cero a 13 puntos) de violencia fueron evaluadas con relacion a los resultados: auto-evaluacion de salud, actividades diarias, presencia de dolor o incomodidad, concepcion de idea e intento de suicidio, grande consumo de alcohol y presencia de trastorno mental comun. RESULTADOS: Fueron definidos tres factores con varianza acumulada semejante (0,6092 en Sao Paulo y 0,6350 en la Zona de Mata). Para Sao Paulo, el primer factor fue determinado por la violencia fisica, el segundo por la sexual y el tercero por la psicologica. Para la Zona de Mata, el primer factor estuvo compuesto por la violencia psicologica, el segundo por la fisica y el tercero por la sexual. Coeficientes de alfa de Cronbach fueron 0,88 en Sao Paulo y 0,89 en la Zona de Mata. Los promedios de los escores de violencia fueron significativamente mayores para resultados menos favorables, excepto intento de suicidio en Sao Paulo. CONCLUSIONES: El instrumento se mostro adecuado para estimar la violencia de genero contra la mujer perpetrada por su pareja intima y puede ser utilizado en estudios sobre el tema. El mismo tiene alta consistencia interna y capacidad de discriminar las formas de violencia psicologica, fisica y sexual, perpetrada en contextos sociales diversos. El instrumento tambien caracteriza a la mujer agredida y su relacion con el agresor, facilitando analisis de genero.

Violência vivida: a dor que não tem nome

E dificil o relato de violencia sofrida por mulheres. Trata-se da invisibilidade da violencia que afeta as relacoes usuarias - profissionais, criando impasses comunicacionais. Buscou-se caracterizar este silencio, estudando usuarias de atencao primaria na rede publica de Sao Paulo, quanto a prevalencia de violencia, a percepcao de ter sofrido violencia, a definicao de violencia em geral e a nomeacao dada por quem a experimentou. Entrevistaram-se 322 usuarias de 15 a 49 anos, sobre agressoes fisica, sexual e/ou psicologica, o agressor, e a percepcao de ter sofrido violencia, solicitando-se o relato de um episodio marcante, o nome que daria a este e a definicao de violencia em geral. Das entrevistadas, 69,6% referiram alguma agressao fisica, psicologica ou sexual e, destas, 63,4% nao consideraram haver sofrido violencia na vida; 64,3% relataram algum episodio marcante e 46,5% atribuiram um nome ao vivido. A definicao de violencia mais comum foi a de agressao fisica (78,8%), seguida pela psicologica (39,7%) e sexual (24,2%). Conclui-se que a maioria das mulheres que referiu alguma agressao nao considerou haver sofrido violencia na vida. Houve grande dificuldade em contar episodios e nomea-los, e apesar de a maioria desses episodios serem do âmbito domestico, na definicao de violencia esta referencia nao aparece. Palavras-chave: Comunicacao; violencia; invisibilidade da violencia; violencia domestica; mulheres maltratadas. ABSTRACT The account of the violence that women undergo is a difficult one. One is dealing with the invisibility of violence affecting users of care services and professionals, which gives rise to communication impasses. The authors attempted to characterize this silence by studying users of primary care in the Sao Paulo public network as regards the prevalence of violence, the perception of having suffered violence, the definition of violence in general and the designation given by the person who experienced violence. 322 users aged 15 to 49 were interviewed concerning physical, sexual and/or psychological aggression, the aggressor, and the perception of having suffered violence. The interviewees were asked to tell the interviewer about a striking episode, as well as what they would call it and what their definition of violence would be. 69.6% of the interviewees referred to some physical, psychological or sexual aggression; of these, 63.4%% did not consider that they had undergone violence in life; 64.3% told of some striking episode and 46.5% of them gave a name to the experience. The most common definition of violence was physical aggression (78.8%), followed by psychological aggression (39.7%) and sexual aggression (24.2%). One concludes that most women that referred to some aggression did not consider that they had suffered violence in life. They had great difficulty in narrating their episodes and giving them names and, even though most of these episodes had taken place within the domestic sphere, in the definition of violence this reference was omitted. Key words: Communication; violence; invisibility of violence; domestic violence; violence against women. RESUMEN Es dificil el relato de violencia sufrida por mujeres. Se trata de la invisibilidad de la violencia que afecta las relaciones usuarias - profesionales, creando impasses comunicacionales. Se trato de caracterizar este silencio, estudiando usuarias de atencion primaria en la red publica de Sao Paulo, respecto a predominancia de violencia, a percepcion de haber sufrido violencia, a definicion de violencia en general y al nombre dado por quien la sufrio. Se entrevistaron 322 usuarias de 15 a 49 anos, sobre agresiones fisica, sexual y/o psicologica, el agresor y la percepcion de haber sufrido violencia, solicitando el relato de un episodio marcante, el nombre que daria a este y la definicion de violencia en general. De las entrevistadas, 69,6% refirieron alguna agresion fisica, psicologica o sexual y, de estas, 63,4% no consideraron haber sufrido violencia en la vida; 64,3% relataron algun episodio marcante y 46,5% atribuyeron un nombre a lo vivido. La definicion de violencia mas comun fue la de agresion fisica (78,8%), seguida por la psicologica (39,7%) y sexual (24,2%). Se concluye que la mayoria de las mujeres que refirio alguna agresion no considero haber sufrido violencia en la vida. Hubo gran dificultad en contar episodios y nombrarlos y, a pesar de que la mayoria de esos episodios sean do ambito domestico, en la definicion de violencia esta referencia no aparece. Palabras clave: Comunicacion; violencia; invisibilidad de la violencia; violencia domestica; violencia contra la mujer.E dificil o relato de violencia sofrida por mulheres. Trata-se da invisibilidade da violencia que afeta as relacoes usuarias - profissionais, criando impasses comunicacionais. Buscou-se caracterizar este silencio, estudando usuarias de atencao primaria na rede publica de Sao Paulo, quanto a prevalencia de violencia, a percepcao de ter sofrido violencia, a definicao de violencia em geral e a nomeacao dada por quem a experimentou. Entrevistaram-se 322 usuarias de 15 a 49 anos, sobre agressoes fisica, sexual e/ou psicologica, o agressor, e a percepcao de ter sofrido violencia, solicitando-se o relato de um episodio marcante, o nome que daria a este e a definicao de violencia em geral. Das entrevistadas, 69,6% referiram alguma agressao fisica, psicologica ou sexual e, destas, 63,4% nao consideraram haver sofrido violencia na vida; 64,3% relataram algum episodio marcante e 46,5% atribuiram um nome ao vivido. A definicao de violencia mais comum foi a de agressao fisica (78,8%), seguida pela psicologica (39,7%) e sexual (24,2%). Conclui-se que a maioria das mulheres que referiu alguma agressao nao considerou haver sofrido violencia na vida. Houve grande dificuldade em contar episodios e nomea-los, e apesar de a maioria desses episodios serem do âmbito domestico, na definicao de violencia esta referencia nao aparece.

Violência sexual por parceiro íntimo entre homens e mulheres no Brasil urbano, 2005

OBJETIVO: Estimar a prevalencia de violencia sexual por parceiro intimo entre homens e mulheres da populacao urbana brasileira e fatores a ela associados. METODOS: Os dados analisados fazem parte de pesquisa realizada em 1998 e 2005 no Brasil, em populacao urbana. Os dados foram obtidos por meio de questionarios aplicados a amostra representativa de 5.040 individuos, homens e mulheres de 16 a 65 anos. Analise descritiva foi realizada com dados ponderados, usando-se os testes F design-based, com significância de 5%. RESULTADOS: A prevalencia global de violencia sexual por parceiro intimo foi de 8,6%, com predominância entre as mulheres (11,8% versus 5,1%). As mulheres apresentaram taxas sempre maiores de violencia do que os homens, exceto no caso de parcerias homo/ bissexuais. Foi significativa a diferenca da maior taxa verificada para homens homo/bissexuais em relacao aos heterossexuais, mas nao para mulheres. A populacao negra, independente do sexo, referiu mais violencia que a branca. Quanto menor a renda e a escolaridade, maior a violencia, mas homens de regioes mais pobres referiram mais violencia, o que nao ocorreu com mulheres. Situacoes diversas do trabalho, uso de condom, menor idade na primeira relacao sexual e numero de parceiros nos ultimos cinco anos diferiram significativamente para mulheres, mas nao para homens. Para homens e mulheres a violencia sexual associou-se a ser separado(a) ou divorciado(a), ter tido doenca sexualmente transmissivel, auto-avaliar-se com risco para HIV, mas nao a sua testagem. CONCLUSOES: Confirma-se a alta magnitude da violencia sexual e a sobretaxa feminina. Reitera-se a violencia como resultado de conflitos de genero, os quais perpassam a estratificacao social e a etnia. Quanto a epidemia de Aids, a violencia sexual e um fator importante a ser considerado na feminilizacao da populacao atingida.