Lilia Blima Schraiber

Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women's health and domestic violence against women

Suicidal behaviours are one of the most important contributors to the global burden of disease among women, but little is known about prevalence and modifiable risk factors in low and middle income countries. We use data from the WHO multi-country study on womens health and domestic violence against women to examine the prevalence of suicidal thoughts and attempts, and relationships between suicide attempts and mental health status, child sexual abuse, partner violence and other variables. Population representative cross-sectional household surveys were conducted from 2000-2003 in 13 provincial (more rural) and city (urban) sites in Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia, Thailand and Tanzania. 20967 women aged 15-49 years participated. Prevalence of lifetime suicide attempts, lifetime suicidal thoughts, and suicidal thoughts in the past four weeks were calculated, and multivariate logistic regression models were fit to examine factors associated with suicide attempts in each site. Prevalence of lifetime suicide attempts ranged from 0.8% (Tanzania) to 12.0% (Peru city); lifetime thoughts of suicide from 7.2% (Tanzania province) to 29.0% (Peru province), and thoughts in the past four weeks from 1.9% (Serbia) to 13.6% (Peru province). 25-50% of women with suicidal thoughts in the past four weeks had also visited a health worker in that time. The most consistent risk factors for suicide attempts after adjusting for probable common mental health disorders were: intimate partner violence, non-partner physical violence, ever being divorced, separated or widowed, childhood sexual abuse and having a mother who had experienced intimate partner violence. Mental health policies and services must recognise the consistent relationship between violence and suicidality in women in low and middle income countries. Training health sector workers to recognize and respond to the consequences of violence may substantially reduce the health burden associated with suicidal behaviour.

Violence against women: a study in a primary healthcare unit

OBJECTIVES There is scarce information on violence against women in the Brazilian society. This fact is rarely reported in medical records as part of the diagnosis and case management, despite evidence showing the significant impact of violence on the populations health. The study aim was to estimate the occurrence of violence against women, and to determine the nature and magnitude of the violent action and the relationship between women and her aggressors. METHODS The study was conducted among women seen in a primary care unit of the city of São Paulo, Brazil, in a two-month period in 1998. The occurrence of violence cases was ascertained using standardized interviews to all women aged 15 to 49 years who sought health care during the study. Three-hundred and twenty-two women were interviewed. RESULTS Of the participants, 143 (44.4%; IC95%=38.9-49.8%) reported at least one episode of physical violence in their adult life, 110 of those perpetrated by their partners or family members (34.1%; IC95%=28.9-39.3%). Thirty-seven women (11.5%; IC95%=8.0-14.9%) reported at least one episode of sexual violence in their adult life, 23 of those perpetrated by their partners or family members (7.1%; IC95%=4.3-9.9%). CONCLUSIONS As reported in other countries, physical and sexual violence is highly frequent among women seen in primary care services. In most cases their partners and family members are the perpetrators and the episodes are mostly serious and recurrent.

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.

O homem na atenção primária à saúde: discutindo (in)visibilidade a partir da perspectiva de gênero

This paper presents an ethnographicstudy on the rel ationship between menand primary healthcare in eight clinics infour Brazilian states. The objectiv e was tocomprehend the (in)visibility of menwithin the daily routine of care, based ongender perspecti ves, with discussion ofthe mechanisms that favor inequalities inhealthcare work. Different dimension s ofmale (in)visibility were identified withinthis context: targeting of men ininterventions within th e field of publichealthcare policies; male users who facedifficulties in seeking attendance;difficul ty in stimulating effectiveparticipation among men; and malesubjects of care (for themselves and f orothers). The paper emphasizes theimportance of gender studies and theirrelationship with health , while discussingthe production of social inequalities thatare (re)produced by the genderineq ualities that are present in the socialimaginaryEste trabalho apresenta estudo de carater etnografico acerca da relacao entre homens e a assistencia a saude na Atencao Primaria, realizado em oito servicos de quatro estados brasileiros. Seu objetivo e compreender a (in)visibilidade dos homens no cotidiano da assistencia a partir da perspectiva de genero, que discute os mecanismos promotores de desigualdades presentes no trabalho em saude. Foram identificadas, nesse contexto, diferentes dimensoes desta (in) visibilidade: os homens como alvo de intervencoes no campo das politicas publicas de saude; como usuarios que enfrentam dificuldades na busca por atendimento e no estimulo a sua participacao efetiva; como sujeitos do cuidado (de si e de terceiros). O trabalho reforca a importância dos estudos de genero e sua relacao com a saude, na medida em que discute a producao das iniquidades sociais (re) produzidas pelas desigualdades de genero presentes no imaginario social e nos servicos de saude.

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.

Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens

This study deals with the relations between masculinities and health care, approaching the recognition of health needs among male users of primary health care and the responses by the services. The study is part of a larger research project in four Brazilian States, with a convenience sample of eight health services. Ethnographic observation was compared with semi-structured interviews with 182 health care users from 15 to 65 years of age and 72 health professionals. Thematic analysis of the ethnographic records and interviews was based on gender references and studies on health work. The findings show how medicalization of health needs affects users, professionals, and services, disguising issues related to masculinity. Primary care focuses mainly on women, thereby reproducing gender inequalities in health services operations and professional performance, with women receiving disciplined care and men receiving insufficient attention and care.

Violência contra mulheres: interfaces com a Saúde

This essay deals with the theme of violence from the standpoint of violence against women. It discusses the historical precedence of taking violence against women as a Legal issue and as an object of Justice, outlining parallels with the emergence of the problem as a Healthcare issue, as well as one of the targets of the Public Health area and of medical and sanitation practices.

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.