Márcia Thereza Couto

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.

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.

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.

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 e saúde: contribuições teóricas, metodológicas e éticas de estudos da violência contra a mulher

This article discusses theoretical, methodological, and ethical aspects pertaining to violence against women as both a form of gender violence and a public health issue. The text provides epistemological reflections based on daily research experience with qualitative and quantitative, population-based, and service-user studies that address both women and men. Violence is defined as a complex and sensitive theme of a medical and social nature in terms of its theoretical-methodological approach, pointing to interdisciplinarity as the reference for its construction as an object of health. The article discusses the difficulties in linking the various sciences, methodologies, and theoretical perspectives. It also highlights the special dynamic between visible and invisible violence, with implications for research design, particularly for demarcating the object of study, a relevant issue given the technological needs of health intervention. These specificities of violence raise further ethical issues for the production of knowledge, and there is a need for special care as part of methodological quality in the research. Research ethics is also responsible for the scientificity of the resulting data. Situations stemming from specific studies are used to illustrate the articles commentary.

A visão dos profissionais sobre a presença e as demandas dos homens nos serviços de saúde: perspectivas para a análise da implantação da Política Nacional de Atenção Integral à Saúde do Homem

In 2009, the Brazilian Comprehensive Healthcare Policy for Men (PNAISH) was launched in Brazil, seeking to reduce morbidity and mortality in this population group. This article strives to analyze the conceptions that health professionals have about the specific demands and behaviors of the male population served by the healthcare services. The data analyzed are part of a larger research project, the objective of which was to evaluate the initial actions of the implementation of PNAISH. Ethnographic observations in 11 health services and semi-structured interviews were conducted with 21 health professionals. From the perspective of health professionals, the presence of men in the healthcare services is still limited. According to them, it is comprised of two types of clients: workers and the elderly. The male behavior characteristics - haste, objectivity, fear and resistance - and the difficulty faced by health services in receiving this population are the main factors that drive men away from health services. Although the concept of gender is central to PNAISH, it is only triggered by healthcare professionals in order to justify the social standards expected in terms of mens behavior. The attribution of mens behavior to cultural factors ultimately obscures the relations of power that underlie gender relations.

Factors associated with intimate partner violence against Brazilian women

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.

Homens, saúde e políticas públicas: a equidade de gênero em questão

The scope of this article is to pose questions on the theme of Men, Health and Public Policies to render debate on the subject viable, based on theoretical and empirical references related to these issues. Initially, some historical landmarks on the theme are presented to provide guidelines for debate. An overview of the gender agenda in public policies is then presented to introduce the discussion about the inclusion of a gender perspective in healthcare policies. After this discussion, queries are raised about whether or not policies geared to mens health promote gender equality. In the closing remarks, the complexity involved in the development, implementation and evaluation of health policies aimed at gender equality is highlighted. The need for the Brazilian policy geared towards mens health to be implemented with other policies such that the gender matrix is transversal in the healthcare field is also stressed.