Autonomy as a structural need to face gender violence

Abstracts

Objetiva-se apresentar categoria referente a necessidades relacionadas à autonomia, reconhecidas pelos profissionais da Estratégia Saúde da Família no que concerne à atenção à saúde de mulheres que vivenciam violência. Para a produção do material empírico foram feitas entrevistas com profissionais de saúde que compõem as equipes da ESF e com mulheres usuárias do serviço. Os significados conformam a necessidade de autonomia relacionada à mulher como sujeito na tomada de decisões. Entretanto, alguns significados revelaram o reducionismo que se traduz na desresponsabilização do serviço em relação ao problema. A autonomia financeira foi um aspecto convergente entre os discursos dos profissionais e das usuárias do serviço de saúde. Concluiu-se que para o enfrentamento da violência é fundamental a inclusão da perspectiva de gênero tanto nas políticas de saúde quanto nas práticas concretizadas no processo de trabalho, condição que abre possibilidades de respostas a necessidades práticas e estratégicas de gênero, contribuindo para a redução da iniqüidade entre homens e mulheres e a promoção da emancipação feminina.

Violência contra a mulher; Autonomia pessoal; Feminismo; Gênero e saúde

ORIGINAL ARTICLE

Autonomy as a structural need to face gender violence

Rebeca Nunes Guedes^I; Rosa Maria Godoy Serpa da Fonseca^II

^IRN. Doctoral student, Inter-unit Program, School of Nursing, University of São Paulo. São Paulo, SP, Brazil

^IIFull Professor, Collective Health Nursing Department, School of Nursing, University of São Paulo. Head of the Research Group "Gênero, Saúde e Enfermagem". CNPq Fellow– Level 1D. São Paulo, SP, Brazil. [e-mail]

ABSTRACT

The objective if this article is to present a category regarding the needs related to autonomy, recognized by professionals working in the Family Health Strategy (FHS), in terms of the health care for women who experience violence. To produce the empirical material, interviews were performed with health care professionals that comprise the FHS teams and with women users of the service. The meanings confirm the need for autonomy related to women as subjects in making decisions. However, some meanings revealed the reductionism that is translated by the de-responsabilization of the service in relation to the problem. Financial autonomy was a converging aspect among the discourses between the health service professionals and users. In conclusion, in order to deal with violence, it is essential to include the gender perspective in the health policies as well as in the practices implemented in the working process. This condition would open windows of opportunity of answers to the practical and strategic needs of the gender, and, thus, contribute to reducing the inequity between men and women and promote female emancipation.

Descriptors: Violence against women; Personal autonomy; Feminism; Gender and health

RESUMEN

Se objetiva presentar categoría referente a necesidades relativas a la autonomía, reconocidas por profesionales de Estrategia Salud de la Familia, concernientes a atención de salud de mujeres víctimas de violencia. Para producir el material empírico se hicieron entrevistas con profesionales de salud que componen los equipos de ESF y con pacientes femeninos del servicio. Los significados conforman la necesidad de autonomía relacionada a la mujer como sujeto en la toma de decisiones. Mientras tanto, algunos significados revelaron reduccionismo traducido en desentendimiento del servicio frente al problema. La autonomía financiera fue un aspecto convergente entre los testimonios de profesionales y pacientes del servicio. Se concluyó en que para enfrentar la violencia es fundamental incluir la perspectiva de género en políticas sanitarias y prácticas concretas del proceso laboral, condición que posibilita respuestas a necesidades prácticas y estratégicas de género, reduciendo la inequidad entre hombres y mujeres y promoviendo la emancipación femenina.

Descriptores: Violencia contra la mujer; Autonomía personal; Feminismo; Género y salud

INTRODUCTION

Violence against women may be explained as a phenomenon resulting from the naturalization of inequality between genders, which exists in the hierarchical categories, historically built, as one of the ideological mechanisms capable of legitimizing the status quo, among which social classifications and the classifications regarding the differences between the genders are based. This classification allows the subjugation of women in relationships of gender, disqualifying them as inferior because they are biologically different.

Nevertheless, the stage of female submission is also a platform for the acknowledgement of her status as author of her own history alongside men, and not only of conformism as a subjected individual viewed only as an object. In this perspective, violence against women reproduces a phenomenon that happens even in the most advanced society, which is class violence, viewed as something natural, rational and legal; based on this worldview the process of violence is invisible to the public eye.

In the privacy of the home, this ideological mechanism is translated into domestic violence against women, where it is understood as being a woman's fate which can only be faced in counter-discourse, in opposition to the determinism that the focus on gender and the health field allow, by making known the needs of oppressed women: the need for freedom and autonomy as an essential condition for her full existence as a subject with rights.

Autonomy (a word that comes from the Greek autós=self + nomos=custom, law) etymologically means the power of giving oneself his/her own law. Philosophically, it refers to the idea of freedom, through which human beings intend or are permitted to choose the laws that govern their behavior; in other words, it permits the possibility and capability of decision-making for individuals and groups regarding their own actions in life⁽¹⁾.

In the report Objetivos de Desarrollo del Milenio: una mirada desde América Latina y el Caribe, autonomy was defined as the

level of freedom a woman has in order to be able to act according to her choice instead of the choice of others. In this context, there is a narrow relationship between the gain of autonomy by women and the bodies or forces of power that may institute it, both individually and collectively⁽²⁾.

Autonomy, in this context, would be the capability and concrete conditions that allow women to freely make decisions that affect their lives and the power to act accor-ding to these decisions, qualifying autonomy as a necessary condition for health.

A study developed in a service that operates under the Family Health Strategy (FHS) in São Paulo (SP), whose objective was to understand how the health needs of women who experience violence are recognized by health professionals, examined limits and evaluated possibilities of the FHS in the face of this phenomenon and revealed the presence of needs referring to strengthening and autonomy⁽³⁾.

OBJECTIVES

The present study aims to present a category regar-ding the previously mentioned needs so as to understand the meanings related to autonomy, revealed between the lines of the discourses of health professionals and women who use the service and experience situations of gender-related violence.

METHOD

This is an exploratory study using a qualitative approach, which included gender, gender violence and health needs as analysis categories. It was developed in the municipality of São Paulo, at a Basic Health Unit (BHU) located in the suburb of the southern region of the city. Detailed interviews with 22 professionals who compose the family health teams in the service were performed for the production of the empiric material. The interviews were recorded and, following transcription, the technique of content analysis was applied⁽⁴⁾. The study complied with all the ethical requisites proposed by Resolution 196/96 of the National Health Council⁽⁵⁾, which regulates studies involving human beings, and had the approval of the Committee of Ethics in Research of the USP School of Nursing, under protocol number 822/2009/CEP/EEUSP.

RESULTS

The meanings found in the statements confirm the need for autonomy, whose meaning is related to the woman as a subject in charge of making her own decisions regarding her health care, as well as the need for tools to help her cope with conflicts in order to become stronger in handling her life.

So that she can handle conflicts better, the conflicts are a result of the change in the life of this person and not of paralysis, because this conflict has paralyzed her life (...) handling this so that it may become a lesson and a challenge for her to keep handling life (I21).

It was possible to identify needs that broaden the classic public health concept and evoke conditions that intensify the strengthening and autonomy of women as fundamental for coping with violence, such as affection and self-esteem.

It is the need for self-esteem and for her to be able to take care of her health (...) strengthening the emotions of these women, showing them the paths (I16).

Data evoke self-management, individual internal motivation and decision-making as acknowledged needs. However, in reading between the lines of the statements, the risk of reductionism may be implicit, which is translated into the withdrawal of responsibility of the service regarding the problem.

She really needs help, but it must come from her, first (I1).

In the following statements the need for education also appears as an essential need to strengthen women's autonomy and their ability to cope with oppression.

Education regarding how these women can search for it in another way, without believing this is something normal. Education regarding the services, regarding her options, the law and her rights (I19).

The patient needs to be oriented regarding the fact that she does not need to be subjected to situations simply because she thinks she needs him. But making her see this is very difficult, too difficult! It is like helping a drug addict stop using drugs because it may harm him (I20).

The achievement of financial independence and working in the public world was found, in some statements, to be the key to the women's need for transformation and release from oppression and violence. This was a convergent aspect between the discourses of the professionals and the women who use the health service.

It is necessary to help her find employment options and show her that there are other paths. In the case of financial independence, the social worker helps her find other activities she may develop, so that she is not dependent on her husband (I22).

Courage to get a job, because once I am working I am healthy, but unemployed I am not healthy (W1).

Other revealed meanings referred to making the user more responsible or culpable for any non-compliance with the interventions proposed by the service.

The doctor scheduled an appointment with her and she does not come, the problem is not the help available, it is the attitude she must have, but she does not. (I1).

He is living there. If she had taken measures, it would not be happening (I1).

The following statement shows not only the conjugal violence to which the interviewed user was subjected, but also the structural violence in the field of social production to which many women are subjected. Pregnant, living in São Paulo with her husband, over three thousand kilometers away from her family, the interviewed user was deprived of the ability to work due to her pregnant condition and this is an aspect that limits her ability to cope with the violence to which she has been subjected by her husband, father of the child she is expecting and the current and only provider for the family.

The only solution I would have now is separation. I cannot separate now, because I used to work (...) But I discovered I was pregnant and was fired. Who is going to offer me a job, now that I am pregnant? I would like the service to help me. But how is the service going to do that? The health service cannot provide for me (W11).

DISCUSSION

The discourses of the professionals showed the acknowledgement of the need for autonomy, pointing to the needs that broaden the classic public health concept and evoke conditions that intensify the strengthening and autonomy of women as essential for coping with violence. The statements call to mind the necessity for autonomy in the face of personal and individual strengthening.

Nevertheless,

in health and in other fields, there is the shaping of the chimera of release by personal self-management and the simple personal self-confidence (...) who can deny the strength of self-management and the importance of personal self-confidence as an instrument of release and intervention? However, they only work in the democratic meaning if employed as nourishment of the collective organization, rather than a replacement for it⁽⁶⁾.

This aspect regarding motivation centered only on the person reveals the reductionism of the excessively individualized focus from which health professionals understand the meanings related to violence and health needs. Between the lines of the statements, the risk of reductionism may be implicitly translated into the withdrawal of responsibility of the service in facing the problem. In the field of public health, the co-responsibility of the health service, women and society as a whole is fundamental for coping with a complex issue that involves, dialectically, both subjective aspects and those of social structure.

Some statements implicitly reduce education to a meaning more related to the gaining of information. In the theoretical context of education regarding awareness, autonomy is one of the central themes, being the social-historical condition of an individual or collectivity that has been released and emancipated from the limitations that restrict or nullify freedom. The notion of autonomy is opposite to that of heteronomy, a situation of an individual or social group in alienation, in which they live to be the other⁽⁷⁾.

Situations of oppression, such as the oppression of gender, promote situations of heteronomy in which people live alienated from others due to the social rules imposed on them. Thus, education focused on awareness and release is powerful in leading people to be more autonomous.

Education presupposes that individuals are free to choose their behaviors and actions⁽⁸⁾. In the hierarchy of health needs⁽⁹⁾, autonomy constitutes one of the four required needs composing it and refers to the need of individuals to have growing degrees of autonomy in terms of their way of living. The reconceptualization of this need is that health education, as well as information, constitutes only part of the construction process of growing autonomy of the subjects. Autonomy is implicated in the possibility for reconstruction, by the individuals, of meanings in their lives, which would have a significant impact on their way of living. This includes the struggle to satisfy their needs in the broadest possible sense.

A detailed analysis of autonomy is central to the comprehension of gender violence and the needs of women who experience it. Violence is defined as deprivation, or denial of freedom, which interferes with the autonomy of women as individual subjects of their existence. It is a relationship of power characterized both by domination and by objectification.

Perfect violence is one that obtains the interiorization of the other person's will and action by the will and action of the dominated partner, so that the loss of autonomy is not recognized, but submerged in an unperceived heteronomy⁽¹⁰⁾.

Patriarchy presupposes male ownership over the universe of women, which is incompatible with the ideal of freedom and equality among human beings. This is the greatest contradiction, an internal contradiction that prohibits the dialectical focus in the gender relationships, since the subordination of one half of a conjugal partnership, legitimized in the sexual contract, produces asymmetry and a paternalist focus on the relationship. This is due to the fact that, as women are subjected to inequality and can determine neither their own freedom nor the autonomy of being an equal human being, physical and/or psychological violence is triggered.

Despite work being frequently mentioned by women when questioned regarding their health needs, it is important to highlight that financial independence provides women with a greater ability to overcome the inequalities of gender, but it does not release them from these chains. This overcoming requires the construction of new social relationships, which implies the deconstruction of the hegemonic gender relationship in our society.

The achievement of greater autonomy presupposes releasing women from the chains determined by gender, including gender violence, overburden due to the exclusivity in reproductive and care responsibilities, being excluded from productive activities and, consequently, being financially dependent. Autonomy also presupposes exercising reproductive rights and adopting all necessary measures to allow women equality in decision-making. In each one of the above-mentioned aspects there are inequalities and discriminatory practices to which the State must respond with consistent policies to promote the physical, political and economic autonomy of women.

Social inequality is absolute in the reality of subjects excluded from work and, added to the gender inequality that permeates the conjugal relationship, intensely compromises society through the iniquities produced by two categories: class and gender, both of which produce obstacles to the autonomy, health and existence of women, as observed in the statement previously mentioned.

The ability of subjects to make their own choices is the fundamental principle of autonomy and equality, needs that cannot be ignored in a transformation of the current social structure. However, the recovery of autonomy is an urgent and fundamental requirement for health and discussion is necessary regarding how the lives of the individuals are institutionalized and medicated, and the disregard of this dimension by the services. It is impossible to talk about absolute autonomy, since it is not possible to deny that determining forces are difficult to control and spaces of freedom can almost be considered privileges. On the other hand, it is important to at least attempt to restore certain elements of human autonomy, since the disease and the related destructive processes are also determined by human alienation⁽¹¹⁾.

The achievement of autonomy, understood as the control over the individual's own life and body and the right to an independent identity and to self-respect, is preceded by two conditions: the consideration of the needs and interests of men and women in the policies and programs to achieve the gender equality; and supporting strategies that aim at strengthening females and supporting empowerment⁽¹²⁾. In order to face the challenge of achievement of gender equality and the autonomy of women it is necessary to

take a new look, carefully and accurately, at the situation of thousands of women who suffer iniquities in their daily life, to be offended by it and to move towards transformations, rather than the unreachable idealization of the decontextualized and historical individual and collective happiness. Female working citizens must be treated according to the needs of their health-disease profile, understood in the light of their gender condition, class situation, generation profile and other analytical data⁽¹³⁾.

CONCLUSION

Regarding female autonomy in coping with violence, it is fundamental to include the perspective of both genders in the health policies and in the practices executed in the working process, allowing possibilities of responses to practical and strategic needs of gender, contributing, thus, to the reduction of iniquities between men and women and to the promotion of female emancipation.

The work model that qualifies the health care provided to women in situations of violence must overcome the biomedical care model, limited to the process of biological reproduction, which still characterizes most of the working processes of women's health practices, remaining loyal to the positivist concept of science. Overcoming this model requires reviewing professional practice under the perspective of the emancipation of women. Gaining critical knowledge regarding health needs as a consequence of oppression constitutes one of the elements that must guide the work of the professional practices in this area.

In this context, public health, due to its social interface and interdisciplinary nature, constitutes the health care field that can best respond to the violence problem, giving it the responsibility of the challenge of building knowledge to produce interventions for the prevention of gender violence.

Therefore, it is believed that this study may contribute to the knowledge in this area, relating health care needs to the perspective of gender, which is not limited to purely academic knowledge, creating an ethical and political perspective due to its praxeological relevance, which presupposes the knowledge to transform and understand the health of women from an emancipating perspective.

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La autonomía como necesidad estructuradora para el enfrentamiento de la violencia de género

Correspondence addressed to

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Accepted
  11 Nov 2011
• Received
  29 Oct 2011