Domestic violence against women and medical education: pathways and challengesABSTRACT
Introduction: Domestic violence against women is a serious public health issue in Brazil and worldwide, with many implications to women´s health, from physical injuries to social relations concerns. However, it remains an invisible problem on the daily practices of health care services, particularly to primary health care. The training of health care professionals, especially physicians, might represent an obstacle to the comprehensiveness of health assistance; moreover, it contributes to increase the vulnerability of women to domestic violence and to the critical pathways of women seeking for care.
Objective: Given that context, the purpose of this study is to understand the perception of recently graduated physicians and students attending the final years of medical education, from a medical school in the state of São Paulo, about their training regarding full assistance to women in situation of violence.
Methods: This research is an exploratory study with a qualitative design, conducted through individual interviews using a script of open-ended questions. The study participants included medical students attending the fifth and sixth years and recently graduated alumni of the University. The participants’ selection was based on convenience and considered the completion of most or all of the mandatory subjects in the curriculum. The participation was voluntary, and the participants signed an informed consent form. The interviews were conducted in the University Health School Center and via Google Meets, depending on the epidemiological context of the COVID-19 pandemic by the time of data collection. The gathered data were analyzed using thematic analysis of the interview contents.
Results: The results highlight the invisibility of the topic in medical training and the individual pursuit of knowledge by the students through extracurricular activities. Furthermore, is highlights the participants’ effort to provide care to women within the normative framework of comprehensiveness. Conclusion: Therefore, it is observed that, despite of the homogeneity of the research group, the study allows a deeper understanding of the nuances of medical training and the construction of a medical undergraduate curriculum focused on a more humanized and holistic approach to the issue of domestic violence against women.
Keywords:
Violence Against Women; Comprehensive Women’s Health Care; Medical Education
RESUMO
Introdução: A violência doméstica contra mulheres é um grave problema de saúde pública no Brasil e no mundo, com diversas implicações à saúde da mulher, desde agravos físicos até questões de âmbito social. Todavia, trata-se de um problema invisível no cotidiano das práticas dos serviços de saúde, com destaque para a atenção primária à saúde. A formação de profissionais de saúde, especialmente médicos, pode representar um obstáculo à integralidade da atenção à saúde, além de contribuir para o aumento da vulnerabilidade de mulheres à violência doméstica e para a rota crítica das mulheres na busca por cuidado.
Objetivo: Neste contexto, o presente estudo teve por objetivo compreender a percepção de médicos recém-formados e alunos dos últimos anos do curso de medicina, de uma escola médica paulista, sobre a sua formação em relação à atenção integral à mulher em situação de violência.
Método: Trata-se de estudo qualitativo de caráter exploratório, realizada por meio de entrevistas individuais, com roteiro de questões abertas. Participaram do estudo alunos dos quinto e sexto anos médico e recém-egressos da universidade em questão. A escolha dos participantes foi por conveniência e considerou o cumprimento total ou a maioria das disciplinas obrigatórias da grade curricular do curso. A participação dos entrevistados foi voluntária e mediante assinatura do termo de consentimento livre esclarecido. Os ambientes utilizados para as entrevistas foram, sala do Centro de Saúde Escola da universidade, e plataforma do Google Meets, dependendo do contexto epidemiológico da pandemia da covid-19, à época da coleta dos dados. Os dados obtidos foram analisados por meio da análise temática do conteúdo das entrevistas.
Resultado: Os resultados apontam para a invisibilidade do tema na formação médica e a busca de conhecimento de modo individual pelos estudantes, em atividades extracurriculares. Também, o esforço dos participantes em oferecer cuidado às mulheres sob o horizonte normativo da integralidade.
Conclusão: Assim, observa-se que, apesar da homogeneidade do grupo pesquisado, o estudo permite aprofundar as nuances da formação médica e a construção de um currículo de graduação em medicina, com busca em um olhar mais humanizado e integral para a temática da violência doméstica contra a mulher.
Palavras-chave:
Violência Contra a Mulher; Atenção Integral à Saúde da Mulher; Educação Médica
INTRODUCTION
Defined as any action or omission based on the female gender that causes death, injury, physical, sexual or psychological suffering and moral or patrimonial damage within the domestic unit in any intimate relationship of affection, in which the aggressor lives or has lived with the woman, regardless of cohabitation)1_1, domestic violence against women is a public health problem with high prevalence and serious consequences in the daily lives and health of women, in Brazil and worldwide2)-(7.
According to the fourth edition of the research “Visible and invisible: the victimization of women in Brazil”, carried out by the Brazilian Forum of Public Security together with the Datafolha Institute, 33.4% of Brazilian women aged 16 or older suffered physical and/or sexual violence from an intimate partner or ex-partner - the main perpetrators of domestic violence against women - which is higher than the global average, especially considering the reality of black women. During the COVID-19 pandemic, social isolation, along with their partners, intensified the problem, with eight women suffering physical violence in Brazil every eight minutes8),(9.
In emergency services, domestic violence is the second leading cause of bodily injury, surpassing traffic accidents1),(10. Furthermore, domestic violence against women is associated with a higher risk of miscarriage11 and is related to depression, anxiety, and post-traumatic stress disorders12. Despite its high prevalence, health problems caused by violence are rarely recognized in the daily routine of health services13),(14, which makes it difficult to identify the violence, as well as to report and manage the case appropriately, especially in primary health care (PHC).This occurs because it is the main gateway to the Unified Health System (SUS, Sistema Único de Saúde) and proposes comprehensive care delivered through a network. Based on its guidelines and assumptions, it constitutes a strategic point in the network for the prevention, identification, notification, and coordination of care and assistance to women in situations of violence4. And, in PHC, the medical professional has one of the central and reference roles in monitoring the health of the population in the service’s coverage area.
In this context, the World Health Organization (WHO) warns about the need to train health professionals capable of providing comprehensive care to women in situations of domestic violence, since violence against women is often underreported, hidden, or undocumented4,15 and the inadequate or blame-laden responses offered by health services and other social facilities end up reiterating the violence and contributing to a critical path12),(16.
Considering that healthcare for women experiencing violence requires action within the scope of expanded clinical practice12, involving the embracement of lived experiences and pain, expressed in different spheres - ‘from body to soul’, as well as the clinical recognition of complaints, notification to SINAN and a unique therapeutic project, which considers the multiplicity of aspects that make up a woman’s life, including the limits imposed by social and economic reality16, it is essential to understand the obstacles faced by professionals to act more effectively, aiming to guarantee women’s rights.
Recent investigations have pointed to gaps in medical training for comprehensive care for women experiencing domestic violence. Schraiber and D’Oliveira15 observe a great difficulty for medical professionals to associate as an illness something that does not necessarily have an anatomopathological basis. Furthermore, D’Oliveira15 emphasizes that medical knowledge, due to its conceptual and technical apparatus, reduces the problem of violence to a matter of the individual body, to the point that the same diagnosis and treatment are prescribed and offered to a woman who suffered a fracture due to a car accident and to one who suffered a fracture due to a beating by her partner. Moreover, historically, the medical course has a conservative tradition with the hegemony of the biomedical model; thus, topics such as violence, ethnicity and gender are rarely included from a socio-political perspective and remain focused on the health-disease-conduct approach10.
In this sense, studying how domestic violence is incorporated into medical training curricula can bring new reflections and point out paths that contribute to the implementation of new curricula.
METHOD
This is an exploratory study, of a qualitative nature, developed through semi-structured interviews. The justification for the semi-structured interview methodology lies in its ability to delve deeper into and explore the investigation object through a structured script, but one that allows flexibility in the interaction between the participants, enabling the creation of new topics that are relevant to the interviewees17),(18. The project was approved by the institution Ethics and Research Committee, according to Opinion number 4,860,812 and CAAE 45894621.6.0000.5411.
The script was previously constructed by the researcher and tested in a pilot interview, containing ten questions, which aimed to identify the perceptions and experiences of students attending the final years of medical school and recent graduates regarding their medical training in relation to domestic violence against women. These participants voluntarily took part in the research and signed the informed consent form.
The interviewees’ selection was carried out using the snowball sampling technique. Snowball sampling (or link-tracing) is a non-probability sampling method that uses referral chains built from people who share certain characteristics of interest to the study or know of others who have them. It is applicable when the object of study is composed of hard-to-reach groups or when the study seeks to investigate private or specific matters. The technique begins with the selection of a first interviewee, who can be called a “seed,” and who helps the researcher to initiate contacts and identify the group to be researched. Subsequently, the people indicated by the seed indicate new contacts with the desired characteristics, from their own personal network, and so forth19.
It is important to highlight that the interviews took place in 2022, and considering the epidemiological context of the COVID-19 pandemic, data collection was carried out in person, in a large and well-ventilated room at the university’s School Health Center, or through a virtual environment, Google Meet, depending on health guidelines. The participants are university students, in their fifth and sixth years, or recent graduates of the medical course. The choice of fifth and sixth-year students, as well as recent graduates, was due to the fact that they had already completed the curriculum or the subjects involving women’s health, thus allowing more reliable and in-depth perceptions regarding the object of study. The interviews lasted an average of 45 minutes and were recorded and transcribed in full for content analysis. Data collection was interrupted when the completed interviews did not yield new data17),(18, ending with seven participants.
The interview data were explored from the perspective of thematic content analysis, which consists of investigating the core meanings that compose communication so that their presence or frequency has significance for the analytical object. For this purpose, the content analysis methodology includes pre-analysis, exploration of the material, and treatment of the results based on the interpretation of the content from emerging themes17),(18. To work with the content, the technique of elaborating categories was chosen, and, according to Gomes20, the word category, in general, refers to a concept that encompasses elements and/or aspects with common characteristics or that are related to each other20. Respecting the ethical principles of research with human beings, in the analysis of the results, the interviewees were given the nomenclature Interviewee, followed by an ordinal number.
RESULTS
Seven interviews were conducted, with the sample selection being intentional, as all participants were either recent medical school graduates (between 2020-2022) or students attending their final years of undergraduate studies under the same curriculum - prior to the 2014 National Curriculum Guidelines - at the same university, and freely agreed to participate in the research. This selection was made to investigate training according to the final years of the 1996 curriculum’s validity, thus allowing the analysis of the impact of this curriculum on the most recently graduated physicians from the institution.
The thematic analysis of the data was structured based on the development of three categories: Training gap: The critical path of domestic violence in the medical curriculum; Active search: the possibility of overcoming the training gap?; The integrality of care: the inseparability of theory and practice.
Category 1. Training gap: The critical path of domestic violence in the medical curriculum.
Paraphrasing studies that address the critical pathways of women experiencing violence15, this research sought to identify and understand the inclusion of the topic of domestic violence against women in the medical curriculum. In this context, the fragility of medical training regarding attention to women experiencing violence is evident: the interviewees unanimously perceived a lack of longitudinal and in-depth activities on this issue in mandatory curriculum subjects. The few learning experiences were context-dependent: either as an object of study in one of the third-year public health groups or with a case treated by the student or a colleague during the Gynecology and Obstetrics internship, between the fifth and sixth years of undergraduate studies.
“We didn’t have specific discussions about that (domestic violence against women), we didn’t. What we had most of, as I mentioned, was more related to sexuality, about women’s health, but a discussion more specifically about violence against women, we never had, at least I’m trying.” - Interviewee 1
“There were groups that experienced domestic violence, but I think that undergraduate topics that put us there, to be able to reflect and talk about it and, in a way, empower us to be able to treat and provide assistance to patients, I don’t think we have a direct undergraduate proposal related to this topic.” - Interviewee 3
“And then, something that I was perhaps lucky about, I don’t know, but in the third year, I don’t know if also in the fourth, we go through Public Health, we have a group project and then, my group was about obstetric violence and then, I think it was really good, and then we went deeper into this topic, everything, I think it was a moment when I learned more specifically about women’s health.” - Interviewee 7
Similarly, even in formal discussions about women’s health, with topics such as sexuality and STIs, there is a predominance of a biomedical perspective, making the social determinants involved in the health-disease-care process invisible.
“We have little debate about what determines human and women’s illness; it’s… and much more focused on pathology, pathophysiology, medication, post-illness intervention, and I think that, in general, universities fail in this, in that we have a pathophysiological understanding, but not a social understanding of illness. I think that’s a criticism, but despite that, I think we’re still in a bubble of excellence in Brazilian universities, despite the dismantling, despite the neglect.” - Interviewee 6
“It was brought up that… it was a woman they couldn’t determine if she was a virgin because she only had sexual relations with women, so it was this… “she is a virgin, isn’t she?’ due to speculative issues, so it was very focused on the anatomical part, like ‘Oh, I’ll have to use a virgin speculum on the woman…’” - Interviewee 1
Issues related to subjectivity, psychological suffering, and the social dimensions that permeate the experience of violence tend to be delegated to other specialties, such as psychiatry, instead of being understood as an integral part of healthcare. This dynamic can distance professionals from the perspective of integrality, since addressing domestic violence against women involves approaches sensitive to the multiple dimensions of the health-disease process.
“The focus always ends up being, in the vast majority of cases, right? For example, in gynecology, the focus ends up being the treatment of the disease itself and the partner’s as well, right? Because many diseases, if you don’t treat them together, will continue, right? And, in obstetrics as well, the discussions are always focused on things like finishing the pregnancy, everything alright with the pregnancy, focused on their respective areas. They even have interconsultations. Sometimes they call in psychiatry and everything else, but nothing that I’ve clearly seen that’s really good or that helps these women, you know…” - Interviewee 2
Category 2. Active search: the possibility of overcoming the training gap?
Interviewees pointed to extracurricular activities, such as academic leagues and the student movement, as spaces for learning and deepening theoretical understanding of the topic. On the one hand, the parallel curriculum allows students to fill the gaps in the formal curriculum, providing spaces for awareness and thematic exploration; on the other hand, it depends on the students’ interest in seeking such knowledge, which can be hindered by a curriculum that leads them to a more biologically-oriented reasoning.
“I think where I learned the most was actually with the Genis Collective, because it was about health, you know, about women who have sex with women or women who have sex with men, and then there were also issues of… ah, prostitution, that debate too, quite a lot, so… domestic violence, how the shelters in Botucatu were organized, that kind of thing, so I think that the training, specifically, helped us think about and talk about women’s health.” - Interviewee 7
“At DENEM, every event has dozens of workshops, panels, and discussions about gender, about gender violence, so it ended up being a more suitable space to learn about… It covered everything from women’s role in society, why there is a hierarchy between men and women, the importance of understanding what in society leads to the role of men as the dominators of the home and women as social reproducers, because even in the student movement there is a hierarchy… the trans issue, which ends up being neglected when thinking about gender, we end up having a more hegemonic view of thinking about cis women... There were several very rich debates that we had at DENEM and at the Academic Center as well” - Interviewee 6
Category 3. The integrality of care: the inseparability of theory and practice
A. Educator: the power of a dialectical education
Based on the interviews, it is noteworthy that, even without a formal curriculum, the presence of an educator who demonstrates the holistic nature of care in their medical practice serves as a reference for students and also allows more meaningful and qualitative learning for them.
“I remember a lot of discussions with a specific teacher, E., right? She always focused a lot on that, it’s what she likes in gynecology, the part about women talking about sexuality, about how they see themselves, and in gynecology, something very frequent is that you’re attending to a patient and she talks about dissatisfaction with her marriage, with her husband” - Interviewee 1
“It was never anything formal, I never had a class on it, but, in a shift I did as a monitor, there was a case that they suspected might involve violence… uh… a case of domestic violence against a woman that we were attending to. And then, the teacher ended up addressing and discussing it with us, I saw all the conduct she was taking, so, it was more like points of, in practice, if the topic came up, there was a more informal discussion.” - Interviewee 5
B. The 2014 National Curriculum Guidelines: the possibility of change
While learning experiences for the care of women in situations of violence do not follow a consolidated path in the training of these professionals, the interviewees demonstrate the potential of the studied medical school in understanding the practice of comprehensive care, which provides a certain basis for holistic care. Similarly, the institutional concern with medical education is highlighted because, although the Flexnerian foundations of the curriculum under study are pointed out21, the process of constructing a new curriculum at the faculty is also noted, which, based on the 2014 National Curriculum Guidelines, transcends the biomedical focus22.
“I think there has been progress, and it’s no coincidence that we’ve spent ten years discussing the curriculum to try to make some changes. Before that, I think the people who participated in building this project were well-intentioned and aimed for this, just like I said. If in the construction of the SUS, there were activists who participated in this struggle and raised these women’s issues, I think our political-pedagogical project also has many limitations, I think, and that are still very present.” - Interviewee 4
“I’ve never had the opportunity to attend to (a case of domestic violence), but I think that if I find myself in that situation, I will try my best to... to be able to address it comprehensively in the consultation with her, because, regardless of whether or not the issue of domestic violence against women has been so widely discussed, comprehensiveness in our care has always been something that has been very much emphasized, so I think I can transfer that to more specific situations, you know.” - Interviewee 3
Considering the high prevalence of domestic violence against women, it is possible that Interviewee 3, or even the professionals who accompanied him in clinical practice, did not recognize situations of violence in their daily care. In this sense, the difficulty in identifying these cases may reflect processes of non-recognition of violence, often associated with the absence of specific training for its approach and the predominance of care models focused on immediate biomedical complaints.
Thus, comprehensive care, although present as a formative principle, also requires the development of skills to recognize social and subjective dimensions that permeate the health-disease process.
DISCUSSION
Comprehensive health care is one of the basic precepts of humanized care advocated by the SUS, in which the person must be seen in their entirety, encompassing biopsychosocial aspects23. Contrary to this normative horizon, the interviewees’ perception points to weaknesses in medical education regarding the comprehensiveness of care for women in situations of violence.
Among the obstacles to be overcome, the neglect of the approach to social determinants of health stands out. From this perspective, an expression of the hidden curriculum is evident, that is, in accordance with Jurjo Torres24, the set of knowledges and values acquired through participation in teaching-learning processes and in daily interactions that reinforce the needs and interests of the hegemonic ideology. In this sense, the superficial study of the problem, which discusses little of the related historical, cultural and socioeconomic aspects, converges with the predominant heteronormative, racist and patriarchal values in order to train doctors who ratify them in their practice.
This biologizing and interventionist model of training future doctors21 results in a reification of these women’s suffering by future professionals, and in the unpreparedness of doctors to identify and deal with the situation and offer adequate support and care, also considering the intersectionality of violence, in addition to contributing to the invisibility of the problem. A complex and difficult cycle to break is formed from this: women are the largest users of health services in primary care23, but they suffer a series of obstacles in this process: unpreparedness of health professionals, medicalization of female emotions and classification of these women as “polycomplainers”4),(25.
It is worth highlighting that the respondents in this research have as their educational background a curriculum with a course pedagogical plan prior to the 2014 National Curriculum Guidelines (DCN)22. In this curriculum, comprehensive care for women in situations of domestic violence is hampered by its own extremely technical apparatus, little focused on socio-political issues21),(26 and by the lack of technical preparation to relate aspects of human life in the social sphere and human rights in the daily practice.
In contrast, regarding learning opportunities, the students’ comments about public health subjects are noteworthy, with particular emphasis on the Teaching, Service and Community Integration (IUSC) as a unique place for learning about expanded clinical practice, social determinants of health, territorialization and teamwork27. According to Ricardo Ayres28, health care refers to the therapeutic encounter that is interested in and sensitive to the experience of illness, whether physical or mental, and guided by people’s projects of happiness. This therapeutic encounter of a different quality, more “humanized,” has technical characteristics that are different from the traditional one; it demands new bases for the therapeutic relationship, new technical mediations, in order to guarantee, beyond technical success, practical success28.
The integrality of care and empathy must be inseparable from medical practice, regardless of the scenario and health context in which the person finds themselves 29),(30. In this context, IUSC emerged as a result of the recognition of the need for students and teachers to experience practices focused on the integrality of actions in health, seeking to break with the biomedical conception in the teaching/learning process. Its main concern is to place the student in extra-hospital settings, where they can interact with residents, community leaders, and health professionals in the area covered by basic and family health units, thus experiencing the various points that make up the SUS care network, the health sector, or other sectors, in activities that prioritize work-based learning, theoretical-practical integration, interdisciplinarity, interprofessionalism, and university extension, using resources from the problem-based learning methodology 27),(30.
Although the interviewees were under a curricular training prior to the DCN, significant advances can be observed in the production of a more humanistic health degree with a holistic view of the human being, encompassing their psychosocial, economic, cultural, historical, and biological aspects22, in line with recent directions towards a curricular change in medical education, initiated in the mid-2000s, with the aim of training professionals capable of providing comprehensive and humanized care, and who know how to make decisions that take into account the life context of users and the available resources27.
In this sense, the interviews also highlight the power of an educator who is a link between theory and practice and points out possible paths for the effective implementation of comprehensive care, allowing the students’ more meaningful and qualitative learning. Over the last decade, a great effort has been made, within the scope of health professions undergraduate programs, to reorient training aiming to better meet the needs of the SUS, with significant influence from the DCN for health professions and the inductive role played by the Ministries of Health and Education to achieve a more humanized and developed training through teaching and learning processes in different scenarios and with interprofessional practices. From the perspective of training ‘for and in the SUS’, the mediating teacher is “no longer just the one who educates, but the one who, while educating, is educated in dialogue with the student who, while being educated, also educates [...]” 31. In addition, it is characterized by promoting spaces and moments for the exchange of knowledge among students, and between students and health service professionals, corroborating the various opportunities for interprofessional education and collaborative practice32.
As a way to overcome the existing gaps in the medical curriculum for comprehensive care for women in situations of violence, the interviewees indicated academic leagues and the student movement as spaces that produce reliable and in-depth knowledge. Regarding extracurricular spaces, these can foster critical reflections by the student about the social role of the physician, of women, and of violence itself. However, criticisms regarding these spaces, especially academic leagues, are based on non-systematic learning, the possibility of subverting the formal curricular structure, the occupation of students’ free time, the possibility of reinforcing academic vices and the illegal practice of medicine when there is a lack of teacher supervision, and the learning of erroneous concepts and practices. Furthermore, they open space for the intervention of the pharmaceutical industry, favor the early specialization of students, can reinforce aspects of the hidden curriculum, such as the sexist and patriarchal culture, and transform into mere scientific societies, disregarding their essence of university extension and weakening the formal curriculum 33.
Regarding university extension, the recent curricularization of extension points to a possible path for students and the university to be closer to everyday social life. In this context, more appropriate and referenced by the health problems and needs of the population33.
FINAL CONSIDERATIONS
The disease-focused and biomedical approach to sociocultural issues is very present in the medical curriculum and contributes to the invisibility of the problem and women’s suffering, in addition to hindering the humanized and comprehensive care advocated by the SUS. Based on the interviews and the qualitative analysis of their content, it is observed that there is a formative gap regarding the topic of domestic violence against women in the medical curriculum, and this can be explained by the very theoretical construction of the medical curriculum, based on the Flexnerian biomedical model21, and by the hidden curriculum22, with patriarchal values, to which students are subjected. The results obtained point to the importance of learning about sociocultural issues and their impacts on the health-disease process in a thorough and critical way, developing competencies for a welcoming, humanized, and comprehensive care for women in situations of domestic violence29. Similarly, they demonstrate that violence against women is a social issue that requires structural changes to be addressed, demanding not only adjustments to the medical curriculum, but also a university and a society committed to social and human rights, and legitimate in confronting social, gender, and ethnic inequalities through policies, guidelines, and strategies aimed at addressing them. The homogeneity of the researched group, while not allowing generalizations for the entire academic community of undergraduate medical students in the country, does allow a deeper understanding of the nuances of medical training in a renowned medical school in the country, a reference in the training of doctors and in the construction of undergraduate medical curricula over the years.
ACKNOWLEDGEMENTS
Universidade Estadual Paulista Júlio de Mesquita Filho (Unesp) and National Council for Scientific and Technological Development (CNPq, Conselho Nacional de Desenvolvimento Científico e Tecnológico)
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Research data are only available upon request.
