Abstract

This paper aimed to identify in the discourses of managers and workers assisting women in situations of sexual violence the conditions that compromise the care to these women, and the structuring of the network. This is a qualitative study conducted with 19 professionals of these services through semi-structured interviews. The method of discourse analysis underpinned the analytical process, evidencing two discursive formations: weaknesses that affect the work process, and limitations imposed by professional practice. The results indicate that the daily routine of these services is permeated by the lower number and turnover of professionals, poor working conditions, inadequate physical structure for the development of care, as well as gaps in training and awareness. Workers and managers must be urgently assigned to the care teams to reduce turnover, and the implementation of qualified care by these workers, effective incorporation into the service network, ensuring interdisciplinarity, intersectoriality, and comprehensive care, to ensure and respect the sexual and reproductive rights of these women.

Key words
Sex Offenses; Work; Health Staff

Introduction

Sexual violence against women is a severe violation of human rights¹1 Souza MMS, Oliveira MVP, Jesus LA. Violência Sexual contra a mulher e o papel do enfermeiro, revisão de literatura. Cad Graduação-Cien Biol Saude 2016; 3(3):257-274. related to gender issues²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes: norma técnica. Brasília: MS; 2012.. Its extent requires effective coping actions³3 Signorelli MC, Hillel S, Oliveira DC, Ayala Quintanilla BP, Hegarty K, Taft A. Voices from low-income and middle-income countries: a systematic review protocol of primary healthcare interventions within public health systems addressing intimate partner violence against women. BMJ Open 2018; 8(3):e019266., which include the organization of a care network that articulates different actors and devices in the areas of health, public safety, promoting actions for prevention, and coping in an intra and intersectorally⁴4 Oliveira CS, Delziovo CR, Lacerda JT. Redes de atenção à violência. Florianópolis: Universidade Federal de Santa Catarina; 2014..

In the health sector, actions must follow the logic of comprehensive care, paying attention to social, economic, environmental, and emotional vulnerabilities⁵5 Cecílio LCO, Merhy EE. A integralidade do cuidado como eixo da gestão hospitalar. In: Pinheiro R, Mattos RA. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: IMS ABRASCO; 2003. p.197-210., as well as recognizing individual needs⁶6 Menezes PRM, Lima IS, Correia CM, Souza SS, Erdmann AL, Gomes NP. Enfrentamento da violência contra a mulher: articulação intersetorial e atenção integral. Saude Soc 2014; 23(3):778-786.. To this end, health professionals are required to be creative in the forms of care, investment, and desire to care for users in psychological distress⁷7 Ruas APF. A precarização do trabalho em saúde mental e os possíveis impactos clínicos nos centros de atenção psicossocial de Campinas [dissertação]. Campinas: Universidade Estadual de Campinas; 2018..

However, these professionals are exposed to a work process with vertical, hierarchical, and fragmented models⁸8 Vieira EM, Hasse M. Percepções dos profissionais de uma rede intersetorial sobre o atendimento a mulheres em situação de violência. Interface (Botucatu) 2017; 21(60):52-62.^,99 Lettiere A, Nakano AMS. Rede de atenção à mulher em situação de violência: os desafios da transversalidade do cuidado. Rev Eletr Enferm 2015; 17(4):1-8.. At the same time, they must follow management rules that call them to submit to uncertain working conditions⁷7 Ruas APF. A precarização do trabalho em saúde mental e os possíveis impactos clínicos nos centros de atenção psicossocial de Campinas [dissertação]. Campinas: Universidade Estadual de Campinas; 2018.. Despite efforts to modify the care models, comprehensive care is compromised by fragmented healthcare systems⁸8 Vieira EM, Hasse M. Percepções dos profissionais de uma rede intersetorial sobre o atendimento a mulheres em situação de violência. Interface (Botucatu) 2017; 21(60):52-62. in the provision of care based on biomedical standards coupled with substandard health work⁷7 Ruas APF. A precarização do trabalho em saúde mental e os possíveis impactos clínicos nos centros de atenção psicossocial de Campinas [dissertação]. Campinas: Universidade Estadual de Campinas; 2018..

Given the evidence of fragility in the actions of care to women in situations of sexual violence and the need to restructure health services¹⁰10 Cavalcanti LF, Moreira GAR, Vieira LJES, Silva RM. Implementação da atenção em saúde às violências sexuais contra as mulheres em duas capitais brasileiras. Saude Debate 2015; 39(107):1079-1091., the demand for the assessment of the work processes involved emerges. The knowledge produced by this analysis may foster strategic actions for the improvement and qualification of care, even avoiding re-victimization of women seeking services.

In this context, the following question emerged: what are the main weaknesses that interfere in the work process to provide women in situations of sexual violence with comprehensive care? To understand this phenomenon, we aimed to identify in the statements of managers and workers who assist women in situations of sexual violence the conditions that compromise care to these people and the structuring of the network.

Methodology

The municipality in which the research institutions are located is in northeastern Brazil, and ranks fifth in the country in population size, with 53.19% of females¹¹11 Instituto Brasileiro de Geografia e Estatística (IBGE). Brasil em síntese 2010 [página na Internet]. 2010 [acessado 2019 Jul 7]. Disponível em: https://cidades.ibge.gov.br/brasil/ce/fortaleza/panorama
https://cidades.ibge.gov.br/brasil/ce/fo... , and 504 cases of rape recorded in 2017, which corresponds to a rate of 19.2/100,000 inhabitants¹²12 Fórum Brasileiro de Segurança Pública. Anuário Brasileiro de Segurança Pública. Ano 12 [página na Internet]. 2018 [acessado 2019 Jul 7]. Disponível em: http://www.forumseguranca.org.br/wp-content/uploads/2019/02/Anuario-2019-v6-infogr%C3%A1fico-atualizado.pdf
http://www.forumseguranca.org.br/wp-cont... .

Nineteen workers participated in the research: four from the reference center for women, and 15 health professionals, among whom, seven also served as managers working to assist women in situations of sexual violence from eight different institutions, namely, two reference centers, and six hospitals, meeting the inclusion criteria: working in the care of women in situations of sexual violence, availability to participate in the research, signing the Informed Consent Form (ICF) and with at least six months seniority in the service. Workers removed from work activities due to vacation or sick leave were excluded. Participating workers were selected with the snowball technique¹³13 Vinuto J. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Temáticas 2014; 22(44):203-220., through the key informant in the area of women’s health, who provided the contact of a manager/worker who triggered the initial interview. With this access, the participant was asked to indicate another worker assisting women in situations of sexual violence, and so forth. The saturation of this stage occurred when they indicated a person who had already been interviewed.

Semi-structured interviews were conducted, guided by open-ended questions, allowing participants to discuss the protocol and care flow freely, referrals made, activities performed in the service, and the service’s strengths and weaknesses. Interviews were previously scheduled, held in a separate place chosen by each participant, with a mean duration of 15 minutes. Audios were recorded and transcribed in full. A protocol consisting of a notepad to record daily observations, reflections, and concerns arising from observation¹⁴14 Creswell JW, Clark VLP. Pesquisa de Métodos Mistos. 2a ed. Porto Alegre: Penso Editora; 2013. was adopted.

After transcription, the analysis was based on the principles of Discourse Analysis (DA)¹⁵15 Orlandi EP. Discurso e Texto: formulação e circulação dos sentidos. Campinas: Editora Pontes; 2001.. The material was read exhaustively and in-depth in search of the discourse marks that would allow situating its materiality in a discursive and, therefore, ideological affiliation¹⁶16 Orlandi EP. Análise de Discurso: princípios e procedimentos. 8ª ed. Campinas: Editora Pontes; 2009.. Based on these marks, the texts were segmented, and the semantic groups were organized, and convergent segments were gathered. The discursive formations were then contextualized and associated with the current social discourses, in order to bring out the underpinning Ideological Background. Ideological background is understood as “a complex set of attitudes and representations that are ‘neither individual’, ‘nor universal’, but are more or less directly related to class positions in conflict with each other”¹⁷17 Pêcheux M, Fuchs C. A propósito da Análise Automática do Discurso: atualização e perspectivas. Tradução de Péricles Cunha. In: Gadet F, Hak T, organizadores. Por uma análise automática do discurso: uma introdução à obra de Michel Pêcheux. 3ª ed. Campinas: Unicamp; 1997 [1975]. p. 163-252., to reach discursive processes. The discursive formations were related to the ideological background and semantic phenomena in the light of the socio-historical context, giving rise to the discursive memories that guide the limits of interdiscourse, as well as what is the unspoken¹⁶16 Orlandi EP. Análise de Discurso: princípios e procedimentos. 8ª ed. Campinas: Editora Pontes; 2009.. In this process, two discursive formations emerged: (i) Strengths and Weaknesses that affect the work process; and, (ii) Limitations imposed by professional practice.

The ethical principles contained in Resolution No. 466/12 of the National Health Council¹⁸18 Brasil. Resolução nº 466, de 12 dezembro de 2012. Diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União; 2012. were respected. Managers used the letters T or G, respectively, followed by the number (1, ..., 19), as follows T1, T2, G1, G2, and the like, to safeguard workers’ identities. Next to the identification, the first reference of each participant contains professional training and gender.

Results

Characterization of participants

Nineteen workers participated in this research (seven also held management positions), from eight different services that assist women in situations of sexual violence, two of which are reference centers, and six are hospitals (Table 1).

Strengths and weaknesses identified that affect the work process

Strengths and weaknesses affecting the work process emerge among the points raised by participants. Concerning strengths, the service provided by the professionals stands out:

Among the weaknesses, worth highlighting is a lower number of workers as a factor that compromises comprehensive care with scheduled follow-up, not allowing systematization of care based on the user’s needs:

Besides not allowing the planning of actions, the shortage of workers reverberates in care. If the professional is in the service, the service is streamlined, as illustrated by T1:

However, the lack of a professional in the service will result in a delay in specific care, breaking the care chain. In this context, the organization of the professionals’ shifts is an intervening factor for the failure to achieve comprehensive care. T1 reinforces the challenge of this offer, to the extent that it interconnects the low number of professionals and their mismatches with the service users, justifying that:

Associated with the lower availability of human resources is the loss of supplies required for the service; for example, the loss of the car used to carry out the home visit that:

It is noteworthy that the municipality in question experiences the disruption of the psychosocial care network, exposing these women to pronounced suffering and narrowing the possibilities of being received in the recovery and maintenance of their mental health, because:

A good part of the participants signaled the disarticulation of the mental health care network and fragmentation in the search for comprehensiveness:

In order to fill this gap, workers use the psychology offices of the universities so that users can access the psychosocial service, recognizing the incipience in the implementation, implantation, and monitoring of public policies:

Besides weaknesses are the scarce professional training actions to address sexual violence, which was identified by one of the participants as a vital point of the services:

The gaps in the academic training of workers, which should be filled by training and in-service training, are learned in daily practice through the services provided, which cover inadequate and non-resolving flows. These workers would only need to know the existence of the flows, but they admit that:

We have a staff turnover that ends up interfering in the awareness and involvement with the theme in question due to the workforce’s labor recruitment modalities, which overly weakens the work process’ longitudinality, as explained in this statement:

Workers are also concerned about the lack of intersectoral articulation and announce that the Care Network is far from establishing itself, as:

The inappropriate environment is also cited as a complicating factor in the work process. Inadequate physical structures hinder humanized practices that consider and respect the antagonistic moments to which these women are exposed. The outburst of T7 outlines how far the services are from implementing the guidelines and strategies to provide ethical and legal assistance:

Another point highlighted for interfering adversely in the work practice is related to the loss of financial resources. This question ends up anchoring all the points mentioned above, because, as a reference to verbalization:

Limitations imposed by the practice of professionals and managers

Besides issues identified as weaknesses are those that emerge from silencing actions. For example, although pointing to the lack of network articulation, T4 is silent about protocols and flows agreed as guiding axes for comprehensive care. When questioned directly about the flows, the informant exposes the lack of training offered by the service, as well as exempts herself from a commitment signed with the service for which she was assigned:

Some statements are thus filled with silence and contradictions. T10’s statement verbalizes that there is no protocol, although she recognizes that it is described in the booklet. She justifies this lack because a service has not been created. Soon afterward, she states that professionals had been trained for the service. Then, T10 confirms the existence of the protocol, but justifies the non-use for personal reasons of some professionals, silencing the existing and recommended strategies to alleviate this issue:

In this context, the recurring discourse that instructive and legal devices are restricted to roles, and the inertia of texts comes to the fore. This understanding can be detected in the statement that borders on common sense, by venting that:

It is worth mentioning that the unit where T10 operates, in the initial project, there was a space for the care of women in situations of sexual violence, keeping confidentiality, and reception. That space was equipped with a place geared to interrupt rape-related pregnancies. The building was delivered with these reserved spaces, but institutional decisions shifted the use of this area to other purposes. While the lack of flows and protocols is pointed out as fragility, its existence is ignored by some professionals, as illustrated by G5’s statement below:

Silencing the reason why the banner with the care flow was not redone reveals the lack of interest in favoring the effective functioning of the network, a recurring weakness in the participants’ statements. The statements also expose a verticalized care model organized in a production line rationale, in which some professionals are limited to technical aspects, neglecting the recommended comprehensive care:

It is identified that the distancing of many prevents recognizing care to women in situations of sexual violence as inherent to their work so that there is not only ignorance about the theme, but a clear lack of interest in the issue. In this context, G2 states:

The manager’s recognition that the alleged ignorance is actually a reflection of disinterest did not, however, motivate sensitizing actions. Although silent about the need for awareness, G2 emphasized the existence of documentary aspects:

It is evident that even in institutions with protocol documents and flows, these are not accessed by workers, seeking other ways to encourage reading and familiarizing with the theme:

Discussion

The results found in this research reveal that the lapses in the work processes can forcefully interfere in the care to women in situations of sexual violence. The statements verbalize complaints about the lack of an effective network, which has progressively deteriorated in recent years. The dismantling of women’s health care, especially with regard to sexual and reproductive rights¹⁹19 Zanatta LF, Grein MI, Álvarez-Dardet C, Moraes SP, Brêtas JRS, Ruiz-Cantero MT, Roses M. Igualdade de gênero: por que o Brasil vive retrocessos? Cad Saude Publica 2016; 32(8):e00089616., traverses the institutional route²⁰20 Oliveira ACD. Agendas de gênero nas políticas públicas no Brasil (1980-2016). Rev Feminismos 2018; 5(2/3):1-6. and low investments in this area¹⁹19 Zanatta LF, Grein MI, Álvarez-Dardet C, Moraes SP, Brêtas JRS, Ruiz-Cantero MT, Roses M. Igualdade de gênero: por que o Brasil vive retrocessos? Cad Saude Publica 2016; 32(8):e00089616.. These care lapses are not exclusive to women’s health care. The lower number of professionals, high turnover and lack of training are events associated with factors such as the fragile employment relationships and the growing outsourcing of health services, compromising the health of workers²¹21 Druck G. A terceirização na saúde pública: formas diversas de precarização do trabalho.Trab Educ Saude 2016; 14(Supl. 1):15-43. and the quality of care²²22 Vieira LJES, Silva ACF, Moreira GAR, Cavalcanti LF, Silva RM. Protocolos na atenção à saúde de mulheres em situação de violência sexual sob a ótica de profissionais de saúde. Cien Saude Colet 2016; 21(12):3957-3965.. This reality, however, is associated with the dismantling of public health policies, and is present in other spheres²³23 Silva EB, Padoin SMM, Vianna LAC. Mulher em situação de violência: limites da assistência. Cien Saude Colet 2015; 20(1):249-258.^,2424 Santos WJ, Freitas MIF. Fragilidades e potencialidades da rede de atendimento às mulheres em situação de violência por parceiro íntimo. REME 2017; 21(e-):1-8..

Another emerging weakness in the statements that is not exclusive to care to women in situations of sexual violence is the fragmented, verticalized care. Although efforts are being made towards horizontal and integrated practice, changes in this health care model are modest²⁵25 Santos DS, Mishima SM, Merhy EE. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Cien Saude Colet 2018; 23(3):861-870., since the biomedical paradigm predominates in traditional urgent and emergency services, which “continue to operate traditionally, complaint-conduct-based, resulting in a reductionist and ineffective clinic [...]”⁵5 Cecílio LCO, Merhy EE. A integralidade do cuidado como eixo da gestão hospitalar. In: Pinheiro R, Mattos RA. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: IMS ABRASCO; 2003. p.197-210.. Thus, when it comes to sexual violence, service follows this same logic, based on evident signs and symptoms focused on medicalization and with little attention to psychosocial aspects²⁶26 Barros LA, Albuquerque MCS, Gomes NP, Riscado JLS, Araújo BRO, Magalhães JRF. The (un) receptive experiences of female rape victims who seek healthcare services. Rev Esc Enferm USP 2015; 49(2):193-200.. Thus, care is directed to the chief complaint, which ends up succumbing to comprehensive care⁸8 Vieira EM, Hasse M. Percepções dos profissionais de uma rede intersetorial sobre o atendimento a mulheres em situação de violência. Interface (Botucatu) 2017; 21(60):52-62.. Despite the evidence that associates sexual violence with the development of mental disorders²⁷27 Medeiros MP, Zanello V. Relação entre a violência e a saúde mental das mulheres no Brasil: análise das políticas públicas. Estud Pesq Psicol 2018; 18(1):384-403., lapses and barriers of access that culminate in lack of care are recursive⁸8 Vieira EM, Hasse M. Percepções dos profissionais de uma rede intersetorial sobre o atendimento a mulheres em situação de violência. Interface (Botucatu) 2017; 21(60):52-62.^,2828 Minayo MCS, Souza ER, Silva MMA, Assis SG. Institucionalização do tema da violência no SUS: avanços e desafios. Cien Saude Colet 2018; 23(6):2007-2016.. It is important to note that these services have a history of insecurity, deepening and reflecting notable setbacks in mental health policies²⁹29 Sousa FSP, Jorge MSB. O retorno da centralidade do hospital psiquiátrico: retrocessos recentes na política de saúde mental. Trab Educ Saude 2019; 17(1):e0017201..

However, the weaknesses of care to women in situations of sexual violence have singularities, insofar as the ideological context reinforces them. The contingent silence of the unequivocal¹⁵15 Orlandi EP. Discurso e Texto: formulação e circulação dos sentidos. Campinas: Editora Pontes; 2001. marked the absence more than evidence of the main lapses recorded in the work processes in question.

Regarding the environment, its adequacy is one of the strategies planned to ensure the privacy of these women seeking care³⁰30 Pinto LSS, Oliveira IMP, Pinto ESS, Leite CBC, Melo AN, Deus MCBR. Políticas públicas de proteção à mulher: avaliação do atendimento em saúde de vítimas de violência sexual. Cien Saude Colet 2017; 22(5):1501-1508.. It is undisputed that the legal interruption of shared pregnancy in areas destined for deliveries and births compromises humanization and contributes to women revictimization, which is partly associated with the decision to incorporate health care services for women in situations of sexual violence into public maternity hospitals, where inadequate physical structure predominates³¹31 Madeiro AP, Diniz D. Serviços de aborto legal no Brasil - um estudo nacional. Cien Saude Colet 2016; 21(2):563-572.. On recognizing the seriousness of these non-conformities, there is no coherent explanation for the use of planned spaces, built and delivered for the specific purpose of assisting women in situations of sexual violence, and reallocated for other purposes.

The results reinforce the need for continued training of workers for the consolidation of public policies³²32 Bezerra JF, Lara SRG, Nascimento JL, Barbieri M. Assistência à mulher frente à violência sexual e políticas públicas de saúde: revisão integrativa. Rev Bras Prom Saude 2018; 31(1):1-12., since the non-use of care protocols and flows limits the assistance provided²²22 Vieira LJES, Silva ACF, Moreira GAR, Cavalcanti LF, Silva RM. Protocolos na atenção à saúde de mulheres em situação de violência sexual sob a ótica de profissionais de saúde. Cien Saude Colet 2016; 21(12):3957-3965.. Failure to follow protocols and flows also reflects lapses of management, which does not incorporate sexual violence as a demand inherent in the service, culminating in hostilities without accountability and mistaken referrals²⁵25 Santos DS, Mishima SM, Merhy EE. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Cien Saude Colet 2018; 23(3):861-870.. However, the statements show that the lack of training is coupled with the lack of interest of managers and workers.

It is essential to point out that “comprehensiveness is a central element for the consolidation of a health model that incorporates more effectively universality and equity in the care of people to achieve resolutive actions in health” ³³33 Viegas SMF, Penna CMM. As dimensões da integralidade no cuidado em saúde no cotidiano da Estratégia Saúde da Família no Vale do Jequitinhonha, MG, Brasil. Interface (Botucatu) 2015; 19(55):1089-1100.. Based on the ethical dimension of care, Franco and Merhy³⁴34 Franco TB, Merhy EE. Cartografias do trabalho e cuidado em saúde. Rev Tempus Actas Saude Colet 2012; 6(2):151-163.^,3535 Franco TB, Merhy EE. O reconhecimento de uma produção subjetiva do cuidado. In: Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013. p. 151-171. argue that the ability to accommodate the needs of others cannot be “learned” by any specific knowledge, and is linked to relational and intersubjective processes. In this case, it is necessary to contextualize these statements in order to bring out the ideological formations that guide this lack of interest – and, in some cases, obstruction – on the part of workers in structuring services or following care flows.

Besides the standardization disciplines originating from biopower³⁶36 Foucault M. História da Sexualidade 1: a vontade de saber. São Paulo: Paz e Terra; 2015. are sex-political devices that place “sex” (genital anatomy, sexual practices, socio-cultural codes of masculinity and femininity, and identities) in the calculation of power, making an agent of life control³⁷37 Preciado B. Multidões queer: notas para uma política dos "anormais". Rev Estud Feministas 2011; 19(1):11-20. of these discourses. In this context, one cannot ignore that the subjectivity of many of these professionals was built amid these discursive processes³⁸38 Scott J. Gênero: uma categoria útil de análise histórica. Educ Realidade 1995; 20(2):71-99. and sexopolitics³⁷37 Preciado B. Multidões queer: notas para uma política dos "anormais". Rev Estud Feministas 2011; 19(1):11-20. guided by the control of women’s bodies and sexuality³⁶36 Foucault M. História da Sexualidade 1: a vontade de saber. São Paulo: Paz e Terra; 2015.^,3939 De Lauretis T. Technologies of Gender: Essays on Theory, Film, and Fiction. Bloomington: Indiana University Press; 1987.. Advances in arguments marked by political conservatism and religious fundamentalism, such as those that have gained strength in Brazil in recent years¹⁹19 Zanatta LF, Grein MI, Álvarez-Dardet C, Moraes SP, Brêtas JRS, Ruiz-Cantero MT, Roses M. Igualdade de gênero: por que o Brasil vive retrocessos? Cad Saude Publica 2016; 32(8):e00089616., do not appear so vehemently without the guidance of socially standardized statements¹⁵15 Orlandi EP. Discurso e Texto: formulação e circulação dos sentidos. Campinas: Editora Pontes; 2001.^,3838 Scott J. Gênero: uma categoria útil de análise histórica. Educ Realidade 1995; 20(2):71-99.. These statements are legitimized by social organizations and were previously standardized socially and culturally supported by diverse gender processes, discourses, and technologies³⁸38 Scott J. Gênero: uma categoria útil de análise histórica. Educ Realidade 1995; 20(2):71-99.^,3939 De Lauretis T. Technologies of Gender: Essays on Theory, Film, and Fiction. Bloomington: Indiana University Press; 1987.. It is not a coincidence that the obstruction to sexual and reproductive rights has been exposed and questioned in several countries⁴⁰40 Stahl RY, Emanuel EJ. Physicians, not conscripts-Conscientious objection in health Care. New Engl J Med 2017; 376(14):1380-1385.^,4141 Harries J, Cooper D, Strebel A, Colvin CJ. Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study. Reprod Health 2014; 11:16., as it is not justified in the context of Public Health. On the contrary, it results in increased female mortality⁴²42 Machado CL, Fernandes AMS, Osis MJD, Makuch MY. Gravidez após violência sexual: vivências de mulheres em busca da interrupção legal. Cad Saude Publica 2015; 31(2):345-353., reinforces a social structure that subordinates the social role of women to their reproductive capacity⁴³43 Despentes V. Teoria King Kong. São Paulo: n-1edições; 2016., and predisposes them to psychic illness⁴⁴44 Fiala C, Arthur JH. There is no defence for 'Conscientious objection' in reproductive healthcare. Eur J Obstet Gynecol Reprod Biol 2017; 216:254-258..

It should be noted that the lack of identification with the demands of women in situations of sexual violence was not linear among professionals. The respondents’ statements stemmed from different ideological backgrounds, which recognized the health needs of the women they assisted and sought to provide comprehensive care to⁴⁵45 Santos DS, Mishima SM, Merhy EE. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Cien Saude Colet 2018; 23(3):861-870.. Noteworthy is that the ideological differences concerning the care and reception of users are unrelated to the professional category, with higher affinity in the statements, depending on the care scenario instead of the profession itself. These professionals effectively participate in this care and see their work process obstructed on countless fronts⁴⁶46 Faúndes A, Duarte GA, Osis MJ. Conscientious objection or fear of social stigma and unawareness of ethical obligations. Int J Gynaecol Obstet 2013; 123:S57-S59.^,4747 Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22(43):141-148., because besides stigmatization⁴⁶46 Faúndes A, Duarte GA, Osis MJ. Conscientious objection or fear of social stigma and unawareness of ethical obligations. Int J Gynaecol Obstet 2013; 123:S57-S59., obstacles at work already cause suffering. Clot⁴⁸48 Clot Y. O ofício como operador de saúde. Cad Psicol Social Trab 2013; 16(esp. 1):1-11. affirms that “(...) professional effectiveness is a source of health at work when performance is not reduced to the abstraction of numbers”.

Thus, the perception of workers in doing a job well done is a health operator, and the inexistence of this experience could be seen as a source of frustration and loss of sense of work for those who feel sensitized to the importance of this issue. The low number of sensitized professionals leads to work overload, which added to the intense pressure and the lack of breaks, rest, and recovery times can affect the mental health of workers, which is inseparable from health as a whole⁴⁹49 Franco T, Druck G, Seligmann-Silva E. As novas relações de trabalho, o desgaste mental do trabalhador e os transtornos mentais no trabalho precarizado. Rev Bras Saude Ocup 2010; 35(122):229-248..

Final considerations

The study advances in the discussion of the theme of care to women in situations of sexual violence, insofar as it analyzes the work processes involved, starting from Discourse Analysis, which unveils what is not said, but is there and more naturalized in daily practices.

Fragmented care, service underfunding, inadequate physical structures, gaps in training, the low number of professionals and their high turnover in services act in line with ideological beliefs based on the control of sexuality and female bodies, building an intricate system of weaknesses, which impairs the work processes of assisting women in situations of sexual violence. These obstructions compromise the performance of sensitized professionals and managers, limiting the effectiveness of specific public policies.

These findings lead to an urgent need for structuring the network to implement and ensure the position of workers and managers involved in the care teams, so as to enable their continued qualification and promote awareness actions for others. The inclusion of continuing education aimed at addressing sexual violence in the workload of workers can be a tool for professional participation and continuous qualification, as well as the effective incorporation of care for women in situations of sexual violence in the service network by managers to ensure interdisciplinarity, intersectoriality, comprehensive care, and respect for the sexual and reproductive health of these women.

The effectiveness of these measures requires the recognition of the ideological background that hinders them. It is worth highlighting the Brazilian macro-political context that, despite the secularity of the Brazilian State, issues such as the guarantee of women’s sexual and reproductive rights, and interference in emergency contraception, are discussed based on religious dogmas and moralist attitudes of representatives of the legislative power, whose decisions are retroactive in the achievement of public policies for women. Thus, services must be organized to provide protection and care to women in situations of sexual violence, placing themselves in the countercurrent of loss of rights.

References

Publication Dates

History