Abstract

The cisheteropatriarchal capitalist system has developed by class, racial and sexual oppression and exploitation in establishing unequal, hierarchical power relations. One of these kinds of oppression involves the use of violence against bodies considered wayward and transgressive within this structure. Of the different types of violence, this study focused on obstetric violence, understood as patriarchal gender violence designed to remove the rights, autonomy and agency of trans women and men during the processes of pregnancy, childbirth, postpartum and abortion. This article reflects on obstetric violence and its impacts on homo-parenthood for lesbian women and trans men, on the understanding that the LGBTQIA+ population is one of the most vulnerable and removed from health services, mainly because of the institutional violence suffered by these bodies. Accordingly, the intention is to understand, through social and historical analysis, how these sexist, heteropatriarchal violations, interlacing and reflecting in health care for these people, generate even more forms of oppression against this population.

Key words:
Obstetric violence; Patriarchy; Homo-parenthood; Lesbophobia; Transphobia

Introduction

This article endeavours to respond to concerns raised during the authors’ research into obstetric violence from an intersectional perspective. It is part of broader research on the topic coordinated by one of the authors five years ago, involving Social Work and Psychology master’s and undergraduate course supervisions. In those five years, one certainty emerged: it is impossible to talk universally about obstetric violence. It occurs in many, diverse ways and especially to many, diverse subjects.

From a materialist, historical, dialectic, feminist and anti-racist perspective, it was necessary from the outset to understand obstetric violence as a result of capitalist, racist and patriarchal sociality, which, at the same time, is an instrument for maintaining the hierarchical power relations in that sociality.

When discussing that sociality, one encounters a construct, particularly with the establishment of capitalism, whose pre-existing conditions were the processes of colonisation and witch hunts, which structured an existing social, political and economic system on the basis of relations of class, race and sex/gender oppression and exploitation by instituting unequal and hierarchical power relations.

On that perspective, obstetric violence is understood to be sexist violence against women and trans men who are pregnant, characterised by dehumanised treatment by health services, abuse of medicalisation and pathologisation of natural processes by appropriating the body and reproductive processes of women and trans men, which can be achieved physically, psychologically, sexually, institutionally, materially and even through the media. Obstetric violence results in loss of autonomy and the ability to decide freely about bodies and sexuality, while maintaining control and domination of those bodies.

When thinking about the subjects of this violence, it is essential to understand that patriarchy decrees domination by men and subjugation and domination of women. In doing so, based on the sexual division of labour, it necessarily entails impacts on social relations of sex and sexuality, making sexual diversity and all its forms of expression unfeasible. This sociality establishes the male/female, masculine/feminine and manhood/womanhood model on a binary perspective that demarcates heterosexuality. Accordingly,

Accordingly, it is more than necessary to ask: although obstetric violence is understood to be sexist violence against women, what other factors permeate this issue in a cisheteropatriarchal society?

Drawing on an understanding of the process of objectification and dehumanisation of trans women and men, this article reflects on obstetric violence traversed by lesbophobia and transphobia, framing the debate on how obstetric violence occurs with different sexes/genders, races and classes, often interrelating and causing more violence, which creates greater benefits and opportunities for those (white, heterosexual and bourgeois men) who enjoy positions of privilege and prestige in this sociality²2 Diniz SG. Gênero, saúde materna e o paradoxo perinatal. J Hum Growth Develop 2009; 19(2):313-326..

To that end, a bibliographical and documentary search was conducted for studies on the topic and data about the experience of LGTBphobia, as well as a literature review involving patriarchy, racism, colonisation, obstetric violence, lesbophobia and transphobia.

When the major journal platforms SciELO, PubMed, PePSIC and Periódicos Capes were searched using the descriptors in Portuguese “obstetric violence and lesbians”; “obstetric violence and lesbophobia”; “obstetric violence and trans people”; “obstetric violence and transphobia” and “obstetric violence and LGBT”, no results were found in the combination of these descriptors. Repeating the search using the descriptors in Portuguese “motherhood and lesbians”; “motherhood and lesbophobia”; “motherhood and trans people” and “motherhood and transphobia” returned some articles addressing motherhood or homoparenting, but with no relation to obstetric violence, the closest topic being the different forms of assisted reproduction and pregnancy.

In a country with 2.9 million people aged 18 or over who declare themselves lesbian, gay or bisexual, 3.6 million who say they do not know their sexual orientation³ and which received, via the Dial 100 hotline, 2,536 complaints of LGBTQIA+ rights violations in the first five months of 2023⁴4 Brasil. Ministério dos Direitos Humanos e da Cidadania. Disque 100 registra aumento de mais 300% em denúncias de violações contra pessoas LGBTQIA+ nos primeiros cinco meses de 2023 [Internet]. [acessado 2023 out 15]. Disponível em: https://www.gov.br/mdh/pt-br/assuntos/noticias/2023/junho/disque-100-registra-aumento-de-mais-300-em-denuncias-contra-pessoas-lgbtqia-nos-primeiros-cinco-meses-de-2023.
https://www.gov.br/mdh/pt-br/assuntos/no... , it would seem more than necessary also to discuss the violence that lesbian women and men trans people are subjected to conception to birth, with a view to addressing LGBTQIA+ people’s right to parenthood, as well as children’s right to a loving upbringing.

We hope that this article will contribute to debate on these issues, broaden the perspective on obstetric violence and show the LGBTQIA+ population the need to think about, and take a stance on, this kind of patriarchal violence, because giving visibility to this issue is also a way to combat the violations.

Interlacing violations in the entanglement among class, race, gender/sex and sexuality

Federici⁶6 Federici S. Mulheres e caça às bruxas: da Idade Média aos dias atuais. 1ª ed. Trad.: Candiani HR. São Paulo: Boitempo, 2019. argued that, at the same time that the State and men appropriated women’s bodies, these also served as the chief terrain for their exploitation and resistance and thus gained deserved importance in all respects, such as motherhood, childbirth and sexuality.

Resistance to patriarchy confronts the power of large institutions, which respond by dehumanising subjects who transgress this model. They are opposed by religious and biological medical ideologies, on the belief that women’s bodies are unpredictable and potentially dangerous and that it must thus be corrected by interventions²2 Diniz SG. Gênero, saúde materna e o paradoxo perinatal. J Hum Growth Develop 2009; 19(2):313-326..

Hetero- (or cishetero-) patriarchy can be considered a political and social system in which cisgender male heterosexuality has supremacy over other forms of gender identity and over other sexual orientations, reducing human diversity to a cis, heterosexual, masculine and bourgeois standard.

Understood as a structuring part of capitalist development, patriarchy serves the social and economic interests of private property and the social and sexual division of labour, in which women become responsible for reproduction not understood as part of social production. In Saffioti’s words, women become “objects of men’s sexual satisfaction and reproducers of heirs, the workforce and new reproducers”⁵5 Saffioti HI. Gênero, patriarcado, violência. 1ª ed. Sa~o Paulo: Fundação Perseu Abramo; 2004.(p.105).

To understand better how sex, class, race and sexuality relate to obstetric violence, it is important to provide a historical contextualisation of the roots of this form of rights abuse.

Federici⁶6 Federici S. Mulheres e caça às bruxas: da Idade Média aos dias atuais. 1ª ed. Trad.: Candiani HR. São Paulo: Boitempo, 2019. discussed how the enclosure of English lands, once the commons, influenced accusations of witchcraft in the late 15^th century. That privatisation increased land taxes, ended customary rights and displaced the farming population, which polarised relations of reciprocal ties and, as properties became private, brought with it the loss of communal life and intensified hostility. The figure of the “witch” was used to punish types of behaviour considered “problematic”, such as attacks on private property, social insubordination, spreading magical beliefs and what were considered to be deviations from the sexual norm because, at that time, sexual behaviour and procreation were the domain of the State⁷7 Guimarães CS. Mulher: corpo incivilizado - A crítica feminista marxista de Silvia Federici a Michel Foucault. In: XVII Semana Acadêmica do PPG em Filosofia da PUCRS [Internet]. Porto Alegre: Editora Fi; 2018 [acessado 2023 jun 20]. p. 131-144. Disponível em: http://wap.precog.com.br/bc-texto/obras/2019-pack-045.pdf#page=131..

Spink⁸8 Spink MJ. Capítulo 10 - As origens históricas da obstetrícia moderna. In: Psicologia social e saúde: práticas, saberes e sentidos. Petrópolis: Editora Vozes; 2003. p. 169-193. added that these women, considered witches, healers and midwives, challenged the main medieval hierarchies, because they went against the sovereign power of the church, of man over woman and the feudal lord over the peasant.

It can be seen that the idea of burning these women was also to eliminate social beliefs and practices seen as dangerous to the church and necessary for the birth of capitalism, because they represented a source of power independent of these latter two. The process culminated in an “enclosure of knowledge, of our body, of our relationship with other people and with nature”⁶6 Federici S. Mulheres e caça às bruxas: da Idade Média aos dias atuais. 1ª ed. Trad.: Candiani HR. São Paulo: Boitempo, 2019.(p.55).

That same historical period experienced the process of colonisation, which dominated African bodies and the original peoples of Latin America. A parallel can be drawn between the oppression and violations experienced by women during the witch hunts, the enslavement of Africans and the extermination of indigenous peoples in the “New World”.

Góes⁹9 Góes WL. Capítulo 1: racismo e eugenia na formação social brasileira. In: Silva MLO, Passos RG, Eurico MC, Gonçalves R, organizadores. Antirracismos e serviço social. São Paulo: Cortez Editora; 2022. p. 25-37. argued that capitalism was only effective worldwide because it availed itself of the exploitation of slave labour and trafficking of Africans, which in addition to causing numerous racial inequality effects, helped concentrate power and capital still further in the hands of the few.

Importantly, the construction we are talking about was fully supported by Catholic church ideology, in a contradictory process of a bourgeois political and economic revolution together with the assertion of conservative customs and values that defended tradition, the family and the church - just as in the elaborations of the great exponent of conservative thought, Burke¹⁰10 Burke E. Reflexões sobre a revolução na França. In: Weffort F. Os clássicos da política. São Paulo: Editora Ática; 2001. - as fundamental elements for modernity. “Burke wants capitalist economic development to continue without breaking with pre-capitalist social institutions [...] Burke wants capitalism without Modernity”¹¹11 Escorsim Netto L. O conservadorismo clássico: elementos de caracterização e crítica. Sa~o Paulo: Cortez Editora; 2011..

Violence is, therefore, part of the structure maintaining power relations in this sociability and is used as an instrument of control to this day, its main targets being those who do not abide by the morally constructed models.

Accordingly, it is argued here that one cannot talk about one kind of oppression without talking about the others and that, in order to combat violence and gain rights, one must first understand that oppressions cannot be hierarchised, as demonstrated by Lorde¹³13 Lorde A. Não existe hierarquia de opressão [Internet]. Portal Géledes; 2015 [acessado 2023 out 13]. Disponível em: https://www.geledes.org.br/nao-existe-hierarquia-de-opressao.
https://www.geledes.org.br/nao-existe-hi... :

Cisheteropatriarchal violence can be understood as expressed in diverse forms, “physical, sexual, psychological, patrimonial, moral, obstetric and social”, as specified by Cisne and Santos¹1 Cisne M, Santos SMM. Capítulo 1: Fundamentos teórico-políticos da diversidade humana, do heteropatriarcado e do racismo. In: Santos SMM. Feminismo, Diversidade Sexual e Serviço Social. São Paulo: Cortez Editora; 2018.(p.70). In these terms, let us return to our assumption that obstetric violence must be understood as one patriarchal gender violence.

The Public Defender’s Office describes obstetric violence as

Discriminatory and inhumane attitudes in childbirth care, in both public and private spheres, are marked by “labour dominated by fear, loneliness and pain, in institutions that delegitimise the sexuality and reproduction of women considered inferior, especially black, single and low-income women, and stigmatise teenage motherhood”²2 Diniz SG. Gênero, saúde materna e o paradoxo perinatal. J Hum Growth Develop 2009; 19(2):313-326.(p.320).

It is important to remember that obstetric violence comprises processes that occur from conception, through pregnancy to postpartum, involving abortions, the postpartum period and breastfeeding, and can be committed by any health professional and/or family member or companion.

The Parto do Princípio network¹⁵15 Rede Parto do Princípio. Dossiê Violência obstétrica "Parirás com dor" [Internet]. 2012 [acessado 2023 maio 6]. Disponível em: https://www.senado.gov.br/comissoes/documentos/SSCEPI/DOC%20VCM%20367.pdf.
https://www.senado.gov.br/comissoes/docu... summarised how this violence occurs and gave several examples:

Media: actions by professionals through the media, aimed at violating women in reproductive processes psychologically, as well as denigrating* their rights by messages, images or other publicly circulated signs; defence of scientifically contraindicated practices, for social or economic purposes or for domination [...]¹³13 Lorde A. Não existe hierarquia de opressão [Internet]. Portal Géledes; 2015 [acessado 2023 out 13]. Disponível em: https://www.geledes.org.br/nao-existe-hierarquia-de-opressao.
https://www.geledes.org.br/nao-existe-hi... (p. 60-61; *The term “denigrating” was maintained in the direct quote, although it is important to stress that the term is pejorative, as it reinforces blackness as something offensive. This term may be replaced by defaming or slandering).

In the last survey of obstetric violence in Brazil, carried out in 2010 by the Perseu Abramo Foundation¹⁶16 Fundação Perseu Abramo. Mulheres brasileiras e gênero nos espaços público e privado [Internet]. São Paulo: Fundação Perseu Abramo; 2010 [acessado 2023 abr 24]. Disponível em: http://www.apublica.org/wp-content/uploads/2013/03/www.fpa_.org_.br_sites_default_files_pesquisaintegra.pdf., 25% of Brazilian women declared having suffered a human rights violation of this kind (as defined by the UN). Data on obstetric violence are often underreported, both because people are unaware that this category of violence exists or how it occurs and because more recent studies and research are lacking.

These questions of freedom and knowledge are already raised recurrently by heterosexual and cis women; with regard to the LGBTQIA+ population, these data are even more scarce and healthcare staffs even less thoughtful, added to which there is a lack of knowledge of how obstetric violence can interlace with other patriarchal violence, such as lesbophobia and transphobia.

Obstetric violence, LGBTQIA+phobia and multiple rapes

Because the issues it involves are so important and heterogeneous, this discussion becomes very complex, as it is experienced differently in different bodies. LGBTQIA+ people’s experiences of violations are heightened, because generally there is already discrimination due to non-acceptance in social and emotional relationships, because these people stand outside the heterocisnormative model, which tends to lead to loneliness, sex work, physical, verbal, psychological and sexual violence and even death resulting from LGBTphobia¹⁷17 Santana ADS, Lima MS, Moura JWS, Vanderley ICS, Araújo EC. Dificuldades no acesso aos serviços de saúde por lésbicas, gays, bissexuais e transgêneros. Rev Enferm UFPE Online 2020; 14:e243211.. These bodies, uniquely, have experienced singular forms of violence that can interweave and produce multiple other violations.

Despite the existence in Brazil of a National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (LGBT) and a transsexualisation process available through the national health system (SUS), the LGBTQIA+ population continues to be the most marginalised from health service access and universal care through the SUS, as well as suffering most from inappropriate professional conduct.

Like sexist violence against women and trans people, obstetric violence affects women’s bodies directly. As already mentioned, however, this occurs in different ways depending on class, race and sexual orientation. Obstetric violence suffered by bi- or homosexual women and trans men may, thus, involve other violations and endow obstetric violence with different characteristics deriving from lesbo- and transphobia.

Health service staff may take discriminatory attitudes towards lesbian women, because of the delegitimisation of homosexual couples, as well as denying specific care even before pregnancy, for example, necessary tests or treatment, mainly for the unjustified and unscientific reason that their sexual practices involve no penile penetration, as if that were the only type of relationship where complications arise, making preventive tests unnecessary in same-sex female couples¹⁷17 Santana ADS, Lima MS, Moura JWS, Vanderley ICS, Araújo EC. Dificuldades no acesso aos serviços de saúde por lésbicas, gays, bissexuais e transgêneros. Rev Enferm UFPE Online 2020; 14:e243211..

Specifically in obstetric care for same-sex couples, there is once again enormous unpreparedness and discrimination on the part of professionals, who deny from the outset the experience of homoparenthood resulting from conception that is different from that of heteronormative couples and who do not know to deal with this family formation. This even involves denying the woman and mother who is not pregnant and rendering her invisible.

In a chapter entitled “The desire to be a mother alongside another mother”, Marcela Tiboni¹⁸18 Tiboni M. O desejo de ser mãe ao lado de outra mãe. In: Bacarat A, Bastos D, Batista G, Moreiras L, Tiboni M, Camardelli M. Maternidades no plural: Retratos de diferentes formas de maternar. Sa~o Paulo: Fontanar; 2021. comments on the pleasures of being a mother alongside another woman, without the need to get pregnant, as this had never been her wish, and the whole journey involving decisions and pathways, as well as pain and prejudice, not experienced by heteronormative couples.

I had never considered the possibility of becoming a mother without having to get pregnant, but now, in a lesbian relationship, that was actually a possibility. In addition to discovering myself and discovering a new way of relating, I discovered a new way of thinking about family compositions, of thinking about motherhood and of understanding the different forms of motherhood¹⁸18 Tiboni M. O desejo de ser mãe ao lado de outra mãe. In: Bacarat A, Bastos D, Batista G, Moreiras L, Tiboni M, Camardelli M. Maternidades no plural: Retratos de diferentes formas de maternar. Sa~o Paulo: Fontanar; 2021.(p.15).

Almost everywhere we were together, people addressed Mel to talk about the issues of motherhood. [...] Many did not know how to name my presence in this Parenthood. Obviously, I couldn’t be the father, because I was female, nor did I seem to be the mother, because there was a pregnant woman in the couple. So who could I be?¹⁸18 Tiboni M. O desejo de ser mãe ao lado de outra mãe. In: Bacarat A, Bastos D, Batista G, Moreiras L, Tiboni M, Camardelli M. Maternidades no plural: Retratos de diferentes formas de maternar. Sa~o Paulo: Fontanar; 2021.(p.48).

Discrimination has impacts not only on aspects of emotion and affect, but on women’s bodies and health, ultimately interfering with their comprehensive care by fostering violations of their sexual and reproductive rights resulting from lack of specific information, lack of guidance on reproductive techniques, the possibility of one or both women’s participating biologically, dual breastfeeding, as well as deprivation of rights, as in not allowing the mother who is not pregnant to attend the birth¹⁹19 Soares MC. Mulheres homossexuais sofrem preconceito no sistema de saúde na maternidade [Internet]. Agência Universitária de Notícias, Universidade de São Paulo; 2018 [acessado 2023 maio 25]. Disponível em: https://aun.webhostusp.sti.usp.br/index.php/2018/07/03/mulheres-homossexuais-sofrem-preconceito-no-sistema-de-saude-na-maternidade..

The Paraná State Public Defender’s Office stipulated:

Soares¹⁹19 Soares MC. Mulheres homossexuais sofrem preconceito no sistema de saúde na maternidade [Internet]. Agência Universitária de Notícias, Universidade de São Paulo; 2018 [acessado 2023 maio 25]. Disponível em: https://aun.webhostusp.sti.usp.br/index.php/2018/07/03/mulheres-homossexuais-sofrem-preconceito-no-sistema-de-saude-na-maternidade. argues that there is also a class barrier to many of these women’s becoming pregnant and gestating, because there is as yet no national law providing for same-sex couples to undergo the assisted reproduction process through the SUS, causing many women to resort to home methods, which do not always guarantee the necessary tests for safe insemination with no risk of infections, or to the private health system, which not only charges extremely high prices, but also discriminates.

In cases of assisted reproduction, there are biological, emotional and cultural decisions to be made om choosing which woman will bear the baby; this does not hierarchise the mothers, because the relationships they have built override any genetic connection. Nonetheless, a place of effacement is reserved for the mother who will not be pregnant and for her motherhood, from the outset of pregnancy and especially after birth, in that everyday life and our society itself - built along heteronormative lines - ultimately marginalise that woman, even from legal decisions regarding the children²¹21 Amorim ACH, Oliveira MB. Dupla Maternidade: Conexões entre Antropologia e Direito. Seminário Internacional Fazendo Gênero (Anais Eletrônicos) [Internet]. 2012 [acessado 2023 dez 12]. Disponível em: https://www.mprj.mp.br/documents/20184/151138/amorim.pdf.
https://www.mprj.mp.br/documents/20184/1... .

In such cases, once again there is patriarchal sexist violence, strongly related to the institutional and symbolic violence suffered by these mothers, since cross-cutting concerns of gender and sexual orientation, added to a cisheteropatriarchal social construction, mean that once again these women’s rights and motherhood are denied.

The experience of obstetric violence can be seen to interlace with that of lesbophobia, with one often being denied or concealed to the detriment of the other.

Within the LGBTQIA+ population, there is also the situation of trans men who conceive and give birth, which entails other layers of reflection in understanding obstetric violence and its interweave with transphobia. Trans parenthood is even more stigmatised and less recognised, with implications and conditions different from those mentioned here in relation to homoparenthood by couples of cis women.

In addition to clashing with heteronormativity, trans people come up against legal procedures and the ambivalence between social invisibility and constant threat that can accompany the status of trans parenthood, which is seen socially as strange.

It is essential that more in-depth research and studies be conducted on this parenting, which can be hetero- or homo-affective, and all the specific features and demands of these relationships, so as to ensure precisely that there is no further effacement of all expressions of these parenthoods²²22 Souza É. Papai é homem ou mulher? Questões sobre a parentalidade transgênero no Canadá e a homoparentalidade no Brasil. Rev Antropol 2013; 56(2):397-430.. These need to consider, for example, what the appropriate nomenclature for trans parenthood would be: transparenthood? And what if the trans parenthood is experienced by a same-sex couple: homotransparenthood?

In the great majority of situations (perhaps all), trans men have been socialised as women and thus still display aspects of that socialisation, often including the idea of compulsory pregnancy. On the other hand, they are seen and position themselves socially as men, often enjoying male privileges and reproducing male superiority in their relationships. They also experience all the prejudices still present in cisheteropatriarchal society and, during pregnancy, childbirth and postpartum, they are regarded biologically as women and require care to meet the needs and demands of the body that carries female sexual and reproductive organs, but they are generally mistreated for their daring to transgress the patriarchal model and seeking to belong to their gender, in which they are totally disrespected in their condition as trans men.

In many cases, the relationship with the body features is strongly in trans men. For some of them, dealing with examinations and exposure of sexual organs can be a disturbing experience and may “be related to the violations experienced by these men in a context of transphobia institutional, which do not recognise this ‘abject’ body as possibly able to ‘gestate’ and because they are placed in health care settings, such as ‘maternity wards’ facilities designed to provide care for cisgender women”²⁴24 Pereira DMR, Araújo EC, Silva ATCSG, Abreu PD, Calazans JCC, Silva LLSB. Evidência Científicas Sobre Experiências de Homens Transexuais Grávidos. Texto Contexto Enferm 2022; 31:e20210347.(p.9), which leads to feelings of non-belonging and accentuates physical and psychological health vulnerabilities²⁴24 Pereira DMR, Araújo EC, Silva ATCSG, Abreu PD, Calazans JCC, Silva LLSB. Evidência Científicas Sobre Experiências de Homens Transexuais Grávidos. Texto Contexto Enferm 2022; 31:e20210347..

Another specific feature of the trans population, which also interferes strongly with reproductive health relationships, is sterility, not only that caused by the transsexualisation process, which can in fact make biological reproduction impossible, but also a symbolic sterility, as if even choosing to reproduce and experience parenthood, whether biological or not, were an impossibility²⁵25 Angonese M, Lago MCS. Direitos e saúde reprodutiva para a população de travestis e transexuais: abjeção e esterilidade simbólica. Saude Soc 2017; 26(1):256-270..

The outcome of these violations is care that is transphobic, discriminatory and invasive, closed to dialogue and understanding the subjectivity and specifics of the experience. The failings range from misuse of pronouns to non-use of hormones and masculinising mammoplasty, for example, which violates the right to comprehensive care and reaffirms stigmatisation.

Soares¹⁹19 Soares MC. Mulheres homossexuais sofrem preconceito no sistema de saúde na maternidade [Internet]. Agência Universitária de Notícias, Universidade de São Paulo; 2018 [acessado 2023 maio 25]. Disponível em: https://aun.webhostusp.sti.usp.br/index.php/2018/07/03/mulheres-homossexuais-sofrem-preconceito-no-sistema-de-saude-na-maternidade. found that health service care was naturalised to serve society to heteronormative standards and, therefore, that LGBTQIA+ people often do not feel represented and welcome in that system. The heteronormative model, which ultimately excludes other family formations, is naturalised and reaffirmed and the whole service is organised on the basis of that format, from posters and photos to forms that offer fields for men and women as the only options, once again demonstrating structural, systemic discrimination.

That structural effect is so forceful that some trans men are afraid of how their trans status may lead to stigma and make victims of their children, whose father deviated from the established standard. This internalised transphobia is so strong that they are afraid of violating their children’s rights by experiencing parenthood, as if it were forbidden to them. This once again, shows how these cisheteropatriarchal structures are so deeply rooted that denial of rights seems inherent to the individuals’ lives²⁷27 Dantas DS, Neves ALM. Parentalidade de homens trans: uma revisão interativa. Rev Bras Estud Hemocultura 2023; 6(20):60-82..

Here again, one sees how oppressions and hierarchies of power relations intertwine with obstetric violence, demonstrating that it is fundamentally important to think about parenthood in the lives of the LGBTQIA+ population - from conception, through pregnancy, childbirth and the postpartum period - in such a way as to guarantee rights and safe experiences.

Final remarks

Given these reflections, it can be reaffirmed that, as a form of patriarchal sexist violence, obstetric violence is enormously influenced by its interweaving with various other forms of oppression. This study focused on aspects involving homoaffective couples of women and couples including a trans man, whether in heterosexual or homoaffective relationships. There is also a need to think about other bodies, such as non-binary people, queers, which unfortunately was not possible in this study. There is also an entanglement with other social markers, such as disability, obesity, ageism, adolescence and many others that certainly deserve thinking about when discussing obstetric violence.

And why is this important? Not only because it acknowledges human and sexual diversity, but fundamentally towards thinking about public policies to combat obstetric violence in all its forms and with all its different nexuses in the entanglement of oppression and rights violations. How the knot is tied can change its shape, its function and how it will be untied.

It has to be understood that, in a patriarchal, racist, capitalist society, care will certainly suffer the impact of issues that cut across the hierarchies of race, class and gender/sex, as well as various social markers, to produce violent institutional practices, which result in a lack of receptiveness and appropriate conduct, as occurs in several situations where moral judgment overrides professional ethics²¹21 Amorim ACH, Oliveira MB. Dupla Maternidade: Conexões entre Antropologia e Direito. Seminário Internacional Fazendo Gênero (Anais Eletrônicos) [Internet]. 2012 [acessado 2023 dez 12]. Disponível em: https://www.mprj.mp.br/documents/20184/151138/amorim.pdf.
https://www.mprj.mp.br/documents/20184/1... .

In that respect, obstetric violence can also occur in situations of miscarriage and abortion, which, as it is criminalised in Brazil, is regarded as a major taboo. Health care professionals are already unprepared to manage these events in heterosexual and cis women; with the LGBTQIA+ population, this service will be even more violent, which alienates them still further from these services.

It is of the utmost importance to be able to bring this population to health services, so that subjects can feel welcome in these places that have committed numerous violations of their rights: this requires support groups and other means of discussing this issue, which is still very much unspoken in services. At the same time, it is necessary to demand continued professional development and capacity-building for health professionals, as well as institutional reorganisation so as to produce comprehensive care without abuses¹⁹19 Soares MC. Mulheres homossexuais sofrem preconceito no sistema de saúde na maternidade [Internet]. Agência Universitária de Notícias, Universidade de São Paulo; 2018 [acessado 2023 maio 25]. Disponível em: https://aun.webhostusp.sti.usp.br/index.php/2018/07/03/mulheres-homossexuais-sofrem-preconceito-no-sistema-de-saude-na-maternidade., because it must be the State’s responsibility to combat the reproduction of abuses.

Pregnancy, childbirth and the postpartum period can be moments of great happiness, but they are a time of very significant physical and emotional changes, which can lead to insecurity, fear, unknowing and anguish. So many changes in a short period of time can place the trans woman or man in a situation of even greater psychosocial vulnerability and, associated with a lack of staff and service preparedness to provide excellent perinatal care, in addition to other forms of violence that are now recurrent in our society (machismo, LGBTphobia, racism and other diverse rights abuses), can cause great suffering. Therefore, it is essential that the various fields of health care give attention to this population, so as to combat not only obstetric violence, but also to build a more respectful society. As in the classic phrase by Dr. Michel Odent, a person of reference in humanising childbirth, “to change the world, we must first change the way the babies are being born”.

References

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