Abstract:

Little is known about how perceptions of government affects women’s views of violence against women. This qualitative study examines women’s perceptions of violence against women laws and trust in the health and legal sector response in São Paulo State, Brazil. Thirty interviews with female residents of Santo André, 18 years and older, were audio recorded, transcribed, coded, and analyzed for themes using MAXQDA12 software. All women were familiar with at least one federal violence against women law. They expressed widespread lack of trust in the government. They viewed the legal sector as ineffective and felt violence against women laws have little impact, or exacerbate violence. Disdain for the health sector was less prominent than for the legal sector. A generalized lack of trust in government manifests as a lack of confidence in these laws for women seeking support through legal and health sectors. Adoption of legal protections for women is a significant accomplishment. However, health and legal sector violence against women response needs to consider perceptions of government, how violence against women laws are operationalized, and the role of each sector in ensuring women’s safety. Violence against women response efforts should include standardized intersectoral procedures including referral to accessible resources and means of screening women who may be at high risk for femicide.

Keywords:
Violence; Gender and Health; Criminal Law; Government

Resumo:

Há poucos estudos sobre a maneira pela qual o governo é percebido e como isso afeta as opiniões das próprias mulheres sobre a violência contra mulheres. Este estudo qualitativo examina as percepções das mulheres em relação as leis sobre violência contra mulheres e a confiança delas na resposta dos setores de saúde e direito no Estado de São Paulo, Brasil. Foram realizadas 30 entrevistas com mulheres acima de 18 anos de idade, residentes em Santo André. As entrevistas foram gravadas, transcritas, codificadas e analisadas tematicamente com o uso do software MAXQDA12. Todas as mulheres conheciam pelo menos uma lei federal sobre violência contra mulheres. Elas manifestavam uma desconfiança generalizada em relação ao governo. Consideravam ineficazes as respostas do setor jurídico. Achavam que as leis sobre violência contra mulheres tinham pouco impacto, e que eventualmente exacerbavam a violência. Havia menos desconsideração em relação ao setor de saúde, comparado ao setor jurídico. A desconfiança generalizada em relação ao governo se manifesta enquanto falta de confiança nas leis para mulheres que buscam apoio através dos setores jurídico e sanitário. A adoção de salvaguardas formais para as mulheres representa um avanço significativo. Entretanto, a resposta à violência contra mulheres pelos setores jurídico e sanitário deve levar em conta as percepções em relação ao governo, e de como as leis sobre a violência contra mulheres são operacionalizadas, além do papel de cada setor na garantia da segurança das mulheres. As respostas à violência contra mulheres devem incluir procedimentos intersetoriais padronizados, incluindo o encaminhamento para triagem de mulheres expostas a risco elevado de feminicídio.

Palavras-chave:
Violência; Gênero e Saúde; Direito Penal; Governo

Resumen:

Se sabe poco acerca de cómo las percepciones sobre el gobierno afectan los puntos de vista de las mujeres sobre la violencia que se ejerce sobre ellas. Este es un estudio cualitativo que examina las percepciones de las mujeres sobre las leyes relativas a la violencia contra mujeres y su confianza en la salud y en la respuesta del sector legal en el estado de São Paulo, Brasil. Se realizaron 30 entrevistas con mujeres residentes de Santo André, de 18 años y edad superior, se grabaron en audio, transcribieron, codificaron y analizaron para los temas usando el software MAXQDA12. Todas las mujeres estuvieron familiarizadas con al menos una ley federal sobre violencia contra mujeres. Ellas expresaron una falta generalizada de confianza en el gobierno. Consideraban al sector legal como ineficiente. Sentían que las leyes sobre la violencia contra mujeres tenían un escaso impacto ante la exacerbada violencia. El desdeño por el sector de salud fue menos prominente que por el sector legal. Una falta generalizada de confianza en el gobierno se manifiesta en una falta de confianza en estas leyes para las mujeres que buscan apoyo legal a través del mencionado sector y el de salud. La adopción de medidas legales para las mujeres es un logro significativo. No obstante, la respuesta sobre los sectores de salud y legal, en cuanto la violencia contra mujeres, necesita considerar las percepciones acerca del gobierno, de qué forma se aplican las leyes, así como el rol de cada sector para asegurar la seguridad de las mujeres. Los esfuerzos para atajar la violencia contra mujeres deberían incluir procedimientos estandarizados intersectoriales que proporcionen recursos accesibles y medios de supervisión a las mujeres que tal vez estén en alto riesgo de feminicidio.

Palabras-clave:
Violencia; Género y Salud; Derecho Penal; Gobierno

Introduction

Public trust in government plays a critical role in the success or failure of policies that require the cooperation and compliance of citizens ¹1. Organization for Economic Co-operation and Development. Trust and public policy: how better governance can help rebuild public trust. http://dx.doi.org/10.1787/9789264268920-en (accessed on 23/Jan/2019).
Trust and public policy: how better gove... ^,22. Organization for Economic Co-operation and Development. Trust in government. http://www.oecd.org/gov/trust-in-government.htm (accessed on 23/Jan/2019).
http://www.oecd.org/gov/trust-in-governm... . In Brazil, an ongoing corruption scandal is negatively impacting trust in government ³3. Watts J. Brazil's health system woes worsen in economic crisis. Lancet 2016; 387:1603-4.^,44. Watts J. Brazil faces fresh turmoil after President Temer charged with corruption. The Guardian 2017; 27 jun. https://www.theguardian.com/world/2017/jun/27/brazils-president-michel-temer-charged-over-alleged-corruption.
https://www.theguardian.com/world/2017/j... ^,55. Phillips D. Brazil's ex-president Lula sentenced to nearly 10 years in prison for corruption. The Guardian 2017; 12 jul. https://www.theguardian.com/world/2017/jul/12/brazil-president-lula-convicted-corruption.
https://www.theguardian.com/world/2017/j... . Citizens believe most politicians are corrupt and act in their own self-interest; trust in government institutions remains objectively low ⁴4. Watts J. Brazil faces fresh turmoil after President Temer charged with corruption. The Guardian 2017; 27 jun. https://www.theguardian.com/world/2017/jun/27/brazils-president-michel-temer-charged-over-alleged-corruption.
https://www.theguardian.com/world/2017/j... ^,66. Barbara V. Brazil's new President isn't even in office and he's already damaged our health care. The New York Times 2018; 11 dec. https://www.nytimes.com/2018/12/11/opinion/brazil-health-care-bolsonaro.html
https://www.nytimes.com/2018/12/11/opini... .

In 2006, the Maria da Penha Law on Domestic and Family Violence became Brazil’s first national law to define and criminalize violence against women, and establish mechanisms to punish perpetrators ⁷7. Brasil. Lei nº 11.340, de 7 de agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher, nos termos do § 8º do art. 226 da Constituição Federal, da Convenção sobre a Eliminação de Todas as Formas de Discriminação contra as Mulheres e da Convenção Interamericana para Prevenir, Punir e Erradicar a Violência contra a Mulher; dispõe sobre a criação dos Juizados de Violência Doméstica e Familiar contra a Mulher; altera o Código de Processo Penal, o Código Penal e a Lei de Execução Penal; e dá outras providências. Diário Oficial da União 2006; 8 aug.^,88. Roure JG. Domestic violence in Brazil: examining obstacles and approaches to promote legislative reform. Columbia Human Rights Law Rev 2009; 41:67-97.^,99. Uchoa P. Maria da Penha: the woman who changed Brazil's domestic violence laws. BBC News 2016; 22 sep. http://www.bbc.com/news/magazine-37429051.
http://www.bbc.com/news/magazine-3742905... . As a result of massive public education campaigns, over 95% of Brazilians are aware of the law’s existence ¹⁰10. Data Popular; Instituto Patrícia Galvão. Percepção da sociedade sobre violência e assassinatos de mulheres. São Paulo: Data Popular/Instituto Patrícia Galvão; 2013.. Several studies suggest widespread awareness of the law has resulted in greater reporting ¹¹11. Instituto DataSenado. Violência doméstica e familiar contra a mulher. Brasília: Instituto DataSenado; 2017.^,1212. Waiselfisz JJ. Mapa da violência 2015: homicídio de mulheres no Brasil. Rio de Janeiro: Faculdade Latino-Americana de Ciências Sociais; 2015.. Yet widespread impunity for crimes against women remains a major contributing factor to high female homicide rates in Latin America, including Brazil ¹²12. Waiselfisz JJ. Mapa da violência 2015: homicídio de mulheres no Brasil. Rio de Janeiro: Faculdade Latino-Americana de Ciências Sociais; 2015.^,1313. United Nations Entity for Gender Equality and the Empowerment of Women. Model protocol: ending impunity for femicide across Latin America. https://www.unwomen.org/en/news/stories/2014/9/model-protocol-on-femicide-launched (accessed on 23/Jan/2019).
https://www.unwomen.org/en/news/stories/... ^,1414. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138.. Following the law’s passage, the female homicide rate experienced a slight decrease and then rose quickly in subsequent years; a similar pattern was observed among reported rates of violence against women ¹²12. Waiselfisz JJ. Mapa da violência 2015: homicídio de mulheres no Brasil. Rio de Janeiro: Faculdade Latino-Americana de Ciências Sociais; 2015.^,1414. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138..

Half (50%) of Brazilians believe the way the justice system punishes perpetrators does not reduce violence against women, and 85% agreed women who denounce an abusive partner are at greater risk of murder ¹⁰10. Data Popular; Instituto Patrícia Galvão. Percepção da sociedade sobre violência e assassinatos de mulheres. São Paulo: Data Popular/Instituto Patrícia Galvão; 2013.. These attitudes and perceptions demonstrate a lack of public confidence in the legal sector response to violence against women ⁸8. Roure JG. Domestic violence in Brazil: examining obstacles and approaches to promote legislative reform. Columbia Human Rights Law Rev 2009; 41:67-97.. The inadequate legal sector response is attributed, in part, to the lack of human and financial resources devoted to addressing violence against women ¹⁵15. Mello Rangel VCT. As práticas de atendimento à mulher vítima de violência em um núcleo de atendimento de uma cidade do interior do estado do Rio de Janeiro. Habitus 2010; 8(1). https://revistas.ufrj.br/index.php/habitus/article/viewFile/11325/8275.
https://revistas.ufrj.br/index.php/habit... ^,1616. Gama Lima LL, Barbosa LM. A intervenção policial na violência de gênero no Estado do Rio de Janeiro: da criação das Delegacias Especializadas à Lei Maria da Penha. In: Anais do XXVI Simpósio Nacional de História. http://www.snh2011.anpuh.org/resources/anais/14/1308192870_ARQUIVO_TEXTOANPUHREVISADOLANALAGE.pdf.
http://www.snh2011.anpuh.org/resources/a... . Though Brazil implemented the Femicide Act in 2015 to stiffen penalties for gender-motivated killings, it continues to be recognized as a country with limited sanction for the murder of women ¹⁷17. Brasil. Lei nº 13.104, de 9 de março de 2015. Altera o art. 121 do Decreto-Lei nº 2.848, de 7 de dezembro de 1940 - Código Penal, para prever o feminicídio como circunstância qualificadora do crime de homicídio, e o art. 1º da Lei nº 8.072, de 25 de julho de 1990, para incluir o feminicídio no rol dos crimes hediondos. Diário Oficial da União 2015; 10 mar.^,1818. WomanStats Project. Social sanction for the murder of women/femicide. http://mailchi.mp/c658490d1c99/property-rights-law-mobility-and-femicide-scales-complete?e=b15d1cdad6 (accessed on 23/Jan/2019).
http://mailchi.mp/c658490d1c99/property-... . Despite the existence of progressive laws, more action is needed ¹⁹19. Borges CMR, Lucchesi GB. Machismo in the dock: a critical feminist analysis of Brazilian criminal policy concerning the combat of violence against women. Revista da Faculdade de Direito da UFPR 2015; 60:249-77..

Lack of trust in government institutions to protect the well-being of all citizens may also be found beyond the legal sector, including the health arena. In Brazil, a universal right to health is enshrined in the 1988 Federal Constitution. The Brazilian Constitution upholds the right to health through its public health system (Brazilian Unified National Health System - SUS), which is charged with providing free and comprehensive health care through a nationwide network managed at the municipal level. Unfortunately, SUS and its beneficiaries have been impacted by negative public views that were exacerbated by the recession, during which the public health budget was subject to several rounds of budget cuts at a time when demand for services and costs of treatment increased ³3. Watts J. Brazil's health system woes worsen in economic crisis. Lancet 2016; 387:1603-4.. Additionally, Brazilian Ministry of Health appointments have been used to leverage political power among warring political parties ³3. Watts J. Brazil's health system woes worsen in economic crisis. Lancet 2016; 387:1603-4.. Despite the wide-ranging health consequences of violence against women, only one in five of Brazilian women who have experienced domestic or family violence seek health care ¹⁰10. Data Popular; Instituto Patrícia Galvão. Percepção da sociedade sobre violência e assassinatos de mulheres. São Paulo: Data Popular/Instituto Patrícia Galvão; 2013.^,1111. Instituto DataSenado. Violência doméstica e familiar contra a mulher. Brasília: Instituto DataSenado; 2017.^,1212. Waiselfisz JJ. Mapa da violência 2015: homicídio de mulheres no Brasil. Rio de Janeiro: Faculdade Latino-Americana de Ciências Sociais; 2015.^,1414. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138.^,1515. Mello Rangel VCT. As práticas de atendimento à mulher vítima de violência em um núcleo de atendimento de uma cidade do interior do estado do Rio de Janeiro. Habitus 2010; 8(1). https://revistas.ufrj.br/index.php/habitus/article/viewFile/11325/8275.
https://revistas.ufrj.br/index.php/habit... ^,1616. Gama Lima LL, Barbosa LM. A intervenção policial na violência de gênero no Estado do Rio de Janeiro: da criação das Delegacias Especializadas à Lei Maria da Penha. In: Anais do XXVI Simpósio Nacional de História. http://www.snh2011.anpuh.org/resources/anais/14/1308192870_ARQUIVO_TEXTOANPUHREVISADOLANALAGE.pdf.
http://www.snh2011.anpuh.org/resources/a... ^,2020. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359:1331-6.. Low levels of health-seeking behaviors are attributable to feelings of stigma and shame ²⁰20. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359:1331-6.^,2121. Ashford L, Feldman-Jacobs C. The crucial role of health services in responding to gender-based violence. Washington DC: Interagency Gender Working Group; 2010.^,2222. World Health Organization; London School of Hygiene and Tropical Medicine; South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013.^,2323. Kiss LB, Schraiber LB, d'Oliveira AFPL. Possibilidades de uma rede intersetorial de atendimento a mulheres em situac¸a~o de viole^ncia. Interface (Botucatu) 2007; 11:485-501.^,2424. Pinto LSS, Oliveira IMP, Pinto ESS, Leite CBC, Melo ADN, Deus MCBR. Women's protection public policies: evaluation of health care for victims of sexual violence. Ciênc Saúde Colet 2017; 22:1501-8..

Health professionals may reproduce stigma and shame when they hold women responsible for their victimization ²⁵25. Kiss L, Schraiber LB.two weeks Social medical themes and the health intervention: violence against women in the professional's discourse. Ciênc Saúde Colet 2011; 16:1943-52.. They may also fail to acknowledge and address violence because they view it as a private matter, further contributing to the culture of silence ²¹21. Ashford L, Feldman-Jacobs C. The crucial role of health services in responding to gender-based violence. Washington DC: Interagency Gender Working Group; 2010.^,2525. Kiss L, Schraiber LB.two weeks Social medical themes and the health intervention: violence against women in the professional's discourse. Ciênc Saúde Colet 2011; 16:1943-52.. Health professionals may refer women to other services to avoid addressing the issue themselves, thereby requiring women to repeatedly recount their violent experiences risking retraumatization ²⁶26. Arboit J, Padoin SMM, Vieira LB, Paula CC, Costa MC, Cortes LF. Health care for women in situations of violence: discoordination of network professionals. Rev Esc Enferm USP 2017; 51:e03207.. Such attitudes and behaviors contribute to women’s low expectations for support and assistance from health professionals and low levels of abuse disclosure ²⁵25. Kiss L, Schraiber LB.two weeks Social medical themes and the health intervention: violence against women in the professional's discourse. Ciênc Saúde Colet 2011; 16:1943-52.^,2626. Arboit J, Padoin SMM, Vieira LB, Paula CC, Costa MC, Cortes LF. Health care for women in situations of violence: discoordination of network professionals. Rev Esc Enferm USP 2017; 51:e03207.^,2727. Kiss L, d'Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and help-seeking behaviors. Health Hum Rights 2012; 14:64-77..

Given the context of broad government corruption, pervasive violence against women, and perceived impunity despite legal protections and comprehensive health services, the aim of this study was to examine the relationship between women’s perceptions of federal violence against women laws and their trust in health and legal sector response to violence against women in Santo André, São Paulo State, Brazil. We hypothesize the overall lack of trust in government institutions relates to a lack of trust in not only the legal sector response to violence, but also the ability of the health sector to provide care for women experiencing violent relationships.

Methods

This analysis was part of a larger study examining individual experiences and community perceptions of violence against women. Detailed information on the methods of the parent study are available elsewhere ²⁸28. Evans DP, DeSousa Williams N, Wilkins JD, Chiang ED, Manders OC, Vertamatti MAF. 'He said he was going to kill me': case studies of attempted intimate femicide in São Paulo, Brazil. Journal of Comparative Social Work 2018: 13:57-80..

Study site

Santo André, a municipality located in metropolitan São Paulo, has approximately 710,000 inhabitants (Instituto Brasileiro de Geografia e Estatística. http://cod.ibge.gov.br/4BW, accessed on 23/Jan/2019). Santo André has one specialized police station for women, three service locations for psychological and social support for survivors of violence against women, one women’s hospital, one health unit focused on women’s health (also one of our study sites) and four legal service locations whose services include legal counseling and services ²⁹29. Consórcio Intermunicipal Grande ABC. Enfrentamento à violência contra as mulheres. Santo André: Consórcio Intermunicipal Grande ABC; 2014..

It boasted the only Municipal Secretariat for Women’s Policies (SPM) in the region from 2014 to 2016. The SPM was a government body charged with articulating, formulating, and implementing policies and programs that address gender inequality and promote gender equality ³⁰30. Prefeitura de Santo André. Mulheres de Santo André em pauta: perfil socioeconômico e mapa de violência. Santo André: Secretaria de Políticas para as Mulheres, Prefeitura de Santo André; 2015.. It fostered intersectoral coordination and collaboration in addressing violence against women before it was absorbed into the Department of Social Policies in 2017 following the election of the Brazilian Social Democracy Party - part of a broad shift away from the progressive left-wing Worker’s Party which previously dominated ³⁰30. Prefeitura de Santo André. Mulheres de Santo André em pauta: perfil socioeconômico e mapa de violência. Santo André: Secretaria de Políticas para as Mulheres, Prefeitura de Santo André; 2015.. SPM was a key partner for this project.

Data collection

A native Portuguese speaker conducted 30 in-depth interviews with participants who self-identified as women, were aged 18 and older, and resided in Santo André. Participants were recruited using convenience and respondent driven sampling from public health clinics in three neighborhoods. Additional local partners included the Municipal Secretariat of Health, and the ABC School of Medicine (FMABC), who facilitated access to data collection sites.

Using an in-depth interview guide described elsewhere, participants were asked open-ended questions about individual experiences and community perceptions of violence against women, health care access and quality, and federal legislation addressing violence against women ²⁸28. Evans DP, DeSousa Williams N, Wilkins JD, Chiang ED, Manders OC, Vertamatti MAF. 'He said he was going to kill me': case studies of attempted intimate femicide in São Paulo, Brazil. Journal of Comparative Social Work 2018: 13:57-80.. Follow-up questions, probing, and prompts were used to explore topics such as interactions with clinic staff and police officials. The World Health Organization (WHO) protocol for conducting research on violence against women was applied throughout recruitment and data collection processes to ensure the safety of everyone involved ³¹31. Ellsberg M, Heise L. Researching violence against women: a practical guide for researchers and activists. Washington DC: World Health Organization/PATH; 2005..

Data management and analysis

In-depth interviews were audio recorded, transcribed verbatim in Portuguese, and de-identified. Data were coded and analyzed in Portuguese for deductive and inductive themes using MAXQDA12 software (https://www.maxqda.com/). The codebook was refined over multiple rounds of coding, with two Portuguese-speaking coders discussing discrepancies between each round; a subset of transcripts was coded by a second coder in the final iteration to ensure consistency. For the purposes of this analysis, we examined the relationship between the violence against women, law, and healthcare codes using means of modified grounded theory ³²32. Hennink M, Hutter I, Bailey A. Qualitative research methods. Thousand Oaks: SAGE; 2011.. We performed multiple close reads of the coded segments for the three codes through which inductive themes were identified. We developed thick descriptions for each theme for developing our resulting theory.

Study ethics

The study protocol was reviewed and approved by Emory University’s Institutional Review Board (Atlanta, United States), the Santo André municipal government, and Plataforma Brasil, the Brazilian national institutional review board (CAAE 57344616.0.0000.5484). All participants provided written informed consent before each interview and were informed they could withdraw from the study at any time. There was minimal risk to participants given that participation and data were kept confidential. All participants were given violence against women-related educational materials and contact information for the clinic-based support person responsible for violence against women case management.

Results

Thirty in-depth interviews were conducted with women at three public health posts in Santo André; all women were familiar with at least one federal violence against women law. Among the participants, 30% (n = 13) reported personal violence against women experiences, consistent with previous studies ¹⁴14. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138.^,2222. World Health Organization; London School of Hygiene and Tropical Medicine; South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013.. As depicted in Figure 1, participants described an overall distrust in the Federal Government characterized by a perception of corruption and inefficacy. This distrust seemed to relate to negative views of violence against women laws - including legal sector inefficacy - and finally mixed satisfaction with the health sector and its utility in responding to violence against women cases.

The government is not trusted and the legal system is ineffectual

In addressing violence against women, participants described an overarching distrust in the broader government often referred to as “the law” or “politics” without clear distinctions between strata of government. This was linked to views of inefficacy, corruption and scandals, including as high as the office of the president. This distrust was sometimes described as a hopelessness, including futility in basic political processes like voting, which is mandatory in Brazil. One participant described how this feeling influences her civic engagement:

“Also, the government - so far, I always voted - I’m never going to vote for anyone ever again. I don’t believe in politics, it gets worse and worse. When I vote now, I’m going to void my vote”.

Overall distrust in the Federal Government was linked to the perceived ineffectiveness of the Brazilian legal sector. Though participants recognized there is a legal code in Brazil, participants questioned the general application of the law as illustrated by one participant’s comments:

“Well, there is law on paper, right? But, the law in Brazil is problematic”.

Participants linked the general lack of government efficacy to the feasibility of legal protections for violence against women survivors questioning how women could expect the government to act in their interests when the same government demonstrates inability to ensure protections for everyday citizens across diverse issues:

“It’s like people say: ‘In Brazil, what law?’ There is no law for more serious things, but you are going have one to protect women?”.

This included the perception that domestic violence charges made according to existing laws are viewed as trivial and without force. One participant described blatant disregard for enforcement of laws designed to protect women:

“Today it has turned into, ‘Oh, you got a Maria da Penha charge, so what?’ You know?”.

Participants perceived the legal sector as failing to uphold fundamental laws, even in the presence of violence against women legislation. One participant pointed out possible benefits and protections that survivors derive from existing violence against women laws can be completely undermined, and even reversed by the legal sector’s inability to ensure full compliance with these laws, including the consequences for perpetrators:

“The Maria da Penha law captures them [perpetrators], the justice... legal system frees them”.

This distrust was described by participants as extending into the justice system’s ability to protect women who experience extreme forms violence such as femicide. In the absence of trust in the rule of law, desperation may lead to extralegal adaptive behaviors such as self-defense and in extreme cases retaliatory violence may emerge, as described by one participant:

“There are many women who nowadays no longer trust in the justice system, and there are women who end up killing their husband in order not to die”.

While retaliatory violence may be uncommon, this quote highlights the desperation women may feel. Lacking trust in the efficacy of the broader government and legal protections leaves women in violent relationships with the untenable choice between self-protection and the realistic possibility of their own injury or death at the hands of a violent partner.

Violence against women laws do not protect women and may exacerbate violence

Beyond distrust of the efficacy of the broader government and legal sector, participants also questioned the validity of violence against women laws themselves. Violence against women laws were described as having a limited positive impact on women’s lives. This included legal provisions such as the type of support provided; women indicated the support provided by police may not fully address women’s needs. Additionally, the law’s influence was not viewed as fully permeating the private lives of survivors. An excerpt from one participant illustrated the issue of scope:

“It ends up that women are intimidated by the law. Because she knows that a lot of times... the man that is inside the house is extremely aggressive, vengeful, and that if she goes to make a report then she has to come back home. And then what? Who will be there to support her? The law doesn’t do it, the law is there in the police station, and when she comes home?”.

Within the purview of these laws, possible interventions such as restraining and removal orders were seen as useless. Other participants contrasted the perceived trivial impact of violence against women laws with the grave realities of violent relationships, further illustrating the perceived ineffectiveness of legal provisions on immediate physical danger as described by one participant:

“Sometimes the man beats up the woman and they give a paper [restraining order], and a little while later he is beating her again. What good does it do?”.

Some participants suggested women often fear the consequences of attempting to make use of laws due to widespread impunity for perpetrators of violence. Numerous participants recounted stories of how women who sought to seek justice through violence against women laws were further traumatized by ineffective interactions with health and legal sector actors - or worse - abused or murdered by their partners in retaliation. One participant went so far as to say the strong possibility of violent retaliation leads women to “fear the law more than the abusers”.

Notably, participants perceived the enactment of violence against women laws as increasing the risk for women seeking legal support. Participants linked women’s reporting and ineffectual laws with an increased likelihood of femicide. One participant described this phenomenon:

“Oh, I have my doubts because, like that, we see a lot of cases where the woman goes, reports, and the police does nothing, and two, three months later you receive the news that the person was murdered by the husband, you know? But she went back, she tried, she reported it, but no...”.

Participants pointed out punitive actions such as jail time may anger a perpetrator without addressing the source of his violent behavior, resulting in worse outcomes for effected women. One participant made this point:

“It doesn’t work because... the guy gets locked up, then when he gets out he goes there and kills the woman”.

Participants emphasized rather than reforming a perpetrator, or addressing the source of the aggression, temporary punitive solutions like incarceration could actually worsen a perpetrator’s behavior and put a woman at greater femicide risk.

“And why do they kill? Because after he gets locked up he gets more aggressive. So much so that he goes and kills the woman, right? That’s the truth”.

Satisfaction with health sector services is mixed

In addition to a description of distrust in the legal system, participants’ discontent bled into descriptions of interactions with the health sector, where women sometimes seek services following violent experiences. Women described dissatisfaction with the health system, sometimes linking it directly to the broader government health system itself. One participant described her feeling:

“It’s really bad, the service sucks... I’ve seen cases in my family and known people that die and do not get to do a blood test... The public service, the [SUS], it sucks, it gets worse and worse”.

Related to these concerns were complaints about the quality of service rendered by health professionals as well as their bedside manner. Although some participants were pleased with personnel, others had deeply dissatisfying experiences. Participants described incompetence in some cases as illustrated by one participant’s description of doctor visits:

“They do not ask anything. You go to the doctor, you’re dying of pain, you’re running a fever... they look at you, but don’t really look”.

There is a double entendre in this participant’s description of her experience. She maintains that health professionals are not performing their core functions while at the same time implies health professionals treat patients in an inhumane manner. Similarly, some participants described stigmatizing and shaming attitudes among health personnel. One participant even described being demeaned by a health professional who criticized her clothing, the number of children she had, and her use of a public assistance program:

“‘She has a lot of kids, time to close the factory, you here having all these kids here and there’. I was wearing this outfit, shirt. She said ‘see if you have any clothes’ as if I had walked to the health post naked. ‘Wow, she is wearing shorts, it’s too much’. And I stayed there in the health post, I started crying there in the health post... I do not like to talk about the [health] post because it offended me a lot... what this girl did to me, humiliated me a lot... She humiliated me worse than a dog”.

Others had relatively positive experiences with personnel although they complained about the inefficiency of the health system, which was differentiated from the quality of care itself. This was described by one participant:

“The doctors here, the nurses, are very nice, understanding, and very attentive, too; the problem itself is the delay of the service. If you are making an appointment it takes two or three months. That is the difficulty”.

Some women described how the administration of the health system or the government itself was at fault rather than those health personnel who are assigned to a specific post:

“The problem that the post has is not a problem of the post itself, it is a problem with Santo André. The administration of Santo André is a failure. You do not even have basic equipment at the post’s pharmacy, so it’s not the fault of the unit, right?”.

Participants shared mixed views around violence disclosure to health professionals. Those who said they would not disclose violent experiences to a health provider gave a few reasons for their discomfort. One participant described the importance of rapport.

“Let’s suppose, you do not know the doctor, it’s the first time you go, the doctor asks you. You will not want to respond... You may be in the worst situation of your marriage; you will not want to vent with a doctor”.

Another participant described having a deep sense of shame around her violent experiences, and that any health provider that she disclosed to would need to make her feel comfortable and demonstrate empathy and understanding for her experience.

“I was ashamed of the aggressions and the situation, you know? There are people who think we’re in [a violent relationship] because... he says: ‘you are a bad woman, why don’t you leave this guy?’ But, people have to see what is happening in the woman’s head, what she is thinking, what she is feeling... in my case, I would have thought it better not to have this question, because I would be ashamed”.

Some participants didn’t expect health providers to be able to link them to appropriate resources or that there could be any positive results from disclosing to a health provider. One participant plainly stated she did no’t think any good would come of disclosing, saying, “No, it was not going to help anything”.

Discussion

While Brazil has made significant strides in regard to addressing violence against women through federal legal provisions, these strides may be comprised in part by recent recession and a political conflict including a current administration that has been accused of divesting from health and other programs addressing violence against women. Our data suggest within the context of Santo André - in a country that has received international attention both for prevalence of violence and government scandals - widespread lack of trust in the government may be connected to women’s perceived efficacy for violence against women response in the health and legal sectors. The historical and current political corruption, which continues to dominate the consciousness of Brazilians may contribute to a broader sense of distrust in the government. Given the perspectives of the participants in this study, it appears this broader distrust in the government interplays with specific distrust in the legal system, views of federal violence against women laws, and the health system suggesting violence against women interventions need to be intersectoral and multifaceted in nature.

Participants tended to characterize women in Brazil as having a broad distrust in the government which has implications for major pathways to reporting violence against women, namely the legal and health sectors. Women do not trust the legal sector or find its responses effective despite existing provisions; concerns were focused on the implementation and operationalization of existing laws. Survivors of violence have many reasons not to disclose experiences of violence such as stigma, shame, privacy concerns, economic dependency, fear of retaliation, and sometimes to protect the violent partner ²⁷27. Kiss L, d'Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and help-seeking behaviors. Health Hum Rights 2012; 14:64-77.^,3333. Felson RB, Messner SF, Hoskin AW, Deane G. Reasons for reporting and not reporting domestic violence to the police. Criminology 2002; 40:617-48.^,3434. Sylaska KM, Edwards KM. Disclosure of intimate partner violence to informal social support network members: a review of the literature. Trauma Violence Abuse 2014; 15:3-21.. When weighing the perceived benefits of reporting against these barriers, women in violent relationships question the likelihood of a positive outcome given the demonstrated inability of health and legal sectors to effectively comply with the mechanisms enshrined in violence against women laws. A lack of gender sensitization regarding violence against women for responders such as police has resulted in women being blamed for their experience, or turned away by those who do not view it as a real crime ¹⁵15. Mello Rangel VCT. As práticas de atendimento à mulher vítima de violência em um núcleo de atendimento de uma cidade do interior do estado do Rio de Janeiro. Habitus 2010; 8(1). https://revistas.ufrj.br/index.php/habitus/article/viewFile/11325/8275.
https://revistas.ufrj.br/index.php/habit... ^,1616. Gama Lima LL, Barbosa LM. A intervenção policial na violência de gênero no Estado do Rio de Janeiro: da criação das Delegacias Especializadas à Lei Maria da Penha. In: Anais do XXVI Simpósio Nacional de História. http://www.snh2011.anpuh.org/resources/anais/14/1308192870_ARQUIVO_TEXTOANPUHREVISADOLANALAGE.pdf.
http://www.snh2011.anpuh.org/resources/a... . The lack of public confidence in legal sector response to violence against women seems justified when one considers women disproportionately experience extreme violence in the home environment; the legal sector response is known to be inadequate regarding such crimes ¹²12. Waiselfisz JJ. Mapa da violência 2015: homicídio de mulheres no Brasil. Rio de Janeiro: Faculdade Latino-Americana de Ciências Sociais; 2015..

The adoption of federal violence against women laws in Brazil are assumed to have an impact on curtailing violence against women ⁷7. Brasil. Lei nº 11.340, de 7 de agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher, nos termos do § 8º do art. 226 da Constituição Federal, da Convenção sobre a Eliminação de Todas as Formas de Discriminação contra as Mulheres e da Convenção Interamericana para Prevenir, Punir e Erradicar a Violência contra a Mulher; dispõe sobre a criação dos Juizados de Violência Doméstica e Familiar contra a Mulher; altera o Código de Processo Penal, o Código Penal e a Lei de Execução Penal; e dá outras providências. Diário Oficial da União 2006; 8 aug.^,1414. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138.^,1717. Brasil. Lei nº 13.104, de 9 de março de 2015. Altera o art. 121 do Decreto-Lei nº 2.848, de 7 de dezembro de 1940 - Código Penal, para prever o feminicídio como circunstância qualificadora do crime de homicídio, e o art. 1º da Lei nº 8.072, de 25 de julho de 1990, para incluir o feminicídio no rol dos crimes hediondos. Diário Oficial da União 2015; 10 mar.^,2727. Kiss L, d'Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and help-seeking behaviors. Health Hum Rights 2012; 14:64-77.. Indeed, violence against women laws are necessary but not sufficient to address the problem. In our data, these effects were seen as relating to deterrence, potential protections from violence, and the disturbing unintended consequences of exacerbated violence. All participants were familiar with the Maria da Penha Law; however, none recalled the more recent Femicide Law. While women did recall some protective measures provided by the law, they viewed the punitive mechanisms as having a minimal impact on the protection of women who experience violence. While the Brazilian public may positively view the principles behind violence against women laws, the laws themselves cannot have a meaningful impact on targeted beneficiaries while impunity reigns. For now, violence against women laws exist on paper but their protections are limited in practice. If these views of the government systems and actors are widespread they could result in deeper distrust, violence permissiveness, and a decrease in disclosure and reporting, rather than deterrence. Ineffectual and inconsistent punitive measures for perpetrators may lead to severe consequences such as retaliation. In fact, in many cases violence against women laws were perceived as exacerbating violence-specifically via retaliatory action. Participants linked reporting, ineffective laws and an increased likelihood of femicide. While this is counterintuitive, similar perceptions have been observed in other Latin American countries and studies in Brazil have corroborated this perception ¹⁰10. Data Popular; Instituto Patrícia Galvão. Percepção da sociedade sobre violência e assassinatos de mulheres. São Paulo: Data Popular/Instituto Patrícia Galvão; 2013.^,1414. Gattegno MV, Wilkins JD, Evans DP. The relationship between the Maria da Penha Law and intimate partner violence in two Brazilian states. Int J Equity Health 2016; 15:138.^,3535. Luffy SM, Evans DP, Rochat RW. "It is better if I kill her": perceptions and opinions of violence against women and femicide in Ocotal, Nicaragua after Law 779. Violence Gend 2015; 2:107-11..

Participants’ descriptions of their discontent with the health sector were less prominent than the legal sector. Yet the lack of enthusiasm for the health sector response was clear among some participants. This pattern suggests the distrust in government not only permeates multiple levels of the government, but also transfers across sectors of government (both legal and health) when it comes to violence against women. This discontent may be exacerbated by stigma and a lack of trained medical professionals ²⁵25. Kiss L, Schraiber LB.two weeks Social medical themes and the health intervention: violence against women in the professional's discourse. Ciênc Saúde Colet 2011; 16:1943-52.^,2727. Kiss L, d'Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and help-seeking behaviors. Health Hum Rights 2012; 14:64-77.. As seen in our data, when health professionals disrespect or mistreat women, a strategic window of opportunity for violence disclosure and subsequent violence prevention and response closes. Even with the best intentions, transference of distrust to the health system may negatively impact perceptions of health sector efficacy for violence prevention and response ³⁶36. Signorelli M, Taft A, Pereira PPG. Domestic violence against women, public policies, and community health workers in Brazilian Primary Health Care. Ciênc Saúde Colet 2018; 23:93-102.. Distrust in the system may be compounded by negative experiences with health professionals or vice versa.

The transference of distrust undermines the ability to protect women by delegitimizing two major pathways for survivors of violence to disclose and seek support; these results also point toward intersectoral and multifaceted approaches to address violence against women in Brazil. Though interventions for violence against women are often conceived within separate disciplines, negative perceptions of a single sector (e.g. legal) may cause real consequences that reverberate through the complementary responses of other sectors (e.g. health). This speaks to the necessity of interventions that cross sectors. There has been growing attention to the development of more streamlined, integrated approaches to multi-sector violence against women response ³⁷37. Stern E, Martins S, Stefanik L, Uwimpuhwe S, Yaker R. Lessons learned from implementing Indashyikirwa in Rwanda: an adaptation of the SASA! approach to prevent and respond to intimate partner violence. Eval Program Plann 2018; 71:58-67.^,3838. DeGue S, Valle LA, Holt MK, Massetti GM, Matjasko JL, Tharp AT. A systematic review of primary prevention strategies for sexual violence perpetration. Aggress Violent Behav 2014; 19:346-62.. The reinstitution of the SPM at the local level would be a welcome and feasible first step in this regard. In addition to these integrative approaches, there should also be attention to the transference of negative perceptions across sectors, particularly in contexts such as Santo André where health and legal sectors are principally public services under the purview of the State. Regardless of how integrated these services truly are in practice, they are perceived as affiliated with a government that women generally do not trust. If left unaddressed this transference may have profound effects - beyond the current negative repercussions - on the effectiveness of violence against women prevention and response by both the health and legal sectors.

Many factors on multiple levels of the social ecology are theorized to affect women’s decision-making regarding disclosure of violence ³⁸38. DeGue S, Valle LA, Holt MK, Massetti GM, Matjasko JL, Tharp AT. A systematic review of primary prevention strategies for sexual violence perpetration. Aggress Violent Behav 2014; 19:346-62.^,3939. Alaggia R, Regehr C, Jenney A. Risky business: an ecological analysis of intimate partner violence disclosure. Res Soc Work Prac 2012; 22:301-12.. In the absence of viable governmental support women experiencing violence may even resort to extralegal adaptive behaviors in the pursuit of self-protection despite the known legal consequences; alternatively they may suffer violent abuse and even death at the hands of intimate partners. Women are more likely to report violence when it is witnessed by children or when it results in bodily harm ²⁵25. Kiss L, Schraiber LB.two weeks Social medical themes and the health intervention: violence against women in the professional's discourse. Ciênc Saúde Colet 2011; 16:1943-52.^,2727. Kiss L, d'Oliveira AF, Zimmerman C, Heise L, Schraiber LB, Watts C. Brazilian policy responses to violence against women: government strategy and help-seeking behaviors. Health Hum Rights 2012; 14:64-77.^,3434. Sylaska KM, Edwards KM. Disclosure of intimate partner violence to informal social support network members: a review of the literature. Trauma Violence Abuse 2014; 15:3-21.. These patterns taken together may make women more likely to delay reporting violence until they are at higher risk of more severe consequences of violence against women including femicide. Response to violence against women needs to focus on reducing perceived barriers to reporting and maximizing the benefits of reporting to reduce the burden on women. The effective implementation and enforcement of existing legal protections is the starting point. In addition, service providers need to have a system in place to identify cases that are at high risk for immediate physical harm or femicide to facilitate disclosure and allocation of services to women who most need them. Additionally, experiences of violence survivors who have utilized specialized services should be examined in order to understand the degree to which distrust in the health and legal system is true based on the survivors’ own lived experiences.

Limitations

Our participants were not known survivors of violence therefore they may not have had insights into the specialized services available to survivors. However, one third of our participants did disclose their own personal experiences of violence. As a result, our data reflect a mixture of insights grounded in personal experiences and the perceptions of others experiences. The sample was sufficient to see indications of saturation on the themes included in the study; however, due to the qualitative and locally specific nature of the sample the findings are not generalizable. Regardless of this limitation, the findings presented around trust and violence against women services were salient in this sample and may be transferable to other populations in Brazil, which should be explored in future empirical studies.

Conclusion

While the Brazilian State has made laudable efforts to protect women through laws such as the Maria da Penha Law (2006) and Femicide Law (2015), the perceptions of the efficacy of these laws, as well as legal and health services appears to be impacted by a general distrust in the Brazilian government ⁷7. Brasil. Lei nº 11.340, de 7 de agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher, nos termos do § 8º do art. 226 da Constituição Federal, da Convenção sobre a Eliminação de Todas as Formas de Discriminação contra as Mulheres e da Convenção Interamericana para Prevenir, Punir e Erradicar a Violência contra a Mulher; dispõe sobre a criação dos Juizados de Violência Doméstica e Familiar contra a Mulher; altera o Código de Processo Penal, o Código Penal e a Lei de Execução Penal; e dá outras providências. Diário Oficial da União 2006; 8 aug.^,1111. Instituto DataSenado. Violência doméstica e familiar contra a mulher. Brasília: Instituto DataSenado; 2017.. This may be compounded by a current administration that has been accused of divesting from programs to address violence against women. Having laws on the books was the first step in improving the systems that address violence against women; however, these laws need to be enforced. Particular attention should be paid to the perception of violence against women laws as they are currently implemented and the palpable concerns of women who seek support. The results of this study suggest violence against women response in contexts like Santo André may be improved through greater enforcement of existing legal protections, increased quality of care within the health system, greater availability of trusted non-governmental services, and addressing the generalized mistrust in the government. Trust may be improved by addressing these concerns and ensuring that the laws and legal and health systems are adequately meeting the needs of women. Through improved practices such as better tools to detect violence and women at high risk of femicide, police, judges, and health professionals may be able to better identify women who need services and provide them assistance. Such services may include legal, economic, and material support (such as housing and food) as well as referrals to health services including psychosocial support. Improvement in overall trust in the system may facilitate the ability of professionals across sectors to truly address the needs of women who face threats of violence.

Violence against women interventions should consider the integrated nature of governmental trust and its effects on the perception of the legal and health sectors. The legal sector should address the perceived illegitimacy of violence against women laws, perception of inadequate implementation of violence against women laws, and specific concerns among survivors including the fear of retaliation. The health sector should consider the transference of distrust from the legal sector and personnel concerns regarding disclosure readiness and violence against women sensitization. Both legal and health professionals operating within public systems of the Brazilian government are State actors. Their individual actions therefore are reflections of the State and vice versa. The potential to improve public trust lies largely in the hands of these well-intentioned public service officials as well as a transparent government free from corruption ⁴⁰40. Oliveira E. How we are celebrating the unsung heroes of Brazil's public service. Apolitical 2018; 7 dec. https://apolitical.co/solution_article/how-were-celebrating-brazils-public-service/.
https://apolitical.co/solution_article/h... .

The adoption of violence against women laws in Brazil have sought to better protect Brazilian women who continue to be disproportionately affected by violence against women and femicide. This analysis serves as further evidence of the need for additional policies and programming, and a robust multisectoral and multifaceted response in the prevention and response to violence against women.

Acknowledgments

The authors would like to express their gratitude to the participants in our study for sharing their experiences as well as our colleagues from the Brazilian Ministry of Health and the Municipal Secretariat for Women’s Policies in Santo André. We are also grateful to our funders, the Emory University Research Committee and the Emory Global Health Institute which supported this work.

References

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