Ana Flávia Pires Lucas d´Oliveira Associate professor Preventive Medicine Department Faculty of Medicine University of São Paulo November 2005 Primary Health Care Programs Brazil´s response to Gender Based Violence

Research and social action oriented Group Violence, gender and health Multidisciplinary team since 1994 Research Training Advisory to Municipality and State Health Departments Partnerships

Contents Violence and health in Brazil Hospitals – first step Health Center Care – a model for assistance Women and their experience of being cared Network of services – Service´s Guide Remaining Challenges

Sexual Violence Care Brazil: Legal abortion only in cases of rape or mother´s life risk Law from : First public hospital doing legal abortion- SP 2005: more than 50 public hospitals doing legal abortion

Sexual Violence Guideline Ministry of Health Prophylaxis of unwanted pregnancy, Sexually Transmitted Disease and AIDS Legal Abortion Psycho-social support

But... Most of the cases are rape perpetrated by strangers Marital rape invisible within health sector Hospital based programs Programs concentrated in few big cities

Primary Health Care and VAW Easier and more frequent access for women Community based care Access along all the life – time Opportunity to make domestic violence visible Targeted to common health problems highly associated to domestic violence

Establishing a local network West region of São Paulo inhabitants Partnership Municipality-University 1 hospital (sexual violence) and 1 health centre (domestic violence) as reference Monitoring and supervision

Medical School Health Center Attending domestic violence since integral health care 1. Make VAW visible to all professionals 2. Promote listening of women in a non judgemental way 3. Offer a specific activity: the Severe Family Conflict (CONFAD)

If the woman accepts About 1 hour activity 1 to 4 sessions Any female health professional can run the activity, since she is properly trained

At CONFAD Identify risk of life Identify support women already have Discuss gender base of domestic violence Share information on the network to assist domestic violence Share making decisions on womens life project Refer to services she chooses Monitoring womens path ( folowing-up)

The CONFAD statistics Around 3000 women seen every year at the unit 26,4% miss the appointment - very similar to medical appointments 83,6% Interpersonal Partner Violence

One day I came here to bring my son. I guess it was God that put these people on my way ! The nurse asked me how I was and I said: Everything is all right... But... I was hit, had a deep cut in my eye and my husband is threatening to kill me! I said just like that, I don´t know why, I think I was so crazy that I did it... And she wanted to know everything in details... She said they have a program on violence against women, asking me if I didn´t want to attend. She booked an appointment to me. It was very good (...) It was my salvation, they gave me strength, helped me very much (Maria) Quotes: Discovering CONFAD

Quotes: being listened and talking

Quotes: linking violence with illness

Quotes: evaluating and referring other women Every time I see someone with a problem, I say: go to the health centre, it is very good, it was good for me it will be to you too. I refer because it was a very good place to me, I had support, I like it very much (Maria) It was worthwhile, I feel like another person, because I felt as I was nobody, I felt like actual garbage. Nowadays I feel I am someone, I will not say I feel I am more than anybody: I feel I am a regular person and that is good.

Service´s Guide on violence against women services services services Published and distributed to all services

Services of the guide Police - Women´s police station Justice Psycho-social assistance Health Shelters Basic Orientations

Gender based program in a health care centre Support women Guarantee rights Awareness of connections violence-health Change the approach of symptoms and their solutions Less medicines, less exams, more womens rights Reference - Limits of health sector to deal with the problem/connections and referral are fundamental

Challenges Continuous monitoring and supervision Working with men Developing the Network among services from different sectors Evaluation - what is the gold standard