Orofacial Injuries in Women Victims of Domestic Violence : Integrative Literature Review

The issue domestic violence against women has become more visible in our society, regardless of social class, age, ethnicity or educational level. There are numerous cases of violence against women in forensic services, most of which consisting of lesions produced by forceful action. The objective of this article is to investigate the occurrence of orofacial injuries in female victims of domestic violence, the observation of the most commonly affected parts of the body and the offender’s profile. This is an integrative literature obtained through databases SCIELO, LILACS, PubMed, Medline, and Bireme, covering national and international studies published along the years from 1993 to 2013. The keywords used were: violence against women, domestic violence, orofacial injuries and maxillo-facial trauma in the period between 2011 and 2013. It has been observed that the progressive increase in violence against women has become the target of several investigations, and the biggest offender in most cases is the partner/spouse or ex-partner, and the most affected area is the face, because besides the painful symptoms felt, there is aesthetic involvement , which will also affect the victim psychologically. The profile shows women victims, mostly women from the periphery of the city, presenting injuries or blunt cut in regions of the lips, eyelids and orbits without compromising function or permanent 2 Brazilian Journal of Forensic Sciences, Medical Law and Bioethics 4(1):1-11 (2014) M. S. Pereira et al. weakness. Combating violence against women requires the integration of numerous political, legal, and especially cultural factors so that violence can be eradicated from society. It is noteworthy that both clinicians and experts have serious responsibilities in the analyses of maxillo-facial lesions, where a mistake at any stage of the evaluation of lesions (clinical or forensic) may unfairly reflect the application of criminal punishment. Thus, it is believed that the study about violence against women brings together a new concept of prevention, recognizing the compromised ones that sociability is the key part in re-establishing a new family life.


Introduction
The issue domestic violence against women has become more visible in our society, regardless of social class, age, ethnicity or educational level.There is abundant record of women who are domestically abused by their partners or former partners, resulting in physical, moral and psychological damage.
The World Health Organization (2002) defined violence as: the intentional use of physical force or power, threatened or actual against oneself, against another person, or against a group or community, that either results or has a high likelihood of resulting in injury, death, psychological harm, developmental disability or deprivation of freedom 1 .
According to Law 11.340 (Art.5º) of August 7 2006, known as "Maria da Penha Law", it configures domestic violence against women as: any action based on gender that may causes death, injury, physical, sexual or psychological and moral suffering or property damage within the household, family, or any close relationship of affection failure.
It is estimated that at least 2.1 million women are battered each year in the country, which means: 175,000/month 5800/day, or 243/h, 4/min, one every 15 seconds 2 .
The most reported cases of domestic violence against women take place more frequently in the home environment, more specifically inside the household itself.The data reported show that the number of violence against battered women is high, confirming its classification as a social issue and public health 3 .
Just as important as knowing the factors involving domestic violence against women, is to point out solutions to the serious problems originated from it.The aggressor does not just want to leave his marks on the victim, but he also wants her to be morally and psychologically impaired, and that the lesions produced are remarkably perceived; that's the reason why the aggressor chooses the face to batter first.
The large amount of lesions on the face is due, among other factors, to the huge exposure and little protection in the region, and this explains why trauma on this region is often serious 4 .
The study of orofacial injuries in female victims of domestic violence is relevant because violence against women is growing alarmingly and orofacial injuries are the most frequently found in this country.Moreover, it is a topic that supplies information on the academic training of health professionals, including Dentistry, as it requires a minimum knowledge on the subject in order to report the cases in adequate terms.
Given the above, this work aims at conducting a narrative review of the literature in the period 1993-2013, on orofacial injuries in female victims of domestic violence.

Methodology
This is a narrative review of the literature which was registered in the period 2011-2013, encompassing studies that address orofacial injuries in female victims of domestic violence.
For that purpose, we used relevant legislation books and scientific papers published in the databases SCIELO, LILACS, PubMed, Medline, and Bireme data.Indexers in Portuguese (violência contra mulher, violência doméstica, traumatismos faciais), in English (domestic violence, facial injuries, violence against women) and Spanish (violencia doméstica, danos, Violencia contra la mujer, traumatismos faciales) were used.
After identification of the material that contained any of the descriptors listed above, following a rigorous search and selection of the method of research, we proceeded to assess the relevance and validity of the research found, collection, synthesis and interpretation of data from the work in order to make a few remarks about the object of this research.Thus, from the 167 biographies analyzed 136 were excluded through a selective and analytical reading for not completely suiting the purpose of the present study.The studies that met the inclusion criteria were kept: original work, case report, literature review and meta-analysis, published in the period 1993-2013.

Historical aspects of domestic violence against women
Based on the literature, the studies reported that the domestic violence phenomenon has existed since ancient times and is still part of everyday life for men and women all over the world.Domestic and family violence against women have been perceived historically by the human society, and the image of women as serving only for reproduction, has turned into a political struggle in an attempt to show their value, and to ensure their rights as citizens.For the understanding of the complex phenomenon that is violence against women, male physical demonstrations have supported the belief that men, by the power given to them need to exercise control of women and the family.Many believe in the influence of the culture, others argue that such arguments are nothing more than a myth.Be it "[...] myth or reality, reflection attests caused them some importance" 5 .
Women have been victims for several centuries, suffering various forms of discrimination.The only prestige granted to them was related to the fact that they were able to perpetuate life, being conditioned to exercise their sexuality only for reproduction as the only justification for their existence 6 .Domestic violence against women is long standing, but it was from the 1970's that they began to be seen with more attention and started mobilization.The issue included different manifestations such as: murder, rape, sexual and physical assault, emotional abuse, forced prostitution, genital mutilation, racial violence, dowry or because of sexual orientation, and violent action that were committed by different perpetrators: partners, family, acquaintances, strangers, or others 7 .
Over the years, we realize that the expression "domestic violence against women" has been being quoted in different ways.Studies show that during the first half of the twentieth century, it was presented as happening within families.In the 1970's, it came to be called violence against women.In the 1980's, it changed to domestic violence.Finally, in the 1990's, it began to mean violence of gender.The latter encompasses the violence that which is almost by men against women, among men and women in an attempt to assert their masculine and feminine identities.Despite all these references, it is noteworthy that, even today, it is common to hear references to violence against women and domestic violence, with the intention of expressing gender violence, i.e. practiced against women 3 .
It is observed that in Brazil, in the last 20 years, there have appeared a few services focused on this issue such as: the creation of women's police stations, the shelters and centers and multi-references that have mainly focused on physical violence and sexual violence that have been committed by partners or former sexual partners of women.Moreover, services have been created to give attention to sexual violence prevention and prophylaxis of sexually transmitted diseases, unwanted pregnancies and the performing of legal abortions, if applicable 7 .
Violence has increasingly shown up in our country and it has become the focus of discussion in public health since the late 1980s 3 .It is noticed that even the media (newspapers, talk shows, soap operas), have portrayed this issue in our country.It can be seen that the number of notifications is increasingly growing, worrying competent authorities, since it generates high cost to the country.Domestic violence against women is a matter of great complexity.It is no longer seen only as a social phenomenon and came to be regarded as a public health problem, something that generates consequences for health services, in relation to the costs involved and the complexity of care 8 .
The female identity is still attached to the term physical aggression, and that despite the achievements of women in the labor market, many of them are still abused in their own homes.

Around the World
The issue of domestic violence issue is so complex that now it is receiving increasing attention and mobilization, reaching new horizons.Domestic violence against women is now recognized as a public health problem world-wide 8 .Schraiber et al. 7 concluded in their studies that violence against women is of such magnitude that many countries have studied these aggressions, such as the United States, where 25% of women over 15 have experienced at least one episode of physical violence, 30% in Canada and 75% in India 7 .
In Guadalajara, Mexico, through a pilot study, 57 women were selected by multistage sampling, were analyzed and it was observed that 46% of respondents had experienced violence, especially as caused by their companions/spouses (73%).
Women who have experienced violence from their husbands, 33% of cases were referred as emotional abuse, 19% physical violence and 12% the sexual one 9 .
In Commune of Valdivia, Chile, an epidemiological study was held in which 106 women were analyzed; from those, 63 had a history of domestic violence and 43 had no experience of aggression.It was observed that as a result, 92.1% of women had suffered emotional violence experience, and 63.5% physical violence.In 61.5% of cases, the companion was identified as the biggest offender, followed by a family member (26.9%), and the aggressors are still the former companions (11.5%).
Regarding the social level of the interviewees, they fit mostly from medium to medium low 10 .However, it is worth remembering that domestic violence does not depend upon social class, ethnicity, education level or socioeconomic status, it can occur in any situation.Medina et al. investigated  patient was a woman, his main perpetrators were husband, fiancé or boyfriend (74,20%) 11 .
In a study by Bruschi (2006), through a review of the literature on population studies that investigated the prevalence of marital violence throughout life, it was observed that in developed countries the prevalence ranged from 5.3% to 25% for any type of violence and from 7.1% to 18% for severe violence.Already in developing countries, like those located in Asia and Africa, the prevalence ranged from 19.1 % to 47 % for any type of violence and 20 % to 37.8% for severe violence 12 .
For scholars, domestic and family violence against women has taken a very large increase and can occur both in developing as well as in developed countries, confirming once again its existence in various social classes.

In Brazil
Domestic violence in Brazil is a public health issue by the large number of victims who reach for their deleterious effects on women's physical and mental health, as well as for its economic consequences for the country 7 .
Programs to encourage the reporting of domestic violence have been increasingly widespread in our country through television, social networks and others, and this has shown exciting and hopeful results.
In a study by Venturi et al. 13 , it was observed that marital violence is a problem that affects many women.In this study, we performed a stratified sample by age and macro-region of the country respectively to women in public and private spaces.There were a total of 2,502 Brazilian women interviewed, 15 years old or older, living in urban and rural areas in 187 districts of 24 states.The study found a prevalence of 33% for any type of physical violence and 22% for aggression 13 .Galvão e Andrade 6 studied 470 records of women users in the call center for women in Londrina, Paraná, and found that the average women were 34 years old.
The main aggressor is the companion (73.4%) and the home is the place where most aggressions occur 6 .
In a study by Schraiber et al. 7 , in São Paulo, with 322 women from a basic health unit using standardized interviews, 143 of them reported at least one episode of physical violence in adulthood, and in 110 cases, the act of violence came from a room-mate or family, thus concluding that physical and sexual violence is highly frequent among women, and that most cases are severe and repetitive.In João Pessoa, Paraíba, Rabello e Caldas (2006), studied the lesions of maxillofacial complex in women who have suffered domestic violence.130 women filed a complaint at the Specialized Women's Police, from September 2004 to July 2005 were examined.Observed in this study, 73.9% had personal income up to the minimum wage; 96.2% of the offenders were males and 90.0 % were partners or expartners.In 51% of cases women were hit on the head, almost all of the instruments were the striking, 41.1% reached the orbital region, followed by the frontal (24.7%), and oral (17.8%).Regarding injuries, abrasions were 52.1%, followed by bruising (45.2%).In only 1.5% of them there was dental injury 2 .
In a study by Rezende et al. 3 , on oro-dental injuries in women who have suffered violence cases in the Institute of Medicine Legal (IML) in Belo Horizonte-MG, the predominant age of the group was 20-39 years (70.4%).Most of them reported to be single (63.0%), and native from the state (48.1%).As to their occupation it was found: 24% were domestic workers, 21% did not work out and 14% work in trade.The most frequent injury was soft tissue laceration, the hard tissue and pulp were fractures of enamel and dentin without complications, in periodontal tissues concussion, and two lesions were observed in bone tissues.The results pointed out that it is necessary a more careful collection of data, in order to provide more accurate information, it also showed that oral and dental injuries are common and represent a great demand for dental services and public health 3 .

Agent Aggressor
Based on studies, the aggressor of the victim is, in most cases, a close person, who has direct and frequent contact with the victim.
In a study conducted by Andrade et al., in 2011, on women victims of violence assisted in the emergency room of the Hospital das Clinicas-UFU listing, we observed that 38% of the studied women were assaulted by their husbands, 38% by other kind of spouse, 8% by boyfriend, 8% due to fight over drug debt and other 8% not cited 14 .
According to research by Deslandes et al. 15 , the husband was the aggressor in the vast majority of cases (41 cases, 56.9%).Yet, according to a study by Cardoso   (1996), in almost all domestic assaults, the husband or the lover were responsible for the assault 16 .Cardoso (1996) Stations for Women, also found that 77.6 % of perpetrators were husbands, partners, ex-husbands and ex-partners 16 .
It is remarkable that trauma-related effects are exacerbated by the fact that the offender is an intimate acquaintance, which increases feelings of vulnerability, loss, betrayal and hopelessness 11 .
A survey conducted by the Specialized Police Woman Curitiba, from October 1999 to May 2000, allowed the characterization of the perpetrators of the victims, they are people who interact with victims in everyday family life in 91.7 % of cases, keeping with them character conjugal relationship (82.4 %) or kinship (9.3%) 10 .
Services and population studies indicate greater risk of abuse of women by people nearby, as partners and family, than by strangers.They feature a centered pattern of domestic violence, the aggressor being a partner or ex-partner in 77.6 % of the reported cases 11 .
Rabello et al. 2 in their study of facial injuries in women physically assaulted, in João Pessoa, Paraiba, shows a percentage of 90.0% of notifications against fellow/former team-mates, and moreover, men seem to exert power over the body and women's mind, forming a cycle of physical abuse, alternating with periods of promises, and calm tensions, featuring the battered woman syndrome.

Main Areas of Aggression
The offender, when he moves to the violent act, does not want to leave physical marks on the victim, but also psychological and moral ones.Battered women carry the burden of the scars that are often irreparable.
According to Garbin et al. (2006), among all the regions affected, the head and neck were the ones with the highest prevalence (30%), followed by the upper extremities (24.4%) 17 .
Rezende et al. 3 studied the reports of women victims of violence seen in the Autopsy and Necropsy Department in Belo Horizonte, Minas Gerais, reveal that the oro-dental injuries are frequent and represent a great demand for dental public health services 3 .Chrcanovic et al. ( 2004), evaluating facial fractures in women attending a public hospital in Belo Horizonte, state that violence is the second leading cause of this type of fracture in battered women 18 .
A study in England with 100 battered women and welcomed in a shelter, found in 44 of them bloody wounds, and 24 dental fractures 12

Conclusion
After analyzing the work, it can be concluded that domestic violence against women is growing alarmingly in the country, regardless of age, race/ethnicity, socioeconomic status or education level.
The offending agent is usually the spouse/partner or ex-partner and he chooses the face as the most affected region, because it is an area of great exposure, and he knows that the victim will carry along the physical marks, that cannot be hidden bringing along moral and psychological consequences.
With globalization, a new standard has been redefined with respect to the role of women in society, this should not be the suffering of abused woman but that they have freedom of expression, with new possibilities and responsibilities, and giving voice to their critical sense of woman.
It appears that there is still little research related to this topic by dental students, despite the relevance and importance that it has for their education.It is noteworthy that both the clinicians and the expert have responsibilities in the analyses of maxillofacial lesions where a mistake at any stage of the evaluation of lesions (clinical or forensic) may unfairly reflect the application of criminal punishment.Thus, health professionals should be alert to manifestations of violence against women.When faced with a case of raped women they must pay an even more humane and comprehensive care to generate greater effectiveness and guarantee their rights.
the violence between users 4 public hospitals in Mexico City.In relation to domestic violence, the authors interviewed 92 people, 70 women (76.09%) and 22 men (23.91%) and observed that when the Brazilian Journal of Forensic Sciences, Medical Law and Bioethics 4(1):1-11 (2014) M. S. Pereira et al.