Rev Mex Med Forense, 2019, 4(1):1-14 ISSN: 2448-8011

Transgression of sexual and reproductive rights during the professional training of female graduate doctors: a form of violence against women

Original Article

Juan Carlos Araujo-Cuauro 1

Received: July 12th, 2018; Accepted: September 5th, 2018; Online: January 15th, 2019

1 Physician and Lawyer. Professor of Legal Medicine. Faculty of Legal and Political Sciences. University of Zulia Law School, Venezuela

Corresponding author: Juan Carlos Araujo-Cuauro, [email protected].

Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14

SUMMARY the existence of some type of regulation that forced them to abandon postgraduate Introduction. Our purpose is to determine activities because they were pregnant.. if the hospital care institutions and / or the 100% of residents who became pregnant university institutions impose repressive during their academic period (n = 100) norms on the medical graduate students were forced to abandon their teaching due to their pregnancy condition. academic care activities. 100% were Methods: We performed a prospective, unaware of legal legal mechanisms to cross-sectional observational study; 400 protect their right to reproduction and postgraduate residents of the Division of maternity. Graduate Studies of the Faculty of Conclusion: The lack of knowledge of Medicine of the University of Zulia current legal regulations on sexual and answered a survey on reproductive rights reproductive rights of postgraduate in medical residents. medical residents by the Division of Results: 70% of the simple knows the Graduate Studies of the Faculty of existence of a protection law regarding Medicine of the University of Zulia, in any type of violence against women. 90% Maracaibo, Venezuela as well as the of respondents do not know or do not academic committees of each graduate remember the existence of a "Universal residence is evident. Declaration of Sexual Rights". 100% of Keywords: Violence, transgression, the respondents do not know the current medical residencies, medical resident, legal regulations on maternal rights in sexual rights, reproductive rights, human Venezuela. 90% were informed upon rights, postgraduate. admission to the medical residency about

INTRODUCTION Sexual rights are part of the basic Sexuality is an evolving concept rights of all people; therefore, they are that includes sexual activity, gender universal and inalienable. Sexual identities, eroticism, pleasure, intimacy reproductive health can not be achieved and reproduction. It is constituted by the without sexual rights; consequently, it is interaction of biological, psychological, not clear how repressive norms have been social, economic, political, cultural, established for women doctors residing in ethical, legal, historical, religious and postgraduate training in university spiritual factors (Villaverde, 2006). institutions where they carry out their postgraduate studies, in relation to Sexual rights emanate from the pregnancy (Castillo and Garibay, 2015). rights to freedom, equality, privacy, autonomy, integrity and dignity of all Training of human resources people, thus promoting the freedom to through postgraduate medical residences, decide and fully exercise sexuality. an important pillar of the health system, Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14 guarantees the preparation of medical women from have access to public policies professionals, not only in the academic and exercise the rights provided in this part, but also in the human part; under this Act, to ensure a life free of violence. scenario, the medical residences are a social process of great importance that Institutional control has tried to guarantees training and preparation of the maintain the distinction, as a source of future medical specialists, so that they discrimination, through normative reach a greater improvement in their regulation of sexual reproductive professional practice; however, the manifestations of postgraduate medical theoretical conceptions are reluctant to residents, who often ignore important legal consider the reality of institutional aspects such as the right to motherhood violence (hospital and university), (Article 76), the right to education (articles transgressing or discriminating and 102 and 103), the principle of autonomy abusing the right to sexual health of (article 20) and the principle of freedom of medical residents who become pregnant conscience (article 61), all of them during postgraduate studies (Montes- contained in the current Venezuelan Villaseñor, 2018). constitution.

Pregnant medical residents are In this sense, the Venezuelan Civil subjected to an arbitrary disincorporation Code establishes in article 2 that of their postgraduate studies for a period of "ignorance of the law does not excuse six months, under the justification of their compliance"; The Venezuelan Penal Code pre and post-natal rest confered by the establishes in its article 60 that "ignorance Venezuelan legal framework; their school of the law does not excuse any crime or program is suspended despite having lack" (Pérez D'Gregorio, 2010). completed it, based on the regulations for graduate studies at the University of Zulia. Since the 1997 declaration of the "Universal Declaration of Sexual Rights" In this context, we must consider or the so-called "Declaration of Valencia", how institutional care or postgraduate it became one of the fundamental elements university system has implemented labor of the new document on Sexual Health that administrative control mechanisms with was elaborated by the World Organization unfair distinctions to the detriment of a of the Health (WHO) in the year 2000. universal human right that every woman has; it would be a form of violence against Sexual rights are universal human women as stipulated in Article 15 in rights based on inherent freedom, dignity numerals 1, 3 and 6, stating: "It is all and equality for all human beings. Since behavior that threatens or violates the right health is a fundamental human right, of women to voluntarily and freely decide sexual health must be a basic human right, their sexuality,... Omissis" (Gómez, 2014). including reproductive free and The numeral 16 establishes the existence responsible decisions. This includes the of Institutional Violence when the actions right to decide whether or not to have or omissions made by the authorities, children, the number and space between officials, professionals, personnel and them, and the right to full access to agents belonging to any public entity that, methods of fertility regulation. Therefore, contrary to the proper exercise of their sexual rights are fundamental and attributions, delay, hinder or prevent universal human rights (Belli, 2013). Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14

Social Security (IVSS). The training It is important to mention the legal system in postgraduate residences in nature of postgraduate medical residences Venezuela leads to the legal concept of an in Venezuela. The specialty university employment relationship between the medical residency is a fourth level study in training specialist (resident) and the postgraduate university residences under hospital center in which he acquires his the auspices and supervision of a training or learning, a contractual University that grants a specialist degree; relationship that presents the article 1 of the Regulation of Graduate characteristics of a mixed teaching- Studies of the University of Zulia assistance contract; the contract will have approved by the University Council the following characteristics: according to the conferred conferred in ordinal 21 of article 26 of the Law of a. It is a labor contract. There is no Universities dictates the following: doubt that resident doctor is linked "Studies for graduates, are those organized to the institution to which he is for those who have obtained a degree in attached with a postgraduate Higher Education in National or Foreign training contract and medical Universities, or in University Institutes, assistance of an employment and that comply with those established in nature, with training regulations; it the Norms for the Accreditation of Studies involves the provision of for Graduates, of the National Council of professional services in authorized Universities or any other issue issued by hospital centers for that end. the National Council of Universities ". It is b. It has a peculiar nature. The the system for training medical specialties peculiarity of the contract is that exists in Venezuelan universities undeniable; residents are according to article 10 of the General undoubtedly linked to public or Regulations for Postgraduate Studies for private administration by Universities and Institutes duly authorized employment contracts and their by the National Council of Universities relationship is strongly inculcated (CNU). by an academic-educational- training nature; it is classified as a Medical Postgraduate Residencies of Adhesion contract of mixed nature, the different specialties have as main scholarship type and exclusive objective to train doctors in the different dedication. areas or clinical and/or surgical specialties, c. It has a temporary duration. legal according to the scientific and relationship of the resident doctor technological advances, with a humanistic with the hospital institution where approach and with the capacity to aspire to he exercises and acquires his execute an specialty. Postgraduate medical knowledge, has a temporary nature assistance residences have a limited period and jurisprudence also recognizes in their performance, as well as in their that quality. In the case of selection, which will be adjusted to the postgraduate university studies, regulations for the granting of contracts this is contemplated in the and/or postgraduate scholarships and Regulation of studies for graduates welfare residences programmed by the of the University of Zulia, in article Ministerio del Poder Popular para la Salud 45 numeral 3 that states: "The (MPPS) or the Venezuelan Institute of Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14

permanence in the program may teaching hospital units of programmed not be greater than four (4) years". residences of the Graduate Studies d. Permanence regime. It is governed Division of the Faculty of Medicine of the by a permanency system that University of Zulia. A bibliographic generates rights and obligations for search was carried out concerning resident physicians. transgression of the sexual and reproductive rights during the professional The objective of this research is to training of the postgraduate medical identify the experiences of hospital residents as a form of violence against institutional and/ or university violence women, as well as the legal implications of towards the medical graduate residents of their action or omission. the Division of Graduate Studies of the Faculty of Medicine of the University of Variables of the sample are Zulia, Maracaibo, Venezuela, through displayed in the form of graphs for their standards repressive for the simple better compression, visualization and to be condition of pregnancy during some able to focus the differences. Research was period of their academic teacher training, carried out attentively to ethical, moral and ignoring and violating what is stated in the legal principles, following the current Venezuelan legal system where regulations (requirements of the Good motherhood has protection with Clinical Practices - GCP-, regulatory constitutional rank. provisions and ethical principles originated in the Helsinski Declaration). METHODS The variables included were: This is a prospective, cross- sectional, observational study, using a data a. Medical residence. Set of activities collection instrument based on an that must be fulfilled by a resident anonymous, standardized survey doctor in his training period, to questionnaire with a randomly and carry out studies and postgraduate intentionally chosen simple obtained in the practices, with respect to the units of postgraduate program residency. discipline of the health area in the Division of Studies for Graduates of which they intend to specialize the Faculty of Medicine of the University within an academic medical unit of Zulia, Maracaibo, Venezuela. receiving residents, during the time and in accordance with the We included a pool of open and requirements indicated in the closed questions, using as parameters the respective academic-teaching- content of article 15, numeral 1, 3, 6 and assistance provisions. 16 of the organic law on the right of b. Resident doctor. Those who once women to a life free of violence and other completed the Rotary internship or laws that provide protection to the woman the rural boarding school and have in her pregnancy condition. complied with article 8 of the Law on the Exercise of Medicine Sample was constituted by 400 beginning their stage of specialized female medical residents of the medical training, product of the postgraduate studies programs of the selection by a contest; is hired exclusively by the State to work in Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14

a Hospital for a minimum period of RESULTS four (4) years, according to the plans and programs duly approved 400 female residents were by the university (university included, assigned to the graduate residence) or by the General residence units of the Division of Graduate Directorate of Health and Schools Studies of the Faculty of Medicine of the of respective Doctors (Scheduled University of Zulia, Maracaibo, Residences); they will be assigned Venezuela. to a Department or Service and will share with the active medical body 70% of the population (n = 280) the medical assistance activities to war aware of the existence of a law that the patients and will fulfill the protects them against any type of violence functions and attributions that for against women; in this sense, 90% of the their formation and training have population (n = 360) was unaware of the been contemplated in the program existence of the Universal Declaration of of the respective residence. Sexual Rights, a document that protects the right to reproduction as an important part of sexual health established by the World Health Organization, including the right to decide whether or not to have children, the number and the space between each one (figure 1).

10% CONOCIMIENTO DE LA DECLARACIÓN UNIVERSAL DE LOS DERECHOS SEXUALES

90% NO CONOCE O NO RECUERDA

Figure 1. Percentage of knowledge of the existence of the Universal Declaration of Sexual Rights of Venezuela

The totality of the studied University of Zulia, gave indications to population (n = 400) ignored the legal 90% of the population studied (n = 360) norm on maternal jurisdiction, concerning regarding the implementation of a the right sexual reproduction and therefore supposed normative that allows to the right to protection of motherhood. The disincorporate postgraduate medical coordination of the postgraduate academic residents for a period of one semester, due committees, following indications of the to their condition of pregnant women direction of the Division of Studies for (figure 2). graduates of the Faculty of Medicine of the

10% NO SE LES MENCIONO O NO RECUERDAN

90% SE LES HIZO MENCIÓN DE LA NORMATIVA DESINCORPORACIÓN

Figure 2. Percentage of knowledge about the existence of regulations on the academic and labor disincorporation in case of pregnancy 25% of female residents who hospitalization, guards, among others) for became pregnant during their school the time it lasted, without any type of period were forced to interrupt their contractual benefit; they established that academic, teaching and assistance the salary had been canceled, omitting the activities, in relation to their right to contingency in health that covers social prenatal and postnatal maternity rest, security in the case that the worker is through a written document prepared by pregnant. Finally, the Directorate of the the direction of the Division of Studies for Graduate Studies Division of the Faculty Graduates of the Faculty of Medicine of of Medicine of the University of Zulia the University of Zulia. Likewise, the proceeded to paralyze their degree process academic committees of each graduate despite having completed their schooling, residence rescheduled the activities not violating the right to education performed by the resident physician while contemplated in article 102 of the she was on prenatal and postnatal rest, Venezuelan Political Constitution (figure compensating the assistance activity 3). (consultations, medical journal in

25% MEDICAS RESIDENTES EMBARAZADAS

75 % NO EMBARAZADAS

Figure 3. Percentage of the sample studied in which after their pregnancy they were disincorporated from their work and academic activities.

DISCUSSION The Bolivarian Constitution dedicates its Title III to human rights and Violence against women guarantees, and in its article 19 states that represents a problem that is essentially "The State shall guarantee to every person, social in all the ways in which it occurs; in accordance with the principle of violence against women today represents a progressivity and without any national problem, because it is one of the discrimination, the enjoyment and most frequent violations of human rights; inalienable, indivisible and interdependent constitutes a public health problem that exercise of the human rights". Therefore, violates the human rights of women. One sexual and reproductive rights represent type of violence against women is the fundamental support for the exercise of represented by the violation of their right citizenship, understood this beyond the to sexual health and therefore their right to simple possibility of making decisions in motherhood, that is, violence against the public sphere. Citizenship also implies pregnant women (Benítez, 2004). the possibility for women and men to make autonomous decisions about their own Sexual rights are universal third- bodies and lives in the fields of their generation human rights, based on the sexuality and reproduction (Pérez dignity and equality and inherent freedom D'Gregorio, 2014). for all human beings. Given that health is a primordial human right, sexual and Sexual rights recognize the reproductive health must also be a basic citizenship of women, since they involve human right; women can decide the right the right to be considered as full, worthy to whether or not have children, the and free citizens; it also includes the right number and the space between each one to be treated as people and to position them (Arguedas, 2014). as protagonists of development processes in which health is a condition that demands The experiences of institutional respect throughout its life cycle and not violence within the studied sample of the only during reproductive age (Pérez postgraduate medical residents of the D'Gregorio, 2014). Division of Studies for Graduates of the Faculty of Medicine of the University of The problem arises when this right Zulia Maracaibo-Venezuela allows us to to reproduction is converted into a reason determine these are comparable, or even for administrative sanction, work. slightly higher, than those reported in other According to the Venezuelan Organic Law parts of the world. for a life free of violence against women, in its article 15º numeral 16, the The present investigation was not institutional violence against pregnant designed to evaluate the sources of graduate doctors constitutes a violation of violence against the sexual and their human rights, both as a form of reproductive health rights of postgraduate gender violence and as a form of gender- medical residents in their pregnancy based violence. because of her condition as condition, but, only to identify them, in pregnant women and the perspective of the order to determine the institutions right to sexual and reproductive health; involved. these rights are established in the Bolivarian National Constitution and in the different organic laws; example of this Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14 is the Law on the protection of families, maternity and paternity, which states in It is not logical that the direction of Article 18 that: "The State will develop the Division of Studies for Graduates of programs aimed at ensuring assistance and the Faculty of Medicine forces the resident comprehensive protection of motherhood doctors of postgraduate to complete a and fatherhood, in accordance with the period of six months, once finished their Constitution of the Bolivarian Republic of schooling; the duration of the postgraduate Venezuela and the law ". As well as the course is three to four years, depending on different regulations that refer to the the specialty studied; this is based on the problem treated (Villaverde, 2006). simple fact of enjoying the benefit of the LOTTT on pre and post natal rest in article Our Bolivarian constitutional text 336: "The worker in pregnancy is entitled protects motherhood in its article 76 ° to a break for six weeks before delivery when it states that: "Maternity and and twenty weeks after , or for a longer paternity are fully protected,... The State time because of an illness, which will guarantee assistance and according to medical opinion prevents him comprehensive protection to motherhood, from working ". generally from the moment of conception, during pregnancy, childbirth and In these cases, residents will retain puerperium,... Omissis. " their right to work and to get a salary, in accordance with the provisions of the Likewise, the LOTTT bases the regulations governing Social Security. protection to maternity in its article 335 by That is, the Venezuelan Institute of Social stating that: "The pregnant worker will Security (IVSS), the body responsible for enjoy special protection from immobility paying benefits for the contingency of the from the beginning of the pregnancy and maternity of the resident medical graduate, up to two years after the birth, in is required by law to pay a fee of the wages accordance with the provisions of the earned by the doctor resident on the law". occasion of the pre and post natal period. However, the period of pre and post natal The resident doctor in training does rest is a necessary legal figure for each not have to be forced by her employer worker in a pregnant state, in order to face labor institution, much less adjoin a bad or the difficult process of giving birth to a erroneous interpretation of article 97 of the new life, a new human being. To do this, regulations of studies for LUZ graduates, the Venezuelan labor legislator established which indicates that: The regular student a period of rest prior to childbirth and, after may request his disincorporation to the this as established by article 336 of the program in which it is registered, when LOTTT. there are fully justified and proven causes, in the opinion of the Academic Committee Article 91 of the Constitution of the and approved by the respective Technical Bolivarian Republic of Venezuela clearly Council, without prejudice to the states the following: "Every worker has the provisions of numeral 45.3 of Article 45 right to a sufficient salary that allows him and Article 47 of these Regulations. “Both to live with dignity and cover for himself numerals state that the permanence in the and his family the basic needs... Omissis." program may not be greater than four (4) This article elevates the right to salary to years from its entry. constitutional rank. Araujo JC. 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the damage that this situation produces However, because the Bolivarian must be assumed by its instructors, team Republic of Venezuela is constituted in a leader and, eventually, by the coordinator democratic and social State of Law and or director of the graduate program. This Justice, with the pre-eminence of human damage is direct, as a result of the non- rights and in accordance with the observance of current legal regulations on provisions of Article 2 of the Constitution the sexual and reproductive rights of of the Bolivarian Republic of Venezuela , postgraduate medical residents, which is it is of great human interest to safeguard attributable and compensable in the life and health of people, workers, and Venezuela through the unlawful acts of the their children born or to be born; in this Venezuelan Civil Code in force stipulated sense, it is necessary and just that the in article 1,185: "He who, with intent, or employer should assume the burden of negligence or recklessness, has caused medical assistance in the case of the harm to another, is obliged to repair it", resident medical worker in her pre and post and the 1,196th: "The obligation of natal rest. reparation extends to all material or moral damage caused by the unlawful act”. The graduate medical resident can not be required to comply with an Likewise, the acting civil servants additional period of six months without can assume an objective civil institutional salary compensation for the simple fact of liability, which includes civil subsidiary; it pregnancy, since this decision violates all is verified when the action of violating the regulations both from the workplace and right exposed in the subject is carried out the university; the officials that impose by a third party that is civilly responsible this sanction may incur penalties, both (director, coordinator or administrator of a criminal and administrative; this is hospital institution, postgraduate director, determined by Article 79 of the Law on the dean and academic committee), that is, the Statute of Civil Service that states that one that is refered to the obligated subject. "Public officials shall be held criminally, In this same context, it also includes civilly, administratively and disciplinary supplementary civil liability, which does for the crimes, misdemeanors, wrongful not exist and is imposed on the third party acts and administrative irregularities (director, coordinator or administrator of a committed in the exercise of their hospital institution, postgraduate director, functions . This responsibility shall not dean and academic committee) not as a exclude that which may correspond to consequence of pre-existing civil liability, them by effect of other laws or their status but rather in absence. It is convenient to as citizens". include joint and several liability; in this case, he responds equally civilly, both the Inexcusable fault on the part of the criminally responsible and those who are officials in charge of the hospital or not (director, coordinator or administrator university institutions can not be justified of a hospital institution, postgraduate on the application of a supposed normative director, dean and academic committee). that forces the disincorporation of the medical residents from their teaching- On the other hand, article 1221 of academic-assistance activity during their the civil code establishes that they are postgraduate studies product of the bound to the same thing, so that each one pregnancy situation; the responsibility for can be constrained to compensate the Araujo JC. Rev Mex Med Forense, 2019, 4(1):1-14 damage, even though each one is therefore therefore her sexual and reproductive responsible for their actions. Finally, rights. Article 124 of the Criminal Code provides for the joint and several liability of the With this research, institutional, persons when stating: "If the punishable labor and academic violence is made act is attributable to several persons, they visible as a real problem that affects the are jointly and severally liable for the citizenship of female postgraduate damage caused". residents, which represents a type of violence against women. It will also serve Sexual rights include the ability of as a basis for new lines of research that postgraduate medical residents to express help generate legal, labor and academic and enjoy autonomously and responsibly legal protection mechanisms, aimed at their reproductive sexuality, with planned reducing this problem that occurs during or desired pregnancies, without coercion, the professionalization of female medical violence and discrimination. personnel who are studying postgraduate and working in the sector Health. CONCLUSION REFERENCES The recognition and protection of sexual and reproductive rights as human 1. Villaverde. M. (2006). Salud rights are of very recent date and are not Sexual y Procreación Responsable. enshrined in a single normative body of the Jurisprudencia Argentina, Buenos Venezuelan legal framework. It is a Aires.: 31-32. fundamental pillar for the exercise of citizenship of postgraduate medical 2. Castillo, L. y Garibay, L. (2015). residents to become pregnant during the Presencia de las mujeres en las permanence of postgraduate studies and especialidades médicas una mirada exercise their right to motherhood which is desde la perpectiva de género. enshrined in the constitutional text. Revista Electrónica de Psicología Iztacala. 18(4): 1706-1728. In the present investigation it was evidenced that the causes of the 3. 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