¿Somos iguales? Using a structural violence framework to understand gender and health inequities from an intersectional perspective in the Peruvian Amazon

ABSTRACT

Background: In the Peruvian Amazon, historical events of colonization and political marginalization intersect with identities of ethnicity, class and geography in the construction of gender and health inequities. Gender-based inequalities can manifest in poor health outcomes via discriminatory practices, healthcare system imbalances, inequities in health research, and differential exposures and vulnerabilities to diseases. Structural violence is a comprehensive framework to explain the mechanisms by which social forces such as poverty, racism and gender inequity become embodied as individual experiences and health outcomes, and thus may be a useful tool in structuring an intersectional analysis of gender and health inequities in Amazonian Peru.

Objective: The aim of this paper is to explore the intersection of gender inequities with other social inequalities in the production of health and disease in Peru’s Amazon using a structural violence approach.

Design: Exploratory qualitative research was performed in two Loreto settings – urban Iquitos and the rural Lower Napo River region – between March and November 2015. This included participant observation with prolonged stays in the community, 46 semi-structured individual interviews and three group discussions. Thematic analysis was performed to identify emerging themes related to gender inequalities in health and healthcare and how these intersect with layered social disadvantages in the reproduction of health and illness. We employed a structural violence approach to construct an intersectional analysis of gender and health inequities in Amazonian Peru.

Results: Our findings were arranged into five interrelated domains within a gender, structural violence and health model: gender as a symbolic institution, systemic gender-based violence, interpersonal violence, the social determinants of health, and other health outcomes. Each domain represents one aspect of the complex associations between gender, gender inequity and health. Through this model, we were able to explore: gender, health and intersectionality; structural violence; and to highlight particular local gender and health dynamics. Intersecting influences of poverty, ethnicity, geography and gender served as significant barriers to healthcare in both rural and urban settings.

SPECIAL ISSUE:

• Gender and Health Inequality - intersections with other relevant axes of oppression

KEYWORDS:

• Gender
• social determinants of health
• intersectionality
• structural violence
• Amazon

Responsible Editor Isabel Goicolea, Umeå University, Sweden

Responsible Editor Isabel Goicolea, Umeå University, Sweden

Acknowledgments

The authors would like to acknowledge the traditional custodians of the land on which research was conducted. We would also like to acknowledge the contributions of all participants in the research who gave their time and shared their knowledge. We extend our deep gratitude to the communities of the Lower Napo River and Iquitos for hosting GDS during the extended periods of fieldwork. GDS would in particular like to thank: Diana, Renzo and DB Peru; Pilar, Circo, and the whole Petit family; the team of promotores de salud from the Lower Napo River; Monica and the staff of Nativa Apartments; Enrique, Zulema, Ines, and the team at Loreto Hospital Regional; Jessica Portocarerro and the Diresa de Salud, Loreto; the engaged team at the UPCH Centre for Interdisciplinary Studies in Sexuality, AIDS and Society; the staff of Mazan Centro de Salud; Mangua and Puinahua Puestos de Salud; Mangua and Llachapa schools; ExplorNapo staff; Arco Iris Orphanage; and everyone else who has been truly generous and interested in the project. GDS is particularly indebted to Claudia Sicchar and San Valentin Matute, who started as fantastic research assistants and ended up as good friends.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Ethical approval was secured from both UCL (Project ID: 5406.001) and UPCH (Codigo SIDISI: 63685). Access to research participants was facilitated by the Hospital Regional in Iquitos and Promotores de Salud in the Napo River region. Individual participants gave consent verbally, due to anticipated low literacy rates. Interviewers spoke through the justification of the research, confidentiality and the research process. Anyone who changed their mind or decided to withdraw their consent could do so at any time they requested throughout the whole process. Information about the research has continued to be communicated back to each community via local representatives.

Paper context

Whilst intersectionality and structural violence frameworks have both separately been used to explore either health or violence against women, to our knowledge this is the first attempt to combine the two approaches into an analysis of the intersections of gender, violence and health. Beyond providing a unique insight into local gender dynamics of the Peruvian Amazon, we were able to dissect layered social and structural influences on health through the lens of structural violence.

Notes

¹ Charapa is a term to refer to someone who was born in the jungle.

Additional information

Funding

None.

Notes on contributors

Geordan D. Shannon

GDS conceptualized the research, performed the fieldwork and led the qualitative analysis. JSW provided doctoral supervision to GDS over the course of her PhD research and contributed to editing and critique of the manuscript. AM provided academic and in-country support to the project, and contributed conceptually and theoretically to the research. CFC provided academic and in-country support to the project, contributed conceptually to the research and edited the manuscript. DB facilitated the fieldwork and contributed to the editing of the manuscript. AP provided overall academic doctoral supervision to GDS over the course of her PhD research and contributed to editing and critique of the manuscript.