The confrontation with violence goes through different stages and criteria, ranging from purely political and superficial ambitions to debates of the highest scientific level of experts in the field, which is a frequent cause of mistakes and divisions in the way it is taught and investigates, not always from a scientific basis. The misperception of the risk of violence causes it to be addressed by some States from the police and the criminal response, which sometimes permeates the vision of social sectors on it, however, its manifestations can occur in all scenarios of the life, accessible to preventive actions from many disciplines and social sectors whose objects and problems are superimposed, such as health, beyond its classic role of assisting victims, since many determinants of violence and health are common and interact. This complex and systemic approach, beyond the simple classification into forms and types of violence, is a need to be addressed when designing the problem of violence in the study plans of health professionals, especially that which occurs in family and family settings. community, very within the reach of primary health care, although also important for other levels of care.

Keywords: violence, resilience, social determination of health, medical training

Since the beginning of the 90s of the last century,¹ violence was categorized, by the analysis of the corresponding international organizations, as a health problem, and in a prognostic sense it was considered as “one of the great challenges that humanity would face in the 21^st century”, a vision that to date has been unequivocally correct.

Seen beyond its important repercussion for isolated people, violence, in macrosocial magnitude, is considered as a consequence, as well as reinforcement, of underdevelopment and other social problems that in turn are determinants of health and development, with the that maintains a relationship of dynamic interdependence; Its origins and manifestations go far beyond the interpersonal, family or community sphere, although these are the scenarios with the greatest impact and possibilities of preventive intervention in primary health care.

The organization of violence, at that point only visible in its variants of crime, took off in the nineteenth century due to the level of impunity it had, before which the upper classes of society covered themselves individually by creating private police and systems independent from judging the perpetrators (own-account justice). The evidence of the lack of control and affectation to the power of the State of these methods was immediate and at that moment when society demanded from it the organization of the investigation and confrontation with the crime, despite being an insufficient and superficial level of all violence.

What is paradoxical is that a phenomenon that has always affected humanity is, in the end, contained in a relatively new cognitive product,⁷ the conception of violence, since it is only in the second half of the 20th century that it comes to be given connotation as a category, beyond its simple previous existence as a word of common use and far exceeding the categories of crime or crime to which it was limited until that moment.

As a necessary reaction, since then many social sectors, not only the criminal law classically in charge of the crime, began to deal thoroughly with violence, although perhaps not all or in the most fruitful way. Likewise, many areas of knowledge and social practice have detected violence as a phenomenon linked to its different objects of study, mainstreamed in its various theoretical and social action fields, although more than anything this may be an expression of the objective nexus between them in the reality, beyond the conventional division of the sciences with assigned “objects of study” and the social objects conventionally established to each organization.^2-7 There is no doubt that regardless of whether it is manifested to a lesser or greater extent in different societies human.

Regarding the health sector, violence demands its interest as it directly affects the biological, psychological and social integrity of people and with it their health; although beyond what can be identified as welfare objectives, he is also interested in the impact on development and quality of life, individual and in groups. Hence the need to consider violence not only as a generator of victims to attend, but as a social determinant of health; as part of the determination process itself, especially if one takes into account not only the large number of direct and indirect victims impacted by its various types and forms, only those known to demand assistance and tributary of a diagnosis based on the physical effects or psychological effects of its traumatic effect, rather, how it interacts unfavorably with other social determinants to affect the achievement of health⁸ and set conditions and lifestyles unfavorable to it; as well as the possibility of important contributions that the health sector can make, not only in the rehabilitation of its victims and their report to the justice system, but in their prevention, through intersectoral alliances.

A successful international health inflection¹ led to the proposition late in the second half of the last century, that this sector should transform itself from a passive recipient of its direct or indirect victims, into an active agent of their prevention, in line with the principles of care primary applied to this health problem. From this, the health sector pointed beyond its immediate effects and causes, its triggers and the resulting personal injuries, towards any magnitude and origin of its causes and consequences.

The reality that violence is a problem at a global level and the potential role of the health sector in its prevention, justifies that in the training of health professionals the need to dominate their graduation, in knowledge and potentiality of action, is identified, relative to it, with mastery of procedures to identify their expressions and act accordingly.

Therefore, in Cuba, more than in any country given the multinational composition of its students in health careers, when designing how to teach, learn, research and confront violence in and from the health sector, it is necessary to base on conceptual aspects general and of universal validity, as well as in the direction and scope that the social response to this should have, including that of the health system and its integration with others, which, moreover, is scientifically defined by the science that has it as object, Criminology⁷ and demands to transcend the interdisciplinary.

Problematic situation that concerns us

If they do not receive adequate preparation, graduates of health careers will face violence in their practice without exceeding the classic levels of legal medical notification of cases brought to the system for injuries or deaths suspected of criminality; or the caregiver of known victims who demand assistance, in the most serious cases at the secondary level, for specific health effects directly caused by traumatic effects of a biopsychological type. Both are functions to be carried out, even mastery of the physical or psychological manifestations produced by the effect of violence in a given person should be promoted, to increase their perception by doctors and other professionals in care function, since such detection is a possible activation of the criminal social reaction towards them. However, limiting itself to them would restrict the general social response to the problem and the health system's own vision of itself to that of a passive “reservoir” of victims¹ and reporter of known cases, excluding its own and intersectoral preventive potential, and rehabilitation, which are also applicable to the perpetrator, among other aspects usually omitted.

More general concepts

Violence was defined in 2003 by an international group of WHO experts in the World Report on Violence and Health,⁹ as:

“The deliberate use of physical force or power, whether threatening or effective, against oneself, another person or a group or community, that causes or has a high probability of causing injury, death, psychological damage, disorders of the development or deprivation”.

It should be noted that suicides and their attempts would be included as violence (see in the quote: "... use ..., in a degree of threat or effective ..., against oneself ...")

It was also defined in our environment,¹⁰ in a less phenomenological, more dynamic way, as:

“… A form of exercise of power to eliminate those obstacles that stand in the way of our decisions, actions; and we use force”.

Violence therefore implies:¹⁰

 "... the condition of power imbalance,"that "... may be culturally or context-motivated, or produced by maneuvers in interpersonal relationships to control the relationship," "... this imbalance may be permanent or momentary."

Hence, Jorge Corsí, cited by Artiles,¹⁰ defined that:

"In its multiple manifestations, violence is always a form of exercise of power through the use of force (whether physical, psychological, economic, political) and implies the existence of an" up "and a" down ", real or symbolic , which usually take the form of complementary roles: father-son, man-woman, teacher-student, employer-employee, young-old, etc. ”.

It should be noted how violence is closely linked to inequality, in fact, it is this that makes it possible and at the same time increasing it is often the objective of the perpetrator of violence, to reinforce their power.

 Violence and social determination of health

Once violence is defined in this way, it is not difficult to link it to the concept of the World Health Organization (WHO) on social determinants of health,¹¹ due to its negative effect, opposite to those of social security and stability and that places these determinants as the circumstances in which people are born, grow up, live, work and age, including the health system. These circumstances are the result of the distribution of money, power and resources at the global, national and local levels, which in turn depends on the policies adopted. The social determinants of health explain most of the health inequities, that is, of the unjust and avoidable differences observed in and between countries with regard to the health situation.

Consequently, although violence directly generates specific effects on physical and psychological health in specific people, including disabilities, which can become health problems or are linked to other health problems, it should be located, at a higher level general, as a health determinant linked to others at any level; general, intermediate or individual.

At the general level, violence manifests itself at the level of states or groups of them, in the form of terrorism, violation of the rights of peoples and other states, narco-conflict at national and international levels, damage to the environment, and others. From that level it manifests itself in other levels of intermediate or individual rank; in community, family and personal settings.

Violence as a process of complex origins and levels

In our opinion, already published before,^7,8 violence, in general or in any of its forms, is the result of a process; and it does not have, as a rule, a single causal development,¹² even when appearances sometimes mask it, especially in the interpersonal setting, by making circumstances and triggers more visible than the probable determinants, themselves always complex and ecological. Hence our position of analyzing it from the integrationist cognitive position of complex thought,¹³ beyond disjunctive reductionisms that reflect the anchorage to a certain limited interest or to the orthodoxly restrictive theoretical approach from a science or discipline; or medical specialty in the case of our sector.

As a cognitive product, violence forces us to have it as something general and manifested in different forms and types, without such types or forms being independent entities, such as diseases, but variants of their manifestation, linked to each other by common interdependent determinants. so that it cannot be separated, in essence and other than for organizational or didactic purposes, at individual, group, generational, and community levels of manifestation; or that of biological, psychological or micro or macro causes or social goals. This is the complex level of its definition.^7,8

"Forms" of violence

There are definitions of specific forms of violence. It should be clearly stated for professionals, educators and students that it is not about other definitions of violence, even less about violence that is "different" from each other, but about ways of manifesting the general one already defined, so that they are not even opposed or exclusive with each other, to the point that rather than complementing each other, they can overlap or overlap when describing the same violent event, especially if it is analyzed, as it should always be done in dialectics, from the historicity and dynamics of its development. Being located only from "forms" also has the disadvantage of losing the possibility of vision of the historical dynamics of the phenomenon and the possibility of knowing, to act.

It should be mentioned that there are also forms of violence by omission or abandonment, that is, it occurs when people or groups stop attending to others who require it. It is not uncommon for superficial analysis to lead to qualify events resulting from omission or negligence as "accidents", such as cases classified as child or domestic accidents in general.

We present below the definitions of forms and types of most interest to our sector, while, in the interest of what has already been raised, we show their possible overlap, originated in their common determinants and the complexity of the dynamics between them:

Gender violence it would be precisely "violence against women based on the difference in power that the gender phenomenon determines".¹⁴

Gender: It is the social imposition of attributes linked to sex; “From sexual differences that have a very peculiar subjective representation that occurs in the process of differentiated socialization in women and men (even before birth), in the family, at school, among others through the mass media , and that also comes to us in the process of acquiring culture through objects whose use is highly identified for either sex. It may or may not undergo an awareness at the individual level and is studied from different disciplines”.¹⁰

The social construct of gender, by devaluing women and placing them in a more disadvantaged position (10; 15, 16), facilitates their victimization in various forms of violence. In fact, devaluing or discriminating against people or groups already implies violence.

Currently impossible to pretend to operate socially, not only in relation to violence, without taking gender into account; including that it is impossible without this approach to analyze health problems and design interventions based on them, especially when it comes to women's health. That is why we give it a special presence in our analyzes.

Many health problems specific to women - or when the affected person is a woman - are negatively influenced by the presence of gender in the group, which hinders even the allocation of family resources or their destination, for example, to help the sick or pregnant woman.

Gender violence is a definition that, without discussion, has become a tool for the necessary demand of women,^15,16 but, nevertheless, it does not exhaust all the violence that this phenomenon favors, also affecting men by producing culturally, other routes towards it,¹⁷ such as machismo or homophobia, which is why it does not cease to have a conventional character, although justified by its need. When teaching-learning it, the importance of this category cannot be diminished, but rather shows that, in reality, in its essence, it is closely linked to other forms of violence, some undoubtedly also culturally originated by the gender construct, and it would be counterproductive for it to be definition, applied mechanically, separates them to the detriment of the possible greater scope of subsequent interventions assigned to it.

It is not difficult to understand that interpersonal violence between men based on sexist and guapería attitudes has the same determinant in the gender phenomenon as when they incur violence against women in the family or community, for example. Both “ways” are susceptible to the same preventive interventions and, in fact, it would be counterproductive to try to target only one of them. With other "forms" something similar happens.

Intimate partner violence, it is defined in turn as "inflicting harm on one member of the couple by another, with the intention of causing pain or controlling their behavior".¹⁰

Although conceptually in “intimate partner violence” the manifest victim could be any member of the couple, the most frequent victims are women and, in this case, it would be gender violence in the context of the couple. We draw attention here to another overlap between concepts of violence.

On much less frequent occasions, the violence suffered determines that the woman, whose psychological profile is not always prone to the role of suicide or to adapt to the profile of an abused woman,¹⁸ victimizes the man who is her habitual abuser in reactio.¹ Depending on our objectives, we will comment that this reactive aggression by the woman against her partner would be a violence not classifiable as "gender", according to the official definition, but "partner", but undoubtedly linked to the original gender, if it is analyzed, once again, in its complexity, dynamically and historically.

The need to separate the analysis of the determinants of the violent act, from the criminal interpretation that can be made of it, aimed at establishing responsibilities, as well as the determining dynamics that the same subject, in the same or different scenario according to the moment, should also be seen. or interpersonal environment, passing from perpetrator to victim, or vice versa; or both. They are aspects of great importance for a student to learn to properly direct preventive and rehabilitation interventions.

Domestic violence It would be 19 “any action or omission committed by a member of the family in a relationship of power, regardless of the physical space where it occurs, that harms the well-being, physical and psychological integrity or freedom and the right to full development of the other family member".

Similarly, it does not exclude gender violence at the family level, nor that of a partner, and we draw attention to the fact that, due to a certain interest, which may be fair and necessary for a certain partial or operational purpose, they are making definitions at the end superimposed on reality, if it is about operating with the general of the phenomenon of violence. This is also manifested in others, such as violence against the elderly or child abuse:¹⁹

Child abuse is considered^20-23 "any behavior of an adult that by action or omission negatively interferes with the healthy physical, psychological or sexual development of children." Within it specifically, sexual abuse would be;²⁴ “the involvement of girls, boys and adolescents, dependent and immature in terms of their development, in sexual activities that they do not fully understand and for which they are unable to give voluntary consent, or that violate social taboos or family roles and include pedophilia, incest, pimping and rape”.

Research on sexual crimes against minors in our Havana environment,^8,10,12 show that it is a form of child abuse biased by gender, since most of its victims are female. Conversely, another investigation,²⁵ from the same territory, found that males predominate when minors are victimized in non-sexual crimes. In all of them, a significant association was found between family dysfunction and violence and both forms of child abuse studied. These results show the close link between child abuse, gender violence and domestic violence.

There are other definitions for partial forms or types of violence, even phenomenological or by scenario of occurrence (by action or omission - abandonment, neglect-; "physical", "psychological", "economic", "labor", "school", Bullin²”And the like). These are useful to learn to make it visible, to detect it in all its manifestations and in its specificities in certain settings, but the learner, much less the educator or researcher, should not confuse this with being independent forms with specific absolute causes, then, of In fact, they also tend to overlap and are not mutually exclusive; they are ways of manifesting the same friction. With the so-called childhood “accidents” themselves, there seems to be such an intimate relationship as to consider them a form of child abuse and not something independent.²⁵

In a previous critical analysis it was pointed out that this conceptual fragmentation in forms and types of violence, which we insist is necessary in a certain sense, responded to several reasons:⁸

“… In the first place, for an essential, and initial, descriptive study of the way it is exercised; and identify it: individual or group, predominantly physical or psychological, due to negligence or abandonment, sexual, economic and the like. Second, because sectors that were involved in her confrontation, differentiated from her their ways of demonstrating against people, or in scenarios of interest to their study topics, or to the social sphere that they include: "child abuse", "gender violence "(Focused on the one that reproduces against women),"intrafamily"," domestic","in the couple","against the elderly","work","school","state "violence and others)".

The value of the "forms and types" to theoretically support a complex, intersectoral and broad social action, is, therefore, relatively low, as they poorly reflect the essence of reality, aside - we insist - of their possible didactic and useful utility. definition of the field, because sometimes they also justify linking the destination of resources to the corporate purpose of a certain organization or specialty.

It should be understood that there is no solution of continuity, neither in the way of manifesting, nor in its origin, nor between one or another affected victim, between what in a subject of the Medicine career is treated as intrafamily violence, in another subject as child abuse and in another as suicide, for examples. It is only a question of what type of victim or conventionally defined scenario the violence occurs.

Up to now, the definitions of the most common types of violence in the usual medical scenarios have been included, but in the same line of reasoning that we try to present, it would be equally wrong to try to unlink the manifestation and determinants of violence from other levels, for example, of State, of these with a more circumscribed format. For example: in Cuba, domestic violence or child abuse from the North American blockade would be inseparable and, in fact, this is how it is shown when denouncing the consequences of that for our country; It is equally impossible to separate gender violence from the so-called Islamic terrorism, which especially affects women.

Complex and systemic approach to violence

In the theoretical approach to violence, both to investigate and intervene and to design its teaching-learning, beyond its conventional "forms" and "types", there are two fundamental aspects, however general: the first, the application of the so-called "thought complex”¹³ for analysis; the second, its application to response and organization systems, as “systemic thinking”.²⁶

These cognitive instruments are those that could reflect, for themselves and for the teaching-learning process, the complex links between what we call "forms" or "types" of violence, so as not to operate with them beyond didactic needs, descriptive or administrative due to their special link with the corporate purpose of any institution, organization or medical specialty; as well as to react socially to these phenomena that affect the quality of life and the development of individuals and groups, from the different levels of health care, but especially from the primary level.

Many institutions, researchers and professionals - it could be said that also sciences and sectors of society above their paradigms - have had to incorporate in recent decades new concepts and ways of doing things to address various problems,¹³ including those of violence and violence. the conception of its problematization within their respective classical areas of interest, which did not include it. This may explain that there are different fragmented concepts about the same problem, violence, whose real significance is ecological,^7,8 which gives it its real magnitude when considered within the approach of the social determination of health.

At this point, it is necessary to take into account the most advanced ideas on the direction and organization of scientific thought, which emerged in the second half of the 20^th century in the field of science sciences, in the form of the aforementioned "complex thought" and "thought systemic ”, the latter very much in vogue for the organization and control of systems, such as health, and their relationships with others.¹³ The result is a more comprehensive, "ecological" conceptualization of violence, which shows the dynamism and interdependence existing between its various manifestations, but also between its various origins, never attributable to a single determinant.

One of the characteristics of the scientific development of the 20^th century was that, above established paradigms and above the almost cultural split between social sciences and natural, technical and medical sciences, different forms of horizontal integration were imposed between them (teams, multidisciplinarity, interdisciplinarity, transdisciplinarity), as a necessary resource to generate new knowledge and technology.^13,27,28 The Health Sciences themselves, as a particular example of the above, of supposedly biological, have already come to define themselves as social science, thus expressing their position and methods in the face of the problems that concern them,^26,29,30 neither treatable nor preventable or accessible from the exclusively biological level.

To a large extent, scientific development occurs precisely in the areas of contact between interdependent disciplines, which converge to analyze and respond to phenomena that affect society in a complex way, such as violence, giving rise, among these, to “genetic recombinations", Which generate" hybrid cognitive products","reengineering of processes" and researchers that are" border transgressors ". From the point of view of "intellectual ecology", scientific rationality has also become the ability to evaluate sets of concepts, to modify or replace them with better ones, generating "conceptual innovations" and new fields of knowledge from these applied sciences.^13,28,31,32

All of this is fully applicable to medical specialties and their relationships with each other and has generated the interdisciplinary work that we promote and apply within our sector to face problems, both in the care as well as in the evaluative and preventive, but also in the organizational.

These approaches are also applicable to scientific education in general^33,34 and we consider that in particular to the teaching-learning of violence and the social response to it, because when it manifests itself in connection with the objects of different sciences or medical specialties, obliges them not only to study it from each one, but to all integrate trans and interdisciplinary in their study and establish their most objective complexity; generate more efficient and far-reaching health sector interventions; accept a hermeneutic³common for exchange and alliances; as well as that they generate technologies of intersectoral response, of integrated social reaction to violence, as opposed to creating reductionist plots in each one, dedicated separately to concepts and actions typical of a problem that is objectively common and, furthermore, surpasses all of them in the reality. Obviously, this is also desirable when it comes to the different components, parts or levels of the same sector that intends to face this or any other problem.

In concrete practice, it would not be convenient, for example, that in a health area there is no link between pediatricians who detect, work or investigate child abuse, psychiatrists who do it in relation to suicide and health psychologists who have decided to dedicate themselves to investigate and intervene in domestic or gender violence; at the same time, without joining forces with other organizations that deal with the same problems in the same territory. It is wrong to operate without the idea that violence is the common denominator, the social determinant, which is conceptually fragmented into its "forms", which, if these were independent phenomena, as they are only their ways of manifesting themselves in reality. . It is not about nosographic diagnoses.

In recent years, in exchanges with other specialists, we have found that sometimes each medical specialty has and transmits its own approach, generally of barely phenomenological or descriptive depth, of the "types" and "forms" of violence that are related to its more central field of work, in a sort of lack of intersectorality - lack of transdisciplinarity - within the health sector itself, which precisely has intersectorality as an important component of its policies defined at the global²⁶ and national^29,30 levels.

At the academic level, something similar could be happening: it is not that violence is not investigated, intervened, and violence is not included in various educational programs, but rather that it is not done in a unified, synergistic, voluntarily systematic way and towards a pre-established common goal throughout scientific activity and training of specialists. This may determine that the results of prevention and rehabilitation actions that are being carried out are not disclosed and generalized either; or that the Curriculum to train doctors does not include it as well as it could.

All of the above determines that it is intended to confront violence in a reductionist way, so that it is a matter of containing it all in the conceptual bodies of a single science or of a medical specialty - perhaps even of a special biological charge -, from which it results, for For example, it is intended to restrict it to psychiatric nosography and solve it with therapeutic resources and even exclusively psychopharmacological, although the same could be said exclusively pedagogical or criminally isolated, not necessarily integrated into the system, which indirectly amounts to the fact that each resulting fragment does not reflect the violence as a complex system or conceive of impacting it synergistically with others.

Sometimes the isolated finding of this or that psychological, psychiatric, pedagogical, economic and other peculiarity, in populations of victims or perpetrators of violence, leads to simplistic claims of causality, of inefficient restricted complexity^8,13 and lacking integrationist analysis , when, as we mentioned before, studies already indicate that the roles of victims and perpetrators are successively exchanged in the same person or group of them, depending on the moment in which it occurs or the approach with which the analysis is made.^7,8

As an illustration of this, we will relate how during a recent international congress of Psychiatry, an eminent professional, in an attempt to apply the science in which he is unquestionably an authority, but only from it, raised the supposed exclusively biochemical causality of the aggression of men against their female partners, regardless of the entire system and knowledge established in relation to the gender construct. To other colleagues present who questioned him, his answer to the question of why, if they suffered deficits in the neurotransmitter mechanisms of behavior control, was extremely elusive, then they were selectively "uncontrolled" only with the women who were their partners and not unspecifically in all your conflicts with other people.

We consider that everything mentioned so far reflects problems to be overcome and identifies the need to include complex and systemic forms of approach in a teaching-learning process to design for violence, since it negatively influences, first, the scientific foundation that, applied, must sustain the social reaction to the problem, which is to say an obstacle to the development and integration of segments of our sector or science and other applicable sciences -and of integration with other sectors of the social structure- based on this first-order problem and that is booming.

Secondly, due to inadequate methodological design, the doctor in training may receive separate fragments of the same reality, of the same process, having the perception that they are different problems, with different causes, without integrating them ecologically and erroneously incorporating that each One of them has different origins and will require interventions separate from the rest and in charge of the specialties most closely linked to the type of victim or setting in which it manifests itself; he or she may not perceive, or be slow to perceive, if the matter is left to spontaneity, for example, that the problem of child abuse that is most widely known in Pediatrics is practically the same as that of early pregnancy in adolescents with which It was found in Obstetrics and Gynecology; or that in a reading from a gender perspective, the same woman who is a victim is the necessary perpetrator of child abuse when child abuse is analyzed. Another example, the current abuser of the elderly person may at the time have been a victim of child abuse and domestic violence perpetrated by that elderly person and ignoring this historical element may prevent them from understanding the people involved and achieving good communication for the intervention with them.

The knowledge of a professional about the problem, therefore, cannot be limited to absolutely dividing the actors of violence into "violent and victims", "good and bad" or the "legal" or "medical-legal" aspect of the subject, as this can be something very inaccurate if, as is typical of complex dialectical analysis, people and groups and the dynamics between them are analyzed in their historicity and in their needs to be satisfied.

The simple qualification as "good" -victims and "bad" - abusers-, can be inconvenient to know the real "origin of the evil", access the subjectivity of those involved to operate with them, explain certain phenomena and design preventive interventions or rehabilitation, especially if they are broad-spectrum or long-term.

Didactically, we use the following scheme in teaching content related to violence that shows the interrelation and cyclical nature of different "types" and forms of violence among themselves, as a whole; also the so-called “transgenerational transmission of violence”. Those shown are, by the way, the most visible manifestations of violence for a health professional and many other forms, types and levels could be connected to the scheme:

Cyclical relationship between some types of violence:⁸

  It should be considered that subjectively, interpersonal violence, in its various manifestations, is something learned³⁵ by people who are formed in groups, especially in families, in which it is a form of manifest action and is not excluded or from the affinity affective bond relationships, although it is not only about learning, but also that social conditioning factors will also be present and prevalent, if they are not changed, for the generations in training or subjects that are integrated and must incorporate them to adapt to those media. Sometimes, at the community level, there is the presence of subcultures⁸ that have violence as a value, an accepted and sometimes flaunted part of their lifestyles and enhance it at family levels, as a subset, and individual, in the styles of life.

Violence is linked to the social determination of health, but it also has, ecologically, its own determinants and these are eminently social. Both processes overlap.

It must be emphasized that we do not deny the importance of knowing - to identify - the types and forms of violence that may be manifesting itself in a person, family, community or other human group. Nor should it be denied that it is not important to have established the resources to treat their victims according to the type of affectation, nor that their legal medical report is essential in certificates of care for the injured.

What we defend is that the conception from the health sector on violence, to conceive interventions against it, must be based on the fact that violence, more than the direct traumatic damage to health that it can cause in isolated people, is a social determinant of health and it must also be treated at that level of importance, beyond what is necessary to be done with victims who present these health problems, diagnosable in one way or another; or to support the knowledge and rehabilitation of perpetrators.

The complex, ecological approach of the determinants of violence

It is nothing more than the application of dialectics to its process and leads to the fact that regardless of the fact that certain forms or types of violence may have some specific etiological factors, in reality they will have many more of these in common with other forms and types, as well as many elements of a biological, psychological and, above all, social type will be common denominators to many of them and they are dynamically interwoven with each other and, at the same time, with others linked to the social determination of health, via which interacts with other health problems.

On the other hand, there is seldom any absolute, unique "risk factor" that determines by itself a form or type of violence, because, as in the complexity of all phenomena, they are multiple and are subject to the law of violence. Interactions,¹³ are chained and exert wave or domino effects on others, to enhance or antagonize,^7,8,11 sometimes to enhance or antagonize depending on the circumstances. Some may have the ambiguous property of expressing themselves in favor or against the occurrence of violence, depending on the ecosystem context associates or opposes them, with each other or with others, consequently, from which it is necessary to calculate casuistically in each case, as in clinical method, if it is counteracted or enhanced when conceiving an intervention.

Many professionals, for example, assume the criterion that a low socioeconomic and cultural condition is a necessary "cause" of violence and as a corollary they make the mistake of assuming that in community or family settings with high income and high cultural level violence does not occur; or that this is manifested whenever there is a low economic level. In fact, experts have defined the "theory of doses",^7,8,11,36 to conceptualize the fact that not one, but different determinants, among many, and the dynamics between them, when they coincide Sufficiently, they determine the appearance of violence and that such appearance depends on various combinations. Some of these determinants are long-standing; others circumstantial and among the latter some hardly have the effect of a “trigger” on others.

 "Ecological" interrelation:⁸

Many times "factors" apparently of biological or psychological link, when analyzed in complexity, are actually dependent on other social or transformable from them; or micro-socials, like family members, express in this scenario other more macro or social goals; immediate or mediate in time^8,21,23,36 that are manifested in its members, especially the most dependent, such as girls, boys or the elderly, through the family.

Consequently, the etiological analysis of violence, when teaching-learning it, must be dialectical and historical and the generalities must be applied "clinically" to each particular case, when it comes to cases, in order to intervene at that level, direct the interventions individual and control the subjectivity of those involved, regardless of whether the interventions with medium or large groups are based on the most general and frequent.

An important aspect to consider is to distinguish triggers from determinants, since, on occasions, the frequency in which a certain concurrent circumstantial element is present leads to mechanically attribute an absolute or high value of causality, which unfortunately masks the real underlying determinants that concur and they affect with greater stability and weight in the “dose”. Aspects such as the much-mentioned alcohol consumption, for example, is usually the circumstantial trigger for other more important and historical ones that are sometimes also the determinants of such occasional excessive consumption or habitual alcoholism, which appeared as an apparent, contiguous cause, when in fact, in turn, it has other more general determinants common to the whole context.

For example: many abusive men carry out the most bloody actions of physical abuse against their female partners or their family while under the influence of alcohol, but the prevention of gender or family violence cannot be limited to preventing alcohol consumption by men , since the origins of consumption are far beyond simple drunkenness and if it is looked for it will be seen that there are stable forms of abuse, less spectacular, but that affect as much or more the development and quality of life of these victims and of the violent person himself ; there would be the aspect of victimization of the drunk and the addict, who in such conditions of defensive disadvantage are more vulnerable to intentional or “accidental” violence (the same element, but now in which they emerged as a perpetrator); or the totally opposite aspect.

Then a high presence of alcohol in the corpse of a suicide can become the erroneous criterion that having consumed alcohol was one of the "causes" "favoring" or "determining" suicide, when it was only part of the way to prepare for the same or even a symptom of the same underlying depression, which is a common determinant of suicide and alcohol consumption in the same subject.

Other times, the perpetrator of hetero aggressions is forced to psychiatrize, hoping that psychiatric treatment (drugs, psychotherapy) will solve the problem and leaving out really essential aspects of a social nature. On the other hand, what is valid or functional to rehabilitate at the tertiary level may not be the basic for promotion or primary prevention.

The case of a mass murder in a Florida school⁴ is a good example of how distorted an interpretation of "causality" based on a single element can be, even intentionally: when sectors of North American society request a stricter control of firearms, considering the increasing frequency of this type of attacks, the political sectors of power, including the President of the country, economically committed to the arms industry and trade, try to explain these events as an exclusive expression of "mental health problems" of their perpetrators, without even passing through the reasons - real determinants - for which even a supposedly mentally ill adolescent -if he were to such a degree- can acquire without limitations a combat rifle with ammunition, carry it and have received institutional training for its use.

However, in a scenario and actors in which the criterion of mental insanity cannot be supported, the North American pediatric society, since the 1980s, has been drawing attention to the risk of having firearms in the home, given the high frequency of deaths, injuries and resulting disability of children who access them and shoot themselves or others when handling and playing with them.³⁸ They are also a good example of events classified as “accidents” when in reality they are child abuse due to negligence.

Decriminalization of the analysis of violence and the social reaction to it

Violence and crime are not the same: Hence, the attention of the former as a social problem is not something exclusive to the criminal repressive sector, which is limited to crime as a pre-defined act in the penal code; nor is it contained in what can be classified as "legal". Consequently, the medical legal action of reporting injuries or deaths of violent origin or suspected of being violent, does not even remotely cover everything that the doctor must and can do to face violence, not even to all cases, since they are reported only acquaintances who demand assistance.

It is mandatory and important to report cases of health disorders, such as deaths and injuries of violent origin, but if a professional or social sector conceives of facing the problem of violence only by reporting to activate the criminal repression of its executors, the responsibility would be lost most of the social potential of its prevention and rehabilitation of victims and perpetrators. What is more important: forms of violence that are not classified as a crime would not receive treatment, those that are more frequent than this and as harmful to health, development and quality of life as crime, but those that would be socially very expensive to include in those that lead to criminal sanction.³⁹

Possibly until the sixties of the last century, only the so-called Criminal Sciences^7,8 were in charge of the study and control (by them called "formal") of part of this phenomenon, that qualifiable as "crime" or "crime”, characterized as such in the Penal Code. From that moment on, there is a victimological reorientation of Criminal Sciences, especially Criminology,⁷ and of the awareness of groups and social structures, which are sensitized to the victimization of socially disadvantaged people and groups, such as women , not only in conventional crimes or only to establish penalties for those who commit crimes.⁴⁰

Since then, at the social level, the narrow category of "crime" (socially dangerous behavior typified as such in the Penal Code by the legislative bodies of a country and only by these) has ceased to operate in order to incorporate the much broader category of violence,³⁹ seen also in a sense not so of proclivity or of conventional individual legal responsibility for an act, but in a historical sense and beyond the formal legislation and penal controls of a country; more criminological and, at times, especially victimological.⁷

From the complex links between culture, development, economy, politics, society in general and science, in that period violence, thus defined to draw attention to something that affected the quality of life and the development of people or groups, hence its importance as a social determinant, emerged as a problem in the area of ​​disciplines outside the Criminal Sciences and that until that moment had not dealt with it (or not systematically) and did not consider it as an influencing factor in their respective objects of study or its corporate purpose. At that time, Criminology was declared a trans and interdisciplinary science to link with all of them. Such is the case of Medicine and the health sector, which until recently hardly assumed the role of recipient of victims.

For this reason, not every violent act constitutes a crime; Not all violence is the object of a formal reaction from the penal system, nor are the individual and general effects attributed to the penalty or sanction, the main resource of said system, destined for the person considered responsible for the crime, although this role is also not only the victim, requires prevention and rehabilitation.

Thus, it went from the exclusive social interest in finding a culprit and punishing him, sometimes also proclaiming an interest in rehabilitating him, to the more criminological interest in preventing violence, whether or not it was a crime, and not only with the interest reduced to labeling and punishing the immediate "culprits".^7,8

This is valid for the design and development of the prevention and rehabilitation reactions of victims and perpetrators,⁴⁵ beyond their medical treatment, roles sometimes clearly influenced by the same immediate factors in time and space, others by some that arrive from far behind or far from the protagonists in the complex fabric and evolution of social groups and the relationships between them,^41-46 or are the inadvertent or tolerated current determinants of future violence. Much of this is outside the horizon of Criminal Law and the scope of formal criminal reaction, while it is close to other sciences and to the social objects and missions of other sectors of society, state or civil society.

 However, it cannot fail to state that there is a relationship between violence and crime that is much more important than the simple one that conceptually the former encompasses the latter, since many acts that qualify as crime usually occur in the immediate or historical context of others. Catalogable as violence, as well as that some begin at levels of violence that do not criminally classify as a crime and end up being it. It is also deductible and expected that where there is high crime (high concentration of crime in a space and period of time) there is also a high presence of violence that, despite its relationship with the crime, is not criminally registered as such.

In fact, violence and crime depend on the same determinants and, therefore, are approachable from the same prevention actions, except for the criminal response, only applicable to the second and, sometimes, only if the victim formally reports it to the competent authority. .

 Violence, crime and social reaction:⁸

For the sake of our purpose, we must also reflect on how many or almost all of the so-called social determinants, in their origin and scenarios, approachable from measures of that level, will remain unaltered if the social reaction to the problem is only the criminal, product of which the perpetrator will receive a necessary and just sentence and may be subject to prison rehabilitation measures, but the rest of the protagonists and their environment will not be subject to preventive and rehabilitation actions, so their determinants will remain unaltered or enhanced, Unless other sectors include them in their interventions.

One could think of the solution of expanding the definition of crime to everything that is violent, in which case criminal intervention will be, in many cases, the "remedy worse than the disease."

Many people starting out in this field are inclined to advocate “criminalizing” these forms of violence, however, the most modern criminal law itself tends to be “minimist” and to classify itself as a “last-rate” solution, when not there is no other choice, that is, to reduce itself in its application, since its penalties can have an inverse effect to that attributed to serving as containment to people and rehabilitating them; or cause further damage.

As for the direct victim, but not the indirect ones that accompany her and other potential ones, she will perhaps be protected by a criminal action, but only from that perpetrator and -maybe- for the duration of the sentence imposed on him, since she and Others potentially or indirectly affected by it, will maintain the same risks or, even, these will be increased in some cases by circumstances derived from the accusation and the penalti,²⁴ such as having to leave the common home if it is owned by the perpetrator or his family; decrease the economic income in the house; and dividing the family and its relatives into detractors and defenders of the abuser / abuser, since some will not want or will not be able to see him as such, but as a victim of intrigue and, for example.

All of this increases the vulnerability and re-victimization of the victim and the effect on her of social determinants opposed to her health, but also to her development and quality of life in general.

Even all this can be “perhaps”, since it happens that, once the sentence has been completed, the abuser returns to the same family setting. We have worked forensic cases in which they then went on to more serious forms of violence, or repeated in other families, created after that, the same violence.

These reflections illustrate the "collateral effects" of the application of criminal solutions to all cases of violence in the family or parent-child environment. In the largest area of ​​the problem, in which the formal control of the penal system is inefficient, the social reaction of other organizations and civil society can be decisive, especially in the long term and with stable results.

By establishing the complex nature of violence, its determinants and ways of manifesting itself, as well as its links with those who would be objects of study of various sciences and the weight that overcoming paradigms and integration had in scientific development in the 20^th century horizontal of various disciplines, it is deduced that, as is raised from the critical self-review of Criminal Sciences, the social reaction against violence must come from all sectors of society, including health and not only because he identifies, report, receive and assume the treatment of their victims; Such specific social reaction to it can only be intersectoral,^46,47 and this intersectoral reaction will require interdisciplinary research of all kinds.

Even with regard to the reintegration of offenders, after the sentence, and the execution of certain types of extra-penitentiary penal sanctions, such as correctional work without internment, the penal system itself makes use of resources from other sectors of society; It uses the resource of intersectorality.

But the foregoing does not mean that all redoubts are equally violated, even in times of economic improvement, so violence cannot stop being expressed where its complex determinants (individual, family, psychological, biological) reach a climax, the “ dose ”sufficient. Family lifestyles and traditions, couples, parent-child relationships, toxic habits and lifestyles or tensions arising from injustices in relations between countries, for example, cannot be fully regulated and controlled by laws, except to influence them, if there is the will to do so, and to direct resources in that direction. It is impossible to fully counteract, only by law or decree, the negative manifestations of gender in this area, even when they are fought from the media.

Many disciplines and many sectors of society, from the State or from Civil Society, not only find links between violence and its social objects, but also have the potential to confront it, and it would be more cost-effective and efficient to do so with broad spectrum integrative measures led by the State, which designing exclusive reactions directed at the supposedly reduced determinants of each of its “forms and types”, according to a vision of restricted complexity for them.

Some authors familiar with the promotion and application of Intersectoriality, give us important response guidelines: this cannot be “the product of spontaneity”, but rather requires a political will to sustain it and “attend to the political, economic context and social, scientific and technical development, global policies and especially the country's policies regarding economic and social development ”.²⁹ We consider that the same intentional directionality should characterize the satisfaction of the need for their teaching-learning in a Medicine curriculum.

In the same line of thought, it can be affirmed that it cannot happen that the entire social structure of the country and international academic organizations and spaces practice and promote the analysis and claims of the problems that affect women in matters of gender others adopted by the Cuban revolutionary ideology from the period of the guerrilla struggle and the first years of the revolutionary power, but this aspect is totally excluded from the training of doctors in whom certain values ​​are aspired and they are actors of social rank.

In summary, when training health professionals - and those from other non-legal sectors - they must appropriate the attitude that is consistent with the fact that the criminal or "legal" reaction is not applicable to all violence, because it goes beyond it, in addition to Its preventive value is very tertiary, since it is not applied until the damage classified as a crime occurs and this is known, and, sometimes, being known, it is not criminally prosecuted if the victim's complaint is not mediated (essential legal requirement in some countries for, for example, criminally prosecuting a sex crime). The essence is that attending to and preventing violence and its actors, including perpetrators, is something that falls within the competence of its sector, that of health, either in its own actions or integrated into other sectors; and their actions in this regard are not only medico-legal.

Regarding this legal medical report, it is known, both for the educational activity in healthcare centers and for the usual content of the Legal Medicine subject, that it is ethically and criminally obligatory for the doctor, upon learning of injuries or probable cause of death originated in facts violent, is obliged to declare it by means of a certificate to the penal system. It is an unavoidable and necessary act, but the action of notifying does not guarantee the end of the problem, but only momentarily interferes in the determinants and relationships of violence; It is a mechanism from public health to collaborate to measure the real amplitude of cases of violence in a crime range and, in this way, invest in measures that support the criminal protection of that case or that vulnerable population, as well as creating epidemiological bases that promote scientific studies that establish its importance. Therefore, in addition to notification, active action is expected from the health sector and its professionals in cooperating with the interruption of this type of aggression and going to its comprehensive prevention at the social level,^48,49 otherwise it would be alienated from the essence of the problem.

Limiting oneself to the mode of action or procedure "to declare", for example, the already consequences of domestic violence, alienates the problem of the medical model to which one aspires. The behaviors that would be desired of him would not be that he limit himself to testifying, but to intervene, even if it were a crime with a mandatory medical declaration - which not all of them are, we insist - in a much more complex way, in addition to "declaring it". Furthermore, if the violence does not reach the rank of a crime: to whom can he “declare” what is his turn and it is not the responsibility of the penal system? Especially if he works in primary care. “Declare” does not include organizing a sectoral, inter-sectoral response, or joining it.

The doctor must differentiate that he has to master two totally different skills or procedures related to his response to the problem of violence: the “Skills in relation to the medical legal aspects”, of an eminently notifying nature, of which they would be“ skills in identifying violence, treating its victims and perpetrators and preventing it ”.

Resilience as a means of individual and collective solution

It is an aspect of interest in the rehabilitation of individual victims and groups affected by violence, not only for the health sector, but of special interest to its professionals, so it is unavoidable to treat it as part of the problem and incorporate it as part of the training that in terms of violence and reaction to it, it is designed for future professionals, since it avoids a fatalistic vision of harm as the only expectation for those who suffer it.

Resilience as an adaptive phenomenon has its conceptual origins from the very emergence of violence and It has become a topic of health research because it is associated with mental health and the mechanisms of adaptation to the environment on the part of the individual. Likewise, it is related to confidence and optimism in the face of adversity, because it allows the individual to recognize their own possibilities, trust in the help that they can obtain from others and the management of the circumstances before which they must know how to resist and attack, preserving the quality of life.⁵⁰

The person measures his own strength in the face of different challenges and demands, not only academic but also psychosocial, dodging demanding situations that lead him to dilemmatic instances in which he must confront himself in order to better understand his potential and capacities to strengthen himself, learn and respond effectively, maintaining their mental health and confidence in their potential and abilities.⁵¹

Among the most accurate definitions we find that of Becoña, who analyzed this construct in depth and considers that there is still no complete agreement on its definition, although he points out that the most accepted is that of Garmez: "ability to recover and maintain adaptive behavior after of abandonment or initial disability at the beginning of a stressful event".⁵²

Block and Block considered it as "the dynamic capacity of an individual to modify his modal level of ego control, in one direction or another, as a function of the characteristics of the environmental demand".⁵³

Fletcher believes that it constitutes a key factor for a successful adaptation in the different contingencies of life and a set of meta-skills that can be practiced, learned and applied.^54,55

It was at the beginning of this century that more attention is paid to resilience, perhaps due to the social perception of violence, especially gender violence and bulling, and Psychology is the science that has investigated it the most and because of its accompanying social purpose. to the victims in their adaptation, whether it is presented individually or collectively as we show in the following:

In the scientific literature, Adaptive Behavior is defined as the set of conceptual, social and practical skills that the individual has learned and that allow him to respond to the circumstances of daily life, which are sometimes not ideal, but still man has the ability to take advantage of the circumstances and even modify them. This last aspect is important, since the person cannot be seen as a passive entity reactively adapting to the environment, but also as an active and interacting entity that is reflected in its environment, which it is potentially capable of changing.

Resilience is not in exceptional beings, it is a tendency of normal people and in the natural variables of the immediate environment. That is why it is understood that it is a universal human quality present in all kinds of difficult situations and disadvantaged contexts, war, violence, disasters, mistreatment, exploitation, abuse, and it serves to face them and leave strengthened and even transformed from the experience individually. or collective. It is an idea that must be accepted when one sees how humanity and human beings have always been capable of overcoming and surpassing themselves in the face of great unfavorable events.

The most advanced studies on resilience have been carried out mainly in individuals, however, it must be remembered that people are always immersed in social groups, so it must be considered that part of these results are due to the influence of these groups. A more recent concept is that resilience also refers to aspects of coping with trauma and collective conflicts by human groups, which are influenced by other psychosocial aspects, in addition to individual responses to stress.

The community, the great stage of primary health care, is a social entity of greater significance than the simple number of people located in a territory. In it, above the number of its members, they maintain human and economic relationships with each other, share ideas, values, customs, goals, institutions and services with different degrees of conformity and conflict. These variables largely determine both strengths and vulnerability, and consequently also affect the social impact of disasters and catastrophes and the ability to cope, recover and transform possible.

This type of resilience is not only perceptible in issues of violence, but also in the way that human groups respond to adversities that as a group affect them at the same time and in a similar way: earthquakes, floods, droughts, attacks, political repression and others. , while showing how the resources that the community already has are developed and strengthened.

Resilience is the ideal or desired outcome, but the reality is that adaptation very often takes a negative course and the person moves into deviant behaviors typical of the one that motivated their original trauma and develops a proactive resilience, but with negative behavior. becomes part of the group or organization, alliance, this is observed with great intensity in places or red zones as it is often called neighborhoods or towns where there are high rates of delinquency and crime, marginal neighborhoods, with dysfunctional families, for example populations of Mexico close to the border with the United States, areas that are not violent by nature, in which the circumstances of drug, arms and human trafficking have nuanced a subculture associated with the indicators and rates of homicides and organized crime.⁵⁶

1. Didactically, types of violence can and should be identified, according to their occurrence scenarios or types of victims, such as gender violence, against the elderly, intrafamily or child abuse, but in essence these forms are actually ecologically intertwined and are dependent on each other. the others, as occurs with forms of psychological, physical, sexual or economic violence, among others. This is only visible from a complex and systemic approach to this problem, which should be the guiding force in the design of its teaching.
2. The occurrence of violence determines direct victims who suffer damage from a biological, psychological or social level, which as injuries or causes of death require specific diagnoses, but the problem of violence for health goes much further by having an impact on quality life and development of affected individuals and groups; and it is also much greater than the numerical representation of its trauma victims.
3. It is of great interest for the health sector and for the training of its professional, to link violence to the social determination of health, by itself and by its association with many other determinants; and because of its negative influence on other health problems and those that affect other sectors of society.
4. The training of professional skills for the health sector, especially for doctors, cannot be limited to legal reporting and the provision of assistance to known victims, but must include intervention procedures, their own and intersectoral, that preventively impact their complex origins. essential, from the individual, family and community levels.
5. It is important that the professional in training acquires the non-fatalistic vision of resilience, as an element to be fostered in people who individually or collectively have been impacted by violence.

None.

None.

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