Comunicación efectiva sobre el embarazo, el parto, la lactancia, la lactancia materna y el cuidado del recién nacido: la importancia del lenguaje sexuado

Artículo original en inglés
Traducción al español (Traducción automática, sin revisión detallada)

Introducción

El 24 de septiembre de 2021, la revista médica The Lancet destacó un artículo en su portada con una sola oración en texto grande; “Históricamente, la anatomía y la fisiología de los cuerpos con vaginas se han descuidado”. 

Esta declaración, en la que la palabra «mujeres» fue reemplazada por la frase «cuerpos con vaginas», es parte de una tendencia a eliminar términos sexuados como «mujeres» y «madres» de las discusiones sobre la reproducción femenina. La buena e importante intención detrás de estos cambios es la sensibilidad y el reconocimiento de las necesidades de las personas que son biológicamente mujeres y, sin embargo, no se consideran mujeres debido a su identidad de género (1). Sin embargo, estos cambios a menudo no se deliberan con respecto a su impacto en la precisión o el potencial de otras consecuencias no deseadas. En este documento presentamos algunos antecedentes de este problema, describimos varios impactos observados, consideramos una serie de consecuencias potencialmente perjudiciales y sugerimos un camino a seguir.

 

El sexo (una categoría reproductiva), el género (un rol social) y la identidad de género (un sentido interno de uno mismo) no son sinónimos (2, 3). El sexo es importante para la reproducción, ya que solo hay dos gametos y vías puberales hacia la edad adulta y la producción de gametos, y solo un tipo de cuerpo productor de gametos que queda embarazada (2). Como principio general de la comunicación, está bien establecido que el sexo de las personas debe hacerse visible cuando es relevante y no debe invocarse cuando no lo es (4–9). Esto facilita evitar los estereotipos sexuales al tiempo que garantiza que no se pasen por alto las necesidades y los problemas basados en el sexo (4–9). En la comunicación relacionada con la reproducción femenina ha predominado, por tanto, el lenguaje sexuado que incluye las palabras “mujeres” y “madres”. Sin embargo, este uso ha sido cuestionado en respuesta al aumento del número y la visibilidad de las personas que tienen una identidad de género, lo que significa que no desean que se las mencione como tal (10, 11). Como se describe a continuación, debemos dirigirnos a las personas como lo deseen (12), pero, en términos más generales, existen riesgos en el lenguaje de castración cuando se describe la reproducción femenina.

 

La discusión aquí se presenta con una audiencia explícitamente global en mente. Si bien las personas que no se ajustan a las expectativas sociales de su sexo son omnipresentes en todo el mundo, la respuesta a tales individuos está influenciada por la cultura en la que residen. Esto incluye en el nivel de aceptación o marginación que experimentan, las formas en que se acomodan y las formas en que se conceptualiza su inconformidad (13). Debe reconocerse que la sanción por no conformidad con los roles de género puede ser alta (14). Donde el concepto de identidad de género es destacado, la castración del lenguaje de la reproducción femenina ha surgido como una adaptación para remediar la marginación (10, 11). Sin embargo, debe tenerse en cuenta que las mujeres embarazadas y que dan a luz y las nuevas madres y sus bebés tienen vulnerabilidades únicas y también requieren protección.

 

Cada día mueren unas 810 mujeres durante el embarazo, el parto y después, y la mayoría de las muertes se producen en países de ingresos bajos y medios (15). Más mujeres en países de ingresos bajos, medianos y altos sufren complicaciones en el embarazo y el parto que amenazan sus vidas con consecuencias a corto y largo plazo (16). El maltrato y la violencia obstétrica ocurren en todas partes y contribuyen significativamente al trauma del parto (17, 18). La psicosis puerperal afecta a 1 o 2 de cada 1000 madres, a menudo en los primeros días después del parto (19) y es una de las principales causas de muerte materna por suicidio, así como por infanticidio (20). Las muertes maternas por causas no médicas, como el suicidio y las lesiones, están atrayendo cada vez más la atención de los principales organismos de salud, como la Organización Mundial de la Salud, con llamados para extender la notificación hasta un año después del nacimiento (21). A nivel mundial, 3,9 millones de bebés mueren cada año (22). Más de 800 000 de estas muertes son atribuibles a la interrupción prematura de la lactancia materna exclusiva o de cualquier tipo (23). Incluso en los contextos más ricos, la interrupción temprana de la lactancia materna es responsable de una gran proporción de hospitalizaciones infantiles (24). Así, el artículo 25 de la Declaración Universal de los Derechos Humanos dice que los estados de “maternidad e infancia tienen derecho a cuidados y asistencia especiales” (25) y la Convención de las Naciones Unidas sobre los Derechos del Niño establece que el interés superior del niño son primordiales (26).

El concepto de identidad de género

La identidad de género se puede describir como el sentido internalizado de un individuo de ser masculino, femenino o de otra manera, o como una comprensión interna de uno mismo como hombre, mujer, ambos o ninguno, y es independiente del sexo (27, 28). El concepto de identidad de género se originó en la década de 1960 en los Estados Unidos de América (EE. UU.) (29), se perfeccionó en la década de 1990 a través de una filosofía posmoderna llamada Teoría Queer (30) y continúa evolucionando. En el centro de la Teoría Queer se encuentran las proposiciones gemelas de que tanto el sexo como el género se construyen socialmente (31, 32) y que el género es el más importante de los dos (3, 33)1. Las ideas basadas en la teoría queer se han extendido desde los EE. UU. para volverse influyentes en muchos otros países occidentales y más allá (30). El número de niños, adolescentes y adultos que reportan identidades de género en conflicto con su sexo (descritos como “transgénero”) ha crecido dramáticamente en los últimos años (35). Junto a este aumento, ha cobrado protagonismo la idea de que no todas las personas que dan a luz son mujeres.

 

Fundamentalmente, palabras como «mujer» y «madre» pueden tener significados tanto sexuados como de género. Los significados sexuados establecidos desde hace mucho tiempo son que “mujer” significa un adulto del sexo femenino2, y “madre” significa una progenitora (36). Sin embargo, cuando se aplican nuevos significados de género informados por la Teoría Queer, “mujer” significa un adulto con una identidad de género de “mujer” y “madre” significa un padre con una identidad de género de “mujer” (37). Los mismos principios se aplican a las interpretaciones sexuadas y de género de «hombre» y «padre». En este documento y los Materiales complementarios asociados, a menos que se indique lo contrario, utilizamos los significados sexuados de estas palabras.

 

En respuesta a las preocupaciones derivadas de la Teoría Queer, muchas organizaciones e individuos están cambiando el lenguaje que utilizan para describir a las mujeres a fin de priorizar la comprensión de género y evitar la terminología sexuada3 (38–41). Estos cambios de lenguaje están destinados a evitar la angustia, se describen como inclusivos (42) y son alentados por iniciativas de diversidad, equidad e inclusión. El lenguaje castrado es más común en el oeste de habla inglesa, pero se aplica cada vez más a nivel internacional (43–45). Sin embargo, parece haber habido poca consideración de la ética de estos cambios, incluidos los principios de evitar daños y maximizar la salud (46), o cómo pueden afectar los derechos de las mujeres y los niños. El ejercicio de la ética médica requiere equilibrar “autonomía” y “justicia”. En este contexto, apoyar la autonomía es un objetivo legítimo y ético, pero también deben ser considerados los principios de justicia distributiva, de respeto a la igualdad y dignidad de cada individuo de la población (47). Aunque los cambios de lenguaje propuestos se relacionan con las mujeres, también afectan a los niños, ya que la madre y el bebé forman una díada, cuyas funciones fisiológicas dependen una de la otra y están íntimamente interconectadas en un estado de desarrollo único, vital y transitorio (48–50). Por lo tanto, nos corresponde estar seguros de cómo las necesidades de las mujeres y los requisitos previos del desarrollo de los niños pueden verse afectados por estos cambios en el lenguaje y cómo pueden afectar la promoción de la salud maternoinfantil y los derechos humanos.

 

¿Cómo se está cambiando el lenguaje?

La evitación de los términos sexuados más comúnmente da como resultado que las palabras «mujer» y «mujeres» se reemplacen con «persona», «personas» o «familias» y las palabras «madre» y «madres» se reemplacen con «padre», «padres». ”, “familia” o “familias” (51). A veces, también se utilizan partes del cuerpo (p. ej., «propietarios de la vagina») o procesos (p. ej., «nacimientos»). Se pueden utilizar términos como «no hombres» o «no hombres» para referirse a las mujeres. “Maternidad” (52), “materno” (53), “partera” (54) y “lactancia materna” (52) también se han convertido en términos polémicos.

 

En contraste con el uno o el otro de la sustitución de palabras sexuadas, a veces se propone utilizar ambos/y palabras. Entonces, en lugar de referirse a “mujeres” o “madres”, uno podría decir “mujeres y personas que dan a luz”, “mujeres y otras personas que dan a luz” o “madres y padres”, una estrategia comúnmente descrita como “lenguaje aditivo” (54). ). El texto también se puede construir de modo que se eviten «mujeres», «madres» o una alternativa a estos términos. En cambio, se hace referencia a “embarazos”, “nacimientos” o “alimentación infantil” / “amamantamiento”, eludiendo por completo la necesidad de indicar quién experimenta estos estados. Se puede evitar el término “niñas” en conjunto con las menores no desagregadas de las mujeres adultas embarazadas o madres. A veces se puede usar una mezcla de términos sexuados y algunas o todas estas estrategias dentro del mismo documento, descritas como “uso de una variedad de términos” (55). En particular, el lenguaje de castración en relación con los hombres ocurre con menos frecuencia (56). Algunos de los términos castrados de reemplazo se muestran en la Tabla 1 y se pueden encontrar ejemplos detallados de cambios de idioma y su interpretación en el Material complementario 1.

¿Cuáles son las consecuencias de estos cambios de idioma?

La esterilización del lenguaje de la reproducción femenina se ha hecho con miras a ser sensible a las necesidades individuales y como algo beneficioso, amable e inclusivo. Sin embargo, esta amabilidad ha tenido consecuencias no deseadas que tienen serias implicaciones para las mujeres y los niños. Estos incluyen: disminución de la inclusión general; deshumanizante; incluyendo a las personas que deberían ser excluidas; ser impreciso, inexacto o engañoso; y desencarnando y socavando la lactancia materna. Además, evitar el término “madre” en su sentido sexuado corre el riesgo de reducir el reconocimiento y el derecho a la protección de la díada madre-hijo.

 

Disminuye la inclusión general

Evitar la terminología sexuada en relación con la reproducción femenina va en contra del principio del lenguaje sencillo de la comunicación sanitaria y corre el riesgo de reducir la inclusión de los grupos vulnerables al hacer que las comunicaciones sean más difíciles de entender (57). Aquellos que son jóvenes, con bajo nivel de alfabetización o educación, con discapacidad intelectual, de antecedentes religiosos conservadores, o a quienes se les comunica en su idioma no nativo, corren un mayor riesgo de malinterpretar el lenguaje castrado (58–62). Sin embargo, incluso las mujeres con altos niveles de educación pueden no estar familiarizadas con los procesos reproductivos femeninos y los términos de la anatomía y fisiología femenina y, por lo tanto, es posible que no comprendan algunos términos relacionados con la castración (63–65). Es posible que no sepan, por ejemplo, que “una persona con cuello uterino” es una mujer y se refiere a ellas (59). La traducción de un texto castrado a otros idiomas también puede ser más difícil, especialmente cuando no existe un equivalente directo del inglés sex-neutral “parent” (por ejemplo, el español que solo tiene “padre”) (66).

 

deshumaniza

Numerosos términos alternativos para «mujeres» y «madres» implican referencias a partes del cuerpo o procesos fisiológicos. Referirse a los individuos de esta manera reducida y mecanicista se percibe comúnmente como «otro» y deshumanizante (67). Por ejemplo, el término “mujer embarazada” identifica al sujeto como una persona que experimenta un estado fisiológico, mientras que “portadora gestante” o “pariente” margina su humanidad. Los esfuerzos para eliminar el lenguaje deshumanizante en la atención médica son de larga data (68), incluso en relación con las mujeres durante el embarazo, el parto y la nueva maternidad (67, 69–71). Es imperativo utilizar un lenguaje que respete a las mujeres en edad fértil dada la prevalencia de la violencia obstétrica (18, 72, 73). Considerar a las mujeres en relación con los hombres como “no hombres” o “no hombres”, trata el cuerpo masculino como estándar (8) y se remonta a la conceptualización sexista aristotélica de las mujeres como hombres fallidos (74).

 

Incluye personas que deberían ser excluidas

Términos como “padres” y “familias” en reemplazo de “madres” pueden incluir de manera inapropiada a los padres y otros miembros de la familia, disminuyendo e invisibilizando así a las mujeres (75). El uso de «personas» y «familias» como reemplazos de «mujeres» puede incluir de forma igualmente inapropiada a hombres y otros miembros de la familia. Las mujeres tienen experiencias, necesidades y derechos únicos en relación con el embarazo, el parto y la lactancia que no comparten con otros (18, 76–79). No se puede suponer que los intereses de una mujer se alinearán con los de su esposo o pareja. Esto se ilustra con mayor claridad en el problema de la violencia doméstica, que a menudo comienza o aumenta durante el embarazo y cuya prevalencia mundial oscila entre el 5% y el 63% (80). Las mujeres, incluso cuando están embarazadas, no pierden sus derechos humanos individuales y deben ser apoyadas para tomar decisiones autónomas durante el embarazo, el parto y la lactancia. Esto incluye, por ejemplo, a su compañero de elección durante el parto (81), que puede ser o no el padre de su hijo. Sin embargo, el texto que se refiere a “familias biológicas” puede sugerir que otros miembros de la familia tienen derechos con respecto a la toma de decisiones de la mujer durante el parto. De manera similar, el texto que se refiere a apoyar a los “padres” o las “familias” para tomar decisiones sobre la alimentación infantil (82) sugiere que otras personas además de la madre deberían tomar decisiones sobre la lactancia (75). Esto pasa por alto que las parejas y los miembros de la familia pueden socavar directa o indirectamente la lactancia (75, 83). También oscurece la posición de la mujer como titular de derechos y de los miembros de la familia como garantes de deberes en relación con la lactancia materna (76). La terminología que incluye a otros puede, por lo tanto, impedir la provisión de atención adecuada y erosionar los derechos de las madres y sus bebés.

 

La intención del “lenguaje aditivo” es encapsular a las mujeres embarazadas y dando a luz o a las madres como un grupo, pero hacerlo de una manera que evite ofender a quienes no desean ser nombradas como mujeres o madres. Sin embargo, la adición de términos como “personas que dan a luz” o “padres que amamantan” cambia los significados de “mujeres” y “madres” de términos sexuados que incluyen a todas las mujeres y todas las madres, a términos de género que pueden ser confusos o inapropiadamente inclusivos. . Por ejemplo, ¿qué significa realmente la frase “mujeres y personas que dan a luz”? Esta construcción podría interpretarse de forma literal en el sentido de que “mujeres”

El imperialismo cultural en la salud pública mundial

Como se explicó anteriormente, el ímpetu del lenguaje desexuado en relación con la reproducción femenina fluye de una filosofía desarrollada en los EE. UU. y dentro de la cual predominan los entendimientos y las prioridades estadounidenses (147). En el contexto de la salud pública global, un estímulo o requisito cada vez mayor para el lenguaje sexual por parte de organizaciones internacionales o financiadores con sede en los EE. UU./Occidente puede experimentarse no solo como confuso sino también como imperialismo cultural y lingüístico (148, 149). Esta opinión fue expresada recientemente por más de 250 consejeras de lactancia de 45 países a la Junta de la organización de apoyo a la lactancia La Leche League, con sede en los EE. Las organizaciones y los individuos tienen la responsabilidad de evitar la imposición de ideas occidentales que puedan causar daño a aquellos con quienes trabajan4. Además, los riesgos asociados con el lenguaje de castración deben ser cuidadosamente considerados con una evaluación de impacto realizada, incluso cuando el concepto de identidad de género tenga relevancia cultural.

 

Caminos a seguir para aquellas que están embarazadas, dando a luz y amamantando pero que no se identifican como mujeres o madres

En algunas circunstancias, la aplicación de significados de palabras de género en lugar de sexo es apropiado y respaldamos plenamente la importancia de ser inclusivos y respetuosos (12). Para aquellas que están embarazadas, dando a luz y amamantando pero que no se identifican como mujeres, se debe usar la terminología preferida de la persona para referirse a sí mismas y a las partes de su cuerpo siempre que sea posible (1, 151). Esto puede significar evitar el lenguaje sexuado por completo y usar términos de género en esta base de uno a uno. Sin embargo, el uso del idioma preferido no debe presumirse para nadie (151). Las campañas de salud pública dirigidas deben abordar las necesidades de este grupo, no solo para garantizar que el lenguaje utilizado sea adecuado (152), sino porque pueden tener necesidades sociales adicionales o necesidades médicas asociadas con tratamientos como el uso de testosterona o la cirugía para extirpar tejido mamario ( 153, 154). De manera similar, los materiales de apoyo de salud específicos son valiosos y ya han sido producidos por algunas organizaciones [p. (155-157)]. El desarrollo de materiales castrados separados (al igual que podría ocurrir con personas de diferentes orígenes lingüísticos) puede ser una estrategia útil [p. (158, 159)].

 

La inclusión de todas las que están embarazadas, dando a luz o amamantando, independientemente de su identidad de género, se puede hacer explícita a través de declaraciones o definiciones de inclusión, algunos ejemplos de los cuales se proporcionan en el Material complementario 2. Estas adaptaciones pueden ser adecuadas en circunstancias en las que el lenguaje de castración es no es apropiado debido al impacto negativo en la claridad o cualquiera de los otros perjuicios mencionados anteriormente. Por ejemplo, la Guía de atención postnatal NICE del Reino Unido establece que “La guía utiliza los términos “mujer” o “madre” en todo momento. Debe entenderse que incluyen a las personas que no se identifican como mujeres pero que están embarazadas o han dado a luz” (160). Una variedad de estrategias pueden ser apropiadas en diferentes circunstancias. Reconocemos que es un desafío continuo aplicar el lenguaje de una manera que sea clara, concisa y que preserve la dignidad de todas las personas descritas.

 

Hay preocupaciones relacionadas con los registros médicos de las personas transgénero. En algunos países, las personas pueden cambiar los marcadores de sexo en sus registros médicos sobre la base de su identidad de género (109, 161). El caso de un marcador de sexo inexacto que puede haber contribuido a una identificación tardía del embarazo con un mortinato resultante, ilustra el impacto adverso potencial de esta práctica (162). También se han informado problemas asociados con la detección del cáncer de cuello uterino cuando se han alterado los marcadores sexuales (163). La Alianza de disforia de género de Canadá ha enfatizado la importancia de que el sexo se registre con precisión en los registros de salud y la necesidad de un lenguaje claro en torno al sexo (164). Anotar tanto el sexo como la identidad de género (cuando corresponda) en los registros médicos puede brindar una solución (2, 165). También se debe enfatizar que existe una escasez de conocimiento sobre cómo apoyar las necesidades de salud de las personas transgénero, particularmente en lo que respecta a los efectos a largo plazo en la salud de los tratamientos hormonales. Se necesita con urgencia más investigación y en esta investigación, los datos sobre el sexo siguen siendo vitales. Aquellas que no se identifican como mujeres o madres y, sin embargo, quedan embarazadas y dan a luz, se benefician más de una cultura y un servicio de salud que reconozca y comprenda profundamente los aspectos moleculares, celulares, conductuales y orgánicos subyacentes necesarios para reproducirse. Incluidos en tales entendimientos están la adaptación y la posible carga alostática que la acompaña con mala adaptación cuando no se cumple la expectativa biológica (166-168). Tal mala adaptación puede evitarse y manejarse si se caracteriza adecuadamente desde la biología básica y el uso de una terminología clara (169).

 

Recomendaciones y Conclusión

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Footnotes

1. ^Another idea associated with Queer Theory is that sex is a spectrum or that there are more than two sexes. Individuals with intersex variations may be brought in as proof of this. However, the conceptualisation of people with intersex variations as being of a “third” sex is misconstrued and has been opposed by intersex organizations (34).

 

2. ^In this sexed meaning, everyone who gives birth is indeed a woman.

 

3. ^Sometimes the desexing of language is referred to as using “gender neutral” or “non-gendered” language. Such characterisation is misleading. Gender neutral or non-gendered language more properly means not ascribing a gender role when the sex of the person undertaking the role is irrelevant. For example, as they can be male or female is it appropriate to avoid “policemen” and instead refer to “police officers”.

 

4. ^This includes understanding that an interpretation of gender non-conformity in non-Western cultures through a Queer Theory lens risks misunderstanding and neocolonialism, see (13).

 

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2. ^In this sexed meaning, everyone who gives birth is indeed a woman.

 

3. ^Sometimes the desexing of language is referred to as using “gender neutral” or “non-gendered” language. Such characterisation is misleading. Gender neutral or non-gendered language more properly means not ascribing a gender role when the sex of the person undertaking the role is irrelevant. For example, as they can be male or female is it appropriate to avoid “policemen” and instead refer to “police officers”.

 

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