Women ’ s protection public policies : evaluation of health care for victims of sexual violence

Violence against women has increased over the years and is a serious violation of human rights. This study aimed to evaluate public policies, women’s rights legislation and health care for victims of sexual violence. This is an exploratory and descriptive study, with interviews to professionals of the Care Center for Women Victims of Violence of Teresina-PI, and collection of medical records data of victims. We analyzed data in the light of legislation and guidelines recommended by the Ministry of Health, according to the established public policies. We noted an improvement of the Brazilian legislation and increasing intervention of government in order to control the violence. The evaluated service calls for the humanization of care, the principles of dignity, non-discrimination, confidentiality and privacy, avoiding exposure and distress of victims. Physical and gynecological examination are conducted, besides laboratory tests such as serological tests and collecting traces aiming at identifying the offender, as well as pharmaceutical care and multi-professional support. We can conclude that the current legislation and the guidelines and procedures recommended by public policies to protect women are effective in the referral service studied.


Introduction
Violence against women, whose understanding dates back to a deep-rooted plot, has tragic and indelible consequences for those who suffer it.Crossing historical periods, nations and territorial borders, as well as permeating the most diverse cultures, regardless of social class, race, ethnicity or religion, it has pandemic proportions and universal characteristics 1 .
For more than three decades, violence against women has grown and is a major human rights' violation 2 .While statistics are fragile and the exact incidence and prevalence of sexual violence are unknown due to underreporting, it is estimated that sexual violence affects around 12 million people every year worldwide.Research and reports from international organizations indicate that one in four women in the world is a victim of gender-based violence and loses one potentially healthy life year to every five 1 .With regard to homicides, accounting for 66 countries, the killer is an intimate partner of the woman 3 in more than a third of the cases.
Around the world, the United Nations estimates that one in five women will be the victim of rape or attempted rape.Sexual violence against women is regarded as a public health issue in the world and requires the establishment of effective public policies.Women between the ages of 15 and 44 years are at greater risk of being raped and beaten than of suffering from cancer or car accidents.It is estimated that only 16% of rapes are reported to the competent authorities in the USA.In incest cases, these percentages are below 5% 4 .
It is believed that most women do not file a complaint, especially those with the best economic condition 5 , whether it is out of embarrassment and humiliation, or out of fear of partners' reaction, being discriminated against or held accountable by family, friends, neighbors and authorities.It is also common for aggressors to threaten women not to reveal what has happened.Women also fear being discredited, which can be confirmed by the countless reports of discrimination, prejudice, humiliation and power abuse 4 .The fear of being held accountable and the lack of support from family, friends and public services leads to a smaller number of complaints.In addition, it is known that the most common form of violence against women is perpetrated by an intimate partner [1][2][3]5,6 .
In recent decades, in response to pressures from feminist movements and from society itself, governments have implemented public policies and actions to prevent violence against women.One of the main strategies has been to establish and improve norms, as well as to expand services in order to assist victims 2 .
In the case of rules, it is generally known that the effectiveness of laws can cover the legal and social spheres.Legal, when it is qualified to produce effects, considering its validity, and social, when it effectively produces effects and is applied to concrete cases.
In Brazil, legislation aimed at ensuring the constitutional rights of women has been established and improved over the years, emphasizing in this process the clear attempt to ensure assistance to victims of violence, especially health care.There is, however, a gap with regard to assessing the effectiveness of such legal provisions.Thus, the present study aims to review historically the development of Brazilian legislation to protect women's rights, as well as to evaluate the social effectiveness of these norms, in order to verify, in relation to health care, compliance with the guidelines and procedures recommended by the National Policy to Combat Violence against Women.

Methodology
We performed an exploratory and descriptive study and used articles from the Bireme database, with descriptors "Public Policies", "Sexual Violence" and "Violence against Women", as well as the relevant Brazilian legislation on the matter.We interviewed six professionals responsible for the reception and analysis of medical records of sexual violence victims attended in the period 2013-2015 at the Care Center for Women Victims of Violence (SAMVVIS) in Teresina-PI.The present study was submitted to and approved by the Research Ethics Committee.
The study included the six professionals responsible for reception at the care center.In the period from January 1, 2013 to December 31, 2015, 1,335 victims of sexual violence were attended, of which 135 medical records were analyzed by lot, 45 medical records each year.The interview consisted of the application of a structured questionnaire composed of eight questions elaborated from Decree 7.958/13 7 , Art. 2, which establishes guidelines for the care of victims of sexual violence by the professionals of the service network of the Unified Health System (SUS), and Law 12.845/13 8 , which provides for the compul-sory and comprehensive care of people living in sexual violence situations within the SUS.We examined the medical records of sexual violence victims in order to observe the performance of the procedures defined by Article 4 of Decree 7.958/13 7 and Article 3 of Law 12.845/13 8 .We inserted data collected in the database for further analysis.

Analysis of public policies for the protection of women's rights
In Brazil, until the mid-twentieth century, homicides committed by partners, usually with female victims, were justified as being in self-defense of honor.Progress in this area was fleshed out in 1984, when the country ratified the International Convention on the Elimination of All Forms of Discrimination against Women, but its national approval was only enacted in 2002.The 1988 Magna Carta 9 formally declared gender equality in its article 5º, I: Art. 5 All are equal before the law, without distinction of any kind, assuring Brazilians and foreigners residing in the country the inviolability of the right to life, liberty, equality, security and property, as follows: I -men and women have equal rights and obligations, under the terms of this Constitution.
In 1990, Law 8.069 10 (Statute of the Child and Adolescent), on addressing situations of violence against adolescents and children, established that the policy of attending to the rights of children and adolescents will be made through an articulated set of governmental and non-governmental actions, the Federal Government, the states, the Federal District and the municipalities, guaranteeing special services for the prevention and medical and psychosocial care of victims of neglect, ill-treatment, exploitation, abuse, cruelty and oppression.Article 87, III of said Law 10 specifies: Art. 87.The following are the service policy lines of action: III -special services for the prevention and medical and psychosocial care of victims of neglect, ill-treatment, exploitation, abuse, cruelty and oppression.
In addition, compulsory notification of violence against children and adolescents was established, and a copy of the notification form should be forwarded to the Child and Adolescent Guardianship Council.
In the 1990s, important international agreements, such as the Cairo Conference (1994), the Belém Convention (1994) and the Beijing Conference (1995) reaffirmed Brazil's position on sexual violence as a violation of Human rights and a public health matter.
In 1999, the Ministry of Health published the first edition of the Technical Standard for the Prevention and Treatment of Diseases resulting from Sexual Violence against Women and Adolescents, containing general recommendations of care and psychosocial support and protocols of prophylactic procedures.The second and third editions of the Technical Standard were published in 2005 and 2012, respectively 1 .
In 2003, the Secretariat of Policies for Women was established and strengthened public policies to combat violence against women through the elaboration of concepts, guidelines, norms and the definition of management and monitoring actions and strategies related to this matter.Henceforth, the establishment of norms and standards of care, improved legislation, the establishment of service networks, support for educational and cultural projects to prevent violence and increased women's access to justice and public security services were encouraged 1 .
Law 10.778 11 of 2003 established the nationwide compulsory notification of cases of violence against women, treated in public or private health services.Defined by this Law, violence against women is any gender-based action or conduct that causes death, harm or physical, sexual or psychological suffering to women, both in the public and private spheres.This law was regulated by Decree-Law 5.099/2004 and by the Health Surveillance Secretariat of the Ministry of Health through Ordinance MS/GM 2.406/2004, which introduced compulsory notification of violence against women under the SUS, through the Notification/Investigation Report of Domestic and Sexual Violence and/or other Violence.
In 2006, Law 11.340 12 (Maria da Penha Law) was enacted and established mechanisms to restrain domestic and family violence against women. 13In its core 12 , a provision was established to ensure assistance to women living in situations of domestic and family violence, to be provided in an articulated way, including by the SUS: Article 9. Assistance to women living in situations of domestic and family violence shall be provided in an articulated manner and in accordance with the principles and guidelines set forth in the Organic Law on Social Assistance, in the Unified Health System, the Unified Public Security System, among others public norms and protection policies, and on an emergency basis, when applicable.§ 3 o Assistance to women living in situations of domestic and family violence shall include access to benefits arising from scientific and technological development, including emergency contraception services, prophylaxis for Sexually Transmitted Diseases (STDs) and Acquired Immunodeficiency Syndrome (AIDS) and other necessary and appropriate medical procedures in cases of sexual violence.
Also in 2006, the Ministry of Health, through the General Coordination of Non-Communicable Diseases and Illnesses, implemented the Violence and Accident Surveillance System (VIVA), aiming to collect data on these types of violence to enable the analysis and management of the situation 1,14 .
In 2011, the National Policy to Combat Violence against Women was defined and aimed at establishing concepts, principles, guidelines and actions to prevent and combat violence against women, as well as to provide assistance and ensure the rights of women living in situations of violence, according to international norms and instruments of human rights and national legislation 14 .
Decrees are acts of the head of the Executive Branch, and more recently, on March 13, 2013, Decree No. 7.958 7 was published, which establishes guidelines for the care of victims of sexual violence by public security professionals and SUS health care network: Article 2. Assistance to victims of sexual violence by public security professionals and the SUS service network shall observe the following guidelines: I -reception in reference services; II -humanized care, in accordance with the principles of respect for the dignity of the individual, non-discrimination, confidentiality and privacy; III -availability of qualified listening space and privacy during care, to provide the victim with an atmosphere of trust and respect; IV -prior information to victims, ensuring their understanding of what will be done at each stage of care and the importance of medical, multi-professional and police conduct, respecting their decision on the performance of any procedure; V -identification and orientation of victims regarding the existence of referral services for victims of violence and rights assurance system facilities; VI -dissemination of information on the existence of reference services for the care of victims of sexual violence; VII -provision of transportation to the victim of sexual violence to reference services; and VIII -promotion of training of public safety professionals and the SUS's service network to provide humanized care to victims of sexual violence, ensuring the suitability and tracking of traces collected.
In addition to the care guidelines, in its Article 4, said Decree 7 provides the procedures of health professionals, such as reception, anamnesis and clinical and laboratory tests; completed medical records, complete physical examination, including gynecological examination, if necessary; thorough description of injuries and traces found, identification of the professionals who attended the victim, completion of the Detailed Written Account and the Informed Consent Form, collection of traces; pharmaceutical care and other supplies and multi-professional follow-up, as needed; as well as guidance to victims or their guardian regarding their rights and the availability of reference services for the care of sexual violence victims.The Decree also provides for the competencies of the Ministry of Justice and the Ministry of Health for their implementation.
Published on August 1, 2013, Law 12.845 8 provided for the compulsory and comprehensive care of people in situations of sexual violence, so that all hospitals members of the SUS network must provide victims of sexual violence with emergency, comprehensive and multidisciplinary care aiming at the control and treatment of physical and psychological injuries resulting from sexual violence, and referral, if necessary, to social welfare services (Art 1).With regard to the service to be provided:

Art. 3. Immediate care, mandatory in all hospitals that are part of the SUS network, includes the following services: I -diagnosis and treatment of physical injuries in the genital tract and other affected areas; II -immediate medical, psychological and social support; III -facilitating the recording of the occurrence and referral to the forensic medicine department and specialized police stations with information that may be useful to identify the perpetrator and confirm sexual violence; IV -pregnancy prophylaxis; V -Sexually Transmitted Diseases -STD prophylaxis; VI -collection of material to perform HIV test for later follow-up and therapy; VII -provision of information to victims on the legal rights and on all available health services. § 1 The services covered by this Law are provided free of charge to those in need.
§ 2 In the treatment of injuries, the physician shall preserve materials that can be collected during the forensic medical examination.§ 3 The forensic medicine department is responsible for the DNA test to identify the offender.
Several critiques, however, have guided the discussions about the mentioned Law.The first one addresses the concept used for sexual violence, as "any form of non-consensual sexual activity", however, it is known that sexual crimes must be observed even if with the victim's consent, as is the case of rape crimes of vulnerable people and those who bring vices in their consent.We also observe that various forms of violence defined by the Maria da Penha Law 12 were not included in Law 12.845 8 .
Undoubtedly, the historical development shown evidences an increasing concern of the public power in reducing the frequency and damage caused by the violence.Notwithstanding, legislation cannot always achieve the expected effect; this can be seen in the countless laws that do not achieve this result in practice and are said to be ineffective laws.The legal effectiveness of a rule means that it is capable of having effects in the occurrence of concrete relationships, since it already produces legal effects from its validity.On the other hand, social effectiveness occurs in the event that the current norm, that is, as potentiality to regulate certain relationships, is effectively applied to concrete cases.To date, there are no studies evaluating the effectiveness of these legal provisions to combat violence against women, according to the public policies established, which justifies the accomplishment of this study.

Analysis of public health care policies for victims of sexual violence in a reference service
Under the pressure of feminist movements and society in general, governments in developing countries, including Brazil, as presented earlier, have implemented public policies and actions to prevent and assist women who are victims of violence, especially in the establishment and improvement of standards and services for victims 2 .
In its Article 1, Decree 7.958 7 aims to establish guidelines for the care of sexual violence victims by professionals of public security and SUS service network and assigns the competencies of the Ministry of Justice and the Ministry of Health for their implementation.
From 2004, when it was established, to 2015, the SAMVVIS of Teresina has already served 3,856 victims, with yearly increasing incidence.Therefore, it complies with Article 2, paragraph I, of Decree 7.958 7 , which is the reception of victims of sexual violence in reference services.We interviewed six professionals responsible for receiving victims in the service.All professionals are women, with an average age of 47 years and working in the service for at least 1 year.When asked about the victims who sought the service, they reported that they were women and children of the female gender, coming from the capital or even from the state's inland.The prevailing age group is 10 to 19 years, although there were cases from children under one year old to the elderly, as described in the literature 15 .
Considering Art. 2, paragraph II, of Decree 7.958 7 , all the respondents revealed that they valued humanized care and respect for the principles of the individual's dignity, non-discrimination, confidentiality and privacy, avoiding victims' exposure and distress.The service also meets the provisions of paragraph III of said article, because qualified listening space and privacy during care are available, providing an atmosphere of trust and respect for the victim.Although it works inside a public maternity, the physical structure of the service perfectly meets the conditions of privacy and confidentiality, with exclusive access door and reserved environment for the provision of care.
As observed in the service, victims are assured of the guidelines prescribed in Art. 2, paragraphs IV and V, that is, they are enabled to understand what will be done in each stage of care and the importance of medical, multi-professional and police conduct, respecting their decision on the performance of any procedure, as well as identification and guidance on the services and the assurance of their rights.
Paragraphs VI and VII concern, respectively, the dissemination of information on the availability of reference services for the care of victims of sexual violence, and the provision of transportation to victims of sexual violence to reference services.Respondents affirm that these issues must still be improved, since in some cases, due to the lack of knowledge or disinformation of the victims and/or health and security operators, the victims are erroneously referred, failing to collect in a timely manner the traces of violence.In addition, while victims are mostly accompanied by the guardianship council, public security or health professionals, by means of vehicles or ambulances, there are often cases of victims who are helpless or accompanied only by family members who seek services on their own, often requiring assistance from the SAMVVIS social service team to return to their homes after care.
All the respondents reported that they had received training during the period in which they provided services to SAMVVIS for the care of these victims of sexual violence, which confirms the effectiveness of Art. 2, paragraph VIII of Decree 7.958 7 , at least with regard to the professionals of the SUS care network.
Article 3 defines that a reference service is qualified to provide care to victims of sexual violence, considering the levels of care and the different professionals who will work in each care facility, according to the technical standards and protocols used by the Ministry of Health.The SAMVVIS studied provides comprehensive care to the victim, its information systems is interconnected with the Forensic Medicine Institute (IML) and counts on a multidisciplinary team, formed by receptionists, nursing technicians, nurses, social workers, psychologists and physicians, on duty 24 hours a day, including weekends, therefore, as recommended by the aforementioned legal provision.
Article 4 provides in its paragraphs the procedures that should be performed by SUS network professionals to victims of sexual violence: IV -Collection of traces to ensure the chain of custody, forwarding to official expertise, with a copy of the Informed Consent Form; V -pharmaceutical care and other supplies and multi-professional follow-up, as required; VI -filling in the Compulsory Notification Form for domestic, sexual and other violence; and VII -guidance to victims or their guardians about their rights and the availability of reference services for the care of sexual violence victims.
Based on the analysis of the records of the victims of sexual violence, referring to the con-sultations carried out in the years 2013, 2014 and 2015, it is possible to report that all the procedures described above are carried out by said SAMVVIS, whenever necessary, according to the patient's care, anamnesis and clinical and laboratory tests sequence.During the reception and anamnesis, all the data necessary to complete the medical records and prescribed terms are recorded and are performed by the reception staff, social workers, nursing or psychology, as required.
Next, a physical and gynecological examination is performed, where injuries are recorded, whenever there is evidence, not only in written clinical descriptions but also through photographs.In addition, additional tests, such as tests for the detection of Sexually Transmitted Diseases (STDs) and collection of traces are carried out in search of semen or any material that helps to identify the offender through DNA test.According to the circumstances of the case, pharmaceutical and other supplies care is also provided, such as the use of analgesics, anti-inflammatories, antibiotics, antiretrovirals, contraceptives, among others, as well as multi-professional follow-up.Abortion is also planned, in compliance with the legal precepts, if this is the victim's option.
With regard to Law 12.845 8 , it is observed that it also provides for the compulsory and comprehensive care of people living in situations of sexual violence, as established in its Article 1, that hospitals must offer victims of sexual violence emergency, comprehensive and multidisciplinary care, aiming at the control and treatment of physical and psychological injuries resulting from sexual violence, and referral, if necessary, to social assistance services.However, Article 3 defines the list of mandatory procedures that must be immediately provided by all the hospitals part of the SUS network, as follows: Art. 3 The immediate, mandatory services in all the hospitals that are part of the SUS network includes the following services: I -diagnosis and treatment of physical injuries in the genital tract and other affected areas; II -immediate medical, psychological and social support; III -facilitating the recording of the occurrence and referral to the forensic medicine department and specialized police stations with information that may be useful to identify the perpetrator and confirm sexual violence; IV -pregnancy prophylaxis; V -Sexually Transmitted Diseases -STD prophylaxis;

VI -collection of material for the HIV test for later follow-up and therapy; VII -provision of information to victims on the legal rights and on all available health services.
We note that such procedures, as previously discussed, are fully performed by SAMVVIS, but the scope of legislation is to cover such assignments not only for reference services, but also for any hospital part of the SUS network.Thus, we understand that said legal device with regard to the service studied is effective, but further studies with this specific objective are required to conclude that it is complied with by SUS hospitals.

Conclusion
Public policies to protect women's rights have been developed over the years, especially with the improvement of relevant legislation and standards and principles for addressing violence against women.In terms of the attributions of the health services evaluated, we can conclude that the guidelines analyzed have been effective, but it is necessary to carry out further studies with a broader scope not only in the services of reference, but the whole SUS service network, for better reporting of cases, minimizing damage to victims and thus enabling the punishment of culprits.

Collaborations
LSS Pinto worked on the design of the research and in the final writing, IMP Oliveira participated in the collection and analysis of data, ESS Pinto worked on data analysis and in the final writing, CBC Leite participated in the collection and analysis of data, AN Melo worked on the design and data analysis and MCBR de Deus participated in the conception and methodology of the research.The work's final version was read and approved by all authors, who have taken full responsibility to make its content public.