Psychological suffering in the daily lives of women who have experienced sexual violence : a phenomenological study

Objective: To understand the daily actions of women who have experienced sexual violence. Method: A qualitative study was conducted with 11 women who suffered sexual violence in southern Brazil. Their testimonies were obtained through phenomenological interviews conducted between October 2014 and April 2015. Results: The daily lives of women after suffering sexual violence were permeated by mental distress, translated into fear. This impacted their mental health by limiting their daily lives, especially social activities (work, school, sentimental, and sexual relations). To overcome the consequences of sexual violence, women sought support from family and friends and reintegration into the labor market and course of studies. Conclusion and implications for practice: Individual and group actions providing psychosocial and social support to women in situations of sexual violence are essential to help victims cope with the consequences of this experience.


INTRODUCTION
In all of its forms, violence is a phenomenon that affects women from different social classes, origins, marital status, education levels, race and sexual orientation.It is one of the main forms of human rights violations, affecting women's lives as regards their psychological and physical integrity.Among the different types of violence, rape is the maximum expression of sexual violence.In this study, it is defined as any action in which women are coerced to have sexual relations, against their will. 1he literature on sexual violence against women depicts it as a severe social problem that affects mainly young women.A retrospective study conducted in Nigeria included 196 cases of sexual assaults that occurred between 2006 and 2015 and found that most of the victims were women (93.9%), under the age of 20.Vaginal penetration was the most frequent (87.2%) form of rape, followed by anal penetration (56%).Most rapes were committed by someone known to the victim (52%).The proportion of individuals sexually assaulted in the country increased from 0.2% in 2006 to 2.0% in 2015. 2 The United States Air Force Institute of Technology Medical Center developed a cross-sectional study in which anonymous surveys were conducted with people over the age of 18 and showed that of the 775 participants who had experienced violent situations, 111 were characterized as sexual violence, of which 14 were men and 97, women.These results highlight that sexual trauma can negatively impact people regardless of gender, although women presented more posttraumatic stress disorders. 3n Brazil, a study developed in the capital city of the state of Paraná with 1,272 sexual assault victims showed that 53.46% of them were between 12 and 18 years old and that 94.66% were women.In over half of the cases, the victim knew the perpetrator (53.38%), assaults occurred at the victim's home (39.30%) and outside (35%), at night (50.33%) and, in 96.67% of cases, there was vaginal penetration. 4nother Brazilian study conducted in the city of Campina Grande analyzed 886 forensic medical records of sexual violence from the Brazilian Institute of Legal Medical.Rape was confirmed in 32.8% of the cases.Over a third of the victims were women, with a predominance of adolescents with low education levels.Assailants were known to the women in 84.2% of the cases. 5egardless of whether or not perpetrators are known to the victim or strangers, sexual violence has the potential to alter the daily lives of women and cause many consequences to their physical, reproductive, psychological and social health, especially among younger individuals. 6he literature on sexual violence is expansive and focuses mostly on statistical surveys, [3][4][5] which contributes to an epidemiological understanding of the object of study.From a comprehensive approach, studies about the consequences of sexual violence from the point of view of women add value to already existing scientific knowledge.
In light of the above, the following questions guided this investigation: What is the daily life of women who experienced sexual assault like?How do these women expect life to be after having suffered sexual violence?The goal was to understand the daily actions of women who had suffered sexual violence.
Based on the principle that sexual violence is a global public health problem, deepening discussions on the theme based on a phenomenological perspective can unveil important elements to broadening the possibilities of reflection and addressing this problem within the context of health care, teaching and research.

THEORETICAL FRAMEWORK
Women who have experienced sexual violence form a social group that acts in the world based on intersubjective relationships that are based on existential motives related to the past, present and future.In the present study, these women's actions before the situation of having suffered this type of violence reveals the consequences of this aggressive event in their daily lives, in addition to how they seek to overcome it.This study used the theoretical and philosophical framework of Alfred Schütz' phenomenology: social world, intersubjectivity, biographical situation, stock of knowledge, and social action.
The social world is cultural, an interwoven mesh that guides daily actions based on a specific social reality, constituted by people who relate with one another.The founding characteristic of this world is intersubjectivity, which produces social meanings for people immersed in a given reality.Such social meanings are part of the stock of knowledge constructed throughout people's lives.This is composed primarily by early references of the world, which are first built in the family universe.Later, it includes relationships that extend towards the social macrostructure, such as school, work, friendship circles, and others.Experiences that occur within these spaces constantly resignify the social world. 7tocks of knowledge, which are constantly changing, result in taking certain stances in the world, which results in people taking on given biographical situations, i.e., positions occupied in the life-world. 7Together, one's stock of knowledge and biographical situation are essential for taking action in this world.Action is the core of social life, for it motivates people, imbued with intentionality, to transform themselves and their social reality.Existential motives are the common thread of social action, woven by past/present experiences (because motive) and by the expectations that individuals launch toward the future (in-order-to motive). 7

METHOD
This was a qualitative study grounded in the phenomenological framework of Alfred Schütz' model of social action. 7It was developed at a specialized center for women who experienced situations of sexual violence in the capital of the state of Paraná, southern region of Brazil.Participants were recruited randomly after the researchers consulted the charts of the women who attended this service.Forty-two charts were included according to the following inclusion criteria: women who reported coerced sexual relations, aged 18 years old or older, who received Psychological suffering after sexual violence Trigueiro TH, Silva MH, Merighi MAB, Oliveira DM, Jesus MCP treatment in 2013 and the first semester of 2014, with a minimum of six months of outpatient care, and who had not fully adhered to this service.Nonadherence was defined as missing at least one of the follow-up appointments scheduled by the service.Only women who were in sufficient clinical and emotional conditions to provide their testimony were included.
The main researcher called the telephone numbers available in the charts to schedule a meeting with the selected women.Fourteen women were successfully contacted, and of these, three declined participation, finding it hard to relive their experience of sexual assault.Thus, 11 women were interviewed and none of the testimonies were discarded, as all had sufficient meaning to reach the objective of the study.The content of the 11 interviews presented convergence of meaning, reaching theoretical saturation. 8he phenomenological interviews followed these guiding questions: Tell me about your life after having experienced sexual violence.After what happened, how do you expect to live with the situation?The interviews lasted an average of 50 minutes and were conducted between October 2014 and April 2015 in a private location, according to the women's preference, (home, school or health service), after signing a free and informed consent form.
The content was organized and analyzed according to the steps suggested by scholars of Alfred Schütz' social phenomenology: 9 first, the interviews were recorded in MP3 format; testimonies were fully transcribed; the researchers conducted an in-depth reading of the transcribed material; units of meaning were identified and grouped based on converging content, and thematic categories were created that congregated the daily actions of women who had experienced sexual violence.The results were discussed in light of literature on the theme, using the phenomenological assumptions of Alfred Schütz' theory of social action as the common thread.
The study was developed in accordance with the ethical standards set forth by the Brazilian National Health Council's resolution on human research ethics, 10

RESULTS
The 11 women who participated in the study were between the ages of 18 and 27, with a mean age of 20.All of them had experienced coerced sexual relations and, in most cases, the victim did not know the assailant.Sexual violence had taken place outside and at night.
By understanding how young women victims of sexual violence acted in their daily lives after the aggressive event, the following categories emerged: "Daily life marked by fear" (because motive) and "Overcoming trauma" (in-order-to motive).

Category 1: Daily life marked by fear
The daily life of the participants was modified by fear that resulted from the assault.The testimonies indicated that the impact of this type of violence transcended the physical dimension, invading the emotional and causing psychological suffering.This then reflected negatively in their performance in routine activities and intersubjective relationships.
Regarding the physical aspects, some women reported that the sexual violence made them afraid of being infected with a sexually transmitted disease (STD):

[...] I was afraid of having been infected by the guy who raped me (M3).
I was afraid of having some type of disease, and because of HIV, afraid of not being able to have a baby after that (M8).
After the sexual assault, the women reported being afraid of interacting with strangers who reminded them of their assailant.

I'm afraid of the male figure, if I see a man with a similar physique as the guy who did that to me, I'm scared, it can be on the bus, or on the street, I'm scared [...] (M10).
Afraid of being raped again, the women mentioned avoiding sentimental and sexual relationships:

I can't get close to boys, I can't like anyone, I'm afraid that it'll happen again (M2).
[...] I had a boyfriend, not anymore...

[...] I broke it off, I'm scared [...] I want to be alone (M5). I don't let a man get close to me no matter what. The other day, at a bus terminal, a man got close to me and I felt chills in my stomach. I feel the same with my husband or anyone who gets close to me (M7).
The testimonies showed that the fear generated by experiencing sexual violence made women dependent on other people to conduct daily activities in addition to interrupting their education: Before, I wasn't afraid of anything, and now, after it happened I feel more dependent on others, because I always need someone to go out with.I don't have the autonomy I had before (M10).

[...] I stopped studying because I was afraid of the guy coming back or everything happening again, I dropped school for a year (M3).
The psychological suffering of women was intensified when they remembered their assault, eliciting feelings such as sadness and anguish.Most participants were not able to call the violent incident by its name: Every time I remember what happened to me on that day, I feel so sad, I feel like crying (M3.) If I remember what happened I don't feel like going to work.I start to cry, I feel so much anguish (M5).

Category 2: Overcoming trauma
The women made reference to the expectation of overcoming the psychological suffering caused by sexual violence.To this end, they sought support from their social network, which consisted of family and friends:

My friends helped a lot, they never left me alone. I decided to forget what had happened. I started going out with my friends again (M11).
Work and school were also considered a way of overcoming the trauma of sexual violence:

I started working to lose my fear of people (M5). I forced myself to get better, I couldn't stay that way forever, that's when I went looking for a technical course (M7).
The possibility of attending an institutional service that supports women victims of sexual violence emerged as one of the contributing factors to overcoming the psychological suffering caused by rape:

DISCUSSION
In this study, fear was a central element (because motive) interfering with the daily lives the women who had experienced sexual violence.It is worth noting that action in the routine world is intentional, as it depends on the stock of knowledge and experiences lived throughout one's life.Thus, the daily actions of these women were permeated by the negative impact of rape in terms of biopsychosocial aspects.
Regarding physical aspects, the women reported fear of STDs.This fear is justified considering that the literature highlights the occurrence of STDs resulting from sexual violence. 6,11In Norway, a study with 412 women rape victims with a mean age of 21 detected STDs in 8.5% of them.Of these, 3.7% tested positive for hepatitis B and C. 11 In another survey conducted mostly with young Hispanic women from Mexico who had been raped, none of them tested positive for HIV; however, some reported being infected with some form of STD. 6 Considering the psychosocial dimension, the fear that results from sexual violence interfered in the women's social, sentimental, sexual, work and school relationships.The participants said they needed someone to go outside with them, expressing fear of meeting strangers that would remind them of their assailant, illustrating the repercussion of sexual violence in these women's mental health.
In England, a study relating mental health and rape showed that the women who had suffered this type of violence were 2.5 times more likely to have a history of neurotic disorders than those who had not.Additionally, people who were raped were also significantly more likely to develop drug and alcohol abuse, be admitted in a mental health ward, and present suicide risk. 12 descriptive study in English conducted with 142 Hispanic women, most of which were under the age of 18, showed that after the rape, a great part of them presented symptoms of depression, some considered or had attempted suicide, and others lost their jobs because of the assault.Furthermore, a significant number stated that they felt insecure in their neighborhoods and had moved. 6n the city of Recife, Brazil, an investigation with adolescents and young women showed that sexual violence significantly impacted the mental and social health of the participants.The main disorders were phobias, panic disorder, posttraumatic stress disorder, anxiety and depression. 13n terms of the fear of establishing sentimental and sexual relationships, a study in the United States associated violence and posttraumatic stress disorders, showing that women who had been sexually assaulted suffered from negative feelings and beliefs, guilt, nightmares, and amnesia, in addition to fear of strangers, which interfered with their sentimental and sexual relationships. 3 Moreover, the women who were sexually assaulted had more chances of presenting dysmenorrhea, menstrual irregularity, dyspareunia, menorrhagia, amenorrhea, and loss of libido and sexual pleasure. 14eelings of sadness and anguish emerged when participants recalled the assault, which serves as a reminder for health Psychological suffering after sexual violence Trigueiro TH, Silva MH, Merighi MAB, Oliveira DM, Jesus MCP professionals to be aware of the consequences of this event for the mental health of women.A study conducted in the Congo highlighted that sexual violence resulted in devastating consequences to the physical and mental health of women, causing damage to victims and, by extension, to their families and communities.These women presented more severe signs and symptoms of psychological disorders when compared to others who had never been victims of this type of violence.Some of the psychological changes included fear, horror, and helplessness. 15lfred Schütz' social phenomenology also refers to expectations (in-order-to motives), which can be applied in the analysis of the daily actions of women who experienced rape.Based on the question of how they intended to live with the fact of having been sexually assaulted, they projected coping strategies to deal with the trauma resulting from this experience.These strategies included seeking support from family and friends, and going back to work and school.
A study in the city of Salvador, Bahia, Brazil, investigated women who suffered intimate partner violence and who belonged to a community supported by nongovernment organizations (NGO) showed that the support of family members, friends and NGOs helped them feel safe, thus contributing to the recovery of their self-esteem and enabling them to resume their lives.This support was considered the key element in coping with the violent situation, whether emotional, spiritual, or material, or even through information received. 16he participants in the present study reported that the women's support service had helped them overcome the traumatic consequences of sexual violence.A study that compared the narratives of men and women who suffered sexual assault, which was based on recordings of a sexual assault telephone hotline in the southeast of the United States showed that the service provided support and guidance to the women who felt guilty about the rape and had been discredited by their families, friends and professionals.Men also accessed the hotline to talk about their experiences with sexual assault, as they perceived lack of support from the people closest to them. 17he complexity of the situation that involves sexual violence requires attention not only from referral centers, but also from the network of health services.Specialized services should be composed of multiprofessional teams, working from an interdisciplinary framework to recover these women's selfesteem and empower them.Ideally, health teams should consist of doctors, psychologists, nurses, social workers, and, when possible, legal professionals. 18Care should include not only technical procedures, but also humanization and embracement to ensure women are heard.Such listening requires that professionals recognize the subjectivity of these women so as to learn about individual care demands. 19he Brazilian Ministry of Health's technical standard for preventing and treating disorders related to sexual violence against women and adolescents 18 does not make a specific mention of nursing actions; however, in referral centers, nurses are the first professional to interact with women in situations of sexual violence.It is worth mentioning that nursing education equips nurses to identify, integrate, coordinate and promote actions to well receive and care for these women at referral centers. 20onsidering that women victims of violence first contact the health service through nurses, it is important that these professionals be qualified to work with this population.A study conducted with 27 nurses in primary health units in the Brazilian Northeast highlighted that most of these professionals (96.3%) recognized that their duty was to investigate violence; 22.2% asked questions about the assault while providing care, 85.1% had cared for suspected and/or confirmed cases, and 15.8% had used some type of protocol.But, only 18.5% felt empowered to deal with cases of sexual violence.The participants reported difficulties in referring cases and recommending treatment, revealing the need for professional training. 21he lens of social phenomenology used here to investigate the issue of sexual violence against women enables the recognition of the intersubjectivity inherent to care practices.Such an approach allows health professionals, especially nurses, to become familiar with these women's biographical situation, stock of knowledge and experiences, and the meaning attributed to such experiences.This makes it easier for professionals to propose therapeutic actions to support victims in coping with the assault. 22n this context, care provided to women in situations of sexual violence must value rapport, acceptance, autonomy and subjectivity of these women, overcoming the biologicistic approach, encouraging co-responsibility, guided by the principle of comprehensiveness. 23imitations of this study include that it was conducted by one group of women cared for at a specialized service for sexual violence in a given Brazilian municipality, which does not allow for its results to be generalized.However, the phenomenological perspective values the experience of these women and therefore shows subjective aspects related to psychological suffering due to sexual violence and the importance of overcoming the marks left by this type of violence, which refer to the need for a professional approach centered on these women's mental health.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
By better understanding the daily lives of women who had experienced sexual violence, this study demonstrated their psychological suffering, translated into fear of being raped again, of having been infected with STDs, and of maintaining social, sentimental and sexual relationships.This fear impacted their mental health, restricting their lives at the biopsychosocial levels.To overcome the consequences of sexual violence, they sought the support from their families and friends and reinsertion into the labor market and school.
The findings of this study, grounded in the principles of Alfred Schütz' social phenomenology, can inform professionals who work in different healthcare contexts on how to approach women who have experienced sexual violence.The subjective and social Psychological suffering after sexual violence Trigueiro TH, Silva MH, Merighi MAB, Oliveira DM, Jesus MCP aspects implied in this experience must be understood and taken into account by nurses and other health professionals who care for these women in the daily routine of healthcare services.
It is believed that such understanding provides access to the experience of women who have been victims of sexual violence, based on the subjective feminine universe (with emphasis to the consequences produced in the biopsychosocial social context), must be considered in order to plan and provide comprehensive care.This type of care is based on shared responsibility and establishing bonds of trust between these women and healthcare professionals.
Due to the emergency of the psychological suffering experienced by the studied group, individual and group actions that provide psychosocial support to women in situations of sexual violence is of utmost importance.These actions must provide them with the necessary psychological and social support so that they can cope with the consequences of this experience.
and was approved by the research ethics committee of the University of São Paulo School of Nursing, no.772.012,August 26, 2014, Certificate of Presentation for Ethical Consideration -CAAE no.31703914.2.0000.5392.