PERCEPTIONS OF A MULTIDISCIPLINARY TEAM ON THE PSYCHOLOGICAL REPERCUSSIONS OF SEXUAL VIOLENCE AGAINST CHILDREN AND ADOLESCENTS

PERCEPCIONES DEL EQUIPO MULTIDISCIPLINARIO SOBRE LAS REPERCUSIONES PSICOLÓGICAS DE LA VIOLENCIA SEXUAL CONTRA LOS NIÑOS

ABSTRACT

Objective:

to understand the perceptions of a multidisciplinary health team in caring for hospitalized children and adolescents with psychological repercussions of sexual violence, in the light of Symbolic Interactionism Theory.

Method:

this is a qualitative study, carried out with 30 professionals from the multidisciplinary health team working in a general public hospital in Salvador, Bahia, Brazil. The interviews took place between June and July 2019, using a semi-structured questionnaire and, after being recorded, the reports were transcribed. In analysis, the data were categorized by similar themes following the steps: pre-analysis, material exploration, treatment of results and interpretation. The project was approved by an Institutional Review Board.

Results:

among the psychological disorders presented by children and adolescents are aggressiveness, mutism, eating disorders, infantilized behavior, hypersexualized behaviors, depressive disorders, anxiety disorders, psychotic episodes, and delusions.

Conclusion:

the study demonstrates the perceptions resulting from the interaction allowed in caring for the multidisciplinary team to children and adolescents who experienced sexual violence and developed psychological disorders. In this way, it raises warning signs for family members, health professionals, education, protective devices and the whole of society about the need to observe signs of these changes on a daily basis, seeking to investigate their possible relationship with sexual assault.

DESCRIPTORS:
Child; Adolescent; Sex offenses; Mental health; Symbolic interactionism

RESUMEN

Objetivo:

aprehender las percepciones del equipo multiprofesional de salud en el cuidado de niños y adolescentes hospitalizados con repercusiones psíquicas de la violencia sexual, a la luz de la Teoría del Interaccionismo Simbólico.

Método:

estudio cualitativo realizado con 30 profesionales del equipo multiprofesional de salud que trabaja en un hospital público general de Salvador, Bahía, Brasil. Las entrevistas se realizaron entre los meses de junio y julio de 2019, mediante un cuestionario semiestructurado y, luego de ser grabadas, se transcribieron los informes. En el análisis, los datos fueron categorizados por temas similares, siguiendo los pasos: preanálisis, exploración de materiales, tratamiento de resultados e interpretación. El proyecto fue aprobado por el Comité de Ética e Investigación.

Resultados:

entre los trastornos psíquicos que presentan los niños y adolescentes se encuentran: agresividad, mutismo, trastornos alimentarios, conducta infantilizada, conductas hipersexualizadas, trastornos depresivos, trastornos de ansiedad, episodios psicóticos y delirios.

Conclusión:

el estudio demuestra las percepciones resultado de la interacción permitida en el cuidado del equipo multiprofesional a niños y adolescentes que experimentaron violencia sexual y desarrollaron trastornos psicológicos. Así, plantea señales de alerta para familiares, profesionales de la salud, educación, dispositivos de protección y toda la sociedad sobre la necesidad de observar en el día a día señales de estos cambios, buscando investigar su posible relación con la agresión sexual.

DESCRIPTORES:
Niño; Adolescente; Delitos sexuales; Salud mental; Interaccionismo simbólico

RESUMO

Objetivo:

apreender as percepções da equipe multiprofissional de saúde no cuidar de crianças e adolescentes hospitalizadas com repercussões psíquicas da violência sexual, à luz da Teoria do Interacionismo Simbólico.

Método:

estudo qualitativo realizado com 30 profissionais da equipe multiprofissional de saúde atuantes em um hospital público geral de Salvador, Bahia, Brasil. As entrevistas ocorreram entre os meses de junho e julho de 2019, valendo-se de questionário semiestruturado e, após serem gravados, os relatos foram transcritos. Na análise, os dados foram categorizados por temáticas similares cumprindo as etapas: pré-análise, exploração do material, tratamento dos resultados e interpretação. O projeto foi aprovado pelo Comitê de Ética e Pesquisa.

Resultados:

dentre os distúrbios psíquicos apresentados por crianças e adolescentes estão: agressividade, mutismo, transtornos alimentares, comportamento infantilizado, comportamentos hipersexualizados, transtornos depressivos, transtornos de ansiedade, episódios psicóticos e delírios.

Conclusão:

o estudo demonstra as percepções resultantes da interação permitida no cuidar da equipe multiprofissional a crianças e adolescentes que vivenciaram a violência sexual e desenvolveram transtornos psíquicos. Desta forma, faz emergir sinais de alerta para familiares, profissionais da saúde, educação, dispositivos protetivos e toda a sociedade acerca da necessidade de observar cotidianamente sinais dessas alterações, buscando investigar sua possível relação com a agressão sexual.

DESCRITORES:
Criança; Adolescente; Delitos sexuais; Saúde mental; Interacionismo simbólico

INTRODUCTION

Sexual violence is the practice of the non-consensual sexual act or any attempt to achieve it. Its conceptualization also includes unwanted comments or insinuations of a sexual nature, actions aimed at sexual commercialization or directed at a person’s sexuality. This type of act can affect victims of different ages, in any situation, in different environments, including at home1^-2. Such conditions and their high occurrence rates can trigger repercussions on the victims’ mental health, which is worrisome from an individual and collective point of view.

A scientific study points out that 60% (n=156) of sexual abuse occur within the household, of which 37% (46) are repeated episodes and 53% are perpetrated by family members3. Corroborating with these authors, the scientific literature reports that the main sexual aggressors of children and adolescents are male relatives and close family members1^,3^-4.This configuration of sexual violence can generate conflicting reactions and/or deep psychological trauma in the victims, since, in relationships between entities and/or family members, feelings of protection and security with each other are nurtured.

Thus, authors of sexual violence against children and adolescents are guided by silence in the form of secrecy to prolong their performance for years. At first, offenders seduce victims, while making threats and using the power relationship (and inequality) to impose submission through touching and sexual stimuli1^-2^,4^-5. Taking advantage of the situation of vulnerability victims; therefore, abusers establish a bond of trust very close and eroticized with children/adolescents, culminating in genital contacts. Generally, perpetrators of sexual violence use coercion, threat or physical aggression, in order to obtain personal sexual satisfaction and maintain the confidentiality surrounding the situation1^,4^-5.

It should be noted that the experience of sexual violence can trigger psychological repercussions in the victims. Thus, frequent episodes of fear (which can arise with aggressions) are often triggered after stimuli that recall the initial trauma, generating stress5. These same psychological changes are noticeable in cases of exposure of individuals in extreme situations, as diagnosed in war survivors1.

However, a history of sexual violence in childhood/adolescence can have deleterious effects on an individual’s mental health. This type of violence increases the risk of dictates developing, among other psychological problems, Post Traumatic Stress Disorder (PTSD), which is triggered after an event of extreme violence, such as mistreatment and rape1^,4^-5. International study set in specialized par victims centers in sexual violence warns that 56.9% (n=252) of Senegalese victims presented PTSD6, also, other scholars point out that girls are more likely to develop this disorder than boys4. In this regard, a history of childhood physical or sexual abuse was associated with 5.73 times more chances of PTSD in women7. However, this is not the only psychological problem that children and adolescents who have suffered sexual violence can develop.

Considering that, from a physical, emotional and psychological point of view, people in childhood (and often in adolescence) are not prepared to experience sexualized acts, much less to consent to them1^-2^,5. The induction or imposition of these experiences can cause emotional, cognitive, behavioral and psychopathological damages5^-6^,8. These injuries are related, in part of the registered cases, to suicide attempts and, even, to consummation5^,8^-10. It should be noted that, like suicide attempts, self-injurious behaviors are more likely to occur in individuals who have experienced sexual violence11.

Such psychological consequences can vary from mild to severe, be acute or chronic, with more likely to require hospitalization due to psychiatric diagnoses4^-5^,8^,10. Moreover, there are difficulties related to the multidisciplinary team, tangent to the identification, diagnosis, treatment and follow-up of diseases related to children’s mental health8^,12^-13. Regardless, the national system has undergone important transformations that attribute quality to the care of people with these disorders, the development and implementation of public policies and programs focused on mental health are still incipient for the demand14.

Thus, considering the multifactorial, complex and consequences of sexual violence, multidisciplinary care is essential in the recovery, treatment and follow-up of these victims. In view of this reality, the following problem issue emerged: what are the multidisciplinary health team’s perceptions in caring for hospitalized children and adolescents with psychological repercussions of sexual violence?

This study warns of psychological repercussions of the experience of sexual violence against children and adolescents. Therefore, it is an information vehicle that can expand the range of knowledge tangent to the identification of cases of sexual violence that result in psychological problems and contribute to care plans for victimized children/adolescents and their families. Thus, this study aimed to understand the perceptions of a multidisciplinary health team in caring for hospitalized children and adolescents with psychological repercussions of sexual violence, in the light of Symbolic Interactionism Theory.

METHOD

This is an exploratory study of a qualitative nature, which had its organization guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Data collection was carried out between June and July 2019 by a researcher, with the support of other members of a Research Group, all previously trained in a preparatory course.

The study was anchored in the philosophical bases of Symbolic Interactionism. It is a theory based on basic concepts and principles of Social Psychology, which focuses on the processes of social interaction that occur between individuals or groups and are mediated by symbolic relationships. Thus, this Theory is based on three premises: 1) The way in which an individual interprets the facts and acts depends on the meaning that is attributed to them; 2) Meaning is built from the processes of social interaction; 3) Meaning may change over time15.

The research site chosen was a General Hospital in Bahia, Brazil, where medical-hospital services are provided exclusively to the clients of the Unified Health System (SUS - Sistema Único de Saúde). The institution provides general, emergency, clinical, surgical, outpatient care for all age groups and of both sexes, in addition to serving as an internship field for various courses in health sciences.

The approach to the field took place from the main author of this study who worked as a nurse at that institution, through the previous presentation of the project to the general management and the coordinators who were part of the multidisciplinary team.

In the field, all health professionals were approached individually and invited to participate in the research. Those who accepted the inclusion criteria were checked: to be working for at least one year in the institution and to have provided assistance to children and adolescents who suffered sexual violence. Professionals who were absent due to different licenses and those who worked only in diagnostic support units were excluded.

Guests were given time to arbitrate their participation in the research. After accepting the invitation, all of them read and signed the Informed Consent Form (ICF) (in two copies). Then, a structured questionnaire was applied (containing professional sociodemographic data) and a semi-structured questionnaire with the following triggering question: report cases of victims of sexual violence that you assisted at this hospital. During the reports, other questions were asked based on an interview script previously created by the responsible researcher, for the purpose of better understanding, clarification and interpretation of the facts that were being narrated.

Multidisciplinary health team members participated, there was no refusal or withdrawal from joining the research. The interviews were recorded on an Android mobile device, took place at working hours of professionals in spaces that offered secrecy, privacy, being conducted by the responsible researcher (in the company of two researchers) and lasting between eight and 40 minutes.

After collection, transcription and correction was performed by the researchers who were present at the time of the interviews. Data validation was performed by the responsible researcher. After this stage, thematic content analysis proposed by Bardin was used and composed of pre-analysis, material exploration, treatment of results and inference, all found in the light of methodological contribution16.

To this end, the reports were read, systematized, organized, interpreted and transcribed, giving rise to six codes under the consensus of three coding researchers16. The themes were previously identified during text skimming, repeated in depth readings of the typed interviews and field diary (written record made individually by the researchers after each interview).

As for data saturation, these were observed during analysis, where the 17^th and 24^th participants repeated the psychological and physical consequences of sexual violence, respectively. However, to confirm this saturation more interviews were carried out, totaling 30 participants with reports of themes that were repeated.

The research was submitted and approved via Plataforma Brasil by an Institutional Review Board, therefore, it respected ethical aspects of research with human beings following the determinations of Resolutions 466/2012, 510/2016 and 580/2018 of the Brazilian National Health Council (Conselho Nacional de Saúde). Thus, to preserve participants’ anonymity, their respective names were replaced by “P” (representing professional) and an Arabic number, which indicates the interview sequence: (P1), (P2), (P3) (P30).

From the structured questionnaire, it was possible to outline employees’ sociodemographic profile. Thirty health professionals participated, being 22 from the nursing team (nurses, technicians, and assistants), three physicians, three social workers, and two psychologists. Of this total, 100% reported being female, self-reported gender identity cis women and heterosexual affective-sexual orientation, 80% were black, 62% reported having two or more children and 47% were single.

RESULTS

The analysis’ results explained six themes that explore the perceptions about victims of sexual violence who had psychological repercussions:

Child and adolescent aggression as a repercussion of the experience of sexual violence

Aggressiveness was a behavior described by professionals under study as behavior common to victimized children and adolescents.

Generally, sexual trauma is so great for the child that some of them make an aggressive picture... (P5, Nurse).

She was an adolescent who was raped by a family member, at times she was a little aggressive ... (P7, Nursing technician).

[...] this adolescent came to the service a little reluctant, aggressive, she had been sexually assaulted (P24, Physician).

The aggressiveness described by professionals was emphasized and symbolized by the use of the word “reluctant” by P24. Likewise, in the experiences of P5 and P7, aggressive behavior symbolized the expression of the experience of sexual violence by children/adolescents assisted.

Victims of sexual violence against children and adolescents who showed mutism

Some professionals highlighted mutism resulting from sexual violence against children and adolescents.

She arrived in silence, as we speak in Psychology, she was self-absorbed. I didn’t say anything, I didn’t speak to anyone! From what I assessed, through her reports, the abuses had been happening for some time (P27, Psychologist).

I assisted a 10-year-old girl, she reported sexual violence, but did not identify any offenders. When she arrived here at the ward, she was in silence (P28, Physician).

The adolescent was abused by her grandmother’s partner, during hospitalization she did not speak, did not show any kind of feeling, was unable to speak (P5, Nurse).

The speeches of P5, P27 and P28 reproduce what was perceived through symbolic images of victims of sexual violence. In these cases, the state of mutism symbolizes, for participants, the consequence that the traumatic experience of sexual violence caused to children/adolescents assisted. The reports are augmented by terms such as “self-absorbed” and the absence of feeling, which consists of participants’ attempt to illustrate that the victims of sexual violence remained in a world apart, perhaps in a state of shock.

Eating disorders due to sexual victimization

According to the interviewees, some eating disorders affected children and adolescents who were victims of sexual violence.

[...] she was about 10 years old, she came without food, she was in that situation of starvation due to lack of appetite, she didn’t eat anything, she was abused by her grandmother’s partner (P5, Nurse).

[...] we admitted an adolescent who had not eaten for some time (P27, Psychologist).

[...] this adolescent has not eaten for some time, lost weight, she reported that she was abused, but did not report offenders (P28, Physician).

In the professionals’ narrative, eating disorders symbolize the way in which sexual violence affected victims’ health. From the perspective of P5, P27 and P28, such repercussions were so severe that they originated, respectively, starvation, weight loss and generated hospitalization.

Childhood and hypersexualization as consequences of sexual victimization

The multidisciplinary team pointed out infantilization and hypersexualization as psychological changes presented by the victims.

[...] the girl was five years old and began to exhibit sexual behaviors, made drawings very related to the house where she lived and drew a child and a man with phallic symbols, which she said was a monster. I asked her to explain the drawing and, in the story, she presented a lot of content related to sexual violence (P27, Psychologist).

[...] this adolescent was abused by her grandmother’s companion and adopted a totally childish behavior for her age. She did not leave the doll, she did not leave the doll, she always clung to that doll, with her finger in her mouth (P5, Nurse).

[...] even at the age of 16, she sucked her finger, called us aunt, had a very childish behavior. The brother raped her at home (P7, Nursing technician).

P27 describes expressions of a child’s hypersexualized behaviors that caught his attention, because, considering his age, this behavior was the result of an early sexual experience. On the other hand, P5 and P7 describe behaviors that, according to their narratives, are incompatible from the point of view of adolescent development, which they call infantilization. In this way, professionals describe behaviors that symbolize behavioral regression and/or inadequacy of adolescents’ and children’s sexual behavior.

Depression and anxiety as psychological repercussions of sexual violence for children and adolescents

According to the narratives of some interviewees, children and adolescents who were victims of sexual violence were affected by these injuries:

[...] it was a 14-year-old adolescent who arrived with anxiety. Due to sexual abuse, she suffered from her uncle, she had several anxiety attacks, she always referred to the sexual violence practiced by her uncle (P27, Psychologist).

[...] I assisted some sexually abused children/adolescents who were depressed, were in depression (P5, Nurse).

The reports of P27 and P25 demonstrate mental distress in victims of sexual violence that, in many cases, can be hidden by the secret that their aggressors imprint on the victims. The identification by professionals that the root of the problem has an aggressive and sexual nature is essential in treatment and follow-up both of the victims and their families.

Psychotic episodes and delusions after child sexual assault

Participants narrated cases in which the victims of sexual violence triggered psychotic episodes and complex psychiatric conditions, as can be identified in the following statements:

[...] it was a 13-year-old girl, it was not known who had abused her, but the case was strong, she had episodes of psychomotor agitation in the corridor, screamed, ran (P30, Nurse).

[...] I assisted a five-year-old child who was convulsing, went through assessment, underwent examinations and the seizures were not of biological cause. When I saw her, she said that her stepfather touched her [...]. In another case of an adolescent, the great-uncle caressed her. I assess that, recently, she had started dating and had relived the trauma, because she realized that what this uncle did was abuse. For me, this discovery was unbearable and she went into a state of psychosis! She screamed around the ward, had delusions, said that seven men were chasing her (P27, Psychologist).

[...] I assisted an adolescent who was diagnosed with an associated psychiatric condition, she had catatonia and her mood varied. She reported sexual violence and was hospitalized for psychiatric follow-up [...] (P28, Physician).

P30 and P27 demonstrated cases of sexual violence that culminated in psychotic episodes and were remarkable occurrences for the victims in participants’ conception, since they attributed adjectives as “strong” and “unbearable” to qualify the sexual violence experienced by children/adolescents and symbolize how they felt from the aggression, starting from empathy to classify the feelings they attribute to the victims.

The richness of details provided by participants derives from the remarkable representation that they had for them to take care of children/adolescents who suffered sexual violence and had psychological repercussions. When thinking, remembering and presenting reports about these victims, the image that professionals kept shows how complex and shocking the experience of caring for these children and adolescents was.

DISCUSSION

The aggressiveness presented by the victims has been the first clinical cause of hospitalization among children and adolescents in psychiatric care units in the state of São Paulo, according to research17. This is because, at the beginning of abusive manipulation, the abused child experiences, concomitantly, feelings of pleasure and displeasure. Such feelings are the subject of confusion for victims and hide their perception of being loved or desired, generating feelings of anger5^,18.

As they lose the ability to regulate and express anger, victims become aggressive. Therefore, the children go beyond fury as a form of indignation, in the face of intolerance with their condition of submission, lack of love and humiliation of which they were the target. In this way, children and adolescents express their dissatisfaction with the sexual violence experienced, becoming aggressive, as one study points out18.

Regarding the reports that suggested the onset of mutism in victims, a study carried out in four care services for victims of sexual violence in Senegal shows that 31.1% (n=252) of children and adolescents assisted have a clinical picture of mutism6. To date, other studies were not found by the authors related to the mutism of children and adolescent victims of sexual violence, because this reaction may not be highly prevalent in this type of injury, or has not been observed in other studies published so far.

However, research on selective mutism is found in the scientific literature. This type of mental disorder is relatively rare, and may be related to or precede anxiety disorder, which affects children in school and is characterized by the absence of speech in certain environments (such as schools, daycare centers), but present in others19^-20. Scholars identify that 80% of 837 children with selective mutism were also diagnosed with other anxiety disorders, including social phobia (69%)20. Later, scholars observed the same correlation, adding the complex and possibly genetic origin of this condition19.

In fact, the experience of sexual violence causes children/adolescents to be in a permanent state of stress. Considering the threats and coercions perpetrated by abusers, as well as the pressure to which victims are subjected to not reveal the nature of the aggression, it can develop a state of shock that, once aggravated, is capable of triggering psychic disorders that need attention.

This is because experiences of abuse, at any stage of life, are considered stressful events of singular importance. These episodes, whether or not they persist for a long time, can generate anxiety and stress to the point of altering victims’ behavior, social interactions and cognition, especially children7^,9. Although stress was not identified as a psychological consequence of sexual violence in this study, this condition has a high prevalence among victims, as highlighted in previous studies1^,3^-7.

As in this study, research reveals that these sequelae from the experience of maltreatment in childhood can become serious psychopathologies, such as eating disorders5^,8^,10. For example, a study demonstrates the increase in cases of anorexia in women who suffered sexual violence in childhood10. Moreover, authors emphasize that there are difficulties and obstacles faced by health professionals when treating and follow-up cases of anorexia nervosa in adolescents, considering its complexity and lack of qualification to manage the cases13.

It should be added that, in the cases reported in this study, children/adolescents mentioned had a history of sexual violence, which increases the complexity of the case for treatment and recovery. Even though, these disorders can develop slowly and originate from sexual trauma, an alert for family members, professionals and other people who monitor the development of children/adolescents.

With regard to hypersexualization, researchers reveal that exposure to sexual violence in childhood/adolescence is associated with the development of early sexual behaviors21. In children, hypersexualized behavior corresponds to the use of sexual games using dolls, the introduction of artifacts or fingers into sexual organs, excessive masturbation, seductive behavior, sexual knowledge that is not appropriate for their age and soliciting sexual stimuli from other people5^,18. They agree with a study developed with women who suffered sexual violence in childhood and developed inappropriate sexual behaviors. Thus, among other problems in the sexual sphere, the victims become involved in prostitution, have difficulties in relationships with people of the same sex as offenders and difficulties to have orgasms9.

In this study, behaviors incompatible with the victims’ age were recognized. In this way, infantilization is pointed out as a symbol of behavior arising from the exposure of children/adolescents to sexual violence. Furthermore, scholars describe symptoms of behavioral regression such as enuresis and encopresis, resulting from the experience of sexual violence3. There are studies that relate these pathophysiological changes to feelings such as guilt and/or shame that are triggered by victimized people4^,22^-23. Therefore, the correlation of these regressive behaviors with exposure to sexual violence allows us to infer that other forms of infantilization may affect victims, as reported in the current study.

Although it is not a result of this study, it should be noted that, until psychiatric disorders develop, children/adolescent victims of sexual violence may initially show signs of Common Mental Disorder (CMD). A study warns of a 52% prevalence of CMD among 230 adolescents in Bahia24, a mental disorder that precedes complex clinical conditions, of considerable severity such as stress and depression. However, these and other psychiatric diagnoses are difficult to recognize in children and adolescents12^-13.

CMD in children and adolescents can be correlated with sexual aggression and often evolve to depression and anxiety, as observed by professionals in the study. A Canadian survey shows that sexually abused men in childhood develop more symptoms of depression than women4, while in Norway, a study reveals that symptoms of depression (p<0.044) and anxiety (p=0.027) are constituted risk factors strongly associated with non-suicidal self-harm in 516 women who suffered sexual abuse in childhood11.

This is because, when subjected to this type of violence, children and adolescent victims often do not understand what happened because they do not have the emotional development to deal with the bodily reactions and sensations resulting from this act. As identified by participants, studies ratify the difficulties that children and adolescents have in dealing with their own feelings when experiencing sexual violence2^,5^,9.

Such sequelae can cause the development of anxiety and/or depression, as reveal several studies by pointing to expressive risk of these changes in cases of sexual abuse7^,10^-11. Anxiety is a relatively common mental health problem in individuals subjected to stressful situations4, being associated with sexual violence practiced by unknown people, while depression is associated with abusive acts perpetrated by people known dvictims25.

Despite the study’s venue being at a general hospital, psychological repercussions of difficult identification in children and adolescents were diagnosed. In general, the diagnosis of these diseases, in people in this age group, occurs through access to specialized services and trained professionals26^-27. Therefore, the relevance of training general practitioners for the identification of cases of sexual violence and raising suspicions about the possible experience of this condition is clear through observation of signs of psychological disorders even in childhood/adolescence.

Similar to the results presented in this study, researchers identify that the experience of abusive episodes in childhood has a strong association with psychotic experiences and that, in 47% of the 1,698 London adults studied, these psychotic episodes are triggered by adverse events in adulthood28.

It was diagnosed in the current study that the experience of sexual violence in childhood/adolescence resulted in delusions and hallucinations presented by the victims. In São Paulo, these symptoms have been the second cause of psychiatric hospitalization among children and adolescents17; however, it is not clear whether these symptoms are correlated with the experience of sexual violence, a fact observed in the present study.

In short, psychological changes of this kind, especially in children, are difficult to diagnose and manage, and victims often encounter barriers when searching for specialized public services26^-27. These obstacles often result in giving up in search of help and, consequently, in the worsening of psychological repercussions throughout the lives of victimized individuals. Studies confirm that people who were raped in childhood/adolescence and did not obtain adequate care developed serious mental health problems9^,11^,21^,25.

Thus, in the case of this age group, we also warn of the need and possibility for people who accompany growth/development (such as general practitioners, daycare providers, educators, and family members) to collaborate in the foundation of these diagnoses; these social actors remain more time in the company of these individuals, being able to perceive these changes in them.

Despite the confluence of high rates of sexual violence against children and a high prevalence of damage related to impairment of the mental health of victims identified in several studies3^,8^,10^,25, specialized services in the health of children and adolescents such as Child and Adolescent Psychosocial Care Centers (CAPSi - Centros de Atenção Psicossocial Infantojuvenil), are scarce in the country26. However, for 20 years, governmental initiatives in Brazil related to Psychiatric Reform aim to develop mental health care services in SUS and have demonstrated tangible advances in the creation of laws, such as those that require the existence of of the Psychosocial Care Network (RAPS - Rede de Atenção Psicossocial)14^,26.

However, professional training can be promoted in other health spaces where children/adolescents live together, and training is not the exclusive competence of specialized services. This measure aims to prevent, identify and/or minimize the psychological damage resulting from sexual violence as well as to prevent these disorders from getting worse and that new episodes are experienced by the victims. Therefore, they must be able to identify them and be attentive to signs of sexual violence interrelated with psychological problems.

This is relevant because, in the Brazilian reality, there is a limited network of attention to the mental health of children and adolescents. Research that sought to analyze the Healthcare Coverage Index in the Psychosocial Care Network (iRAPS - Índice de Cobertura Assistencial da Rede de Atenção Psicossocial) allows us to state that there has been no progress in the implementation of these services in Brazilian metropolises (which concentrate 46% of the population), and only 7.9%, i.e., the total of 439 cities in the country, have full assistance coverage by RAPS, covering only 6.69% of the national population29.

Despite this lack, psychiatric disorders are still causes of hospitalization in the RAPS in the country17, as identified in our study, which awakens to the reassessment of the need to increase this coverage, considering the high prevalence of sexual violence and the risks for children and adolescents to develop psychological disorders resulting from this condition, as mentioned above.

Furthermore, considering the underreporting of cases of sexual violence for children and adolescents and the secrets surrounding this practice, especially in the domestic sphere1^,5, it can be inferred that some victims develop psychological disorders without the health services being aware of the disorder’s origin. In this way, the cases assisted and reported by participants in this study reveal only a small portion of the victims who develop psychological disorders resulting from sexual violence and have access to health services.

Adolescent victims of violence who use CAPSi reveal that, in times of crisis, the therapeutic itinerary fulfilled aims to have access to RAPS27. However, despite the increase in the prevalence of mental disorders in young people from different regions of the country, as well as child and youth sexual violence, it is plausible to predict that these users may encounter difficulties, such as the unavailability of resources and the lack of trained professionals12^-13^,26^,28. What did not happen with victims of sexual violence identified in this study, a fact that may be related to service characteristics where the research was carried out.

However, this unavailability of services that welcome children and adolescents with psychological disorders may become evident at the moment when the challenges arising from the pandemic of the new coronavirus, a pathogen that manifests itself through the COVID-19 disease and is demanding health care, are in vogue, as stated by an international study30. The confluence of health measures (such as mandatory social distancing) and the increase in internet use via social networks provide greater openness to the range of possibilities for attacks by aggressors of children and adolescents. This scenario may be responsible for the increase in the number of individuals who suffer sexual violence with demands for care for mental disorders at this time, without the health services having the means to absorb this public.

The situation of violence against children and adolescents has taken on dimensions that put family members, professionals and entities that aim to combat/prevent this problem on alert1 and need to be intensified in the current world context. As the pandemic prevention requirements keep children and adolescents away from everyday activities that provide development to mental health, still exposing them to greater risks of being the target of domestic violence30, including incestuous sexual abuse, the type of violence high rates worldwide, as studies confirm1^,3.

When confronting this information, the present study warns of the need to make efforts to investigate the possibility of experiencing sexual violence by children and adolescents that have repercussions on psychological changes and vice versa. Thus, it is necessary to train professionals to assist children and adolescents who have suffered sexual violence, seeking to diagnose possible psychological repercussions; assistance to children and adolescents with psychological problems requires investigations in order to reveal possible triggers such as the experiences of sexual violence. Moreover, it is necessary to develop studies that expand and deepen the range of existing scientific knowledge about the psychological repercussions of this condition.

Some results of this study could be compared with limited scientific literature, such as repercussions such as mutism and infantilization. Perhaps, the deficiency of studies that corroborate these results is a consequence of the lack of professionals capable of diagnosing such consequences or studies aimed at unveiling such injuries among the victims, which constitute gaps not yet filled.

This study has as limitations the fact that there is a single health service, of general care and is the result of a punctual observation of women health professionals, considering that, generally, the dynamics of hospital units do not allow daily and prolonged follow-up of these victims. Therefore, it is recommended to replicate it in other scenarios such as specialized services in the care of victims of sexual violence and child and adolescent psychiatric care services. In this way, the involvement of other social actors will serve for the purpose of comparing the results, since methodological rigor was followed and support was sought in Symbolic Interactionism. Cohort and randomized studies that focus on the psychological changes described here are also suggested to identify the extent of these injuries to victims.

CONCLUSION

Multidisciplinary health team professionals described, based on their symbolic interactions and social constructions, cases of children and adolescents who suffered sexual violence with psychological repercussions, such as aggressiveness, eating disorders, mutism, hypersexualization, infantilization and psychotic episodes.

Therefore, we can infer that, according to participants, sexual violence in childhood and adolescence can have marked and relevant repercussions on victims’ mental health, leaving sequelae at different levels of severity, thus requiring multidisciplinary care due to its complexity.

Finally, this study is a foundation in the identification of the experience of sexual violence against children and adolescents by caregivers. Its results collaborate in the construction of care plans, in the creation of effective interventions and a list of justifications for the prolonged follow-up of victims, since such repercussions can be triggered throughout life. Additionally, the results found also serve to train education professionals, people involved in combating sexual violence against children and adolescents, entities responsible for protecting children’s rights and other co-participants in the observation and daily care of children and adolescents.

ACKNOWLEDGMENT

We would like to thank the Child and Adolescent Health Studies group (CRESCER).

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the dissertation - Violência sexual infantojuvenil: percepções de profissionais de saúde, presented to the Graduate Program in Nursing and Health at Universidade Federal da Bahia, in 2020.

• FUNDING INFORMATION

  This work was funded by the Bahia State Research Support Foundation (FAPESB - Fundação de Amparo à Pesquisa do Estado da Bahia), BOL0886/2019.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of the Universidade Federal da Bahia, under Opinion 3,261,813, CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 03599518.3.0000.5531 and Institutional Review Board of Hospital Geral Roberto Santos, under Opinion 3.383.906, CAAE 03599518.3.3001.5028.

Edited by

EDITORS

Associated Editors: Selma Regina de Andrade, Gisele Cristina Manfrini, Melissa Orlandi Honório Locks, Monica Motta Lino. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  22 Sept 2021
• Date of issue
  2021

History

• Received
  22 Oct 2020
• Accepted
  12 Apr 2021