Girls victims of sexual aggression in Baixada Fluminense

SUMMARY

OBJECTIVE:

This study aimed to describe the current situation of sexual aggression and assess the adhesion to ambulatory care follow-up.

METHODS:

This is a cross-sectional study involving female children and adolescents aged 0–19 years, treated at the Center for Multiprofessional Care of Sexual Violence of the General Hospital of Nova Iguaçu, from 2014 to 2018.

RESULTS:

Of the 453 children and adolescents, 264 (58.3%) were <14 years of age and 189 (41.7%) were 14–19 years of age. In both groups, 78% were black. School delay of >2 years was found in 15.6% of children in the age group <14 years and 40.5% of adolescents in the age group 14–19 years [p<0.001; OR=3.7 (2.1–65)]. In girls aged £13 years, abuse usually occurred at home (73.2%), which was perpetrated by one aggressor (91%) and known to the victim (91.2%). In adolescents aged ≥14 years, 84.1% of rapes occurred outside the home, practiced by one aggressor (74.8%), 57.8% were unknown, and in 91.2% of cases, there was use of physical force and/or verbal threats. The victims aged <14 years have 14 times more chance of experiencing aggression within the family setting [p<0.001; OR=14.3 (8.2–25.6)] and 16 times more chance of experiencing aggression from known persons [p<0.001; OR=16.2 (9.2–29.8)]. On the contrary, adolescents aged ≥14 years have three times more chance of being abused by more than one aggressor [p<0.001; OR=3.3 (1.8–6.1)].

CONCLUSION:

Black girls, especially those aged <14 years, are in a situation of greater vulnerability for sexual violence, have less adhesion to follow-up, and often experience aggression in the household setting.

KEYWORDS:
Sex offenses; Gender-based violence; Rape

INTRODUCTION

Sexual violence is defined as any type of activity of an erotic or sexual nature that disrespects the rights of one of the involved persons¹. Regarding children and adolescents aged <14 years, it is a crime to rape a vulnerable person, and it has a strong negative effect on mental health, sociability, and neurodevelopment problems².

It is estimated that 120 million girls worldwide experience some type of forced sexual contact before the age of 20 years³. In Brazil, in 2020, there were 60,926 cases of sexual violence reported, 86.9% of the victims were females, and 44,879 (73.7%) of those cases occurred against girls under the age of 14 years. Although in 2020 social distance measures imposed by the COVID-19 pandemic caused under-notification of sexual violence registration, which makes it impossible to confirm if the number of cases of rape has increased, data indicate that the victims were younger than in 2019, and this profile is confirmed year after year. In 2021, there was an increase of 3.7% in the number of registrations of rape and rape of the vulnerable, with a mean rate of 51.8 per 100,000 women⁴,⁵.

The younger the victim, the greater the possibility that the aggression is perpetrated by an aggressor who is close to or is a member of the family and that it takes place in a household setting. This fact tends to favor abuse chronicity and impairments to make a registration of the violence experienced⁴. It is also known that the younger the victim is, the greater the chances of negative effects, such as the occurrence of sexually transmitted infections and psychic damages, among which the most frequent are post-traumatic stress disorder, schizophrenia, drugs use, and sexual dysfunction⁴,⁶,⁷. Therefore, continued care is necessary for this phenomenon, especially for girls aged <14 years, because this is the most affected age group.

Multiprofessional care for victims of rape is crucial for the reduction of complications resulting from this event. Besides emergency measures, ambulatory care follow-up for 6 months is imperative to achieve this objective. Therefore, one of the challenges is to provide such services to these girls in an anticipatory and opportune way. The literature has few studies on the adhesion to medical follow-up after sexual violence. It is estimated that this rate varies between 10 and 31%. Factors associated with the quality-of-care services impede adherence to ambulatory care follow-up⁸. Therefore, it is important to estimate the parcel of victims with access to emergency care, those who remain for follow-up, and, if possible, assess the obstacles to this process.

The scope of this study was to contextualize the situation of aggression against female children and adolescents treated at a reference center in Baixada Fluminense, in the Rio de Janeiro metropolitan region, Brazil, by comparing age groups <14 years and ≥14 years, and to assess the adhesion to ambulatory care follow-up after the first urgent care.

METHODS

This is a cross-sectional study including female children and adolescents aged 0–19 years, who were treated at the General Hospital of Nova Iguaçu (HGNI) emergency sector and/or followed up at the ambulatory of its Center for Multiprofessional Care of Sexual Violence (CAMVIS), which delivers long-term care to victims of sexual crimes. Data were obtained from emergency care reports and medical records of 453 victims from the CAMVIS follow-up ambulatory in the period of 2014–2018.

As emergency care is objective and carried out through the application of a semi-structured questionnaire, details of sexual aggression are not available. Patients who seek the multidisciplinary follow-up ambulatory present a detailed description of the characteristics of the aggression setting, which is registered on the medical record. For the analysis of the age at the violence occurrence, the group was divided into those aged £13 years and those aged 14–19 years.

The analyzed variables are a place of occurrence, number of aggressors involved, connection with the aggressor, use of force/threat, history of abuse situations, victim's relatives knowing the aggression, use of a condom, the aggressor being under the effect of drugs, and police registration of the offense.

The collected variables were used in the comparative analyses to identify the odds ratio (OR). Data were described through proportions, means, standard deviations, and medians, and the respective confidence intervals (CI) of 95% were estimated. The associations between sexual violence and possible risk factors were evaluated through statistical tests. The magnitude of the associations was observed through the calculation of measures of associations (odds ratio) and the respective CI of 95%. The process of data entry and statistical analysis was performed through the Epi Info 3.5.2 program. The study was approved by the Ethics Committee of the HGNI.

RESULTS

Of the 453 female children and adolescents treated during the period, 264 (58.3%) were <14 years old and 189 (41.7%) were ≥14 years old. There was no difference in color or race between the groups, with the majority being the black race (78%). For the education level, 85% of the girls aged £13 years present an adequate level for their age, and 15% have a delay of >2 years. School delay is more accentuated in the age group ≥14 years (40.5%), corresponding to a 3.7-fold increase in the likelihood of school delay [p<0.001; OR=3.7 (95%CI 2.1–6.5); Table 1].

Table 1
Sociodemographic characteristics of victims.

Characteristics		<14 years	≥14 years	p-value	OR (95%CI)
		Freq/n (%)	Freq/n (%)
Age		264/453 (58.3)	189/ 453 (41.7)
Color/race
	Black	112/144 (77.8)	102/130 (78.5)	0.9	0.9 (0.5–1.7)
	White	32/144 (22.2)	28/130 (21.5)
School delay >2 years
	Yes	24/154 (15.6)	49/121 (40.5)	<0.001	3.7 (2.1–6.5)*
	No	130/154 (84.4)	72/121 (59.5)

• ^*
  p significant.

In general, girls aged £13 years were abused at home (73.2%), perpetrated by one aggressor (91%), known to the victim (91.2%), with 31.1% being the father/stepfather and 39.1% a friend/acquainted, and the girls denied using physical and/or verbal aggression in 53.1% of the episodes. On the contrary, with adolescents aged ≥14 years, 84.1% of rapes occurred on the streets, practiced by one aggressor (74.8%), over half of whom were unknown (57.8%), and in 91.2% of cases, there was use of physical force and/or verbal aggression. In both groups, more than 90% of the reports denied the use of a condom and drugs by the aggressor (97.6 and 78.7%, respectively; Table 2).

Table 2
Characteristics of sexual aggression.

Characteristics		<14 years	≥14 years	p-value	OR (95%CI)
		Freq/n (%)	Freq/n (%)
Place of aggression
	Own home	142/194 (73.2)	21/132 (15.9)	<0.001	14.3 (8.2–25.6)*
	Outside home	52/194 (26.8)	111/132 (84.1)
Number of aggressors
	1	192/211 (91.0)	116/155(74.8)	<0.001	3.3 (1.8–6.1)*
	2 or more	19/211 (9.0)	39/155(25.2)
Aggressor unknown
	Yes	187/205 (91.2)	65/154 (42.2)	<0.001	16.2 (9.2–29.8)*
	No	18/205 (8.8)	89/154 (57.8)
Connection
	Friend/Acquainted	79/202 (39.1)	41/151 (27.2)
	Father	30/202 (14.8)	3/151 (2.0)
	Stepfather	33/202 (16.3)	5/151 (3.3)
	Mother	3/202 (1.5)	0
	Brother	7/202 (3.5)	1/151 (0.7)
	Caregiver	27/202 (13.4)	1/151 (0.7)
	Boyfriend	5/202 (2.5)	3/151 (2.0)
	Ex-spouse	0	1/151 (0.7)
	Institutional relationship person	0	3/151 (2.0)
	Unknown	18/202 (8.9)	93/151 (61.6)
Use of force
	Yes	45/96 (46.9)	104/114 (91.2)	<0.001	0.09 (0.04–0.18)*
	No	51/96 (53.1)	10/114 (8.8)
Previous violence
	Yes	55/73 (75.3)	19/43 (44.1)	<0.001	3.8 (1.7–8.7)*
	No	18/73 (24.6)	24/43 (55.8)
Relatives know
	Yes	238/240 (99.1)	109/111 (98.1)	0.5	2.2 (0.2–21.2)
	No	2/240 (0.8)	2/111 (1.8)
Condom
	Yes	9/114 (7.9)	3/82 (3.6)	0.2	2.3 (0.6–10.6)
	No	105/114 (92.1)	79/ (96.3)
Use of drugs by aggressor(s)
	Yes	3/123 (2.4)	17/80 (21.2)	<0.001	0.09 (0.02–0.3)*
	No	120/123 (97.6)	63/80 (78.7)
Police report
	Yes	114/133 (85.7)	116/150 (77.3)	0.07	1.7 (0.94–3.3)
	No	19/133 (14.3)	34/150 (22.7)

• ^*
  p significant.
Source: The authors.

The victims aged <14 years had 14 times more chance of experiencing aggression by household members (p<0.001; OR=14.3 (95%CI 8.2–25.6)) and 16 times more chance of knowing the aggressor [p<0.001; OR=16.2 (95%CI 9.2–29.8)]. On the contrary, being aged ≥14 years triples the chance of being abused by more than one aggressor [p<0.001; OR=3.3 (95%CI 1.8–6.1)].

It was observed that 75.3% of patients aged £13 years had experienced previous situations of sexual violence, compared to 44.1% of those aged ≥14 years. In both groups, more than 75% of the victims reported the offense to the police, and in more than 98% of cases, the relatives knew about the rape (Table 2).

The comparison between the two groups shows an association between the place of aggression [p<0.001; OR=14.3 (95%CI 8.2–25.6)], the aggressor being acquainted [p<0.001; OR=16.2 (95%CI 9.2–29.8)], the use of force at the moment of the violence (p<0.001; OR=0.09 (95%CI 0.04–0.18)), and the occurrence of violence previously to the aggression [p<0.001; OR=3.8 (95%CI 1.7–8,7); Table 2].

Regarding medical care after sexual exposure in victims aged <14 years, 71.3% received only initial care at the emergency unit, with no ongoing ambulatory care follow-up. In the age group ≥14 years, 57.6% continued ambulatory care (Table 3).

Table 3
Care after sexual exposure.

Characteristics	<14 years	≥14 years	p-value	OR (95%CI)
	Freq/n (%)	Freq/n (%)
Urgency	159/223 (71.3)	70/165 (42.4)	p <0.001	OR=3.4(2.2–5.2)*
Urgency+Ambulatory	64/223 (28.7)	95/165 (57.6)

• ^*
  p significant.
Source: The authors.

DISCUSSION

Child-adolescent sexual violence is a severe and chronic situation with great repercussions for the victim's health and life, and it is virtually invisible, especially in children younger than 14 years, because it is committed by known individuals within the household setting.

This study identified that the majority of rape crimes occurred against girls aged <14 years, who are incapable of consenting to the act, denominated rape of vulnerable by Law 12015/2018. This crime is on the rise in Brazil, because in 2018, over half of the victims were £13 years of age, increasing to 70% in 2019 and 77% in 2020⁴.

In this analysis, 78% of victims in both groups were black girls and adolescents. The distribution by color or race is one feature of the profile of victims of rape aged ≤19 years in Brazil which differs from that observed in other crimes. Racial inequality is not as present as in intentional violent deaths. In the age group between 0 and 4 years, most victims are white. In the other age groups, the majority are black. But, in the age group between 10 and 13 years, 56% are black and 42% are white. Considering all victims from 0 to 19 years, 52% are black and 46% are white⁴.

The fact that victims aged <14 years are subjected to aggression by household members, often without the use of physical or verbal aggression, reaffirms what happens in Brazil, where 85.2% of the perpetrators are known to the victims⁴. The aggressor with some emotional connection uses the trust relationship with the child/adolescent to practice acts that are initially considered as demonstrations of affection, and when the victim starts to understand the situation as abnormal, the aggressor requires silence through all types of threats⁹.

This study demonstrates that school delay is higher for victims aged ≥14 years and that these adolescents have four times more chance of having educational delay. The participation of the school is acknowledged as important for the promotion of actions against sexual violence, identification, and support for the victims. Children who participate in school programs of sexual abuse prevention have greater knowledge about the subject and are three times less likely to become victims as adults¹⁰.

On the contrary, recent years have been atypical due to the coronavirus pandemic, imposing circulation restrictions and rigorous social isolation measures. For children and adolescents, these changes involved classroom lessons suspension, a reduction in the frequency of public services, and for those who live in an aggressive setting, it meant a reduction in possible protection networks and an increase in exposure to violence⁴.

It is known that children who experience sexual violence have a higher probability of re-victimization throughout their lives⁴. The results of this research point out that more than two-thirds (75.3%) of girls aged <14 years had experienced some situation of previous violence, which can be justified by the context of social vulnerability in which they are inserted and by their proximity to the aggressors, hampering the registration and favoring the chronicity of those acts.

This study was conducted at the largest hospital complex in the town of Nova Iguaçu, which delivers health care to the local population and that of the surrounding municipalities of Baixada Fluminense. The region concentrates 22.6% of the population of the State of Rio de Janeiro (RJ) and is characterized by poverty, social inequality, and a predominance of violence¹¹, similar to what occurs in most of the national territory. In 2020, the Baixada Fluminense area presented one of the highest mean rates of rape per 100,000 women in RJ (77.6), even higher than the mean rate in RJ (67.5). In 2021, the mean rate of RJ was 50.5, similar to that of Brazil (51.8)⁵,¹².

In this analysis, most aggressors were not under the effect of drugs and/or alcohol. In the aggression against the age group 14–19 years, the consumption of such substances by the aggressor(s) was 21.2%, and in the age group <14 years was 2.4%, probably due to the aggressor's profile and the setting being often different in the two groups. The literature has been pointing out a relation between the consumption of drugs and/or alcohol with sexual violence, e.g., in extrafamilial sexual aggression alcohol ingestion increases the victim's vulnerability due to cognitive and motor effects¹³.

Immediate care after sexual exposure and the specialized ambulatory care follow-up by a multiprofessional team are the determinants for the reduction of physical and emotional repercussions in the victim's life, both in short and long term.

Despite the promising advances with the creation of reference centers, formulation of protocols, and the mandatory delivery of these services by the Brazilian Unified Health System (SUS), many obstacles hamper the adequate follow-ups, such as non-adherence to the proposed therapy and the continuity of the ambulatory care follow-up, because a considerable number of patients do not return after the first visit. In this study, less than 30% of girls aged <14 years continued with the ambulatory care follow-up, similar to the rates described in other studies, between 10 and 31%⁹. These data demonstrate the need to improve the work of family health teams, tutelary councils, juvenile courts, and other institutions that can constitute an integrated protection network, in the sense of conducting active searches of these girls who are victims of violence, thus enabling more effective follow-up, aiming to minimize the impacts of the violence experienced and to prevent further occurrence, because most of it happens in the family setting.

Factors related to the victim, such as low socioeconomic level, change of address, victim's psychic condition, and association of the care with what motivated it may also jeopardize the adhesion. Further studies are necessary for the improvement of adhesion strategies.

There was difficulty in obtaining data in the urgency/emergency reports due to the objectivity of the description of the aggression scene, which represents a limitation of this study. In the group with ambulatory care follow-up, the description was more detailed, enabling better access to the data of the analyzed variables.

CONCLUSION

Black girls, especially those in the age group <14 years, are more vulnerable to sexual violence and re-victimization because they present lesser adhesion to health care follow-up and experience aggression mostly in the family setting.

This public health problem requires continuous efforts to broaden the network of protection for victims and gradually improve multidisciplinary care because adhesion to the preconized treatment and follow-up consists of challenges of this type.

• Funding: none.

REFERENCES

• ¹
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Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  2023

History

• Received
  25 Nov 2022
• Accepted
  03 Dec 2022