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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.25 no.12 Rio de Janeiro Dec. 2020  Epub Dec 04, 2020

https://doi.org/10.1590/1413-812320202512.19282018 

FREE THEMES

An integrative review of care networks for adolescents who have experienced sexual violence

Gabrielly Becalli Broseguini1 
http://orcid.org/0000-0002-2812-7463

Alexandra Iglesias2 
http://orcid.org/0000-0001-7188-9650

1 Universidade Federal do Espírito Santo (UFES). Av. Fernando Ferrari 514, Goiabeiras. 29075-910 Vitória ES Brasil. gabriellybeccalli@gmail.com

2 Departamento de Psicologia, UFES. Vitória ES Brasil.


Abstract

Interventions aimed at children and adolescents who have suffered sexual violence should be coordinated across different services and include a range of actors if they are to ensure comprehensive, interdisciplinary and continuous care. Sexual violence against adolescents involves specific issues, such as the risk of pregnancy, abortion, the right to emergency contraception, and the difficulty some people have in discerning between violence and consent. The objective of this study was to identify and analyze national literature on care networks for adolescents who have experienced sexual violence. We conducted an integrative literature review, performing a content analysis of 11 articles focusing on the following five thematic categories: concepts of networks, network-based care services, network-based care practices, difficulties in implementing network-based care, and proposals for network-based care. Few of the analyzed articles presented a definition of care networks or described how they work. The findings show that literature focusing specifically on care networks for adolescents who have experienced sexual violence is scarce. Finally, it was noted that few articles discussed the role of the family, health regions and other potentially important actors in care networks.

Key words: Sexual Violence; Adolescent; Care Network; Integrative Review

Resumo

A intervenção na área da violência sexual na infância e adolescência requer articulação entre vários serviços e atores para a garantia do cuidado integral, interdisciplinar e continuado. No caso dos adolescentes, há particularidades nessa questão, como: a possibilidade de uma gestação e de sua interrupção legal; o direito à anticoncepção de emergência; e certa dificuldade, por parte de muitos atores sociais, de discernimento entre violência e consentimento. Objetivou-se levantar e analisar as produções científicas nacionais sobre as redes de cuidados aos adolescentes em situação de violência sexual. Para tanto, utilizou-se da revisão integrativa de literatura, sendo selecionados 11 artigos, submetidos a análise de conteúdo temática. Destacaram-se nos resultados cinco categorias: concepções de rede, serviços disponíveis para o cuidado em rede, práticas para o cuidado em rede, dificuldades da atuação em rede e propostas para o cuidado em rede. Poucos dos artigos analisados trazem o entendimento de redes de cuidados e o modo como elas funcionam. Observou-se ainda desfalque de produções que lidem mais especificamente com a questão da adolescência nesses casos. Além disso, notou-se que poucos artigos abordam a família e o território como componentes possíveis na constituição dessa rede.

Palavras-chave: Violência Sexual; Adolescente; Redes de Cuidados; Revisão Integrativa

Introduction

Sexual violence is a public health problem, primarily due to its physical and psychosocial effects, such as sexually transmitted diseases, mental disorders, fear behaviors, feeling of insecurity, shame, suicidal ideation, difficulties in establishing affective relationships, engagement in sexual exploitation (prostitution), and addiction to psychoactive substances1,2.

According to the Virtual Health Library (VHL), as a Health Sciences Descriptor (DeSC), sexual violence refers to an abuse of power whereby an individual is used for sexual gratification through the induction of sexual practices with or without physical violence. With regard to children and adolescents, this situation is aggravated by the restriction among this group of “maturational and psychobiological conditions of coping, thus violating social, moral and legal norms”3(p.467), such as the right to freedom, autonomy and the responsible exercise of sexuality.

According to the Brazilian Ministry of Health4, sexual violence against children and adolescents consists of homosexual or heterosexual acts of any nature, in which the perpetrator - known to the victim or a stranger and at a more advanced psychosexual stage than the child or adolescent - uses the victim for sexual pleasure, through grooming, physical violence or threats, with or without physical contact. For Habigzang et al3, the abuse of power occurs either against the will of the child or adolescent or “by inducement, through relations of power and confidence between the victim and perpetrator, as well as by the use of physical or psychological violence (threats and bargaining)”3(p.467).

According to the website, Portal Brasil, in 2015 and 2016, the human rights hotline of the National Human Rights Ombudsman, Disque Direitos Humanos - Disque 100, received 37,000 complaints of sexual violence among the zero to 18 years age group. Despite this large number, it is suggested that cases of sexual violence are underestimated, particularly due the prejudice, taboo and silence surrounding sexual crime5.

In the case of adolescents, victim blaming often occurs, combined with what seems to be a difficulty in discerning between violence and consent. Research conducted by De Antoni et al.6 showed that mothers of adolescents trivialized or took for granted the violence suffered by their daughters. Trabbold et al.7 suggest that this discourse may even be adopted by health professionals. This raises the following question: “do adults therefore lack measures to assess what constitutes sexual violence in relation to the sexuality experienced by young people or adolescents?”7(p.81).

Within this context, this study focuses on sexual violence against adolescents in view of the specific issues related to this type of violence in young victims - such as the risk of pregnancy, abortion, and the right to emergency contraception - and the notorious lack of research focusing on this group. In this regard, according to Deslandes et al.8, a search of the SciELO database conducted in January 2015 using sexual violence as the topic and including the descriptor ‘care’ yielded 13 articles, only three of which focused on adolescents.

Introduced on July 13, 1990, Law 8.069, otherwise known as the Child and Adolescent Statute (CAS), states that an adolescent is a person aged between twelve and eighteen years. It is worth mentioning that this statute, a milestone for the protection of children’s and adolescents’ rights in Brazil, highlights the importance of the provision of comprehensive protection by the state, society and family. The Statute also embodies the notion that children and adolescents are no longer objects of protection, but rather subjects of the law who should be safeguarded from all forms of violence9.

Adolescence is a unique developmental period marked by numerous discoveries and clear changes to the adolescent’s body and social and affective life10,11.

Rassial12 defines adolescence as a phase in which individuals experience the reappropriation of a changed body image and have their “own logic in identification processes”12(p.12). Lo Bianco and Nicacio13 characterize the historicity of what is currently understood as adolescence, highlighting that this name emerged with the advent of bourgeois society. In some societies, for example, the passage from childhood to adulthood used to be marked by rites such as mutilation13. In modernity, the “cutting away” from the former self performed in the rites of passage has given way to a prolonged period of preparation in which adolescents are thrown “into a condition marked by ambiguity and uncertainty”13(p.79), because the limits between childhood and adulthood are no longer clear and symbolically demarcated.

Moreover, Menandro et al.14 identified negative content related to adolescents in the media underpinned by representations of rebelliousness, dependence and immaturity. According to these authors, professional and official discourse is increasingly directed at the prevention of risk behaviors among young people, further emphasizing this characteristic of immaturity. Thus, social discourse viewing adolescents as individuals who need to be controlled and disciplined often overrides the perspective of care14.

In light of the specificities of adolescence and sexual violence, it is pertinent to ask: how exactly are adolescents who have experienced sexual violence care for?

With the aim of reinforcing governmental and non-governmental action strategies, in 2000, the Ministry of Justice/State Secretariat for Human Rights introduced the National Plan for Combatting Sexual Violence against Children and Adolescents4. This Plan aims to provide a legitimate instrument to guarantee the rights and protection of children and adolescents, introducing a set of guidelines designed to support the implementation of the care policy established by the CAS through a network of services15.

This requires close coordination across a range of services, actors and sectors in order to guarantee the right to comprehensive care tailored to the specific complexities of each situation. With regard to child and adolescent care, Santos and Ippolito16 explain that networks enable more wide-ranging multidisciplinary actions involving a range of professionals from various institutions. Networks constitute a system that seeks to establish and deepen stable patterns of interrelationships17. For Castells17, networks are new forms of social and state organization based on cooperation, the absence of hierarchy, sharing common goals, confidence, interdependence, and ongoing and lasting exchange between autonomous units.

In other words, interventions designed to address sexual violence against children and adolescents require ongoing, coordinated, interdisciplinary, specialized care delivered by a range of social actors18-20.

In this regard, a number of studies have highlighted just how deficient these interventions can be, often meaning that delicate and intimate stories must be retold in different settings. In this regard, Gava and Dell’aglio21 talk of the “via crucis” that victims commonly undergo when they are passed around different services, highlighting the lack of coordination and cooperation between institutions limited by the logic of referral and more inclined towards the transfer of responsibility, rather than sharing of responsibility and exchange of information between services. Effective partnerships would certainly avoid already fragile individuals having to tell their story in each institution.

In light of the above, the present study sought to identify and analyze national literature on care networks for adolescents who have experienced sexual violence, focusing on concepts of networks, network-based care services, network-based care practices, difficulties in implementing network-based care, and proposals for network-based care.

Method

We conducted an integrative review of literature on care networks for adolescents who have experienced sexual violence. The interest in this topic emerged as a result of the authors’ professional experience of the difficulties in coordinating these networks to provide effective care to these adolescents. We opted for an integrative review because this method is a useful tool for synthesizing research on a given topic and identifying potential knowledge gaps that need to be addressed by future studies22-24.

The review comprised the following stages: definition of the research questions; selection of descriptors; definition of article inclusion and exclusion criteria; study categorization; and analysis of the selected articles to synthesize the knowledge on the topic of concern22-24.

The following guiding questions were used: what are the main institutions and actors that make up care networks for adolescents who have experienced sexual violence? What are concepts of networks that underpin this type of care? What are the strengths and difficulties faced in implementing network-based care? Which current experiences of network-based care in the country provide potential parameters for building new public policies and effective care practices?

A search for relevant national articles was conducted between March and May 2017 using the following databases: the Coordination of Improvement of Higher Education Personnel (CAPES, acronym in Portuguese) periodical portal, SciELO, and Latin American and Caribbean Health Sciences Literature (LILACS, acronym in Portuguese). We used the following descriptors: “adolescente” (adolescent), “adolescência” (adolescence), “abuso sexual” (sexual abuse), “violência sexual” (sexual violence), “assistência integral à saúde” (comprehensive health care), “integralidade em saúde” (comprehensiveness in health care), “saúde do adolescente” (adolescent health), “serviços de saúde” (health services), “assistência à saúde” (health care), and “network” (network). These terms were organized to perform a three-pronged search designed to encompass the core study themes adolescent, sexual violence and network.

It is important to clarify that the terms used in the search (“sexual abuse” and “sexual violence”) were employed in accordance with the recommendations in the literature. According to the DeCS, the descriptor “sexual abuse” is a synonym of “sexual violence”. Although the descriptor “sexual exploration” was not found, “sexual violence” is considered to be a broad term encompassing both sexual abuse and sexual exploration.

There is no consensus over the definition of the terms. Thus, although the differentiation between the terms is important for legal purposes, we opted to use the term sexual violence in its broad sense, followings the lines of the DeSC and not focusing specifically on sexual exploration or human trafficking.

We included full-text articles in Portuguese published between 2007 and 2017 available online that mentioned network-based care for adolescents who have experienced sexual violence in their objectives. Using these criteria, we read the titles and abstracts to identify articles addressing care networks for adolescents who have experienced sexual violence. It is important to note that the articles found did not focus specifically on adolescents and therefore studies addressing both children and adolescents were included. Although the study period was 2007 to 2017, the search only yielded articles published in the period 2010 to 2016.

Theses, dissertations, end of course projects, chapters from books, articles without the full text in Portuguese, articles on sexual violence against adolescents that did not address care networks, articles on sexual violence against groups other than adolescents, and articles that dealt solely with sexual exploration against adolescents were excluded.

The search yielded 2,166 articles: 746 from the Capes periodical portal, 97 from SciELO, and 1,323 from LILACS. Twenty-five articles remained after applying the inclusion and exclusion criteria and discarding duplicate papers. Fourteen of these articles were excluded after reading the full text because they did not address care networks in their objectives, resulting in a final sample of 11 papers.

We then performed a content analysis of these articles25, comprising the following stages: (1) floating reading of the selected articles and synthesis of the objectives and main findings in a table; (2) selection of units of analysis based on the research questions; and (3) categorization. This process resulted in five categories: concepts of networks, network-based care services, network-based care practices, difficulties in implementing network-based care, and proposals for network-based care.

Results

The selected articles are synthesized by author/year of publication, title, journal, and objective in Chart 1.

Chart 1 Characterization of the selected articles - integrative literature review of papers published between 2007 and 2017. 

Item Author (year) Title Journal Objective
1 Paixão and Deslandes (2010)28 Analysis of public policies to combat sexual violence against children and adolescents Saúde e Sociedade To analyze the main public policy for combatting sexual violence against children and adolescents in Brazil, focusing on the core line of care “guaranteeing specialist comprehensive care”.
2 Costa et al. (2010)26 Evaluation of the National Program for Integrated Reference Actions for Combating Sexual Violence against Children and Adolescents (PAIR) in Feira de Santana, Bahia. Ciência e Saúde Coletiva To present an evaluation of the actions developed by the PAIR in Feira de Santana between 2003 and 2006, focusing on political articulation and institutional coordination and strengthening the victim care network.
3 Habigzang et al. (2011)3 Revealing Sexual Abuse: Measures Adopted by a Support Network Psicologia Teoria e Pesquisa To identify and analyze the measures adopted by the child and adolescent support network after disclosure of sexual abuse.
4 Paixão and Deslandes (2011)15 Sexual Abuse of Children and Adolescents: municipal health actions to guarantee care Ciência e Saúde Coletiva To analyze the actions developed by the Rio de Janeiro City Department of Health and Civil Defense to guarantee care for child and adolescent victims of sexual violence.
5 Rodrigues et al. (2011)18 Network against sexual violence in the Federal District: representativeness of health and education in adolescence Comunicação em Ciências da Saúde To highlight the need for the effective implementation of public policies designed to restructure the network against violence, focusing on health and education.
6 Santos et al. (2011)29 Protective measures from the perspective of families in situations of sexual violence Psico To understand the meanings constructed by families with children and/or adolescents who have experienced sexual violence of protective measures during their passage through legal, social, health and other networks from moment the complaint was filed.
7 Kappel et al. (2012)1 Combating sexual violence against children and adolescents from the perspective of participants in a training course Cogitare Enfermagem To identify the difficulties, peoples, and institutions involved and violence coping strategies from the perspective of 57 participants in a training course provided under the National Program for Integrated Reference Actions for Combating Sexual Violence against Children and Adolescents.
8 Faraj and Siqueira (2012)19 Care and protection networks for child and adolescent victims of sexual violence from the perspective of professionals working in CREAS Barbarói To understand the perceptions of professionals working in CREAS who conduct assessments and provide care for children and adolescents who have suffered sexual violence in relation to the care provided and the municipal child and adolescent protection network.
9 Espindola and Batista (2013)27 Sexual Abuse of Children and Adolescents: the Role of the Sentinel Program in Blumenau, State of Santa Catarina Psicologia: Ciência e Profissão To investigate the role of the Sentinel Program in Blumenau in relation to sexual violence against children and adolescents and map care and vulnerability factors.
10 Deslandes and Campos (2015)2 The role of the network in guaranteeing the full protection of children and adolescents who have experienced sexual violence from the perspective of child protection counsellors Ciência e Saúde Coletiva To investigate the perceptions of child protection counsellors in relation to the main difficulties faced by the network in guaranteeing the full protection of children and adolescents in Rio de Janeiro who have experienced sexual abuse and/or been victims of sexual exploration.
11 Deslandes et al. (2016)8 Health care for children and adolescents who have experienced sexual violence in four state capitals in Brazil Interface (Botucatu) To analyze the provision of health care to children and adolescents who have experienced sexual violence in municipal health networks in four state capitals in Brazil - Porto Alegre (RS), Belém (PA), Fortaleza (CE), and Campo Grande (MS).

Concepts of networks

This category encompasses the different understandings of networks expressed in the articles. Five studies failed to provide a definition for the term network or its derivatives (“service network”, “care network”, “protection network”, among others), basically using the composition of the network to describe it8,15,26-28. For example, Deslandes et al.8 state that the municipality provides assistance to children and adolescents via a network system across different levels of the justice, health, education, and social development sectors.

The other six articles1-3,16,18,19 described the concept of network. Faraj and Siqueira19 suggest that networks are “dynamic processes in movement and conflict aimed at implementing joint interventions to improve effectiveness”19(p.77). The point of departure of the article published by Deslandes and Campos2 was the concept of social network, understood as “social fabric articulated around common goal and actions, whose web is built upon a process of collective participation and shared responsibilities”2(p.2175). In line with the idea of shared actions, care networks “imply horizontal relations, where all areas take responsibility”18(p.345).

The definition of social and affective support network also appears, emphasizing the family and family composition: “a set of significant systems and people (structure) that make up the existing relationships perceived by the child”3(p.468). In addition, Santos et al.16 mention institutional networks as an alternative organization that makes it possible to guarantee the flexibility, connectivity and effectiveness of actions developed by each level.

Network-based care services

This category highlights the services identified by the articles as being components of care networks. Eight of the 11 articles analyzed by this study1-3,8,19,26,27,29 presented the component services of networks, highlighting that services linked to education, health, social welfare1,3,26, and the defense of human rights, such as Child Protective Services1,3,8,19,26,29 were partners. Other services mentioned in the articles include the District Attorney’s Office2,3, local child and adolescent bureaus2,8,19, juvenile courts3,19, Public Defender’s Office8, and the Municipal Council for Child and Adolescent Rights1. Habigzang et al.3 also mention the family.

Social services include Social Assistance Referral Centers (CRAS), Social Assistance Specialized Referral Centers (CREAS)2,8,26,29 and health services: “public hospitals that develop intrafamily violence victim assistance programs for psychotherapeutic care”29(p.81).

The articles also mentioned national services - health facilities8,27 and Child and Youth Psychosocial Care Centers (CAPSi)27 - and regional initiatives and institutions, such as the “non-governmental project Vira Vida, Rede Aquarela, Municipal Department of Human Rights”8(p.870) and “the NGO Núcleo de Atenção a Criança e Adolescente (Child and Adolescent Care Center)”2(p.2177).

In Belém, Deslandes et al.8 highlight the role of Santa Casa de Misericórdia Hospital and Institute of Legal Medicine. In Porto Alegre, institutions include the Presidente Vargas Maternal-Child Hospital’s Child and Youth Care Referral Center, while in “Campo Grande, organizations include the CAPSi and Post-Trauma Psychosocial Care Center, which is one of only a few in the country specializing in violence-related trauma”8(p.870). In Fortaleza, the “Rights of Children and Adolescents Referral Center, which monitors complaints made via Disque 100 (child and adolescent sexual abuse and exploration hotline) and Child Protective Services” was cited8(p.870).

Network-based care practices

The only two articles18,19 that describe network-based practices talk about welcoming, treated as a moment for data collection and analysis and definition of treatment for adolescents and their families or, in other words, referrals: “To see if there is a need to refer (the child or adolescent) for examinations, to a clinician or a gynecologist, and also a psychologist or social services”18(p.350). In the case of CREAS, a care plan is developed by psychologists and social workers19. Subsequently, “a report is sent to the Child Protective Services, local child and adolescent bureau or body that refers the case to the CREAS. The report is also sent to the City Council Chamber in cases involving legal procedures”19(p.76).

Difficulties in implementing network-based care

This category presents the difficulties faced in implementing network-based care for children and adolescents who have experienced sexual violence. Seven of the articles1-3,18,19,28,29 mentioned difficulties. One of the main difficulties highlighted was lack of communication between network services, actors and sectors2,3,19. In the words of Faraj and Siqueira19, it is not possible to “maintain adequate communication between institutions, agencies and actors, including the specialist services (CAPS, Outpatient Mental Health Clinic, etc.)”19(p.77) or “work in the referral and counter-referral system”19(p.78) between the care services - CRAS and CREAS: “you can’t refer”19(p.78); “lack of informatization of the service and network”19(p.79).

Santos et al.29 suggest that difficulties include procedure constraints, “referrals to facilities, which can generate a false sense of case resolution”29(p.84). These authors argue that this procedure generates “repeated interventions and assessments and overexposure of the family, leading to family exhaustion and exhausting the possibilities of results”29(p.85). In this regard, some articles highlighted lack of sharing of information about treatment and the child’s/adolescent’s needs1,2,28, “lack of coordinated planning of the different services that make up the network”3(p.472), lack of clarity regarding “working in networks”, lack of standardized practices28, and the “inexistence of a transparent definition of the role played by institutional agents within the network”1(p.221).

The articles also highlighted deficiencies in specialized care and interinstitutional coordination and collaboration18. Within this context, Paixão and Deslandes28 discuss “difficulty in coordination and collaboration between various services, including unfamiliarity within the network with how to cope with the flow of referrals to various areas of interest”28(p.121). The authors suggest that there are “limited options for referring victims to the service networks, and the latter do not prioritize care for [cases of] sexual abuse and exploration”28(p.121).

The articles also mention delays in care18 and staff shortages18,28. Deslandes and Campos2 highlight the high demand for care, which hampers coordination across the network, and “deficiencies in social-assistance and education policies”2(p.2177). Paixão and Deslandes28 also point to a lack of support from public policies, while Rodrigues et al.18 and Kappel et al.1 talk about lack of and deficiencies in public policies in general.

Paixão and Deslandes28 also describe the lack of continuing training and public participation28 and lack of preparedness of professionals for dealing with this type of demand1,2. In the words of Paixão and Deslandes28, there is “little clarity regarding the follow-up of victims, demonstrating a lack of systematization of procedures and deficiencies in technical monitoring and supervision on the part of state, municipal and federal governments”28(p.122).

Proposals for network-based care

This category presents the proposals to promote the effective implementation of network-based care for children and adolescents who have experienced sexual violence. Eight articles1-3,8,18,19,26,28 highlighted proposals for strengthening network-based care, most of which emphasized the need for training of professionals in working in child and adolescent care networks1-3,18,26. Habigzang et al.3 suggest “continuing training and evaluation of training programs to identify possible gaps”3(p.472).

The articles also highlight the need to strengthen protection networks1,26 and institutions1,26, with government and social investment26 and the incorporation of strategic actions in government plans2.

The authors also mention the need to raise awareness of the underlying purpose of working in networks “among all actors and institutions, where political will and determination alone is not enough to ensure a shift in the social policy paradigm”28(p.121). Along this line of reasoning, Deslandes and Campos2 advise that it is vital to “consolidate planned and agreed flows of action between the different services and actors”2(p.2180) that make up the network and “set a common agenda for universalizing an efficient intersectoral care model”28(p.124).

Faraj and Siqueira19 point to “the need to work to raise the awareness of the actors involved, promoting referral and counter-referral, as well regular meetings between actors in the institutions and agencies that work with this problem”19(p.82).

Other proposals included broadening the range of services provided and optimizing human and physical resources18,28. According to Costa et al.26, it is necessary to “strengthen and broaden the role of Sentinel Referral Centers and Child Protective Services in the provision of care during office hours on weekdays and public holidays, and improve the facilities in these services”26(p.571) in order to consolidate the network. These authors also suggest the need to “increase the role of certain sectors, such as the education system, Public Defender’s Office, public security services, Child Protective Services, the Municipal Council for Child and Adolescent Rights, and the media in the violence response network”26(p.571). Finally, one article suggest the need to “increase the capillarity of primary health care services”8(p.873).

Discussion

The Ministry of Health defines networks as “organizational arrangements of actions and services with different levels of technological density, which, integrated by technical, logistical and management support systems, seek to guarantee the provision of comprehensive care”30. Although all of the articles analyzed by this study focused on network-based care, only six defined which network they were referring to. The concepts used were similar and complement each other, confirming to a certain extent the Ministry of Health’s definition involving the idea of working together towards common goals and horizontal relations, whereby responsibilities are shared between those involved in care2,18. In the words of Faraj and Siqueira19, networks are “dynamic processes...”, which means they are not given, but rather built around situations as they emerge.

In this sense, it could be said that the restrictive idea of a network as a set of services presented by other articles fails to consider important questions such as the problematization of the concept of care networks from the perspective of dynamism.

According to Carlson and Pinheiro31, the concept of network tends to be tied to the enumeration of the role of services in a given setting (including referral flows), transforming the discourse into an “administrative vision that, at most, points to what resourses exist/are lacking in the health region”31(p.106). Instead, the authors propose a dynamic network underpinned by “practices that produce care through the interrelation of various existing public policies”31(p.106).

The existence of a range of services is certainly a prerequisite for a network. However, a range of services alone does not ensure effective communication and coordinated care. As Kinoshita32 points out, a network exists when there is synchronized and coordinated interaction between individuals towards a common goal, enabling the emergence of phenomena that otherwise would not happen.

Thus, working in networks extends beyond the presence/lack of services, involving the establishment of common lines of action across a range of social actors, surpassing the logic of referral, and reporting and affirming shared responsibility among those involved31. As Habigzang et al.3(p.468) assert, networks comprise “a set of significant systems and people (...) that make up the existing relationships perceived by the child”.

As mentioned above, the definition of what constitutes a network offered by the articles - a set of services, such as health, education, social welfare, and human rights institutions, formally designated responsible for the care of children and adolescents who have experienced sexual violence - would seem rather limited. It is understood that this definition excludes important and often overlooked elements of network-based care. Thus, it is not about assigning preset roles to the institutions involved in providing care, but rather allowing greater flexibility in the work of the actors involved and in case-to-case actions.

As highlighted by the articles, certain institutions - such as those linked to education, health, social welfare, and justice - are undeniably indispensable in care networks. However, it is important not to restrict the network only to these services, understanding that a network may expand depending on the situation and bonds of trust built with adolescents who have experienced sexual violence. Other people beyond the services can and should be part of the care network, considering the multiple possibilities of organization and needs of each situation. In this direction, one of the articles3 highlights that the family is a potentially important component of social support networks. For most individuals, the family is the first social network, meaning that it should be considered a vital part of the network, both to care for the adolescent and to be cared for.

Given the complexity of violence, health, social, education, and child and adolescent protection services, and other actors such as the family, should “act across sectors in a coordinated manner, allowing flexibility and expanding flow in all possible dimensions of care”30(p.76). Thus, it is not about enumerating an exhaustive list of the services that make up a network, but rather about recognizing that the services and actors involved may vary from case to case.

On the other hand, it is still important to define the services that make up the network in order to hold the relevant institutions accountable for the care of children and adolescents and avoid the risk of certain services exempting themselves from this responsibility due to the difficulties faced in dealing with situations of sexual violence against this group.

With regard to the provision of network-based health care services for children and adolescents who have experienced sexual violence, the articles emphasize hospitals. An article about the role of hospitals in health care networks published in the journal of the National Council of Health Secretaries suggests that the central role played by these facilities is historical, associated with “the way in which Brazil has treated the search for the solution to health problems over the years”33(p.16), guided by a curative and “biologizing” perspective of care. The journal argues that there is a need to strengthen primary care as the main strategy to promote a shift from a hospital-centric and hierarchical logic towards a more horizontal care model conducive to the support network approach.

Only two of the articles8,27 mentioned that primary care was an important component of network-based care, which goes against Ministry of Health guidance30 highlighting that this level of care - in conjunction with specialized, urgent and emergency care, mental health services, and strategic management support services - is an important component of care and protection networks.

The underlying principles of Primary Care include universal access, accessibility, care coordination and continuity, patient-health provider relationships, comprehensiveness, accountability, humanization, equality, and public participation, underlining the key role this level of care plays in responding to cases of sexual violence. The proximity of primary care facilities to the population should enable better access to care which, underpinned by patient-health provider relationships, should ensure the delivery of comprehensive care to children and adolescents who have experienced sexual violence. It is also important to consider the role of this level of care in ensuring the effective coordination and continuity of care.

Primary Care is also uniquely placed to identify signs and symptoms of violence, provide a supportive and welcoming environment, diagnose, treat, and notify cases, and develop health promotion actions targeted at this group, promoting the improvement of the living conditions of children and young people through the implementation of intersectoral network-based care.

With regard to network-based care practices, only two articles19,27 mention how working in networks takes place, highlighting “welcoming” for “data collection and analysis”, “referrals” and reporting. Welcoming therefore appears to be understood more as “administrative screening, or a good referral to specialized services”34(p.124) than an “ethical stance that entails listening to users’ complaints, recognizing their protagonism in the health and disease process and accountability for resolution, with the activation of knowledge sharing networks”35.

That is not to say that “data collection and analysis” is not important, but rather that it is vital in situations of violence that all professionals adopt welcoming as an everyday practice, actively listening to the suffering of others and showing readiness to jointly build healthy alternatives to ensure the well-being of children and adolescents who have suffered sexual abuse.

This also raises questions about referral practices in networks, which generally, instead of promoting interaction between health actions and comprehensive care, reinforce the idea of transfer of responsibility and relationships based on hierarchies of power/knowledge between the referring and receiving facility36. Not to mention the potential fragmentation caused by the referral logic, where specific responsibilities are divided between specific facilities or services. This can lead to poor communication - one of the characteristics of a fragmented network - often leading to the discontinuity of care17. In this regard, Santos et al.29 suggest that this limitation in relation to referrals is an obstacle to the effective implementation of network-based care, due to the idea of case resolution that this practice creates. The authors argue that this practice leads to “repeated interventions and assessments and overexposure of the family, leading to family exhaustion and exhausting the possibilities of results”29(p.85).

This is because, as the articles show, a major difficulty in consolidating care networks for children and adolescents who have experienced sexual violence is precisely lack of communication between the services, sectors and other actors that make up networks. Efforts should therefore be made to improve communication between these actors in order to ensure the effective implementation of network-based care underpinned by co-responsibility. Effective communication involves free sharing of knowledge within services and between services and continuous contact37.

Within this context, it is worth highlighting the lack clarity in the articles in relation to how to put proposals for network-based care into practice. Five of the articles suggest training of professionals. The need for training of professionals in care for children and adolescents who have experienced sexual violence is evident, especially considering the challenges involved in dealing with these situations and the need for intersectoral coordination. The Ministry of Health30 underlines that permanent education is an important step towards structuring care networks.

In this respect, it is important to highlight some of the underlying principles of permanent education. While training is understood as planned actions with previously established objectives aimed at updating knowledge of specific topics, particularly in relation to knowledge gaps38, permanent education is defined as learning at work, whereby “learning and teaching are incorporated into the daily activities of organizations and work”38(p.20). Permanent education therefore aims to transform working practices through everyday experiences, considering current knowledge and skills for institutional change38.

In a study conducted by Trabbold et al.7, most of the professionals interviewed in a family health care facility reported that adolescents have limited contact with the services, indicating that this group show a certain amount of resistance when it comes to seeking health services. However, the authors invert this idea, suggesting that the health service has difficulties in welcoming adolescents due to the lack of preparedness and insecurity of professionals in dealing with young people and the complexity of sexual violence7. In this way, the authors reveal a gaping gap in the approach to child and adolescent care in general and, more particularly, in relation to violence. This gap seems to extend to the national literature, illustrating the importance of continuing investment in the training of the range of actors involved in caring for children and adolescents who have experienced sexual violence.

Final considerations

This study analyzed the national literature on care networks for adolescents who have experienced sexual violence, showing that, in addition to difficulties related to situations of sexual violence, building effective care networks is a major challenge. So much so that, despite the focus on care networks for children and adolescents who have experienced sexual violence, most of the articles failed to present a definition of networks and how they operate in terms of daily care practices. The lack of a definition of network may be associated with practical difficulties in consolidating care networks, underlining the need for further studies investigating the operation of networks to contribute to network-based practices in the country and broaden understanding of the conceptual underpinnings of network-based care.

The literature on care networks for adolescents who have experienced sexual violence is scarce, so much so that we needed to include articles that also included children. In view of the importance of this issue, a major public health problem, and the severe lack of research focusing specifically on care networks for adolescents who have experienced sexual violence, further research in this area is urgently needed.

With regard to broadening the debate on this topic, it is notable that few articles addressed the role of the family, health regions and other potentially important actors in care networks.

In addition to the training of care-providers, as suggested by the articles, it is important to invest in permanent education, with the aim of transforming professionals into agents of change and placing them at the center of the teaching-learning process, in order to create supportive and welcoming settings that promote the reinvention of life by public health care.

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Received: March 03, 2018; Accepted: April 15, 2019; Published: April 17, 2019

Collaborators

GB Broseguini participated in study conception, data collection and in drafting the final version of this manuscript. A Iglesias participated in study conception and in drafting and critically revising this manuscript.

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