Women care in situations of sexual violence: an integrative literature review

Atención a las mujeres en situación de violencia sexual: revisión integrativa de la literatura

Abstract

Objective:

to identify Brazilian and international scientific evidence about women in situation of sexual violence service by a multidisciplinary health team.

Method:

an integrative literature review carried out in four databases and in a digital library, with the following inclusion criteria: type of study, language and temporal cut. The final sample consisted of 34 studies.

Results:

nine categories emerged: service network; teamwork; health professional in the service network; qualification and training; comprehensiveness; protocols; services; access to services and support from managers. They were organized into potentialities, demands and weaknesses, constituting elements necessary for assistance effectiveness by the multidisciplinary team to women in situation of sexual violence.

Conclusion an Implications for practice:

despite the potential of providing women care in situations of sexual violence, weaknesses stand out as an incipient and inexistent articulation of the intersectoral care network, generating demands for the networks’ construction, articulation and sustainability. In addition, professional qualification and support of managers in the performance of public policies make possible care comprehensiveness, updates and service evidence.

Keywords:
Violence Against Women; Sex Offenses; Patient Care Team; Review

Resumen

Objetivo:

Identificar las evidencias científicas nacionales e internacionales acerca de la atención a mujeres en situación de violencia sexual por el equipo multiprofesional en salud.

Método:

Revisión integrativa de la literatura, realizada en cuatro bases de datos y en una biblioteca digital, Criterios de inclusión: tipo de estudio, idioma y recorte temporal. Muestra final de 34 estudios.

Resultados:

De la síntesis de las evidencias, emergieron nueve categorías: red de atención, trabajo en equipo, profesional de salud en la red de atención, capacitación y formación, integralidad, protocolos, servicios, acceso a los servicios y apoyo de los gestores; organizadas en potencialidades, demandas y fragilidades, constituyendo elementos necesarios para la eficacia de la atención por el equipo multiprofesional a la mujer en situación de violencia sexual.

Conclusión e Implicaciones para la práctica:

A pesar de las potencialidades de la atención a la mujer en situación de violencia sexual, sobresalen fragilidades, como incipiente e inexistente articulación de la red de atención intersectorial, generando demanda de construcción, articulación y sostenibilidad de la red. Además, la capacitación profesional y el apoyo de los gestores en la efectividad de políticas públicas posibilitan la integralidad de la atención, actualización y evidencias en el atendimiento.

Palabras clave:
Violencia contra la mujer; Delitos sexuales; Grupo de atención al paciente; Revisión

RESUMO

Objetivo:

Identificar as evidências científicas nacionais e internacionais acerca do atendimento a mulheres em situação de violência sexual pela equipe multiprofissional em saúde.

Método:

Revisão integrativa da literatura, realizada em quatro bases de dados e em uma biblioteca digital, com os critérios de inclusão: tipo de estudo, idioma e recorte temporal. A amostra final foi composta por 34 estudos.

Resultados:

Da síntese das evidências, emergiram nove categorias: rede de atendimento, trabalho em equipe, profissional de saúde na rede de atendimento, capacitação e treinamento, integralidade, protocolos, serviços, acesso aos serviços e apoio dos gestores; organizadas em potencialidades, demandas e fragilidades. Constituindo elementos necessários para a eficácia do atendimento pela equipe multiprofissional à mulher em situação de violência sexual.

Conclusão e Implicações para a prática:

Apesar das potencialidades do atendimento à mulher em situação de violência sexual, sobressaem fragilidades, como incipiente e inexistente articulação da rede de atendimento intersetorial, gerando demandas de construção, articulação e sustentabilidade da rede. Além disso, a qualificação profissional e o apoio dos gestores na efetivação de políticas públicas possibilitam a integralidade da atenção, atualização e evidências no atendimento.

Palavras-chave:
Violência contra a mulher; Delitos sexuais; Equipe de assistência ao paciente; Revisão

INTRODUCTION

The World Health Organization (WHO) advocates interdisciplinary and multisectoral care in situations of sexual violence. It covers public and private services such as health, education, criminal justice, social services, and civil society.1 Women in situations of sexual violence tend to seek out health services, since they are, for the most part, the first contact and point of entry for care. In this sense, the work of health professionals is fundamental to form links and articulate the service with the other intersectoral services.¹

Search for care in health and other services of the intersectoral network comes from impacts of sexual violence on the multiple dimensions of women. The problem of sexual violence, in addition to the negative consequences of emotional and psychic, has impacts on the sexual and reproductive health of women, in addition to exposure to risks such as physical injuries, pregnancy and Sexually Transmitted Infections (STIs).^2,3

Globally, around 35% of women have already suffered sexual and/or physical violence.¹ In the United Kingdom and the US, it is estimated that one in five women and one in six women, respectively, throughout life, will be the victim of sexual violence. It is noteworthy that only 16.5% - 26.1% of offenses are reported showing that sexual violence has high indices of underreporting.⁴

Nationally, data based on information from the Brazilian National Health Information System (SINAN - Sistema de Informação de Agravos de Notificação) of the Ministry of Health (MoH) show that 527,000 people are raped each year in Brazil, of which 89% are female.⁵ A study carried out in Santa Catarina State about the characteristics of cases of sexual violence practiced against women reported by health professionals, showed that 12.9% of the reported violence were sexual violence.⁶ In Federal District, a study that described the epidemiological characteristics of reported cases of violence against women indicated that 22% of women reported sexual violence.⁷

Moreover, the principle of comprehensiveness in care is highlighted, involving assistance based on up-to-date scientific knowledge, appropriate technology, respect for singularities and without discrimination.² It is a process that requires articulation of services, adequate structure and qualified professionals to ensure comprehensive care for women in situations of sexual violence. In this perspective, articulation among care network services, improvement in embracement and valorization of the intersubjective relationship between women and professionals are factors that increase adhesion to the outpatient follow-up. This was demonstrated in a study aimed at understanding the reasons for non-adherence to outpatient follow-up by women experiencing sexual violence. ⁸

Given the importance of joint and intersectoral actions, evidenced in programs that deal with situations of violence,⁹ studies in the area of nursing have been developed in this collaborative direction. It is necessary to strengthen this new perspective of nursing research, taking into account the priorities of the Brazilian and international scientific research agendas.¹⁰

Considering the importance of this issue, in which effective care is essential for women in this situation, the development of this review is justified. This review consisted in identifying the Brazilian and international scientific evidence about care for women in situation of sexual violence by the multidisciplinary health team.

METHOD

It is an integrative review of the literature, with systematization based on Ganong stages.¹¹ Initially, the review question was elaborated: what is the Brazilian and international scientific evidence about assistance to women in situations of sexual violence by the multidisciplinary health team? The search of data sources (database and digital library) occurred with the aid of a librarian, in September 2017, in four databases: Public Medline (PubMed^®), Cumulative Index to Nursing & Allied Health Literature (CINAHL^®), Scopus^®, and Latin American & Caribbean Health Sciences Literature (LILACS^®); and a digital library: Scientific Eletronic Library Online (SciELO^®).

Search terms (descriptors and keywords) were combined using the Boolean operator e “AND”. The descriptors used were: Violence against women; Sex offenses; Patient Care Team; Nursing professionals; Health personnel. Keywords: Domestic and sexual violence against women, Gender violence; Sexual abuse, Sexual assault, Indecent assault, Sexual crimes, Sexual offense, Sexual violence; Sexual misconduct; Health care team, Interdisciplinary health team, Multidisciplinary team, Health team; Health professionals, Health worker. The terms cited in Portuguese and Spanish were also used.

There was inclusion of studies from original research, available in full, online, published in Portuguese, English or Spanish and with a temporal cut (publications between 2012 and 2017). It should be noted that different search strategies were employed in each database and in the digital library, with 1,254 studies identified.

The reason for the temporal cut comes from the increase of publications of documents directed to the service in situations of sexual violence. Among the publications, Decree 7.958 of March 13^th 2013 stands out, which establishes guidelines for the care of victims of sexual violence by public security professionals and the service network of the Brazilian Unified Health System (Sistema Único de Saúde); Law 12,845 of August 1^st 2013, which provides for compulsory and comprehensive care of persons in situations of sexual violence, and Ordinance MoH/Minister’s Office 485, dated April 1^st 2014, which redefines the operation of Service of Care for People in Situation of Sexual Violence within SUS.¹²

In the screening and selection of studies, the title, summary and partial reading of the article. Duplicate studies were considered only once. Reviews, letters, reviews and editorials were excluded, studies not available in full, online, and studies that did not meet the scope of the review. There 41 studies selected and read in their entirety. Of these, 7 were excluded because they did not respond to the guiding question of the review. The final sample consisted of 34 studies organized in a table in Microsoft Word^® for synthesis from the main results and grouping them into categories. The scheme of search and selection of studies is presented in Figure 1.

Figure 1
Scheme of search and selection of studies. Florianópolis, SC, Brazil, 2018.

* Studies considered onlv once

The strength of evidence from the studies was performed according to the levels (L): L1 - systematic review or meta-analysis of randomized controlled trials; L2 - controlled randomized controlled trials; L3 - clinical trials without randomization; L4 - cohort and case-control; L5 - systematic review of descriptive and qualitative studies; L6 - descriptive or qualitative study; L7 - expert opinion.¹³

RESULTS

Regarding characterization of the 34 selected studies, the number of publications per year was five in 2012, four in 2013, seven in 2014, eight in 2015, five in 2016, five in 2017 (until the search date). Brazil (19), the United States of America (7), Canada (1); South Africa, Iran, the Netherlands and England (1). Three studies were developed in multi-country. The predominant language in the publications was Brazilian Portuguese (19), followed by English (14) and Spanish (1). Regarding the methodological approach, there were qualitative studies (24), quantitative studies (7) and studies mixed methods (3). Regarding the level of evidence of the selected studies: L - 6 (30 studies), L - 4 (2 studies) and L - 7 (2 studies). Chart 1 presents the year of publication, country, title and objective of the selected studies.

Chart 1
Characterization of studies about care for women in situation of sexual violence, second year of publication, country, title and objective. Florianópolis, SC, Brazil, 2018

Study	Year	Country	Title	Objective
S 14	2012	Brazil	Violência entre usuárias de unidades de saúde: prevalência, perspectiva e conduta de gestores e profissionais	To estimate the prevalence of violence in women users of Primary Health Care; if these situations were detected and how they were treated by the professionals of those services.
S 15	2016	Brazil	Instrumentos para articulação da rede de atenção às mulheres em situação de violência: construção coletiva	To identify the information necessary for the construction of instruments designed to enable the articulation of professionals of care services. with women in situations of violence with a view to establishing a care network.
S 16	2015	USA	Sexual Assault Response Teams (SARTs): Mapping a Research Agenda That Incorporates an Organizational Perspective	To conceptualize SARTs from an organizational perspective and explore three approaches to researching SARTs that have the potential to increase understanding of benefits and challenges of multidisciplinary service delivery.
S 17	2017	Brazil	As redes sociais de apoio às mulheres em situação de violência pelo parceiro íntimo	To analyze the social network and the types of support provided to women in situations of intimate partner violence.
S 18	2013	Brazil	Mulheres em situação de violência: entre rotas críticas e redes intersetoriais de atenção	To address how the issue of domestic and sexual violence against women has assumed the character of a problem of public health and human rights in recent decades. To contrast these two sides of the question: how women face the problem by seeking support and how services have acted as institutionalized social support.
S 19	2014	Brazil	Enfrentamento da violência contra a mulher: articulação intersetorial e atenção comprehensive	To identify elements that interfere with addressing violence against women.
S 20	2015	Brazil	Mulher em situação de violência: limites da assistência	To analyze the limits of the practice of care for women in situations of violence, by family health teams in the care network.
S 21	2015	Brazil	Cuidar mulheres em situação de violência: empoderamento da enfermagem em busca de equidade de gênero	To know the actions of caring for women in situations of violence by nurses in emergency and emergency services, and to analyze actions that seek the empowerment of women for gender equity.
S 22	2016	Brazil	Intencionalidade da ação de Cuidar mulheres em situação de violência: contribuições para a Enfermagem e Saúde	To understand motivations of the nurse's action when caring for women in situations of violence.
S 23	2017	Brazil	Atenção à saúde de mulheres em situação de violência: desarticulação dos profissionais em rede	To know the conceptions and actions of health professionals about care network to women in situation of violence.
S 24	2015	Multicountry	The health-systems response to violence against women	Review evidence of clinical interventions and discuss components of a comprehensive health system approach that helps health professionals identify and support women who are subjected to sexual or intimate partner violence
S 25	2017	Brazil	Mulheres rurais e situações de violência: fatores que limitam o acesso e a acessibilidade à rede de atenção à saúde	To analyze the access and accessibility to the care network to women in situation of violence residing in rural contexts, from the speeches of professionals.
S 26	2013	Brazil	Análise das práticas profissionais na atenção em saúde às mulheres em situação de violência sexual	To analyze the professionals speeches who assist women in situations of sexual violence; understand the relation of professional practices to the emancipation of gender oppression.
S 27	2014	Brazil	Violência sexual contra mulheres no Brasil: conquistas e desafios do setor saúde na década de 2000	To analyze and reflect on the main policies and public actions produced or instituted in the Brazilian health sector throughout the decade of 2000 and that contributed to the confrontation of sexual violence against women in Brazil, considering the advances and difficulties encountered.
S 28	2015	Brazil	Rede de atenção à mulher em situação de violência: os desafios da transversalidade do cuidado	To understand from the point of view of professionals who work in services that make up the network, how the care of women in situations of violence is configured.
S 29	2013	Multicountry	Clinical care for sexual assault survivors multimedia training: a mixed-methods study of effect on healthcare providers' attitudes, knowledge, confidence, and practice in humanitarian settings	To describe the effect of CCSAS multimedia training on attitudes, knowledge, confidence and practices of health professionals providing clinical care to survivors of sexual abuse in refugee camps in Ethiopia and Kenya, a post-conflict scenario in the Democratic Republic of Congo (DRC) and an urban refugee environment in Jordan.
S 30	2014	South Africa	A cross-sectional study on the effect of post-rape training on knowledge And confidence of health professionals in South Africa	To determine whether a Brazilian post-rape care training program in South Africa has resulted in improvements in knowledge and trust in health professionals, and in distinguishing the basic factors related to these changes in knowledge and trust.
S 31	2012	USA	Care of the Sexually Assaulted Woman	To describe the short- and long-term consequences of female sexual violence and, using case studies, provide a guide for nursing professionals on comprehensive care and trainers, from appropriate screening after sexual assault to sexually transmitted infections and pregnancy prophylaxis, and follow-up and referral to the sexually assaulted woman.
S 32	2014	USA	Original research: Giving sexual assault survivors time to decide: an exploration of the use and effects of the nonreport option	To consider the non-reporting implementation of option in Texas; to explore its impact on SANEs, survivors and the criminal justice system; and to identify strengths and challenges of the non-reporting process.
S 33	2015	Brazil	Violência sexual contra mulheres: a prática de enfermeiros	To investigate the practice of nurses about sexual violence against women.
S 34	2012	Multicontry	An assessment of health sector guidelines and services for treatment of sexual violence in El Salvador, Guatemala, Honduras and Nicaragua	To describe health sector guidelines for the care of victims of sexual violence in the country and document health services (hospitals and health centers) UNFPA and Ipas.
S 35	2013	Canada	Identificación de las fortalezas, preocupaciones y necesidades educativas del Servicio Rural de Agresión Sexual en las comunidades rurales y aborígenes de Alberta (Canada)	To identify a way to address the risks of second victimization within rural practice, building on existing strengths, and understand the educational resources needed for the assistance crisis in workers in rural and indigenous communities.
S 36	2017	Brazil	Aspectos éticos e legais no cuidado de enfermagem às vítimas de violência doméstica	To analyze the nursing nurses' knowledge about the ethical and legal aspects of nursing care for victims of domestic violence.
S 37	2016	Brazil	Conceitos, causas e repercussões da violência sexual contra a mulher na ótica de profissionais de saúde	To analyze the meanings attributed by health professionals to the concepts, causes and repercussions of sexual violence against women.
S 38	2016	Brazil	Protocolos na atenção à saúde de mulheres em situação de violência sexual sob a ótica de profissionais de saúde	To analyze the use of protocols in the health care of women in situations of sexual violence from the perspective of professionals in two Brazilian capitals
S 39	2014	USA	'We desperately need some help here' - The experience of legal experts with sexual assault and evidence collection in rural communities	To consider the experiences of legal providers of rural communities serving victims of sexual assault.
S 40	2012	Brazil	Perfil do atendimento à violência sexual no Brasil	To assess the situation of public health services for women victims of sexual violence in Brazil, in order to determine the prevalence of municipal programs or services for routine and/or emergency care for women and children who suffer sexual violence in Brazilian municipalities, in addition to describe their characteristics and adequacy to the technical standard of the Ministry of Health (1999).
S 41	2016	Iran	Barriers to Healthcare Provision for Victims of Sexual Assault: A Grounded Theory Study	To explore health care and clinical services for victims of sexual assault in Iran's health centers.
S 42	2015	England	"Silly Girls" and "Nice Young Lads": Vilification and Vindication in the Perceptions of Medico-Legal Practitioners in Rape Cases	To explore insights and assumptions regarding rape, raped women and rapists, among legal medical professionals who perform forensic medical examinations in case of rape.
S 43	2017	Netherlands	Challenges in interprofessional collaboration: experiences of care providers and policymakers in a newly set-up Dutch assault centre	To improve our understanding of challenges in interprofessional collaboration at a newly created center for sexual and family violence.
S 44	2012	USA	Prosecution of Adult Sexual Assault Cases: A Longitudinal Analysis of the Impact of a Sexual Assault Nurse Examiner Program	To consider whether adult sexual abuse cases were more likely to be investigated and prosecuted after implementing a SANE program in a large Center-West municipality.
S 45	2014	USA	The Impact of Sexual Assault Nurse Examiner Programs on Criminal Justice Case Outcomes: A Multisite Replication Study	To assess multisite of six SANE programs (two rural programs, two serving middle, two urban communities) to assess how implementation of SANE programs affects adult assault charges.
S 46	2015	Brazil	Vivência de (des)acolhimento por mulheres vítimas de estupro que buscam os serviços de saúde	To know the structure and the functioning of health services from the speech of women who survived rape.
S 47	2014	EUA	Sexual Assault Services Coverage on Native American Land	To show facility coverage with SAE or SART programs on indigenous lands and demonstrate the extent to which the IHS and the tribal hospital supply of sexual assault exams have improved access to Native American victims of sexual assault to appropriate services.

From reading and comparing the results of studies, nine categories emerged, organized in potentialities, demands and weaknesses in the care of women in situations of sexual violence. These categories are presented in Chart 2:

Chart 2
Potentialities, demands and weaknesses identified in the selected studies. Florianópolis, SC, Brazil, 2018.

	Potentialities	Demands	Weaknesses
Service Network	• Constitution of the articulated network14	• Articulation of distinct welfare sectors and resources14,15,17-25	• Care discontinuity and fragmentation15,22,26
	• Feasibility of communication15		• Articulation among services14,19-21,23,24,26-28
	• SARTs16
	• Establishment of links and rescue of women from vulnerability17		• Revictimization23
Qualification and training	• Public policies for professional training27	• Strategies that enable interaction of knowledge and actions in comprehensive care19,28	• Emerging qualification processes and Permanent Education14,20,26,37,38
	• Contribution to health and nursing care28	• Reorientation of vocational training and promotion of transformative work26,30	• Compulsory notification and lack of knowledge of legal obligation33,36
	• Improvements in respect for patient's rights, knowledge, confidence and clinical practice29,30	• Qualification for qualified responses in the care and identification of sexual violence24,25,>29-35	• Lack of training and capacity building for comprehensive care33
		• Consideration of graduation training30	• Professional training not always free of judgments and prejudice37
		• Extension of knowledge on compulsory notification33,36	• Gaps in nurses' knowledge about ethical and legal aspects36
		• Permanent Education for professional qualification36	• Graduation approach38
		• Training programs for SANEs in rural communities39	• Limitations on SANE experiences in rural communities39
Healthcare professional in the care network	• Health professionals assist women for health care and for being articulators for other support services25,31	• Nurses: valuing communication and social role in the health team21	• Difficulties in working with cases of sexual assault in rural communities39
	• SANEs and other nurses: collaborative relationships and important position in the awareness of other health professionals32	• Nurses: organizing work processes and embracing the unique demands of women's care22	• Insufficiency and inexperience of SANEs in rural areas39
	• Importance of the role of SANEs for rural communities39	• SANEs training in rural areas39
Protocols	• Professional empowerment15	• Development of skills in clinical practice, dissemination of evidence about women's rights and autonomy; implementation of policies for comprehensiveness21	• Lack of protocols for service20,33,40
	• Standardized information that can identify actual or potential problems of violence17	• Ensuring the right conditions to approach24	• Use of clinical protocols focusing on physical damage26
	• Quality to care actions and management38	• Construction of assertive conducts28	• Protocol is not understood and adopted38
		• Building of shared protocols38
Comprehensiveness	• Care and listening skills21	• Specialized care for women's needs, without trial17,21,22,24,35,40,41	• Fragmented care based on the biomedical model 21,22,26,28
		• Revival of the Brazilian feminist movement in the right to comprehensive care27	• Practice not consistent with the principles of humanization26
	• Initial embracement, guidelines, referrals and notification23	• Embracement implementation21	• Professional unpreparedness to recognize violence, embrace and refer women19,20
		• Interdisciplinary and intersectoral discussions and approaches to improve practice28,33	• Maintaining the invisibility of violence20
	• Coping with physical, subjective, sexual and affective impacts on lives of raped women33	• Development of resolutive care: listening, embracement, communication, considering the subjectivity of the other22,23	• Inadequate attitudes of professionals focusing on the blame of women29,41,42
		• Protocol building38
Teamwork	• Service qualification,23,25,43	• Creation of interdisciplinary spaces in health education15	• Work processes still centralized in the hierarchical model, with care fragmentation28
	• Integrated actions38	• Promotion of articulation of different disciplinary perspectives25
	• Interdisciplinary collaboration improves prosecution results as well as support for victims after reporting39	• Building good relationships, defining professional roles; shared vision and focused on43
Management support	• Protocols reflect the planning and implementation of policies, the monitoring of actions, favoring management activities, articulation of knowledge and practices of professionals, effecting intersectoral actions38	• Financing policies to address violence and resources to ensure sustainability20,41	• Expansion of care networks and guarantee of access to services27
		• Development, strengthening of multisectoral action plans 24
		• Attention to theme, training, didactic material and actions in the community33,36	• Low approximation of local management to the public policies that guide care38
		• Commitment to SUS and health indicators36
		• Listening to professionals, guiding policy guidelines and normative actions38
Services	• Time for survivors to decide whether to report a sexual assault on law enforcement32	• Assessment of access, acceptability and quality of care, collecting information in a safe and confidential way, to receive priority in health policies, budgets and training of health professionals24	• Unawareness of referral services19
	• Confidentiality, orientation and privacy in nursing care36		• Inefficiency of police, justice and security20
			• Hospitals have no facilities to provide and maintain adequate evidence storage32
	• Increase in sentencing cases after implementation of SANE program44	• Expansion of actions to prevent and recognize sexual violence as a social problem27	• Discrepancy in the number of cases registered by legal and health institutions34
			• Inadequate collection of evidence; lack of forensic nurses and inexperience of some SANEs with forensic examination39
	• SANE: positive impact on the progression of cases of sexual assault in the justice system45		• Dissatisfaction of victims with legal and medical services due to social and legal obstacles41
	• Good embracement in health spaces46	• Standardization of storage and collection of toxicological evidence, access to marginalized populations32	• Inadequate physical infrastructure and human resources to approach46
Access to services	• Public policies for access to antiretroviral agents, patient monitoring and testing27	• Great service dissemination19	• Difficulty access to specialized services by distance and restricted to transportation, dependency of companion, lack of asssitance of professionals and disarticulation of the network25,35,47
		• Approximation of services and qualification for warm practice25
		• SARTs training in rural communities, SANE training for nurses* in rural communities39	• Decentralization of health and medical-legal care34
		• SAE and SART services expansion47	• Victims travel long distances to collect evidence for SANEs and health care9

• Caption: SANE - Sexual Assault Nurse Examiner program; SANEs - Sexual Assault Nurse Examiners; SAE - Sexual Assault Examiner; SART - Sexual Assault Response Team.
• ^*
  Female and male nurses.

DISCUSSION

In selected studies, some issues stand out in the care of women in situations of sexual violence. The service network is one of these issues, because when constituted and articulated is a potential service.^14-17 However, most of studies indicate weaknesses, such as network absence and disarticulation, generating the demand for network construction and service articulation (23 studies). This gap, in the articulation of services or even in the absence of the network, implies care fragmentation^15,22,26 and women victimization.²³

Teamwork^{16,23,25,39,43} is a potential in service and a demand with multiple challenges. It requires building good relationships, defining professional roles, promoting the articulation of different disciplinary perspectives and creating interdisciplinary spaces in health education.^15,25,43 Internationally, care is focused on centers such as the Sexual Assault Centers (SACs)⁴³ and teams such as the Sexual Assault Response Team (SART).^16,39,47 They cover interprofessional and interdisciplinary collaboration, qualifying service. In addition to SACs and SARTs, the Sexual Assault Nurse Examiners (SANEs) are a differential in the treatment of sexual violence. ^32,44,45

Nationally, teamwork, as one of the studies indicates, is a facilitating tool in solving situations of violence against women.²³ Another study also expresses the value of teamwork, since health care demands integrated actions among professionals, due to the complexity of situations of violence.³⁸ However, there is still a need to overcome the work process fragmentation and relationship strengthening among professionals.^23,28

In Brazil, care for women in situations of sexual violence is based on formation of Integrated Cared Networks, with orientation to states and municipalities in the organization of intersectoral networks.²⁷ Services cover, in particular, Health, Social Welfare, Public Security and Justice.

Another potential is the collaborative and influential action of the health professional care network articulation.^25,31,32 Nursing, which integrates multidisciplinary teams, is considered a professional category that plays an important role in the articulation.²⁵ Nurses need to use the potential of communication and the social role in the health team.²¹ Role that, in some situations, consists in the organization of work processes and embracement of the unique needs in care for women.²² When it comes to rural areas, the role of the SANE professional is fundamental in situations of sexual violence, so there is a demand for more nurses trained in rural communities, which would make it possible to overcome the weakness of inexperienced and insufficient SANEs in these communities. displacements of victims to other places.³⁹

In the selected studies, it should be highlighted that the training and qualification of professionals contribute to health and nursing care,²⁸ as well as improve patient respect for patients’ rights, improve knowledge, confidence and clinical practice.^29,30 Among the demands related to training and qualification that need to be carried out (indicated in 16 studies), it is worth pointing out the reorientation of professional training, with emphasis on undergraduate training.^26,30 Thus, there will be qualified answers in the care and identification of sexual violence,^24,25,29-35 making possible the comprehensiveness of care for the woman.^19,28

Absence of qualification and training constitute weaknesses in care.^{14,20,26,33,36-38} In some studies, these weaknesses come from incipient qualification and Permanent Education processes. ^{14,20,26,37,38} In another study, there are gaps in nurses’ knowledge about ethical and legal aspects in the care process in situations of violence, in addition to the (un) knowledge related to the compulsory notification of domestic and sexual violence.³⁶ Another study also indicates the underreporting of violence, showing the need for training.³³

Despite the importance of comprehensive care, weaknesses have been identified in some contexts, such as fragmented care based on traditional knowledge (biomedical model),^21,22,26,28 and with inadequate postures of care professionals, focusing on women’s guilt.^29,41,42 Thus, in order to achieve comprehensiveness, it demands, among other actions, the construction of protocols, specialized care directed to the unique needs of women, without judgments^{17,21,22,24,35,40,41} and skills such as listening, embracement, communication to deal with subjectivity.^21-23,33

Adoption of protocols in services qualifies care, providing appropriate assistance to women in situations of sexual violence.³⁸ Protocols favor the standardization of information, allowing violence identification and professional empowerment.^15,17 Ensuring better conditions for the approach and more assertive behaviors, among others, are demands from the construction of protocols.^24,28,38 However, in some contexts, it is evidenced that these protocols do not exist.^20,33,40 When existing, in the case of clinical protocols, its use is restricted to physical damage²⁶ and, in other situations, are not understood or used.³⁸

Regarding services, there are potentialities, such as good embracement in health spaces⁴⁶ and good results, such as the SANE program implementation.⁴⁴ However, inadequate infrastructure, insufficient quantitative human resources, lack of knowledge of other services for referrals, inefficiency and dissatisfaction with some services were identified weaknesses.^{19,20,32,39,41,46}

Concerning weaknesses in the category of access to services, (mis)information and distance, the lack of assistance of professionals and the destructuring of the network make it difficult for women access specialized services, especially in situations of violence in the rural context.^25,34,39,47 In view of this, it is necessary to increase the dissemination of services¹⁹ that serve women in situations of sexual violence, greater proximity and coverage of services, as well as network articulation.

Finally, support of managers emerges as a relevant demand. Greater attention needs to be paid to sexual violence, policy funding, development or strengthening of multisectoral action plans to address violence against women, listening to professional categories.^{20,23,24,33,36,38,41} It is also necessary the greater support of managers to professionals to work at the network and encouragement to qualification through courses and Permanent Education. ^20,27

Some considerations about care for women in situations of sexual violence in urban and rural contexts: in the urban context, disarticulation between services^19,20,21,23 and the need for professional training to provide resolute care and focus on action comprehensiveness, overcoming care fragmentation.^19,23,21 In the rural context, in addition to the aspects already identified in the urban area, the difficulties of access and accessibility of rural women to the service are increased by distance, limited access to transportation, (mis)information, among other factors, in urban areas.²⁵

The study presents search limitation in five data sources, and other databases are available for consultation, implying the non-inclusion of other studies on the subject.

CONCLUSION

The review presents a context notion about care for women in situations of sexual violence. In the selected studies, potentialities, weaknesses and demands were identified. Although there are weaknesses, such as inadequate services, difficulties of access, lack of professional preparation in the approach, lack of protocols that challenge the implementation of comprehensive care. Although potentialities such as improvements in clinical care through protocols, training and specific programs (in some places). Transcending the clinical aspect, deconstructing the discrimination, stigma and guilt of women are still barriers to be overcome.

The incipient and sometimes inexistent articulation of the intersectoral service network raises the demand for construction, articulation and sustainability. Qualification and training of professionals are another need that strengthens the service, as well as the support of managers in the implementation of public policies. Thus, commitment, qualified staff, protocols and articulation of intersectoral services can enable the quality and comprehensiveness of care.

Although an analysis was made that enabled theme contextualization, strength evidence classification of studies verified the lack of level of evidence L1, L2 and L3. It is inferred that there is a gap of systematic review or meta-analysis of controlled randomized controlled trials, randomized controlled clinical trials and non-randomized clinical trials on the topic of care for women in situations of sexual violence by the multidisciplinary health team.

Contribution of this review to health, nursing and the multidisciplinary team is the reflection on elements that are fundamental in the accomplishment of the effectiveness of the service and to be considered to improve public policies to women in situation of sexual violence.

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Publication Dates

• Publication in this collection
  14 Oct 2019
• Date of issue
  2019

History

• Received
  11 May 2018
• Accepted
  13 June 2019