Sexual violence against women: an analysis of notifications in Espírito Santo, Brazil

Abstract

Objective

To estimate the frequency and factors associated with sexual violence against women in Espírito Santo.

Methods

Cross-sectional study based on data reported between 2011 and 2018 in the Notifiable Diseases Information System. Multivariate analysis was conducted using Poisson regression, with robust variance.

Results

The frequency of sexual violence was 15.6%, being the prevalence higher among children; people without disabilities and/or disorders; urban areas residents; with a sole, male, unknown aggressor and without suspicion of alcohol use. The residence was the place with the highest occurrence and the character of repetition was present.

Conclusion and implications for practice

Sexual violence against women was highly prevalent in the state. The results reinforce the association of this condition with the characteristics of the victim, the aggressor and the event, evidencing the vulnerability of children and the domestic space as a scenario of high frequency of this harm.

Keywords:
Sex Offenses; Notificatio; Women’s Health; Violence; Violence Against Women

Resumo

Objetivo

Estimar a frequência e os fatores associados à violência sexual contra mulheres no Espírito Santo.

Métodos

Estudo transversal realizado a partir de dados notificados entre 2011 e 2018 no Sistema de Informação de Agravos de Notificação. A análise multivariada foi conduzida por meio da regressão de Poisson, com variância robusta.

Resultados

A frequência de violência sexual foi de 15,6%, sendo maior a ocorrência em crianças; pessoas sem deficiências e/ou transtornos; residentes em área urbana; com agressor único, desconhecido, do sexo masculino e sem suspeita de uso de álcool. A residência foi o local de maior ocorrência e o caráter de repetição esteve presente.

Conclusão e implicações para a prática

A violência sexual contra mulheres apresentou alta frequência no estado. Os resultados reforçam a associação desse agravo com características da vítima, do agressor e do evento, evidenciando a vulnerabilidade das crianças e o espaço doméstico como um cenário de grande frequência desse agravo.

Palavras-chave:
Delitos Sexuais; Notificação; Saúde da Mulher; Violência; Violência contra a mulher

Resumen

Objetivo

Estimar la frecuencia y los factores asociados con la violencia sexual contra la mujer en Espírito Santo.

Métodos

Estudio transversal realizado a partir de datos notificados entre 2011 y 2018 en el Sistema de Información de Enfermedades de Declaración Obligatoria. El análisis multivariado se realizó mediante regresión de Poisson, con varianza robusta.

Resultados

La frecuencia de violencia sexual fue del 15,6%. La prevalencia fue mayor en niñas; personas sin discapacidades y/o trastornos; residentes en áreas urbanas; con un único agresor, desconocido, del género masculino y sin sospecha de consumo de alcohol. La residencia fue el lugar de mayor ocurrencia y el carácter de repetición estuvo presente.

Conclusión e implicaciones para la práctica

La violencia sexual contra las mujeres fue altamente prevalente en el estado. Los resultados refuerzan la asociación de esa condición con las características de la víctima, del agresor y del evento, evidenciando la vulnerabilidad de las niñas y el espacio doméstico como escenario de alta frecuencia de esa condición.

Palabras clave:
Delitos Sexuales; Notificación; Salud de la Mujer; Violencia; Violencia contra la mujer

INTRODUCTION

Sexual violence corresponds to acts performed without the consent of the other party, causing embarrassment, maintenance or participation in sexual relations through coercion of the victim. In addition, it also includes the commercialization of sexuality, the prevention of the use of contraceptive methods, matrimony, pregnancy or forced abortion, prostitution and the annulment of women's sexual and reproductive rights.¹

Sexual offenses can affect women in their different life cycles, including children and adolescents. Through the analysis of notifications of sexual violence against children and adolescents at school, between 2010 and 2014, a study concluded that 63.8% of the victims were girls, aged between 0 and 9 years (69.5%).² Focusing on youth population, another study reports that sexual violence was in second place (24.7%) when compared to other types of violence against adolescents in Brazil, from 2011 to 2017.³

According to research carried out with data on sexual abuse against women by the Specialized Police for the Protection of Women in the state of Pará, 72.7% of the victims were between 18 and 30 years old, indicating that adult women are equally likely to suffer this harm.⁴ In addition, a study carried out in the city of Vitória, Espírito Santo, from March to September 2014, showed that 18% of primary care users aged between 20 and 59 years were victims of sexual violence by their intimate partner.⁵

In the elderly population, sexual violence can happen at the victim's residence, carried out by close family members or even services that attend to this public. In Europe, the numbers for the prevalence of sexual violence in the last year in older adults ranged from 0 to 3.1%.⁶ Due to the low occurrence found, assessing sexual victimization in older adults can be challenging. In this way, the study also brings reflection on the view of the sexuality of the elderly, which can be permeated by taboos and different conceptions of younger generations, making notifications difficult.⁶

Experiencing the phenomenon of sexual violence has negative repercussions on the physical, sexual and reproductive health of the victim. Through the analysis of the notifications registered in the System of Diseases and Notifications of Santa Catarina, studies show that 7.6% of the cases resulted in pregnancy, and 3.5%, Sexually Transmitted Infections.⁷ The data become even more expressive when one considers that unwanted pregnancies affected three times more adolescents between 10 and 14 years of age. In addition, psychological complications, such as depressive thoughts and suicide attempts, are also evidenced in victims of sexual violence.⁸

In this sense, health services become essential in the management of victims of sexual violence. It is necessary that the professionals involved in the care welcome and inform the victim about the procedures to be performed, as well as about the right to immediate clinical, laboratory, psychological and social follow-up.⁹ Data show that only 52% of sexually abused victims received antiretroviral prophylaxis and 50%, emergency contraception, demonstrating that the health service is still flawed in this process.⁸ Therefore, it is seen the need for all conducts to be carried out in a timely manner, in order to mitigate the consequences of the injury.⁹

Another point to highlight is the notification of cases of violence throughout the health care service, which is an important tool that gives greater visibility to the panorama of sexual violence, in addition to making possible communication and integration between health services and other sectors of society, such as social assistance and education.¹⁰ Notification contributes as a strategy for establishing adequate public policies to combat sexual violence and, in this sense, it is classified by the WHO as a mechanism to combat sexual violence.¹¹

Given the above, this study aimed to estimate the frequency and factors associated with sexual violence against women in Espírito Santo.

METHOD

Cross-sectional study where all cases of violence against females reported in Espírito Santo from 2011 to 2018 were analyzed. The analyses started in 2011, as it was in this year that compulsory notification of cases of violence was instituted. Espírito Santo is a state in the Brazilian Southeast region with a territorial extension of 46,074.444 km² and a population of 3,514,952 inhabitants, according to the last Demographic Census, of which 50.75% (1,783,735) are women. It has a population density of 76.25 inhabitants/km² and a Human Development Index (HDI) of 0.740.¹²

The database for carrying out this research was provided by the State Health Secretariat of Espírito Santo and contains data on all notifications of cases of violence registered by health services in the Notifiable Diseases Information System (SINAN), through the Notification/Investigation of Interpersonal and Self-Inflicted Violence Form.¹³ This form is divided into ten blocks, where the profile of the victim and the author of the aggression, the characteristics of the violence and the actions and referrals carried out by the service that provided the care are reported.

Before analysis, the database was submitted to a qualification process to correct possible errors and inconsistencies, as per the guidelines of the Ministry of Health.¹³ Cases that had blank or ignored data were excluded from the analyses.

The outcome under analysis was the occurrence of sexual violence (no; yes). As independent variables, the victim’s age group (0 to 9 years; 10 to 19 years; 20 to 59 years; 60 years or more); race/color (white; black/brown); presence of deficiencies/disorders (no; yes); area of residence (urban/peri-urban; rural); aggressor’s age group (0 to 19 years old; 20 to 59 years old; 60 years old or more); aggressor’s gender (male; female; both sexes); link between the aggressor and the victim (relative; known; unknown); suspected use of alcohol by the aggressor (no; yes); number of people involved (one; two or more); place of occurrence (home; public spaces; others); if the violence is repetitive (no; yes); and whether referrals were made to other services in the care network (no; yes).

Relative and absolute frequencies of the variables were calculated, using all notifications of violence against women as a basis. In the bivariate analysis, Pearson's chi-square test was used, in which the variables that reached a p-value less than 0.20 entered the multivariate model, except for the variable “referral”, since this is an event after the violence. Multivariate analysis was performed using Poisson Regression, with robust variance, and the results were expressed using Prevalence Ratios (PR). A hierarchical model was used, where the variables that represented the victim's characteristics were inserted on the first level and, on a second level, those related to the aggressor and the aggression. The permanence of the variable in the model occurred when it reached a p-value less than 0.05. All analyses were performed using Stata 14.1 software.

This study was approved by the Ethics Committee for Research with Human Beings of the Federal University of Espírito Santo, under opinion number 2,819,597.

RESULTS

Reporting of sexual violence against women in Espírito Santo, from 2011 to 2018, represented a frequency of 15.6% (N; 4033; 95%CI: 15.2-16.1). With regard to the characterization of victims of sexual violence, it is observed that, of the total number of cases, the most victimized age group was 10 to 19 years old (43.9%), 71.2% of the black/brown race/color, 90.6% without disability or disorder, and approximately 92% urban area residents. As for the aggressor, most (76.5%) belong to the adult age group and are male (96.5%). It is noted that 37.5% of the aggressors have a family relationship with the victim, 62.4% have no suspicion of alcohol use during the aggression, and in 87.2% of the cases the aggression was committed by one person. The residence was the space with the highest occurrence of sexual violence (71%), with approximately 47% occurring recurrently. Referral occurred in 92.7% of cases (Table 1).

Table 1
Characteristics of notified cases of sexual violence against women. Espírito Santo, Brazil, 2011-2018 (n = 4,033).

Variables	N	%
Age group
0 to 9 years	948	23.5
10 to 19 years	1769	43.9
20 to 59 years	1282	31. 8
60 years or more	34	0.8
Race/Color
White	1036	28.8
Black/Brown	2558	71.2
Disabilities/Disorders
No	3357	90.6
Yes	350	9.4
Area of residence
Urban/Peri-urban	3641	91.9
Rural	320	8.1
Aggressor’s age group
0 to 19 years	418	19.6
20 to59 years	1628	76.5
60 years or more	83	3.9
Aggressor’s gender
Male	3695	96.5
Female	74	1.9
Both	59	1.5
Link with the victim
Familiar	1408	37.5
Known	1377	36.7
Unknown	972	25.9
Suspicion of alcohol use
No	1370	62.4
Yes	827	37.6
Number of people involved
One	3242	87.2
Two or more	477	12.8
Place of occurrence
Residence	2511	71.0
Public place	590	16.7
Others	433	12.3
Repeat violence
No	1736	53.2
Yes	1528	46.8
Referral
No	291	7.3
Yes	3702	92.7

• Source: the authors

In the bivariate analysis shown in Table 2, it is noted that sexual violence was related to the following characteristics of the victim: age group; race/color; and disability/disorder. With regard to the characteristics of the aggressor, there is a relationship with the age group, sex and link to the victim. As for the event, sexual violence was related to the place of occurrence, repetition and referral (p<0.05).

Table 2
Bivariate analysis of the distribution of characteristics according to the occurrence of reports of sexual violence against females (n=4,033). Espírito Santo, Brazil, 2011-2018.

Variables	N	%	CI 95%	p-value
Age group
0 to 9 years	948	54.1	51.8-56.5	<0.001
10 to 19 years	1769	29.3	28.1-30.4
20 to 59 years	1282	7.6	7.2-8.0
60 years or more	34	2.9	2.1-4.0
Race/Color
White	1036	14.8	14.0-15.6	0.001
Black/Brown	2558	16.6	16.0-17.2
Disabilities/Disorders
No	3357	18.0	17.4-18.5	<0.001
Yes	350	11.1	10.1-12.2
Area of residence
Urban/Peri-urban	3641	15.8	15.3-16.3	0.051
Rural	320	14.2	12.8-15.7
Aggressor’s age group
0 to 19 years	418	13.3	12.2-14.6	0.001
20 to59 years	1628	12.0	11.5-12.6
60 years or more	83	17.2	14.0-2.8
Aggressor’s gender
Male	3695	25.6	24.9-26.3	<0.001
Female	74	0.8	0.7-1.1
Both	59	7.6	5.9-9.6
Link with the victim
Familiar	1408	12.1	11.5-12.7	<0.001
Known	1377	35.0	33.5-36.5
Unknown	972	45.7	43.6-47.8
Suspicion of alcohol use
No	1370	13.4	12.7-14.1	0.167
Yes	827	12.6	11.9-13.5
Number of people involved
One	3242	15.3	14.8-15.7	0.131
Two or more	477	16.3	15,0-17.7
Place of occurrence
Residence	2511	14.5	13.9-15.0	<0.001
Public place	590	17.7	16.4-19.0
Others	433	20.1	18.5-21.9
Repeat violence
No	1736	20.4	19.5-21.2	<0.001
Yes	1528	13.2	12.6-13.8
Referral
No	291	7.3	6.5-8.2	<0.001
Yes	3702	17.4	16.9-18.0

• 95% CI: 95% confidence interval.
• Source: the authors

In the adjusted analysis, after controlling for confounding factors, it can be seen that the female group aged 0 to 9 years was about 16 times more frequently victims of sexual violence when compared to the group aged 60 years or older. Female victims without disabilities had 22% more occurrences when compared to the group with disabilities. Sexual violence against women was 1.12 times more frequent in urban areas, with the aggressor being male (PR: 15.76), unknown (PR: 6.31), without suspicion of alcohol use (PR: 1. 13) and sole (PR: 1.15). Reports of sexual violence were 58% more frequent in the household, with this type of abuse being 1.11 times more recurrent when compared to other types of violence against females (Table 3).

Table 3
Multivariate analysis with adjusted and crude prevalence ratio of variables associated with cases of sexual violence against females (n=4,033). Espírito Santo, Brazil, 2011-2018.

Variables	Raw analysis			Adjusted analysis
	PR	CI 95%	p-value	PR	CI 95%	p-value
Age group
0 to 9 years	18.77	13.44-26.22	<0.001	16.29	11.48-23.12	<0.001
10 to 19 years	10.14	7.27-14.16		9.70	6.84-13.75
20 to 59 years	2.64	1.89-3.69		2.52	1.77-3.58
60 years or more	1.0			1.0
Race/Color
White	1.0		0.001	1.0		0.455
Black/Brown	1.12	1.05-1.20		1.03	0.96-1.09
Disabilities/Disorders
No	1.63	1.47-1.80	<0.001	1.22	1.10-1.35	<0.001
Yes	1.0			1.0
Area of residence
Urban/Peri-urban	1.11	0.99-1.23	0.053	1.12	1.01-1.24	0.035
Rural	1.0			1.0
Aggressor’s age group
0 to 19 years	1.11	1.01-1.23	0.001	0.97	0.87-1.09	0.622
20 to59 years	1.0			1.0
60 years or more	1.43	1.17-1.75		1.08	0.87-1.35
Aggressor’s gender
Male	30.67	24.40-38.55	<0.001	15.76	10.84-22.91	<0.001
Female	1.0			1.0
Both	9.05	6.48-12.64		4.62	2.71-7.88
Link with the victim
Familiar	1.0		<0.001	1.0		<0.001
Known	2.90	2.71-3.09		3.19	2.90-3.52
Unknown	3.79	3.54-4.05		6.31	5.62-7.08
Suspicion of alcohol use
No	1.06	0.98-1.15	0.168	1.13	1.04-1.22	0.003
Yes	1.0			1.0
Number of people involved
One	0.93	0.86-1.02	0.129	1.15	1.02-1.30	0.025
Two or more	1.0			1.0
Place of occurrence
Residence	0.82	0.75-0.89	<0.001	1.58	1.42-1.76	<0.001
Public place	1.0			1.0
Others	1.14	1.02-1.27		1.16	1.01-1.32
Repeat violence
No	1.0		<0.001	1.0		0.009
Yes	0.65	0.61-0.69		1.11	1.03-1.19

• 95% CI: 95% confidence interval; PR: Prevalence Ratio
• Source: the authors

DISCUSSION

The prevalence of 15.6% of cases reported on SINAN involving females, shows that the data from the present study is higher than that found in other states of the country, such as Rio Grande do Sul, whose incidence is 10.48% .¹⁴ However, it is noted that the magnitude of this harm follows the violence numbers in Espírito Santo, which are generally above the Brazilian average, even being among the states that most presented this type of occurrence in the country's police stations.¹⁵

The results also revealed that females aged 0 to 9 years old suffered about 16.29 times more sexual violence when compared to the group aged 60 years or more, data similar to that found in the state of Pernambuco, where the higher frequency of this harm was associated with female victims under 18 years of age.¹⁶ This difference between the extremes of age can be understood by the greater exposure of younger people, facilitated by access to technology and by the greater awareness of this group about abusive behavior, including undeniably violent situations previously accepted and naturalized by society.¹⁷

In this study, people without disabilities had a higher prevalence of sexual violence (PR: 1.22) when compared to people with disabilities. On the other hand, other surveys, such as the one carried out in New Zealand, point out that sexual violence is more frequent in people who have some type of disability.¹⁸ A variable that is still little explored, the relationship between sexual violence and the presence of disabilities or disorders should be analyzed considering the scarcity of adequate spaces to accommodate the demands of this population, as well as the difficulties of recognizing an aggression, including the denial of abuse because the victim is considered incapable of denouncing their tormentor, the fear, shame, dependence on care of the victim and the normalization of violence.

Regarding the victims’ place of residence, sexual violence occurred 1.12 times more frequently among residents of urban areas, an association also revealed by a study carried out in the state of Pernambuco.¹⁶ In general, the highest number of notifications occurs in areas with better economic and social indicators, since these regions have more units for notification and assistance services, showing a group of privileged access to public facilities in the statistics of sexual violence.¹⁹

There is a higher occurrence of male aggressors (PR: 15.76), which corroborates the literature that cites men as the main aggressors in cases of sexual violence, both against adolescent and adult women, in Santa Catarina, in the year 2012.⁷ This data is practically hegemonic in the literature and in all life cycles. Throughout Brazil, between the years 2010 and 2014, the analysis of cases of sexual violence against children and adolescents at school showed that most of the occurrences, especially those involving adolescents, were committed by men.² Gender inequality and the discourse that normalizes violent acts against female individuals are the main causes of violence against women perpetrated by men.²⁰

Furthermore, the study notes that there are approximately six times more unknown perpetrators (PR: 6.31) among the reported cases of sexual violence, a fact also pointed out by another study when analyzing the characteristics of victims of sexual violence assisted in a Reference Center in Southern Brazil.²¹ This result of aggressors outside the family nucleus may be associated with the existing affective bond between the familiar perpetrator of the aggression and the victim, which makes it difficult for such data to reach the health services, thus expanding the notified data of unknown aggressors. This phenomenon can be observed, mainly, in cases of violence against children and adolescents, where the victimized person is dependent on the possible perpetrator of the aggression.²² Another aspect is conjugal violence, in which feelings of guilt, fear and shame are some of the causes for not going to the authorities, generating the so-called “cycle of violence”.²³

With regard to alcohol use, 13% more occurrences of sexual violence were observed in non-alcoholic aggressors (PR: 1.13), data that is similar to a study carried out in Santa Catarina.⁸ However, it is worth considering a study carried out with victims of intimate partner violence that highlights the belief in alcohol as a factor that influences the partner’s behavior.²⁴ This view demonstrates the naturalization of violence against women, where there is always a search for justifications that remove the man's guilt in relation to what happened.

Sexual violence occurred 58% more often in the victim’s home (95% CI: 1.58), which is in line with the literature. A study carried out through the analysis of notifications of sexual violence in a reference hospital in the city of Maringá, between the years 2014 to 2016, demonstrated that most cases were reported at home and that the variable was statistically associated with the outcome.²⁵ It should be noted that children and adolescents are more susceptible to suffering the injury in their own homes, mainly because they are abused, most of the time, by parents and stepfathers.²⁶

Regarding the number of aggressors, the results indicate that more often the aggressor acts alone (PR: 1.15). This data reveals similarity with a survey carried out at the reference center for women's health in Maceió (AL), in the years 2007 to 2016, whose cases in which the aggressor is the only one exceed the percentage of 85%.²⁷

As for frequency, sexual violence was more frequently associated with a history of repetition, which is not surprising, since frequent silencing and denial of abuse are factors that collaborate with the perpetuation of the aggression. Thus, the lack of space for reporting due to fear of moral judgments and the lack of acceptance of women imply a cycle of sexual violence that has the ability to transcend generations.²⁸

Article 1 of Law 13,931, enacted on January 10, 2019, includes suspected and confirmed cases of violence against women treated at public and private health services in the list of compulsory notification. In addition, item 4 points out that there must be communication to the police authorities within 24 hours, so that the appropriate referrals can be carried out.²⁹ This contributes to the dimensioning of the seriousness of the problem, which provides subsidies for the construction of public policies, the comprehensiveness of care and the protection of women’s rights.³⁰ Therefore, health services are the main scenario for welcoming the victim and disclosing the harm.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Sexual violence was responsible for 15.6% of the reports of interpersonal violence registered against females in the state of Espírito Santo. This harm was more frequent among victims aged 0 to 9 years compared to the group aged 60 years or older, in addition to being associated with the absence of disabilities or disorders and residence in urban or peri-urban areas. The aggression was committed mainly by a sole, unknown male aggressor with no suspicion of alcohol use. The residence was the main place of occurrence and the event presented a repetition character.

The findings can help establish the current situation of sexual violence against women in Espírito Santo. However, it has some limitations, starting with the use of notification data that does not consider all cases of violence, only those reported by women using the service or identified by the health professional. Another limitation is related to the cross-sectional nature, in which all data are collected simultaneously and, therefore, makes it difficult to establish satisfactory relationships between causality and outcome. However, even in the face of the limitations expressed, the results presented can contribute to the elaboration of policies aimed at the area, as well as strategies to elucidate the population.

The results are relevant for services that provide assistance to people in situations of sexual violence, since they generate greater knowledge, contributing to propositions that expand and qualify the offers of women's health care services.

It is also conjectured about the need for investments in training and qualification of health professionals to increase the perceptions of occurrences of violence and increase notifications of cases attended in health services, in addition to investments in educational policies in the area of sexual education to expand access to information and reducing the number of sexual aggressors and people in situations of violence, thus improving the rates of sexual violence against girls and women.

Referências

• ¹
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Edited by

ASSOCIATE EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  08 Sept 2023
• Date of issue
  2023

History

• Received
  21 Sept 2022
• Accepted
  09 Mar 2023