Bioethics and care of women victims of sexual violence : a review of literature

This article aims to perform a review of literature regarding care of women victims of sexual violence through a search in indexed journals in the Virtual Health Library and Scopus databases, including publications since 2003. Data collection was conducted in May 2013 using the keywords “violência sexual” [“sexual violence”], “assistência” [“assistance”], “serviços de saúde da mulher” [“women’s health services”], “aborto” [“abortion”] and “gravidez” [“pregnancy”]. Fifteen publications were retrieved, and the results were grouped into two thematic categories: bioethical issues related to women’s access to care services, and bioethical aspects present in treatment. The discussion was based in risk and protection bioethics, showing that the government must ensure universal access for the victims of sexual violence, and that health care professionals should be bioethically prepared for such care.

Sexual violence is global, widespread problem, with significant consequences for the physical and psychological health integrity of its victims.However, in many places around the world, the services available do not meet the needs of people who go through such situations 1 .Sexual violence against women can be understood as any sexual act or attempt without consent, by using coercion or intimidation, including physical coercion, serious threat, use of weapons, and psychological pressure 2 .Such violence is not something new for human history, and it has been part of a socio-historical context of gender interrelations that influence women to position themselves as inferior beings in the scale of metaphysical perfection, which creates an array of asymmetric relations between men and women in our society, where women are still victims of prejudice and discrimination 3 .
Violence against women has been reaching alarming proportions worldwide.The Relatório sobre o Desenvolvimento Mundial (World Development Report) 4 has shown that women aged between 15 and 44 lose more years of healthy life due to rape and domestic violence than to diseases, such as breast and cervical cancer, heart disease, AIDS, respiratory diseases, childbirth related problems, car accidents, or wars.According to data provided by the Sistema de Informação de Agravos de Notificação (Sinan) 5 do Ministério da Saúde (Ministry of Health's Notifiable Disease Surveillance System, 720,076 cases of sexual violence throughout Brazil were reported between 2009 and 2014, of which 481,105 victims were women.
It is clear that this type of violence against women is a serious public health concern that requires specific, differentiated professional and Governmental Attention 6 .Even though it is difficult to estimate the impact caused by all types of violence on health systems and their effects on economic productivity around the world, evidence shows that victims of domestic and sexual violence usually present long-term health issues; which generate significantly higher treatment costs.These victims will need frequent emergency care throughout their lives as compared to those who never endured such abuses 7 .
Faced with this problem, the Ministério da Saúde (Ministry of Health) launched, in 1998, a milestone in care regulations entitled "Prevention and treatment of injuries resulting from sexual violence against women and adolescents", which consisted of a technical standard that aimed to promote appropriate care to victims of sexual violence, reissued in 2005 8 .Violence against women then became an interlocutory mandatory reporting, substantiated by Law 10.778/2003 9 , and regulated by Ordinance 2.406/2004 10 .Later on, the National Agreement on How to Prevent Violence Against Women 11 was launched to prevent and address all forms of violence against women; and the Política Nacional de Enfrentamento à Violência contra as Mulheres (National Policy of Violence against Women) 12 was published to ensure assistance and rights to women exposed to violence.
Yet, most health professionals assigned to provide victims of sexual violence with proper care often prove not to have the training required 1 .Such scenario requires, among other things, qualified and humanized care able to minimize suffering, a stronger health care network, and skilled professionals 12 ; mostly because the consequences of sexual violence involve physical, psychological, and social aspects that must be prioritized in terms of the formulation and implementation of public health policies, considering the bioethical dilemmas involved in the event 13 , especially from a risk and protection bioethics perspective.
Originated in Latin America, this bioethics wave focus on the vulnerability inherent to specific layers of the population, still aware of the inequalities that hurt the social structure of poorly developed countries.Thus, it is designed to cater to the specific needs of those susceptible to violence, or to protect those in need 14 .With the multidimensionality of the problem in mind, we've decided to conduct an integrative literature review.Our guiding tool was to question which bioethical issues are, in fact, present in studies that include health care to women victims of sexual violence.As a result, we've established as the main objective of this study to question, according to risk and protection bioethics, the conclusive results provided by studies on health care for women victims of sexual violence.This kind of study will bring several contributions to the current knowledge available on the subject, especially to risk and protection bioethics, which will encourage discussions throughout the academic and the health care environment, leading to a broader access of women victims of sexual violence to specialized services, as well as the improvement of such services.This exchange of knowledge and information will expand the perception of concerned professionals, enabling them to plan and implement powerful actions specifically aimed towards the needs of the victims.

Method
The content of the present study is an integrative review of the data collected between April and May of 2013.The research on periodic publications was made possible through The Biblioteca Virtual de Saúde (Virtual Health Library) -BVS and Scopus.Descritores em Ciências da Saúde (Health Sciences Descriptors -DeCS) were combined, and included: "sexual violence" AND "assistance", "sexual violence" AND "women's health services", "sexual violence" AND "abortion", "sexual violence" AND "pregnancy".
The criteria for inclusion covered scientific articles freely available online, published between January, 2003 to May, 2013, including health care to women victims of sexual violence in Brazil.Works, as well as forums, theses, dissertations, and monographs on the subject that have not met the established criteria were excluded from this research.The search interval aimed to identify issues related to bioethics in long periods of health care, including the possibility of gathering a greater number of studies focused on hospital care and/or assistance to women exposed to sexual violence, including changes or current characteristics of health care.
The comprehensive analysis of the articles researched revealed two themes that represent the access women victims of sexual violence have to specific services, and the care provided by those services; which led to further bioethical discussion on risk and protection.

Results and discussion
The initial research revealed 285 articles, 49 resulting from BVS access, and 236 from Scopus.After analysis based on established criteria, 15 articles were included in the corpus-based research.The selected studies were summarized in Table 1, where authors, participant profile, research objectives, and Brazilian regions where the research was conducted were introduced; followed by discussions on the two themes derived from the comprehensive analysis of the material.Thirteen of the fifteen studies included were conducted in hospital referral services intended to care for victims of sexual violence.Most of them suggested the existence of multidisciplinary teams composed of doctors, psychologists, social workers, and nurses.Regarding ethical aspects, in compliance with Resolution 466/2012 30 of the Conselho Nacional de Saúde (National Health Council), which involves human related research, we have concluded that the Comitê de Ética em Pesquisa (Research Ethics Committee) approved all studies.In seven of them, data was collected through semi-structured interviews; however, one "no" mentioned the implementation of free and informed consent.

Bioethical issues and access to care services
Issues related to the access of women victims of sexual violence to specialized services were presented in seven of the studies analyzed [16][17][18][19]21,25,29 . Access isues take even greater proportions when less privileged groups with fewer resources are indeed more exposed to violence 29 , and services are still unable to reach the most disadvantaged layer of the population 16 , which proves that only a small portion of society has access to health care 29 .
When a human being suffers from a disability -weakness, illness, physical disabilities -he or she is no longer vulnerable and becomes "permanently injured", requiring therapeutic protective actions 14,31 .The consequences of sexual violence involve physical, psychological, and social aspects 13 , causing a tremendous impact on the sexual and reproductive health, not to mention devastating, often irreversible, mental health issues, which also affect the victim's social reintegration 21 .Thus, from a risk and protection bioethics perspective, women who have suffered from sexual violence are considered permanently injured, and not just vulnerable or susceptible, which proves that access to specialized, proper care services is essential.
The lack of knowledge of women regarding the existence of specialized services able to provide care to victims of sexual violence, as well as the right they have to access them 17,19 , in addition to the deficiencies these services present within the health care service network, and how misinformed health care professionals are about such services 17 , were issues also highlighted in this review.Sexual violence is one of the least reported and recorded incidents throughout the world 22,26 .The authors surveyed admit the need to expand and decentralize care, still concentrated in large urban areas 17 , with more investment in the health care network, and improvement of professional specialization 25 , the coordination of specialized services and the reciprocity between municipalities 16 .It was concluded that the disclosure of information is imperative to women 25 , to the various segments of society 17,29 , and to health care professionals 29 .
In terms of protection bioethics, it is the State's mission to protect all members of society 14 .Based on this assumption, the State is responsible for establishing preventive and confronting actions against sexual violence, by expanding, qualifying, and integrating the health care network specifically for this purpose, also ensuring comprehensive, humanized care and skilled service, observing the precepts of bioethics, and considering the segments exposed to vulnerable situations.
From a feminist bioethics perspective, restraining this type of gender violence and the care for its victims still require the elaboration of reflections and multi-sectoral, interdisciplinary actions capable of influencing [directly] gender structure, [working on] cultural norms and values that have been established unequally by social reality (...) between men and women 32 , which demonstrates the complexity of the problem and the urgent need for the creation and strengthening of discussion spaces within the multi-sectoral context, in order to better expose the issue and generate appropriate responses to explicit demands.
The study also revealed that women are seeking specialized services less often.Preliminary assistance is provided by: health care services 16,17,21,29 , and police 16,21,29 .In the first case, understanding and recognizing the violence inflicted becomes a dilemma, as accepting the credibility of the complaint and avoiding medicalizing the events observed are often recurring practices 17 .
In the case of law enforcement response, the studies reveal that the police do not always provide the right assistance 17 , which leads many women not register their complaint 29 .Injury inflicted upon individuals, groups, or social segments, such as the female portion of the population, is particularly relevant to the protection of ethics 14 .Protection can be understood as an effective practice to assist the needy, and it is related to the main role of ethics in this context, which precisely cares for those who need the most protection: the permanently injured 31 .Thus, assistance related issues imposed by law enforcement and the health care service deserve a much closer look, so that the protection principle is observed and victims are treated respectfully.

Bioethical aspects and the assistance provided to victims exposed to sexual violence
Issues related to insufficient vocational training and/or professional health education on "sexual violence" have been highlighted in four of the studies analyzed 17,23,24,27 .Several authors admit that a coherent set of knowledge is necessary to enable health care professionals to assist women victims of sexual violence 19,23 ; and adding this subject to undergraduate health programs is imperative 17,19 .
Recognizing that sexual violence is a major health concern and a serious violation against women's rights has required immediate response from services and vocational training institutions over the recent years 33 .As a result, it is vital that future professionals are able to provide solutions to upcoming challenges faced by the health care services intended to care for this segment of the population.In order to accomplish these objectives, it is urgent to incorporate ethics into the daily routine of health care professionals, both as a support factor and molder of individual character, and as an element indispensable to the health care and integrity of fellow human beings 34 .
The training of professionals and future professionals in sexual violence aims to face subjective questions nestled in the situation, and the need for professional preparation in the case of absence of authoritative subjects.In addition, professionals must obtain proper training on how to develop the ability to withstand suffering, distress, and discomfort, as they are constantly exposed to individuals who have experienced sexual violence, something that definitely changes the daily routine of the professionals, especially women 35 .
Amongst the problems related to the care of women victims of sexual violence, the studies highlighted four that are shown to be the most frequent: 1) double gynecological examination -conducted at the hospital and at the Institute of Forensic Medicine -which reinforces the violence inflicted 17 ; 2) several medications that the victim is required to take 16 ; 3) difficulty to conduct abortion due to the lack of adequate assistance, which can also lead the victim to opt for a clandestine procedure, exposing her to physical and psychological risks 17 ; 4) those who provide direct assistance often lack adequate and specific professional training, which consists of a different kind aggression 27 .
When it comes to ethics, we often idealize society as just and fair, an environment where human dignity must be respected.In various areas of health care, compliance with ethical principles associated with daily professional practices means that moral and cultural values must be observed.Therefore, the care of women who have suffered from any kind of sexual violence must be conducted in order to preserve the dignity of the human being, which requires vigilant application of ethical principles 34 .
The studies 19,28 included in this revision present reflections on inadequate professional postures, influenced by personal beliefs and values.They also suggest that professional training programs must include, in addition to technical subjects, courses related to the subjectivity inherent in the context 28 , emphasizing the relevance of technical and emotional preparation of the professional 19 .
Therefore, it is necessary to engage professionals into a self-criticism process and encourage them to understand that their conceptions and professional conducts are associated with an ideology able to affect the lives of the individuals they care for; and the unpreparedness of teams can cause dissatisfaction, promoting socio-cultural prejudice against women patients who have suffered sexual violence 32 .
Regarding the care of pregnancy resulting from sexual violence and its interruption, studies report that health care professionals often encounter difficulties when dealing with legal abortion 29 .Assistance is provided based on the idea that abortion is a crime, without any reference to reproductive rights or to social issues that derive from clandestinely issues 15 .Some professionals retain a biased attitude towards the problem and openly express their discrimination against colleagues who conduct termination of pregnancy in compliance with the law 17 .
It is necessary to mention that the Código Penal Brasileiro (Brazilian Penal Code) classifies abortion as a crime against life, punishable by law, classifying cases of pregnancy resulting from rape, among other specific situations, as exceptions 36 .Even before this prerogative, the interpretation of studies leads to the conclusion that bioethical, ethical, and moral dilemmas nestled in the situation tend to greatly influence health care professionals.

Research articles
A study that included health care professionals dealing with legal abortion services in Brazil revealed that these professionals often demonstrate a distrustful attitude towards the narratives of women seeking legal abortion, subjecting them to further investigation and forensic services intended to prove the veracity of the complaint; which completely goes against the very same public policies that determine the narrative of the victim as sufficient enough for them to obtain rightful access to legal abortion through health services in Brazil 37 .
The selected studies conclude that, in order to reverse this situation, there is a need for continuous education actions, psychological support, respect towards internal conflicts and the beliefs/ moral values of the professionals involved in health care, giving them the right to choose to participate in this process or not, which aims to provide quality, safe, respectful services 20 .Discussing the assistance to victims of sexual violence extensively poses a challenge to the health sector; and dealing with it, while ensuring the women's right to health and autonomy over their bodies, is a task that certainly requires continuous professional effort, which not only requires partnerships with different sectors of society 38 , but also joint and effective action.

Final considerations
The integrative literature review has demonstrated that various aspects inherent to the care of women victims of sexual violence by hospital services deserve further discussion, especially if bioethical arguments and, in this context, risk and protection bioethics are considered.The analyzed studies revealed that access to specialized care services is still difficult and potentially problematic, due to the lack of cohesive, homogeneous care.It was also observed that the care for women exposed to sexual violence, and especially the service provided to those who opt for the termination of pregnancy resulting from violence, are considered controversial situations that health care professionals find difficult to deal with.
The analysis of the studies in the light of risk and protection bioethics have shown that the challenges faced by the context studied must be dealt with effective public policies that guarantee access to specialized services, and ensure training of health care professionals that includes deeper bioethical reflection in order to enable them to provide service that is decent, friendly, free of prejudice and discrimination.In addition to these aspects directly related to the care of victims of sexual violence, it is important to emphasize that the Brazilian government must promote civic education on human, sexual, and reproductive rights, aiming to definitely suppress violence against women in domestic and public environments, ensuring civil rights to a segment that constitutes the majority of the country's population.
Considering the importance of the topic herein discussed, its various particularities, and the myriad of aspects that can and must be better understood, we suggest that further studies are conducted in the light of bioethics, focusing on the care provided by health professionals to women victims of sexual violence, including legal interruption of pregnancy.Such studies are extremely necessary, considering that violence against women is a persistent phenomenon inherent to Brazilian society, sadly illustrated by recent cases of gang rape reported by national and international media [39][40][41] .

A R T I G O R E T R
A T A D O

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Bioethics and care of women victims of sexual violence: a review of literature http://dx.doi.org/10.1590/1983-80422016242127

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Bioethics and care of women victims of sexual violence: a review of literature http://dx.doi.org/10.1590/1983-80422016242127The evaluation of the number of included studies published per year has shown that there was one publication per year in 2003, 2006, and 2011; two publications in 2005, 2007, 2009, and 2010; and four in 2008, the most number of studies published over a twelve-month period.The identification of periodic publications, such as the Caderno de Saúde Pública (Reports in Public Health) and the Revista de Saúde Pública (Public Health Magazine) reveals a large number of publications; the first included five, and the second has included three of the studies analyzed, most of them developed in the country's Southeast region, especially in the state of São Paulo.

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Bioethics and care of women victims of sexual violence: a review of literature http://dx.doi.org/10.1590/1983-80422016242127

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Bioethics and care of women victims of sexual violence: a review of literature http://dx.doi.org/10.1590/1983-80422016242127

O Bioethics and care of women victims of sexual violence: a review of literature
http://dx.doi.org/10.1590/1983-80422016242127

Table 1 .
Data, objectives, and region pertaining selected articles (Jequié/BA, 2014) Southeast 5 Freitas FC, Lima MG, Dytz JLG 19 ; 2007 Six health professionals working in the Violet Program, Federal District, Brazil Evaluate care provided by health professionals to women victims of sexual violence in the Violeta Program, and its compliance with the technical recommendations established by the Ministry of Health

Bioethics and care of women victims of sexual violence: a review of literature
http://dx.doi.org/10.1590/1983-80422016242127Search on nurse's knowledge about the Serviço de Atenção às Mulheres Vítimas de Violência [Service for Sexual Women Victims of Sexual Violence] -(Samvvis).Analyze some characteristics of women who have suffered sexual violence, especially during outpatient follow-up care.Southeast