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

Trentin, Daiane; Vargas, Mara Ambrosina de Oliveira; Lino, Monica Motta; Leal, Sandra Maria Cezar; Ferreira, Micheli Leal; Saioron, Isabela

doi:10.1590/2177-9465-EAN-2018-0324

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REVIEW • Esc. Anna Nery 23 (4) • 2019 • https://doi.org/10.1590/2177-9465-EAN-2018-0324 linkcopiar

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

Autoría SCIMAGO INSTITUTIONS RANKINGS

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

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.

	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		• Articulation among services¹⁴,¹⁹-²¹,²³,²⁴,²⁶-²⁸
	• 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	• Insufficiency and inexperience of SANEs 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
	• Quality to care actions and management³⁸	• Building of shared protocols³⁸	• Protocol is not understood and adopted³⁸
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
	• Care and listening skills²¹	• 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

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[TFN1] Caption: SANE - Sexual Assault Nurse Examiner program; SANEs - Sexual Assault Nurse Examiners; SAE - Sexual Assault Examiner; SART - Sexual Assault Response Team.

[TFN2] ^*
Female and male nurses.