Descriptive study of reported cases of sexual violence and specialized care services in the state of Minas Gerais, Brazil, 2019

Study contributions Main results Over 12 notifications of sexual violence were reported per day in the state of Minas Gerais in 2019, with a higher prevalence in females, children and adolescents, mixed-race/Black people. Care gaps were identified in four macro-regions of the state. Implications for services There was a need for victims to travel long distances to receive care in municipalities with referral services for comprehensive care for sexual violence, which may hinder access and timely care. Perspectives It is expected that the results can contribute to improving public policies, considering the need to strategically plan the location of specialized services for people subjected to sexual violence.


INTRODUCTION
Sexual violence is def ined as any forced, coerced, or threatened sexual act, including rape, attempted rape, unwanted sexual touching, or non-contact forms of sexual violence. 1Although it can occur among both women and men, gender inequality contributes to girls and women, Black race/ skin color, transgender women and/or people with disabilities being more likely to experience sexual violence. 2cal social characteristics, such as (i) lower levels of education, (ii) attitudes and norms that normalize violence and gender inequalities, (iii) lack of employment opportunities for women, (iv) gender-discriminatory laws concerning property, marriage, divorce, (v) beliefs in family honor and sexual purity, (vi) ideologies of male sexual entitlement, and (vii) weak legal sanctions for sexual violence, pose a greater risk for the occurrence of this condition. 3orldwide, one in three women has been subjected to physical and/or sexual violence by an intimate partner and/or non-partner at least once in their lifetime; and 13% have experienced such violence in the past 12 months. 3 Brazil, 66,348 cases of rape were reported in 2019, with 5,009 of them in the state of Minas Gerais, 85% and 86%, respectively, among females. 4It is common knowledge that female rape survivors face social stigmas, feelings of guilt for having experienced sexual violence, rejection f rom their families and communities, inducing factors that contribute to the underreporting of records of this form of violence 3,4 and hinder its visibility.Therefore, the need for public policies aimed at addressing sexual violence is widely acknowledged. 5,6 addition to providing care for survivors of sexual violence, the health sector, together with Public Security, plays an important role in data collection on the phenomenon.Since 2011, cases of sexual violence have been compulsorily reported on the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação -SINAN). 7Cases of sexual violence should be reported to the municipal health department within a 24-hour period, upon gaining knowledge of the case. 8his urgency is justified by the need to ensure immediate access to prophylaxis for the human immunodef iciency virus (HIV) and other sexually transmitted infections (STIs), as well as emergency contraception for people who may get pregnant. 9In Brazil, care for people subjected to sexual violence is guaranteed by Law No. 12,845, of August 1, 2013, which ensures the provision of emergency, comprehensive and multidisciplinary care by hospitals. 10In order to organize the care network for these cases, Ordinances No. 485 In Minas Gerais, a state with 853 municipalities, all four classifications of SAP/VS can be found within the SUS.However, despite the mandatory hospital care 10 and the organization of SAP/ VS, [11][12][13] a survey conducted in 2017 showed that specialized services provided were insufficient to meet the demands for care, leading to care gaps. 14e aim of this study was to describe the sociodemographic profile of reported cases of sexual violence and the distribution of care services for this health condition.SINAN and CNES data were publicly available on the Brazilian National Health System Information Technology Department (Departamento de Informática do SUS -DATASUS) website. 15,16The year 2019 was selected for the study because it refers to the latest database with final data made available by the Ministry of Health, which means that the database had already undergone the cleaning process and exclusion of duplicates at the federal level.The SINAN database was accessed on November 24, 2021.The CNES database was accessed on September 20, 2021.

METHODS
Incidence rates of notif ication of sexual violence (per 100,000 inhabitants) were calculated according to three age groups (in years: 0 to 9; 10 to 19; 20 or over), for both females and males, across the 89 health micro-regions in the state of Minas Gerais.For the numerator, we took into consideration the total number of notifications of sexual violence reported on the SINAN in 2019, according to sex, age group and health microregion; 17 The denominator

ORIGINAL ARTICLE
Specialized care services for sexual violence in the state of Minas Geraiss was comprised of the total population of the micro-region in 2019, according to sex and age group, based on resident population estimates. 18For the age group of 20 years or older, the standardized rate of notification of sexual violence was calculated using the direct method and the distribution of the Brazilian population as the standard.
The number and geographical distribution of SAP/VS were described according to the 14 health macro-regions 17 of the state, within the four classifications of the Service.
In order to analyze the distance traveled by people with notifications of sexual violence to the nearest AIP/VS referral service and within the same health macro-region, the calculation of distance -in a straight line and in kilometers -between the municipality of notification and the nearest referral service (municipality with the AIP/VS referral service classification, within each health macro-region) was performed.Macro-regions that were not registered in the CNES for this classification were not included in this analysis, namely: Noroeste, Nordeste, Leste e Leste do Sul.The Euclidean Distance function (ArcGIS software) and meshes provided by the Institute for Applied Economic Research/ Ministry of Planning and Budget (Instituto de Pesquisa Econômica Aplicada/Ministério do Planejamento e Orçamento -IPEA/MPO) were used to calculate the distance. 19r comparisons between the state's health macro-regions, we took into account the maximum distances calculated between the place of notifications and the specialized care service, considering that this would be the longest distance traveled by a person with a notification of sexual violence to the nearest AIP/VS referral service within the macro-region.R 20 software and the ArcGIS software (version 10.5) were used for the analyses.
The study was based on secondary, aggregate data, without personal identification.As these data are available in public domain databases, the project was exempted from approval by a Research Ethics Committee (REC).

RESULTS
In 2019, 4,429 notifications of sexual violence were identified in Minas Gerais; one case was classified as "unknown" sex, nine cases had "unknown" age and one case had "unidentified" municipality of residence.These 11 cases with missing data for sex, age and municipality of residence were excluded from the study, and a total 4,418 notif ications remained to be analyzed: 87.0% were female, 72.0% were children and adolescents (0 to 19 years old) and 18.0% were in the age group of 20 years and older, showing "rape" as the most commonly reported type of sexual violence: 60.8% (Table 1 and Table 2).
Regarding all age groups, females showed a higher frequency of notifications of sexual violence, exceeding 90% among people aged 10 years and older.The majority of notifications were related to mixed-race/Black people, of both sexes, and in all age groups.Sexual violence against people with disabilities was more f requently reported in males, for all age groups, reaching 42.6% of adults.Among female adolescents and adults, previous occurrences of sexual violence were reported in 40.4% and 35.2% of the cases, respectively.Regardless of sex and age group, the primary place of occurrence was the residence, and the most commonly reported type of sexual violence was rape (Table 1 and Table 2).
With regard to females, aged 0 to 9 and 10 to 19 years old, the main aggressors were family members (34.5% and 26.0%, respectively) and f riends or acquaintances (27.9% and 30.8%, respectively); among adult females, the main aggressors were strangers (33.9%) and partners/ ex-partners (30.1%) (Table 1 and Table 2).Among males, in the age groups of 0 to 9 years and 10 to 19 years, the main aggressors were friends or acquaintances (33.3% and 37.3%, respectively), followed by family members    1 and Table 2).The highest incidence rates of notification were found among female adolescents: 455/100,000 inhabitants.in Diamantina; 405/ 100,000 inhabitants in Serro; and 396/100,000 inhabitants in Uberaba (Figure 1 and Supplementary Figure ).
In the state of Minas Gerais, in July 2019, the AIP/VS, AAP/VS and CV/VS referral services were the most frequently registered in the CNES,

Figure 1 -Ranking of the ten health micro-regions with the highest incidence rates of violence notification, by sex and age groups, state of Minas Gerais, Brazil, 2019
with 28, 20 and 19 services respectively (Table 3).Among the 89 health microregions in the state, only 30 had some type of SAP/VS registered in the CNES (Table 3).Regarding the 14 health macro-regions, four of them (Leste; Leste do Sul; Nordeste; Noroeste) did not have AIP/VS services, and in the Southeast microregion no SAP/VS was identified.It is noteworthy that only seven referral services for termination of pregnancy (interrupção da gravidez -GI) were registered in the whole state.The Centro macro-region showed the highest number and of registered services (Table 3).

ORIGINAL ARTICLE
Specialized care services for sexual violence in the state of Minas Geraiss As for the distance traveled by a person with a notification of sexual violence to the nearest AIP/VS referral service within the health macro-region, maximum distances ranging from 327 km to 93 km were observed.The five macro-regions with the largest maximum distances were: Triângulo do Sul (327 km); Norte (301 km); Triângulo do Norte (262 km); Jequitinhonha (257 km); and Centro (242 km).Average distances ranged from 42 km (Vale do Aço) to 149 km (Norte) (Figure 2).

DISCUSSION
Notifications of sexual violence in 2019, in the state of Minas Gerais, showed a worrying scenario: over 12 notifications per day in the state's health services.The records were concentrated in females, children and adolescents and mixed-race/Black people, with the house being the primary place of violence perpetration and males the main aggressors.
The evaluation of the distribution of the SAP/VS showed care gaps in the provision of AIP/VS in four health macro-regions; the absence of any type of SAP/VS in one (1) macroregion of the state stood out.Regarding the distances traveled by people with notifications of sexual violence, among the ten macroregions with a referral service for AIP/VS, five had an average distance greater than 100 km, a considerable displacement for people subjected to sexual violence.In six macro-regions, the maximum distance traveled to a referral service for AIP/VS was even greater, exceeding 200 km.Overall, these findings are similar to those of other studies on gender-based violence and sexual violence, reinforcing that mixed-race/ Black, young women and sometimes with disabilities are more vulnerable in this regard. 14,21hese findings show how the intersection of the dimensions of gender, race/skin color, age and disability is related to the experience of sexual violence, reflecting the inequalities imposed by distinct and overlapping power relations that affect people in different ways. 22spite th e existin g legal coercion mechanisms, such as the Maria da Penha Law (Law No. 11,340, of August 7, 2006)  23 and the Femicide Law (Law No. 13,104, of March 9, 2015), 24 in addition to public initiatives to address and provide care for people who experienced sexual violence, the historical prevalence of this health condition among women and its chronicity, often associated with these occurrences, demonstrate that society and especially women are still entangled in mental models and/or imagery, produced under power relations and domination based on a symbolic order, whose main beneficiaries are men and their intentions. 25derative pacts, such as the National Plan to Confront Sexual Violence against Children and Adolescents, 26 aiming at ensuring protection for children and adolescents, have not prevented the highest occurrence of this form of violence against these age groups, showing a historical tradition of intrafamilial abuse, as supported by some findings of the present study, such as the identification of the residence as the primary place of the aggression; and predominantly committed by family members, whether the person subjected to violence is female or male.
Poor access to protection policies and reporting mechanism are factors directly related to the worsening and emergence of new cases of sexual violence against children and adolescents, as demonstrated here; and especially against girls, whose discursive place occupied by their bodies still includes the sadistic idea of property and dominance, sustained by a colonized patriarchal system.In these cases, early interventions performed by health professionals, have been an important strategy, pointed out by research in various fields of knowledge interested in the subject, such as psychology. 27ta from SINAN reveal a partial picture of this serious problem: a significant underreporting of cases of sexual violence.Although it is mandatory to report this form of violence

ORIGINAL ARTICLE
Specialized care services for sexual violence in the state of Minas Geraiss against people of any age or sex, this record depends on the academic training of health professionals.The notification of sexual violence also depends on the understanding and sensitization of these professionals in the healthcare setting, in the guidance on care and in the promotion of the health of the affected individuals, in addition to the correct completion of the Notif ication Form as an instrument for recording essential data for the epidemiology of the health condition and the public health response actions. 14 this sense, it is necessary to consider the following hypotheses for approaching the issue: difficulty in understanding and sensitivity of professionals regarding the notification and the care for children and adolescents victims of this violence and its prevention; difficulty in identifying and recording sexual violence in adult males; diff iculty in understanding and recording cases in women when the aggressors are their intimate partners or friends/ acquaintances; and a higher registration of more severe cases that seek care in specialized centers.
E ve n c o n s i d e r i n g t h e ex i s te n c e o f underreporting of sexual violence, the incidence rates based on the notification of cases proved to be alarming.In situations where not all cases that receive care are reported, the calculation of the incidence rate may unfairly highlight microregions with municipalities that are more sensitized and active in the surveillance of sexual violence as having the highest rates.
The assessment of the distribution of the SAP/VS showed care gaps or points of low resolubility in the following macro-regions: Noroeste, Leste do Sul, Leste and Nordeste.Health macro-regions constitute the territorial basis for planning tertiary health care, offering hospital health services with higher-density technology.Health micro-regions, on the other hand, are the territorial basis for planning secondary health care, by providing outpatient and hospital services of medium complexity and, exceptionally, some high complexity services.In summary, the macro-region encompasses all three levels of tertiary, secondary and primary health care, while the micro-region encompasses services of primary and secondary health care.
In this context, the territorial unit of the macro-region should have registered health facilities of the three levels of health care, to assist subjected to sexual violence, as well as the unit of the micro-region should have registered existing outpatient services within its jurisdiction.
A study based on data from notifications of sexual violence in Minas Gerais, including specialized services in the state, observed that in 2017, there were 40 health centers registered as SAP/VS, distributed in 11 out of the 14 macroregions in the state, with the majority (37.5%) located in the Centro macro-region.The same study showed that approximately 10% of the cases of rape among women in the state, that same year, occurred in health macro-regions where there were no specialized healthcare centers and 23% occurred in macro-regions with only one specialized healthcare center. 14his study identif ied 48 healthcare centers registered as SAP/VS, that is, only eight new services were registered in the two-year period.Moreover, Leste do Sul macro-region, where significant rates of sexual violence were found, the care gap remains.These findings reveal that despite the investment made by the Brazilian government in the organization of SAP/VS -especially since 2015, when the Ministry of Health created mechanisms for registration and remuneration of healthcare centers providing this type of care -there has not been significant expansion of these services in Minas Gerais.
In addition to the care gaps found, the distances that people subjected to sexual violence must travel to have access to comprehensive care services hinder timely care, compromising the provision of care within 72 hours after the act of sexual violence, as recommended by health institutions.
This study had some limitations: (i) the calculation of rates by health microregion could hide particular situations in specif ic municipalities; (ii) the distances calculated corresponded only to the territory of the macroregion where the case occurred, while in the cases that occurred in border regions, there is the possibility of receiving care in other health macro-regions in Minas Gerais and even in other states, although it was not possible to consider these situations in this study, given that the distances were calculated in a straight line and under different aspects, both related to the organization of the road network and of cultural nature, imposing greater distances to be traveled by people seeking care; and finally (iii) services providing care to people subjected to sexual violence may not be registered with the CNES.
As a potential strength of the study, it can be seen that, despite the underreporting, the rates of sexual violence are much higher than the rates of several diseases considered as public health emergencies.Therefore, addressing sexual violence in the state of Minas Gerais requires policies that better integrate the training of healthcare professionals, and a coordinated service network available throughout the territory, as recommended by the Regionalization Master Plan. 17 can be concluded that the study presented a picture of sexual violence in Minas Gerais in 2019, characterized by the concentration of cases in females, children and adolescents, mixed-race/Black people, and its occurrence in the domestic, intimate and family space.If, on the one hand, high incidence rates of notification were found in the health microregions of the state, on the other hand, a scarcity of care services for people subjected to sexual violence (Serviço de Atenção às Pessoas em Situação de Violência Sexual -SAP/VS) and care gaps between these micro-regions, were identified, especially services classified as Outpatient Care for People Subjected to Sexual Violence (Atenção Ambulatorial às Pessoas em Situação de Violência Sexual -AAP/VS).The maximum distances that people with notif ications of sexual violence must travel to receive care in a Comprehensive Care for People Subjected to Sexual Violence" (Atenção Integral às Pessoas em Situação de Violência Sexual -AIP/VS) service -, are high, with average distances exceeding 100 km.These results highlight the need for improving public policies and their implementation, strategic planning in the location of services and expansion of specialized care coverage for cases of sexual violence in the state of Minas Gerais.

Figure 2 -
Figure 2 -Distance between municipalities with notifications of cases of sexual violence and municipalities that offer services registered in the National Health Establishment Registry classified as Comprehensive Care for People Subjected to Sexual Violence, according to health macro-regions, state of Minas Gerais, Brazil, 2019

Table 1 -Description of the characteristics of notifications of sexual violence against children and adolescents, by sex and age group, state of Minas Gerais, Brazil, 2019
a) Variable with multiple-choice possibility, in which, among children, 1,279 records were identified for females and 399 for males, and among adolescents, 1,888 records for females and 206 for males; b) Variable with multiple-choice possibility, in which, among children, 1,036 records were identified for females and 321 for males, and among adolescents, 1,517 records for females and 161 for males.

Table 1 -Description of the characteristics of notifications of sexual violence against children and adolescents, by sex and age group, state of Minas Gerais, Brazil, 2019
Isabella Vitral Pinto et al.Epidemiologia e Serviços de Saúde, Brasília, 32(2):e2022907, 2023 a) Variable with multiple-choice possibility, in which 1,320 records were identified for females and 72 for males; b) Variable with multiple-choice possibility, in which 1,155 records were identified for females and 65 for males.

Table 2 -Description of the characteristics of notifications of sexual violence among adults, by sex, state of Minas Gerais, Brazil, 2019 ORIGINAL ARTICLE
Specialized care services for sexual violence in the state of Minas Geraiss (29.0% and 18.6%, respectively); among adult males, the main aggressors were strangers (38.5%) and friends or acquaintances (30.8%) (Table