Epidemiological Profile of the Victims of Sexual Violence Treated at a Referral Center in Southern Brazil

Objective  To characterize the sociodemographic profile of women victims of sexual violence treated at a university hospital in southern Brazil. Method  The present cross-sectional study included all female victims of sexual violence who attended the sexual violence unit at the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym) from April 18, 2000 to December 31, 2017. Data were extracted from the electronic record of the patients and stored in a standardized questionnaire database with epidemiological aspects of the victim, the perpetrators and the type of aggression. Statistical analysis was performed using the chi-squared test for trend and descriptive statistics with 95% confidence interval (CI). Results  During the length of the study, 711 women victims of sexual violence were treated. The mean age of the patients was 24.4 (±10) years old (range from 11 to 69 years old) and most of the victims were white (77.4%), single (75.9%) and sought care at the unit within 72 hours after the occurrence (80.7%). In most cases, violence was exerted by a single perpetrator (87.1%), who was unknown in 67.2% of cases. Victims < 19 years old showed a higher risk of not using contraception (relative risk [RR] = 2.7; 95% CI = 1.9–3.6). Conclusion  Most victims of sexual violence were treated within 72 hours of the occurrence. The majority of these victims were white and young, and those < 19 years old had a higher risk of not using contraception and to know the sexual perpetrator.


Introduction
Violence against women is defined as "any act based on gender that causes death, harm or physical, sexual or psychological distress to women, whether in the public or the private sphere," or as "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person's sexuality using coercion, by any person, regardless of their relationship to the victim, in any setting, including but not limited to home and work." 1,2 This type of violence has been a public health problem. Sexual violence can expose the victims to sexually transmitted infections, to unwanted pregnancy and to emotional problems in the short or long term, for instance, suicide and depression. 3 Twenty to 60% of the victims do not tell anyone or do not seek institutional help to report intimate partner violence. 4 The lack of official data and the underreporting problem are challenging for researchers in this area. 5 Data from specialized centers for the care of women victims of sexual abuse are scarce. 6 Homicide rates against women in Brazil have been steadily increasing since 2007, reaching 4.8 cases of female homicides/ 100,000 inhabitants in 2013. 7 Data from the informatics department of the Brazilian Unified Health System (DATASUS), the official electronic database of the Brazilian Ministry of Health, revealed that 243,259 domestic, sexual and/or other violence were registered in Brazil in 2016, of which 22,648 rapes were reported. 8 Around 21.9 women seek health care services for sexual violence every day and there are 14.2 reports of women victims of rape daily. 9 A study revealed that the number of police reports against women in the state of Rio Grande do Sul, Brazil, more specifically in the cities of Santa Maria, Erechim and Santana do Livramento, ranged from 66 to 361 cases between 2005 and 2009. 10 This variability in the number of police reports may be due to the systematic lack of data collection in a specialized unit for this activity. The gynecological emergency unit (GEU) of the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym) has been a reference center for the care of women victims of sexual violence since April 2000. This unit offers multidisciplinary care in emergency and outpatient settings. The staff of this unit comprises gynecologists, psychiatrists, nurses, psychologists, and social workers. The consultation for this type of victim is aimed at the prevention of sexually transmitted infections (STIs) and unwanted pregnancy. This first emergency contact is a great opportunity to offer emergency contraception for those who need it. 11 The GEU follows the Brazilian Ministry of Health protocols in this area and collects data from these victims in a systematic manner. 12 This systematic data collection may reveal some aspects of this population and the conditions in which sexual violence had occurred. The objective of the present study is to characterize the socioepidemiological profile of these victims of sexual violence who were treated at the HCPA, a university hospital in the southern region of Brazil. As a secondary objective, the average age was compared between women who were or were not using contraception at the time of violence.

Study Design and Setting
This is a cross-sectional study, conducted from April 1, 2000 to December 31, 2017, at the Gynecological Emergency Unit at the Hospital de Clínicas de Porto Alegre (GEU-HCPA, in the Portuguese acronym), Porto Alegre, Rio Grande do Sul, Brazil.
Palavras-chave ► serviço de saúde da mulher ► violência contra a mulher ► violência sexual ► delitos sexuais ► estupro Variables Age (in years), ethnicity (by self-declaration), marital status, years of education, profession, characterization of sexual violence, that is, place where the violence occurred, number of perpetrators, characteristics of the perpetrator, whether or not there was a previous relationship between the perpetrator and the victim, form of intimidation, type of sexual assault, occurrence or not of ejaculation, first or repeated aggression, use of contraceptive method at the time of the violence, existence or not of police report and presumed age of the perpetrator were evaluated as study variables. The time elapsed between the sexual assault and the medical care and whether exams, prophylaxis, referrals for hepatitis B vaccination were provided or not were also evaluated.

Data Sources/Measurements
After direct interviews with the patient, data were entered into an electronic medical record. Data from the electronic medical records of the patients were obtained and transferred to a specific database developed for this purpose (GoogleForms, Google LLC, Mountain View, CA, USA). Data was collected for a period of 215 months. A training period of 3 months was performed to assure the consistency of the database input. No strategy for statistical analysis was applied for missing values.

Bias
Data were entered independently by two researchers (Marmontel M. and Santarem M. D.), which were later compared for reducing bias. Discrepancies were solved by reviewing the electronic medical record by a senior professional (Savaris R. F.) or reinterviewing the patient. Reinterview of the patient was performed either in the follow-up consultation, or by telephone by one of the authors (Marmontel M.), responsible for the outpatient clinic. In case of outdated telephone numbers, the social service of the hospital was activated.

Sample Size
The sample was for convenience and included all cases treated within 18 years.

Quantitative Variables
Quantitative variables were described as means and standard deviations (SD). The population was divided into 2 groups based on a cutoff of the age most likely of not using any contraceptive method.

Statistical Methods
Statistical analysis was descriptive using percentage and 95% confidence interval (CI), mean with SD. The identification of a cutoff of age as the most likely of not using any contraceptive method was verified by the curve receiver operator characteristics (ROC). After identifying this cutoff, the sample was divided into 2 groups for further comparisons, using the chisquared test for trend or the Mann Whitney test. Statistical analyses were performed using the Prism 8 software (GraphPad Software, San Diego, California, USA).

Ethical Aspects
The present study was submitted and approved by the Research Ethics Committee of the HCPA (CAAE ¼ 84939318000005327).

Participants
Between April 18, 2000 and December 31, 2017, a total of 711 female victims of sexual violence (100%) were screened for consultation and entered in the analysis. There were no exclusions.

Descriptive Data
The mean (SD) and median age of the studied population were 24.1 (AE10) years old and 22 years old, respectively, ranging from 11 to 69 years old. Further details of the population characteristics, the characteristics of violence and the provided care given at the first visit are described in ►Tables 1, 2 and 3, respectively.

Outcome Data
The median age of the victims using contraception (n ¼ 215) was significantly higher compared with those not using any method (n ¼ 496) (      From our data, it was possible to verify that only 31.1% (221 of 711; 95%CI ¼ 27.7%-34.6%) of the victims of violence were using some contraceptive method. This information is relevant and there are scant data to be compared. Most of the studies use the numbers of unwanted pregnancies as proxy. [17][18][19] Most victims of violence were assaulted by unknown perpetrators (67.2%; 95%CI ¼ 63.7-70.6%) in their residence (23.3%; 95%CI ¼ 20.4%-26.6% [►Table 2]), which is in line with data presented by Delziovo et al 20 in a sample of a public service in southern Brazil, in the state of Santa Catarina. Most victims of violence sought care within 72 hours after the occurrence (80.7%; 95%CI ¼ 77.7-83.5% (►Table 3). There was a low incidence of physical injuries in these victims (►Table 3). These findings are different from other authors, 21 but they are in agreement with those found in a Danish cohort, where they reported a 2% incidence of physical injury. 22 The low incidence of physical injuries does not allow us to find a plausible explanation. Some authors explain it by the degree of resistance by the victim, 23 while others explain this finding by the paralysis presented by the victim during the sexual assault. 24 Both explanations seem valid but we are not able to perform such analysis.
Analysis of the ROC curve showed that abused women < 19 years old had a 2.7 higher risk of not using any contraceptive method, compared with older women. This information is new and reveals the importance, for health professionals, to evaluate the contraceptive method used by the victim. Patel et al 25 published that only 40% of emergency departments offer counseling and provision of emergency contraceptives.
After dividing the sample by the age of 19 years old, some significant differences were found, such as the type of sexual contact with the victims (►Tables 1 and 3). The majority of women > 19 years old had a previous or current relationship, had > 10 years of education and were employed. In contrast, most women 19 years old were single, had < 9 years of education and were students (►Table 1). These findings are expected, since these social events, for example, to be married, are more frequent in older women. According to the literature, the younger the women who suffered sexual assault, the higher the incidence of psychologic and physical abnormalities in the future. 26 The prevalence of known perpetrators was higher among women 19 years old, compared with those > 19 years old (►Table 2). This finding is in accordance with the data provided by Rapee, Abuse & Incest (RAINN), an American anti-sexual violence organization (rainn.org). According to RAINN, 80% of the rapes are committed by someone known to the victim. 27 Similar results were presented by Sodipo et al 28 in Nigeria. Other authors have reported that rapists can be friends, colleagues or family members 29,30 but they do not mention a difference in age. Possible explanations for this association can be related to cultural aspects of the community and the abusive behavior of the perpetrator, associated with the economic dependency of the victim. 29 Further research is necessary on this topic.
The present study has some limitations. The sample is limited to one region in southern Brazil. A significant proportion of information, such as the location of the occurrence, the form of aggression, if ejaculation occurred, the age of the rapist and the form of violence (►Tables 2 and 3) were lacking, jeopardizing further analysis. Some variables, for instance, the age and number of rapists, were impossible to obtain from the history of the patient; many women were drugged or intoxicated and they were not able to recall the events. Others were traumatized and did not want to tell the details. However, although these variables were missing, others, from the same patient, were present, such as relationship with perpetrators and marital status, which had 99% of completeness. Thus, caution is required for interpreting our results on these variables.
A positive aspect of the present study is its 17-year span. This cohort presents data from the region of Porto Alegre, the city with the highest number of notifications in Rio Grande do Sul, according to the DATASUS. 15 Efforts were made to minimize the inherent biases of this type of study, such as double-checking the data and active search with the patient in outpatient follow-up.

Conclusion
The victims of violence seen at the HCPA were mostly white, with a mean age of 24.4 years old. Those < 19 years old had a higher RR: 2.7 (95%CI ¼ 1.96-3.6) of not using contraception, and the majority of the perpetrators are known by these young women. Health professionals must provide emergency contraception to these victims, mainly to those < 19 years old. Emergency contraception is more effective before 72 hours and most victims seek care within 72 hours of the occurrence. Finally, the relationship with the perpetrator should be investigated and proper measures must be taken when the victim knows the perpetrator.

Contributions
All authors contributed to the writing of the article, relevant revision of the intellectual content and approved the final version submitted for publication.

Conflicts to Interests
The authors have no conflict of interests to declare.