Keywords
adolescence - women - sexual violence - sexual assault - mental health - emergency
care - retrospective study
Palavras-chave
adolescência - mulher - violência sexual - agressão sexual - saúde mental - atendimento
de emergência - estudo retrospectivo
Introduction
Adolescence is the most vulnerable period for sexual violence due to the intrinsic
changes in neurodevelopment[1]
[2] and some individual factors, including a history of domestic violence in childhood
and risky behaviors such as the consumption of alcohol and/or other psychoactive substances
(PASs).[3]
[4]
[5]
[6]
[7] Socioeconomic factors such as poverty, low level of schooling, and living in a society
with high levels of violence can also influence and increase the vulnerability of
adolescents.[5]
There are ∼ 1.2 billion adolescents aged 10 to 19 years in the world.[8] According to statistical data collected in 190 countries,[9] ∼ 120 million girls have experienced forced sexual intercourse or other sexual acts
at some point in their lives.
The consequences of sexual abuse to the health of women can be devastating and, their
negative effects may be brief or last for a long time. In addition to physical injuries,
the risk of unwanted pregnancy and sexually-transmitted infections (STIs), including
by the human immunodeficiency virus (HIV),[5] as well as mental health disorders such as depression, anxiety, suicide, and posttraumatic
stress, have also been described.[10] Although prophylactic treatment is effective to prevent and/or cure physical trauma,
subsequent follow-up is essential to reduce the negative emotional responses, as well
as the development of individual tools to deal with the trauma suffered and personal/family
prejudices regarding sexual violence.
Studies[4]
[11]
[12]
[13] have shown differences in the characteristics of the episodes of sexual violence
against the pediatric and adolescent populations. In Brazil, these differences have
been shown in studies[14]
[15]
[16] based on national or regional reporting data. However, we do not know if there are
differences in physical and emotional reactions, and in the expression of feelings
triggered in the first months after sexual violence in adolescents of different ages.
The objectives of the present study were: to characterize the sexual violence suffered
by adolescents in the age groups of 10 to 14 (early adolescence) and 15 to 18 years
(late adolescence); to compare the physical, psychological and social reactions observed
in the first six months of outpatient follow-up; and to characterize the medical care
and social/legal demands of both groups.
Methods
The present was a retrospective cohort study conducted at the Department of Gynecology
and Obstetrics, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP),
in the state of São Paulo, Brazil. The institutional Ethics Committee approved the
project (under CAAE 20479819.4.0000.5404). We followed all items in the Strengthening
of the Communication of Observational Studies in Epidemiology (STROBE) statement.
The study setting is a reference hospital in the city of Campinas and its metropolitan
region, which covers a population of around 1.3 million inhabitants. It is a university
hospital that provides emergency care to women who were victims of sexual violence,
as well as a six-month outpatient follow-up conducted by a multidisciplinary team
of gynecologists, psychiatrists, psychologists, nurses, and social workers.
We assessed adolescents aged 10 to 18 years who underwent emergency care from January
1st, 2011, to December 31st, 2018. We consulted the digitalized medical records of
emergency care and outpatient follow-up performed by the multidisciplinary team. The
last patient included had her medical records evaluated until July 1st, 2019, when
the data collection was completed. Our service provides assistance regarding requests
for the legal termination of pregnancy. The women are initially received by the social
service professional and have an outpatient consultation scheduled for evaluation
by the multiprofessional team. As this study aimed to evaluate the adolescents from
of emergency care, it was not part of the scope to evaluate the adolescents who consulted
with this condition.
The variables studied were: sociodemographic data (age, self-reported skin color,
marital status, level of schooling, occupation, intellectual disability, and religion);
type of abuse (acute: an event that is not repeated; and chronic: when the aggression
is repeated over time and is perpetrated by the same aggressor/aggressors); the characteristics
of the episodes of violence (time of occurrence, place of approach, form of intimidation,
known aggressor and link with the aggressor, number of aggressors, type of violence,
if the adolescent was under the influence of alcohol and/or other PASs at the time
of the event, and whether there was “blackout” during the aggression); personal history
(if the adolescent has started sexual activity, mental disorders, PASs addiction;
affective disorders [depression, bipolarity; self-injurious behavior; eating disorders];
suicide attempts; need for psychotherapy or previous psychiatric treatment; intellectual
disability; psychosis [psychotic disorder, schizophrenia, psychotic condition]; attention
deficit hyperactivity disorder [ADHD]; anxiety disorder [panic attacks, phobias, generalized
anxiety, obsessive compulsive disorder, adjustment disorder], previous sexual violence
and age of occurrence); characteristics of the emergency care (time until emergency
care was sought; prophylaxis performed [emergency contraception, prophylaxis against
STIs, including HIV]; and collection of biological material for counterproof with
the suspected offender); social needs/legal aid (shelters; contact with the Childhood
Court of Justice and the Public Defender; protective measures; change of guardian;
Guardian Committee notifications; and the calls for medical returns for which they
did not attend); posttrauma reactions and changes referred/expressed during the follow-up
(perception of violence; disclosure about the violence and which person she told;
support received; physical disorders [sleep and appetite disturbances, physical disposition,
gastrointestinal and urinary symptoms]); mental disorders (symptoms of anxiety and
depression, suicidal ideations, suicide attempts, cutting, fears, flashbacks); social
reactions (social isolation, changes in daily routine [irregular bedtime/wake-up and
meal times; missed school/work/other activities; does not stay alone at home/does
not go out alone], changes of address/city or changes of school); feelings expressed
(apathy, anguish, crying, guilt, humiliation, insecurity, rage, shame) and psychotropic
prescription during follow-up; and if a six-month follow-up with a multidisciplinary
team was completed.
The psychologists who provided care defined the “perception of sexual violence” based
on the reports of the adolescent reports, her mental organization and interpretation
of the event, and by the experience lived as an act of sexual violence. “Feelings”
are listed on the psychologists' clinical observation forms. All reactions and psychiatric
symptoms were noted in medical records by the psychiatrists who cared for/followed
up the adolescents.
For the comparison between the groups of women in early adolescence (10 to 14 years)
and late adolescence (15 to 18 years),[17] we used the Chi-squared or Fisher exact tests for the categorical variables, and
the Mann-Whitney and Kruskal-Wallis tests for the numerical variables. We used the
Statistical Analysis System for Windows (SAS, SAS Institute Inc., Cary, NC, United
States) software, version 9.2, and the level of significance adopted was 5%.
Results
A total of 1,174 women received emergency care after sexual violence during the period
of the present survey, 44.3% (521) of whom were adolescents aged 10 to 18 years (mean
age: 14.8 ± 2.0 years) (data not shown). The sample was divided into 2 comparison
groups consisting of 242 (46.5%) women in early adolescence and 279 (53.5%) in late
adolescence ([Fig. 1]).
Fig. 1 Flowchart of female adolescents who underwent emergency care after sexual violence,
at an early age (10 to 14 years) and late (15 to 18 years) age, and who completed
or were lost to the 6-month follow-up.
Most adolescents were single (92%), students (80%), and 78% reported practicing some
religion ([Table 1]). About 8% of them lived with a partner, 14% were not enrolled in school (they were
employed or without occupation), and 4.6% had some intellectual disability ([Table 1]). The comparison between the groups showed significant differences in relation to
occupation; the early group contained a higher number of students, and there were
more adolescents employed or without occupation in the late group ([Table 1]). Regarding personal history, there were more adolescents in the late group who
had already started sexual life (p < 0.001), who had a history of sexual violence (p = 0.007), and had some kind of mental health disorder (p = 0.008) ([Table 1]). Among the 87 adolescents who reported a history of sexual violence, 70 referred
to the age of occurrence of the event; of these, 54% reported the event occurred when
they were between 4 and 10 years of age ([Table 1]).
Table 1
Sociodemographic characteristics and personal history of female adolescents who were
victims of sexual violence at the time of emergency care, according to age group
|
Sociodemographic characteristics and personal history
|
Age groups
|
p-value[a]
|
|
10–14 years
|
15–18 years
|
|
n = 242
|
n = 279
|
|
n (%)
|
n (%)
|
|
|
Self-reported skin color (n = 517)
|
|
|
|
|
White
|
145 (60.6)
|
187 (67.2)
|
0.119
|
|
Non-White
|
94 (39.3)
|
91 (32.7)
|
|
|
Intellectual disability (n = 521)
|
|
|
0.082
|
|
Yes
|
7 (2.9)
|
17 (6.1)
|
|
|
No
|
235 (97.1)
|
262 (93.9)
|
|
|
Years of schooling (n = 517)
|
|
|
< 0.001
|
|
≤ 8
|
193 (80.1)
|
67 (24.3)
|
|
|
> 8
|
48 (19.9)
|
209 (75.7)
|
|
|
Marital status (n = 521)
|
|
|
0.321
|
|
Single
|
226 (93.4)
|
254 (91.0)
|
|
|
Cohabiting with partner
|
16 (6.6)
|
25 (8.9)
|
|
|
Occupation (n = 491)
|
|
|
< 0.001
|
|
Student
|
222 (97.3)
|
197 (74.9)
|
|
|
Employed
|
1 (0.4)
|
30 (11.4)
|
|
|
No occupation
|
5 (2.2)
|
36 (13.7)
|
|
|
Religion (n = 480)
|
|
|
0.448
|
|
Protestant
|
81 (37.5)
|
118 (44.7)
|
|
|
Catholic
|
73 (33.8)
|
76 (28.8)
|
|
|
Others
|
13 (6.0)
|
15 (5.7)
|
|
|
Unaffiliated
|
49 (22.7)
|
55 (20.8)
|
|
|
Sexual activity initiated (n = 506)
|
44 (18.9)
|
108 (39.5)
|
< 0.001
|
|
History of sexual violence (n = 511)
|
29 (12.2)
|
58 (21.2)
|
0.007
|
|
Age at first episode of violence (n = 70)
|
|
|
0.585
|
|
4–10 years-old
|
13 (59.1)
|
25 (52.1)
|
|
|
11–18 years-old
|
9 (40.9)
|
23 (47.9)
|
|
|
History of mental disorders (n = 428)
|
18 (8.6)
|
38 (17.2)
|
0.008
|
Note:
a Chi-squared test.
The characterization and context of the episodes of sexual violence are shown in [Table 2]. Even with the high prevalence of acute abuse perpetrated by a single aggressor,
we observed differences in the characteristics of the episodes of sexual violence
between the groups. In the early group, a greater number of assaults occurred during
the day (p = 0.031), in their own residence or in those of acquaintances/family members (p <0.001), and by a known abuser (p <0.001) with a family or friendship bond (p = 0.003); and a higher frequency of unsuccessful attempted sexual assaults was observed
(p = 0.008) when compared with the late group ([Table 2]). The late group was more affected by nightly sexual assaults, perpetrated in public
and in places routinely visited by the victims, or at parties, and the violence was
perpetrated in greater number by unknown aggressors. Further, the late group experienced
intimidation more often (p = 0.002), as well as episodes of violence involving the use of a cutting weapon (p = 0.008), and a higher frequency of oral intercourse (p = 0.006). A greater number of the late adolescents did not know the type of violence suffered
(p = 0.036), were more often under the influence of alcohol (p = 0.005), and reported that they had “blacked out” during the aggression (p = 0.044) when compared with the early group. No other differences regarding the characteristics
of the episodes of sexual violence were observed between the groups ([Table 2]).
Table 2
Characteristics and context of the episode of sexual violence suffered by adolescent
women according to age group
|
Characteristics and context of the episode of sexual violence
|
Age groups
|
p-value
|
|
10–14 years
|
15–18 years
|
|
n (%)
|
n (%)
|
|
Type of abuse
|
|
|
0.998[a]
|
|
Acute
|
229 (94.6)
|
264 (94.6)
|
|
|
Chronic
|
13 (5.3)
|
15 (5.4)
|
|
|
Time of approach (n = 512)
|
|
|
0.031[a]
|
|
18:01–00:00 hours
|
82 (34.6)
|
94 (34.2)
|
|
|
00:01–07:00 hours
|
50 (21.1)
|
84 (30.5)
|
|
|
07:01–18:00 hours
|
105 (44.3)
|
97 (35.2)
|
|
|
Place of approach (n = 511)
|
|
|
< 0.001[b]
|
|
Victim's residence
|
81 (34.4)
|
57 (20.6)
|
|
|
Family residence
|
13 (5.5)
|
5 (1.8)
|
|
|
Perpetrator's residence
|
12 (5.1)
|
10 (3.6)
|
|
|
Acquaintance's residence
|
3 (1.28)
|
6 (2.1)
|
|
|
Street
|
79 (33.6)
|
114 (41.3)
|
|
|
Bus stop
|
5 (2.1)
|
13 (4.7)
|
|
|
Other public places
|
3 (1.3)
|
11 (3.9)
|
|
|
School
|
12 (5.1)
|
4 (1.4)
|
|
|
Work
|
0
|
1 (0.3)
|
|
|
Party
|
12 (5.1)
|
31 (11.2)
|
|
|
Does not know
|
11 (4.7)
|
23 (8.3)
|
|
|
Referred consent
|
4 (1.7)
|
1 (0.3)
|
|
|
Known abuser (n = 521)
|
154 (63.6)
|
126 (45.1)
|
< 0.001[a]
|
|
Relationship with the aggressor (n = 521)
|
|
|
0.003[a]
|
|
Father
|
14 (5.8)
|
5 (1.8)
|
|
|
Stepfather
|
14 (5.8)
|
8 (2.8)
|
|
|
Other family member
|
16 (6.6)
|
12 (4.3)
|
|
|
Friend
|
38 (15.7)
|
31 (11.1)
|
|
|
School/work colleague
|
15 (6.2)
|
8 (2.8)
|
|
|
Neighbor
|
9 (3.7)
|
10 (3.6)
|
|
|
Intimate partner
|
8 (3.3)
|
10 (3.6)
|
|
|
Other acquaintances
|
40 (16.5)
|
42 (15.0)
|
|
|
Unknown
|
88 (36.3)
|
153 (54.8)
|
|
|
Number of aggressors (n = 516)
|
|
|
0.896[a]
|
|
1
|
208 (87.0)
|
239 (86.3)
|
|
|
2
|
21 (8.8)
|
24 (8.6)
|
|
|
3–10
|
10 (4.2)
|
14 (5.0)
|
|
|
Presence of intimidation (n = 491)
|
188 (81.7)
|
230 (88.1)
|
0.002[a]
|
|
Verbal threats (n = 472)
|
37 (16.7)
|
58 (23.1)
|
0.085[a]
|
|
Use of physical force (n = 472)
|
120 (54.3)
|
132 (52.6)
|
0.710[a]
|
|
Use of firearm (n = 472)
|
12 (5.4)
|
20 (7.9)
|
0.274[a]
|
|
Use of cutting weapon (n = 472)
|
7 (3.1)
|
23 (9.1)
|
0.008[a]
|
|
Forced inhalation (n = 472)
|
9 (4.0)
|
7 (2.8)
|
0.452[a]
|
|
Type of sexual violence (n = 521)
|
|
|
|
|
Vaginal aggression
|
156 (64.4)
|
175 (62.7)
|
0.681[a]
|
|
Oral aggression
|
27 (11.6)
|
56 (20.0)
|
0.006[a]
|
|
Anal aggression
|
34 (14.0)
|
42 (15.0)
|
0.746[a]
|
|
Frustrated attempt
|
21 (8.7)
|
9 (3.2)
|
0.008[a]
|
|
Undetermined aggression[*]
|
6 (2.5)
|
3 (1.1)
|
0.315[b]
|
|
Does not know[**]
|
47 (19.4)
|
76 (27.2)
|
0.036[a]
|
|
Alcohol consumption (n = 469)
|
22 (9.8)
|
47 (19.1)
|
0.005[a]
|
|
Consumption of other psychoactive substances (n = 420)
|
6 (2.9)
|
11 (5.1)
|
0.247[a]
|
|
“Blackout” during the aggression (n = 515)
|
43 (18.0)
|
70 (25.3)
|
0.044[a]
|
Notes:
a Chi-square test.
b Fisher's test.
* Undetermined aggression: the adolescent had memories of what happened, but could
not distinguish the type of violence.
** Does not know: the adolescent was unable to answer because she couldn't remember
what happened.
[Table 3] shows their reactions and changes after the trauma. The perception of the experience
as an act of sexual violence was highly prevalent in both groups. About two-thirds
of the adolescents in both groups disclosed the episodes of sexual violence; the majority
disclosed the event to parents or family members and reported having received support.
There were no differences in these variables between the groups ([Table 3]).
Table 3
Reactions, changes and feelings reported during the outpatient follow-up according
to age group
|
Reactions and feelings after violence
|
Age groups
|
p-value
|
|
10–14 years
|
15–18 years
|
|
n (%)
|
n (%)
|
|
Perception of sexual violence (n = 521)
|
210 (86.8)
|
255 (91.4)
|
0.301[a]
|
|
Disclosure of the episode of sexual violence (n = 414)
|
129 (65.8)
|
151 (69.2)
|
0.454[a]
|
|
Person to whom the adolescent disclosed
|
|
|
|
|
Mother (n = 414)
|
48 (24.5)
|
48 (22.0)
|
0.552[a]
|
|
Father (n = 414)
|
17 (8.6)
|
22 (10.1)
|
0.622[a]
|
|
Other relative (n = 326)
|
15 (10.0)
|
13 (7.4)
|
0.401[a]
|
|
Intimate partner (n = 326)
|
4 (2.6)
|
12 (6.8)
|
0.084[a]
|
|
Friend (n = 414)
|
9 (4.6)
|
17 (7.8)
|
0.179[a]
|
|
Other people (n = 414)
|
4 (2.0)
|
12 (5.5)
|
0.068[a]
|
|
Received support from someone (n = 361)
|
123 (71.9)
|
145 (76.3)
|
0.341[a]
|
|
Physical and/or psychosocial disorders (n = 364)
|
155 (89.1)
|
173 (91.0)
|
0.529[a]
|
|
Physical disorders (n = 364)
|
73 (41.9)
|
101 (53.1)
|
0.033[a]
|
|
Sleep disorders
|
58 (33.3)
|
93 (48.9)
|
0.003[a]
|
|
Appetite disorders
|
37 (21.2)
|
44 (23.1)
|
0.664[a]
|
|
Gastrointestinal disorders
|
6 (3.4)
|
8 (4.2)
|
0.706[a]
|
|
Urogenital disorders
|
2 (1.1)
|
3 (1.6)
|
1.000[b]
|
|
Changes in physical well-being
|
12 (6.9)
|
12 (6.3)
|
0.824[a]
|
|
Mental Disorders (n = 364)
|
106 (60.9)
|
132 (69.4)
|
0.087[a]
|
|
Symptoms of anxiety
|
67 (38.5)
|
93 (48.9)
|
0.045[a]
|
|
Symptoms of depression
|
25 (14.3)
|
39 (20.5)
|
0.123[a]
|
|
Suicidal ideations
|
14 (8.0)
|
17 (8.9)
|
0.758[a]
|
|
Suicide attempt
|
6 (3.4)
|
7 (3.7)
|
0.904[a]
|
|
Cutting
|
5 (2.8)
|
2 (1.0)
|
0.266[b]
|
|
Fear of the consequences of the episode of sexual violence
|
21 (12.0)
|
26 (13.7)
|
0.646[a]
|
|
Fear of suffering sexual violence again
|
18 (10.3)
|
22 (11.6)
|
0.707[a]
|
|
Flashbacks
|
24 (13.8)
|
41 (21.6)
|
0.053[a]
|
|
Social changes (n = 364)
|
135 (77.6)
|
160 (84.2)
|
0.107[a]
|
|
Social isolation
|
38 (21.8)
|
55 (28.9)
|
0.120[a]
|
|
Changes in daily routine
|
36 (20.7)
|
39 (20.5)
|
0.969[a]
|
|
Changed address
|
14 (8.0)
|
17 (8.9)
|
0.758[a]
|
|
Changed schools
|
13 (7.4)
|
4 (2.1)
|
0.015[a]
|
|
Feelings expressed/perceived during health care (n = 364)
|
|
|
|
Shame
|
97 (55.7)
|
111 (58.4)
|
0.607[a]
|
|
Guilt
|
77 (44.2)
|
82 (43.1)
|
0.833[a]
|
|
Crying
|
14 (8.0)
|
23 (12.1)
|
0.201[a]
|
|
Humiliation
|
8 (4.6)
|
16 (8.4)
|
0.142[a]
|
|
Apathy
|
11 (6.3)
|
7 (3.7)
|
0.246[a]
|
|
Anguish
|
2 (1.1)
|
12 (6.3)
|
0.011[a]
|
|
Rage
|
4 (2.3)
|
5 (2.6)
|
1.000[b]
|
|
Insecurity
|
3 (1.7)
|
8 (4.2)
|
0.166[a]
|
Notes:
a Chi-squared test.
b Fisher exact test.
There were significant differences in the reactions after the episodes of violence
and changes reported between the groups. The late group reported more physical symptoms
(p = 0.033), sleep disorders (p = 0.003), symptoms of anxiety (p = 0.045), and were prescribed more psychotropics, whereas those in the early group
changed schools more often (p = 0.015) ([Table 3]). The feeling most expressed by both groups was shame, followed by guilt; only anguish
was mentioned by a greater number of adolescents in the late group (p = 0.011) ([Table 3]).
[Table 4] shows the care provided to the adolescents. Emergency care was provided up to 72 hours
after the episode of violence to a greater number of adolescents in the late group
(p = 0.048), most of whom often received prophylaxis in the form of emergency contraception
(p = 0.003) and against STI and HIV (p < 0.001), and had more biological samples collected (p = 0.002) when compared with the early group ([Table 2]). The early group required legal aid more often compared with the late group (p = 0.001); only 53% of the families notified the police about the event, with no difference
between the groups ([Table 4]). Of the 521 adolescents admitted to the the emergency department, 337 (64.7%) started
outpatient follow-up, and 272 completed the 6-month follow-up ([Fig. 1]). The ages of the adolescents who completed the follow-up and of those lost to outpatient
follow-up were similar, with a mean of 14.6 (standard deviation [SD]: ± 1.9) years
and 14.7 (SD: ± 2.0) years respectively (data not shown).
Table 4
Emergency care and needs during the multidisciplinary follow-up according to age group
|
Characteristics of care
|
Age groups
|
p-value
|
|
10–14 years
|
15–18 years
|
|
n (%)
|
n (%)
|
|
Emergency care
|
|
|
|
|
Time until search for medical care (n = 514)
|
|
|
0.048[b]
|
|
≤ 24 hours
|
108 (45.7)
|
154 (55.4)
|
|
|
> 24–72 hours
|
44 (18.6)
|
54 (19.4)
|
|
|
> 72 hours–5 days
|
19 (8.0)
|
23 (8.2)
|
|
|
> 5 days until 6 months
|
63 (26.7)
|
44 (15.8)
|
|
|
> 6 months
|
2 (0.8)
|
3 (1.0)
|
|
|
Emergency contraception (n = 462)
|
134 (62.9)
|
188 (75.5)
|
0.003[a]
|
|
Prophylaxis against sexually-transmitted infections (n = 511)
|
167 (75.5)
|
234 (87.3)
|
< 0.001[b]
|
|
HIV prophylaxis (n = 508)
|
135 (57.7)
|
197 (71.9)
|
< 0.001[a]
|
|
Collection of biological sample (n = 487)
|
98 (44.5)
|
156 (58.4)
|
0.002[a]
|
|
Six-month multidisciplinary follow-up
|
|
|
|
|
Assistance from social worker and/or legal aid (n = 521)
|
181 (74.8)
|
172 (61.6)
|
0.001[a]
|
|
Filing of police report (n = 450)
|
112 (52.8)
|
127 (53.3)
|
0.910[a]
|
|
Prescription of psychotropics (n = 371)
|
42 (23.3)
|
70 (36.6)
|
0.005[a]
|
|
Completed the 6-month follow-up (n = 337)
|
128 (79.0)
|
144 (82.3)
|
0.447[a]
|
Notes:
a Chi-square test.
b Fisher exact test.
Discussion
The prevalence of adolescents in relation to all women presenting to our service was
similar to that of other studies, in which up to 50% of the reported cases of sexual
violence occurred among adolescents.[9]
[12]
[13]
[16] In Brazil, sexual violence was the second most reported type of violence in the
age group of 10 to 19 years, only exceeded by physical violence.[16] These rates show the impact of sexual violence on the health of women at a very
young age, as well as the importance of ensuring access to emergency care for adolescents.
In particular, there is a need to guarantee access to subsequent mental health disorders
triggered by the sexual violence.
The fact that 1 out of 4 adolescents in the late group was not enrolled in school,
added to the rate of 8% of adolescents living with a partner, raises the discussion
about the adverse living conditions and the lack of conditions to complete formal
education. These are situations that increase the vulnerability to sexual violence,
and limit opportunities and personal development. Additionally, we observed 3.4% of
intimate partner violence, a rate much lower than the 24% described in an analysis
of health sector reports in Brazil from 2011 to 2017.[16] It is possible that the difference between the rates is related to the intrinsic
characteristics of the population care for in our service. The prevalence of intellectual
disability was higher than that of the general population, which has been reported
to be of around 1%, corroborating the need for specific measures of protection, guidance,
and care for these adolescents.[18]
The largest number of adolescents who had initiated sexual life in the late group
was expected and is in agreement with a national population-based study[19] that described a mean age of 15.3 years at first sexual intercourse among female
adolescents aged between 16 and 19 years. On the other hand, the large number of adolescents
with a history of child sexual abuse (CSA), 17% in the general sample and significantly
higher in the late group, drew attention. Studies with adolescents[20]
[21] suggest that those exposed to CSA have greater sexual vulnerability during adolescence.
In addition, the experience of sexual violence in childhood or adolescence can increase
vulnerability to new episodes of abuse and the development of risky behaviors.[6]
[13]
[22]
[23] History of mental disorder was more frequently reported in the late group, which
was expected. Difficulties in adapting to the transition to adulthood usually require
some specific intervention.
The differences found in the characteristics of the episodes of violence between the
groups can be explained by the greater exposure to social life and to experiences
of new behaviors in late adolescence, while among the early group, the fact that they
tend to remain closer to familiar environments, such as home and school, facilitates
their exposure to aggressors who are their relatives or acquaintances. These differences
are known and have been described in different studies[4]
[11]
[12]
[13]
[16] with children and adolescents, and are shown in the number of reports in Brazil.
Adolescents in the late group self-reported being under the influence of alcohol more
often, as well as “blackouts” during the aggression due to the ingestion of alcohol
and not knowing how to describe the aggression suffered; however, the rate of consumption
was lower than the rates of 40% to 60% of consumption of alcohol and other PASs reported
in studies[3]
[4] with victims of sexual violence. Despite the scarcity of national data, a recent
article[24] reinforced this relationship. It is possible that the lower prevalence of PASs use
may be related to the younger age of the women in the present study and because the
information was self-reported, and no toxicological analyses were performed. Recent
studies[25]
[26] have described drug-facilitated sexual assault (DFSA), a form of sexual violence
against an individual incapacitated by a mind-altering substance such as alcohol or
“rape drugs.” These drugs, when used in association with alcohol, can result in loss
of consciousness and inability to consent to sexual intercourse. It is difficult to
estimate the yearly number of DFSAs, considering the low report rates. Victims are
often reluctant to report incidents out of embarrassment, because they feel judged,
or because they do not clearly remember the attack.
At the time of the event, one in seven adolescents in the present study reported being
under the influence of alcoholic beverages. This result reinforces the need to develop
policies that encourage the system of attention to DFSA suspects in health services
to collect detailed information about the individual's history with legal and illegal
drugs. Adequate and more complete contextual information will serve to improve the
quality of the care.
The late group was more symptomatic, with sleep disturbances, symptoms of anxiety,
feelings of anguish, and psychotropic drugs were prescribed to 36% of them. This result
shows the greater need for psychotherapy or mental health support in this period after
trauma. A Brazilian study[27] performed with students at the end of Elementary School reported that students with
a history of sexual abuse in childhood/early adolescence already showed an impact
on some indicators of mental health, such as insomnia, a decrease in or absence of
friends, and feelings of loneliness.
The perception of sexual violence was one of the reactions observed, and, 9 out of
10 adolescents evaluated realized they had suffered violence. This result corroborates
the experience of more serious violence, such as perpetration by multiple aggressors
and aggression by anal intercourse, experienced by one in seven victims, in addition
to the fact that two-thirds of the adolescents had had their first sexual intercourse
through aggression. These characteristics have been associated with worse emotional
repercussions, which can hinder the recovery process of the adolescents.[9]
During the outpatient follow-up, most adolescents described some type of physical,
psychological and/or social reaction triggered by the aggression. We found a similar
frequency regarding the feelings most mentioned by the two groups, guilt and shame,
which surprised us. Although these feelings are often recognized after sexual violence
in adult women, we believed that the younger group could be immersed in a less-prejudiced
sociocultural environment. The “culture of rape” that sustains the victim's accountability,
globally and in Brazil, promotes feelings of shame and guilt in victims. Unfortunately,
we note that this representation is still very strong, even among the youngest; cultural
and family values may influence the triggering of these feelings. These data indicate
the relevance of evaluating this thematic in a future prospective study and the need
for strategies to deal with this deleterious scenario.
In the present study, one in three adolescents did not disclose the experience to
or did not feel supported by their family. Studies[28] have indicated that adolescents and children may never tell others about the aggression
suffered or delay its disclosure for a long time, either because of fear, threats,
lack of opportunity, or the nature of their relationship with the aggressor. This
delay may have influenced the search for emergency care up to 72 hours after the incident
for 35% of the early group and for 25% of the late group, which compromised the use
of prophylaxis. The late search for care may also have been influenced by the lack
of information about the service, the belief in the little importance of emergency
care, or the difficulty in accessing the most peripheral regions of the city. A Brazilian
study[29] analyzed data from 489 victims aged between 0 and 15 years, 369 of them female,
reported by a pediatric hospital of reference in the city of Florianópolis, state
of Santa Catarina, from 2008 to 2014, and included care data at the time of the report.
Among girls, the most affected age group was between the ages of 10 and 15 years,
and more than 70% of the victims did not undergo prophylactic procedures and material
collection. The low rate of these procedures was attributed by the authors[29] to the non-application of the recommended protocol in cases of suspicion alone,
without confirmation, to situations in which there was no indication for its application,
and to the fact that care occurred after 72 hours. There is a lack of studies on the
treatment/follow-up of adolescents who are victims of sexual violence in Brazil.
The early group required more the assistance of social workers or legal aid, a result
that we attribute to the younger age of the victims, who often need protective measures.
These results draw attention to the high vulnerability of this population, which largely
depends on public policies and government protection.
Although two thirds of the adolescents started the six-month outpatient follow-up,
just over half completed it, despite the measures taken to increase adherence. Our
service routinely performs three calls for teenage victims who are not monitored by
a multidisciplinary team, when necessary, with the assistance of the Guardian Committee.
The limitations of the present study include its retrospective design, which may have
induced some bias in the results, mainly due to omissions in inserting information
into the medical records. Another limitation was the low frequency of PAS consumption
at the time of the aggression, when compared with reports in the literature. This
result may be related to the difficulty of the victim to report this piece of information,
and to the fact that we do not routinely carry out clinical tests to investigate the
presence of drugs. Moreover, the possible diversity of professionals who provided
care to the adolescents and the absence of a previous definition of “feelings,” forming
a subjective basis for classification, may also have contributed to a bias in the
results. On the other hand, the strength of the present study is that it enabled us
to get to know the reactions caused after the trauma of sexual violence in both age
groups of female adolescents. Due to the considerable number of adolescents followed
by the multidisciplinary team, it was possible to compare the needs for change in
routine life, the physical and emotional reactions, and feelings presented by adolescents
after experiencing sexual violence in early and late adolescence. We did not find
comparative studies on the subject. Sexual violence experienced during adolescence
should be better analyzed in prospective studies.
It is important to highlight that, in the present study, psychological changes were
described by 65.4% of the adolescents, which shows the impact of violence on mental
health, and that medical services must be prepared to provide a multidisciplinary
team, with nurses, gynecologists, social workers, and a mental health team for the
follow-up aimed to minimize consequences. There is a need to improve the quality of
information on the prevention and identification of cases of sexual violence against
female adolescents and girls aimed at family members, caregivers and society, to reduce
the time until the search for health care and the potential damage to the mental and
sexual health of the adolescents. Our services must train professionals with sensitivity
regarding the care of girls and adolescents who experience a situation of sexual violence.
Conclusion
Universal health coverage for adolescents has been proposed to public policy managers
as one of the paths to the sustainable development of nations. The Brazilian Unified
Health Service (Sistema Único de Saúde, SUS, in Portuguese) provides universal coverage,
that is, it provides care for the entire population; however, public policies for
prevention, treatment and health education aimed at women's sexual and reproductive
rights are very much needed.
