Emergency Care for Children and Adolescents after Sexual Violence, in Brazil’s Capital, Brasilia ()
1. Introduction
Gender-based violence is widespread in all regions of the world and has been documented throughout history. The type of gender violence that affects women most profoundly is sexual violence. [1] [2] [3] [4] Sexual violence affects women of all ages; however, it is much more common among younger girls. According to one Brazilian publication, 40% of female victims of sexual violence are under fifteen years of age. [5]
Studies published as long ago as the beginning of the 21st century already warned of the consequences of sexual violence and highlighted the inadequacy of the training given to the professionals providing the care required by these women. This failure to provide training was to a great extent attributed to the “invisibility” of the problem. [6] [7] [8] The document “Technical Guidelines for the Prevention and Treatment of Injuries Resulting from Sexual Violence against Women and Adolescents” published by the Brazilian Ministry of Health lists each item required for the care of women and girls in situations of violence. [9] According to these recommendations, the care provided to women who suffer sexual violence should follow a systematic protocol of actions that includes: an interview, the report of the occurrence, clinical and gynecological examinations, additional examinations, and psychological follow-up care, with emergency interventions and hospitalization being considered exceptional conditions. [9] Prophylactic treatment for infections and emergency contraception to prevent pregnancy should be administered as soon as possible after the sexual assault takes place.
The general objective of the present study was to identify the extent to which these services are indeed being provided at the hospitals responsible for the emergency care of women who have suffered sexual violence. The specific question here is whether there is any difference in the provision of such services as a function of the age of the women or girls who suffer sexual violence.
2. Methods
This is a cross-sectional study conducted to evaluate differences in the care received by female children and adolescents who suffer sexual violence according to age, comparing girls under 15 years of age with adolescents of 15 to 19 years of age. The data for the study were extracted from the compulsory notification forms filled out at all public hospitals within the State Department of Health network during the provision of care to girls and adolescents who had suffered sexual violence in this capital city. The study included all female children and adolescents seeking care at one of these hospitals following sexual assault between January 1, 2012 and December 31, 2016.
The care recommended in the Ministry of Health’s guidelines includes prophylactic treatment against human immunodeficiency virus (HIV) infection, sexually transmitted infections (STIs), and hepatitis B, as well as emergency contraception. The services provided must be recorded on the compulsory notification form.
The following hypotheses were analyzed: (a) Were children under 15 years of age less likely to receive emergency contraception? (b) Were adolescents of 15 to 19 years of age more likely to receive contraception? (c) Were adolescents of 15 to 19 years of age more likely to be given prophylaxis against STI? (d) Were children under the age of 15 less likely to be given prophylaxis against HIV? (e) Were children under 15 years of age less likely to be given prophylaxis against hepatitis B?
Only female sexual assault victims were included in this study. They were classified into two different groups according to age: < 15 years, 15 - 19 years. Statistical analysis was performed using the chi-square test, the test of homogeneity, test of independence, and Fisher’s exact test. The data used in the study are freely available in the public domain and can be found on the public health surveillance website where all compulsory notifications are registered. For all tests, significance was established at p < 0.05.
The data used in the study are freely available in the public domain and can be found on the public health surveillance website where all compulsory notifications are registered. As it was impossible to identify the women included in this study, the institutional review board waived the requirement for ethical approval.
3. Results
This sample consisted of 2,576 female victims of sexual violence: 2,041 children under 15 years of age and 535 adolescents aged between 15 and 19 years of age. Girls under fifteen years of age were found to be much less likely to receive prophylactic treatment against HIV, STIs or hepatitis B compared with adolescents aged 15 to 19 years (Tables 1 - 3), with the percentage of girls under 15 years of age who were given prophylactic treatment being around a third to a quarter of the percentage of adolescents treated prophylactically. Between 75% and 81% of the children under 15 years of age were not given prophylactic treatment for HIV, STIs or hepatitis B compared to 36 - 47% of adolescents aged 15 to 19 years. Only 10% of the group of younger girls was given emergency contraception, with adolescents being 3.8 times more likely to receive emergency contraception compared to the younger age group (Table 4).
The poorer care provided to girls under 15 years of age is also reflected in a greater failure to record data appropriately. In many of these cases, it remains unknown if treatment was provided or not due to missing data or incomplete notification forms.
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Table 1. Provision of prophylactic treatment against HIV to women who reported sexual violence in Brazil’s capital (Brasilia) between 2012 and 2016, according to age.
HIV: Human immunodeficiency virus; Source: SinanNet - Giass/Divep/SVS/SES-DF.
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Table 2. Provision of prophylactic treatment for STIs to women who reported sexual violence in Brazil’s capital (Brasilia) between 2012 and 2016, according to age.
STIs: Sexual transmitted infections.; Source: SinanNet - Giass/Divep/SVS/SES-DF.
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Table 3. Provision of prophylactic treatment for hepatitis B to women who reported sexual violence in Brazil’s capital (Brasilia) between 2012 and 2016, according to age.
Source: SinanNet - Giass/Divep/SVS/SES-DF.
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Table 4. Provision of emergency contraception to women who reported sexual violence in Brazil’s capital (Brasilia) between 2012 and 2016, according to age.
Provision of emergency contraception; Source: SinanNet - Giass/Divep/SVS/SES-DF.
4. Discussion
The proportion of girls under 15 years of age who were provided with emergency contraception was considerably lower than the percentage of older women receiving this care, with the number of younger girls representing only around one-third to a quarter of the percentage of older women provided with emergency contraception. In the case of emergency contraception, the proportion of women ≥ 30 years of age who received this care was around ten percentage points lower than that of women 15 - 29 years of age. The percentage of women for whom this information was missing was about 15 percentage points higher in the under-15 years age group compared to the groups of older women.
Sexual violence against women is not new and may have existed in all or nearly all civilizations throughout history. In the case of Brazil, it was first recognized in the 1940 Penal Code, which cited pregnancy following rape as one of the situations in which abortion was legally permitted. It was only in the late 1990s, following annual nationwide meetings of Professors of Obstetrics and Gynecology, together with Professors of Legal Medicine and Ethics, representatives of the Ministry of Health and of the Brazilian Federation of Associations of Obstetrics and Gynecology, social scientists, and women’s groups, that the relevance and frequency of the issue of sexual violence became visible and broadly discussed. [10] [11] [12] [13]
The Brazilian Ministry of Health took the recommendations proposed during these discussions into consideration when establishing guidelines for the care of women and adolescents who suffer sexual violence. These include not only the legal termination of pregnancy but also the care that should be provided at all emergency care services immediately after the sexual assault. These guidelines include the provision of prophylactic treatment for HIV, STIs, and hepatitis B, as well as emergency contraception to prevent an unwanted pregnancy that would almost certainly result in an induced abortion. [14] [15] [16] [17]
These actions led to an increase in the number of cases of sexual violence reported within the National Health Service, providing a better idea of the dimension of the problem, the characteristics of the victims and those of the environment in which the violence takes place.
The present results clearly show that girls under 15 years of age are discriminated against in that, compared to older women, they are not given the care established as standard by the Ministry of Health. Moreover, the information regarding whether or not such services were provided is missing in a much higher percentage of cases in this younger age group. It is difficult to understand why there is such discrimination with respect to younger females. It may be that emergency health services are intended for an adult population, with providers possibly feeling unprepared to care for children and perhaps referring them to a pediatric clinic. However, unfortunately, no information is available in this regard. Nevertheless, since the time between the assault and the provision of prophylactic treatment should necessarily be short, there is no valid justification for failing to provide emergency care to girls in this age group.
The present study was conducted using Brazilian Health Surveillance data from the Federal District State Health Department, which were then used to analyze the association between the age of the sexual assault victim and the care provided to her by the health services in Brazil’s capital city, Brasilia. The considerable amount of missing data resulting from inadequate completion of the notification forms constitutes the main limitation of this investigation.
5. Conclusions
The finding that girls under 15 years of age are not receiving the care established by the Ministry of Health highlights the need for an urgent debate on the issue with all the providers of emergency care in Brasilia and, probably, throughout the entire country, as there is no reason to believe that the situation is any different in other regions of the country.
Acknowledgements
The authors are grateful to all the gynecologists and obstetricians who completed notification forms after providing care to victims of sexual violence and also to Adelson Guimarães da Costa, a nurse at the Public Health Surveillance Department, Brasilia. We would also like to thank Eulalia Nascimento for her assistance in preparing this manuscript.
Data availability
The data used in the study are freely available in the public domain and can be found on the public health surveillance website where all compulsory notifications are registered.