HealthMED - Volume 6 / Number 1 / 2012

Maria Auxiliadora F. Vertamatti1,2, Luiz Carlos de Abreu2, Fabiana Celi Otsuka1, Paulo Roberto F. da
Costa2, Jefferson Drezett Ferreira2, Carlos Tavares2, Marcelo Ettruri Santos1,2, Caio Parente Barbosa1,2
1
Department of Gynecology and Obstetrics, School of Medicine of the ABC - Santo Andre/SP, Brazil,
2
Multiprofessional team of the Program for the Care of Violence and Sexual Abuse in Sao Bernardo do
Campo/SP, Brazil.

We aimed to describe the soci-

Health Organization (WHO) as "any act of gen-
sexual violence and its association with the lapsed der-based violence that results in serious physical,
time between the aggression and the search for sexual or psycho-emotional impairment to women,
medical attention, in order to help professionals on occurring in public or private life". It is a type of cri-
me characterized as universal, covered by underre-
of a painful situation, identifying the possible rea- porting and lack of discussion with respect to this
sons for delay in access to hospital services. theme, although it is a serious public health pro-
We reviewed 439 female cases, vo-
luntarily treated through the medical services of the The Pan American Health Organization estima-
Program for the Care of Violence and Sexual Abuse tes that 20% of women were sexually abused at least
in Sao Bernardo do Campo, Brazil (PAVAS-SBC), once in their lives, and the incidence of this type of
during a seven years period, from 2000 to 2007. Of
the 439 patients, 374 arrived at the hospital within McIntyre, 2002). In Brazil, these data remain vacant
72 hours after the aggression. The average age was due the lack of studies regarding this matter, but the
24.5 years old and the most part of the population minimum incidence rate is estimated at 7% in the
(45.1%) completed or were coursing high school.
The most common form of sexual aggression was Sexual violence can directly lead to unwan-
vaginal penetration in 43.9% of the cases, followed ted pregnancies and sexually transmitted diseases
by multiple forms of penetration, like vaginal plus -
anal, or vaginal plus oral in 31.4% of the patients. ciency Virus (HIV), other physical injuries and
the impact on the psychological status of women.
group presenting after 72 hours was the absence of Thus, the health professional is in position to early
diagnosis and to prevent problems resulted from
such violence, noting that the health service does
IC95%: 1.58; 4.78), and prior knowledge of the not obligate patients to report the police, further-
more, it is offered host and guidance.
In summing, the extra-genital According to the technical standard of the Mi-
-
tective of the victims; while the known aggressor -
implied in the delayed arrival to the hospital. Pu- cy of the prevention mechanisms is higher when
blic policies to qualify, make public and integrate adopted earlier. In this case, it means that 72 hours
after sexual aggression is the deadline for admini-
complications involving such crime. stration of drugs against unwanted pregnancy and
: public health, women health, -
sexual violence, rape, sexual assault, , prevention de, 2005; Draucker and Martsolf, 2009; Ahrens et
and control, HIV infection, epidemiology al, 2009; Brozowski and Hall, 2009). It is under-

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HealthMED - Volume 6 / Number 1 / 2012

stood that the situation of sexual aggression impo- tive age between 20 and 39 years old and peri or
ses varied degrees of embarrassment to the victim, postmenopausal from 40 years old on (Li et al,
thus inhibiting their attendance to the police and 2002). The inclusion criteria was the free demand
even to the health service. It is therefore crucial to and the exclusion criteria was male gender and
obtain data able to help professionals on the dif dif- cases of chronic sexual abuse against children.
In order to evaluate normality of the variables
unfair and painful situation, identifying the possi- we used the Anderson-Darling test. Tests of hy-
ble reasons for delay in access to hospital services. potheses for proportions used were chi-square or
Thus, the aim of this study is to describe the so- Fisher exact test. The odds ratio was calculated
by logistic regression. We adopted the level of si-
violence victims and its association with the time 5%. All variables with a p-value
lapsed between the aggression and arrival at the 0.20 in logistic regression or chi-square test or
health service. Fisher were included in the hierarchical model. In

association with the time of arrival at health ser-

vice remained 0.05, controlling for age. In or-
This is a retrospective descriptive study by free der to analyze factors such as school degree and
demand of 439 women attended at the Program marital status, it was assumed that age would be
for the Care of Violence and Sexual Abuse in Sao a variable that modify the effect in logistic regres-
Bernardo do Campo (PAVAS-SBC), State of São sion models. We analyzed two models: model A,
Paulo (SP), Brazil, from 2000 to 2007. The study with the independent variables not controlled by
was conducted after approval of the Ethics Com- age, and a model B, variables controlled by age.
mittee in Research of the College of Medicine of
the ABC (protocol number 100/2008). with p-value -
Sao Bernardo do Campo is a brazilian city in dence intervals (CI) of 95%.
the state of Sao Paulo, in the Metropolitan region
of Sao Paulo, Brazil. The total area of Sao Bernar-
do is 406 km² and its population is approximately
781,390 habitants (421,918 are female), according The total number of patients included in the
to the Brazilian Institute of Geography and Stati- study was 439. We observed that 374 (85.19%)
stics (IBGE, 2007). arrived within 72 hours at the hospital, while 65
(14.81%) arrived 72 hours after the aggression. The
contained a semi-structured questionnaire and de- average age was 24.5 years, 44.4% were between
scription of the victim clinical examination. The 10 and 19 years old and 47.3% between 20 and
independent variables were listed: age, school de- 39 years old (Table 1). Regarding school degree,
gree, marital status, pregnancy at the time of the the majority (45.1%) was studying or completed
aggression, time of arrival at the hospital, previ- high school. Table 1 also shows that the most fre-
ous use of contraception, previous sexual activity, quent crime was the vaginal coitus (43.9%), while
identity of the aggressor, number of aggressors, the oral penetration was exclusively in 8.9% and
type of crime, conducting police report and pres- anal penetration in 3.6%. The association of two
or more crimes occurred in 31.4% of the cases.
The dependent variable was the time between sex- In 11.9% of women more than one aggressor was
ual aggression and the arrival at the hospital. involved in the crime.
The age groups were divided into three groups In relation to physical trauma we also noted in
after calculation of mean and standard deviation Table 1 that 14.8% of the victims suffered geni-
using quantitative data. For composition of the tal trauma whereas 18.6% suffered extragenital
- trauma. The aggressor was known by the victim
olescence as the period between 10 and 19 years in 18.4% of cases and 62.4% attended the police
old (World Health Organization, 2002), reproduc-

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 HealthMED - Volume 6 / Number 1 / 2012

The variables that did not present p 0.20 during old and 47.3% aged between 20 and 39 years old.
the univaried analysis were not presented in Table After applied statistical tests we found, however,
1, which were: previous sexual activity, contracep- that the age group of victims does not contribute to
tive use and pregnancy on the crime date. Table 2 advance or delay the search for the health service.
presents the variables with p 20% after multiple HIV infection is great concern for sexually ag-
logistic regression for the dependent variable (time gressed women. Previous investigations showed
to arrival at the hospital after the crime), whereas that the risk of infection in these cases ranges
in the model B we applied the control of variables
by age. There was no statistical difference between 2005), a risk comparable to other forms of sexual
the results of p and odds ratio (OR) between A and exposure, heterosexual single piercing or cutting
B models, which means that the high number of accidents. The risk of infection depends on se-
young women did not alter results in any variable. veral conditions, including type of sexual expo-
According to Table 3, we may identify the vari- sure (anal, vaginal, oral), number of aggressors,
ables associated to the interest event with p 5%. susceptibility of women, trauma or genital lesi-
The non-genital trauma and the conducting police ons associated, viral status of the aggressor, but
report presented as protective factors with respect mainly the time elapsed between the contact with
to the interest event. The known aggressor was as- the infected person and the onset of prophylactic
sociated to delay in the search for the health service.
Moreno and Watts, 2000). There is consensus in
the literature that anti-HIV prophylaxis must be
initiated as early as possible (Andrade et al, 2001;
Gender disparity affects women not only due Riggs et al, 2000; Garcia-Moreno and Watts,
their biological differences compared to men, but 2000; Drezett, 2002), after its penetration through
also by social, cultural and economic discrepan- the failure of the skin and mucosal barriers, the
cies (Bergamo et al, 2000). These differences ge- virus will reach the bloodstream and will be able
nerate discrimination, sometimes accompanied by to infect macrophages after about 48 hours, which
physical violence, which contributes to the genesis determined that 72 hours would be the acceptable
of alterations of growth and development at the re- limit within which the antiretroviral drugs could
productive period (Oshikata et al, 2005; Casanueva exert a protective effect (Plata, 1988; Ball, 2001).
and Martin, 2007). The physical and social comfort Although new and poor understood in the lite-
of women is essential to the development and ma- rature, prevention of HIV with the use of antiretro-
intenance of an equal and integral universal society. viral brings preceding success in situations such as
- the transmission during pregnancy and childbirth
men or children requires integrated actions of edu-
cation, justice, social action, civil society and he- da Saúde, 2005). It is worth to remember that the-
alth. The last endeavors to protect the victim from re are no reports regarding seroconversion in any
pregnancy risk, sexually transmitted diseases and patient who has correctly used the scheme after
psychological damage. sexual aggression (Oshikata et al, 2005; Garcia-
The literature evidenced that women cho- Moreno and Watts, 2000), and neither our patients.
sen by the aggressors were very young, ranging The scheme suggested by the Brazilian Mini-
between 50 and 60% of girls younger than 19 ye-
ars old (Oshikata et al, 2005; Andrade et al, 2001; Standards for Prevention and Treatment of injuri-
Riggs et al, 2000). This is not explained only by es resulting from sexual violence against women
the physical attraction for younger woman but published in 2005, was zidovudine, lamivudine
also because their immaturity makes it more vul-
nerable to aggression (Oshikata et al, 2005; Bro- 2005). On the other hand, according to the anti-
-
the average age of the population studied was 24.5 placed by the association between lopinavir and
years old, 44.4% aged between 10 and 19 years

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HealthMED - Volume 6 / Number 1 / 2012

In the same way, emergency contraception sho- On the other hand, statistical analysis shows
uld be made within 72 hours, as suggested by the that the presence of non-genital trauma and poli-
Ministry of Health, through two options: Levo- ce report were protective factors for the outcome
norgestrel 1500 milligrams as a single dose as the studied, responsible for arrival of the patient in a
- period able to the prophylaxis. It is natural to su-
grams of ethinyl estradiol plus 100 milligrams of ppose that professionals in police and emergency
levonorgestrel in two doses with an interval of 12 send post-sexual aggression as soon as possible to
the reference service, which demonstrates an inte-
- grated and well coordinated municipal net in order
ded for its use, the prophylaxis for hepatitis B and to assist the victims of crime.
non-viral infections (chlamydiosis, gonorrhea, An interesting fact was observed in relation to
syphilis and trichomoniasis) is also more effecti- the genital trauma that even in similar proportions

Andrade et al, 2001). time of arrival of women. Whereas the vast majo-
In the literature concerning populations simi- rity of injuries were of small gravity, such as exco-
lar to ours, we observed numbers between 7 and
33% of patients coming to the health service after ecchymosis, it amazes us that genital injuries were
not also served as a protective factor. It seems that
et al, 2001), however, none of them examined the
variables related to the delay. The lack of impor- victims to exhibit the injuries in their intimacy,
tant technical details discussed before may have such as lacerations and vulvar or vaginal bleeding.
contributed to 14.8% of women in our study arri- In conclusion, most of the victims arrived wi-
ve after 72 hours, which avoided them from recei- thin 72 hours after the crime to the hospital. The
ving appropriate care. average age was 24.5 years old, the great part
was studying or completed high school. The va-
aggressor, when known, is one of the factors that ginal penetration was the most committed crime,
delay the search for the hospital. Besides the em- followed by the association of this with indecent
barrassment and humiliation experienced by the anal or oral aggression. Considering that 72 ho-
victim, the fear of retaliation by an aggressor that urs after sexual abuse is the maximum time reco-
mmended for effective prophylaxis against STD
pregnancy and infection. It is worth to remember / AIDS and unwanted pregnancies, two factors
were shown to be protective for the victims: the
relationships ends in supposedly consensual aggre- presence of non-genital trauma and conduction of
ssion, however, it is rarely reported (Schraiber et al, police complaint. Since the aggressor was known
2007). The literature indicates rates around 70% of by the patient, it was noted delay in the search
known aggressors, which the main aggressors were for the health service. Therefore, public policies
partners and from the own family (Oshikata et al, aiming more preparation, dissemination and inte-
2005; Drezett, 2005), however, great part of the gration between the different sectors involved in
researches regarding sexual abuse discusses atten- the issue of sexual violence may bring positive
tion to children or does not exclude them, which impact in reducing and controlling the complicati-
ons of this type of crime.
studies in several countries (Draucker and Martsolf,
2009; Riggs et al, 2000; Garcia-Moreno and Watts,
2000; Gomes et al, 2006; Grossin et al, 2003). In
emergency room visits studies such as emergency
rooms or reference services like ours, the numbers
of known aggressors range from 10-20%, (Oshika-
ta et al, 2005; Andrade et al, 2001) which supports
the 18.4% of our data.

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 HealthMED - Volume 6 / Number 1 / 2012

15. Krug E. G., Dahlberg L. L., Mercy J. A., Zwi A. B.,

Lozano R. (2002). World report on violence and
1. Ahrens, C. E., Abeling, S., Ahmad, S., Hinman, J. health. Geneva, Switzerland; World Health Organi-
(2009). Spirituality and Well-Being: The Relationship zation; p.351.
Between Religious Coping and Recovery From Sexual
16. Li, C., Wilawan, K., Samsioe, G., Lidfeldt, J., Agardh,
2. Assault. Journal of Interpersonal Violence, Sep.
[Epub ahead of print]. aged women: The Women's Health in the Lund Area
3. Andrade, R. P., Guimarães, A. C. P., Fagotti Filho, (WHILA) study. Human Reproduction, 17, 1379-85.
A., Arrabal, N. S. C. J. S., Rocha, D. M., Medeiros, 17. McIntyre P. (2002). Adolescent friendly health ser-
vices: an agenda for change. Geneva, Switzerland;
- World Health Organization [WHO]; p.43.
18.
23(9), 583-7.
de Saúde. Norma Técnica para Prevenção e Trata-
4. Ball, S. (2001). Prophylaxis following sexual expo- mento dos Agravos Resultantes da Violência Sexual
sure. AIDS Read, 11, 126-8.
5. Brozowski, K., Hall, D. R. (2009). Aging and Risk: 19. Ministério da Saúde. (2007). Secretaria de Vigilân-
Physical and Sexual Abuse of Elders in Canada. JourJour- cia em Saúde. Programa Nacional de DST e AIDS.
nal of Interpersonal Violence, Aug 28. [Epub ahead Recomendações para Terapia Anti-Retroviral em
of print]. Adultos e Adolescentes Infectados pelo HIV. Bra-
6. Casanueva, C. E., Martin, S. L. (2007). Intimate partner
violence during pregnancy and mothers' child abuse po- 20. Oshikata, C. T., Bedone, A. J., Faúndes, A. (2005).
tential. Journal of Interpersonal Violence, 22, 603-22. Atendimento de Emergência a Mulheres que Sofre-
7. Draucker, C., Martsolf, D. (2009). Life-Course Ty-
pology of Adults Who Experienced Sexual Violence. em resultados até seis meses pós-agressão. Caderno
Journal of Interpersonal Violence, Sep. [Epub ahead de Saúde Pública, 21, 92-99.
of print]. 21.
8. -
res estupradas. In: Conferência internacional sobre humano. Acta Médica Colombiana, 13, 282-4.
infecção pelo HIV em mulheres e crianças. Rio de 22. Riggs, N., Housry, D., Long, G., Markovchick, V.,
Janeiro: Universidade Federal do Rio de Janeiro e Feldhaus, K. M. (2000). Analysis of 1076 Cases of
Institute of Virology of Maryland, 20-2. Cases Assault. Annals of Emergency Medicine, 35,
9. Drezett, J. (2005). Abuso Sexual contra Crianças e 358-62.
- 23. Schraiber, L. B., D’Oliveira, A. F. P. L., França-
vista Pediatria Atual, 15, 7-13. Junior, I., Diniz, C. S. G., Portella, A. P., Luder-
10. Faúndes, A., Netom J, A. (2000). IV Fórum Inter Inter- mir, A. B., Valença, O. A. A., Couto, M. T. (2007).
Prevalência da violência contra a mulher por par-
Violência Sexual. Revista Femina, 28, 9. -
11. Garcia-Moreno, C., Watts, C. (2000). Violence blic Health, 4, 797-807.
Against Women: Its importance for HIV/AIS. AIDS, 24. World Health Organization [WHO]. (2002). Global
14, 253-265. Consultation on Adolescent Friendly Health Servic-
12. Gomes, M. L. M., Falbo Neto, G. H., Viana, C. H., es – a Consensus Statement. Geneva, Switzerland;
World Health Organization; p.29.
-
mas de Violência atendidas em um Serviço de apoio
à Mulher. Revista Brasileira de Saúde Materna In- Corresponding Author
fantil, 6, 519-38. Luiz Carlos de Abreu,
13. Grossin, C., Sibille, I., Lorin de la Grandmaison, G., Departamento de Morfologia e Fisiologia,
Banasr, A., Brion, F., Durigon, M. (2003). Analysis Faculdade de Medicina do ABC,
of 418 cases of sexual assault. Forensic Science In- Santo André, SP,
ternational, 131, 125-30. Brazil,
14. - E-mail: [email protected]
stica. Ministério do Planejamento, Orçamento e
Gestão. (2007). Contagem da População 2007;
http://ww.ibge.gov.br/
home/estatistica/populacao/contagem2007

Journal of Society for development in new net environment in B&H