Sexual violence against children and adolescents: an analysis of prevalence and associated factors^*

ABSTRACT

Objective:

To analyze the prevalence and factors associated with sexual violence against children and adolescents in the city of Petrolina/Pernambuco.

Method:

Ecological study carried out with data from children and adolescents who were victims of sexual violence, collected in the Information System for Notifiable Diseases and analyzed according to descriptive and inferential statistics, with multiple logistic regression.

Results:

A total of 1,232 cases of sexual violence against children and adolescents were registered, with a prevalence of 30.6%. Sexual violence was more likely to occur among female victims (Odds Ratio = 11.39), in their own home (Odds Ratio = 1.96), and the father was the most likely aggressor (Odds Ratio = 8.97). Alcohol use by the aggressor increased the chance for the outcome (Odds Ratio = 2.26).

Conclusion:

The prevalence of sexual violence and associated factors point to the need to implement humane practices within a network of health services integrated with other public systems, with the objective of promoting, protecting and defending the rights of children and adolescents.

DESCRIPTORS
Sex Offences; Child Abuse, Sexual; Child; Adolescent; Pediatric Nursing; Health Information Systems

RESUMO

Objetivo:

Analisar a prevalência e os fatores associados à violência sexual contra crianças e adolescentes, residentes no município de Petrolina/Pernambuco.

Método:

Estudo do tipo ecológico, realizado com os dados de crianças e adolescentes vítimas de violência sexual, coletados no Sistema de Informação de Agravos de Notificação e analisados conforme estatística descritiva e inferencial, com regressão logística múltipla.

Resultados:

Foram registrados 1.232 casos de violência sexual contra crianças e adolescentes, com uma prevalência de 30,6%. A violência sexual apresentou maior chance de ocorrência para vítimas do sexo feminino (Odds Ratio = 11,39), em sua própria residência (Odds Ratio = 1,96), sendo o pai o agressor com mais chance de praticar o ato violento (Odds Ratio = 8,97). O consumo de álcool pelo agressor aumentou a chance para o desfecho (Odds Ratio = 2,26).

Conclusão:

A prevalência da violência sexual e os fatores associados apontam para a necessidade de implementação de práticas humanizadas dentro de uma rede integrada de serviços de saúde com os demais sistemas públicos, visando a promoção, proteção e defesa dos direitos de crianças e adolescentes.

DESCRITORES
Delitos Sexuais; Abuso Sexual na Infância; Criança; Adolescente; Enfermagem Pediátrica; Sistemas de Informação da Saúde

RESUMEN

Objetivo:

Analizar la predominancia y los factores asociados a la violencia sexual contra niños y adolescentes residentes en la ciudad de Petrolina, Pernambuco.

Método:

Se trata de un estudio ecológico realizado con los datos de niños y adolescentes víctimas de violencia sexual, recogidos en el Sistema de Información de Agravantes de Notificaciones y analizados mediante la estadística descriptiva e inferencial, con regresión logística multinomial.

Resultados:

Se registraron 1.232 casos de violencia sexual contra niños y adolescentes, con una prevalencia del 30,6%. El acaecimiento de la violencia sexual era mayor en las víctimas femeninas (Odds Ratio = 11,39), en su propia residencia (Odds Ratio = 1,96), siendo el padre el agresor con mayor probabilidad de practicar el acto violento (Odds Ratio = 8,97). El consumo de alcohol por parte del agresor aumentaba la posibilidad de ese desenlace (Odds Ratio = 2.26).

Conclusión:

La predominancia de la violencia sexual y los factores relacionados demuestran la necesidad de implementar prácticas humanizadas dentro de una red integrada de servicios de salud y demás sistemas públicos con el fin de promover, proteger y defender los derechos de los niños y adolescentes.

DESCRIPTORES
Delitos Sexuales; Abuso Sexual Infantil; Niño; Adolescente; Enfermería Pediátrica; Sistemas de Información en Salud

INTRODUCTION

According to the Child and Adolescent Statute (ECA – Estatuto da Criança e do Adolescente), no child or adolescent must be the object of any form of negligence, discrimination, exploitation, violence, cruelty, or oppression, and any attempt, by action or omission, to violate the fundamental rights of a child or adolescent must be punished according to the law⁽¹⁾.

Sexual violence is considered a complex, multifaceted and endemic public health problem, born out of relations of inequality and power within a social and cultural context. All social classes are affected, regardless of gender, race or ethnicity. It is structured on an arbitrary dynamic between aggressor and children and adolescents that involves the family and damages the entire social fabric⁽²⁾.

This type of violence is characterized by sexual stimulation of children or adolescents by an abuser who is older or in a higher level of psychosexual development than the victim. It can involve homosexual or heterosexual relationships and situations such as rape, incest, sexual harassment and exploitation, pornography, pedophilia, manipulation of the genitals, breasts or anus, sexual encounter with penetration, enforced intimacy, exhibitionism, sexual games, non-consensual and imposed erotic acts and “voyeurism”⁽³⁾.

According to the report of the United Nations Children’s Fund (UNICEF), “A Familiar Face: Violence in the lives of children and adolescents”, published in 2017, every 7 minutes, somewhere in the world, a child or an adolescent is a victim of an act of violence, and around 15 million adolescent girls aged 15 to 19 have experienced forced sex or other types of sexual abuse⁽⁴⁾.

In Brazil, data from “Disque 100” (Dial 100) showed that sexual violence against children and adolescents was the fourth most recurrent type of violence in the country in 2017⁽⁵⁾. In addition, according to records of the Information System for Notifiable Diseases (SINAN – Sistema de Informação de Agravos de Notificação), in 2011, 10,425 children and adolescents who were victims of sexual violence were treated; most of them were female (83.2%) and the highest incidence was in the 10-14-year age group, with a rate of 23.8 notifications for every 100 adolescents⁽⁶⁾.

In the Northeast Region of Brazil, a study on sexual violence against children and adolescents, carried out in Recife, Pernambuco state in 2012 and 2013, identified that the majority of victims were female (92.1%) and in the 10-14-year age group (59.2%)⁽⁷⁾.

To give visibility to this issue and identify its magnitude, typology, severity, profile of the people involved, place of occurrence and other characteristics related to the event, the Ministry of Health implemented, in 2016, the Surveillance System for Violence and Accidents (VIVA), with a standard collection instrument called Notification Form for Interpersonal/Self-Directed Violence, registered in the SINAN⁽⁸⁾.

Notification is part of a comprehensive health care for children, adolescents and families in situations of violence, ensuring reception, attention, prophylactic care, treatment, follow-up in the care network and social protection, in addition to surveillance actions, violence prevention, health promotion and a culture of peace⁽⁹⁾.

Sexual violence is often invisible, either because of fear of reporting episodes or because public health services are fragile when it comes to receiving and following up children and adolescents in situations of violence. Knowing the magnitude of the cases allows more precise conclusions about the phenomenon and can enhance public policies against sexual violence against children and adolescents. Thus, this study aimed to analyze the prevalence and factors associated with sexual violence against children and adolescents in the city of Petrolina, Pernambuco, from 2010 to 2017.

METHOD

Study design

This is an ecological, descriptive and inferential study.

Setting

The city of Petrolina, located in the countryside of the state of Pernambuco, has a population of 293,962 inhabitants. The population of boys and girls from zero to 19 years old, living in the municipality, corresponds to 56,722 and 55,637 inhabitants, respectively⁽¹⁰⁾.

The care network for children and adolescents who are victims of violence is mainly within primary health care, which coordinates care in the territory through a total of 55 Basic Care Units distributed throughout the city⁽¹¹⁾. Other specialized care services are also part of this care network: University Hospital; Hospital Dom Malan – reference in the care of victims of sexual violence in the state; Counseling and Testing Center (CTA), Child and Adolescent Psychosocial Care Center (CAPS i); legal and police services; police stations – assistance to the general public; Women’s Police Station and the Public Prosecutor’s Office; legal and social assistance services: Reference Center for Social Assistance (CRAS), Specialized Reference Center for Social Assistance (CREAS), Child Protective Services and Reference Center for Assistance to Women Valdete Cezar, among others, such as the Violence Prevention Center, the Women’s Secretariat and the Municipal Council for People with Disabilities⁽¹²⁾.

Population

The study population consisted of the records of cases of sexual violence registered in the SINAN from January 2010 to December 2017, involving children and adolescents from zero to 19 years old living in the city of Petrolina, Pernambuco. Cases met the following inclusion criteria: cases of sexual violence, registered in the SINAN, involving children and adolescents living in the city, aged 0 to 19, according to the age parameters established by the World Health Organization (WHO), who defines children as individuals in the 0-9-year age group, and adolescents as individuals in the 10-19-year age group⁽³⁾. Cases that did not have a record of the type of violence, cases that did not meet the established age criteria, and cases involving victims that did not live in the city were excluded.

Data collection

Data was collected from August to September 2018, based on the information available in the notification/investigation forms of domestic, sexual and/or other interpersonal and self-directed violence in the SINAN database, provided by the Municipal Health Secretariat of Petrolina. As for the selection of information, the dependent variables was the sexual violence and the independent variables were divided into: data related to the victim (age and gender of the victim) and the occurrence (area and place of occurrence, if it happened other times, gender of the aggressor, relationship between the aggressor and the victim, suspicion of alcohol use by the aggressor and number of people involved).

Data analysis

The data were organized in Microsoft Excel 2016 and then exported to Stata version 14.0, the software used for data processing. Initially, a descriptive analysis based on the distribution of absolute and relative frequencies was carried out, with the objective of characterizing cases of sexual violence. Central tendency was used to calculate the median age of the victims. Then, binary logistic regression was performed in two stages.

In the first stage, bivariate analysis with a p-value <0.20 was performed to select variables to be included in the multivariate model. After this stage, a multivariate analysis was carried out to verify the association between sexual violence and independent variables, estimating the Odds Ratio (OR) with 95% confidence intervals (95% CI) and a statistical significance of 5% (p<0.05).

Ethical aspects

The research complied with the legal and ethical principles established in Resolution No. 466/2012 of the National Health Council. The study was assessed by the Research Ethics Committee for Scientific Research of the Universidade de Pernambuco and approved under opinion No. 2.701.141, in 2018.

RESULTS

From January 2010 to December 2017, 1,232 cases of sexual violence against children and adolescents were recorded, determining a prevalence of 30.6% (95%CI: 29.2 – 32.0) over the years. The highest percentages of cases of sexual violence were in the years 2013 (18.3%), 2014 (28.0%) and 2016 (16.0%) (Figure 1).

Figure 1
Percentage of cases of sexual violence against children and adolescents, according to year of occurrence – Petrolina, PE, Brazil, 2010 to 2017.

Regarding the variables related to the victims (Table 1), the median age of the victims was 13 years, the largest number of cases were in the 10-19-year age group (80.4%), and most of the children and adolescents were female (95.8%). The evaluation of the variables related to the occurrence (Table 2) showed that the urban area had the highest percentage of cases (67.3%) and the residence was the place with the most records of sexual violence (89.9%). There was no recurrence of sexual violence in most cases (52.9%). Most of the victims were assaulted by male individuals (97.3%), and boyfriends/girlfriends were the most frequent aggressors (33.8%). It was found that alcohol use by the aggressor had not occurred in most episodes (92.8%) and, regarding the number of people involved, sexual abuse was perpetrated by one person in most cases (95.1%).

Table 1
Distribution of socio-demographic characteristics of children and adolescents’ victims of sexual violence – Petrolina, PE, Brazil, 2010 to 2017.

Variables related to the victim	N.	%	95%CI
Age group
Less than 1 year	10	0.8	0.4	—	1.5
1 to 9 years	232	18.8	16.7	—	21.1
10 to 19 years	990	80.4	78.0	—	82.4
Gender
Male	52	4.2	3.2	—	5.4
Female	1,180	95.8	94.5	—	96.7

Table 2
Distribution of the characteristics of the occurrence of sexual violence against children and adolescents – Petrolina, PE, Brazil, 2010 to 2017.

Variables related to the occurrence	N.	%	95%CI
Area of the occurrence
Urban	818	67.3	64.6	—	69.9
Rural	388	31.9	29.3	—	34.6
Peri-urban	9	0.7	0.3	—	1.4
Place of the occurrence
Residence	1,140	89.9	88.0	—	91.4
Others	117	10.1	8.5	—	11.9
Did it happen other times?
Yes	501	47.1	44.1	—	50.1
No	562	52.9	49.8	—	55.8
Gender of the aggressor
Male	1,150	97.3	96.1	—	98.0
Female	24	2.0	1.3	—	3.0
Both genders	8	0.7	0.3	—	1.3
Relationship between aggressor and victim
Father	46	4.0	3.0	—	5.3
Mother	13	1.1	0.6	—	1.9
Stepfather	58	5.1	3.9	—	6.4
Boyfriend/girlfriend	388	33.8	31	—	36.5
Acquaintance	178	15.5	13.5	—	17.7
Stranger	112	9.8	8.1	—	11.6
Caregiver	2	0.2	0.04	—	0.6
Suspicion of alcohol use by the aggressor
Yes	44	7.2	5.4	—	9.5
No	564	92.8	90.4	—	94.5
Number of people involved
One	1,110	95.1	93.7	—	96.2
Two or more	57	4.9	3.7	—	6.2

After adjusting the study variables in the multiple model, a statistically significant association was observed between sexual violence and the victim’s age (OR = 0.91), with a lower chance of sexual victimization with each one-year increase in age. Female children and adolescents had an 11 times greater chance of being victims of violence (OR = 11.39). In addition, the residence was associated as the place with the highest occurrence of cases (OR = 1.96). There was a lower chance of recurrence (OR = 0.45) and, regarding the gender of the aggressor, there was a lower possibility of violence being perpetrated by women (OR = 0.02) or by both genders (OR = 0.03). The father had a greater chance of being the perpetrator of the aggression (OR = 8.97) and the use of alcohol by the aggressor was associated with a higher occurrence of sexual violence (OR = 2.26). The other variables were not associated with violence (p> 0.05) (Table 3).

Table 3
Multivariate logistic regression model between sexual violence against children and adolescents and the variables related to the victim and the occurrence – Petrolina, PE, Brazil, 2010 to 2017.

Variables	Adjusted OR	p-value	95%CI
Age of the victim	0.91	0.000	0.87	—	0.95
Gender of the victim
Male	1
Female	11.39	0.000	6.63	—	19.56
Area of the occurrence
Urban	1
Rural	1.14	0.405	0.84	—	1.54
Peri-urban	1.08	0.923	0.22	—	5.23
Place of the occurrence
Residence	1.96	0.005	1.23	—	3.12
Other places	1
Did it happen other times?
Yes	0.45	0.000	0.34	—	0.60
No	1
Gender of the aggressor
Male	1
Female	0.02	0.000	0.01	—	0.04
Both genders	0.03	0.000	0.01	—	0.13
Relationship between aggressor and victim
Father	8.97	0.000	4.44	—	18.11
Other aggressor	1
Suspicion of alcohol use by the aggressor
Yes	2.26	0.003	1.32	—	3.85
No	1
Number of people involved
One	1.24	0.633	0.51	—	2.98
Two or more	1

DISCUSSION

The prevalence of sexual violence against children and adolescents was similar to other data in the literature, unveiling the magnitude of this problem and its higher occurrence among females^(13–15). Data published by the WHO, based on studies carried out in regions such as Africa, Asia and Australia, estimated that the prevalence of sexual abuse by gender was 18% for girls and 8% for boys⁽¹⁶⁾. Another survey, carried out in low- and middle-income countries, indicated that the prevalence of forced sexual intercourse among girls between 15 and 19 years old ranged from zero to 22% in countries like Kyrgyzstan and Cameroon, respectively⁽¹⁷⁾.

The analysis of the 1,232 cases of sexual violence against children and adolescents showed a variation in the frequency of occurrences, with higher percentages in the years 2013, 2014 and 2016. This finding may indicate an improvement in the performance of agents responsible for the notification, in relation to the protection of the rights and needs of children and adolescents, through the training of personnel in the area of violence and dissemination of the violence module of SINAN as an electronic tool to combat violence^(18–19). However, underreporting of violence is possibly higher, making it difficult to accurately characterize the situation of violence⁽⁷⁾.

Regarding the variables related to the victim, a younger age was associated with sexual violence, showing that each one-year increase in the age of the victim reduces the chance of experiencing sexual violence. Although children are more vulnerable at all ages, the risks to which they are exposed vary according to the stage of development, since younger children have less experience, maturity and physical strength than adults, which might make them the target of people in whom they trust and on whom they depend. This condition is also a barrier to the disclosure violence^(17,20).

It is also worth noting that female children and adolescents were more likely to experience sexual violence, corroborating several other studies in the literature^{(13–17,19–24)} and reinforcing the evidence regarding the fragility of females in gender relations, whether arising from the superior physical strength of men, the inequality in gender relations and vulnerability, or the risk of women experiencing violence, especially if they are children and adolescents⁽⁷⁾.

Although girls are more likely to experience sexual violence when compared to boys, research in Saudi Arabia found that male were 2.9 times more likely to experience sexual abuse than female children⁽²¹⁾. Studies believe that there is an underrepresentation of sexual violence among boys, due to factors that constitute a barrier to the disclosure of violence, such as feelings of guilt for the abuse, gender stereotypes, fear of being seen as homosexuals or the belief that boys are rarely abused⁽²⁰⁾.

As for the place of the occurrence, the residence of the victim remained as the most common setting for the outcome. This finding is in line with other studies, which also found that the home environment was the most likely place for coexistence with aggressors^(25–26). The home is the scenario of several types of violence, and its privacy contributes to the silence surrounding recurrent violent episodes, deconstructing the image of a place of protection and trust for children and adolescents. This whole context makes it difficult to know these particularities and to adopt intervention measures⁽²⁶⁾.

After adjusting in the multivariate model, it was found that the father had a greater chance of being the sexual aggressor. In addition, aggressors were mostly men, which is in agreement with the multiple model, which showed a reduced chance for female or male and female aggressors in relation to males. Other research has also identified aggressors as people known or familiar to the victim, including parents, and mostly male perpetrators^{(19,21,24–25,27)}.

The use of alcohol by the aggressor was not frequent; however, this variable was associated with a higher occurrence of sexual violence. Harmful use of alcohol and use of illicit drugs are risk factors commonly associated with the experience and perpetration of sexual violence⁽²⁸⁾.

There was a low proportion and reduced chance of sexual revictimization, unlike other studies which have found a higher risk of recurrence of sexual violence among children and adolescents, since the proximity between aggressor and victim is a factor that makes it difficult to identify violence and the lack of severe punishments associated with the protection of the aggressor by family members contribute to the recurrence of the event^(15,22,26).

It is worth noting that a lot of cases of sexual violence are not reported, which contributes to the perpetuation of violence and causes irreparable damage to the growth and development of children and adolescents⁽¹⁸⁾, which can persist into adulthood and may include depression, obsessive compulsive disorder, suicidal behavior, lack of social adjustment, lack of trust and unsafe relationships with parents, unwanted pregnancy, cardiovascular diseases and sexually transmitted diseases, including the human immunodeficiency virus (HIV)^(14–15).

The notification of cases of violence gives more visibility to this phenomenon and provides indicators that can promote the integration of health services with other services, such as social assistance, education, legal services, public security, Public Prosecutor’s Office, Public Defender’s Office, Childhood and Youth Court, Child Protective Services, rights councils, and the organized civil society, with the objective of implementing and strengthening a network of care and social protection to provide comprehensive care for children, adolescents and families in situations of violence⁽¹⁸⁾.

A comprehensive care network for the care of children and adolescents in situations of violence has the objective of guiding, strengthening and encouraging the work of professionals and managers planning actions to promote health, prevent violence and protect the rights of children and adolescents. As part of this network, Primary Health Care represents the preferred gateway to the SUS (Unified Health System) and the professionals who work in it, who are closer to families, are able to identify signs and symptoms of violence in children and adolescents and can thus receive and care for these patients, notify cases and refer victims to other institutions of the care network⁽²²⁾.

The limitation of this research lies in the fact that sexual violence can be underreported, which hinders the perception of the real prevalence of this phenomenon in the city. The cases that occurred serve as an alert for the importance of recognizing violence as a public health problem and reinforce the need for the engagement of services that work with protection of the rights of children and adolescents as a strategy for prevention, qualified reception, care and follow-up in a care network.

CONCLUSION

The prevalence of sexual violence against children and adolescents from 2010 to 2017 can be considered high. The scenario, characterized by underage and female victims, who experienced sexual violence inside their own homes and had their father as perpetrator of acts of violence, highlights the intimate and relational character of this event, which contributes to its high rate of occurrence and perpetuation of the cycle of violence.

The implementation of humane practices within a network of health services integrated with other public systems can sensitize managers and professionals to fight sexual violence, with the objective of promoting, protecting and defending the rights of children and adolescents.

• *
  Extracted from the monograph: “Prevalência da violência contra crianças e adolescentes e fatores associados”, Instituto de Medicina Integral Prof. Fernando Figueira, Hospital Dom Malan, Programa de Residência em Área Profissional de Saúde, Residência de Enfermagem em Saúde da Criança, 2019.

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Publication Dates

• Publication in this collection
  06 Nov 2020
• Date of issue
  2020

History

• Received
  24 May 2019
• Accepted
  12 Dec 2019