Abstract

Sexual violence against children and adolescents is a serious threat to the rights and full health of this age group. This study aims to describe the characteristics of mothers aged up to 13, and analyze the profile of cases of notified rape in this age range and repercussions of this violence during pregnancy and childbirth. It is a comparative study of the characteristics of gestation and childbirth of girls aged up to 13 who have had children, without or with notification of rape, in the Violence & Accidents Vigilance (VIVA) System of the Brazilian Case Registry Database (Sistema de Informação de Agravos de Notificação – SINAN). A significant percentage (67.5%) of the girls aged up to 13 with children were of the black race/color category. There was repeated violence in 58.2% of cases. The notified rape victims have a higher percentage of birth by cesarean section, late onset and a lower number of prenatal consultations; and their babies had lower birthweight and lower 1-minute Apgar scores than mothers without rape notification. Rape of children and adolescents is an important risk factor that has repercussions during pregnancy, and complications in delivery and childbirth.

Rape; Children’s health; Adolescents’ health; Teenage pregnancy; Sexual violence

Introduction

Violence against children and adolescents is a grave threat to the human rights and the health of this age group¹1. Sullca TF, Schirmer J. Violência Intrafamiliar na Adolescência na cidade de Puno-Peru. Rev Latino-am Enfermagem 2006; 14(4):578-585.

2. Brasil. Ministério da Saúde (MS). Linha de cuidado para atenção integral à saúde de crianças, adolescentes e suas famílias em situação de violência: orientação para gestores e profissionais de saúde. Brasília: MS; 2012.^-33. Onu Mujeres. Um marco de apoyo a la prevención de la violência contra la mujer. Washington: United Nations Women; 2015.. Females are more susceptible to situations of sexual violence, due to the inequalities in gender relationships and society’s patriarchal values⁴4. Contreras JM, Bott S, Guedes A, Dartnall E. Violência Sexual na América Latina e no Caribe: uma análise de dados secundários. Pretoria: Iniciativa de Pesquisa sobre Violência Sexual; 2010., which have individual and social consequences⁴4. Contreras JM, Bott S, Guedes A, Dartnall E. Violência Sexual na América Latina e no Caribe: uma análise de dados secundários. Pretoria: Iniciativa de Pesquisa sobre Violência Sexual; 2010.

5. Silva LMP, Cardoso MVLML. Abuso sexual: o atendimento a crianças e adolescentes e os profissionais de saúde. Recife: EDUPE; 2007.^-66. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... .

The Brazilian Penal Code⁷7. Brasil. Lei nº 12.015, de 07 de agosto de 2009. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 2009; 10 ago.^,88. Ventura M. Direitos Reprodutivos no Brasil. São Paulo: UNFPA; 2009. treats sexual relations with people aged less than 14 as a sexual crime against vulnerable people, independently of proof of whether or not consent of the victim is discerned, and of any other circumstances⁸8. Ventura M. Direitos Reprodutivos no Brasil. São Paulo: UNFPA; 2009..

In cases of rape of children or adolescents, a crime against sexual dignity and liberty⁹9. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. which includes sexual intercourse¹⁰10. Brasil. Ministério da Saúde (MS). Viva: instrutivo notificação de violência interpessoal e autoprovocada. Brasília: MS; 2016. or other acts of libido, the consequences are even more serious, able to result in undesired pregnancy, sexually transmitted diseases, injuries to sexual organs, and damage to mental health, potentially generating long-term and/or inter-generational effects⁴4. Contreras JM, Bott S, Guedes A, Dartnall E. Violência Sexual na América Latina e no Caribe: uma análise de dados secundários. Pretoria: Iniciativa de Pesquisa sobre Violência Sexual; 2010.^,55. Silva LMP, Cardoso MVLML. Abuso sexual: o atendimento a crianças e adolescentes e os profissionais de saúde. Recife: EDUPE; 2007.^,99. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014.^,1111. Organización Panamericana de la Salud (OPS). Violencia contra la mujer en América Latina y el Caribe: Análisis comparativo de datos poblacionales de 12 países. Washington: OPS; 2013..

In a study in Latin America, between 7% and 36% of women reported having suffered some type of sexual abuse in infancy⁴4. Contreras JM, Bott S, Guedes A, Dartnall E. Violência Sexual na América Latina e no Caribe: uma análise de dados secundários. Pretoria: Iniciativa de Pesquisa sobre Violência Sexual; 2010.. In Brazil, the data of the Brazilian Public Safety Annual reported 45,460 cases of rape in 2015, including rapes of women and of men¹²12. Fórum Brasileiro de Segurança Pública. Anuário Brasileiro de Segurança Pública 2016. São Paulo: Fórum Brasileiro de Segurança Pública; 2016.. However it is known that on average 89% of the victims are female¹²12. Fórum Brasileiro de Segurança Pública. Anuário Brasileiro de Segurança Pública 2016. São Paulo: Fórum Brasileiro de Segurança Pública; 2016. and that there is a very high level of under-registration with the Police. It is estimated that every year there are 527,000 cases of attempted rape or rape in Brazil, of which only 10% are reported to the police⁹9. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014.. In 2015, the Viva/Sinan survey reported 162,575 cases of violence against women, of which total 17,871 (10.99%) were notifications of rape, and of these 6,706 (37.52%) were in girls between the age of 0 and 12¹³13. Brasil. Ministério da Saúde (MS). Violência contra a mulher: o desafio de articulação da vigilância com a rede de atenção e proteção. In: MS. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zica e por outras doenças transmitidas pelo Aedes aegypti. Brasília: MS; 2016. p. 131-154.

The objective of this study was to describe the characteristics of mothers aged up to 13, to analyze the profile of those that were notified for rape in this age range, and the repercussions of this violence during pregnancy and childbirth. The hypothesis is that as well as the effects inherent to precocious pregnancy, rape becomes an important additional risk factor in pregnancy, delivery and birth. The study aims to provide inputs for integrated policies and actions to deal with the problem, with occupational health playing an important role in the care of children and adolescents that are victims of this violence, and also in articulation of the inter-sectorial network.

Method

This is a comparative study of the characteristics of pregnancy and childbirth of girls aged up to 13 who have had children, with or without notification of rape in the survey by the Viva-Sinan (Violence & Accidents Vigilance (VIVA) System of the Brazilian Case Registry Database (Sistema de Informação de Agravos de Notificação – SINAN). The age range was chosen due to the legal cut-off level in the definition of rape, which is the age of 14.

Firstly, characteristics of all the girls aged up to 13 who have had children (total) were described. This was done using data from the Live Births Declaration Registry (DN) of the Live Births Information System (SINASC). The variables described were: region of residence (North, Northeast, Southeast, South, Center-West); year of birth (2011 to 2015); mother’s age (8 to 13 years); race or color (‘black [comprising black and mixed-race]; white; indigenous; and unknown [‘yellow’ (n = 51) were included in unknown, because the number is very small]; marital status (married, single, stable union, and unknown [widows (n = 7) and those with status separated (n = 16) were included in unknown due to the small number].

A linkage was established between the databases of SINASC and SINAN, for the category of girls aged up to 13 with children (SINASC) and girls aged up to 13 with notification of rape (SINAN). The cases were correlated using a Bloom filter¹⁴14. Schenell R, Bachteler T, Reiher J. Privacy-preserving record linkage using Bloom filters. BMC Medical informatics and decision making 2009; 9(41):1-11.. The following variables were used for pairing between the databases: name of patient in the SINAN and name of mother in the SINASC, date of birth of the patient in the SINAN and date of birth of the mother in the SINASC and municipality of residence in the two systems. The pairs with maximum score (10,000) were considered to be true pairs. All the pairs with score below 10,000 were then analyzed considering the name of the patient and the date of birth (when one of the databases did not have the information on birth date, validation was made using the age of the victim). After the process of validation of pairs, a total of 1,273 cases were obtained.

The period of analysis was from 2011 to 2015. Ministerial Order GM104 issued by the Health Ministry on January 25, 2011¹⁵15. Brasil. Portaria MS/GM nº 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. Diário Oficial da União 2011; 26 jan. “defines the terminologies adopted in Brazilian legislation according to the International Health Regulations 2005 (IHR 2005) criteria, the list of illnesses, adverse effects, and events in public health subject to compulsory notification throughout the whole of Brazil and establishes flow, criteria, responsibilities and duties of health professionals and services, and added notification for “domestic violence, sexual and/or other forms of violence” to the Compulsory Notification List (Lista de Notificação Compulsória – LNC) and ordered that related adverse events must be notified and registered in the SINAN, through an Individual Notification Form¹⁶16. Brasil. Ministério da Saúde (MS). Sistema de Informação de Agravos de Notificação (Sinan). Ficha de Notificação Individual. [acessado 2017 mar 6]. Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2015/julho/02/Ficha-Viol-5.1-Final_15.06.15.pdf.
http://portalarquivos.saude.gov.br/image... . 2015 is the last year with consolidated information. Duplications of notifications of violence were excluded before the two databases were related.

For the cases identified in the linkage, a description of the violence was carried out through the following variables: probable perpetrator of the rape (boyfriend/ex-boyfriend, friend/acquaintance, father/stepfather, spouse/former spouse, unknown, others [includes carer, work boss, institutional relationship, police or law officer, mother/stepmother]); place of occurrence (home, streets, school, collective housing/sport location, other [includes bar or similar, retail/services, industry/construction]); repetition of violence (yes, no); procedure carried out (STD prophylactic, HIV prophylactic, hepatitis B prophylactic, emergency contraception, no procedure).

Finally, the comparison was made between characteristics of pregnancy and childbirth of children of girls aged up to 13 with and without notification of rape. The variables compared were: age; race/color; marital status (as per categorization described above); prenatal consultations (none, 1 to 5 and 6 or more); 3-month period of first prenatal consultation (first, second, third or unknown); type of birth (natural or caesarean); weeks of pregnancy (premature – up to 37 weeks; term – 37-41 weeks; and late – 42weeks or more); birth weight (less than or more than 2.500 kg); Apgar score in first and fifth minutes (0-3, 4-7, 8-10 and unknown); and place of birth (hospital, home, other health establishment, others, or unknown). The two groups were compared using a chi-square test for independence to check whether there was a statistically significant difference between the proportions. For the test, the unknown categories were excluded.

Results

According to the SINASC, in the years 2011-2015 a total of 31,611 girls up to the age of 13 had children – this group was predominantly of the negro race (67.5%). The largest proportion of births was in the Northeastern region (39.4%), nearly twice the percentage in the Southeastern region (23.2%), which is more highly populated. Although the greater part (76.1%) of these girls were single, a fact that called attention was that 19.6% of them were reported as being in a stable relationship (Table 1).

From integration of the SINAN and SINASC data, it was possible to identify that the greater part of the notified cases of sexual violence (n = 1,273) were probably committed by the boyfriend, ex-boyfriend, spouse or ex-spouse (51.6%), followed by the category friend/acquaintance (17.6%) and father/stepfather (13.0%). The most frequent location was the home (69.3%), which shows a direct relationship with the person committing the crime, that is to say people who are close to or within the family circle. Repetition of violence took place in 58.2% of the cases (Table 2).

As to procedures carried out in the health services to prevent unwanted pregnancy and sexually transmissible diseases (STDs), it was found that only 6.4% of the victims carried out any prophylactic for STDs, 7.1% for HIV, 4.8% for hepatitis B, and 1.3% emergency contraception (Table 2).

Comparing the proportions of the data relating to characteristics of the pregnancy, birth and baby children of girls up to age 13 with and without notification of rape, there was a statistically significant difference in all the variables, with the exception of fifth-minute Apgar (p = 0.557) and type of birth (p = 0.463) (Tables 3 and 4).

In the group of cases with notification of rape, among girls up to the age of 12, there was a higher proportion with notification of rape – 29.9% compared to 14.7% for the whole group up to age 13. In both groups black and single mothers were the majority, and a higher proportion in the group with notified rape: 77.2% and 86.2% respectively, compared to 75.8% and 77.6% (Table 3).

Mothers with notification for rape had the highest percentage of premature children (birth at 37 weeks or less): 26.4%, compared to 20.8% among mothers without the notification; and also began prenatal care later, with 48.6% having their first consultation in the first three months of pregnancy, compared to 56.8% for the non-notified group. In the group with notification of rape, the percentage of girls making the recommended number of consultations (6 or more) was lower (51.7%), than in the non-notified group (56.5% (Table 3).

As to characteristics of the birth and the newborn child, there was a higher percentage of cesarean section in notified rape victims (42.3%) than in those without rape notification (41.2%). Underweight babies were also more frequent in mothers that had been victims of notified rape, at 19.5%, compared to 14.5% for the group without this notification (Table 4).

The score on the Apgar test – of the baby’s general health at birth, taken in both the first and the fifth minute of life – showed a higher percentage (3.6%) with low score (0.3%) in the 1-minute Apgar test, compared to 2.4% for the non-notified group; for the 5-minute test, the respective percentages were 1.1% and 0.8%, but this result is not statistically significant (Table 4).

The percentage of mothers up to age 13 with birth in a hospital was higher (99.1%) for those with notification of rape, than for those without (97.4%). The percentage giving birth at home was significantly higher, at 1.8%, for those without notified cases of rape – vs. 0.5% for those with such cases.

Discussion

The study indicates a high number of girls aged up to 13 with children. These child-mothers that were cases with notification of rape had a higher percentage of birth by cesarean section, later start of prenatal consultations, and a lower number of them; their babies had lower weight at birth; and their Apgar first-minute scores were weaker than those of the mothers without the rape notification. Rape of a child or adolescent is an important risk factor which has repercussions on gestation, complications in delivery and birth.

In spite of the law’s rigor in characterizing all pregnancies in the universe of girls considered in this study as rape, other questions such as precocious sexual initiation, and consent, need to be considered for public health policies to be better designed. In this context, it is believed that the majority of the girls with notification of rape were victims of a forced sexual relationship, which would generate more repercussions for the physical and mental health of them as mothers, with consequences in health during the pregnancy and delivery. It is also possible that the cases that reached the health services are those that were more serious. If this were not so, from the point of view of healthcare, if we were to treat all the cases in the same way, that is to say, all girl-mothers as rape victims, one would expect better results for the cases that are notified, due to the possibility of greater access to the health and protection system. Thus, in the universe of child-mothers, the data revealed that those who suffered sexual violence, as captured through notification, are more vulnerable than those which did not notify the rape.

The higher concentration in the Northeast of births from mothers aged up to 13 points to issues related to socioeconomic conditions and historically known social inequalities, which contribute to the greater vulnerability of these girls. Data of the PeNSE 2012 survey, a population survey of 110,109 students in the 9^th grade of daytime basic education at public and private schools in Brazil, indicates that school children whose mothers have less schooling and work in jobs have a higher chance of sexual relationship¹⁷17. Oliveira-Campos M, Nunes ML, Madeira FC, Santos MG, Bregmann SR, Malta DC, Giatti L, Barreto SM. Comportamento sexual em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Supl. 1):116-130.. The level of schooling is usually adopted in the literature as a proxy for socioeconomic conditions.

Analysis by race/color also underlined the condition of social inequality, in that black children and adolescents were more susceptible to sexual violence.

As is to be expected from the young age, the majority of the girls who had children were single. However, the noticeable proportion having a stable union or marriage can be explained, in part, by the attempt to rise socially, and to seek independence from the family circle, substituting the links with parents for the links of dependency, in terms of affection and finance, of the couple¹⁸18. Adamo FA. Sexualidade: alguns aspectos. In: Saito MI, Silva LEV, organizadores. Adolescência: prevenção e riscos. São Paulo: Atheneu; 2001., although in many cases this expectation is not reciprocated.

In Brazil, the legal age for marriage is 18, but under the Civil Code teenagers can marry before the age of 16 without the parents’ consent if there is pregnancy¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015.. Among the countries of Latin America and the Caribbean, Brazil stands out for the high number (in absolute terms) of marriage in childhood and adolescence¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015.. Although SINASC records the high prevalence of girls up to the age of 13 married or with a stable union in the period 2011-15, it is not possible to determine the age of the partners, and it is estimated that there is a major sub-notification of this item of data, since marriages in childhood, in Brazil, are predominantly informal in nature¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015..

Childhood marriage, defined by the United Nations Convention on the Rights of the Child (UNCRC) as a stable union involving at least one spouse aged under 18¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015., is a violation of human rights, and in the majority of cases is a damaging practice³3. Onu Mujeres. Um marco de apoyo a la prevención de la violência contra la mujer. Washington: United Nations Women; 2015.^,1919. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015.. A study carried out in the urban areas of Belém and São Luis¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015. highlighted the principal consequences of marriage in childhood and adolescence: pregnancy and problems related to maternal and child health; educational delays and challenges; a limitation on girls’ mobility and social networks; and exposure to violence from the intimate partner¹⁹19. Taylor AY, Lauro G, Segundo M, Greene ME. “Ela vai no meu barco.” Casamento na infância e adolescência no Brasil. Resultados de Pesquisa de Método Misto. Rio de Janeiro, Washington: Instituto Promundo, Promundo-US; 2015.. Thus, pregnancy in this age range represents a risk factor and a destructuring element in the life of these girls²⁰20. Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2010..

Rape is one of the most perverse of crimes, since it affects the victims’ body, mind and dignity. The suffering that is generated can lead to depression or other mental disorders, and can even result in attempted suicide²¹21. Prieto D, Tavares M. Fatores de risco para suicídio: incidência, eventos estressores e transtornos mentais. J. bras. Psiquiatria; 2005; 54(2):146-154., as well as other serious impacts on the victims’ health and quality of life, such as a higher risk of deterioration of physical health, principally of sexual and gynecological health⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... . Other factors described as consequences of this violence include: lower use of contraceptive methods, a higher possibility of precocious pregnancy; and a higher risk of repetition of the aggression¹1. Sullca TF, Schirmer J. Violência Intrafamiliar na Adolescência na cidade de Puno-Peru. Rev Latino-am Enfermagem 2006; 14(4):578-585.^,66. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... .

Our comparative analysis based on integration of the data for notification of rape (SINAN) and births of children (SINASC) from mothers up to age 13, over the period 2011-15, evidence a percentage of notified rapes of 4%, comprising a total of 1,273 cases in this period. It is estimated that there is sub-notification of cases, having in mind that the process of implementation of the VIVA did not take place homogeneously, throughout the whole of Brazil, since some municipalities are more sensitive to this vigilance. This result points to a phenomenon that is complex, and often difficult to characterize.

If on the one hand, under the Brazilian Penal Code⁷7. Brasil. Lei nº 12.015, de 07 de agosto de 2009. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 2009; 10 ago.^,88. Ventura M. Direitos Reprodutivos no Brasil. São Paulo: UNFPA; 2009. sexual relations with children under the age of 14 are treated as a sexual crime against a vulnerable person, independently of proof of discernment or not for consent of the victim, or of any other circumstances⁸8. Ventura M. Direitos Reprodutivos no Brasil. São Paulo: UNFPA; 2009., at the same time, when it is a case of relationship with intimate partners, other characteristics including the question of consent, the start of sexual activity and the age of the possible perpetrator, for example, need to be taken into consideration case by case, within the context, for the most faithful identification of this violence, with a view to setting out more specific strategies that are appropriate for dealing with it.

A limitation of this study is considered to be the sub-notification of cases of sexual violence, and at the same time, the occurrence of notification of rape only due to the legal issue, even when the sexual relationship was by consent. This is because, in some cases, pregnancy can represent a choice within the scope of the person’s family repertoire and social context¹1. Sullca TF, Schirmer J. Violência Intrafamiliar na Adolescência na cidade de Puno-Peru. Rev Latino-am Enfermagem 2006; 14(4):578-585.; and in others, one cannot omit to mention the fact that the precocious start of sexual activity is not always a conscious decision, in which the risks and consequences are evaluated, nor one that is free of doubts²²22. Almeida AMB. Primeira Infância e Gravidez na Adolescência. Fortaleza: Instituto da Infância (IFAN); 2013/2014..

Precocious start of sexual activity is a reality in Brazil and is similar to the profile of Latin America, in which recent decades have shown a significant increase in this profile²³23. Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N. Sexual behaviour in context: a global perspective. Lancet 2006; 368(9548):1706-1728.. In Brazil, data of the PeNSE 2012 indicated that 13.7% of people under 13 have already had sex at least once, and 9.6% were children younger than 12 – of the total of 107,468 pupils participating in the survey of pupils in 9^th-grade basic education¹⁷17. Oliveira-Campos M, Nunes ML, Madeira FC, Santos MG, Bregmann SR, Malta DC, Giatti L, Barreto SM. Comportamento sexual em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Supl. 1):116-130.^,2424. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2012. Rio de Janeiro: IBGE; 2012..

Thus, it is found that public policies face difficulties in guaranteeing the sexual and reproductive rights to these adolescents and their partners, whether because of the cultural conservatism that negates the practice of sex in the early years of adolescence, or due to the lack of effectiveness of the health, education and social support services²⁵25. Cavasin S, organizador. Gravidez entre adolescentes de 10 a 14 anos: estudo exploratório em cinco capitais brasileiras e vulnerabilidade social: relatório de pesquisa. São Paulo: ECOS; 2004..

As well as the analysis of the aggressors a highlight is that an important part of the sexual violence against children and adolescents is committed by the father, stepfather, or a friend or acquaintance – a total of 30.6% of the cases. These results are similar to the various studies⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... ^,99. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014.^,2626. McAlister A. La Violencia Juvenil en Las Americas: Estudios innovadores de investigation, diagnostic y prevention. Organization Panamericana de la Salud; 2000.

27. Llave TV. Abuso Sexual: Estadísticas para la reflexión y pautas para la prevención. Programa Nacional Contra la Violencia Familiar y Sexual. Peru: Ministerio de la Mujer y Poblaciones Vulnerables; 2012.^-2828. Escobedo-Chávez E, Loeza-Fuentes DV, Nájera RIG, Díaz-Aguirre MJ, Flores-Nava G, Thompson-Chagoyán O. Abuso sexual en pediatria: factores epidemiológicos. Bol. Med. Hosp. Infant Mex 1995; 52(9). and reveal the relational and intimate character⁵5. Silva LMP, Cardoso MVLML. Abuso sexual: o atendimento a crianças e adolescentes e os profissionais de saúde. Recife: EDUPE; 2007. of this type of violence. A survey in Curitiba indicated that in the group of children up to age 12 that had suffered sexual aggression, 83.6% of the aggressors were fathers, stepfathers, close relatives, friends or acquaintances²⁹29. Brasil. Ministério da Saúde (MS). Política nacional de atenção integral à saúde da mulher: princípios e diretrizes. Brasília: MS; 2004.. A study by Ipea, with data for notification of violence in 2011, revealed that 56.3% of the aggressors of the children were fathers, stepfathers, friends or acquaintances of the victim⁹9. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014.. It also highlighted that, in general, 70% of rapes are committed by relatives, boyfriends or friends/acquaintances of the victims, and in these cases the home is the principal location 79% where the rape took place⁹9. Cerqueira D, Coelho DSC. Nota Técnica nº 11: Estupro no Brasil: uma radiografia segundo os dados da Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014..

Violence of repetition, in 58.2% of the cases, reveals the chronic and perverse character and tends to become progressively more serious³⁰30. Heise L, Pitanguy J, Germain A. Violence against women. The hidden health burden. Washignton: World Bank; 1994. (World Bank Discussion Papers, 255).. Violence when not interrupted can generate illness, death or physical or emotional consequences that will accompany the victim over the whole of her life. Non-lethal consequences of repetition of violence against women that generate illness include chronic problems such as headaches, stomach pain, vaginal infections, sleep disturbances and eating disorders; and illnesses with delayed effect, including arthritis, high blood pressure and heart disease³⁰30. Heise L, Pitanguy J, Germain A. Violence against women. The hidden health burden. Washignton: World Bank; 1994. (World Bank Discussion Papers, 255).. A case study in the Dr. Manuela Gea González General Hospital in México of adolescents up to age 18 indicated that 49% reported repeated abuse, between two and more than ten times²⁸28. Escobedo-Chávez E, Loeza-Fuentes DV, Nájera RIG, Díaz-Aguirre MJ, Flores-Nava G, Thompson-Chagoyán O. Abuso sexual en pediatria: factores epidemiológicos. Bol. Med. Hosp. Infant Mex 1995; 52(9).. Another study in the Center for Reproductive Health & Integral Development of Adolescents at the University of Chile, with young people up to age 19, reported that in 39% of the case the aggression was reiterated⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... . Thus, the violence of repetition in women with notified rape shows the fragility of the network in providing healthcare and protection with the objective of interrupting the cycle of violence and saving lives.

The difference in figures between mothers aged up to 13 in the notified and non-notified groups shows that this type of sexual violence reproduces a situation of vulnerability and risk for the mother and the newborn, principally among children and adolescents who are black. Child mothers with rape notification had worse performance, in terms of early start of prenatal care (first three months) and higher percentages of caesarean section and hospital birth. Similarly, children of mothers with rape notification were born with a higher percentage of low weight and weaker results in the 1-minute Apgar test.

Pregnancy in young people under the age of 15 can mean various complications for the child, including: higher frequency of premature birth, lower birthweight, lower Apgar scores, respiratory conditions, obstetric trauma, more perinatal illness, and child mortality²⁵25. Cavasin S, organizador. Gravidez entre adolescentes de 10 a 14 anos: estudo exploratório em cinco capitais brasileiras e vulnerabilidade social: relatório de pesquisa. São Paulo: ECOS; 2004..

In the case of pregnancy arising from rape, the situation of vulnerability of the child or adolescent is worse, in that it represents an unwanted event and one that is the product of an occurrence of violence⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... . Thus, the indices of the various health problems of early pregnancy are increased, with the addition of the lower chance of adequate prenatal care, depression and contracting sexually transmitted infections, including HIV¹1. Sullca TF, Schirmer J. Violência Intrafamiliar na Adolescência na cidade de Puno-Peru. Rev Latino-am Enfermagem 2006; 14(4):578-585.^,33. Onu Mujeres. Um marco de apoyo a la prevención de la violência contra la mujer. Washington: United Nations Women; 2015.^,3131. Bohn DK, Holz KA. Sequelae of Abuse: Health Effects of Childhood Sexual Abuse and Rape Domestic Battering. J Nurse Midwifery 1996; 41(6):442-456.^,3232. Berenson, AB, San Miguel VV, Wilkinson GS. Prevalence of physical and sexual assault in pregnant adolescents. J Adoles Health 1992; 13(6):466-469.. Women’s health is more fragile in cases where violence occurs while they are pregnant, and can result in various traumas, which can have consequences for the fetus and of the child¹1. Sullca TF, Schirmer J. Violência Intrafamiliar na Adolescência na cidade de Puno-Peru. Rev Latino-am Enfermagem 2006; 14(4):578-585.^,3131. Bohn DK, Holz KA. Sequelae of Abuse: Health Effects of Childhood Sexual Abuse and Rape Domestic Battering. J Nurse Midwifery 1996; 41(6):442-456.^,3232. Berenson, AB, San Miguel VV, Wilkinson GS. Prevalence of physical and sexual assault in pregnant adolescents. J Adoles Health 1992; 13(6):466-469..

Also, these women have to make difficult decisions, such as whether to continue or terminate the pregnancy⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... . In a study in the city of Cali, Colombia⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... , of women who continued with gestation arising from rape, it was observed that for most of them it was not a conscious or personal decision, and arose from absence of access to abortion, failings in the methods employed, external pressures, or even lack of knowledge about their condition⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... .

A study at the Center for Reproductive Health & Integral Development of Adolescents at the University of Chile accompanied 48 adolescents who became pregnant after sexual violence and compared the results of adolescents that were pregnant as outcome of a relationship. In the study group there was found to be a negative attitude in relation to the pregnancy, with feelings of frustration and blame persisting, and also a greater tendency for the adolescent to become ill during the pregnancy, at birth and puerperium, with a higher frequency of scores under 7 in the fifth-minute Apgar test⁶6. Universidad de Chile. Violencia Sexual y Embarazo: produto de Violación. Diálogos sobre el Aborto “Parir las Hablas”. [acessado 2017 fev 24]. Disponível em: http://web.uchile.cl/archivos/VEXCOM/ParirLasHablas/#2/z
http://web.uchile.cl/archivos/VEXCOM/Par... .

A survey of data on a cohort of mothers and children by the Public Health Institute of Norway indicated that the preference for cesarean birth was higher among women who suffered violence in infancy, as also was the prevalence of pre-eclampsia, with a statistically significant difference from the group of women not exposed to violence in infancy³³33. Lukasse M, Vangen S, Øian P, Scheie B. Childhood abuse and caesarean section among primiparous women in the Norwegian Mother and Child Cohort Study. BJOG 2010; 117(9):1153-1157.. The proportion of women with natural spontaneous childbirth was equivalent for both groups³³33. Lukasse M, Vangen S, Øian P, Scheie B. Childhood abuse and caesarean section among primiparous women in the Norwegian Mother and Child Cohort Study. BJOG 2010; 117(9):1153-1157..

Article 128 of the Brazilian Penal Code allows abortion in two exceptional circumstances: if there is no other means of saving the life of the mother, or in cases of pregnancy arising from rape, with the consent of the mother or her legal representative³⁴34. Souza CM, Adesse L. Violência Sexual no Brasil: perspectivas e desafios, 2004. Rio de Janeiro: Lidador; 2005.. Brazil’s public Single Health System (SUS) offers the service of legal abortion – the legal understanding is that the mother has a right to do it in the case of rape, independently of authorization by a Court or any proceedings against the perpetrator of the crime⁸8. Ventura M. Direitos Reprodutivos no Brasil. São Paulo: UNFPA; 2009., though in practice this right is not always guaranteed.

Thus it is concluded that pregnancy in infancy and adolescence is a controversial subject in the debate on sexual and reproductive health²⁰20. Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2010.. One has to weigh aspects such as the girl’s age, the start of sexual activity, consent, and the age of the child’s father, for a more reliable characterization of violence and for proposal of public policies to confront the problem. And for this, among other things, more qualification of the information in the SINASC is needed, with more variables filled in about the mother, the pregnancy, and principally, the age of the child’s father. It also becomes necessary to qualify the information on ‘location of the event’ and ‘repeated violence’ in the SINAN, due to the high number of cases in the ‘unknown’ category, which indicates a limitation of this study.

Repetitive violence, pregnancy resulting from rape and the low occurrence of minimal procedures such as offer of prophylactics for STDs, emergency contraception, and legal abortion (provided for by Article 128 of the Brazilian Penal Code), show that the healthcare networks are failing. In spite of the institutionalization of these services³⁵35. Schraiber LB, d’Oliveira AFPL, França-Junior I, Pinho AA. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Rev Saude Publica 2002; 36(4):470-477., in practice the results suggest that this supply does not happen in a satisfactory and appropriate way.

The violence inflicted on children and adolescents is recognized to be one of the principal threats to health, human rights and public safety in Brazil and the Americas²⁶26. McAlister A. La Violencia Juvenil en Las Americas: Estudios innovadores de investigation, diagnostic y prevention. Organization Panamericana de la Salud; 2000.. Thus, promotion of health and of a culture of peace should result from a combination of public policies that provide a social structure for individual development of the child and adolescent and their families²⁶26. McAlister A. La Violencia Juvenil en Las Americas: Estudios innovadores de investigation, diagnostic y prevention. Organization Panamericana de la Salud; 2000..

Basic Healthcare is a privileged space for protection of the program because, in theory, it has a large-scale coverage and contact with women, being able to recognize and shelter cases of violence against children and adolescents at the earliest point possible³⁵35. Schraiber LB, d’Oliveira AFPL, França-Junior I, Pinho AA. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Rev Saude Publica 2002; 36(4):470-477.^,3636. Schraiber LB, D’Oliveira AFPL. Violência contra mulheres: interfaces com a saúde. Interface (Botucatu) 1999; 3(5):11-27.. A major challenge of the health sector is to overcome fragmentation and guarantee integral care, and information necessary for the decision on whether or not the pregnancy should be continued, and also referral access to the service that carries out legal opportunity, at the appropriate time.

The inter-sectorial network should be sensitive to the cases of violence against children and adolescents, and also attend to the specificities of adolescents in the field of sexual health and reproductive health, taking into account the inequalities of gender, race/color, sexual orientation and social class, and involving adolescents and young people of the male sex²⁰20. Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2010..

References

Publication Dates

History