Abstract

The scope of this study was to identify the characteristics of sexual abuse against children including the profiles of the victims and the perpetrators, and associated factors notified in a health service of reference with the database of the Brazilian Case Registry Database, in a city in the south of Brazil. Categorical variables are presented in prevalence with 95% confidence intervals. There were 489 notifications from 2008 to 2014 of confirmed or suspected child sexual abuse. The majority was related to female victims, but the repeated abuse was reported mainly with male victims. In most cases, the abuse took place at the victims’ or perpetrators’ homes and the main perpetrators of abuse were male and acquainted with the victims. Twelve victims have contracted sexually transmitted infections; pregnancies were six, five of them legally terminated. This study highlights that the child sexual abuse profiles were similar in almost all of Brazilian regions, showing that it is possible to have a coordinated national action to prevent this offence.

Key words
Sexual violence; Children

Introduction

According to the World Health Organization (WHO), every child has the right to violence-free health and life. Children Sexual Abuse (CSA) occurs when children are subjected to a sexual activity that they cannot understand, with which they have an incompatible development, cannot consent and/or that violates society laws or rules¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389..

Although the results clearly show that CSA experience is highly prevalent in all societies investigated, a meta-analysis with international studies has estimated an average CSA prevalence of 20.0% for women and 8.0% for men²2. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl 2009; 33(6):331-342.. Rate variations are probably due to different definitions of CSA in terms of age and methodological gaps between studies³3. Andrews G, Corry J, Slade T, Issakidis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneve: WHO; 2004. p. 1851-1940.. In Nordic countries, rates ranged from 14.0% for women and 7.0% for men in Denmark; 2.4%-9.3% for women and 0.7%- 4.6% for men in Finland; in Sweden, the overall prevalence ranged from 2.0% to 11.0%, and Norway reported a prevalence of 10.0%⁴4. Laaksonen T, Sariola H, Johansson A, Jern P, Varjonen M, von der Pahlen B, et al. Changes in the prevalence of child sexual abuse, its risk factors, and their associations as a function of age cohort in a finnish population sample. Child Abuse Negl 2011; 35(7):480-490..

Brazilian studies⁵5. Aded NLO, Oliveira SF, Dalcin BLGS, Moraes TM, Cavalcanti MT. Children and adolescents victimized by sexual abuse in the city of Rio de Janeiro: an appraisal of cases. J Forensic Leg Med 2007; 14(4):216-220.

6. De Lorenzi DRS, Pontalti L, Flech RM. Maus tratos na infância e adolescência: análise de 100 casos. Rev Cient AMECS 2001; 10(1):1-6.

7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^-88. Machado HB, Lueneberg CF, Régis EI, Nunes MPP. Abuso sexual: diagnóstico de casos notificados no município de Itajaí/SC, no período de 1999 a 2003, como instrumento para a intervenção com famílias que vivenciam situações de violência. Texto Contexto Enfem 2005; 14(n. esp.):54-63. show that most cases of sexual abuse occur in girls aged 5-10 years. Boys also suffer abuse, but to a lesser degree, especially when it is intrafamiliar¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389.. In 2005, a study carried out in the state of Santa Catarina (SC) with data obtained from records of notifications from the Guardianship Council and Sentinel Program of the city of Itajaí from 1999 to 2003 showed that a large part of the children and adolescent sexual violence occurred within homes, and the father was the main perpetrator⁸8. Machado HB, Lueneberg CF, Régis EI, Nunes MPP. Abuso sexual: diagnóstico de casos notificados no município de Itajaí/SC, no período de 1999 a 2003, como instrumento para a intervenção com famílias que vivenciam situações de violência. Texto Contexto Enfem 2005; 14(n. esp.):54-63.. O PAI FOI O MAIOR RESPONSAVEL POR ESSES ABUSOS

CSA is an important risk factor for several health problems in childhood and in adult life¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389.^,99. Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 2008; 32(6):607-619.^-1010. Committee on Child Abuse and Neglect (COCAN). Protecting children from sexual abuse by health care providers. Pediatrics 2011; 128(2):407-426. that have a great impact on the physical and mainly psychological health of victims. It is also a substantial burden to the health system (medical consultations and hospitalizations)¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389.^,1010. Committee on Child Abuse and Neglect (COCAN). Protecting children from sexual abuse by health care providers. Pediatrics 2011; 128(2):407-426.

11. Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, Elamin MB, Seime RJ, Shinozaki G, Prokop LJ, Zirakzadeh A. Sexual abuse and lifetime diagnosis of psyquiatric disorders: systematic review and meta-analysis. Mayo Clin Proc 2010; 85(7):618-629.

12. Salter D, McMillan D, Richards M, Talbot T, Hodges J, Bentovim A, Hastings R, Stevenson J, Skuse D. Development of sexually abusive behaviour in sexually victimised males: a longitudinal study. Lancet 2003; 361(9356):471-476.

13. Modelli ME, Galvão MF, Pratesi R. Child sexual abuse. Forensic Sci Int 2012; 217(1-3):1-4.

14. Cummings M, Berkowitz SJ, Scribano PV. Treatment of childhood sexual abuse: an updated review. Curr Psychiatry Rep 2012; 14(6):599-607.

15. Jenny C, Crawford-Jakubiak JE. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 2013; 132(2):e558-567.

16. Wilson DR, Vidal B, Wilson WA, Salyer SL. Overcoming sequelae of childhood sexual abuse with stress management. J Psychiatr Ment Health Nurs 2012; 19(7):587-593.

17. Paraventi F, Claudino AM, Morgan CM, Mari JJ. Estudo de caso controle para avaliar o impacto do abuso sexual infantil nos transtornos alimentares. Rev Psiq Clín 2011; 38(6):222-226.^-1818. Pérez-Fuentes G, Olfson M, Villegas L, Morcillo C, Wang S, Blanco C. Prevalence and correlates of child sexual abuse: a national study. Compr Psychiatry 2013; 54(1):16-27..

Estimating the prevalence of CSA is crucial to determine the extent of the problem and possible interventions, and the organization of reporting of this problem is instrumental to comprehensive care for people in situations of violence¹⁹19. Brasil. Ministério da Saúde (MS). Instrutivo de notificação/investigação de violência doméstica, sexual e/ ou outras violências. Brasília: MS; 2009.. Due to the relatively recent inclusion of sexual violence data in the Notifiable Disease Information System (SINAN) (2008) as a means of universalizing continuous surveillance, using it systematically is the best way to evaluate it and improve it.

This study aimed to identify characteristics of child sexual abuse, such as the profile of the victim and the perpetrator of abuse and factors associated with sexual violence, reported in a referral service, using SINAN records.

Methods

This is a cross-sectional, descriptive and analytical study with secondary data from SINAN. All suspected or confirmed children sexual abuse cases, from January 2008 to December 2014, reported by a pediatric hospital in Florianópolis, Santa Catarina were analyzed.

The place where this research was developed is a regional child and adolescent care reference for CSA victims since 2000 and is part of the “Protocol of Care to Victims of Sexual Violence of the Municipality of Florianópolis”. It provides data to SINAN with notifications of any suspected or confirmed cases of domestic violence, sexual violence and/or other violence against children and adolescents, in accordance with the instructions in the notification form.

The information of interest in this study was retrieved from the registration form completed by the professional responsible for the service. The variables described were categorized according to the Ministry of Health's “Instructions for reporting domestic violence, sexual violence and other violence”¹⁹19. Brasil. Ministério da Saúde (MS). Instrutivo de notificação/investigação de violência doméstica, sexual e/ ou outras violências. Brasília: MS; 2009., in data related to the victim, the occurrence, type of sexual violence, consequences, probable perpetrator, referrals and procedures performed with the victims.

Regarding the victim, the following data were considered: age, ethnicity or skin color, disability or disorder and place of residence. Age was recorded in full years at the time of notification and categorized, according to Marcondes et al.²⁰20. Marcondes E, Vaz FAC, Ramos JLA. Pediatria básica: Tomo III - Pediatria clínica especializada. São Paulo: Sarvier; 2004., in the following age groups: 0-2 years (exclusive), 3-6 years (exclusive), 6-10 years (exclusive) and 10-15 years (exclusive). Ethnicity or skin color followed the self-reference of victim/informant according to the options used in the 2010 Census of the Brazilian Institute of Geography and Statistics (IBGE), namely, white, black, yellow, brown or indigenous²¹21. Instituto Brasileiro de Geografia e Estatística (IBGE). População. Indicadores sociais mínimos. Rio de Janeiro: IBGE; 2014.. Disabilities or disorders were classified into visual, hearing, mental, physical and behavioral. They were grouped and generated the variable “disability”, which was dichotomized into “present” or “absent”. The place of residence considered the municipality and its respective Federative Unit (UF)²²22. Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades@. Santa Catarina. Rio de Janeiro: IBGE; 2014..

Regarding the occurrence, the following data were investigated: municipality and respective UF; urban situation (urban, rural or peri-urban); nature of the place where the abuse occurred (residence, collective housing, school, place of sports practice, bar or similar, public highway, trade or services, industries or construction); and number of times the victim was abused (categorized as “once” or “twice and over”). The places of residence and collective housing, which according to instructions, for the pediatric age group, includes shack (workers’ camp), student house (republic), barracks, psychiatric hospital (when used as housing by the person receiving treatment/victim), host institution (shelter), colony hospitals, hostel, socioeducational unit, shelter unit, hostel; they were grouped and generated the variable “residence” and the other places were grouped under the variable “any other place”.

Sexual violence was defined in terms of the presence or absence of sexual harassment, indecent assault and rape.

The occurrence or not of penetration was also analyzed. If it occurred, we established the type: anal, oral or vaginal. Even if Brazilian Federal Law N° 12.015 of 2009²³23. Brasil. Lei n° 12.015, de 07 de agosto de 2009. Altera o Título VI da Parte Especial do Decreto-Lei n° 2.848, de 7 de dezembro de 1940 - Código Penal, e o art. 1o da Lei no 8.072, de 25 de julho de 1990, que dispõe sobre os crimes hediondos, nos termos do inciso XLIII do art. 5o da Constituição Federal e revoga a Lei no 2.252, de 1o de julho de 1954, que trata de corrupção de menores. Diário Oficial da União 2009; 10 ago.^,2424. Brasil. Decreto-Lei n° 2.848, de 7 de dezembro de 1940. Código Penal. Diário Oficial da União 1940; 31 dez. merges under a single item the crimes of rape and indecent assault, we decided to analyze the two concepts separately and jointly, since the record kept the categorization unchanged until 2015. The aforementioned legislation defined Indecent Assault as “to constrain people through violence or serious threat to practice or allow to practice with them a libidinous act other than the carnal conjunction”, whereas rape is defined as “constraining women toward carnal conjunction through violence or serious threat”.

The procedures indicated at the time of notification were listed, according to the need to perform prophylaxis for sexually transmitted infections (STIs), human immunodeficiency virus (HIV), Hepatitis B or Tetanus. The need to collect blood, semen, vaginal secretion and emergency contraception or legal abortion was described. The presence of abortion, pregnancy, STI, attempted suicide, mental or behavioral disorder and Posttraumatic Stress Disorder (PTSD) were investigated as to the consequences of the occurrence detected at the time of notification.

The likely perpetrator of sexual violence was identified regarding gender, number of involved, suspected use of alcohol (if yes or no) and relationship/degree of kinship with the victim (father, mother, stepfather, stepmother, spouse, former spouse, boyfriend, former boyfriend, brother, friend, caregiver, stranger, person in institutional relationship or others). This last variable was analyzed separately and in a grouped form, generating the variable “acquaintance”. In this group, “to be a victim's acquaintance” consisted of “perpetrators”: father, mother, stepfather, stepmother, spouse, former spouse, boyfriend, former boyfriend, brother, friend, caregiver, friend, person in institutional relationship and others.

Victim referral place was also investigated: Guardianship Council, Childhood and Youth Court, Shelter, Sentinel Program, Child and Adolescent Protection Police Department, Public Prosecutor's Office or Institute of Forensic Medicine (IFM).

Data obtained were exported from SINAN in the EXCELÒ format, evaluated separately by three observers and, in case of any issue or disagreement, were verified back in the notification form. These data were then analyzed using statistical software Stata 11.0.

Category variables are shown with prevalence and respective 95% confidence intervals (CI: 95%). The chi-square test was performed to determine the gaps of several variables between genders.

The Human Research Ethics Committee of the Joana de Gusmão Children's Hospital approved the project of this study under Consolidated Opinion N° 922.978. The human research ethics principles found in the resolutions of the National Health Council were respected.

Results

From January 2008 to December 2014, 490 suspected or confirmed cases of CSA were reported. A notification was duplicated and was excluded. Ten cases had two notifications on different dates and one had three separate notifications. Thus, the final sample consisted of 477 children and adolescents.

The distribution of the number of notifications over seven years is shown in Figure 1.

Most victims were female (75.5%), white (78.0%) and had no disability (94.5%). One notification corresponded to an indigenous victim. The most affected female age group was 10-15 years (41.2%) and 2-6 years (42.5%) for males. When the sample was stratified in children and adolescents, according to the Statute of the Child and Adolescent (ECA), CSA prevalence was more frequently observed in children under 12 years of age (67.7%) (Table 1).

Among the municipalities of occurrence, Florianópolis had the highest number of notifications, with 57.9% of cases. The urban area was the most cited area (98.5%), and the victim's or perpetrator's residence was the most frequent place of abuse (81.6%) in both genders. Victims came from 25 different municipalities of Santa Catarina and two municipalities of Rio Grande do Sul.

Regarding characteristics of CSA perpetrators, 66.5% (95% CI: 62.3-70.7) were acquaintances of the victims; predominantly males 91.9% (95% CI 89.3-94.4); had not consumed alcohol during the abuse 68.6% (95% CI 63.174.0); and acted alone 85.2% (95% CI, 81.988.6). The variable “victim acquaintance” appeared more frequently as a perpetrator in both genders (Table 2).

As shown in Table 3, we decided to analyze the types of abuse separately, as described in the notification form, and jointly, in accordance with current legislation²³23. Brasil. Lei n° 12.015, de 07 de agosto de 2009. Altera o Título VI da Parte Especial do Decreto-Lei n° 2.848, de 7 de dezembro de 1940 - Código Penal, e o art. 1o da Lei no 8.072, de 25 de julho de 1990, que dispõe sobre os crimes hediondos, nos termos do inciso XLIII do art. 5o da Constituição Federal e revoga a Lei no 2.252, de 1o de julho de 1954, que trata de corrupção de menores. Diário Oficial da União 2009; 10 ago.. Indecent assault was the most observed abuse among male victims, while rape was more than three times more frequent in females. When associated with the types of violence “indecent assault and rape”, now categorized as “rape” according to the current legal definition, we observed that it was twice as frequent among female victims. When abuse was followed by anal or oral penetration, male victims were the most affected. Vaginal penetration occurred in 59% of the cases (95% CI, 52.4-65.6).

Regarding the procedures performed, referred to at the time of notification, we observed that most of the victims did not perform prophylaxis for STI (71.7%), HIV (72.9%) or Hepatitis B (78.6%). There was no semen collection in 89.2% of cases and vaginal secretion in 75.4%. In the analyzed period, five adolescents (3.5%, 95% CI 0.4-6.5) were referred for legal termination of pregnancy and 48 (16.7%, 95% CI 93.5-99.6) made use of the medication used for emergency contraception. One case of pregnancy (1%) was carried to term, and twelve cases of STIs (3.4%) due to abuse were reported. When analyzed by gender, these data showed no statistically significant difference (Table 4).

Among the immediate consequences, the impact of CSA on the mental health of victims stands out, since four (1%) of these attempted suicide; five (1.3%) developed mental disorder; 90 (22.4%) evidenced behavioral disorders; and 77 (20.0%) had posttraumatic stress disorders. These changes were more prevalent in males and statistically significant in both genders.

The compulsory notification of any suspected or confirmed violence to guardianship councils occurred in 90.5% of the cases. Twenty cases (4.4%) were referred to the Child and Youth Court; 36 (7.9%) to the Sentinel Program; and 26 (5.7%) and 6 (1.3%), respectively, to the Protection Police Department and the Public Prosecutor's Office.

Seven children/adolescents (1.5%) were separated from their families and sent to a Shelter Home. The need for evaluation by an IFM expert physician occurred in 39.4% of notifications (183 cases).

Discussion

For the first time, a detailed evaluation of the data of the state of Santa Catarina on the subject was made, characterizing the profile of victims and their perpetrators.

With data collected in an environment where notifications and victim care occurred simultaneously, it was possible to check the information in medical records, clarify filling issues, eliminate duplicity and perform inferential and association analyses.

Although the Notification Form was not updated in 2009 - when Brazilian legislation changed the concept of abuse classification - it was possible to evaluate the types of abuse in order to consider both old and current concepts in this study.

In Brazil, the phenomenon of violence has mobilized different areas of knowledge to establish partnerships that seek to promote prevention and intervention strategies in addressing the problem²⁵25. Minayo MCS. O significado social e para a saúde da violência contra crianças e adolescentes. In: Westphal MF, organizador. Violência e criança. São Paulo: Ed. USP; 2002. p. 95-11.. This practice aims to ensure compliance with principles legally assured in the ECA regarding policies and programs aimed at social and interpersonal violence against children and adolescents¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389.^,33. Andrews G, Corry J, Slade T, Issakidis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneve: WHO; 2004. p. 1851-1940..

In this country, since 1997, a social reporting tool called Disque Denúncia, popularly known as Disque 100²⁶26. Disque Direitos Humanos - Disque 100 - Disque Denúncia. [acessado 2015 Jun 5]. Disponível em: http://www.crianca.mppr.mp.br/modules/conteudo/conteudo.php?conteudo=3
http://www.crianca.mppr.mp.br/modules/co... is available to people.

It was observed that, although the violence module was entered in SINAN in 2008, the number of notifications remained stable until 2010. The implementation of personnel training policies in the area of violence and dissemination of the electronic tool may have given greater visibility to it or its best use, or both, thus reflecting increased notifications.

The prevalence of reports in females corroborates with literature, which points to a higher frequency of CSA in girls⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^,2727. Cartón Duarte J, Cortés Arboleda MR, Cantón-Cortés D. Variables associated with the nature os sexual abuse to minors. Span J Psychol 2012; 15(2):571-581.

28. Maier T, Mohler-Kuo M, Landolt MA, Schnyder U, Jud A. The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: results from a nationwide agency survey. Int J Public Health 2013; 58(6):875-883.^-2929. Mohler-Kuo M, Landolt MA, Maier T, Meidert U, Schönbucher V, Schnyder U. Child sexual abuse revisited: a population-based cross-sectional study among swiss adolescents. J Adolesc Health 2014; 54(3):304-311..

As in previous studies, this study showed that the association of age and gender evidences a tendency for boys to be abused at earlier ages⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^,99. Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 2008; 32(6):607-619., possibly because they do not have the physical development to offer resistance³⁰30. Aded NLO, Dalcin BLGS, Cavalcanti MT. Estudo da incidência de abuso sexual contra crianças no Rio de Janeiro, Brasil. Cad Saude Publica 2007; 23(8): 1971-1975.

31. Hohendorff JV, Habigzang LF, Koller SH. Violência sexual contra meninos: dados epidemiológicos, características e consequências. Psicol USP 2012; 23(2):395-415.^-3232. Martins CBG, Melo Jorge MHP. Abuso sexual na infância e adolescência: perfil das vítimas e agressores em município do Sul do Brasil. Texto Contexto Enferm 2010; 19(2):246-255.. On the other hand, girls suffer abuse later in life³³33. Bassani DG, Palazzo LS, Beria JU, Gigante LP, Figueiredo ACL, Aerts DRGC. Child sexual abuse in southern Brazil and associated factors: a population-based study. BMC Public Health 2009; 9:133.

34. Silva MCM, Brito AM, Araújo AL, Abath MB. Caracterização dos casos de violência física, psicológica, sexual e negligências notificados em Recife, Pernambuco, 2012. Epidemiol Serv Saúde 2013; 22(3):403-412.^-3535. Furniss T. Abuso Sexual da criança: uma abordagem multidisciplinar: manejo, terapia & intervenção legal integrados. Porto Alegre: Artes Médicas; 1993., which was also observed in this study.

The fact that most of the notifications correspond to female victims may be partly justified by the underreporting of CSA in males, due to the prejudice that arises regarding sexual identity after the boy is abused⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665..

A question debated by Araújo that also justifies the greatest number of female cases is because CSA involves two basic inequalities, namely, gender and generation. In the author's case reports, gender and the economic factor were prominent issues: Male domination and female submission are crystallized and naturalize the production and repetition of abusive behaviors by the man holding the power of father, the material provider and head of the family. By placing themselves in the condition of inferiority, women themselves delegate powers to their husbands, companions and fathers. And this is where they reproduce abusive behavior³⁶36. Araújo MF. Violência e abuso sexual na família. Psicologia em Estudo 2002; 7(2):3-11..

The highest occurrence of abuse occurred among children under 12 years of age (67.7%). In a meta-analysis conducted by WHO, it was observed that the age of the abuse event varied considerably between the 22 studies; however, its onset was consistently more prevalent at the age range of 5-14 years for both males and females³3. Andrews G, Corry J, Slade T, Issakidis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneve: WHO; 2004. p. 1851-1940.. Aded et al.³⁰30. Aded NLO, Dalcin BLGS, Cavalcanti MT. Estudo da incidência de abuso sexual contra crianças no Rio de Janeiro, Brasil. Cad Saude Publica 2007; 23(8): 1971-1975. inferred that, for victims in a higher age group, there could be some difficulty in reporting complaints of sexual abuse due to the possible embarrassment and family and social repercussions³⁵35. Furniss T. Abuso Sexual da criança: uma abordagem multidisciplinar: manejo, terapia & intervenção legal integrados. Porto Alegre: Artes Médicas; 1993.. In some societies, the practice of sexual activity at ages greater than twelve years may not be considered abuse³⁵35. Furniss T. Abuso Sexual da criança: uma abordagem multidisciplinar: manejo, terapia & intervenção legal integrados. Porto Alegre: Artes Médicas; 1993..

People with physical or mental disabilities are more at risk and more vulnerable to violence of all kinds, including sexual violence³⁵35. Furniss T. Abuso Sexual da criança: uma abordagem multidisciplinar: manejo, terapia & intervenção legal integrados. Porto Alegre: Artes Médicas; 1993.. Although no significant difference was evidenced by the chi-square test, we found that 27 victims (5.5%) had some disability, whether physical or mental, disorder or syndrome. A hypothesis considers that the physical/mental limitation itself is a determinant of the low reporting rate due to its high degree of physical and sensorial dependence, and because the clinical signs and symptoms of abuse are often ignored because they are considered a result of the main disease³⁷37. Pfeiffer L, Salvagni EP. Visão atual do abuso sexual na infância e adolescência. J Pediatr (Rio J) 2005; 81(5-Supl.):s197-s204..

The population of the southern region of the country is predominantly white²¹21. Instituto Brasileiro de Geografia e Estatística (IBGE). População. Indicadores sociais mínimos. Rio de Janeiro: IBGE; 2014.^,3838. Instituto Brasileiro de Geografia e Estatística (IBGE). População: indicadores sociais mínimos. Rio de Janeiro: IBGE; 2014. and therefore most of the victims are expected to be white, corroborating with a study carried out in Rio Grande do Sul³⁹39. Zanatta EA, Dal Pai D, Resta DG, Argenta C, Motta MGC. Caracterização das notificações de violência contra adolescentes. Enferm foco 2012; 3(4):165-168. and differing from the survey conducted by Silva et al., in Recife, where most victims were brown³⁴34. Silva MCM, Brito AM, Araújo AL, Abath MB. Caracterização dos casos de violência física, psicológica, sexual e negligências notificados em Recife, Pernambuco, 2012. Epidemiol Serv Saúde 2013; 22(3):403-412.. The low prevalence of indigenous race in the study, one case of an indigenous girl residing in the municipality of José Boiteux, where there is an indigenous reserve, was also observed by Zanatta et al.³⁹39. Zanatta EA, Dal Pai D, Resta DG, Argenta C, Motta MGC. Caracterização das notificações de violência contra adolescentes. Enferm foco 2012; 3(4):165-168..

The highest number of CSA notifications in the urban population of this study can be attributed to the greater population concentration in this area or to rural communities’ difficult access to the reference sites⁴⁰40. Pires JM, Goldani MZ, Vieira EM, Nava TR, Feldens L, Castilhos K, Simas V, Franzon NS. Barreiras, para a notificação pelo pediatra, de maus tratos infantis. Rev Bras Saúde Mater Infant 2005; 5(1):103-108.. It may also stem from cultural issues typical of rural areas that hinder the disclosure of abuse³⁷37. Pfeiffer L, Salvagni EP. Visão atual do abuso sexual na infância e adolescência. J Pediatr (Rio J) 2005; 81(5-Supl.):s197-s204.^,4141. Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson textbook of pediatrics [e-book]. 19th ed. Philadelphia: Saunders Elsevie; 2011.. Of these features, while not exclusive to the rural population, we can mention the tendency to value family life privacy, or even the reproduction of a family culture of violence and sexual abuse that are protected by the law of silence³⁶36. Araújo MF. Violência e abuso sexual na família. Psicologia em Estudo 2002; 7(2):3-11.. There is also the possibility of non-confrontation with parents’ discourse to avoid intra-family conflict⁴¹41. Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson textbook of pediatrics [e-book]. 19th ed. Philadelphia: Saunders Elsevie; 2011..

CSA records in other municipalities besides Florianópolis is because the hospital where the notifications were made is a regional reference in the pediatric services. It is worth noting that small municipalities have referred victims to this hospital without prior notification in the health facility of their city. The possible fear of the professional who made the diagnosis suffering community or victims’ parents retaliation arises⁴⁰40. Pires JM, Goldani MZ, Vieira EM, Nava TR, Feldens L, Castilhos K, Simas V, Franzon NS. Barreiras, para a notificação pelo pediatra, de maus tratos infantis. Rev Bras Saúde Mater Infant 2005; 5(1):103-108.. Gonçalves and Ferreira do not point this as a relevant factor for non-notification. These authors argue that threats of perpetrators to relatives who try to seek the health sector are of greater impact⁴²42. Gonçalves HS, Ferreira AL. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde. Cad Saude Publica 2002; 18(1):315-319.. The family may also be fearful in seeking help in services from their place of residence because it is a health problem that generates prejudice and stigmatization³⁷37. Pfeiffer L, Salvagni EP. Visão atual do abuso sexual na infância e adolescência. J Pediatr (Rio J) 2005; 81(5-Supl.):s197-s204.. This shows how important it is to ensure information confidentiality by the entire team of professionals attending these victims³⁵35. Furniss T. Abuso Sexual da criança: uma abordagem multidisciplinar: manejo, terapia & intervenção legal integrados. Porto Alegre: Artes Médicas; 1993..

Other justifications for the large number of notifications in Florianópolis is due to the fact that this municipality is more populous⁴³43. Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades@. Santa Catarina. Rio de Janeiro: IBGE; 2014., has a more organized health care network and with a protocol to service people in situations of sexual violence implanted 15 years ago⁴⁴44. Prefeitura Municipal de Florianópolis, Secretaria Municipal de Saúde, Programa Saúde da Mulher. Protocolo de atenção as vítimas de violência sexual do município de Florianópolis. Tubarão: Copiart; 2010..

Worth mentioning are cases that occurred in other federative units and notified in Florianópolis. It is known that in some situations children and adolescents are sent to live with relatives when abuse is discovered or the family moves to another location. Only after the change of environment does the disclosure of abuse occur⁴⁵45. Drezett J, Caballero M, Juliano Y, Prieto ET, Marques JA, Fernandes CE. Estudo de mecanismos e fatores relacionados com o abuso sexual em crianças e adolescentes do sexo feminino. J Pediatric (Rio J) 2001; 77(5):413-419..

The home of the victim or the perpetrator as the predominant place of abuse agrees with literature⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^,2727. Cartón Duarte J, Cortés Arboleda MR, Cantón-Cortés D. Variables associated with the nature os sexual abuse to minors. Span J Psychol 2012; 15(2):571-581.^,2929. Mohler-Kuo M, Landolt MA, Maier T, Meidert U, Schönbucher V, Schnyder U. Child sexual abuse revisited: a population-based cross-sectional study among swiss adolescents. J Adolesc Health 2014; 54(3):304-311.^,3232. Martins CBG, Melo Jorge MHP. Abuso sexual na infância e adolescência: perfil das vítimas e agressores em município do Sul do Brasil. Texto Contexto Enferm 2010; 19(2):246-255.^,4545. Drezett J, Caballero M, Juliano Y, Prieto ET, Marques JA, Fernandes CE. Estudo de mecanismos e fatores relacionados com o abuso sexual em crianças e adolescentes do sexo feminino. J Pediatric (Rio J) 2001; 77(5):413-419., which alerts us to the realization that the traditional “private barrier” between domestic and public spheres has inhibited the development of policies and legal devices to prevent domestic violence and provide services to those affected by it¹1. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics 1978; 62(3):382-389.^,4242. Gonçalves HS, Ferreira AL. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde. Cad Saude Publica 2002; 18(1):315-319.. Pfeiffer and Salvagni³⁷37. Pfeiffer L, Salvagni EP. Visão atual do abuso sexual na infância e adolescência. J Pediatr (Rio J) 2005; 81(5-Supl.):s197-s204. says this phenomenon is concealed by secrecy, the “wall of silence”, which includes family members, neighbors and sometimes professionals who provide care to children who are victims of violence.

Results from national and international studies indicate that the main perpetrator of the abuse is known to victims and their families⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^,2727. Cartón Duarte J, Cortés Arboleda MR, Cantón-Cortés D. Variables associated with the nature os sexual abuse to minors. Span J Psychol 2012; 15(2):571-581.^,2828. Maier T, Mohler-Kuo M, Landolt MA, Schnyder U, Jud A. The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: results from a nationwide agency survey. Int J Public Health 2013; 58(6):875-883.^,4545. Drezett J, Caballero M, Juliano Y, Prieto ET, Marques JA, Fernandes CE. Estudo de mecanismos e fatores relacionados com o abuso sexual em crianças e adolescentes do sexo feminino. J Pediatric (Rio J) 2001; 77(5):413-419.. This was also evidenced in this study, emphasizing that the perpetrator of the abuse had close relationships with its victims.

In 2006, in the U.S., in confirmed cases, 26.0% of CSA perpetrators were parents⁴⁶46. Baptista RS, França ISX, Costa CMP, Brito VRS. Caracterização do abuso sexual em crianças e adolescentes notificado em um Programa Sentinela. Acta Paul Enferm 2008; 21(4):602-608.. In Switzerland, in 2013, Maier et al.²⁸28. Maier T, Mohler-Kuo M, Landolt MA, Schnyder U, Jud A. The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: results from a nationwide agency survey. Int J Public Health 2013; 58(6):875-883. identified the father as the most frequent culprit. These authors said children are more often threatened and victimized by members of their own family, in the following decreasing order of incidence: parents, siblings, mothers and other caregivers.

In this study, the father as the perpetrator of the abuse occurred in 17.5% of the cases. A prevalence of 21.7% of the father being the culprit of the abuse was found by Drezett et al.⁴⁵45. Drezett J, Caballero M, Juliano Y, Prieto ET, Marques JA, Fernandes CE. Estudo de mecanismos e fatores relacionados com o abuso sexual em crianças e adolescentes do sexo feminino. J Pediatric (Rio J) 2001; 77(5):413-419. and Baptista et al.⁴⁶46. Baptista RS, França ISX, Costa CMP, Brito VRS. Caracterização do abuso sexual em crianças e adolescentes notificado em um Programa Sentinela. Acta Paul Enferm 2008; 21(4):602-608. pointed out the abuser's bond with the victim in the following order: father, stepfather, uncle, grandfather, cousin. Gawryszewski et al.⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665., in São Paulo, found that, in 43.8% of cases, those responsible for the victims were the perpetrators of the abuse.

Most of the abusers were male, a result similar to several surveys⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665.^,2929. Mohler-Kuo M, Landolt MA, Maier T, Meidert U, Schönbucher V, Schnyder U. Child sexual abuse revisited: a population-based cross-sectional study among swiss adolescents. J Adolesc Health 2014; 54(3):304-311.^,3232. Martins CBG, Melo Jorge MHP. Abuso sexual na infância e adolescência: perfil das vítimas e agressores em município do Sul do Brasil. Texto Contexto Enferm 2010; 19(2):246-255.^,3636. Araújo MF. Violência e abuso sexual na família. Psicologia em Estudo 2002; 7(2):3-11.. In this study, female authors victimized both genders, with a rate of 4.7%, unlike that observed by Cartón Duarte et al.²⁷27. Cartón Duarte J, Cortés Arboleda MR, Cantón-Cortés D. Variables associated with the nature os sexual abuse to minors. Span J Psychol 2012; 15(2):571-581., in which female perpetrators only made victims of the same gender. The prevalence of female authorship found by Maier et al.²⁸28. Maier T, Mohler-Kuo M, Landolt MA, Schnyder U, Jud A. The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: results from a nationwide agency survey. Int J Public Health 2013; 58(6):875-883. was 4.5%, and 2.1% by Martins and Melo Jorge³²32. Martins CBG, Melo Jorge MHP. Abuso sexual na infância e adolescência: perfil das vítimas e agressores em município do Sul do Brasil. Texto Contexto Enferm 2010; 19(2):246-255.. According to Linsay et al.⁴⁷47. Lindsay W, Steptoe L, Haut F. Brief report: the sexual and physical abuse histories of offenders with intellectual disability. J Intellect Disabil Res 2012; 56(3):326-331., CSA female authors had higher rates of prior child abuse.

Usually, the perpetrator acts alone. The prevalence of more than one person in the crime of abuse occurred in 14.8% in this study, similar to that described by Drezett et al.⁴⁵45. Drezett J, Caballero M, Juliano Y, Prieto ET, Marques JA, Fernandes CE. Estudo de mecanismos e fatores relacionados com o abuso sexual em crianças e adolescentes do sexo feminino. J Pediatric (Rio J) 2001; 77(5):413-419., which was 10.0%.

Regarding the type of abuse, if the definition of indecent assault that existed prior to the amendment of the 2009 legislation was used, the prevalence of 40.7% is observed, similar to that described by Maier et al.²⁸28. Maier T, Mohler-Kuo M, Landolt MA, Schnyder U, Jud A. The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: results from a nationwide agency survey. Int J Public Health 2013; 58(6):875-883., in which abuse without contact or with contact but without penetration had a prevalence ranging from 36% and 42%. In the study by Cartón Duarte et al²⁷27. Cartón Duarte J, Cortés Arboleda MR, Cantón-Cortés D. Variables associated with the nature os sexual abuse to minors. Span J Psychol 2012; 15(2):571-581., this rate was 63.0%.

In 2009, Gilbert et al.⁴⁸48. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009; 373(9657):68-81. reported that, during childhood, 5-10% of girls and 5.0% of boys are exposed to CSA with penetration. Mohler-Kuo et al.²⁹29. Mohler-Kuo M, Landolt MA, Maier T, Meidert U, Schönbucher V, Schnyder U. Child sexual abuse revisited: a population-based cross-sectional study among swiss adolescents. J Adolesc Health 2014; 54(3):304-311. reported a prevalence of 2.5% of CSA with contact and penetration in female victims, and 0.6% in males. This prevalence is much lower and contrary to that found in this study where, of the 285 cases evaluated in this issue, 56.1% of female victims and 72.5% of male victims had some type of penetration.

This discrepancy may be due to the fact that the study was carried out in Switzerland and the design of this study - population-based studies and case studies produce quite different results, and due attention should be paid to existing methodological gaps. Thus, as Collin-Vézina et al.⁴⁹49. Collin-Vézina D, Hélie S, Trocmé N. Is child sexual abuse declining in Canada? An analysis of child welfare data. Child Abuse Negl 2010; 34(11):807-812. warn, the results of studies in this area cannot be extrapolated to the other countries without considering the gaps between cultures and social contexts.

STIs and pregnancy prophylaxis is indicated in cases in which the victim arrives at the service until 72 hours after the abuse and there is contact with secretions⁴²42. Gonçalves HS, Ferreira AL. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde. Cad Saude Publica 2002; 18(1):315-319.. Diagnostic serological tests before prophylaxis are recommended internationally³3. Andrews G, Corry J, Slade T, Issakidis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneve: WHO; 2004. p. 1851-1940. because they allow the identification of STIs mainly in children under 10 years of age. It should be noted that, in developed countries, reliable rapid tests are available through polymerase chain reaction (PCR), not routinely advocated in Brazil, which may explain the low prophylaxis rates in this study⁴¹41. Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson textbook of pediatrics [e-book]. 19th ed. Philadelphia: Saunders Elsevie; 2011..

The routine of the consultations carried out in the analyzed cases followed the Protocol of the Network of Comprehensive Care to People in Situation of Sexual Violence (RAIVS). This protocol uses serological tests to investigate infectious diseases. Because the results of these tests are not immediate, when treated within the first 72 hours and given an indication of drug use, victims receive antibiotics for bacterial STIs prophylaxis and two antiretroviral medications, in addition to emergency contraception⁴³43. Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades@. Santa Catarina. Rio de Janeiro: IBGE; 2014.. The cases of non-accomplishment of drug prophylaxis may correspond to the failure to comply with what is recommended in the RAIVS Protocol, since many cases were only suspected, there was no contact with secretion and the notification occurred after 72 hours.

The procedures recommended for the prophylaxis of Hepatitis B were less successful when compared to those of STIs and HIV. This can be attributed to the possibility of the victim having the complete vaccination scheme, checked in the child or adolescent health booklet during care. As the number of treatment to female victims was proportionally higher than male victims, the highest number of procedures occurred for females, although statistical differences were not significant.

The compulsory referral to protective institutions, such as the Guardianship Council seen by Gawryszewski et al.⁷7. Gawryszewski VP, Valencich DM, Carnevalle CV, Marcopito LF. Child and adolescent abuse in the state of São Paulo, Brazil, 2009. Rev Assoc Med Bras 2012; 58(6):659-665., was 70.7%. Despite the obligation to notify any suspected or confirmed cases of violence to the guardianship councils since 1990⁵⁰50. Brasil. Portaria n° 1.968/GM/MS, de 25 de outubro de 2001. Dispõe sobre a notificação, às autoridades-competentes, de casos de suspeita ou de confirmação de-maus-tratos contra-crianças e adolescentes atendidos nas entidades do Sistema Unido de Saúde. Diário Oficial da União 2001; 26 out., we note that it did not occur in its entirety.

Flahertye et al.⁵¹51. Flaherty EG, Macmillan HL, Committee on Child Abuse and Neglect. Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics 2013; 132(3):590-597. report that some pediatricians are reluctant to involve protection agencies, even if there is a strong indication of abuse. These authors cite as reasons for this reluctance the distrust in these agencies, the fear that the child will be withdrawn from the family life, implying a double effect situation, since it creates another harm⁵²52. Ferreira AL, Schramm FR. Ethical implications of domestic violence against child for the health care professionals. Rev Saude Publica 2000; 34(6):659-665., as well as the belief that they can solve the whole problem alone⁴⁹49. Collin-Vézina D, Hélie S, Trocmé N. Is child sexual abuse declining in Canada? An analysis of child welfare data. Child Abuse Negl 2010; 34(11):807-812.. It is observed that when the abuse is revealed, the family system can be undone, with the possibility of children being removed from their own homes¹⁴14. Cummings M, Berkowitz SJ, Scribano PV. Treatment of childhood sexual abuse: an updated review. Curr Psychiatry Rep 2012; 14(6):599-607.. In this study, this situation was seen in seven cases, less than reported by Pereda et al.²2. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl 2009; 33(6):331-342. in their publication in 2006.

Shocking issues like CSA cause numerous sequels with lifelong repercussion. The SINAN Notification Form allowed the evaluation of some of them. In the seven-year period covered by this study, pregnancy rates, legal abortion and STIs were respectively 1.0%, 3.5% and 3.4%. According to the American Academy of Pediatrics⁵³53. American Academy of Pediatrics Committee on Infectious Diseases, Kimberlin DW, Brady MT, Jackson MA, SS Long, editors. Red book®: 2009 - Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village: American Academy of Pediatrics; 2009. p. 758., approximately 5.0% of sexually abused children contract an STI from their victimizers. Hillis et al.⁵⁴54. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics 2004 [acessado 2014 Jan 15];113(2):320-327. noted the small to moderate effects of CSA on increasing rates of adolescent pregnancy, abortion and the risk of contracting STIs.

The suicide attempt observed in this study is different from that found in the population-based cohort of Fergusson et al.⁹9. Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl 2008; 32(6):607-619. in New Zealand, which showed a prevalence of suicide attempts of 11.021.0% in young adults and adolescents who experienced severe physical violence and penetrative sexual abuse, against 1.0-3.0% of controls. It is possible to presume that, if follow-up data on victims were available, the repercussion could be better evaluated by a specialized professional and the prevalence would be higher.

Cummings et al.¹⁴14. Cummings M, Berkowitz SJ, Scribano PV. Treatment of childhood sexual abuse: an updated review. Curr Psychiatry Rep 2012; 14(6):599-607. found a prevalence of PTSD ranging from 37.0% to 53.0% among abused children; Chen et al.¹¹11. Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, Elamin MB, Seime RJ, Shinozaki G, Prokop LJ, Zirakzadeh A. Sexual abuse and lifetime diagnosis of psyquiatric disorders: systematic review and meta-analysis. Mayo Clin Proc 2010; 85(7):618-629. found a prevalence of 23.0% in pre-adolescent victims. In the data collection tool used is the alternative of PTSD, which appeared in this study in 20.0% of the cases. This data can be analyzed critically, since in order to establish the PTSD diagnosis, some requirements are necessary, such as a minimum time of symptoms of three months⁵⁵55. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: DSM; 2013., which is impossible in cases of acute CSA, with less than 72 hours of development. Another suggestion to the “PTSD consequence” in the record would be the presence of the Acute Stress Disorder option.

The potential limitations of this study may be those related to the use of secondary data, minimized by the verification of their veracity in the medical records of the victims who underwent the institution's follow-up. Underreporting, which can be attributed both to the family's denial of seeking help and by simulating other situations to justify the injuries of the victims, which is not always identified as sexual abuse by the care provider³⁰30. Aded NLO, Dalcin BLGS, Cavalcanti MT. Estudo da incidência de abuso sexual contra crianças no Rio de Janeiro, Brasil. Cad Saude Publica 2007; 23(8): 1971-1975..

Some CSA-relevant indicators were not included in the analysis because they used a nationally standardized record for reporting cases of sexual violence with pre-determined data.

It is fundamental to make SINAN's filling instructions more accessible, since when analyzing the database, we asked whether the person who filled the database was aware of the definitions, and incomplete filling compromises the analysis of some variables¹²12. Salter D, McMillan D, Richards M, Talbot T, Hodges J, Bentovim A, Hastings R, Stevenson J, Skuse D. Development of sexually abusive behaviour in sexually victimised males: a longitudinal study. Lancet 2003; 361(9356):471-476.. It is important to carry out more frequent multidisciplinary trainings on CSA and on the reporting tool in all regions of the state and to actively search for notified cases that do not return to outpatient follow-up⁵⁶56. Brasil. Portaria n° 485/GM/MS, de 1 de abril de 2014. Redefine o funcionamento do Serviço de Atenção às Pessoas em Situação de Violência Sexual no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2014; 2 abr..

When faced with situations of violence against children, professionals mobilize emotions and feelings that do not always allow rational decision-making, a fact that may hamper the proper completion of the notification form. The importance of multidisciplinary and inter-sectoral work that involves integrated actions of care and health care, punishment of perpetrators and protection of children and families subjected to situations of violence and sexual abuse are high-lighted³⁶36. Araújo MF. Violência e abuso sexual na família. Psicologia em Estudo 2002; 7(2):3-11..

It is also necessary to think that the incomplete filling can occur from the place where it is usually performed: emergency room of public hospitals, with great demand for patients, long queues and the time required for its completion.

Conclusions

In the 7-year period analyzed, of the 489 CSA reports, 369 corresponded to female victims and 120 male victims. The most affected age group was 10-15 years in girls and 2-6 years in boys. Residence was the most frequent place of abuse and perpetrators were mostly men, who in 66.5% of the cases were known to the victims. Recurrent abuse was more frequent in male victims. In 3.5% of the cases, there was a legal interruption of gestation and 1.0% carried the pregnancy to term.

CSA's features were very similar to those of several places in Brazil, showing that national coordinated actions are possible to prevent this.

This is an extremely important issue in the social area, with great repercussion on the future lives of those involved, especially children, and therefore actions are urgently required to control this serious Brazilian Public Health problem.

Acknowledgments

We wish to thank Dr. Eliane Vieira Araújo, Epidemiology Center of the Joana de Gusmão Children's Hospital, as well as children in situations of violence, for their motivation to make this data public.

References

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