Abstract

Violence against women is characterised by male symbolic domination underpinned by patriarchy and expressing gender inequality in society. This study examined reporting of interpersonal violence against cisgender and transgender women 20 to 59 years old in Brazilian municipalities, from 2015 to 2021. This repeat panel study used data from the information system, and time-trend analysis by the Prais-Winsten method. A total of 605,983 notifications were eligible, 1.8% of which involved transgender women. Notifications regarding cisgender women were recorded in 84.8% of the municipalities and transgender women, in 31.7%. Notifications involved predominantly women who were younger (71.9%) and black (55.3%), and proportionally more transgender women (p<0.001). Most notifications were of physical violence (84.8%), followed by psychological violence (40.1%), which was higher among cisgender women (p<0.001) and at shorter intervals among transgender women (β=-0.71; p=0.005). Notifications of violence still do not reflect the realities, particularly as regards transgender women. Psychological violence, however, which usually starts the cycle of aggression, now ranks second among notifications in Brazil, despite conservative reverses of recent years.

Key words:
Gender-based violence; Health Information Systems; Human Rights

Introduction

Interpersonal violence is behaviour in which an individual uses physical force, power or psychological influence to dominate or exclude another. Violent methods have been common since Antiquity, but it is only since the 19^th century that have been discussed by researchers in various fields, when interpersonal violence began to be considered a social phenomenon¹1 Hayeck CM. Refletindo sobre a violência. RBHC 2009; 1(1):1-8..

In the health field, the first International Classification of Diseases (ICD) included violence as a cause of death in the chapter on conditions from external causes²2 Laurenti R. Análise da informação em saúde: 1893-1993, cem anos da Classificação Internacional de Doenças. Rev Saude Publica 1991; 25(6):407-417.. It was not until the late 20^th century, however, that violence came to be regarded as an avoidable public health problem and a World Health Organization priority³3 Krug EG, Dahlberg LL, Mercy JA, Zwi BA, Lozano R, editores. Relatório mundial sobre violência e saúde [Internet]. 2002 [acessado 2022 maio 5]. Disponível em: https://www.opas.org.br/relatorio-mundial-sobre-violencia-e-saude.
https://www.opas.org.br/relatorio-mundia... . Before publication of the WHO’s World Report on Violence and Health, Brazil had introduced a National Policy to Reduce Morbidity and Mortality from Accidents and Violence⁴4 Brasil. Ministério da Saúde (MS). Portaria nº 737, de 16 de maio de 2001. Política nacional de redução da morbimortalidade por acidentes e violências. Diário Oficial da União 2001; 18 maio. and later set up a National Violence Prevention and Health Promotion Network⁵5 Brasil. Ministério da Saúde (MS). Portaria nº 936, de 19 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União 2004; 20 maio..

Violence against women is characterised especially by male symbolic domination rooted in patriarchy and expressing the gender inequality that exists in society⁶6 Bandeira LM. Violência de gênero: a construção de um campo teórico e de investigação. Soc Estado 2014; 29(2):449-469.. Violence against women gained a voice through feminist movements, leading to a number of gains, including implementation, in 1986, of Brazil’s first specialised police station to assist women and, in 2003, of the federal Special Secretariat for Women’s Policies⁷7 Brasil. Secretaria de Políticas para as Mulheres (SPM). Política Nacional de Enfrentamento à Violência contra as Mulheres Brasília: SPM; 2011.. It was not until 2005, however, that the criminal code was reformed so that the crime of sexual violence would no longer be annulled in the event the aggressor or another man married the rape victim. Articles on the crime of adultery by women and prejudiced terms such as “honest woman” and “virgin woman” were also excised⁸8 Brasil. Lei nº 11.106, de 28 de março de 2005. Altera os arts. 148, 215, 216, 226, 227, 231 e acrescenta o art. 231-A ao Decreto-Lei nº 2.848, de 7 de dezembro de 1940 - Código Penal e dá outras providências. Diário Oficial da União 2005; 29 mar.. The following year, the “Maria da Penha” law⁹9 Brasil. Lei nº 11.340, de 7 de agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher, nos termos do § 8º do art. 226 da Constituição Federal, da Convenção sobre a Eliminação de Todas as Formas de Discriminação contra as Mulheres e da Convenção Interamericana para Prevenir, Punir e Erradicar a Violência contra a Mulher; dispõe sobre a criação dos Juizados de Violência Doméstica e Familiar contra a Mulher; altera o Código de Processo Penal, o Código Penal e a Lei de Execução Penal; e dá outras providências. Diário Oficial da União 2006; 8 ago. was sanctioned to curb and prevent violence by instituting care and protection measures for women in situations of family and domestic violence. Violence against women is any gender-based action, in the public or private sphere, that causes physical, psychological or moral suffering or death. Almost ten years later, the term femicide was subsumed under qualified homicide, that is, murder of a woman because of her womanhood¹⁰10 Brasil. Lei nº 13.104, de 9 de março de 2012. Altera o art. 121 do Decreto-Lei nº 2.848, de 7 de dezembro de 1940 - Código Penal, para prever o feminicídio como circunstância qualificadora do crime de homicídio, e o art. 1º da Lei nº 8.072, de 25 de julho de 1990, para incluir o feminicídio no rol dos crimes hediondos. Diário Oficial da União 2012; 13 mar..

The rights of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (LGBT) were included on public policy agendas much later, particularly those of transvestites and transsexuals. Among the rights established were recognition for same-sex unions, the inclusion of social names in documents, access through Brazil’s national health system (Sistema Único de Saúde, SUS) to specific healthcare policies and sexual reassignment surgery with follow-up throughout the transsexualisation process, as well as recognition that discrimination based on sexual orientation and gender identity is a crime under Brazil’s anti-racism law. Brazil, however, appears still to be the country most intolerant of diversity¹¹11 Grupo gays da Bahia (GGB). Mortes violentas de LGBT+ no Brasil: relatório 2018 [Internet]. 2019 [acessado 2022 out 3]. Disponível em: https://observatoriomorteseviolenciaslgbtibrasil.org/wp-content/uploads/2022/05/Relatorio-2018.pdf.
https://observatoriomorteseviolenciaslgb... , ranking fifth worldwide in violence against cisgender women¹²12 Waiselfisz JJ. Mapa da violência 2015: homicídios de mulheres no Brasil [Internet]. 2015 [acessado 2022 fev 2]. Disponível em: https://oig.cepal.org/sites/default/files/mapaviolencia_2015_mulheres.pdf.
https://oig.cepal.org/sites/default/file... and first among countries that kill transgender people, most of whom are transvestites and transsexual women¹³13 Transgender Europe (TGEU). TMM annual report 2016 [Internet]. 2016 [cited 2022 maio 5]. Available from: https://transrespect.org/wp-content/uploads/2016/11/TvT-PS-Vol14-2016.pdf.
https://transrespect.org/wp-content/uplo... .

Reporting of self-inflicted and interpersonal violence was implemented gradually in Brazil, but not until 2011 did it feature on the compulsory reporting list¹⁴14 Brasil. Ministério da Saúde (MS). Portaria nº 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme 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 estabelecer fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. Diário Oficial da União 2011; 26 jan. and entered the national Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação - Sinan). The variables “sexual orientation” and “gender identity” were not included on the notification form until 2015¹⁵15 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. VIVA: instrutivo notificação de violência interpessoal e autoprovocada. 2ª ed. Brasília: MS; 2016., to comply with the National Comprehensive Health Programme for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (Política Nacional de Salud Integral LGBT, PNSI LGBT)¹⁶16 Brasil. Ministério da Saúde (MS). Portaria nº 2.836, de 1 de dezembro de 2011. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Diário Oficial da União 2011; 2 dez..

Notification of interpersonal and self-inflicted violence, besides providing information, is a dimension of the line of care that can bring to light the problem of violence and inform public prevention policies, which is the first step towards overcoming the problem¹⁷17 Brasil. Ministério da Saúde (MS). Notificação de violências interpessoais e autoprovocadas. Brasília: MS; 2017..

This study examined notification of interpersonal violence against cisgender and transgender women in Brazilian municipalities, from 2015 to 2021, as a contribution to the debate on action to combat violence.

Methods

This is a repeat panel study - a hybrid design combining cross-sectional and cohort studies¹⁸18 Klein CH, Block KV. Estudos Secionais. In: Medronho RA, Block KV, Luiz RR, Werneck GL. Epidemiologia. 2ª ed. São Paulo: Editora Atheneu; 2009. p. 193-219. - on interpersonal violence against a population of 20 to 59 year old transgender and cisgender women, from 2015 to 2021, in Brazilian municipalities. Files of compressed anonymised microdata were downloaded from the website of the SUS Informatics Department (DATASUS), in the second fortnight of April 2022. The variables analysed with regard to socioeconomic and demographic characteristics of victims and aggressors, violence and motivation for violence were available on the notification forms. The study was exempted from ethics scrutiny by the research ethics committee of the Sérgio Arouca National School of Public Health (Escola Nacional de Saúde Pública Sérgio Arouca - ENSP) of the Osvaldo Cruz Foundation (Fiocruz), as in opinion 03/2022 of 12 April, 2022.

Each category of each study variable was expressed as a percentage, which was then stratified by cisgender and transgender women. Pearson’s chi-square test was used to assess for statistically significant differences between strata (p≤0.05), with Yates correction where necessary.

The time trend was described using year of notification as the independent variable and the proportions of types of violence reported, and other characteristics, for each population (transgender and cisgender women), as the dependent variable. The data were evaluated by applying a generalised linear model, with the Prais-Winsten method and respective statistical significance (p≤0.05). Also, the Durbin-Watson (d) statistic was used to assess for the existence of residual autocorrelation¹⁹19 Gujarati DN, Porter DC. Econometria básica. 5ª ed. Porto Alegre: AMGH; 2011., with results between 1.356 and 2.644 confirming there is no autocorrelation, while values above 3.300 indicate the existence of negative autocorrelation, and below 0.700, positive autocorrelation. The intervals between the specified points are inconclusive (Indecision Zone) and thus cannot rule out autocorrelation. The data were analysed in the R statistical programme, version 3.4.3, using the read.dbc, foreign, MASS and prais libraries.

Results

A total of 2,107,819 cases of violence were reported during the study period, 605,983 (28.7%) of which were eligible for the study. Of these latter, 11,211 (1.8%) occurred against transgender women. Percentage reports of violence against transgender women was stable during the period (p=0.406): lowest in 2019 (1.7%) and highest in 2016 (2.2%).

Of the notifying municipalities, 84.8% recorded violence against cisgender women, ranging from 74.0% in the Northeast region to 92.7% in the Southeast (Table 1). Only 31.7% of the municipalities reported violence against transgender women, ranging from 20.2% in the Northeast to 46.9% in the Southeast, with highest percentages in municipalities of the state of Acre (54.5%) and Rio de Janeiro (60.9%). The percentage of municipalities notifying violence against transgender women increased in the study period in the states of Amazonas (β=0.54; p=0.015; d=1.990) and Rio de Janeiro (β=0.84; p=0.018; d=1.572). On the other hand, the percentage of municipalities reporting violence against transgender women declined in the states of Rio Grande do Norte (β=-0.37; p=0.005, d=1.993), Pernambuco (β=-0.63; p=0.022; d=2.288) and Tocantins (β=-0.41; p=0.037; d=1.901).

Table 2 shows the characteristics of cisgender and transgender women reporting interpersonal violence. Notifications related predominantly to women who were either younger, 20 to 39 years old (71.7%) or black (55.3%), and proportionally more numerous among transgender women, 74.8% and 59.8%, respectively (p<0.001). A high percentage of records left “Education” blank or gave “Unknown” (33.1%), especially among cisgender women (33.2%; p<0.001), but this remained stable over the period (p=0.853).

Most notifications were of physical violence (84.8%), and involved a larger proportion of transgender women (88.3%; p<0.001) (Table 3). Psychological violence was the second type most reported (40.1%), and again proportionally higher in cisgender women (40.2%; p<0.001). Also, the proportion of reports of psychological violence against transgender women decreased over the study period (β=-0.71; p=0.005; d=1.981). Torture accounted for 3.8% of reports, but the proportion of transgender women involved was greater (5.7%; p<0.001).

There were proportionally more reports of sexual violence against cisgender women (p<0.001), but these increased among transgender women over the period (β=0.67; p=0.003; d=2.368). Of the 53,336 notifications of sexual violence (8.8%), most were of rape (83.0%), with an upward trend among transgender women (β=0.71; p=0.001; d=2.146). Sexual exploitation was more common among transgender women (4.2%; p<0.001).

The most common reasons for the aggression were sexism (20.2%), particularly against cisgender women (p<0.001), and generational conflict (10.8%), which was proportionally higher against transgender women (14.8%; p<0.001) (Table 4). Both held stable over the study period (p≥0.115). Homophobia and transphobia were mostly against transgender women (7.1%; p<0.001) and tended to increase over the period (β=0.96; p=0.003; d=2.004). Xenophobia, which accounted for a small percentage of notifications (0.1%), was also more frequent among transgender women (0.2%; p<0.001), with a tendency to increase over the period (β=0.21; p=0.021). There was, however, a possibility of negative autocorrelation (d=2.800).

The aggressors were mainly men (76.9%), proportionally more so against cisgender women (84.1%; p<0.001) (Table 5). By aggressors’ relationship, spouses (33.8%) and former spouses stood out against cisgender women, while transgender women mainly reported spouses (27.4%) and strangers (19.2%). Aggression against transgender women caused by a child declined over the period (β=-0.61; p=0.050; d=1.870) and, by a sibling, increased (β=0.88; p=0.002; d=1.949). Aggression against transgender women caused by bosses decreased (β=-0.34; p=0.008), but there is the possibility of negative autocorrelation (d=2.82).

Discussion

Only 1.8% of notifications of interpersonal violence against women were found to relate to transgender persons, a proportion that remained stable throughout the study period. Moreover, only 31.7% of municipalities reported violence against transgender women. Nonetheless, Brazil ranks first among the countries that kill most LGBT people, especially transsexual women and transvestites¹³13 Transgender Europe (TGEU). TMM annual report 2016 [Internet]. 2016 [cited 2022 maio 5]. Available from: https://transrespect.org/wp-content/uploads/2016/11/TvT-PS-Vol14-2016.pdf.
https://transrespect.org/wp-content/uplo... ^,2020 Benevides BG, organizador. Dossiê assassinatos e violências contra travestis e transexuais Brasileiras em 2021 [Internet]. 2022 [acessado 2022 jan 3]: Disponível em: https://antrabrasil.files.wordpress.com/2022/01/dossieantra2022-web.pdf.
https://antrabrasil.files.wordpress.com/... . The conservative groups brought to power in Brazil’s 2018 elections have worked, using aggressively homophobic, sexist and racist discourse, to foster an extreme right-wing worldview²¹21 Miguel LF. O mito da "ideologia de gênero" no discurso da extrema direita Brasileira. Cad Pagu 2021; 62:e216216.. That view has also contributed to reversals of social protection policies and the dismantling of government action programmes and policies²²22 Teixeira MAC. Dilemas Brasileiros em políticas públicas e democracia. Rev Adm Publica 2020; 54(5):1-4.

23 Cohn A. As políticas de abate social no Brasil contemporâneo. Lua Nova 2020; 109:129-160.

24 Cunha LLN. A antipolítica de gênero no governo Bolsonaro e suas dinâmicas de violência. REB 2020; 7(14):49-61.^-2525 Brasil. Presidência da República. Decreto nº 10.883, 6 de dezembro de 2021. Aprova a Estrutura Regimental e o Quadro Demonstrativo dos Cargos em Comissão e das Funções de Confiança do Ministério da Mulher, da Família e dos Direitos Humanos, e remaneja e transforma cargos em comissão e funções de confiança. Diário Oficial da União 2021; 6 dez., which may have restrained any expansion of notifications of violence against this population.

Notifications of violence against younger and black women, especially transgender women, were proportionally more numerous. Disproportionate rates of violence against black women form part of a complex process based on heteronormative, patriarchal racism, that is, a strongly sexist and LGBT-phobic phenomenon, especially as regards lesbian, transsexual and transvestite women²⁶26 Werneck J, Iraci N. A situação dos direitos humanos das mulheres negras no Brasil: violências e violações [Internet]. 2016 [acessado 2022 set 9]. Disponível em: http://fopir.org.br/wp-content/uploads/2017/01/Dossie-Mulheres-Negras-.pdf.
http://fopir.org.br/wp-content/uploads/2... .

Unfortunately, about one third of the “Unknown” records in study period related to education, which undermined analysis of this variable. Poor education contributes to social vulnerability, particularly from difficulty in obtaining formal work or any kind of preparation for the employment market. School dropout is also a very present factor in the lives of the poorest population, who need to work from very early on to help their families. This is especially true of the transgender population, adding to the prejudice they experience in the school environment²⁷27 Scote FD, Garcia MRVG. Trans-formando a universidade: um estudo sobre o acesso e a permanência de pessoas Trans no Ensino Superior. Perspectiva 2020; 38(2):1-25.^,2828 Cunha SN, Oliveira AJ, Franco N. Fracasso, evasão e abandono escolar de pessoas trans: Algumas reflexões necessárias. Rev Educ Publica 2021; 30:1-18.. Also, they end up with prostitution, especially at night, being their only means of support, thus subjecting themselves to the risks posed by that profession²⁹29 Cortes GR, Silva LF, Silva LKR, Soares GS. Violência contra travestis e transexuais: a mediação da informação no espaço LGBT [Internet]. 2017 [acessado 2022 jan 3]. Disponível em: http://hdl.handle.net/20.500.11959/brapci/105518.
http://hdl.handle.net/20.500.11959/brapc... ^,3030 Pedra CB. Acesso à cidadania por travestis e transexuais no Brasil: um panorama da atuação do Estado no enfrentamento das exclusões [dissertação]. Minas Gerais: Fundação João Pinheiro, Escola de Governo Professor Paulo Neves de Carvalho; 2018.. Many difficulties, however, still prevent the barriers from being brought down, so that they can secure employability and success²⁰20 Benevides BG, organizador. Dossiê assassinatos e violências contra travestis e transexuais Brasileiras em 2021 [Internet]. 2022 [acessado 2022 jan 3]: Disponível em: https://antrabrasil.files.wordpress.com/2022/01/dossieantra2022-web.pdf.
https://antrabrasil.files.wordpress.com/... .

Most assaults were committed by acquaintances, but the proportion of assaults by strangers against transgender women was proportionally higher than against cisgender women. Studies have shown that transgender women often suffer violence in public places, mainly because of their vulnerability as sex workers²⁰20 Benevides BG, organizador. Dossiê assassinatos e violências contra travestis e transexuais Brasileiras em 2021 [Internet]. 2022 [acessado 2022 jan 3]: Disponível em: https://antrabrasil.files.wordpress.com/2022/01/dossieantra2022-web.pdf.
https://antrabrasil.files.wordpress.com/... . However, one meta-analysis that included articles published until 2019 found that transgender women were more likely to experience intimate partner violence than cisgender women³¹31 Peitzmeier SM, Malik M, Kattari SK, Marrow E, Stephenson R, Agénor M, Reisner SL. Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates. Am J Public Health 2020; 110(9):e1-e14..

Most notifications were of physical violence. This type of violence was more frequent in studies based on notifications³²32 Marinho Neto KRE, Girianelli VR. Evolução da notificação de violência contra mulher no município de São Paulo, 2008-2015. Cad Saude Colet 2020; 28(4):488-499. and women’s police stations³³33 Sousa BS, Oliveira MPA, Musse JO, Maciel NTVG, Batista JFC, Lima GCBB. Violência contra mulher no nordeste Brasileiro: tendência temporal de 2009 a 2018. Interfaces Cien 2022; 9(1):53-67.^,3434 Acosta DF, Gomes VLO, Barlem ELD. Perfil das ocorrências policiais de violência contra a mulher. Acta Paul Enferm 2013; 26(6):547-553.. Physical violence is generally visible, which facilitates identification and finding care, particularly in more serious cases, and is therefore more likely to be reported than other types of violence which require that both victims and professionals be aware of its scope. Violence against women, however, is an ongoing process of various kinds of violence, including verbal, psychological and other aggressions, often interspersed with non-violent periods³⁵35 Lucena KDT, Deininger LSC, Coelho HFC, Monteiro ACC, Vianna RPT, Nascimento JA. Análise do ciclo da violência doméstica contra a mulher. J Hum Growth Dev 2016; 26(2):139-146.. Such processes can lead to irreparable physical and/or emotional trauma³⁶36 Lourenço LM, Costa PD. Violência entre Parceiros Íntimos e as Implicações para a Saúde da Mulher. Gerais Rev Interinst Psicol 2020; 13(1):1-14. or culminate in femicide. This study also found proportionally more reports of physical violence against transgender women, probably because notification mechanisms made no provision for this group until later¹⁵15 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. VIVA: instrutivo notificação de violência interpessoal e autoprovocada. 2ª ed. Brasília: MS; 2016..

Psychological violence, the second most reported, accounting for fewer than half the notifications of physical violence, was proportionally greater against cisgender women. This type of violence tends to be more prevalent in studies based on interviews of healthcare users, whose requirements do not necessarily relate directly to violence³⁷37 Leite FMC, Amorim MHC, Wehrmeister FC, Gigante DP. Violência contra a mulher em Vitória, Espírito Santo. Rev Saude Publica 2017; 51(33):1-12., signalling that the magnitude of the problem must be much greater. However, a study based on notification data for interpersonal violence against the LGBT population in the city of São Paulo found proportionally more psychological violence against homosexual and bisexual women³⁸38 Fernandes H, Bertini PVR, Hino P, Taminato M, Silva LCP, Adriani PA, Ranzani CM. Violência interpessoal contra homossexuais, bissexuais e transgêneros. Acta Paul Enferm 2022; 35:eAPE01486.. A study of 16 transvestites and transsexuals found that verbal aggression was most frequent, followed by psychological violence, and that both occurred also in health services³⁹39 Silva GWS, Souza EFL, Sena RCF, Moura IBL, Sobreira MVS, Miranda FAN. Situações de violência contra travestis e transexuais em um município do nordeste Brasileiro. Rev Gaucha Enferm 2016; 37:e56407.. Also, health services’ and staffs’ prejudice and unpreparedness in providing care to transgender populations reveal discriminatory processes that can lead to dropout from treatment for various illnesses⁴⁰40 Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS. Assistência de enfermagem à população trans: gêneros na perspectiva da prática profissional. Edição temática: trabalho e gestão em enfermagem. Rev Bras Enferm 2019; 72(3):11-19..

Many women, however, have difficulty realising that they are suffering psychological violence and arrive at health units with symptoms including chronic pain, depression, eating disorders and so on⁴¹41 Almeida APF, Sousa ER, Fortes S, Minayo MC. Dor crônica e violência doméstica: estudo qualitativo com mulheres que frequentam um serviço especializado de saúde. Rev Bras Saude Mater Infant 2008; 8(1):83-91.. Health personnel also have difficulty recognising the violence experienced by their patients and report that women do not address the issue⁴²42 Kiss LB, Schraiber LB. Temas médico-sociais e a intervenção em saúde: a violência contra mulheres no discurso dos profissionais. Cien Saude Colet 2011; 16(3):1943-1952.. This difficulty may relate to a lack of training and the very nature of the violence experienced⁴³43 Hasse M, Vieira EM. Como os profissionais de saúde atendem mulheres em situação de violência? Uma análise triangulada de dados. Saude Debate 2014; 38(102):482-493.. Training of health personnel, particularly doctors, has also not contemplated gender-based violence⁴⁴44 Pedrosa CMA, Spink MJP. Violência Contra Mulher no Cotidiano dos Serviços de Saúde: desafios para a formação médica. Saude Soc 2011; 20(1):124-135.. This unpreparedness results in missed opportunities for interventions that could help break the cycle of violence. Decades of activism, however, have contributed to greater social understanding, making the “expression of violence” less acceptable and more visible. Also, strategies have been proposed to train personnel in providing better informed primary care in family, particularly marital, conflicts, as well as to structure and extend an inter-sector network to guarantee quality, comprehensive care⁴⁵45 Souza MB, Silva MFS. Estratégias de enfrentamento de mulheres vítimas de violência doméstica: uma revisão da literatura brasileira. Pensando Fam 2019; 23(1):153-166..

Sexual violence accounted for 10% of the physical violence reported, with most notifications being of rape. It was proportionally more common against cisgender women, but increased in transgender women in the study period. A study of 284 transvestites and transgender women found that about half had suffered sexual violence⁴⁶46 Nery ECS. Prevalência de violência sexual contra mulheres trans e travestis da região metropolitana de Goiânia, Goiás [tese]. Goiás: Pontifícia Universidade Católica de Goiás; 2021..

The crime of sexual exploitation, which corresponded to less than 2% of reports of sexual violence, was proportionally more common against transgender women. Navas⁴⁷47 Navas KM. Vidas e corpos em trânsito: tráfico de travestis e transexuais Brasileiras com a finalidade de exploração sexual no contexto da crise do capital [tese] São Paulo: Pontifícia Universidade Católica; 2016. argued that trafficking for the purpose of sexual exploitation is different for transsexual and transvestite women. Because of their vulnerability, they are more easily co-opted by groomers, are generally aware that they will be subjected to exploitation and sexual servitude and do not recognise this to be criminal act, because they give their consent. Rejection by the family, difficulty entering the job market and the endeavour to modify their bodies are the main reasons for their vulnerability to trafficking for sexual exploitation²⁰20 Benevides BG, organizador. Dossiê assassinatos e violências contra travestis e transexuais Brasileiras em 2021 [Internet]. 2022 [acessado 2022 jan 3]: Disponível em: https://antrabrasil.files.wordpress.com/2022/01/dossieantra2022-web.pdf.
https://antrabrasil.files.wordpress.com/... .

Sexism stood out among motivations for violence, particularly against cisgender women, followed by generational conflict, especially involving transgender women. Sexism hinges on a rationale of male domination present in institutions, as well as in public and private environments, and continues to be expressed in Brazilian culture, but remains difficult to combat, since it is not easily recognisable⁴⁸48 Alves NFT, Souza LEC, Maia LM, Silva RN, Gomes AAAM. A mulher no Facebook: Uma análise a partir do Sexismo Ambivalente. Intercom RBCC 2021; 44(1):131-147..

The third most-reported motivation for violence against transgender women was transphobia and/or homophobia, which trended upward during the study period. Transphobia against trans women falls within the scope of gender violence, as it attempts to show what it is to be a woman and primarily to deny that trans women are also women independent of the sex-gender system where gender is given by genitals²⁰20 Benevides BG, organizador. Dossiê assassinatos e violências contra travestis e transexuais Brasileiras em 2021 [Internet]. 2022 [acessado 2022 jan 3]: Disponível em: https://antrabrasil.files.wordpress.com/2022/01/dossieantra2022-web.pdf.
https://antrabrasil.files.wordpress.com/... .

One of the limitations of this study was that the prevalence of violence could not be estimated, because the LGBT population was of unknown size. Despite pressure from social movements and the Victim Support Centre of Acre State Public Attorney’s Office to include the variables “sexual orientation” and “gender identity” in the 2022 Demographic Census questionnaire, Brazil’s official bureau of statistics, the Instituto Brasileiro de Geografia e Estatística (IBGE), went to court arguing that, for technical, operational and financial reasons, this was not yet possible⁴⁹49 Instituto Brasileiro de Geografia e Estatística (IBGE). IBGE divulgará em maio PNS com pergunta sobre orientação sexual [Internet]. 2022 [acessado 2022 nov 9]. Disponível: https://www.ibge.gov.br/novo-portal-destaques/33302-ibge-divulgara-em-maio-pns-com-pergunta-sobre-orientacao-sexual.html.
https://www.ibge.gov.br/novo-portal-dest... . The questionnaire only offered the option to indicate, in the item “Relationship or cohabitation with the person responsible”, that the spouse or partner was of the same sex⁵⁰50 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2022: questionário básico [Internet]. 2022 [acessado 2022 nov 9]. Disponível: https://censo2022.ibge.gov.br/np_download/censo2022/questionario_basico_completo_CD2022_atualizado_20220906.pdf.
https://censo2022.ibge.gov.br/np_downloa... . The 2019 National Health Survey, a probability sampling survey conducted every five years, only considered sexual orientation as a variable of the adult population. In that survey, 1.9% responded that they were homosexual or bisexual⁵¹51 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de Saúde 2019: tabelas Orientação sexual autoidentificada da população adulta [Internet]. 2019 [acessado 2022 nov 9]. Disponível: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=resultados.
https://www.ibge.gov.br/estatisticas/soc... . A survey by the Data Folha Research Institute of 5,858 adults from Brazil’s state capitals, metropolitan regions and the federal district estimated that 4.4% reported being homosexual or bisexual⁵²52 Spizzirri G, Eufrásio RA, Abdo CHN, Lima MCP. Proportion of ALGBT adult Brazilians, sociodemographic characteristics, and self-reported violence. Sci Rep 2022; 12:11176.. The difference between the surveys may reflect the influence of prejudice and lack of information.

Underreporting was another limitation. This occurs in relation to several diseases familiar to health personnel and the public, generally when symptoms are mild or clinical signs are absent or from non-compliance by health personnel. Nonetheless, it continues to be strategically essential to understand its magnitude and characteristics and is thus fundamental to support public policies. Reporting of violence poses other challenges, such as health staffs’ lack of knowledge and prejudice⁵³53 Melo IRA, Garcia THB, Polejack L, Seidl EMF. O Direito à Saúde da População LGBT: Desafios Contemporâneos no Contexto do Sistema Único de Saúde (SUS). Rev Psicol Saude 2020; 12(3):63-78.. Staff unpreparedness, lack of proper care and receptiveness can mean that women avoid approaching institutions, which prevents reporting of aggression, leading to underreporting of cases.

The violence notification form, however, has one peculiarity: since 2015, it is completed not only by health personnel and institutions, but requires agreement with various municipal institutions¹⁵15 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. VIVA: instrutivo notificação de violência interpessoal e autoprovocada. 2ª ed. Brasília: MS; 2016.. It is essential to include LGBT Reference Centres, general and specialised Social Assistance Reference Centres, schools and non-governmental organisations in this process in order to minimise existing underreporting. On the other hand, the notification form enables only part of the LGBT+ population to be identified: asexual and intersexual people, for example, are not yet covered.

Reporting of violence still does not reflect the actual situation, particularly as regards transgender women. Meanwhile, psychological violence, which usually begins the cycle of aggression and can culminate in femicide, now ranks second among reports in Brazil, despite the reverses of recent years. Investment in extending the range of reporting institutions beyond the health field, as is planned, can help minimise existing underreporting and improve the quality of information.

There is a need for research and policymaking in this field of study, mainly in the public health domain, to foster understanding of social representations of women as a mechanism in gender-based violence in order to develop efficient practices and preventive measures to address and combat that violence. With time, many rights have been attained in different areas, enabling what was long silenced now to be heard, studied and reflected on.

References

Publication Dates

History