Abstract

Introduction

It is estimated that one in three women worldwide experienced intimate partner violence or sexual violence at some point in their lives ¹1. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress - sexual and reproductive health and rights for all: report of the Guttmacher - Lancet Commission. Lancet 2018; 391:2642-92.. In Brazil, there is an alarming number of rapes, with a 4.1% increase in reported cases from 2014 to 2018. In 2018, 180 rapes were reported per day ²2. Fórum Brasileiro de Segurança Pública. Anuário brasileiro de segurança pública. São Paulo: Fórum Brasileiro de Segurança Pública; 2019.. The consequences of this violence affect the physical and mental health of the victims, hampering their social achievements and their socioeconomic maintenance ³3. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11)..

According to the Brazilian law, rape is a crime against sexual freedom. Zapater ⁴4. Zapater M. Pode a lei penal impedir que mulheres sejam sexualmente assediadas? In: Bueno S, Lima RS, organizadores. Visível e invisível: a vitimização das mulheres no Brasil. 2ª Ed. São Paulo: Fórum Brasileiro de Segurança Pública; 2019. p. 29-36. attributes to this crime the nature of human rights violations. When the victim is under 14 years of age, sexual intercourse, or a libidinous practice, regardless of consent, is considered rape of a vulnerable person. This is due to the legal understanding that, until that age, the person does not have full capacity to decide on their actions yet, which also applies to people who, due to a temporary or permanent disability, are unable to consent, because of some deficiency or because they are under the influence of psychoactive substances ⁵5. Brasil. Lei nº 12.015 de 07 de agosto de 2009. Altera o Título VI da Parte Especial do Decreto-Lei nº 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..

Unintended pregnancy may be one of the consequences of rape, occurring in approximately 7% of cases ³3. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11).^,66. Blake MD, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion for pregnancy resulting from rape. Int Arch Med 2015; 8:41-2.. Discovering a pregnancy after sexual violence is often perceived as a new violence ⁷7. Lima MCD, Larocca LM, Nascimento DJ. Abortamento legal após estupro: histórias reais, diálogos necessários. Saúde Debate 2019; 43:417-28. and can trigger complex psychological and social reactions ⁸8. Drezett J. Aspectos biopsicossociais da violência sexual. Jornal da Rede Feminista de Saúde 2000; 22:9-12.^,99. Giugliani C, Ruschel AE, Patuzzi GC, Silva MCB. Violência sexual e direito ao aborto legal no Brasil: fatos e reflexões. Rio de Janeiro: Editora Fiocruz; 2021.. Despite having been provided for in law since 1940, abortion in these cases is not a guaranteed right in Brazil yet, and women have a long way to go in the search for the procedure ⁷7. Lima MCD, Larocca LM, Nascimento DJ. Abortamento legal após estupro: histórias reais, diálogos necessários. Saúde Debate 2019; 43:417-28.. The scarcity of services is one of the obstacles, and health care, when provided, is often marked by moral judgments, hostility, and discrimination, consisting in another source of violence ¹⁰10. Madeiro AP, Diniz D. Serviços de aborto legal no Brasil: um estudo nacional. Ciênc Saúde Colet 2016; 21:563-72..

In this article we discuss the search for legal abortion due to rape, considering the trajectory taken by women from the occurrence of sexual violence to the completion of the procedure. As literature on the topic is scarce in Brazil, and most of the research comes from large centers in the Southeast and Northeast regions of the country ³3. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11)., we will contribute to the understanding of the dynamics involved in legal abortion by providing data from the South Region.

Methodology

This is a qualitative, retrospective, and documentary research conducted at a referral service for legal abortion in a public hospital in the city of Porto Alegre (Rio Grande do sul State, Brazil), by the analysis of the medical records of women who suffered sexual violence and had a legal abortion from 2000 to 2018. The technical team of this service is composed of professionals from the fields of medicine, nursing, psychology, and social work. The average number of cases attended up to 2013 was two per year, with a gradual increase reaching a total of 29 legal abortions in 2018, with an average of 18 cases per year in the last five years analyzed. Data on history, psychological or clinical symptoms, and other information on the patient and the suffered violence, as well as the discussion on the issues that involved decision-making about abortion, completed protocols, and referrals made, were registered in the clinical records. Until 2016, data were collected in physical medical records; and thereafter, in electronic medical records.

The (re)construction of the historical series of abortion due to rape was carried out in two stages. The first, based on the association of diagnoses related to sexual violence and pregnancy, according to The ICD-10 Classification of Mental and Behavioural Disorders¹¹11. Centro Colaborador da Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde - CID-10. São Paulo: Edusp/Porto Alegre: Artmed Editora; 1993.: Y05 Sexual assault with physical force; Y04 Assault by bodily force; T742 Sexual abuse, confirmed; and Z35.1 Supervision of pregnancy with history of abortive outcome; Z32 Encounter for pregnancy test and childbirth and childcare instruction; Z32.0 Encounter for pregnancy test, result unknow; Z32.1 Encounter for pregnancy test, result positive. The list of abortions for medical and legal reasons (ICD O04) was also analyzed. The total number of identified cases was 223, of which, after reading the medical records, 96 were excluded because the abortion was not related to sexual violence or it was not the outcome. Cases in which the abortion was not performed were excluded due to the lack of records in the medical records referring to these situations. Another two cases were excluded because the physical record was not located, resulting in a total of 127 cases of legal abortion due to rape attended during the period.

The obtained information was submitted to content analysis ¹²12. Minayo MCS, Sanches O. Quantitativo-qualitativo: oposição ou complementaridade? Cad Saúde Pública 1993; 9:239-62., as it allowed, in addition to the description of the occurrences, the understanding of subjective aspects such as values, beliefs, attitudes, and opinions reported by women and registered in the medical records. The analysis categories were based on the concept of critical paths by Sagot ¹³13. Sagot M. A rota crítica da violência intrafamiliar em países latino-americanos. In: Meneghel SN, organizador. Rotas críticas mulheres enfrentando a violência. São Leopoldo: Editora Unisinos; 2007. p. 23-50., who discusses the process of seeking help as a way to trace women’s trajectories and decisions to leave the situation of violence. In the medical records, the authors sought to identify the paths taken to access the right to legal abortion. The trajectory begins with the woman’s decision to break the silence about rape and continues with the identification of the difficulties faced and the impact of violence and institutional experience on her life. The present analysis identified the trajectory (critical paths) and the encountered difficulties (critical nodes), explaining factors that inhibited or impelled women in the search for legal abortion after sexual violence and the discovery of pregnancy. These factors, in addition to the geographical route, included the biopsychosocial aspects involved in the situation.

After reading the medical records, the results were divided into three analysis categories: (1) between the secrecy of violence and the silencing of right; (2) psychological illness and social disorganization; and (3) institutional flows: validation of the word and conscientious objection. These categories are interrelated and demonstrate the sequence of facts, actions, and complications in women’s lives according to the dynamics of the critical paths produced. To guarantee anonymity, the participants’ names were encoded with letters and numbers (with 01 being the oldest case and 127, the most recent).

This study was approved by the Ethics Research Committee of the Presidente Vargas Maternal-Child Hospital (CAAE 98117718.5.0000.5329 and opinion n. 2.926.060.

Results and discussion

In Table 1 we show the general characteristics of the 127 cases of legal abortion due to sexual violence attended during the period.

Of the 127 cases, most participants (60%) were over 18 years old, and 23% of them were under 14 years of age. Ages ranged from 10 to 42 years, with an average age of 22. Most women were white (77%), single (75%), with unconcluded elementary school (34.6%), and lived in Porto Alegre and the Metropolitan Region (73%). Regarding occupation, 33% were formally employed and 55% were students. In 30% of the cases, violence was the first sexual intercourse and in 64% it was the first pregnancy. Violence was a unique episode in 74% of the cases, and 68.5% reported the violence to the police. Regarding the aggressors, 45% were unknown to the victim; the means of coercion used in the violence were use of physical strength (42%), threats (34%), firearm/knife (25%), and use of psychoactive substances (27%). According to Article 217-A of Law 12,015/2009⁵5. Brasil. Lei nº 12.015 de 07 de agosto de 2009. Altera o Título VI da Parte Especial do Decreto-Lei nº 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., 55% of the cases were deemed rape of vulnerable person: 23% of adolescents under 14 years of age; 5% of women over 18 years of age with intellectual disabilities; and 27% who were under the influence of a psychoactive substance at the time of the sexual assault. The sample profile complements and qualifies the qualitative analysis presented next.

Between the secrecy of violence and the silencing of right

In this category we highlight the secrecy regarding sexual violence and present factors that inhibited or delayed the search for help. Denial, the desire to forget, guilt, stigma, and misinformation about the right to abortion were the main aspects involved in this dynamic between secrecy and silencing. Our data showed that many women believed that keeping the suffered violence secret would allow them to forget what happened and move on with their lives. The secret is uncovered with the discovery of pregnancy, as we can see in the following descriptions:

“She says it was the worst thing that had happened in her life and that she just wanted to forget it, not tell anyone and wait for it to pass, but with the pregnancy her plans fell apart” (B115, 20 years old).

“She told her grandmother that she had a misunderstanding with her boyfriend and that’s why she was crying (...) she only told her boyfriend when she felt strange, queasy, with sore breasts, suspecting that she was pregnant” (Y91, 19 years old).

Studies show that only 10% of cases of sexual violence are reported to public security ²2. Fórum Brasileiro de Segurança Pública. Anuário brasileiro de segurança pública. São Paulo: Fórum Brasileiro de Segurança Pública; 2019.^,33. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11)., and of these, only half receive emergency prophylactic care at health services ⁹9. Giugliani C, Ruschel AE, Patuzzi GC, Silva MCB. Violência sexual e direito ao aborto legal no Brasil: fatos e reflexões. Rio de Janeiro: Editora Fiocruz; 2021., which shows us the social scope of the aforementioned reports, in which secrecy becomes a strategy to avoid trauma, guilt, and social stigma.

Silencing also results from lack of information, and this is one of the reasons for the long journey until arriving at the referral hospital. The hospital was the first service sought in only 19 cases (15%), evidencing women’s misinformation regarding the right to interrupt the pregnancy. The healthcare reports show that women only learn about the right to abortion after confirmation of the pregnancy, and this occurs through different means and sectors of society, including: health services (32%); security or protection agencies (39%) - police stations, judiciary, Public Prosecution, Child Protective Council; friends (9%); furthermore, as of 2015, the information was also accessed via the Internet (11%). In these cases, women report having typed the word “abortion” or “how to have an abortion” and found news or reports about sexual violence and legal abortion. Thus, the search for information on the Internet and the creation of a service network with various sectors of society seem to enhance access to abortion rights. Primary health care proved to be an important reference in the search for help by women, as did the security and protection agencies, together representing almost 70% of the sources of information on legal abortion.

However, these services and resources also presented access barriers, such as moral judgments, poor infrastructure, bureaucracy, lack of professionals, and misinformation about laws and flows, as shown in the following reports:

“She sought care at hospital F last Friday, but there was no doctor to attend this type of situation on that day. She was instructed to seek another hospital (...) she felt judged by the emergency care, cause when she arrived, the doctor told her that it wasn’t that simple to go there and have an abortion” (S130, 30 years old).

“She went to hospital Z, where she discovered the pregnancy by abdominal ultrasound due to pain in the lower abdomen, but she didn’t tell about the rape. Then, she went to hospital F to request an abortion. She was instructed to return the following week. A friend took her to the Referral Center M and there a social worker accompanied her to hospital G, but they said it was overcrowded due to childbirths. Then, she arrived here at 17 weeks pregnant already” (P99, 24 years old).

“She felt even worse at the Women’s Police Station (...) she was exposed, humiliated ‘cause everyone who was there heard her story. She stayed there for 3 hours and her testimony was interrupted several times by other cases, either in person or by telephone. The attendant at the Women’s Police Station said that ‘it was a shame to have twins aborted’ - this made her feel even more guilty. She says that this sentence still echoes in her head after the abortion” (S37, 36 years old).

“At the Women’s Police Station, she was referred to the public defender’s office and a hearing was scheduled with a judge to authorize the abortion” (J133, 21 years old in 2018).

We observe that the misinformation affecting women also affects the service network, both health care and public security, resulting in unnecessary referrals or erroneous guidance. The reports illustrate a trajectory that intensifies the trauma of the suffered violence to the extent that it victimizes women.

The fear of social judgment also encourages the maintenance of the secrecy of violence. There are recurrent verbalizations regarding “why did they go to the party, have drunk, or even about the clothes they were wearing, of guilt for not remembering precisely what happened, or how they ended up in that place after accepting a drink at the party”. Women themselves question their behavior, blaming themselves for what happened:

“She feels guilty. She says she believes that if she wasn’t wearing a skirt this might not have happened” (L105, 25 years old).

“She says she woke up dirty with sperm in one of the rooms in a house. She felt so ashamed and guilty. That’s why she didn’t tell anyone (...) she figured that someone might have had sexual intercourse with her, but she immediately decided to pretend nothing had happened” (D85, 20 years old).

Giugliani et al. ⁹9. Giugliani C, Ruschel AE, Patuzzi GC, Silva MCB. Violência sexual e direito ao aborto legal no Brasil: fatos e reflexões. Rio de Janeiro: Editora Fiocruz; 2021. address the victims’ blaming through their attitudes and behaviors and the social tolerance in relation to sexual violence, which naturalizes abusive dynamics rooted in gender inequalities and reproduces the culture of rape. Women report feeling judged by professionals, both in healthcare services and police stations, and fear that this will happen with their families, which is why many decide not to disclose the situation of violence. In a nationwide opinion survey, 42% of men and 37% of women ¹⁴14. Bueno S, Lima RS, Pinheiro M, Astolfi R, Santos T, Hanashiro O. A polícia precisa falar sobre estupro. Percepção sobre violência sexual e atendimento a mulheres vítimas de estupro nas instituições policiais. São Paulo: Fórum Brasileiro de Segurança Pública; 2016. agreed with the sentence “Women who respect themselves are not raped”, which shows the strength with which moral assessment affects women. It is a judgment that triggers feelings of guilt and makes women themselves responsible for the suffered violence ⁷7. Lima MCD, Larocca LM, Nascimento DJ. Abortamento legal após estupro: histórias reais, diálogos necessários. Saúde Debate 2019; 43:417-28..

This dynamic, which ranges from secrecy to silencing, maintains the lack of information that led some women to try abortive alternatives, such as teas or pills, before seeking hospital care, attempting to solve the pregnancy issue on their own:

“She took four Cytotec pills the previous week, but was unable to abort” (L83, 15 years old).

“She used herbal infusions and medications she can’t even name - trying to abort” (L62, 34 years old).

In other cases, concerning children and adolescents, the arrival at the hospital occurred due to various clinical complaints such as gastric disorders or abdominal pain. Cognitive and psychosocial immaturity may hinder the perception of physical changes associated with pregnancy and even the understanding of the violence to which they were subjected. Hospitalization and clinical investigation demonstrated the diagnosis of pregnancy, uncovering the secret of sexual violence:

“She was hospitalized for nausea, abdominal pain, and gastric problems, with no improvement. Only then was the pregnancy diagnosis made and she told us she was sexually abused by the stepfather” (E81, 10 years old).

Several authors report that fathers and stepfathers are the main sexual aggressors of children and adolescents, and also point to early age as hindering the understanding of the abusive relationship ¹⁵15. Scoldelário AS. A família abusiva. In: Ferrari DCA, Vecina TCC organizadores. O fim do silêncio na violência familiar. São Paulo: Ágora; 2002. p. 95-106.^,1616. Ribeiro MA, Ferriani MGC, Reis JN. Violência sexual contra crianças e adolescentes: características relativas à vitimização nas relações familiares. Cad Saúde Pública 2004; 20:456-64.. We add that the reduced number of referral services and the need for a large geographical displacement in the search for the procedure is an additional obstacle to be overcome and that denotes the insufficiency of this public policy. In the study population, less than 50% of women lived in the capital, and some traveled more than 400km to access the service. In most Brazilian municipalities, there are no accredited facilities for carrying out legal abortion ¹⁰10. Madeiro AP, Diniz D. Serviços de aborto legal no Brasil: um estudo nacional. Ciênc Saúde Colet 2016; 21:563-72.^,1717. Andalaft-Neto J, Faúndes A, Osis MJD, Pádua KS. Perfil do atendimento à violência sexual no Brasil. Femina 2012; 40:301-6.. In the country, of the 68 referral hospitals registered, only 37 had performed at least one legal abortion from 2013 to 2015 ¹⁰10. Madeiro AP, Diniz D. Serviços de aborto legal no Brasil: um estudo nacional. Ciênc Saúde Colet 2016; 21:563-72., which evidences inequality in access as an important critical issue in the exercise of the right to abortion ¹⁸18. Jacobs MG, Boing AC. O que os dados nacionais indicam sobre a oferta e a realização de aborto previsto em lei no Brasil em 2019? Cad Saúde Pública 2021; 37:e00085321..

Psychological illness and social disorganization

In this category, we highlight the different psychological reactions resulting from violence, such as fear, shame, anger, disgust, worthlessness, anhedonia, sleep disorders, and suicidal ideation, and discuss their impact on various spheres of life. We identified that emotional reactions made it difficult to seek help, impaired the victims’ psychosocial resources to respond to the trauma, and were characterized as one of the obstacles to accessing legal abortion:

“She says she is deeply afraid, she feels that the aggressors are going to invade her house. She can’t stand the presence of her partner. She feels angry and disgusted by the fetus” (K25, 28 years old).

“She is frightened, angry, tearful, and has negative feelings about the pregnancy and the fetus. She says her life is over. She can’t sleep, eat, or work. She has resigned from her job” (C20, 27 years old).

“She has trouble sleeping, eating, caring for her 4-year-old daughter” (L105, 25 years old).

The reports we analyzed corroborate studies that demonstrate the intensity of the clinical conditions and psychological reactions triggered by situations of sexual violence, from the most immediate, such as shame, fear, anger, and disgust ¹⁴14. Bueno S, Lima RS, Pinheiro M, Astolfi R, Santos T, Hanashiro O. A polícia precisa falar sobre estupro. Percepção sobre violência sexual e atendimento a mulheres vítimas de estupro nas instituições policiais. São Paulo: Fórum Brasileiro de Segurança Pública; 2016.^,1919. Nunes MCA, Morais NA. Violência sexual e gravidez: percepções e sentimentos das vítimas. Rev Spagesp 2016; 17:21-36., to chronic conditions of alcohol and/or other drugs abuse, or the triggering or aggravation of other mental illnesses ¹1. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress - sexual and reproductive health and rights for all: report of the Guttmacher - Lancet Commission. Lancet 2018; 391:2642-92.. In addition, we identified that pregnancy resulting from sexual violence can be experienced as a new traumatic situation, intensifying the symptomatic condition already established as a consequence of violence ⁸8. Drezett J. Aspectos biopsicossociais da violência sexual. Jornal da Rede Feminista de Saúde 2000; 22:9-12.. Thoughts of death, with or without previous suicide attempts, were identified in some cases:

“She cries a lot, has insomnia, thoughts of death (...). She can’t access the memory of the situation and that makes her very anxious” (E87, 31 years old - raped when she was unconscious).

“She’s ashamed and guilty. She shows great psychological fragility. She still has thoughts of death and ruin. She’s very close, her affective and social bonds are scarce and fragile. She has intense recurring nightmares. She’s afraid of being alone and going out on the street. There were two suicide attempts after the sexual violence: one taking two and a half tablets of medicine - she told her family that she attempted suicide because she was feeling very much alone in city X and was depressed [because she didn’t tell anything about the sexual assault]. When her period was late and she noticed she was pregnant, she attempted suicide again, this time at her mother’s house, by hanging herself” (N97, 19 years old).

A study conducted with 37 women victims of sexual violence found changes in sleep quality, an increase in the sense of fear of having contracted a sexually transmitted infection, fear of others’ reaction and judgment, difficulty in interpersonal relationships, negative impact on the quality of sexual life, in addition to a negative perception about themselves and their own body. The presence of post-traumatic stress disorder (PTSD), depression, and decreased self-esteem were also identified, with a significant correlation between depression and PTSD ²⁰20. Souza FBC. Consequências emocionais de um episódio de estupro na vida de mulheres adultas [Dissertação de Mestrado]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2013.. In the aforementioned reports, we can see that the idea of suicide, in the face of psychological disorganization and lack of information, was an attempt to solve the problem of pregnancy. Self-harm, including suicide attempts, is not always analyzed when discussing this type of violence ²¹21. Engel CL. A violência contra a mulher. In: Fontoura N, Resende M, Querino AC, organizadores. Beijin +20 anos: avanços e desafios no Brasil contemporâneo. Brasília: Instituto de Pesquisa Econômica Aplicada; 2020. p. 159-216..

Abandonment from work, withdrawal from studies, difficulties with children, avoidance of partner, family members, and friends are part of the disorganization that characterizes this situation and, in our data, these elements are directly related to sexual violence and unintended pregnancy:

“She didn’t go to school for several days. She tried to resume it, but she saw the aggressors and had the feeling they were laughing at her, so she dropped out of college for good” (N97, 19 years old).

“She realizes she’s not ok. She was unable to keep her job (...) now she has had constant nightmares of persecution. She’s afraid to meet the men who raped her. (...) The family kept away because they are against abortion” (J132, 39 years old).

“She no longer had sexual intercourse with her husband after that (...) she’s been absent from work” (S130, 30 years old).

“She doesn’t leave the house anymore and she won’t let her kids out. She gave up starting her job” (T90, 25 years old).

We notice that disorganization in daily life increases the suffering and the risks of mental illness, entails new obstacles, and prevents the resumption of the way of life prior to violence. The impacts of rape and subsequent pregnancy affect the world of work and relationships altogether, causing social, occupational, and financial losses ³3. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11).. These are problems that also affect families and close people and that break up social ties, hinder care relationships, and access to resources ³3. Cerqueira D, Coelho D. Estupro no Brasil: uma radiografia segundo os dados da saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2014. (Nota Técnica, 11)..

Institutional flows: word validation and conscientious objection

This category analyzes the obstacles that arise in the search for abortion, even after discovering the right to have it and arriving at the referral service. These flows are related to the scrutiny of violence and the denial of assistance due to conscientious objection. Hospital records are marked by the team’s concern to seek the veracity of the facts, and in order to perform a legal abortion, a woman must be qualified as a victim of rape. This is what guarantees her access to the law. As we can see in the records, this legality must be reconstructed in each case:

“There are no indications of a false allegation of violence” (M107, 32 years old).

“According to the psychological assessment, confusion in the patient’s memory is common in this type of traumatic situation (...) the new date of the rape reported by the patient was reconstituted by seeking help from her friend and is now in line with the gestational age, as well as the consistency of the patient’s report” (E87, 31 years old).

We notice that the arrival of a woman victim of rape at the service raises a certain suspicion about what happened and requires teams to validate the report so that the right to legal abortion can be exercised ²²22. Diniz D, Dios VC, Mastrella M, Madeiro AP. A verdade do estupro nos serviços de aborto legal no Brasil. Rev Bioét 2014; 22:291-8.. It is an investigative process to prove the suffered violence and serves to attest the “victim status”, insofar as a truth about the rape is established. Fassin & Rechtman ²³23. Fassin D, Rechtman R. The empire of trauma: an inquiry into the condition of victimhood. Princeton: Princeton University Press; 2009. address the moral economy of the transformation of a person into a victim as a process that considers the symbolic effects of trauma, while demanding the adaptation of the narrative to moral values, removing the autonomy of the victimized subjects and objectifying them.

The reception and evaluation carried out by the multidisciplinary team of the referral service comply with internal flows and technical criteria established by the regulations of the Brazilian Ministry of Health ²⁴24. Ministério da Saúde. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes. Norma técnica. 3ª Ed. Brasília: Ministério da Saúde; 2012. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos - Caderno 6)., so as to demonstrate the legitimacy of the indication of legal abortion. Nevertheless, even after this evaluation and the signing of all the terms required by the protocol, during hospitalization, new questioning about the woman’s decision can retrace the decision-making process regarding abortion, as a way of (re)validating the decision to abort. There are several signs in the medical records that indicate the constant search for (re)confirmation of the violence and the decision made:

“On hospital discharge, the doctor on duty questions again the certainty of the decision to have an abortion” (E87, 31 years old).

“Upon admission, a new ultrasound was performed to confirm the gestational age” (T90, 25 years old).

These questions can be understood as seeking the protection on the part of medical professionals against possible risks of criminalization, which are part of the social imaginary about abortion, but which represent another critical node in the trajectory taken, as they generate exhaustion, doubts, and suffering. We can observe that the suspicion about the truth of the rape and the decision for legal abortion trigger other types of violence, creating new scenes and sensations that are added to the previous trauma:

“She says that the hospitalization was a very difficult experience, that she was frightened, she felt a lot of pain (...) the worst part was seeing the fetus! She didn’t want to see it, but the doctor insisted [on it] three times and she ended up agreeing [to see it] (...) she says that image accompanies her and that this was the most difficult part, and it ends up being a recurrent memory” (V89, 36 years old).

Thus, even when a woman has access to legal abortion, she does not escape punishment for this act in various situations, either by being questioned several times about her choice or being exposed to situations, such as the aforementioned one, confronting her decision. The inclusion of a humanized model of care for women having abortion seeks to guarantee a safe and effective practice, emphasizing welcoming, non-judgment, guidance, and care ²⁵25. Ministério da Saúde. Atenção humanizada ao abortamento. Norma técnica. 2ª Ed. Brasília: Ministério da Saúde; 2011. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos - Caderno 4).. However, we observe that the clinical routine still presents gaps and misconceptions in this regard. In the medical records, legal abortion practices are mixed with those related to prenatal care and desired pregnancy, which can be perceived by the use of several clinical descriptors in hospitalizations for legal abortion:

“Request for prenatal and sexual abuse exams. (...) Labor induction” (K25, 28 years old).

“The patient is well, good fetal movement” (B72, 12 years old).

According to Madeiro & Diniz ¹⁰10. Madeiro AP, Diniz D. Serviços de aborto legal no Brasil: um estudo nacional. Ciênc Saúde Colet 2016; 21:563-72., religious beliefs and the fear of stigma permeate abortion practices in the health area and end up alienating professionals from the teams, as many doctors fear being seen as “abortionists” by their peers. The use of terms related to prenatal care in the records we analyzed in this study may be linked to these beliefs and fears, in an attempt to transpose the pregnant woman’s health care to the practices involved in the abortion process.

The fear of being framed can also trigger questions about the veracity of the sexual violence suffered by women. In our analysis, we identified allegations of conscientious objection as another critical node. In these cases, doctors and other health professionals refused to adopt the necessary procedures to perform the abortion, declaring an impediment due to moral, religious, or ethical principles.

“I admit the patient and await the professional to agree to the procedure (...) I talk to the patient about the team’s decision not to initiate the procedure due to ethical conflict” (medical note - F42, 17 years old).

“The anesthesiologist registers in the medical record that he is against abortion, exempting himself from providing care due to conscientious objection” (A5, 12 years old).

“As it is not an emergency, we will resume the procedure the next day [medical note]. The patient heard the doctor of the department saying she is against abortion and that she should keep the pregnancy and give the child up for adoption” (L17, 37 years old).

In these excerpts, we can see explicit conscientious objection, in which a professional publicly denies performing the procedure, but we also see implicit behavior, such as “resume the procedure the next day.” These situations demonstrate that institutional flows are an important critical node in the path towards access to legal abortion and hinder its implementation in a humanized manner. Both in the bureaucratic procedures for validating the word, and in the nuances of “medical conscience” that lead to treating a legal abortion as prenatal care or the allegation of conscientious objection, we observe a moral economy that must be denounced and confronted.

It is worth emphasizing that the prerogative of conscientious objection provided for in the Code of Medical Ethics is not an absolute right and cannot be used in the absence of another physician, in urgent cases, or if the refusal causes irreversible harm to the patient ²⁴24. Ministério da Saúde. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes. Norma técnica. 3ª Ed. Brasília: Ministério da Saúde; 2012. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos - Caderno 6).. When health care is denied due to conscientious objection, the person to whom care was denied is the most seriously affected party. Neglect in providing care in abortion cases with conscientious objection is a phenomenon that violates the ethical principle of nonmaleficence and has serious consequences for women, especially those who are more vulnerable and marginalized. A woman who has been denied an abortion may be forced to continue with the unintended pregnancy, or may resort to a clandestine and unsafe abortion ²⁶26. Truong M, Wood SY. Unconscionable. When provides deny abortion care. Montevidéu: International Women's Health Coalition/Mujer y Salud en Uruguay; 2018..

According to research conducted in Brazil, medical decisions regarding the performance of legal abortion differ when the victims are adult women, to whom healthcare teams tend to present greater conscientious objection, considering that children and adolescents are more easily perceived as innocent victims ²²22. Diniz D, Dios VC, Mastrella M, Madeiro AP. A verdade do estupro nos serviços de aborto legal no Brasil. Rev Bioét 2014; 22:291-8.. We perceive a social assessment of sexual crimes, which may consider them both heinous, especially when they involve children, and may involve a certain trivialization of the situation, based on the image made of the victim, their behavior, and morality ²⁷27. Oliveira EM, Barbosa RM, Moura AAVM, Kossel K, Morelli K, Botelho FF, et al. Atendimento às mulheres vítimas de violência sexual: um estudo qualitativo. Rev Saúde Pública 2005; 39:376-82., which reproduces the moral economy and social construction of the victim ²³23. Fassin D, Rechtman R. The empire of trauma: an inquiry into the condition of victimhood. Princeton: Princeton University Press; 2009.. Nonetheless, in the analyzed population, we could not verify differences between the levels of conscientious objection in relation to the victims’ age, and the allegation was present in both adolescents and adult women cases.

Final considerations

The trajectory taken by women to have an abortion due to rape is unique and permeated by obstacles. The emotional impact and the attempt to keep the suffered violence secret are added to the psychological reactions that result from trauma, behavioral changes, and social disorganization with emotional and financial losses.

Misinformation, present both in society and in the healthcare and protection network, was one of the main barriers identified, creating unnecessary referrals, lengthening the trajectories, and delaying the abortion. This study reinforces the findings of Machado et al. ²⁸28. Machado CL, Fernandes AMS, Osis MJD, Makuch MY. Gravidez após violência sexual: vivências de mulheres em busca da interrupção legal. Cad Saúde Pública 2015; 31:345-53., indicating that, in addition to the formulation of public policies that address these situations, there must be adequate dissemination of this right and of the services that can be accessed by women after suffering sexual violence. Furthermore, in the circumstances in which abortion is allowed, healthcare teams and managers must ensure safe access to the procedure, adopting an institutional approach with the necessary measures to guarantee this right.

We emphasize the importance of raising awareness and continuing education for professionals who provide care for women who have suffered sexual violence and who seek abortion, focusing on humanized care and non-judgment ²⁵25. Ministério da Saúde. Atenção humanizada ao abortamento. Norma técnica. 2ª Ed. Brasília: Ministério da Saúde; 2011. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos - Caderno 4).. It is worth highlighting that this educational work must extend to the actors and services that compose the broad service network such as those in public security, social service, sectors of the judiciary and the Public Prosecution, and the healthcare network altogether. As we demonstrated, these services produce situations that aggravate the critical trajectories.

When pointing out the critical nodes involved in performing legal abortion, even after arriving at the referral service, we listed aspects that are still barely visible on this trajectory. We infer that the context of illegality contributes to the maintenance of the stigma related to abortion. Allegations of conscientious objection, for example, burden the cost of the procedure, as they extend the length of hospital stay and cause more suffering. We noticed how the work related to performing legal abortion is on the margin of other healthcare services, as it involves social pressures and constant tensions that hinder its implementation in accordance with technical guidelines and standards.

This study has limitations regarding the fact that the data source is restricted to information and documents contained in medical records, which were completed in a non-standard manner and by different professionals. In addition, the study was restricted to a single service and excluded from the analysis of women who sought the service and did not have an abortion. We believe that the issues raised in this article can be expanded in future research, which includes a wider range of services as well as situations in which the procedure was not performed. Nevertheless, the analysis highlighted problematic aspects that are likely to be repeated in the scarce referral services throughout the country.

All in all, we emphasize that questioning the right to legal abortion is to reaffirm the inferiority, objectification, and blaming of women, and that projects aimed at the extinction of this already-restricted right represent a social throwback and a threat to the construction of gender equity and democracy.

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