ABSTRACT

Objective

to describe the sociodemographic profile of reported cases of sexual violence (SV) and the distribution of care services for this health condition in the state of Minas Gerais, Brazil, 2019.

Methods

this was a descriptive study of the cases of sexual violence reported on the Notifiable Health Conditions Information System and care services registered in the National Health Establishment Registry.

Results

a total of 4,418 notifications of SV were identified during the study period, representing more than 12 notifications per day; the majority of notifications were among females (87.0%) and among children and adolescents (72.0%); the distribution of care services showed care gaps in four of the 14 health macro-regions of the state of Minas Gerais; the maximum distances traveled to access referral services ranged from 93 to 327 km.

Conclusion

the scarcity of care services for people subjected to sexual violence in the micro-regions and macro-regions of Minas Gerais highlights the need for planning public policies aimed at increasing access to these services.

Keywords
Gender-based Violence; Childhood Sexual Abuse; Abuse Notification; Health Information Systems; Descriptive Epidemiology

Study contributions

Main results

Over 12 notifications of sexual violence were reported per day in the state of Minas Gerais in 2019, with a higher prevalence in females, children and adolescents, mixed-race/Black people. Care gaps were identified in four macro-regions of the state.

Implications for services

There was a need for victims to travel long distances to receive care in municipalities with referral services for comprehensive care for sexual violence, which may hinder access and timely care.

Perspectives

It is expected that the results can contribute to improving public policies, considering the need to strategically plan the location of specialized services for people subjected to sexual violence.

Keywords
Gender-based Violence; Childhood Sexual Abuse; Abuse Notification; Health Information Systems; Descriptive Epidemiology

RESUMEN

Objetivo

describir el perfil sociodemográfico de los casos notificados de violencia sexual (VS) y la distribución de los servicios para esta condición.

Métodos

estudio observacional descriptivo basado en datos del Sistema de Información de Enfermedades de Declaración Obligatoria y servicios registrados en el Registro Nacional de Estabelecimientos de Salud, en Minas Gerais, Brasil, en 2019.

Resultados

se identificaron 4.418 notificaciones de SV que representan más de 12 notificaciones por día; los registros se centraron en el sexo femenino (87,0%), niños y adolescentes (72,0%); la distribución de los servicios mostró brechas de atención en cuatro macrorregiones entre las 14 existentes; la distancia máxima recorrida para asistencia en un servicio de referencia osciló entre 93 y 327 km.

Conclusión

la escasez de servicios de atención a personas en situación de SV en las micro y macro regiones, indican la necesidad de planificación de políticas públicas para ampliar el acceso.

Palabras-clave
Violencia de Género; Abuso Sexual Infantil; Notificación Obligatoria; Sistemas de Información en Salud; Epidemiología Descriptiva

INTRODUCTION

Sexual violence is defined as any forced, coerced, or threatened sexual act, including rape, attempted rape, unwanted sexual touching, or non-contact forms of sexual violence.¹1 World Health Organization. Violence against women prevalence estimates, 2018: global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women [Internet]. Geneva: World Health Organization; 2021 [cited 2022 May 15]. 87 p. Available from: https://www.who.int/publications/i/item/9789240022256
https://www.who.int/publications/i/item/... Although it can occur among both women and men, gender inequality contributes to girls and women, Black race/skin color, transgender women and/or people with disabilities being more likely to experience sexual violence.²2 World Health Organization, Pan American Health Organization. Understanding and addressing violence against women: intimate partner violence [Internet]. Geneva: World Health Organization; 2012 [cited 2022 May 15]. 12 p. Available from: https://apps.who.int/iris/handle/10665/77432
https://apps.who.int/iris/handle/10665/7...

Local social characteristics, such as (i) lower levels of education, (ii) attitudes and norms that normalize violence and gender inequalities, (iii) lack of employment opportunities for women, (iv) gender-discriminatory laws concerning property, marriage, divorce, (v) beliefs in family honor and sexual purity, (vi) ideologies of male sexual entitlement, and (vii) weak legal sanctions for sexual violence, pose a greater risk for the occurrence of this condition.³3 World Health Organization. Violence against women: intimate partner and sexual violence against women: intimate partner and sexual violence have serious short- and long-term physical, mental and sexual and reproductive health problems for survivors : fact sheet [Internet]. Geneva: World Health Organization; 2014 [cited 2023 Mar 7]. 4 p. Available from: https://apps.who.int/iris/handle/10665/112325
https://apps.who.int/iris/handle/10665/1... Worldwide, one in three women has been subjected to physical and/or sexual violence by an intimate partner and/or non-partner at least once in their lifetime; and 13% have experienced such violence in the past 12 months.³3 World Health Organization. Violence against women: intimate partner and sexual violence against women: intimate partner and sexual violence have serious short- and long-term physical, mental and sexual and reproductive health problems for survivors : fact sheet [Internet]. Geneva: World Health Organization; 2014 [cited 2023 Mar 7]. 4 p. Available from: https://apps.who.int/iris/handle/10665/112325
https://apps.who.int/iris/handle/10665/1...

In Brazil, 66,348 cases of rape were reported in 2019, with 5,009 of them in the state of Minas Gerais, 85% and 86%, respectively, among females.⁴4 Fórum Brasileiro de Segurança Pública. Anuário brasileiro de segurança pública 2020 [Internet]. São Paulo: Fórum Brasileiro de Segurança Pública; 2020 [citado 2022 Jul 1]. 331 p. Disponível em: https://forumseguranca.org.br/wp-content/uploads/2020/10/anuario-14-2020-v1-interativo.pdf
https://forumseguranca.org.br/wp-content... It is common knowledge that female rape survivors face social stigmas, feelings of guilt for having experienced sexual violence, rejection from their families and communities, inducing factors that contribute to the underreporting of records of this form of violence³3 World Health Organization. Violence against women: intimate partner and sexual violence against women: intimate partner and sexual violence have serious short- and long-term physical, mental and sexual and reproductive health problems for survivors : fact sheet [Internet]. Geneva: World Health Organization; 2014 [cited 2023 Mar 7]. 4 p. Available from: https://apps.who.int/iris/handle/10665/112325
https://apps.who.int/iris/handle/10665/1... ,⁴4 Fórum Brasileiro de Segurança Pública. Anuário brasileiro de segurança pública 2020 [Internet]. São Paulo: Fórum Brasileiro de Segurança Pública; 2020 [citado 2022 Jul 1]. 331 p. Disponível em: https://forumseguranca.org.br/wp-content/uploads/2020/10/anuario-14-2020-v1-interativo.pdf
https://forumseguranca.org.br/wp-content... and hinder its visibility. Therefore, the need for public policies aimed at addressing sexual violence is widely acknowledged.⁵5 World Health Organization. Guidelines for medico-legal care for victims of sexual violence. Geneva: World Health Organization; 2003.,⁶6 Melo CM de, Soares MQ, Bevilacqua PD. A violência sexual contra mulheres: contextualização do tema e reflexões para o campo da saúde. In: Pereira LI, Gomes MC, Xavier MRP (orgs.). Gênero, sexualidades e violências [recurso eletrônico] [Internet]. Viçosa-MG: Divisão de Gráfica Universitária; 2023. p. 137-62. Disponível em: https://www.editoraufv.com.br/
https://www.editoraufv.com.br/...

In addition to providing care for survivors of sexual violence, the health sector, together with Public Security, plays an important role in data collection on the phenomenon. Since 2011, cases of sexual violence have been compulsorily reported on the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN).⁷7 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: instrutivo notificação de violência interpessoal e autoprovocada [Internet]. 2. ed. Brasília: Ministério da Saúde; 2016 [citado 2022 Maio 15]. 91 p. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco... Cases of sexual violence should be reported to the municipal health department within a 24hour period, upon gaining knowledge of the case.⁸8 Brasil. Ministério da Saúde. Portaria nº1.271, de 6 de junho de 2014. Define a Lista Nacional de Notificação Compulsória de doenças, agravos e eventos de saúde pública nos serviços de saúde públicos e privados em todo o território nacional, nos termos do anexo, e dá outras providências [Internet]. Diário Oficial da União, Brasília (DF), 2014 Jun 09 [citado 2021 Maio 15], Seção 1:53. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=67&data=09/06/2014
https://pesquisa.in.gov.br/imprensa/jsp/... This urgency is justified by the need to ensure immediate access to prophylaxis for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), as well as emergency contraception for people who may get pregnant.⁹9 Ministério da Saúde (BR), Ministério da Justiça (BR). Secretaria de Políticas para as Mulheres. Norma técnica: atenção humanizada às pessoas em situação de violência sexual com registro de informações e coleta de vestígios [Internet]. Brasília: Ministério da Saúde; Ministério da Justiça; 2015. [citado 2021 Maio 15]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/atencao_humanizada_pessoas_violencia_sexual_norma_tecnica.pdf
https://bvsms.saude.gov.br/bvs/publicaco... In Brazil, care for people subjected to sexual violence is guaranteed by Law No. 12,845, of August 1, 2013, which ensures the provision of emergency, comprehensive and multidisciplinary care by hospitals.¹⁰10 Brasil. Casa Cívil. Lei nº 12.845, de 01 de agosto de 2013. Dispõe sobre o atendimento obrigatório e integral de pessoas em situação de violência sexual [Internet]. Diário Oficial da União, Brasília (DF), 2013 Ago 02 [citado 2022 Maio 18], Seção 1:1. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2013/lei/l12845.htm
http://www.planalto.gov.br/ccivil_03/_at... In order to organize the care network for these cases, Ordinances No. 485, of April 1, 2014, No. 618, of July 18, 2014, and No. 1,662, of October 2, 2015, redefined the operation of Care Service No. 165 for People Subjected to Sexual Violence (Serviço nº 165 de Atenção às Pessoas em Situação de Violência Sexual - SAP/VS) within the Brazilian National Health System (Sistema Único de Saúde - SUS), organized according to four classifications:¹¹11 Brasil. Ministério da Saúde. Portaria no 485, de 01 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) [Internet]. Diário Oficial da União, Brasília (DF), 2014 Abr 02 [citado 2022 Maio 18], Seção 1:53. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=53&data=02/04/2014
https://pesquisa.in.gov.br/imprensa/jsp/...

12 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 618, de 18 de julho de 2014. Altera a Tabela de Serviços Especializados do Sistema de Cadastro Nacional de Estabelecimentos de Saúde (SCNES) para o serviço 165 Atenção Integral à Saúde de Pessoas em Situação de Violência Sexual e dispõe sobre regras para seu cadastramento [Internet]. Diário Oficial da União, Brasília (DF), 2014 Jul 22 [citado 2022 Maio 18], Seção 1:82. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=82&data=22/07/2014
https://pesquisa.in.gov.br/imprensa/jsp/... -¹³13 Brasil. Ministério da Saúde. Portaria no 1.662, de 2 de outubro de 2015. Define critérios para habilitação para realização de coleta de vestígios de violência sexual no Sistema Único de Saúde (SUS), inclui habilitação no Sistema de Cadastro Nacional de Estabelecimentos de Saúde (SCNES) e cria procedimento específico na Tabela de Procedimentos, Medicamentos e Órteses, Próteses e Materiais Especiais (OPM) do SUS [Internet]. Diário Oficial da União, Brasília (DF), 2015 Out 07 [citado 2022 Maio 18], Seção 1:18. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=18&data=07/10/2015
https://pesquisa.in.gov.br/imprensa/jsp/... Comprehensive Care for People Subjected to Sexual Violence (Atenção Integral às Pessoas em Situação de Violência Sexual - AIP/VS); Outpatient Care for People Subjected to Sexual Violence (Atenção Ambulatorial às Pessoas em Situação de Violência Sexual - AAP/VS); Termination of Pregnancy (Interrupção da Gravidez - IG), in the cases provided for by law; and Sexual Assault Evidence Collection (Coleta de Vestígios de Violência Sexual - CV/VS).

In Minas Gerais, a state with 853 municipalities, all four classifications of SAP/VS can be found within the SUS. However, despite the mandatory hospital care¹⁰10 Brasil. Casa Cívil. Lei nº 12.845, de 01 de agosto de 2013. Dispõe sobre o atendimento obrigatório e integral de pessoas em situação de violência sexual [Internet]. Diário Oficial da União, Brasília (DF), 2013 Ago 02 [citado 2022 Maio 18], Seção 1:1. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2013/lei/l12845.htm
http://www.planalto.gov.br/ccivil_03/_at... and the organization of SAP/VS,¹¹11 Brasil. Ministério da Saúde. Portaria no 485, de 01 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) [Internet]. Diário Oficial da União, Brasília (DF), 2014 Abr 02 [citado 2022 Maio 18], Seção 1:53. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=53&data=02/04/2014
https://pesquisa.in.gov.br/imprensa/jsp/...

12 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 618, de 18 de julho de 2014. Altera a Tabela de Serviços Especializados do Sistema de Cadastro Nacional de Estabelecimentos de Saúde (SCNES) para o serviço 165 Atenção Integral à Saúde de Pessoas em Situação de Violência Sexual e dispõe sobre regras para seu cadastramento [Internet]. Diário Oficial da União, Brasília (DF), 2014 Jul 22 [citado 2022 Maio 18], Seção 1:82. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=82&data=22/07/2014
https://pesquisa.in.gov.br/imprensa/jsp/... -¹³13 Brasil. Ministério da Saúde. Portaria no 1.662, de 2 de outubro de 2015. Define critérios para habilitação para realização de coleta de vestígios de violência sexual no Sistema Único de Saúde (SUS), inclui habilitação no Sistema de Cadastro Nacional de Estabelecimentos de Saúde (SCNES) e cria procedimento específico na Tabela de Procedimentos, Medicamentos e Órteses, Próteses e Materiais Especiais (OPM) do SUS [Internet]. Diário Oficial da União, Brasília (DF), 2015 Out 07 [citado 2022 Maio 18], Seção 1:18. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=18&data=07/10/2015
https://pesquisa.in.gov.br/imprensa/jsp/... a survey conducted in 2017 showed that specialized services provided were insufficient to meet the demands for care, leading to care gaps.¹⁴14 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Cien Saude Colet. 2022;27(9):3715-28. doi: 10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279...

The aim of this study was to describe the sociodemographic profile of reported cases of sexual violence and the distribution of care services for this health condition.

METHODS

This was a descriptive study of cases of sexual violence reported on the SINAN in Minas Gerais, in 2019, and the distribution of SAP/VS in the state of Minas Gerais, registered in the Brazilian National Health Establishment Registry (Cadastro Nacional dos Estabelecimentos de Saúde - CNES), in July 2019.

All notifications made in 2019 with the form of violence indicated as “sexual violence” in the Notification Form were included, regardless of sex or age group of the case.

The following variables were used according to sex (female; male) and age groups [in years: 0 to 9 (children); 10 to 19 (adolescents); 20 or over (adults)]:

1. a) demographic – race/skin color (White; Black; Asian; mixed-race; Indigenous; unknown) and marital status (single; married or in consensual union; widowed; separated; not applicable; unknown) –;

2. b) disability status (has a disability; does not have a disability; unknown);

3. c) pregnancy status (yes; no; not applicable; unknown);

4. d) previous occurrence of violence (yes; no; unknown);

5. e) place of occurrence (home; collective housing; school; sports facility; bar or similar establishment; public thoroughfare; trade/services; industries/construction site; other; unknown);

6. f) type of sexual violence (sexual harassment; rape; child pornography; sexual exploitation; others);

7. g) number of aggressors involved (one; two or more; unknown);

8. h) sex of the probable aggressor (male; female; both sexes; unknown);

9. i) relationship to the person receiving care [family members; partners or ex-partners; friends or acquaintances; strangers; others].

SINAN and CNES data were publicly available on the Brazilian National Health System Information Technology Department (Departamento de Informática do SUS - DATASUS) website.¹⁵15 Ministério da Saúde (BR). Departamento de Informática do SUS. DATASUS: Violência interpessoal/autoprovocada – Brasil [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 Nov 24]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinannet/cnv/violebr.def
http://tabnet.datasus.gov.br/cgi/deftoht... ,¹⁶16 Ministério da Saúde (BR). Departamento de Informática do SUS. DATASUS: CNES Estabelecimentos - Classificação do serviço [Internet]. Brasília: Ministério da Saúde; 2021 [2021 Set 20]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?cnes/cnv/servc2br.def
http://tabnet.datasus.gov.br/cgi/deftoht... The year 2019 was selected for the study because it refers to the latest database with final data made available by the Ministry of Health, which means that the database had already undergone the cleaning process and exclusion of duplicates at the federal level. The SINAN database was accessed on November 24, 2021. The CNES database was accessed on September 20, 2021.

Incidence rates of notification of sexual violence (per 100,000 inhabitants) were calculated according to three age groups (in years: 0 to 9; 10 to 19; 20 or over), for both females and males, across the 89 health micro-regions in the state of Minas Gerais. For the numerator, we took into consideration the total number of notifications of sexual violence reported on the SINAN in 2019, according to sex, age group and health microregion;¹⁷17 Secretaria de Estado de Saúde (MG). Subsecretaria de Gestão Regional. Ajuste do Plano Diretor de Regionalização de Saúde de Minas Gerais (PDR/MG) [Internet]. Belo Horizonte: Subsecretaria de Gestão Regional de Minas Gerais; 2020 [citado 2021 Set 4]. Disponível em: www.saude.mg.gov.br
www.saude.mg.gov.br... The denominator was comprised of the total population of the micro-region in 2019, according to sex and age group, based on resident population estimates.¹⁸18 Ministério da Saúde (BR). Departamento de Informática do SUS. DATASUS:. Projeção da população das unidades da federação por sexo e grupos de idade: 2000-2030. [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 1]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/projpopuf.def
http://tabnet.datasus.gov.br/cgi/deftoht... For the age group of 20 years or older, the standardized rate of notification of sexual violence was calculated using the direct method and the distribution of the Brazilian population as the standard.

The number and geographical distribution of SAP/VS were described according to the 14 health macro-regions¹⁷17 Secretaria de Estado de Saúde (MG). Subsecretaria de Gestão Regional. Ajuste do Plano Diretor de Regionalização de Saúde de Minas Gerais (PDR/MG) [Internet]. Belo Horizonte: Subsecretaria de Gestão Regional de Minas Gerais; 2020 [citado 2021 Set 4]. Disponível em: www.saude.mg.gov.br
www.saude.mg.gov.br... of the state, within the four classifications of the Service.

In order to analyze the distance traveled by people with notifications of sexual violence to the nearest AIP/VS referral service and within the same health macro-region, the calculation of distance – in a straight line and in kilometers – between the municipality of notification and the nearest referral service (municipality with the AIP/VS referral service classification, within each health macro-region) was performed. Macro-regions that were not registered in the CNES for this classification were not included in this analysis, namely: Noroeste, Nordeste, Leste e Leste do Sul. The Euclidean Distance function (ArcGIS software) and meshes provided by the Institute for Applied Economic Research/Ministry of Planning and Budget (Instituto de Pesquisa Econômica Aplicada/Ministério do Planejamento e Orçamento - IPEA/MPO) were used to calculate the distance.¹⁹19 Instituto de Pesquisa Econômica Aplicada. IpeaGEO: malhas [Internet]. Brasília: Instituto de Pesquisa Econômica Aplicada; [2020?] [citado 2021 Out 10]. Disponível em: https://www.ipea.gov.br/ipeageo/malhas.html
https://www.ipea.gov.br/ipeageo/malhas.h...

For comparisons between the state’s health macro-regions, we took into account the maximum distances calculated between the place of notifications and the specialized care service, considering that this would be the longest distance traveled by a person with a notification of sexual violence to the nearest AIP/VS referral service within the macro-region.

R²⁰20 R Core Team. A language and environment for statistical computating [Internet]. Vienna: R Foundation for Statistical Computing; 2013 [cited 2022 May 15]. Available from: http://www.R-project.org/
http://www.R-project.org/... software and the ArcGIS software (version 10.5) were used for the analyses.

The study was based on secondary, aggregate data, without personal identification. As these data are available in public domain databases, the project was exempted from approval by a Research Ethics Committee (REC).

RESULTS

In 2019, 4,429 notifications of sexual violence were identified in Minas Gerais; one case was classified as “unknown” sex, nine cases had “unknown” age and one case had “unidentified” municipality of residence. These 11 cases with missing data for sex, age and municipality of residence were excluded from the study, and a total 4,418 notifications remained to be analyzed: 87.0% were female, 72.0% were children and adolescents (0 to 19 years old) and 18.0% were in the age group of 20 years and older, showing “rape” as the most commonly reported type of sexual violence: 60.8% (Table 1 and Table 2).

Regarding all age groups, females showed a higher frequency of notifications of sexual violence, exceeding 90% among people aged 10 years and older. The majority of notifications were related to mixed-race/Black people, of both sexes, and in all age groups. Sexual violence against people with disabilities was more frequently reported in males, for all age groups, reaching 42.6% of adults. Among female adolescents and adults, previous occurrences of sexual violence were reported in 40.4% and 35.2% of the cases, respectively. Regardless of sex and age group, the primary place of occurrence was the residence, and the most commonly reported type of sexual violence was rape (Table 1 and Table 2).

With regard to females, aged 0 to 9 and 10 to 19 years old, the main aggressors were family members (34.5% and 26.0%, respectively) and friends or acquaintances (27.9% and 30.8%, respectively); among adult females, the main aggressors were strangers (33.9%) and partners/ex- partners (30.1%) (Table 1 and Table 2).

Among males, in the age groups of 0 to 9 years and 10 to 19 years, the main aggressors were friends or acquaintances (33.3% and 37.3%, respectively), followed by family members (29.0% and 18.6%, respectively); among adult males, the main aggressors were strangers (38.5%) and friends or acquaintances (30.8%) (Table 1 and Table 2).

The highest incidence rates of notification were found among female adolescents: 455/100,000 inhabitants. in Diamantina; 405/100,000 inhabitants in Serro; and 396/100,000 inhabitants in Uberaba (Figure 1 and Supplementary Figure).

In the state of Minas Gerais, in July 2019, the AIP/VS, AAP/VS and CV/VS referral services were the most frequently registered in the CNES, with 28, 20 and 19 services respectively (Table 3). Among the 89 health microregions in the state, only 30 had some type of SAP/VS registered in the CNES (Table 3). Regarding the 14 health macro-regions, four of them (Leste; Leste do Sul; Nordeste; Noroeste) did not have AIP/VS services, and in the Southeast microregion no SAP/VS was identified. It is noteworthy that only seven referral services for termination of pregnancy (interrupção da gravidez - GI) were registered in the whole state. The Centro macro-region showed the highest number and of registered services (Table 3).

As for the distance traveled by a person with a notification of sexual violence to the nearest AIP/VS referral service within the health macro-region, maximum distances ranging from 327 km to 93 km were observed. The five macro-regions with the largest maximum distances were: Triângulo do Sul (327 km); Norte (301 km); Triângulo do Norte (262 km); Jequitinhonha (257 km); and Centro (242 km). Average distances ranged from 42 km (Vale do Aço) to 149 km (Norte) (Figure 2).

DISCUSSION

Notifications of sexual violence in 2019, in the state of Minas Gerais, showed a worrying scenario: over 12 notifications per day in the state’s health services. The records were concentrated in females, children and adolescents and mixed-race/Black people, with the house being the primary place of violence perpetration and males the main aggressors.

The evaluation of the distribution of the SAP/VS showed care gaps in the provision of AIP/VS in four health macro-regions; the absence of any type of SAP/VS in one (1) macro-region of the state stood out. Regarding the distances traveled by people with notifications of sexual violence, among the ten macro-regions with a referral service for AIP/VS, five had an average distance greater than 100 km, a considerable displacement for people subjected to sexual violence. In six macro-regions, the maximum distance traveled to a referral service for AIP/VS was even greater, exceeding 200 km. Overall, these findings are similar to those of other studies on gender-based violence and sexual violence, reinforcing that mixed-race/Black, young women and sometimes with disabilities are more vulnerable in this regard.¹⁴14 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Cien Saude Colet. 2022;27(9):3715-28. doi: 10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279... ,²¹21 World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence [Internet]. Geneva, World Health Organization, 2010 [cited 2022 May 15]. 94 p. Available from: https://apps.who.int/iris/handle/10665/44350
https://apps.who.int/iris/handle/10665/4... These findings show how the intersection of the dimensions of gender, race/skin color, age and disability is related to the experience of sexual violence, reflecting the inequalities imposed by distinct and overlapping power relations that affect people in different ways.²²22 Crenshaw KW, Bonis O. Mapping the margins: intersectionality, identity politics, and violence against women of color. Cah Genre. 2005;39(2):51-82. doi: 10.3917/cdge.039.0051
https://doi.org/10.3917/cdge.039.0051...

Despite the existing legal coercion mechanisms, such as the Maria da Penha Law (Law No. 11,340, of August 7, 2006)²³23 Brasil. Casa Cívil. Lei nº 11.340, de 07 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 [Internet]. Diário Oficial da União, Brasília (DF), 2006 Ago 08 [citado 2021 Abr 10], Seção 1:1. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11340.htm
http://www.planalto.gov.br/ccivil_03/_at... and the Femicide Law (Law No. 13,104, of March 9, 2015),²⁴24 Brasil. Ministério da Justiça. Lei nº 13.104, de 09 de março de 2015. 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 [Internet]. Diário Oficial da União, Brasília (DF), 2015 Mar 10 [citado 2021 Abr 18], Seção 1:1. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/l13104.htm
http://www.planalto.gov.br/ccivil_03/_at... in addition to public initiatives to address and provide care for people who experienced sexual violence, the historical prevalence of this health condition among women and its chronicity, often associated with these occurrences, demonstrate that society and especially women are still entangled in mental models and/or imagery, produced under power relations and domination based on a symbolic order, whose main beneficiaries are men and their intentions.²⁵25 Bourdieu P. A dominação masculina. [Rio de Janeiro]: Bertrand Brasil; 2012.

Federative pacts, such as the National Plan to Confront Sexual Violence against Children and Adolescents,²⁶26 Ministério dos Direitos Humanos (BR). Conselho Nacional dos Direitos da Criança e do Adolescente. Plano Nacional de Enfrentamento da Violência Sexual Contra Crianças e Adolescentes [Internet]. Brasília: Ministério dos Direitos Humanos; 2013 [citado 2022 Jun 7]. Disponível em: https://crianca.mppr.mp.br/arquivos/File/publi/sedh/08_2013_pnevsca.pdf
https://crianca.mppr.mp.br/arquivos/File... aiming at ensuring protection for children and adolescents, have not prevented the highest occurrence of this form of violence against these age groups, showing a historical tradition of intrafamilial abuse, as supported by some findings of the present study, such as the identification of the residence as the primary place of the aggression; and predominantly committed by family members, whether the person subjected to violence is female or male.

Poor access to protection policies and reporting mechanism are factors directly related to the worsening and emergence of new cases of sexual violence against children and adolescents, as demonstrated here; and especially against girls, whose discursive place occupied by their bodies still includes the sadistic idea of property and dominance, sustained by a colonized patriarchal system. In these cases, early interventions performed by health professionals, have been an important strategy, pointed out by research in various fields of knowledge interested in the subject, such as psychology.²⁷27 França CP. Um corpo maculado na infância: a necessidade de intervenção precoce dos profissionais de saúde. Pesquisas e Práticas Psicossociais. 2017;12(3):1-10.

Data from SINAN reveal a partial picture of this serious problem: a significant underreporting of cases of sexual violence. Although it is mandatory to report this form of violence against people of any age or sex, this record depends on the academic training of health professionals. The notification of sexual violence also depends on the understanding and sensitization of these professionals in the healthcare setting, in the guidance on care and in the promotion of the health of the affected individuals, in addition to the correct completion of the Notification Form as an instrument for recording essential data for the epidemiology of the health condition and the public health response actions.¹⁴14 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Cien Saude Colet. 2022;27(9):3715-28. doi: 10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279...

In this sense, it is necessary to consider the following hypotheses for approaching the issue: difficulty in understanding and sensitivity of professionals regarding the notification and the care for children and adolescents victims of this violence and its prevention; difficulty in identifying and recording sexual violence in adult males; difficulty in understanding and recording cases in women when the aggressors are their intimate partners or friends/acquaintances; and a higher registration of more severe cases that seek care in specialized centers.

Even considering the existence of underreporting of sexual violence, the incidence rates based on the notification of cases proved to be alarming. In situations where not all cases that receive care are reported, the calculation of the incidence rate may unfairly highlight microregions with municipalities that are more sensitized and active in the surveillance of sexual violence as having the highest rates.

The assessment of the distribution of the SAP/VS showed care gaps or points of low resolubility in the following macro-regions: Noroeste, Leste do Sul, Leste and Nordeste. Health macro-regions constitute the territorial basis for planning tertiary health care, offering hospital health services with higher-density technology. Health micro-regions, on the other hand, are the territorial basis for planning secondary health care, by providing outpatient and hospital services of medium complexity and, exceptionally, some high complexity services. In summary, the macro-region encompasses all three levels of tertiary, secondary and primary health care, while the micro-region encompasses services of primary and secondary health care.

In this context, the territorial unit of the macro-region should have registered health facilities of the three levels of health care, to assist people subjected to sexual violence, as well as the unit of the micro-region should have registered existing outpatient services within its jurisdiction.

A study based on data from notifications of sexual violence in Minas Gerais, including specialized services in the state, observed that in 2017, there were 40 health centers registered as SAP/VS, distributed in 11 out of the 14 macro-regions in the state, with the majority (37.5%) located in the Centro macro-region. The same study showed that approximately 10% of the cases of rape among women in the state, that same year, occurred in health macro-regions where there were no specialized healthcare centers and 23% occurred in macro-regions with only one specialized healthcare center.¹⁴14 Melo CM, Soares MQ, Bevilacqua PD. Violência sexual: avaliação dos casos e da atenção às mulheres em unidades de saúde especializadas e não especializadas. Cien Saude Colet. 2022;27(9):3715-28. doi: 10.1590/1413-81232022279.07242022
https://doi.org/10.1590/1413-81232022279... This study identified 48 healthcare centers registered as SAP/VS, that is, only eight new services were registered in the two-year period. Moreover, Leste do Sul macro-region, where significant rates of sexual violence were found, the care gap remains. These findings reveal that despite the investment made by the Brazilian government in the organization of SAP/VS – especially since 2015, when the Ministry of Health created mechanisms for registration and remuneration of healthcare centers providing this type of care – there has not been significant expansion of these services in Minas Gerais.

In addition to the care gaps found, the distances that people subjected to sexual violence must travel to have access to comprehensive care services hinder timely care, compromising the provision of care within 72 hours after the act of sexual violence, as recommended by health institutions.

This study had some limitations: (i) the calculation of rates by health microregion could hide particular situations in specific municipalities; (ii) the distances calculated corresponded only to the territory of the macro-region where the case occurred, while in the cases that occurred in border regions, there is the possibility of receiving care in other health macro-regions in Minas Gerais and even in other states, although it was not possible to consider these situations in this study, given that the distances were calculated in a straight line and under different aspects, both related to the organization of the road network and of cultural nature, imposing greater distances to be traveled by people seeking care; and finally (iii) services providing care to people subjected to sexual violence may not be registered with the CNES.

As a potential strength of the study, it can be seen that, despite the underreporting, the rates of sexual violence are much higher than the rates of several diseases considered as public health emergencies. Therefore, addressing sexual violence in the state of Minas Gerais requires policies that better integrate the training of healthcare professionals, and a coordinated service network available throughout the territory, as recommended by the Regionalization Master Plan.¹⁷17 Secretaria de Estado de Saúde (MG). Subsecretaria de Gestão Regional. Ajuste do Plano Diretor de Regionalização de Saúde de Minas Gerais (PDR/MG) [Internet]. Belo Horizonte: Subsecretaria de Gestão Regional de Minas Gerais; 2020 [citado 2021 Set 4]. Disponível em: www.saude.mg.gov.br
www.saude.mg.gov.br...

It can be concluded that the study presented a picture of sexual violence in Minas Gerais in 2019, characterized by the concentration of cases in females, children and adolescents, mixed-race/Black people, and its occurrence in the domestic, intimate and family space. If, on the one hand, high incidence rates of notification were found in the health micro-regions of the state, on the other hand, a scarcity of care services for people subjected to sexual violence (Serviço de Atenção às Pessoas em Situação de Violência Sexual - SAP/VS) and care gaps between these micro-regions, were identified, especially services classified as Outpatient Care for People Subjected to Sexual Violence (Atenção Ambulatorial às Pessoas em Situação de Violência Sexual - AAP/VS). The maximum distances that people with notifications of sexual violence must travel to receive care in a Comprehensive Care for People Subjected to Sexual Violence” (Atenção Integral às Pessoas em Situação de Violência Sexual - AIP/VS) service -, are high, with average distances exceeding 100 km. These results highlight the need for improving public policies and their implementation, strategic planning in the location of services and expansion of specialized care coverage for cases of sexual violence in the state of Minas Gerais.

REFERÊNCIAS

Supplementary Figure 1   Incidence rates of notifications of sexual violence, per 100,000 inhabitants, by sex and age group, state of Minas Gerais, Brazil, 2019

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