Analysis of reported cases of sexual violence against the adult population

Abstract

Objective

To identify the prevalence of sexual violence in the adult population of the state of Espírito Santo and analyze its association with characteristics of the victim, the aggressor and the occurrence.

Methods

Epidemiological, analytical, cross-sectional study developed with notifications of sexual violence in adults aged 20-59 years between 2011 and 2018 from the Information System for Diseases and Notification. Data were obtained by the Health Department after project approval by the Ethics Committee in August 2019. The dependent variable was sexual violence and the independent variables were the characteristics of the victim, the aggressor and the occurrence. The analysis was performed using Stata 14.1 and the Poisson regression results were presented by prevalence ratio.

Results

Sexual violence accounted for 6.2% of reports of interpersonal violence and was about six times more prevalent among women. Victimization in the age group of 20-29 years was 1.51 times higher compared to the group of 40-49 years and 1.86 times higher in those who did not have a partner. It was also associated with residence in an urban area (PR: 1.60), aggressor aged 25 years or older (PR: 1.50), unknown (PR: 9.37), a single perpetrator (PR: 1.62) and occurrence in public places (PR: 1.38).

Conclusion

Violence is present among adults and some are more vulnerable, such as women, young adults without a partner, victims in urban areas, occurrences in public places and perpetrated by an older, unknown, single aggressor. These findings can support strategic actions to combat violence.

Violence; Sex offenses; Health information systems; Adult

Resumo

Objetivo

Identificar a prevalência de violência sexual na população adulta do estado do Espírito Santo e analisar sua associação com as características da vítima, do agressor e da ocorrência.

Métodos

Estudo epidemiológico, analítico, transversal, realizado com notificações de violência sexual em adultos de 20 e 59 anos, entre 2011 e 2018, no SINAN. Os dados obtidos pela Secretaria de Saúde após aprovação do projeto em Comitê de Ética, em agosto de 2019. A variável dependente foi a violência sexual e as independentes as características da vítima, do agressor e da ocorrência. A análise ocorreu pelo Stata 14.1 e os resultados da regressão de Poisson apresentados pela razão de prevalência.

Resultados

A violência sexual foi responsável por 6,2% das notificações de violência interpessoal, e cerca de seis vezes mais prevalente entre mulheres. A vitimização na faixa etária de 20 a 29 anos foi 1,51 vezes maior do que entre 40 e 49 anos e nos que não possuíam companheiro foi 1,86 vezes maior. Esteve associada ainda a residência em zona urbana (RP: 1,60), a agressor com 25 anos ou mais (RP: 1,50), desconhecido (RP: 9,37), a perpetrador único (RP: 1,62) e a ocorrência em via pública (RP: 1,38).

Conclusão

A violência está presente entre os adultos, e alguns são mais vulneráveis como as mulheres, os adultos jovens e sem companheiro, as vítimas de zona urbana, a ocorrência em via pública e por único agressor, desconhecidos e mais velhos. Os achados podem subsidiar ações estratégicas de enfrentamento à violência.

Violência; Delitos sexuais; Sistema de informação em saúde; Adulto

Resumen

Objetivo

Identificar la prevalencia de violencia sexual en la población adulta en el estado de Espírito Santo y analizar su relación con las características de la víctima, del agresor y del episodio.

Métodos

Estudio epidemiológico, analítico, transversal, realizado con notificaciones de violencia sexual en adultos de 20 a 59 años, entre 2011 y 2018 en el SINAN (Sistema de Información de Agravios de Notificación). Los datos fueron obtenidos por la Secretaría de Salud, luego de la aprobación del proyecto en Comité de Ética, en agosto de 2019. La variable dependiente fue la violencia sexual, y las independientes fueron las características de la víctima, del agresor y del episodio. El análisis se realizó a través del Stata 14.1 y los resultados de la regresión de Poisson fueron presentados por la razón de prevalencia.

Resultados

La violencia sexual fue responsable por el 6,2 % de las notificaciones de violencia interpersonal y cerca de seis veces más prevalente entre mujeres. La victimización en el grupo de edad de 20 a 29 años fue 1,51 veces mayor que entre 40 y 49 años, y en los que no tenían compañero fue 1,86 veces mayor. Además, estuvo asociada a la residencia en zona urbana (RP: 1,60), agresor de 25 años o más (RP: 1,50), desconocido (RP: 9,37), perpetrador único (RP: 1,62) y episodio en vía pública (RP: 1,38)

Conclusión

La violencia está presente entre los adultos y algunos son más vulnerables, como las mujeres, los adultos jóvenes y sin compañero, las víctimas de zona urbana, los episodios en vía pública y por único agresor, desconocido y de mayor edad. Los resultados pueden respaldar acciones estratégicas de enfrentamiento a la violencia.

Violencia; Delitos sexuales; Sistemas de información en salud; Adulto

Introduction

Sexual violence is a public health problem that affects different areas of society worldwide. This problem is defined by the World Health Organization (WHO) as any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person, regardless of their relationship to the victim, in any setting, including but not limited to home and work.(¹)

It extends to all cycles of human life in different ways at each stage of development, causing harm to the health of men and women. In productive ages, its impacts on society go beyond the health sector. Broad and heterogeneous, it is estimated that the global prevalence rate of sexual violence among women is 2,816 cases per 100,000 people, and among men is 1,194 cases per 100,000 people.(²)

It is important to consider that sexual violence has very variable estimates, since it is a problem with a broad concept and strongly influenced by cultural values, especially among men, where sexual crimes are less understood and less recognized by society.(²) In Brazil, the average rate of reported cases of sexual violence is 4.38 notifications per 100,000 inhabitants, a worrying fact, since institutional records of sexual violence are only a fraction of the dimension of this problem, representing only victims who somehow accessed care services.(³)

Feelings of guilt, shame and fear commonly affect people in situations of violence and prevent them from seeking support services. Health professionals play a relevant role in this context by offering qualified and safe embracement to the victims and making referrals to various care sectors.(⁴)

Likewise, health notification systems play an important role in the line of care by giving visibility to the problem and supporting services and public policies.(⁵) Timely and systematized notification of violence allows the coordination between health services and a joint action with other sectors of society, such as education, social services, the judiciary and non-governmental organizations.(⁶)

In view of the above, we understand that sexual violence is a broad and complex public health issue that needs to be better understood in order to be addressed appropriately. This study expands knowledge about the phenomenon, providing support for the development of strategies to prevent and cope with violence in the adult population. In this perspective, the objective of this study was to identify the prevalence of reported cases of sexual violence in the adult population of the state of Espírito Santo between 2011 and 2018, and analyze its association with the characteristics of the victim, the aggressor and the aggression.

Methods

This is an epidemiological, analytical cross-sectional study performed with data from the Information System for Diseases and Notification - SINAN in the state of Espírito Santo, Brazil, between 2011 and 2018. Data were extracted from the system by the State Health Department in September 2019 after approval of the study by the ethics committee. All cases of this condition registered in the system during the established period were included in the analysis.

The choice for the data collection period was due to the mandatory notification of cases of violence by all health services as of Ordinance 104 of January 2011.(⁷) As a condition of compulsory notification, cases of violence are monitored through the interpersonal and self-inflicted violence notification form.

The study outcome variable was interpersonal sexual violence (yes/no). Independent variables were composed by the victim’s characteristics: sex (female/male), age (20-29 years old/30-39 years old/40-49 years old/50-59 years old), race/color (white/black or mixed race), education (0-4 years/5-8 years/9 years or more), marital status (with a partner/without a partner), area of residence (urban or peri-urban/rural) and presence of disability or disorder (yes/no); by characteristics of the aggressor: sex (female/male), age group (up to 24 years old/25 years old or more), relationship with the victim (current intimate partner or ex/acquaintance/unknown) and suspected alcohol use (yes/no); and characteristics of the occurrence of the event: number of people involved (one/two or more), place of occurrence (residence/public place/others), history of repetition (yes/no) and referrals to other services (yes/no).

Descriptive analysis was performed using relative and absolute frequencies and 95% confidence intervals. The Pearson’s chi-square test was used in bivariate analysis. In multivariate analysis, Poisson regression was used through the hierarchical model with the victim’s characteristics as the first level and the characteristics of the aggressor and the aggression as the second level. The variables that entered the model were those with a p-value lower than 0.2 in bivariate analysis; their maintenance in the model followed the criterion of p less than 0.05. Results were expressed in crude and adjusted Prevalence Ratio (PR) with the respective 95% confidence intervals (95% CI). The author’s sex variable was not included in the model due to the low number of cases in the categories. All analyzes were performed using the Stata 14.1 software. The STROBE initiative recommendations were used for the presentation of the study.

This study was approved by the Research Ethics Committee of the Universidade Federal do Espírito Santo under opinion number 2.819.597 and the norms and guidelines of Resolutions 466/2012 and 510/2016 of the National Health Council were observed (CAAE: 88138618.0.0000.5060).

Results

Between years 2011 and 2018, 1,332 (P:6.2%; 95% CI:5.9-6.5) notifications of sexual violence in the adult population of Espírito Santo were reported; of these, 1,282 notifications were against women and 50 cases against men (data not shown in table). Table 1 presents the characteristics of the population. In most cases, victims of sexual violence were women (P: 96.2%; 95% CI: 95.1-97.1), with 44% (95% CI: 41.4-46.7) aged 20-29 years, self-declared as black or mixed race (P: 67.3%; 95%CI: 64.7-69.9), about six out of ten victims had nine years of schooling or more and did not have a partner. It was also observed that 84.4% (95% CI: 82.3-86.3) did not have disabilities and 94.3% (95% CI: 92.9-95.5) lived in urban or peri-urban areas. As for characteristics of the aggressor, almost all were men (P: 98.6%; 95% CI: 97.8-99.1); aged 25 years or older (P: 80.0%; 95% CI: 77.0-82.8); and 45.2% (95% CI: 42.5-48.0) were unknown to the victim. Suspected alcohol use occurred in 55.6% (95% CI: 52.3-58.9) of notifications, in 84.1% of cases there was only one aggressor (95% CI: 82.0-86.0) and the residence was the main place of occurrence (P: 54.1%; 95% CI: 51.3-56.9). There was no recurrence of the condition in 62.6% of cases and nine out of ten were referred to follow-up at other services (Table 1).

Table 1
Characterization of reported cases of sexual violence in the adult population according to victim, aggressor and occurrence data

Variables	n(%)	95% CI
Sex
Male	50(3.8)	2.9-4.9
Female	1282(96.2)	95.1-97.1
Age group
20-29 years	586(44.0)	41.4-46.7
30-39 years	412(30.9)	28.5-33.5
40-49 years	215(16.1)	14.3-18.2
50-59 years	119(8.9)	7.5-10.6
Race/Color
White	397(32.7)	30.1-35.3
Black/mixed race	819(67.3)	64.7-69.9
Education
0-4 years	116(11.4)	9.6-13.5
5-8 years	285(28.1)	25.4-30.9
9 years or more	615(60.5)	57.5-63.5
Marital status
No partner	813(66.1)	63.5-68.7
With partner	416(33.9)	31.3-36.6
Disabilities/disorders
No	1023(84.4)	82.3-86.3
Yes	189(15.6)	13.7-17.8
Zone of residence
Urban/peri-urban	1212(94.3)	92.9-95.5
Rural	73(5.7)	4.5-7.1
Sex of the aggressor
Male	1289(98.6)	97.8-99.1
Female	10(0.8)	0.4-1.4
Both	8(0.6)	0.3-1.2
Age group of aggressor
0 – 24 years	145(20.0)	17.2-23.1
25 years or older	581(80.0)	77.0-82.8
Relationship with the victim
Intimate partner (current or former)	358(28.0)	25.6-30.5
Known	343(26.8)	24.4-29.3
Unknown	579(45.2)	42.5-48.0
Suspected alcohol use
No	391(44.4)	41.1-47.7
Yes	490(55.6)	52.3-58.9
Number of people involved
One	1063(84.1)	82.0-86.0
Two or more	201(15.9)	14.0-18.0
Place of occurrence
Residence	668(54.1)	51.3-56.9
Public place	358(29.0)	26.5-31.6
Others	208(16.9)	14.9-19.1
Repeated violence
No	758(62.6)	59.9-65.3
Yes	452(37.4)	34.7-40.1
Referral
No	130(9.9)	8.4-11.6
Yes	1187(90.1)	88.4-91.6

• 95% CI - 95% confidence interval

In bivariate analysis, there is a relationship between sexual violence and the variables sex, age group, education, marital status and area of residence of the victim, as well as age group and sex of the aggressor, relationship with the victim, suspected alcohol use by the aggressor, number of people involved, place of occurrence, history of repetition and referral to other services (p<0.05). Only the variables race/color and presence of disabilities/disorders were not related to this type of violence (Table 2).

Table 2
Bivariate analysis of reported sexual violence in the adult population according to characteristics of the victim, the aggressor and the occurrence

Variables	n(%)	95% CI	p-value
Sex
Male	50(1.2)	0.9-1.6	<0.001
Female	1282(7.3)	7.0-7.7
Age group
20-29 years	586(7.6)	7.0-8.2	<0.001
30-39 years	412(5.6)	5.1-6.1
40-49 years	215(4.8)	4.2-5.5
50-59 years	119(5.7)	4.8-6.8
Race/Color
White	397(6.6)	6.0-7.2	0.706
Black/mixed race	819(6.4)	6.0-6.9
Education
0-4 years	116(5.4)	4.5-6.4	<0.001
5-8 years	285(6.8)	6.1-7.6
9 years or more	615(7.9)	7.4-8.6
Marital status
Without partner	813(8.6)	8.1-9.2	<0.001
With partner	416(4.8)	4.4-5.3
Disabilities/disorders
No	1023(6.9)	6.5-7.3	0.152
Yes	189(6.2)	5.4-7.1
Zone of residence
Urban/peri-urban	1212(6.4)	6.1-6.8	<0.001
Rural	73(3.4)	2.7-4.2
Sex of the aggressor
Male	1289(9.6)	9.1-10.1	<0.001
Female	10(0.2)	0.1-0.3
Both	8(2.7)	1.3-5.2
Age group of aggressor
0-24 years	145(4.1)	3.5-4.9	0.006
25 years and older	581(5.3)	4.9-5.7
Relationship with the victim
Intimate partner (current or former)	358(4.4)	4.0-4.9	<0.001
Known	343(8.7)	7.9-9.6
Unknown	579(30.8)	28.8-32.9
Suspected alcohol use
No	391(4.9)	4.5-5.4	<0.001
Yes	490(7.4)	6.8-8.1
Number of involved
One	1063(6.1)	5.7-6.4	<0.001
Two or more	201(8.4)	7.3-9.5
Place of occurrence
Residence	668(4.8)	4.5-5.2	<0.001
Public place	358(11.0)	9.9-12.1
Others	208(11.0)	9.7-12.5
Repeated violence
No	758(10.2)	9.6-10.9	<0.001
Yes	452(4.8)	4.4-5.3
Referral
No	130(3.4)	2.9-4.0	<0.001
Yes	1187(7.0)	6.6-7.4

• 95% CI - 95% confidence interval

Table 3 shows that after adjusted analysis, sexual violence was 6.26 times (95% CI: 4.63-8.48) more frequent in women. In addition, victimization in the group of 20-29 years was 1.51 times (95% CI: 1.28-1.77) higher than in the group of 40-49-years. Another associated finding was not having a partner (PR: 1.86; 95% CI: 1.66-2.09). Also, the frequency of the occurrence (95% CI: 1.25-2.05) was 1.60 times greater in residents of the urban/peri-urban area. As for characteristics of aggressors, a higher prevalence of perpetrators aged 25 years or older was found (PR: 1.50; 95% CI: 1.26-1.78). Sexual aggression against adults is about eight times more committed by strangers (PR: 9.37; 95% CI: 7.80-11.24), and 1.62 times more frequent involving one aggressor in the occurrence (CI 95 %: 1.32-1.98). As for the place where the sexual assault took place, public places were 1.38 (95% CI: 1.06-1.16) times more frequent than other places (Table 3).

Table 3
Crude and adjusted analysis of characteristics of the victim, the aggressor and the occurrence related to reported sexual violence in the adult population

Variables	Crude analysis			Adjusted analysis
	PR	95% CI	p-value	PR	95% IC	p-value
Sex
Male	1.0		<0.001	1.0		<0.001
Female	6.03	4.55-7.98		6.26	4.63-8.48
Age group
20-29 years	1.57	1.35-1.83	<0.001	1.51	1.28-1.77	<0.001
30-39 years	1.16	0.98-1.36		1.13	0.95-1.34
40-49 years	1.0			1.0
50-59 years	1.19	0.95-1.48		1.27	1.01-1.60
Education
0-4 years	1.0		<0.001	1.0		0.477
5-8 years	1.27	1.03-1.56		1.06	0.85-1.32
9 years or more	1.47	1.21-1.78		1.12	0.91-1.38
Marital status
Without partner	1.80	1.60-2.02	<0.001	1.86	1.66-2.09	<0.001
With partner	1.0			1.0
Disabilities/disorders
No	1.12	0.96-1.30	0.153	0.99	0.83-1.19	0.964
Yes	1.0			1.0
Zone of residence
Urbana/peri-urban	1.90	1.51-2.40	<0.001	1.60	1.25-2.05	<0.001
Rural	1.0			1.0
Age group of aggressor
0-24 years	1.0		0.006	1.0		<0.001
25 years and older	1.28	1.07-1.53		1.50	1.26-1.78
Relationship with the victim
Intimate partner (current or former)	1.0		<0.001	1.0		<0.001
Known	1.97	1.70-2.27		2.40	1.98-2.91
Unknown	6.96	6.16-7.86		9.37	7.80-11.24
Suspected alcohol use
No	1.0		<0.001	1.0		0.240
Yes	1.50	1.32-1.71		1.10	0.94-1.30
Number of involved
One	0.73	0.63-0.84	<0.001	1.62	1.32-1.98	<0.001
Two or more	1.0			1.0
Place of occurrence
Residence	0.81	0.79-0.84	<0.001	1.02	0.98-1.07	<0.001
Public place	1.09	1.06-1.13		1.38	1.06-1.16
Others	1.0			1.0
Repeated violence
No	2.12	1.89-2.37	<0.001	1.09	0.91-1.30	0.362
Yes	1.0			1.0

• PR - prevalence ratio; 95%CI - 95% confidence interval

Discussion

The results show that 6.2% of reports of interpersonal violence between adults were classified as sexual. In addition, victimization was about six times more prevalent among females, more frequent among younger adults aged 20-29 years and almost twice more prevalent among those who reported not having a partner. This type of violence was also associated with the fact of the victim living in an urban or peri-urban area, aggressors over 25 years of age, occurring in public places and inflicted by a single aggressor. Aggression by strangers was about nine times more prevalent than any group of aggressors who had any relationship with the victim.

Regarding its magnitude, sexual violence was responsible for 6.2% of reports of violence recorded in the adult population of Espírito Santo. The VIVA Inquérito, a national study conducted in different Brazilian capitals, estimates that 1.5% of consultations for violence in urgent and emergency hospitals are motivated by sexual assaults.(⁸) This result follows the general scenario of violence in the country and its trends, reinforcing the position of Espírito Santo as a state where high levels of violence still persist.(⁹)

It was also observed that sexual violence was 6.26 times (95% CI: 4.63-8.48) more frequent in women. This finding is similar to national studies in which 86% of notifications were from females.(¹⁰) This scenario expresses the unequal power relations surrounding men and women, the result of cultural and religious values that place women in a situation of vulnerability and men in a position of domination and strength. Added to this, we highlight the difficulties of access and of understanding this type of violence on the part of assistance services, which make this equation even more unequal.(²)

The analyzes also indicate that sexual violence affects a higher prevalence of young adults, with a prevalence 1.51 times higher (95% CI: 1.28-1.77) in the age group 20-29 years compared to victims aged 40-49 years; similar to a study conducted in Piauí, where women aged 20-29 years were 1.33 times more victims of this occurrence.(¹¹) Sexual victimization, especially among women, is more frequent among younger women and becomes less prevalent with aging, as victims become more economically productive and independent.(¹¹)

Regarding marital status, prevalence was 1.86 times higher (95% CI: 1.66-2.09) among those who reported not having a partner. In a study conducted in Belgium, having a partner was associated with a decrease in the risk of sexual victimization in the prior year compared to respondents who did not have a partner.(¹²) This association is still little explored, but it has been justified in the possibility of the lack of affective bond being an encouraging factor for the complaint.(¹¹)

The prevalence of sexual violence was 1.60 times higher (95% CI: 1.25-2.05) among residents of urban or peri-urban areas, corroborating the results of other studies conducted in the states of Minas Gerais,(¹³) Pernambuco(¹⁴) and Bahia,(¹⁵) where the urban area appeared with the highest frequency of victims. These results indicate that people in rural areas may suffer or report less situations of violence(¹⁵) or that places more economically and socially developed have a greater number of reporting units.(³)

In addition, a higher prevalence of aggressors aged 25 years or older (PR: 1.50; 95% CI: 1.26-1.78) and of occurrences with only one perpetrator (PR: 1.62; CI95 %: 1.32-1.98) was evidenced. In São Paulo, the most prevalent age group of aggressors was young adults.(¹⁶) In Paraná, only one aggressor was observed in about 79% of cases,(¹⁷) and in the state of Piauí, it was close to 90% in a study conducted with women aged 10-49 years.(¹¹)

Regarding the relationship with the aggressor, sexual violence was 9.37 times more perpetrated by strangers. This information is similar to that of a study of victims of sexual violence in Piauí, justifying the probable underreporting of these cases, since the guilt and shame felt by the victim when the aggressor is part of their family circle are obstacles to the recognition and registration of these cases in care services.(¹¹)

Another result of this study was that the most frequent places of occurrence of sexual violence were public places. In general, this is the scenario for this type of violence in the adult population and the occurrence of aggression in public places is associated with sexual violence.(¹¹) Such an association should serve as a warning to public safety, since the approach to victims by their aggressors in a public space during their daily trips shows the need for greater visibility of this type of aggression and protective actions to face this problem.(¹⁸)

The limitations of this study are associated with its cross-sectional design that does not allow a causal relationship between variables and limits the results to the population studied. In addition, the study addresses the analysis of a secondary database of a health information system within a limited period of time, thereby making impossible to do broader and more current analyzes as this theme requires. However, it provides important information to elucidate this scenario.

Conclusion

This is the first known study on the frequency of sexual violence in the adult population of Espírito Santo that highlights the problem and its magnitude in the state. The results point to a significant prevalence of this type of violence in the adult population, associated with female victims, young adults who do not have a partner and live in urban or peri-urban areas. As for aggressors and aggression, violence was associated with perpetrators over 25 years of age, unknown to their victims, involvement of a single aggressor and occurring in a public place. Knowledge of the prevalence of sexual violence and its associated factors contributes substantially to the planning of strategic public health actions and to combat the problem, as well as to the qualification of professionals and services involved in the embracement and management of people in situations of violence. Therefore, it is necessary to strengthen health information systems as powerful resources to provide these data and recognize the leading role of the health sector and its professionals in the specialized follow-up of cases.

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• ¹
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Edited by

Associate Editor (Peer review process): Rosely Erlach Goldman (https://orcid.org/0000-0002-7091-9691) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  29 Aug 2022
• Date of issue
  2022

History

• Received
  13 July 2021
• Accepted
  10 Dec 2021