Artigos

INTRODUCTION
Sexual abuse, which may include rape, is characterized as any form of non-consensual or unwanted sexual contact, obtained through physical force, threat, or in situations where the victim is unable to consent. This phenomenon is recognized as a serious public health issue ¹,². Globally, over 35% of women report having been victims of sexual or physical and/or sexual assault perpetrated by an intimate partner, although there is more limited data on prevalence in men, being more common in men who have sex with other men, drug users, and alcohol users 3,4.In 2018, Latin America reached a prevalence of physical and/or sexual violence committed by an intimate partner similar to the global average (25%), which was 27% that year, behind Southeast Asia (35%) and sub-Saharan Africa (33%)5.
Further, cardiovascular diseases (CVDs) are one of the leading causes of mortality on a global scale, resulting in significant costs for healthcare systems and leading to considerable work disability. The prevalence of these diseases is influenced by a variety of factors, including cardiometabolic, behavioral, environmental, and social factors. In 2019, according to the Global Burden Disease (GBD), CVDs were responsible for about 6.2 million deaths in people aged 30 to 70 years, with 28.2% of these deaths occurring only in Brazil 6,7. Additionally, psychosocial factors, such as exposure to lifetime sexual violence with repercussions in adulthood, are increasingly being recognized as important contributors to their development 8.
The psychological trauma resulting from sexual abuse affects a wide range of aspects, including emotional, mental, and physical ones, and can influence the development of CVDs and their risk factors through coping behavioral mechanisms 9,10. Longitudinal studies conducted in Ireland and the United States have shown a relationship between exposure to sexual violence in childhood 11, 12, 13, as well as in adolescents 14, 15 and the development of cardiovascular outcomes in adulthood, especially in women. However, research focused on the adult population, particularly in men, is scarce, especially in developing countries, resulting in a knowledge gap regarding the prevalence of sexual violence and its implications for cardiovascular complications 16.
Furthermore, for the authors' understanding, there are gaps in research on exposure to sexual violence and its cardiovascular impacts. Knowledge about the effects of this type of violence over a lifetime allows us to understand how even late lifetime exposure can influence the onset of cardiovascular diseases 17. Thus, in a population-based study conducted in Brazil, we analyzed the relationships between exposure to sexual violence over a lifetime and the occurrence of CVDs, separately for adult men and women.

MATERIALS AND METHODS
Study population and design
This cross-sectional study utilized data from the Brazilian National Health Survey (NHS), conducted by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE) in collaboration with the Ministry of Health (MS), 2019 edition. The NHS is a population-based survey designed to shed light on the determinants, barriers, and healthcare needs of the Brazilian population. It aims to support the development of effective public policies in healthcare 18.
Participants in the study comprised residents of both urban and rural private households across Brazil, selected through probabilistic sampling. The sample size was determined by establishing a Master Sample 19. These primary sampling units were further stratified using a conglomerate design. To identify the subsample within each primary sampling unit, a simple random sampling technique was applied. Interviews were conducted with individuals aged 15 and above 19.
A three-stage conglomerate sampling plan was adopted. In the first stage, census sectors or groups of sectors were selected to create the primary sampling units. In the second stage, households were chosen. In the third stage, one resident aged 15 or older from each household was randomly selected to respond to the specific questionnaire, based on the list of residents compiled at the time of the interview.
The interviews were conducted with a total of 90,846 residents. In relation to questions concerning violence, 88,531 participants aged 18 years and older were interviewed, with a non-response rate of 16.2% (below the planned 27.0%). This coverage spanned all designated areas within the sample plan. The overall non-response rate was 13.2%, also falling short of the planned rate of 20%. In this study, individuals aged 64 years or older were excluded, recognizing that the clinical presentation and progression of CVDs differ significantly between younger and older adults. CVDs often manifests more subtly and with atypical symptoms in elderly patients, frequently complicated by comorbidities and polypharmacy. This distinction is crucial for a more accurate understanding of cardiovascular conditions, allowing for a more focused and relevant analysis of the adult population, whose clinical and behavioral characteristics related to disease are more homogeneous. Additionally, their experiences of violence and risk behaviors differ from those of younger adults. Therefore, the decision to exclude older individuals aims to ensure clarity and precision in the results, facilitating the identification of patterns and interventions that may be applicable to this specific age group 20,21. This resulted in a study population of 70.896 participants.
Response Variables
The dependent variable of interest is the self-reported diagnosis of CVDs, assessed by the question: 'Has any doctor given you a diagnosis of cardiovascular disease, such as a heart attack, angina, heart failure, or another condition?' Individuals who answered 'yes' to this question were considered to have CVDs. Additionally, if they answered 'yes,' they were further asked to indicate whether they had been diagnosed specifically with myocardial infarction, angina, heart failure, or arrhythmia. We also examined each individual disease alongside the overall CVDs diagnosis.
Explanatory Variables
The independent variable in this study relates to exposure to lifetime sexual violence, inquired through the following questions: "Has anyone ever touched, manipulated, kissed, or exposed parts of your body against your will in lifetime?" and "Has anyone ever threatened or forced you to have sexual relations or engage in any other sexual acts against your will in lifetime?". Participants were categorized as "yes" if they responded affirmatively to one or more questions and "no" if they responded negatively to all the questions.
Covariates
Variables related to both the exposure and outcome were considered as covariates:
? Race/skin color (white, brown, and black), excluding yellow and indigenous individuals due to their low frequency;
? Age in years (mean and 95% confidence intervals);
? Current level of education (complete university education, complete high school, complete elementary school, and incomplete elementary school);
? Macro-regions of the country (southeast, south, midwest, northeast, and north);
? Income levels (>2 minimum wages [$ 494.83], more than 1 to 2 minimum wages [$ 247.41 to $ 494.83], ½ minimum wage up to 1 minimum wage [$ 123.70 to $ 247.41], ¼ minimum wage up to ½ minimum wage [$ 61.85 to $ 123.70], and <¼ minimum wage [$ 61.85]);
? Sexual orientation (heterosexual, bisexual, homosexual, other/don't know/refused to answer).
Statistical analysis
All analyzes were performed stratified by sex (men and women), used as a “proxy” for gender. We performed the descriptive analysis by the relative (percentage) and absolute frequencies for all study population characteristics. Differences between CVDs and other specific conditions (myocardial infarction, angina, heart failure, and arrhythmia) among those exposed to lifetime sexual violence by gender were measured using Pearson's chi-square (?2) test.
Logistic regression was performed to estimate the Odds Ratio (OR) and their respective 95% confidence intervals (95% CI) between the explanatory variable of interest and the outcomes (Model 1) and later sequential adjustments were made by age, race/skin color, (Model 2); sexual orientation, (Model 3); education and region (Model 4). Additionally, for each outcome, in a model considering the total population the presence of sex effect modification on those relationships was formally investigated in an additive and multiplicative scales (data non shown).
The analyzes were carried out in the Stata program, version 14.0 (Stata Corporation, College Station, United States), using the survey module, suitable for complex sampling, capable of considering the effects of stratification and conglomeration in the estimation of indicators and their measures of precision.
Ethical aspects
The 2019 NHS was approved by the National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa – CONEP), of the National Health Council (Conselho Nacional de Saúde – CNS) in August 2019, under Opinion N°. 3.529.376. Before the interviews, the participants agreed to participate in the research through the Term of Free and Informed Consent, and all respondents were informed and consulted about their acceptance of the interviews.
RESULTS
The mean age of the participants was 39.60 years (95% CI: 39.33-39.80) for men and 40.36 years (95% CI: 40.10-40.61) for women, reflecting a similar age distribution between the genders. There was a high prevalence of brown skin color among both women (44.71%; 95% CI 43.79-45.64) and men (46.18%; 95% CI 45.18-47.18). Regarding the country's regions, the data indicate a significant concentration in the Southeast for both genders (43.08%; 95% CI 42.02-44.15 for women and 42.67%; 95% CI 41.36-43.98 for men) (Table 1).
Considering the educational level, women (18.82%; 95% CI 17.99-19.67) have higher prevalence of university degrees than men (14.50%; 95% CI 13.65-15.40). However, men (30.80%; 95% CI 29.88-31.74) show a higher prevalence of lower levels of education, such as incomplete elementary school, than women (27.35%; 95% CI 26.52-28.20). In terms of income, we observed that men have higher levels, especially up to 2 minimum wages ($494.83, 28.81%; 95% CI 27.78-29.87), while women tend to have lower levels, with the majority earning below 1 minimum wage ($247.41, 28.90%; 95% CI 27.99-29.83). The majority of the population identifies as heterosexual (94.27%; 95% CI 93.76-94.74 for men and 94.55%; 95% CI 94.13-94.94 for women) (Table 1).
Both sexes presented similar frequencies of self-reported CVDs diagnosis (3.42%; 95% CI 3.05-3.82 for men and 3.87%; 95% CI 3.56-4.21 for women). However, they reveal a significant discrepancy in the experience of sexual violence, with 2.10% (95% CI 1.84-2.39) of men and 8.61% (95% CI 8.10-9.15) of women reporting cases in their lives (Table 1).
Figure (1) presents the prevalences of CVDs and specific cardiovascular conditions among those who reported lifetime sexual violence exposure, stratified by gender. Notably, the prevalence of CVDs in women reaches 12.77% (95% CI 10.21-15.87), compared to men, who have a prevalence of 2.21% (95% CI 1.15-4.21) (p<0.01). Additionally, the prevalence of myocardial infarction, angina, heart failure, and arrhythmia are also higher among women compared to men, highlighting significant gender differences in these conditions.
Table 2 presents the association between lifetime sexual violence and CVDs in adulthood by gender. After adjusting for age, skin color, sexual orientation, education, and region (Model 4), we observed that the odds of CVDs for women who experienced lifetime sexual violence were 74% higher (95% CI 1.32-2.29) compared to the non-exposed. Evaluating cardiovascular conditions individually, women were also associated to higher odds of myocardial infarction (OR 1.70; 95% CI: 1.03-2.81) and arrhythmia (OR 1.47; 95% CI: 1.03-2.08). While no significant associations were noted for angina or heart failure among women. Interestingly, men exposed to lifetime sexual violence remained not associated at any outcome.
Significant effect modification by sex was tested on both the additive and multiplicative scales for CVDs as a whole, as well as for specific conditions such as myocardial infarction, angina, heart failure, and arrhythmia, in relation to lifetime sexual violence. In an additive scale, the effect modification was significant for CVDs and myocardial infarction (p-value < 0.05), which led us to present the analyses stratified by sex for these variables (data non shown).
DISCUSSION
This study represents an innovative initiative in Brazil, utilizing data from a population-based survey to investigate the prevalence of lifetime sexual violence in men and women and its associations with the diagnosis of CVDs. The results are remarkable, highlighting a significant disparity in prevalence between genders. Surprisingly, women exposed to sexual violence showed a high prevalence of 12.77% of CVDs, compared to 2.21% among men. Additionally, it was evidenced that women who experienced sexual violence had 74% higher odds of CVDs compared to the non-exposed, while no significant association was observed for men.
These findings underscore the serious cardiovascular implications of such trauma, particularly in women, who demonstrated a statistically significant increase in the odds of myocardial infarction and arrhythmia. Although associations for other conditions like angina and heart failure were not statistically significant, the observed relationship warrant further research. This emphasizes the necessity of recognizing the cardiovascular health impacts of sexual violence, especially for women, within public health strategies.
The repercussions of sexual violence are intricately linked to social inequalities, with gender, education, and income serving as tangential variables. United Nations (UN) indicators suggest that low levels of education contribute to the perpetuation of sexual violence, defining both victims and perpetrators 22, 23. Our research corroborates this, revealing lower education levels, particularly primary education completion, prevalent across genders. Analysis of 2019 national data further illustrates this issue, with a significant prevalence of violence exposure at 18.3% (95% CI 17.8-18.8), notably higher among women (19.4%; 95% CI 18.7-20.0). This disparity is particularly pronounced in the 18–29 age group (27.0%; 95% CI 25.7–28.4), among Black (20.6%; 95% CI 19.3–21.9) and mixed-race individuals (19.3%; 95% CI 18.6–20.1), and residents of the Northeast region (18.7%; 95% CI 18.0–19.5) 24.
Although women have higher levels of education, which is understood as a protective condition against violence, it is important to emphasize that women are still seen as ongoing targets based on their gender. Despite women having higher levels of education, it's noteworthy that they often experience lower incomes, leading to greater vulnerability 25. Thus, there is a social explanation for this, as pointed out by Carneiro 26, who considered that relations, and consequently vulnerability, are determined by what sets groups apart. In the scenario of the present study, the most significant difference between groups is gender, with women being the main targets of sexual violence and its repercussions, specifically those mediated by CVDs.
The recognition of exposure to various forms of violence as a public health problem is an emerging field in many countries, with childhood exposure being associated with the development of cardiovascular risk factors that persist into adulthood 27, 28, 29, 30. The psychological trauma resulting from sexual abuse can contribute to the development of CVDs and its risk factors through coping behavioral mechanisms. Chronic stress can affect the body's ability to regulate its stress response system, leading to increased heart rate and blood pressure, atherosclerosis development, and insulin resistance, all of which are risk factors for CVDs 16, 10. Previous studies suggest that obesity may link childhood sexual abuse and CVDs-related outcomes in adults 8, 31.
Additionally, the psychoemotional trauma associated with sexual abuse can trigger harmful lifestyle behaviors such as inadequate diet, decreased physical activity, smoking, and excessive alcohol consumption. These behaviors, in turn, can lead to increased blood pressure, obesity, and susceptibility to diabetes, established risk factors for the development of chronic diseases, especially in women 32, 33, 34, 35, 17.
A population-based study with over 115,000 respondents in 25 states in the US found an association between non-consensual sex and health problems such as high cholesterol, stroke, heart disease, as well as risk behaviors for sexually transmitted infections (STIs), smoking, and excessive alcohol consumption34. Similarly to our finding’s, sexually victimized women were more likely to report heart attacks or heart disease than non-exposed women 36.
Experiences of sexual aggression are common among middle-aged women and are correlated with hypertension, sleep disturbances, and mental health problems, all associated with worse cardiovascular health 37. A study in the USA found a link between sexual abuse and carotid artery thickness in women, even after adjustments for various risk factors such as age, location, race/ethnicity, income, education, body mass index, lipids, blood pressure, insulin resistance, smoking, alcohol consumption, and physical activity 38.
Other factors such as sex and gender impact various aspects of cardiovascular health, from epidemiology to treatment response. Gender differences influence the risk of exposure to violence, affecting cardiovascular disease risk factors 39, 40. Women with a history of sexual abuse have a higher incidence of depressive symptoms, associated with chronically elevated levels of cortisol, catecholamines, and inflammatory markers, which contribute to the development and progression of cardiovascular diseases 41.
The issue of sexual violence against men is often ignored and underestimated by various social segments, resulting in a lack of data on the subject. Our results did not reveal an association with cardiovascular outcomes over the life course in this group, which may be attributed to the lack of available information on sexual violence, which tends to focus predominantly on women, children, and adolescents 42.
In terms of associated factors, significant negative health consequences are observed for men, such as post-traumatic stress disorder, substance abuse and dependence, suicidal ideation, social isolation, sexually transmitted infections, feelings of guilt, reduced self-esteem, psychosomatic illnesses, and challenges in the physical and emotional development of victims. However, it is important to consider that underreporting is common due to stigma and lack of awareness. Additionally, since our study is cross-sectional, even though we have investigated past exposures, it is likely that many of the exposed individuals may have died due to other causes associated with violence, which could pose a competitive risk for cardiovascular diseases. These findings highlight the serious public health problem caused by sexual violence 43,4.
Following this path, although underreporting is considered, it is valid that the social morality attributed to sexual violence events be understood as something that strengthens the least reported crimes against sexual dignity, which can be evidenced especially by feelings of guilt and fear stimulated in traumatic events such as these 44.
In this study, it was observed that the reported prevalence of sexual violence among women is similar to that found in other national studies, which indicate that the prevalence of sexual violence, particularly due to cultural factors, is much more concentrated among females. According to national studies, the prevalence of sexual violence among women can range from 6.26%, while it is important to note that 86% of reported cases of sexual violence were against women 45, 46. Furthermore, the aforementioned data indicating the predominance of female victimization may be even higher among the child and adolescent population, where the notifications of sexual violence range from 76.9% to 92.7% 47.
Thus, the present data suggest that power dynamics are crucial in maintaining the vulnerability of the female gender, while the male gender is attributed to tools of power and domination. Furthermore, in a national context, the prevalence of sexual violence is higher among women, which is also related to the fact that the majority of perpetrators are male, accounting for 81% to 86% of cases, respectively, against children and adolescents, specifically in the age ranges of 0 to 9 years and 10 to 19 years, both among females 47.
Ageism, in turn, helps explain the prevalence of sexual violence among women, particularly younger ones. A study conducted in Piauí indicated that women aged 20 to 29 years are 1.33% more likely to be victims of sexual violence. The frequency of victimization can be linked to youthfulness, as aging is associated with a decrease in the prevalence of sexual violence among women. Once again, it is evident how stereotypes attributed to genders hinder equitable socialization between them 48.
In addition to the broad classification of CVDs, our analysis highlighted that arrhythmia and myocardial infarction are the most relevant conditions associated with exposure to lifetime sexual violence. Previous studies indicate that psychosocial factors, such as trauma resulting from violence, may contribute to the development of arrhythmias and increase the risk of myocardial infarction, especially in women 49, 50. Therefore, recognizing sexual violence as a specific risk factor for these conditions is crucial for directing timely diagnosis and appropriate treatment strategies at the population level. Investigating these associations can not only enhance the understanding of the repercussions of sexual violence on cardiovascular health but also inform public health policies aimed at the prevention and management of these conditions.
In this scenario, underreporting affects both genders, but does not mitigate the violence suffered by women, which continues to be, constantly and independently of other variables, the most affected by gender violence, especially in its sexual form. Women are often not recognized as rights holders, making them more vulnerable to human rights violations, including sexual violence. This reduces the victims' ability to achieve economic independence, as it can lead to decreased productivity, absenteeism from work or school, unemployment, and housing instability 51.
This context highlights the relevance of research like ours, which benefit from an approach based on a population survey, employing the application of a validated questionnaire with a high response rate for inquiries related to violence, enabling the analysis of health-damaging behaviors. Additionally, the study also investigated these relationships in men individuals, adding a substantial dimension to the research.
We also acknowledge some limitations in our results, including the use of secondary data, which limits our ability to conduct more detailed analyses. It is important to note that we do not have specific information on whether this violence occurred in childhood, adolescence, or adulthood, only information on whether there was a lifetime experience of violence, without specification of the period.
Although we recognition that the psychoemotional trauma associated with sexual abuse can trigger harmful lifestyle behaviors such as poor diet, decreased physical activity, smoking, and excessive alcohol consumption, we did not adjust for these variables. This is because they could potentially mediate these relationships, and due to the lack of temporal precision between events, exposure, mediators, and outcomes in a cross-sectional design, further investigation into this mechanism is limited.
We also recognize that a cross-sectional design may not be ideal for establishing a clear causal relationship between sexual violence and its effects over time; however, this does not prevent us from investigating the association of this exposure with the outcome of cardiovascular disease. Furthermore, it is understood that the questions used to assess exposure to sexual violence do not specify the intensity of violence, the frequency or the exact moment in life in which the event occurred, and these aspects are not addressed in this study, which may limit the ability to understand all dimensions of sexual violence and its impacts.
Although the validated questionnaire used to assess violence also measured in the last 12 months, this would not have been suitable for assessing the development of cardiovascular outcomes due to the natural history of the diseases. Therefore, we chose to select the question that asked about exposure over the lifetime, seeking to better capture the temporal relationship between exposure to sexual violence and cardiovascular outcomes.
It is important to emphasize that, in this study, the presence of CVD was measured based on the responses provided by the participants, without diagnostic confirmation through clinical tests or direct medical evaluations. This approach may introduce limitations, as self-reports may be subject to information bias. Therefore, future research may benefit from more rigorous diagnostic validation to strengthen the observed associations between exposure to sexual violence and CVDs.
Despite these limitations, we emphasize that this is a study that uses a large and representative sample of the Brazilian population, which allows observation of the phenomenon in all regions of the country. Also, our results provide valuable information for public health experts, educators, healthcare professionals, and decision-makers. This is because individuals experiencing violence are at risk of developing non-communicable chronic diseases (NCDs), especially cardiovascular diseases, and contribute to widening social inequalities. These findings underscore the need for stronger actions to prevent sexual violence, especially among women, and to improve access to information for men. Such information can guide the development of interventions aimed at preventing violence and implementing violence screening programs, thereby expanding prevention efforts for these events.

CONCLUSION
These findings underscore significant gender disparities in the prevalence of sexual violence and its association with CVDs. Despite similar rates of self-reported CVDs between sexes, women experience a markedly higher prevalence of sexual violence, which is related to higher CVDs prevalence among those exposed. Notably, women with a history of sexual violence exhibit 74% higher odds of CVDs compared to those unexposed, highlighting the profound impact of such experiences on women's cardiovascular health. Furthermore, women demonstrate a statistically significant increase in the risk of myocardial infarction and arrhythmia, reinforcing the serious cardiovascular implications of such trauma. Conversely, men exposed to sexual violence show no significant association with CVDs, suggesting potential gender-specific mechanisms underlying this relationship. These insights emphasize the urgent need for targeted interventions to address the intersection of sexual violence and cardiovascular health, particularly among women.

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