Artigos

INTRODUCTION

Sexual violence, as defined by the World Health Organization (WHO), encompasses any sexual act or attempt to perform such an act, as well as unwanted sexual insinuations or actions imposed on a person, regardless of their relationship with the perpetrator¹. It is a multifactorial phenomenon that occurs in familial, school, community, and institutional settings, resulting in lasting physical, psychological, and social impacts.
It is estimated that approximately 120 million girls under the age of 20 have experienced forced sexual contact worldwide2. In middle and high-income countries, the prevalence varies between 8% and 31% for girls and between 3% and 17% for boys under the age of 182,3. Research conducted in Latin America has revealed a prevalence of child sexual violence involving physical contact ranging from 3% to 6% among male children and from 13% to 16% among female children3. In Brazil, 14.6% of school-aged adolescents reported exposure to sexual violence, including 6.3% who reported experiencing rape4. In the USA, about 40% of women experience sexual violence throughout their lives, and 4.6% of girls between the ages of 14 and 17 have reported episodes of sexual assault5,6.
Risk factors for sexual victimization in childhood and adolescence involve individual, familial, and contextual aspects. A meta-analysis by Assink et al. identified family history of sexual abuse, marital conflicts, unstable family arrangements, social isolation, presence of chronic illnesses, and female sex as determinants of greater vulnerability7. Studies demonstrate that early abuse is associated with an increased risk of suicide and mental disorders such as depression and anxiety8,9, as well as underreporting of these events among male children and adolescents10.
Social vulnerability contexts, such as poverty, low parental education, and psychoactive substance use, intensify the risk of childhood sexual violence11-13. In middle-income countries, impoverished urban areas concentrate higher rates of severe childhood sexual abuse14.
In the context of Brazil, the prevalence of self-reported rape among females is associated with multiple vulnerabilities, including childhood sexual abuse, lack of social support, and psychological distress15. These adverse experiences have been shown to promote the use of alcohol, marijuana, and other drugs, as well as sleep disorders and interpersonal difficulties16-18.
Research has shown that children and adolescents exposed to sexual violence have limited access to health services and experience significant impacts on their mental health, including feelings of loneliness, insomnia, and difficulties in social relationships. The observed effects differed according to gender17-21
Sexual violence in childhood and adolescence is linked to behavioral problems and serious mental health issues, especially among those from vulnerable social populations. These consequences manifest in the form of elevated rates of school absenteeism, anxiety, depression, post-traumatic stress, and an escalated utilization of psychoactive substances, notably alcohol18-22.
The National School Health Survey (PeNSE), conducted by the Brazilian Institute of Geography and Statistics (IBGE) since 2009, monitors risk and protective factors among students aged 13 to 17 years through questionnaires on mental health, violence, and substance use23. The 2019 edition23 investigated sociodemographic characteristics, substance use, and episodes of violence, underpinning etiological and epidemiological studies.
The aim of this research is to analyze the prevalence and factors associated with self-reported sexual violence among Brazilian adolescents, based on data from PeNSE 201923. Specifically, it seeks to investigate associations between sociodemographic characteristics, substance use, and symptoms of psychological distress with the experience of self-reported sexual violence.

METHODOLOGY

This cross-sectional study utilized data from the 2019 National School Health Survey (PeNSE)23, which was conducted by the Brazilian Institute of Geography and Statistics (IBGE) in collaboration with the Ministry of Health. The sample population comprised students aged 13 to 17 years, enrolled from the 7th grade of elementary school to the 3rd year of high school, attending both public and private schools, and covering all Brazilian capitals, the 27 federative units, and the five major regions of the country.
The sampling design that was implemented was a two-stage cluster sampling design. In the first stage, schools were selected. In the second stage, students from randomly selected classes were sampled. The data collection process was executed through the utilization of Mobile Data Collection Devices (MDC), which were operated via smartphones. These devices employed two questionnaires: the Student Questionnaire, which was self-administered by the students, and the School Environment Questionnaire, which was completed by the school principals.
The instrument underwent validation in Brazil during its development, a process conducted by the IBGE in partnership with the Health Surveillance Secretariat of the Ministry of Health18.
Participants were included in the analysis only if they provided complete responses for all variables considered in the study. Participants who did not respond to the item on sexual violence, had missing data on independent variables, or did not complete the questionnaire were excluded from the analysis.
The dependent variable was defined as self-reported lifetime sexual violence, which was assessed by item 141 of the safety module of the Student Questionnaire. This item inquired about experiences of threat, intimidation, or coercion to engage in sexual relations or acts against one's will, according to the definition established by the WHO. The responses were subsequently categorized as either "yes" or "no."
The current investigation incorporated three distinct groups of independent variables: sociodemographic factors, substance use, and indicators of mental health and self-image. The sociodemographic variables encompassed the following: sex (male; female), age (<16 years; ?16 years), race/skin color (black, brown, and indigenous; white and yellow), type of school (public; private), internet access (yes; no), and geographic region. For description, the regions were classified into five large areas (North, Northeast, Southeast, South, and Center-West), and for statistical analysis, grouped into two categories: North/Northeast and South/Southeast/Center-West.
This research considered a range of variables related to the use of psychoactive substances. These variables included lifetime drug use (categorized as "yes" or "no") and recent consumption of crack, marijuana, and alcohol within the preceding 30 days (also categorized as "yes" or "no").The mental health indicators encompassed self-reported instances of frequent worry, feelings of helplessness ("no one cares about me"), sadness, irritability, and morbid thoughts (defined as the perception that life is not worth living). Additionally, the present investigation examined the perception of self-image. The latter was dichotomized into "satisfied" (very satisfied, satisfied, indifferent) and "dissatisfied" (dissatisfied, very dissatisfied).
The characterization process involved the use of both absolute and relative frequencies. The prevalence of sexual violence was estimated on a global scale and stratified by explanatory variables. A comparison was made between adolescents who had self-reported experiences of sexual violence and those who had not. This was achieved by conducting univariate analyses, utilizing Pearson's Chi-Square test with Rao-Scott correction to adjust for the complex sampling design.
Subsequently, a multivariate analysis was conducted using logistic regression to estimate odds ratios (OR) and 95% confidence intervals, to identify factors that are independently associated with sexual violence. Variables with p<0.05 in the univariate analysis were included in the initial model in the following order: sociodemographic variables, use of psychoactive substances and mental symptoms. A stepwise selection method was used to create the final model. All statistical analyses were performed using JASP software (version 0.19.3), which provides advanced statistical modeling resources and allows control of the complex sampling design.
PeNSE 201923 was approved by the National Research Ethics Commission (CONEP) in accordance with Resolution No. 196/96 of the National Health Council (Opinion No. 3249268). This ensures that adolescent data is handled in accordance with confidentiality and ethical principles.

RESULTS

A total of 159,245 adolescents aged 13 to 17 years participated in PeNSE 201923, providing valid responses and meeting the eligibility criteria for the study. The final analysis sample comprised 15,754 participants with complete responses for all variables analyzed.
The sample was predominantly composed of male adolescents (51.4%) and those under 16 years of age (82.2%). The majority of participants (60.9%) were enrolled in public schools and reported regular internet access (91.7%), suggesting a sociodemographic profile that is strongly characterized by digitally connected youth.
With respect to geographic distribution, a greater proportion of the participants resided in the Northeast (27.2%) and Southeast (23%) regions, while the majority self-identified as brown (41.4%) and black (11.4%) ethnic groups. About the prevalence of sexual violence, 2,259 participants reported having been victims of this type of abuse, with a significantly higher prevalence among girls, who accounted for 70.8% of cases.
The analysis indicated a higher probability of exposure to sexual violence among female adolescents (OR = 2.97; 95% CI: 2.69 – 3.28). The probability was also found to be significantly higher among participants older than 16 years (odds ratio [OR] = 1.23; 95% confidence interval [CI]: 1.10–1.38), those enrolled in public schools (OR = 1.21; 95% CI: 1.10–1.33), and those without regular internet access (OR = 1.46; 95% CI: 1.26–1.69). Conversely, no significant association was observed between self-declared race and the occurrence of sexual violence. Table 1 presents the percentage distribution of the sample according to sociodemographic variables and the stratification of the prevalence of sexual violence reports. It also presents the odds ratios (OR) that facilitate the identification of associations between demographic factors and the outcome of sexual violence.
Regarding psychoactive substance use, 38.5% of the sample reported having consumed at least one drug in the 30 days prior to data collection. Among participants who reported having been victims of sexual violence, this prevalence was even higher, with 43% reporting recent substance use, thereby evidencing an association between sexual violence and involvement with drug use behaviors.
Excessive alcohol consumption, typified by social or behavioral impairments, was identified in 85% of the sample. In relation to crack and cannabis use, 2.7% and 38.4% of participants, respectively, reported consumption in the last 30 days. The analysis indicated a substantial correlation between sexual violence and crack use (OR = 4.38; 95% CI: 3.57–5.36). Furthermore, a positive correlation was identified between sexual violence and cannabis use (OR = 1.30; 95% CI: 1.19–1.43), while no such association was observed between sexual violence and excessive alcohol consumption.
Furthermore, an association has been demonstrated between sexual violence and mental health problems. Self-reported instances of sadness within the preceding 30 days were found to be significantly more prevalent among participants who had previously experienced sexual violence (odds ratio [OR] = 2.29; 95% confidence interval [CI] = 2.01–2.60). A similar trend was observed for symptoms of morbid thoughts (OR = 2.59; 95% CI = 2.35–2.85) and dissatisfaction with self-image (OR = 2.05; 95% CI = 1.87–2.24). These factors were widely observed among those who suffered sexual violence, suggesting an important relationship between psychological problems and abuse experience. Table 2 provides a detailed description of the distribution OR for sexual violence and self-reported drug use, as well as mental symptoms.
Multivariate analysis revealed that several variables were significantly associated with sexual violence. In the context of sociodemographic characteristics, the female sex was found to be a significant predictor of sexual violence, with an odds ratio of 2.50 (CI 2.24 – 2.78). A positive association was identified with the age group over 16 years (OR = 1.15; CI 1.02 – 1.29), residence in the North and Northeast regions (OR = 1.20; CI 1.10 – 1.32), and lack of internet access (OR = 1.33; CI 1.13 – 1.55). The findings revealed a robust correlation between substance use, specifically cannabis (odds ratio [OR] = 1.23; confidence interval [CI] 1.11 – 1.35) and crack (OR = 4.80; CI 3.86 – 5.97), and sexual abuse. Table 3 presents the odds ratio estimates obtained through univariate and multivariate models, allowing identification of the magnitude of associations between variables and the outcome of sexual violence.



DISCUSSION

The analysis of PeNSE 2019 data23 reveals that sexual violence among adolescents is associated with sociodemographic factors, psychoactive substance use, and mental distress. The present study identified a heightened vulnerability among female adolescents, students from public schools, residents of the North and Northeast regions, and those with limited internet access. The robust correlation between sexual abuse and morbid thoughts, in addition to crack use, serves to substantiate the prevailing perception of heightened vulnerability within this demographic.
The investigation yielded a robust correlation between these outcomes and indicators of social disadvantage, including sadness, loneliness, sleep disturbances, and psychosomatic symptoms. These results underscore the interconnected nature of adverse experiences in contexts characterized by social vulnerability and limited family support. The data are consistent with the results of the Health Behaviors in School-aged Children (HBSC) study24-25. Furthermore, the HBSC24-25 study demonstrated that peer violence, including humiliation and verbal aggression, is associated with worse mental health outcomes in adolescence.
The preponderance of female adolescents is consistent with scientific literature that demonstrates girls are more likely to be exposed to sexual violence, considering violence against women and girls across multiple social contexts 6-8,18-21. This combination of factors has been shown to increase the exposure of adolescent girls to abuse, particularly in settings such as public schools or environments with limited internet access.
While most sexual violence statistics are focused on female populations, recent investigations have reported an increase in notifications among male adolescents and boys. As demonstrated by Nicholas, Krysinska and King10, this increase may be indicative of advancements in awareness, a reduction in stigma, and an increased propensity to report such events. Nevertheless, the persistent underreporting of symptoms among boys and male adolescents remains a significant barrier, driven by social norms that discourage the expression of male vulnerability from an early age.
Previous data demonstrates that socioeconomic factors play a role in determining the risk of childhood and adolescent sexual violence. In low-and middle-income countries, as evidenced by the analyses conducted by Danaeifar et al.11 and Meinck et al.12, there is a robust correlation between conditions of poverty, limited caregiver education, and caregiver substance use, and the occurrence of abuse. The review by Veenema, Thornton, and Corley10 lends further support to this understanding, emphasising poverty as vulnerability determinant in developing countries. Evidence suggests that, even in high-income contexts such as Canada, the incidence of severe sexual violence is higher11.
In Brazil, there is a higher prevalence of sexual violence among adolescents in the North and Northeast regions, which are also characterized by higher levels of poverty. The findings of the present research are corroborated by studies demonstrating increased risk of sexual victimization among adolescents, especially those living in communities characterized by poverty, violence, and social degradation11-13,24-28.
The correlation between socioeconomic vulnerability and sexual violence is also evident in the school environment. A higher prevalence of abuse was reported by students at public schools when compared to students at private schools. This discrepancy may be indicative of disparities in access to health and public safety resources. A notable proportion of victims have been observed to experience a lack of internet access, which can act as an exclusion marker, potentially impeding access to information, knowledge, and digital support networks.
In the context of behavioral factors, the relationship between sexual violence and psychoactive substance use is a salient consideration. PeNSE data23 corroborates earlier international findings that exposure to traumatic childhood experiences, such as sexual abuse, is strongly associated with early initiation and problematic use of alcohol and drugs20-22,29-31.
Despite the absence of a statistically significant association between recent alcohol use and reports of sexual violence in our findings, prior research indicates that victims of abuse are more likely to exhibit a lifetime pattern of alcohol abuse. As demonstrated in numerous studies, there is a higher propensity for individuals with a history of sexual victimization to exhibit more severe patterns of alcohol consumption20-22, 24-25, 30-31.
Hayatbakhsh et al.32 and Sartor et al.33 identified childhood sexual abuse as a predictor of early substance use initiation, even after controlling for familial and socioeconomic factors. In Brazil, Hoffmann et al.34 posit that distinct categories of childhood trauma have the capacity to influence preferred substances, with particular emphasis on the association between sexual abuse and polysubstance dependence, particularly crack. Horta et al.34 observed that the use of illicit substances among adolescents is associated with various factors, including family violence, feelings of loneliness, and the concurrent use of alcohol and tobacco. As previously mentioned, the link between childhood sexual violence and substance use is extensively documented18,36-37.
The present study observed a higher prevalence of psychoactive substance use, including marijuana and crack, among adolescents reporting instances of sexual violence. This tendency was particularly evident in cases of crack consumption; a substance commonly linked to contexts characterized by elevated levels of psychosocial vulnerability. Research conducted with African American female populations and Brazilian crack users has demonstrated that childhood sexual abuse is prevalent in these groups and may contribute to problematic substance use trajectories38-39.
The repercussions of sexual violence extend beyond the realm of substance use, encompassing the domain of mental health. The experience of sexual abuse has been demonstrated to be associated with the development of major depressive disorder, anxiety disorders, insomnia, eating disorders, psychosis, schizophrenia and particularly suicidal behavior. Preliminary research indicates that adverse childhood experiences have a significant and enduring impact on mental well-being9,41-44.
According to Silva et al.18 demonstrated a correlation between juvenile sexual abuse and a higher prevalence of mental disorders among university students in Brazil. Chinese data demonstrated that adolescents exposed to sexual violence exhibited elevated rates of depression, suicidal ideation, and substance use45-46, furthermore, Conway et al. observed increased rumination and profound sadness among adults with histories of childhood sexual abuse47.
In the present study, adolescents reporting sexual violence also exhibited indicators consistent with psychological distress, including morbid thoughts, dissatisfaction with body image, and persistent feelings of sadness. These symptoms indicate not only the repercussions of sexual violence exposure on mental health but especially its impact on self-image and morbid thoughts.
The convergence of sociodemographic disadvantage, constrained access to resources, psychoactive substance use, and mental distress underscores the cumulative and mutually reinforcing nature of these risks. The conclusions of the present study are consistent with those of the PeNSE 201923 and international evidence, as evidenced by the HBSC study24-25,48. Therefore, the results highlight the notion that violence, whether sexual or relational, interacts with social inequality to exacerbate psychological suffering.
Nevertheless, the substantial findings in the observed population, the present investigation has methodological limitations that must be considered when interpreting the results. The cross-sectional design of PeNSE23 precludes causal inference, thus limiting the analysis to the identification of associations. The collection of self-reported data may be subject to underreporting or overreporting bias, particularly in cases involving sensitive subjects such as sexual violence, as evidenced by research on underreporting among males. Moreover, the exclusion of participants with missing data may have compromised the representativeness of the sample. Additionally, confining the conclusions to school-enrolled adolescents may have excluded out-of-school youth, who may be even more vulnerable. The absence of additional contextual variables, such as family or community support networks, also limits understanding of the complexity involved.
The convergence of sociodemographic disadvantage, constrained access to resources, psychoactive substance use, and mental distress underscores the cumulative and mutually reinforcing nature of these risks.
In summary, the results indicate that adolescent sexual violence is strongly related to sociodemographic factors, psychoactive substance use, particularly crack and cannabis, as well as behavioral and emotional factors. The interaction among these dimensions underscores the necessity for intersectoral public policies that consider the phenomenon complexity. A comprehensive prevention strategy should entail the following measures: the reinforcement of protective networks, the promotion of rights-based sexual education, the training of professionals for the early identification of abuse signs, and the expansion of access to mental health and psychosocial support services. The reduction of social inequalities and the reinforcement of child and adolescent protection policies are foundational pathways to effectively address the devastating effects of sexual violence.
Data availability statement
The sources of the data used in the research are indicated in the body of the article.

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