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Temporal trend and spatial distribution of reported sexual violence cases in Brazil between 2013 and 2022

Schuelter-Trevisol F1, Orige IA2, Parma GOC3, Traebert J4, Traebert E5, Trevisol DJ6

1 Fabiana Schuelter-Trevisol. Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: fastrevisol@gmail.com ORCID: https://orcid.org/0000-0003-0997-1594

2 Iara Aurélio Orige. Curso de Medicina, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: iaraorigee11@hotmail.com ORCID: https://orcid.org/0009-0008-6845-2771

3 Gabriel Oscar Cremona Parma. Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: gcremona@gmail.com ORCID: http://orcid.org/0000-0001-9540-6908

4 Jefferson Traebert. Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: jefferson.traebert@gmail.com ORCID: http://orcid.org/0000-0001-9540-6908

5 Eliane Traebert. Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: elisazevedot@gmail.com ORCID: https://orcid.org/0000-0001-9667-7216

6 Daisson José Trevisol. Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina, Tubarão 88704-900, SC, Brasil.
E-mail: daissont@uol.com.br. ORCID https://orcid.org/0000-0002-7053-9082

Corresponding author
Prof. Dr. Daisson José Trevisol Universidade do Sul de Santa Catarina
E-mail: daissont@uol.com.brTelefone +55(48) 999764933
 
ABSTRACT

Objective: To review the temporal trend and spatial distribution of reported cases of sexual violence in Brazil from 2013 to 2022. Methods: This is a mixed ecological study, descriptive of multiple groups, with a temporal trend analysis. Notifications of sexual violence from the Information System for Notifiable Diseases were reviewed. Results: A total of 386,141 cases was recorded during the period. There was an annual increase of 3,387 cases (95% CI 2,276-4,498), which is statistically significant (p < 0.001). Acre was the state with the highest incidence rate. Victims’ profile: predominantly female (88.5%), adolescents (44.6%) and children (30.6%), brown skin color (49.6%); the perpetrator was predominantly a close or family member (76.1%). Conclusion: There was a significant annual increase in cases of sexual violence in Brazil, revealing a worsening scenario over time, with a consequent increase in reporting. The North, Center-West, and South regions exhibited the highest sexual violence incidence rates.

Keywords: Sex Offenses, Violence Against Women, Rape, Temporal Distribution, Spacial Analysis
 
INTRODUCTION
Sexual violence is a severe and devastating violation of human rights, widely recognized as a persistent global issue that affects people of all ages, genders, sexual orientations, and gender identities. It can occur in different contexts, ranging from armed conflicts and natural disasters to domestic and institutional settings1.
According to the World Health Organization (WHO), sexual violence is defined as any sexual act or attempt to carry out such an act without the victim\'s consent, regardless of the relationship between the parties involved2. Sexual violence encompasses various types of acts against human beings, whether male or female. These include rape, sexual harassment, sexual exploitation, child pornography, indecent assault, among others3.
Rape is a traumatic experience, recognized as a serious social and public health problem and a predominant form of violence against women. This phenomenon takes different forms and is perpetrated by individuals in different social frameworks. Rape includes oral sex, vaginal or anal penetration without consent or through coercion of the victim. This coercion can involve different degrees of force, psychological intimidation, abuse, and threats4.
In the Brazilian context, all forms of sexual violence have been classified as rape since 2009. Rape is defined as coercing someone, through violence or serious threat, into sexual intercourse, or forcing the victim to engage in or allow other sexual acts5. For those under 14 years of age, rape is designated as "statutory rape" according to Law 5102/20. In these cases, the victim\'s consent, prior sexual experiences, or romantic relationship with the perpetrator are considered irrelevant5.
The underreporting of sexual violence cases, especially against children and adolescents, is a significant problem due to the silencing of the victims out of fear of retaliation and disbelief of family members6. Healthcare professionals play a crucial role in the early identification of signs of violence, providing appropriate support to victims and their families, and reporting to the relevant authorities7.
A notifiable violence reporting form was introduced in 2006 and integrated into the Notifiable Diseases Information System (SINAN) in 2009. This form is essential for collecting data on domestic, sexual, and other forms of interpersonal as well as self-inflicted violence at a national level8.
It is estimated that over one billion children worldwide experience some form of violence each year. However, the prevalence of reported sexual abuse by children to the authority figures is 30 times lower than what is officially recorded9. This likely occurs due to underreporting of claimed rape. Underreporting can be attributed to the victims\' fear of retaliation, especially when the perpetrator is a close or distant family member such as a parent, grandparent, stepfather, or uncle2,6.
All forms of violence should be considered a public health issue; therefore, sexual violence not only hampers the health, dignity, and development of victims but also poses a serious challenge to public health10,11. In this connection, this study aimed to review the temporal trends and spatial distribution of reported cases of sexual violence in Brazil between 2013 and 2022.

METHODS
This is a mixed ecological study, descriptive of multiple groups, with a temporal trend analysis.
All the data on sexual violence reported in all the Brazilian states and the Federal District that were recorded in the Notifiable Diseases Information System (SINAN) between January 1, 2013, and December 31, 2022, were used. The data were extracted from the TABNET Information System via the DATASUS website of the Federal Government12. The SINAN link, "Interpersonal/Self-Inflicted Violence" was selected and filters applied to record the variables of interest, selecting only cases of sexual violence.
The study variables included: Sociodemographic Data–age group, gender, skin color/ethnicity (White, Black, Yellow, Brown, Indigenous), Education level (Not applicable – children outside school age, incomplete primary, complete primary, incomplete secondary, complete secondary, incomplete higher education, complete higher education) Occurrence Data -year of notification, setting (residence, collective housing, public space, workplace, school, daycare, healthcare facility, socio-educational institution, long-term care institution, prison, vacant lot, bar or similar, other), State of occurrence, kind of sexual violence (sexual harassment, rape, indecent assault, child pornography, sexual exploitation), Relationship with the victim (parent, stepparent, spouse, ex-spouse, boyfriend/girlfriend, ex-boyfriend/girlfriend, friend/acquaintance, stranger, caregiver, employer/supervisor, institutional relationship, other), Suspect\'s alcohol use (yes, no, unknown), referral (outpatient or hospital care) and outcome (death, discharge, or dropout).
Data were obtained directly or indirectly through the review of the compulsory notification form entered in the system, with aggregated data. They were organized and reviewed using a Microsoft Office Excel spreadsheet. Qualitative variables were described using absolute and rate frequencies.
To calculate the incidence rate, the total number of reported cases in each Brazilian state and the Federal District during the period assessed was divided by the total population in each state, considering the base year 2023; the population number was retrieved from the Brazilian Institute of Geography and Statistics (IBGE) records. The result was multiplied by 100,000 inhabitants.
For the maps, the Geographic Information System (GIS) software Quantum GIS (QGIS) and Microsoft Excel (Microsoft Corporation, 2023) were used. The cartographic data used were shapefiles in the official Brazilian cartographic system, covering the states and regions based on the official data provided by IBGE. Annual population data from the same institute, published in the Federal Official Gazette were also utilized.
Using QGIS, the linkage was performed based on state codes between the tables of total reported sexual violence cases and annual population by state. The incidence rates of cases per 100,000 inhabitants were then calculated within the same GIS environment. This variable was thematically mapped using the "Natural Breaks (Jenks)" classification method. The Jenks Natural Breaks statistical method generates a set of thematic classes based on natural groupings in the data and groups similar values to maximize the differences between classes. This method divides features into classes where there are relatively large differences in data values, minimizing the variance within each class (clustering method).
The temporal trend analysis was conducted using a simple linear regression model. The dependent variable was the incidence of sexual violence, while the independent variable represented the year of observation. The significance of the regression coefficient and intercept was determined through the analysis of variance. The regression coefficient was interpreted as the average annual variation in sexual violence cases, while the model\'s intercept provided an estimate of occurrences for the base year. To measure the effectiveness of the regression model in explaining data fluctuations, the coefficient of determination R2 was calculated. A significance level of α=0.05was set for statistical tests. These analyses were performed using the Microsoft Excel MS365.
Given the ecological design and the use of publicly available data, ethical approval was waived according to Resolution 466 and 510 of the National Health Council,

RESULTS
During the study period, a total of 386,141 cases of sexual violence were reported in Brazil. Figure 1 shows the temporal trend analysis of the cases reported during this period.
During the study period, there was a linear growth in the number of reported cases of sexual violence in Brazil, with an annual increase of 3,387 cases (95% CI 2,276-4,498). This growth was statistically significant (p < 0.001). Additionally, the coefficient of determination (R2) was 86%, indicating that 86% of the variability in the cases can be explained by the passage of time.
The spatial distribution of cases is illustrated in Figure 2. It shows that the state with the highest incidence rate of sexual violence notifications was Acre, followed by Amazonas, Roraima, Tocantins, and the Federal District.

Table 1 presents a description of the sociodemographic characteristics of sexual violence victims in Brazil between 2013 and 2022.

Table 2 presents a description of the characteristics of perpetrators, the assistance provided, and the outcome of sexual violence cases in Brazil between 2013 and 2022.

DISCUSSION
During the study period, there was a significant growing number of reported sexual violence cases in Brazil. This rise may not only reflect an actual increase in sexual violence but also indicate greater encouragement for victims to report perpetrators. This could be due to improved response rates from the multidisciplinary teams within the Unified Health System (SUS), better support, and increased social discussion on the topic in recent years. Although there was an increase in notifications, there was a slight decrease in 2020, which can be attributed to the onset of the COVID-19 pandemic. The pandemic caused a restricted access to police and health services. Physical distancing and reduced mobility likely hindered victims\' ability to report incidents, since a significant portion of sexual violence occurs in domestic settings. Oliveira et al. highlight that due to the pandemic\'s worsening and the restrictive measures set in March 2020, victims of sexual violence faced greater vulnerability, being distanced from their main support network—schools13. This situation underscores the difficulties victims, especially vulnerable ones like children and adolescents, had to report the situation.
Regarding the geographic distribution, the study found that the state with the highest incidence rate of sexual violence notifications was Acre, followed by Amazonas, Roraima, Tocantins, and the Federal District. Overall, the highest rates were concentrated in the North and Central-West regions, followed by the South and some states in the Northeast. It is important to note that these data do not fully reflect the reality of sexual violence in Brazil due to underreporting by victims and entities such as health services and specialized women’s services, which may help contributing to the perpetuation of the cycle of violence14,15.Silva et al. in the state of Maranhão revealed over 1,300 deaths attributed to violence among children and adolescents from 2014 to 2020. During this period, 8,187 reports of violence against individuals aged 0-17 were recorded, highlighting the increase in violence over time16.
Higher rates may reflect a greater number of sexual violence cases but can also be explained by a more effective reporting system or increased public and service awareness about reporting and recording data for statistical purposes.
The present study revealed a higher incidence of female victims. This may be related to physical vulnerability and gender inequality, which enhances the discrimination and exploitation that women face compared to men1,2,14. The fact that most victims are female in early adolescence, specifically aged 10 to 19 years, might lead to self-blame for the assault, as some are in a transitional phase between childhood and adulthood, awakening to their femininity. In the Brazilian society, which is predominantly patriarchal, this condition is often mistakenly seen as voluntary provocation of the perpetrator, as the girl/woman is subjected to a submissive role17,18.
There are several reasons why the number of sexual violence cases involves more children and adolescents. First, their vulnerability stems from their dependence on the support of adult caregivers which can include parents, family members, teachers, or other authority figures19. Additionally, children and adolescents lack knowledge and skills to recognize inappropriate behaviors or to protect themselves from sexual abuse and this significantly contributes to this issue20.A study conducted in Brasília between 2012 and 2018 found 4,617 cases of sexual violence, with 78.3% of the cases involving individuals under 15 years of age, averaging 659 children and adolescents per year20. This is consistent with the data from the present study, which show that more than two-thirds (75.2%) of reported sexual violence cases involved children and adolescents.
Additionally, manipulation by perpetrators is common, exploiting the naivety and trust of children and adolescents. Easy access to the victim also plays a crucial role, as abusers often have closer proximity to their victims, whether through family ties, community connections, or in schools and extracurricular activities. Other factors include the fear of reporting and the inability to defend themselves, which complete the complex picture contributing to the prevalence of this type of violence in this age group3,7. Sometimes, the violence is only detected when pregnancy or sexually transmitted infections occur.
Our work is in line with another study that was published by the WHO, which demonstrated that approximately one in three women worldwide experiences physical or sexual violence throughout her life, perpetrated by an intimate partner or non-partner. Most of these victims are young women aged 15 to 24. They endure different forms of violence, encompassing a broad spectrum of violence from verbal abuse and other forms of emotional abuse to physical or sexual violence22.
Regarding skin color/ethnicity, a significant percentage of notifications involved individuals with brown skin (49.6%), followed by those with white and black skin. These data may reflect different factors, including greater vulnerability to sexual violence or a higher number of women within these ethnic groups. A study conducted by Lourenço et al. showed that sexual violence is predominant among victims with black skin23.
In Brazil, although often hidden and silent, racism manifests as a systematic form of discrimination through practices that lead to disadvantages or privileges for individuals based on their ethnic group, and it is reproduced in the realms of politics, economics, and everyday relationships. As an integral part of social organization, violence thus becomes structural24. Minority ethnic groups frequently face structural inequalities, such as limited access to justice, mental health services, and social support, which can make them more vulnerable to sexual violence and less able to seek help11,25.
Regarding the location of sexual violence, the results indicated that most cases occurred in the residential setting. This suggests that the perpetrators were likely known to the victims, often with a familial relationship, highlighting the complexity and intimacy of the interpersonal relationships involved in these cases. Additionally, domestic sexual violence often takes place in an environment where the victim theoretically feels safe, making it even more difficult to report and seek help11. Underreporting is a critical concern in this framework due to the stigma associated with sexual offense, fear of retaliation, and power dynamics within the family unit. Public spaces, another location where such incidents occur, are generally associated with perpetrators who are unknown to the victims or who do not have prior access to them, unlike in the home setting.
In terms of kind of sexual violence, rape represented most notifications during the study period. These results are consistent with the widely recognized prevalence of rape as one of the most frequently discussed acts in society, especially in Brazil, where it is the most common type of sexual violence faced by women. Rape is a widespread public health issue with a number of consequences, including long-term physical and psychological health effects26. Physical injuries, sexually transmitted infections, unwanted pregnancies, health issues, and psychological disorders such as post-traumatic stress disorder (PTSD) are some of the numerous consequences associated with rape27,28. The exact rate of rape cases is not known in many countries for several reasons, including victims’ fear of retaliation for reporting, sociocultural issues, stigma, and inadequate victim support services26. Additionally, other types of sexual violence, such as harassment, sexual exploitation, and child pornography, are more challenging to prove in the absence of reports and evidence, which often places the burden of proof on the victims and exposes them to scrutiny.
A ten-year systematic review of the global prevalence of sexual violence showed that, despite regional variations, sexual aggression is widespread worldwide and affects men, women, and the LGBTQ+ population (lesbians, gays, bisexuals, and transgender individuals)29. Therefore, even though the number of reported rapes may be high, it still does not reflect the true extent of the issue, as many cases remain underreported4.
Regarding the characteristics of perpetrators, the majority of notifications involve violence committed by friends or acquaintances of the victim, followed by strangers. However, when adding cases involving the father, stepfather, boyfriend, and spouse to the first group, we can see that more than half of the assaults are perpetrated by individuals known to the victim. This finding correlates with another result of the present study, which indicates that most cases of sexual violence occur in the victim\'s own residence, where the perpetrator often lives with the victim.
The data from this study showed that most cases reported required the victim’s outpatient or hospital care. It is important to emphasize that assistance to victims of sexual violence should be provided with a humanized approach, including specialized listening, respecting dignity, and ensuring confidentiality and privacy, to avoid further physical and psychological harm to the victim. The following measures are required: physical and gynecological examinations, serological tests, collection of biological evidence for legal purposes, medications prescription to prevent pregnancy and sexually transmitted infections, and psychological and multidisciplinary care. However, as previously mentioned, rape is not limited to penetration, making individualized care essential in each case, especially for children and adolescents30. Long-term effects also need to be monitored, including cases of late reporting or notification.
The limitations of this study include the use of secondary databases with aggregated data. Ecological studies depend on the quality of available data, and the system does not present all the information from the sexual violence reports that would be fundamental for a more comprehensive assessment. Since these are reported data, the rates are likely underestimated. Nevertheless, this study provides a national overview, and the temporal analysis allows for an assessment of the worsening scenario of sexual violence in Brazil, particularly against women, children, and adolescents. Reviewing these indicators can aid in health education campaigns and in the development of public policies for the prevention and timely support of victims.
Based on the data from this study, we can conclude that there has been a significant annual growth of sexual violence cases in Brazil. The profile of the victims is predominantly composed of female, adolescents, or children with brown skin, and the perpetrator is often someone with a close or familial relationship to the victim. The issue of sexual violence in Brazil has worsened over time, reflecting either an actual increase in cases or an increase in the number of reports and notifications.
 
REFERENCES

1. United Nations. Division for the advancement of women. Handbook for Legislation on Violence Against Women. Nova York: 2012.
2. World Health Organization (WHO) and Pan American Health Organization. Understanding and addressing violence against women: intimate partner violence. WHO, 2012, https://apps.who.int/iris/handle/10665/77432
3. Teixeira-Filho FS, Rondini CA, Silva JM, Araújo MV. Tipos e consequências da violência sexual sofrida por estudantes do interior paulista na infância e/ou adolescência. Psicol Soc 2013;25(1):90-102.
4. Basile KC, Smith SG, Breiding M, Black MC, Mahendra RR. Sexual violence surveillance: uniform definitions and recommended data elements. Version 2.0. National Center for Injury Prevention and Control (U.S.). Division of Violence Prevention, 2014. Disponível em: https://stacks.cdc.gov/view/cdc/26326. Accessed in 17 jun 2024.
5. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei n°. 12.015, de 7 de agosto de 2009. Disponível em https://www.planalto.gov.br/ccivil_03/_Ato2007-2010/2009/Lei/L12015.htm. Acesso em 18 jun 2024.
6. Kellogg ND, Menard SW. Violence among family members of children and adolescents evaluated for sexual abuse. Child Abuse Negl. 2003 Dec;27(12):1367-76.
7. Leite JCS, Albuquerque GA. A Estratégia Saúde da Família e o enfrentamento à violência contra crianças e adolescentes: revisão integrativa. Cien Saude Colet. 2023 Nov;28(11):3247-3258.
8. Brasil. Ministério da Saúde. 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 [recursoeletrônico] / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. – 2. ed. – Brasília: Ministério da Saúde, 2016.
9. Hillis S, Mercy J, Amobi A, Kress H. Global Prevalence of Past-year Violence Against Children: A Systematic Review and Minimum Estimates. Pediatrics. 2016 Mar;137(3):e20154079.
10. World Health Organization (WHO). Global status report on preventing violence against children. Geneva: WHO; 2020. Available in: https://iris.who.int/bitstream/handle/10665/332394/9789240004191-eng.pdf?sequence. Accessed in: 20 Jun 2024.
11. Ministério dos Direitos Humanos. Secretaria Nacional de Proteção dos Direitos da Criança e Adolescente. Violência contra Crianças e Adolescentes: Análise de Cenários e Propostas de Políticas Públicas / elaboração de Marcia Teresinha Moreschi – Documento eletrônico – Brasília: Ministério dos Direitos Humanos, 2018, 377p.
12. Brasil. Ministério da Saúde. Informações de Saúde. DATASUS Tecnologia da Informação a Serviço do SUS. TabNet. Available in: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinannet/cnv/violebr.def. Accessed in 17 Jun 2024.
13. de Oliveira SMT, Galdeano EA, da Trindade EMGG, Fernandez RS, Buchaim RL, Buchaim DV, et al. Epidemiological Study of Violence against Children and Its Increase during the COVID-19 Pandemic. Int J Environ Res Public Health. 2021 Sep 24;18(19):10061.
14. Kind L, Orsini Mde L, Nepomuceno V, Gonçalves L, Souza GA, Ferreira MF. Subnotificação e (in)visibilidade da violência contra mulheres na atenção primária à saúde. Cad Saude Publica. 2013 Sep;29(9):1805-15. Portuguese.
15. Ferreira DG, Bortoli MC, Pexe-Machado P, Saggese GSR, Veras MA. Sexual violence against men in Brazil: underreporting, prevalence, and associated factors. Rev Saude Publica. 2023 Apr 14;57:23.
16. Silva DPAD, Ribeiro MRC, Branco MDRFC, Marques MTS, Almeida JDS, Gomes JA, et al. Deaths, crimes and violence not classified as a crime among children and adolescents in Maranhão, Brazil (2014 to 2020). Cien Saude Colet. 2023 Feb;28(2):421-435.
17. Rogers P, Lowe M, Reddington K. Investigating the Victim Pseudomaturity Effect: How a Victim\'s Chronological Age and Dress Style Influences Attributions in a Depicted Case of Child Sexual Assault. J Child Sex Abus. 2016;25(1):1-19.
18. George SS, Denne E, Stolzenberg SN. Blaming Children: How Rape Myths Manifest in Defense Attorneys\' Questions to Children Testifying About Child Sexual Abuse. J Interpers Violence. 2022 Sep;37(17-18):NP16623-NP16646.
19. C Silva F, Monge A, A Landi C, A Zenardi G, C Suzuki D, S Vitalle MS. Sexual Victimization of Children and Adolescents: A Qualitative Study with Brazilian Undergraduates on Disclosure, Detection, Outcomes, and Consequences. J Child Sex Abus. 2023 Apr;32(3):259-279.
20. Mascarenhas MD, Malta DC, Silva MM, Lima CM, Carvalho MG, Oliveira VL. Violência contra a criança: revelando o perfil dos atendimentos em serviços de emergência, Brasil, 2006 e 2007. Cad Saude Publica. 2010 Feb;26(2):347-57.
21. da Costa EL, Faúndes A, Nunes R. The association between victim-offender relationship and the age of children and adolescents who suffer sexual violence: a cross-sectional study. J Pediatr (Rio J). 2022 May-Jun;98(3):310-315.
22. World Health Organization. (WHO). Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013. Available in: http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625eng.pdf .Accessedin 21 Jun 2024.
23. Lourenço SDS, Polidoro M, Piloto LM, Martins AB. Notifications of sexual violence against children and adolescents in Rio Grande do Sul, Brazil: a descriptive study, 2014-2018. Epidemiol Serv Saude. 2023 Jul 14;32(2):e2022853.
24. Silva MEB, Anuciação D, Trad LAB. Violence and vulnerability: the everyday life of black youth in suburbs of two Brazilian state capitals. Cien Saude Colet. 2024 Mar;29(3):e04402023.
25. Pereira S, Schraiber LB, d\'Oliveira AFPL. "I Am from the Ghetto, I Am Black, I Live in the Slum and They Think: Why Bother with Her?" - Racism in Seeking Help Experiences for Domestic Violence in Brazil. J Interpers Violence. 2024 Jun 3:8862605241256389.
26. Farahi N, McEachern M. Sexual Assault of Women. Am Fam Physician. 2021 Feb 1;103(3):168-176.
27. Mhlongo S, Seedat S, Jewkes R, Myers B, Chirwa E, Nöthling J, et al. Depression and post-traumatic stress symptoms two years post-rape and the role of early counselling: Rape Impact Cohort Evaluation (RICE) study. Eur J Psychotraumatol. 2023;14(2):2237364.
28. Basile KC, Smith SG, Chen J, Zwald M. Chronic Diseases, Health Conditions, and Other Impacts Associated With Rape Victimization of U.S. Women. J Interpers Violence. 2021 Dec;36(23-24):NP12504-NP12520.
29. Dworkin ER, Krahé B, Zinzow H. The Global Prevalence of Sexual Assault: A Systematic Review of International Research Since 2010. Psychol Violence. 2021 Sep;11(5):497-508.
30. Pinto LSS, Oliveira IMP, Pinto ESS, Leite CBC, Melo ADN, Deus MCBR. Women\'s protection public policies: evaluation of health care for victims of sexual violence. Cien Saude Colet. 2017 May;22(5):1501-1508.