Services on Demand
On-line version ISSN 1518-8787
Rev. Saúde Pública vol.42 suppl.1 São Paulo Jun. 2008
Lilia Blima SchraiberI; Ana Flávia P L D'OliveiraI; Ivan França-JuniorII; Grupo de Estudos em População, Sexualidade e Aids*
de Medicina Preventiva. Faculdade de Medicina. Universidade de São Paulo
(USP). São Paulo, SP, Brasil
IIDepartamento de Saúde Materno-Infantil. Faculdade de Saúde Pública. USP. São Paulo, SP, Brasil
estimate the prevalence of intimate partner sexual violence among men and women
of the Brazilian urban population and factors associated to it.
METHODS: The data analyzed is part of the study conducted between 1998 and 2005 among urban populations in Brazil. The data was obtained by means of a questionnaire applied to a representative sample of 5.040 individuals, men and women 16 to 65 years of age. Descriptive analysis was undertaken with weighted data, utilizing F design-based tests, with 5% significance.
RESULTS: The global prevalence of intimate partner sexual violence was 8.6%, being predominant among women (11.8% versus 5.1%). Women consistently reported higher rates of violence then men, except in cases involving homo/bissexual partners. The rate verified for male homo/bisexuals was significantly greater than that found among male heterosexuals, but this difference in rates was not significant among women. The Black population, irrespective of sex, referred more violence than theWhite population. The lower the income and years of formal education, the greater the rates of violence. However, men from poorer regions referred more violence, but this did not occur with respect to women. Diverse situations with respect to work, use of condoms, lower age at first intercourse and number of partners during the last five years differed significantly among women, but not among men. For both men and women sexual violence was associated with being separated or divorced, having had STDs, self-evaluation of being at risk for HIV, but was not associated with testing positive for HIV.
CONCLUSIONS: The high magnitude of sexual violence as well as female surtax is confirmed. Violence as a result of gender conflicts, that pervades social stratification and ethnic groups is reiterated. As to the Aids epidemic, sexual violence is an important factor to be taken into consideration when discussing the feminization of the population affected by the disease.
Descriptors: Violence against women. Sexual violence. Spouse abuse. Gender and health. Sexual and reproductive health. Cross-sectional Studies. Brazil.
Sexual violence is a worldwide problem. Although there are many different ways of delimiting this form of violence, Krug et al18 define sexual violence as undesired sexual acts, attempts to obtain a sexual act or advances, in which coercion is utilized and that are practiced by any person, regardless of their relationship to the victim and in any setting, whether or not it be the home. It includes acts of rape, (forced penetration) within marriage or dating relationships, or as practiced by strangers or even in the midst of armed conflicts. It also includes sexual harassment: acts or advances, such as coercion and forms of payment or of demanding sexual favors in return for benefits accrued within the context of hierarchical relationships (at work or school). Sexual acts in which penetration does not occur, that in Brazil are defined as violent assaults against modesty, are also considered sexual violence. These acts include coercion, exhibitionism and voyeurism, coercion in the practice of pornography, forced prostitution, forced genital mutilation and traffic of boys, girls and women.15
Designations are also diversified, such as sexual crimes, sexual abuse, sexual aggression and sexual violence. The term abuse, very common in medical literature, is sometimes considered as pertinent to those cases in which there is no penetration. Furthermore, there is the designation sexual assault, the use of which is restricted to the English language.
Excluding sexual violence involving children and adolescents, this theme has not been studied a great deal. The major difficulties are those posed by conducting populational inquiries more frequently. As a result, studies rely on estimates with respect to prevalence based on data collected in schools,22 organisms that denounce violence such as police departments or services that attend victims of violence.7,18 This holds true for the majority of Brazilian publications, almost always undertaken in conjunction with the evaluation of the service being considered.1,12,19
In a revision of international studies referring to the period between 1992 and 2007 with adults of both sexes, Krug et al,18 indicated that, on the average, approximately 20% of the female and 5% to 10% of the male population suffered sexual abuse in childhood. As to the occurrence of sexual aggression between youth and adults, this same publication,18 revealed that among women aged 16 or over, the prevalence varied from 0.8% in Gaborone (Botswana), 2% in Budapest (Hungary), 2%-3% in Johannesburg (South Africa), to 8% in Rio de Janeiro (Brazil). In 2004, a Brazilian populational survey undertaken with a representative sample of 2,502 women aged 16 years and over, revealed a 13% prevalence of reported sexual violence at least once in their lifetimes.28
As to the male population, international data indicate rates of sexual aggression at least once in their lifetimes among adolescents in third world countries that vary from 3.6% in Namibia to 20% in Peru.18 A Brazilian study undertaken with 798 men aged 18 to 60 years old, who sought two public primary health care services within São Paulo for assistance,ª revealed rates of sexual violence of 6.1%. On the other hand, the occurrence of sexual violence at least once during the lifetime among women always reveals higher rates than those found among men. A national survey conducted in the United States in 1998, with 8,000 men and 8,000 women over 18 years old identified a lifetime prevalence of sexual violence of 17.6% and 3.0%, for women and men respectively.27 Among adolescents, young women also present higher rates of forced sexual initiation than young men: 29.1% versus 6.9% respectively in Tanzania,20 and 40% for female versus 11% for male adolescents in Peru.3
This differential indicates that sexual violence is a gender specific event, in which aggression is itself a form of identifying women's subordination to men.
The rates of sexual intimate partner violence are even less well known. Such studies concerning violence perpetrated against men are rare. Considering only heterosexual relationships, Tjaden & Thoennes27 obtained higher rates of physical and/or sexual violence by an intimate partner experienced at least once in their lives among women: 25%, than among men: 8%. In the above mentioned Brazilian study,ª a rate of 1.4% of sexual violence by an intimate partner was verified among 775 men attending primary health care services within the public health system of the city of São Paulo, who had had female partners at least once in their lifetimes.
As to women, since non-consensual sexual practice is considered in many cultures as a wife's obligation, it is difficult to circumscribe sexual violence within stable partnerships. 6,9,15 A study designed and coordinated by the World Health Organization (WHO) 14 for transcultural comparison, conducted between 2000 and 2003 in ten countries, identified that, among reproductive-aged women, the prevalence of intimate partner violence, occurring at least once in a lifetime, varied from 6% (cities in Japan, Serbia and Montenegro) to 59% (rural province in Ethiopia). In the majority of the sites of the study, rates oscillated between 10% and 50%. In this study, Brazil presented a prevalence of 10% in the southeastern city of São Paulo and of 14% in 15 municipalities of the Northeastern region, Zona da Mata, Pernambuco. Sexual violence occurred less frequently than physical or psychological violence, following the general pattern found in the countries included in this study. 14
On the other hand, at least among the women, there was a considerable amount of overlapping of physical and sexual violence (between 30 and 56%). The occurrence of isolated sexual violence was rare. Although it occurs less frequently, sexual violence, in association with other forms of physical and psychological violence, has appeared as a risk factor for several health disorders.4,15 Furthermore, sexual violence is always considered a severe form of violence.15 Even if it occurred in the past, it produces greater and longer lasting impacts, such as mental disorders, than other current, but less severe forms of violence such as slaps and shoves. 10
Special attention is given to the occurrence of sexually transmitted diseases, particularly HIV/Aids, as a health condition aggravated by sexual violence. Studies have demonstrated the relevance of this type of violence in the transmission of HIV/Aids,8,13 emphasizing that it is an important component of the feminization of the epidemic.
Few population studies have focused simultaneously on men and women when investigating sexual violence. 26 The objective of this study was to describe the occurrence and forms of sexual violence perpetrated by intimate partners in urban Brazil, for men and women.
The data analyzed is part of the survey "Comportamento Sexual e Percepções da População Brasileira sobre HIV/AIDS", [Sexual Behavior and perceptions of the Brazilian population concerning HIV/AIDS] conducted in 2005.b
The sample is composed of 5,040 individuals, 2,298 men and 2,742 women ranging in age from 16 to 65 years, representing the Brazilian urban population, as described by Bussab.2
Research is based on representative samples, collected in urban micro-areas, as defined by the Instituto Brasileiro de Geografia e Estatística [The Brazilian Institute of Geography and Statistics] (IBGE). According to the sample plan, stratified in stages, census sectors, private households and individuals over 16 years of age were assorted successively within each micro region. The data analyzed was adjusted according to primary statistical unit and sample strata, as described by Bussab.2
As to sexual violence, the methodology recommended by the World Health Organization and utilized in a transcultural study sponsored by WHO (Garcia-Moreno14), that included Brazil was adopted in this study. A cultural adaptation of the instrument and analysis of the internal consistency of its questions had been undertaken26 at the time of the former study. The questionnaire was based on behaviorally specific questions that encouraged greater disclosure than requiring respondents to agree upon certain definitions of violence or to identify themselves as victims of abuse or rape.
People who replied positively to at least one of the following questions were considered as having experienced sexual violence by an intimate partner at least once in their lives:
1) "Were you physically forced to have sexual intercourse when you did not want to?"; 2) "Did you have sexual intercourse when you did not want to because you were afraid of what your partner might do?" and 3) "Were you forced to do something sexual that you found degrading or humiliating?"
The sociodemographic variables selected for analysis were: age; self-referred skin color; dichotomized in Whites and Blacks (Black and Mulatto); educational level; per capita family income in terms of minimal salaries when research was conducted (R$350,00 - US$150); macro region of the country; conjugal status; and current working status.
Sexual and reproductive variables were analyzed: age at first sexual intercourse; existence of the desire to consummate first sexual intercourse; use of condoms in the first sexual intercourse; Type of sexual partner in the past five years; number of sexual partners in the past five years; and occurrence (or diagnosis) of sexually transmitted disease (STD) at least once during one's life. Furthermore, analysis of the experience of physical intimate partner violence was conducted.
Variables referring to life and health experiences with respect to Aids were: do you know someone personally that has HIV?; what is your self-evaluation concerning your risk of contracting HIV?; have you ever taken an anti-HIV test?; has your partner ever wanted to have sexual intercourse and you did not want to? In cases in which there was a positive response to the last question, the common reaction of the partner (insists, obliges, seduces, becomes quiet and does not talk about it, tries to find out what is happening and other reactions).
Descriptive analysis comprehended the examination of the differences with respect to sexual violence among men and women according to variables of interest. The F design-based tests were conducted with a 5% level of significance and the fact that the survey had a complex sample was taken into consideration. Strata 8.0 was the statistical program utilized. The complex survey commands (svy) were employed in correcting the weight, strata and primary statistical unit.
The project of the survey "Comportamento Sexual e Percepções da População Brasileira Sobre HIV/Aids" was approved by the Ethics Committee of Faculdade de Saúde Pública of Universidade de São Paulo.
The sample interviewed was representative, and the rate of refusal was relatively low.
Sexual partner violence affected both men and women, having a global prevalence of 8.6% in the urban Brazilian population. It is significantly predominant among women (11.8% versus 5.1%; p< 0,001). One in ten women reported having experienced this type of violence at least once in their lives. This frequency was 2.2 times greater than the frequency reported by men.
In the Figure, the differences between men and women with respect to the prevalence of the various forms of sexual violence are notable. Whereas one third of the women declared that they had experienced all three forms of violence (forced sexual intercourse; intercourse due to fear of what the partner might do and submission to humiliating and degrading sexual practices), one third of the men declared they had experienced only one of these forms of violence, having been physically forced to have sexual intercourse. For both men and women, being forced physically to have sexual intercourse or having intercourse because they were afraid of their partner's reaction was more frequent than being submitted to practices considered humiliating or degrading.
By comparing Tables 1 and 2, it becomes clear that women present greater rates than men for all characteristics studied, except for male and female homo/bisexuals in which case the rates are similar. The proportion of women that reported episodes of sexual violence increased with age, reaching its peak at 25 years of age. As for the men, only "sex because they were afraid of their partner's reaction" and "humiliating/degrading practices" presented significant differences according to the individual's age. The Black population reported a higher frequency of episodes of sexual violence, irrespective of sex. When violence was disaggregated in its forms, Black men referred experiencing forced sexual intercourse more frequently than White men. Black women, in turn, referred having experienced more sex due to fear of their partner's reaction than White women. There was no difference in terms of skin color with respect to submission to degrading or humiliating sex practices.
The smaller the income and the level of education, the larger were the proportion of both women and men who had experienced sexual violence in general. However this relation was not observed with respect to degrading/humiliating sex practices among men and women. Both sex due to fear of their partner's reaction and physically forced sex were more prevalent among women the lower the income and educational level. As to the men, only sex due to fear of their partner's reaction was more frequent among those who had lower educational levels. There was, however, no association between men's income and the frequency of sexual violence. As to the level of income, this was not associated with changes in the frequency of any form of sexual violence. On the other hand, men residing in poorer regions and those that are less industrialized - North, Northeast and Central West - presented significantly higher prevalences. There were no significant regional differences with respect to the prevalence of sexual violence among the women.
As to conjugal status, men and women that are separated or divorced presented higher rates of sexual violence, being that women's rates were always higher than men's. The prevalence of sexual violence among widows was five times greater than among widowers. Separated, divorced or widowed women report greater frequencies of sex due to fear of their partner's reaction or humiliating /degrading sexual practices than other women whereas the rates among men do not vary according to their conjugal status.
As to occupations and current working status, greater rates of sexual violence were registered among women, in decreasing order: maids, unemployed, retired, autonomous worker, owner of a business, housewives, liberal professionals, employees of the private sector, civil servants and students. Furthermore for women, their current working status was significant with respect to all forms of violence. Whereas, among the men, only sex due to fear of their partner's reaction presented different frequencies according to working status, being reported more often among the unemployed, autonomous workers and students.
As Table 3 indicates, significant differences in reports of sexual violence among men and women can be observed according to sexual and reproductive status. Sexual violence occurred more frequently among women who declared they had had sexual intercourse before they were 15 years old, who were obliged or who did not want to have their first experience in sexual intercourse, who did not use condoms that time, or who had some kind of STD at any time in their lives. Sexual violence was also greater among women with four or more partners in the five years previous to the interview. Among the men, there was no variation in the prevalence of sexual violence according to the age at which they had their first experience in sexual intercourse, the use of condoms at that time or the number of sexual partners in the five years previous to the interview. On the other hand, like the women, prevalence of sexual violence was greater among the men who did not want to or were forced to have their first experience in sexual intercourse and among those who had some kind of STD at any time in their lives. Men with homo or bisexual partners in the five years prior to the interview presented the highest prevalence of sexual violence. It was five times higher than the rates of sexual violence among men with heterosexual partners in the five years prior to the interview. This difference was not observed among the women.
Differences with respect to the occurrence of sexual violence according to some life and health experiences are presented on Table 4.
As indicated in this table, greater rates of sexual violence were reported by both men and women who knew someone personally who had HIV; who evaluated themselves as being at risk for contracting HIV; whose sexual partner wanted to have sexual intercourse, when he/she didn't; whose partner usually insists or seduces (when the individual interviewed was a man) and usually obliges or insists (when the individual interviewed was a woman) in having sexual intercourse; and whose partner is physically violent. However, there were no significant differences in the rates of sexual violence among men and women who had submitted themselves to anti-HIV tests at least once in their lives.
This is the first nationwide population based study undertaken with both men and women that documents the occurrence of sexual violence by an intimate partner in Brazil. It is also the first study of this nature to consider both heterosexual and homo and bisexual individuals. The results of this study indicate that the entire Brazilian population experiences episodes of sexual violence although this occurs in different rates, depending on a series of factors, and in smaller magnitudes than physical and psychological violence.26,ª However, it should be emphasized that the meaning of violence for the subjects involved, whether these are victims or aggressors, does not ensue mechanically from its magnitude.25
The magnitudes reported by both men and women are always high, coinciding with findings from the international literature.14,15,18 However, among homo and bisexual individuals, the prevalence of sexual violence is greater, among both men and women. On the other hand, among heterosexuals, women present a rate twice as high as men. Yet, for men, the prevalence of sexual violence among homosexuals was approximately four times greater than among heterosexuals. Among women, the difference between homo/bisexuals and heterosexuals was not significant.
According to the theoretical perspective of gender relations, 14,15, 21, 25 violence, above all sexual violence, is explained as a kind of behavior, principally masculine. This masculine behavior is explained as an attempt to reinstate the individuals power or to avoid the loss of power in situations in which male and female attributions are changing and result in conflicts with respect to traditional hierarchical relationships. In this sense, the results of this study reiterate this theoretical perspective, making it possible to pose the following hypothesis: among heterosexual couples, the woman is the major victim of violence, whereas among both male and female homosexual partners, there seems to be a crisis in the relationships with respect to traditional identities that also generates violence.
The general results of this study coincide with those of the literature in several aspects: the greater rate of sexual violence perpetrated against women than among men as well as the increase in prevalence among women as they grow older. An increase in the prevalence of sexual violence is also associated with lower educational level and lower income. There is also a greater prevalence of sexual violence among both men and women who are separated or divorced.
However, the distinct magnitudes in the rates found among men and women and their profile with respect to differentials such as educational level and income also lead to a discussion of the role of gender in behavior classified as sexual violence in different social strata. In this sense, the existence of diverse gradients was observed between men and women, with respect to the prevalence of sexual violence according to both educational level and income.
An unprecedented finding within Brazil was the larger rate of sexual violence among Blacks, both men and women. These findings are reiterated with respect to forced sex for fear among Black women and sex forced physically among Black men. Despite the higher rates of sexual violence among Blacks when compared to Whites, White women still attain higher rates than those of Black men. In this case as well gender relations permeate ethnic issues.
On the contrary of the possible common sense assumption with regard to the greater vulnerability of housewives, or of women who remain in the domestic sphere, the results of this study reveal a greater complexity with respect to the association between sexual violence and permanence within the domestic sphere, for some working segments presented elevated rates of sexual violence. Once again, the issue of the crises in traditional gender identities comes forth, being this traditional identity represented by the woman whose occupational sphere is restricted to the home. This argument is reinforced by the fact that among the men, different current working statuses did not significantly affect the rates of sexual violence. Once again, gender relations interact differentially with class relations for men and women.
In this same sense, for men, sexual partnership with more than one partner in the five years prior to the interview or the fact that they reported that their first experience with sexual intercourse occurred before they were 15 years old or that condoms were not utilized in this first experience had no significant impact on rates of sexual violence. On the other hand, these factors result in different rates of sexual violence among women, implying in gender issues and women's particular vulnerability to STDs.
Another finding that is coherent with the literature is the higher prevalences of sexual violence among men and women who reported that they were obliged to have their first experience with sexual intercourse, and in the case of the women, those who stated they did not desire that first experience although it was consummated.
As to the relation between sexual violence and the greater vulnerability to sexually transmitted diseases and HIV/AIDS, the results of this study also reinforce data from the international literature,9,13,18 particularly in regard to the association with the perception of greater risk for HIV or the previous occurrence of STDs. Yet, having anti-HIV tests at least once in their lives did not present differences between men and women with respect to reported sexual violence. This contrasts with the self perception of being at risk for contracting HIV, suggesting that being tested is not subordinated to a perception of risk and, perhaps, is related to the fact that this test is systematically offered, for example, as part of routine pre-natal care and when individuals donate blood. From the perspective of life and health experiences related to the AIDS epidemic, this study confirms that sexual violence is an important factor to be considered in research and in the organization of services for the prevention of HIV and care for those that test positively.
One of the limitations of this study is a possible information bias. Studies on violence undertaken with women usually point out that it is underestimated due to difficulties with respect to disclosure.11,15,16 Studies involving men are less frequent, particularly those in which they figure as victims of sexual violence. When the victim is an adult man, disclosure seems to be even more jeopardized. This is indicated by the fact that among denunciations to the police, less than 5% of the cases of sexual violence notified are perpetrated against men.17,23 Another study that reinforces the occurrence of male sub notification was conducted in São Paulo and dealt with sexual crimes.5 This study certified that 8.8% of the cases were perpetrated against men, the majority of whom had been abused during childhood or adolescence. A third study in the same vein, but undertaken with a qualitative approach, reports the case of a man who, after having sexual violence perpetrated against him was discouraged from seeking assistance in a municipal hospital in the city of São Paulo that attends victims of sexual violence.24
Gender issues are at the root of these problems related to disclosure. For men, it is a question of avoiding a proximity to female identity, whose socio-cultural devaluation explains the surtax of women. For women, shame and self-blame with regard to the episodes of violence perpetrated against them is what makes them refuse disclosure.15,16 This aspect is illustrated by the finding that 40% of the face to face interviews had less disclosure than anonymous information solicited from the same women interviewed concerning sexual violence perpetrated against them when they were under 15 years of age, in a Brazilian populational study,c with women from 15 to 49 years of age, that was part of a WHO multi-country study.14 Another Brazilian study with 1,193 adolescents, both men (45.6% of the sample) and women, studying in the 8th grade in Porto Alegre, the capital of the Southern State of Rio Grande do Sul, indicated that if, on one hand, 2.3% of them disclosed that they had been victims of sexual violence, on the other, 4.5% had witnessed some form of sexual violence and 27.9% reported that they knew someone who had been a victim of sexual violence.22
However, considering the magnitudes found in this study and the effects of sexual violence, particularly when perpetrated by an intimate partner, in various dimensions of human health, new investigations are necessary in order to better understand its determinants and impacts. Such research can also contribute to the discussion of effective forms of assistance as well as the creation of policies for the eradication of sexual violence. The results of the present study shall be the object of future analyses by means of multivariate models.
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Correspondence: Received: 8/27/2007 Article based on
the data from the survey "Comportamento sexual e percepções da
população brasileira sobre HIV/Aids (Sexual behavior and perceptions
of Brazilian population on HIV/AIDS)", sponsored by the Brazilian Ministry of
Health through the Centro Brasileiro de Análise e Planejamento (Process
n. ED 213427/2004).
Lilia Blima Schraiber
Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde
Departamento de Medicina Preventiva Faculdade de Medicina Universidade de São Paulo
Av. Dr. Arnaldo, 455 - 2ºandar
01246-903 São Paulo, SP, Brasil
This article followed the same peer-review process as any other manuscript submitted to this journal, anonymity was guaranteed for both authors and reviewers.
Editors and reviewers declare they have no conflict of interests that could affect the judgment process.
The authors declare they have no conflict of interests.
* (Study Group on Population, Sexuality and AIDS) members: Elza Berquó, Francisco Inácio Pinkusfeld Bastos, Ivan França Junior, Regina Barbosa, Sandra Garcia, Vera Paiva, Wilton Bussab.
a Schraiber LB, Couto MT, Figueiredo W, Pinho AP, Kotovicz F, Pedreira F, Biondo M , Souza F. Men, Violence and Health: a contribution to research and intervention on Gender, Domestic Violence and Health [ Research Report to FAPESP, 2004 - Project FAPESP N. 02/00413-9].
b Research conducted by the Centro Brasileiro de Análise e Planejamento [Brazilian Center of Analysis and Planning] (CEBRAP) and the Brazilian Ministry of Health.
c Schraiber LB, d Oliveira AFPL , França -Jr I, Diniz C S G, Portella A P, Ludermir A B, Valença O, Couto M T. WHO: Multi Country Study on Womens Health and Domestic Violence against Women, Brazil, 2002. [Scientifi c report. WHO Project reference: W6/181/13] - unedited data.
Article based on
the data from the survey "Comportamento sexual e percepções da
população brasileira sobre HIV/Aids (Sexual behavior and perceptions
of Brazilian population on HIV/AIDS)", sponsored by the Brazilian Ministry of
Health through the Centro Brasileiro de Análise e Planejamento (Process
n. ED 213427/2004).