Analysis of notifications of intimate partner violence against women, Brazil, 2011-2017

Márcio Dênis Medeiros Mascarenhas Gabriela Rodrigues Tomaz Gabriel Medina Sobreira de Meneses Malvina Thais Pacheco Rodrigues Vinícius Oliveira de Moura Pereira Rafael Bello Corassa About the authors

ABSTRACT:

Objective:

To analyze notifications of intimate partner violence (IPV) against women.

Methods:

Cross-sectional study on IPV against women (≥ 15 years old) registered in Brazilian Notification Disease Information System (Sinan) from 2011 to 2017, analyzed using the chi-square test (χ2) and Poisson regression with robust variance to estimate proportion ratios (PR) and their respective 95% confidence intervals (95%CI).

Results:

A total 454,984 cases of violence perpetrated by men against women were reported, of which 62.4% were IPV. The most reported types of violence were physical (86.6%), psychological (53.1%) and sexual (4.8%) abuse. IPV was positively associated with women aged 20-39 years (PR = 1.70; 95%CI 1.68; 1.71), pregnant women (PR = 1.07; 95%CI 1.06; 1.08), marital partnership (PR = 1.55; 95%CI 1.54; 1.56), occurrence at home (PR = 1.80; 95%CI 1.79; 1.81), recurrence of violence (PR = 1.77; 95%CI 1.76; 1.78) and alcohol intake by the aggressor (PR = 1.12; 95%CI 1.12; 1.13). Physical violence was associated with the 20-39 age group (PR = 1.03; 95%CI 1.02; 1.03). Psychological violence predominated among women ≥ 40 years old (PR = 1.33; 95%CI 1.31; 1.35). Sexual violence was reported in greater proportion among pregnant women (PR = 2.71; 95%CI 2.59; 2.83) and women with disabilities or disorder (PR = 2.30; 95%CI 2.17; 2.44).

Conclusion:

Most reports of violence against women recorded in health services were perpetrated by an intimate partner, especially physical, psychological and sexual violence. It was possible to identify factors associated with IPV such as age, education, pregnancy, occurrence at home, recurrence and alcohol consumption by the aggressor.

Keywords:
Intimate partner violence; Gender-based violence; Domestic violence; Spouse abuse; Cross-sectional studies; Mandatory reporting

INTRODUCTION

Intimate partner violence (IPV) is a major public health issue, taking on many forms such as physical and sexual abuse, stalking and psychological aggression. Around the world, women suffer most of the IPV burden. A multicenter study of the World Health Organization (WHO), carried out from 2000 to 2003, including more than 24 thousand women aged from 15 to 49 years, in urban and rural areas of ten countries, showed that 15-71% of the women suffered from physical and/or sexual violence perpetrated by an intimate partner at some point in their lives11. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet 2006; 368(9543): 1260-9. http://doi.org/10.1016/S0140-6736(06)69523-8
https://doi.org/http://doi.org/10.1016/S...
,22. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008; 371(9619): 1165-72. http://doi.org/10.1016/S0140-6736(08)60522-X
https://doi.org/http://doi.org/10.1016/S...
. In Brazil, according to the same analysis, 36.9% and 28.9% of the women living in rural and urban areas, respectively, reported having suffered from physical and/or sexual violence perpetrated by an intimate partner at least once. Other forms of IPV are particularly underestimated22. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008; 371(9619): 1165-72. http://doi.org/10.1016/S0140-6736(08)60522-X
https://doi.org/http://doi.org/10.1016/S...
.

Even though violence is not a problem specifically or exclusively related to health, this sector is a privileged field to detect this condition, since this is where women who are victims of violence look for care and orientation33. Chisholm CA, Bullock L, Ferguson JE. Intimate partner violence and pregnancy: epidemiology and impact. Am J Obstet Gynecol 2017; 217(2): 141-4. http://doi.org/10.1016/j.ajog.2017.05.042
https://doi.org/http://doi.org/10.1016/j...
. In fact, the frequency with which women who are victims of violence look for health services is associated with the repetition and severity of the type of violence, caused by physical or psychological injuries44. Schraiber LB, Barros CR dos S, Castilho EA de. Violência contra as mulheres por parceiros íntimos: usos de serviços de saúde. Rev Bras Epidemiol 2010; 13(2): 237-45. https://doi.org/10.1590/S1415-790X2010000200006
https://doi.org/https://doi.org/10.1590/...
.

The IPV has a substantial impact on women’s physical and mental health. Physical damage includes the direct consequences of the injuries suffered in physical violence, such as fractures, lacerations and craniocerebral trauma; sexually transmitted infections and unwanted pregnancies as a result of sexual violence, besides several pain disorders. The impacts on mental health include increased risk of depression, anxiety, post-traumatic stress disorder, abuse of psychoactive substances and suicidal behavior55. Wong J, Mellor D. Intimate partner violence and women’s health and wellbeing: Impacts, risk factors and responses. Contemp Nurse 2014; 46(2): 170-9. https://doi.org/10.5172/conu.2014.46.2.170
https://doi.org/https://doi.org/10.5172/...
.

Besides, IPV often produces negative impacts on the emotional and social well-being of the entire family. Its occurrence during pregnancy is associated with adverse outcomes, such as abortion, preterm birth, low weight at birth and stillbirth66. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: Maternal and neonatal outcomes. J Womens Health 2015; 24(1): 100-6. https://doi.org/10.1089/jwh.2014.4872
https://doi.org/https://doi.org/10.1089/...
. A cross-sectional study conducted in Recife (State of Pernambuco, Brazil), between 2013 and 2014, involving 631 mother-child pairs, showed prevalence of 24.4% of IVP, and prevalence of 93.8% of violent maternal educational practices. Children whose mothers reported IVP presented with higher changes of undergoing psychological aggression, thus suggesting that the violence suffered by the mother interferes in parental education77. Silva JMM da, Lima M de C, Ludermir AB. Intimate partner violence and maternal educational practice. Rev Saúde Pública 2017; 51: 34. https://doi.org/10.1590/S1518-8787.2017051006848
https://doi.org/https://doi.org/10.1590/...
.

Considering the impact of these types of violence on the health of women, Law n. 10,714 was instituted on 2003 and established that notification of violence against women assisted in health services be mandatory. However, only after 2009 the data about violence began to be registered in the Notifiable Diseases Information System (Sinan), in sentinel or reference services for assisting victims of violence. After 2011, violence notification became part of the list of compulsory notifications, thus generalizing the notification for all public and private health services. Therefore, the individual notification file for violence became the instrument used to notify any suspect or confirmed case of domestic / intrafamily violence against women and other specific groups of the population88. 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 [Internet]. Brasil: Ministério da Saúde; 2016 [acessado em 18 out. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.

It is important to know these occurrences and their characterization in order to address the implementation health initiatives that are able to promote the improvement in quality of life, besides preventing situations of violence through preventive and protective measures. The study can help to understand the factors associated with the occurrence of IPV against women, highlighting this issue and educating professionals about this public health problem. In this scenario, the relevance of this study is justified. The objective was to analyze the notifications of IPV against women in Brazil from 2011 to 2017.

METHODS

Cross-sectional study with a database of IPV against women, registered in Sinan. The study included the period of 2011, when cases of violence began to be notified in all public and private health services in the country (and not only in the sentinel or reference units, as practiced from 2009 to 2010), until 2017, last year available for analyses, after the process of data revision (exclusion of data with inconsistent information and duplicity of records) carried out by the Ministry of Health.

Of the total 1,015,631 notifications of violence against women, the following were excluded: self-made injuries, female aggressor or without information (even though IPV may occur in homosexual relationships), notification of violence against children aged less than 15 years. The analysis began with 454,984 records of violence against women (Figure 1).

Figure 1.
Flowchart of the selection of violence against women records. Brazil, 2011-2017.

IPV against women was considered as the record of notification of violence against women whose informed aggressor was the spouse, former spouse, boyfriend or ex-boyfriend, according to the relationship/degree of kinship with the person assisted in the notification form.

The dependent variable (IPV against women) was categorized as yes and no. The co-variables were: age group (15-19, 20-39 and ≥ 40 years); race/skin color (white, black [black + brown], yellow/indigenous; schooling (≤ 8, > 8 school years); being pregnant (yes, no); marital status (with a partner, without a partner); person with disability/disorder (yes, no); occurrence in the household (yes, no); repetition of violence (yes, no) and intake of alcoholic drinks by the aggressor (yes, no). The types of violence were classified according to the definitions established by the Ministry of Health88. 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 [Internet]. Brasil: Ministério da Saúde; 2016 [acessado em 18 out. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
, in: physical, psychological/moral; sexual; financial and other types of violence.

The statistical analyses were processed with Stata, version 14 (Stata Corp., College Station, United States of America). The proportion of IPV against women was calculated by dividing the number of records by the total of notifications of violence against women. Proportions were calculated and comparisons were made between qualitative variables using the χ2 test, with a 5% significance level. Using the Poisson regression with robust variance, proportion ratios (PR) and respective 95% confidence intervals (95%CI) were estimated for general IPV and by the most frequent types, according to the selected variables.

Since this is a study with secondary data, without identifying the subjects, this research project did not require the evaluation of an Ethics Research Committee.

RESULTS

Of the total notified cases of violence against women, the proportion of IPV was 62.4%. The states with the highest proportions of notification were Espírito Santo (67.6%), Acre (67.5%), Rio Grande do Sul (67.2%), Mato Grosso do Sul (66.0%) and São Paulo (65.9%). The lowest proportions of IPV notification were observed in the Federal District (35.2%), Sergipe (36.4%), Alagoas (42.8%), Roraima (45.2%) and Amazonas (48.5%) (Figure 2A).

Figure 2.
Proportion of notifications of intimate partner violence against women according to Federate Notification Unit (A) and type of violence (B). Brazil, 2011-2017.

Table 1 shows the proportion and proportion ratio of IPV in comparison to other forms of violence against women, according to the victims’ characteristics. Higher proportions of IPV, in comparison to other forms of violence against women, were associated with women aged between 20 and 39 years (PR = 1.70; 95%CI 1.68; 1.71), pregnant women (PR = 107; 95%CI 1.06; 1.08) and with current partner (PR = 1.55; 95%CI 1.54; 1.56). There was an inverse association regarding black women (PR = 0.98; 95%CI 0.97; 0.98), those with more than 8 school years (PR = 0.97; 95%CI 0.96; 0.97) and the ones with disabilities/disorders (PR = 0.71; 95%CI 0.70; 0.72).

Table 1.
Proportion (%) and proportion ratio (PR) of intimate partner violence (IPV) against women according to the victims’ characteristics. Brazil, 2011-2017.

There was a positive association between cases of IPV and the occurrence in the household (PR = 1.80; 95%CI 1.79; 1.81), recurrence of violence (PR = 1.77; 95%CI 1.76; 1.78) and consumption of alcohol by the aggressor (PR = 1.12; 95%CI 1.12; 1.13) (Table 2).

Table 2.
Proportion (%) and proportion ratio (PR) of intimate partner violence (IPV) against women according to the characteristics of violence. Brazil, 2011-2017.

The most frequently reported types of violence were physical (86.6%), psychological (53.1%) and sexual abuse (4.8%). In a lower proportion, cases of financial violence (3.3%) and other types of violence (2.5%) were reported (Figure 2B).

Table 3 shows the proportion and the proportion ratios of the most common types of IPV against women according to the selected characteristics. Physical violence was positively associated to the group of women aged from 20 to 39 years (PR = 1.03; 95%CI 1.02; 1.03) and consumption of alcohol by the aggressor (PR = 1.08; 95%CI 1.08; 1.09). Psychological violence was positively associated with people aged more than 20 years, with disabilities/disorders ((PR = 1.05; 95%CI 1.04; 1.07), occurrence in the household (PR = 1.13; 95%CI 1.12; 1.14) and recurrent violence (PR = 1.47; 95%CI 1.46; 1.48). Sexual violence was more frequent among adolescents, and positively associated with pregnant women (PR = 2.71; 95%CI 2.59; 2.83), women with disabilities/disorders (PR = 2.30; 95%CI 2.17; 2.44), occurrence in the household (PR = 1.42; 95%CI 1.34; 1.50) and recurrent episodes (PR = 1.28; 95%CI 1.23; 1.34).

Table 3.
Proportion (%) and proportion ratio (PR) of the main types of intimate partner violence according to the selected variables. Brazil, 2011-2017.

DISCUSSION

IPV is a major social and public health issue around the world, and the most common type of violence against women. In developed countries, one out of three women is a victim of abuse perpetrated by the partner. It is believed that the frequency of IPV against women can be even higher in developing countries, like Brazil99. Fidan A, Bui HN. Intimate Partner Violence Against Women in Zimbabwe. Violence Against Women 2016; 22(9): 1075-96. https://doi.org/10.1177/1077801215617551
https://doi.org/https://doi.org/10.1177/...
.

Regarding the most frequently types of reported IPV, a cross-sectional study carried out in Recife77. Silva JMM da, Lima M de C, Ludermir AB. Intimate partner violence and maternal educational practice. Rev Saúde Pública 2017; 51: 34. https://doi.org/10.1590/S1518-8787.2017051006848
https://doi.org/https://doi.org/10.1590/...
showed that 24.4% of the interviewed women declared to have suffered at least one type of IPV in the past year, and psychological violence was the main type of IPV reported (48.1% of the total cases of violence). The prevalence of psychological abuse is a common finding in gender-related studies1010. Schraiber LB, D’Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalência da violência contra a mulher por parceiro íntimo em regiões do Brasil. Rev Saúde Pública 2007; 41(5): 797-807. https://doi.org/10.1590/S0034-89102007000500014
https://doi.org/https://doi.org/10.1590/...
,1111. Leite FMC, Amorim MHC, Wehrmeister FC, Gigante DP. Violence against women, Espírito Santo, Brazil. Rev Saúde Pública 2017; 51: 33. https://doi.org/10.1590/S1518-8787.2017051006815
https://doi.org/https://doi.org/10.1590/...
, which is contrast with the result obtained in this study, according to which 86.6% of the notified IPV cases referred to physical aggression, and only 53.1%, to psychological aggression.

Such differences can be reasonably explained by obvious methodological distinctions between cross-sectional surveys and studies based on records from information systems, especially when considering that psychological abuse tends to be more neglected and hardly recognized. Besides, in most cases, women only look for health or police care when violence exceeds the barrier of psychological damage and starts causing injuries caused by physical violence1212. Siqueira VB, Leal IS, Fernandes FECV, Melo RA, Campos MEAL. Violência psicológica contra mulheres usuárias da Atenção Primária à Saúde. Rev APS 2018; 21(3): 437-49. https://doi.org/10.34019/1809-8363.2018.v21.16379
https://doi.org/https://doi.org/10.34019...
. Many women have difficulties to recognized themselves as being victims of violence1313. Oliveira MT, Ferigato SH. A atenção às mulheres vítimas de violência doméstica e familiar: a construção de tecnologias de cuidado da terapia ocupacional na atenção básica em saúde. Cad Bras Ter Ocup 2019; 27(3): 508-21. http://dx.doi.org/10.4322/2526-8910.ctoao1729
https://doi.org/http://dx.doi.org/10.432...
. Another important factor is that many cases of psychological violence arrive to health services reported as chronic pain, panic disorders, depression, attempted suicide and eating disorders, thus not being recognized as violence1414. Silva LL, Coelho EBS, Caponi SNC. Violência silenciosa: violência psicológica como condição da violência física doméstica. Interface 2007; 11(21): 93-103. http://dx.doi.org/10.1590/S1414-32832007000100009
https://doi.org/http://dx.doi.org/10.159...
. Therefore, this study suggests the hypothesis of underreported psychological violence perpetrated by an intimate partner.

A higher proportion of IPV notifications was observed among women with lower schooling. This result is, apparently, counterintuitive, since women with higher schooling would presumably have more resources to have more autonomy, thus having more skills to recognize and stop abusive relationships1515. Vieira EM, Da Silva Castro Perdona G, Dos Santos MA. Fatores associados à violência física por parceiro íntimo em usuárias de serviços de saúde. Rev Saúde Pública 2011; 45(4): 730-7. http://dx.doi.org/10.1590/S0034-89102011005000034
https://doi.org/http://dx.doi.org/10.159...
. Therefore, some explanatory hypotheses appear to understand how the income and education factors contribute with the occurrence of this type of violence. One of the risk factors for female victimization that is consistently found in studies is low schooling. However, among the socioeconomic status indicators, unemployment and low income seem to be more robust predictors than schooling. Besides, even though higher schooling may represent the acquisition of social skills and resources to handle violent situations, thus providing women with protection, it can also involve them in riskier situations of victimization. Better schooling enable women through relationship networks, self-confidence and skills regarding the use of information and resources from society, thus constituting protection against violent events1616. Bhona FMC, Gebara CFP, Noto AR, Vieira MT, Lourenço LM. Socioeconomic Factors and Intimate Partner Violence: A Household Survey. Trends Psychol 2019; 27(1): 205-18. http://dx.doi.org/10.9788/tp2019.1-15
https://doi.org/http://dx.doi.org/10.978...
.

There was a higher proportion of IPV reports during pregnancy, especially at the cost of sexual violence, since the proportion of physical and psychological violence was effectively lower among pregnant women. In the literature, few studies directly approached pregnancy as a trigger or protective factor for the occurrence of IPV, which interferes in the data obtained here. Besides, there is conflicting evidence regarding this matter1717. Van Parys A-S, Verhamme A, Temmerman M, Verstraelen H. Information sheet Intimate partner violence during pregnancy. PLoS One 2014; 9(1): 183-97. http://dx.doi.org/10.1371/journal.pone.0085084
https://doi.org/http://dx.doi.org/10.137...
.

As an example, a national study compared the prevalence of IPV before, during and after pregnancy. Regarding the pregestational period, pregnancy was not associated with general improvement or aggravation in the prevalence of IPV, but the type of violence changed, that is, physical violence decreased and psychological violence increased; sexual violence remained a constant1818. Silva EP, Ludermir AB, Araújo TVB de, Valongueiro SA. Freqüência e padrão da violência por parceiro íntimo antes, durante e depois da gravidez. Rev Saúde Pública 2011; 45(6): 1044-53. http://dx.doi.org/10.1590/S0034-89102011005000074
https://doi.org/http://dx.doi.org/10.159...
. On the other hand, other studies found that the prevalence of IPV was lower in pregnancy in comparison to the 12 months before its beginning1919. Silverman JG, Decker MR, Reed E, Raj A. Intimate partner violence around the time of pregnancy: Association with breastfeeding behavior. J Womens Health 2006; 15(8): 934-40. http://dx.doi.org/10.1089/jwh.2006.15.934
https://doi.org/http://dx.doi.org/10.108...
. It is possible that, for some women, pregnancy is a protective factor, whereas for others it is a period of more violence, often caused by partners doubting that the child is really theirs66. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: Maternal and neonatal outcomes. J Womens Health 2015; 24(1): 100-6. https://doi.org/10.1089/jwh.2014.4872
https://doi.org/https://doi.org/10.1089/...
.

In any case, the strong association between sexual violence and pregnancy is a matter of concern. It is possible that part of this phenomenon is associated with the existence of pregnant women who are forced to engage in intercourse against their will, especially considering the different changes in sexuality that occur during pregnancy2020. Gałazka I, Drosdzol-Cop A, Naworska B, Czajkowska M, Skrzypulec-Plinta V. Changes in the Sexual Function During Pregnancy. J Sex Med 2015; 12(2): 445-54. http://dx.doi.org/10.1111/jsm.12747
https://doi.org/http://dx.doi.org/10.111...
. Additionally, it is likely that part of the association is spurious, because of the occurrence of pregnancies that are consequence of rape, perpetrated by current and former partners.

There was also a positive association between the IPV notification and the presence of a current partner. According to a study that assessed reports in a reference center for women in Paraíba, de main reason mentioned by women to stay in a violent marital status was financial dependence2121. Costa MS, Serafim MLF, Nascimento ARS do. Violência contra a mulher: descrição das denúncias em um Centro de Referência de Atendimento à Mulher de Cajazeiras, Paraíba, 2010 a 2012. Epidemiol Serv Saúde 2015; 24(3): 551-8. https://doi.org/10.5123/S1679-49742015000300022
https://doi.org/https://doi.org/10.5123/...
. However, it is important to mention that many population, cross-sectional studies already showed higher prevalence of IPV among separated, divorced and widowed women. It is likely that these women have experienced violent relationships in the past, and were able to get rid of this situation, thus breaking the cycle of violence, which contradicts the stereotype that IPV is a hopelessly chronic situation1111. Leite FMC, Amorim MHC, Wehrmeister FC, Gigante DP. Violence against women, Espírito Santo, Brazil. Rev Saúde Pública 2017; 51: 33. https://doi.org/10.1590/S1518-8787.2017051006815
https://doi.org/https://doi.org/10.1590/...
,1515. Vieira EM, Da Silva Castro Perdona G, Dos Santos MA. Fatores associados à violência física por parceiro íntimo em usuárias de serviços de saúde. Rev Saúde Pública 2011; 45(4): 730-7. http://dx.doi.org/10.1590/S0034-89102011005000034
https://doi.org/http://dx.doi.org/10.159...
,2222. d’Oliveira AFPL, Schraiber LB, França-Junior I, Ludermir AB, Portella AP, Diniz CS, et al. Fatores associados à violência por parceiro íntimo em mulheres brasileiras. Rev Saúde Pública 2009; 43(2): 299-311. http://dx.doi.org/10.1590/S0034-89102009005000013
https://doi.org/http://dx.doi.org/10.159...
. This divergence occurs because studies based on notifications from information systems tend to reflect the earlier stages of women coping with IPV, when they are still living with the aggressor. The literature2323. Ellis D. Marital Separation and Lethal Male Partner Violence. Violence Against Women 2017; 23(4): 503-19. https://doi.org/10.1177/1077801216644985
https://doi.org/https://doi.org/10.1177/...
,2424. Dobash RE, Dobash R. When men murder women. Oxford; Nova York: Oxford University Press; 2015.,2525. Spencer CM, Stith SM. Risk Factors for Male Perpetration and Female Victimization of Intimate Partner Homicide: A Meta-Analysis. Trauma Violence Abuse 2018. https://doi.org/10.1177/1524838018781101
https://doi.org/https://doi.org/10.1177/...
shows the period of separation as a moment of increasing feelings of possessiveness, jealousy and general hostility, especially in litigious separations, which can lead to accentuated violence, with increased risk of homicide in the period close to separation.

There was a negative association between the presence of disabilities/disorders and the proportion if IPV reports, which is in conflict with previous studies2626. Breiding MJ, Armour BS. The association between disability and intimate partner violence in the United States. Ann Epidemiol 2015; 25(6): 455-7. http://dx.doi.org/10.1016/j.annepidem.2015.03.017
https://doi.org/http://dx.doi.org/10.101...
,2727. Krnjacki L, Emerson E, Llewellyn G, Kavanagh AM. Prevalence and risk of violence against people with and without disabilities: Findings from an Australian population-based study. Aust N Z J Public Health 2016; 40(1): 16-21. http://dx.doi.org/10.1111/1753-6405.12498
https://doi.org/http://dx.doi.org/10.111...
. It is true that the association between IPV and disabilities/disorders of the victim is well established in the literature. The higher vulnerability among people with disabilities is multifactorial, and includes possible physical and functional dependence on the aggressor (the partner), as well as higher levels of poverty and social isolation2626. Breiding MJ, Armour BS. The association between disability and intimate partner violence in the United States. Ann Epidemiol 2015; 25(6): 455-7. http://dx.doi.org/10.1016/j.annepidem.2015.03.017
https://doi.org/http://dx.doi.org/10.101...
. So, it is possible that the lower proportion of IPV observed among people with disabilities is simply owed to the barriers and impediments related to the victims’ impossibilities, which leads to higher levels of underreporting. However, when analyzed according to type of violence, the considerable proportion of sexual IPV among women with disabilities/disorders is considerable.

The prevalence of the household as the main location of violence occurrence shows that this place is the most dangerous one for women who are victims of different types of IPV, when it should actually be a place of protection and refuge against violence in general2121. Costa MS, Serafim MLF, Nascimento ARS do. Violência contra a mulher: descrição das denúncias em um Centro de Referência de Atendimento à Mulher de Cajazeiras, Paraíba, 2010 a 2012. Epidemiol Serv Saúde 2015; 24(3): 551-8. https://doi.org/10.5123/S1679-49742015000300022
https://doi.org/https://doi.org/10.5123/...
.

Alcohol consumption was associated with a higher proportion of general and physical IPV notifications, which is in agreement with other studies, including worldwide. In a study carried out in Ghana, alcohol consumption increased the risk of a woman suffering physical or sexual abuse perpetrated by the partner in 2.5 times, thus being a significant risk factor for the occurrence of IPV2828. Alangea DO, Addo-Lartey AA, Sikweyiya Y, Chirwa ED, Coker-Appiah D, Jewkes R, et al. Prevalence and risk factors of intimate partner violence among women in four districts of the central region of Ghana: Baseline findings from a cluster randomised controlled trial. PLoS One 2018; 13(7): e0200874. http://dx.doi.org/10.1371/journal.pone.0200874
https://doi.org/http://dx.doi.org/10.137...
. A study carried out by the research unit on alcohol and drugs of Universidade Federal de São Paulo suggests that the consumption of alcohol by the aggressor, even if not in a abusive manner, has a significant role in the perpetration of violence. The study also suggests that the use of illicit drugs, especially cocaine, is also related to the occurrence of IPV. 2929. Ally EZ, Laranjeira R, Viana MC, Pinsky I, Caetano R, Mitsuhiro S, et al. Intimate partner violence trends in Brazil: Data from two waves of the Brazilian National Alcohol and Drugs Survey. Rev Bras Psiquiatr 2016; 38(2): 98-105. http://dx.doi.org/10.1590/1516-4446-2015-1798
https://doi.org/http://dx.doi.org/10.159...
.

The role played by alcohol in the perpetuation of IPV is a result both of the effect of physiological disinhibition and the effect regarding the expectation that other people should accept such behaviors,, usually leading to violent behavior. Alcohol consumption is also associated to the severity of the consequences of violence for the woman. Some studies point out that the higher the level of alcohol intake, the more severe the injuries caused by the abuse3030. Crane CA, Godleski SA, Przybyla SM, Schlauch RC, Testa M. The Proximal Effects of Acute Alcohol Consumption on Male-to-Female Aggression: A Meta-Analytic Review of the Experimental Literature. Trauma Violence Abuse 2016; 17(5): 520-31. http://dx.doi.org/10.1177/1524838015584374
https://doi.org/http://dx.doi.org/10.117...
,3131. Wilson IM, Graham K, Taft A. Living the cycle of drinking and violence: A qualitative study of women’s experience of alcohol-related intimate partner violence. Drug Alcohol Rev 2017; 36(1): 115-24. http://dx.doi.org/10.1111/dar.12405
https://doi.org/http://dx.doi.org/10.111...
.

Sexual violence, in many variables, had an opposite behavior in comparison to physical and psychological violence. Regarding age, it was prevalent in the group aged from 15 to 19 years, knowingly one of the age groups that is more vulnerable for sexual violence in general3232. Black MC, Basile KC, Breiding MJ, Ryan GW. Prevalence of sexual violence against women in 23 states and two U.S. territories, BRFSS 2005. Violence Against Women 2014; 20(5): 485-99. http://dx.doi.org/10.1177/1077801214528856
https://doi.org/http://dx.doi.org/10.117...
. Besides, despite the general increase in the proportion of IPV associated to alcohol intake, there was an inverse association between sexual violence and the use of this substance by the aggressor. A possible explanation is that, in the scope of affectionate relationships, sexual violence is often naturalized by the aggressor, without the need for a catalyst factor for the perpetration, such as alcohol. In fact, there is a culturally built belief that a loving relationship imposes the permanent consent to the partner’s desire on women, so that they cannot say no to sexual intercourse. Such a belief implies the naturalization of the use of force and embarrassment, to the detriment of the autonomous exercise of will form the women in the relationship3333. Kalra G, Bhugra D. Sexual violence against women: Understanding cross-cultural intersections. Indian J Psychiatry 2013; 55(3): 244-9. http://dx.doi.org/10.4103/0019-5545.117139
https://doi.org/http://dx.doi.org/10.410...
.

To sum up, the frequency of notifications of IPV against women was of approximately six cases for every 10 notifications in heterosexual relationships. Most cases involved physical violence, followed by psychological and sexual violence. Most proportions of IPV notifications were observed among adult young women aged from 20 to 39 years, with lower schooling, pregnant and in a relationship. The reported episodes presented higher occurrence in the household, were recurrent and perpetrated by an aggressor who had consumed alcohol.

This analysis was based on secondary data, contemplating the universe of reported notifications of violence in Sinan for the entire national territory in the period between 2011 and 2017. It is essential to use the data presented here to better understand the phenomenon of violence against women, in order to support the elaboration of effective measures of prevention for this type of violence. However, it is worth to mention that there may be limitations in this study, considering the potential fragility in the quality of data from the Health Information Systems3434. dos Santos TMB, Cardoso MD, Pitangui ACR, Santos YGC, Paiva SM, Melo JPR, et al. Completitude das notificações de violência perpetrada contra adolescentes em Pernambuco, Brasil. Ciênc Saúde Coletiva 2016; 21(12): 3907-16. http://dx.doi.org/10.1590/1413-812320152112.16682015
https://doi.org/http://dx.doi.org/10.159...
. One of these problems is the inadequate filling out of the notification form, showing the need for improving the quality of information that is collected and registered. Therefore, the recommendation is to invest in training about approaching the victim of violence and promoting the improvement in the quality of data registered in Sinan, as a national and essential strategy to strengthen the fight against violence.

References

  • Financial support: The student Gabriel Medina Sobreira de Meneses is a PIBIC / CNPq fellow.

Publication Dates

  • Publication in this collection
    03 July 2020
  • Date of issue
    2020

History

  • Received
    21 Oct 2019
  • Reviewed
    29 Nov 2019
  • Accepted
    14 Dec 2019
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil
E-mail: revbrepi@usp.br