¹Iraneide Nascimento dos Santos

²Taciana Lima de Paula Black

³Gerbson da Silva Lima

⁴Lygia Maria Pereira da Silva

⁵Kalina Vanderlei Silva

¹Universidade de Pernambuco, Recife/PE, Brasil. Orcid: 0000-0001-8449-7840

²Universidade de Pernambuco, Recife/PE, Brasil. Orcid: 0000-0002-5766-337X

3Universidade de Pernambuco, Recife/PE, Brasil. Orcid: 0000-0001-5991-311X

⁴Universidade de Pernambuco, Recife/PE, Brasil. Orcid: 0000-0003-4512-4990

⁵Universidade de Pernambuco, Recife/PE, Brasil. Orcid: 0000-0002-8370-1894

Corresponding author

Iraneide Nascimento dos Santos

Avenida Armindo Moura, 581, Quadra d, Bloco 9, apt. 102, Boa Viagem, Recife/PE, Brasil. CEP: 51130-180. Telefone: +55 81-997363682. E-mail: iraneide.nascimento@upe.br

Support and Acknowledgment: None.

ABSTRACT

Objective: to identify the scientific evidence in the Nursing literature on sexual violence against adolescents from the perspective of race/color. Method: integrative review whose searches took place in February 2022 in the PubMed/MEDLINE, CINAHL, Scopus and Web of Science databases and in the Virtual Health Library portal. The selection took place in two stages and for the extraction of information, a form developed by the authors was used. Results: the analysis of the eight studies included showed that sexual offenses against adolescents are still predominantly gender-based violence perpetrated in the field of family relationships, with a predominance of the age group between 10 and 14 years, with consequences for sexually transmitted infections and pregnancy. The scarcity of data on the race/color issue and the debate about the (in)visibility of this issue in studies produced by nursing were verified. A study deepens the discussion on this issue, exposing the intersectionality between race and gender. It was observed that most authors have stricto sensu postgraduate studies. Final considerations: it is evident the need to include the analysis of the race/color issue in publications to promote the scientific advancement of nursing, given the visibility of the problem in a historically vulnerable population, it becomes essential to face sexual violence.

Keywords: Race Factors; Ethnicity and Health; Sex Offenses; Adolescent; Nursing.

RESUMEN

Objetivo: identificar las evidencias científicas en la literatura de Enfermería sobre la violencia sexual contra adolescentes bajo la perspectiva de la raza/color. Método: revisión integradora cuyas búsquedas se realizaron en febrero de 2022 en las bases de datos PubMed/MEDLINE, CINAHL, Scopus y Web of Science y en el portal Biblioteca Virtual en Salud. La selección se realizó en dos etapas y se utilizó un formulario elaborado por los autores para extraer la información. Resultados: el análisis de los ocho estudios incluidos mostró que los delitos sexuales contra adolescentes siguen siendo predominantemente violencia de género perpetrada en el ámbito de las relaciones familiares, con predominio del grupo etario entre 10 y 14 años, con consecuencias para las infecciones de transmisión sexual y embarazo. Se constató la escasez de datos sobre la cuestión raza/color y el debate sobre la (in)visibilidad de esta cuestión en estudios producidos por enfermería. Un estudio profundiza la discusión sobre este tema, exponiendo la interseccionalidad entre raza y género. Se observó que la mayoría de los autores tienen estudios de postgrado stricto sensu. Consideraciones finales: se evidencia la necesidad de incluir el análisis de la cuestión raza/color en las publicaciones para promover el avance científico de la enfermería, dada la visibilización del problema en una población históricamente vulnerable, se vuelve imprescindible para enfrentar la violencia sexual.

Palabras clave: Factores Raciales; Origen Étnico y Salud; Delitos Sexuales; Adolescente; Enfermaría.

RESUMO

Objetivo: identificar as evidências científicas na literatura de Enfermagem sobre violência sexual contra adolescentes na perspectiva da raça/cor. Método: revisão integrativa cujas buscas ocorreram em fevereiro de 2022 nas bases de dados PubMed/MEDLINE, CINAHL, Scopus e Web of Science e, no portal da Biblioteca Virtual em Saúde. A seleção se deu em duas etapas e para extração das informações utilizou-se formulário elaborado pelos autores. Resultados: a análise dos oito estudos incluídos evidenciou que delitos sexuais contra adolescentes ainda se revelam preponderantemente como uma violência de gênero e perpetrada no campo das relações familiares, com predomínio da faixa etária entre 10 a 14 anos, tendo como consequências infecções sexualmente transmissíveis e gravidez. Foi verificada a escassez de dados sobre o quesito raça/cor e do debate acerca da (in)visibilidade desta questão em estudos produzidos pela enfermagem. Um estudo aprofunda a discussão sobre essa problemática, expondo a interseccionalidade entre raça e gênero. Observou-se que a maioria dos autores possui pós-graduação stricto sensu. Considerações finais: evidencia-se a necessidade de incluir a análise do quesito raça/cor nas publicações para fomento do avanço científico da enfermagem, dada a visibilidade da problemática em uma população historicamente vulnerabilizada torna-se fundamental ao enfrentamento da violência sexual.

Palavras-chave: Fatores Raciais; Origem Étnica e Saúde; Delitos Sexuais; Adolescente; Enfermagem.

INTRODUCTION

Sexual violence is one of the cruelest and most persistent forms of violence. According to the Ministry of Health, it is characterized by an action caused by a person with power, which uses physical force, coercion, intimidation, or psychological influence, with or without carrying weapons, and, forcing another person to have, witness, or participate in some sexual interaction, or even use it aiming at profit, revenge or other intentions⁽¹⁾.

The repercussions of perpetrated sexual violence cause global damage to its victims in the physical, reproductive and mental health fields. They might culminate in bodily injuries, unwanted pregnancies, sexually transmitted infections, phobias, panic, post-traumatic stress syndrome, depression, and other psychological alterations, in addition to family and social damages that involve dropping out of school, unemployment, marital separation, leaving home, among others⁽²⁾.

To characterize sexual violence against adolescents, it is essential to understand some aspects, including sociodemographic characteristics such as gender, age group, race/color, as well as the relationship with the perpetrator. According to the Panorama of Lethal and Sexual Violence against Children and Adolescents in Brazil, between 2017 and 2020, around 91% of the victims were female between the ages of 10 and 19, and in terms of race/color, the data show a trend towards an increase in sexual offenses over the years for black and brown adolescents. Finally, both boys and girls were more frequently abused in their homes, 64% and 67%, respectively, and of the total number of crimes analyzed, 86% were committed by perpetrators known to the victims⁽³⁾.

As sexual violence can be enhanced by the articulation of social markers of difference, this article approaches race/color as a variable, according to the parameters adopted by the information systems of the Brazilian Ministry of Health⁽¹⁾, and race and color, as a social category.

In Brazil, although veiled and silent, racism manifests as a systematic form of discrimination, through practices culminating in disadvantages or privileges for individuals depending on their racial group and reproduced in the spheres of politics, economics, and daily relationships. As an integral part of the social organization, violence becomes, therefore, structural⁽⁴⁾.

Given this scenario, nursing, as a science, art and social practice, is essential to the organization and functioning of health services, through its commitment to the production and management of care provided in different socio-environmental and cultural contexts, which provides responses to the needs of the individual, the family and the community⁽⁵⁾.

The role of nursing, wide and complex, in institutions involved in the care of people in situations of sexual violence, in the Brazilian public health system, covers all the necessary stages of care at the various levels of health care. This includes prevention, emergency, follow-up, rehabilitation, and treatment of possible injuries and impacts resulting from sexual offenses on physical and psychological health, in addition to legal abortion assistance, if requested by the victim, following current legislation⁽⁶⁾.

In this sense, nursing, as a professional practice, crosses social relations, having the duty to actively face structural racism, to stop the reproduction of racial inequalities through professional practice within institutions, in particular, those working in the field of health and education, in addition to reflecting on profound changes in social, political and economic relations⁽⁴⁾, thus guaranteeing respect for human rights as a prerogative of the profession⁽⁵⁾.

Establishing, developing, promoting, implementing, and supervising care practices arising from sexual offenses, as well as carrying out actions within the scope of public health policies, require nurses to have a technical-scientific and legal background on the subject, the ability to identify situations of violence and potential victims, as a way to support the recognition of power relations and the maintenance of privileges arising from racism.

Assistance to victims of sexual violence, a common area of nursing work, especially among forensic nurses⁽⁷⁾, requires skills for comprehensive care, especially for adolescents, due to the particularities of this phase of life, such as the development of care for the victim and their families, through welcoming, setting priorities and intervention strategies. Thus, understanding how racism makes this population segment even more vulnerable is essential for improving policies and improving the care provided by nursing.

In Brazil, “racism provides the meaning, the logic, and the technology for the reproduction of the forms of inequality and violence that shape contemporary social life”⁽⁴⁾. Therefore, considering the race and color of adolescent victims in scientific research allows for a better understanding of the phenomenon, to encompass the aspects present in this type of violence and, once the research has been carried out, greater knowledge about the phenomenon makes it possible to contribute to the proposition of more effective policies for preventing and coping with sexual violence. In addition, making public the vulnerability of these young people to violent practices corroborates with the construction of a nursing that meets the different contexts experienced, in addition to the singularization of the care offered, to combat racist practices that reproduce violence at the individual and institutional level in professional practice.

Thus, considering the structural racism experienced in Brazilian society, its reflection in the perpetration of violence, and the need to recognize this problem in the scientific field of professions that deal directly with these victims, this article aims to identify scientific evidence in the nursing literature on sexual violence against adolescents from the perspective of race/color.

METHODS

Type of study

This is an integrative literature review that allows synthesizing scientific evidence, providing recommendations based on research results in clinical practice, as well as identifying gaps in knowledge that guide the development of future research, carried out in six steps⁽⁸⁾: 1) development of the review question; 2) search and selection of primary articles; 3) extraction of study data; 4) assessment of the included studies; 5) summary of the results, and 6) and review presentation. The study used the support of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)⁽⁹⁾ tool for the study development.

The search strategy for the articles and the research question was developed using the POV strategy. The population refers to adolescents (P); the variable of interest, the issue of race and color in nursing publications (V); and the outcome, sexual violence (O). The following research question was elaborated: What is the scientific evidence in the Nursing literature about sexual violence against adolescents from the perspective of race/color? To conduct the search strategy, controlled terms that reflected the research question were used, with the Boolean operators AND and OR.

Period and data collection

The simple search took place in February 2022, without language and period filter, through registration on the Federated Academic Community website (CAPES CAFe). The electronic databases most relevant to nursing were consulted: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus (ELSEVIER), Cochrane, Scientific Electronic Library Online (SciELO) and Web of Science (WOS), and the Virtual Health Library portal (VHL). The search strategy used containing Descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH), and Boolean operators was: (“Sex Offenses” OR “Sexual Assault” OR “Sexual Assaults” OR “Sexual Violence” OR “Sexual Violences” OR “Sexual Abuse” OR “Sexual Abuses”) AND (Adolescent OR Adolescence OR Adolescents OR Teen OR Teenager OR Teenagers OR Teens OR Youth OR Youths) AND (Nursing OR Nurs*) AND (Brazil).

In VHL, the search key was used in Portuguese: (Adolescente OR Adolescência OR Adolescentes) OR (“Delitos sexuais” OR “Violência sexual” OR “Agressão sexual” OR “Agressões sexuais” OR “Atentado ao pudor” OR “Atentados ao pudor” OR “Crimes sexuais” OR “Delitos de discriminação sexual” OR “Ofensas sexuais”) AND (Enfermagem) AND (Brasil).

After identification of the records in the databases and portal, the duplicates were manually removed. Then, the selection of studies occurred in two stages. The first is through a screening by reading the titles and abstracts performed by a pair of independent reviewers. In case of divergences, a third reviewer would be consulted, but it was not necessary. The second step was the assessment of eligibility by reading the manuscript in full. As a way of guaranteeing the inclusion of the maximum number of studies, manual searches were also carried out in the references of articles previously selected in this phase and which did not appear in the electronic search.

Selection Criteria

Primary studies on sexual violence against Brazilian adolescents conducted by nurses or multidisciplinary teams in which this professional was the first author were included. Studies with populations of children and adolescents were only included when the results specified data related to sexual violence in individuals aged between 10 and 19 years, which is the age group considered in this study for adolescence⁽¹⁰⁾. The excluded studies were the following: literature review studies, letters to the editor, opinion articles, case studies, experience reports, theses, dissertations, monographs, conference summaries, and book chapters.

Instrument used for data collection

Two independent reviewers extracted information from the selected articles using an instrument constructed by the authors, containing the following information: identification (number of the article in ascending order, author(s) and year, the title of the article, place of research, and journal); study design, objective, and level of evidence; and main results concerning race/color and sexual violence. Thus, data from all selected studies were double-extracted to check consistency and any discrepancies that emerged were discussed and resolved between reviewers or referred to the third reviewer for final decision.

Data treatment and analysis

Data were analyzed qualitatively, synthesizing evidence from primary studies descriptively. For the stage of evaluating the articles, it was performed according to the hierarchy of evidence classification, such as Level I – systematic reviews or meta-analysis; Level II – randomized controlled trials; Level III – non-randomized controlled studies; Level IV – case-control study or cohort study; Level V – a systematic review of qualitative or descriptive research; Level VI – qualitative or descriptive research; Level VII – opinion or consensus⁽¹¹⁾.

Ethical aspects

This is a literature review that used articles, not human beings, as a sample. Also, copyrights were respected by preserving the content exposed by the authors and by referencing the information extracted from the articles available in the public domain. Therefore, the ethics committee's opinion was not consulted.

RESULTS

This study is a sample of eight articles. The entire process of identifying, selecting, and including studies was described in Figure 1.

Table 1 – Demonstration of the articles that were part of the integrative review. Recife, Pernambuco, Brazil, 2022.

Identification	Study design / Objective / Level of evidence	Main results
Identification	Study design / Objective / Level of evidence	Sexual violence	Race
1. Diniz et al.⁽¹²⁾ Year: 2007 Women victims of sexual violence: adherence to chemoprevention of HIV Salvador, Bahia (BA) Latin American Journal of Nursing	Descriptive study. Evaluating the adherence of women victims of sexual violence to the chemoprophylaxis treatment of human immunodeficiency virus – HIV. Level of evidence: VI.	The results showed that the age group most affected by sexual violence is between 12 and 18 years old (45.4%). At least 60.3% of adolescent victims of sexual violence have been raped.	It was found that 77.3% of the total number of victims belonged to the black race, however, the age group of the population was not described. The issue of color was considered relevant and reinforced that ethnic, socioeconomic, cultural, and gender factors cannot be suppressed when violence is discussed.
2. Trindade et al.⁽¹³⁾ Year: 2014 Sexual violence against children and vulnerability Paraíba (PB) Journal of the Brazilian Medical Association	Descriptive study. Analyzing the demographic and epidemiological profile of children and adolescents who are victims of sexual violence treated at a Legal Medicine Unit and the relationship between victims and perpetrators. Level of evidence: VI.	In 2009, 421 victims of sexual violence were assisted. Of these, 379 (90%) were younger than 18 years old, with 66 individuals excluded from these reports. The majority were female (81.2%). The most affected age group was between 10 and 13 years old (36.7%). In the majority of cases (86.3%), there was a family or friendship link between the victims and the accused, the most frequently the accused being a known person or family friend (42.3%), followed by the stepfather (16.6%) and the father (10.9%).	Not addressed.
3. Gessner, Fonseca e Oliveira⁽¹⁴⁾ Violence against adolescents: an analysis in the light of gender and generation categories Curitiba, Paraná (PR) Journal of the School of Nursingof the University of São Paulo – USP	Descriptive study with quantitative and qualitative approach. Analyzing violence against adolescents in the light of gender and generation categories. Level of evidence: VI.	Of the notified cases of violence against adolescents, 20.2% occurred in an extra-family environment, and of these, 44.8% reported being sexual. Regarding sexual violence, 88.22% of the notified cases were committed by a male aggressor. The main abusers were acquaintances of the victims (27.69%), strangers (27.58%), and stepfathers (12.70%). The percentage of sexual violence practiced by relatives (33.16%) stood out. Sexual violence was more prevalent among girls (25.44%).	Violence against adolescents in the period analyzed prevailed in white subjects (72.83%), followed by brown (22.78%) and black (4.21%).
4. Justino et al.⁽¹⁵⁾ Year: 2015 Sexual violence against adolescents in Campo Grande, Mato Grosso do Sul Campo Grande, Mato Grosso do Sul (MS) Journal of Nursing of Rio Grande do Sul	Cross-sectional study. Analyzing the situation of sexual violence against adolescents. Level of evidence: VI.	The adolescents in situations of violence were mostly girls (94.8%). Intrafamily violence prevailed (51.7%) and violence with a perpetrator (66.9%). Pregnancy (8.7%) was one of the outcomes. The most frequent place of events was the adolescents' homes (92; 53.5%), followed by public roads (28; 16.3%).	Of the total number of adolescents, 65 (37.8%) were white and 63 (36.6%) were brown or black.
5. Santos et al.⁽¹⁶⁾ Year: 2017 Factors associated with the type of violence perpetrated against adolescents in the state of Pernambuco, Brazil Pernambuco (PE) Child Abuse & Neglect	Cross-sectional study. Analyzing factors associated with types of violence against adolescents reported in Pernambuco, Brazil, from 2009 to 2012. Level of evidence: VI.	Sexual assault probability was 2.4 times higher in the 10 to 14-year-old group (Prevalence ratio – PR = 2.4; Confidence interval – 95% CI 1.2-2.6) when compared to the group aged 15 to 19, but it was 80% lower in males (PR=0.2; 95% CI: 0.1-0.2) compared with females. Also, co-occurrence between physical, psychological, and sexual violence (3.7%) was observed.	The issue of color arises in the sociodemographic characterization of all cases of violence reported in the analyzed period, in which a higher prevalence was observed in a group of brown or black people (80.5%). Regarding sexual violence, 40.2% of the victims were black adolescents.
6. Sena, Silva and Falbo Neto⁽¹⁷⁾ Year: 2018 Incidence of sexual violence in children and adolescents in Recife/Pernambuco in the 2012-2013 biennium Recife, Pernambuco (PE) Science & Collective Health	Descriptive study. Identifying the incidence of sexual violence in children and adolescents in Recife/Pernambuco, in the 2012-2013 period. Level of evidence: VI.	Of the 328 investigated cases of sexual violence in children and adolescents, 59.2% were in the 10 to 14 age group, with a predominance of female victims (92.1%).	No disaggregation of data regarding the item for adolescents was carried out. The general distribution of cases by race/color was 80.5% in brown and 1.8% in black. According to the type of sexual violence, 88.9% of carnal intercourse occurred in brown people and 2.7% in black people.
7. Santarem et al.⁽¹⁸⁾ Year: 2020 Epidemiological Profile of the Victims of Sexual Violence Treated at a Referral Center in Southern Brazil Porto Alegre, Rio Grande do Sul (RS) Brazilian Journal of Gynecology and Obstetrics	Cross-sectional study. Characterizing the sociodemographic profile of women victims of sexual violence treated at a university hospital in southern Brazil. Level of evidence: VI.	The majority of victims aged between 10 and 19 knew the perpetrators of sexual violence. Concerning the type of contact, the most common was vaginal (59.2%). It was also found that victimized adolescents were the ones who received emergency contraception the most.	The majority of these victims were white and young. Children under 19 were at greater risk of not using contraceptives and knowing the sexual aggressor, and of the total number of victims, 74% were white, 24.4% non-white and 1.5% unknown.
8. Barreto et al.⁽¹⁹⁾ Year: 2021 Knowledge of nursing professionals about sexual violence against adolescents Rio de Janeiro, Rio de Janeiro (RJ) Journal of Research: Fundamental Care Online	Qualitative study Revealing the knowledge of nursing professionals about sexual violence against adolescents. Level of evidence: VI.	The perception of sexual violence against adolescents by nursing professionals points to three important issues: touching the adolescent without consent, the sexual act itself, and sexual violence not just being the physical act.	Not addressed.

Source: Authors’ elaboration, 2022.

Table 2 – Training of authors by publication. Recife, Pernambuco, Brazil, 2022.

Title of the article	Author	Undergraduate and Graduate Stricto Sensu
1. Women victims of sexual violence: adherence to chemoprevention of HIV	1. Normélia Maria Freire Diniz	Nursing Degree Master’s in Nursing Ph.D. in Nursing
	2. Lilian Conceição Guimarães de Almeida	Nursing Degree Master’s in Nursing
	3. Bárbara Cristina dos S. Ribeiro	Undergraduate in Nursing
2. Sexual violence against children and vulnerability	1. José Carlos Martins	Nursing Degree Master’s in Bioethics Ph.D. in Nursing Sciences
3. Violence against adolescents: an analysis in the light of gender and generation categories	1. Rafaela Gessner	Nursing Degree Master’s in Science
	2. Rosa Maria Godoy Serpa da Fonseca	Nursing Degree Master's in Public Health Ph.D. in Public Health
	3. Rebeca Nunes Guedes Oliveira	Nursing Degree Master’s in Nursing Ph.D. in Sciences
4. Sexual violence against adolescents in Campo Grande, Mato Grosso do Sul	1. Lucyana Conceição Lemes Justino	Nursing Degree Master’s in Nursing
	2. Cristina Brandt Nunes	Nursing Degree Master's in Pediatric Nursing Ph.D. in Sciences
	3. Maria Auxiliadora de Souza Gerk	Nursing Degree Master’s in Nursing Ph.D. in Sciences
	4. Simone Sousa Oliveira Fonseca	Nursing Degree Master’s in Nursing
5. Factors associated with the type of violence perpetrated against adolescents in the state of Pernambuco, Brazil	1. Taciana Mirella Batista dos Santos	Nursing Degree Master's in Hebiatrics Ph.D. in Public Health
	2. Mirian Domingos Cardoso	Nursing Degree Master's in Public Health Ph.D. in Public Health
	3. Lygia Maria Pereira da Silva	Nursing Degree Master’s in Nursing Ph.D. in Sciences
6. Incidence of sexual violence in children and adolescents in Recife/Pernambuco in the 2012-2013 biennium	1. Cláudia Alves de Sena	Nursing Degree Master's in Hebiatrics Ph.D. in Mother and Child Health
7. Epidemiological Profile of the Victims of Sexual Violence Treated at a Referral Center in Southern Brazil	1. Michele Dornelles Santarem	Nursing Degree Master’s in Research and Innovation Processes Ph.D. in Epidemiology
	2. Nathalia Lima Pereira	Nursing Degree
	3. Letícia Becker Vieira	Nursing Degree Master’s in Nursing Ph.D. in Nursing
8. Knowledge of nursing professionals about sexual violence against adolescents	1. Amanda Alves Barreto	Nursing Degree
	2. Ellen Marcia Peres	Nursing Degree Master’s in Nursing Ph.D. in Biomedical Sciences
	3. Helena Ferraz Gomes	Nursing Degree Master’s in Nursing Ph.D. in Nursing
	4. Dayana Carvalho Leite	Nursing Degree Master's student in Nursing
	5. Bruna Maiara Ferreira Barreto Pires	Nursing Degree Master's in Health Care Sciences Ph.D. in Health Care Sciences
	6. Priscila Cristina da Silva Thiengo de Andrade	Nursing Degree Master’s in Nursing Ph.D. in Nursing

Source: Authors’ elaboration, 2022.

After analyzing the articles, similar information was found in the results and discussions, to categorize the selected studies, which included three themes that will be presented in the discussion: Sexual violence against adolescents; The (in)visibility of race and color in nursing publications on sexual violence against adolescents; and Nursing publication about sexual violence against adolescents and their education.

DISCUSSION

Sexual violence against adolescents

Cases of violence during adolescence continue to grow and this growing trend has already been evidenced in research conducted with notification data from the Violence and Accident Surveillance System – VIVA⁽¹⁶⁾. In this perspective, in the studies that analyzed the prevalence of types of violence perpetrated against adolescents^(14,16), sexual violence did not show a higher prevalence over the others, with a predominance of physical violence.

In the notifications of violence against adolescents in the period from 2010 to 2012 in Curitiba-PR, 6,677 cases of aggression against adolescents between 10 and 18 years old were registered, of which 14.5% were sexual⁽¹⁴⁾. However, the co-occurrence of different forms of violence is observed, 8.5% of physical and psychological violence, 3.7% of physical, psychological, and sexual violence, as well as cases involving all four types of violence in the same episode⁽¹⁴⁾.

As for the type of sexual violence committed against adolescents, with or without physical contact, a study found that at least 60.3% of adolescents assisted at a referral service for victims of sexual violence in Salvador-BA were raped⁽¹²⁾. Likewise, research that sought to identify the incidence of sexual violence in children and adolescents in Recife-PE, in the 2012-2013 biennium, according to data obtained from the records of sexological tests performed at the Institute of Legal Medicine, observed that of the 328 cases of sexual crimes analyzed, 75.9% corresponded to sexual intercourse, in this case, the classification of violence took place in two ways: sexual intercourse (seduction, rape) or libidinous acts (violent indecent assault)⁽¹⁷⁾. In a study conducted in Porto Alegre-RS⁽¹⁸⁾, it was verified that the most common type of sexual contact against adolescent victims was vaginal. Despite having a higher prevalence of sexual crimes, rape has high rates of underreporting and there are still many flaws in the police report records⁽³⁾.

Sexual violence against adolescents in the selected articles is still preponderantly presented as gender violence practiced mainly against girls^(13-17). In this sense, it is important to point out that this phenomenon is historically, culturally, and socially constructed, pertinent to the existing contradictions in generational, gender, class, and ethnic-racial relations, which are often asymmetrical, domination, and exploitation⁽¹⁴⁾.

Concerning age, the occurrence of sexual offenses among female adolescents occurs mainly during puberty, with a high number of cases involving girls aged between 10 and 14 years⁽³⁾. Accordingly, most reports indicated a higher prevalence of sexual aggression in the aforementioned age group^(16-17) or between 10 and 13 years⁽¹³⁾. Also, a study highlighted a 2.4 times greater probability of the group aged 10 to 14 years (PR = 2.4; CI 95% 1.2-2.6) suffering sexual violence when compared to the group aged 15 to 19 years⁽¹⁶⁾.

In the majority of cases of sexual violence against adolescents, the aggressor was not a stranger^{(13-14,16,18).} Research on the profile of children and adolescents who are victims of sexual violence treated at a Legal Medicine Unit in Paraíba⁽¹³⁾ found that there was a bond between victims and perpetrators, the most frequently being the accused being a known person or a family friend (42.3%), followed by the stepfather (16.6%) and the father (10.9%)⁽¹³⁾, individuals who have a trusting relationship with the victim. In this context, sexual violence practiced by family members stands out.

Intrafamily sexual violence, in the domestic space, gains prominence, because in this environment abuse is difficult to discover, protected by the pact of silence, fear, and non-punishment of its agents. Accordingly, a survey showed that the most frequent place of domestic violence against adolescents was the home (53.5%), followed by public roads (16.3%)⁽¹⁵⁾. However, the cycle of violence is difficult to break, especially sexual violence, when it takes place in the domestic space. In addition, when the act is revealed, the victims themselves are often identified as the cause of the problem, being blamed for the aggression⁽¹⁴⁾.

Sexual offenses may result in serious consequences for the adolescent, such as sexually transmitted infections – STIs and HIV. In addition to susceptibility to STIs, pregnancy might be another harm resulting from sexual violence, this fact was found in the study that analyzed the situation of sexual violence against adolescents in Campo Grande-MS⁽¹⁵⁾, in which 8.7% of victims became pregnant. Regarding exposure to the risk of pregnancy, it was found in the study carried out in Porto Alegre-RS⁽¹⁸⁾, that adolescent victims of sexual crimes used emergency contraceptives the most. However, it is worth noting that the result of this type of violence entails not only physical harm to the lives of adolescents but also social and psychological ones⁽²⁾.

The (in)visibility of race and color in nursing publications on sexual violence against adolescents

The included studies provide relevant epidemiological data on the perpetration of violence, in particular, sexual violence against black adolescents. An epidemiological study conducted in Pernambuco⁽¹⁶⁾ found that 40.2% of adolescents who suffered sexual violence were of this race. Similarly, a study carried out in Recife⁽¹⁷⁾, identified in the data analysis the majority occurrence of sexual violence against black children and adolescents (82.3%), maintaining the high prevalence of this racial group in the distribution of types of violence due to sexual intercourse and other acts.

Certain surveys corroborate the Epidemiological Bulletin of the Ministry of Health of Brazil regarding violence, released in 2018, about the time between 2011 and 2017, in which 55.5% of adolescent victims of sexual violence were reported as black or brown⁽²⁰⁾. According to the Atlas of Violence against Children and Adolescents (2019-2021), 73,442 cases of rape committed against this population were registered between January 2019 and June 2021, corresponding to 56.6% of the total identified records, of which 48% of the victims were white and 51.6% were black⁽²¹⁾. Another important indicator is reported in the Panorama of Lethal and Sexual Violence against Children and Adolescents in Brazil, published in 2021 by the United Nations International Children's Emergency Fund – UNICEF, which found an increase of 6.5% in the number of black victims of rape, as opposed to a 26.8% reduction in the number of white victims⁽³⁾.

However, studies conducted in the southern region of the country^(14,18), reported that violence prevailed in white adolescents (74%), followed by black adolescents (26.9%). Both justified the higher occurrence of cases in this population stratum due to the fact that these cities have a population made up mostly of people of the white race/color. Differently, from what was found in the aforementioned studies, another research carried out in the state of Mato Grosso do Sul⁽¹⁵⁾, reported that adolescents in situations of violence were mostly white (37.8%), however, these data were not justified throughout the article and maximize the proportion in this group despite the close occurrence in blacks (36.6%).

Another study that aims to analyze the demographic and epidemiological profile of children and adolescents who are victims of violence assisted by a Forensic Medicine Unit located in the state of Paraíba⁽¹³⁾ does not mention race/color in the research results. This was aggravated by the fact that the instrument applied in the specialized unit considers only sex and age as sociodemographic variables, with the absence of the race/color variable, even though sexual violence is inserted in a social, historical, and cultural context in the body of the article. Distinctly, another survey⁽¹⁶⁾ carried out in the same region of the country describes the proportion of variables with missing and blank data as a limitation, among which race/color; acknowledging the importance of such analysis.

It should be noted that the cited studies^(13,16) were carried out prior to the publication of Ordinance No. 344/2017⁽²²⁾, which provides for the mandatory completion of the race/color item in the forms of health information systems. A certain action becomes essential for the integral performance of nursing and for the elaboration, implementation, and evaluation of public policies aimed at violence and health for Afro-descendant adolescents.

The publication of this regulation arose in response to a specific objective of the National Comprehensive Health Policy for the Black Population (PNSIPN)⁽²¹⁾, to improve the quality of health information systems. However, its consolidation with health indicators is still weak⁽²³⁾. In light of this, the unsatisfactory implementation of a qualified data record compromises the understanding of the racial issue as a social determinant in the health-disease process⁽²⁴⁾.

Faced with this fact, it is necessary to consider that “health inequalities may be ignored and made invisible if the data to document them are not collected, either by conscious intention or by unconscious negligence”, as highlighted by Krieger⁽²⁵⁾. Although some of the included studies^(13-18) presented data on the race/color variable, the absence or incipient deepening of the discussion regarding this issue in studies about sexual violence against adolescents, demonstrate how the treatment given to an important social marker of differences is made invisible as an indicator of health, preventing the recognition of racism and ethnic-racial inequalities as part of the social determinants of health⁽²³⁾. In this sense, Gonzalez and Hasenbalg (1982) point out that, in Brazilian historiography, structural racism tends to expose black people to the condition of invisibility⁽²⁶⁾.

From the point of view of academic research, racism is not always explicitly and measurably present in social interactions, therefore, studies must go far beyond the comparison of statistical data⁽²⁷⁾, and must consider the set of historical, sociopolitical, economic, and cultural factors that imply the existence, maintenance or expansion of differences, privileges, and violence within racial groups^(4,27). In the case of sexual violence, it is important to recognize the structural expressions of the violation of rights historically inherited by the racialized population, such as hypersexualization and exploitation of the black woman's body^(26,28), as well as the myth of the virile, animal and reproductive man⁽²⁸⁾.

It is worth noting that the Operational Plan of the National Comprehensive Health Policy for the Black Population describes, among others, the following objectives: identification, fight, and prevention of situations of abuse, exploitation, and violence, as well as the guarantee of the use of the race/color item in the production of epidemiological information for the definition of priorities and decision making⁽²³⁾. Determining steps to improve health care, interest, and awareness in confronting violence, based on the visibility of ethnic-racial inequalities in health and the fight against racism and discrimination in institutions and services of the Unified Health System – SUS. However, particularly in Brazil, the myth of the non-existence of racism in the country based on theories such as "racial democracy", prevents the objective awareness of this problem and the knowledge of its practices, becoming essential for the maintenance of domination structures in society^(4,26).

Only one study⁽¹²⁾ deepens the discussion around the race/color variable, arguing that some factors, including ethnic ones, cannot be suppressed when violence is discussed. Added to this issue is the intersectionality between gender and race, where black adolescents suffer doubly from discrimination and devaluation in situations of violence when compared to white adolescents. The vulnerability created by intersectionalities is reported in the Technical Standard published by the Ministry of Health in partnership with the Ministry of Justice and the Secretariat of Policies for Women on Humanized Care for People in Situations of Sexual Violence, which points out that the population of black women and adolescents are more vulnerable to this type of health problem⁽⁶⁾ because, in a society that portrays them as sexually silent, violence is discredited, especially when the perpetrator is someone close to the victim⁽²⁹⁾.

However, the intersection of oppressions was not verified in a study whose objective was to analyze violence against adolescents in the light of gender and generation markers, despite the understanding that these relations are historically and socially constructed⁽¹⁴⁾. Given this, since black bodies are much more susceptible to experiences of violence, it becomes central to recognize that racism, sexism, and related violence overlap, discriminate, and create unique charges with violent effects on black women, including adolescents^(26,30). Given the above, it is fundamental that society understands the importance of the intersectional perspective, especially in expressions of violence.

Publication of nursing about sexual violence against adolescents and their training

The data of the authors of the articles included, accessed through the Lattes Platform, demonstrate that professionals/researchers have invested massively in academic training, especially in postgraduate studies at the stricto sensu level. The vast academic production is directly connected to the strengthening of nursing as a science, from the moment when it is verified that the most recent data from the Coordination for the Improvement of Higher Education Personnel (CAPES) – 2019 – expose the existence of 54 graduate programs in the Nursing Area; of these, 16 have a master's course, while another 36 programs already offer master's and doctoral courses, and only two programs exclusively offer a Ph.D. course. Regarding the courses of the professional postgraduate programs in the Nursing Area, there are currently 22 programs that work exclusively with the master's degree and two others, with the master's and doctoral degrees, totaling 24 programs⁽³⁰⁾.

However, access to postgraduate studies has not been equal among the regions of Brazil, nor has it been democratized, from the moment when only 20% of the more than 330,000 nurses with postgraduate degrees concluded their training at a stricto sensu level: academic master's (10.9%), professional master's (3.6%), Ph.D. (4.7%) and postdoctoral (0.4%)⁽³⁰⁾.

The included reports also demonstrate the diversity of the academic background of the study researchers, where only the northern region of Brazil did not have localized production with the parameters adopted in this review. Coincidentally, the northern region has the lowest presence of master's courses in the field of nursing (four) and the only one that does not have a Ph.D.⁽³⁰⁾.

During the evaluation process of the studies made available in the aforementioned databases, there was majority of articles excluded because they did not present data that worked with the populations of children and adolescents differently. However, it is necessary to mention that among the eight articles included, two had researchers trained at the master's level by the Hebiatrics Program – health determinants in adolescence, at the University of Pernambuco, the only stricto sensu graduate program in the country exclusively dedicated to adolescent health⁽³¹⁾.

Although this review is related to the field of teaching and research in nursing, it is necessary to connect it with what these professionals do in health facilities. Although the notification of suspected or confirmed cases of sexual violence is compulsory, this attitude is a challenge for nursing, since these professionals have restricted their practice to the care of injuries, culminating in the underestimation of cases of violence⁽³²⁾ and, when this notification occurs, in about 30% of the records the race and color field is not completed⁽³⁾ which also underestimates the issue of race in a country that has 55.8% of the population consisting of blacks and browns⁽³³⁾.

The reflection of underreporting permeates the scientific production, from the moment it is verified that there are studies^(13,17,19), that do not mention the variable race/color as essential to the data analysis and, even when it is mentioned, studies^(14-16,18) did not produce any debate. It is emphasized in such a way that the nurses who usually have the first contact with the victim of violence⁽³⁴⁾, play a fundamental role in the investigation processes⁽³⁵⁾, from the moment they properly fill out the individual notification/investigation form of domestic, sexual and/or other interpersonal violence⁽³⁶⁾, and when they are referred to the social assistance network. This was evidenced in a study in which the majority of victims were referred to primary health care (69.8%) and the tutelary council (46.5%)⁽¹⁵⁾.

Considering the scope of nursing work, it is not restricted to bureaucratic practices. The only qualitative study in this review points to the establishment of empathy and trust with the adolescent victim of violence as essential for the development of effective biopsychosocial care by nurses. However, there is an enormous gap in qualification and professional training for the assistance of this public, permeating the training paths, as well as the disarticulation of the multi-professional teams that deal with these situations⁽¹⁹⁾.

Faced with this finding, the National Curriculum Guidelines for the Undergraduate Nursing Course warn that nursing education must meet the social needs of health and also must be able to form a professional able to recognize the structures and forms of social organization, in addition to its transformations and expressions⁽³⁷⁾. In addition, the training of professional nurses should enable them to act with a sense of social responsibility and commitment to citizenship, as a promoter of integral human health, identifying the biopsychosocial dimensions of its determinants employing technical-scientific, ethical-political and socio-educational skills that provide the establishment of new relationships with the context.

Among the limitations, the study highlights the scarcity of literature to subsidize the evidenced data, in addition, few analyzed the issue of race and color, which made it difficult to deepen the debate, demonstrating the need for advancement and improvement of technical, scientific and cultural knowledge that support the professional practice of nursing. It is recommended to include the themes of racism and the health of the black population in the training processes, in addition to encouraging the production of scientific and technological knowledge in health for this public.

The visibility of the discussion about the perpetration of sexual violence in the black adolescent population allows a different look at this population segment, the monitoring of this grievance according to racial profile, and, the strengthening of the fight against structural racism, showing subsidies for the implementation of public policies to confront it.

FINAL CONSIDERATIONS

When analyzing the studies referring to the scientific production of nursing on sexual violence against adolescents, it was found that this predominates in gender relations, in the family environment, and in the age group of 10 to 14 years. Furthermore, there was a lack of data on the issue of race/color, in addition to the superficiality of the discussion of this variable due to the complexity of the phenomenon of sexual violence, considering the socio-historical context of structural racism in Brazil, despite the quality of the academic training of its authors.

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Submission: 06-07-2022

Approval: 14-12-2022

Women victims of sexual violence: adherence to chemoprevention of HIV

Sexual violence against children and vulnerability

Paraíba (PB)

5. Santos et al.⁽¹⁶⁾

Year: 2017

Factors associated with the type of violence perpetrated against adolescents in the state of Pernambuco, Brazil

Pernambuco (PE)

Child Abuse & Neglect

6. Sena, Silva and Falbo Neto⁽¹⁷⁾

Year: 2018

Incidence of sexual violence in children and adolescents in Recife/Pernambuco in the 2012-2013 biennium

Recife, Pernambuco (PE)

Science & Collective Health

7. Santarem et al.⁽¹⁸⁾

Epidemiological Profile of the Victims of Sexual Violence Treated at a Referral Center in Southern Brazil

8. Barreto et al.⁽¹⁹⁾