Article Title	Author	Year	Name of Journal or Magazine	Methods used in the study	Significant outcomes
Characterization of sexual violence against children and adolescents in school – Brazil, 2010-2014	Santos, Mascarenhas, Rodrigues, Monteiro	2018	Epidemiologia e Serviços de Saúde	Descriptive study of cases of sexual violence using data from the Notifiable Diseases Information System (SINAN)	The proportion of female victims (77.1%) and those with black skin color (56.5%) was significantly higher among adolescents (p<0.001) The cases of rape (70.9%; p<0.001) and sexual harassment (33.4%; p=0.014) were more frequent among adolescents, while the notifications of indecent assault prevailed among children (24.1%; p<0.001).
The incidence of sexual violence among children and adolescents in Recife, State of Pernambuco, Brazil, in 2012 and 2013	Sena, Silva, Neto.	2018	Ciência e saúde coletiva	Descriptive, retrospective study using data from the Antônio Persivo Cunha Institute of Forensic Medicine	Rape was significant (p < 0.001) when associated with the age group between 10 and 14 years old, female sex (95.6%) and an acquaintance of the victim, and sexual abuse not involving rape (p < 0.001) was positively associated with the 5-9-year-old age group, female sex and a family member as the most frequent perpetrator (92.1%)
Sexual violence against children: authors, victims and consequences	Platt, Back, Hauschild, Guedert	2018	Ciência e Saúde coletiva	Cross-sectional, descriptive and analytical study with secondary data from SINAN.	The impact of CSA on the mental health of victims stands out, since four (1%) of these attempted suicides; five (1.3%) developed mental disorder; 90 (22.4%) evidenced behavioral disorders; and 77 (20.0%) had posttraumatic stress disorders.
Evolução da notificação de violência sexual no Brasil de 2009 a 2013	Gaspar & Pereira	2018	Cadernos de Saúde Pública	Observational time series study using data of the national base of SINAN	There was an increase in notification of sexual violence in relation to all variables. Rape cases were the most frequent within the analyzed period, going from 54.61% in 2009 to 74.39% in 2013
Factors associated with reporting delays and severity of childhood sexual abuse in São Paulo, Brazil	Vertamatti et al.	2018	Psychology, Health & Medicine	Cross-sectional analysis, using secondary data obtained from medical records of the PAVAS of São Bernardo do Campo	Sexual abuse was prolonged among children whose mothers had eight or more years of formal education (PR = 1.65) The time between abuse and reporting was longer when the perpetrator lived in the same household as the child, and when the abuse was reported by a relative or friend.
Prevalence of sexual violence in Brazil: associated individual and contextual factors	da Silva & Roncalli	2018	International Journal of Public Health	A multilevel analysis performed with cross-sectional data from 2010	Sexual violence is more prevalent in federal units that presented lower years of schooling expectancy at 18 years old (PR 1.27; CI95% 1.09–1.48), lower per capita income (PR 1.23; CI95% 1.05–1.43), lower HDI (PR 1.17; CI95%1.01–1.37), higher proportion of poverty vulnerability (PR 1.18; CI95% 1.02–1.38), higher proportion of unemployment(PR 1.68; CI95% 1.45– 1.96) and higher proportion of people who neither work nor study (PR 1.26; CI95% 1.08–1.46)
Factors associated with violence against children in sentinel urgent and emergency care centers in Brazilian capitals	Malta, Bernal, Teixeira, Silva, Freitas	2017	Ciência e saúde coletiva	Cross-sectional study conducted using the 2014 VIVA survey data.	Victims were predominantly male. The most common form of violence was neglect/ abandonment, followed by physical violence and sexual violence. The most common perpetrators were parents (ages zero to one and two to five years), followed by friends (ages six to nine years). The most common place of occurrence was the home.
Factors associated with child sexual abuse confirmation at forensic examinations	Silva et al.	2018	Ciência e saúde coletiva	Cross-sectional, retrospective study using the forensic files of the Nina Rodrigues Institute of Forensic Medicine	In 10.4% of the cases, the forensic physician was able to confirm the sexual abuse based on material evidence (95% CI: 8.4-12.7) In the final model, a report of penetration was associated with a five-fold greater likelihood of sexual abuse confirmation. When the victim was 10 to 11 years of age (pre- adolescent) rather than younger, there was a two-fold greater likelihood of the sexual abuse being confirmed in the forensic examination
Gender and generation perspectives in the narratives of sexually abused women in childhood	Fornari, Sakata-so, Egry, Fonseca	2018	Revista latino- americana de enfermagem	Descriptive research of a qualitative approach, based on reports from the users of Twitter	The reports revealed that the aggressors expressed desire for the female body during the childhood of the victims and their adolescence was the moment for the consummation of that desire. domestic environment is a frequent place for the occurrence of sexual abuse. Violations generally occurred in situations understood as caring and affection. The reports show that sexual abuse in childhood consisted of a traumatic experience that had many repercussions in the life of the participants
Prevalence of sexual violence and associated factors among primary school students – Brazil, 2015	Santos, Mascarenhas, Malta, Lima, Silva	2019	Ciência e saúde coletiva	Cross-sectional study, with data from the National School Health Survey (PeNSE) conducted in 2015.	Sexual violence among school-age adolescents was associated with characteristics such as: age of < 13 years old; female; black skin color; working; being assaulted by family members; having insomnia; feeling lonely; not having friends; consuming tobacco / alcohol regularly; having tried drugs; having started sexual activity; feeling insecure on the way to or at school; and having suffered bullying.
Childhood and adolescent sexual abuse, victim profile and its impacts on mental health	Fontes, Conceição, Machado	2017	Ciência e Saúde Coletiva	Microdata of the National School Health Survey 2015 was used, applying the methodology of Propensity Score Matching	Abused youngsters are more likely to have used illicit drugs (OR = 2.15), alcohol (OR = 1.80) and have friends who have already done the same (OR = 1.02). They are twice more likely to have been bullied (OR = 2.09) and more likely to have an age-grade gap (OR = 1.20). Students report having less intention to go further than elementary school and are more likely to be working, which is indicated by the coefficients of ‘Future in school’ and ‘Employment’ (OR = 1.54)
Influence of childhood abuse and neglect subtypes on late- life suicide risk beyond depression	Behr Gomes Jardim et al.	2018	Child Abuse & Neglect	Cross-sectional study looking at a sample of 449 individuals 60 years old or older from the Multidimensional Study of the Elderly of Porto Alegre Family Health Strategy, Brazil (EMI-SUS/POA	In the multivariate analysis, controlling for age, gender, income, marital status, ethnicity, and smoking, all maltreatment subtypes remained associated with suicide risk (OR EA = 4.36; PA = 3.61; SA = 3.74; EN = 3.24; PN = 1.91; p≤0.01). Individuals with three maltreatment subtypes reported were 5.66 times (p≤0.01) more likely to present suicide risk than those with no maltreatment subtypes, and individuals with four maltreatment subtypes reported were 6.72 times (p≤0.01) more likely to present suicide risk. Finally, those with five maltreatment subtypes were 10.76 (p≤0.01) times more likely to experience suicide risk. Depressive symptoms and each maltreatment subtype dimension individually predicted suicide risk (Depressive Symptoms OR 5.11, CI 2.72– 9.58, p≤0.001)
“A boy, being a victim, nobody really buys that, you know?”: Dynamics of sexual violence against boys	Hohendorff, Habigzang, Koller	2017	Child Abuse & Neglect	Interviews were conducted with four male victims of sexual abuse between the ages of six and 10, as well as four psychologists employed in the health care system and involved in the treatment of sexually abused boys.	Proximity between victims and offenders, who were mostly adolescent boys, was a facilitator of abuse. Victims faced significant levels of disbelief and discrimination
Childhood sexual abuse, intimate partner violence during pregnancy, and posttraumatic stress symptoms following childbirth: a path analysis	Oliveira, Reichenheim, Moraes, Howard, Lobato	2016	Arch Womens Ment Health	Cross-sectional study at a maternity service for women at high risk for fetal and neonatal complications in Rio de Janeiro, Brazil.	CSA are strongly and positively linked to PTSD symptoms, which indicates a substantial indirect connection be-tween CSA and the outcome. The direct path from CSA to PTSD symptoms had a borderline significance (p=0.066)
Child Sexual Abuse Confirmed by Forensic Examination in Salvador, Bahia, Brazil	Silva & Barroso Jr.	2017	The American Journal of Forensic Medicine and Pathology	Retrospective, cross- sectional descriptive study	In 94% of the cases, the reason for carrying out the forensic examination was a report of sexual abuse. Less than 1% of the aggressors were female. A ruptured hymen was the finding that confirmed sexual abuse in 172 cases, corresponding to 83% of cases in girls. There were2 cases of pregnancy. Recent anal or perianal lesions were present in 35(87.5%) of the confirmed cases involving boys.

Table 1: Description and results of the included reviews

Figure 1: PRISMA flow diagram

Introduction

Sexual violence is an enormous social and health issue. It is a difficult crime to investigate as well as to prove it, mainly when its victims are children and adolescents. Most of the time, the victims feel ashamed and embarrassed of denouncing this kind of tragedy. This creates an unfavorable scenario and increases the difficulty to help the victims and their families with their multiple pains, including the physical as well as the emotional harms [1]. Child Sex Abuse (CSA) sets up also as a gender and race problem, because it affects mainly girls and black girls; in addition, the crime is committed more than 90% of times by males [2-8].

Every day, thousands of children are abused in places that were supposed to be safe. Several studies show that the most common places where this kind of crime occurs were at home and school, not to mention that such atrocity is perpetrated by those who are close to the victim [1,3,4,6,7,9].

Sexual abuse is a harmful, humiliating, and traumatic experience to the physical and mental health of men and women with immediate and late consequences. When it comes to immediate repercussions victims usually experience suicidal thoughts, mental disturbs, behavioral disturb, post-traumatic stress disorder (PTSD) [10], and regarding the late consequences, they stumble upon senile depression, and high risk of suicide in elder individuals [11]. Thus, the aim of this study was to analyze the psychiatric and psychological repercussion of children and adolescents, victims of CSA in Brazil.

Methods

A systematic literature search was performed according to guidelines in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Searches were conducted in PubMed. Keywords included combinations of the words "sex offenses" and children and Brazil.

Studies were considered if they were published between January 2015 and September 2020 and appeared in peer-reviewed, English, Portuguese, and Spanish language journals. Further articles were identified by a manual search of reference lists from retrieved papers. Studies were included if they (i) appeared in peer-reviewed journals; (ii) were published in full; (iii) were not dissertation papers, editorials, letters, conference proceedings, books, and book chapters; (iv) had primary and sufficient data derived from longitudinal, cross-sectional, case-control, or cohort studies. For the aim of this systematic review, only reviews that investigated prevalence, psychiatric symptoms or disorders following CSA in Brazil were included.

Results

The search strategy yielded 121 hits in PubMed. Titles and/or abstracts of these records were screened, and 84 did not meet eligibility criteria. Out of the remaining 38 full-text articles, 22 were excluded for various reasons. Thus, our systematic review includes 15 publications (Figure 1) (Table 1). Figure 1: PRISMA flow diagram

Discussion

As it is known, Child Sex Abuse (CSA) is a difficult crime to investigate and prove. Children and adolescents’ dependence on their parents aggravate the problem, once victims usually take too long to report the crime, and when this occurs, it is still difficult to find physical evidence to confirm the rape. It is important to remember that parents generally have no knowledge regarding the abuse, and when they notice it, they fear about the consequences of notification [1].

Despite this, according to Gaspar & Pereira [12] from 2009 to 2013 there was an increase on the number of notifications of CSA. Sexual abuse notification tripled, due to a real increase in the number of cases, to greater awareness of the victims and/ or health professionals, or even to better structuring and the number of reporting units. It is clearly observed that girls are the most affected. In almost all the studies, the number of girls who suffered a sexual abuse was bigger than the number of boys [2-8].

Machismo is still – in the 21^st century – a very big social problem. It affects all social spheres of most of the Latin-American countries which could explain the underreporting of CSA in boys. The low notification of sexual violence against men is partially due to the toxic masculinity. Men fear having their virility questioned, which leads them not to seeking for health services after having suffered sexual violence [12]. Machismo perpetuates a mistaken conviction that men who are victims of violence tend to homosexuality. This stereotype causes a delay on reporting the abuse. As a result of this delay, they may experience more severe CSA over time [8].No one believes that boys may be victims of CSA which decreases the visibility of this cases. In the familiar context, the possibility that boys may suffer unbelief and

Figure 1

Table 1

even physical punishment after reportion, shows how difficult it is to individuals to understand that boys may be victims of CSA. In the social context, these cases are permeated by misconceptions regarding gender identity or sexual orientation of the victim, contributing to a lesser visibility of male sexual abuse as a public health problem [13]. Besides that, da Silva & Roncalli [2] affirm that men tend to have less access to health services when compared to women. Although a tremendous amount of men suffers this type of violence, women are still the main victims in all age groups which characterizes a marked gender violence [12].

The socioeconomic conditions of families are a risk predictor for CSA. Significantly higher rates of sexual violence were observed among black-skinned students from public schools, children of mothers with low levels of education, students who did not live with their mother and/or father, and among those who were already working and receiving retribution for that. Associated and protective factors as for the occurrence of CSA included attending to a private school, being son of a highly educated mother, living with the mother and/or father and having family supervision [5].

Victim’s residence was alarmingly the most frequent place of abuse, and the aggressors were mostly men who in most of the cases were known by the victims. Even scarier than this, only the fact that the own children’s parents were the most common perpetrators [3,4,10]. The violations generally occurred in situations understood as affection, when the aggressor and the child were alone. The moments of play, a characteristic activity of childhood, were favorable situations for adults to practice sexual violence. The aggressors took advantage of childhood situations such as playing to perpetrate the crime. Thus, the victims cannot immediately recognize the violence, which prevents the aggressors from being reported [3]. Home, which should be a place of protection and care, has become a place of violence and child victimization.

A curious contradiction exists in the literature as to the safety of children at school. While some studies show that the number of cases of CSA within educational institutions is increasing [9] others describe schools as a protective factor for CSA [8].

Regarding the types of sexual violence, the following were identified: rape, sexual harassment, indecent exposure, sexual exploitation, child pornography and others. It was observed that, among the types of sexual violence, rape was the most frequent, possibly related to the fact that other types of sexual violence are not recognized as violence. It seems to be more difficult for children to define harassment, indecency, pornography and other types of violence, which makes complaints and/or explanation of the facts difficult [8].

According to Silva & Barroso-Junior [6],in a study realized from January of 2008 and December of 2009 in the city of Salvador, the most common findings in children bodies were anogenital lesions, hymen ruptured in 82.7% of confirmed cases in girls. There were signs of recent abuse such as hematomas, drops of blood and edema in 30% in which the hymen was ruptured. Two girls of this study, both aged 11, were already pregnant and despite abortion being authorized by law in cases of sexual abuse, there are still a lot of girls who have to carry on with an undesired pregnancy, this because legal abortion in Brazil, has become a religious and moral debate.

It is well known that children who have been sexually abused suffer the negative effects of this throughout their lives. The most common manifestations are inadequate school performance, psychological problems (depression, anxiety, suicide attempt and post-traumatic stress disorder) and personal relationships [3]. Among the immediate consequences, the impact of CSA on the mental health of the victims stands out, according to Platt et al. [10] From all analyzed children in their study, four of them (1%) attempted suicide; five (1.3%) developed mental disorder; 90 (22.4%) showed behavioral disorders; and 77 (20.0%) had PTSD. CSA also was related positively to another psychiatric traumas, violence perpetrated by a relative during pregnancy and fear of the childbirth, for those victims who had to carry on with the pregnancy [14].

Sexual violence was more frequent among students who reported insomnia, feeling alone and having no friends. This type of violence was more reported among school children with risky behaviors, such as smoking, alcohol consumption, drug experimentation and early sexual life. The chances of suffering sexual violence were greater for students who felt insecure on the way between the school and their home and at the school itself, as well as those who reported having suffered bullying [5]. Agreeing with this idea, Fontes et al. ¹⁵ found that abused young people were more likely to use illicit drugs, alcohol and have friends who already did. Sexually abused students appear to be less likely to continue their studies in high school and graduation and are more likely to be already working. The victims of sexual violence avoid staying at home and tries to spend as much time as possible outside their house to feel more secure. Insomnia can be explained by the presence of nightmares, fears and mood disorders such as depression. The lack of friends and loneliness can be associated with aggressive behaviors or the withdrawal from the creation of new social bonds, as well as characteristics of low self-esteem and bullying.

Finally, Gomes Jardim et al. [11] claims that all childhood maltreatment types were significantly associated with the risk of suicide, and an emphasis is placed on sexual abuse, which, unlike other mistreatment subtypes, is more strongly associated with the risk of suicide in the elderly.

Conclusion

CSA is a rarely notified crime, due to this, it is necessary to learn how to identify behaviors that the victims show, in order to be able to act in a precocious way and prevent more serious consequences of this crime. It is necessary to create strategies that can minimize physical and psychological damage than children and adolescents may suffer immediately or belatedly. Children and teenagers represent the future of our countries, the hope that there are better days coming. It is extremely important to remember the importance of preserving their lives and their futures, for which we must take action now. Literature clearly shows us the various and different forms of psychic suffering that abused children suffer. In order to save the future of children and adolescents we must first save their present.

We call for attention from government authorities around the world, as we find that social inequality, poverty, a general lack of education has a direct impact on the lives of children. Without saying that, the religious polarization, surrounding governmental decisions and important debates such as abortion, is being harming and will continue to harm the future of more young people. More studies are needed, so health professionals, teachers and especially families can recognize early signs of CSA, besides that, public policies need to be implemented urgently in order to reduce these egregious cases.

References

1. Sena C, Silva M, Falbo Neto G (2018) Incidência de violência sexual em crianças e adolescentes em Recife/Pernambuco no biênio 2012-2013. Ciência & Saúde Coletiva 5: 1591-9.
2. da Silva J, Roncalli A (2018) Prevalence of sexual violence in Brazil: associated individual and contextual factors. International Journal Of Public Health 63: 933-44.
3. Fornari L, Sakata-So K, Egry E, Fonseca R (2018) Gender and generation perspectives in the narratives of sexually abused women in childhood. Rev. Latino-Am. Enfermagem 26: e3078.
4. Malta D, Bernal R, Teixeira B, Silva M, Freitas M (2017) Fatores associados a violências contra crianças em Serviços Sentinela de Urgência nas capitais brasileiras. Ciência & Saúde Coletiva 22: 2889-98.
5. Santos M, Mascarenhas M, Malta D, Lima C, Silva M (2019) Prevalência de violência sexual e fatores associados entre estudantes do ensino fundamental – Brasil, 2015. Ciência & Saúde Coletiva 24: 535-44.
6. Silva W, Barroso-Junior U (2017) Child Sexual Abuse Confirmed by Forensic Examination in Salvador, Bahia, Brazil. The American Journal Of Forensic Medicine And Pathology 38: 54-8.
7. Silva W, Ribeiro F, Guimarães G, Santos M, Almeida V, et al. (2018) Factors associated with child sexual abuse confirmation at forensic examinations. Ciência & Saúde Coletiva 23: 599-606.
8. Vertamatti M, Strufaldi R, Evans D, Drezett J, Barbosa C, et a l. (2018) Factors associated with reporting delays and severity of childhood sexual abuse in São Paulo, Brazil. Psychology, Health & Medicine 24: 739-48.
9. Santos M, Mascarenhas M, Rodrigues M, Monteiro R (2018) Caracterização da violência sexual contra crianças e adolescentes na escola - Brasil, 2010-2014. Epidemiol Serv Saúde 27: e2017059.
10. Platt V, Back I, Hauschild D, Guedert J (2018) Violência sexual contra crianças: autores, vítimas e consequências. Ciência & Saúde Coletiva 23: 1019-31.
11. Gomes Jardim GB, Novelo M, Spanemberg L, von Gunten A, Engroff P, et al. (2018) Influence of childhood abuse and neglect subtypes on late-life suicide risk beyond depression. Child Abuse & Neglect 80: 249-56.
12. Gaspar R, Pereira M (2021) Evolução da notificação de violência sexual no Brasil de 2009 a 2013. Cad. Saúde Pública 34: e00172617.
13. Hohendorff J, Habigzang L, Koller S (2017) “A boy, being a victim, nobody really buys that, you know?”: Dynamics of sexual violence against boys. Child Abuse & Neglect 70: 53-64.
14. Oliveira A, Reichenheim M, Moraes C, Howard L, Lobato G (2016) Childhood sexual abuse, intimate partner violence during pregnancy, and posttraumatic stress symptoms following childbirth: a path analysis. Archives Of Women's Mental Health 20: 297-309.
15. Fontes L, Conceição O, Machado S (2017) Violência sexual na adolescência, perfil da vítima e impactos sobre a saúde mental. Ciência & Saúde Coletiva 22: 2919-28.