Understanding of multiprofessional Primary Health Care residents regarding sexual violence against adolescents

Juliane Carina da Silva Araujo¹, Paulo Roberto da Silva Júnior², Débora Carollyne Santos da Silva³, Alana dos Santos Reinaux⁴, Dayanne Caroline de Assis Silva⁵, Juliana Lourenço de Araújo Veras⁶, Mariana Boulitreau Siqueira Campos Barros⁷, Valesca Patriota de Souza⁸

^{1,2,3,4,6,7,8}Universidade Federal de Pernambuco. Vitória de Santo Antão (PE), Brazil. ⁵Universidade Federal de Pernambuco, Recife (PE), Brazil.

Introduction

Adolescence represents a stage of life marked by the transition between childhood and adulthood, encompassing individuals aged between 10 and 19 years. This period is characterized by unique processes of identity construction, sexuality, and autonomy resulting from changes in physical, mental, emotional, sexual, and social aspects.¹ These factors make adolescents vulnerable to involvement in various forms of violence, with particular emphasis on sexual violence, which represents a phenomenon that permeates cultural experience over time and is recognized as a global public health problem.^2-3

Sexual violence is characterized by any intentional, unwanted, and unnecessary act of a sexual nature, whether consummated or attempted, against a child or adolescent, including for purposes of exploitation, that results in or poses a risk of causing injury, pain, or psychological suffering.²

The global situation of sexual violence in early stages of life demonstrates gender differences, with an estimated global occurrence affecting 650 million (or one in every five) girls and women alive. Among boys and men, it is estimated that between 410 and 530 million (or approximately one in seven) have experienced sexual violence during childhood or adolescence.³ These findings highlight the need for educational approaches aimed at preventing violence against adolescents, involving family, school, and community, with most countries assigning responsibility for combating this problem to sectors such as education, health, justice, and social assistance.²

The role of the health sector is not limited solely to addressing the impacts resulting from violence; it also encompasses actions aimed at prevention and health promotion, especially within the scope of Primary Health Care (PHC), such as groups and discussion circles with adolescents and articulation with schools through the School Health Program (Programa Saúde na Escola - PSE), thus maintaining a focus on population well-being at both individual and collective levels, with the objective of providing continuous care. In this way, PHC plays a crucial role as the main entry point to the system, offering comprehensive and decentralized coverage, which facilitates access and ensures universality, comprehensiveness, and equity in health.⁴

The role of PHC in the prevention, promotion, and care of the effects of violence plays a fundamental role in promoting well-being and protecting community health, as well as in identifying cases of violence through a multidisciplinary team that works collaboratively to provide greater comfort and physical and emotional development for children and adolescents.⁴

In PHC, health promotion is primarily carried out through health education activities, which serve as a guide for population reflection by offering comprehensive care that transforms behaviors, promotes autonomy, and encourages self-care, thereby contributing to improved quality of life. This enables individuals to reassess their reality and make healthier choices, in addition to encouraging changes in risk behaviors.⁵

In the context of health in Brazil, the integration between education and service seeks to qualify professional training within the Unified Health System (Sistema Único de Saúde - SUS), promoting closer ties between universities and health units. Programs such as Multiprofessional Residency strengthen this integration by offering quality education that combines theory and practice. These programs are essential for the advancement of health services, prioritizing both professional and institutional development.⁶

Given the complexity surrounding professional qualification in addressing sexual violence in adolescence and the role of Multiprofessional Residency in strengthening PHC, there is a clear need to deepen the discussion on the perceptions and challenges faced by these professionals. This deepening seeks to understand educational and operational weaknesses, as well as to support the improvement of continuing education, interprofessional practices, and care strategies, contributing to the protection of adolescents and the effectiveness of preventive actions in PHC. Therefore, this study aimed to understand the perception of multiprofessional PHC residents regarding sexual violence against adolescents.

Method

This is a qualitative study of an exploratory-descriptive nature, conducted using the Focus Group (FG) technique with residents of a Multiprofessional Residency Program in Family Health in Pernambuco, linked to the Universidade Federal de Pernambuco (UFPE), during the second semester of 2024.

Health professionals from the aforementioned residency program participated in the study, constituting an intentional, non-probabilistic sample composed of 10 participants. The inclusion criterion was being a resident who completed the Multiprofessional Residency Program in Family Health in 2023. Exclusion criteria included residents who were on medical leave or away from activities during the data collection period.

The research was conducted in accordance with the ethical principles of Resolution No. 466/12 of the Brazilian National Health Council (CNS). After authorization from the coordination of the training institution, volunteers confirmed their participation by signing the Free and Informed Consent Term (FICT) before data collection. Respect for individuality and privacy was ensured, as well as anonymity and confidentiality of names and data that could identify the volunteers. The project was approved by the Research Ethics Committee (REC) of the Academic Center of Vitória of UFPE, under opinion No. 7,120,644.

For data collection, the FG strategy allowed participants to explore their viewpoints based on reflections on a given social phenomenon, using their own vocabulary, seeking responses relevant to the research question. This enabled the exchange of experiences, concepts, and opinions among participants.⁷

The FG was conducted in a single session, lasting approximately 90 minutes, in a reserved environment at the educational institution of the residency program, allowing participants freedom to express themselves without interference. The circular arrangement of the room favored eye contact and strengthened discussions. During the discussion process on the topic, no discomfort among participants was identified. In this study, the lead researcher acted as the moderator, with the support of two observers, undergraduate Nursing students previously trained for the proposed strategy. To capture participants’ statements, two audio recorders were used, ensuring fidelity, confidentiality, and anonymity; participants were identified by the letter “A” followed by a numeral corresponding to their order in the circle. Transcription of the material was carried out by the research team itself.

The session was organized according to the following activities: in the first moment (preparation), the study proposal was presented, as well as an explanation of the FICT and the respective individual consent; in the second moment (presentation), the theme was introduced, objectives were presented, and the FG technique was explained; in the third moment (development), the debate was conducted according to the thematic guide, focusing on residents’ perspectives on the proposed topic, guided by the following questions: “What is sexual violence to you? How do you identify cases of sexual violence in adolescents? What are your guidelines and referrals when faced with a case of sexual violence in an adolescent? As a family health resident, what difficulties do you encounter in caring for adolescents who are victims of sexual violence?”; in the fourth moment (synthesis), the central ideas of the discussion were revisited, allowing participants to validate the information apprehended; and in the fifth moment (closure), acknowledgments and socialization were carried out.

For data analysis, the phenomenological trajectory of Maurice Merleau-Ponty was used, which unfolds into three distinct stages: description of the phenomenon, reduction, and phenomenological understanding. The initial phase, description, enables the collection of relevant discourses, which are subjected to phenomenological analysis and interpretation in order to explore the underlying essence and its transcendence. In the reduction stage, the focus lies on the selection of fragments perceived as essential, allowing a reflective analysis to identify their potential concepts, resulting in the formation of units of meaning. Finally, understanding emerges during interpretation, revealing the awareness that the subject has regarding the phenomenon.⁸

After identifying convergent units of meaning in participants’ discourses, a final synthesis of these units was performed, resulting in the emergence of the following thematic categories: “Perception of Family Health residents regarding sexual violence against adolescents” and “Difficulties in the care of adolescents who are victims of sexual violence”.

Results

10 professionals from the fields of Psychology, Nursing, Nutrition, Physical Education, and Collective Health participated in the study, of whom seven identified as female and three as male. The thematic categories are described separately.

Perception of Family Health residents on sexual violence in adolescents

The discourses regarding the understanding associated with sexual violence were related to rape, sexual harassment, non-consensual relationships within marriage, and the imposition of power, as evidenced by the following statements:

I believe that sexual violence can take many forms [...] whenever we talk about sexual violence, we usually associate it a lot with the issue of rape, of physical violence, but it is not only that. It is something much broader. (A3)

I understand sexual violence as anything that goes beyond someone’s consent [...] in relation to sexuality itself. Not only in a physical way. (A8)

Something that happens a lot is that women do not realize that it happens to them, that they are sexually violated, in marriage, in dating, in casual relationships. When a woman has sex without wanting to. When a woman has sex just to please her partner [...]. Sometimes the man has sex with the woman while she is sleeping [...]. All of this is sexual violence. [...] many times, we end up giving in and having sexual relations with our partner without wanting to, just so he does not look for someone else. And we do not realize it. But this is rape, this is abuse as well [...]. Women do not know that they are constantly being violated in their relationships. Because they are engaging in a sexual act without it constantly being their will. This is also considered sexual violence. (A2)

I believe it is when a person is able to impose power over the victim, that is, when they place the person in a situation where there is no way out. Consequently, the abuser has the possibility to do whatever they want to the child. They put the child in a context that will cause trauma. Especially not only physical trauma, but also psychological trauma. (A9)

Regarding the identification of cases of sexual violence in adolescents, the residents reported the presence of certain behavioral aspects in the victims, which can be observed during professional practice. These aspects are highlighted below:

In that first contact with the patient, we can see it. Especially in the psychological aspect [...]. They are more introverted people, people who have difficulty expressing certain types of behaviors, even talking about how they feel. There is difficulty explaining things. (A9)

Even in the way of asking for help, of seeking support. I have heard some reports from a child, an adolescent, when making a request to the psychologist [...] “I don’t want a male psychologist. I want it to be only a woman.” [...] this more withdrawn behavior, like this [...]. Afraid, apprehensive about talking too much. (A7)

Behavior change is something that happens a lot with a child when they go through some type of abuse. The child starts to show sexualized behaviors that are not appropriate for their age. So, the child shows behaviors that indicate some type of sexual violence. Usually, they will reproduce the violence they suffer, usually with another child. These are the so-called sexual games. [...] there is also the opposite. The child, and the adolescent, start wearing loose clothing that does not show much of the body, they start feeling ashamed of their own body. Self-harm may occur. Suicide attempts [...]. They try to hide, avoid contact with people of the opposite sex. (A2)

In addition to behavioral characteristics, the residents reported strategies for identifying cases of sexual violence through the use of tools and soft technologies present in the daily routine of Primary Health Care:

I already had an experience where we were able to identify it through the school health program. [...] we asked the adolescents to express themselves, anonymously, about what made them anxious, what bothered them, whatever they wanted to talk about, as a form of venting. And then we were able to identify some cases of sexual violence among adolescents [...] anonymously. If we were to ask them, “what bothers you?” For sure, most of them would not have the courage to open up. And then, anonymously, they were able to vent. (A8)

Through drawings. Asking the child to draw what their relationship with the family is like, what their home is like. [...] identifying through speech, through listening, through welcoming. (A10)

In the analysis of guidance and referrals in cases of child and adolescent sexual violence, knowledge was identified regarding the conduct to be followed, such as qualified listening, welcoming, mandatory reporting, and the performance of examinations. However, the statements revealed doubts and uncertainties regarding which agencies should be activated.

The first thing I do is listening. Welcoming. And then, afterwards, the notification of interpersonal self-inflicted violence. And activation of the competent bodies. So, I would initially contact the Child Protection Council. And I believe that’s it. I don’t know if the Specialized Reference Center for Social Assistance (Centros de Referência Especializado de Assistência Social - CREAS). I really get kind of lost. I don’t know if I am the one who contacts the legal service. But I would leave it with the Child Protection Council. And the Child Protection Council would follow up. [...] perform the rapid tests: Human Immunodeficiency Virus (HIV), syphilis, hepatitis, and others, and refer for Post-Exposure Prophylaxis (PEP), if it is still within the appropriate time frame, right?, 72 hours. (A3)

I think the school as well. Seeking information from the school is also essential [...] bringing people together to discuss the case. (A4)

Provide psychological follow-up. And, based on psychological follow-up, see if there will be a need for any other type of referral, if there will be a need to see a psychiatrist, if there will be a need to see a physician [...] to see how she is, her physical condition itself. [...] there is that forensic examination, at the Legal Medical Institute (Instituto Médico Legal - IML). (A2)

Furthermore, participants emphasized the creation of a bond of trust between the professional and the patient who is a victim of abuse, so that the patient feels comfortable continuing this communication, highlighting the importance of multidisciplinary work in welcoming and directing this patient.

I believe that, still in the welcoming process, in the listening process, you use a language that is able to reach the patient. [...] because, even when you activate all these agencies, the first person and the first contact, and this patient’s trust, is first placed in you. So, consequently, you have to strengthen this relationship between you and the patient. (A9)

Category 2: Difficulties in the care of adolescents who are victims of sexual violence

One of the main difficulties identified was the recognition of and approach to adolescents within health services. It was highlighted that this population does not constitute the primary group assisted in Primary Health Care Units, which makes both professional practice in approaching this group and adolescents’ access to the services offered more difficult.

Having the identification and providing that first care, that welcoming, would be the most difficult. I believe that the difficulty for the child or the adolescent to arrive at the unit is already great, so I think access would really be the entry point for this child. [...] I believe that care at the health unit is more difficult with children, we see a lot of adults at the health unit. [...] so, identifying these cases, I believe, is difficult because of that, because there is no openness for children and adolescents within the health unit. (A1)

Generally, adolescents only go to the health unit when they are sick. There comes a certain age when they stop attending the health unit frequently, when they are no longer of an age for childcare follow-up, for example. And then it becomes difficult to identify cases because of that, because these children/adolescents do not go to the health unit and are afraid to talk at home. So, if they do not talk at home and do not go to the health unit, there is no way to identify it. Because if they attended the health unit more often, or participated in groups, or took part in routine consultations, they might have an opportunity there to tell what is happening. (A2)

In this context, the importance of education was emphasized as a fundamental tool for the identification and prevention of sexual violence, encompassing both health education actions promoted by professionals and the active role of schools in sexual education.

When we are in a work environment, some professionals have certain difficulties. For example, talking to children in groups about sexual education. “Oh no, we have to be careful because of the parents”, you know? Even the professionals themselves have this taboo about talking. When we go to schools, we have to be careful not to talk to children under 10 years old, but children under 10 are also abused. So, really, health at school should have a much stronger role in this. (A5)

Both the school and health professionals are there to break this paradigm. It is not our role to be afraid of what parents are going to say. Our role is to protect children, because many times parents have this kind of taboo because they themselves did not receive sexual education. Then they already think that sexual education is teaching children and adolescents how to have sex, which is the opposite. [...] from the moment health professionals and schools refuse to do this [sexual education] out of some kind of fear or concern, they end up being complicit, because they are putting children and adolescents at risk. (A2)

Another challenge identified was professionals’ insecurity when dealing with issues related to sexual violence, especially due to fear of retaliation, whether from social and cultural pressures or from the aggressor themselves.

This issue of feeling fear, this concern about being in the community, about being there every day. And the professional, for example, who does not live in that neighborhood, finishes their shift and leaves. (A7)

The issue of safety is that many professionals do not feel safe taking that responsibility upon themselves, you know? Especially those professionals who live in the neighborhoods. I have already heard, “Am I going to take that responsibility on myself? So-and-so knows me, you all leave, and I stay here.” So, one of the greatest difficulties I perceive is this issue of risk and safety. Many professionals do not feel safe and sometimes also distrust the resolution, you know? From other agencies. (A8)

The need for greater proactivity on the part of professionals was also mentioned, emphasizing the importance of putting oneself in the patient’s place and acting more assertively in such situations.

I believe there is a lack of initiative on the part of the professional, regarding reporting. A lot is hidden [because of] this issue of good coexistence, good neighborly relations, because there will be continuity, and it ends up being let go. But many times, people do not put themselves in the other person’s place, nor do they see what that child, that adolescent, may be suffering there, in that situation. And, as we know well, several types of reporting can be anonymous [...]. And people simply let it pass. So, I think the professional themselves need to have this awareness of the seriousness of the situation they are allowing to pass, once they put themselves in the other person’s place. “What would I do if it were me? If it happened in my family? If it happened to my child?” In these cases, it is not necessarily that we need to impose ourselves and put our name at risk, but at least we should have the attitude to report. (A1)

Many of the things we identify in the territory were changed, had some type of action by the resident’s initiative. Because many times, in many cases, things were stagnant. They started moving from the moment we got together to act. But what happens is that, when we respond to the preceptors, many times there are things we want to do and cannot, because they do not authorize it. But we, as residents, are able to activate many things that were not activated before. (A2)

Discussion

This study’s results highlight the complexity of the topic and the need to improve professional training to ensure qualified and resolutive welcoming.

Although, in common sense and even in professional practice, “children and adolescents” are often referred to together, adolescents occupy a borderline position between dependence and protagonism. The experience of sexual violence presents particularities related, for example, to affective-sexual relationships and forms of expressing suffering, which is why it requires specific care and preventive approaches.¹

The discourses revealed expanded perceptions of sexual violence, encompassing rape, sexual harassment, marital rape, non-consensual relationships within marriage, and the imposition of power. There is a tendency to recognize sexual violence only in its explicit forms, while subtle manifestations, especially in the conjugal context, are often neglected.⁹ Many women, influenced by the naturalization of female submission, do not identify unwanted sexual relations within marriage as rape. In addition, the association between sexual violence and the imposition of power is also evident, particularly in child abuse, which occurs in contexts marked by power asymmetry, making reporting and recognition of violence more difficult.^9-10

Although sexual violence is predominantly perpetrated by individuals of the male gender, women may also be perpetrators of this type of violence, especially in family or caregiving contexts, even though such occurrences are less visible. Likewise, despite the higher incidence of sexual violence among girls, boys are also victims, albeit to a lesser extent. In this group, underreporting tends to be greater due to the influence of social gender constructions that associate masculinity with strength and invulnerability, which also creates a barrier to seeking help.^2,11

Among the main behavioral aspects associated with sexual violence in adolescents are introversion, difficulty expressing emotions, and abrupt changes in behavior. Victims of this type of violence often present characteristic psychological and behavioral signs, such as depression, anxiety, aggressiveness, fear, shame, and self-harm; however, these manifestations may also be related to other types of violence.^11-12

The manifestation of sexualized behaviors in children and adolescents who are victims of abuse, identified mainly in schools, where victims may reproduce the abuse suffered in the school environment and in interactions with other children, highlights the severity of emotional impacts and reinforces the importance of a multidisciplinary approach in welcoming and caring for victims.¹²

In addition to behavioral aspects, it is important to highlight the use of tools and soft technologies in the identification of cases of sexual violence in PHC. The experience reported with the PSE illustrates how anonymous and expressive methodologies can facilitate the disclosure of situations of violence. A study demonstrated that health professionals use playful and expressive activities, such as drawings and games, as indirect forms of communication, allowing adolescents to express feelings and experiences that are difficult to verbalize directly.¹³

These approaches are especially relevant in PHC, as they contribute to the construction of a safe and welcoming environment, which is essential for adolescents to feel comfortable reporting their experiences. Qualified listening and welcoming emerge as central strategies in case identification. Professionals who adopt an empathetic and nonjudgmental posture prove to be more effective in building bonds of trust, enabling adolescents to feel safe to share experiences of sexual violence and express their feelings.¹³

In line with this understanding, Article 7 of Federal Law No. 13,431/2017 legally consolidates qualified listening as a protective practice by instituting specialized listening for children and adolescents who are victims or witnesses of violence, emphasizing that its purpose is not the production of evidence, but the guarantee of protection and care.¹⁴

Knowledge was observed regarding the main conduct to be followed in cases of child and adolescent sexual violence, such as qualified listening, welcoming the victim, mandatory reporting, and requesting medical examinations. However, the statements indicated uncertainties regarding the agencies responsible for referral and follow-up of cases, revealing a gap in professional training. Some studies corroborate this finding, reinforcing that insecurity may compromise the effectiveness of care and emphasizing the need for more targeted training for professionals working in this context.¹⁵

The practices mentioned are aligned with the Technical Standard of the Brazilian Ministry of Health¹⁶, which guides a comprehensive, humanized, and intersectoral approach aimed at preventing and treating conditions resulting from sexual violence. A systematic review highlighted the importance of a multidimensional and coordinated clinical response by health services. This care ranges from early identification of signs of abuse to the implementation of specific clinical interventions, such as the timely provision of Post-Exposure Prophylaxis (PEP) against the Human Immunodeficiency Virus (HIV), the performance of rapid tests for Sexually Transmitted Infections (STIs), and referral for psychological and psychiatric support. These procedures are essential to reduce the risks of STIs, provide emotional support to victims, and avoid revictimization within health services.¹⁷

Psychological assessment is emphasized as another important component of comprehensive care, supported by CFP Resolution No. 31/2022, consisting of a technical-scientific process that uses validated instruments, such as tests, scales, and interviews. This process allows for the identification of emotional and behavioral impacts that are not always visibly expressed, supports appropriate therapeutic interventions, guides referrals within the care network, and contributes to victim protection.¹⁸

Moreover, the study participants’ reports evidenced concern with intersectoral articulation, especially with schools and social protection services. This is also supported by the literature, which emphasizes the need for collaboration among health professionals, social assistance, the judicial system, and educational institutions to ensure comprehensive and effective care.^16-17 Therefore, the analyzed data demonstrated that, although there are still specific insecurities and doubts regarding interinstitutional flows and responsibilities, professionals understand the complexity of sexual violence and seek to act ethically and responsibly.

In addressing the response network, doubts emerged among participants regarding which institutions should be activated, reflecting a challenge for health professionals. Given the complexity surrounding situations of rights violations, intersectoral action is essential, so that each public policy and institution assumes its role in the processes of prevention, protection, care, and accountability in cases of sexual violence against children and adolescents.¹⁹

Within the protection network, articulation with the Child Protection Council and the CREAS becomes a central element in addressing sexual violence against adolescents. According to the Brazilian Statute of the Child and Adolescent (ECA), the Child Protection Council is responsible, among other actions, for ensuring the guarantee of rights and applying protective measures, while CREAS, through the Specialized Protection and Assistance Service for Families and Individuals, provides psychosocial follow-up for victims and their families. The integration of these mechanisms with PHC and the school environment strengthens intersectoral action, prevents fragmentation of care, and contributes to the comprehensive protection of children and adolescents in situations of violence.²⁰

The inclusion of the school as a relevant institution in the investigation and discussion of cases, as mentioned by one of the participants, reinforces the importance of intersectoral articulation. Some authors have highlighted that schools play an essential role in the early identification of sexual violence, since, as spaces of daily coexistence for children and adolescents, teachers and staff can perceive behavioral changes and emotional and physical signs indicative of violence. Thus, strengthening communication between health units and educational institutions may contribute to both referral and follow-up in a more agile and effective manner.²¹

The difficulty in accessing and approaching adolescents in health services, as pointed out by the residents, reflects a recurring challenge in PHC practice. In general, adolescents tend to seek care in specific situations, such as vaccination or acute illness.²² In addition, the traditional organization of PHC services, predominantly focused on the care of younger children, pregnant women, and adults with chronic diseases, contributes to the invisibility of the specific demands of this age group.²³

This issue is reinforced by the low frequency of adolescents in programmatic and preventive activities within Primary Health Care Units. The absence of specific strategies to attract and engage adolescents in PHC actions significantly reduces the capacity of services to identify vulnerabilities such as sexual violence. The lack of care protocols aimed at this population and the absence of educational activities for adolescents limit their proximity to health services, creating barriers that must be overcome to ensure comprehensive care.²³

Analysis of the statements shows that residents recognize the importance of sexual education as an essential strategy for preventing and identifying cases of sexual violence. This understanding is corroborated by national guidelines for comprehensive health care for adolescents and young people, which highlight sexual education as a crucial strategy to promote autonomy, strengthen protective factors, and reduce child and adolescent vulnerability.²⁴

Despite this, participants also indicated practical difficulties in implementing these actions, mainly due to cultural barriers, such as fear of reactions from parents or guardians and the perpetuation of taboos surrounding sexuality. This aspect was also described in a study²⁵, which identified family relationships as a barrier to PSE actions and to adolescent care itself, referring to discomfort and inability to address sexuality between parents and children. Sexual education is not limited to guidance on sexual acts, but involves promoting values such as respect, consent, self-esteem, and autonomy over one’s own body. When neglected due to fear or taboo, the absence of adequate information exposes children and adolescents to greater risks of abuse.²⁴

Residents also highlighted the active role that health and education professionals must assume in breaking these paradigms, reaffirming the need to strengthen health education actions related to sexuality from childhood onward, within school and community contexts, creating safe spaces for dialogue for children and adolescents, as well as the need to qualify health and education professionals to address the topic ethically and safely.^24-25

Fear, insecurity, and lack of initiative among some professionals were identified as challenges in addressing sexual violence in PHC. Fear of retaliation or threats from perpetrators, combined with feelings of vulnerability in the work environment, contributes to the persistence of underreporting within health services.²⁶ This impasse may be mitigated through Disque 100 ─ a strategic instrument that enables anonymous and safe reporting, reducing professional exposure and strengthening the protection network.²⁷ Article 245 of the ECA¹⁴ highlights the legal duty of professionals to mandatorily report suspected or confirmed cases of violence against children and adolescents, providing for sanctions in cases of omission.

Furthermore, the lack of articulation between health services and social protection agencies also contributes to professionals’ feelings of powerlessness.²⁶ In this context, the importance of comprehensiveness and intersectorality within the network of care for situations of violence is emphasized, noting that the absence of coordinated action among different sectors hinders the effectiveness of response measures.

This reality highlights the need to create institutional strategies that ensure greater protection and support for professionals, fostering a safe environment for fulfilling their ethical and legal duties in addressing sexual violence²⁶, such as the organization of clear care flowcharts aligned with municipal public policies to guide and support professional practice in the territory. Grounded in the System for Guaranteeing the Rights of Children and Adolescents (SGDCA), supported by Resolution No. 113/2006²⁸, which addresses the need for articulated action across the axes of promotion, defense, and social control, as provided for in Articles 86 and 87 of the ECA¹⁴, well-defined flows reduce insecurity, clarify institutional responsibilities, prevent revictimization, and ensure continuity of care.

In this context, the transformative role of resident professionals was highlighted. Despite experiencing institutional limitations, residents are able to drive practical changes within their territories of practice. Initiatives led by residents tend to energize care processes and expand the response capacity of health units in situations of violence. This capacity for mobilization and service strengthening is corroborated by a study²⁹, which shows that the inclusion of multiprofessional residents in health services promotes reconfigurations in care practices, strengthening commitment to comprehensive care and the implementation of SUS principles, while also providing spaces for the development of competencies oriented toward equity, including in addressing sexual violence.

Based on the findings and grounded in the assumptions of Maurice Merleau-Ponty’s phenomenology⁸, it is possible to understand that residents’ perceptions are not constructed solely through technical knowledge, but emerge from the lived body, concrete experience in the territory, being-with-the-other, and relationships established in the daily routine of PHC. Their insecurities, strategies, and re-significations are permeated by intersubjectivity, feeling, and action, within a continuous learning process that does not occur in isolation, but through interaction with lived realities, reaffirming the resident’s transformative role in care and in the protection of adolescents.

The way residents frequently associate adolescents with the child population in their discourses reveals a perceptive construction of adolescent invisibility as a singular subject. In this perspective, the association is not merely conceptual, but reflects how professionals perceive and relate to the world.⁸ By not dissociating adolescents from children, residents reproduce a socially rooted perception that disregards the specificities of this group, reducing them to childhood and, consequently, limiting their autonomy and protagonism in care.

This perception directly impacts professional practices, since failure to recognize adolescents as subjects of rights, with their own demands and vulnerabilities, compromises the quality of listening, welcoming, and preventive actions. Thus, it is necessary to re-signify how professionals perceive and relate to adolescents, recognizing them not as an extension of childhood, but as individuals in development, with a voice and the capacity to actively participate in care and in the construction of strategies that promote their protection and autonomy.³⁰

The study presents limitations related to the specific sample of residents linked to a single residency program, which restricts the generalization of findings to other contexts. Additionally, the exclusive use of the FG technique may have limited the expression of more sensitive experiences that could emerge through other methods. Despite these limitations, the findings offer relevant contributions to strengthening educational and care practices in addressing sexual violence within PHC.

Final considerations

This study showed that Family Health residents have an expanded understanding of sexual violence against adolescents, recognizing its multiple manifestations. However, challenges persist in the identification, approach, and management of cases, related to the lack of specific training, insecurity regarding referrals, absence of clear protocols, resistance from some professionals, and cultural barriers present in the territory. Qualified listening, the use of playful tools, sexual education, and the strengthening of bonds within the territory stand out as fundamental strategies.

In this context, the role of residents proves to be essential, as their insertion qualifies work processes, promotes more humanized practices, expands the capacity for early identification, and strengthens comprehensive care within PHC. The performance of multiprofessional residents actively contributes to network articulation, community awareness, and the transformation of practices, fulfilling their role in in-service training aligned with health promotion, care management, and health education.

The need for continuous investment in continuing education, the development of well-structured care flows, institutional support, and integrated public policies capable of strengthening PHC performance in the promotion, prevention, and guarantee of the rights of children and adolescents is reaffirmed.

In this sense, it is suggested that further studies be conducted, including analyses of the impact of residents’ performance and the effectiveness of training strategies for PHC professionals, as well as the implications of implementing specific protocols, care flows, and intersectoral actions in the territories for addressing sexual violence against adolescents.

Authors contributions

Study design: Juliane Carina da Silva Araujo e Valesca Patriota de Souza. Data collection: Juliane Carina da Silva Araujo; Débora Carollyne Santos da Silva e Alana dos Santos Reinaux. Data analysis and interpretation: Juliane Carina da Silva Araujo e Valesca Patriota de Souza. Manuscript writing: Juliane Carina da Silva Araujo e Dayanne Caroline de Assis Silva. Manuscript critical review: Paulo Roberto da Silva Júnior; Dayanne Caroline de Assis Silva; Juliana Lourenço de Araújo Veras; Mariana Boulitreau Siqueira Campos e Valesca Patriota de Souza. Approval of the final version of the manuscript: Juliana Lourenço de Araújo Veras; Mariana Boulitreau Siqueira Campos e Valesca Patriota de Souza.

Conflict of interest

The authors declared that there is no conflict of interest.

References

1. Dourado JVL, Arruda LP, Ferreira Júnior AR, Aguiar FAR. Adolescence: definitions, criteria and indicators. Rev enferm UFPE on line [Internet]. 2020 [cited 2025 dec 12];14. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/245827

2. World Health Organization. Global status report on preventing violence against children 2020: executive summary. World Health Organization; Geneva: WHO; 2020. [cited 2025 Aug 17]. Available from: https://www.who.int/teams/social-determinants-of-health/violence-prevention/global-status-report-on-violence-against-children-2020

3. Fundo das Nações Unidas para a Infância. Sexual violence. United Nations Children’s Fund, International Classification of Violence against Children, UNICEF, New York, 2023. [cited 2025 Dec 04] Available from: https://data.unicef.org/topic/child-protection/violence/sexual-violence/#status

4. Setti SM, Trindade AD, Hohendorff JV. Family Health Strategy's Performance in Cases of Sexual Violence Against Children and Adolescents. Rev. Estud Pesqui Psicol. [Internet]. 2022 [cited 2024 Oct 5];22(1):105-24. DOI: https://doi.org/10.12957/epp.2022.66482

5. Correia BOP de C, Silva ABC, Correia BOP de C, Meira LP, Moreira C de A, Cabral F de A, Carvalho M Érika da S, Silva CLK e, Farias Ítalo G, Ribeiro LP. The importance of Primary Health Care in the identification of child violence. REAS [Internet]. 2022 [cited 2024 nov 25];15(7):e10728. DOI: https://doi.org/10.25248/reas.e10728.2022

6. Pereira MS, Martins OVM. The multiprofessional resident and its performance according to Primary Health Care Teams in the Municipality of Campinas - SP. [Internet]. 2023 [cited 2025 Jul 18];24(2):189-94. Available from: https://periodicos.saude.sp.gov.br/bis/article/view/40179

7. Corrêa AMC, de Oliveira G, de Oliveira AC. The focus group on qualitative research: principles and fundamentals. Rev. Pris. [Internet]. 2021 [cited 2025 Jul 7];2(1):34-47. Available from: https://revistaprisma.emnuvens.com.br/prisma/article/view/41

8. Motta LJ da. A Fenomenologia da percepção de Maurice Merleau-Ponty. Prim. Escritos [Internet]. 2021 [cited 2025 Jul 7];11(1):212-31. Available from: https://revistas.usp.br/primeirosescritos/article/view/176887

9. Souza GKO, Carvalho RC, Souza SL, Lima JDS, Almeida VRS, Nery GDS. Violence in intimate relationships among young university students: theoretical reflections in the light of bioecological analysis. Cien Saude Colet. 2025 [cited 2025 Oct 25];30(suppl 2):e05642024. DOI: https://doi.org/10.1590/1413-812320242911.05642024

10. Schraiber LB, Aguiar JM de, Graglia CGV, Pereira S, Lima NP, Kalichman BD, Reis MS dos, Azeredo YN, Colombini M, Lucas d’ Oliveira AFP. Sexual violence against women by intimate partner and gender inequality in the voice of Primary Health Care professionals. Interface (Botucatu). 2023 [cited 2025 jul 16]; 27:e220656. Available from: https://www.scielo.br/j/icse/a/Lfwtxjp6sSWTHjVvZY4zVwH/abstract/?lang=pt

11. Conceição MIG, Souza MR, Rosa TS, Machado RN. Male child sexual abuse: symptoms, notification and reporting on restoration of protection. Psicol Clin. 2020 [cited 2025 May 22];32(1):101–21. Available from: https://pepsic.bvsalud.org/scielo.php?script=sci_abstract&pid=S0103-56652020000100006

12. Siqueira VT, Holanda PCM, Almeida TG, Souto RQ, de Souza VP, Guedes TG. Signs and symptoms of sexual violence identified in children: integrative review. CLCS [Internet]. 2024 [cited 2025 Jun 8];17(1):7896-91. DOI: https://doi.org/10.55905/revconv.17n.1-476

13. Stragliotto BJ, Souza SM, Marten MV, Irmgard BGR, Freitag LV, Hense DT. Strategies adopted by Health professionals for the care of children/adolescents victims of violence. RBPS [Internet]. 2022 [cited 2025 Jul 12];23(3):16–23. Available from: https://periodicos.ufes.br/rbps/article/view/34480

14. Brasil. Lei nº 13.431, de 4 de abril de 2017. Estabelece o sistema de garantia de direitos da criança e do adolescente vítima ou testemunha de violência e altera a Lei nº 8.069, de 13 de julho de 1990 (Estatuto da Criança e do Adolescente). Diário Oficial da União, Brasília (DF), 5 abr. 2017. [cited 2025 Dez 12]. Available from: https://www.planalto.gov.br/ccivil_03/_Ato2015-2018/2017/Lei/L13431.htm

15. Brunatti Júnior JMB, Rogenski Lopes R, Lopes VJ. Desafios do enfermeiro no atendimento às vítimas de abuso sexual infantil. In: Fundamentos e Práticas Pediátricas e Neonatais. 14ª ed. São Paulo: Editora Pasteur; 2022 [cited 2025 Jun 10]. Cap. 8. DOI: https://doi.org/10.59290/978-65-6029-070-9.8

16. Brasil. Ministério da Saúde. Nota Técnica n.º 2/2025- COSAJ/CGCRIAJ/DGCI/SAPS/MS: orientações sobre promoção da saúde sexual e prevenção da violência sexual em adolescentes. Brasília: Ministério da Saúde; 2025 [cited 2025 Jul 15]. Available from: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/notas-tecnicas/2025/nota-tecnica-no-2-2025-cosaj-cgcriaj-dgci-saps-ms

17. Rahnavardi M, Shahali S, Montazeri A, Ahmadi F. Health care providers' responses to sexually abused children and adolescents: a systematic review. BMC Health Serv Res. 2022 [cited 2025 Jul 19];22(1):441. DOI: https://doi.org/10.1186/s12913-022-07814-9

18. Brasil. Conselho Federal de Psicologia. Resolução CFP nº 31, de 15 de dezembro de 2022. Estabelece diretrizes para a realização de avaliação psicológica no exercício profissional da psicóloga e do psicólogo, regulamenta o Sistema de Avaliação de Testes Psicológicos - SATEPSI e revoga a Resolução CFP nº 09/2018. Brasília: CFP; 2022. [cited 2025 Dez 10]. Available from: https://atosoficiais.com.br/cfp/resolucao-do-exercicio-profissional-n-31-2022-estabelece-diretrizes-para-a-realizacao-de-avaliacao-psicologica-no-exercicio-profissional-da-psicologa-e-do-psicologo-regulamenta-o-sistema-de-avaliacao-de-testes-psicologicos-satepsi-e-revoga-a-resolucao-cfp-no-09-2018

19. Ulyana SDA, Polizel AL, Dias FMV. Social Assistance Policy in Addressing Sexual Violence Against Children and Adolescents. Saúde Coletiva (Barueri) [Internet]. 2025 [cited 2025 Jun 10];15(94):15001-16. Available from: https://revistasaudecoletiva.com.br/index.php/saudecoletiva/article/view/3361

20. Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Conselho Nacional de Assistência Social (CNAS). Resolução nº 109, de 11 de novembro de 2009. Aprova a Tipificação Nacional de Serviços Socioassistenciais. [Brasília]: MDS; 2009. [cited 2025 Dez 15]. Available from: https://www.mds.gov.br/webarquivos/public/resolucao_cnas_n109_%202009.pdf

21. Dias GA, Bergamo TMM. A importância da escola no combate à violência contra crianças e jovens. Morrinhos: Instituto Federal Goiano; 2023 [cited 2025 May 11]. Available from: https://repositorio.ifgoiano.edu.br/bitstream/prefix/4455/1/tcc_Geovanna%20Alves%20Dias.pdf

22. Silva AG, Gomes CS, Ferreira ACM, Malta DC. Demand and use of health services by Brazilian adolescents, according to the National School Health Survey 2019. Rev Bras Epidemiol. 2023 [cited 2025 Jun 10];26(Suppl 1):e230008.supl.1.1. DOI: https://doi.org/10.1590/1980-549720230008.supl.1.1

23. Arruda MFA, Xavier LN, Escobara AMPR, Ferreira BC, Souza MC, Sobrinho JEL. Barriers to adolescent access to primary health care in Recife, Pernambuco. Rev Baiana Saúde Pública. 2024 [cited 2025 Jun 22];48(3):128-143. DOI:
https://doi.org/10.22278/2318-2660.2024.v48.n3.a4210

24. Gazetta GHAK, dos Santos JP, Cardin MA, Gonçalves ERG, Medeiros TEG, Carli FVBO, Grecca SHSG, da Silva LEM de P. Abordagem da equipe multiprofissional à criança e adolescente vítima de maus tratos na atenção primária. Rev. Foco [Internet]. 30º de agosto de 2023 [cited 2025 Dec. 13];16(8):e2791. Available from: https://ojs.focopublicacoes.com.br/foco/article/view/2791

25. Guedes EM, Fernandes DER, Parmejiani EP, Cunha AJG, Moreira KFA, Freitas JLG. Difficulties and possibilities in health care for adolescents: perceptions of primary health care professionals. Contrib Ciênc Sociais. 2024 [cited 2025 Jun 10];17(7):e8633. DOI: https://doi.org/10.55905/revconv.17n.7-325

26. dos Santos TR, Farias PJD de L, Ferreira M Ângela F, Amorim KPC. The Comprehensiveness and Intersectoral Approach of Primary Health Care in the Network for Addressing Violence Against Women. Rev. Cont. Saúde [Internet]. 2024 [cited 2025 Jul 16];24(48):e14695. Available from: https://www.revistas.unijui.edu.br/index.php/contextoesaude/article/view/14695

27. Brasil. Ministério da Mulher, da Família e dos Direitos Humanos [homepage on the Internet]. Ouvidoria Nacional de Direitos Humanos (ONDH). Disque 100. Relatório violência contra crianças e adolescentes. Brasília, DF: ONDH; 2019 [cited 2025 Dez 15]. Available from: https://www.gov.br/mdh/pt-br/ondh/dados-e-estudos/disque100/relatorios/relatorio-2019_disque-100_criancas-e-adolescentes.pdf/view

28. Brasil. Conselho Nacional dos Direitos da Criança e do Adolescente. Resolução nº 113, de 19 de abril de 2006: dispõe sobre os parâmetros para a institucionalização e fortalecimento do Sistema de Garantia dos Direitos da Criança e do Adolescente [Internet]. Brasília: Ministério dos Direitos Humanos e da Cidadania; 2006 [cited 2025 Dez 15]. Available from: https://bibliotecadigital.mdh.gov.br/jspui/handle/192/2732

29. Souza VA, Gurgel IGD, Albuquerque PC. Multiprofessional Residency in Health: (trans) formation for SUS in quilombola communities. Physis. 2022 [cited 2025 Jun 17];32(3):e320313. Available from: https://www.scielo.br/j/physis/a/mN7KyHFRVvSFgwM5P7JYyFR/​

30. Silva KL, Pinheiro PN, Mesquita KK, Sales JM, Mondragón-Sánchez EJ, Ximenes LB, et al. Preventing sexual violence in adolescence: digital booklet construction and validity. Acta Paul Enferm. 2024 [cited 2025 Dec 10] 37:eAPE02612. DOI: https://doi.org/10.37689/acta-ape/2024AO0002612

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Juliane Carina da Silva Araujo

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