Introduction

Violence affects the lives of millions of people and results in significant consequences.¹ Standing out among the victims of violence are people with disabilities, who account for some 15% of the global population.²

It is estimated that people with disabilities are 50% more likely to experience violence, compared to people without disabilities.^3,4 This marked disproportion is due to asymmetry in power relations to which those with disabilities are submitted, making them very vulnerable.^5,6

Notification of violence against people with disabilities is required by law, the purpose of which is to give visibility to this complex problem and strengthen the fight for equity in public policies.⁷ In this context, several instruments have been built to address this form of violence, including: the 2007 Convention on the Rights of Persons with Disabilities;⁸ the 2010 National Policy on the Health of People with Disabilities;⁹ and the 2015 Brazilian Law on Inclusion of People with Disabilities.¹⁰

Given the relevance of the topic, the unprecedented nature of studies on violence against people with disabilities thus far, and in order to support public policies aimed at addressing, preventing and assisting victims and perpetrators of this form of violence, this study aimed to describe cases of violence against people with disabilities notified by Brazilian health services between 2011 and 2017.

Methods

This is a descriptive epidemiological study of cases of violence against people with disabilities, notified in Brazilian health services between 2011 and 2017.

The data used in this study were retrieved from the Notifiable Health Conditions Information System (Sinan), which holds information derived from Individual Interpersonal and Self-Inflicted Violence Notification Forms filled out in health services. With effect from 2011, this form of violence has been included on the mandatory notification list recommended and adopted in all health services in Brazil.⁷

The following variables were defined for analysis, relating to:

We used the types of disability/disorder and violence listed in the document entitled Instructions for Notifying Interpersonal and Self-inflicted Violence (VIVA), prepared and published by the Brazilian Ministry of Health.⁷

Pearson's chi-square test was used to assess differences between the proportions calculated for the variables according to gender. The statistical analyses were performed using SPSS version 21.0.

As the study project was based on anonymous secondary data, it was exempted from review by a Research Ethics Committee.

Results

In Brazil, 1,429,931 cases of interpersonal or self-inflicted violence were reported between 2011 and 2017, of which 116,219 (8.1%) were cases of violence against people with disabilities.

The notified cases were concentrated in females (66.7%). Half of the victims (50.7%) were of white race/skin color and 61.6% were between 20 and 59 years old. Mental disability was the most frequent among the types of disability reported in this study (58.1%), followed by intellectual disability (22.1%) (Table 1).

No record of the victim's type of disability was found for 5,855 notifications (5.0%), while 18,486 (15.9%) reported people with multiple disabilities, and it is noteworthy that there were 8,405 cases of overlapping mental disability and intellectual disability.

Self-inflicted violence among people with disabilities corresponded to 44.5% of total notifications. As for interpersonal violence, physical violence was the most reported type (51.6%), with psychological/moral violence (23%) and neglect/abandonment (15.0%) standing out, in addition to sexual violence (12.2%), especially against women. More than half of the notifications (51.7%) reported recurrent violence, with the majority of victims being women (54.6%) (Table 2).

The main probable aggressors were family members (36.5%), followed by intimate partners (21.5%). Most aggressors were male (60.2%). In most cases, alcohol use was not suspected (48.0%) (Table 3).

Discussion

Most cases of violence against people with disabilities notified in Brazilian health services between 2011 and 2017, related to victims who were female, of white race/skin color, adults and people with mental disability. Occurrence of multiple disabilities, especially mental and intellectual disabilities, was frequent. Notifications of self-inflicted violence and physical violence stood out. The main probable aggressor was a member of the victim's own family.

The main limitation of this study is the possibility of case underreporting. The notifications we analyzed represent an approximation, but not the totality of cases. They are limited to people in situations of violence who sought health services, received care, and whose cases were notified by the health workers who saw to them.¹¹

Another limitation of this study is the fragility or imprecision of the information on the type of disability, making it difficult to analyze the data corresponding to each form of disability. In the specific case of mental and intellectual disabilities, several changes in these definitions over the years - and over the course of history - have led to possible confusion between the terminologies used;^12,13 in addition to the quality of the information produced, which is at times incomplete or contains errors.

Violence against people with disabilities occurred more frequently among females, corroborating the findings in the literature.^3,14,15 It has been noted that overlapping of vulnerabilities associated with disability, race/color/ethnicity, social class and age group can make some people even more prone to suffering violence.^14,16

The notifications indicated that people with disabilities who suffered violence were predominantly of White race/skin color. However, the possibility of underreporting exists, resulting, for example, from Black people having less access to health services, in addition to the naturalization of violence among this population.¹⁷ The high percentage of notifications with no information on race/skin color could also influence the analysis performed in this study.

Such underreporting can also be significant in relation to the most vulnerable age groups, such as the elderly and children. These groups tend to have a higher degree of dependence, more difficulties in accessing health services and other impediments; or, simply, reluctance to report what happened, especially when the aggressor is the victim's own carer, father and/or mother.³

The main disabilities reported were mental and intellectual disabilities, similarly to what is found in the literature.^2,3,18 Greater exposure of children and young people with mental disabilities or multiple disabilities to different types of violence may be explained by difficulties they face in doing their daily activities, as well as by the care provided by carers.¹⁸

The high proportion of notified self-inflicted violence among people with disabilities (44.5%), especially those with mental disabilities, has been revealed by research and analysis of the relationship between mental disability, self-inflicted violence and suicide. According to those studies, having a mental disorder is an important risk factor for suicide.^19-21

When someone with a disability has difficulty communicating, his or her guardian or carer is usually the person who provides information about him or her.⁷ In these cases, it is possible that part of the violence reported as self-harm is, in fact, perpetrated by the carers themselves.²¹

The greater notification of physical violence we found may be related to visible marks on the victims’ bodies as they are easier to identify; this does not occur with other forms of violence, which require more detailed investigation.^1,12

Another aspect that stood out was the occurrence of psychological/moral violence and sexual violence among women with disabilities, besides repeated violence, and this is in keeping with the literature.^15,22 In this context, the intersectional analysis we performed made it possible to examine and understand crosscutting issues for women with disabilities who are also victims of violence, including social, attitudinal, and welfare issues.²³

The probable perpetrators of violence against people with disabilities were predominantly male, who had close or intimate involvement with the victims.³ Given this finding, the difficulty in making the problem visible is greater, given the relational nature of the occurrence, the victims having less autonomy to communicate the event or even the stigma and feeling of shame regarding the aggression they suffered.

Another important issue raised by the study was the identification of the carer (in many cases, a family member) as the aggressor. The burden of care work can also generate violence²⁴ and in these cases, it is important that health workers pay close attention in order to detect hidden or sublimated violence, provide appropriate care and timely referral, in a humanized manner, within the health care and social protection network. In this sense, there is an urgent need for regulatory policies, policies on training and policies aimed at strengthening the act of caring, enabling qualification of carers of people with disabilities.

The violence surveillance system and the health care network for people with disabilities have different levels of coverage in states and municipalities. Added to this are the difficulties families face in seeking to guarantee their rights, access health services and, consequently, report the violence they experience.^11,25,26

The study revealed that violence causes serious consequences for people who experience it, and represents an even greater challenge for people with disabilities when they face barriers of various kinds and suffer all kinds of discrimination, prejudice, stigma and oppression.^1,2

We conclude that the description and assessment of cases of violence against people with disabilities, as notified by Brazilian health services, can contribute to the formulation and improvement of specific public policies on this important problem. Future studies should deepen the knowledge and analysis of the theme.