violence Interrelation between functional constipation anddomestic Coloproctology Journal of

w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Interrelation between functional constipation and domestic violence ^夽

Ana Lucia Couto Coronel

, Helena Terezinha Hubert Silva

UniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFCSPA),PortoAlegre,RS,Brazil

a r t i c l e i n f o

Articlehistory:

Received13September2017 Accepted27December2017 Availableonline3February2018

Keywords:

Domesticviolence Constipation Digestivesystem Healthcare

a bs t r a c t

Introduction:Functionaldisordersofthedigestivesystemareoftenrelatedtovariousforms ofabuseandtheintegralapproachoftheproblemrequiresamultidisciplinarynetwork.The objectivesofthisresearchwere:toevaluatetheprevalenceofdomesticviolenceinadults withfunctionalconstipationandtoidentifytheservicesandstandardsavailabletocarefor thevictims.

Methodology:Thestudywasdevelopedintwocomplementaryparts.PartI:Across-sectional study,whichevaluatedtheprevalenceofdomesticviolenceinpatientsattendedinthecolo- proctologyoutpatientclinicoftheHospitalMaterno-infantilPresidenteVargas,fromSeptember toDecember2016.PartII:Anarrativereview,withbibliographicalanddocumentaryresearch thatsoughttoidentifytheservicesandnormsavailableinBraziltoassistvictimsofdomestic violence.

Results:146womenwereevaluated,42ofwhomhadFCand,ofthese,26hadahistoryof domestic violence(p=0.007),withanOddsRatioof2.71(CI95%O:1.29–5.67).Anetwork ofserviceshasbeenidentifiedtoassistvictimsofviolence,theNetworkofAttentionto Violence,formedbythehealthservices,socialassistance,publicsecurity,justice,human rights,andorganizedcivilsociety.However,astandardsystemfortheoperationofthis networkhasnotbeenidentified.

Conclusion: Theprevalenceofdomesticviolenceinwomenwithfunctionalconstipationis highandacarefulinvestigationofthispossibleinterrelationshipinclinicalpracticeissug- gested.Besidesthat,itisnecessarytopromoteanintegrationoftheNetworkofAttentionto Violence,inordertoofferintegralcaretothevictimsandabestutilizationoftheresources.

©2018SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

夽StudydevelopedattheProgramadeMestradoProfissionalEnsinonaSaúde,UniversidadeFederaldeCiênciasdaSaúdedePortoAlegre (UFCSPA),PortoAlegre,RS,Brazil.

∗ Correspondingauthor.

E-mail:alc.coronel@hotmail.com(A.L.Coronel).

https://doi.org/10.1016/j.jcol.2017.12.003

2237-9363/©2018SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Inter-relac¸ãoentreConstipac¸ãoIntestinalFuncionaleViolência Doméstica

Palavras-chave:

Violênciadoméstica Constipac¸ãointestinal Sistemadigestório Atenc¸ãoàsaúde

r e s u m o

Introduc¸ão: Osdistúrbiosfuncionaisdoaparelhodigestivosãofrequentementerelaciona- dos a diversasformasde abuso ea abordagemintegral doproblemarequer umarede multidisciplinardecuidados.Osobjetivosdesteestudoforam:avaliaraprevalênciadevio- lênciadomésticaemadultosportadoresdeconstipac¸ãointestinalfuncionaleidentificaros servic¸osenormasdisponíveisparaatenderasvítimas.

Metodologia: Oestudofoidesenvolvidoemduaspartescomplementares.ParteI:estudo transversal,queavaliouaprevalênciadeviolênciadomésticaempacientesatendidosno ambulatóriodecoloproctologiadoHospitalMaterno-infantilPresidenteVargas,desetembro adezembrode2016.ParteII:revisãonarrativa,compesquisabibliográficaedocumental, quebuscouidentificarosservic¸osenormasdisponíveisparaatendervítimasdeviolência domésticanoBrasil.

Resultados: Foramavaliadas146mulheres,sendo42portadorasdeCIFe,destas,26tinham históricodeviolênciadoméstica(p=0,007),comOddsRatiode2,71(IC95%OR:1,29–5,67).Foi identificadaumarededeservic¸osparaatendervítimasdeviolência,aRededeAtenc¸ãoà Violência,formadapelosservic¸osdesaúde,assistênciasocial,seguranc¸apública,justic¸a, direitoshumanose sociedadecivilorganizada.Porém,nãofoiidentificadaumanorma sistematizadadefuncionamentodessarede.

Conclusão: Aprevalênciadeviolênciadomésticaemmulheresportadorasdeconstipac¸ão intestinalfuncionaléelevadaesugere-seainvestigac¸ãocuidadosadessapossívelinter- relac¸ãona práticaclínica. Além disso,é necessáriopromover a integrac¸ãoda Redede Atenc¸ão à Violência, a fim de oferecerum atendimento integral às vítimas e melhor utilizac¸ãodosrecursos.

©2018SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Over the last decades, several studies have pointed to an interrelationshipbetweendomesticviolenceandfunctional digestivediseases.^1–5Themechanismsrequiredinthisasso- ciationhavealsobeeninvestigatedandresearchindicatesthat thestressinducedbychronicviolencemaycompromisethe regulationoftheresponseoforgansystemstoanumberof stimuli.^6–8Despitethisevidence,inmanyhealthservices,the investigationofdomesticviolenceandanadequatereferralof victimsarenotyetpartoftheirroutineofcare.^9–11

Inconceptualterms,domesticor intrafamilyviolenceis understoodasthatviolencepracticedbetweenpersonswith consanguineous or social parental ties, which may occur athome and outside.The mostfrequent types ofdomes- tic violence are: psychological, physical and sexual abuse, neglectandabandonment;andthemostvulnerablegroupsare femaleadults,children,youngsters,theelderly,besidespeo- plewithdisabilities,notablyinanunfavorablesocioeconomic scenario.¹²A2002WorldHealthOrganization(WHO)reporton violenceandhealth,whichpresenteddatafrom70countries, foundthatabout10–69%ofwomensurveyedinthestudies reportedhavingsuffered aggressionfromintimate partners duringtheirlifetime;about20%ofwomenand5–10%ofmen haveconfirmedsexualabuseinchildhood;and4–6%ofthe elderlysufferedsometypeofaggressionintheirhomes.¹³

Theconsequencesofdomesticviolenceonvictims’health are variable,but are oftencomplex onesandcan manifest indifferentways.¹⁴Amongthediseasesoftenrelatedtothis typeofviolence,functionaldisordersofthedigestivetract– thosewithnoapparentcauseinthediagnosticevaluation,for example,functionaldyspepsia,functionaldiarrhea,irritable bowel syndromeandfunctional intestinalconstipation,can beobserved.¹⁵

Intestinal constipation is the most frequent complaint amongpeoplewhoseekcarebecauseofdigestiveproblems,¹⁶ and FIC was indicated as the subtype with the high- est prevalence. Women, the elderly, and people in poor socioeconomic conditions are the most affected groups¹⁷ and studies in children and adolescents victims of mal- treatment also found a high prevalence of intestinal constipation.¹⁸

Ascanbeobserved,thereisanoverlapbetweenpopula- tiongroupswiththehighestnumberofvictimsofdomestic violenceandthosewiththegreatestnumberofpeoplewith intestinalconstipation.Thus,itisnecessarytodeepenthis investigationinordertodetermineapossibleinterrelation- ship of these phenomena, for the sake of better welfare services.

Thepurposeofthisstudyistoinvestigatetheprevalenceof domesticviolenceinadultswithfunctionalconstipationand toidentifytheservicesandnormsavailableinBraziltoassist thevictims.

Methodology

Thepresent study was proposed by the Universidade Fed- eral de Ciências da Saúde de Porto Alegre (UFCSPA) and performed at the coloproctology outpatient clinic of the Hospital Materno-infantil Presidente Vargas (HMIPV). The study was approved by the ethics and research councils of the two institutions: by UFCSPA, through Opinion No.

168626, under registration CAAE 52245615.4.0000.5345; and byHMIPV,throughOpinionno.1,715,512,underregistration CAAE52245615.4.3001.5329.

Thisstudywascarriedout intwocomplementaryparts, heredesignatedasPartIandPartII:

PartI

Tolookintotheprevalenceofdomesticviolenceinpatients withfunctionalintestinalconstipation,wecarriedonaquan- titativesurveywithacross-sectionaldesign. Samplingwas obtainedforconvenienceandtherecruitmentanddatacol- lectionoccurredfromSeptembertoDecember2016.Afterdue medicalcareoftheailmentwhichmotivatedtheconsultation, allpatientsagedover18yearswereinformedofthenatureof thestudyandconceptsofdomesticviolenceandthenwere invitedtoparticipate.Onlythosewithintellectuallimitations tounderstandthestudyproposalortoanswerthequestions wereexcluded.Patientswhoagreedtotakepartinthestudy signedtheFreeandInformedConsentTerm,accordingtoRes- olution466/12oftheNationalHealthCouncil.

Participantswereclassifiedinrelationtothemaindiag- nosis; in this study, “main diagnosis” was defined as that which,aftermedicalevaluation,wasconsideredresponsible forthepatient’sreferralandadmissiontothecoloproctology outpatientclinic. Participantsthen answered the question:

“Atsomestageinyourlifetime,haveyoueverbeen physi- callyorpsychologicallyassaulted,sexuallyabused,neglected or suffered abandonment bya member ofyour household or a close person, at home or outside?”. This question should be answered with a “yes” or “no.” All participants answeredastructuredquestionnaire,basedontheIndivid- ualNotification/InvestigationForm:Domesticviolence,sexual violenceand/orotherinterpersonalviolence.¹⁹Thequestion- naireconsistedoffour sections:personalanddemographic data, violence-related data, abuser-related data, and per- sonalassistance-relateddata.Participantswhodeniedhaving suffered violence answered only the first session of the questionnaire,andallparticipantsaffectedbyintestinalcon- stipationwerealsoevaluatedbyRomeIIIcriteria,²⁰andthe BristolScale²¹forthecharacterizationofFunctionalIntesti- nalConstipation(FIC).Allparticipantswhomettwoormore RomeIIIcriteriain25%oftheirbowelmovements,overthree months,duringthelastsixmonths,andwhoinformedfecal formsofTypes1and2intheScaleofBristolwere consid- eredasFICsufferers.Toestimatethefrequencyofoccurrence ofsymptoms,theresponseoptionswere:never,occasionally, frequently,andalways.Accordingtoliteratureconsensus,as toRomeIIIcriteriaweconsiderthattheresponse“frequently”

meant“25%ofthetime”.²²

The collected data were reviewed and doubly digitized intoEpidata3.0(EpidataAssociation,Odense,Denmark),with subsequentprocessingwiththeStatisticalPackageforSocial Science (SPSS)program, version 23.0. Wedid a descriptive analysiswithanabsoluteandrelativedistributionofdata(n-

%)andwiththecalculationofmeansandstandarddeviation (SD). For the bivariate analysisofthe categoricalvariables, weappliedthePearson’sChi-squaredtest(²)withaconti- nuity correctionandan effectmeasureestimation,that is, crudeoddsratio(OR) fora95%confidenceinterval (IC95%).

Inthecontingencytablesinwhichatleast25%ofcellshad anexpectedfrequencyoflessthan5,weappliedtheFisher’s exacttestand,inthoseconditionswhereatleastonevariable hadapolytomiccharacteristic,weusedtheMonteCarlosim- ulation.Forcontinuousvariables,inthecomparisonbetween twoindependentgroupsweappliedtheStudent’st-test.This portionoftheresearchwasreviewedandmettherecommen- dations ofthe TREND StatementChecklist, whichcontains guidelinesfortheevaluationofnon-randomizedpublichealth studies.²³

PartII

Theinvestigationofexistingservices,andnormsinBrazilto assistvictimsofdomesticviolencewascarriedoutthrough a narrative review, with bibliographical and documentary research.ThechannelsusedforourreviewwerethePortalde PeriódicosdaCoordenac¸ãodeAperfeic¸oamentodePessoalde NívelSuperior(CAPES)andthePortaldaSaúdedoMinistério daSaúde,aswellasamanualreviewofselectedstudies’ref- erences.Inourselection,wetookasabasisthetheme,which shouldmandatorilyaddresstheservicesandstandardsforthe careofvictimsofdomesticviolenceinBrazil.Publishedscien- tificarticlesfrom2007to2016inpeer-reviewedjournals,in Portuguese,andavailableforreadinginfullinthechannels researched(guidelines,manuals,protocols)developedinthe period2007–2016, anddocuments(regulations,laws,guide- lines and norms) related tothe theme were selected. The qualitativeanalysisofthedatawasdonebasedontheclas- sification,criticalreading,andcross-referencingofthedata foundintheselectedmaterial.²⁴

Results

Duringtherecruitmentperiod,154patientswereattendedat theHMIPVColoproctologyoutpatientclinic:152womenand 2men.Amongadultfemales,twodidnotwanttotakepart inthestudy,twowereunder18yearsofage,onehadintel- lectuallimitationssothatshecouldunderstandthestudy’s proposals,andonediscontinuedherconsentatasubsequent clinicalappointment.Amongmen,twodidnotwanttopartici- pateinthestudy:onewasunder18andtheotherdidnotagree totakepartinthestudy.Therefore,forourstudyofthepreva- lence ofdomesticviolenceinpatientswithFIC,theresults refertoasampleof146womeninvestigated.

Among the participants, the mean age was 52.5 years (SD=13.2), withapredominanceoftheagegroupsof50–59 years(n=53,36.3%)and60–69years(n=32,21.9%).Themajor- ity(n=102,70.8%)livedinthecityofPortoAlegreandwere

predominantlywhitewomen(n=116,79.5%).Asformarital status,themajorityweremarried(n=99;67.8%)andthemost frequentlevelsofschoolinginthesamplewere:42(28.8)fin- ishedsecondaryeducationand3(21.2%)finishedelementary school.

Domesticviolencewasconfirmedbyasubstantialnum- berofparticipants(n=65,44.5%);inthesewomen,although psychologicalviolence (n=62,95.4%) and physical violence (n=53,81.5%)havebeenconfirmedmorefrequently,almost allvictims(n=59;90.8%)sufferedmorethanonetypeofvio- lencethroughouttheirlives.Approximatelyhalfofthevictims (n=35,53.8%)hadundergonesexualabuse,andthemostfre- quenttypewassexualintercourseagainsttheirwill(n=19, 54.3%),followedbyrape(n=12;3%)and sexualharassment (n=6,17.1%).Twowomen(5.7%)reportedhavingsufferedmore thanonetypeofsexualviolence.

Regardingthenumberofaggressors,almosthalfofthevic- tims(n=30;46.2%)wereharassedbymorethan oneabuser in their lifetimes. Among these aggressors, the most fre- quentwere theformerpartner(n=27,41.5%),father(n=23, 35.4%),mother(n=12,18.5%),andspouse(n=12,18.5%).Alco- holabusebytheaggressorwasreportedbythemajorityof victims(n=47;72.3%).Table1liststhecompletedataregarding typesofviolence,theiroccurrences,andtheprofileofperpe- trators.

Ofthe 65 victims ofdomestic violence, onlyabout one third(n=21;32.3%)soughtassistanceafterthe aggressions:

themostsought-afterplaceswerethehealthnetwork(n=12, 18.5%),non-specializedpolicestations(n=10,15.4%),andspe- cialized police precincts (n=5, 7.7%). Some victims sought assistanceinmorethanoneplace(n=10;47.6%).

Fifty-oneparticipants(34.9%)sufferedintestinalconstipa- tion,andfunctionalsubtypewasthemostfrequentdiagnosis (n=42,82.4%), accounting for 28.8% of the total diagnoses establishedinoursample.Theothertypesofintestinalconsti- pation,groupedundertheheading“SecondaryConstipation”

(SC),occurredin9women,representing17.6%ofourconsti- patedparticipantsand6.2%ofthetotalsample.Thecauses identifiedforSCwere:blockade ofevacuation byrectocele, useoftricyclic antidepressants,hypothyroidism,neurologi- caldisease,anddiabetes.Table2liststhedistributionofthe otherdiagnosesestablishedinoursampleandthecomparison versusdomesticviolence.

Aninferential analysisrevealedastatisticallysignificant associationbetweenFICanddomesticviolence(p=0.007);the estimatedriskofoccurrencesuggeststhatvictimsofdomestic violenceare2.71timesmorelikelytosufferfromFIC(95%CI:

1.29–5.67)versusnon-victims.Whenevaluatedindependently, the other diagnosesdid notshow astatisticallysignificant associationwithdomesticviolence.

Theresultsofournarrativereviewstudy,carriedoutwith theaimofidentifyingtheexistingservicesandstandardsfor thecareofvictimsofdomesticviolenceinBrazil,revealeda networkofservicescalledRededeAtenc¸ãoàViolência(Vio- lenceCareNetwork)toprovidecareforvarioustypesofviolence and,amongthem,domesticviolence.^25,26Thisnetworkcon- sistsofhealthservices,socialwelfare,publicsafety,justice, humanrights,educationalnetwork,andorganizedcivilsoci- ety. Table3liststhe distributionand assignments ofthese services.

Table1–Absoluteandrelativedistributionofdomestic violenceanditsspecificcharacteristics.

Variable Totalsample(n=146)

n %

Domesticviolence^a

No 81 55.5

Yes 65 44.5

Life-timeviolence^b

Childhood 30 46.2

Adolescence 31 47.7

Adulthood 40 61.5

Oldage 6 9.2

Morethanonephase 34 52.3

Aggressors^b

Father 23 35.4

Mother 12 18.5

Stepfather 4 6.2

Stepmother 1 1.5

Spouse 12 18.5

Ex-partner 27 41.5

Ex-boyfriend 6 9.2

Son 4 6.2

Friend 9 13.8

Other 6 9.2

Placeofoccurrence^b

Residence 64 98.5

Collectivehousing 6 9.2

Publichighway 7 10.8

Other 1 1.5

Violencetype^b

Physical 53 81.5

Psychological 62 95.4

Torture 4 6.2

Sexual 35 53.8

Neglect/abandonment 8 12.3

Childlabor 2 3.1

Others 3 4.6

Source:directresearch.Preparedbytheauthor.2017.

a Percentagesobtainedbasedonthetotalsample.

b Percentagesobtainedbasedonthenumberofoccurrenceofcases.

AsforthenormsfortheViolenceCareNetworkactuation, itwasnotpossibletoidentifyaconductsystematization;on the otherhand,low-gradeintegrationwasobservedamong the services that comprise this network.^27–29 The mecha- nismsfound,designedtoguidecareprocedures,aretargeted atspecificportionsofthepopulation,oratspecifictypesof violence,^30–34 directed to particularprofessional groups^35,36 and,insomecases,withalocalorregionalscope.^37–39

According to the data found, the Violence Care Net- work isstill underthe guidelines ofthePolítica Nacional de Reduc¸ão da Morbimortalidade por Acidentes e Violências (PNR- MAV)(NationalPolicytoReduceMorbidityandMortalityfrom Accidents and Violence).²⁷ This policy, establishedin2001, aimedtoincludeviolenceinthehealthagendaandproposed the implementationofsomeguidelines,includinganinter- sectoralandmultidisciplinaryapproachtoviolence,human resourcestraining,anddevelopmentofpreventionandrescue practices.⁴⁰

Table2–Absoluteandrelativedistributionfor diagnosis,Bristolscale,anddiagnosisaccordingto domesticviolence.

Variables Domesticviolence^a

Yes(n=65) No(n=81) p

n % n %

Diagnosis 0.020^b

FIC 26 40.0 16 19.8

Diarrhea 7 10.8 5 6.2

Orificialdisease 10 15.4 16 19.8

Monitoring 8 12.3 18 22.2

Intestinalcancer 1 1.2

Pelvicpain 2 2.5

Diverticulardisease 2 3.1 7 8.6

IBD 1 1.2

Analincontinence 6 9.2 3 3.7

IBS 5 7.7 4 4.9

SC 1 1.5 8 9.9

Constipation 0.007^c

FIC 26 40.0 16 19.8

Otherdiagnostics 39 60.0 65 80.2

Diarrhea 0.483^c

Diarrhea 7 10.8 5 6.2

Otherdiagnostics 58 89.2 76 93.8

Orificial 0.640^c

Orificial 10 15.4 16 19.8

Otherdiagnostics 55 84.6 65 80.2

Monitoring 0.181

Monitoring 8 12.3 18 22.2

Otherdiagnostics 57 87.7 63 77.8

Diverticulardisease 0.297^c

Diverticulardisease 2 3.1 7 8.6

Otherdiagnostics 63 96.9 74 91.4

Analincontinence 0.187^c

Analincontinence 6 9.2 3 3.7

Otherdiagnostics 59 90.8 78 96.3

IBS 0.512^c

IBS 5 7.7 4 4.9

Otherdiagnostics 60 92.3 77 95.1 Bristolscale(cases

ofconstipation)

<0.001^d

Type1 15 23.1

Type2 11 16.9 1 1.2

Source:Directresearch.Preparedbytheauthor.2017.

a Percentagesobtainedbasedonthetotalofeachclassificationof domesticviolence.

b Fisher’sexacttest(MonteCarlosimulation).

c Pearson’schi-squaredtestwithcontinuitycorrection.

d Pearson’sChi-squaredtest.

Discussion

Inthe databases researched, wedidnot findother studies thathaveevaluatedtheinterrelationshipbetweendomestic violenceandfunctionalintestinalconstipation,andthathave investigatedtheservicesandnormsofassistancetovictims.

Oursisagroundbreakingapproach.

Regardingtheoutcome,wenoticedahighprevalenceof domesticviolenceamongFICpatientsinthesampleevalu- ated,and althoughthereare services aimedatthe careof victimsofdomesticviolenceinBrazil,nosystematizednorms fortheintegrationoftheseserviceswereidentified.

Otherstudieshavealreadypointedouttherecurrencesof violencethroughoutthelifeofwomenintheirsamples,as wellastheoccurrenceofmorethanonetypeofaggression andofabuser,forthesamevictim.^41,42Thesefindingsreflect the lackof early and preventive actionsfor the most vul- nerablepopulationsand,inaddition,pointtoanimportant assistancegap.Alcoholabusebytheaggressor–afrequent occurrence–hasalsobeenobservedinotherstudies,⁴³which emphasizestheneedforamoreaggressiveapproachtothe problem.

The high prevalence ofdomestic violence foundin our sample,especiallyamongFICcarriers,isanalertforprofes- sionals who take careofpeople withdigestive complaints.

Althoughthemechanismsthatexplainthisassociationare notcompletelyelucidated,itisnecessarytogobeyondthe biomedicalfocusandapproachdomesticviolenceasapos- sible factor involved, sincethis will allowthe integral and adequate referral for these individuals. Also found in this studywasanassociationbetweenthecharacteristicoffeces and the history ofdomestic violence, suggesting agreater severity ofsymptoms in those who suffered some typeof violence. The severity and refractoriness of the symptoms havealsobeenpointedout assignssuggestiveofahistory ofabuse.⁴⁴

None ofthe participantsinthis study reportedherhis- toryofviolencespontaneously,andsomereportedthatthis was the first time a health professional questioned them aboutit.Thisapproachhasalreadybeendiscussedbyother researchers,^10,44 who discussed the importance oftraining professionalsinthisquestandtheneedtocreateanefficient victims’assistancesystem.

Asforhealthservices,thediversityofinstrumentsfound, aimedattheguidanceofprofessionalsdealingwithvictimsof domesticviolence,indicatesthefragmentationofcare,which wasperceivedinthisstudyasanothertherapeuticgap.⁴⁵In contrast,oneofthefactorsresponsibleforthelimitedcompli- anceofPNRMAVguidelinesmaybeitsbroadscope,sinceeach ofits guidelinescould bedisaggregatedinto specificpublic policies.

Althoughthegenderwasnotacriterionintheselectionof participants,thesampleconsistedonlyofwomen;thisisone ofthelimitationsofthepresentstudy.Thejustificationfor thisoccurrenceisthefactthatHMIPVisareferencehospital forthecareofwomenandchildren,thesebeingthelargest groups attended in the service where this study was per- formed.Anotherlimitationofourstudyrelatestothecriteria adoptedforthediagnosisofFIC,since,althoughtheyconsti- tutetheclassificationwidelyusedinresearchonFunctional Intestinal Constipation, newrevisions are currently under- wayinRomecriteria.⁴⁶Moreover,observationalstudiesfail todemonstrateatemporalityrelationshipbetweencauseand effect;thus,biasesmayoccurduetouncontrolledvariables.⁴⁷ Inthissameline,non-systematicreviewsmayfailtoselect thebestevidenceoncertainsubjects,beingboundtothesub- jectivityoftheresearcher.²⁴

Despite these limitations, the data found in this study point to very important issues and can create new assis- tance paradigms, as well as encouraging the creation of programs and public policiesto assist victims ofdomestic violence.

Table3–Violencecarenetwork.

Component Assignment Services

Healthservices Toshelter;diagnose;notify;treattheacuteand chronicdamagesresultingfromviolence;refer toothercomponentsofthenetwork.

Healthcareproviders,Basicandfamilyhealth units,EmergencyCareUnits,EmergencyRooms, MobileEmergencyCareServices,Hospitals, PsychosocialCareCenters,FamilyHealthCare Centers,PreventionCentersforViolenceand HealthPromotion,Hospitals,Laboratories, AccidentandViolenceSurveillanceSystem Socialassistance Toshelter;refer;toaccompanythevictimsand

theirfamiliesinsituationsofviolenceandsocial vulnerability;refertoothercomponentsofthe network.

ReferenceCentersforSocialAssistance;

SpecializedReferenceCentersforSocial Assistance.

Publicsecurity Toshelter;registerinstancesofviolence;tocarry outexpertreports;refertoothercomponentsof thenetwork.

Generalandspecializedpolicestations, Medical-LegalInstitute

JusticeandHumanRights Toshelter;judge;punishperpetratorsaccording tolegalordinances;protectthevictims;referto othercomponentsofthenetwork.

Judges,PublicProsecutors,PublicDefenders, GuardianshipCouncils,Dial100,Dial180, Shelters,homes,halfwayhouses.

OrganizedCivilSociety Toshelter;denounce;representthepopulation;

protect;refertoothercomponentsofthe network.

Non-governmentalorganizations.

Source:Directresearch.Preparedbytheauthors.

Conclusion

Ourfindingssuggest thattheinvestigationofdomesticvio- lenceanditsconsequencesshouldbepartoftheroutineofall healthservices,especiallythoseonesdealingwithdigestive problems.Inaddition,thereisaneedtocreatemechanisms forintegrationamongthecomponentsoftheRededeAtenc¸ão àViolência(ViolenceCareNetwork),inordertoguaranteea comprehensiveassistancetoitsvictims.

Therearegapsrelatedtothetopicaddressedinthisstudy thatdeserveattentionsothatassistancepracticesandpub- licpoliciesensurethebestpossibleuseofexistingresources.

Amongthesegaps,wecanlistthemechanismsresponsiblefor thesicknessofvictimsofdomesticviolence,theprevalenceof domesticviolenceinwomenwithFIC,theroleofalcoholism intheoccurrenceofthesephenomena,andpossiblefactors ofprotectionandresilienceforthevictims.Finally,thereisa needforfurtherresearchinordertoobtainanswerstothese andothershortcomingsrelatedtodomesticviolence.

Anomissionisalsoakindofviolenceandthereforeneeds tobeeliminatedthroughresearch,professionaltraining,and thecreationofefficientsystemsofmultidisciplinaryintegra- tion.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

references

1. DrossmanDA.Sexualandphysicalabuseandgastrointestinal disordersinwomen:whatisthelink?EmergMed.1992:171–5.

2. LesermanJTT,DrossmanDA.Medicalconsequencesin womenofsexualandphysicalabuse.HumMed.1995:23–8.

3.LeroiA,BernierC,WatierA,HémondM,GoupilG,BlackR, etal.Prevalenceofsexualabuseamongpatientswith functionaldisordersofthelowergastrointestinaltract.IntJ ColorectDis.1995;10:200–6.

4.HobbisICA,TurpinG,ReadNW.Are-examinationofthe relationshipbetweenabuseexperienceandfunctionalbowel disorders.ScandJGastroenterol.2002;37:423–30.

5.PhilipsEM,PeetersB,TeeuwAH,LeendersAGE,BoluytN, Brilleslijper-KaterSN,etal.Stressfullifeeventsinchildren withfunctionaldefecationdisorders.JPediatrGastroenterol Nutr.2015;61:384.

6.BauerME.Estresse.CiênciaHoje.2002;30:20–5.

7.LesermanJ,DrossmanD.Relationshipofabusehistoryto functionalgastrointestinaldisordersandsymptoms–some possiblemediatingmechanisms.TraumaViolenceAbuse.

2007;8:331–43.

8.CoelhoRPS.Copeptinacomomarcadordeestresseem crianc¸asvítimasdemaus-tratos;2014.Availableat:

http://tede.pucrs.br/tdearquivos/20/TDE-2015-02-

09T130840Z-5494/Publico/465110.pdf[accessedin19.6.2017].

9.LimaMADdS,RückertTR,SantosJLGd,ColoméICdS,Acosta AM.Atendimentoaosusuáriosemsituac¸ãodeviolência:

concepc¸õesdosprofissionaisdeunidadesbásicasdesaúde.

RevGaúchaEnfermagem.2009;30:625–32.

10.NicolaiMPJ,FidderHH,BeckJJH,BekkerMD,PutterH, PelgerRCM,etal.SexualabusehistoryinGIillnesshow dogastroenterologistsdealwithit?JSexMed.2012;9:

1277–84.

11.VieiraEM,HasseM.Percepc¸õesdosprofissionaisdeumarede intersetorialsobreoatendimentoamulheresemsituac¸ãode violência.Interface.2017;21:52–62.

12.DayVP,TellesLEdB,ZorattoPH,AzambujaMRFd,Machado DA,SilveiraMB,etal.Violênciadomésticaesuasdiferentes manifestac¸ões.RevpsiquiatriadoRioGrandedoSul.2003;25 supl1:9.

13.KrugEG,DahlbergLL,MercyJA,ZwiAB,LozanoR.Relatório mundialsobreviolênciaesaúde:Organizac¸ãoMundialda Saúde-Genebra;2002.

14.HusseyJM,ChangJJ,KotchJB.Childmaltreatmentinthe UnitedStates:prevalence,riskfactors,andadolescenthealth consequences.Pediatrics.2006;118:933–42.

15.LongstrethGF,ThompsonWG,CheyWD,HoughtonLA, MearinF,SpillerRC.Functionalboweldisorders.

Gastroenterology.2006;130:1480–91.

16.SanchezMIP,BercikP.Epidemiologyandburdenofchronic constipation.CanJGastroenterol.2011;25:11B.

17.BharuchaAE,PembertonJH,LockeGR.American gastroenterologicalassociationtechnicalreviewon constipation.Gastroenterology.2013;144:218–38.

18.DevanarayanaNM,RajindrajithS.Associationbetween constipationandstressfullifeeventsinacohortofSriLankan childrenandadolescents.JTropPediatr.2010;56:144–8.

19.Brasil-MS-SecretariadeVigilânciaemSaúde.Fichade Notificac¸ão/Investigac¸ãoIndividual:ViolênciaDoméstica, sexuale/ououtrasviolênciasinterpessoais.Availableat:

http://bvsms.saude.gov.br/bvs/folder/fichanotificacao violenciadomestica.pdf[accessed24.4.17].

20.DrossmanDA,DumitrascuDL.RomeIII:newstandardfor functionalgastrointestinaldisorders.JGastrointestinalLiver Dis.2006;15:237.

21.RieglerG,EspositoI.Bristolscalestoolform.Astillvalidhelp inmedicalpracticeandclinicalresearch.TechColoproctol.

2001;5:163–4.

22.ColleteVL,AraujoCL,MadrugaSW.Prevalênciaefatores associadosàconstipac¸ãointestinal:umestudodebase populacionalemPelotas,RioGrandedoSulBrasil,2007.

CadernodeSaúdePública.2010;26:1391–402.

23.TREND.TRENDStatementChecklist.Availableat:

http://www.cdc.gov/trendstatement/[accessed11.6.16].

24.RotherET.RevisãosistemáticaXrevisãonarrativa.Acta PaulistadeEnfermagem.2007;20:V–VI.

25.OliveiraCSd,DelziovoCR,LacerdaJTd.Redesdeatenc¸ãoà violência–ares.unasus.gov.br;2014.Availableat:

https://ares.unasus.gov.br/acervo/handle/ARES/1882 [accessed15.7.17].

26.WeberMAL.Violênciadomésticaerededeprotec¸ão:

dificuldades,responsabilidadese

compromissos.tede.bibliotecadigital.puc-campinas;2005.

27.deSouzaMinayoMC,DeslandesSF.Análisedaimplantac¸ão darededeatenc¸ãoàsvítimasdeacidenteseviolências segundodiretrizesdaPolíticaNacionaldeReduc¸ãoda MorbimortalidadesobreViolênciaeSaúde.CiêncSaúde Coletiva.2009;14:1641–9.

28.GomesNP,BomfimANA,DinizNMF,SouzaSS,CoutoTM.

Percepc¸ãodosprofissionaisdarededeservic¸ossobreo enfrentamentodaviolênciacontraamulher.Revenferm UERJ.2012;20:173–8.

29.AlvesMdCL,DumaresqML,SilvaRV.Aslacunasno enfrentamentoàviolênciacontraamulher:análisedos bancosdedadosexistentesacercadaviolênciadomésticae familiar;2016.

30.MuraroHMS.Protocolodarededeprotec¸ãoàcrianc¸aeao adolescenteemsituac¸ãoderiscoparaaviolência.Org:Hedi MarthaSoederMuraro;2008.p.3.

31.ConselhoFederaldeMedicina.ManualdeAtendimentoàs Crianc¸aseAdolescentesVítimasdeViolência;2011.Available at:https://portal.cfm.org.br/images/stories/biblioteca/

manual%20atendimento%20crianca%20adolescente.pdf [accessed15.7.17].

32.WaksmanRD,HirschheimerMR.Manualdeatendimentoás crianc¸aseadolescentesvitimasdeviolência.Conselho

FederaldeMedicinaeSociedadedePediatriadeSãoPaulo Brasília;2011.

33.MinistériodasMulheres-DF.DiretrizesGeraiseProtocolosde Atendimento-Programamulher,ViversemViolência;2013.

34.deSouzaVieiraLJE,daSilvaACF,MoreiraGAR,CavalcantiLF, daSilvaRM.Protocolosnaatenc¸ãoàsaúdedemulheresem situac¸ãodeviolênciasexualsobaóticadeprofissionaisde saúde.CiêncSaúdeColetiva.2016;21:3957–65.

35.MPDFT.ManualdeProcessoseProcedimentosProtec¸ão IntegralàMulheremSituac¸ãodeViolênciaDoméstica;2016.

Availableat:

http://www.mpdft.mp.br/portal/pdf/nucleos/nucleogenero/

processostrabalho/manualprocessosprocedimentos protecaointegralmulhersituacaoviolenciadomestica MPDFT.pdf[accessed15.7.17].

36.ConselhoNacionaldeJustic¸a.Manualderotinase

estruturac¸ãodosJuizadosdeViolênciaeDomésticaeFamiliar contraamulher.Brasília:CNJ;2010.Availableat:

http://www.cnj.jus.br/images/programas/mutiroes-da- cidadania/manualmariadapenha.pdf[accessed15.7.17].

37.VilelaLF,CastroALC,MoriMP.Manualparaatendimentoàs vítimasdeviolêncianarededesaúdepúblicadoDF.

SecretariaEstadualdoDFBrasília;2009.

38.SecretariadoEstado-Paraná.ProtocoloparaoAtendimentoàs PessoasemSituac¸ãodeViolênciasexual;2015.Availableat:

http://bvsms.saude.gov.br/bvs/publicacoes/manual atendimentovitimasviolenciasaudepublicaDF.pdf [accessed15.7.17].

39.DF-Circunscric¸ãoJudiciáriadeSobradinho–Juizadode ViolênciaDomésticaeFamiliar.ManualdeBoasPráticas;

2016.Availableat:http://www.cnj.jus.br/files/conteudo/

arquivo/2016/09/3e7055e277daf8b375ca3146e196bda8.pdf [accessed15.7.17].

40.Brasil.MinistériodaSaúde:PolíticanacionaldeReduc¸ãoda MorbimortalidadeporAcidenteseViolência-PortariaMS/GM n.^◦737de16/5/01PublicadanoDOUn.^◦96Sec¸ão1E–de 18/5/01.

41.AnacletoAJ,NjaineK,LongoGZ,BoingAF,PeresKG.

Prevalênciaefatoresassociadosàviolênciaentreparceiros íntimos:umestudodebasepopulacionalemLages,Santa CatarinaBrasil,2007.CadernosdeSaúdePública.2009;

25:800.

42.MarinheiroALV,VieiraEM,SouzaL.Prevalênciadaviolência contraamulherusuáriadeservic¸odesaúde.RevSaúde Pública.2006;40:604–10.

43.ZaleskiM,PinskyI,LaranjeiraR,Ramisetty-MiklerS,Caetano R.Violênciaentreparceirosíntimoseconsumodeálcool.

RevistadeSaúdePública.2010;44:53–9.

44.DrossmanDA.AbusetraumaandGIillness:thereisalink&

quest?AmJGastroenterol.2011;106:14–25.

45.daSilvaEB,deMelloPadoinSM,ViannaLAC.Mulherem situac¸ãodeviolência:limitesdaassistência.CiênciaSaúde Coletiva.2015;20:249–58.

46.DrossmanDA,HaslerWL.RomeIV—functionalGIdisorders:

disordersofgut-braininteraction.Gastroenterology.

2016;150:1257–61.

47.FronteiraI.Estudosobservacionaisnaeradamedicina baseadanaevidência:breverevisãosobreasuarelevância, taxonomiaedesenhos.ActaMedPort.2013;26:161–70.