Warning: The following report contains descriptions of sexual violence.
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Not all hospitals and health centers have rape kits, essential for the correct collection of evidence in cases of sexual assault. There are women who may have to travel hundreds of kilometers to secure evidence against the person who raped them, and many health professionals are not prepared to deal with these cases.
A screen fixed on the wall indicated an average waiting time of no more than five minutes for the yellow wristband. Telma has it engraved in her memory that on that night there were about 29 people in the hospital emergency room. Three years have passed.
In early March 2020, a week before the mandatory lockdown because of COVID-19 was declared, Telma returned to the emergency room waiting room after having gone through triage, yellow wristband on her arm. Several operational assistants were circulating back and forth, in and out through two large doors that led to a long hallway. "I needed to get out of there," Telma recalls, after waiting two hours. She was at the hospital to report that she had been a rape victim four days earlier.
"The last thing a person who has gone through these experiences wants is to sit in a chaotic waiting room for hours, waiting to be called and examined. This goes against all the procedures for helping a victim," explains Ilda Afonso, executive director of the Union of Women Alternatives and Answers (UMAR), referring to the deficiencies of action and prevention in hospital settings in such cases.
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Telma was so anxious that she found herself walking through forbidden doors asking for an isolated place to wait. "Entering those corridors was an act of total desperation," she says. There, she was told she would have to wait in the room where she was. At that point, she found herself looking for the emergency exit door. She needed to be alone, to get away from that crowded space.
Telma was sexually abused by her gynecologist three years ago, when she was 30 years old. She had known the doctor for six years, since she had been a mother, and often went to the outpatient consultations at the health center in her village. During the cytology, commonly known as pap smear, he masturbated her, penetrating her successively with a speculum, which is used to keep the vaginal canal open during the examination. "I remember I was talking to him when I told him it hurt, asking him to stop, and he continued, forcefully, with in and out movements with a pleasurable air," she says.
It was not the first time Telma had had a pap smear. She knew every step of the way, because when she was young she had interned at the medical center of a hospital and volunteered at the village health center for cervical cancer screenings. "This is a common exam when you want to detect, for example, lesions on the cervix," she explains.
After the "exam," Telma continued to feel pain. "I knew something wasn't right, I was bleeding." She left the doctor's office, took a cab and went home. As soon as she could, late the next day, she went to the nearest health center, but was unable to be seen. "I tried to seek help [at the health center] the day after the abuse, but they had no professionals available and referred me to the nearest hospital."
After another three days, she then went to a hospital. She had marks and bruises around her crotch, small lacerations, from the force the doctor put on her each time he used the speculum. From the security guard to the front desk receptionist to the nurse she spoke with, no one knew how to respond to her plea for help. Nor did they know how to face her.
"Everything was even worse, because suddenly I felt a double discomfort, a double vulnerability. They treated me with pity, and at the same time they had a posture of distrust," says Telma, now 33.
Telma is one of 47 women survivors that Setenta e Quatro interviewed who were victims of sexual abuse between 2000 and 2023. This woman's name is fictitious not only because of fear of the abuser, given the closeness and familiarity, but also because of all the faults, pain, and shame she felt with the lack of "sensitivity and support in a place that ceased to be safe" for her.
There is a significant lack of knowledge by health professionals on how to deal with survivors of sexual abuse. A study by the Emancipation, Equality and Recovery (EIR) Care Center, coordinated by UMAR and to which Setenta e Quatro had access, reveals that only 38.9% of the professionals surveyed say they feel safe to respond to a request for help from a victim of sexual violence.
Sitting on the stairs by the emergency exit door, Telma was finally called and directed to a medical office. That location reminded her of the same office at the health center in the village where she lived, about 100 kilometers from the hospital she was in.
This hospital had rape kits, but there are local units and hospital centers that still do not have these kits, which are used to collect the traces of evidence of rape. The Central region is one of the most affected, as Teresa Maria Magalhães, a specialist and professor of Forensic Medicine, points out. As a rule, this collection should be done by a forensic doctor, called by the hospital. These procedures are not carried out in health centers, which means that victims sometimes have to travel hundreds of kilometers to get to the nearest hospital center.
The solution presented by some specialists, as is the case of Teresa Maria Magalhães, is to resort to Crisis Care Centers. But there are only two in Portugal: one in Lisbon and another in Oporto.
If in 2009, women rape victims were reported to be waiting up to 12 hours for a coroner's report at Santa Maria Hospital in Lisbon, the scenario is not much different these days. This is the opinion of Luís Mós, SINDEPOR union leader and Obstetrics nurse at the former Amadora-Sintra Hospital: "It is important to recognize that progress has been made, but not enough: this still happens today, which shows that hospitals are still not prepared to receive victims of sexual violence.
Whenever specialist experts are not available, these women survivors run the risk of not securing the evidence to substantiate the criminal complaint. "When forensic specialists are not doing the collections, [who know how to do them], according to the standards, they may not be as well done. And, sometimes, a badly done collection, a badly preserved or badly sent sample may have no value in terms of evidence," explains Teresa Maria Magalhães.
This professor at the Department of Public Health Sciences, Forensics, and Medical Education at the Faculty of Medicine of the University of Porto stresses that every year she repeats to her fifth-year medical students the importance of improvising to collect traces in an emergency room. "If there are no kits, doctors have to come up with material and packaging to consign [the traces]. They can't refuse to see the victim, and that still fails a little bit," she says. "Whereas if it's an expert from the Forensic Medicine Institute, he has all the material with him at all times."
Telma had washed up. It is common for sexual abuse victims to wash themselves: they feel dirty. This leads to the presence of the abuser's fluids in the victim's body being dramatically reduced. The examination must be done within 72 hours.
Despite the fact that the Forensic Medicine Act allows the doctor on duty in the emergency room to receive the person and collect the evidence in certain situations, most victims do not arrive within that "window of opportunity," says Teresa Maria Magalhães, that is, the time that the specialists consider adequate to collect the evidence safely.
What happens in most cases, explains this forensic specialist, is that these women think and ponder for a long time whether or not to go ahead, eventually giving up. "And when they go to a hospital service, they do so after urinating, after eating, after washing themselves, after doing their laundry, after throwing their clothes away," she considers. "After a series of things that have translated into, no less, destruction of traces."
Telma was unable to comply with the recommended period, at the health center they didn't examine her. Already at the hospital, in the next 30 minutes after entering the medical office, she felt violated again. "I had to get naked, covered by a white sheet, and let a nurse clean my entire body to collect any evidence that might contain the doctor's DNA," she recalls. One more person entered the room, the expert. "My intimate areas were investigated, scoured, rubbed, and intensely examined by a stranger," she recalls, at some cost. Telma eventually gave up filing charges against the gynecologist. "That whole environment, the way I felt, completely abandoned … it was traumatizing."
Are hospitals ready to receive and care for victims of sexual violence?
Health institutions, whether public or private, have, since 2022, guidelines for dealing with situations of violence among adults, defined in the National Program for the Prevention of Violence in the Life Cycle, a guide prepared by the Directorate-General of Health to deal with cases of violence among health professionals, but which can be adapted to other types of occurrences.
But this guidance has not reached everyone: from the data collected in UMAR's study, 46.4% of health professionals say they are not aware of any protocol or consider that it was not useful for their intervention. But there's more: 73% of professionals responded that they didn't know of any specialized support services for victims of sexual violence.
Teresa Maria Magalhães does not cease to regret the fact that a large part of the health professionals do not know how to contact the experts. "The contacts of the forensic doctors are always there, they're the ones who don't know." Why? There are gaps in internal and external communication in hospital facilities and offices, health professionals say. The "benevolence" or "discrediting" of patients is "very common" particularly when a complaint or grievance is made by some clinical staff member. Sometimes it doesn't come out of middle management. "It depends on how the complaint is made and what type of complaint it is. And it depends on whether the person is liked or disliked on the service", explains Mário Macedo, a nurse and coordinator of the Epidemiological and Hospital Public Health Unit at Professor Doutor Fernando Fonseca Hospital, formerly Amadora-Sintra Hospital.
In cases of verbal harassment or insult, the probability of the case passing "through the raindrops," says the nurse, is even greater. "If it's a nurse or a doctor who said this or that, no one will call. They'll probably ask the nurse or doctor what happened, he'll give a very nice answer, and the case is over.
Luís Mós, union leader of SINDEPOR, warns about poor management and internal communication in hospitals since the early 1990s. "When I started practicing, in the Emergency Room of São Francisco Xavier [Lisbon Hospital Center], a nurse was accused of sexually abusing three female patients and nothing happened. It just stayed there." All his colleagues knew, but did nothing. "It stayed in the middle management, which has a lot of power, and it didn't even reach the hospital management."
The guidelines are clear and transversal: although regulations vary from institution to institution, all must follow the same criteria. The first step is to advise victims to make a formal complaint and report the case to the team leader, explains Mário Macedo. This is followed by "more bosses of the bosses," until it reaches the hospital's legal department and the board of directors.
Setenta e Quatro asked the Ministry of Health about these procedures and their obligations in all hospital and medical scenarios, but did not get any answer until the publication of this article.
We also questioned the Order of Physicians and the Order of Nurses to see if they had received any complaints from health professionals regarding these procedures. Both have not answered anything on this subject.
"Corporativism exists, it's a fact", recognizes Mário Macedo. "There is no profession that is immune to this type of corporatism, but some may be more so than others, they just need to have more power," argues this Pediatric nurse.
The doctors, nurses, and operational assistants that Setenta e Quatro interviewed do not deny the possibility of these cases happening inside the hospital or a doctor's office.
Although the Doctors' Union of the North has not identified cases of sexual abuse between doctors and patients, the same is not true among professionals. "Moral harassment also exists among professionals and an emergency room, for example, is a very propitious place for this, given the stress that is experienced," says Joana Bordalo Sá, president of this union. "A person in an emergency room can be the target of physical, verbal and, eventually, sexual aggression. But this goes in all directions, both from users to professionals, and vice versa, and among the professionals themselves," she recognizes.
The accusations that “do not pass through the raindrops”
Since 2020, there are several news about cases of rape and sexual coercion in medical-hospital contexts. In recent weeks, the news about a radiologist doctor with a private practice in Bragança has multiplied: he was presented to an examining judge accused of two rape crimes. The case will go forward for trial, since the judge considered that there are indications of a crime.
About a month ago, an orthopedic doctor from the Penafiel hospital was suspended from his duties, suspected of having raped two patients. The 60-year-old doctor was arrested by the Judiciary Police and brought before an examining magistrate, who let him go free, imposing as a measure of coercion the suspension of functions and the prohibition of contact with the victims.
In addition to these two cases, there is a third case of an orthopedic doctor, 68 years old, who in July 2021 was suspended from his duties at the Covilhã public hospital for allegedly committing a crime of rape and four crimes of sexual coercion. Two months after he was suspended, the doctor was acquitted of the two charges that went to court, one for rape and one for sexual coercion. Today practicing in the same hospital, the doctor is awaiting the verdict of the Castelo Branco Court of Appeal, since the victims have appealed the decision.
The cases in this news always involved more than one patient, in the context of exams, without any other professional present. In specialties such as Gynecology, the World Health Organization recommends the presence of two professionals when performing gynecological exams, a recommendation that Portuguese hospitals include in their rules and regulations. But in other specialties, the tendency has been to devalue.
In adult care, it is recommended that, in any more intimate or more guarded observation, a nurse of the same sex as the patient be asked to be present. "But this is a practice that, in any specialty other than Gynecology, is not written down," warns Mário Macedo.
Health professionals reveal that it is impossible to follow this rule to the letter, not only because of the lack of resources. That's why they say it's important to "follow safe appropriations to the letter", so that places like hospitalization, emergency rooms, and examination rooms are not conducive to this type of practice.
Safe endowments are based on a standard — published in 2019 in the Official Gazette — that requires a calculated management of nursing teams to ensure the quality and safety of health care delivery, requiring boards of directors to provide more resources for their services.
For Mário Macedo, safe assignments are a very important detail, but the question is different: are they being effectively fulfilled? "It depends on the strength that nursing and medical teams have from service to service," he assures. "Safe staffing is especially important in emergency rooms, both with nurses and doctors, in inpatient units, and in psychiatric wards, because this is the only way to guarantee enough people per shift, especially at night."
The difficulty in controlling these situations is increasing. Although the Health Regulatory Authority had registered 58 complaints and claims about violence, aggression and/or harassment by the end of May this year, since 2015 this number has increased exponentially. This year alone, the complaints filed are equivalent to 69% of those from the previous year.
Recalling these data is relevant because experts put them in perspective, with regard to what can be done to prevent, combat and protect patients from places prone to sexual abuse. But the doubt is widespread: "It's very difficult. Patients are in a closed environment, what they will want is to defend their own intimacy. We can't put cameras in. It's a question of security versus privacy. Unfortunately, this will always be a minefield", Luís Mós laments.
The hiring of operational assistants is another concern. The professional career of auxiliary health technician was extinguished in 2008 and this decision meant that there were no more specific criteria for hiring them. "This not only threatens any merit in the profession, but also opens the door for anyone to enter", says João Fael, representative of the Association of Health Assistants (APTA) and an operational assistant at Castelo Branco Hospital. Since May of this year, there has been a decree-law project underway in the Assembly of the Republic to create the career of auxiliary health technician, which will cover all operational assistants in the SNS.
After the abuse, Telma was never seen by a gynecologist again. She refuses to go to a hospital and to the health center in her village. Going back to these spaces is synonymous with reliving traumatic events, and in the last three years she has had several episodes of epileptic seizures and anxiety attacks, diagnosed after the abuse. "I can't control it. What makes me most upset is that my life was completely normal until that day."
Telma returned, however, to review the screen with the patient count from that emergency room waiting room. She had passed out, they took her to a hospital. "As soon as I woke up, I panicked," she says. She hid the catheter where her medication was being administered, because she didn't want anyone to touch it. She signed the disclaimer and asked for the bed rails to be lowered, "I ran out because I just felt like I had to get out of there."
On the way out, she still had time to notice that the number on the screen in the emergency room waiting room was exactly the same as when she had entered there on her own to report the sexual abuse she had been a victim of: 29 patients were waiting their turn.
With Cláudia Marques Santos, an investigation in collaboration with the Público newspaper, supported by the Pulitzer Center's Gender and Equality journalism grant.