Introduction

Violence against women knows no boundaries and it is a human rights violation. According to Dr. Helene Gayle, President of CARE, an international humanitarian organization which fights poverty and provides training to marginalized women and youth, violence against women is one of the many causes of destitution, being both a human rights violation and an obstacle to the resolution of global challenges, such as HIV¹.

This violation causes much more pain than any visible traces of wounds or scars. In 11 years of operation, the women’s assistance office “Marque 180” (Dial 180) has provided assistance in nearly 5.4 million cases. In the first semester of 2016, the service recorded 555,634 consultations, at a monthly average of 92,605, equivalent to 3,052 per day. Nearly 68,000 cases, equivalent to 12.23% of the total number of cases, are reports of violence: 51% correspond to physical violence; 31.1% to psychological violence; 6.51% to moral violence; 1.93% to violence against property; 4.30% to sexual violence; 4.86% to violence in private prisons, and 0.24% to human trafficking².

In many other poor countries, this form of gender violence reaches epidemic proportions. Statistically speaking, one every three women is mistreated, coerced into sex, or otherwise abused in her lifetime³.

Domestic violence includes any language and actions which may cause suffering to one member of a family, as well as any behavior which forces someone to do something against their will, or prevents them from doing something they want to do. Moreover, most aggressions are perpetrated by individuals familiar to the victims⁴.

It is not easy to address cases of family violence, for they are not the result of disease or accidents. This kind of injuries are intentional and avoidable, especially in the case of people with disabilities, who become stigmatized and marginalized⁵.

According to Cavalcante et al.⁶, the increased risk for violence against people with disabilities is linked to a combination of social, cultural, and economic factors, and not only to the disability itself; it depends on the way in which it interacts with risk factors (social isolation, stigma, psychosocial stress, other issues) or protection factors (personal and social care, access to services, schooling, and benefits) or to vulnerability associated to their disability (inability to walk, see, hear, scream and ask for help, to tell right from wrong). The authors claim that people with mental, behavioral, or multiple disabilities are more exposed to different forms of violence, probably due to the difficulty in dealing with their particular situations and the care they receive from their caregivers.

We know that 65% of the injuries caused by violence affect the area of the head, the neck, the face, and the mouth, thus putting the dentist in a privileged position to detect them, and to therefore inform the relevant authorities of the cases of violence⁷. In this case, it is not the dentist's role to solve personal conflicts or to give advice to the victim, but to act in a way that will stop said violence. Dentists must be able to recognize signs of violence, discuss their concerns with the patient and, needless to say, guide the victims to the relevant services where they can seek assistance⁸. Giving therapeutic advice to victims of violence does not fall within the scope of the dentist's tasks, and it could have harmful rather than beneficial effects⁹.

On a final note, in this fight against violence, respect for Human Rights requires the promotion of life in society with no discrimination, based on social class, culture, religion, race, ethnicity or sexual orientation. To achieve equality of rights, it is necessary to respect differences. This idea contributes to the understanding that people with disabilities also have the right to live their sexuality, and to be respected¹⁰.

Because of their language and cognitive impairment, people with intellectual disabilities can be easily seduced: for the lower their language abilities, the less aware they will be of the reality of the world around them, and of the notion of right and wrong¹¹.

In their 2006 work, Cursino, Rodrigues, Maia and Palamin¹² state that people with hearing loss have noticeable speech problems, and they are powerless against sexual assault, for they are unable to communicate successfully either to defend themselves at the moment of the assault, or to report the assault to the authorities. They are thus easy victims to the aggressors, who anticipate that they will not be reported and they will go unpunished. Cavalcante et al.⁶⁾ have stressed that people with hearing loss are the preferred victims of human trafficking because it is guaranteed that they will not reveal any information.

Furthermore, the visually impaired find it difficult to communicate, for most people are not familiar with gestural language. As they are not able to visually recognize the aggressors, it is difficult to report the cases and it easier for attackers to go unpunished¹³. Women with disabilities are even more vulnerable, as they are more exposed to all forms of violence¹⁴.

In 2012, Souto, Leite, França and Cavalcanti¹⁵ expressed the need for the health professional to look out for and be prepared to meet the needs of women who are victims of violence.

In view of the above, this paper joins the fight of some authors in the defense of the integrity of women with disabilities who are victims of violence, regardless of their physical, sensory, or intellectual impairments, by presenting a clinical case featuring a patient who has Down syndrome and is the victim of domestic violence.

Materials and methods

This descriptive work focuses on a clinical case and adopts a qualitative approach, and aims to analyze the subjective questions related to the feelings experienced by a female patient with Down syndrome that was the victim of violence within her family.

The patient and her caregiver sought dental attention in March 2016, at the School of Dentistry of the Federal University of Rio Grande do Sul (Brazil), specifically in the area specializing in dental care for patients with special needs.

Data were collected based on a simplified version of the original document “WHO multi-country study on women's health and domestic violence against women” (2005), which gathers assessments on all the dimensions and forms of violence. The input used to write this paper were the study of the patient's clinical process, observation, assessment, and discussion with the caregiver/interviewee, prior scientific knowledge, descriptive method and bibliographical research ⁽¹⁸ (ANNEX A).

The interview with the patient's caregiver was held in a quiet room located in the first floor clinic of the UFRGS School of Dentistry.

The project was submitted to the Research Ethics Committee of the UFRGS School of Dentistry, and it was approved under No. 21988 on December 12, 2011; and to the Research Ethics Committee of the Porto Alegre Municipal Health Division, which approved it under No. CEP 638 on June 17, 2011 (ANNEX C).

The caregiver was informed of the aim of this study prior to the interview, and she signed a consent form authorizing the use of the answers and images for this paper (ANNEX B).

Results and discussion

E.M.C.P. is a 42-year-old female, single patient who did not complete primary school and lives in the city of Porto Alegre. She was referred to the area specializing in dental care for patients with special needs of the UFRGS School of Dentistry. During the anamnesis, which was conducted in the presence of her caregiver and guardian, a medical report was requested, as a requirement prior to starting the dental treatment of the patient. The report stated that she needed special care because she had Q90.1, Trisomy 21, Down syndrome (Fig. 1), and F31.2 bipolar affective disorder, current severe manic episode with psychotic features.

Down syndrome is caused by the presence of three 21 chromosomes in all or most of the cells of an individual. This happens at the time of conception. People who have Down syndrome or Trisomy 21 have 47 chromosomes in their cells instead of 46 like most people.

Her caregiver stated that she had scars all over her body from the frequent aggressions she suffered when she lived with her brother who used to abuse her (Figs. 2 and 3).

This physical and psychological abuse made it difficult for her to relate to people outside her family environment. She was therefore reluctant to treatment in the first few dental appointments (Fig. 4). Healthcare professionals must pay attention to this detail when treating this kind of patients. Article 7 of Law 11.340 dated August 7, 2006¹⁹, categorizes violence as: physical violence, understood as any behavior affecting the person's bodily integrity or health; psychological violence, understood as any behavior which emotionally harms and reduces the person's self-esteem, affecting and hindering their full development or which degrades or controls their actions, behaviors, beliefs, and decisions by means of threats, constraints, manipulation, isolation, constant surveillance, persistent persecution, insults, blackmailing, ridiculing, exploring, and limitation of their right to move around freely or by any other means which may harm their psychological health and self-determination.

The interview revealed that she had been abused on a daily or weekly basis by her 54-year-old brother, who was addicted to cocaine and alcohol and used drugs in the home with his wife. Research suggests that domestic violence episodes involving alcohol tend to be more serious and increase the risk of other kinds of violence^20-22. From the pharmacological perspective, alcohol causes disinhibition and it impairs judgment, thus facilitating or justifying certain more aggressive behaviors²³. The patient was the victim of abuse for a period spanning at least five years, where she developed the bipolar affective disorder, current manic episode with psychotic features. She was finally removed from her aggressor's care after a neighbor reported the situation to the authorities and became her guardian. The Maria da Penha Act was enforced on the basis that “the law was intended to protect women from domestic and family violence” and that it was not necessary for them to live under the same roof²⁴:

“For domestic violence to be typified as an offense, the parties do not necessarily have to be husband and wife, nor do they have to be or have been married. In the case of cohabitation, which is nothing but an intimate and emotional relationship, abuse is also considered domestic, whether the relationship is still going or it has finished. The active party may be the man or the woman, there must only be a domestic, family, or sentimental relationship; the law gives priority to the enforcement of mechanisms that contain and prevent domestic violence against women, regardless of the gender of the aggressor”.

E.M.C.P. came to the School of Dentistry with clinical symptoms of gingivitis. She had a Gingival Bleeding Index of 25%, and a Visible Plaque Index of 35%, the largest accumulation of supragingival plaque being in the lower anterior area. The literature explains this through the limited access of patients with special needs to oral healthcare, and also by their inability to identify the cause or to correctly assess their oral health. Prevention is a fundamental strategy, and it mainly involves giving guidance and education to patients and caregivers²⁵. The patient's gingivitis was treated with scaling, smoothing, and polishing with curettes. Furthermore, in each consultation the caregiver received instructions on how to enhance the patient’s oral hygiene, which allowed her to maintain the supragingival plaque under control.

The patient’s treatment consisted mainly in tartar removal and oral hygiene education between March and October 2016, there being no medical or dental events. The patient is currently in the control stage: she must visit the clinic every six months for maintenance purposes.

The case attracted the attention of the clinicians involved in the patient's treatment, not because of the clinical aspect but because of the family background of domestic violence from a brother towards his sister with disabilities. Many important issues arose in relation to patients who were victims of abuse, and it became clear that it was necessary to train clinicians to deal with patients with disabilities who were victims of domestic violence. According to Corrêa, one of the most interesting aspects of providing dental care to patients with disabilities is the relationship between the dental surgeon and the patient. Therefore anamnesis plays a very important role in the dental approach²⁶.

It is thus crucial that the healthcare professional know how to conduct the interview. It was the dentist who gained knowledge of the aggressions that the patient had been subject to for years. Dentists must watch out for hints of abuse in children, the elderly, or spouses, which may be presence of uncommon injuries, particularly those which are accompanied by trauma to the head or body. The following findings must be a red flag for dentists to consider the possibility of abuse: fractured teeth, lip laceration, laceration of the lingual or labial frenulum, missing or displaced teeth, fractures of the mandible and maxilla, wounds and scars. Nasal bone and zygomatic arch fractures, as well as periorbital trauma and injuries are the most frequent kind of wounds left by domestic violence episodes. There is more room for suspicion when the kind of injury clashes with the patient’s story about how or when it happened⁷.

When a dental surgeon comes across a case such as the one described above, they must take adequate action to be able to tell or give a statement regarding the state of the patient (evidence) to the authorities, if necessary. The evidence must include full and precise records of the event, including photographs and X-rays of the injuries. Unfortunately, the number of dentists who describe cases of abuse and violence is quite low. One of the main reasons is their lack of awareness of the abuse and their inability to recognize the signs and act upon them²⁷.

Healthcare professionals are required by law to report this kind of cases. Failure to do so could result in a penalty for disregarding these statutory requirements. The Dental Code of Ethics establishes that dentists should watch over their patients’ health and dignity. Therefore, patient protection becomes a fundamental aspect of their professional practice. There are measures to protect the victims from their aggressor, guaranteeing the physical and psychological protection of women with disabilities. These include distancing the aggressor from the victim’s home, and the prohibition to come near her. Victims can resort to shelters in undisclosed locations, where women and their children cannot be found by their aggressors²⁷. Depending on the crime that they have been victims to, women with disabilities may need a lawyer, in which case the state can appoint one to defend them.

Finally, working on a clinical case involving a person with disabilities who was the victim of domestic violence as a final term paper for the School of Dentistry has opened an institutional door to a new perspective: dentistry for patients with disabilities and victims of domestic violence. We expect that this information will be useful to the academic and professional world.

Conclusion

The main challenge is to warn and guarantee that people with disabilities and their families have access to the necessary care. Dental surgeons, as well as other healthcare professionals, must be able to recognize the signs of violence, discuss their concerns with the patient and show the victims how to get help. Dentists have a legal obligation to inform the authorities in order to break the cycle of domestic violence.