[Special Report] Transforming Trauma

How Brazil’s Unified Health System (SUS) and other public services transformed a municipality once marked by sexual violence

One of the meanings attributed to the word stigma relates to the mark left by a wound or trauma. For the past five years, the residents of Castelo do Piauí — a city in northeastern Brazil, located 187 km from the state capital Teresina — have been trying to overcome a story that dominated national headlines and left its mark on each of its 20,000 inhabitants.

“My husband works with freight transportation and travels mainly around the Northeast. He thought about changing the truck’s license plate because whenever someone saw ‘Castelo do Piauí,’ they immediately started asking about the girls. Outsiders always wanted to know details about what happened. That story changed everyone in the city,” says Vera Lúcia Rodrigues, a nurse at the Manuel Furtado de Morais Primary Health Unit (UBS).

The girls were four teenagers who, on the afternoon of May 27, 2015, went to Morro do Garrote, a well-known local tourist spot. What they chose as a backdrop for photos to post on social media turned, within two hours, into a stage of horror. They were raped, thrown from a height of nearly ten meters, and stoned by four underage boys and one adult fugitive from the police. The oldest, a 17-year-old, died ten days later from her injuries.

The Castelo do Piauí case confirmed alarming trends regarding sexual violence against minors in Brazil. According to the Brazilian Yearbook of Public Security, on that same May 27, another 93 children and adolescents were raped nationwide. Historical data shows that this type of crime has increased: in 2018, 66,000 cases were reported — the highest number in ten years. Most victims are female, but the most revealing statistic is that 75% are between 0 and 19 years old. The report also shows that 6 in 10 minors who suffer abuse are assaulted by members of their own family.

The small city, once known in the state for its natural beauty and high levels of basic education, saw its reality transformed overnight. Something had to be done. “Trauma is not something that can be forgotten, but it can be reframed,” says psychologist Enilda da Silva Alves, coordinator of the Psychosocial Care Center (CAPS) in Castelo do Piauí. “The victims and their families were our main focus, but we also needed to support the townspeople. People got sick; they suffered from collective sadness. If we wanted this tragedy not to repeat, public authorities and the community had to face the pain together, learn from it, and change behaviors,” adds municipal health secretary Leila de Almeida Soares, in an interview with Conasems Magazine.

Working in a Network

In March 2016, nearly a year after the case gained national attention, managers from different sectors — health, education, social assistance, public safety — together with representatives from the Judiciary, the Public Prosecutor’s Office, and the Guardianship Council gathered to design joint, intersectoral actions against child and adolescent abuse in the municipality. Based on the principle that every public sector depends on one another to reduce these cases, the month of May was chosen to concentrate key actions, although activities continue throughout the year.

“We named the project ‘May 18’ because this is Brazil’s National Day to Combat Child Sexual Abuse and Exploitation. Beyond the central message, the aim is to gradually give our city a new identity. This is how we want to be known: as a population that faced a very common social problem head on,” explains community health agent Cleudiana Silva, one of the project’s authors.

In addition to improving access to services, whether at health centers after a case of abuse or in registering police reports, several community actions took place simultaneously, targeting different audiences. “We handed out flyers at bank lines and notary offices, gave mini-lectures in Primary Health Unit (UBS) waiting rooms, and organized meetings with bar and nightclub owners to raise awareness about pedophilia and child prostitution. Perhaps the most important initiative is visiting schools to talk with children and adolescents, guiding them and helping build a generation more aware of their rights and less tolerant of abuse,” adds Silva, who is also president of the local Association for the Protection of Children and Adolescents.

“The importance of May 18 is to break away from the notion that cases of sexual abuse and rape are the sole responsibility of the police. This is a public health problem, which is why the health sector must be involved; it is a cultural issue, requiring education to change behaviors; and it is a social disorder that must be addressed by both the judiciary and social assistance,” explains health secretary Leila de Almeida Soares.

Awarded in 2019 at the 16th Mostra Brasil, Aqui tem SUS during the 35º National Congress of Municipal Health Secretariats, the May 18 project not only strengthened the network of assistance and victim protection but also took its first steps toward transforming sexist attitudes in the region. “One of the main challenges was discussing sexual education in schools, given the many taboos. Only with knowledge of the human body and respect for all bodies can we begin raising awareness about sexual abuse. Information is empowerment, and more than that, it is respect,” says psychologist Enilda.

At the 27 schools of Castelo do Piauí, the partnership between health and education has shown remarkable results. Professionals from the Family Health Support Center (NASF) and Psychosocial Care Center (CAPS) trained teachers, coordinators, and principals to detect changes in students’ behavior. “It has happened more than once that a kindergarten teacher accompanied a child to the bathroom, noticed suspicious marks, and immediately informed the school management so that the Guardianship Council could be called. We cannot be afraid to face such situations, because many of these children are too young to report mistreatment or abuse and depend on our intervention,” explains municipal education secretary Idála Soares Moreira.

School initiatives also included lectures with NASF professionals, film clubs followed by debates on sexuality, and discussion circles with parents. “Another initiative that has given voice to many children and adolescents is the ‘Little Box of Secrets.’ We placed it in common areas at schools, and victims could report abuse by leaving a note or drawing, which was especially useful for children who were not yet literate,” adds Idála.

The Many Roles of SUS

Primary Health Units (UBS), Emergency Care Units (UPA), and hospitals have taken on a role that goes beyond their traditional services: becoming safe spaces for reporting mistreatment, violence, or sexual abuse. “In daily practice, it is common for women to come for a Pap smear or for mothers to schedule consultations for their children and, during the conversation with me or the doctor, reveal violence they suffered. Health units have become neutral places where aggressors don’t suspect they will be denounced,” says nurse Vera Lúcia.

Since 2011, reporting violence has been mandatory for all public and private health services in Brazil, according to the Ministry of Health. From 2014 onwards, sexual abuse cases became subject to immediate notification, requiring communication to the Municipal Health Secretariat within 24 hours of the victim’s care. Another requirement is to inform the Guardianship Council of any violation against children and adolescents, as mandated by the Child and Adolescent Statute (ECA).

According to the Ministry of Justice, fewer than 10% of sexual violence victims report crimes to the police. Investing in health professionals trained to detect the smallest details became the first step to transforming Castelo do Piauí. From community health agents, who know the housing and family conditions of residents, to clinical professionals, all took part in awareness sessions.

“Every SUS professional in our city understands the importance of their work in the lives of victims. Working as a network strengthens the services we provide and allows us to deliver better responses to residents,” explains health secretary Leila.

Stories That Repeat

“Of course, the natural reaction is to question and condemn those who commit abuse and violence, but one of my roles as a social worker is also to seek understanding from the other side. Most perpetrators come from violent homes, from mothers who are beaten by their husbands, among other realities,” says municipal social assistance secretary and pedagogue Maria das Graças da Silva. “Most of these people are not evil by choice, and our role is to also support their social reintegration,” she adds.

In the 2015 case, all the underage offenders lived in the city and were part of the community. “As a former teacher of some of the victims and perpetrators, this story hurt me deeply. I questioned myself as a professional because I never noticed such aggressive behavior in any of those boys. That’s why a networked effort involving professionals from multiple sectors is essential,” stresses education secretary Idála.

According to the Social Assistance Secretariat, the young offenders came from vulnerable families where violence, neglect, and poverty were constant. “Let me be clear: no one downplays the crimes they committed. But as public authorities, we must also support these individuals and assist their families. They were followed by psychologists from the Social Assistance Reference Center (CRAS), as determined by the judge during hearings,” explains Leila.

Rebirth

Two of the four victims of the 2015 collective rape spoke to Revista Conasems about how they moved forward after the assault. Bruna Souza* is now 21, finishing her Psychology degree in Teresina, and wants to return to Castelo do Piauí to serve the local population. Luciana Ribeiro*, now 20, still lives in the city and recently had her first child.

“In these past years, we’ve seen both the best and the worst of human beings. Many times we were questioned about the case and heard very sad comments, but at the same time we met amazing professionals who supported us from the start. That’s why I believe humanized care transforms the experience of being a victim of violence,” says Luciana.

Initially, both received care in Teresina, the state capital. Upon returning home, Luciana continued being supported by CAPS staff and received prenatal care. “I want to be an example for my daughter that I moved on, because it’s not fair to always be remembered for that story. I can only be grateful for the care I received from health and social assistance professionals. Their work transformed me and continues to change the lives of dozens of children and adolescents who suffer constant abuse here in Castelo,” she adds.

“I want to graduate and return to work here, to serve the people of my city. This means a lot to me because I was welcomed like a daughter by many nurses, doctors, and psychologists. When I moved to Teresina and said I was from Castelo do Piauí, people always asked if I knew ‘the girls from the rape case,’ and I never answered. I was one of those girls, but I am more than that. I want to be part of the health team here and show the strength of my work,” concludes Bruna.

The names marked with an asterisk (*) are fictional to protect the victims’ identities.

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This special report was written by me for a planned edition of Conasems Magazine. However, due to the COVID-19 pandemic, the reporting trips for other stories in the issue were suspended, and the publication was postponed for two years before ultimately being canceled. This piece, produced during fieldwork in Castelo do Piauí, remains unpublished.