Relationship of Sexual Violence to Depression in Female Students of Faculty of Medicine, Pelita Harapan University

Background: Sexual violence can take many forms to anyone. The increase in the number of sexual violence against women in Indonesia is quite significant. These incidents are reported to occur frequently in women in young adulthood. These experiences can have long-term effects, one of which is depression. There are several studies that show an association between sexual violence and the incidence of depression. However, there has not been much quantitative research to look at the relationship on this matter in Indonesia, especially on female students. This study aims to understand the relationship between sexual violence and the incidence of depression in female students of the Faculty of Medicine, Universitas Pelita Harapan. Methods: This study use a cross-sectional study design. The data has been collected using questionnaires filled in by the respondents. This study involved 149 female students of the Faculty of Medicine, Pelita Harapan University. The results of the study were processed and statistically analyzed using SPSS 25. Result: Based on research data, there are 149 respondents from female students of the Faculty of Medicine, Universitas Pelita Harapan. with a mean age of 19.29 (SD = 1.086). The youngest age of the respondent is 17 years old and the oldest is 24 years old. A total of 55 respondents had experienced sexual violence. Based on the results of the Beck's Depression Inventory (BDI) questionnaire, 16% had mild depression, 9% had moderate depression, and 2% had severe depression. Chi-square test showed a significant relationship between experiences of sexual violence and the incidence of depression, with p <0.001. Conclusions: Sexual violence is related to the incidence of depression in female students of the Faculty of Medicine, Pelita Harapan University.


Introduction
Sexual violence without realizing it becomes a thing that is often found in people's lives, which can occur in various forms. This event can happen to anyone, regardless of age or gender. However, more forms of sexual violence against women are reported and are often in the spotlight. 1,2 Based on the Annual Records of the National Commission on Violence Against Women, it was found that the incidence of violence against women has increased almost eight times over a period of 12 years. These data are the result of reported cases, so it is said that this incident is still an iceberg phenomenon. 3 Sexual violence is theoretically said to be a major stressor to the mental and physical health of the victims. 4,5 Psychological problems that are often found as a result of sexual violence include depression, anxiety, and anger. 6 In addition to mental health, these experiences can also have an impact on the physical and reproductive condition of the victim. 7 Besides that, sexual violence ranks as the second type of violence in the personal realm, where most of the victims are in the early adult age group. 3 The female students belong to the early adult age group, and these data indicate that there are quite a number of incidents of sexual violence in the age group belonging to female students, so that female students can be said to be one of the risk factors. 8 This study aims to examine the relationship between sexual violence and depression in female students of Faculty of Medicine, Pelita Harapan University.

Material And Methods
This analytical study had been conducted in female students of faculty of medicine Pelita Harapan University between January 2021 and March 2021. Informed consent had been conducted from all of the students.
Inclusion criteria is students of faculty of medicine Pelita Harapan University who are willing to fill out research questionnaires. Exclusion criteria is students of faculty of medicine Pelita Harapan University who are nor willing to fill out research questionnaires, have a history of mental disorders, have a metabolic or chronic disease, have experience of other types of violence, and who are not filling out the questionnaire completely.
The research design applied in this study was a cross-sectional analytic study. Statistical analysis was performed by using SPSS 25 version and Microsoft Office Excel 2010 version. Statistical tests have been carried out using the chi-square method.

Result
There were 171 respondents who were successfully collected, with 22 respondents included in the exclusion criteria. Samples characteristics: batch 2018 (41%), batch 2019 (28%) batch 2020 (31%), never experienced sexual violence (63%), have experienced sexual violence at the age of <6 (4%), 6 -12 (3%), >12 -16 (15%), >16 (15%). Of the 15 types of sexual violence based on Komnas Perempuan, only seven types of sexual violence were experienced by respondents. The most common types of sexual violence experienced by respondents were sexual harassment (53 respondents), followed by sexual intimidation (six respondents), sexual control (four respondents), sexual exploitation (two respondents), inhumane punishment and sexual nuances (one respondent), and the practice of sexually nuanced traditions (one respondent). The description of the relationship between the experience of sexual violence and the incidence of depression in students of the Faculty of Medicine, Pelita Harapan University can be seen in Table 2. The description of the relationship between the experience of sexual violence and the four depression scales in students of the Faculty of Medicine, Universitas Pelita Harapan can be seen in Table 3. The description of the relationship between the experience of sexual violence and the two depression scales in students from the Faculty of Medicine, Universitas Pelita Harapan can be seen in Table 4. The description of the relationship between the amount of experiences of sexual violence with the incidence of depression in students of the Faculty of Medicine, Pelita Harapan University can be seen in Table 5. The description of the relationship between the age of experience of sexual violence and the incidence of depression in students of the Faculty of Medicine, Pelita Harapan University can be seen in Table 6.

Discussion
This study examines the relationship between sexual violence and the incidence of depression in students of the Faculty of Medicine, Pelita Harapan University which was carried out in the period January 2021 to March 2021. The grouping of respondents who experienced depression was obtained from three categories of depression grouped by researchers, namely mild depression, moderate depression, and depression. major depression. The results obtained from this study indicate that of the 149 respondents involved, as many as 55 people have experienced sexual violence, with the most common form of sexual violence experienced is sexual harassment. Among the 55 people, 45.5% of them were depressed while the other 54.5% were not depressed. A total of 94 people have never experienced sexual violence, and 17% of them are depressed, while 83% are not depressed. The results of the statistical test obtained a p value of < 0.001, which indicated that there was a significant relationship between the experience of sexual violence and the incidence of depression.
This study also saw that there was an increase in depressive symptoms in respondents who experienced sexual violence. The increase in these symptoms can be seen based on a depression scale which is grouped into normal, mild, moderate, and severe categories. To fulfill the requirements of the chi-square test, the authors grouped the categories into two, namely the normalmild and moderatesevere categories. Of the 55 respondents who had experienced sexual violence, 80% were classified as normal-mild depression, and 20% were classified as moderatesevere depression. Meanwhile, of the 94 respondents who had never experienced sexual violence, 93.6% were classified as normalmild depression, and 6.4% were classified as moderate severe depression. The results of the statistical test got a p-value of 0.024, which indicates a significant relationship between sexual violence and depression scale.
The results of this study are in accordance with research conducted by Tarzia which examined the relationship between sexual violence and poor mental health in women in Australia. The results of this study indicate that women who have experienced sexual violence tend to feel depressed compared to women who have not experienced sexual violence. 7 This is also in accordance with the theory which states that if there is an experience that is negative and unexpected, it will increase the occurrence of depression. 9,10 An unexpected experience will also trigger stress, which if it lasts a long time. it will affect a person to be vulnerable to depression. This is also stated in a study conducted by Houle who found that sexual violence was also stated as an unwanted approach that became a trigger for stress, and was associated with an increase in depressive symptoms. 4 Of the seven types of sexual violence experienced by respondents, as many as 20% of respondents who have experienced sexual violence claim to have experienced more than one type of sexual violence, while the other 80% only experienced one type of sexual violence. The results of the analysis test found that there was a significant relationship between the amount of experiences of sexual violence and the incidence of depression. However, this result can also be influenced by bias, namely the gap between the number of respondents who experienced one type of sexual violence and those who experienced more than one type of sexual violence. However, research conducted by Tarzia suggests that fewer experiences of sexual violence may be related to women's mental well-being at that time. Women who experience at least one type of sexual violence are also said to have a tendency to experience depression. 7 The results of research conducted by Houle also stated that someone who experienced sexual violence more often would have a higher incidence of depression than someone who had never experienced sexual violence. 4 The cause of the occurrence of depression can be caused by several things, one example is the presence of an experience in early life that is unwanted or negative. 4,9 This is not in accordance with the results of this study, where there was no significant relationship between the time of experience sexual violence with the incidence of depression, which is obtained p value of 0.897. However, this is in accordance with the results of research conducted by Tarzia. The study found a relationship between sexual violence in adulthood with the onset of depression, but the association disappeared after adjusting for childhood sexual abuse. 7 This could be due to the absence of an association between the experience of sexual violence in early life and the occurrence of depression in this sample, the absence of a strong enough effect of the experience of sexual violence to cause depression, or the presence of a group that had protective factors against depression. Vulnerability to depression can be caused by a person's ability to overcome a stressor, such as by having good coping mechanisms, reasons for living, and spirituality. 7,11 Conclusion Based on the results of the study, it can be concluded that there is a significant relationship between sexual violence and the incidence of depression in students of the Faculty of Medicine, Pelita Harapan University.

Recommendation
It is hoped that further research will be able to examine the experience of sexual violence more deeply, by looking for further factors that can affect mental health conditions as a result of the experience. Further research is also expected to find out whether there is sexual violence that occurs in the Faculty of Medicine, Pelita Harapan University. It is also hoped that female students who have experienced sexual violence can report and seek help in order to avoid the impact of mental health problems that can occur, such as depression.