*Corresponding Author:

Dr. Adewale Ashimi
Department of Obstetrics and Gynecology, P.M.B 1022 Birnin-Kudu, Jigawa State, Nigeria.
E-mail: adewaleashimi@yahoo.com

Abstract

Background: Various forms of sexual violence including: Coerced marriage or wife inheritance, female genital mutilation, forced exposure to pornography, rape by intimate partner or strangers, unwanted sexual advances, and sexual abuse occurs, especially in vulnerable groups. However, most of these cases are not reported. Aim: The aim was to review reported cases in the facility, determine the prevalence and pattern of presentation. Subjects and Methods: This was a prospective longitudinal study undertaken at the Gynecological Emergency Unit of a Tertiary Health Facility in a rural setting Northwest Nigeria. A study of survivors of alleged sexual violence who presented to the hospital from the September 1, 2011 to August 31, 2013. Results: During the study period, there were 24 cases of sexual violence (22 were alleged rape and 2 were others) of 973 gynecological consultations at the emergency unit, giving a prevalence of 3% (24/973) for sexual violence and 2.3% (22/973) for alleged rape. Majority 91.7% (22/24) of the cases were children < 16 years; 45.8% (11/24) had no formal education while 33.3% (8/24) hawked homemade drinks and snacks. The assailants were known in 83.3% (20/24) of the cases; of which 45.8% (11/24) were neighbors, 29.2% (7/24) were buyers of snacks and drinks while 8.3% (2/24) were family members. Conclusion: The prevalence of reported sexual violence in this facility was low with the majority of the survivors being children and nonstranger assailants’, mostly neighbors.

Keywords

Sexual abuse, Sexual assault, Sexual violence

Introduction

The term “sexual assault,” “sexual abuse,” and “sexual violence” are generally used synonymously and interchangeably; according to the World Health Organization, sexual violence is defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic or otherwise directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.”[1] It is a violation of basic human rights[2] and remains as a public health issue with the implication at all levels of the society. Sexual violence is a common phenomenon worldwide, and it is particularly precarious. In the developing world though it is often ignored and under reported. Nevertheless, majority of the cases often reported are attempted rape or rape in adults and children.[3-8] The prevalence of rape from facility-based studies vary from 2.1% in Osogbo[4] to 5.6% of all gynecological consultations in Jos[7] while it is responsible for 0.06% in Zaria[6] to 0.2% in Minna[9] of pediatric outpatient consultations in northern Nigeria. There are several reports on sexual violence in Nigeria but few are from the northern part of the country and those available are from urban-based centers; hence, we sought to document a review of reported cases in this rural health facility in order to identify the prevalence and the pattern of presentation. This will help to raise public awareness and assist in planning interventions to reduce its prevalence and associated consequences in the community.

Subjects and Methods

Study setting

The study was conducted at a tertiary health facility located in a rural community, northwest Nigeria. The hospital is a 250 bedded facility established in year 2000, and it serves the health care needs of people in the state and other neighboring northern states. Birnin Kudu is a town and a local government headquarters in the south of Jigawa state of Nigeria. According to the 2006 population census, it had a population of 333,757 inhabitants, and they are predominantly Muslims and Hausa/Fulani by ethnicity. Their major occupation is farming. The Obstetrics and Gynecology Department is one of the four clinical departments of the hospital and is run by two consultant Obstetrician/Gynecologists and six medical officers. The Gynecological emergency unit has six beds with a manual vacuum aspiration room attached to it.

Study design

This is a prospective longitudinal study of survivors of sexual violence. All cases of sexual violence that presented to the hospital from September 1, 2011 to August 31, 2013 were identified as they presented. All the patients that were seen were referred from the only police station in the town which is adjacent to the hospital for medical evaluation and care. They were all attended to at the Gynecological Emergency Unit of the hospital in the company of their parents or legal guardian and were subsequently followed-up at the Gynecological Clinic. A proforma was completed after the consultation at the emergency unit. The information obtained included sociodemographic characteristics of the survivors, the approximate time the incidence took place, where it took place, was the assailant known, under what circumstances was the assault and the physical findings at presentation which were all documented by the attending physician.

Results of investigations such as high vaginal swab, hepatitis, and human immunodeficiency virus (HIV) screening were obtained from the survivor during the follow-up visit.

Ethical consideration

The study proposal was approved by the Ethics and Research Committee of the hospital and consent to use the information collected, obtained from the parents or legal guardian of the survivors as appropriate. They were assured of confidentiality and that the information obtained would be anonymous.

\Data analysis

The data obtained were analyzed using Statistical Package for the Social Sciences version 17.0 (Chicago IL, USA). Qualitative variables were summarized using frequencies and percentages while mean and standard deviation were used to summarize quantitative variables. The ages of the survivors were grouped based on the degree of sexual development as used in a previous study.[7]

• Infantile (below 7 years)

• Prepuberty (7–11 years)

• Peri-puberty (12–16)

• Adolescent (over 16 years).

Results

The study lasted 2 years during which there were 24 cases of sexual violence; 91.7% (22/24) were alleged rape while 8.3% (2/24) were described as others. Of the 973 gynecological consultations at the emergency unit over the period, 3% (24/973) were due to sexual violence and 2.3% (22/973) were alleged rape. The other cases mentioned above were insertion of the assailants’ finger into the vagina of the survivors.

Of the survivors, 8.3% (2/24) were married while 91.7% (22/24) were single. They were all of Hausa ethnicity except one that was Igbo, and their ages ranged from 3 to 25 years with a mean of 8.8 (5.8). About ninety two percent (22/24) of the cases were children <16 years; 45.8% (11/24) had no formal education and were the ones in preschool age group while 33.3% (8/24) hawked nonalcoholic homemade drinks and snacks. This is shown in Table 1.

Table 1: Sociodemographic characteristics of survivors of alleged sexual violence (n=24)

Only 8.3% (2/24) of the cases occurred before 12 noon, 75.0% (18/24) of the cases occurred between 12 noon and 7 pm and 16.7% (4/24) occurred after 7 pm. 45.8% (11/24) of the cases took place at the assailants’ house while 16.7% (4/24) occurred in uncompleted building. This is shown in Table 2. The assailants were known in 83.3% (20/24) of the cases; of which 55% (11/20) were neighbors, 35% (7/20) were buyers of snacks and drinks while 10% (2/20) were family members (an uncle and a cousin).

Table 2: Venue of alleged sexual violence

The time interval between alleged sexual violence and presentation to the hospital varied from 2 h to 11 days with 41.7% (10/24) of the cases presenting after 48 h. This is shown in Table 3. The number of times sexual violence took place before it was reported varied from one to five times, in 25.0% (6/24) of the cases it had occurred at least twice while in 75.0% (18/24) of the cases it only happened once. In all the cases except one, only one assailant was involved. Only one case of gang rape involving four men was reported.

Table 3: Interval between alleged sexual violence and presentation at the hospital

The method used to overcome the survivors’ resistance involved a combination of verbal threat, physical force while some were lured with money by the assailants. In 83.3% (20/24) of cases, they were threatened verbally, 70.8% (17/24) were physically forced, 29.6% (7/24) of the survivors were lured with money while one of the survivors was threatened with a knife. Majority, 70.8% (17/24) were given money after the incidence.

Physical findings in the survivors included: No abnormality was noted in Majority, 70.8% (17/24) of the survivors, 20.8% (5/24) had copious whitish vaginal discharge while 8.4% (2/24) had perineal lacerations at presentation.

The 91.7% (22/24) survivors who were allegedly raped were requested to have their high vaginal swab sent for microscopy culture and sensitivity, hepatitis, and HIV screening (after they were counseled with their legal guardian). 45.5% (10/24) of the survivors were screened for HIV, and they were negative. Of the assailants, 37.5% (9/24) were screened for HIV and 33.3% (3/9) were positive. Three of the survivors had their high vaginal swab analyzed of which two had vagina candidiasis while the only survivor that was screened for hepatitis B was negative.

After the second visit to the hospital, none of the survivors turned up for subsequent follow-up appointment.

Discussion

Sexual violence is not uncommon in Nigeria, but few of these cases are reported; hence, the few available reports are a “tip of the iceberg.” The 3.0% prevalence of reported sexual violence noted in this study is low and mainly comprised of rape cases which accounted for 2.5% of the emergency gynecological consultations. These figures merely attest to the fact that this violation of basic human rights exists in this rural community, and many are unreported. It is interesting to note that majority (91.7%) of the survivors are children below 16 years with about a third involved in child labor. These children who are enrolled in school, hawk homemade snacks and drinks after school hours due to poverty at the risk of irregular attendance at school, high likelihood of being involved in crime and sexual abuse as noted above.[10] About four in ten cases were seen in the hospital after 48 h of the alleged violence and this may be related to the fact that these assailants were known to the survivors, although they had threatened them and some also gave money to keep the incident a secret. As such, the act took place more than once in 25% of the survivors. This may cause a delay in commencement of emergency contraception and anti-retroviral prophylaxis among those that are at risk. In almost half (45.8%) of the cases, the unpleasant incident took place in the assailants’ home and this may be related to the fact that majority of assailants were neighbors who were known; thus, it was easy to lure survivors by giving them money after being sent on an errand or leaving their change with them after buying snacks. A third of the screened assailants was HIV positive. This might have motivated the sexual abuse as some HIV-positive patients erroneously believe that having sexual intercourse with a child or virgin cures the disease.[11] This is also of grave consequences as they pose a risk of infecting the younger generation with the disease.

The 2.3% prevalence of rape among women and children noted in this study are similar to the 2.2% in Calabar[3] and the 2.1% from Osogbo[4] while it is lower than the 5.6% from Jos.[7] Majority (91.7%) of the survivors in this study were children and this is higher than the 73.7% from Osogbo[4] and the 63.8% from Jos[7] though children are still the majority of survivors in these studies. The assailants were known in 83.3% of the cases which is slightly higher than the 79.1% reported from Osogbo[4] and 77.4% in Jos[7] but much higher than the 31.8% from Calabar.[3] The most common venue for sexual violence was the assailants’ house accounting for 45.8%, while contrastingly in the study from Jos the commonest venue was the survivors’ house observed in 46.6% of the cases.[7] The most common time of presentation to the hospital after the alleged sexual violence was after 48 h, noted in 41.7% of cases and this is similar to the 41.3% who also reported after 48 h in the study from Jos[7] but departs from the findings of < 24 h noted in 39.8% of the survivors in the study from Osogbo.[4]

Though this study was longitudinal and prospective in design, the survivors were lost to follow-up, and it was not possible to establish the outcome and late complications associated with the assault. Furthermore, the small number of survivors studied may limit the extrapolation of the findings in this study. However, in spite of these limitations, useful information concerning sexual violence in this rural setting were generated.

All cadres of health care workers need be aware of the fact that many of the survivors involved in sexual violence may not comply with follow-up appointments which may be related to the emotional trauma or fear of stigmatization and nonappreciation of the need to do so, hence they and their legal guardian should be counseled on doing the requested investigations and complying with the follow-up appointments.

The high attrition rate of the survivors did not allow for further evaluation for complications of sexual violence among the survivors, hence we would recommend a prospective study of survivors of alleged sexual violence, looking out for complications that may be associated with it. This study should be community-based.

Conclusion

The prevalence of reported sexual violence in this facility was low with the majority of the survivors being children and nonstranger assailants, mostly neighbors.

References

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2. National Research Council. Preventing Violence against Women and Children: Workshop Summary. Washington DC: The National Academies Press; 2011.
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