IJG-08283; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx

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CLINICAL ARTICLE

Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria Robsam S. Ohayi a, Euzebus C. Ezugwu b,⁎, Chibuike O. Chigbu b, Susan U. Arinze-Onyia c, Chukwuemeka A. Iyoke b a b c

Department of Pathology, Enugu State University Teaching Hospital, Enugu, Enugu State, Nigeria Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Enugu State, Nigeria

a r t i c l e

i n f o

Article history: Received 13 October 2014 Received in revised form 19 January 2015 Accepted 26 March 2015 Keywords: Enugu Nigeria Rape Sexual abuse Sexual assault Sexual violence

a b s t r a c t Objective: To determine the prevalence and pattern of rape in Enugu, southeast Nigeria. Methods: A prospective descriptive study was conducted among female survivors of rape who presented at the emergency gynecologic and/or forensic unit of Enugu State University Teaching Hospital between February 2012 and July 2013. Data were collected via a pretested interviewer-administered questionnaire. Results: Among 1374 gynecologic emergencies, there were 121 (8.8%) rape cases. The mean age of the rape survivors was 13.1 ± 8.1 years. Ninety (74.4%) survivors were younger than 18 years. At least 72 hours had passed since the rape for 74 (61.2%) cases. The perpetrator was known to 74 (82.2%) patients younger than 18 years and 18 (58.1%) aged at least 18 years (P = 0.013). The location of the rape was the bush or an uncompleted building for 36 (29.8%) and the perpetrator’s residence for another 36 (29.8%). Four (3.3%) individuals became pregnant after the rape. Conclusion: A considerable proportion of patients with gynecologic emergencies had been raped. Individuals should be encouraged to report to the hospital quickly to prevent unwanted pregnancy and sexually transmitted infections. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction Violence is a global public health problem that affects individuals of both sexes. It presents in different forms and dimensions. Sexual violence, with its resultant emotional and psychological morbidity, is more common among female than among male individuals [1]. It can take the form of rape, sexual slavery, forced prostitution, forced pregnancy, and forced sterilization [2]. Rape of women is a global problem. It has been reported that 14.8% of women older than 17 years in the USA have been raped in their lifetime, with another 2.8% reporting attempted rape [3]. A study among female undergraduate students in Nnewi, southeast Nigeria [4], found that approximately 16.5% of the respondents were past survivors of rape. In Ethiopia, sexual assault, including rape, was found to account for 3% of all gynecologic outpatient visits [5]. In Jos, north-central Nigeria, rape constitutes 5.6% of all gynecologic emergencies [6]. On the basis of the resolution of the fourth International Conference on Women held in Beijing in 1995, it is the right of women to decide freely about their fertility and sexuality without coercion, discrimination, or violence [7]. Rape and other forms of sexual violence against ⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129, Enugu State, Nigeria. Tel.: + 234 8037020295. E-mail address: [email protected] (E.C. Ezugwu).

women are therefore an abuse of a woman’s sexual and reproductive rights, and an infringement of a woman’s reproductive autonomy [8]. Rape is socially and morally unacceptable in all cultures and civilizations, and is prohibited by laws protecting human rights even during armed conflicts [2]. Rape can lead to physical, emotional, and psychological trauma with both immediate and long-term consequences. It can result in physical injury, unwanted pregnancy, and sexually transmitted infections (including HIV transmission) [9]. In Nigeria, rape is a criminal offence. Section 357 of the country’s criminal code states that “Any person who has unlawful carnal knowledge of a woman or girl without her consent, or with her consent if the consent is obtained by force, or by means of threats or intimidation of any kind, or by fear of harm, or by means of false and fraudulent representation as to the nature of the act, or, in the case of a married woman, by personating her husband, is guilty of an offence which is called rape” [10]. If convicted, offenders are liable to life imprisonment with or without whipping, and attempted rape has a 14-year sentence of imprisonment with or without whipping [10]. Rape and other forms of sexual violence are usually under-reported because guilt, shame, fear of retaliation, and taboos prevent many survivors from coming forward [2]. Despite its occurrence, few studies in southeastern Nigeria have investigated this criminal act. Highlighting the prevalence and the pattern of presentation of this unacceptable form of violence against women in the region might assist policy makers, government agencies at all levels, and women’s advocacy

http://dx.doi.org/10.1016/j.ijgo.2015.02.017 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Ohayi RS, et al, Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.02.017

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R.S. Ohayi et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx

groups as they campaign for the protection of the sexual and reproductive rights of women in the region. Therefore, the aim of the present study was to determine the prevalence of rape and its pattern of presentation among females attending Enugu State University Teaching Hospital (ESUTH), a tertiary health institution in Enugu that offers care to the population of Enugu, Anambra, Ebonyi, and Abia in southeast Nigeria, and some parts of Benue State in north-central Nigeria.

Table 1 Age and educational status (n = 121). Characteristics

2. Materials and methods In the present prospective descriptive study, data were collected from female survivors of rape who presented at the emergency gynecologic and/or forensic unit of ESUTH between February 1, 2012, and July 31, 2013. Study approval was obtained from the ethics committee of ESUTH. All rape survivors who reported at the hospital were counseled, and informed consent was obtained from each participant. For participants younger than 18 years, the child’s assent was obtained in addition to informed consent from the parent or guardian. Data were collected via a structured pretested intervieweradministered questionnaire. Information including the age and educational status of the participants was collected. For the younger rape survivors, the parent or guardian provided the necessary information. On the basis of the definition of a child as anyone younger than 18 years [11], participants were classified into two groups: younger than 18 years and aged 18 years or older. The primary outcome measures of the study included the prevalence of rape, the form of intimidation used by the perpetrators, the relationship with the perpetrator, and the place of rape. Other outcomes assessed were the nature of the sexual violence, whether the perpetrator acted alone or in group, the type of sex (whether penetrative or nonpenetrative), time between rape and presentation at the clinic, and complications of the rape. For the purpose of the study, neighbor was defined as someone who lived very near to the survivor’s residence, whereas acquaintance was defined as a man whom the survivor had met before but did not know well. Multiple perpetrator rape was defined as rape by more than one perpetrator occurring within a single assault experience that might or might not be related to gang activity [12]. Penetrative sex was defined as rape in which the perpetrator achieved vaginal penetration. Study data were analyzed by using Epi Info version 17 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Frequency tables were generated for relevant variables. Statistical comparison was done by Pearson χ2 test or Fisher exact test as appropriate. P b 0.05 was considered statistically significant. 3. Results During the study period, there were 121 rape cases and 1374 gynecologic emergencies. Therefore, the prevalence of rape among all gynecologic emergencies was 8.8%. The mean age of the survivors was 13.1 ± 8.1 years; the median age was 12.5 years (range 2–47). Most of the rape survivors were younger than 18 years (Table 1). Among the individuals younger than 18 years, the mean age was 9.4 ± 4.5 years (range 2–17). Among the adults, the mean age was 24.0 ± 6.7 years (range 18–47). The sexual act was penetrative in 90 (74.4%) cases, although nonpenetrative sex was significantly more common among children (Table 2). None of the survivors reported that the perpetrator had used a condom. A condition of vulnerability was significantly more common among children than among adults (P b 0.001), whereas force or physical violence was more common among adults (P = 0.002) (Table 2). The perpetrator was known to the survivors in 92 (76.0%) cases. A significantly higher proportion of perpetrators were unknown among adult survivors than among children (P = 0.013) (Table 3). Whereas the crime was perpetrated mainly by neighbors among survivors

No. (%)

Age, y b18 ≥18 Educational status No formal education Nursery/preschool Primary education Secondary education Tertiary education

90 (74.4) 31 (25.6) 1 (0.8) 22 (18.2) 41 (33.9) 45 (37.2) 12 (9.9)

younger than 18 years, rapes among adults were perpetrated mainly by acquaintances and strangers (Table 3). The rapes occurred most often along a bush path or in an uncompleted building, at the perpetrator’s residence, or at the survivor’s residence (Table 4). Rape within the survivor’s residence was almost three times more common among children than among adults (P = 0.078) (Table 4). Multiple perpetrator rape was reported more often among the adult survivors than among those younger than 18 years (P = 0.004). More than half the survivors in both groups presented at the hospital more than 72 hours after the incident (Table 5). Late discovery by the parent or guardian was the most common reason for delayed reporting by those younger than 18 years, whereas reluctance owing fear of stigmatization was the most common reason among adults (data not shown). Other reasons for late reporting included fear of perpetrator, peaceful settlement, lack of money for hospital pill, ignorance, and the fact that the rape occurred on a weekend or public holiday. A hymenal tear was the most common type of genital injury (Table 5). More children than adults had a genital injury, although the difference was not significant (P = 0.361). Four (3.3%) of the survivors became pregnant after the rape.

4. Discussion The present study has shown that approximately 9% of all gynecologic emergencies at ESUTH are due to rape. Most of the rape survivors were younger than 18 years. Non-penetrative rape was more common among the younger individuals. Most perpetrators were known to the girl or woman. Additionally, a high proportion of the rapes occurred in bushes or uncompleted buildings. Late presentation was common. The proportion of gynecologic emergencies caused by rape in the present study is higher than was previously reported in Jos, northcentral Nigeria [6], and Ile-Ife, southwest Nigeria [13] (5.6% for both). The high prevalence of rape recorded in Enugu is a cause of concern. Similar concerns about the rising incidence of rape in Nigeria have been raised previously [14]. Table 2 Characteristics of sexual violence.a Characteristics

Type of sexual act Penetrative Non-penetrative Form of intimidation used Force/physical violence Serious threat Condition of vulnerabilityb Drugging

Rape survivors aged b18 y (n = 90)

Rape survivors aged ≥18 y (n = 31)

P value

60 (66.7) 30 (33.3)

30 (96.8) 1 (3.2)

b0.001

25 (27.8) 23 (25.6) 42 (46.7) 0

18 (58.1) 9 (29.0) 2 (6.5) 2 (6.5)

0.002 0.705 b0.001 0.064

a

Values are given as number (percentage) unless indicated otherwise. Condition of vulnerability indicates age b14 y among individuals younger than 18 years, or mental illness among those aged at least 18 years. b

Please cite this article as: Ohayi RS, et al, Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.02.017

R.S. Ohayi et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 3 Characteristics of the perpetrators.a

Table 5 Time of reporting and nature of injury.a

Characteristics

Rape survivors aged b18 y (n = 90)

Rape survivors aged ≥18 y (n = 31)

Known to the individual Type of perpetrator Neighbor Acquaintance Step relation Customer Home-help Parent’s friend Stranger Armed robber No of perpetrators One Multiple

74 (82.2)

18 (58.1)

0.013

52 (57.8) 5 (5.6) 8 (8.9) 5 (5.6) 3 (3.3) 1 (1.1) 16 (17.8) 0

0 10 (32.3) 1 (3.2) 6 (19.4) 0 1 (3.2) 8 (25.8) 5 (16.1)

b0.001 b0.001 0.44 0.031 0.569 N0.99 0.334 b0.001

85 (94.4) 5 (5.6)

23 (74.2) 8 (25.8)

0.004 0.004

a

P value

Values are given as number (percentage) unless indicated otherwise.

The finding that most survivors were children is similar to findings from high-income countries, where a higher prevalence among children and adolescents has been reported [15]. Young female individuals are vulnerable and can be coerced or forced into non-consensual sex. In 2002, WHO estimated that over 150 million girls younger than 18 years had experienced forced sexual intercourse or other forms of sexual violence involving physical contact [16]. Therefore, training on self-defense might help to reduce the incidence of sexual assault among young girls. Recently, Sinclair et al. [17] reported the effectiveness of such a self-defense training program in reducing the incidence of sexual assault among school girls in an urban slum. Another vulnerable group of women who should be protected are those with learning difficulties. Such women might not have the capacity to make an informed decision and consent to sex. These women might be at risk of sexual exploitation and should be protected. The finding that most perpetrators were known to the individuals is in line with reports from Nnewi and Jos in Nigeria, and Ethiopia [4–6], but contrasts with a study in Sao Paulo, Brazil [18], in which most perpetrators were unknown. In the present study, significantly more survivors younger than 18 years than adult survivors knew the perpetrators. In addition, most perpetrators of rape against young females were neighbors. This finding has implications particularly within the society of the study population, where communal lifestyle is the norm. Children and young adults are often left by their parents in the custody of neighbors, especially on market days or when going to their farm. Such sexual abuse of children could also go unnoticed by their parents or guardians if the child fails to report it. Even when they discover the rape, some parents might not report it because of stigma, fear, and lack of trust in the authorities [16]. Under-reporting of sexual abuse has been shown to be higher when the perpetrator of the crime is known to the female [15]. Notably, bushes or uncompleted buildings were the location for many of the rapes. In Nigeria, uncompleted buildings serve as a Table 4 Place where rape was performed.a Place where act of rape was performed

Rape survivors b18 y (n = 90)

Rape survivors ≥18 y (n = 31)

Total (n = 121)

P value

Bush or uncompleted building Perpetrator’s residence Survivor’s residence Hotel/guest house At school At shop Friend’s home Hospital

29 (32.2)

7 (22.6)

36 (29.8)

0.311

26 (28.9) 24 (26.7) 1 (1.1) 3 (3.3) 5 (5.6) 2 (2.2) 0

10 (32.3) 3 (9.7) 6 (19.4) 0 1 (3.2) 1 (3.2) 3 (9.7)

36 (29.8) 27 (22.3) 7 (5.8) 3 (2.5) 6 (5.0) 3 (2.5) 3 (2.5)

0.723 0.078 b0.001 N0.99 N0.99 N0.99 0.016

a

3

Values are given as number (percentage) unless indicated otherwise.

Factor

Time of reporting, h b72 ≥72 Genital injury Yes No Type of genital injury Hymenal tear Perineal tear Vaginal lacerations/bruises Type of non-genital injury Bruises Abrasion Echymoses Fracture None a

Rape survivors Rape survivors Total P value aged b18 y aged ≥18 y (n = 121) (n = 90) (n = 31) 34 (37.8) 56 (62.2)

13 (41.9) 18 (58.1)

47 (38.8) 74 (61.2)

0.85 0.85

65 (72.2) 25 (27.8)

19 (61.3) 12 (38.7)

84 (69.4) 37 (30.6)

0.361 0.361

59 (65.6) 4 (4.4) 2 (2.2)

14 (45.2) 2 (6.5) 3 (9.7)

73 (60.3) 6 (5.0) 5 (4.1)

13 (14.4) 5 (5.6) 1 (1.1) 0 (0) 71 (78.9)

6 (19.4) 2 (6.5) 3 (9.7) 1 (3.2) 19 (61.3)

19 (15.7) 7 (5.8) 4 (3.3) 1 (0.8) 90 (74.4)

Values are given as number (percentage) unless indicated otherwise.

hideout, and unaccompanied women passing by such buildings are easy targets. This finding might be useful for female rights and protection advocacy groups to pass on to the population during awareness outreach. Women should be advised to avoid lonely and isolated places where possible. There is also need for security agents to conduct regular checks around abandoned uncompleted buildings to help minimize the use of such places for crimes such as rape. Although most survivors in both groups were subjected to penetrative, mainly vaginal sex, non-penetrative rape was ten times higher among the younger survivors. This finding is in line with a recent report from Brazil [15], in which non-penetrative sexual crime occurred five times more frequently among adolescents than among adults. Worryingly, none of the rape survivors who had penetrative sex reported use of condom by the perpetrator, which could place the women at risk of sexually transmitted infections, including HIV infection, and unwanted pregnancy [16]. In approximately 10% of cases, the female was raped by more than one perpetrator. This percentage is higher than was previously reported in both Ethiopia (5%) [5] and Uganda (7%) [19]. Rape involving multiple perpetrators was four times more frequent in the adult group. The higher the number of perpetrators involved, the higher the risk of transmission of sexually transmitted infections. Survivors of sexual assault are particularly at risk for sexual and reproductive health problems, such as sexually transmitted infections including HIV and unwanted pregnancy [5]. Furthermore, in a country such as Nigeria with restrictive abortion laws, unwanted pregnancy might predispose survivors to unsafe abortion—one the leading causes of maternal death in Nigeria [20]. Although timely administration of emergency contraceptives can prevent unwanted pregnancy, most survivors in both groups presented at the hospital for the first time more than 72 hours after the abuse. Late presentation might pose a challenge to the use of an emergency oral contraceptive (e.g. Postinor 2), which is considered less invasive and more acceptable in the study setting than are other methods of emergency contraception. None of the women who presented late accepted other forms of emergency contraception despite the risk of pregnancy. The late presentation and the refusal to accept other forms of emergency contraceptive might account for the four females who eventually became pregnant. Survivors of sexual violence should be encouraged to report the incident as soon as it happens. Early reporting at the hospital creates an opportunity for the women to access medical care, including emergency contraception for the prevention of unwanted pregnancy and postexposure prophylaxis against HIV infection. The present study has some limitations. Because the study was set in a hospital-based referral center, the findings might not be generalizable to the general population.

Please cite this article as: Ohayi RS, et al, Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.02.017

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In conclusion, a considerable number of women who presented at the gynecologic emergency/forensic unit of ESUTH, southeast Nigeria, were survivors of rape that had been perpetrated mainly by individuals known to them. Rape survivors should be encouraged to report early at the hospital for prompt intervention to prevent unwanted pregnancy and possibly sexually transmitted infections. All efforts should be made by law enforcement agencies to identify and punish perpetrators of this crime to serve as a deterrent to others. Conflict of interest The authors have no conflicts of interest. References [1] World Health Organization. World report on violence and health: summary. http://www.who.int/violence_injury_prevention/violence/world_report/en/ summary_en.pdf. Published 2002. Accessed January 15, 2015. [2] ICRC. Advancement of women: ICRC statement to the United Nations. http://www.icrc. org/eng/resources/documents/statement/2013/united-nations-women-statement2013-10-16.htm; 2013. Published 16 October 2013. [3] Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. https://www.ncjrs.gov/pdffiles1/nij/183781.pdf. Published 2000. [4] Adogu PO, Adinma ED, Onyiaorah VI, Ubajaka CF. Perception, Prevalence and Predictors of Rape among Female Students in a Tertiary Institution. Int J Clin Med 2014; 5(14):819–28. [5] Amenu D, Hiko D. Sexual assault: pattern and related complications among cases managed in Jimma University Specialized Hospital. Ethiop J Health Sci 2014;24(1): 3–14. [6] Daru PH, Osagie EO, Pam IC, Mutihir JT, Silas OA, Ekwempu CC. Analysis of cases of rape as seen at the Jos University Teaching Hospital, Jos, North Central Nigeria. Niger J Clin Pract 2011;14(1):47–51.

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Please cite this article as: Ohayi RS, et al, Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.02.017

Prevalence and pattern of rape among girls and women attending Enugu State University Teaching Hospital, southeast Nigeria.

To determine the prevalence and pattern of rape in Enugu, southeast Nigeria...
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