Sexual assault reported at a law enforcement health facility in Makurdi, North-central Nigeria

Background: Sexual assault is a social problem of public health concern worldwide. It is a violation of the rights of victims irrespective of gender. Objective: This study was design to assess the incidence, profile of victims and clinical presentation by victims of reported cases of rape at the health facility. Methods: The study was a prospective assessment of rape cases seen at the Police clinic Makurdi, Nigeria over a period of 21 months. The data was collected with a proforma and analyzed using SPSS version 20. Chi Square was used as a test of statistics with P-value of 0.05 (95% CI) as statistical significance. Results: Within the study period, 178 gynecological cases were managed out of which 46 were rape cases given an incidence of 25.8%. Average age of victims was 14±0.9 years. The most affected age group is pre-teens (8-12years) 39.1% and teens (13-18years) 34.8%, majority therefore been pupils/students 84.4% of primary schools (50.0%) and secondary (34.8%) education. Majority of them staying in urban environment (82.6%) with both parents (50%). The commonest clinical presentation was abnormal vaginal discharge (23.9%), bleeding (21.7%) and genital tear (21.7%). In most cases the victim was assaulted by one assailant (91.3%), at his home (56.5%), in the afternoon (43.5%) and he was either a friend/acquaintance (39.1%) or stranger (34.8%). Only 39.1% of victims presented within 24 hours of the incident. Conclusion: Sexuality education by parents and school authorities as well as legislation against this crime and punishment of offenders will halt the rampant trend of this malady. *Correspondence to: Bernard Terkimbi Utoo, Senior Lecturer/Consultant Obstetrician and Gynecologist, Benue State University Teaching Hospital, Makurdi, Nigeria, Tel: +2348033725168, +2348179614268; E-mail: bernardutoo@yahoo.com; utoobt86@gmail.com Received: December 07, 2018; Accepted: December 20, 2018; Published: December 24, 2018 Introduction Sexual assault is a worldwide crime mostly committed against women. It is a form of sexual violence in which the sexual activity is unwanted, non-consensual and with application of physical force, threat or verbal intimidation of the victim [1-3]. In assault the force used is immediate, short duration or infrequent [1]. It is a brutal form of violation of the rights of women that has been condemned worldwide [4,5]. It has been under-reported majorly because of the intent of protecting victims; avoidance of stigmatization, lack of successful prosecution of offenders and the fact that our society is predominantly male dominated [2,5,6]. It is however unfortunate that its prevalence is on the increasing trend especially in societies with high rates of poverty, social and moral decadence, drug abuse, breakdown of family values and general violent unrest [6]. The prevalence of sexual assaults has been reported variously in different societies; 8.6% in USA, Democratic Republic of Congo 16%, Ethiopia 14.3%, and South Africa 24.9% [2]. In Nigeria rates of 0.06% in Zaria, 0.76% in Lagos, 2.1% in Calabar, 5.2% in Ife, 5.6% in Jos, 2.1% in Oshogbo and 0.2% in Mina have been reported [1,3]. Rates in community-based studies are obviously higher than the urban facility-based studies. A woman who is sexually assaulted faces a lot of social, medical and psychological problems in the immediate and long term. Problems such as genital tract traumas leading to bleeding, fistulas; abnormal vaginal discharges, sexually transmitted infections including HIV/AIDS, unwanted pregnancies leading to unsafe abortions and their sequellae as well as sexual disorders and mental illnesses just to mention a few [2,3,5]. Perpetrators of this crime are usually said to be family members, friends, acquaintances much more than strangers [4,6,7]. The assailant could be alone or more in number as in gang rape [8]. Some victims have been sexually assaulted more than once leaving a long-term scar on the life and reproductive career of those victims [6]. The laws in Nigeria against this crime have not been implemented fully against offenders thereby paving way for the perpetuation of the crime [3,7]. It is reported that only about 28% 0f sexual assaults have been reported to the law enforcement agents for arrest and subsequent prosecution of offenders. No study of this nature has been reported in the literatures from Benue state of Nigeria hence the need to conduct this research; the aim therefore is to determine the incidence, profile of victims and clinical presentation of sexually assaulted victims as seen at the police clinic in Makurdi. Utoo BT (2018) Sexual assault reported at a law enforcement health facility in Makurdi, North-central Nigeria Volume 2(6): 2-5 J Pregnancy Reprod , 2018 doi: 10.15761/JPR.1000157 Materials and methods Study Area: The study was conducted in Makurdi, the capital of Benue State in North Central Nigeria. The state is called the food basket of Nigeria due to its great agricultural potentials. The inhabitants are predominantly farmers, civil servants and petty traders. The major ethnic groups are; Tiv, Idoma and Igede. Study Population: This comprise of all victims who reported to the Clinic for sexual assault within the study period irrespective of age. Study Design: This was a longitudinal prospective study. Victims who were brought to the clinic by a police officer in company of relations for investigation and treatment were interviewed and the information recorded into a proforma designed for the study. The information documented included; social demographic characteristics of the victim, where and when the incidence occurred, profile of assailant, number of assailants involved, weapon used if any, relationship between assailant and victim, injuries sustained by victim, number of times victim has been assaulted, clinical presentation and time of presentation to the clinic. Study setting: This is a facility-based study conducted at the police Clinic in Makurdi. The clinic is located in the police headquarter in Makurdi metropolis. The clinic is a cottage health facility with 4 medical officers. The gyneacology department has 5 nurses and a senior registrar in Obstetrics and Gynaecology from the Federal Medical Centre Makurdi who visit regularly. There are 11 bed spaces for inpatient treatment, laboratory for basic tests and a pharmacy. Sample Size: The sample size was estimated using the Fisher’s formula below


Introduction
Sexual assault is a worldwide crime mostly committed against women. It is a form of sexual violence in which the sexual activity is unwanted, non-consensual and with application of physical force, threat or verbal intimidation of the victim [1][2][3]. In assault the force used is immediate, short duration or infrequent [1]. It is a brutal form of violation of the rights of women that has been condemned worldwide [4,5]. It has been under-reported majorly because of the intent of protecting victims; avoidance of stigmatization, lack of successful prosecution of offenders and the fact that our society is predominantly male dominated [2,5,6].
It is however unfortunate that its prevalence is on the increasing trend especially in societies with high rates of poverty, social and moral decadence, drug abuse, breakdown of family values and general violent unrest [6]. The prevalence of sexual assaults has been reported variously in different societies; 8.6% in USA, Democratic Republic of Congo 16%, Ethiopia 14.3%, and South Africa 24.9% [2]. In Nigeria rates of 0.06% in Zaria, 0.76% in Lagos, 2.1% in Calabar, 5.2% in Ife, 5.6% in Jos, 2.1% in Oshogbo and 0.2% in Mina have been reported [1,3].
Rates in community-based studies are obviously higher than the urban facility-based studies. A woman who is sexually assaulted faces a lot of social, medical and psychological problems in the immediate and long term. Problems such as genital tract traumas leading to bleeding, fistulas; abnormal vaginal discharges, sexually transmitted infections including HIV/AIDS, unwanted pregnancies leading to unsafe abortions and their sequellae as well as sexual disorders and mental illnesses just to mention a few [2,3,5]. Perpetrators of this crime are usually said to be family members, friends, acquaintances much more than strangers [4,6,7].
The assailant could be alone or more in number as in gang rape [8]. Some victims have been sexually assaulted more than once leaving a long-term scar on the life and reproductive career of those victims [6]. The laws in Nigeria against this crime have not been implemented fully against offenders thereby paving way for the perpetuation of the crime [3,7]. It is reported that only about 28% 0f sexual assaults have been reported to the law enforcement agents for arrest and subsequent prosecution of offenders. No study of this nature has been reported in the literatures from Benue state of Nigeria hence the need to conduct this research; the aim therefore is to determine the incidence, profile of victims and clinical presentation of sexually assaulted victims as seen at the police clinic in Makurdi.

Materials and methods
Study Area: The study was conducted in Makurdi, the capital of Benue State in North Central Nigeria. The state is called the food basket of Nigeria due to its great agricultural potentials. The inhabitants are predominantly farmers, civil servants and petty traders. The major ethnic groups are; Tiv, Idoma and Igede.

Study Population:
This comprise of all victims who reported to the Clinic for sexual assault within the study period irrespective of age.

Study Design:
This was a longitudinal prospective study. Victims who were brought to the clinic by a police officer in company of relations for investigation and treatment were interviewed and the information recorded into a proforma designed for the study. The information documented included; social demographic characteristics of the victim, where and when the incidence occurred, profile of assailant, number of assailants involved, weapon used if any, relationship between assailant and victim, injuries sustained by victim, number of times victim has been assaulted, clinical presentation and time of presentation to the clinic.
Study setting: This is a facility-based study conducted at the police Clinic in Makurdi. The clinic is located in the police headquarter in Makurdi metropolis. The clinic is a cottage health facility with 4 medical officers. The gyneacology department has 5 nurses and a senior registrar in Obstetrics and Gynaecology from the Federal Medical Centre Makurdi who visit regularly. There are 11 bed spaces for inpatient treatment, laboratory for basic tests and a pharmacy.
Sample Size: The sample size was estimated using the Fisher's formula below N= (1.96) 2 X0.021X0.979/ (0.05) 2 = 31.6. The sample size was however increased to 46 to give room for 10% attrition rate and to increase the statistical power (Tables 1 and 2).

Ethical consideration
This study was approved by the ethics and research committee of the Benue State University Teaching Hospital (BSUTH) Makurdi.

Results
Within the study period, 178 gynecological cases were managed out of which 46 were rape cases given an incidence of 25.8%. The mean age was 14±0.9 years. The most affected age group was pre-teens (8-12years) 39.1% and teens (13-18years)

Discussion
The study finds an incidence of 25.8%. This is overwhelmingly higher than any of the published rates in Nigeria. It is however similar to that of 24.9% reported in South Africa. We are however not surprised at the high incidence recorded at the facility because rape is a medico-legal issue. The study setting is police clinic where cases of sexual assaults reported to the law enforcement agents are attended to medically. South Africa that has similar reported rates has been recognized for generations as the "headquarter" of rape in the world. This is to illustrate how frequent this violent crime against women is committed in that country.
Although the crime of sexual assault against women has assumed a worldwide dimension the involvement of preteens and teenagers is extremely worrisome. This finding is similar to the reports of a good number of studies done in Nigeria [1,3,8,9]. Actually, rape among this group of the population is more likely to be reported to the law enforcement agent [1]. It is worthy to mention that this age bracket has not yet begun their reproductive carrier and the negative consequence of this abuse is bound to have not only an immediate but long-term impact on their lives.
The myth propagated in some parts of the world about the cure of STIs such as HIV by a male who have sex with a virgin girl few years ago did a lot of harm towards violation of the sexual rights of women [6]. The communal lifestyle in African nations which has dismantled sociocultural barriers among people in the communities is also contributory, coupled with the breakdown of cultural values thereby promoting immoral activities among the youths. Advancement in technology and increasing westernization of our societies has also played a negative role. Crimes against humanity of this nature could also have been prompted by anger as a result of frustration from joblessness, poverty, illiteracy and the general lawlessness in the society [6]. In some cases, the men wants to demonstrate their dominance over the female victim rather than sexual pleasure.
The abuse of these young girls of primary and secondary school age is a wakeup call to both parents and school authorities. Parents are admonished never to shy away from sexuality education any more. Gone are the days that parents hid sexuality education from their children with the fear that they will become wayward. Children must be empowered with the relevant information so as to build their capacity to overcome the traps set by people who want to take advantage of their ignorance to violate their sexual rights [10,11]. By the way if we do not educate our children in this regard, they will still learn but from wrong sources. Some studies have reported sexual harassment in schools by boys, teachers and other male workers towards young girls through verbal and physical contacts [10]. The school curriculum of these children who are at the formative years should take into consideration this aspect of societal complexity [11]. Girls of school age should also be taught on how to dress well and not provocatively in such a manner that attracts violators. A dress code in all the schools can help in this regard.
Another worrisome finding which has also been reported in other studies is the involvement of family members, acquaintances and friends as assailants [12]. Sometimes, close relations such as father, brother, cousin, nephew, friends to parents or victims themselves are implicated. The victims in most cases are unsuspecting because of the level of trust and confidence they have in the culprits. Sometimes prosecuting offenders could also be hampered by this close family ties. There has to be measures put in place at home, school, and other public places to protect the girl child from sexual assault [11]. The finding that most of these crimes were committed in the day time is in keeping with the usually reported social demographic profile of victims in this age group. They are usually very young, pupil/college, single girls. Rape of Juvenile victims has been found to occur in the day time during school hours unlike that of adults that occur after midnight [1,5].
Genital tract injuries, vaginal bleeding and vaginal discharge were common clinical presentation findings amongst the victims [8]. This is an incident with not only physical but psychological trauma for the victims. Unfortunately, a good number report to the clinic late as was the case in this study in which only 39.1% reported within 24 hours of the incident. Most victims report late because of fear as a result of treats to their lives by assailants or their acquaintances. Victims also want to avoid stigmatization which may affect their self-esteem as well as the possibility of getting a good suitor. Some of these cases are not even reported because of the involvement of family relations [13][14][15].
The absence of legislation in some climes against rape as well as lack of successful prosecution and punishment for offenders makes under reporting common [13,14]. The different definition of rape amongst various cultures, and even the law needs to be looked into, for example some societies will not see forceful sexual exploitation of a young woman by her boyfriend as rape. Some children also do not acknowledge that sex with an elderly man was actually sexual abuse. Law enforcement agents may even make mockery of sexual violence involving intimate partners [15].
The finding of more cases of this violent crime amongst urban dwellers has brought to fore the need for a more intensive policing of our societies to curb these vices. If community policing as been suggested in some quarters and subscribed to by the top brass of the Nigerian police force could be implemented as well as equipping and catering for the warfare of the force to motivate them in fighting criminality, such crimes could be reduced to the barest minimum [16].
The absence of rape kit and other essential instruments for proper investigation and treatment of rape victims makes the care of victims suboptimal [14]. If clinics in towns and cities lack the necessary equipping for medical care of rape victims, then one can imagine the suffering faced by rape survivors in the community where more of these crimes take place. There is no uniform protocol in managing victims and follow up programs to handle post-traumatic stress disorders and even suicidal ideation that may arise after rape [17]. Taiwo MO et al enumerated several other psychological consequences of sexual harassment to include among the following; persistent sadness, negative outlook, irritability, mood swings, impulsivity, emotional flooding, anxiety, fears of loss of control, excessive guilt and shame, escape fantasies, compulsive thoughts, rage episodes, obsession fears, crying spells, persistent anger and fear, decreased self-esteem, self-doubt, diminished self-confidence, decreased concentration, feelings of humiliation, helplessness, vulnerability and alienation. Psychiatric disorders reported have included anxiety disorders, acute stress disorder, dissociation disorders, somatization disorders, sleep disorders, sexual dysfunction disorders, psychoactive substance abuse disorders, depressive disorders and adjustment disorders [18][19][20][21].
More workshops and trainings for health workers on rape are needed to increase awareness and build capacity of personnel in handling rape cases that present to the hospital. There should also be capacity to do forensic assessment of assailants so as to stop the network of rape offenders, which is catching up with and administering punitive measures on individuals who commit the crime in a locality and escape to another to commit similar crime.
Unfortunately the survivors did not only present late for treatment but were also lost to follow up which is again an indication that they may not want much publicity because of stigmatization and the fact that a good number of the assailants were acquaintances or people known to the victims. This is similar to the findings in similar other studies [19]. This however makes evaluation of victims to ascertain long term complications and further treatment difficult. More enlightenment campaigns are needed to encourage victims present early for treatment [22]. Also, campaigns against rape should seek to encourage victims to speak out irrespective of how the offender is related to the victim (Figures 1 and 2).
Civil societies, religious bodies, non-governmental organizations as well as civil right activists should roll out their drums against rape in order to augment the efforts of government in fighting rape.

Conclusion
The incidence of rape in the study is 25.8%. Most of the victims are pre-pubertal and teenage girls that presented with genital tract injuries, vaginal bleeding and discharge. Sexuality education, legislation and punishment of offenders will reduce the increasing trend of rape.