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REVIEW AND EPIDEMIOLOGICAL DESCRIPTION OF RAPE CASES AMONG FEMALE ADOLESCENTS SEEN AT SECONDARY HEALTHCARE FACILITY IN ABAK, SOUTH-SOUTH NIGERIA

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Sunday Bassey Udoh, FWACP, FMCFM, Victory Edet Iyanam,FWACP,
Olayinka Samuel Akinbami, FWACP

ABSTRACT

BACKGROUND: The rising incidence of rape pandemic among female adolescents is a worrisome phenomenon. This is made worse by the negative culture of underreporting of this devastating crime due to stigmatization of its victims resulting in under prosecution, especially in developing countries.

OBJECTIVE: We undertook a review and epidemiological description of rape survivors among adolescent girls seen at a secondary missionary health care facility in Abak, Akwa Ibom State, South-South Nigeria.

METHODS: This was a retrospective review and description of all rape survivors among female adolescents seen at Mercy Hospital, Abak, Akwa Ibom State between January 2016 and December 2017. The case records of all the adolescent females who presented at the facility during the period of the study were sorted out from the health information unit of the facility. Cases of rape among them were identified. Data from the rape survivors case notes including socio-demographic characteristics, location and nature of the attack, time interval between attack  and presentation, notification of police, profile of the perpetrators and treatment response offered to the victims were extracted,  collated and entered into a spread sheet for analysis.

RESULTS:
Out of 278 adolescent girls who presented at the facility during the period of the study due to one morbidity or the other, 15(5.40%) were cases of rape survivors. The mean age of the rape victims was 14.17 + 2.35 years. Results obtained show that most of the victims (66.67%) were younger adolescents (10-15years), 80% had formal education while 73.33% of them lived with their parents. Also 33.33%  of the attacks occurred in the perpetrators residence,  86.67% of the attacks were penetrative, 46.67% of the victims kept quiet, only 40.0% of the cases were reported to the police, 26.67% reported to hospital within 24 hours, 60% of the attacks were by acquaintance while 80% of the attacks were perpetrated by one assailant. Those who presented within stipulated time received appropriate  treatment interventions including PEP (46.67%). Only age had statistically significant association with rape (p=0.03).

CONCLUSION:
The prevalence of rape among adolescent girls in the study, especially younger adolescents, is high. This portends devastating consequences on the psychophysical health of adolescent girls in the society. It calls for concerted effort from stake holders in adolescent care to be more proactive in working to ensure that sexual  assault against adolescent girls is averted.

KEY WORDS: Rape, female adolescents, Abak, South-South Nigeria

INTRODUCTION
The adolescent transition stage of development, especially among females, is replete with lots of biopsychosocial challenges, one of such challenges is rape.1-3 Rape is sexual intercourse or other forms of sexual penetration of one person by another without the consent of the victim.4-7 It is a serious human right violation, a public health problem and one of the most under-reported and under-prosecuted violent crimes globally.4,8-11 As a violent crime and human right abuse, rape carries several negative consequences and complications on the affected victims including rape trauma syndrome, post traumatic stress disorder, major depression, suicidal attempt, substance abuse, eating disorder, delinquencies, re-victimization, sexually transmitted infections including HIV/AIDS, and unwanted pregnancies,3-4,12-14 which may cause long term negative impact on the victims productivity. Even with the complications associated with rape, studies all over the world show that the prevalence of rape especially among adolescent girls and under aged children is on the increase globally. For instance UNICEF documented that around 120 million girls under the age of 20 years world wide (1in 10) have experienced forced intercourse or other sexual acts.8,15 According to Human Right Watch, 2010, all over the world, there were 35 cases of rape for every one reported to the police.7 Regionally, studies have shown that rape prevalence especially among adolescent girls is as high as 15-40% in Subsaharan Africa,12 40% in South Africa,16-17 16% in Democratic  Republic of Congo,18 14% in Ethopia,19 11% in Uganda 20 and 29.6/100,000 in the United States.21 In Nigeria, according to UNICEF, 2015, one in four (1 in 4) girls had experienced sexual violence before the age of 18years.22 While incidence of rape among adolescent girls in Nigeria is put at 11-55%,12 Azikiwe, etal10 and Folayan etal,23 have found that 32.4% of school girls in Ebonyi State and 68.3% of sexually experienced intellectually disabled girls in Oyo State respectively, have been raped. However, facility based studies done in tertiary hospitals showed lower rates of 0.06% (Zaria),24 0.76(Lagos),25 0.84% (Sokoto),13 2.1% (Calabar)26 and 5.2% (Jos).11
Various type of rape have been identified including  date rape, gang rape, marital rape, incestual rape, child sexual abuse, prison rape, war rape and statutory rape.27-29  High risk victims include homeless/runaway adolescents, those in military camps, prostitutes, prisoners, victims of war, refugees, injection drug users, elderly, individuals who have experienced assault as children and people with mental or physical disabilities.27,29,30
Motive for rape is multi-factorial and is a subject of complex psychosocial and scientific debate. It includes anger, power, sadism, sexual gratification, evolutionary proclivity, blackmail of the victim, punishment of the victim and curiosity of the rapist.27,28 Other factors found to contribute to rape include non-challant attitude of the police and the judiciary, indecent dressing among victims, illicit drugs consumption including alcohol both by the victim and the rapist, frustration on the part of the rapist, susceptible physical environment and dysfunctional family background which results in parents not being together with their children.28,29,31
As a multifaceted societal malady, the  fight against rape requires a highly organized and concerted effort from all stakeholders including parents, teachers, religious organizations, mass media, non-governmental organizations, the government at various levels, the law enforcement  agents, the judiciary and the entire citizenry, playing one role or the other in stemming the tide of this dehumanizing crime.32-33
This was a hospital based study aimed at reviewing and epidemiologically describing cases of rape victims among adolescent females attending a secondary missionary health care facility, Mercy Hospital, Abak, Akwa Ibom State, South-South Nigeria.
The study was carried out at Mercy Hospital, Abak, Akwa Ibom State, South-South Nigeria. Mercy hospital was established by the Catholic Diocese of Ikot Ekpene. It is located at Hospital Road, Abak.  It is a secondary missionary health care facility that takes care of the health care needs of Abak Community and beyond. The facility is also the home of the prestigious Mercy Eye centre, reputed to be one of the best eye care facilities in the country. Mercy Hospital operates a 24-hour emergency services and outpatient clinics which run from 8am to 4pm from Monday to Friday and attends to health needs of adults and children.  There are also adults and children wards for admission. Patients in the facility are seen by medical officers and consultants. The facility has a general laboratory manned by qualified laboratory scientists, a well organized health information unit with standard health records library.

PATIENTS AND METHODS:
This was a retrospective descriptive study involving all adolescent girls (10-19 years) who presented at the facility between January 2016 and December 2017 for treatment of one illness or the other. Their case notes were carefully sorted out. Case notes of rape survivors among them were identified. Data from the rape victims’ case notes were extracted, collated using a proforma and entered into a spread sheet for analysis. The data obtained include socio-demographic characteristics of the victims, rape details (location of the rape, nature of rape, reaction  to rape, report to police and interval between rape and presentation to hospital), assailants’ profile (relationship to the victims, number of culprit involved and use/non-use of weapon) as well as treatment interventions offered to the victims. Diagnosis of rape was made by the medical personnel based on the medical history obtained from the patients/relations, clinical examination and laboratory investigations. The investigations done for the victims for those who presented within the stipulated time include HIV test, pregnancy test, urinalysis, microscopy, culture and sensitivity of high vaginal  swab, Hepatitis B and C tests, veneral disease research laboratory (VDRL) test while the treatment intervention, based on the time of presentation, included post exposure prophylaxes (PEP) for HIV, emergency contraceptives, prophylaxes against other sexually transmitted infections (STI’S),  counseling and follow up.

Data analysis: The data obtained were analysed using statistical package for social sciences (SPSS) version 22.0. The percentage of the independent and primary outcome variables were determined. Tables were used to show data distribution as appropriate. The level of statistical significance was set of P < 0.05.

Ethical Clearance:
Approval for the study was obtained from the management of Mercy Hospital, Abak and health research and ethical committee of Akwa Ibom State ministry of health.

Consent:
No consent was needed from the adolescent girls (victims) since it was retrospective study.

Results:
A total of 278 female adolescents (10-19 years) presented at the facility during the period of the study. Results obtained are shown on the tables below.

REVIEW_AND_EPIDEMIOLOGICAL_T1-3

REVIEW_AND_EPIDEMIOLOGICAL_T4-6

DISCUSSION
The prevalence of rape in this study is similar to the rate obtained by Duru, etal,11 in Jos, North Central Nigeria, which was also a facility based study. It is however higher than the rates obtained by Hassan, etal13 in Sokoto, north eastern Nigeria,  Akinlusi, etal25 in Lagos, South Western Nigeria and Ekabua, etal26 in Calabar, South South Nigeria, which also were  hospital based studies. These lower rates could be explained based on  the study population which were mostly gynaecology cases,  location of study (mostly teaching hospitals) and study methodology some of which were prospective studies. Several studies have shown that rape is one of the most under-reported violent crimes worldwide  due to stigmatization. This results in the reduction  in number of cases reported to hospitals, especially tertiary hospitals. This calls for renewed  and intense public enlightenment on the need to report cases of rape to relevant institution and on time. The prevalence in this study was however lower than the rates obtained from South Africa,16-17 Ethopia,19 Uganda,20 USA,21 Ibadan and Abakiliki (Nigeria)10,28 which were all community based studies. It was also shown in the study that most of the victims were younger adolescents (10-15years) and  there was statistically significant association between age of the victims and rape. This is similar to findings from South Africa,16 Lagos, Nigeria25 and Kebbi, North Eastern Nigeria35 It calls for closer monitoring of younger and under aged girls by care givers with the aim of preventing sexual assault of this category of females by male predators in the society.
On the location of rape, the study reveals that of all the locations of the attacks, most of the incidents took placed on the culprit’s residence. This is similar to findings by Ashimi, etal35 and Abbey, etal.36 It further emphasizes the need to train young girls on how to recognize susceptible rape proned environment and avoid such environment as much as possible. With regards to nature and reaction to the assaults, it was found from the study that majority of the victims had penetrative rape and kept quiet respectively. This is similar to findings from other studies.13,25,32 Again this re-emphasizes the need for early institutionalized empowerment and training of female adolescents on self-defensive strategy against attack of rape, as done in Kenya and United State, which have been found to result in significant de-escalation of rape incidence among female adolescents in those countries.37-38
Greater percentage of the victims did not  report to the police, as found in the study. While the finding is similar to findings from other studies,12,34,35,39 there is need for greater public awareness campaign on the need to report rape cases to the law enforcement agents for prosecution to serve as deterrence. However, among those who sought medical help after the attack, the study found that greater percentage of them presented in the hospital after 24 hours. This is however contrary to finding by Ijadem, etal40 in which greater percentage of the victims sought help in the hospital within 24 hours. This has serious clinical implication regarding emergency contraception, prophylaxis against HIV and other STI’s, treatment of injuries and evidence collection for prosecution, which must all be done within stipulated time frame, for favourable outcome.41-42
On the culprit profile, the study found that majority of the culprits were acquaintance/person known to the survivors (neighbours, teachers, family members, school mates and boyfriend). This trend in culprit profile is similar to most findings on rape studies all over the world. While rape as a dehumanizing crime generally carries grave consequences on the victim, the psychological trauma associated with rape by a known person is more devastating. This again calls for closer look at rape with the aim of making it a capital offence with more intense punitive measure against offenders as a means of deterrence. Moreover, incorporation of rape awareness and danger into the curriculum of Universal Basic Education (UBE) as earlier recommended by Eze,43 as part of health education, will result in the production of future generation of men and women who will not only be aware and detest the crime  of rape but will work towards sanitizing the society from this human  desecration.
Finally while the survivors were appropriately investigated and offered treatment interventions  as appropriate, none of them was referred for psychotherapy by clinical psychologist or psychiatrist. The role of psychotherapy as a means of resolving the psychological conflict arising from rape trauma, thereby enhancing normal functioning of rape survivors and subsequent integration into the society,44-46 cannot be over-emphasized.

CONCLUSION
The study has shown high rape prevalence among female adolescents seen in Mercy Hospital, Abak, South-South Nigeria and this compares with what obtains in other hospital based rape studies. It calls for concerted effort by stakeholders in adolescent care to be more proactive in  ensuring that rape of adolescent girls, with its attendant sequelae, is prevented. Also increased public awareness against rape and early instituionalized empowerment and training of adolescent girls in rape prevention and self-defensive strategies, are recommended.

ACKNOWLEDGMENT:
We acknowledge the management, the medical superintendent, medical officers, records staff and other staff of Mercy Hospital, Abak for the approval given for the study and their immeasurable support throughout the study.

CONFLICT OF INTEREST:
We hereby declare that we have no conflict of interest.

FUNDING:
We have received no external financial support for the study.

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