|Year : 2011 | Volume
| Issue : 1 | Page : 15-19
Child sexual abuse: A review of cases seen at General Hospital Suleja, Niger State
Isa Abdulkadir1, Lawal Waisu Umar1, Hafsatu Hassan Musa1, Shuaibu Musa1, Olusegun Abegunde Oyeniyi2, Oluwaseyi Mary Ayoola-Williams2, Ladi Okeniyi2
1 Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State, Nigeria
2 Department of Paediatrics, General Hospital, Suleja, Niger State, Nigeria
|Date of Web Publication||24-Aug-2011|
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background : Sexual abuse of children is a global health and human rights problem that has been largely underreported and understudied in sub-Saharan Africa. Little is therefore known regarding information on the nature of child sexual abuse and the predisposing factors in our communities.
Objective : To study the demographic features of individuals involved in sexual abuse and the pattern of presentation of cases at the General Hospital Suleja, Niger state.
Materials and Methods : The study is a retrospective analysis of case records of patients who presented to the Out Patient Department of General Hospital Suleja. All cases of sexual abuse seen over an 18 month period from 1 st January 2007 to 30 th June 2008 were reviewed. Data obtained were analysed in Epi-Info software version 3.04 and results presented as percentages, contingency tables, and charts.
Results : A total of 81 cases of sexual abuse were recorded over the period of review where children (77 cases) accounted for 95.1% of the cases. There were 41 cases of sexual abuse seen in 2007, while 40 cases were documented within the first half of 2008. All the victims of sexual abuse were girls and all the perpetrators were males of whom six adolescent boys constituted 7.6%. There was no documentation on evaluation and management of sexually transmitted infections, HIV infection, emergency contraception, or scheduled follow-up.
Conclusion : The incidence of reported child sexual abuse is on the increase in our communities. There is a need for studies on the predisposing factors to inform policy and preventive strategies as well as efforts to build the capacity of public health systems and care providers to manage cases reporting to our health care facilities.
Keywords: Child, sexual abuse, demographic features
|How to cite this article:|
Abdulkadir I, Umar LW, Musa HH, Musa S, Oyeniyi OA, Ayoola-Williams OM, Okeniyi L. Child sexual abuse: A review of cases seen at General Hospital Suleja, Niger State. Ann Nigerian Med 2011;5:15-9
|How to cite this URL:|
Abdulkadir I, Umar LW, Musa HH, Musa S, Oyeniyi OA, Ayoola-Williams OM, Okeniyi L. Child sexual abuse: A review of cases seen at General Hospital Suleja, Niger State. Ann Nigerian Med [serial online] 2011 [cited 2019 May 20];5:15-9. Available from: http://www.anmjournal.com/text.asp?2011/5/1/15/84223
| Introduction and Literature Review|| |
Sexual abuse has been defined as the involvement of a child in sexual activity that he or she does not fully comprehend and is unable to give informed consent to.  It includes acts, forceful or otherwise, of inappropriate sexual solicitation, genital touching or fondling, exposure of a child by an older person, intercourse through oral, anal or vaginal penetration and attempted intercourse.  Children may be sexually abused by both adults and other children (who are by virtue of their age or stage of development) in a position of responsibility, trust or power over the child victim. ,, The WHO estimated that about150 million girls experienced sexual violence with physical contact in 2002.  Most perpetrators of sexual abuse are males and are often known to their victims.  While it is generally acknowledged that sexual abuse is pervasive in all countries and at all levels of society, available statistics concerning the prevalence of sexual abuse in children around the world in general and in sub-Saharan Africa in particular are very limited. ,,
Terry and Tallon  in their review, showed that between 7% and 36% of girls, and between 3% and 29% of boys have suffered child sexual abuse, with sexual violence against girls being up to 1.5-3 times more frequent than in boys. In the US, as much as 50% of reported cases of sexual abuse occurred in children.  In South Eastern Nigeria,  a systematic survey of reported cases of child sexual abuse in three major towns including the capital city of Enugu indicated that 60% involved girls below the age of 12 years, with abuse including acts of genital exposure and stimulation, seduction, and witnessing adults performing the act of sex.  In the North Western Nigerian city of Kano, Tukur et al., in a retrospective study of victims of sexual abuse admitted to a teaching hospital, found a much lower incidence over a 3-year period, with a total of 16 cases, all but one of which were children below the age of 17 years.
There is a tendency for under-reporting of sexual abuse. The reasons for non-reporting are complex and multi-faceted.  These reasons may include a number of factors such as the age of the abused child at the time of the event, the relationship between the perpetrator and the abused, the gender of the abused, the severity of the abuse, developmental and cognitive variables related to the abused, and the likely consequences of the disclosure.  Girls are more likely to report sexual abuse than boys and more importantly when the perpetrator is a relative, there is less tendency to report abuse.  Others may choose not to report due to fear of negative consequence of the disclosure, which may range from more abuse and injury to fear of retribution or ridicule, stigmatization and a lack of confidence in investigators, police and health workers. , There is no stereotype perpetrator as sexual abuse offenders may come from all backgrounds  including the rich and poor, educated and uneducated, religious and non-religious and may be persons in positions of authority who are respected and trusted. Children have been reported as perpetrators of sexual abuse; in the US, Langan  in his review found that 40% of sex offenders were minors (less than 18 years), while in South Africa  adolescent boys aged 7-15 years were found to be perpetrators of gang rape. Although most victims of child sex abuse are females, a hospital based review in Kwazulu-Natal, South Africa  found 131 cases of sexually abused boys over a three year period suggesting sexual abuse of boys constitutes a sizeable and possibly underreported problem in the study communities. In North Central Nigeria,  however, a one year hospital based review in Minna found two cases of sexually abused boys accounting for 7% of the total cases of child sexual abuse reported within that period. Additionally social circumstances such as street hawking, attendance at day care institutions, and membership in certain social organisations have been found to be risk factors for child sexual abuse. ,
Generally sexually abused children are often physically traumatised with increased risk of HIV and other sexually transmitted infections (STIs), unwanted pregnancy, and psychological trauma. ,
There are scanty reports on child sexual abuse as seen in health facilities in our communities, particularly so with Suleja where no such previous study has been undertaken. The study was thus designed to evaluate the demographic features of individuals involved in sexual abuse and the pattern of presentation of cases at the General Hospital Suleja over an 18 month period.
| Materials and Methods|| |
The case notes of all patients who presented and were diagnosed and managed as cases of sexual abuse between 1 st January 2007 and 30 th June 2008 were manually retrieved from the Medical Record Unit of General Hospital Suleja, Niger State. The hospital is one of the highly patronized public health facilities located in the metropolitan area of Suleja, one of the major towns in the state with an estimated population of 216,578 in 2006.  Consent for conducting the study was obtained from the State Hospital Management Board to extract information from the case records including biodata of the victims and the perpetrators, relationship of the perpetrator to the victim, type of sexual abuse, screening for STI, HIV, pregnancy, and management offered. Data obtained were analyzed using Epi-Info software version 3.04 and results presented as means, percentages, tables, and figures.
| Results|| |
A total of 81 cases of sexual abuse were recorded over an 18 month period of review. There were 41 cases of sexual abuse reported over a one year period from January to December 2007, while 40 were reported during the first half of 2008 giving an average incidence of 3.4 and 6.7 cases per month for 2007 and the first half of 2008, respectively. Seventy seven (95.1%) of the 81 cases were children and all girls while the remaining four (4.9%) cases were female adults over the age of 28 years [Table 1].
|Table 1: Age distribution of victims and perpetrators involved in sexual abuse seen at General Hospital Suleja between 1st January 2007 and 30th June 2008|
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Of the 77 sexually abused children, all but one (forced fellatio) were cases of penile vaginal penetration. The age range of the victims was between 3 and 18 years and the average age of victims was 9 years. The age group most affected was 3-5 years (35.1%), followed closely by adolescents aged between 11-15 years [Figure 1].
|Figure 1: Age distribution of child victims of sexual abuse seen at General Hospital Suleja|
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All the perpetrators were males, known to their victims, and resident within their victim's neighborhood. Out of a total of 79 perpetrators of child sexual abuse, six (7.6%) were adolescents aged between 12 and 16 years. One of the cases was that of gang rape of a 10-year-old girl by three adolescent boys aged 12, 13, and 15 years. The only case of forceful oral sexual abuse was perpetrated by a 16-year-old adolescent whose victim was a 9-year-old girl.
In 2007, cases of sexual abuse were reported all through the year except in January and April [Table 2], while July had the highest number of reported cases. In the first half of 2008, however, not less than three cases were reported monthly and up to a maximum of four cases presented on a particular day in April 2008.
|Table 2: Number of cases of sexual abuse reported between 1st Jan 2007 and 30th June 2008 in General Hospital Suleja|
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There was no documentation in the medical records of the circumstances when the individual incidents of abuse took place except for two of the victims who were reported to be street hawking at the time they were abused. Similarly, there was no documentation whether screening for HIV, sexually transmissible infection and pregnancy or contraception was offered to any of the victims. There was no existing protocol or guidelines for evaluation, management, and follow-up of sexual abuse victims in the hospital at the time of this study.
There appeared to be a rising trend in the incidence of reported cases of sexual abuse over the 18 months period studied as shown in Figure 2. It illustrates a sharp increase in cases reported between the 1 st and 2 nd halves of 2007 with 5 and 36 recorded cases, respectively, followed by a slower rise in the 1 st half of 2008 when 40 cases were recorded.
| Discussion|| |
Child sexual abuse accounted for a vast majority (95%) of reported cases of sexual abuse over the 18 months period reviewed. Although this is higher than the 50% reported by Langan and Wolf Harlow  in the USA, it conforms to the findings of Tukur et al., whose review of reported cases of sexual abuse in a public healthcare facility showed that 94% of the cases of sexual abuse occurred in children. The differences in study methodology and sociocultural background could have accounted for the contrast between our study and that of Langan and Wolf Harlow.  Both studies, however, suggest an unacceptable occurrence of child sexual abuse. Moreover this retrospective review of hospital data was only able to analyze cases that came to medical attention, while other contact forms without physical injury and the non-contact forms may have remained unreported. It is also possible that many other cases presented for care in private health facilities for reasons of confidentiality.
In the year 2007, a total of 38 cases of child sexual abuse were reported with an average of 3.4 cases per month and a maximum of 12 cases were reported in the month of July. This is much higher than the finding of Tukur et al., where 15 cases of child sexual abuse were recorded over a three year period with an average of 0.4 cases per month. The study of Tukur et al., was conducted in a tertiary healthcare facility which receives referrals from secondary facilities. It is therefore possible that most cases of child sexual abuse went to secondary facilities like ours so that the difference in healthcare facility level may have accounted for this observed difference. This appears more so when our finding is compared to that from another secondary health facility in Minna  where 29 cases of child sexual abuse were reported over a one year period with an average of 2.4 cases per month. It is also possible that the incidence from our study is truly higher than those from other quoted studies; however, substantiation of this will require further elaborate studies to evaluate the presence and extent of risk factors of child sexual abuse in these communities.
The number of cases reported almost doubled in the first half of 2008 with an average of 6.7 cases per month. The observed rise in reporting suggests a trend around the period, which appears more prominently when the monthly figures were summed up to half yearly totals as shown in [Figure 2]. Being a retrospective study, however, the reason for this observed rise remains speculative. It may have been due to an increasing wave of sexual assault resulting from possible inadequate measures to apprehend and appropriately punish perpetrators of child sexual abuse to the extent that it transformed from an act committed individually to that perpetrated in an organized fashion by gangs. This study has revealed one such instance of gang rape perpetrated by three adolescents. Around the same period, there was also an intense public educational campaign against child sexual abuse and rape within the community and in the media spearheaded by various arms of government, which may explain increasing awareness and vigilance in tracking and reporting of such cases.
|Figure 2: Trend in the incidence of reported cases of sexual abuse over an 18-month period from January 2007 to June 2008|
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It is also noteworthy that we did not find cases of sexual abuse involving boys as victims in contrast to findings of studies where both genders have been identified as victims. , It has been observed that disclosure rates of sexual abuse are generally quite low regardless of victim's gender; however, male victims are even less likely to disclose their experience following sexual abuse ,, and this could have accounted for our finding of only girls as victims of child sexual abuse. Our finding also conforms to other studies that documented a male predominance of perpetrators of sexual abuse. ,,,
The average age of victims in our study was 9 years and this compares well with findings of Tukur et al., who documented a mean age of victims of 9.4 years. Our finding of up to a third of the cases studied being under 5 years, however, contrasts with that in studies that found a predominance of victims in older age groups. ,, We could not explain why this age group were the most abused, but where such event in our cases was the first sexual abuse experience, it may suggest that victims are at risk of repeated episodes of subsequent abuse over a long period.
We found a smaller proportion of child perpetrators (7.6%) of sexual abuse in this study with the only case of group rape perpetrated by children, a proportion much lower than those documented by Langan  in the US and Woodmark  in South Africa. Further studies are needed to elucidate why children are becoming sexual offenders in our communities.
All the cases of sexual abuse in this study involved physical contact and these reported cases presumably represent only a fraction of the actual incidents of child sexual abuse as other forms of child sexual abuse were not documented. This could have been as a result of lack of awareness that child sexual abuse includes both non contact and other contact forms such as fondling. Unfortunately, the non contact form of child sexual abuse does not result in physical evidence and there are often no obvious signs that a child has been sexually abused, so that such abuse can be difficult to detect and thus likely to go unreported, with the attendant risk of subsequently resulting into contact forms of sexual abuse.
Peculiar circumstances of children such as street hawking, could make them vulnerable to being sexually abused as seen in the case of two girl victims on whom such information was available in our study. This number though certainly small, may point to the fact that street hawking may have exposed them to danger of sexual abuse as has been documented by Nzewi  who identified street hawking as an important etiological factor in sexual abuse of children in South Eastern Nigeria. Street hawking is widespread in Nigeria even amongst school-aged children, and parents see it as a means of augmenting family income.
There was no existing protocol or guidelines for evaluation, management and follow-up of sexual abuse victims in the hospital at the time of this study. Therefore, there was no consistency in the documentation of identities of persons who brought the child victims to medical attention and the overall management of the cases seen. There was also no documentation of screening for HIV or other sexually transmissible infections for any of the victims. The absence of clinical follow-up to determine and manage short and long term sequelae of sexual abuse leaves victims at risk of developing psychosocial problems such as post traumatic stress disorder, which may have long-term effect on their adulthood.
The study has revealed a high incidence of reported cases of child sexual abuse, which appears to be on the increase in Suleja in spite of a known tendency for under reporting characteristic of child sexual abuse. Mitigating the impact of child sexual abuse and its consequences requires efforts to identify predisposing factors at which preventive measures will be targeted. Additionally there is need to strengthen the capacity of public health systems and care providers to manage cases of sexual abuse reporting to our health care facilities. This will include developing a standard comprehensive protocol for the management of the sexually abused and focused training and re training of health care providers to improve their proficiency. Similarly policies should be geared towards raising public awareness on the risks of child street hawking and possibly to enact appropriate legislation against child street hawking. Because most children who engage in street hawking do so to augment family income, properly designed and implemented economic empowerment programs targeted at families may help mitigate against child street hawking.
The study has limitations of being a retrospective analysis of medical records, and therefore, could only reflect on what the prevailing practice was over the study period. Many questions will remain unanswered without a standard, uniformly applied protocol and data collection tool to capture relevant information on reported cases of child sexual abuse at presentation.
| Acknowledgment|| |
We wish to thank the Medical Director, the staff of the department of paediatrics, and medical record of General Hospital Suleja, Niger state for their assistance.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]