|Year : 2019 | Volume
| Issue : 13 | Page : 10-17
Medicolegal analysis of sexual assault victims in Benin, Nigeria
Chukwuemeka Charles Nwafor1, Wilson Oberaifo Akhiwu2
1 Department of Pathology, University of Uyo, Uyo, Akwa Ibom State, Nigeria
2 Department of Pathology, Medico-Legal Unit, Police Clinic, Benin City, Edo State, Nigeria
|Date of Web Publication||19-Feb-2019|
Chukwuemeka Charles Nwafor
Department of Pathology, University of Uyo, Uyo, Akwa Ibom State
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study, done in a police clinic, was to understand sexual assault (SA) victim characteristics. Subjects and Methods: All SA cases seen at the Police Clinic, Benin City, Edo State, Nigeria, were retrospectively reviewed. Results: A total of 146 cases were seen involving 144 females and 2 males. Age group of 11–15 years was mostly affected (37%). The majority of SA victims (72.6%) had no sexual activity before the assault. In 95.9% of cases, no contraceptive was used. The perpetrators were known in 52.7% of cases, and most of them (20.5%) were cotenants. There was penovaginal penetration in 91.8% of situations, with verbal threats been the most common means of subjugation. About 76.9% of SA occurred during the daytime. The hymen in 56.2% of cases showed signs of fresh injury and, in 17.9% of cases, it was intact. Seminal acid phosphatase was seen in 29.6% of cases. Conclusion: SA victims should present very early so that adequate evidence will be collected. Modern diagnostic kits including DNA profiling are needed so that perpetrators can be convicted beyond doubt, while psychological care of victims should be included in medical care.
Keywords: Perpetrators, police clinic, sexual assault, victims
|How to cite this article:|
Nwafor CC, Akhiwu WO. Medicolegal analysis of sexual assault victims in Benin, Nigeria. N Niger J Clin Res 2019;8:10-7
| Introduction|| |
The World Health Organization defines sexual violence 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. A wide range of sexually violent acts can take place in different circumstances and settings. These include, for example, rape within marriage or dating relationships, rape by strangers, systematic rape during armed conflict, unwanted sexual advances or sexual harassment (including demanding sex in return for favors), sexual abuse of mentally or physically disabled people, sexual abuse of children, forced marriage or cohabitation (including the marriage of children), denial of the right to use contraception or to adopt other measures to protect against sexually transmitted diseases, forced abortion, violent acts against the sexual integrity of women (including female genital mutilation and obligatory inspections for virginity), and forced prostitution and trafficking of people for the purpose of sexual exploitation., A major component of sexually violent act is rape, which is defined as physically forced or otherwise coerced penetration, even if slight of the vulva or anus, using a penis, other body parts, or an object, or simply defined as sexual intercourse without valid consent., The attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is known as gang rape.
Sexual violence occurs throughout the world and can be directed against both men and women., The global incidence of rape varies between 0.2/100,000 people in Azerbaijan and 92.9/100,000 people in Botswana, with 6.3/100,000 people in Lithuania as the median. In Nicaragua, a population-based survey detected sexual abuse in 20% of men and 26% of women, with most of the perpetrators (66%) been family members of the females. In Pakistan, age group of 10–19 years accounted for 64% of sexual assault (SA) victims, with 57% of the perpetrators known, while 76% of the survivors presented after 72 h. In India, 10–15 years' age group is the most involved, with most of the perpetrators (64%) known and most survivors presented within 24 h of the assault. In South Africa, the prevalence of rape, from community-based reports, shows a figure of 2070/100,000/year. In Kenya, more than 80% of the victims were <30 years of age and majority (73.4%) did not know the perpetrator; however, 80% of them presented in health facility within 24 h of the assault. In Addis Ababa, most perpetrators were not known, and the average presenting time to a health facility was 15.6–18.4 days.
In Nigeria, rape is a criminal act, punishable under the criminal code act, with a punishment of life imprisonment with or without canning. All the previous studies in Nigeria are hospital based except one.,,,, Various studies reported a range of 0.76%–8.3%, while adolescent girls were most involved (range of 60%–91%) and more than 50% of the victims knew their perpetrators.,,,,
Most of these studies had different study designs and methodologies. Some were limited to females that presented in the gynecology units, whereas others were done in respect to children and adolescents that presented in pediatric clinic. Studies have shown that reports on sexual violence using hospital-based data are highly deficient, as they represent just a tip of the iceberg.
SA is a major example of “Locard's Principle of Exchange” which states that every contact leaves a trace; hence in SA, physical and biological evidence collection is very important. The decision to collect evidence is best made by the timing of the examination.
SA has a profound impact on mental health (depression, posttraumatic stress disorder, anxiety, sleep difficulties, somatic complaints, suicidal behaviors, feelings of betrayal, and panic disorder) and behavior of survivors (unprotected sexual intercourse, early consensual sexual initiation, multiple sexual partners, alcohol, and drugs).,, SA is also associated with an increased risk of a range of sexual and reproductive health problems (gynecological trauma, unintended pregnancy, unsafe abortion, sexual dysfunction, sexually transmitted diseases, and traumatic fistulae), with both immediate- and long-term consequences. It can also have fatal outcomes (deaths from suicide, pregnancy complications, unsafe abortions, AIDS, murders during rape or for honor, and infanticide of a child born of rape).,
This study was done in a police clinic, which is not the usual teaching hospital or tertiary health center where health-related studies are done. Although a study of this nature has been done previously, 13 years ago in the same center, we decided to do a new study to check for any significant changes, so as to increase the understanding of victim characteristics, treatment offered with a view to reducing the overall incidence, and to see ways for better identification of perpetrator.
| Subjects and Methods|| |
This is a review of all the SA cases seen and examined by the police pathologist (a senior police officer) and medical officers at the Police Clinic, Benin City, Edo State, Nigeria, from January 1, 2013, to December 31, 2013. Whenever there is a complaint of SA in any police station or post in Benin City, Nigeria, the attending/investigating police officer will refer the victim to the police clinic which is centrally located in the town and very close to the state police headquarters. On presentation to the clinic, which generally handles assault cases, the SA victims and their parents/guardians are usually requested to give a detailed history of the event, while the medical doctor performs the examination and treatment and serves as expert witness for the very few cases that go to court. The major sources of information were the SA registers and reports of the police clinic. The demographic features (age and sex); time of assault; number of episodes of assault; marital status; contraceptive device used (if any); educational status; occupation; venue of assault; interval between the incident and presentation to the hospital; results of screening for sexually transmitted infection, HIV, and pregnancy; seminal acid phosphatase (SAP) estimation; under which circumstances was the assault carried out; the physical findings at presentation; and relationship with perpetrator were analyzed statistically using Statistical Package for the Social Sciences software version 17 (Chicago, Illinois, USA), and P < 0.05 was accepted as statistically significant. Ethical clearance was given by the Ethics and Research Committee of Police Clinic.
| Results|| |
[Table 1] shows the sociodemographic characteristics of the SA victims. During the period of study, a total of 145 cases were seen involving 143 females and 2 males in a ratio of 71.5:1. The youngest victim was 1 year old, whereas the oldest was 56 years old, with a mean age of 13.7 ± 7.58 years. Age group 12–17 years was mostly affected (51%), followed by 6–11 years (21%) and ≤5 years (11.7%). Only eight victims were aged 25 years and above. Nearly 44.1% of the victims had secondary education, whereas 37.2% had primary education and 11.1% had no education. Most of the SA victims (41.8%) were pupils in either kindergarten or primary school, closely followed by secondary school students who accounted for 37.7%. Almost 11.6% of the victims were self-employed, whereas 2.7% of the victims were unemployed. Nearly 95.7% of the SA victims were single, whereas 4.1% of them were married. The majority of the SA victims (72.6%) had no sexual activity before the assault, whereas 26.7% were sexually active and 0.7% were postmenopausal (not sexually active). During the assault, contraceptive devices were rarely utilized. In 95.9% of situations, no contraceptive was used, while during a gang rape (by two males), one person in the group used a condom as was seen in 1.4% of situations. During a gang rape by four males, all except one used a condom in 0.7% of situations.
[Table 2] shows the pattern of SA and its perpetrators. Overall, 52.7% of the perpetrators were known by the victims and most of them (20.5%) were cotenants in the same house, whereas 19.7% of them were living in the neighborhood (area) very close to the victims' house. In the unknown group, which accounted for 47.2% of cases, most of them (32.2%) were total strangers with no form of history. Among the unknown group, 8.2% and 5.5% of the crimes were committed by cult boys and during armed robbery attacks, respectively. Around 80.9% of assaults were committed by just a boy (≤17 years) or a man (18 years and above), whereas 19.1% of SAs were committed by two or more boys/men. Boys (young males ≤17 years) were involved in 11.7% of situations, whereas males aged 18 years and above were involved in 88.3% of situations. Most of the perpetrators used their penis to penetrate in 91.8% of situations, whereas finger penetration was seen in 7.5% and a combination was seen in 0.7% of occasions. In 97.3% of the cases, there was penetration, whereas in 2.7% of the cases, it was an attempted rape, characterized by rubbing of phallus on the vulva. Various means of subjugation were used. Coercion was the most common method (62.8%). Verbal threats of beating up, killing, shooting (during armed robbery) and showing of “juju” accounted for 21.3% of cases. Abduction was used in 7.5% of situations, whereas in 2.1% of the situations, the SA victims were beaten up.
[Table 3] shows findings from forensic history taking and examination. In 58.2% of cases, the SA was once, whereas in 25.3% of victims, the perpetrator had penetrated 2–4 times. In 16.4% of the SA victims, the perpetrator had committed the act five or more times. Following a SA, most victims (42.3%) reported after 7 days, whereas 33.1% reported <24 h after the assault. Those that reported 2 days after assault and 3–7 days after accounted for 12.3% each. Nearly 76.9% of the assaults occurred during the daytime, whereas 23.1% of the assaults occurred at nighttime. The hymen in 56.2% of the cases showed signs of fresh injury, whereas in 24.8% of the cases, an old hymen scar was seen. In 17.9% of the cases, the hymen was intact.
[Table 4] shows the investigations and treatment of SA victims. Nearly 55.2% of the victims did retroviral screening and were all negative. Some victims declined retroviral screening and accounted for 35.9% of the cases. None of the victims returned after 3 months for a retroviral screening repeat. Based on the age and menstrual history, in ten victims, pregnancy test was indicated. Six victims were not pregnant, whereas three victims tested positive and one victim declined. Few of the victims (6.9%) were given postcoital contraception, whereas 89.7% of them were counseled for postexposure prophylaxis against HIV. SAP was detected but at very low levels in 70.4% of victims and markedly elevated in 29.6%.
| Discussion|| |
Usually in Nigeria, since SA is considered a criminal offence, when such a crime is committed or comes to the fore, the initial response by matured victims or parents/guardians of immature victims is to report to the nearest police station. On arrival at the police station, before further investigation/prosecution can occur, the SA victim is referred to the police clinic for proper examination for the confirmation of SA and treatment. Thus, all cases of SA in Benin, which are reported to the police, must be seen/reviewed at the police clinic. Cases of SA accounted for 23.4% of all 620 assault cases seen during the period of study. This is much higher than 8.3% reported 13 years ago in a study from the same facility which also lasted for the same period (1 year) as the current study, despite the much reduced number of total number of assaults in the index study. The reason for the large number is due to an increase in awareness. Many women groups and nongovernmental organizations have openly criticized and campaigned against all types of violence against women, with rape mainly topping the list. SA female victims and parents/guardians now can go to the law enforcement agencies and complain. Recent studies have shown that it is very vital for SA victims to talk about rape. Apart from increase in awareness, the high rate may be an indication of rising incidence in our environment. The reasons for the rising incidence locally are not clear; however, majority of the cases occurred in a particular area of the city. This finding will increase the knowledge of the security forces so as to beef up local security in that area. The index study rate is higher than the range of 0.76%–8.4% reported in other previous Nigerian studies.,,, The denominator used may have played a big role because the previous studies analyzed SA victims with respect to all gynecological emergencies that presented to the various hospitals. Studies in Pakistan reported a rate of 10.6%. Studies in India and Canada reported very high rates of 30% and 42%, respectively., The reasons for these high rates may be due to the holistic inclusion of all that encompass sexual violence against women, including things such as sexual advances and forced abortion, whereas this study and likewise other Nigerian studies are mainly in reference to vaginal penetration and very few cases of attempted rape (mainly rubbing of phallus on the vulva).
Age groups 11–15 and 16–20 years were affected most. This is similar to findings in Pakistan, India, Addis Ababa, Lagos, Ife, and a previous study from this center.,,,,, The most common age groups reported in two other studies from northern part of Nigeria are 1–6 and 6–10 years., This may be linked to the early age of marriage in northern part of Nigeria as against marriage in later ages in southern part of Nigeria where this study was done because, most times, married females are not sexually assaulted as compared to single females or, even when domestically sexually assaulted in our environment, married women rarely voice it out. However, McGregor et al. in Canada reported 20–29 years as the most common age group to be assaulted. The younger age of SA victims in our environment is due to the fact that adolescents lack choice and face severe physical, psychological, and social consequences if she refuses sexual advances from the perpetrators. Furthermore, the traditional norms condone sexual coercion of female if a man has spent a lot of money on a female. A major danger of experience of SA at an early age is that it reduces a woman's ability to see her sexuality as something over which she has control. As a result, it is less likely that an adolescent girl who has been forced into sex will use condoms or other forms of contraception, increasing the likelihood of her becoming pregnant. Adolescent girls are particularly susceptible to HIV infection through forced sex, and even through unforced sex, because their vaginal mucous membrane has not yet acquired the cellular density providing an effective barrier that develops in the later teenage years. Nearly 30.3% of the victims were <10 years old. Child victims are often preferred by a rapist for reasons such as they offer little resistance, they can be seduced easily, they can be threatened successfully and keep the event secret, and a “false belief” of curing venereal diseases. A common observation from this study is that many preschool and primary school-age girls were always sent on errands by the perpetrators, and these men most times asked the young females to keep the change (usually in the range of 5–10 American cents) at the end of such errands. These young females do not understand the implications of such gifts which usually have little monetary value. It is usually when the girl child is delivering the items she bought that she is invited or dragged into the perpetrator's room. Previous studies have shown that the perpetrators were usually known, with deceit and verbal threats been the major means of subjugation, and this study agrees with the finding.,,,,, The African system of utmost respect and fear of one's seniors and elders may have contributed. Of the known perpetrators, more than 80% of them in almost equal proportion were either cotenants or living in the same neighborhood, usually about 2–3 houses apart. Parents should teach their children the extent of errands to go for any one, and those children should not enter the rooms of single men cotenants even if the male is a teacher or a disciplined man. Children should not be left under the care of grandparents because at times their sense of judgment may be weak, and they will allow children under their care to go anywhere of their choice as was observed in this study. As 88.2% of the victims in the index study were either in primary or secondary schools, we advocate for dedicated teaching and sensitization of girl child both at home and in school.
Only 2.1% of the victims were >30 years of age, whereas a previous study in this center reported none. This may still be underreported because of many logical reasons including inadequate support systems, shame, fear or risk of being blamed, fear or risk of not being believed, and fear or risk of being mistreated and/or socially ostracized (such as fear of losing friends and social respect)., Some women still believe that the rape victim is not completely innocent. Such attitudes are deeply rooted in the society, which makes it very difficult for rape victims to speak about their experiences.
Gang rapping is a SA involving at least two or more perpetrators, and it is widely reported to occur in many parts of the world, though systematic information on the extent of the problem, however, is scant. About 19.3% of the perpetrators in the index study were involved in gang rapes. This rate is higher than 10% reported previously, 15% reported in India, and <28.2% and 30% observed in Ife and Pakistan, respectively.,,, These gang rapes were reported mainly in a certain area of the city, with high population density, broken down social amenities, and high level of poverty. National data on rape and SA in the United States reveal that about one out of ten SAs involves multiple perpetrators. Most of the gang rapes were done by cult of boys (members), and they used it to celebrate or mark the initiation of new members. The victims of cases usually give a history of waiting and watching the perpetrators' gang rape other females before it gets to their own turn of the SA. Another group of gang rapes was SA involving male friends (boyfriends) of the victims. These male friends deceived their adolescent girlfriends and arranged for their rapping. We suspect that this may be a modus operandi, whereby different members of a gang go out to deceive innocent adolescent females in the name of “friendships” and later arrange for the females to be gang raped. This pattern is similar to findings in South Africa but different from reports from the USA. During gang rapes, a common observation was that, while other members of the gang use condom for contraception, the boyfriends of the victim do not use. Gang rape is often viewed by the men involved, and sometimes by others too, as legitimate, in that it is seen to discourage or punish the perceived “immoral” behavior among women – such as wearing short skirts or frequenting bars. For this reason, it may not be equated by the perpetrators with the idea of a crime. Adolescent girls need to be cautioned about the kind of friends they make and the places they visit in the name of “seeking fun.” Efforts should be made to increase security and carrying out of targeted police patrolling in the localities identified with high incidence.
An important observation is the presence of boy perpetrators, and they accounted for 11.7% of cases. No previous study reported this. These boys were 12 years old and below, whereas some even had a past history of sexually molesting younger females that were cotenants. When interviewed, some said that they saw the act of “sex” on the television and felt like practicing it. These young males were usually caught during the SA act. Parents should be mindful of television channels/programs that their children watch. Although most films in Nigeria are age rated, it is common to see children watching most films without parental guidance, and it is not uncommon to see films with scenes not good for children to watch. Although both experimental and correlation studies found mixed results, critics still contend that pornography has a considerable effect on committing SA and rape. Exposure to pornography increases negative attitudes about females and sexuality and desensitizes viewers, thereby increasing the risk of committing SA or rape.
Almost all the perpetrators (96.6%) did not use a contraceptive device during the SA, which further complicates the woes of the victim because, in addition to the devastating emotional trauma, the victim stands a risk of sexually transmitted diseases, including HIV/AIDS and been pregnant.
Only 29% of SA victims presented within 24 h of the incident. This is higher than 4.9%, 18.9%. 19%, and 26.2% reported in Pakistan, Kenya, Minna, and Addis Ababa, respectively, but less than 35.5%, 43.5%, 58%, 58.4%, 76%, and over 90% reported in Lagos, Benin, India, Jigawa, Ife, and the USA, respectively.,,,,,,,, These high rates in some studies have been linked to increased awareness of the importance of early reporting. Studies have shown that, the longer the interval before presentation, the lower the quantity and quality of forensic evidences, and the higher the risk of negative health outcomes., This leads to limited evidence collection and only identification of hymenal injuries in many cases. The occurrence of SA more than once in the same victim was seen in 42.1% of the cases. This further complicates the chances of early perpetrator identification because SA victims will present late. Parents should be the best friends of their children so as to make their children confide in them, whatever they are doing or is happening to them at any time. They should take a close interest in things happening around them and monitor their children closely, especially those living in public houses (low-income houses where toilet, bathroom, and kitchen are shared). Majority of the SAs occurred in the daytime, which is similar to other Nigerian studies except the SA involving females aged greater than 20 years, which mainly occurred at night during armed robbery attacks.
During the examination of a virgin victim, the observation of a recent rupture is of maximum corroborative value, noting the site and degree of tears. In 56.6% of cases, recent hymen rupture was seen, which is higher than 6.5%, 7.5%, and 42.9% reported in India, Pakistan, and Addis Ababa, respectively. Penetration is sufficient to constitute the sexual intercourse necessary to the offense of rape; however, the depths of penetration, seminal emission, rupture of hymen etc., are not considered as important factors in justifying the offense of rape. Following perineal examination, 17.9% of SA victims had an intact hymen. Lakew reported that 24.1% of SA victims in Addis Ababa had an intact hymen, whereas in Pakistan, it accounted for 4.8%., In child victims, the actual penetration may not be accomplished due to the disproportion of the sex organs, but other injuries might have resulted due to the force used, for example, perineal tears, inflammation/abrasion/bruises of the vulva, contusions of the labia, inflammation of the urethra, and the hymen may be intact/torn/destroyed. Genital injuries were seen in 16.6% of cases. This is similar to 13.5% and 14.4% reported in India and Pakistan, respectively, but much less than 33% seen in Canada.,, Longer interval before reporting in developing countries may be the reason such that, when SA victims present, some of the mild but important injuries may have healed. An observation from the index study is that of 52.9% of cases in which the perpetrators were young males, the hymen was intact. This agrees to the fact that anatomical disproportion in the genitals of both the victim and perpetrator (in very young people) is important.
For proper identification of the perpetrator based on the Locard's Principle, collection of the following evidence is important: stains and foreign materials present on the clothing or body; fingernail scrapings; brushing/combing of the person's hairy region (head, body, and pubic); urethral, perianal, vulval swabs; vaginal content aspiration and swab and cervical swab and sample of blood.,, The presence of semen is indicative of the occurrence of sexual activity; however, its absence does not exclude the possibility of sexual activity. On confirmation of the presence of semen, attempts are made to individualize the semen by putting it in a genetic marker system and comparing it with reference samples obtained from suspected individuals. Based on the time interval after the SA that the victims presented, microscopic examination for semen was not done, though the mere detection of sperms/semen is of little value especially in married females and sexually active unmarried females. SAP estimation was done in 71 victims (49%); its value was elevated in 29.6% and in 70.4% of the victims, there was low levels of SAP. SAP is sensitive but not specific for semen owing to the presence of the enzyme in other tissues including vaginal fluid., SAP is normally lost 48 h postcoitus though its levels start reducing after 24 h., Late presentation of SA victims in our setting has reduced the efficacy of simple investigations such as motile and nonmotile sperm detection and SAP estimation. DNA profiling was not done for any of the cases, which makes medical evidence incomplete or reduced to proving that there was SA, but leaving a huge gap to the identification of the perpetrators. Only three (2.1%) SA victims presented without change of clothing or taking bath, thus making evidence retrieval from clothing and linen almost impossible. This is comparable to findings from Pakistan. Studies in the USA had shown that the decision to collect evidence is best made by the timing of the examination and that clothing and linens yield the best or majority of evidence if adolescents present after 24 h.
| Conclusion|| |
Although there is an increase in the number of cases, because victims and parents/guardians are coming out to report, there is a need to increase knowledge that victims and guardians should present very early so that adequate evidence will be collected. Concerned authorities should make modern diagnostic kits available so that perpetrators will be identified and prosecuted adequately. Medical care for victims should be improved upon, so as to offer psychological treatment. Special security should be increased in high-risk areas of the city so as to reduce the incidence.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]