Health Science Journal

Introduction

Sexual violence is a significant public health and human rights problem worldwide, including developing countries such as Ethiopia (1). It is widely recognized as a major public health problem, both due to the acute morbidity and mortality associated with it. More specifically, sexual violence causes long-term impact on women's health, including chronic pain, gynecological problems, sexually transmitted diseases, depression, posttraumatic trauma, stress disorder and suicide (2,3,4). It is generally defined as the use of force or manipulation to get someone to participate in unwanted sexual activities without once permission.
Rape is a crime seriously underreported with surveys showing dark figures of up to 91.6%. The reasons for not reporting the violation varies by country. They may include fear of reprisals, uncertainty about whether a crime was committed or if the offender intended to harm, not wanting others to know about the violation, not wanting the offender to get into trouble and doubting the local police (5, 6). Teens around the world often face tremendous sexual violence; a growing problem and a major reproductive health concern. The prevalence of this violence ranges from 15 to 40% in sub-Saharan Africa (7, 8).

Ethiopia is estimated to have one of the highest rates of violence against women in the world. A UN report found that women in Ethiopia are the most likely to suffer domestic violence at the hands of their partners, and that almost 60% of Ethiopian women are victims of sexual violence (9). The Criminal Code of Ethiopia of 2004 creates the crime of rape, under article 620, which states that: "Who obliges a woman to undergo sexual intercourse outside of marriage, whether by the use of violence or intimidation serious, or after having left it unconscious or incapable of resistance, is punishable by rigorous imprisonment from 5 years to 15 years."
Most rape problems are hidden, undocumented and unreported and the area of research is also neglected and, therefore, a deeper understanding of the subject is critical to promote a coordinated movement against it.

As far as we know, there have been no studies related to sexual violence in the study area. Based on this understanding, it is important to investigate and document the prevalence and associated factors of rape among females attending the gynecological clinic at the Yirgalem General Hospital, Southern Ethiopia.

 Materials and Methods

Study Area and Study Period

This study was conducted at the Yirgalem General Hospital, which is located in the Sidama Zone, in Southern Ethiopia. The city of Yirgalem is 317 km south of Addis Ababa, the capital of Ethiopia, and 42 km east of the city of Hawassa. According to reports from the 2008 national census, the city of Yirgalem has a total population of 42,000 of which 21,420 are women and 20,580 are men. The study was conducted between January 2016 and December 2017.

Study Design

A retrospective study was carried out in the emergency gynecology clinic between January 2016 and December 2017. Health Management Systems (HMS) data were retrieved and analyzed following standard methodologies

Source population

The source population of this study was all clients who attended the Gynecology clinic of the Yirgalem General Hospital during the study period. The study population of this study was that all clients went to the clinic with complaints of sexual assault. Health Management System (HMS) data was retrieved and analyzed following standard methodologies.

Data Analysis

The data collected was cleaned, fed to the computer and analyzed using SPSS version 20.0. For descriptive statistics, the results were presented in terms of proportions or percentages and the associations between the variables were calculated using the chi-square test and the value of p < 0.05 was considered statistically significant.

Ethical Consideration

Prior to data collection, an ethical letter was obtained from Institutional Review Board (IRB) of Yirgalem Hospital Medical College. Subsequently, an official permission letter was obtained from the Administration of the Yirgalem General Hospital.

 Results

Socio-demographic Characteristics of the victims

During the study period, 1,311 cases of gynecological emergencies were reported at the Yirgalem General Hospital. Of which, 118 (9.0%) cases were rape. Socio-demographically, all study participants were women. The majority 63 (53.4%) of the study participants were in the age group <15 years and only 3 (2.5%) clients were over 49 years old. Regarding marital status, 105 (89%) and 10 (8.5%) of the survivors were single and married, respectively. Educationally, 59 (50.0%) and 34 (28.8%) of the clients completed primary and secondary education, respectively, while 20 (17.0%) of the participants were illiterate (Table 1).

Age		Frequency	Percentage
<1515-49>49		63	53.4
		52	44.1
		3	2.5
Educational status	Illiterate	20	17.0
	Primary education	59	50
	Secondary education completed	34	28.8
	Tertiary education completed	5	4.2
Marital status	Unmarried	105	89
	Married	10	8.5
	Undocumented	3	2.5

Table 1: Age and educational status of the clients (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

The circumstance of sexual assault

Regarding the circumstance of sexual assault, fifty-one (43.2%) of the aggressors were used more frequently threatening to control the surviving children, while sixty-one (51.7%) of the aggressors were beaten to control teenagers and adult survivors. Regarding the time of the assault, the majority (73%) of the survivors were assaulted during day time. Over forty six point six percent of the survivors were raped by their neighbors; while 71.2% of the cases were assaulted by people they know (Table 2).

Items	Frequency	Percentage	P value
Brother	2	1.7	0.06
Step father	7	5.9	0.03
Other family member	8	6.8	0.02
Neighbor	55	46.6	0.001
Husband/boy friend	12	10.2	0.005
Others	34	28.8	0.002
Total	118	100.0

Table 2: Relationship of victim with the perpetrator (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

Most (51.7%) of the assaulters used hitting to control 15 years and above aged victims before performing rape while over 43.2% of assaulters used threatening mechanism for the below 15 years age group (Table 3).

Items	Frequency	Percentage	P value
Hitting	61	51.7	0.003
Threatening	51	43.2	0.006
Made drunk	2	1.7	0.04
Smoked drug	4	3.4	0.06
Total	118	100.0

Table 3: Mechanisms used to force sex during rape (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

Most 48 (40.7%) of the assaulters committed rape in victims’ home. About 80% of the survivors were assaulted by one assailant while 20% of the cases were raped after abduction and it was repeated (Table 4).

Items	Frequency	Percentage	P value
At victim home	48	40.7	0.001
While traveling alone	38	32.2	0.02
On street	10	8.5	0.04
In the forest	11	9.3	0.06
At friends home	11	9.3	0.06
Total	118	100.0

Table 4: The place where rape happened (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

 Consequences of rape

Of all survivors of sexual assault, 110 (93.2%), 109 (92.3%) and 102 (86.4%) had undergone a pregnancy test, HIV test, detection of one or more sexually transmitted infections (STIs), respectively. The test results were positive at the time of the evaluation of pregnancy, HIV and HBsAg in 20 (17%), 1 (0.8%) and 0 (0%), respectively. More than nineteen (16.1%) of the rape cases presented with STI symptoms (Table 5). Depression was the most common problem faced (59.3%) of the victims and 24.6% of the cases had additional physical trauma.

Variables	Items	Frequency	Percentage	P value
Sero-status	Reactive	1	0.8	0.07
	Non- reactive	108	91.5	0.003
	Unknown	9	7.6	0.03
STIs symptoms	Yes	19	16.1	0.05
	No	99	100.0	0.001
Pregnancy test	Positive	20	17	0.08
	Negative	90	76.2	0.004
	Not done	8	6.8	0.06
	Total	118	100.0

Table 5: Test for sero-status, STIs and Pregnancy after rape (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

Treatments given

Regarding the time of the presentation in the hospital after the sexual assault, although 52.5% of the victims showed up within 72 hours and were eligible for emergency contraception, only 8.5% received the service. On the other hand, only 8.5% of survivors who presented within three days after sexual assault received post-exposure prophylaxis for HIV and 81.4% of those who presented within 24 hours received STI prophylaxis and all received advice (Table 6).

Variables	Items	Frequency	Percentage	P value
Use of emergency contraceptives	Yes	10	8.5	0.08
	No	108	91.5	0.005
Use of RVI prophylaxis	Yes	10	8.5	0.6
	No	108	91.5	0.002
Use of STI prophylaxis	Yes	96	81.4	0.004
	No	22	18.6	0.07
	Total	118	100.0

Table 6: Use of emergency contraceptives, RVI prophylaxis and STIs prophylaxis after rape (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

Prevalence of rape

 Eighty percent of the cases were taken medical certificate. Of which, 30 (25.4%) cases showed evidence of rape and 74.6% of the cases were attempted rape (Table 7).

Items	Frequency	Percentage	P value
Given	95	80.5	0.001
Not given	23	19.5	0.08
Total	118	100.0

Table 7: Clients who were given medical certificate (n =118) Yirgalem General Hospital, Yirgalem, Ethiopia, 2017.

Discussion

Rape is the least reported crime against individual integrity, sexual freedom and affects up to one third of women worldwide during their lifetime. Although determining the true magnitude of the violation from a hospital study is difficult, it is the only means by which it is possible to assess the prevalence of rape, the interventions provided and the related complications.

In this study, the majority (53.4%) of rape victims were children below fifteen. All survivors were women, most were less educated. This finding is in agreement with studies conducted in Ethiopia and other African countries (9, 13, 17). Children of this age group are vulnerable to sexual assault and other acts of gender violence due to traditional gender norms that support superiority and male law, social norms that tolerate or justify violence against women, weak community sanctions against perpetrators and the prevalence of poverty (11).

Alcohol was used to control survivors in 1.7% of the incidents, which shows that alcohol is consumed less frequently as identified in this study during or before sexual assault compared to other studies where it was used in 50% (12, 16). This could be due to the fact that religious and cultural problems contributed to the low tendency of alcohol consumption in our study population.

Around the world, sexual assault by a stranger is generally not common and rather begins in a home environment, neighborhood, school and work environment. This is true in our study, where the majority (71.1%) of the assailants were known to survivors, assaults committed in assailants or in the survivor's home, 59 (50%). This implies that most sexual assaults are committed by a person known to survivors and there may be some degree of intimacy (4, 13, 14).

Study on sexual assault against women shows an increased risk of current physical or sexual violence against women of a younger age, especially those aged 15 to 19 years, living in single parent stays and grandparent headed lodging (12). In our study, however, about 80% of the survivors were living with their biological mothers and fathers and were aged fifteen years and below. This implies that, in our country, the mere presence of mother and father will not safeguard children and family from sexual assault as debate or dialogue on sexuality is not a custom especially in rural areas and other factors like poverty and illiteracy in the family may contribute to sexual assault.

Most health care interventions can only be given when survivors present in the first three days of sexual assault to prevent complications. However, studies in developing countries have shown that this effective window for intervention is generally delayed 18.4 days (12), compared to the average time from the start of the assault to the 16-hour presentation in the US. Similarly, in our study, the interval between the incident of sexual assault and the first presentation in the hospital varies from 1 day to 45 days and only 52.5% of cases seek medical attention within the first 72 hours. Among the reasons for delays in seeking care in Ethiopian contexts are the threat of the aggressor, financial limitations, kidnapping and lack of services in the nearby health center (10).

Survivors of sexual assault are vulnerable to a range of sexual and reproductive health problems, particularly HIV infection and sexually transmitted infections (STIs) in addition to unwanted pregnancy. Due to this fact, screening tests are crucial for all survivors for STI, HIV infection and pregnancy when they are believed to be of reproductive age or develop secondary sexual characteristics (15, 16). In our study, among survivors believed to be of reproductive age, 110 (93.2%) underwent a pregnancy test and 20 (17%) were pregnant at the time of evaluation. This is much higher than the result of previous studies reported by Addis Ababa, Ethiopia. This may be because people in Addis Ababa have a better awareness about the complications of sexual assault and sought attention relatively sooner (10). Ninety-two percent of the survivors were tested for HIV and one (0.8%) was positive at the time of the evaluation. This figure is much lower than the results of other studies (10), which could be due to the fact that the tests were carried out before the seroconversion time and most of the victims did not return with an appointment after three months for the second test.

Eighty six percent of the survivors were screened for one or more STIs other than HIV, of whom, 19 (16.1%) had symptoms of STI. Although 52.5% of the survivors of sexual assault were potentially eligible for emergency contraception (EC) at the time of presentation, only 10 (8.5%) received the service from the hospital staff. This is very much lower than the study results reported from Ethiopia (10) and Zambia (14). In addition, eight point five percent of the survivors presented within three days were provided with post-exposure prophylaxis (PEP) for HIV, 81.4% cases were provided with STIs prophylaxis and all cases were given counseling (18). This shows that there is a huge gap in providing care for survivors of sexual assault from the health provider in this study.

The provision of a medical-legal certificate containing the result of the forensic examination, sample collection, analysis and documentation provides a vital link between health and criminal justice systems, and is a crucial component in ensuring prosecution and the sentence (16, 19). In our study, with respect to medical-legal certificates, only eighty percent of the cases have been handed over to the police. This shows that there is a gap in the justice system in the protection of women against crime.

In conclusion, in this study, a considerable proportion of clients with gynecological emergencies had been violated. All survivors of sexual assault were women. The majority of assault survivors were children below fifteen and less educated. Although screening tests were offered for survivors, there was a great missed opportunity regarding the provision of PEP for HIV, and prophylaxis for STIs. Therefore, awareness among the community should be created to help survivors to appear early in the health institution to prevent unwanted pregnancies and sexually transmitted infections. Health professionals should pay special attention to provide screening tests and packages. The right to sexual and reproductive health of women and children survivors of sexual assault must be strengthened from the side of policy makers and must be promulgated accordingly by government agencies and the community to protect people.

Limitation

The lack of adequate study reports was one of the limitations to make a more comparative discussion. Since the study was cross-sectional retrospective, it may not be strong enough to demonstrate direct cause and effect between dependent and independent variables. In addition, since the study was only quantitative, it is difficult to obtain detailed information.

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