This is a 5 year retrospective study of cases of sexual assault in LASUTH between January 2008 and December 2012. The incidence of sexual assault of 0.76% is low compared to similar studies in Nigeria where incidences of 2.1%, 5.6%, 7.7% and 13.8% were reported in Calabar, Jos, Benin and Maiduguri respectively [9, 14, 18, 19]. This low figure is probably due to the very large denominator of 39,770 new gynaecological consultations during the study period. LASUTH attends to referred patients from several General and Private Hospitals in the state and neighbouring states.
An age range of 2 to 50 years was found in this study. This is in contrast to the findings in Calabar and Benin, Nigeria with 4 to 23 and 3 to 25 years respectively. An Indian study of victims of sexual assault however reported a similar range of 3 and 42 year . This disparity in the maximum age of victims may be due to underreporting to police and health authorities by the older survivors who may fear loss of societal respect especially in the traditional and less metropolitan cities of Calabar and Benin.
In this study, girls less than 19 years accounted for 83.6% of cases seen. This is comparable with other surveys [9, 19, 21], where a disproportionate number of sexual assaults occurred among children and adolescents.
Children 10 years and below contributed almost 40% of this vulnerable age group in this study. They tend to offer little or no resistance to their assailants. Additionally, inadequate parental care may be more prevalent in the Lagos setting where high cost of house rents prevents accommodation near work places. The heavy traffic situation further delays the return of parents and guardians to their homes. These children may have to be left to the care of neighbours or in some other places where supervision is inadequate. These expose them to potential abuse by minders who may even use them as errand girls. The above may explain why most assaults (77.3%) occurred during the daytime since parents are away from home at this period.
In 73.1% of cases, the victims knew their assailant. This is documented in studies elsewhere where the perpetrators of the sexual assaults were blood relations, neighbours, acquaintances, authority figure and stranger [9, 19, 21, 22]. Neighbours were assailants in 54.9% of cases which explains why 54.6% of rape occurred in neighbours’ homes where the possibility of being caught in the act is quite slim. In the Jos study however, most assaults (46.6%) occurred in the victim’s home.
The time interval between the alleged rape and disclosure varied widely from less than 24 hours to three months. In 35.5% of victims, reports were made within 24 hours while most (45%) reported between 24 hours and 6 days of the incident. The wide variation in the interval of disclosure could be attributed to threats of violence or death which has been found in this study to be the most common means of subduing the victims. Children particularly believe assailants’ threats and would not report until parents discover; some fear they may not be believed . For the older victims, the fear of stigmatization could be responsible for delayed disclosure .
The longer the interval, the lower the quantity and quality of forensic evidences , and the higher the risk of negative health outcomes.
Ninety two point two percent of the victims had made reports to the police prior to presentation. This may suggest that victims are more interested in having their assailants punished than for their own medical care. An official report to the police will however mandate a hospital assessment and report which ensures appropriate medical, legal and psychological actions .
Few of the victims had body abrasions (9.4%). It may be that the late presentation had allowed for healing while submission of the victim may be achieved by emotional manipulation or verbal threats leaving no injuries.
The standard of clinical management of sexual violence involves documentation and treatment of injury, getting forensic materials, detecting prior pregnancy, screening for sexually transmitted infections including HIV and provision of adequate contraception, post exposure prophylaxis  and supportive psychosocial counselling.
High vaginal swab testing and HIV screening were done in 63.7% and 73.6% of cases respectively while just about half of the victims were screened for Hepatitis B surface Antigen (HBsAg) and Venereal Disease Research Laboratory Test (VDRL).
Of the 201 victims who presented within 72 hours of assault, only 59 (29.4%) were referred for post exposure prophylaxis of HIV (PEP) at the Haematology Department despite the importance of HIV prevention. PEP might have been withheld in survivors with apparent low risk of HIV transmission from the assault. The recommendation is that post exposure prophylaxis be provided to sexual assault victims especially when there is mucosal exposure; trauma and bleeding; in cases of repeated sexual abuse or multiple perpetrators; when the assailant is known to be HIV positive or has high risk behavior for HIV infection; or in places of high HIV prevalence .
Only 55.7% of the post-pubertal victims had pregnancy test done and just 22.4% of same group had emergency contraceptives. It was found that the nature of the assault and disclosure interval contributed to this low proportion. This is in keeping with other studies where emergency contraception to prevent post rape pregnancy was not consistently offered to rape victims .
This review revealed that no forensic samples were collected, neither were there referrals for psychotherapy. The lack of forensic evidence will no doubt hinder justice, encourage perpetuation of rape and promote non-disclosure. Since psychological consequences may occur in the acute period or in the long run and psychotherapy is a recognized way of moderating the negative effects on victims, this should be offered in all cases.
A heightened risk for sexual victimization among adolescents and young girls consistent with other studies is further supported here and this underscores the need for prevention and intervention efforts targeted at this population. There is a need to encourage organizations and policy makers to create programs to prevent sexual assault in this vulnerable population. Such will include age-appropriate sexual assault education which will not only help in reducing risk for sexual assault, but also improve chances that an assault will be reported when it occurs.
Of note is the fact that most cases are not reported early which translates to delay in seeking care. Since the very low incidence may also suggest gross underreporting, it is necessary to incorporate a thorough violence/assault assessment into routine history-taking procedures for non-sexual assault-related consultations. This will help increase the disclosure of any previous sexual assaults.
Survivors want justice as evidenced by the proportion of those who had made police reports. The judicial system will need to be strengthened to handle assault cases effectively as this encourages formal reporting and helps to hold perpetrators accountable while deterring like-minded individuals from committing similar crimes.
Regular in-service training of health care providers and the utilization of written guidelines for the management of sexually assaulted victims will prevent omissions and ensure prompt and comprehensive post-rape care.
The hospital-based nature of this study limits the generalizability of its findings to the larger population. Being a retrospective review, this study was also constrained by the availability of data in the case records.