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R E S E A R C H A R T I C L E Open Access
Sexual assault in Lagos, Nigeria: a five year
retrospective review
Fatimat M Akinlusi
*
, Kabiru A Rabiu, Tawa A Olawepo, Adeniyi A Adewunmi, Tawaqualit A Ottun
and Oluwarotimi I Akinola
Abstract
Background: Cases of sexual assault are increasingly reported. However, Nigerian researchers have not given
adequate attention to this subject despite its attendant social, physical and psychological consequences.
This study assessed survivors’characteristics, circumstances of assault and treatment offered with a view to reducing
the incidence as well as improving evaluation and management.
Methods: A retrospective review of survivors’case records at Lagos State University Teaching Hospital, Ikeja,
between January 2008 and December 2012. Data was analysed using the Epi-info 3.5 statistical software of the
Centre for Disease Control and Prevention, Atlanta U S A.
Results: Of the 39,770 new gynaecological cases during this period, 304 were alleged sexual assault giving an
incidence of 0.76% among hospital gynaecological consultations. Only 287 case notes had sufficient information for
statistical analysis. Of these, 83.6% were below 19 years, 73.1% knew their assailants (majority were neighbours),
most assaults (54.6%) occurred in the neighbours’homes and over 60% of victims presented after 24 hours of
assault.
Although 77.3% were assaulted at daytime, teenagers were likely to be raped during the day and non-teenagers
at night (P < 0.001). Threat and physical violence were mostly used to overcome victims. Seventy three point six
percent had Human Immunodeficiency Virus (HIV) screening with one positive at onset. Post Exposure Prophylaxis
for HIV was given in 29.4% of those eligible and emergency contraception in 22.4% of post-menarcheal victims
(n = 125).
There were neither referrals for psychotherapy nor forensic specimen collected. No record of post-assault
conception or HIV infection was found during follow-up.
Conclusions: Adolescents remain the most vulnerable requiring life skills training for protection. Survivors delay in
presenting for care. Therefore, public enlightenment on the benefits of early interventions and comprehensive care
of survivors with the use of standardized protocols are recommended.
Keywords: Rape, Sexual assault, Violence against women, Survivors
Background
Sexual assault is a severely traumatic experience that dis-
proportionally affects adolescent and young adult women
[1] and is often associated with psychological, physical and
social distress [2].
Though researchers’definition of sexual assault varies
[3], it includes a spectrum of activities ranging from
rape to physically less intrusive sexual contacts, whether
attempted or completed [3].
Rape is not a medical diagnosis. It is a legal termin-
ology reserved for cases of penile penetration of the vic-
tim’s vagina, mouth, or anus without consent [4]. Other
types of sexual assault include forced or coerced vaginal
or anal penetration by any other body parts or object;
breast or genitalia fondling; or being forced or coerced
to touch another person’s genitalia [5]. It involves lack of
consent; the use of physical force, coercion, deception or
threat; and/or the involvement of a victim that is mentally
* Correspondence: fatimatakinlusi@yahoo.co.uk
Department of Obstetrics and Gynaecology, Lagos State University College
of Medicine, Ikeja, Lagos, Nigeria
© 2014 Akinlusi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Akinlusi et al. BMC Women's Health 2014, 14:115
http://www.biomedcentral.com/1472-6874/14/115
incapacitated or physically impaired (due to voluntary or
involuntary alcohol or drug consumption), asleep or un-
conscious [6].
Sexual assault is not peculiar to any particular race or
socio-economic class. The World Health Organization
reports that one in every five women is a victim of
sexual assault [7] and globally, 35% of women have expe-
rienced either physical and/or sexual intimate partner
violence or non-partner sexual violence [8]. The regions
of the world with the highest reported rates of sexual
and physical violence towards women are Africa, the
Middle East and Southeast Asia [8].
In Africa, 5–15% of the females report a forced or co-
erced sexual experience [9]. In South Africa, prevalence of
rape, from community based reports show a figure of 2070
per 100,000 per year [10]. Reports from Ethiopia showed
from a study of 367 high school girls, that 11.4% of them
had started having intercourse and 33.3% of this group was
rape [11]. Adolescents however have the highest rates of
rape and other sexual assaults of any age group [12].
In Nigeria, the reported incidence of sexual assault
varies depending on study design and methodology. A
study in Ibadan showed that 15% of young females re-
ported forced penetrative sexual experience [13], while
13.8% prevalence rate was found in female Maiduguri
students [14]. True incidences are inaccurate and often
underestimated since most cases of sexual assault are
under-reported by the victims because of the associated
stigma [14].
The violence involved in an attempted sexual assault
can have the same impact on the survivor as a com-
pleted one. The impact can be immediate or delayed
with long-term health consequences for survivors. Sig-
nificant social and economic consequences also occur.
Health consequences include physical injuries, unwanted
pregnancies, unsafe abortions and sexually transmitted
diseases, including HIV. Immediate psychological reac-
tions such as shock, shame, guilt and anger may be exhib-
ited [15] while long-term psychological outcome include
depression, post-traumatic stress disorder, suicidal idea-
tion, lack of sexual enjoyment, and fear [15]. A recent sys-
tematic review found that women who have been sexually
assaulted by non-partners are 2.3 times more likely to use
alcohol and 2.6 times more likely to experience depression
or anxiety while those abused by partners are 1.5 times
more likely to have a sexually transmitted disease, includ-
ing HIV [8].
Adolescents are particularly susceptible to HIV trans-
mission through forced and unforced sex because their
vaginal mucous membranes have not yet acquired cellu-
lar density significant to provide an effective barrier that
develop in later teenage years [7].
In Nigeria, cases of sexual assault are increasingly re-
ported. Lagos, like other megacities world over predisposes
its women population to higher risks of sexual violence
[16] amongst other crimes. Despite this, many Nigerian
researchers have not given adequate attention to this
subject especially in terms of the evaluation of care
given to survivors.
At the Lagos State University Teaching Hospital
(LASUTH),Ikeja,noreviewhasyetbeendoneonsex-
ual assault. This has therefore necessitated a review of
these cases with the aim of determining survivors’char-
acteristics, circumstances of assault and treatment of-
fered with a view to reducing the overall incidence as
well as improving survivors’evaluation and management.
Methods
Design
This is a retrospective descriptive study.
Setting
The study was carried out at the Lagos State University
Teaching Hospital (LASUTH), Ikeja. Patients come from
within and outside Lagos and an average of 12 new gy-
naecological patients is seen every day of the week [17].
Study population
Survivors of alleged sexual assault who self- presented to
Lagos State University Teaching Hospital (LASUTH), Ikeja
during the study period of January 2008 to December 2012
were the subjects of review. The hospital has a 20-bedded
gynaecological ward that will soon be replaced by a sub-
stantive facility nearing completion. The staff population is
a mixture of 11 specialist gynaecologists, variable number
of resident doctors, nurses and other support staff.
The medical records department was approached for
the identification of case notes of all females that self-
presented to LASUTH for medical care within the study
period having experienced any form of sexual assault.
A sexual assault case was defined as any person, irre-
spective of age reporting any type of non-consensual
sexual activity whether attempted or completed.
The hospital does not have a written protocol for the
management of cases of sexual assault.
However, when a victim of sexual assault presents at
the emergency room, the triage nurse will perform the
initial assessment, including vital signs. Consultation is
then arranged with the duty registrar who identifies emer-
gent needs, provides comfort and explains services. Subse-
quent evaluation will include obtaining detailed history,
conducting a thorough physical examination, obtaining fo-
rensic evidence if indicated, as well as testing for sexually
transmitted infections, pregnancy and HIV. Comprehen-
sive treatment includes treatment of injury, provision of
emergency contraception, prophylactic antibiotics for sexu-
ally transmitted infections, tetanus and hepatitis B vaccin-
ation and post-exposure prophylaxis for HIV. Appropriate
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documentation of physical findings and care provided are
made. Counselling and psychosocial support are also of-
fered. The client is supported if she decides to involve po-
lice or legal authority.
Of recent, a non-governmental sexual assault re-
sponse centre, MIRABEL CENTRE now operates within
LASUTH. This centre also provides acute care and long
term follow of survivors.
Data collection
The case records of survivors were retrieved, reviewed
and information extracted was entered into a proforma
that evaluated socio-demographic characteristics, place
and time of the incident, relationship of assailants to
victims, methods employed by assailant to overcome vic-
tims, forensic specimen collection, treatment offered and
follow up of survivors.
Analysis
Categorization of open-ended questions was done and
data obtained was entered into the computer and ana-
lysed using Epi-info statistical software (2008 version).
These were then presented in tabular and descriptive
forms. Bivariate (inferential) analysis was also done.
Chi square test was used to compare proportions be-
tween variables where appropriate, at 95% confidence
level. A p-value of less than 0.05 was considered to be
statistically significant.
Ethics
Ethical approval was given by the research and ethics Com-
mittee of the Lagos State University Teaching Hospital.
Confidentiality was maintained by omitting survivors’
names from the proforma.
Written informed consent was not obtained from par-
ticipants as this is a retrospective study.
Results
During the study period, there were 39,770 Gynaeco-
logical consultations, 304 of which were for alleged sex-
ual assault. Only 287 of these had sufficient information
for statistical analysis. The incidence of those reporting
to the hospital with suspected or confirmed sexual assault
among hospital gynaecological consultations was thus
0.76% for the period under review.
Table 1 shows the socio-demographic characteristics
of assaulted victims. The ages ranged from 2 to 50 years
with a mean of 12.9 ± 8.758 years. Most victims were of
Christian faith and Yoruba ethnic group and majority
lived with their parents (70.7%). Adolescents (age group
10–19) accounted for the majority (44.6%) of the cases,
followed by children less than 10 years (39.0%), making
the entire under 19 age group 83.6% of all victims. This
is also depicted in Figure 1.
Students accounted for 74.2% of the occupation cadre
and 40.1% of them were assaulted in neighbors’houses
but no assault occurred in the school. Pre-pubertal vic-
tims constituted 56.4% while 43.6% were post pubertal.
Although 77.3% of all victims were assaulted at daytime
and 22.7% at night, as many as 88.9% of victims raped
during the day were less than 19 years. Teenagers and
young girls were more likely to be raped during the day
than at night when compared to older adults (P < 0.001).
This is depicted in Table 2. The chance of a teenager ex-
periencing daytime sexual assault was more than 17 times
higher than that of an older adult.
Sixty four point five percent (64.5%) of the victims
presented after 24 hours of assault as shown in Table 3.
The assailants were well known to the victims in 73.1%
of cases and were mostly neighbours. A description of
the place of assault is presented in Table 4 where the
neighbors’home accounted for 54.6%.
Methods of overcoming the victims included threat
(35.5%), deceit (24.1%), physical violence (28.7%), money
(9.8%) or alcohol (2.1%). Thirty six point one percent
(104) of the victims reported previous sexual exposure.
The total number of assailants involved at different in-
stances ranged from 1 to 9.
Table 1 Socio-demographic characteristics of assaulted
victims
Characteristic Frequency Percentage (%)
Age group
<10 112 39.0
10-19 128 44.6
20-24 23 8.0
>24 24 8.4
Occupation
Student 213 74.2
Pre- school 18 6.3
Apprentice 17 5.9
Professional 16 5.6
Domestic servant 12 4.2
Unemployed 6 2.1
Hawker 5 1.7
Religion
Christianity 223 77.7
Islam 64 22.3
Tribe
Yoruba 151 52.6
Igbo 87 30.3
Others 45 15.7
Hausas 4 1.4
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The management offered is summarized in Table 4.
Seventy three point six percent (73.6%) had Human Im-
munodeficiency Virus (HIV) screening with one positive
at onset. Post Exposure Prophylaxis for HIV was given
in 29.4% of those eligible and emergency contraception
in 22.4% of post-menarcheal victims (n = 125).
The commonest isolated organism was candida species
(13.1%). There were neither referrals for psychotherapy
nor forensic specimen collected. No record of post-assault
conception or HIV infection was found during follow-up
and more than a quarter of the victims (27.7%) did not re-
turn for follow-up.
Discussion
This is a 5 year retrospective study of cases of sexual as-
sault 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 [20]. 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 trad-
itional 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 sur-
veys [9,19,21], where a disproportionate number of sex-
ual 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. Addition-
ally, inadequate parental care may be more prevalent in
the Lagos setting where high cost of house rents pre-
vents accommodation near work places. The heavy traf-
fic 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
Figure 1 Age distribution of victims. Adolescents (age group 10–19) accounted for the majority (44.6%) of the cases, followed by children less
than 10 years (39.0%).
Table 2 Comparison of age versus time of incidence
Characteristics Day time Night OR CI P-value
Teenagers (<20 year) 208 (87.0%) 31 (13.0%) 17.548 8.354 -36.862 <0.001
Non-teenagers (>20) 13 (27.7%) 34 (72.3%) 0.057 0.027 - 0.120 <0.001
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[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 dis-
closure 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 [23]. For the older victims, the fear
of stigmatization could be responsible for delayed dis-
closure [23].
The longer the interval, the lower the quantity and
quality of forensic evidences [24], 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 hos-
pital assessment and report which ensures appropriate
medical, legal and psychological actions [23].
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 emo-
tional manipulation or verbal threats leaving no injuries.
The standard of clinical management of sexual vio-
lence 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 ex-
posure prophylaxis [24] 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 Depart-
ment 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 [25].
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 as-
sault 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 [26].
This review revealed that no forensic samples were
collected, neither were there referrals for psychotherapy.
The lack of forensic evidence will no doubt hinder just-
ice, encourage perpetuation of rape and promote non-
disclosure. Since psychological consequences may occur
Table 3 Disclosure interval and relationship of the
assailants to victims
Characteristics Frequency Percentage (%)
Disclosure interval
Within 24 hours 102 35.5
24 hours –6 days 129 45.0
7 days –1 month 31 10.8
>1 month 25 8.7
Assailants
Neighbours 157 54.9
Stranger 77 26.9
Acquaintances 36 12.6
Family member 13 4.6
Boy friend 3 1.0
Table 4 Place of assault and management of assaulted
victims
Characteristics Frequency Percentage (%)
Place of assault
Neighbour’s house 156 54.6
Victim’s home 60 21.0
Uncompleted building 34 11.9
Street corner 27 9.4
Friend’s house 9 3.1
Treatment
HIV screening 209 73.6
Follow up (once) 204 72.3
HVS 181 63.7
HBsAg screening 143 50.5
VDRL Testing 131 46.2
Pregnancy test 86 30.5
PEPs 72 25.4
Emergency contraceptives 28 9.7
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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 ado-
lescents 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 in-
crease the disclosure of any previous sexual assaults.
Survivors want justice as evidenced by the proportion
of those who had made police reports. The judicial sys-
tem 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 manage-
ment 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 con-
strained by the availability of data in the case records.
Conclusions
Sexual assault is a grievous under reported offence with
detrimental physical, social and psychological effects on
its victims. Adolescents continue to have the highest rates
of all age groups. Assailants are often known to their vic-
tims who perpetrate this act during the daytime. Survivors
delay in seeking care. There is a need for a more compre-
hensive evaluation and care of victims in order to prevent
serious sequelae and deter assailants. This may be achieved
by the utilization of standardized protocols.
Increased public awareness and preventive interventions
are required particularly within the at-risk age group to
enhance their safety.
Abbreviations
HIV: Human Immunodeficiency Virus; LASUTH: Lagos State University
Teaching Hospital; HBsAg: Hepatitis B surface Antigen; VDRL: Venereal
Disease Research Laboratory Test; PEP: Post exposure prophylaxis of HIV;
HVS: High Vaginal Swab.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
KAR conceived the study and participated in its design, data collection,
analysis and helped to draft the manuscript. FMA participated in the study
design, data collection, analysis and wrote the first draft of the paper. TAO
participated in the study design, data collection, analysis and helped to draft
the manuscript. AAA participated in the study design, data collection,
analysis and helped to draft the manuscript. TAO participated in the study
design, data collection, analysis and helped to draft the manuscript. OIA
participated in the study design, data collection, analysis and helped to draft
the manuscript. All authors read and approved the final manuscript.
Acknowledgements
The authors acknowledge the assistance of all members of staff of the
medical records department and gynaecology clinic of the Lagos State
University Teaching Hospital.
Received: 22 November 2013 Accepted: 16 September 2014
Published: 23 September 2014
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doi:10.1186/1472-6874-14-115
Cite this article as: Akinlusi et al.:Sexual assault in Lagos, Nigeria: a five
year retrospective review. BMC Women's Health 2014 14:115.
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