This was a cross-sectional study based on secondary data analysis. We sought to determine the clinical care given to victims of sexual abuse at Kadoma General Hospital, Zimbabwe between 2014 and 2016. The median age of victims in our study was 14 years. Sexual assault has been reported to be more common in this age group owing to the phase of sexual development that is adolescence [10]. This is also supported by the fact that the majority (40%) of the perpetrators in our study were boyfriends of the victims. However, our findings could be attributed to less reporting by older and married females owing to the fear of stigma and perceived social consequences associated with reporting sexual assault. In our study, females constituted 98.8% of the total victims of sexual assault. Our finding is consistent with that reported by Ige et al. [11] and Abdulkadir et al. [12] who reported a vulnerability of females to sexual assault owing to the patriarchal social norms that expose women to social injustice and exploitation. In our study, 74% of the perpetrators were known to their victims. We also found that the majority of perpetrators were boyfriends 81 (40%), relatives 46 (21%), stranger 51 (25%) and neighbour 15 (7%). Most of the victims fell prey to the people they knew unexpectedly, and this may be a result of the trust and relationship between the perpetrator that makes the victim assaulted unexpectedly. Girgira et al. [13] and Birdthistle et al. [14] reported similar findings in their studies in Ethiopia and Zimbabwe respectively.
In our study, the modal time to present to a health facility following sexual assault was between four and seven days. In Ethiopia, the median length of time taken to present to a health facility was found to be four days [13]. The delay in presentation to health facilities following sexual assault compromises medical interventions, as we expect victims to receive prophylactic therapy within 72 h of sexual assault to optimise the benefits. We found condom usage by perpetrators of sexual violence in 2% of the victims. The low condom usage results in a higher risk of contracting sexually transmitted infections and unwanted pregnancies among victims hence the need for optimum preventive interventions following sexual assault.
In a sub-analysis of 81 medical affidavits, genital discharge was recorded in 15 (19%) and bleeding in 13 (16%) of the victims. External body injury was reported in 185 (39%), anal injury 128 (27%), external female genital injury 182 (42%) and internal vaginal injury in 182 (42%). The presence of genital discharge and genital injury in these victims is substantial evidence of penetrative sexual assault. The presence of bleeding results in a breach in the mucosal surface of the genital tract hence predisposing the victims to acquire sexually transmitted infections. The importance of standard quality of care in victims of sexual assault cannot be underestimated. However, there could be more asymptomatic victims who later suffer sexual assault related complications such as subfertility and post-traumatic stress disorders. Vaginal lacerations with bleeding, hymeneal tear, and soft tissue injury have been reported in similar studies [11, 13].
In our study, prophylactic antibiotics were given in 36 (33%). However, one of the victims who had a vaginal discharge was not given antibiotics. Similar studies have also reported administration of post-exposure prophylaxis for sexually transmitted infections in 53.9% of the victims [13]. Ideally, prophylactic antibiotics should be given to all victims who present with or without symptoms of sexually transmitted infections as long as there is possible evidence of penetration. This prophylaxis is necessary to prevent the development of sexually transmitted infections and future sequelae associated with sexual assault [10].
The proportion of victims (30%) who were eligible to receive Post Exposure Prophylaxis (PEP) for HIV was low. This finding was due to delayed presentation for health care by victims following sexual assault. However, among those who presented on time, only 35 (51%) received PEP for HIV and 9 (69%) got emergency contraception. Owing to the services being provided in a busy outpatient department there is a possibility of missing some of the essential components of the clinical care delivered to victims of sexual assault. The victims also present to the hospital with a police officer whose priority is to have the medical affidavit signed for court proceedings and once the form is completed the victim is likely to leave the hospital without receiving the full package of care as required. There is need to prioritise the acute clinical care given to victims and this can be done by a multisector approach. Birdthistle et al. [14] in a study in Zimbabwe reported a high PEP coverage (92%) for victims presenting within 72 h [11]. The high PEP coverage found by Birdthistle owed to the model of service delivery at the health facility, in this case, it was a specialised clinic for sexual assault victims as compared to the outpatient model used at Kadoma General Hospital.
In our study, the proportion of victims who had baseline HIV testing was 22% which is low as we expect all victims to have a baseline HIV test. At baseline HIV testing, six (6%) of the victims were HIV-positive. Among these victims, three were adults who were sexually active but had never been screened for HIV infection before. Owing to the high HIV prevalence in Zimbabwe there is need to screen all victims for HIV as recommended by the guidelines. Of the eight victims tested for HIV at three months’ follow-ups, three became HIV-positive (38%). Missing PEP and appropriate care in the victims could have caused transmission of HIV in these three victims following the sexual assault. However, in settings with low HIV prevalence, the baseline and second HIV tests have been found to be negative in all victims [9, 13].
Our findings show that few victims were offered vaginal swab microscopy despite the overwhelming evidence of penetration and infection. Vaginal swab microscopy is essential for guiding antibiotic treatment in the victims with vaginal discharge. Despite 45 victims with definite evidence of penetration having presented within 72 h, forensic evidence was gathered in only six (13%) of the victims. Insufficiency of evidence during prosecution and lenient penalties for the perpetrators have resulted from the lack of adequate and convincing forensic evidence. Few of the victims (10%) in our study received follow-up care whilst there were no proper counselling sessions documented. This finding could be attributed to the non-existence of a proper follow-up mechanism for sexual assault clients. Counselling and follow up in sexual abuse victims has been shown to be suboptimal in several studies [11, 13]. Abdulkadir et al. [12] also reported non-documentation of the management of sexually transmitted infections, emergency contraception, HIV infection and scheduled follow up in a retrospective study of 81 sexual abuse victims in Niger State.
The major limitation encountered in our study was the incompleteness of variables relating to laboratory investigations and forensic tests and this could be attributed to the poor recording practices among clinicians. The insufficiency of the dataset could also affect generalisation of our study findings.
