Multiple sexual abuse among children in Kaduna State, North-western Nigeria: Does victim’s gender play a role?

INTRODUCTION

Child sexual abuse (CSA) as defined by the World Health Organization (WHO) is “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society.”¹ It is a global public health tragedy that affects millions of children and transcends social, economic and cultural divides.² In 2002, the WHO estimated about 73 million boys and 150 million girls below the age of 18 years were sexually abused.³ In 2016, more than half of all children below the age of 18 years suffered some form of violence in the past year, including sexual abuse.⁴ In 2009, Africa was reported to have the highest burden of CSA with an estimated prevalence of 34.4%.⁵ In Nigeria, early hospital-based studies suggested very low prevalence of CSA (often less than 1.0%).^6–10 However, recent population-based studies among adolescents reported much higher prevalence rates (25-40%).^11–13 According to the United Nations Children’s Fund (UNICEF), 25% of all girls and 10% of all boys in Nigeria have been victims of sexual violence and fewer than 5% of them received any support.¹⁴

CSA could be devastating to victims and their families. Victims are often exposed to trauma and sexually-transmitted infections (STIs) including human immunodeficiency virus (HIV), hepatitis B, hepatitis C, gonorrhea and syphilis.^15,16 Psychological problems such as post-traumatic stress disorder (PTSD), attention deficit disorder, anxiety, phobia, substance abuse, depression and suicidal ideation may develop either as immediate or long-term complications.^17-19 Despite such consequences, a significant number of victims do not get the appropriate care they needed due to delayed or non-disclosure of abuse.^20-22 Victims may withhold disclosure of abuse for various reasons that include self-blame, fear of negative repercussions, fear of not being believed, familiarity with assailant and failure to recognize abuse as a wrongful act.^23,24

However, not all victims of CSA develop adverse manifestations. Several factors including age when abused, duration of abuse, invasiveness of abuse, use of force during abuse, familiarity with assailant, lack of family protective factors and frequency of abuse are all believed to contribute to the development of adverse sequelae in CSA victims.²⁵

Frequency of abuse or multiple victimization include both poly-victimization, defined as co-occurrence of multiple forms of abuse in one victim or re-victimization, the repeated experience of a particular form of abuse by same victim.²⁶ Multiple victimization in the context of CSA is associated with greater tendency for both internalizing and externalizing behaviors including inappropriate and risky sexual behaviors (early sexual debut, teenage pregnancy, multiple sexual partners and unprotected intercourse).^27-31 Unlike childhood-adolescence and adolescence-adulthood re-victimization patterns which have been extensively studied, multiple sexual abuse during childhood remains largely understudied.³² The aim of this study was to assess the role of gender in multiple sexual abuse victimization during childhood using data from CSA victims in Kaduna State, North-western Nigeria.

METHODS

This cross-sectional study was part of a larger project that reviewed medical reports of CSA victims retrieved from one of seven police area commands in Kaduna State, North-western Nigeria.³³ The primary aim of that project was to assess the magnitude and quality of care offered to CSA victims. Details about the study area and data extraction were described in the main paper.³³ The observation that nearly half of the victims were abused more than once necessitated this analysis.

The ethical approval for the study was obtained from Ahmadu Bello University Teaching Hospital’s Health Research Ethics Committee. Medical reports were included for review if they were generated between 2018 and 2021 and if the victim was a child below the age of 18 years. Only reports of CSA were included in the review. At the end of the review process, a total of 420 reports met the eligibility criteria and all were included in the review. Chi-square and Fisher’s exact tests were used to check for associations between multiple CSA experience and certain variables of interest including gender, age, familiarity with assailant, age and number of assailants. The analysis was repeated on male and female victims’ data subsets to identify any gender-specific associations. A P-value less than 0.05 was considered statistically significant.

RESULTS

Four hundred and twenty records were included in the analysis, consisting of 145 (34.5%) male and 275 (65.5%) female CSA victims. The socio-demographic characteristics of the victims and their assailants were described in the main review paper.³³ One hundred and ninety-seven (46.9%) victims were abused more than once. Table 1 shows the association between multiple CSA experience and certain characteristics related to the victims and their assailants. There was significant association between multiple CSA experience and male gender (χ²=11.99, p=0.001) and also with familiarity with assailant (χ²=13.63, p<0.001). There was, however, no significant association between multiple CSA experience and age of victim, age of assailant and number of assailants (Table 1).

Among male victims only, no significant association was found between multiple CSA experience and age of victim, victim’s familiarity with assailant, age of assailants as well as number of assailants as shown in the Table 2.

However, among female victims, a significant association was found between multiple CSA experience and older age of victims (χ²=8.57, p=0.036), being familiar with assailants (χ² =14.78, p<0.001) and older age of assailants (χ² = 8.13, p=0.017) as shown in the Table 3. No significant association was found between multiple CSA experience among female victims and number of assailants.

*Significant association.

^aFisher’s exact.

*Significant association.

DISCUSSION

This study examined the association between multiple CSA experience and gender of victims. About half of the victims were abused more than once. Previous studies have shown that this is a common pattern. In Abakaliki, for instance, a review of hospital records showed that about 36.4% of CSA victims were abused more than once.⁸ Another hospital-based study in Zaria noted that 70% of CSA victims seen over a 15-month period were abused more than once and in up to 60%, the same assailants were involved.⁷ Even in community-based studies, multiple sexual abuse is common. A study which examined the pattern of both contact and non-contact forms of CSA among secondary school adolescents in southeast Nigeria found that 70.9% were abused more than once.¹² The reason for this may be attributed to the outcome of the first abuse incident. Once a child is abused by a particular assailant, he or she becomes extremely vulnerable to a repeat abuse by that same assailant, who now knows about the child’s weaknesses and that they could be abused without any adverse consequences. The only deterrent would be if the abuse was discovered and actions were taken to either protect the child or punish the assailant.

In this review, multiple abuse was found to be significantly associated with male gender. This may be attributed to a greater tendency for male victims to delay or withhold disclosure compared to their female counterparts, thus, allowing abuse to persist for longer periods of time.²⁴ Several factors including shame, gender stereotypes, fear of being considered instigators rather than victims and fear of being considered homosexuals may deter male victims from disclosing abuse incidents.^34,35 Abuse disclosure is an important first step in the recovery process because it enables families, caregivers and communities to offer assistance, including immediate family protection, health-seeking for the victims, and in some cases, deterrent and legal actions against the assailants.

Another factor significantly associated with multiple CSA experience was familiarity with assailants. This association was suggested in the past by a study that examined the rates of re-victimization among CSA victims in the US.³⁶ The study found that victims abused by family members (incestuous abuse) had the highest rates of re-victimization compared to those abused by peers or non-familiar assailants.³⁶ An important likely mediator for this association is the proximity of victims to their assailants. Because familiar assailants are likely to be living together or close to their victims, they may have far more opportunities to abuse them compared to non-familiar assailants, who are typically restricted by the need to create the right circumstances every time they intend to abuse their victims.

Interestingly, while this association holds true among female victims, the study found no statistically significant association between multiple CSA experience and familiarity with assailants among male victims. In theory, two explanations may be proposed. In the first instance, previous studies have shown that male victims are most often abused by people outside the family.^24,35 It may be proposed that even though male and female victims share certain vulnerabilities, the two are likely to attract different profile of assailants due to their contrasting gender roles and divergent contexts of abuse. Secondly, multiple CSA victimization itself may be considered as a composite function of both victims’ vulnerabilities and assailants’ aggressiveness. Familiarity with and proximity to assailants are more likely to play a decisive role in multiple abuse situations enabled by victim’s vulnerabilities rather than in situations driven by assailant’s aggressiveness. Female victims tend to be abused by opportunistic assailants who exploit them primarily by virtue of their vulnerabilities, unlike their male counterparts, who are largely abused by purpose-driven aggressive assailants who preyed upon them outside their homes.

This review also found significant association between multiple CSA experience and older age among female but not male victims. While it is not immediately clear why this pattern was observed, a possible explanation may have to do with maturity of victims. Abusing a young female victim may provide little pleasurable experience and this may discourage her assailant from re-victimizing her. An older female victim, on the other hand, may provide pleasurable experience to her assailant and that may incentivize him to keep re-victimizing her, ignoring the fact that she is still an adolescent child. In addition, abusing older girls may cause less guilt to their assailants, who often rationalize their actions by believing their victims are matured enough to have sexual intercourse. In some cases, assailants often justify their actions by claiming their victims equally derived pleasure from the sexual encounters, especially if they did not disclose or complain to anyone after the abuse. An additional incentive that assailants often have for targeting older girls is that in the event of being caught, it would be more plausible to claim the sexual act was consensual. Such claims would be totally implausible if the victim was a very young child, say 5 or 6 years of age. Furthermore, while such counter claims from the assailants may not necessarily absolve them completely, they generally lessen the gravity of their crime and in most instances, shifts part of the blame to their victims, further complicating any attempt by the victims and their families to claim abuse.

Also, a significant association was observed between multiple abuse and older age of assailant among female but not male victims. it is not clear whether this was a result of more means and experience that often comes with age or other factors. Carefully-designed studies are therefore needed to further explore these associations between multiple CSA experience and sociodemographic profile of assailants.

This review has important limitations. The retrospective nature of the study and the problem of missing data that affected several variables rendered certain statistical analyses impractical. In this study, multiple logistic regression analysis would have provided more useful information since it could be used to control for potential confounding. Chi-square analyses used in this review could not achieve that and therefore, the results presented must be interpreted along with this understanding. Likewise, the paucity of published studies on problem meant that results reported in this review could not be contextualized and discussed with certainty. The review is therefore, at best, exploratory. More studies are needed to provide further insights on the dynamics of multiple CSA victimization as well as appropriate strategies needed to address it among other issues pertaining to CSA.

CONCLUSION

Nearly half of the victims in this review were abused more than once. Multiple CSA experience was associated with male gender. Among male victims, multiple CSA experience was not associated with age of victims, age of assailants, number and familiarity with assailants. This might be as a result of limited sample size or the tendency for male victims to be abused by non-familiar people outside their family settings. Among female victims, multiple CSA experience was significantly associated with older age of victims, older age of assailants and familiarity with assailants, attributed to maturity of victims, better experience of assailants that often comes with age, and greater role of vulnerability-related factors among female victims. More research is needed in this area to further understand the dynamics of multiple CSA victimization and provide appropriate recommendations.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by Ahmadu Bello University Health Research Ethics Committee

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