**4. Methodology**

116 Sexual Abuse – Breaking the Silence

report unwanted or forced sexual intercourse before the age of 18 years (Lalor 2004). Jewkes et al. surveyed 11, 735 South African women between the ages of 15 and 49 years about their history of rape during childhood. Overall, 1.6% reported unwanted sexual intercourse before the age of 15 years of age. 85% of child rape occurred between the age of 10 and 14 years and 15% between the ages of 5 and 9 years (Jewkes, Levin et al. 2002). In a study in Zimbabwe, Birdthistle reports that among unmarried, sexual active adolescents, 52.2% had experienced forced intercourse at least one time. 37.4% of first sexual intercourse acts were forced (Birdthistle IJ 2008). In a study of 487 university students in Tanzania, 11.2% of women and 8.2% of men reported unwanted sexual intercourse. The average age at the time of abuse was 13.6 years (McCrann D 2006). Collings et al (Collings 2002) surveyed a sample of 640 female university students in South Africa and found that 34.8% had experienced contact sexual abuse before the age of 18 years. Another study among high school students in South Africa (Nadu 2002), found that almost 20% were victims of parental or guardian sexual abuse. Additional research suggests that the prevalence of child sexual abuse in sub-

In the era of HIV infection with the highest mortalities in the sub-Saharan region documenting the characteristics of children who are at risk of being sexually abused is an

The current preventative strategies for children from acquiring HIV are enveloped in the Prevention of Mother to Child Transmission (PMTCT) and there are no studies in Zambia to characterise risk factors on children who may be sexually abused nor strategies to prevent

In a survey by Mathews et al (Mathews et al, 2011) of girls aged between 13 -24 years, respondents who lived in a rural environment were significantly less likely than those in an urban environment to report having experienced sexual violence before the age of 18. Compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence,

In the second quarter of 2003, Zambian police handled 300 cases of child rape and some experts believe that for every case reported another 10 go unreported. (Agence France-Presse 2003). The number of reported cases and the realization that these cases were likely to be the tip of iceberg, in combination with high HIV prevalence led to the identification of the need to establish a comprehensive multidisciplinary centre to train health workers in the recognition of CSA, to increase public awareness of CSA, to improve management of sexually abused children with an emphasis on preventing HIV acquisition and document

The aim is to identify risk factors of child sexual abuse in children reporting to the OSC and propose possible interventions. Currently the OSC is offering PEP to children who are at

risk of contracting HIV through sexual abuse. Other services offered include;

Saharan Africa is similar to other countries across the world (Lalor 2004).

important strategy to reduce horizontal transmission of HIV in children.

HIV acquisition in these vulnerable children as far as we are aware.

as did those who had had no relationship with her at all.

the characteristics and risk factors of sexually abused children.

**2. Rationale** 

**3. Objective** 

In most western countries Child Advocacy Centers (CACs) are not located within medical institutions and offer a more comprehensive package to include physical abuse as well as child neglect (Downing 2002, Hansen 1998). We chose to establish the multidisciplinary centre within the pediatric department because most the sexually abused children came to the attention of the health workers because of medical complications (Chomba,Kasese-Bota Haworth, Fuller, Amaya, 2006) and in order to offer PEP to abused children, which was only available at the UTH. The centre would not provide services for isolated physical abuse cases nor neglected children.

The One Stop Centre was established in the pediatric department on 26th April 2006. A location was selected where there was minimal foot traffic, and there are no conspicuous notices indicating its function to help preserve the confidentiality of the children and their guardians attending the center. The Centre included a physical examination room and several interview rooms including one with a two way mirror, microphone and speakers which allows one person to interview (usually a medical person) whilst the police officers and counsellors take notes from another room. The centre is equipped with comfortable child-friendly waiting facilities (TV set, toys and educational materials).

The Centre has employed one medical doctor who oversees medical examinations and attends to court cases, one clinical officer who performs physical examinations; one police officer who documents on police medical forms and ensures that they are delivered to the prosecutors; one social worker who follows up children in the community and advises on rehabilitation; and three nurses who assist the physician and the clinical officer.

Intake interviews are conducted with the caregiver and child separately (if the child is able). Information on demographic characteristics and abuse history is collected. A medical/laboratory form includes the following tests: HIV, RPR, pregnancy, Hepatitis B and forensic specimens (High vaginal swab for wet prep, gram stain and culture to identify gonorrhoea, trichomonas, and spermatozoa).

Mental health assessments for the youth include the Post-traumatic stress disorder – Reaction Index, the Strengths and Difficulties Questionnaire, and My Feelings About the Abuse. This last measure specifically examines the construct of shame, which is considered to be critical in the Zambian culture. The mental health assessment administered to the caregivers about the abused child is the Child Behaviour Checklist.

A systematic flow has been designed to promote excellence in the care of sexually abused youth.


Risk Factors in Sexually Abused

for only 7% (Table 2) (Figure 1)

Table 2. Who is the Abuser?

Fig. 1. Summary of Abuser Information

26.6% of these children were reported to be orphans (Table 3)

**Known Adult** 

**Multiple people at the same** 

with the analysis.

Children Reporting to the One Stop Centre at University Teaching Hospital in Zambia 119

Of the 1068 children who reported to the centre only 628 (59%) had complete data consistent

Most of the abusers are non relative adults known to the child (66.4%). Strangers accounted

**Father** 18 2.9

**(Neighbor, teacher)** 417 66.4 **Stranger** 44 7.0

**time** 5 .8 **Grandfather** 4 .6 **Auntie** 1 .2 **Uncle** 33 5.3 **Cousin** 13 2.1 **Sibling** 11 1.8 **Don't know** 82 13.1 **Total** 628 100.0

**Frequency Percent** 


Drugs used for PEP were Zidovudine 240mgs/m2 in combination with Lamivudine 4mg/kg (Combivir) twice daily for 28 days. No syrups were available initially leaving the very young children without any PEP options until later when syrup formulations were made available. Initially, a two drug regimen was recommended as effective (WHO, Geneva Report 2006) though currently a 3 drug regimen is in place in accordance with current guidelines

### **5. Results**

For the purposes of this chapter, data for 2010 was analysed. A total of 1068 children were seen during this period.

Of the total 1068 children , most of the abused children were girls 1042 (97.6%),boys 46 (2.4%) were boys. Those most likely to be abused were aged between 0-5 years 246 (23%), 6- 10 years 223 (20.9%) and 11 and 16 599 (56.1%) (Table 1).


Table 1. Age and Sex Distribution

Of the 1068 children who reported to the centre only 628 (59%) had complete data consistent with the analysis.

Most of the abusers are non relative adults known to the child (66.4%). Strangers accounted for only 7% (Table 2) (Figure 1)


Table 2. Who is the Abuser?

118 Sexual Abuse – Breaking the Silence

forms are completed.

form.

guidelines

**5. Results** 

seen during this period.

Age

 Sex

Table 1. Age and Sex Distribution

a. If abuse occurred within 72 hours, the child is immediately brought to a nurse to take the necessary blood tests, and administer PEP if appropriate. After blood tests and PEP administration, the intake forms and the questionnaire for assessment of level of trauma are completed by the nurse or social worker. A physical exam is completed and the UTH treatment form and police medical

b. If abuse did NOT occur within 72 hours, the child/care-giver is interviewed by one of the staff , blood tests are performed, a physical exam of the child is conducted and the forms are completed as well as the police medical form are completed (The police officer stationed at the centre completes the relevant potion of the

c. If a child is HIV positive, they are referred to the Paediatric Antiretroviral Therapy

d. If a child is found to be pregnant, she is referred to the Antenatal and/or

e. If abuse did NOT occur within 72 hours, the child/care-giver is interviewed by one

Drugs used for PEP were Zidovudine 240mgs/m2 in combination with Lamivudine 4mg/kg (Combivir) twice daily for 28 days. No syrups were available initially leaving the very young children without any PEP options until later when syrup formulations were made available. Initially, a two drug regimen was recommended as effective (WHO, Geneva Report 2006) though currently a 3 drug regimen is in place in accordance with current

For the purposes of this chapter, data for 2010 was analysed. A total of 1068 children were

Of the total 1068 children , most of the abused children were girls 1042 (97.6%),boys 46 (2.4%) were boys. Those most likely to be abused were aged between 0-5 years 246 (23%), 6-

1068 100.0

Prevention of Mother to Child HIV Transmission (PMTCT) clinic.

(ART) Clinic for further management and follow up.

of the staff, blood tests are performed.

10 years 223 (20.9%) and 11 and 16 599 (56.1%) (Table 1).

Frequency Percent

0-5 Years 246 23.0 6-10 Years 223 20.9 11-16 Years 599 56.1 Total 1068 100.0

F 1042 97.6 M 26 2.4

Fig. 1. Summary of Abuser Information

26.6% of these children were reported to be orphans (Table 3)

Risk Factors in Sexually Abused

**Who referred you to the** 

**Abuse Reporting Time** 

**PEP Administration** 

genital pain. (Table 6)

**clinic?**

Children Reporting to the One Stop Centre at University Teaching Hospital in Zambia 121

Of the 628 children reporting to the centre 86% were referred by the police. Most of the

Frequency Percent

children reporting within 72hrs of abuse at the OSC were given PEP (Table 5).

Medical facility/doctor 55 8.8

Police 540 86.0

Parent/caregiver/relative 20 3.2

Friend 3 .5

VSU 7 1.1

Total 625 99.5

No 245 39.0

Yes 353 56.2

Don't know 30 4.8

No 6 1.7

Yes 347 98.3 Total 353 100.0

Table 5. Refferal, Reporting Time and PEP Adminstration of CSA victims

Total 628 100.0

At the OSC physical force was used in about 20% of the victims of CSA, 23.7% playful/gentle coaxing was applied. 52% had no presenting complaints and 28.2% had

Other 3 .5


Table 3. Number of Orphans

15.6% reported that the were living in the same household as the abuser during the time of the abuse. About 24% of the children in contact with the abuser (Table 4).


Table 4. Abuser location and Contact with child

15.6% reported that the were living in the same household as the abuser during the time of

**FREQUENCY PERCENT** 

**Orphan Frequency Percent** 

**No** 461 73.4

**Yes** 167 26.6

**Total** 628 100

the abuse. About 24% of the children in contact with the abuser (Table 4).

**No** 508 80.9

**Yes** 98 15.6

**Don't Know** 22 3.5

**Total** 628 100.0

**No** 480 76.4

**Yes, seen around** 140 22.3

**Yes, unsupervised contact** 3 .5

**Yes, in court, VSU,police** 4 .6

**999** 1 .2

**Total** 627 99.8

**Total** 628 100.0

**Did abuser live in the child's household during the abuse?** 

**Since the abuse had been disclosed, does the child has any contact with the abuser?** 

Table 4. Abuser location and Contact with child

**Is this child an** 

Table 3. Number of Orphans

Of the 628 children reporting to the centre 86% were referred by the police. Most of the children reporting within 72hrs of abuse at the OSC were given PEP (Table 5).


Table 5. Refferal, Reporting Time and PEP Adminstration of CSA victims

At the OSC physical force was used in about 20% of the victims of CSA, 23.7% playful/gentle coaxing was applied. 52% had no presenting complaints and 28.2% had genital pain. (Table 6)

Risk Factors in Sexually Abused

putting females at higher risk of HIV acquisition.

in injuries. However this study was retrospective.

health authorities as opposed to when the abuser is a stranger.

economically disadvanted and lack adult protection from abuse.

evaluate the prevalence of this in these children.

factors associated with sexual abuse.

**7. Conclusion** 

**8. Limitations** 

Children Reporting to the One Stop Centre at University Teaching Hospital in Zambia 123

(Zambia NAC 2009). These high rates amongst females may suggest that CSA may be

There is a high proportion of children aged below 10 reporting to the OSC and 23% of these are aged below 5 years. In Zambia, the school enrolment is between 6 to 7 years for the first grade suggesting that about 20% of the children are being abused right in the home. The statistics also show that 66% of the abusers were non-relative adults (neighbours, teachers, etc). Only 7% was attributed to strangers. This finding explains the absence of clinical presenting complaints and lack of pathological findings on examination inspite of the history of physical force having been used in 20% of those who were sexually abused. This could be attributed to delayed in reporting to the OSC allowing for healing which occurs rapidly in children. However in a review of CSA literature done by Pitche (Pitche 2005), though 30-60% abusers were known to the child, 97% of cases had penetrative sex resulting

Among the 628 children seen, 56.2% reported within the 72hrs required leaving a large number of children who did not qualify for PEP. This also has been shown in several studies (Birdthistle et al, Bablet al 2000, Chesshyre et al 2009,Speight et al 2006) that PEP as a strategy for preventing HIV acquisition has not been very successful. This may be due to the fact that the very nature of the abuse being committed by some trusted adult or on who the child depends on for upkeep becomes the abuser. This may lead to delays in reporting to

In Zambia a large number of children are orphans. One estimate is that 1.656 million children, or more than one-third of those under the age of 15, are orphans who have lost one or both parents (Kelly 2000). Of the 628 children who had complete data 26.6% were orphans.In another study (Birdthistle 2009) 30.1% reporting to a the facility were orphans. This puts this group of children at high risk of sexual abuse.They more likely to be greatly

Though the OSC set-out to screen for syphilis which is known to increase HIV aquisition (Dunkle et al 2006, Pitche 2005 ) most children did not have this labortatory test done due to the shortage of re-agents. Hepatitis B similarly was not performed consistently for us to

Child sexual abuse is prevalent in Lusaka.The female child is by far the most vulnerable and there needs to urgent policy and support for prevention of CSA for this vulnerable group. Communities need to be sensitised on the dangers of CSA as numbers reporting to the OSC are the tip of the iceberg. The 23% of children abused aged 0-5 years pose a great challenge as this is a helpless vulnerable group when abuse is occurring within the home.Understanding family dynamic should be part of the prevention strategy of CSA. There needs to be more resources and better tools for collection of data to better unravel risk

The data was not obtained in a research setting but in a clinic setting where the workers are busy with managing acute cases. Lack of adequate human and material resources led to


Table 6. Methods used to engage the child and presenting signs and symptoms

### **6. Discussion**

Child sexual abuse in the sub-saharan region is a risk factor to the acquisition of HIV infection ( Dunkle 2006, UNICEF 2001, WHO 2006). Risk factors to child sexual abuse are evaluated in this chapter to help guide health workers, psychosocial counsellors, organisations and other professionals tasked in the protection of children to help manage sexually abused children. Planning strategies to mitigate against child sexual abuse requires understanding risk factors associated with CSA.

The female child was by far more likely to be abused. Other studies in the sub-Saharan region have reported similar findings (Birdthistle et al2009, Mathew et al 2011). Zambia has one of the highest HIV prevalence rates 14% (Zambia NAC 2009) and females aged between 15-19 are more likely to be HIV infected 16% as compared to their male counterparts 10% (Zambia NAC 2009). These high rates amongst females may suggest that CSA may be putting females at higher risk of HIV acquisition.

There is a high proportion of children aged below 10 reporting to the OSC and 23% of these are aged below 5 years. In Zambia, the school enrolment is between 6 to 7 years for the first grade suggesting that about 20% of the children are being abused right in the home. The statistics also show that 66% of the abusers were non-relative adults (neighbours, teachers, etc). Only 7% was attributed to strangers. This finding explains the absence of clinical presenting complaints and lack of pathological findings on examination inspite of the history of physical force having been used in 20% of those who were sexually abused. This could be attributed to delayed in reporting to the OSC allowing for healing which occurs rapidly in children. However in a review of CSA literature done by Pitche (Pitche 2005), though 30-60% abusers were known to the child, 97% of cases had penetrative sex resulting in injuries. However this study was retrospective.

Among the 628 children seen, 56.2% reported within the 72hrs required leaving a large number of children who did not qualify for PEP. This also has been shown in several studies (Birdthistle et al, Bablet al 2000, Chesshyre et al 2009,Speight et al 2006) that PEP as a strategy for preventing HIV acquisition has not been very successful. This may be due to the fact that the very nature of the abuse being committed by some trusted adult or on who the child depends on for upkeep becomes the abuser. This may lead to delays in reporting to health authorities as opposed to when the abuser is a stranger.

In Zambia a large number of children are orphans. One estimate is that 1.656 million children, or more than one-third of those under the age of 15, are orphans who have lost one or both parents (Kelly 2000). Of the 628 children who had complete data 26.6% were orphans.In another study (Birdthistle 2009) 30.1% reporting to a the facility were orphans. This puts this group of children at high risk of sexual abuse.They more likely to be greatly economically disadvanted and lack adult protection from abuse.

Though the OSC set-out to screen for syphilis which is known to increase HIV aquisition (Dunkle et al 2006, Pitche 2005 ) most children did not have this labortatory test done due to the shortage of re-agents. Hepatitis B similarly was not performed consistently for us to evaluate the prevalence of this in these children.
