Sexual Assault in the Department of Obstetrics and Gynaecology of the Bamako ’ s 5 th Municipality Medical Center

Background: The authors report cases of sexual assault reported to the obstetrics and gynecology department of the Bamako’s 5th municipality medical center during a prospective study of eight months from 1st January to 31st August 31st, 2012. Results: Twenty-one cases of assault were reported out of a total of 13,482 consultations, representing a frequency of 0%, 15%. Most victims were represented by students and accounted 43% of the study population. In 76% of cases the victims knew their assailant. The type of sexual contact was genito-genital vaginal penetration in 67% of cases and the condom was used in only one case. The average time before consultation was 3 days. The preventive ARV treatment was administered in 24% of cases and emergency contraception in 43% of cases. Conclusion: Sexual assault is common in Bamako. The reality is probably underestimated because many cases are not reported. The victims are mostly children and adolescents. The risk of transmission of STIs and HIV is very high during the sexual assault. Education and awareness of the population are essential for early consultation. Training of health workers to care for victims of sexual assault is needed.


Introduction
Sexual violence affects every year millions of people worldwide.It undermines the honor of the person and his family and may have repercussions in long term.
In 1997, WHO [1] estimated that at least 20% of women worldwide had suffered during their lives of physical or sexual abuse.
In 2004, sexual offenses accounted for 9% of all overall crime in France [2].In the US, approximately 32,000 pregnancies occur each year due to sexual assault [3].
In Mali, the frequency of sexual assault was 0.12% according to a study conducted by Drama B. in 2002 [4].The consequences of these assaults on victims could result in trauma, gynecological and psychological injuries.The purpose of this study was to investigate cases of sexual assault seen in the Bamako's 5 th municipality medical center in the purpose to contribute to better management.

Material and Method
The study was conducted in the obstetrics and gynecology's department of the Bamako's 5 th municipality medical center.It was a descriptive prospective study over a period of eight month from January 2012 to August 2012, on cases of sexual assault seen and managed in the obstetrics and gynecology's department during the study period.The Data were collected from clinical records and consulting records using a survey sheet.
The variables of interest were: age, marital status, occupation, origin, circumstances of the sexual assault, the lesions observed, the profile and the number of aggressor, additional examinations and care.Entry and data analysis were performed using the Epi-Info Version 6.0 software

Epidemiology
Frequency During the study period, we received 21 cases of sexual assault among 13 482 patients who came for consultation, representing a frequency of 0.15% Demographics Age: The mean age of our patients was 18 years with extremes of 7 and 29 years.The distribution of sexual assault by age group is as follows: • 7 -9 years: 2 cases (9.5%).
Marital status: The single women accounted for 86% of the study population while married women representing 14%.
Profession: out of a total of 21 patients, students accounted for 43%.The distribution of victims by occupation is as follows: • Students: 9 cas (43%).

The profile and the number of aggressor
The age of the aggressors: The mean age was 26 years with extremes of 17 and 33 years.In 12 cases there was only one assailant and in other cases there were two and more assailants.
Table 1 below shows the distribution of patients by number of aggressors.

Circumstances of Sexual Assault
The time of sexual assault According to the time, the distribution of victims of aggression was: • 08:00 -18:00 Hours: 10 cases (48%).
Fifty two percent of sexual assaults occurred after sunset while 48% occurred in the day.

The place of sexual assault
Fifty two percent of sexual assaults occurred at homes while 29% occurred in an uninhabited area.

The type of sexual contact
In thirteen cases (61.9% of the study population), it was vaginal penetration while in 5 cases (23.8% of the study population) it was other types of contact.The distribution of victims by sexual contact types is as follows: • Genito-genital penetration: 13 cases (61.9%).
The relationship between the victim and the aggressor.
The perpetrators were of the family circle in 33% of cases, Known by the victims in 43% of cases and unknown in 24% of cases.

The use of means of protection
The condom was used as protection in only 1 case.

Clinical Data
The average time before consultation The distribution of victims according to the consultation period was as follows: • Within 1 st day: 5 cases (23.8%).
The mean of consultation was 8 days.Twelve patients (57% of the study population) was seen within the 1 st to 7 th day.

The pattern of injuries
Physical examination allowed to observe bodily harm to such abrasions in 14% of cases.Lesions of bruising type at the vulva in 9 cases and a sore in one case.Lesions of tears at the hymen were present in 6 cases (28.5%).

Para Clinical Aspects
All cases of sexual assault seen in the department, after the clinical examination, the following sample's laboratory investigation were requested: • the search of sperm in the genital tract: The presence of sperm was found in one case.
• the immunological pregnancy test: it was performed in 19 cases with negative results.However it was not performed in 2 cases because the victims were 7 and 8 year old and were not in the puberty period.

Management
• Psychological support was provided to all victims by a psychologist.
• Antibiotics per os and local care based on clinical the findings were provided to 14 cases.Tetanus prophylaxis and immunization were given to these patients.
• Post coital contraception was given to all victim of childbearing age seen within a period of 72 hours after the assault.
• HIV infection prophylaxis was provided to 7 victims after they had a negative serology (5 case within 24 hours, 2 after 48 hours).
• Prevention of hepatitis B infection through vaccination was provided to 6 patients after they had a negative serology.Twelve cases could not benefit, due to lack of financial means.

Follow up of the Victims
Medical follow up was recommended for victims with a first appointment at 1 month and a second appointment at 3 months.
For the first appointment, they benefited a medical consultation and immunological management of sexual assault it is imperative to prevent STIs and HIV, especially when the victim is seen earlier.For the relationship between the victim and the aggressor, most studies show that the perpetrator was known and familiar to the victim.This link was reported in 76% of cases in our study, 57.9% of cases for Buamba-Bamanga in Congo Brazzaville [2], 76% of cases for Lankoande in Burkina Faso [10], 70% for Faye Dieme in Senegal [5] and 92.4% for Mbassa in Cameroon [7].

Clinical Aspects
Our average period before consultation of 8 days is similar to that in Burkina which is 8.2 days [12] and lower than what Mbaye reported in Senegal which is 4 weeks [14].
This long delay is due to the disco; fort of families to discuss issues that affect family honor, especially when the perpetrator is a relative of the victim.often preferred <washing dirty linen within family>.It is when, it appears obvious disagreements that the family brings the problem to the health and judicial authorities.The lesions at the hymen were identified in 28.5% of cases.Traore in Mali has found those lesions in 13.48% of cases [15], while Faye Dieme reported those lesions in 54.5% of cases [5].

Para Clinical Aspects
The results of various blood tests were negative in the first investigations.Search for sperm came back positive in one case.The high costs of investigations (about 34 US $) were in the charge of the family pending a hypothetical repayment by aggressor after a trial in court or a settlement.

Therapeutic Aspects
We provided oral antibiotics and local care in 14 cases.The morning after pill was administered to all victims of childbearing age.Prophylaxis for HIV infection was administered in 7 cases.The morning after pill, antibiotic therapy and prophylaxis for HIV infection were performed in other studies [5] [12] [14] for victims seen earlier for consultation.

Follow up of the Victims
In our study, the 3rd month follow-up, we reviewed 7 victims, and the findings were unremarkable in 6 case.In 1 case the HIV test was positive.Many cases of HIV/AIDS have been reported after sexual assault in South Africa, Cameroon and Congo-Brazzaville [7] [13] [16].After sexual assault especially within 24 hours, the practitioner needs to initiate prophylactic treatment of HIV infection for 1 month, as it is difficult to take samples from the aggressors.

Conclusion
Sexual assault is common in Bamako.The reality is probably underestimated because many cases are not reported.The victims are mostly children and adolescents.The risk of transmission of STIs and HIV is very high during the sexual assault.Education and B. Moussa et al. awareness of the population are essential for early consultation.Training of health workers to care for victims of sexual assault is needed.

Table 1 .
Distribution of victims according to the number of aggressors.

Table 2 .
Distribution of victims depending on venue of the sexual assault.