Dr Ijeoma Nnodim is a lecturer and consultant paediatrician at Imo State University and Imo State University Teaching Hospital respectively. She talks to ALEXANDER OKERE about the prevention and treatment of violence against women and girls, including child sexual abuse, which seems to be on the increase in Nigeria
When is a female or male child or minor said to have been defiled?
The term, ‘defilement of a child,’ used here, is more accurately called child sexual abuse. Child sexual abuse is any act in which a child is used for the sexual stimulation of an adult (or another child). Under the Child Rights Act, a child or a minor is someone who is under 18 years of age. Note that this sexual abuse can be the non-touching type, such as looking at a child’s naked body for sexual stimulation (voyeurism), showing one’s genitals to a child (exhibitionism), exposing a child to pornography, etc.
Child sexual abuse can also involve touching and this includes the more notoriously known rape. This can be penetrative, in which an object or a body part is used to penetrate the vagina, anus or mouth. Or it can be non-penetrative.
What are the physical signs that show that a child has been defiled?
In some cases, physical force or violence is not used because the perpetrator tries to gain the trust of the child over a period of time in a process known as ‘grooming’. Some physical signs of sexual abuse in both male and female children include unexplained genital injury. This might be observed as pain on washing the genital area or bloodstained panties or clothes. It can also be given away by bleeding, bruising or swelling in the genital areas or difficulty in walking or sitting.
Another sign can be bed-wetting or the child defecating on themselves. When this occurs at an age beyond which a child should have achieved control, it should be looked into. For urinary continence (control), the normal age is from five years of age and for faecal control, it is from four years of age. Note that there are medical causes of urinary or faecal incontinence (lack of control). Recurrent vaginal or urinary tract infection in girls is another red flag that might point to sexual abuse. For vaginal infection, it can show as a vaginal discharge. For a urinary tract infection, this can manifest as pain on urination, frequent urination, foul-smelling urine, etc. Other signs that may be seen in girls include cuts and bruises around the genitals, a bruised or absent hymen, the presence of semen around or in the genitals and of course, pregnancy. Some signs that may be seen in boys include cracks, pain or bleeding in the anus, and discharge from the genitals.
What are the behavioural signs?
A sexually abused child can become clingy and/or irritable, especially younger children. Some show a regression in school performance or a delay in achieving milestones. Other behavioural signs include eating disorders, nightmares, depression, poor self-esteem, unexplained changes in behaviour or personality, becoming withdrawn and having few friends, knowledge of adult issues inappropriate for the child’s age and inappropriate sexualised behaviour. An example of inappropriate sexualised behaviour includes a seven-year-old girl masturbating repeatedly at school, a five-year-old boy forcing another to indulge in mutual fondling of genitals, and children imitating sexual intercourse.
What is the first thing a parent should do if they suspect that their child has been defiled?
Finding out that one’s child has been sexually abused can be very distressing for a parent. The first thing that should be done is to take the child to hospital to get medical attention (this should involve the health worker asking some questions and doing a thorough physical examination), do some laboratory investigations and start treatment with some medications which might include a contraceptive (depending on the age of the child and timing/duration of the sexual abuse), treatment for sexually-transmitted infections and a preventive medication against Human Immunodeficiency Virus infection. It is also important to get emergency medical care for those with extensive physical injuries.
Are there different ways or stages of examining a child who has been sexually assaulted or defiled?
An examination of a child who has been sexually abused as done by a physician and documented is very important. There are no specific stages or particular ways but the examination is usually a complete physical examination, including of the mouth and anal region. This examination is done under good illumination with or without magnification and a trained eye will also pick up things like bruises, cuts, bite marks, etc. Physical findings may be observed if the sexual abuse occurred recently, e.g. within 72 hours. In many cases, especially when it has been going on for a while, there may be little or no physical signs.
What are the other common sexually transmitted diseases or infections that a defiled minor could be exposed to?
A sexually abused child can be exposed to sexually-transmitted infections such as HIV, gonorrhoea, syphilis, hepatitis B infection and bacterial vaginosis. Others include infections caused by chlamydia trachomatis, herpes simplex virus, and Treponema vaginalis.
What are the signs or symptoms to look out for?
Signs and symptoms of sexually transmitted infections include clear, white, greenish or yellowish discharge from the genitals, itching or irritation around the genitals, pain on urination, sores or bumps around the genitals. For HIV infection, it could manifest as recurrent illness, poor growth, etc.
At what stage is surgery required?
When extensive physical damage has been inflicted, such as causing a fistula (connection) between two body cavities, surgery may be necessary. Large cuts and tears may also require stitching.
Does defilement affect puberty?
Young girls who are sexually abused may undergo puberty earlier than their peers as shown by some studies. This has been postulated to be caused by the release of stress hormones that jump-start puberty eight months to one year ahead of the usual time. These hormones are released in the body during high-stress situations such as sexual abuse. If a girl who has started menstruating is raped, she can get pregnant. Menstruation can start as early as nine years in some girls and there have been cases of girls that got pregnant at that age. Although the average age of menstruation is 12 to 13 years, recently, girls are starting menstruation earlier.
What are the risks involved when a minor conceives?
The body of a child is not in any way prepared to carry a pregnancy or deliver a child. The pelvis does not fully widen until a girl is in her late teens, so young girls may not be able to push the baby through the birth canal. If they labour, they may die. If they survive it, they may develop vesicovaginal fistula (VVF), which causes urine and faeces to leak from the vagina.
What can parents do at that stage?
The parents should see a doctor who will advise them on the best course of action.
Is there any other long-term effect of defilement that could affect the child’s reproductive organs?
Stress-induced early puberty and the early intercourse (rape) also put the child at a higher risk of reproductive cancers later in life.
What are the measures parents can take to avoid exposing their children to defilement or sexual assault?
Parents should show interest in the day-to-day activities of their lives. Ask them what they did during the day and who they did it with. This includes family members, because in many cases, the perpetrator of child abuse is a known, trusted person. Know the people in your child’s life, including other children and adults. Talk about these people and ask questions. Choose your child’s caregivers carefully. Know the warning signs of child sexual abuse such as the physical and behavioural signs discussed earlier in order to step in at once.
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