DR. EMADAU C. PAPA Registrar, Mental Health, Moi University, School of M edicine

1. PSYCHOLOGICAL OUTCOMES OF SEXUAL ABUSE: A CASE REPORT FROM MOI TEACHING AND REFERRAL HOSPITAL (MTRH) DR. EMADAU C. PAPA Registrar, Mental Health, Moi University, School of Medicine

2. MTRH • Moi Teaching and Referral Hospital (MTRH) is the second National Referral Hospital in Kenya after Kenyatta National Hospital (KNH). • The Hospital is located along Nandi Road in Eldorettown, UasinGishu County, in the North Rift region of Western Kenya. • Serves Nyanza, North rift and Western provinces of Kenya with a catchment population of 16.24million(KNBS-2010 Kenya population Census survey report).

3. CASE SUMMARY • A 17 year old house help who had been sexually abused severally by her employer • She attempted suicide by drinking approximately 50ml of triatix upon being chased away by the culprit’s wife without being given a chance to explain her part of the story. • She was managed using gastric lavage, fluids and counseling. • One week later she is coping well back at home and is due for follow up in a week. • This case report summarizes the impact of sexual abuse in the family

4. INTRODUCTION AND BACKGROUND • Sexual violence occurs any time a person is forced, coerced, and/or manipulated into any unwanted sexual activity. It violates a person’s trust, autonomy and feeling of safety. • The range of sexual violence includes rape, incest, child sexual assault, ritual abuse, date and acquaintance rape, statutory rape, marital or partner rape, sexual exploitation, sexual contact, sexual harassment, exposure, human trafficking and voyeurism.

5. INTRODUCTION AND BACKGROUND 2 • Rape is a crime. It is motivated by the need to control, humiliate, and harm. Rapists use sex as a weapon to dominate and hurt others. • It may also be motivated by sexual desire if the perpetrator lacks/is unable to find opportunity for sex. • Whenever a person experiences sexual assault, the idea that they will not be believed, the fear and pain associated with their lived experiences often acts as a deterrent to seeking help.

6. INTRODUCTION AND BACKGROUND 3 • “Research suggests that marital rape accounts for 25 percent of all rapes” (Bachman et al., 1994). • Sexual assault between persons in a relationship, or what is called intimate partner rape (IPR), occurs in various ways – not just rape’’. • “At least 50 percent of college students’ sexual assaults are associated with alcohol use” (Abbey, 2002).

7. INTRODUCTION AND BACKGROUND 4 • A rapists is more likely to be a serial criminal than a serial rapist. • 46% of rapists who were released from prison were re-arrested within 3 years of their release for another crime. (2002 Recidivism of Prisoners Released in 1994 Study).

8. INTRODUCTION AND BACKGROUND 5 • Approximately 2/3 of rapes were committed by someone known to the victim. • 73% of sexual assaults were perpetrated by a non-stranger • 38% of rapists are a friend or acquaintance, 28% are an intimate. • 7% are a relative of the victim. (U.S. Department of Justice. 2005 National Crime Victimization Study).

9. INTRODUCTION AND BACKGROUND 6 • Nairobi, 27 October 2005 (IRIN) - Sexual violence is increasingly prevalent in Kenya and police statistics show that more than 2,800 cases of rape were reported in 2004 - an increase of close to 500 compared to the previous year. • A demographic health survey carried out by the Ministry of Planning in 2003 revealed that at least half of all Kenyan women had experienced violence since the age of 15, with close family members among the perpetrators.

10. METHODS • Patient interview • Family contacts interview • Review of patient’s medical record.

11. CASE PRESENTATION • A 17 year old female house help was brought in by neighbours reportedly having taken triatix four hours prior to the time of admission because she was so angry that her employer, who is also her aunt unconditionally terminated her services and chased her away. • On arrival at casualty,she was nauseated, vomiting, lethargic and drooling saliva. • She is a third born in a family of five. The parents are peasant farmers, she attained form 2 education, average performer and lacked school fees to progress with her education. There was no family or personal history of substance use, prior psychiatric illness history or problems with the law. • Her vitals were fairly stable, she was fully conscious and had epigastric tenderness. Other systems examination was generally normal.

12. CASE PRESENTATION 2 • On mental state examination, she appeared well kempt, and oriented, but was shy, did not maintain eye contact, her mood was low, with a congruent affect. She had normal speech, cognition, memory and insight. • A complete blood count, urinalysis, renal function test,andserum electrolytes were normal, She was HIV negative and was admitted to the medical ward.

13. MANAGEMENT • At casualty gastric lavage was successfully performed, put on intravenous fluids, lasix, esomeprazole, bathed and changed. • On day two in the ward and stable, she was counseled and in the process, she opened up and disclosed that the household head had been forcing her to having sexual activity with him and that it had happened repeatedly untill when his wife caught them in the act. • She was then expelled from the house and in her bitterness she took poison because the household head did not side with her, an eventuality that left her feeling rejected and hopeless. • The patient also reported that she did not intend to die but attract attention.

14. MANAGEMENT 2 • Working with the social worker the mother was traced and came to hospital, the patient was further taken through individual psycho education, social and occupation counseling. • It was established that the patient no longer had suicidal ideations or plan and she was motivated to live a positive life going forward. • The patient’s mother and the employers (Man and wife) were also counseled.

15. OUTCOME AND FOLLOWUP • The perpetrator reconciled with the victim as well as with his wife during one of the counseling sessions. • The family members opted to solve the issue with the village elders and declined to press charges and on the third day the patient was discharged and scheduled for follow up in the psychiatric and medical out patient clinics. • One week later she is coping well back at their home and she is due for follow up in a week.

16. CONCLUSSION • This case clearly demonstrates the effects of sexual abuse in the family setting that included pain (physical and emotional), guilt as they still believe it is somehow their fault, erosion of family harmony (marital discord), post traumatic stress disorder, depressive disorder, suicidality, social and occupational strain, potentially sexually transmitted diseases among others. • ‘’They begin to see the connection between their childhood abuse and their damage: a lifetime inability to trust, or to maintain intimate relationships, or to experience religious transcendent faith, or to stay unaddicted’’ (Kelly Clark, For The Register-Guard,2007).

17. CONCLUSSION 2 • In this case the victim was sexually abused by her aunt’s husband with whom they lived under the same roof and the incident took place in the home setting. • This finding concurs with a study done by the United States Department of Justice, 2005; National Crime Victimization Study. found; • Approximately two thirds of rapes were committed by someone known to the victim, • 73% of sexual assaults were perpetrated by a non-stranger, • 38% of rapists are a friend or acquaintance, • 28% are an intimate, • 7% are a relative”.

18. CONCLUSSION 3 • Another study by the United States found : • More than 50% of all rape/sexual assault occurred within 1 mile of their home or at their home, • 84% of victims reported the use of physical force. (Department of Justice, Bureau of Statistics. 1997 ;Sex Offenses and Offenders Study)

19. CONCLUSSION 4 • A demographic health survey carried out by the Ministry of Planning in 2003 revealed that at least half of all Kenyan women had experienced violence since the age of 15, • close family members among the perpetrators. • The chilling statistics, however, do not tell the full story of the emotional devastation of individual rape victims.

20. CONCLUSSION 5 • Whenever a person experiences sexual assault, the idea that they will not be believed, the fear and pain associated with their lived experiences often acts as a deterrent to seeking help. • The majority people who commit sexual assault are everyday people and most victims/survivors of sexual assault know their perpetrators.

21. RECOMMENDATIONS • Community sensitization and education - pointers and triggers of the vise and on evasive mechanisms. • Education/retraining of health workers on how to identify and promptly respond to sexual abuse incidents. • More resources and energy need be channeled/allocated to this campaign. • Policy review to better address sexual violence among both males and females.