Sexual Assault Magnitude, Complications and Associated Factors among Females Who Visited Gynecologic Outpatient Department of Hawassa University Comprehensive Specialized Hospital

Sexual assault is a major form of sexual violence affecting one out of every ve women in the world. It is a complex problem with many consequences including sexually transmitted infections, posttraumatic stress disorder and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Objective Cross sectional study was conducted from January 1 to October 30, 2019. Self-administered questionnaire developed using variables taken from WHO multi-country study on women health and from sexual violence medical evaluation certicate format were used to collect data. Descriptive analysis was done on sexual assault related characteristics and binary and multivariate logistic regression analysis were done to identify factors associated with sexual assault. variables taken from multi-country from evaluation certicate The magnitude of sexual assault among found to be 10.8%. 25% of the victims tested for pregnancy were positive and 7% were positive for Hepatitis B and Trichomonas vaginalis. Our study also revealed that females and were directly being a of sexual


Abstract
Background Sexual assault is a major form of sexual violence affecting one out of every ve women in the world. It is a complex problem with many consequences including sexually transmitted infections, posttraumatic stress disorder and risk of unintended pregnancy in reproductive-aged survivors of sexual assault.

Objective
To assess the magnitude, complication and factors associated with sexual assault among female visited gynecologic outpatient department of Hawassa University Comprehensive Specialized Hospital.

Methods
Cross sectional study was conducted from January 1 to October 30, 2019. Self-administered questionnaire developed using variables taken from WHO multi-country study on women health and from sexual violence medical evaluation certi cate format were used to collect data. Descriptive analysis was done on sexual assault related characteristics and binary and multivariate logistic regression analysis were done to identify factors associated with sexual assault.
Results 399 clients were participated in the study and prevalence of sexual assault was 10.8% (43) of which 79.1% (34) of the victims were under the age of 18 years. 25% of the victims tested for pregnancy were positive and 7% (3)

Conclusions
In this study, Age, marital status, monthly income and educational level were signi cantly associated with sexual assault.

Plain English Summary
Sexual assault, which includes rape, attempted rape, sexual abuse and sexual exploitation, is a major form of sexual violence affecting women and its consequences may be manifested biologically, psychologically and sociologically. Though sexual assault is currently an issue at the forefront of public life, there are limited institutional based studies in Ethiopia. So, this study was aimed to identify the magnitude of sexual assault and associated factors among females who visited gynecologic outpatient department of Hawassa University Comprehensive Specialized Hospital. Data was collected from 399 clients by a questionnaire developed using variables taken from WHO multi-country study on women health and from sexual violence medical evaluation certi cate format. The magnitude of sexual assault among the female clients was found to be 10.8%. 25% of the victims tested for pregnancy were positive and 7% were positive for Hepatitis B and Trichomonas vaginalis. Our study also revealed that females who were younger, unmarried, low educational status and nancially instable were directly associated with being a victim of sexual assault.

Background
Sexual violence is de ned as a sexual act committed against someone without person's freely given consent [1]. Sexual assault is a major form of sexual violence affecting women and it includes rape, attempted rape, sexual abuse and sexual exploitation [2].
Globally 1 in 5 women, experienced completed or attempted rape during their life time [1,2]. According to a 2013 WHO analysis conducted using existing data from over 80 countries, 1 in 3 women have experienced physical and/ or sexual violence. Large population-based surveys indicated a life time prevalence of 13-39% sexual violence among women and 3% among men though vulnerable groups are not included in the study [2,3].
In Ethiopia, according to the 2016 DHS report, more than one-third of ever-married women (35%) reported that they have experienced physical, emotional, or sexual violence from their husband or partner at some point in time and 11% experienced sexual violence [4].
Consequences of a sexual assault may be manifested biologically, psychologically, and sociologically [5].
Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductiveaged survivors of sexual assault [6].
The risk of sexual assault varies among individuals and some groups of individuals are at a higher risk of sexual assault. Women who are young, poor, living in social housing, in poor health, single and separated or divorced, migrant and tra cked women and those involved in the sex industry are more likely to encounter sexual violence [7].

SUBJECTS AND METHODS
Study area and period: The study was conducted at Gynecologic Outpatient Department of Hawassa University Comprehensive Specialized Hospital from January 1 to October 30, 2019.
Study design: Cross sectional study design was applied.
Study participants: Females who visited gynecologic outpatient department of Hawassa university comprehensive and specialized hospital for service care.
Exclusion criteria: Females with psychiatric and critical illness were excluded from the study.
Sample size determination: The desired sample size was calculated using a single population proportion formula.
Sampling technique and procedure: The study participants were selected by systematic random sampling. Data obtained from OPD registry book showed that, ten months prior to the study period, around 5000 clients visited Hawassa University Comprehensive Specialized Hospital Gynecologic Outpatient Department. Considering 10 months of data collection, a total population of 5000 were used to calculate the sampling interval. Thus, dividing the total population with the sample size, the sampling interval was found to be 12. After random selection of the rst sample, every 12 th unit were included in the study.
Data collection: Self-administered questionnaire developed using variables taken from WHO multi-country study on women health and from sexual violence medical evaluation certi cate format were used to collect data. Additional data was extracted from information documented by senior or year four residents on assaulted patient's chart and from attendants for minors and children's. The data was collected by trained year two residents during working hours and completeness of the data was consistently checked by the principal investigators.
Data processing and analysis: Each questionnaire was checked for completeness and consistency and cleaned. The data was analyzed using SPSS version 21. Descriptive analysis was done on sociodemographic characteristics and sexual assault related characteristics. Binary and multivariate logistic regression analysis were done to identify factors associated with sexual assault. A level of p < 0.05 was considered statistically signi cant.

Results
Socio-demographic Characteristics of the Study Participants Table 1 summarizes socio-demographic characteristics of the study participants. A total of 399 clients were participated in the study. The mean age of the respondents was 28.97 ± 10.61 and about 79.1% (34) of the victims were under the age of 18 years. Most of the victims were single (90.7%, n = 39), primary school attendees (88.4%, n = 38) and average monthly family income of less than 1500 birr (60.5%, n = 26).

Characteristics of Sexual Assault
The overall prevalence of sexual assault was 10.8% (43). Rape was the most prevalent type of sexual assault (72.1%, n = 31) followed by rape attempt (25.6%, n = 11). About 14.3% (7) (Table 2). However, duration of presentation to the hospital after sexual assault ranges from 1 day to 120 days with the mean duration of 17 days.   (14) had sexual assault associated genital injuries and non-genital injuries respectively.
Among the cases who were potentially eligible for emergency contraception, 46.7% (7) of them were provided with the service. Those victims who came to the hospital with in the rst 72 hours after sexual assault (50%, n = 7) were provided with post exposure prophylaxis for HIV and 74.4% (32) victims were provided with STI prophylaxis (Table 4).   with sexual assault. In this study, being married was found to be less likely to be sexually assaulted.
Single females were about 9.2 times more likely to be sexually assaulted. In addition, being in primary school [AOR = 18.0, 95% CI (1.63, 199.19)] were also signi cantly associated with sexual assault.  [9][10][11]. In the USA, approximately 1 in 5 (21.3%) women reported completed or attempted rape at some point in their life time [2]. The most likely cause of lower rate of assault in this study may be due to poor reporting and disclosure of sexual assault in due to different cultural reasons.
Most of sexual assault cases will end up with some sort of sexual and reproductive health problems like unwanted pregnancy, sexually transmitted infections and other genital and non-genital injuries. The rate of pregnancy and sexual transmitted infection among sexual assault cases at the time of presentation in this study was were comparable with the results of the study done at Jimma university comprehensive hospital [12]. However, in this study, among the victims who were potentially eligible for emergency contraception and post exposure prophylaxis for HIV, only a small number of victims were provided with the service. This indicates that the coverage for these services in this institution is very low and the victims didn't get proper care provision.
According to the WHO report, being a younger age is one of the risk factors for sexual assault [2]. Studies done in Jimma university comprehensive hospital, Adigrat hospital and Mekelle University reported a similar nding [12][13][14]. Similarly, in the present study, being under the age of 18 years was signi cantly associated with sexual assault.
Our study showed that female with low monthly income were more likely to be a victim of sexual assault.
Our nding was supported by the WHO report which indicated that factors like low socioeconomic status increases females risk of sexual assault [2].
In this study, educational status of primary school was signi cantly associated with being sexually assaulted. Our result was consistent with the study done among female administrative staff of Mekelle University which reported that female with educational status of secondary school or less [AOR: 1.981 (1.126-3.485)] were signi cantly associated with sexual violence [14].
In this study, being married were less likely to be associated with sexual assault. This nding was comparable with the study conducted in Butajira Town, South Ethiopia and in Nairobi, Kenya which showed that being unmarried were signi cantly associated with sexual assault [9,15]. However, our result was inconsistent with the WHO report which showed that one of the most important risk factor for women in terms of their vulnerability to sexual assault is being married or cohabiting with a partner [2].
This might be due to the fact that most women in our country don't report sexual violence committed by their husband.

Conclusions
In this study, the prevalence of sexual assault was unacceptably high, and most of the victims were under the age of 18 years. The common type of sexual assault was rape and most of the victims had genital injuries. The overall provision of emergency contraception, post exposure prophylaxis for HIV and