CHILD RAPE & ABUSE
Infant rape in South Africa - The Lancet, April, 2002 by Professor Doulas Bowley

and Dr Graeme Pitcher

The Crime Information Management Centre of the South African Police Force recorded 221 072 sexual offences in 1999 against persons aged under 17 years.1 This number should be seen in the context of a nationwide average of 83·5 reported rapes and attempted rapes per 100 000 population.2 As described in today's Lancet by Rachel Jewkes and colleagues, child and adolescent rape is a problem worldwide and a growing concern in sub-Saharan Africa. By contrast, infant rape is inordinately rare and infrequently described. Media reports of three such rapes in South Africa in the past few months have caused widespread anger and concern.3,4 In addition, a review from Cape Town covering 9 years describes a further ten rapes of children aged under 1year.5

The motivations for rape are complex. Rape is associated with a close linkage between the concepts of sex and power.6 In South Africa, women are commonly viewed as being inferior to men, as possessions, and as needing to be led and controlled.7 Elsewhere throughout Africa, widespread and systematic sexual violence against women and girls has been described as a weapon with which factions terrorise the civilian populations during conflicts.8,9 These motivations do not satisfactorily account for the emergence of infant rape.

Infant rapes seem to have several striking features. To penetrate the vagina of a small infant, the perpetrators first need to create a common channel between the vagina and the anal canal by forced insertion of an implement. This action is analogous to the most severe form of female genital mutilation practised in parts of Africa, introcision, in which the perineum is split with a finger, knife, or similar object,10 presumably to facilitate penetrative intercourse in girls as young as 5 years old sold into early marriage.11

Rape in this manner can be immediately life threatening. The tearing of the perineal body, rectovaginal septum, and anterior anal sphincter can cause infants to die from haemorrhage or abdominal sepsis despite medical care, especially in deprived rural communities.

Cases have generally been committed by apparently "normal" individuals with no history of mental illness.5 Frequently there are multiple rapists, as many as six in one case, and many perpetrators are first-degree or second- degree relatives.12 There is growing support for the theory that infant rape is related to a myth that intercourse with a very young virgin infant will enable the perpetrator to rid himself of HIV/AIDS or other sexually transmitted infections. This myth12 is thought to have originated in Central Africa and has moved south along with the HIV pandemic. A study from the Red Cross Children's Hospital in Cape Town confirmed a 1% seroconversion rate in a cohort of 200 child rape victims.5 The presence of a sexually transmitted infection increases the risk of HIV-1 transmission two-fold to five-fold13 and young girls in South Africa have been shown to be at very high risk of becoming infected after a limited number of sexual exposures,14 possibly because of the high prevalence of other sexually transmitted diseases.

Despite pleas in the medical press,15 state hospitals are not funded to provide antiretroviral prophylaxis in cases of child rape. The cost of a 28-day course of double therapy (zidovudine and lamivudine) in a child is 300-500 Rand (£18-30). The reasoning behind the state's reluctance to supply or endorse antiretrovirals for rape victims is based on its contention that the efficacy of such treatment is unproven. Although prospective trials showing the effectiveness of antiretroviral prophylaxis after sexual assault are lacking, the US Centers for Disease Control and Prevention recommends post-exposure prophylaxis.16 In the case of infant rape, the risk of HIV transmission is likely to be very high because physical injury is common5 and, in view of the prevailing myth, because the assailants are probably HIV positive. If the green light is given for the provision of antiretroviral agents to children, strategies must be put in place to improve compliance with follow-up and treatment, a serious problem in developing countries.17

Since victims of infant rape cannot give verbal testimony or be cross-examined, convictions depend on a clear chain of medical and forensic evidence. Current mechanisms for collection of forensic evidence are wholly inadequate, so conviction rates are very low even though most perpetrators are known to the victim's family.5 The naïve and dishonest view that there is no proven, causal link between HIV and AIDS will perpetuate crimes of this nature. The failure of the political leadership to frankly acknowledge the causes, effects, and treatment of HIV/AIDS has been the fertile ground for bizarre and dangerous myths to take root and flourish. The central government should openly debunk the "young-virgin myth". And it should heed the call in the South African Law Commission's discussion paper on sexual offences for the state to assume responsibility for providing the financial means to cover the cost of prescribed medication for victims of rape.18

Community education programmes must be vigorously expanded and appropriately targeted to the populations at risk. Traditional healers must play an important role in delivering appropriate messages. A system of obligatory reporting of all infant and child rapes is needed with standardised protocols for the collection of forensic evidence. All rape victims, but especially child rape victims, must be offered post-assault antiretroviral prophylaxis. In South Africa the current circumstances surrounding HIV testing of alleged rapists is confused and has been described as a legal minefield,19 so urgent clarification is needed in this area. Legislative changes should be made to ensure harsh deterrent sentencing for rapists.

Infant rape is a brutal act, which appears to be increasing in frequency in South Africa. Medical practitioners cannot stand idly by and merely treat these horrendous injuries; concerted action is needed to halt this abhorrent crime.

*Graeme J Pitcher, Douglas M G Bowley

Division of Paediatric Surgery, Johannesburg Hospital and the University of the Witwatersrand Medical School, Johannesburg 2193, South Africa (e-mail:[email protected])
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