Rape and STDs (sexually transmitted infections)

Case Description

A 30-year-old man who considered himself harmed by his mistreatment of women in his personal life decided to take revenge on them through rape. He commits a series of rapes of women arbitrarily chosen by him on the street. At the same time, he concealed his face under a mask and threatened the victims with a knife. After committing eight rapes, he was arrested and convicted. He was sentenced to life imprisonment. During his imprisonment, he successfully completed a program for the treatment of a sex offender within the prison system.

A young man of 25 years had a fantasy of kidnapping an unknown woman from the street, linking her and then raping. Earlier, he already had phone calls of indecent content. Against the background of these fantasies, he masturbated and often traveled in his car, covering his face with a mask and carrying a rope and a knife. One day he saw a lonely woman standing at a bus stop and tried to kidnap her, threatening with a knife. His attempt failed, and he was arrested and charged with attempted abduction. Although he denied the sexual motives of his crime, the court, taking into account his past history and the objects found with him, leaned in favor of sexual motives. He was sentenced to six years in prison. In prison, he was examined for participation in a program for the treatment of sexual offenders, and in this connection plethysmography of the penis was performed. During the test, he was shocked by the degree of his own excitement at the images of violence and rape. As a result, he was able to consciously accept the true motive of his crime and successfully completed a treatment program for sex offenders. After his release, he was asked to continue to participate now in a community-based treatment program, and this was a condition for obtaining the rights to drive a car.

However, the two groups described are a minority of sexual abusers. In recent years, the so-called "date rape" (rape) has been increasingly recognized. A 30% increase in convictions for rape between 1973 and 1985 was associated with an increase in the number of rapes committed by persons known to victims and often at the victim's home. At the same time, there was a decrease in the number of "rapes committed by strangers" and group rape. The number of crimes against children and older women remained unchanged. According to a 1989 study by the Ministry of the Interior, the apparent increase in rape by friends and relatives of victims during this period was due not so much to the growth of this crime as to the statement of rape cases to the police. The reasons for the increase in the registration of rape were associated with the improvement in the work of police and courts with women reporting rape. Since 1989, the number of rapes has increased by 170%, and this fact is still partly attributed to the statements and registration of these crimes in the police.

As the study of prisoners of sexual abusers shows, among those convicted earlier for sexual crimes, the possibility of serial violators or committing crimes against strangers is increased. The author reduced the subjects of these crimes into four groups:

1. Sexual abusers who abuse psychoactive substances are impulsive and have high rates of sexual crimes in the past.
2. Sexual abusers who actively use physical violence against a victim - these persons are often serial offenders, use violence without cause, and among them paraphilia level is increased.
3. "Socialized misogynists", 20% of whom committed sexual assault. Among the crimes committed by them, anal sex and physical abuse of victims are more frequent.
4. Uninitialized sexual abusers, who were more likely to develop behavioral disorders and aggression in their childhood. They were also more likely to be among the serial criminals (second group). One-third of their rapes began as robberies, and 42% had sexual dysfunction with rape.

Of particular concern are sexual abusers - sadists and, accordingly, the role of sadistic sexual fantasies in the crimes they commit. Grubin suggested that in men with sadistic sexual fantasies, the predictive factors of attempts to implement them are factors of social and emotional isolation. He makes a convincing argument: at the heart of this isolation lies the frustration of empathy. The disorder of empathy includes two components: the recognition of the feelings of others and the emotional response to this recognition. The disorder of one or both of the components can lead to the reaction of sadistic sexual fantasies. The etiology of this disorder can be both organic and related to development.

The recommendations contained in this article are limited only to the identification and treatment of sexually transmitted infections, as well as the conditions that are commonly observed in the management of cases of these infections. Coverage of the registration of obtained data and obtaining samples for forensic examination, management of cases of potential pregnancy, as well as mental and physical trauma is not included in the tasks of this manual. In sexually active adults with an existing infection, the detection of STDs after rape is usually more important for the provision of psychological and medical care to patients, rather than for judicial purposes.

Trichomoniasis, chlamydia, gonorrhea and bacterial vaginosis are most often diagnosed in women after rape. Since the prevalence of these infections is high among sexually active women, their identification after rape does not always mean that they are a result of rape. Chlamydia and gonococcal infections require special attention, since they can cause an upward infection. In addition, there is the possibility of infection with viral hepatitis B, which can be prevented by vaccination after rape.

Examination of sexually transmitted infections

Primary examination

The primary examination should include the following procedures:

• Culture examination on N. Gonorrhoeae and C. Trachomatis specimens collected from all penetration sites or sites of possible penetration.
• If culture tests for detecting chlamydia are not available, non-cultural tests are necessary, especially DNA amplification tests, which serve as an acceptable substitute. DNA-amplification tests have advantages due to their high sensitivity. If noncultural tests are used, the positive test result should be confirmed by a second test based on another diagnostic principle. IFA and UIF are not recommended, t. When using these tests, false-negative and sometimes false-positive results are often obtained.
• Preparation of a moist preparation and culture test on T. Vaginalis. If there are vaginal discharge or an unpleasant odor, the moist preparation should also be examined for signs of BV or infection caused by yeast-like mushrooms.
• Immediate serum testing for HIV, HSV and syphilis (see Prevention, HIV Risk and Follow-up Examination 12 weeks after the rape).

Follow-up examination

Although it is often very difficult for a person who has been raped to complain with a complaint within the first week after the rape, such an examination is essential (a) to identify STD infection, when or after rape; b) for immunization against hepatitis B, if indicated; and c) the full counseling and treatment of other STDs. For these reasons, it is recommended that victims of rape be examined and followed up.

Follow-up examination after rape

It is necessary to repeat the examination for sexually transmitted infections 2 weeks after the rape. Since infectious agents caught during the rape may not multiply in sufficient quantity to obtain positive results of laboratory tests during the initial examination, then in 2 weeks the culture test, wet examination and other tests should be repeated, unless preventive treatment was performed.

Serological tests for syphilis and HIV infection should be conducted 6.12 and 24 weeks after the rape, if the initial tests were negative.

Prevention

Many experts recommend routinely conducting preventive treatment after rape. Most patients would probably benefit from this, since further monitoring of patients who have been raped may be difficult, and treatment or prevention can insure the patient against possible infection. The following preventive measures are directed against the most common microorganisms:

• Vaccination against GB, conducted after rape (without the use of GVIG) should provide adequate protection against HBV. Vaccination against hepatitis B should be carried out to victims of rape during their first examination. Subsequent doses of the vaccine should be given 1-2 and 4-6 months after the first dose.
• Antimicrobial therapy: an empirical scheme for chlamydia, gonorrhea, trichomoniasis and BV.

Recommended schemes

Ceftriaxone 125 mg IM once

Plus Metronidazole 2 g orally once

Plus Azithromycin 1 g orally in a single dose

Or Doxycycline 100 mg 2 times a day for 7 days.

NOTE: For patients in need of alternative regimens, see the relevant sections of this manual for specific infectious agents.

The effectiveness of these schemes to prevent gonorrhea, bacterial vaginosis of chlamydiosis after rape has not been studied. The doctor can advise the patient about the possible benefits, as well as the possible toxicity of the recommended drugs, since side effects from the gastrointestinal tract are possible.

Other observations on patient management

At the initial examination and, if shown, during follow-up, patients should be consulted regarding the following issues:

• Symptoms of STDs and the need for immediate examination when they are detected, and
• Refusal of sexual contacts until the course of preventive treatment is over.

The risk of acquiring HIV infection

Despite the fact that seroconversion of HIV antibodies was reported in persons for whom only one risk factor was known - rape, in most cases the risk of acquiring HIV during rape is low. On average, the frequency of HIV transmission from an HIV-infected person with single sexual contact depends on many factors. These factors may include the type of sexual contact (oral, vaginal, anal); presence or absence of oral, vaginal or anal trauma, the place of ejaculation and the number of viruses in the ejaculate.

Prevention of HIV zidovudine (HFA) after infection contributes to reducing the risk of HIV infection, as shown in small studies by health workers who have had transdermal contact with the blood of HIV-infected patients. In large prospective studies in pregnant women treated with HFA, the direct protective effect of HFA in the fetus and / or in the baby was expressed in a 2/3 decrease in the incidence of perinatal HIV infection, regardless of the therapeutic effect of this drug on the virus yield (its amount) in the mother's blood. It is not yet known whether these findings can be used for other HIV transmission situations, including rape.

In many cases of rape, it is impossible to determine the HIV status of a person who has committed rape in a timely manner. The decision to conduct a PEP may depend on the nature of the rape, the available information about the risk of HIV in the behavior of the perpetrator (injecting drug use or crack, risky sexual behavior) and local HIV / AIDS epidemiology data.

If it is known that a person who has committed rape is infected with HIV, it is presumed that there is a significant risk of HIV transmission with such rape (for example, with vaginal or anal intercourse without a condom), and if the patient asked for help within 24-36 hours after the rape , it should be offered antiretroviral prophylaxis, as well as information on the unknown efficacy and known toxicity of antiretroviral drugs used in this situation. In other cases, the doctor should discuss with the patient the features of this situation and develop an individual solution. In all cases, the discussion should include information:

• about the need for frequent medications,
• conducting control studies,
• careful monitoring of possible complications, and
• about the need to begin treatment immediately.

A preventive regimen should be prepared in accordance with the guidelines for the production of mucous membranes.

Sexual harassment of children and rape

The recommendations contained in this guide are limited to identifying and treating STDs. The questions of psychological assistance and the legal aspects of rape or abuse against children are very important, but are not the purpose of this guide.

Identification of the causative agents of STD in children after the period of newborns indicates sexual abuse. However, there are exceptions; for example, rectal or genital chlamydial infection in young children may be due to perinatal infection of C. Trachomatis, which can persist in the body of the child for about 3 years. In addition, genital warts, bacterial vaginosis, and genital mycoplasma have been found in both raped and non-raped children. There are several ways of infection with viral hepatitis B in children, the most common is household contact with a person who has chronic hepatitis B. The possibility of sexual violence should be considered if no obvious risk factor for infection is identified. If the only evidence of rape is the isolation of microorganisms or the presence of antibodies to the causative agents of STDs, the results of the studies need confirmation and careful interpretation. To determine whether there has been sexual coercion of children who have an infection that can be sexually transmitted, a joint examination of the child with a doctor with experience in conducting an examination of raped children is necessary.

Examination of sexually transmitted infections

The examination of children who have undergone rape or sexual harassment should be conducted in such a way as to minimize trauma to the child. The decision about the examination of a child for STDs is made in each case individually. To situations accompanied by a high risk of infection with STD pathogens and mandatory indications for testing include the following:

• It is known that the alleged person who commits rape, has an STD or has a high risk of STDs (many partners, a history of STDs)
• The child has symptoms or signs of STDs
• High incidence of STDs in the community.

Other indicators recommended by experts include: a) signs of genital or oral penetration or ejaculation, b) the presence of STDs in the brothers or sisters of the affected child or other children or adults in the home. If a child has symptoms, signs or evidence of an infection that can be sexually transmitted, he or she should be examined for other common STDs. Obtaining the necessary samples requires the medical worker to have certain skills and should be carried out so as not to cause the child psychological and physical trauma. The clinical manifestations of some STDs in children differ from those of adults. Survey and sample collection should be carried out by a medical professional who has special training and experience in conducting similar studies in raped children.

The main purpose of the survey is to obtain evidence of the presence of an infection in the child, to which he could have acquired sexual transmission. However, due to the legal and psychological consequences of obtaining false-positive results, it is necessary to use tests with high specificity. In such situations it is justified to use more expensive and time-consuming tests.

The survey scheme depends on the history of rape or sexual harassment. If this happened recently, the concentration of infectious agents may be insufficient to obtain positive results. At the subsequent visit in 2 weeks it is necessary to re-examine the child and obtain additional samples. Another visit, during which serum samples are taken, is needed, approximately, after 12 weeks; this time is sufficient for the formation of antibodies. One survey can be limited if the child has been subjected to violence for an extended period of time or the last episode, suspicious of violence, occurred some time before the medical examination.

The following are general recommendations for the survey. The time and method of further contact with the patient is determined individually, taking into account the psychological and social conditions. Follow-up can be carried out more professionally if representatives of the judiciary and child protection services participate in it.

Initial examination and examination after 2 weeks

The initial examination and, if necessary, the examination after 2 weeks should be carried out as follows:

Inspection, perianal and oral areas for the presence of genital warts and ulcerative lesions. 

Culture examination on N. Gonorrhoeae samples obtained from the pharynx and anus (in boys and girls), vaginal discharge in girls, urethra in boys. It is not recommended to obtain samples from the cervix in girls at prepubertal age. In boys in the presence of secretions from the urethra, instead of a sample obtained with an intraurethral tampon, sample samples can be used. To isolate N. Gonorrhoeae, only standard cultivation media should be used. All the obtained N. Gonorrhoeae isolates should be identified by at least two methods based on different principles (for example, biochemical, serological or pathogen detection). Isolates should be retained, as additional or repeated tests may be required. 

Culture examination in C. Trachomatis specimens obtained from the anus (in boys and girls) and vaginal discharge in girls. There is limited information that the probability of isolation of chlamydia from the urethra in pre-pubertal boys is too low, so a sample from the urethra should be obtained if there are secretions. Obtaining samples from the pharynx for study in C. Trachomatis is not recommended in either boys or girls, since chlamydia is rarely found in this area. There is a probability of persistence in children of infection acquired in the perinatal period, and the systems for cultivation that are used in some laboratories do not allow distinguishing C. Trachomatis from C. Pneumoniae. 

To isolate C. Trachomatis it is necessary to use only standard systems for cultivation. All the C. Trachomatis isolates obtained must be confirmed by microscopic identification of the inclusions, using monoclonal antibodies to C. Trachomatis. Isolates must be preserved. Noncultural tests for chlamydia are not specific enough to be used for diagnosis in situations of possible rape or abuse of children. There is insufficient data to evaluate the possibilities of DNA amplification tests for diagnosis in children who may have been raped, but these tests may be an alternative in situations where it is not possible to conduct culture diagnosis of chlamydia.

Culture study and study of a wet preparation obtained with a vaginal tampon on T. Vaginalis. The presence of key cells in the wet preparation confirms the presence of bacterial vaginosis in children with vaginal discharge. The clinical significance of the detection of key cells or other indicative signs of bacterial vaginosis in the absence of secretions is also not clear. 

The resulting serum samples should be examined immediately and stored for further comparative analysis, which may be required, | if the results of subsequent serological tests are positive. If more than 8 weeks have passed since the last episode of sexual violence, the serum should be immediately examined for antibodies to sexually transmitted agents (T. Pallidum, HIV, HbsAg). Serologic examinations should be conducted taking into account the situation in each specific case (see Survey 12 weeks after the rape). There are reports of the detection of antibodies to HIV in children whose sexual abuse was the only risk factor for infection. Serological reactions to HIV in raped children should be carried out depending on the likelihood of infection of the person (s) who committed the violence. There is no data on the efficacy or safety of prevention in children after rape. Immunization against hepatitis B should be recommended if history or serological findings suggest that it was not performed in a timely manner (see Hepatitis B).

Examination 12 weeks after the rape

Examination about 12 weeks after the last suspicious episode of rape is recommended for detection of antibodies to pathogens, since this time is sufficient for their formation. It is recommended to conduct serological tests to identify T. Pallidum, HIV, HBsAg.

The prevalence of these infections varies considerably in different communities and the degree of risk of this infection in the abuser depends on this. In addition, the results on HBsAg should be interpreted with caution, as the hepatitis B virus can be transmitted both sexually and not sexually. The choice of the test should be carried out depending on each specific case.

Preventive treatment

There is little data to determine the risk of infection of STDs in children as a result of rape. It is believed that in most cases the risk is not too high, although the documentary evidence of this provision is not adequate.

It is not recommended that preventive treatment for raped children be widely implemented, since the risk of developing an ascending infection in girls is lower than in adolescents or adult women, and usually regular follow-up is sufficient. However, some children or their parents and carers may be more concerned about STDs, even if, in the opinion of the health worker, the risk is minimal. Given this circumstance, in some medical institutions it is considered possible to conduct preventive treatment in these cases after collecting the material for the study.

Notice

In all states, in the District of Columbia, in Puerto Rico, Guam, the Virgin Islands and in Samoa, there is a law requiring that all rape cases be notified. In each state, the registration requirements may be slightly different, however, as a general rule, if there are sufficiently strong suspicions of rape, it is necessary to notify the relevant services. Medical workers need to maintain close contact with local child protection authorities and know the rules for recording cases of rape.