Rape and STDs (sexually transmitted infections)

Of all the sexual crimes, rape has been used by feminists as an example of male dominance and control over women. This has gone to the extreme of believing that rape is not a sexual crime but a way of subjugating women in a male-dominated society. An example of this thinking is the statement that "any man is capable of rape." To some extent, this view is supported by the use of rape in wartime. This statement is also supported by the fact that sexual rapists typically have fewer previous convictions for sexual crimes but higher rates of violent crimes. Research on male attitudes toward rape indicates widespread rape myths. Classifications of sexual rapists have failed to provide a satisfactory description of even the majority of sexual rapists. Most likely, this is due to the fact that rapists differ from each other much more than, for example, pedophiles or incest offenders. From a simplified perspective, sexual rapists can be roughly divided into those for whom the act of rape is part of a system of sexual fantasies, which they ultimately implement, and those for whom the act of rape is an act of violence against a woman, and sexual intercourse is an extreme form of humiliation of a woman and her subordination to themselves.

Between 1973 and 1985, the number of rapes reported to police increased by 30%. From 1986 to 1996, the number of reported rapes of women increased annually from 2,288 to 6,337 in 1997. Rapes account for 2% of all violent crimes reported to police, which in turn accounts for 7% of all crimes reported.

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Case Description

A 30-year-old man, who felt that he had been wronged by women in his personal life, decided to take revenge on them by raping them. He committed a series of rapes of women he randomly selected from the street. He hid 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 sex offender treatment program within the prison system.

A young man had been entertaining a fantasy for 25 years about abducting a strange woman from the street, tying her up, and raping her. He had a history of making obscene phone calls. He masturbated while entertaining these fantasies and often drove around in his car wearing a mask and carrying a rope and a knife. One day, he saw a woman standing alone at a bus stop and attempted to abduct her at knifepoint. His attempt failed, and he was arrested and charged with attempted abduction. Although he denied sexual motives for his crime, the court, taking into account his past history and the items found on him, found that he had a sexual motive. He was sentenced to six years in prison. In prison, he was assessed for participation in a sex offender treatment program, and a penile plethysmography was performed. During the test, he was shocked by the degree of his own arousal to images of violence and rape. As a result, he was able to consciously accept the true motive for his crime and successfully completed a treatment program for sex offenders. Upon his release, he was asked to continue to participate in a community-based treatment program as a condition of obtaining a driver's license.

However, these two groups constitute a minority of sexual offenders. In recent years, so-called "date rape" has gained increasing recognition. The 30% increase in rape convictions between 1973 and 1985 was due to an increase in rapes committed by persons known to the victims, often in the victim's home. During the same period, there was a decrease in "stranger rape" and gang rapes. The number of crimes against children and older women remained unchanged. According to a 1989 Home Office study, the apparent increase in rapes committed by friends and relatives during this period was due less to an increase in the crime itself than to the reporting of rapes to the police. The increase in rape reporting was attributed to improved police and court responses to women reporting rapes. Since 1989, the number of rapes has increased by 170%, a fact that is still partly linked to the reporting and recording of these crimes to the police.

A study of incarcerated sex offenders found that those previously convicted of sex crimes were more likely to become serial rapists or to commit crimes against strangers. The author classified the perpetrators of these crimes into four groups:

1. Substance-abusing sexual offenders are impulsive and have high rates of sexual offending in their past.
2. Sexual abusers who actively use physical violence against their victims - these individuals are often serial offenders, use violence without reason, and have a high level of paraphilias.
3. "Socialized misogynists," 20% of whom committed sexually motivated murders. Their crimes most often include anal intercourse and physical humiliation of victims.
4. Unsocialized sexual predators, who were more likely to have behavioral disorders and aggression in childhood. They were also more likely to be serial offenders (the second group). One third of their rapes began as robberies, and 42% had sexual dysfunction during the rapes.

Of particular concern are sadistic sexual offenders and, accordingly, the role of sadistic sexual fantasies in their crimes. Grubin suggested that in men with sadistic sexual fantasies, social and emotional isolation are predictive factors for attempting to realize them. He makes a compelling argument: an empathy disorder underlies this isolation. An empathy disorder involves two components: recognizing the feelings of others and an emotional response to this recognition. A disorder in one or both components can lead to acting out sadistic sexual fantasies. The etiology of this disorder can be either organic or developmental.

The recommendations in this article are limited to the detection and treatment of sexually transmitted infections and conditions commonly encountered in the management of these infections. Coverage of data recording and forensic specimen collection, management of potential pregnancy, and management of trauma are beyond the scope of this guideline. In sexually active adults with preexisting infections, detection of STDs following rape is usually more important for patient care and medical management than for forensic purposes.

Trichomoniasis, chlamydia, gonorrhea, and bacterial vaginosis are the most commonly diagnosed infections in women after rape. Since these infections are quite common among sexually active women, their detection after rape does not always mean that they are a consequence of rape. Chlamydia and gonococcal infections require special attention, as they can cause ascending infection. In addition, there is a possibility of infection with viral hepatitis B, which can be prevented by vaccination after rape.

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Examination of sexually transmitted infections

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Initial examination

The initial examination should include the following procedures:

• Culture for N. gonorrhoeae and C. trachomatis of specimens collected from all penetration sites or potential penetration sites.
• If culture tests for chlamydia are not available, non-culture tests should be performed, especially DNA amplification tests, which are an acceptable substitute. DNA amplification tests have the advantage of being highly sensitive. When using non-culture tests, a positive result should be confirmed by a second test based on a different diagnostic principle. ELISA and PIF are not recommended, as these tests often yield false negative and sometimes false positive results.
• Obtaining a wet mount and culture for T. vaginalis. If vaginal discharge or odor is present, the wet mount should also be examined for signs of BV or yeast infection.
• Immediate serum testing for HIV, HSV, and syphilis (see Prevention, Risk of HIV Infection, and Follow-up testing 12 weeks after rape).

Follow-up examination

Although it is often difficult for a rape survivor to present in the first week after the rape, such evaluation is essential to (a) detect STD infection, either during or after the rape; (b) provide hepatitis B immunization if indicated; and (c) provide full counseling and treatment for other STDs. For these reasons, evaluation and follow-up are recommended for rape survivors.

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Follow-up examination after rape

Repeat testing for sexually transmitted infections should be done 2 weeks after the rape. Because sexually transmitted pathogens may not have multiplied in sufficient numbers to produce positive laboratory tests on the initial evaluation, repeat cultures, wet mounts, and other tests should be done 2 weeks later unless prophylactic treatment has been given.

Serologic testing for syphilis and HIV infection should be performed at 6, 12, and 24 weeks after rape if initial tests were negative.

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Prevention

Many experts recommend routine prophylactic treatment after rape. Most patients would probably benefit from this, since follow-up of patients who have been raped can be difficult, and treatment or prophylaxis can protect the patient from developing an infection. The following prophylactic measures are directed against the most common microorganisms:

• Post-rape HBV vaccination (without the use of HBVIG) should provide adequate protection against HBV disease. Hepatitis B vaccination should be given to rape victims at the time of their first examination. Subsequent doses of vaccine should be given 1-2 and 4-6 months after the first dose.
• Antimicrobial therapy: empirical regimen for chlamydia, gonorrhea, trichomoniasis and BV.

Recommended schemes

Ceftriaxone 125 mg intramuscularly 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 requiring alternative regimens, please refer to the relevant sections of this guideline for specific infectious agents.

The effectiveness of these regimens for preventing gonorrhea, bacterial vaginosis, or chlamydia after rape has not been studied. The physician may advise the patient about the possible benefits as well as the possible toxicity of the recommended medications, as gastrointestinal side effects are possible.

Other considerations for patient management

At the initial examination and, if indicated, at follow-up, patients should be counseled regarding the following issues:

• Symptoms of STDs and the need for immediate examination when they are detected, and
• Abstain from sexual intercourse until the course of preventive treatment is completed.

Risk of acquiring HIV infection

Although cases of HIV antibody seroconversion have been reported in individuals for whom rape was the only known risk factor, in most cases the risk of acquiring HIV from rape is low. On average, the rate of HIV transmission from an HIV-infected person during a single sexual encounter depends on many factors. These factors may include the type of sexual contact (oral, vaginal, anal); the presence or absence of oral, vaginal, or anal trauma; the site of ejaculation; and the amount of virus in the ejaculate.

Post-exposure prophylaxis with zidovudine (ZDV) reduces the risk of HIV infection in small studies of health care workers exposed to the blood of HIV-infected patients. In large prospective studies of pregnant women treated with ZDV, the direct protective effect of ZDV on the fetus and/or infant was a two-thirds reduction in the incidence of perinatal HIV infection, independent of any therapeutic effect of the drug on maternal viral yield (quantity). It is not yet known whether these findings can be generalized to other HIV transmission situations, including rape.

In many rape cases, it may not be possible to determine the HIV status of the perpetrator in a timely manner. The decision to administer PEP may depend on the nature of the rape, available information about the degree of HIV risk in the perpetrator's behavior (injection drug or crack use, risky sexual behavior), and local HIV/AIDS epidemiology.

If the perpetrator of a rape is known to be HIV-infected, the rape is considered to have a significant risk of HIV transmission (e.g., vaginal or anal intercourse without a condom), and the patient presents within 24 to 36 hours of the rape, antiretroviral prophylaxis should be offered and information about the unknown efficacy and known toxicity of antiretroviral drugs used in this situation should be provided. In other cases, the physician should discuss the specifics of the situation with the patient and develop an individualized solution. In all cases, the discussion should include information about:

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

The prophylaxis regimen should be drawn up in accordance with the guidelines for occupational exposure to mucous membranes.

Child sexual abuse and rape

The recommendations in this guide are limited to the detection and treatment of STDs. The psychological care and legal aspects of rape or child abuse are important but are not the focus of this guide.

The detection of STDs in children after the neonatal period suggests sexual abuse. However, there are exceptions; for example, rectal or genital chlamydial infection in young children may be due to perinatal infection with C. trachomatis, which may persist in the child for about 3 years. In addition, genital warts, bacterial vaginosis, and genital mycoplasmas have been found in both raped and nonraped children. There are several routes of infection for hepatitis B in children, the most common being household contact with a person with chronic hepatitis B. Sexual abuse should be considered if no obvious risk factor for infection is identified. If the only evidence of rape is the isolation of organisms or the presence of antibodies to STDs, the results of the tests need to be confirmed and interpreted with caution. To determine whether a child who has been diagnosed with a sexually transmitted infection has been sexually abused, the child must be examined by a physician experienced in examining children who have been raped.

Examination of sexually transmitted infections

Examination of children who have suffered rape or sexual abuse should be carried out in a way that causes minimal trauma to the child. The decision to examine a child for STDs is made on a case-by-case basis. Situations associated with a high risk of infection with STD pathogens and mandatory indications for testing include the following:

• The alleged perpetrator of rape is known to have an STD or is at high risk for an STD (multiple partners, history of STDs)
• The child has symptoms or signs of an STD
• High incidence of STDs in the community.

Other indicators recommended by experts include: a) evidence of genital or oral penetration or ejaculation, b) the presence of STDs in the child's siblings or other children or adults in the home. If the child has symptoms, signs, or evidence of an infection that may be sexually transmitted, the child should be tested for other common STDs. Obtaining the necessary specimens requires skill on the part of the health care provider and must be done in a manner that does not cause psychological or physical trauma to the child. The clinical manifestations of some STDs in children differ from those in adults. The examination and collection of specimens should be performed by a health care provider who has special training and experience in conducting such examinations of children who have been raped.

The main purpose of the examination is to obtain confirmation of the presence of an infection in the child, which he/she may have contracted sexually. 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, the use of more expensive and time-consuming tests is justified.

The testing schedule depends on the history of rape or sexual abuse. If it is recent, the concentration of infectious agents may not be sufficient to yield positive results. At a follow-up visit in 2 weeks, the child should be re-examined and additional samples obtained. Another visit, during which serum samples are obtained, is necessary approximately 12 weeks later; this is enough time for antibodies to develop. A single test may be sufficient if the child has been abused for a long period of time or if the most recent episode of suspected abuse occurred some time before the medical examination.

General guidelines for conducting the examination are provided below. The timing and manner of further contact with the patient are determined individually, taking into account psychological and social conditions. Follow-up can be carried out more efficiently if representatives of judicial authorities and child protection workers are involved.

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Initial examination and examination after 2 weeks

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

Examination of the perianal and oral areas for genital warts and ulcerative lesions.

Culture of specimens from the pharynx and anus (in boys and girls), vagina (in girls), and urethra (in boys) for N. gonorrhoeae. Cervical specimens are not recommended in prepubertal girls. In boys, if urethral discharge is present, a specimen from the urethral swab may be used instead of a specimen from an intraurethral swab. Only standard culture media should be used to isolate N. gonorrhoeae. All N. gonorrhoeae isolates should be identified by at least two methods based on different principles (e.g., biochemical, serologic, or enzyme detection). Isolates should be saved because additional or repeated tests may be required.

Culture of specimens from the anus (in boys and girls) and vagina (in girls) for C. trachomatis. There is limited information that the likelihood of isolating chlamydia from the urethra in prepubertal boys is low, so a urethral specimen should be obtained if discharge is present. Obtaining a pharyngeal specimen for C. trachomatis is not recommended in either boys or girls because chlamydiae are rarely detected in this area. Perinatally acquired infection may persist in children, and culture systems used in some laboratories cannot differentiate C. trachomatis from C. pneumoniae.

Only standard culture systems should be used to isolate C. trachomatis. All C. trachomatis isolates should be confirmed by microscopic identification of inclusion bodies using monoclonal antibodies to C. trachomatis. Isolates should be stored. Culture-free tests for chlamydia are not specific enough to be useful for diagnosis in situations of possible rape or abuse of children. There are insufficient data to evaluate the performance of DNA amplification tests in children who may have been raped, but these tests may be an alternative in situations where culture for chlamydia is not available.

Culture and wet mount studies of vaginal swabs for T. vaginalis. The presence of clue cells in wet mounts confirms bacterial vaginosis in children with vaginal discharge. The clinical significance of finding clue cells or other indicator features of bacterial vaginosis in the absence of discharge is also unclear.

Obtained serum specimens should be tested immediately and stored for further comparative testing, which may be necessary if subsequent serologic tests are positive. If more than 8 weeks have elapsed since the last episode of sexual abuse before the initial evaluation, serum should be tested promptly for antibodies to sexually transmitted agents (T. pallidum, HIV, HbsAg). Serologic testing should be performed on a case-by-case basis (see Evaluation 12 weeks after rape). HIV antibodies have been reported in children in whom sexual abuse was the only risk factor for infection. HIV serologic testing in raped children should be performed depending on the likelihood of infection of the perpetrator(s). There are no data on the efficacy or safety of post-rape prophylaxis in children. Hepatitis B immunization should be considered if history or serologic testing suggests that it has not been given in a timely manner (see Hepatitis B).

12 Week Post Rape Examination

Conducting a survey approximately 12 weeks after the last episode suspected of rape is recommended to detect antibodies to pathogens, as this period of time is sufficient for their formation. Serological tests for T. pallidum, HIV, HBsAg are recommended.

The prevalence of these infections varies considerably in different communities, and this affects the risk of the rapist having the infection. In addition, HBsAg results should be interpreted with caution, since hepatitis B virus can be transmitted both sexually and non-sexually. The choice of test should be made on a case-by-case basis.

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Preventive treatment

There are few data to determine the risk of sexually transmitted diseases in children as a result of rape. It is believed that in most cases the risk is not very high, although this is not well documented.

Routine prophylactic treatment of children who have been raped is not recommended because the risk of ascending infection in girls is lower than in adolescents or adult women and regular surveillance is usually sufficient. However, some children or their parents and caregivers may have heightened concerns about STDs even when the health care provider believes the risk is minimal. Given this, some health care settings may consider prophylactic treatment in these cases after collection of specimens.

Notice

All states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, and Samoa have laws requiring reporting of all cases of child rape. Each state may have slightly different reporting requirements, but generally, if there is a reasonable suspicion of rape, the appropriate authorities should be notified. Health care providers should maintain close contact with local child protection agencies and be familiar with the procedures for reporting rape.