Original Article
Sexually Transmitted Diseases in Victims of Rape
N Engl J Med 1990; 322:713-716March 15, 1990
- Abstract
- Abstract
The risk of acquiring a sexually transmitted disease as a result of rape is not known, in part because it is difficult to ascertain whether infections were present before the assault or acquired during it. To investigate this question, we examined female victims of rape within 72 hours of the assault and again at least one week after the assault.
Of the 204 girls and women initially examined within 72 hours of the rape, 88 (43 percent) were found to have at least one sexually transmitted disease. These diseases included infections caused by Neisseria gonorrhoeae (6 percent of those tested), cytomegalovirus (8 percent), Chlamydia trachomatis (10 percent), Trichomonas vaginalis (15 percent), herpes simplex virus (2 percent), Treponema pallidum (1 percent), and the human immunodeficiency virus type 1 (HIV-1; 1 percent) and bacterial vaginosis (34 percent). Among the 109 patients (53 percent) who returned for at least one follow-up visit (excluding those who were found to be infected at the first visit or who were treated prophylactically), the incidence of new disease was as follows: gonorrhea, 4 percent (3 of 71); chlamydial infection, 2 percent (1 of 65); trichomoniasis, 12 percent (10 of 81); and bacterial vaginosis, 19 percent (15 of 77). There were no new infections with herpes simplex virus, cytomegalovirus, Trep. pallidum, or HIV-1, but follow-up serologic testing was performed in only 26 percent of the patients.
On the basis of our assumptions that most venereal infections present within 72 hours of a rape were preexisting and that new infections identified 1 to 20 weeks later were acquired during the assault, we conclude that the prevalence of preexisting sexually transmitted diseases is high in victims of rape and that they have a lower but substantial additional risk of acquiring such diseases as a result of the assault. (N Engl J Med 1990; 322:713–6.)
Media in This Article
Table 1
Frequency of Sexually Transmitted Diseases in the Victims of Sexual Assault, as Identified at the Initial and Follow-up Medical Visits.Table 2
Rates of Infection at the Initial Visit in Victims of Sexual Assault Who Did and Did Not Return for Follow-up.Article Activity
- Article
THE acquisition of a sexually transmitted disease as a result of sexual assault can have serious physical and emotional consequences. In previous studies, the prevalence of gonorrhea in victims of rape ranged from 2.5 to 13.3 percent, and the prevalence of syphilis ranged from zero to 1.0 percent.1 2 3 4 5 6 7 8 Only one study investigated the frequency of vaginitis and nonbacterial sexually transmitted disease. In that study, the intervals between the reported assaults and the follow-up examinations ranged from 10 days to one year; the relation of the infections identified to the assaults was therefore uncertain.7
No published studies have investigated the incidence of infection at follow-up visits in an attempt to differentiate preexisting infection from infection acquired at the time of the rape. In this paper we report the results of a prospective study of vaginal and cervical sexually transmitted disease in girls and women evaluated initially within 72 hours of a sexual assault and again at follow-up.
Methods
Patients
The study population was made up of postmenarcheal girls and women who presented to the Harborview Medical Center in Seattle because of a recent sexual assault. Patients were enrolled if they reported a vaginal assault within the previous 72 hours by a man who was not their regular sexual partner. The patients were at least 12 years old and gave informed consent for their participation in the study. Adolescent victims of incest or chronic sexual abuse were not included in the study.
Collection of Data and Specimens
A description of the assault was obtained by the emergency room social worker and the examining physician. General physical and pelvic examinations were performed. Forensic specimens were obtained according to a standard protocol.
Separate specimens were obtained on endocervical swabs for isolation of Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus, and cytomegalovirus by published methods.9 10 11 A Pap smear was obtained for cytologic study and examination for evidence of infection with human papillomavirus. Human papillomavirus was considered to be present if koilocytosis was seen on the Pap smear.12
In order to diagnose bacterial vaginosis and trichomoniasis, we obtained vaginal specimens for determination of pH, examination of a saline wet mount for motile trichomonads and vaginal epithelial cells covered with adherent bacteria (clue cells), and examination for characteristic odor after the addition of 10 percent potassium hydroxide.13 , 14 In addition, one slide prepared from vaginal secretions was placed in Pap fixative to test for Trichomonas vaginalis with use of fluorescein-tagged monoclonal antibodies.13
Gram's stains of vaginal secretions were reviewed for evidence of bacterial vaginosis according to the criteria of Spiegel et al.15 by an investigator who had no knowledge of the clinical findings in the patient's case. This method of diagnosing bacterial vaginosis was chosen because it is based on objective criteria and is highly correlated with a clinical diagnosis of bacterial vaginosis.15 Serum samples were obtained for a rapid-plasma-reagin test for syphilis and an enzyme-linked immunosorbent assay for antibodies to human immunodeficiency virus type 1 (HIV-1). The one positive HIV test was confirmed by Western blot analysis.16 Seropositivity for herpes simplex virus was also assessed by Western blot analysis.17 , 18 Serologic tests for antibodies to cytomegalovirus were performed on all paired serum samples from a patient's initial and follow-up visits and for all patients who had cultures positive for cytomegalovirus at follow-up.19
The medical records of the patients were reviewed in order to identify preexisting medical and psychiatric disorders.
Antimicrobial Treatment
Vaginal and cervical infections diagnosed by the examining clinicians were treated according to standard protocols. Emergency room physicians were instructed to prescribe prophylactic antimicrobial agents effective against N. gonorrhoeae and C. trachomatis if any of the following criteria were met: the patient had had more than one assailant; the patient was not expected to return for a follow-up visit; or the patient was extremely anxious about contracting a sexually transmitted disease.
Untreated patients whose cultures were positive were contacted before the scheduled follow-up visit and asked to return for appropriate antimicrobial treatment.
Follow-up Evaluation
The patients were asked to return to the clinic for a follow-up visit two weeks after the initial visit. At the second visit, the pelvic examination was repeated, as were endocervical cultures for N. gonorrhoeae, C. trachomatis, cytomegalovirus, and herpes simplex virus, the vaginal wet mount, and Gram's stain. A sample of vaginal secretions was obtained and cultured for Trich. vaginalis according to published methods.13 The patients were asked to return for repeat serologic studies six weeks after the initial visit. Attempts were made by telephone and mail to contact patients who did not return for follow-up in order to reschedule the visit.
Evaluation of Data
For purposes of this study, an infection was attributed to the sexual assault if it was detected at the follow-up visit in patients who had had no evidence of infection at the initial visit and who had not been treated with an antimicrobial agent effective against the particular pathogen.
Results
Patient Characteristics
Of the 335 girls and women evaluated after sexual assaults from April 1, 1985, to May 30, 1986, 204 (61 percent) consented to participate in the study. The mean age of the study population was 24.8 years (range, 12 to 67). Sixty-seven percent were white, 21 percent were black, 4 percent were Asian, 4 percent were Native Americans, and 4 percent were Hispanic.
Thirty-eight of the patients (19 percent) reported assault by more than one assailant. Sperm were detected on examination of the Pap smear or the saline wet mount of vaginal fluid from 135 patients (66 percent). Eighty-two percent (23 of 28) of the patients with a new sexually transmitted disease diagnosed at follow-up (excluding cytomegalovirus) had had sperm detected in specimens obtained at the initial visit.
Ten patients (5 percent) had injuries requiring follow-up visits or hospitalization. Ninety-four (46 percent) had minor nonpelvic injuries such as abrasions or bruises, and 35 (17 percent) had minor injuries in the pelvic region. Fifty-nine (29 percent) received prophylactic antibiotics.
Forty-seven patients (23 percent) were being treated for preexisting chronic medical illnesses such as hypertension, asthma, nephritis, and sarcoidosis. Three (1.5 percent) were pregnant at the time of the assault. Seventy-three (36 percent) had been treated at Harborview Medical Center for major mental disorders such as depression or personality disorder or for substance abuse.
One hundred nine of the girls and women (53 percent) returned for the first follow-up evaluation. The mean length of time to this visit was 2.6 weeks (range, 1 to 20). Fifty-two patients (25.5 percent of the initial group) returned for a second follow-up visit for serologic studies a mean of 8 weeks (range, 2 to 40) after the initial visit.
Prevalence of Sexually Transmitted Disease after Sexual Assault
The prevalence of sexually transmitted disease among the patients at the initial and follow-up visits is shown in Table 1Table 1
Frequency of Sexually Transmitted Diseases in the Victims of Sexual Assault, as Identified at the Initial and Follow-up Medical Visits.. At enrollment, 57 patients (28 percent) were found to have one sexually transmitted disease, 19 (9 percent) had two, and 12 (6 percent) had three or more. Fifty-six percent had at least one sexually transmitted disease at either the initial or the follow-up visit. Thirteen patients (6 percent) were found to be infected with N. gonorrhoeae and 20 with C. trachomatis (10 percent) at the initial visit. At follow-up, three (3 percent) were found to be infected with N. gonorrhoeae and two (2 percent) with C. trachomatis. One woman with C. trachomatis infection had a positive culture at the initial visit as well. The prevalence of trichomoniasis and bacterial vaginosis was found to be very high at both the initial and follow-up examinations. Patients with a history of mental illness did not have a higher rate of infection than others in the study.The rates of infection at the initial visit among patients who did and did not return for follow-up visits are compared in Table 2Table 2
Rates of Infection at the Initial Visit in Victims of Sexual Assault Who Did and Did Not Return for Follow-up.. At the initial visit to the emergency room, the patients who later returned for follow-up had a significantly lower prevalence of bacterial vaginosis (P = 0.03), a lower prevalence of gonococcal infections (P not significant), and a significantly higher prevalence of trichomoniasis (P = 0.05).Cytologic Studies of Cervical Specimens
Pap smears were obtained from 199 girls and women at the initial visit. On cytologic examination, 11 patients (5.5 percent) had smears consistent with Class I, II, or III cervical intraepithelial neoplasia. Koilocytosis was noted on 13 smears (6.5 percent), indicating the presence of human papillomavirus infection. Nine of the patients found to have koilocytosis on examination of the Pap smear were among those whose smears showed cervical intraepithelial neoplasia Class I, II, or III. Fifteen (7.5 percent) had either koilocytosis or cervical intraepithelial neoplasia on cytologic examination of cervical specimens.
Risk of Sexually Transmitted Disease Attributable to Sexual Assault
Estimates of the risk of acquiring a sexually transmitted disease from a sexual assault are shown in Table 3Table 3
Risk of Acquiring a Sexually Transmitted Disease (STD) after a Sexual Assault.*. These estimates were derived by determining the number of new infections present at follow-up among the subjects who were not treated prophylactically with antibiotics and who were not found to be infected at the initial visit. The risk of acquiring a vaginal infection appeared to be much greater than the risk of acquiring a cervical infection.Viral infections were not likely to be acquired as a result of assault. Three patients had initial cultures that were negative for cytomegalovirus and follow-up cultures that were positive, but all three had positive antibody titers at the time of enrollment. Thus, these three "new" infections could have represented either recurrent cervical shedding or newly acquired cervical infection. None of the patients had evidence of seroconversion for herpes simplex virus. None of those who returned for follow-up visits had antibody to HIV. However, only 26 percent of patients returned for the second follow-up visit, which included serologic testing, a mean of eight weeks after the assault.
No patient who was initially seronegative for Trep. pallidum had a positive test at the follow-up visit.
Discussion
The prevalence of gonococcal and chlamydial infections in our study was similar to that reported in other studies of women who had been raped.1 2 3 4 5 6 7 8 The prevalence of N. gonorrhoeae, C. trachomatis, Trich. vaginalis, and bacterial vaginosis in the study population was also similar to the rates reported for women attending clinics specializing in the treatment of sexually transmitted disease.
At the initial emergency room visit (within 72 hours of the assault), it was impossible to distinguish between preexisting infections and those that had resulted from the presence of infected semen from the assailant. Only 53 girls and women (26 percent) were noted by the examining physician to have signs of vaginitis or cervicitis, although some preexisting infections may have been subclinical or missed by the examiner.
The risk of acquiring a sexually transmitted disease as a result of a sexual assault is obviously affected by the presence or absence of sexually transmitted disease in the assailant. Although no studies have been made of the prevalence of sexually transmitted disease in sex offenders, published data on the sexual behavior of convicted offenders suggest that they are at high risk for sexually transmitted diseases because of the nature and variety of sexual contacts they report.20 Penile penetration and ejaculation during assault also increase a victim's risk of contracting a sexually transmitted disease. The frequent occurrence of sexual dysfunction during assaults, as reported by sex offenders,21 may reduce the risk. Other factors that may be associated with a woman's risk of acquiring a sexually transmitted disease as a result of rape are the number of assailants, the size of the inoculum, the infectivity of the organisms transmitted, the type of assault (vaginal, anal, or oral), the susceptibility of the victim to infection, and the prophylactic administration of antibiotics.22
Our estimates of the risk of sexually transmitted disease attributable to sexual assault are based on several assumptions. First, the patients who returned for follow-up were taken as representative of the study population. Those who had symptoms of sexually transmitted disease after the assault may have been more likely to return for follow-up visits than those who were not symptomatic. This difference might have resulted in an overestimation of risk. Although differences were noted between the patients who did and did not return for follow-up in terms of the rate of infection identified at the initial visit, the incidence of infections should depend more heavily on the characteristics of the assailants than on those of the victims. Second, we assumed that infections present at follow-up in patients who were not found to be infected at the initial visit did not represent preexisting infections that were missed during the first visit. Third, we assumed that infections present at follow-up in previously noninfected patients were contracted from the assailant and not through intervening sexual contacts. Because the patients' sexual activity after the rapes was not studied, the calculated rates of infection from the assault may have been falsely elevated. Fourth, infections present at the first visit were assumed to be preexisting and not the result of the assault. This assumption could have led to the underestimation of risk.
Another factor affecting the rates of sexually transmitted disease after sexual assault is the length of time between the rape and the follow-up examination. Eighty-three percent (24) of the 29 new infections identified in 28 patients at follow-up occurred in patients who returned within one month of the assault. Two cases of trichomoniasis and three of bacterial vaginosis occurred in patients who returned later for follow-up; we believe these infections are less likely to have been related to the assault. Although the length of time to the second follow-up visit was 40 weeks for one subject, there were no seroconversions for the pathogens we examined. The long time to the second follow-up for some subjects did not, then, influence the calculated rates of syphilis and viral infections.
The estimated risk of acquiring trichomoniasis after a rape may have been falsely elevated by our use of cultures to diagnose infections at follow-up but not at the initial visit. We believe this potential bias was minimized by our evaluation of the immunofluorescent monoclonal-antibody preparations from specimens obtained during the patients' initial visits. The immunofluorescence method we used has been shown to correlate well with the results of cultures for Trich. vaginalis.13
The risk of acquiring gonococcal or chlamydial infection after a rape appeared to be low in this population, whereas the risk of contracting bacterial vaginosis or Trich. vaginalis was high. This difference may be due to the lower prevalence of N. gonorrhoeae and C. trachomatis in the population, as compared with the vaginal pathogens. Another factor may be the relatively high rate of infectivity of Trich. vaginalis among vaginal pathogens.
We found no evidence in serologic studies or cultures of the transmission of syphilis, herpes simplex virus, cytomegalovirus, or HIV to our study population. This negative finding suggests that the risk of acquiring these diseases after sexual assault is low, at least in Seattle. However, our estimates may not be representative of girls and women who have been raped, since only 26 percent of our patients returned for follow-up serologic studies; moreover, follow-up might have identified cases of HIV or syphilis. Many victims of assault are now requesting serologic testing for HIV. We believe testing should be done at the patient's request, but we do not recommend the routine testing of the victims of sexual assault in areas where the seropositivity rate is low in the population, unless the assailant is known to be in a group at high risk for HIV infection.
Supported by grants (AI12192, AI20381, and DK38955) from the National Institutes of Health.
Source Information
From the Departments of Pediatrics (C.J.), Medicine (T.M.H., M.K.C., W.E.S., K.K.H.), Urology (J.N.K.), Obstetrics and Gynecology (S.L.H.), Pathology (N.K.), and Laboratory Medicine (L.C.) and the Harborview Sexual Assault Center (C.J.), University of Washington School of Medicine (A.B.), Seattle. Address reprint requests to Dr. Jenny at the Harborview Medical Center, ZA-07, 325 Ninth Ave., Seattle, WA 98104.
- References
References
1
Hayman
Web of Science | Medline2
Kaufman
CrossRef | Web of Science | Medline3
Everett
Web of Science | Medline4
Soules
Web of Science | Medline5
Evrard
Web of Science | Medline6
Tintinalli
CrossRef | Web of Science | Medline7
Forster
Medline8
Hayman
Web of Science | Medline9
Martin
Medline10
Yoder
Web of Science | Medline11
Wentworth
Medline12
Gross
CrossRef | Web of Science | Medline13
Krieger
CrossRef | Web of Science | Medline14
Amsel
CrossRef | Web of Science | Medline15
Spiegel
Web of Science | Medline16
Tsang V, Hancock K, Wilson M, et al. Immunoelectrophoresis blot technique (Western blot) for HTLV-III/LAV antibodies. Atlanta: Centers for Disease Control, 1985.
17
Ashley
CrossRef | Web of Science | Medline18
Ashley
Web of Science | Medline19
Meyers
Web of Science | Medline20
Abel
CrossRef21
Groth
Full Text | Web of Science | Medline22
Glaser
CrossRef | Medline
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Hollye R. Gallion, Lisa J. Dupree, Theresa A. Scott, Donald H. Arnold. (2009) Diagnosis of Trichomonas vaginalis in Female Children and Adolescents Evaluated for Possible Sexual Abuse: A Comparison of the InPouch TV Culture Method and Wet Mount Microscopy. Journal of Pediatric and Adolescent Gynecology 22:5, 300-305
CrossRef8
Janice Du Mont, Deborah White, Margaret J. McGregor. (2009) Investigating the medical forensic examination from the perspectives of sexually assaulted women. Social Science & Medicine 68:4, 774-780
CrossRef9
Louisa Gilbert, Nabila El-Bassel, Elwin Wu, Mingway Chang. (2007) Intimate Partner Violence and HIV Risks: A Longitudinal Study of Men on Methadone. Journal of Urban Health 84:5, 667-680
CrossRef10
Nkolika Ijeoma Aniekwu, Ayo Atsenuwa. (2007) Sexual Violence and HIV/AIDS in Sub-Saharan Africa: An Intimate Link. Local Environment 12:3, 313-324
CrossRef11
Iryna Mogilevkina, Viveca Odlind. (2006) Some reproductive and sexual health indicators in rape victims in Ukraine. Central European Journal of Medicine 1:4, 399-415
CrossRef12
B.L. Meel. (2005) HIV-seroconversion following sexual abuse. Journal of Clinical Forensic Medicine 12:5, 268-270
CrossRef13
Amanda Konradi, Patty L. DeBruin. (2003) Using a Social Marketing Approach to Advertise Sexual Assault Nurse Examination (SANE) Services to College Students. Journal of American College Health 52:1, 33-39
CrossRef14
Carol A. Spiegel. (2002) Bacterial vaginosis. Reviews in Medical Microbiology 13:2, 43-51
CrossRef15
MICHAEL P. POIRIER. (2002) Care of the female adolescent rape victim. Pediatric Emergency Care 18:1, 53-59
CrossRef16
Nabila El-Bassel, Susan S. Witte, Takeshi Wada, Louisa Gilbert, Joyce Wallace. (2001) Correlates of Partner Violence Among Female Street-Based Sex Workers: Substance Abuse, History of Childhood Abuse, and HIV Risks. AIDS Patient Care and STDs 15:1, 41-51
CrossRef17
Gina M. Wingood, Ralph J. DiClemente, Anita Raj. (2000) Identifying the Prevalence and Correlates of STDs Among Women Residing in Rural Domestic Violence Shelters. Women & Health 30:4, 15-26
CrossRef18
Suzanne Maman, Jacquelyn Campbell, Michael D Sweat, Andrea C Gielen. (2000) The intersections of HIV and violence: directions for future research and interventions. Social Science & Medicine 50:4, 459-478
CrossRef19
Gina M Wingood, Ralph J DiClemente, Anita Raj. (2000) Adverse consequences of intimate partner abuse among women in non-urban domestic violence shelters. American Journal of Preventive Medicine 19:4, 270
CrossRef20
Matthew W. Reynolds, Jeffrey F. Peipert. (2000) Epidemiologic Issues of Sexually Transmitted Diseases in Sexual Assault Victims. Obstetrical & Gynecological Survey 55:1, 51
CrossRef21
MELISA HOLMES. (1999) Sexually Transmitted Infections in Female Rape Victims. AIDS Patient Care and STDs 13:12, 703-708
CrossRef22
Gene R. Pesola, Richard E. Westfal, Carol A. Kuffner. (1999) Emergency Department Characteristics of Male Sexual Assault. Academic Emergency Medicine 6:8, 792-798
CrossRef23
Margaret R Hammerschlag. (1998) The Transmissibility of Sexually Transmitted Diseases in Sexually Abused Children. Child Abuse & Neglect 22:6, 623
CrossRef24
ELIZABETH A. DeLAHUNTA, DAVID A. BARAM. (1997) Sexual Assault. Clinical Obstetrics and Gynecology 40:3, 648-660
CrossRef25
Melisa M. Holmes, Heidi S. Resnick, Dean G. Kilpatrick, Connie L. Best. (1996) Rape-related pregnancy: Estimates and descriptive characteristics from a national sample of women. American Journal of Obstetrics and Gynecology 175:2, 320-325
CrossRef26
Stacey B. Plichta, Carmella Abraham. (1996) Violence and gynecologic health in women <50 years old. American Journal of Obstetrics and Gynecology 174:3, 903-907
CrossRef27
(1995) Care of the Victim of Rape. New England Journal of Medicine 332:25, 1714-1715
Full Text28
Hampton, Harriette L., . (1995) Care of the Woman Who Has Been Raped. New England Journal of Medicine 332:4, 234-237
Full Text29
M. López-Varela, J. García-Rodríguez, R. Martínez-Zapico. (1994) Low risk of HIV transmission in rape victims. European Journal of Clinical Microbiology & Infectious Diseases 13:7, 622-622
CrossRef30
Lisbeth Bang. (1993) Rape victims - assaults, injuries and treatment at a medical rape trauma service at Oslo Emergency Hospital. Scandinavian Journal of Primary Health Care 11:1, 15-20
CrossRef31
Lorena M. Siqueira, Scott H. Barnett, Elaine Kass, Melvin Gertner. (1991) Incubating syphilis in an adolescent female rape victim. Journal of Adolescent Health 12:6, 459-461
CrossRef32
Gerard Mantese, Vito Mantese, Theresamarie Mantese, Joseph Mantese, Mary L. Mantese, Christine Essique. (1991) Medical and legal aspects of rape and resistance. Journal of Legal Medicine 12:1, 59-84
CrossRef33
(1990) Sexually Transmitted Diseases and Rape. New England Journal of Medicine 323:16, 1141-1142
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- Letters
