Research Article, J Womens Health Vol: 12 Issue: 5

Risk Assessment of Sexually Transmitted Infections in Sexual Assault Victims

Hee Jeung Lim^1,2, Kyu Ri Hwang^1,2*, Da Yong Lee^1,2, Byoung Jae Kim^1,2, Sun Min Kim^1,2 and Hye Won Jeon^1,2

¹Department of Obstetrics and Gynecology, SMG-SNU Boramae Medical Center,Seoul, Republic of Korea

²Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea

*Corresponding Author: Kyu Ri Hwang,
Department of Obstetrics and Gynecology, SMG-SNU Boramae Medical Center,Seoul, Republic of Korea
Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
E-mail: orangemd@snu.ac.kr

Received date: 04 September, 2023, Manuscript No. JWHIC-23-112600;

Editor assigned date: 06 September, 2023, PreQC No. JWHIC-23-112600 (PQ);

Reviewed date: 21 September, 2023, QC No. JWHIC-23-112600;

Revised date: 29 September, 2023, Manuscript No. JWHIC-23-112600 (R);

Published date: 09 October, 2023, DOI: 10.4172/2325-9795.1000461.

Citation: Lim HJ, Hwang KR, Lee DY, Kim BJ, Kim SM, et al. (2023) Risk Assessment of Sexually Transmitted Infections in Sexual Assault Victims. J Womens Health 12:5.

Abstract

Keywords:

Sexual assault victim; Antibiotics; Prophylaxis; Sexually transmitted infections

Introduction

Sexual assault refers to a broad spectrum of nonconsensual sexual violence, ranging from any type of unwanted sexual contact to vaginal or anal penetration. It also includes the use of physical force, coercion, or threat and often accompanies intoxication by drugs or alcohol [1-3]. Risks of exposure have been increasing as younger generations have more access to meeting online acquaintances that may have sexually violent intentions, in addition to increased prevalence within colleges or universities [4-6]. In the United States, approximately 1.5 million rape-related assaults against women are reported annually, and approximately one in five women aged 18 years or older have been reported to be victims of completed or attempted rape in their lifetime [7]. Sexual assault is a significant health burden, with multiple medical and legal consequences. It includes not only physical and psychological problems, but also social and legal sequelae [8-10]. Acute traumatic injuries include bruising, laceration, fracture, and those that even lead to death [11]. Psychological consequences include depressive disorder, alcohol abuse, and posttraumatic stress disorder [12]. Particularly, sexual assault victims are at high risk of acquiring Sexually Transmitted Infections (STIs). The most common STIs diagnosed among sexual assault survivors are chlamydia, gonorrhea, bacterial vaginosis, and trichomoniasis; and the overall STIs prevalence in victims is approximately 30%-60% according to previous reports [13-15]. STIs can easily spread and may cause long-term complications, such as pelvic inflammatory diseases, infertility, and chronic pelvic pain. Thus, this study was conducted to assess the risk of STIs in sexual assault victims and establish standard protocols to provide appropriate care or medical treatment, psychological support, STI management, and prevention of repeat sexual assault.

Materials and Methods

Participants

The participants of this study were women aged 19 years and above who were sexual assault victims and visited the Seoul Southern Sunflower Center at Boramae Medical Center between October 2015 and October 2020. Victims who were underage, had intellectual disabilities, or could not consent to participate in the study were excluded. This study was approved by the Institutional Review Board of the SMG-SNU Boramae Medical Center (IRB No. 26-2014-16).

Study design

We recorded the participants’ initial visit to the hospital immediately after the sexual assault incidence and the follow-up visits after one month (second visit) and six months (third visit). The visits consisted of the assessments and tests as described below.

Assessment: Co-existing diseases, medical/obstetrical/gynecological medical history, contraceptive, sexual assault situation.

Initial blood test: Complete blood count, electrolyte levels, liver function test, creatinine, urine test, pregnancy test.

STI test: Serology (Syphilis, Hepatitis B antigen, Human immunodeficiency virus), vaginal discharge PCR test (Chlamydia trachomatis, Neisseria gonorrhea, Cytomegalovirus, Mycoplasma, Ureaplasma).

Bacterial vaginitis test: Gram staining and culture of vaginal secretion.

Analytical method

We included the age of the participant, prior sexual experience before the sexual assault incidence, and administration of prophylactic antibiotics at the initial visit of Seoul Southern Sunflower Center as the exposure variables. The result variables were positive for Polymerase Chain Reaction (PCR) test for STIs (conducted on vaginal discharge samples), Gram staining, and culture. IBM SPSS statistics 26.0 package was used to apply the Fisher’s exact test and logistic regression with Firth’s penalized likelihood method on risk factors evaluation. Values with P<0.05 were noted statistically significant.

Results

From a total of 117 alleged sexual assault victims who initially consented and agreed to enroll in the study at their initial visit, 63 completed the follow-up at both the 1^st and 6^th months period. All 63 subjects showed negative serology test results at every visit. The participants’ age, previous experience of sexual intercourse, use of alcohol or prophylactic antibiotics at the first follow-up visit were analyzed as exposure variables by contingency tables.

Participants were grouped by age into those <30 years old and those 30 years old, according to logistic regression results simplifying risk assessment. Of the 63 participants, 53 were <30 years old and 10 were >30 years old. Five participants had no prior sexual experience before the assault. There were 52 survivors who were in a drunken state when the assault occurred. Of the 63 survivors, 36 prophylactically administered antibiotics, while, 27 did not take prophylactic antibiotics. The results of the PCR test for Chlamydia trachomatis, Neisseria gonorrhea, Cytomegalovirus, Mycoplasma, Ureaplasma, vaginal Gram staining, and culture were used as the primary outcomes.

In the univariate analysis, there were no significant correlations with STIs. The use of prophylactic antibiotics at the initial visit did not result in a lower risk of STIs at the second and third visit. However, victims who had previous experience of sexual intercourse showed a higher risk of positive vaginal Gram staining and culture at the initial visit than those with no prior sexual experience (P=0.028) (Table 1).

Table 1: Logistic regression with Firth's penalized likelihood for related factors for sexually transmitted infections.

Discussion

Despite the recent increase in sexual assault reports and increased risk of exposure to sexual assault, there are very limited studies on predictive models of health risks of sexual assault victims. The health risks associated with sexual assault, including STIs, posttraumatic stress, and sexual dysfunction, have not been studied actively. Although this study consisted of a small number of participants, it provides great value as the first prospective study in the country to follow-up on sexual assault victims and evaluates the risks of STIs.

In this study, there was no statistically significant relationship between the exposure variables of the subject’s age, past sexual experience, alcohol consumption at the time of the incident, and administration of prophylactic antibiotics at the initial visit, with the results of the PCR test for STIs. However, there was a significant decrease in the incidence of bacterial vaginal infection at the initial visit among participants who had no prior sexual experience compared to those with past sexual experiences. Bacterial vaginal infection occurs as a consequence of a change in normal vaginal flora, with the main resident normal flora (Lactobacillus species) being out numbered by anaerobic bacteria. Although bacterial vaginal infection is often asymptomatic, it can pose a risk to the health of premenopausal women. From a gynecological standpoint, bacterial vaginal infection can increase the risk for pelvic inflammatory disease, pelvic inflammation after abortion, vaginitis after hysterectomy, and atypical cervical cells; whereas from an obstetrical perspective, it can increase the risk for premature rupture of membranes, preterm birth, intraamniotic infection, chorioamnionitis, and cesarean delivery after intrauterine infection [16].

On the initial visit, victims who had previous experience of sexual intercourse showed a higher risk of positive vaginal Gram staining and culture than those with no prior sexual experience. This difference was not seen in subsequent follow-up tests. Therefore, despite the positive results of vaginal discharge Gram staining and culture, prophylactic antibiotics could potentially reduce the risk of bacterial vaginal infection with women who had previous experience of sexual intercourse. This emphasizes the importance of prescribing prophylactic antibiotics to sexual assault victims who visit the Sunflower Centers.

According to the latest Sexually Transmitted Infections Treatment Guidelines provided by the US Department of Health and Human Services/Centers for Disease Control and Prevention, for sexual assault victims who are treated during the initial visit, regardless of whether testing was performed, post-treatment testing should be conducted only if the person reports any symptoms [17]. These guidelines appear to be quite consistent with the results of our study. Furthermore, all women who are diagnosed with chlamydial or gonococcal infection should be retested after 3 months from the start of treatment, regardless of whether their sex partners have been treated [18]. Starting prophylactic antibiotics for STIs at the initial visit would be beneficial, although, conclusive evidence on its necessity has not been proven by our research results. For sexual assault victims who were properly administered with prophylactic antibiotics at the initial visit, it is cautiously expected that STI repeat testing can be omitted at the 1^st month follow-up.

A limitation of this study is the exclusion of intellectually impaired individuals, who have a high probability of being included in the highrisk group for STIs [19]. We recommend separate studies on intellectually impaired or underage sexual assault victims, and subsequently analyzing sexual assault risk factors, STIs, and longlasting sequelae for each group.

Predictive modeling studies of diseases aim to predict whether the disease will occur in currently healthy individuals within a given amount of time. Such studies help predict the incidence rate of disease in individuals vulnerable to the disease. Of the indices being evaluated, the index that can be easily observed, regularly repeated, and is an important contributor in predicting the disease incidence, should be selected as the risk factor to conveniently predict the incidence of the disease. For efficient disease control, it is important to predict the risk groups that would be diagnosed with the disease and estimate the risk rate through predictive modeling studies of diseases. However, it is equally important to select the most relevant risk factors that predict disease incidence. In predicting incidence, the risk factor that could most closely reflect the current status of the disease needs to be selected first, to increase the level of prediction. To establish a nationwide risk index, constant effort is needed to measure and monitor various risk factors for further collective analysis.

Conclusion

In this study, with respect to the small number of participants who completed both the 1^st and 6^th months follow up, we observed that it was difficult to continously monitor sexual assault victims. If this study was continued with the acquisition of more participants, the results could be analyzed using multivariate logistic regression analysis, and a larger range of statistically significant results could be expected.

Despite the failure to develop a risk assessment model, it is imperative to continue this study and its design as it could serve as a basis for developing a nationwide, large data analysis and coding system. With this type of analysis, accurate data on the current situation and characteristics of sexual assault victims can be obtained prospectively, which would allow the construction of a systematic model of prevention, intervention, and treatment for the survivors.

References

1. ACOG Committee Opinion No. 777: Sexual Assault. Obstet Gynecol 2019;133:e296-e302.

   [Crossref][Pubmed]

2. Vrees RA. Evaluation and management of female victims of sexual assault. Obstet Gynecol Surv 2017;72:39-53.

   [Crossref] [Google Scholar] [Pubmed]

3. Blayney JA, Read JP. Sexual assault characteristics and perceptions of event-related distress. J Interpers Violence 2018;33:1147-1168.

   [Crossref] [Google Scholar] [Pubmed]

4. Mellins CA, Walsh K, Sarvet AL, Wall M, Gilbert L, et al. Sexual assault incidents among college undergraduates: Prevalence and factors associated with risk. PLoS One 2017;12:e0186471.

   [Crossref] [Google Scholar] [Pubmed]

5. Marret MJ, Choo WY. Victimization after meeting with online acquaintances: a cross-sectional survey of adolescents in Malaysia. J Interpers Violence 2018;33:2352-2378.

   [Crossref] [Google Scholar] [Pubmed]

6. Rowse J, Mullane S, Bassed R, Tully J. Technology-facilitated sexual assault in children and adolescents; is there a cause for concern? Fourteen years of experience at a metropolitan forensic paediatric medical service. J Paediatr Child Health 2022;58:409-414.

   [Crossref] [Google Scholar] [Pubmed]

7. Basile KC, Smith SG, Liu Y, Kresnow MJ, Fasula AM, et al. Rape-related pregnancy and association with reproductive coercion in the U.S. Am J Prev Med 2018;55:770-776.

   [Crossref] [Google Scholar] [Pubmed]

8. Jina R, Thomas LS. Health consequences of sexual violence against women. Best Pract Res Clin Obstet Gynaecol 2013;27:15–26.

   [Crossref] [Google Scholar]

9. Dworkin ER, Menon SV, Bystrynski J, Allen NE. Sexual assault victimization and psychopathology: A review and meta-analysis. Clin Psychol Rev 2017;56:65-81.

   [Crossref] [Google Scholar] [Pubmed]

10. Lorenz K, Kirkner A, Ullman SE. A qualitative study of sexual assault survivors' post-assault legal system experiences. J Trauma Dissociation 2019;20:263-287.

    [Crossref] [Google Scholar] [Pubmed]

11. Tjaden PG, Thoennes N, National Institute of Justice (U.S.), Centers for Disease Control and Prevention (U.S.). Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. Washington, D.C. (810 Seventh St., N.W., Washington 20531): U.S. Department of Justice, Office of Justice Programs, National Insitute of Justice; 2000.
12. Dworkin ER. Risk for mental disorders associated with sexual assault: a meta-analysis. Trauma violence abuse 2020;21:1011-1128.

    [Crossref] [Google Scholar] [Pubmed]

13. Sachs CJ, Ladd M, Thomas B. Sexual assault infectious disease prophylaxis. 2021.

    [Google Scholar] [Pubmed]

14. Jo S, Shin J, Song KJ, Kim JJ, Hwang KR, Bhally H. Prevalence and correlated factors of sexually transmitted diseases-chlamydia, Neisseria, cytomegalovirus--in female rape victims. J Sex Med 2011; 8: 2317-2326.

    [Crossref] [Google Scholar] [Pubmed]

15. Park JH, Kim N, Shin S, Roh EY, Yoon JH, Park H. Prevalence and correlated factors of sexually transmitted infections among women attending a Korean sexual assault center. J Forensic Leg Med 2020; 71:101935.

    [Crossref] [Google Scholar] [Pubmed]

16. Berek. Berek & Novak's Gynecology. Sixteenth edition. Philadelphia: Wolters Kluwer. 2020.
17. US Department of Health and Human Services/Center for Disease control and Prevention. Sexually transmitted infections treatment guidelines. 2021:128-129.
18. Hosenfeld CB, Workowski KA, Berman S, Zaidi A, Dyson J, et al. Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis 2009; 36:478-489.

    [Crossref] [Google Scholar] [Pubmed]

19. Rein DB, Anderson LA, Irwin KL. Mental health disorders and sexually transmitted diseases in a privately insured population. Am J Manag Care. 2004; 10: 917–24.

    [Google Scholar] [Pubmed]