Prevalence of and risk factors for hepatitis in a forensic population of rapists and child molesters
Συγγραφέας Ορέστης Γιωτάκος Γράφτηκε στις ,
INTRODUCTION
Sexual abuse is a frequent and violent crime and it is the most underreported of all crimes [1]. Victims can include male and female adults and children. The victims may suffer from depression or post-traumatic stress disorder, even many years after the assault [1]. They are also at risk for acquisition of many sexually transmitted diseases, such as infections with herpes simplex virus, hepatitis B or C viruses, and HIV [2]. Evidence suggests that the prevalence of preexisting sexually transmitted diseases is high in victims of rape, but there is a substantial additional risk of acquiring such diseases as result of the assault [3].
It is widely known that sex offenders are characterized by high psychiatric comorbidity. A large proportion of them meet the criteria for a personality disorder, manifesting high levels of impulsiveness, aggression, risk taking behaviours, and drug abuse, while one fifth of them report a history of sexual abuse during childhood [4, 5]. In addition, both rapists and child molesters have a high risk of re-offending even many years after being discharged from prison [1, 6] and thus being a high risk group for transmitting sexually transmitted diseases to their victims.
The aim of the present study was to assess the prevalence of HIV, HBV and HCV infections in a forensic population of rapists and child molesters, and to investigate for possible risk factors of these infections.
METHODS
One hundred and ninety four males (mean age 35.2 years, range 19-63 years), convicted for rape (n=105) or child molestation (n=89), participated in this study. They were all held in the only prison for sexual offenders in Greece (Tripolis prison) during the years 2000 and 2001. Their mean education was 7.8 (SD 4.0) years, and their mean sentence 9.0 (SD 5.2) years. Eighty-two (42%) subjects were foreigners, and most of them (93%) were immigrants from Albania living in Greece for a period of 1 to 5 years. All participants signed an informed consent form to be interviewed and to submit a blood sample for HIV, HBV and HCV testing during the first two weeks of their admission. Inmates who refused to participate, as well as inmates with early release and language problems were excluded for the study.
The participants completed a standard questionnaire seeking data on sociodemographic variables, penal status, number of life-time sexual partners, history of bisexual behavior, and history of intravenous drug use (IVDU). They also were assessed on the Barratt Impulsiveness Scale (BIS) [7] consisting of 30 four-grade answer scale questions. It contains three subscales measuring “motor” (act without thinking), “cognitive” (making-up one’s mind quickly), and “no-plan” impulsiveness. The Life-Time History of Aggression (LTHA) [8] consisting of 23 five-grade answer scale questions that concern life-time aggressive or violence acts was also completed. The questionnaires were administered to all subjects by the same clinician (O.G.).
Blood was prepared for examination and stored in a -70oC freezer according to standard procedures. HIV-1/2 antibody testing was carried out using third-generation anti-HIV assays combined with p24 antigen test (Vidas HIV DUO, Bio Merieux.sa, France) [9]. The tests used to detect HBV infection were enzyme-linked immmunosorbent assays (ELISA) for anti-HBc, HBeAg, and anti-HBe, and radio-immunoassay for HBsAg (Abbott, Gernany). A third-generation ELISA also was used to detect antibodies to HCV (Ortho-Clinical Diagnostics, USA). We did not use extra certification procedures for verification of the anti-HCV results.
The prevalence of hepatitis markers was calculated. For further investigation of possible risk factors, the variables age, education, total number of sexual partners, history of bisexual behaviour, aggression, impulsiveness, sentence, intravenous drug use, foreigner, and the type of conviction were investigated separately using multiple logistic regression analysis.
RESULTS
All findings concerning the hepatitis markers, as well as the sociodemographic and the psychometric measures are shown in Table 1. Anti-HIV antibodies were not found in any of the prisoners. HBsAg was found in 25 (13%) subjects, anti-HBc in 94 (49%) subjects, anti-HBs antibody in 40 (21%) subjects, and anti-HCV in 13 (6.5%) subjects. The anti-HCV antibody was found in seven subjects with past HBV infection and in two HBsAg carriers. The anti-HBs antibody was found in eleven subjects with history of immunization, in twenty-eight subjects with past HBV infection, in one HBsAg carrier, and in three anti-HCV positive subjects.
Logistic regression analysis showed that anti-HCV positivity was associated with intravenous drug use (OR: 20.7, 95%Cl: 1.1-4.9, p<.001), while HBsAg positivity was associated separately with being foreign (OR: 4.0, 95%Cl: 0.2-2.5, p<.01), as well as with the score of the impulsiveness (OR: 1.06, 95%Cl: .01-.11, p<.02).
DISCUSSION
In contrast to previous findings of studies in prisoners [10, 11], none of the participants in this study was found to be infected by HIV although a high proportion had had a history of bisexual activity (37%) and intravenous drug use (10%). However, we found that 13% were HBsAg carriers, 48% had a past HBV infection, and 6.5% were anti-HCV positive. The HBsAg positivity was found to be significantly associated with the foreign origin, a finding which is in agreement with previous studies that showed increased prevalence of HBV infection in immigrants from Albania [12]. The reasons that Albanian immigrants are over-represented in this prison's population are probably similar to the reasons why many socially excluded groups appear to be more vulnerable when facing criminal justice procedures. These reasons include poverty, low educational level, poor social skills and poor use of the spoken language, which is a disadvantage when standing in front of a court of law. As far as the Greek members of the sample are concerned, 6.25% were found to be HBsAg carriers, which is very much higher than the prevalence in the general Greek population (estimated between 0.8% to 2%) [13, 14, 15].
As expected, anti-HCV positivity was found to be associated with intravenous drug use. Nineteen subjects (10%) of the whole sex offender sample were intravenous drug users and eight of them were anti-HCV positive. We consider these findings to confirm the results of earlier studies on the prevalence of anti-HCV in intravenous drug users [16, 17].
As far as comorbid psychopathology is concerned, life-time aggression was not associated in our study with either past or present infections. On the contrary, impulsiveness was found to be an additional risk factor for HBV infection. As a further hypothesis, we suggest that impulsiveness is an important risk factor for spreading HBV to others, since risk taking behaviours, like novelty and sensation seeking in sexual behaviour, constitute parts of this personality dimension. It is widely known that sex offenders are characterized by high psychiatric comorbidity [4,5]. They show also a tendency for reoffending throughout their lifetime, quite often targeting several victims, even many years after being discharged from prison [1, 6]. Thus the epidemic of hepatitis B and C among sex offenders identified by this study constitutes a major public health problem. All the above reveal the necessity of close systematic monitoring of the mental and physical health of the sex offenders, through planned integrated prevention and rehabilitation programmes.
Table 1. Sociodemographic data, questionnaire scores and hepatitis markers in whole the sample, as well as in the subgroups with no infection, with past HBV infection, HBsAg positivity , and anti-HCV positivity.
Whole sample (N=194)
No infection
(N=95)
Past HBV infection (N=69)
HBsAg
positive
(N=25)
anti-HCV positive
(N=13)
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Age
35.2 ± 11.2
34.3 ± 10.2
37.0 ± 12.0
31.8 ± 8.5
35.0 ± 10.3
Education (years)
7.8 ± 4.0
8.0 ± 3.5
8.0 ± 4.6
6.0 ± 4.6
6.1 ± 4.7
Sentence (years)
9.0 ± 5.2
8.2 ± 4.4
9.6 ± 6.3
9.7 ± 4.6
11.5 ± 6.9
Sexual
Partners
34.9 ± 34.1
29.1 ± 318
39.7 ± 36.0
34.1 ± 30.9
65.0 ± 34.3
Aggression (LTHA)
17.0 ± 4.6
15.0 ± 4.2
18.9 ± 4.1
18.5 ± 5.0
19.0 ± 4.7
Impulsive-ness (BIS)
84.0 ± 14.5
78.5 ± 13.2
87.6 ± 15.0
91.2 ± 9.3
94.0 ± 12.3
N
N
N
N
N
Foreigner
82
30
31
18
4
Rapists
105
48
42
13
10
Child Molesters
89
47
27
12
3
IVDU
19
2
13
3
8
Bisexual
71
27
28
13
5
HBsAg positive
25
0
0
25
2
Anti-HBc positive
94
0
69
25
9
Anti-HBs positive
40
11
28
1
3
Anti-HCV positive
13
0
7
2
13
