Civil liberties vs. rape victims' rights
MASSACHUSETTS Governor Mitt Romney has recently engaged in political grandstanding around the rights of sexual assault survivors. In two cases, he chose to ignore data, clinical practice, and civil liberties. While prevailing political winds shifted his stance on emergency contraception, there is unlikely to be a similar groundswell of opposition to his proposed mandatory testing of rapists for sexually transmitted diseases and HIV. However, that silence is a reflection of the complexity of the issue.
Rape is a physically and emotionally violent crime, and sexual assault survivors deserve the best care and support possible. In Massachusetts they get it, for the most part. Supporting and empowering the victim is closely linked to needed physical and mental healthcare and aggressive criminal justice interventions.
Advocacy groups, healthcare providers, and organizations such as the Massachusetts Medical Society and the Massachusetts Department of Public Health have developed state-of-the-art health and psychological protocols for the care and support of sexual assault survivors. These include the first-in-the-country HIV prophylaxis recommendations for sexual assault and other nonoccupational exposures.
The keystone of this collaboration has been the Sexual Assault Nurse Examiner program, combining accurate forensic data collection with sophisticated and caring clinical support. These efforts have all been guided by survivors' needs and solutions that are known to be effective.
Until now. If Romney really wants to diminish the likelihood of STD or HIV transmission after sexual assault, he should be expanding the SANE program, the reimbursement mechanisms for prophylactic care, and the support needed to guide patients through various treatment regimens. Focusing on testing perpetrators provides an illusory response to real imperatives, including:
Prophylactic treatment needs to begin immediately. By its nature, post-exposure prophylaxis must begin as soon as possible but no later than 72 hours after the exposure in order to effectively prevent HIV infection. In Massachusetts, as elsewhere, the majority of sexual assault survivors who seek medical care do so well after 72 hours. For those who do seek treatment within that time period, the likelihood that their assailant is known or available for testing is remote. Predicating a treatment decision on knowledge of a perpetrator's status, therefore, is impractical.
The decision to go on treatment should be determined by the nature of the exposure. Existing state protocol and national guidelines provide good direction for triaging cases appropriately into treatment and are considered standard of care. The governor's focus should be on assuring universal access to this protocol. Moreover, patients need to be supported in their decision-making, preferably by a trained sexual assault nurse examiner. Evidence shows that nurse examiner support makes a difference in patient treatment decision-making.
Staying on prophylactic treatment requires support.
Reported side effects in people taking prophylactic treatment are significant, at least in the older medications. Newer agents appear to have markedly improved tolerability. But for survivors of sexual assault, following through with any treatment can be difficult because of the emotional ties of the treatment to the assault. There is virtually no evidence supporting the assertion that knowledge of the source's HIV status helps one to complete postexposure prophylaxis. On the other hand, there is data showing that supportive case management through the treatment period makes a substantial difference.
Eroding the rights of the perpetrator has potential implications for survivors.
Experience has shown that survivors who are positive also suffer because their civil rights are eroded.
Aligning HIV status with criminal activity diminishes people's understanding of real risk.
The third decade of the epidemic finds politicians and others opportunistically appropriating the threat of HIV in order to pose as tough on crime. Lately, these have been the only times that public leadership addresses the challenges of the epidemic.
But criminalizing HIV by linking it to rape sends out mixed, confusing, and misleading messages, and obscures the reality of HIV transmission. Such messages erode understanding of the disease and diminish the likelihood of people incorporating prevention into their lives.
Legislation that deliberately pits civil liberties and survivors' rights against each other serves only to inflame and divide. The resources spent on the governor's proposal would be better spent providing quality services. Real survivors require real answers, not the illusory help this proposal provides.
Jean McGuire, former assistant commissioner of the Massachusetts Department of Public Health, is a visiting professor at Northeastern University's Institute of Urban Health Research. Dr. Michael Wong is chairman of the board of directors of the AIDS Action Committee of Massachusetts. 
