Journal of the Royal Society of Medicine Volume 84 November 1991
657
Rape and sexually transmitted diseases: patterns of referral and incidence in a department of genitourinary medicine
J D C Ross MRcP' G R Scott MRCP' A Busuttil FRCPath2 'Department of Genitourinary Medicine, Lauriston Building, Edinburgh Royal Infirmary, Edinburgh, 2Forensic Medicine Unit, University of Edinburgh Keywords: rape; sexually transmitted diseases; police
Summary A retrospective study was carried out of all women attending a Department of Genitourinary Medicine over a 3-year period. Note was taken of referring source, presenting symptoms, infection detected at STD screening and follow-up attendance. Comparison was also made between the number of women referred by the police surgeon and the number who actually attended. We observed an overall incidence of STD of 35% and noted that many infections had a similar prevalence to that of our normal clinic population over the same time period. Only 13% of the women referred by the police attended although after the initial visit attendance was similar regardless ofreferral source. A number of asymptomatic women were noted to have infection with Neisseria gonorrhoeae and Chlamydia trachomatis. Although the risk of significant STD following sexual assault is low greater efforts should be made to encourage women to attend for screening whether or not they are symptomatic. Introduction The incidence of rape is increasing in many communitiesl2 although exact figures for sexual assault are impossible to obtain due to the persistently low reporting rate associated with this crime"3. Apart from the psychological and physical trauma that may result from rape there is also the additional risk of acquiring a sexually transmitted disease (STD) during such an assault. The risk of becoming infected with an STD under such circuimstances is not known and attempting to assess this risk has a number of intrinsic handicaps. In the first instance not all these women will present for specific screening following an alleged sexual assault and it is difficult to extrapolate from the percentage that do attend to the entire cohort at risk. Those with symptoms are perhaps more likely to attend than those without, giving rise to a positive bias. Any infection deteced at post-rape screening may have been present previously and women reporting recent sexual activity prior to the rape have a higher incidence of STD on screening4. One study reported that rape victims may have a higher prevalence of STD prior to an assault than the normal population5. Additionally these women may present originally to a wide variety of agencies including their general practitioner, the police, departments of genitourinary medicine, rape crisis centres and well women clinics6. Having attended one department they may be reluctant to be referred or to attend for a second
examination elsewhere, making global figures difficult to obtain. Although a number of studies have reported the incidence of STD in rape victims in America, there are less data relating to the United Kingdom. One study of London patients quoted a rate of 30% for STD in patients seen after sexual assault3, whilst another London study found an incidence of 5% and 12% for chlamydial and gonorrhoeal infection respectively with an overall rate, excluding candida infection and non-specific vaginosis, of 29%7. A recent MaDcester study found rates of 2.2% for gonorrhoea and 7.7% for
chlamydiae4.4 We therefore set out to determine the incidence of STD in our area following an -allegation of rape and also to study the attedance rate of women referred by the police. Additionally we attempted to correlate the occurrence of symptoms to the presence of infection.
Patients and methods A retrospective study of all female patients over the age of 16 who attended the Department of -Genitourinary Medicine (GUM) at Edinburgh Royal Infirmary with a history of sexual asault involving penetrative vaginal intercoprse between 1987 and 1989 was performed. A'list of all sexual assaults in women aged over 16 examined by the police surgeon (forensic physician) attached to Lothian an4 Borders Police Force over the same time period was compared with the hospital records.' All examin tio were carried out by two doctors, one of whom was a gynaecologist, and took place in a gynaecology ward of a general hospital. All the women were given written advice,to attend the Department of Genitourinary Medicine for STD screening and also to attend their general practitioner. Note was taken as to whether the patient had any symptoms related to the urinary-genital tract at presentation and an examination ofthe genital tract was performed. Each patient had a routine STD screen that included microscopy for Trichomonas vaginalis and Candida albicans, cultures for the gonococcus from the urethra, endocervix and rectum, chlamydia cultures from the endocervix and syphilis serology. A human immunodeficiency virus (V) antibody test was offered at the initial attendance and at 6 months after the assault. Although not done as a routine, culture and serological tests for herpes simplex virus were performed when indicated clinically as was a high vaginal swab for Gardnerella vaginalis. Routine
0140 0768/91/
1O68/91/ 110657-034$02.00/0 < 1991
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Society of Medicine
658
Journal of the Royal Society of Medicine Volume 84 November 1991
appointments at 2 weeks (when gonococcal cultures month and 6 months were offered. A comparison with the prevalence of STD in our clinic population was also made.
were repeated), one
Results Over this 3-year period 43 women attended GUM with a history of alleged sexual assault. Over the same period 124 women reported sexual assault to the police in Edinburgh, of whom only 16 women (13%) attended our department. Therefore 28 women out of the 43 seen were referred from other sources, usually self referral (33%) or from their general practitioner (23%). There was no difference in the age of the women referred by the police who attended for STD screening (average age 26.1, range 16-63) compared with those who did not (average age 25.6, range 16-63). Overall the police had been informed in 17 (40%) of those attending with a history of sexual assault. The age distribution of the women attending the department is illustrated in Figure 1 and they had been assaulted on average 7 weeks previously (range 0-36 weeks). The results of STD screening and comparative prevalence rates in our general clinic population are shown in Table 1. Antibodies to HIV were tested for in 25 patients (58%) with no positive results. Nineteen (44%) patients defaulted before follow-up was completed although 30 (70%) attended on at least two occasions. Of these defaulters, eight had been referred through the police. This compares with eight patients referred by the police who did complete follow-up (Table 2). Thirteen women (30%) were symptomatic complaining of vaginal discharge, vulval itch, abdominal pain and/or dysuria. Of these, eight were subsequently found to have a positive finding on investigation requiring treatment. Eight out of the 30 asymptomatic patients (27%) also had conditions requiring treatment, including two cases of chlamydia and one case of gonorrhoea together representing 10% of asymptomatic women. Discussion Overall the incidence of STD in this patient population is 37% (16% if candida infection is excluded) although this figure does not necessarily represent infections transmitted during the assault. It is interesting to note that there was little difference in the incidence of most types of STD detected Age
46-50
Table 1. Results of STD screening compared to the female clinic population
Rape victims
Femane clinic
population Negative screen Candida Chlamydia Gonorrhoea Gardnerella Herpes Trichomonas Genital warts Total
27 (64%) 9 (21%) 2 (4.7%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 43 (100%)
23% 18% 12% 5.2% N/A 3.2% 2.2% 32%
N/A, not available
compared to that of the clinic population over the same time period. This data in itself is however insufficient to show any correlation between background regional levels of STD and rates found in rape victims. The absence of any seropositivity to HIV would indicate that the risk of contracting HIV from a sexual assault is low at the present time2'4'5. Nonetheless HIV has been transmitted following a sexual assault8 and we feel that all patients should be counselled and offered a test for HIV in view of the importance of excluding this as a potential source of anxiety in the future. Although all those who reported the alleged crime to the police had been advised to attend for STD screening only 13% eventually did so. However, this figure did increase from 3% to 19% between 1987 and 1989. This may have been a consequence of the establishment of a Woman and Child Unit in 1988; the female plain clothes officers attached to this unit are responsible for the initial interview and for arranging further medical examination and for followup. Even so very few women appear willing to be examined for a second time in order to exclude STD. The alternative is that the police surgeon carry out screening tests during his examination, but this is hampered by a lack of specialist microbiological facilities available. The same problem applies if the general practitioner were to perform the initial examination. One answer to these problems would be specialized sexual assault centres where forensic examination and STD screening are carried out simultaneously with facilities for appropriate followup. Although this approach would undoubtedly increase the number of women being screened at their first visit, a recent Manchester study quotes a default rate of 46%4 for the first follow-up visit compared with 30% in our patient group. The relevance of this is difficult to determine as it is not clear how
41-45
Table 2. Follow-up rates compared by referral source
36-40
31-35f~ ;.-;
;i
Referral source
Follow-up completed
Self referral Police surgeon General practitioner Total
13 8 4 25
26-30
21-I5
No. qf Women
Figure 1. Age distribution of women attending with a history of sexual assault
Follow-up not completed 4 8 6
18
Journal of the Royal Society of Medicine Volume 84 November 1991
many of the women in the Manchester study received STD screening on their first visit. It was noted that a number of asymptomatic women had significant infections. If one was to extrapolate the figure for infections with either chlamydiae or gonorrhoea in asymptomatic women to all the women reporting rape to the police but not attending for STD screening, then approximately 11 asymptomatic women presenting to the police with either of these conditions would have gone undetected, with obvious potential detriment to health. Although screening for hepatitis B infection was not offered routinely to these patients, 18 (42%) were tested and all were negative. Although hepatitis B is a potential STD in women following sexual assault8 the risk of infection appears low. In summary, in common with other'studies we have found the incidence of STD following sexual assault to be low although a number of asymptomatic women may have significant infection. The low attendance for STD screening rate amongst women seen by the police has not been previously described and should be a source of concern.
Forthcoming events
The Health of the Nation Depends on the Mother and Child: A Response to the Document The Health of the Nation' 9 November 1991, Royal Society of Medicine, London Further details from: The Conference Secretary, The McCarrison Society, Institute of Brain Chemistry and Human Nutrition, Hackney Hospital, Homerton High Street, London E9 6BE (Tel: 081 533 6922, Fax: 081 533 6910) 7th International Symposium on Cardiopulmonary Urgencies and Emergencies 19-22 November 1991, Rotterdam, The Netherlands Further detail from. Dr 0 Prakash, Chief, Thorax Anesthesia Thorax Centre, Dijzigt Hospital, Dr Molewaterplein 50, 3015 GD Rotterdam, The Netherlands (Tel 31-10-463 5230; Fax: 31-10463 5240)
Paediatric and Adolescent Gynaecology 20 November 1991, Royal College of Obstetricians and Gynaecologists, London Further details from: Postgraduate Education Department, The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG (Tel: 071-262 5425, ext 207)
Audit in Obstetrics and Gynaecology 21 November 1991, Royal College of Obstetricians and Gynaecologists, London Further details from: (see entry for 20 November 1991) Accidents in the Home 26 November 1991, The Lansdowne Club, London Further details from: Conference Department, The Royal Society of Health, 38A St George's Drive, London SW1V 4BH
Risks, Dignity & Responsibility in Residential Homes 5 December 1991, The Lansdowne Club, London Further details from: (see entry for 26 November 1991)
References 1 Glaser JB, Hanmerschlag MR, McCormack WM. Epidemiology of sexually transmitted diseaes in rape victims. Rev Infect Dis 1989;11:246-54, 2 Murphy SM. Rape, sexually transniitted diseases and human immunodeficiency virus infection. Int J STD AIDS 1990;1:79-82 3 Forster GE, Pritchard J, Munday PE, et aL Incidence of sexually transmitted diseases in rape victims during 1984. Gentourin Med 1986;62:267-9 4 Lacey HB. Sexually transmitted diseases and rape: the experience of a sexual assault centre. Int J STD AIDS 1990;1:405-9 5 Jenny C, Hooton C, Bowers A, et aL Sexually transmitted disase in victims of rape. NEngl JMed 1990;322:713-16 6 Boag F, Barton S, Hawkins D. Rape, STDs and HIV (letter). Int J STD AIDS 1990;1:291-2 7 Estreich S, Forster GE, Robinson A. Sexually transmitted diseases in rape victims. Genitourin Med 1990;66:433-8 8 Murphy S, Kitchen V, Harris JRW, et aL Rape and subsequent conversion to HIV. BMJ 1989;299:718 9 Van Damme P, Eylenbosch W, Meheus A. Sexually tansmitted diseases and rape. N Engi J Med 1990;823:1142
(Accepted 12 March 1991)
3rd International Conference on Drug Delivery and Targ g Systems: Prospects for theA 90s 5-6 December 1991, Royal Lancaster Hotel, London Further details fiom: Georgina Mason, EBC Technical Services Ltd, Bath House (3rd Floor), 56 Holborn Viaduct, London EClA 2EX (Tel: 071 236 4080, Fax 071 -489 0849) Technique & Applications of Molecular Biology: A Course for Medical Practitioners 10-13 December 1991, University of Warwick Further details from Dr Rachel Strachan, Department of Biological Sciences, University of Warwick, Coventry CV4 7AL (Tel: 0203 523540)
World Congress on Cardiology 12-15 December 1991, New Delhi, India Further details from: Miss M Passi, Committee Executive, IJCP, 495 R ings Lane Hall Green, Birmingham Bll 3DF (Tel: 021-777 7933)
Fibrinogen - A Cardiovascular Risk Factor 27-28 January 1992, Vienna Further details from: Professor B Ernst, AKH, University of Vienna, Department of Phys Med Rehab, Wahringer Gurtel 18-20, A-1097 Vienna (Tel: 0222 40400 4330; Fax: 0222 40400 5281 Post-Reproductive Gynaecology (Postgraduate Meeting) 28 January 1992, RCOG, London
Further details from: (see entry for 20 November 1991) Fetal Assessment/Well-Being (Postgraduate Meeting) 29 January 1992, RCOG, London Further details from: (see entry for 20 November 1991) Obstetric Ultrasound 10-14 February 1992, RCOG, London Further details from: (see entry for 20 November 1991) MRCP Courses 10-14 February 1992, Royal Free Hospital, London Further details from: Dr D Geraint James, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG (Tel: 071 794 0500, ext 3931) Screening in Gynaecology 20 February 1992, RCOG, London Further details from: (see entry for 20 November 1991) -continued on p 674
659
657
Rape and sexually transmitted diseases: patterns of referral and incidence in a department of genitourinary medicine
J D C Ross MRcP' G R Scott MRCP' A Busuttil FRCPath2 'Department of Genitourinary Medicine, Lauriston Building, Edinburgh Royal Infirmary, Edinburgh, 2Forensic Medicine Unit, University of Edinburgh Keywords: rape; sexually transmitted diseases; police
Summary A retrospective study was carried out of all women attending a Department of Genitourinary Medicine over a 3-year period. Note was taken of referring source, presenting symptoms, infection detected at STD screening and follow-up attendance. Comparison was also made between the number of women referred by the police surgeon and the number who actually attended. We observed an overall incidence of STD of 35% and noted that many infections had a similar prevalence to that of our normal clinic population over the same time period. Only 13% of the women referred by the police attended although after the initial visit attendance was similar regardless ofreferral source. A number of asymptomatic women were noted to have infection with Neisseria gonorrhoeae and Chlamydia trachomatis. Although the risk of significant STD following sexual assault is low greater efforts should be made to encourage women to attend for screening whether or not they are symptomatic. Introduction The incidence of rape is increasing in many communitiesl2 although exact figures for sexual assault are impossible to obtain due to the persistently low reporting rate associated with this crime"3. Apart from the psychological and physical trauma that may result from rape there is also the additional risk of acquiring a sexually transmitted disease (STD) during such an assault. The risk of becoming infected with an STD under such circuimstances is not known and attempting to assess this risk has a number of intrinsic handicaps. In the first instance not all these women will present for specific screening following an alleged sexual assault and it is difficult to extrapolate from the percentage that do attend to the entire cohort at risk. Those with symptoms are perhaps more likely to attend than those without, giving rise to a positive bias. Any infection deteced at post-rape screening may have been present previously and women reporting recent sexual activity prior to the rape have a higher incidence of STD on screening4. One study reported that rape victims may have a higher prevalence of STD prior to an assault than the normal population5. Additionally these women may present originally to a wide variety of agencies including their general practitioner, the police, departments of genitourinary medicine, rape crisis centres and well women clinics6. Having attended one department they may be reluctant to be referred or to attend for a second
examination elsewhere, making global figures difficult to obtain. Although a number of studies have reported the incidence of STD in rape victims in America, there are less data relating to the United Kingdom. One study of London patients quoted a rate of 30% for STD in patients seen after sexual assault3, whilst another London study found an incidence of 5% and 12% for chlamydial and gonorrhoeal infection respectively with an overall rate, excluding candida infection and non-specific vaginosis, of 29%7. A recent MaDcester study found rates of 2.2% for gonorrhoea and 7.7% for
chlamydiae4.4 We therefore set out to determine the incidence of STD in our area following an -allegation of rape and also to study the attedance rate of women referred by the police. Additionally we attempted to correlate the occurrence of symptoms to the presence of infection.
Patients and methods A retrospective study of all female patients over the age of 16 who attended the Department of -Genitourinary Medicine (GUM) at Edinburgh Royal Infirmary with a history of sexual asault involving penetrative vaginal intercoprse between 1987 and 1989 was performed. A'list of all sexual assaults in women aged over 16 examined by the police surgeon (forensic physician) attached to Lothian an4 Borders Police Force over the same time period was compared with the hospital records.' All examin tio were carried out by two doctors, one of whom was a gynaecologist, and took place in a gynaecology ward of a general hospital. All the women were given written advice,to attend the Department of Genitourinary Medicine for STD screening and also to attend their general practitioner. Note was taken as to whether the patient had any symptoms related to the urinary-genital tract at presentation and an examination ofthe genital tract was performed. Each patient had a routine STD screen that included microscopy for Trichomonas vaginalis and Candida albicans, cultures for the gonococcus from the urethra, endocervix and rectum, chlamydia cultures from the endocervix and syphilis serology. A human immunodeficiency virus (V) antibody test was offered at the initial attendance and at 6 months after the assault. Although not done as a routine, culture and serological tests for herpes simplex virus were performed when indicated clinically as was a high vaginal swab for Gardnerella vaginalis. Routine
0140 0768/91/
1O68/91/ 110657-034$02.00/0 < 1991
The Royal
Society of Medicine
658
Journal of the Royal Society of Medicine Volume 84 November 1991
appointments at 2 weeks (when gonococcal cultures month and 6 months were offered. A comparison with the prevalence of STD in our clinic population was also made.
were repeated), one
Results Over this 3-year period 43 women attended GUM with a history of alleged sexual assault. Over the same period 124 women reported sexual assault to the police in Edinburgh, of whom only 16 women (13%) attended our department. Therefore 28 women out of the 43 seen were referred from other sources, usually self referral (33%) or from their general practitioner (23%). There was no difference in the age of the women referred by the police who attended for STD screening (average age 26.1, range 16-63) compared with those who did not (average age 25.6, range 16-63). Overall the police had been informed in 17 (40%) of those attending with a history of sexual assault. The age distribution of the women attending the department is illustrated in Figure 1 and they had been assaulted on average 7 weeks previously (range 0-36 weeks). The results of STD screening and comparative prevalence rates in our general clinic population are shown in Table 1. Antibodies to HIV were tested for in 25 patients (58%) with no positive results. Nineteen (44%) patients defaulted before follow-up was completed although 30 (70%) attended on at least two occasions. Of these defaulters, eight had been referred through the police. This compares with eight patients referred by the police who did complete follow-up (Table 2). Thirteen women (30%) were symptomatic complaining of vaginal discharge, vulval itch, abdominal pain and/or dysuria. Of these, eight were subsequently found to have a positive finding on investigation requiring treatment. Eight out of the 30 asymptomatic patients (27%) also had conditions requiring treatment, including two cases of chlamydia and one case of gonorrhoea together representing 10% of asymptomatic women. Discussion Overall the incidence of STD in this patient population is 37% (16% if candida infection is excluded) although this figure does not necessarily represent infections transmitted during the assault. It is interesting to note that there was little difference in the incidence of most types of STD detected Age
46-50
Table 1. Results of STD screening compared to the female clinic population
Rape victims
Femane clinic
population Negative screen Candida Chlamydia Gonorrhoea Gardnerella Herpes Trichomonas Genital warts Total
27 (64%) 9 (21%) 2 (4.7%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 1 (2.3%) 43 (100%)
23% 18% 12% 5.2% N/A 3.2% 2.2% 32%
N/A, not available
compared to that of the clinic population over the same time period. This data in itself is however insufficient to show any correlation between background regional levels of STD and rates found in rape victims. The absence of any seropositivity to HIV would indicate that the risk of contracting HIV from a sexual assault is low at the present time2'4'5. Nonetheless HIV has been transmitted following a sexual assault8 and we feel that all patients should be counselled and offered a test for HIV in view of the importance of excluding this as a potential source of anxiety in the future. Although all those who reported the alleged crime to the police had been advised to attend for STD screening only 13% eventually did so. However, this figure did increase from 3% to 19% between 1987 and 1989. This may have been a consequence of the establishment of a Woman and Child Unit in 1988; the female plain clothes officers attached to this unit are responsible for the initial interview and for arranging further medical examination and for followup. Even so very few women appear willing to be examined for a second time in order to exclude STD. The alternative is that the police surgeon carry out screening tests during his examination, but this is hampered by a lack of specialist microbiological facilities available. The same problem applies if the general practitioner were to perform the initial examination. One answer to these problems would be specialized sexual assault centres where forensic examination and STD screening are carried out simultaneously with facilities for appropriate followup. Although this approach would undoubtedly increase the number of women being screened at their first visit, a recent Manchester study quotes a default rate of 46%4 for the first follow-up visit compared with 30% in our patient group. The relevance of this is difficult to determine as it is not clear how
41-45
Table 2. Follow-up rates compared by referral source
36-40
31-35f~ ;.-;
;i
Referral source
Follow-up completed
Self referral Police surgeon General practitioner Total
13 8 4 25
26-30
21-I5
No. qf Women
Figure 1. Age distribution of women attending with a history of sexual assault
Follow-up not completed 4 8 6
18
Journal of the Royal Society of Medicine Volume 84 November 1991
many of the women in the Manchester study received STD screening on their first visit. It was noted that a number of asymptomatic women had significant infections. If one was to extrapolate the figure for infections with either chlamydiae or gonorrhoea in asymptomatic women to all the women reporting rape to the police but not attending for STD screening, then approximately 11 asymptomatic women presenting to the police with either of these conditions would have gone undetected, with obvious potential detriment to health. Although screening for hepatitis B infection was not offered routinely to these patients, 18 (42%) were tested and all were negative. Although hepatitis B is a potential STD in women following sexual assault8 the risk of infection appears low. In summary, in common with other'studies we have found the incidence of STD following sexual assault to be low although a number of asymptomatic women may have significant infection. The low attendance for STD screening rate amongst women seen by the police has not been previously described and should be a source of concern.
Forthcoming events
The Health of the Nation Depends on the Mother and Child: A Response to the Document The Health of the Nation' 9 November 1991, Royal Society of Medicine, London Further details from: The Conference Secretary, The McCarrison Society, Institute of Brain Chemistry and Human Nutrition, Hackney Hospital, Homerton High Street, London E9 6BE (Tel: 081 533 6922, Fax: 081 533 6910) 7th International Symposium on Cardiopulmonary Urgencies and Emergencies 19-22 November 1991, Rotterdam, The Netherlands Further detail from. Dr 0 Prakash, Chief, Thorax Anesthesia Thorax Centre, Dijzigt Hospital, Dr Molewaterplein 50, 3015 GD Rotterdam, The Netherlands (Tel 31-10-463 5230; Fax: 31-10463 5240)
Paediatric and Adolescent Gynaecology 20 November 1991, Royal College of Obstetricians and Gynaecologists, London Further details from: Postgraduate Education Department, The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG (Tel: 071-262 5425, ext 207)
Audit in Obstetrics and Gynaecology 21 November 1991, Royal College of Obstetricians and Gynaecologists, London Further details from: (see entry for 20 November 1991) Accidents in the Home 26 November 1991, The Lansdowne Club, London Further details from: Conference Department, The Royal Society of Health, 38A St George's Drive, London SW1V 4BH
Risks, Dignity & Responsibility in Residential Homes 5 December 1991, The Lansdowne Club, London Further details from: (see entry for 26 November 1991)
References 1 Glaser JB, Hanmerschlag MR, McCormack WM. Epidemiology of sexually transmitted diseaes in rape victims. Rev Infect Dis 1989;11:246-54, 2 Murphy SM. Rape, sexually transniitted diseases and human immunodeficiency virus infection. Int J STD AIDS 1990;1:79-82 3 Forster GE, Pritchard J, Munday PE, et aL Incidence of sexually transmitted diseases in rape victims during 1984. Gentourin Med 1986;62:267-9 4 Lacey HB. Sexually transmitted diseases and rape: the experience of a sexual assault centre. Int J STD AIDS 1990;1:405-9 5 Jenny C, Hooton C, Bowers A, et aL Sexually transmitted disase in victims of rape. NEngl JMed 1990;322:713-16 6 Boag F, Barton S, Hawkins D. Rape, STDs and HIV (letter). Int J STD AIDS 1990;1:291-2 7 Estreich S, Forster GE, Robinson A. Sexually transmitted diseases in rape victims. Genitourin Med 1990;66:433-8 8 Murphy S, Kitchen V, Harris JRW, et aL Rape and subsequent conversion to HIV. BMJ 1989;299:718 9 Van Damme P, Eylenbosch W, Meheus A. Sexually tansmitted diseases and rape. N Engi J Med 1990;823:1142
(Accepted 12 March 1991)
3rd International Conference on Drug Delivery and Targ g Systems: Prospects for theA 90s 5-6 December 1991, Royal Lancaster Hotel, London Further details fiom: Georgina Mason, EBC Technical Services Ltd, Bath House (3rd Floor), 56 Holborn Viaduct, London EClA 2EX (Tel: 071 236 4080, Fax 071 -489 0849) Technique & Applications of Molecular Biology: A Course for Medical Practitioners 10-13 December 1991, University of Warwick Further details from Dr Rachel Strachan, Department of Biological Sciences, University of Warwick, Coventry CV4 7AL (Tel: 0203 523540)
World Congress on Cardiology 12-15 December 1991, New Delhi, India Further details from: Miss M Passi, Committee Executive, IJCP, 495 R ings Lane Hall Green, Birmingham Bll 3DF (Tel: 021-777 7933)
Fibrinogen - A Cardiovascular Risk Factor 27-28 January 1992, Vienna Further details from: Professor B Ernst, AKH, University of Vienna, Department of Phys Med Rehab, Wahringer Gurtel 18-20, A-1097 Vienna (Tel: 0222 40400 4330; Fax: 0222 40400 5281 Post-Reproductive Gynaecology (Postgraduate Meeting) 28 January 1992, RCOG, London
Further details from: (see entry for 20 November 1991) Fetal Assessment/Well-Being (Postgraduate Meeting) 29 January 1992, RCOG, London Further details from: (see entry for 20 November 1991) Obstetric Ultrasound 10-14 February 1992, RCOG, London Further details from: (see entry for 20 November 1991) MRCP Courses 10-14 February 1992, Royal Free Hospital, London Further details from: Dr D Geraint James, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG (Tel: 071 794 0500, ext 3931) Screening in Gynaecology 20 February 1992, RCOG, London Further details from: (see entry for 20 November 1991) -continued on p 674
659
