Statement by
Roberto Hugh Potter, Ph.D.
Office of Health Disparities
Corrections and Substance Abuse Activities
National Center for HIV, STD, and TB Prevention
Coordinating Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Disease Transmission and Injury in Prisoner Rape Events:
Concerns for Corrections and the Community

The National Prison Rape Elimination Commission

June 14, 2005

Good afternoon Mr. Chairman and Members of the Commission. My name is Roberto Hugh Potter and I am with the Corrections and Substance Abuse Activities group in the Office of Health Disparities of the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC). Thank you for the opportunity to discuss injury and infectious disease concerns associated with sexual assaults occurring within correctional environments.

Since the identification of persons infected with the Human immunodeficiency virus (HIV/AIDS) in jails and prisons in the 1980s, concern has been raised about the possible transmission of HIV through sexual assault in jails and prisons ("prison rape"). Within the past decade, media attention and scientific research have examined claims that prison rape and other sexual activities occurring inside prison have spread HIV further. While the potential for HIV transmission has focused attention on prison sex and sexual assault, criminal justice and public health professionals have also been concerned with other sexually transmitted diseases (STDs), injuries, and psychological damage associated with prison rape for decades.

My testimony today will focus on what we know from the best available science about prison rape and related issues of disease transmission and injury. My testimony primarily summarizes an article I have co-written with Dr. Richard Tewksbury of the University of Louisville (2005, "Sex and Prisoners: Criminal Justice Contributions to a Public Health Issue". Journal of Correctional Health Care, 11(2): 171-190; attached for the Record).

The Problem
Section 2, paragraph 7, Public Law 108-79 (117 Stat. 972; "Prison Rape Elimination Act of 2003") states:

    (7) "HIV and AIDS are major public health problems within America's correctional facilities. In 2000, 25,088 inmates in Federal and State prisons were known to be infected with HIV/AIDS. In 2000, HIV/AIDS accounted for more than 6 percent of all deaths in Federal and State prisons. Infection rates for other sexually transmitted diseases, tuberculosis, and hepatitis B and C are also far greater for prisoners than for the American population as a whole. Prison rape undermines the public health by contributing to the spread of these diseases, and often giving a potential death sentence to its victims."

The potential public health effect of sexual violence (and of unsafe consensual sex) between incarcerated persons, with correctional staff and/or visitors is substantial. The actual amount of disease transmission that occurs while incarcerated, however, is unknown.

The prevalence of HIV and other STDs in correctional settings, coupled with consensual and non-consensual sexual behavior within correctional settings has led several writers to suggest there might be a high risk of HIV and other STD transmission inside prisons (e.g., Hammett, Harmon, and Maruschak, 1999; Tewksbury, Vito, and Cummings, 1998). Establishing the extent of actual disease transmission as a result of prison rape is difficult.

What We Know and How We Know It
A critical analysis of the disease burden and transmission empirical literature leads to the following observations:

  1. Most research shows that inmates entering all levels of the correctional system have higher rates of disease or history of disease and injury than the general population; though we do not necessarily know how the observed rates relate to the community from which the inmates come;

  2. There is limited empirical research that directly demonstrates the sexual transmission of diseases within correctional facilities (e.g., Brewer, et al., 1988; MMWR, 2004);

  3. Sexual transmission of disease does occur in these settings, but we do not document it well and cannot accurately describe the scope of the problem;

  4. Given that there is little empirical direct documentation of disease transmission within correctional facilities, there is little empirical evidence that former prisoners transmit STDs, HIV, or hepatitis A or hepatitis B that they might have acquired as the result of prison sex, including coercive sex, upon their release back into the community;

  5. We lack sufficient injury monitoring and disease surveillance processes to adequately assess these issues; and,

  6. Our knowledge of disease burden and transmission within correctional facilities is based primarily on cross-sectional studies, often confined to one institution or, at best, one state.

"Surveillance" is the systematic, continuing observation of a particular phenomenon and is the first step in a public health approach to disease prevention and control. Surveillance is also an area in which both public health professionals and criminal justice professionals can work together toward better understanding of the burden of disease, and development of intra-facility and post-release disease transmission.

At present there is no systematic, continuous monitoring of sexual activity, sexual violence, or of treatment for STDs, in correctional settings. Maruschak and Beck (2001) provide an overview of the various surveys of inmates in Federal and State prisons, as well as local jails, but note that none of these measure sexual activity among inmates, voluntary or otherwise. There is some surveillance of assaults among prisoners and against staff in correctional settings (MMWR, 1996; Camp and Camp, 1997; Maruschak and Beck, 2001), but little detailed information is collected on the degree of injury or type of injury suffered in these events. These sources do not include a break-out of sexual assaults.

Currently each state requires medical providers to report cases of the following diseases to their respective health departments. The states voluntarily report these cases without personal identifiers to the Centers for Disease Control and Prevention (CDC). These diseases may be associated with prison sexual activity, consensual or otherwise:

    Chlamydia trachomatis genital infection
    Hepatitis A (acute)
    Hepatitis B (acute)
    Hepatitis C (acute)
    HIV Infection (adult)
    Syphillis, primary
    Syphillis, secondary

In most states, none of the reporting for these diseases includes a direct question about the incarceration status of the individual at the time of diagnosis. In some instances that information may be drawn from special coding or written comments (see Dean-Gaitor and Fleming, 1999; Dean, Lansky, and Fleming, 2002). In sum, our official systematic knowledge of disease transmission within correctional facilities is patchy, at best.

In 1997, the CDC's Division of STD Prevention and state STD program managers surveyed a sample of jails in counties in which more than 40 cases of primary or secondary syphilis were reported, and counties with cities larger than 200,000 residents (DSTDP, 1998). The purpose of the survey was to examine how STD screening programs operated in these jail settings. They reported that, overall, jails do not routinely screen for STDs (including HIV); they screened primarily when there were obvious signs of infection in detainees or when detainees requested testing. Most jails received test results 48 hours after the test was conducted, a timeframe in which many of those tested had already bonded-out of detention and were therefore difficult to locate if they required treatment. Of those tested in jails at that time, 10 percent of the detainees were reactive for syphilis. Of the 10 percent, approximately one-half were treated in the jail; of those who were released before treatment, only about one half were located and treated in the community. Information from CDC-funded jail-based STD projects (DSTDP, 2000 - 2002) suggests higher rates of sexually transmitted infections in jail detainees upon intake than observed in the communities from which detainees come.

Relating Disease Burden to Sexual Transmission
Lacking systematic surveillance data, we must turn to cross-sectional studies of prisoners' sexual behavior to examine the incidence and prevalence of sexual behavior in correctional settings and how these might relate to disease transmission. The relatively small amount of literature on the incidence of the sexual behavior of incarcerated populations (primarily men's prisons) has been reviewed by Tewksbury (1989), Saum, et al. (1995), and in Hensley, Struckman-Johnson, and Eigenberg (2000; see also, Hensley, 2002). Estimates of the prevalence of sexual violence and consensual sex in jails and prisons vary widely (Saum, Surrat, Inciardi and Bennett, 1995; Kunselman, Tewksbury, Dumond, and Dumond, 2002). Regardless of the context, most research since 1980 reports low to moderate (i.e., 2% - 24% consensual; 0% to 40% coerced, [broadly defined]) sexual activity between inmates.

Making a link between STD identified at entry into a correctional facility, and STD acquired while incarcerated is difficult. Our present surveillance systems do not allow us to document how often this occurs.

Unintended Consequences
While focusing on the potential problems associated with prison rape and disease transmission, we do not want to overstate the risk to prisoners and those with whom they will interact upon returning to the community. In recent focus group work, former prisoners and their families recommended that we avoid adding yet another layer of stigma to the status of "former prisoner" they feared would occur by linking inmates to disease and disability.

The Commission can play a key role in the development, conduct, and dissemination of high-quality empirical research and evidence-based programs to guide not only prison rape elimination, but disease and injury prevention and health promotion among those who pass through our correctional facilities and systems. Reliance on empirical evidence linked to such programs should help avoid further stigmatization.

In summary, the potential public health effect of sexual violence (and of unsafe consensual sex) between incarcerated persons, with correctional staff and/or visitors, has been described as substantial. The best available scientific research on the topic, however, does not substantiate assertions of high levels of within-corrections disease transmission.

The risk potential documented in high levels of certain STDs at intake among prisoners does offer us a chance to intervene with a population beset by health disparities of all sorts, especially STDs and injury-related trauma. For hepatitis A and hepatitis B transmission can be averted through vaccination of all prisoners (recommended since 1992 by CDC, MMWR, 2003); for other diseases and injuries behavioral prevention will be required. The Prison Rape Elimination Act of 2003 offers a unique opportunity to develop not only sexual violence prevention programs for incarcerated persons, but programs that foster safer sexual and interpersonal relationship skills within the correctional setting and upon the prisoner's return to the community. The Act can make sexual assault and intimate partner violence prevention a part of the re-entry preparation process, reducing further the potential for disease transmission and violence-related injuries, inside and outside of correctional settings.

Thank you for your invitation to provide testimony.

I declare under penalty of perjury that the foregoing is true and correct. Executed on this 14th day of June, 2005.


Roberto Hugh Potter, Ph.D.


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Last Revised: June 6, 2006