The preceding analysis provides preliminary estimates of the risk of HIV acquisition due to male–male rape in prison. These estimates are subject to considerable uncertainty, as discussed next. Nevertheless, the results of this analysis are cause for concern. A man who is raped just once by five assailants faces, on average, a 1 in 477 risk of acquiring HIV as a consequence of this assault. If he subsequently is raped 7 to 35 additional times, his risk of becoming infected could rise as high as 1 in 98. The implication of these findings is clear: Men who are raped in prison face a substantial risk of acquiring HIV.
Fortunately, only a small minority of men are raped in U.S. prisons. Still, with the male prison population growing to 1.4 million men at the end of 2003 (Harrison & Beck, 2004
), even if the prevalence of prison rape is as “low” as 1%, 14,000 incarcerated men already have been or will be raped while imprisoned. We estimate that between 43 and 93 of these men have or will acquire HIV as a result.
The physical and psychological consequences of prison rape are manifest. Victims of particularly violent sexual assaults may require hospitalization for broken bones, bleeding, or worse (Dumond & Dumond, 2002
). Rape victims may experience severe psychological trauma (Cotton & Groth, 1982
; Fagan et al., 1996
; Robertson, 2003
), which can adversely affect adjustment to prison life and subsequently interfere with successful reintegration into the community following release (Dumond & Dumond, 2002
). The analysis presented here highlights another potential source of both physical and psychological harm to victims of prison rape—specifically, the possible acquisition of HIV infection as a consequence of being raped. HIV disease is an incurable, lifelong health condition that is both difficult and costly to manage effectively, particularly in prison settings (Frank, 1999
; Ruby, 2002
), and that may contribute to the spread of other diseases, such as tuberculosis and sexually transmitted infections, in these settings (Braun et al., 1989
; Centers for Disease Control, 1996
). Moreover, upon release, persons who have acquired HIV while in prison may transmit the virus to their sexual and needle-sharing partners, helping to sustain the pool of infection in the community (Grinstead, Zack, Faigeles, Grossman, & Blea, 1999
; MacGowan et al., 2003
; Mutter, Grimes, & Labarthe, 1994
; Skolnick, 1998
). Only by reducing the incidence of prison rape can these various harms be diminished.
The preceding analysis was limited by the paucity of detailed empirical data regarding the prevalence and context (number of assailants and incidents) of prison rape, the prevalence of HIV among prison rapists, and the impact of the often-violent prison rape context on the per-act HIV transmission probability. Prison rape is an underreported crime (Eigenberg, 1989
; Gaes & Goldberg, 2004
; Mariner, 2001
), as is male–male rape in general (Groth, 1979
; Lipscomb, Muram, Speck, & Mercer, 1992
); estimates of HIV prevalence in prison are likely to underrepresent the true prevalence because not all persons in prisons are tested for HIV (Maruschak, 2002
), and available estimates of the per-act transmission probability for anal intercourse likely underestimate the risks faced by persons with traumatic exposures such as rape. Individually and in combination our relatively conservative assumptions with regard to each of these factors would tend to minimize the impact of prison rape with regard to HIV acquisition. Conversely, our analysis incorporates several assumptions that could have inflated our estimates of the number of men who acquire HIV after being raped in prison. Specifically, we assumed that all acts of prison rape are perpetrated by other prisoners, not by prison staff (equivalently, we assumed that the prevalence of HIV infection among prison staff equals the prevalence of infection among inmates); that condoms are not used during forced or coerced anal intercourse; and that prison rapists are no more and no less likely than other inmates to be infected with HIV.
Finally, values for several key prison rape experience parameters were drawn from Struckman-Johnson et al.'s (1996)
study of sexual coercion in a Nebraska prison. The generalizability of this study's findings is unknown. Moreover, our analysis required additional assumptions regarding the relationship of sexual coercion and prison rape experiences—for example, that the number of perpetrators did not differ for rape and other forms of sexual coercion. We believe that our assumptions generally are conservative. Nevertheless, in light of the acknowledged uncertainty in the analysis, the results presented here are best viewed as indicating the scope of the problem rather than as providing exact estimates of the number of HIV infections due to prison rape.
From a policy standpoint the key questions are: What incidence of prison rape is acceptable, and how many people should be allowed to acquire HIV while in the protective custody of the U.S. penal system? The answer to the first question is explicit in the Prison Rape Elimination Act of 2003, and the answer to the second is implicit therein: No man, woman, or adolescent should be raped while incarcerated, and none should acquire HIV. Our results—uncertainties notwithstanding—suggest that significant policy and structural initiatives will be needed to achieve the “zero tolerance” objective of the Prison Rape Elimination Act.