There is no reliable statistics about the incidence of sexually transmitted infections (STI) in Russia because many people concealed the disease, gonorrhea in particular, and practiced self-treatment. The main reason has been the lengthy and unpleasant therapy in the dermatovenereological dispensaries (prevention and treatment centers). Responsible individuals administered themselves regular courses of antibiotics, but others treated themselves inadequately and continued spreading STI. Thanks to the free internet resources, many guidelines are adjusted to the international standards today. However, the human factor has remained largely unchanged, so that a relapse of suboptimal practices and policies is not excluded. Several extracts from instructions by the Ministry of Health, handbooks and manuals recommending invasive methods of therapy and provocation are discussed here. It is too early to discard the topical therapy of gonorrhea. There are concerns that some infections may become untreatable by antibiotics. One of the factors contributing to antimicrobial resistance is the use of antibiotics in the cattle feeding, addition of antibiotics to milk and other perishable foodstuff in this country. Irresponsible use of antibiotics beyond their evidence-based medical applications may accelerate the acquisition of resistance by different microbial populations. Furthermore, some aspects of sexual and reproductive coercion are discussed here.

A recently published book [1], discussed invasive procedures used in Russian healthcare without sufficient indications. Among others, the following has been analyzed: the overuse of thoracic surgery for tuberculosis, bronchial asthma and other respiratory diseases, overtreatment of radiation-related lesions, spleno-renal anastomosis in diabetes, excessive and compulsory treatments of alcoholics, cauterization of cervical ectopy regardless of the presence of epithelial dysplasia. Some methods are reappearing, notably, in publications from military medical instructions, e.g. gastrectomy (resection) for peptic ulcers [2], discussed in [3]. Considering the breast cancer incidence, millions of women in the former Soviet Union (SU) underwent Halsted and lately of Patey mastectomy with removal of pectoral muscles without indications, often sans informed consent [1]. Justifications of surgical hyper-radicalism could be heard in private conversations among medics, for example: “The hopelessly ill are dangerous” i.e. may commit reckless acts undesirable by the totalitarian state. For example, glioblastoma patients were routinely operated on, while it was believed by some staff that the treatment was generally useless, just forcing many patients to spend the rest of their lives in bed. The training of medical personnel has been another motive. This topic is interconnected with certain features of Russian healthcare, namely paternalism, authoritative management style, occasional disregard for the principles of informed consent, professional autonomy and scientific polemics. In conditions of paternalism, misinformation of patients, persuasion and compulsory treatments are deemed permissible.

Some human factors and guidelines in Russian healthcare have not substantially changed since the Soviet time. The non-observance of professional autonomy has been a contributing factor. The exaggerated care of war veterans is showcased these days. They enjoy advantages in the healthcare and everyday life; there are, however, misgivings that the veteran status has been awarded gratuitously to some individuals from the privileged milieu. In fact, many World War II veterans had been maltreated in 1990-2005, when the average expectation of life at birth has fallen especially for males; by 1993 it had slumped to 58-58 years. The healthcare deteriorated at that time. It is known that percentage of alcohol consumers is relatively high among military veterans. In the course of the anti-alcohol campaign (1985-1989) they were factually coerced to queue hours on end at bottle stores or to consume non-beverage alcohol. Inexpensive beerhouses were crowded while visitors usually stood on their feet. Standing for a long time is undue hardship for aged people especially after work. Their counterparts in Europe are sitting in comfortable beerhouses consuming products of better quality than those available in the Russian Federation (RF). Since the 1990s poor-quality toxic liquids have been sold in ordinarily labeled bottles through legally operating shops, kiosks and eateries generally with the knowledge of authorities. There have been mass poisonings with lethal outcomes; details and references are in the book [4].

Sexually transmitted infections (STI)

There is no reliable statistics about the incidence of STI in RF because many people conceal the disease, gonorrhea (Gn) in particular, and practice self-treatment. A reason was the lengthy and unpleasant therapy at the dermatovenereological dispensaries (prevention and treatment centers). Responsible individuals administered themselves regular courses of antibiotics, but others treated themselves inadequately and continued spreading STI. Thanks to the free Internet resources, many guidelines are adjusted to the international standards, which is discussed here below. Therapy of STI is available in private clinics. However, the human factor has remained largely unchanged, so that a comeback of suboptimal practices and policies is not excluded. Finally, the obstacles to the importation of drugs and medical equipment should be mentioned. Domestic products are promoted sometimes despite suboptimal quality and possible counterfeiting. Therefore, some efficient drugs are unavailable in Russian pharmacies.

Here are presented and discussed several extracts from instructions by the Ministry of Health, handbooks and manuals that contained essentially the same recommendations. If the signs of inflammation persist longer than 5-7 days after a course of antibiotics, even in the absence of Neisseria gonorrheae in urethral smears, a topical therapy was recommended. In the Instruction by the Health Ministry it was written that in acute gonorrhea topical treatment should be started after the completion of a course of antibiotics [5]. In torpid or chronic form of the disease, topical therapy is performed prior to the antibiotic treatment (at a hospital) or thereafter (in ambulant patients). The sexual contacts were to be treated the same way as the patients with chronic Gn, also if no N. gonorrheae are found in the smears [5]. Earlier instructions and monographs recommended the topical therapy for acute Gn [6]. The following treatments were recommended: instillations into the urethra of potassium permanganate or 0.25-1 % silver nitrate solution with an additional treatment of focal lesions by 10-20 % silver nitrate via urethroscope. Bougienage, urethral massage on the urethroscope, and tamponade of the urethra were recommended both for soft and hard infiltration (beyond the acute phase) with subsequent smearing of the urethral mucosa by Ichthammol (Ichthyol), a substance derived from oil shale [6,7]. Carcinogenicity of Ichthammol and Vishnevski liniment containing xeroform and tar cannot be excluded. According to another instruction, “In case of a mixed or hard infiltration a tamponade of the urethra should be performed… Colliculitis is treated by bouginage” [8]. The same recommendations, including instillations of silver nitrate, tamponade and bouginage can be found in textbooks [9,10]. There was also research on Gn with instillation into the urethra of different substances such as oxygen foam, gastric juice or various herbal decoctions [11-13].

The tests of cure, recommended for all treated patients, included different kinds of provocations. Chemical provocations in men included instillations of silver nitrate solution into the urethra, in women - smearing of the urethral mucosa with 1-2 % and cervical canal with 2-5 % silver nitrate solution or Lugol’s iodine solution with glycerol. Mechanical provocations included urethroscopy and urethral massage on the urethroscope or bougie [5,9]. If symptoms reappear, also in the absence of gonococci in the smears, the treatment and tests of cure were to be repeated. The urethral discharge is examined 24, 48 and 72 hours after the provocation; in the absence of discharge, an examination of secretions from the prostate and seminal vesicles was recommended. If no N. gonorrheae were found after the first provocation, a combined provocation including urethroscopy must be performed a month later [5].

In women, the topical treatment was recommended for “fresh torpid” and chronic Gn [5,10]. However, some earlier instructions and monographs recommended topical treatment (urethra washings, instillations) in women also for acute Gn [5,14]. Bimanual examination and urethroscopy, quite unpleasant in cases with inflammation, were recommended for women both in acute and chronic Gn [15], whereas technical difficulties of the urethroscope insertion were pointed out [16]. Considerable discomfort must have been associated with those “technical difficulties”. The following was recommended for patients with chronic urethritis: instillations of silver nitrate solution, smearing of the urethral and cervical mucosa with Ichthammol [17] or Vishnevski liniment [18], urethral massage on the urethroscope, coagulation of inflamed paraurethral glands [7,15,17], coagulation of cervical ectopies (ectropions). It should be commented that diathermocoagulation (electrocautery) or other ablative treatments of the cervical ectopy in the absence of epithelial dysplasia was performed routinely without preceding Pap-smears. Cervical erosions and ectopies were found at mass prophylactic checkups and treated by electro- or thermocautery [19].

If at the first appointment N. gonorrheae is not found in the urethral smears, a provocation by means of an instillation of silver nitrate solution into the urethra and cervical canal was recommended [15]. The test of cure included urethroscopy [14]. The combined provocation in women was performed 7-10 days after the treatment, then repeated after the next menstruation, and then again after 2-3 menstrual periods. The combined provocations repeated thrice have been recommended also for Gn in female adolescents and children [20-22]. If the symptoms persisted, but no gonococci are found in the smears, the treatment like for chronic Gn was prescribed. In consequence of such approach, non-gonococcal urethritides were sometimes treated by means of the topical procedures described above. For women with suspected gonorrhea and for those with urogenital inflammatory conditions of unclear etiology, some instructions recommended the same treatment as for chronic Gn [7,15].

The methods of local treatment and provocation described above were not mentioned by internationally used handbooks, reviews and recommendations by the World Health Organization (WHO), while the bougienage is recommended only for strictures. The topical treatment was inherited from the pre-antibiotic era. However, observant tactics without invasive manipulations was advocated in the 1930s [23]. After the discovery of antibiotics, the topical treatment of Gn and rigorous tests of cure have largely lost their significance. Nevertheless the topical treatment could have been meaningful in some cases because of the limited availability of modern antibiotics in the former SU. Furthermore it is not entirely clear to a pathologist, what kind of morphological substrate corresponds to the “hard infiltration”, where the bougienage was recommended [14]. Obviously, inflamed and edematous mucosa can be traumatized, possibly contributing to scarring and formation of strictures. Moreover, excessive instrumentation in conditions of suboptimal procedural quality assurance might have contributed to the spread of infections such as viral hepatitis.

Many physicians realized the obsoleteness of instructions and made exceptions. Vaguely formulated recommendations in some manuals left space for individual judgment. Under these conditions, ideation of punishment coupled with irresponsibility has apparently played a role in some medical personnel and health care functionaries. There are witnesses that abortions and gynecological manipulations were sometimes performed in a harsh manner and were painful, especially in women seen as socially unprotected or “immoral”. At the same time, Pap-smears for early detection of cervical cancer and precancerous lesions have been performed infrequently and not up to international standards [19].

Today the situation is changing. At least at central dermato-venereological dispensaries no mechanical provocations are performed. The tests for Chlamydia and other pathogens are available. Some recent editions still recommend topical therapy and instillations for acute and chronic gonorrhea [24,25]; but in many new textbooks and reviews antibiotic therapy of Gn is discussed, while the provocations and topical therapy are not mentioned at all. According to the recommendations by the Russian Society of Dermatovenerologists and Cosmetologists, the provocations for diagnostic purposes are not indicated. In regard to the topical therapy, that is, instillations of antimicrobial solutions into the urethra, it is written that it is “inefficient” [26,27]. Apparently, this is a “shot over the target” after realization of the fact that such therapy is outdated. It seems to be too early to completely discard the topical therapy of Gn. The antimicrobial resistance (AMR) is developing. There are concerns that Gn might become untreatable by antibiotics [28], which would bring the topical therapy back to the agenda. One of the factors contributing to AMR might be the broad use of antibiotics in the cattle feeding, addition of antibiotics to milk and other perishable foodstuff, e.g., water where frozen fish is stored, which occurs in RF [29]. Antibiotics in food might cause gastrointestinal dysbiosis and have other adverse effects [30]. Irresponsible use of antibiotics beyond their evidence-based medical applications might generally accelerate the acquisition of AMR by diverse microbial populations. The need to update the treatment of the gonococcal infection to respond to the AMR has been pointed out in Recommendations on the management of Gn issued by the WHO [31].

Intimate partner violence, sexual and reproductive coercion

Reproductive coercion (RC) interferes with a woman’s decision regarding reproductive health; it may consist of contraception sabotage and/or pressure to either carry a pregnancy to term or to have an abortion [32]. The RC definitions include male partners’ attempts to promote pregnancy through verbal pressure and threats. The contraception sabotage includes hiding, withholding or destroying contraceptives, deliberate tearing or removing of condoms or failing to withdraw in an attempt to induce pregnancy despite a female partner’s wishes to prevent the pregnancy [33]. Reproductive coercion is not always defined as such by the victim; in particular, intimate partner violence (IPV) may prevent a woman from naming certain behaviors as coercion [32]. In the literature, RC is usually discussed as intentional act. The definition may be extended by adding the “RC by negligence”, in particular, the sabotage of agreed or presupposed method of contraception, which sometimes happens under the impact of alcohol. Admittedly, it may be difficult to distinguish between the negligence, subconscious and conscious intentions.

The abortion rate in the former Soviet Union (SU) was the world highest until 2010 at least [34], caused not only by the insufficient availability of modern contraception but also by an irresponsible behavior sometimes in conditions of excessive alcohol consumption. According to a systematic review and meta-analysis, consistent condom use was less prevalent among hazardous vs. regular drinkers in RF [35]. Fortunately, both the abortion rate and alcohol consumption tend to decrease in Russia. There have been directives at different times, aimed at the birth rate elevation, initially in conditions of the gender imbalance after the World War II. This resulted in a limited availability of contraceptives, unavailability of voluntary sterilization, and prohibition of abortions till 1955 along with the consumerist attitude to women: corresponding talks and behaviors have been quite usual. The widespread atheism probably contributed to irresponsible and immoral behavior [36]. In the meantime, the gender imbalance has reverted and global overpopulation has come to the fore; but fertility is stimulated now as before. For example, popular TV series such as the “Sled” (Trace) and “Slepaia” (The Blind) regularly present unexpected and unintended pregnancies both in and out of wedlock as something natural and unavoidable, while contraception is mentioned rarely. Remarkably, in the Episode 306 of the latter series, a gynecologist at a husband’s request surreptitiously replaced contraceptive pills by vitamins. This was presented by the filmmakers as a good deed as the husband wanted children but the wife did not. The risks associated with oral contraceptives are invented or exaggerated by mass media and some professional literature. Obviously, the propaganda follows policies aimed at the birth rate elevation. Among the background factors are the machismo ideation, disrespect for some laws and regulations, abundant violence and death on TV indirectly trivializing the child and elder abuse, sexual and reproductive coercion. In 2017 Vladimir Putin has signed into law an amendment decriminalizing some forms of domestic violence.

In the author’s opinion, authorities should handle the neglectful and intentional contraception sabotage as offenses with infliction of bodily harm, if an abortion or unintended pregnancy, sexually transmitted or hereditary disease had been inflicted. Of note, a majority of studies on these topics were performed in developed countries, while dimensions of the problem in less open societies are difficult to assess. In particular, myths or ideology excusing sexual assault and/or blaming victims for their own sexual victimization, are widespread the former SU and some other regions [37-39]. 

Alcohol and sexual misbehavior

An association between the alcohol consumption and negligent behavior is explainable within the framework of the alcohol myopia theory. The cognitive capacity is impaired under the impact of alcohol, so that intoxicated individuals concentrate their attention on the cues that are momentarily significant for them. The immediate sexual engagement involves the limited cognitive resources, while more remote cues, such as the risk of unintended pregnancy, are ignored. Domestic and sexual violence is often combined with alcohol abuse, while the use of condoms in the context of violence is less convenient. RC is regarded to be a form of IPV; it can lead to unintended pregnancy, abortion, poor pregnancy outcomes, STI, psychological trauma and depression [40,41]. Among potential contributing factors are disrespect for laws and regulations, impunity of some offenses and offenders, habitual display of death and violence on TV, indirectly trivializing less spectacular phenomena such as the IPV, sexual and reproductive coercion.

Furthermore, relationships between the safer sex decision making and alcohol intake depend on the level of socio-cultural development. Multiple studies performed in more developed countries did not unequivocally confirm the association between alcohol consumption and non-use of condoms [42-48]. According to some research, only very high levels of alcohol intake reduce the probability of condom use [49]. On the contrary, all known studies performed in less developed or recently industrialized parts of the world confirmed the association of the alcohol intake with the non-use of condoms and other risky sexual behaviors [50-57]. It can be reasonably assumed that the social progress correlates with improvements of morality, so that distracting factors such as alcohol partially lose their significance. However, international migrations confound this scheme while alcohol-related negligence gives way to migration-related and geopolitical motives [58]. Fictive and temporary marriages have been used for obtaining the registration and accommodation in Moscow as well as in other cities attracting migrants. The sexual and reproductive coercion are sometimes used intentionally for the purpose of migration, to cement a relationship and/or to spread a certain genotype. Cases are known when heritable disease in a perpetrator was concealed from the partner and then acquired by the offspring. In particular, Ashkenazi population has comparatively high frequency of hereditary conditions; referenced in [58]. Various methods are applied: persuasion and seduction, alcohol and drugs, sexual and reproductive coercion, intimidation and IPV. Considering the forthcoming globalization, women should be aware of these strategies.

Reportedly, about 70-75% of sexual violence cases in Moscow are committed by immigrants from Central Asia; some other ethnic groups are also active in this field [59]. Of note, people coming from the North Caucasus and ethnic minorities are not counted as foreigners because they are Russian citizens. According to a monograph published in 2012, 1 out of 7 murders and ~50% of rapes in Moscow were committed by foreigners [60]. Similar figures have been reported by other researchers [61]. At that, many crimes remain unreported or unsolved, especially those committed by migrants [60]. Among foreign citizens residing in the Russian Far East, crime was most frequently committed by Chinese (55%) and Uzbeks (23%). The criminality in this milieu was found to be proportional to the share of illegal immigrants [62]. The criminal activity of migrants was estimated to be 4 times higher than the average for RF [63]. Analogous data are difficult to find in the recent literature; the topic seems to be avoided these days. 

As far as we know, the Soviet and present rulers, the party and military nomenklatura [64], did not allow the use of invasive procedures without indications on themselves and their relatives. Functionaries’ sons did not treat gonorrhea by tamponade and bougienage of the urethra; alcoholics from their milieu have not been compulsorily treated by drip infusions days on end, being infected with viral hepatitis, neither did they drink technical ethanol sold in vodka bottles through legally operating shops [4]. As for the medical personnel, it is unlikely that they applied dry cutting and poor-quality fillings to discolored pits and fissures in their children [1], cauterized cervical ectopies [19], or performed Halstead mastectomy procedures on their family members [1]. This implies that there has been conscious infliction of bodily harm. Military functionaries and their relatives will become more dominant thanks to the war in Ukraine. Those participating in it, factually or on paper, are obtaining the veteran status and hence privileges over fellow-citizens. Some of them will occupy leading positions in universities without adequate preparation and selection. War veterans enjoy advantages in healthcare and everyday life; there are, however, misgivings that the status has been awarded gratuitously to some individuals from the privileged milieu. At the same time, relatives of superior officers evaded conscription under various pretexts. In particular, many institutions of higher education grant exemption from military service. Being not accustomed to hard and meticulous work, some of the functionaries’ protégées have been involved in professional misconduct of a different kind [65]. Admittedly, the problems discussed above are overshadowed these days by migration-related societal transformations.

Some invasive methods with questionable indications have been introduced or advocated by first generation military surgeons. The Soviet period brought about an expansion of admission numbers to universities and medical educational institutions, sometimes with little regard for the quality of the academic preparation of students [66]. One of the motives to overuse invasive procedures was personnel training, among others, with the objective of readiness for war. Note that military and medical ethics are not the same. The comparatively short life expectancy in RF is a strategic advantage as it necessitates less healthcare investments and pensions. Besides, a well-known Russian medical term “football” should be mentioned: it means sending an aged patient from one physician to another to drag out time and to avoid an operation. Malignancies are diagnosed and treated in RF relatively late. Furthermore, among factors contributing to the use of invasive procedures with questionable indications have been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, as well as a paternalistic attitude to patients. Most importantly, the human factor has not sufficiently changed since the Soviet time. The ethical and legal basis of medical practice and research has not been sufficiently known and observed in RF. The term “deontology” is often used for medical ethics in this country. Textbooks and monographs on deontology explained the matter somewhat vaguely, with truisms and generalities, but not much practical guidance. Today, the growing economy enables the acquisition of modern equipment; and medical research is on the increase. Under these circumstances, the purpose of this review was to remind us that, performing invasive procedures, the risk-to-benefit ratio must be kept as low as possible. Insufficient coordination of medical studies and partial isolation from the international community can result in parallelism in research, unnecessary experimentation, and application of invasive procedures without sufficient indications. Considering shortcomings of medical practice, research and education, governmental directives and the increase in funding are unlikely to be a solution. Measures for improvement of the healthcare in RF must include the participation of authorized foreign advisors.

Conflict of interests 

The authors have no conflict of interest to declare. The authors declared that this study has received no financial support.