Law & Order: SVU Looks at Gray Rape, Medical Abortion

Misoprostol facts: Off-label use in abortions
If you watch any of the Law & Order shows on a regular basis you have seen the disclaimer that says the characters and plots are works of fiction, but often the episodes do treat controversial legal, social or medical issues that are themselves based in fact. In a recent Law & Order: SVU episode entitled "Gray," Benson and Stabler investigate a college student accused of "gray rape" after he has sex with a drunk co-ed. In the course of the investigation the detectives of the Special Victims Unit discover the same student had also been accused of causing a miscarriage in his pregnant girlfriend against her will. The story is that he was a pre-med student and knew he could induce an abortion without her knowing, by using a homemade lubricant that contained the ulcer medication misoprostol.

So were the writers of this SVU episode using a good bit of creative license, or could a man actually cause his partner to miscarry without her knowing it? Misoprostol, the ulcer medication referred to in the episode, actually is used off-label in dozens of countries to induce medical abortions. This option is often seen by women as preferable to a surgical abortion, as it is less invasive both medically and in terms of a woman's privacy. It is also less expensive, and more accessible in places where abortion is not legal. It is also seen as carrying fewer risks than a surgical procedure carried out in unsafe conditions, and when complications arise it is easier to treat them from both a medical and legal standpoint.

Misoprostol is a hormone-like substance that causes the cervix to ripen, and induces uterine contractions. As it does not cause the embryo to be detached from the uterus, it is generally used in combination with another drug that will do this. If this is impossible, using misoprostol alone can work. But according to the medical abortion fact sheet, this method requires a higher dose of the drug and can result in greater risks.

Abortions can be induced when misoprostol is swallowed whole, or when the tablet is dissolved under the tongue. It is also applied vaginally, sometimes in the form of a gel designed for use in gynecological and obstetrical settings. Where the gel is not available, the pills can be dissolved in the vagina. So, it seems it would be possible for a woman's sexual partner to crush misoprostol pills and mix them with a lubricant in order to cause her to miscarry. It should be noted that even medical abortions carry certain risks, including death. This is a procedure that should be performed by a trained health professional. The SVU episode gave good indication of the medical and legal repercussions of an untrained individual inducing an abortion, especially in the case of a woman who is neither aware nor consenting to the act. The scenario played out in "Gray" could be seen as another form of rape - ethically, even if not legally.

Misoprostol facts: Use in erectile dysfunction
The college student's lawyer in this SVU episode is both clever and creative when it comes to defending her client against the charges. She claims that he was not intentionally trying to cause an abortion in his girlfriend, but was actually using the misoprostol because he suffered erectile dysfunction (ED) from drinking too much alcohol. The detectives learn that this is one of the other off-label uses of the drug, but that it isn't effective without a vacuum pump. I saw a number of references to a 1998 study published in the journal Sexual Dysfunction, all of which claimed that the study showed misoprostol by itself was not effective as a treatment for ED. A review of the abstract shows that the study never tested misoprostol alone, and therefore could not support such a conclusion.

Misoprostol facts: Toxic shock syndrome
In the SVU episode, the young woman is set to testify that she miscarried the morning after her boyfriend used his misoprostol-containing "love potion #9." When she fails to turn up in court, police go to look for her and find her dead from what the coroner characterizes as a form of toxic shock syndrome. The infection is blamed on the vaginal introduction of the misoprostol.

Misoprostol has been administered by mouth as well as vaginally to induce abortion. Around 2000 there were seven reports of death due to infection after women received large doses of misoprostol intravaginally to induce abortion. Animal and in vitro testing at the University of Michigan in 2008 linked vaginal application of misoprostol to serious infection. Women who are offered intravaginal misoprostol should discuss the risk of infection with their doctors.

Sources:
David M. Aronoff et al, "Misoprostol impairs female reproductive tract innate immunity against Clostridium sordellii." Journal of Immunology

Marge Berer, "Medical abortion: A fact sheet" and "Medical abortion: Issues of choice and acceptability." Reproductive Health Matters

Ekmekçioğlu et al,"Intraurethral misoprostol: A different agent in the treatment of erectile dysfunction." Sexual Dysfunction