Immediate needs after sexual assault include safety and privacy in the first instance, followed by treatment of injuries and prevention of unwanted pregnancy and sexually transmitted infections, including human immunodeficiency virus. Management should include risk identification of self-harm and suicide, as well as safeguarding children and vulnerable adults. Pregnancy prevention can be achieved through oral or mechanical methods of emergency contraception. Availability of emergency contraception may vary between districts and countries, depending on local laws and cultural or religious beliefs. Sexually transmitted infections, including gonorrhoea, chlamydia, hepatitis B and human immunodeficiency virus, represent an important part of management of victims of sexual assault. They can be prevented immediately by offering bacterial and viral prophylaxis followed by sexual health screening 2 weeks later unless symptomatic. In deciding what antibiotics to use as prophylaxis, local prevalence of infections and resistance to antibiotics should be considered. Prophylaxis against human immunodeficiency virus infection after sexual exposure should be discussed and offered in high-risk cases for up to 72 h after exposure. This should be accompanied by baseline human immunodeficiency virus test and referral for follow up. In high prevalence areas, prophylaxis against human immunodeficiency virus infection after sexual exposure should be offered as a routine. Psychosocial support and risk assessment of vulnerabilities, including self-harm or domestic violence and practical support should be addressed and acted on depending on identified needs.
Introduction
Medical care may be offered immediately after a forensic examination. It may also be offered alone in another setting, such as a sexual health clinic, general practice, emergency medicine or gynaecology clinic if forensic medical examination is not carried out or is delayed.
It should also be offered to those who do not wish to have a forensic examination as a police or non-police referral, but are concerned about the physical consequences of an assault.
Components of immediate medical care after sexual assault
After a sexual assault, the following immediate care and support can be offered: (1) assuring safety and privacy; (2) treatment of minor injuries by first aid and major injuries in a hospital setting if necessary (3) management of intoxication with, or withdrawal from, alcohol, illicit drugs, or both; (4) management of medical emergencies: asthma, panic attacks, epileptic fits, diabetic hyper or hypoglycaemia; (5) risk identification and prevention of pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), self-harm and suicide; (6) referrals for sexual health screening, counselling and psychology; (7) safeguarding children and vulnerable adult referrals (e.g. social care, community paediatrics, school or Multiagency Risk Assessment Conference in domestic violence); (8) practical support (e.g. referrals to Independent Sexual Violence Advisor or Child and Young People Sexual Violence Advisor available in the UK; and (9) referrals to voluntary agencies.
Components of immediate medical care after sexual assault
After a sexual assault, the following immediate care and support can be offered: (1) assuring safety and privacy; (2) treatment of minor injuries by first aid and major injuries in a hospital setting if necessary (3) management of intoxication with, or withdrawal from, alcohol, illicit drugs, or both; (4) management of medical emergencies: asthma, panic attacks, epileptic fits, diabetic hyper or hypoglycaemia; (5) risk identification and prevention of pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), self-harm and suicide; (6) referrals for sexual health screening, counselling and psychology; (7) safeguarding children and vulnerable adult referrals (e.g. social care, community paediatrics, school or Multiagency Risk Assessment Conference in domestic violence); (8) practical support (e.g. referrals to Independent Sexual Violence Advisor or Child and Young People Sexual Violence Advisor available in the UK; and (9) referrals to voluntary agencies.
Safety and privacy
Safety and privacy are important when dealing with individuals who have been sexually assaulted, some of whom may be distressed and many may feel ashamed to talk about what has happened to them.
Empathy, sensitivity, a non-patronising attitude and listening skills are paramount in dealing with people who have been sexually assaulted.
Treatment of injuries
Presence of injuries after sexual assault depends on the degree of physical violence and resistance during the assault, as well as level of consciousness, time of presentation and age of complainants, among other factors.
Most complainants of sexual assault have no injuries on genital examination. The vast majority of complainants of rape have extragenital injuries found of which head injury is the most dangerous and may require hospital admission.
Minor extra-genital injuries, such as open wounds and lacerations, bites and minor burns, may be treated using simple first aid consisting of sterilisation, sterile dressing and antibiotics. Prophylaxis against tetanus is particularly important in countries in which the vaccination rate for tetanus in childhood is low and tetanus prevalence high. Bites should be treated using topical and oral treatment to prevent the development of local skin infection or, in severe cases, systemic septicaemia.
Where high risk exposure occurs (seropositive individual, man having sex with man, intravenous drug user, commercial sex worker, someone from area of high prevalence of HIV infection, in anal penetration and in the presence of genital injury) consider hepatitis B immunoglobulin and HIV post-sexual exposure prophylaxis (HIV PEPSE), particularly if the assailant was known to be seropositive.
Minor genital injuries are usually superficial and do not require treatment other than saline washing and reassurance, as they heal quickly and spontaneously within days.
Major injuries, including head injuries, deep open wounds that require suturing, heavy pelvic bleeding, and rectal bleeding, should be investigated and treated in an emergency department of a hospital. This may need to take precedence over forensic examination.
Genito-rectal lacerations may require examination and suturing in the theatre under general anaesthesia ( Table 1 ).
| Minor injuries | First aid: cleaning, dressing. | Antibiotics. |
| Tetanus ovoid. | ||
| Major injuries | Hospital admission and observation. | Hepatitis B immunoglobulin. |
| Investigations: X-ray, computed tomography and ultrasound scans. | Hepatitis B booster or first dose of vaccination. | |
| Suturing under general anaesthesia. | Human immunodeficiency virus prophylaxis after sexual exposure. | |
| Pain relief. |
Prevention of pregnancy
Prevention of pregnancy alongside STI and concern about the possibility of internal injuries is the main reason female complainants of sexual assault seek advice in medical settings after the assault.
Emergency contraception
Prevention of pregnancy consists of the administration of emergency contraception and termination of pregnancy. Emergency contraception comes in two forms: insertion of an intrauterine device (IUD) and hormonal oral methods (e.g. Levonelle or EllaOne). The IUD, an intrauterine device, is the most reliable form of emergency contraception, and should be discussed and offered to those at highest risk and those who choose this method. If it is not possible to insert an IUD immediately, smooth referral pathways should be in place.
Most complainants of sexual assault prefer to take oral forms of emergency contraception such as Levonelle or Ella One. Levonelle l (Norgestrel) is licensed to be given for up to 72 h after unprotected sexual exposure in females over the age of 16 years. It is most effective in the first 24 h, after which its efficacy diminishes with some residual efficacy after 5 days.
Ella One (Ullipristol) is a new oral emergency contraception that is licensed for females 16 years or older for up to 5 days after unprotected sexual exposure.
The International Federation of Gynecology and Obstetrics guidance 10a states that the victim should be offered a pregnancy test before taking emergency contraception to reduce the chance they are already pregnant with their partner’s child.
A pregnancy test should be considered 3 weeks after oral emergency contraception in the absence of inter-menstrual bleeding.
Termination of pregnancy
If pregnancy is not prevented by using emergency contraception, women should be offered the option of termination of pregnancy. In some jurisdictions, rape is one of the rare indications for a legal termination of pregnancy. They may, however, wish to continue with the pregnancy, which is not uncommon, and they are referred to an antenatal clinic. The latter usually occurs on religious or moral grounds or when the assailant was a husband or partner.
Those who opt out of terminating their pregnancy should be advised about the forensic and evidential significance of products of conception, the collection of which should be arranged by liaising with the investigating police officers who would collect the samples, exhibit them and store demonstrating chain of evidence of the custody of the samples or dispatch them for forensic analysis.
In non-police referrals, local policies should be in place about collection, handling of samples, storage and disposal, in line with local guidelines and policies.
In-utero paternity testing
A decision whether or not to terminate the pregnancy may be assisted by in-utero paternity testing, using samples obtained during chorionic villous biopsy in cases where there is uncertainty whether the pregnancy resulted from consensual sexual intercourse with a husband or partner, or from rape. This is usually arranged on a case-by-case basis, and requires co-ordination of the work of the gynaecologist and local DNA experts; in the UK, this is not funded by the National Health Service. Requests should be considered on a case-by-case basis, bearing in mind that alleging rape may be used as a backdoor route to paternity testing.
Risk assessment and management of sexually transmitted infections
Prevention, identification and treatment of STIs represent an important immediate aftercare component of the management of complainants of sexual assault. To offer or not to offer prophylaxis against bacterial or viral STI after sexual assault is a frequently asked question. The decision depends on the local prevalence of STIs, likelihood of the complainant attending for screening, assailant type, assailant’s risk factors, the presence of genital injuries and the complainant’s choice.
Benefits of offering prophylaxis against STIs, apart from prevention of infection, include psychological well-being of having done something positive. Many complainants of sexual assault feel dirty and fear acquisition of an infection as much as unwanted pregnancy.
Irrespective of the choice the complainant makes, STIs screening should be encouraged and referral facilitated to a local sexual health clinic or general practitioner. Taking swabs for STI screening at forensic examination in previously sexually active individuals is controversial, as identification of STI that predated the assault may be used against the complainant in court. This has to be weighed against advantages of early diagnosis and treatment, particularly in symptomatic individuals.
Bacterial prophylaxis against sexually transmitted infections
Gonorrhoea, chlamydia and Trichomonas vaginalis are the most common STIs, each of which can be prevented using antibiotics as a single dose. In the UK, the recent emergence of resistance to oral cefixime in the treatment of gonorrhoea has resulted in an intramuscular ceftriaxone becoming the first-line treatment.
This, together with the risk of anaphylaxis, may be not available in some non-hospital Sexual Assault Referral Centres. Under such circumstances, in low prevalence areas or when a patient has a needle phobia, oral cefixime 400 mg and azithromycin 1 g as a single dose to cover gonorrhoea and chlamydia infections as well as metronidazole 2 g as a single dose or 400 mg twice a day for 5 days in pregnancy may be offered, followed by STI screening 2 weeks later.
Viral prophylaxis against sexually transmitted infections
Hepatitis B and HIV infections are the two viral STIs that may be prevented by vaccination and administration of antiretroviral combinations after risk assessment.
Risk factors for hepatitis B and HIV infections include men having sex with men; contact from sub-Saharan Africa, South East Asia and South America; intravenous drug users; commercial sex workers; exchange of blood and body fluids (semen, saliva); anal intercourse; presence of STIs, genital injuries, or both; and multiple assailants ( Tables 2–5 ).
| Source community | HIV seroprevalence (%) | Source community | HIV seroprevalence (%) |
|---|---|---|---|
| Homosexual men | Heterosexual | ||
| Sub-Saharan Africa | >10 | ||
| London | 15 | Caribbean | <6 |
| Scotland | 2.5 | South and South East Asia | <3 |
| Elsewhere | 2.3 | Latin America | <3 |
| Intravenous drug user | North Africa and Middle East | <3 | |
| London | 4.7 | East Asia and Pacific | <1 |
| Elsewhere UK | 0.23 | Eastern Europe and Central Asia | <1 |
| North America | <1 | ||
| Western Europe | <1 | ||
| UK | <1 | ||
| Australia and New Zealand | <1 |
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