Sexual violence

Overview & Initial Approach

• Immediate Priority: Medical stabilization (ABCs, control hemorrhage, treat traumatic injuries) before forensic exam or history taking.
• Informed Consent: Trauma-informed care. Obtain explicit written consent for physical exam, forensic collection, and photo documentation.
• Patient Autonomy: Competent adult patients may decline any portion of the exam, treatment, or law enforcement involvement.

Acute Clinical & Forensic Evaluation

• Forensic Examination (Rape Kit):
  • Optimal window: < 120 hours (5 days) post-assault.
  • Components: Clothing collection, swab of exposed body sites (oral, vaginal, anal), Wood’s lamp evaluation (semen visualization), nail scrapings, hair clippings.
  • Chain of Custody: Strict documentation and handling required for legal admissibility.
• Baseline Laboratory Testing:
  • Urine Pregnancy Test (uPreg): Rule out pre-existing pregnancy prior to emergency contraception (EC).
  • STI Screening: N. gonorrhoeae & C. trachomatis (NAAT), T. vaginalis (wet mount/NAAT), HBV sAg, HCV Ab, Syphilis (RPR/VDRL), HIV 1/2 antigen/antibody.
  • Toxicology Screen: Obtain urine/blood if drug-facilitated sexual assault (DFSA) suspected (e.g., GHB, Rohypnol, alcohol, benzodiazepines).

Medical Management & Prophylaxis

• Empiric STI Prophylaxis: Administered immediately without waiting for lab results.
  • Ceftriaxone: 500 mg IM x 1 dose (N. gonorrhoeae).
  • Doxycycline: 100 mg PO BID x 7 days (C. trachomatis).
  • Metronidazole: 2 g PO x 1 dose or 500 mg PO BID x 7 days (T. vaginalis).
• HIV Post-Exposure Prophylaxis (PEP):
  • Indication: High-risk exposure presenting < 72 hours post-assault.
  • Regimen: 28-day 3-drug antiretroviral course (e.g., Tenofovir/Emtricitabine + Dolutegravir or Raltegravir).
• Immunizations:
  • Hepatitis B: Give HBV vaccine ± HBIG if attacker status positive/unknown and patient unimmunized.
  • HPV: 9-valent HPV vaccine if eligible (age 9–26 years).
  • Tetanus: Tdap/Td booster if wound present and > 5–10 years since last dose.

Emergency Contraception

• Offer to all non-pregnant females with pregnancy potential presenting < 120 hours post-assault:
  • Ulipristal Acetate (Progesterone receptor modulator): First-line oral option; maintains efficacy up to 120 hours; superior efficacy in higher BMI.
  • Levonorgestrel (Plan B): Most effective within 72 hours (reduced efficacy if BMI > 25–30 kg/m²).
  • Copper IUD: Most effective EC overall (< 120 hours); provides long-term reversible contraception (contraindicated if active severe pelvic infection).
  • 52-mg Levonorgestrel IUD: Highly effective option within 120 hours.

Psychological Care & Safety

• Mental Health Evaluation: Assess for acute crisis, PTSD, Major Depressive Disorder (MDD), and suicidal ideation (SI).
• Crisis Intervention: Provide 24/7 rape crisis network contact and immediate counseling resources.
• Intimate Partner Violence (IPV): Screen for domestic safety; coordinate safe housing/shelter if needed.

Legal & Ethical Considerations

• Adult Victims: Patient autonomy governs police reporting. Reporting to law enforcement is not mandatory unless required by specific state law regarding deadly weapon injuries (e.g., gunshot, knife).
• Pediatric Victims (< 18 yrs) & Vulnerable Adults: Mandatory reporting to Child Protective Services (CPS) or Adult Protective Services (APS) is legally required.

Follow-up Protocol

• 1–2 Weeks: Re-evaluate acute physical trauma, review initial baseline STI results, assess psychological well-being/PTSD symptoms.
• 4–6 Weeks: Repeat uPreg, monitor tolerance of HIV PEP (if started).
• 3–6 Months: Repeat serologic testing for Syphilis, HBV, HCV, and HIV.