Approach

In many countries specific sexual assault centres have been developed, with specially trained staff and facilities, so that excellent care can be provided with dignity and safety. Services should be developed in partnership between the health sector, social services, police, prosecutors, courts and non-governmental organisations.[31]​​

In all cases of sexual abuse or assault, the safety of the child, adolescent, or adult should be ensured via reporting (which may be mandatory) and referral to appropriate agencies (e.g., child protective services or law enforcement). Psychological counselling should be offered.[61]​ Physical injury should be treated as appropriate. Presumptive treatment for sexually transmitted infections (STIs) depends on the circumstance. Local protocols should be consulted for reporting and management of suspected sexual abuse, prophylaxis and treatment of STIs, and the provision of emergency contraception, as these may differ between regions.

Acute sexual assault: ≤72 hours since sexual assault

Patients who report penetrative assault should be counselled about HIV post-exposure prophylaxis (PEP). When indicated, PEP should be started as soon as possible to maximise the chance of efficacy.[62][63]​ Consultation with an infectious disease specialist is recommended for children who will be receiving PEP.

Other treatments include the following:

  • STI prophylaxis for children: as the risk of a child acquiring an STI is generally low, the decision to give antibiotic prophylaxis is dependent on the type of abuse and other circumstances, such as whether violence was involved and the local STI prevalence.[48]

  • STI prophylaxis for adults: females should be given an empirical antimicrobial regimen for chlamydia, gonorrhoea, and trichomoniasis; males should be given an empirical antimicrobial regimen for chlamydia and gonorrhoea.[47]

  • Hepatitis B vaccination: should be considered in all patients unvaccinated against hepatitis B virus.[47][48] Vaccination is most effective if administered within 24 hours of exposure. There is limited evidence to guide the maximum interval for vaccination after exposure, but the vaccine is unlikely to be effective >14 days after sexual exposure.[64]​ If the assailant is known HBsAg positive, dose of hepatitis B immunoglobulin should be administered, preferably within 24 hours of contact.[64]​​

  • Human papillomavirus vaccination: vaccination should be considered in males and females aged 9 to 26 years who are victims of sexual abuse or assault and have not initiated or completed immunisation.[47] Although the vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against virus types not yet acquired.[65]

  • Emergency contraception: females of reproductive age should be offered emergency contraception within 120 hours of sexual assault.[31]

Non-acute sexual assault: >72 hours since sexual assault

Once pre-pubertal children have undergone appropriate testing for syphilis, STI, and HIV serologies, further medical management will be required in accordance with any positive results. The approach for adolescent and adult patients is the same, except that emergency contraception is also offered to females of reproductive age if the patient presents within 120 hours of the sexual assault.[31]​ PEP is not recommended if the assault happened >72 hours ago.[47]

Treatment of STIs

Treatment depends on the causative organism. See Genital tract chlamydia infection (Management approach), Gonorrhoea infection (Management approach), Vaginitis (Management approach), Genital warts (Management approach), Herpes simplex virus infection (Management approach), Syphilis infection (Management approach), and HIV infection (Management approach).

Emergency contraception

Females of reproductive age should be evaluated for pregnancy and offered emergency contraception if presenting within 120 hours of the sexual assault. Oral emergency contraception should be initiated as soon as possible after unprotected intercourse, to maximise efficacy.[66] ​Levonorgestrel can be taken up to 72 hours after sexual contact, while ulipristal can be taken up to 120 hours after sexual contact.[67] A pregnancy test is not necessary before prescription for oral emergency contraception is provided.[31][66]​​[68]​​

The copper intrauterine device (IUD) is the most effective emergency contraceptive and can be inserted up to 120 hours after the assault. It retains its high efficacy over the full 120-hour window.[66] The IUD should not be considered as an option if the patient is pregnant. See Contraception.

If menses are delayed by 1 week or more after the expected time, a pregnancy test should be performed.[38]​

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