Emergency focus: Management of a rape survivor is urgent, comprehensive and survivor-led. Stabilise life-threatening injury first, then offer confidential first-line support, examination, pregnancy/STI/HIV prevention, mental-health care, safeguarding, forensic options and follow-up. Drug doses below are educational adult examples; follow the current Uganda Ministry of Health protocol, product labels and specialist advice for children, pregnancy, renal disease, drug interactions and allergies.
Learning objectives
- Provide safe, trauma-informed first-line support and obtain informed consent.
- Perform emergency triage, examination, injury care and safeguarding assessment.
- Offer emergency contraception, HIV PEP, STI prophylaxis, hepatitis B/HPV prevention and tetanus when indicated.
- Collect forensic evidence without delaying treatment and document findings objectively.
- Plan mental-health support, safety, follow-up testing and referrals for adults, children and people lacking capacity.
1. The first minutes: safety, dignity and stabilisation
- Private welcome: move the survivor away from the alleged perpetrator, provide a chaperone/interpreter if wanted, and ask how they prefer to be addressed.
- ABC and danger: airway/neck injury or strangulation, breathing, circulation/bleeding/shock, head injury, poisoning, severe pain, burns, fractures and altered consciousness.
- Immediate psychological safety: Listen, Inquire, Validate, Enhance safety and Support (LIVES). Do not demand a detailed narrative before treating a critical injury.
- Consent: explain each step—treatment, examination, photographs, samples, police contact and record release. Consent is ongoing and may be withdrawn.
- Safeguarding: assess danger from a partner, weapon access, stalking, children/dependants, trafficking, child abuse and suicide/self-harm.
2. History and examination
Trauma-informed history
Start with open questions and record the survivor’s words. Clarify time, location, acts, penetration sites, ejaculation, barrier use, injuries, bleeding, pain, washing/urination/clothing change, food/drink, substances, threats, weapons, loss of consciousness, last menstrual period, contraception, pregnancy possibility, allergies, medicines, HIV/HBV status and relevant medical conditions. Avoid “why” questions, blame, repeated retelling and assumptions about consent.
Examination
- Record vital signs, mental status, pain score, hydration, weight when medication dosing requires it and pregnancy status where relevant.
- Inspect the whole body and document injuries with site, side, dimensions, shape, colour, tenderness, swelling, discharge, function and associated findings.
- Assess scalp, face, mouth, neck and neurological status carefully after strangulation or head injury. Delayed airway and vascular complications can occur even with minimal external marks.
- Examine genital, anal or oral sites only with informed consent and a chaperone; stop when requested. A normal examination does not exclude assault.
- Offer photographs and forensic specimens separately from treatment. Use the local kit and chain-of-custody procedure; never delay emergency care.
3. Immediate injury care
| Problem | Immediate actions | Escalation |
|---|---|---|
| External bleeding | Direct pressure, wound cleaning, haemostasis, tetanus assessment and analgesia. | Large/deep wound, shock, suspected vascular injury or uncontrolled bleeding—surgery/trauma team. |
| Head injury | GCS, pupils, glucose, cervical-spine precautions and serial observations. | Loss of consciousness, seizure, focal signs, anticoagulants or repeated vomiting—urgent imaging/transfer. |
| Strangulation | Airway and voice assessment, oxygen as indicated, neurological examination, observe for delayed swelling. | Any breathing/voice/swallowing change, neck tenderness, petechiae, syncope or focal deficit—emergency airway/ENT/vascular assessment. |
| Fracture/dislocation | Immobilise, analgesia, neurovascular check before/after splinting. | Open fracture, neurovascular compromise or compartment syndrome—urgent orthopaedic care. |
| Burn/chemical exposure | Remove contaminated clothing, irrigate chemical exposure, analgesia and fluid assessment. | Airway, extensive/deep burns, genital/ocular burns or toxic ingestion—burns/poisoning specialist. |
| Abdominal/chest pain | Vital signs, pregnancy test where relevant, focused examination, analgesia and imaging. | Peritonism, respiratory compromise, internal bleeding or pregnancy complication—urgent surgical/obstetric review. |
4. Laboratory and baseline assessment
Tests are guided by exposure, symptoms, consent and local protocol. They should not delay time-critical prophylaxis.
- Urine or serum pregnancy test before teratogenic medicines or when pregnancy is possible; a negative early test does not exclude very recent conception.
- Baseline HIV test using the national algorithm, with consent and post-test counselling; a baseline negative test does not rule out infection from the current exposure.
- Hepatitis B surface antigen/antibody when available; do not delay vaccine when indicated.
- Syphilis, gonorrhoea, chlamydia, trichomonas and other tests according to local capacity; collect diagnostic specimens before empiric therapy when this does not delay care.
- Full blood count, renal/liver tests, glucose, blood group/cross-match, toxicology or imaging when injury, poisoning, bleeding or treatment risk warrants.
5. HIV post-exposure prophylaxis (PEP)
Offer PEP after a substantial exposure when the survivor presents as soon as possible, ideally immediately and within 72 hours. It is generally not recommended after 72 hours for sexual exposure in WHO emergency protocols, but the survivor still needs HIV testing, counselling, prevention and specialist advice. Do not wait for the alleged source’s HIV result when this would delay starting PEP.
Example adult regimen used in many programmes
| Medicine | Example dose | Duration/notes |
|---|---|---|
| Tenofovir disoproxil fumarate (TDF) | 300 mg orally once daily | Part of a three-drug regimen; assess renal disease and HBV. |
| Lamivudine (3TC) or emtricitabine (FTC) | 3TC 300 mg once daily or FTC 200 mg once daily | Use the locally supplied fixed-dose combination where available. |
| Dolutegravir (DTG) | 50 mg orally once daily | Check interactions (especially polyvalent cations, rifampicin and enzyme inducers) and current pregnancy guidance. |
Continue for 28 days unless a specialist changes the plan. If renal function, pregnancy, breastfeeding, hepatitis B, age/weight or drug interactions are complex, contact the HIV clinician urgently. Provide adherence counselling, side-effect advice, condoms where desired, and a safe method for follow-up. PEP is not a substitute for emergency contraception or STI care.
6. Pregnancy prevention
Offer emergency contraception (EC) as soon as possible after exposure, with shared decision-making and a pregnancy test when appropriate. It does not interrupt an established pregnancy.
| Option | Example dose/timing | Key cautions |
|---|---|---|
| Levonorgestrel | 1.5 mg orally once, as soon as possible and within 120 hours (5 days) | Effectiveness decreases with time and may be reduced by enzyme-inducing drugs or higher body weight; follow local guidance. |
| Ulipristal acetate | 30 mg orally once, within 120 hours | Hormonal contraception may reduce its effect; follow product instructions and specialist advice. |
| Copper intrauterine device | Insertion by a trained provider within 5 days where eligible | Highly effective; assess pregnancy, infection, uterine injury and consent. |
Vomiting within the product’s specified interval may require repeat dosing. Explain expected bleeding, when to return and that EC does not prevent HIV/STIs. Evaluate abdominal pain, syncope or heavy bleeding urgently for ectopic pregnancy or injury.
7. STI prevention and treatment
Where follow-up is uncertain, many protocols offer presumptive treatment after sexual assault; where reliable follow-up exists, testing and targeted treatment may be chosen. Use the current Uganda STI guideline and local resistance patterns. The following are common adult examples, not a replacement for national protocol:
| Target | Example adult regimen | Important notes |
|---|---|---|
| Gonorrhoea | Ceftriaxone 500 mg IM once (1 g IM once if body weight ≥150 kg in many guidelines) | Check severe beta-lactam allergy and local resistance; treat partners through appropriate services. |
| Chlamydia | Doxycycline 100 mg orally twice daily for 7 days | Avoid in pregnancy; azithromycin 1 g orally once is used in some pregnancy protocols. |
| Trichomonas/bacterial vaginosis | Metronidazole 2 g orally once or 500 mg twice daily for 7 days | Use local protocol; assess pregnancy, interactions and alcohol advice. |
| Syphilis | Test and treat according to stage and national guideline (benzathine penicillin regimens are standard when indicated) | Do not give an unverified regimen without checking allergy, stage, pregnancy and local policy. |
Document allergies, pregnancy, renal/liver disease and drug interactions. Provide condoms, explain side effects, and arrange repeat testing because an early negative test does not exclude newly acquired infection.
8. Hepatitis B, HPV and tetanus prevention
- Hepatitis B: If vaccination is incomplete or status is unknown, begin hepatitis B vaccine promptly according to age/product schedule. If the source is known HBsAg-positive or risk is high, hepatitis B immunoglobulin may be indicated as soon as possible with specialist advice; do not delay vaccine while awaiting results.
- HPV: Offer age-appropriate vaccination according to the national programme and individual eligibility.
- Tetanus: Assess wound type and immunisation history. A common adult vaccine dose is 0.5 mL IM; add tetanus immunoglobulin for contaminated/high-risk wounds with inadequate or unknown prior immunisation according to local protocol.
- Rabies: For animal exposure, irrigate wounds and follow the national rabies vaccine/immunoglobulin schedule urgently.
9. Pain, nausea, sleep and mental-health support
Offer analgesia according to injury, pregnancy, renal/liver function and local formulary; avoid blaming or sedating a survivor who needs neurological observation. Provide antiemetic treatment when appropriate. Assess acute stress, dissociation, depression, PTSD symptoms, self-harm and suicide risk. Psychological first aid should be practical, non-judgemental and choice-based; do not force detailed recounting or promise that one counselling session prevents PTSD.
10. Forensic examination and documentation
- Obtain separate consent for medical examination, forensic samples, photographs and release of records.
- Use the current evidence kit. Label, dry/package and seal each specimen; complete every chain-of-custody transfer.
- Document history in the survivor’s words, timing, actions after the event, examination findings, normal findings, treatment, samples offered/declined and limitations.
- Photograph injuries only with consent, a scale and secure storage. Never send images over personal messaging apps.
- Explain that no injury or negative test does not exclude assault and that a positive DNA/STI/toxicology result does not by itself establish assault, consent or perpetrator identity.
11. Children, adolescents and adults lacking capacity
- Follow current Ugandan child-protection law and mandatory reporting policy. A child’s safety takes priority; do not send them back to a suspected perpetrator.
- Use age-appropriate assent and legal permission, avoid leading questions and arrange trained paediatric/forensic examination.
- Use weight-based medication dosing and paediatric HIV/EC/STI protocols; do not extrapolate adult doses.
- For an adult lacking capacity, provide emergency care, involve the legally authorised decision-maker where appropriate and follow safeguarding and best-interest procedures.
12. Follow-up schedule
| When | Review |
|---|---|
| Before discharge | Safety plan, injury treatment, first doses of PEP/EC/vaccine when indicated, analgesia, written/secure instructions, referrals and return precautions. |
| Within 3–7 days | Wound review, side effects/adherence, results, mental-health support, safety and additional forensic/child-protection needs. |
| 1–2 weeks | STI symptoms/results, pregnancy concerns, completion of medication and psychosocial support. |
| 4–6 weeks | Repeat relevant HIV/STI tests and hepatitis B schedule; assess ongoing danger and mental health. |
| 3 months (and local schedule) | Repeat HIV/syphilis testing where indicated, pregnancy assessment, HPV/HBV completion and longer-term trauma care. |
Give clear return precautions: fever, pelvic/abdominal pain, heavy bleeding, worsening headache, breathing or swallowing difficulty, confusion, seizures, suicidal thoughts, medication allergy, severe vomiting or inability to keep medicines down.
13. Discharge checklist
- Life-threatening injury and strangulation red flags assessed.
- Consent, confidentiality limits and survivor choices documented.
- Pregnancy, HIV, STI, hepatitis B, tetanus and mental-health needs addressed.
- PEP/EC/STI prophylaxis or a documented reason for not providing each intervention.
- Evidence samples, packaging and chain of custody complete—or refusal recorded.
- Safety plan, child-protection referral and safe follow-up method arranged.
- Written or discreet instructions and emergency contact supplied.
14. Worked cases
Case 1: Presentation 18 hours after rape
The survivor is haemodynamically stable with genital pain and no major external injury. Provide LIVES, consent-based examination and evidence options, pregnancy test, EC, HIV PEP immediately, STI/HBV/tetanus assessment, analgesia, mental-health support and follow-up. Do not wait for a police report before time-sensitive care.
Case 2: Presentation 90 hours after assault
HIV PEP is generally outside the recommended 72-hour window, but provide HIV testing/counselling, STI/HBV/pregnancy care, EC if within 120 hours, forensic assessment where useful, safety planning and follow-up. Document the timing and discuss specialist advice.
Case 3: Child survivor with unknown weight
Stabilise, protect from further harm and involve paediatric/safeguarding specialists. Obtain weight and use paediatric HIV, STI, EC and vaccine protocols; never give adult doses by guesswork.
15. Quick self-test
- What are the first three priorities before collecting forensic evidence?
- Within what time windows are HIV PEP and emergency contraception most useful?
- What is a common adult HIV PEP duration?
- Does absence of genital injury exclude rape?
- Name three discharge return precautions.
Answers
- Stabilise life-threatening injury, provide privacy/first-line support, and obtain informed consent.
- PEP should start as soon as possible and within 72 hours; EC is most effective early and is offered within 120 hours in WHO-aligned guidance.
- 28 days, using a national three-drug regimen unless a specialist changes it.
- No. Many survivors have no visible injury and findings vary with timing, anatomy and healing.
- Examples: breathing/swallowing difficulty, heavy bleeding, fever/pelvic pain, severe medication reaction, seizures/confusion or suicidal thoughts.
Key take-home points
- Treat the survivor as a patient first: safety, consent, dignity and urgent injury care come before evidence collection.
- Time-sensitive interventions include HIV PEP within 72 hours and EC within 120 hours; start as early as possible.
- Use the current local adult, paediatric and pregnancy protocols for PEP, STI prophylaxis, vaccines and dosing.
- Document objectively, preserve chain of custody and explain that medical findings do not decide legal guilt or consent.
- Safety planning, mental-health support, child protection and follow-up are part of treatment—not optional extras.
References and further reading
- WHO: Clinical management of rape and intimate partner violence survivors
- WHO: Clinical management of rape and IPV in emergencies training curriculum
- WHO: Availability of post-rape care (PEP, EC, STI and first-line support)
- WHO: Guidelines for medico-legal care for victims of sexual violence
- WHO: Caring for women subjected to violence
- Uganda/WHO-aligned SGBV and violence-against-children trainee manual
Educational note: This post is for trained health workers and students. Use current Ugandan national guidelines, local formularies, drug-resistance guidance, safeguarding law and specialist consultation. Doses require patient-specific checks.
