Sexual Assault / Rape Management

Clinical assessment

Based on patient's report of non-consensual sexual contact/penetration. Corroborating physical signs of injury may be present but are often absent. Focus on believing the survivor and providing care.

Investigations

• Medical Examination (requires informed consent):
• - Detailed history of the assault (respectful, non-judgmental, focus on medical needs and evidence collection).
• - Physical examination (general trauma assessment, detailed genital/anal examination using appropriate techniques - colposcope if available). Document all findings meticulously (written notes, diagrams, photos with consent).
• Laboratory Tests (Baseline assessment & Prophylaxis guidance):
• - Pregnancy Test (Urine or Serum).
• - STI Screening: Tests for Gonorrhea, Chlamydia, Trichomonas (swabs/urine). Serology for Syphilis (RPR/VDRL), Hepatitis B (HBsAg, anti-HBc, anti-HBs), HIV (antibody test). Baseline tests establish pre-exposure status; follow-up testing needed.
• Forensic Evidence Collection (Requires specific consent, follow local protocols meticulously):
• - Use standard Sexual Assault Evidence Kit (SAEK) if available.
• - Collect clothing worn during assault (victim should not change/wash beforehand).
• - Collect samples: Hair (combed/plucked head/pubic), Fingernail scrapings, Swabs (oral, vaginal, cervical, anal, skin surfaces), Dried secretions, Foreign material. Document chain of custody rigorously.

Diagnostic criteria

Patient report of sexual assault. Management focuses on care provision and evidence collection based on report, not requiring definitive 'proof'.

Non-pharmacological management

• Immediate Care & Support:
• - Ensure safety and privacy.
• - Approach with empathy, respect, non-judgmental attitude. Believe the survivor.
• - Obtain informed consent for each step (examination, testing, evidence collection, reporting).
• - Explain procedures clearly.
• - Offer immediate emotional support and crisis counseling.
• - Address basic needs (clothing, washing facilities AFTER evidence collection).
• Medical Assessment & Injury Treatment: Treat physical injuries as appropriate (wound care, suturing if needed).
• Forensic Evidence Collection: If survivor consents and presents within specified timeframe (usually <72-120 hours), perform meticulous collection following national protocols/SAEK instructions. Maintain chain of custody.
• Psychological Support:
• - Provide immediate psychological first aid.
• - Counsel on common reactions to trauma.
• - Offer referral for ongoing counseling / mental health support (crucial).
• Social Support & Referral:
• - Provide information on legal rights and options (reporting to police).
• - Offer referral to legal aid services.
• - Refer to social support services (shelters, GBV support groups, child protection services if minor).
• Follow-up: Schedule follow-up appointments (e.g., at 2 weeks, 6 weeks, 3 months, 6 months) for repeat STI/HIV/Hep B testing, pregnancy test confirmation, ongoing psychological support, and monitoring.

Pharmacological treatment

• STI Prophylaxis (Empiric treatment recommended, give ASAP):
• - Gonorrhea: Ceftriaxone 500mg IM stat (preferred) OR Cefixime 400mg PO stat.
• - Chlamydia: Azithromycin 1 gram PO stat OR Doxycycline 100mg PO BID for 7 days.
• - Trichomoniasis (& Bacterial Vaginosis): Metronidazole 2 grams PO stat.
• HIV Post-Exposure Prophylaxis (PEP):
• - Offer if presentation within 72 hours of assault, based on risk assessment (penetration, ejaculation, perpetrator status unknown/positive).
• - Standard 3-drug regimen for 28 days. UCG Rec: TDF + 3TC + ATV/r (Adults); ABC + 3TC + LPV/r (Children). Start ASAP.
• Hepatitis B Prophylaxis:
• - If survivor is unvaccinated or incompletely vaccinated: Administer Hepatitis B vaccine series (dose 1 ASAP, follow schedule).
• - Consider Hepatitis B Immunoglobulin (HBIG) in addition to vaccine if perpetrator known HBsAg positive and survivor unvaccinated (availability likely limited).
• Emergency Contraception (EC):
• - Offer if risk of pregnancy exists and presentation within 120 hours (5 days) of assault (most effective earlier).
• - Levonorgestrel 1.5 mg PO stat (single dose). UCG notes: double dose if patient on HIV ARVs (check specific interactions).
• - Ulipristal acetate (alternative, requires prescription) or Copper IUD insertion also options.
• Tetanus Prophylaxis: Administer TT booster if indicated based on injuries and vaccination history.

Monitoring

Follow-up for STI/HIV/Hep B testing. Monitor for pregnancy. Assess psychological well-being and provide ongoing support/referral. Monitor adherence and side effects if on HIV PEP.