Sexual assault: assessment and care

• Sexual assault is a medical, forensic and psychological emergency. It can leave injuries, pregnancy, infection, and severe distress, and in most legislations it is also a crime. Your first job is to look after the person who has been hurt: safety, pain, bleeding, pregnancy and infection prevention, and dignity come before any paperwork.
• Most assailants are known to the survivor. People of any gender and age can be assaulted, and men, adolescents, older adults and people with disabilities are often missed.
• The evidence that later supports a legal case degrades quickly. Forensic specimens and photographs must be taken as early as possible, with the person's consent, by a clinician trained to collect them.
• Time-critical treatments are emergency contraception within 5 days, HIV post-exposure prophylaxis within 72 hours (best within 24 hours), hepatitis B vaccination at the first visit, and STI prophylaxis.
• A normal examination does not exclude assault. Injuries are often absent, and co-operation is never a reliable clue.
• Everything you do must be consented, private, trauma-informed and non-judgemental, and documented in the person's own words.

By the end of this page you should be able to:

1. Provide trauma-informed first-line care to a person presenting after sexual assault, in a way that supports both their health and their choices about reporting. ^[2]
2. Take a forensic and clinical history that captures the information needed for care, for risk assessment and (with consent) for evidence, without re-traumatising the person.
3. Collect and preserve forensic specimens correctly, knowing the time windows within which each type of specimen remains useful.
4. Decide when emergency contraception, HIV post-exposure prophylaxis, hepatitis B and HPV vaccination and empiric STI treatment are indicated, and name the regimens, doses, routes and follow-up tests.
5. Obtain informed consent, protect confidentiality and follow the reporting requirements of your own setting without imposing your own judgement.
6. Document the encounter, plan follow-up and safety, and refer to the services a survivor is likely to need.

This page is about the care of an adolescent or adult who presents after an assault. Child sexual abuse requires the specialist paediatric and safeguarding services of your setting and is mentioned here only for referral and consent purposes. The medical parts of the WHO definition apply to both men and women: most victims are female and most perpetrators male, but men are assaulted too and are often not asked. ^[1]

The scope of this page is broader than the CDC 2021 STI chapter, which concentrates on identifying and preventing infection. ^[4] STI prevention is only one part of care. The medico-legal side, the pregnancy and psychological dimensions, are covered here using the WHO 2003 medico-legal guidelines and the WHO 2013 clinical guidelines for responding to sexual violence. ^[1][2]

Sexual assault is a crime in most jurisdictions and a reportable injury in many. The law on age of consent, mandatory reporting, confidentiality, access to abortion, and evidentiary privilege differ between countries and sometimes between regions of the same country. What follows are the principles that are widely accepted; apply them inside your own legal framework and consult a clinician, a specialist or a lawyer with experience in this field when in doubt. ^[1]

A person who has been assaulted has three separate sets of needs that all start at once: urgent medical care, evidence that may be lost with washing and delay, and time-critical prophylaxis (emergency contraception and HIV prophylaxis). ^[1] At the same time they may be frightened, in shock, and deciding whether they want the police involved at all. Treating these as competing demands is a common mistake. The safe sequence is:

1. Safety and urgent medical treatment for injury or distress.
2. First-line support while consent is obtained.
3. Time-critical steps that have windows (evidence collection, emergency contraception, HIV prophylaxis, hepatitis B and HPV vaccination).
4. Everything else (STI prophylaxis, full documentation, follow-up).

The WHO 2013 guidelines group the medical work of the first five days into a defined set of early interventions. ^[2] Acting early matters more for evidence than for most treatment: once the person has washed, evidence may be lost, while treatment can be started later within the windows set out below.

Everyone who has been sexually assaulted, whatever their age, gender, orientation, disability, migration status or substance use. Some groups need specific attention:

• Women and adolescents. Reproductive-age survivors need pregnancy assessment and emergency contraception. ^[4]
• Men and boys. They may have anal or oral exposure and are often less likely to be offered prophylaxis or support. The same health steps apply.
• Older adults and those with cognitive impairment. Consent capacity and safeguarding must be assessed carefully; abuse may be ongoing and disguised as care.
• People in conflict, displacement and humanitarian settings. The WHO/UNHCR protocols and the e-learning programme that the WHO 2013 guidelines refer to are written for these settings. ^[2]
• Sex workers and people who inject drugs. HIV risk and barriers to care are high; the same stepped care applies, and blame must be avoided.

Services should be usable around the clock; where a clinic cannot staff 24 hours, there must be a clear route for survivors to be seen elsewhere with a reliable referral. ^[1]

The following order is a teaching skeleton, not a rigid protocol. Adapt it to the person in front of you and to local services.

1. Receive and make safe. Greet by name, offer a private space, and treat medical threats (bleeding, airway, strangulation, head injury, poisoning) first.
2. First-line support. Sit down, introduce yourself and your role, explain what can be offered before talking about the assault. Listen, validate, ask about safety and immediate needs. ^[2]
3. Consent. Explain each option separately: medical care, forensic examination, evidence release to police, photographs, samples. Consent can be given, refused or postponed separately for each, and can be withdrawn.
4. Risk and needs assessment. Time of assault, acts, injuries, pregnancy, HIV and STI risk, contraception, mental state and safety.
5. Examination when consented and needed, from general injuries to the genito-anal area, not the reverse.
6. Evidence collection within windows, with chain of custody.
7. Prophylaxis and treatment for STI, pregnancy, HIV and hepatitis B/HPV.
8. Documentation in the person's own words, with body maps.
9. Follow-up and referral (medical, psychological, social, legal), including a safety plan.

Take the history in a private room with the door closed, with a chaperone if the person wants one and a trained interpreter if their first language or sign language is not yours. Avoid repeating the story in front of relatives or police. Use the person's own words where possible and ask permission before touching.

Start with health, not with the assault. Ask about:

• when the assault occurred (date and approximate time), and when the person last washed, changed, urinated or defaecated, which affects evidence recovery;
• what happened in clinical terms (genital, anal and/or oral penetration; ejaculation; use of condoms, if known; use of objects, fingers or foreign bodies; violence, restraint, strangulation, bites, weapons, and injuries they are aware of);
• last menstrual period, usual contraception, parity and whether pregnancy is possible or wanted;
• current medications, allergies, medical conditions (including renal or liver disease relevant to HIV prophylaxis), hepatitis B and HPV vaccination status, and any current STI or HIV risk behaviour or diagnosis;
• the assailant's known or possible HIV status and risk factors (for example injecting drug use or sex with men), the number of assailants, bleeding during the assault, and whether any site of exposure was mucosal with ejaculate;
• drugs or alcohol: an alteration in consciousness raises drug-facilitated assault and needs full resuscitation facilities and blood and urine samples taken as soon as possible; ^[1]
• previous sexual violence, intimate partner violence, and ongoing safety at home;
• mental state, suicidal thoughts, self-harm, and who to contact if the person leaves alone.

Adolescents. The same steps apply, but a healthcare provider trained in paediatric care should be involved, and consent, capacity and safeguarding rules for minors in your jurisdiction apply from the first minute. Do not perform an intimate examination on a child unless you are appropriately trained; refer to the child sexual abuse service.

History of the examination itself. A forensic examination is not the same as a medical one. Explain what each involves and what it could add, and record consent separately. ^[1]

Consent must be obtained for the examination and, separately, for the release of the findings to third parties. ^[1] Work with a chaperone of the person's choosing. Examine general injuries before the genito-anal area, not after, so the person is not lying exposed while waiting.

General examination:

• vital signs, including oxygen saturation if there is any doubt about the airway or breathing after strangulation or smothering;
• head, neck, mouth and teeth, especially in oral assaults and in restraint;
• all skin for bruises, lacerations, burns, bite marks and patterns of assault (photograph with a scale, with written consent);
• limbs and trunk for fractures or soft-tissue injury;
• neurological examination if head injury, loss of consciousness or strangulation is reported, and a low threshold for imaging.

Genito-anal examination should be done only by a clinician trained in sexual assault care, and only if clinically indicated or with consent for forensic purposes. A speculum examination is not automatic: it is particularly relevant if there is vaginal or pelvic pain, bleeding, a suspected foreign body, or if forensic samples are needed from the endocervical canal. Pressured or painful examinations re-traumatise and may be declined; record refusal without judgement. ^[3]

Baseline tests at the first visit (individualise, per CDC guidance): ^[4]

• NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae at the sites of penetration or attempted penetration;
• for women, NAAT for Trichomonas vaginalis from urine or vaginal specimen; a point-of-care or wet mount test with vaginal pH and whiff test if vaginal discharge, malodour or itching is present;
• for men who have sex with men, screening for C. trachomatis and N. gonorrhoeae if receptive oral or anal sex in the preceding year (regardless of whether those sites were involved in this assault), and anoscopy if anal penetration is reported;
• serum testing for HIV, hepatitis B and syphilis;
• pregnancy test in anyone who could be pregnant.

After 5 days a vaginal sample may still be worth taking in selected cases, and some injuries (bruising, for instance) become more visible after a few days, so a second, documented examination is sometimes needed. ^[3] The person should be told this and offered it.

The table brings together the time-critical decisions. Use it as a checklist at triage and again before discharge.

Compliance with follow-up is poor after sexual assault, so the CDC 2021 guidelines recommend presumptive treatment at the first visit, rather than waiting for test results. ^[4] This is treatment rather than true prophylaxis, but it is standard practice in many settings because failure to treat risks pelvic infection and complications.

The recommended regimen for adolescent and adult female survivors is: ^[4]

• Ceftriaxone 500 mg intramuscularly, single dose, plus
• Doxycycline 100 mg by mouth twice daily for 7 days, plus
• Metronidazole 500 mg by mouth twice daily for 7 days.

For males the regimen is ceftriaxone 500 mg intramuscularly plus doxycycline 100 mg by mouth twice daily for 7 days. ^[4] For anyone weighing 150 kg or more, give 1 g of ceftriaxone. ^[4] Tell people to expect possible gastric side effects and to abstain from sexual intercourse until treatment is completed. ^[4]

If they decline presumptive treatment, or if your service has excellent follow-up, a strategy of treating only confirmed infection is acceptable and prevents over-treatment; document the discussion and the plan. The UK approach, for instance, treats prophylaxis as a selective option rather than a routine one. ^[6]

Reproductive-age survivors who do not already use reliable contraception should be offered emergency contraception at the first visit; discuss it even if the test is negative, because ovulation may not have occurred yet. ^[4]

There are three methods, summarised in Table 3. ^[6][7]

Practical points: ^[6][7]

• Women and adolescents requiring emergency contraception after assault should be offered all methods, including the copper IUD. ^[6]
• A copper IUD is recommended for all at-risk survivors within the window because it is the most effective method. A pregnancy rate that the FSRH describes as extremely low is achieved if it is fitted within 5 days of unprotected intercourse or of the estimated day of ovulation. ^[6] Antibiotic cover for STI should be considered if a copper IUD is fitted, because of the risk of ascending infection. ^[6]
• If the person chooses a copper IUD after assault but wants or needs a forensic examination, defer insertion until after the forensic examination, and give oral emergency contraception in the meantime in case fitting is delayed. ^[6]
• Discuss the option of forensic examination and the timeframe for collecting forensic samples when planning the method. ^[6]
• If oral methods are used at higher body weight, efficacy may be reduced; the evidence favours ulipristal acetate or a double 3 g dose of levonorgestrel at higher body mass index, but which is better is not known. ^[7]
• If a period has not occurred by 3 weeks after the assault, arrange a pregnancy test and discuss the options.

If a pregnancy test is already positive after the assault, stop and discuss continuation, termination where lawful and desired, and in some systems sampling for paternity testing as part of care. ^[1][3]

HIV transmission per act of vaginal intercourse in consensual sex is estimated at about 0.08% and of receptive anal intercourse at about 1.38%. ^[4] Assault may carry a higher risk than consensual sex because of bleeding, mucosal trauma, multiple assailants and possible assailant HIV status. ^[4] HIV infection has been documented in people whose only known risk factor was sexual assault, but it is uncommon. ^[4] Base the recommendation on the characteristics of the assault and the assailant rather than on worry alone.

If HIV post-exposure prophylaxis (PEP) is being considered: ^[4][5]

• start as soon as possible and no later than 72 hours after exposure; the first 24 hours are preferable. ^[4][5]
• do not delay the first dose while waiting for laboratory results. ^[5]
• give a 28-day course of a three-drug regimen. ^[4][5]
• preferred regimens for most adults and adolescents (CDC 2025): bictegravir/emtricitabine/tenofovir alafenamide once daily, or dolutegravir plus tenofovir (alafenamide or disoproxil fumarate) plus emtricitabine or lamivudine. ^[5]
• consult an HIV specialist if the survivor is a child, pregnant, has renal or liver disease, is already taking PrEP, or there is concern about resistance.
• take baseline serum creatinine, AST and ALT. ^[4]
• test for HIV at baseline, at 6 weeks and at 3 months, using methods that detect acute infection when a window-period infection is suspected. ^[4][5]
• give a first course of 3-7 days (a starter pack) with a prescription for the rest of the 28 days, or the entire 28-day supply at the first visit, which improves adherence; ensure the person can actually obtain the remainder. ^[4]
• arrange an early follow-up visit at 24 hours to discuss results, side effects and adherence, and follow-up at 4-6 weeks and 12 weeks after exposure. ^[4][5]
• discuss that most people tolerate these regimens without serious adverse effects, and counsel about ongoing risk and referral for HIV pre-exposure prophylaxis (PrEP) afterwards. ^[4]
• practical decisions can be supported by the National Clinician's Post-Exposure Prophylaxis Hotline (PEP Line, 888-448-4911) in the United States; in other countries use the local HIV specialist line. ^[4]

A 28-day course of zidovudine in a study of healthcare workers with needlestick injuries was associated with an 81% reduction in infection, which is the basis for extending the idea to non-occupational exposures, but no randomised trial of PEP after sexual assault exists. ^[4] Communicate that PEP reduces risk; it does not eliminate it. ^[5]

• Hepatitis B vaccination is recommended after sexual assault if the survivor is not previously vaccinated and the assailant's hepatitis B status is unknown: give the vaccine without hepatitis B immune globulin. ^[4]
• If the assailant is known to be HBsAg positive, give both the vaccine and hepatitis B immune globulin to an unvaccinated survivor. ^[4]
• Give the first doses at the initial examination; follow-up doses at 1-2 and 4-6 months after the first dose. ^[4]
• For survivors previously vaccinated but not post-vaccination tested, a single booster dose is given. ^[4]
• HPV vaccination is recommended for female and male survivors aged 9-26 years who are unvaccinated or incompletely vaccinated, because they are at risk of HPV infection, and the vaccine is highly effective; schedule follow-up doses at 1-2 and 6 months after the first dose, or use the two-dose schedule for those who start before age 15. ^[4]

Follow-up is where much care fails because attendance is poor. ^[4] Book it before the person leaves.

• If tests were taken at the first visit, see them within 1 week to discuss results, start or adjust treatment and arrange further care. ^[4]
• If initial tests were negative and treatment was not given, re-test for STI 1-2 weeks after the assault, when organisms may have reached detectable levels. ^[4]
• For survivors treated at the first visit, re-test only if symptoms develop. ^[4]
• If the assailant's infection status cannot be ruled out, repeat syphilis serology at 4-6 weeks and 3 months, and HIV testing at 6 weeks and 3 months. ^[4]
• If pregnancy did not occur, start effective contraception of the person's choice and provide it until follow-up. ^[6]
• Reassess mental health at every visit, not only at the first. ^[2]

Obtaining informed consent for the examination and for the release of information to third parties is a crucial part of care. ^[1] The WHO 2013 and 2003 guidelines both treat consent and confidentiality as clinical acts, not administrative ones. ^[1][2]

Principles to apply:

• Consent is specific. Consent to medical examination is not consent to release records to the police. Consent to one set of samples is not consent to all. Ask, explain, document each decision.
• Capacity. Assess whether the person understands, retains, weighs and communicates their choice. Intoxication, head injury or severe trauma can impair capacity in the acute phase; recheck as the person recovers, and involve a trusted decision-maker only where your law requires it.
• No coercion by authorities. In many systems police request immediate forensic examination; being a witness is not the same as being a patient. If the person declines, respect that and document. A refusal of evidence collection never means a refusal of care.
• Children and vulnerable adults. Mandatory reporting applies in many jurisdictions; when in doubt, follow local policy and consult the safeguarding lead. Medico-legal examination and evidence collection in children should be carried out only by trained clinicians. ^[3]
• Limits on previous sexual history. Most legal systems restrict the use of a survivor's previous sexual history, including previously acquired STIs, in court. In many jurisdictions an evidentiary privilege protects parts of the examination or record. ^[4]
• Privacy. Secure records, limited access, private space, no public discussion. The records may later be needed both for care and for law; store and label them accordingly.
• Reporting. Know whether your setting has mandatory reporting of sexual assault of adults. In many countries reporting is the survivor's choice for adults and mandatory for children; telling a survivor that reporting is compulsory when it is not is a serious breach of trust. Where possible, arrange an interpreter or advocate and give written information.

Good documentation reads as if written by someone who was there and thought about the person:

• The person's own words, in quotation marks where possible, for how the assault began, what was said and any threats made.
• A timeline (date and time of arrival, of the assault, of washing or changing, and of the examination).
• Injuries described, not diagnosed. Size, shape, colour, location using anatomical terms; body maps and photographs with consent. Note where injuries are absent as well.
• What was examined and what was not. Record refusals without judgement.
• Specimens. What was collected, when, where, and the chain of custody.
• Tests ordered, treatment given, advice given, safety plan, referrals made.
• Interpreter and chaperone names if used.

Clinical descriptions should be factual, neutral and free of opinion about whether the assault happened. The courts, not you, decide whether a crime occurred. ^[1]

For drug-facilitated or alcohol-related cases, record exact sampling times and transfer to the forensic laboratory promptly. ^[1]

Refer early rather than late, and in parallel with rather than in place of care:

• Immediate life threats: call emergency services for airway concerns, strangulation with neurological symptoms, significant haemorrhage, head injury or drug-facilitated unconsciousness.
• Forensic and legal: local sexual assault referral centre, forensic medical examiner, or sexual assault nurse examiner (SANE).
• Specialist sexual health and HIV: infectious diseases for complex PEP, HIV infection or drug interactions; local HIV specialist or the PEP hotline; sexual health clinic for STI follow-up and HPV and hepatitis B series completion.
• Reproductive health: women's health or contraception service for copper IUD insertion when not available on site, and for pregnancy options.
• Mental health and social support: trauma-focused psychologist, sexual assault support service, child and adolescent service, refuge and safety planning, legal advice, interpreter.

These are the mistakes that quietly damage care and evidence:

• Treating the examination as proof of the assault, or reassuring that a normal examination rules it out.
• Performing an intimate examination without consent, or before consent is settled, or by a clinician without training.
• Forgetting pregnancy risk in someone who does not spontaneously mention contraception.
• Delaying HIV PEP to finish investigations, or not starting it because the assailant's status is unknown.
• Giving antimicrobials for prophylaxis without discussing side effects or abstaining, or failing to treat because a culture is still pending.
• Missing hepatitis B and HPV follow-up doses, which are usually where prophylaxis fails.
• Documenting "appears consistent with" or other quasi-legal conclusions.
• Re-taking the story in front of police, family or the same clinician three times, which re-traumatises and can change the record.
• Assuming that men, people with learning disabilities, older adults and sex workers were not assaulted or do not need prophylaxis.
• Sending a person home at 3 a.m. with no safety plan, no follow-up and no one to call.

Another common error is to confuse forensic and clinical specimens: a swab taken for STI diagnosis is not the same as an evidence swab, and both may be needed. ^[1]

• Sexual assault care is health care first: safety, injuries, pregnancy, infection and distress, in a private and non-judgemental setting.
• First-line support (listening, believing, safety, information, referral) is itself a clinical intervention and starts the process. ^[2]
• Forensic specimens are time-critical: skin up to 72 hours, mouth up to 12 hours, vagina up to 5 days, anus up to 48 hours. ^[3]
• Emergency contraception: copper IUD within 5 days (most effective); levonorgestrel 1.5 mg by mouth within 72 hours; ulipristal acetate 30 mg by mouth within 5 days and first-line orally at 96-120 hours. ^[6][7]
• HIV PEP, when indicated, must start as soon as possible and no later than 72 hours (preferably 24 hours), with a 28-day three-drug regimen (CDC 2025 preferred regimens: bictegravir/emtricitabine/tenofovir alafenamide, or dolutegravir plus tenofovir plus emtricitabine/lamivudine). ^[4][5]
• Empiric prophylaxis after assault: ceftriaxone 500 mg intramuscularly, doxycycline 100 mg by mouth twice daily for 7 days, and metronidazole 500 mg by mouth twice daily for 7 days for women. ^[4]
• Hepatitis B vaccination (without hepatitis B immune globulin unless the assailant is known HBsAg positive) and HPV vaccination aged 9-26 years are started at the first visit with scheduled follow-up doses. ^[4]
• Consent, confidentiality and reporting are clinical duties: consent for each step is separate, and child and vulnerable-adult safeguards follow local law. ^[1]
• Document in the person's own words, with body maps; do not offer opinions on whether a crime occurred. ^[1]
• A normal examination does not exclude assault; injuries after assault are often absent.

Emergency contraception; contraception; sexually transmitted infections; HIV prevention and pre-exposure prophylaxis; post-exposure prophylaxis for HIV; hepatitis B infection; human papillomavirus; trauma and post-traumatic stress in psychiatry; paediatric safeguarding; medicolegal documentation.