Immediate Treatment for Sexual Assault Victims
Start empirical antibiotic prophylaxis for STIs (chlamydia, gonorrhea, and trichomoniasis), offer emergency contraception within 120 hours if female, and initiate HIV post-exposure prophylaxis (PEP) within 72 hours for high-risk exposures. 1
Core Medical Interventions
STI Prophylaxis (Immediate)
Empirical treatment is recommended rather than waiting for test results, as follow-up is often challenging 1, 2:
- Chlamydia and gonorrhea prophylaxis for all victims
- Trichomoniasis treatment for females
- Use metronidazole or tinidazole if alcohol was ingested or emergency contraception is being given to minimize drug interactions and GI side effects 1
Emergency Contraception (Within 120 Hours)
Offer emergency contraception to all females who experienced or may have experienced vaginal penetration or genital contact with ejaculate 1. The 5% pregnancy rate per rape in females aged 12-45 makes this critical 1.
- Perform baseline urine pregnancy test first
- Provide within 120 hours of assault for maximum effectiveness 1
HIV Post-Exposure Prophylaxis (Within 72 Hours)
Begin HIV PEP as quickly as possible when indicated 1. High-risk factors include:
- Multiple perpetrators
- Known HIV-positive perpetrator
- Perpetrator with genital lesions
- High HIV prevalence geographic area
- Chronic sexual abuse history 1
Assessment protocol within 72 hours 1:
- Assess HIV risk in the assailant
- Evaluate assault characteristics that increase transmission risk
- Consult HIV treatment specialist
- Discuss antiretroviral prophylaxis risks and benefits
- Perform baseline CBC, chemistry panel, and HIV testing
- Provide 3-7 days of medication initially until tolerance assessment 1
The 2025 CDC guidelines emphasize that nPEP is highly effective when taken as prescribed 2.
Hepatitis B Vaccination
Offer hepatitis B vaccine to those who haven't initiated or completed the series 1. This can be coordinated with primary care for series completion.
HPV Vaccination
Initiate or continue HPV vaccination series for patients age 9 and older who haven't completed all doses 1, though CDC has no specific recommendations for acute assault context.
Testing Approach
STI Specimen Collection
Use nucleic acid amplification tests (NAATs) with urine or vaginal specimens rather than cervical specimens 1:
- For females: Urine or vaginal NAAT for gonorrhea/chlamydia; vaginal NAAT for trichomoniasis
- For males: Urine NAAT, plus testing at penetration sites (anus) if indicated
- Avoid speculum examination when possible, as it may be traumatic and lead to future healthcare avoidance 1
Critical caveat: Positive results may indicate pre-existing infection from prior consensual contact, not necessarily from the assault 1. All 50 states have laws limiting use of victim's previous sexual or infection history 1.
Alternative Testing Strategy
Some clinicians may await STI test results in shared decision-making with the survivor rather than providing presumptive treatment 2. If initial tests are negative and no presumptive treatment was given, repeat STI testing 1-2 weeks post-exposure 2.
Mental Health Assessment
Immediately assess for suicidal or homicidal ideation in conjunction with an experienced mental health professional 1. Evidence shows brief interventions (≤6 sessions) provide moderate certainty evidence for reducing PTSD, depression, and anxiety symptoms 3.
Documentation and Follow-Up
Provide written instructions, as victims often don't recall everything discussed during the evaluation 1.
Schedule follow-up within 1-2 weeks to:
- Assess injury healing and medication adherence
- Evaluate mental health functioning
- Arrange psychological counseling referrals
- Reassess for PrEP indications 1
HIV testing timeline 2:
- 4-6 weeks post-PEP initiation (can be deferred if started within 24 hours, fully adherent, and not considering PrEP)
- Final test at 12 weeks post-PEP initiation using both laboratory Ag/Ab test and diagnostic NAT
Important Pitfalls to Avoid
- No legal complaint or police report is required to provide healthcare 4
- Any health service should provide initial measures even without specialized training, then refer to specialized services 4
- Avoid delaying care waiting for specialized services or legal documentation
- Don't perform evidence collection ("rape kit") unless experienced, due to legal ramifications of improper collection 5
- Secure adolescent consent before communicating with primary care providers due to confidentiality laws 1