Medical Management of Rape
All sexual assault survivors should receive empirical STI prophylaxis (covering chlamydia, gonorrhea, and trichomonas for females; chlamydia and gonorrhea for males), emergency contraception within 120 hours, HIV post-exposure prophylaxis when indicated, and hepatitis B vaccination if not previously immunized 1, 2.
Immediate Medical Interventions
STI Prophylaxis (Empirical Treatment Recommended)
- Provide presumptive STI treatment immediately rather than awaiting test results, as clinical follow-up is often challenging for survivors 2
- For females: Cover chlamydia, gonorrhea, AND trichomonas
- For males: Cover chlamydia and gonorrhea
- Consider metronidazole or tinidazole for trichomonas if alcohol was ingested or emergency contraception is being given to minimize drug interactions and GI side effects 1
- For gay, bisexual, and other men who have sex with men (GBMSM): Consider doxycycline 200 mg single dose within 72 hours of exposure (doxy-PEP) 2
Emergency Contraception
- Offer within 120 hours (5 days) of assault to all females who experienced or may have experienced vaginal penetration or genital contact with ejaculate 1
- Perform baseline urine pregnancy test before administration 1
- Discuss risks of failure and pregnancy management options 1
HIV Post-Exposure Prophylaxis (PEP)
- Initiate as quickly as possible, ideally within 72 hours of exposure 1, 2
- Higher risk scenarios requiring PEP include:
- Chronic sexual abuse
- Multiple perpetrators
- HIV-positive perpetrator(s)
- High HIV prevalence geographic area
- Perpetrator with genital lesions 1
- Assess both the HIV risk of the assailant and characteristics of the assault that increase transmission risk 1
- Follow-up HIV testing schedule: 4-6 weeks post-initiation and final testing at 12 weeks (using both laboratory-based Ag/Ab test and diagnostic NAT) 2
Hepatitis B Prophylaxis
- Offer hepatitis B vaccine to those who have not initiated or completed immunization 1
- Consider hepatitis B immunoglobulin based on the exposed person's immune status and source's infection status 2
HPV Vaccination
- Initiate or continue HPV vaccine series (recommended for ages 9 and older) 1
- Can coordinate completion with primary care provider 1
STI Testing Approach
Use nucleic acid amplification tests (NAATs) on urine or vaginal specimens rather than requiring speculum examination, as speculum exams may be traumatic, especially for adolescents, and can lead to future avoidance of reproductive healthcare 1.
- For females: Urine or vaginal NAAT for gonorrhea and chlamydia; vaginal NAAT for trichomonas
- For males: Urine NAAT, plus testing at penetration sites (e.g., anus) as indicated 1
- Obtain adolescent consent before specimen collection 1
- If presumptive treatment not given and initial tests negative, repeat STI testing 1-2 weeks post-exposure 2
Critical Pitfalls to Avoid
- Do not delay treatment waiting for test results - empirical treatment is recommended because follow-up is often challenging 2
- Do not perform traumatic speculum exams when NAAT alternatives exist - this can cause future healthcare avoidance 1
- Do not miss the 72-hour window for HIV PEP initiation - efficacy decreases significantly after this timeframe 1, 2
- Do not forget emergency contraception can be given up to 120 hours - not just 72 hours 1
Mental Health Assessment
Immediately assess for suicidal or homicidal ideation in conjunction with an experienced mental health professional 1. Provide written instructions for all recommendations, as survivors often cannot recall everything discussed during the evaluation 1.
Documentation and Evidence Collection
Recent evidence demonstrates that Electronic Health Record-integrated clinical pathways significantly improve adherence to recommended care, including advocate consultation, forensic evidence collection, pregnancy testing, emergency contraception, HIV PEP, and STI prophylaxis 3. Active pathway use is essential - passive presence alone does not improve outcomes 3.