What is the appropriate evaluation and management for a 19‑year‑old female presenting to primary care two months after a sexual assault?

Evaluation and Management of a 19-Year-Old Sexual Assault Victim Presenting Two Months Post-Assault

At two months post-assault, the window for emergency contraception, HIV post-exposure prophylaxis, and empiric STI prophylaxis has closed; therefore, focus on comprehensive STI screening, pregnancy testing, mental health assessment with urgent referral for trauma-focused cognitive behavioral therapy, and completion of hepatitis B and HPV vaccination series. 1

Immediate Mental Health Assessment

Screen immediately for suicidal ideation, homicidal ideation, and self-harm behaviors, as sexual assault survivors have markedly elevated rates of depression and suicide attempts. 1, 2

• If any suicidal or homicidal ideation is present, arrange immediate consultation with an experienced mental health professional—this cannot be delayed. 1
• Even without active suicidal ideation, arrange urgent referral to a trauma-informed mental health provider for trauma-focused cognitive behavioral therapy (TF-CBT), which has demonstrated large effect size reductions in PTSD symptoms when initiated within weeks to months after assault. 2, 3
• Address common responses including self-blame, humiliation, anxiety, and avoidance behaviors that may have delayed her presentation. 1

STI Testing and Management

Perform comprehensive STI screening now, as the two-month interval makes this a follow-up timepoint rather than an acute prophylaxis scenario. 1

• Collect nucleic acid amplification tests (NAATs) using urine or vaginal specimens for gonorrhea and chlamydia—avoid traumatic speculum examination if the patient has never had one, as this may lead to future avoidance of reproductive healthcare. 1
• Obtain NAAT vaginal specimen for trichomoniasis. 1
• Perform serologic testing for syphilis and HIV now, and repeat at 3 months and 6 months post-assault if initial results are negative. 1
• Test for hepatitis B surface antigen and antibody to determine infection status and immunity. 1
• Treat any positive STI results according to current CDC guidelines; positive results may indicate infection acquired during the assault or from previous consensual contact. 1

Pregnancy Assessment

Perform urine pregnancy testing immediately, as the assault occurred within the window where pregnancy could have resulted and may still be undetected. 1

• A negative urine pregnancy test at two months post-assault effectively rules out pregnancy from the assault. 1
• If positive, provide non-judgmental counseling about all pregnancy options and arrange appropriate obstetric or pregnancy termination services based on her preference. 1
• If she is pregnant and wishes to continue, arrange coordinated care with obstetrics and trauma-specialized mental health services, as pregnancy can trigger somatic retraumatization in sexual assault survivors. 4

Vaccination Completion

Initiate or complete the hepatitis B vaccine series if she has not received all three doses. 1

• Administer the first dose today if she has never been vaccinated, with follow-up doses at 1-2 months and 4-6 months. 1

Initiate or complete the HPV vaccine series, as the AAP recommends continuing or completing the series if all doses have not been received. 1

• Coordinate completion of the series with ongoing follow-up visits. 1

Documentation and Legal Considerations

• Document her history using her own words when possible, and maintain precise, non-judgmental language in the medical record. 2
• Inform her that all 50 states have laws strictly limiting the use of a victim's previous sexual or infection history in legal proceedings. 1
• Provide written instructions for follow-up care, as patients often do not recall everything discussed during the visit. 1, 3

Follow-Up Care Plan

Schedule follow-up within one week to assess her mental health status, review test results, and ensure trauma counseling has been initiated. 1, 3

• Repeat syphilis and HIV testing at 3 months (one month from now) and 6 months post-assault if initial results are negative. 1, 3
• Ensure she has established care with a trauma-informed mental health provider for ongoing TF-CBT, which is the first-line evidence-based treatment for PTSD in sexual assault survivors. 3
• Coordinate with her primary care provider (with her consent) to ensure continuity of care and avoid the burden of her having to reintroduce the topic. 1

Common Pitfalls to Avoid

• Do not assume that because two months have passed, mental health intervention is less urgent—trauma-focused therapy remains highly effective when initiated weeks to months after assault, and delaying referral increases the burden of untreated PTSD symptoms. 2, 3
• Do not perform unnecessary pelvic examination with speculum—NAAT testing from urine or self-collected vaginal swabs is equally effective and avoids retraumatization. 1
• Do not dismiss her delayed presentation—self-blame, humiliation, and lack of information commonly prevent adolescents from seeking immediate care. 1
• Do not fail to provide written instructions and follow-up plan—patients often cannot recall verbal instructions given during emotionally charged visits. 1, 3