Contraception After Sexual Violence

Sexual violence is a medical emergency requiring same-day, confidential, survivor-centred care that combines emergency contraception, HIV post-exposure prophylaxis, STI prevention and treatment, injury care, forensic documentation and psychological support. Pregnancy can follow a single assault, and time limits apply to every preventive intervention.

Principles. Obtain consent for each step, never examine without permission, ensure privacy and a chaperone of the survivor's choice, believe the account, and avoid repeated questioning. Children and adolescents need age-appropriate care and mandatory reporting where required by law.

Assessment. Time and nature of assault, number of assailants, penetration and ejaculation, condom use, injuries, last menstrual period, current contraception, pregnancy test, HIV status, immunisation (hepatitis B, tetanus), pregnancy intention, safety at home and mental state.

Time windows. Emergency contraception works within 120 hours (copper device within 5 days); HIV post-exposure prophylaxis within 72 hours; hepatitis B vaccination ideally within 72 hours and tetanus as needed.

Pregnancy test. Done before emergency contraception where practical, but treatment is not delayed for the result; a negative result does not rule out pregnancy from the assault.

Emergency contraception. All emergency methods are category 1 after sexual violence, including in obesity and breastfeeding (ulipristal is category 2 in breastfeeding).

Comparison. Copper T 380A within 5 days is the most effective and provides ongoing contraception, but may not be suitable immediately if there is genital injury, infection or the survivor declines. Ulipristal 30 mg is more effective than levonorgestrel. Levonorgestrel 1.5 mg is widely available. Combined pills (Yuzpe regimen) are the least effective and used only if nothing else is available.

Interactions. Enzyme inducers (rifampicin, efavirenz, carbamazepine, phenytoin) lower oral emergency contraceptive effect; the copper device is preferred, or levonorgestrel 3 mg if oral only.

Ongoing contraception. After oral emergency contraception, start a method that suits the survivor: pills, patch or ring from the next day (with backup 7 days, and after ulipristal wait 5 days), implants and injectables at the next period or after a negative pregnancy test (with backup in the interim), or a copper device if not already inserted. Intrauterine insertion is delayed if there is untreated infection or significant genital injury.

Special groups. Adolescents and children need specialist protection services. Survivors who are pregnant at presentation need pregnancy options counselling, including safe abortion care where the law allows.

Regimen lines.

• Levonorgestrel 1.5 mg orally as a single dose (two 750 microgram tablets together), as soon as possible within 120 hours.

• Ulipristal acetate 30 mg orally as a single dose within 120 hours; wait 5 days before starting hormonal contraception, with backup.

• Copper T 380A inserted within 5 days of the assault; continues as a method for up to 12 years.

• HIV post-exposure prophylaxis within 72 hours for 28 days: tenofovir disoproxil fumarate 300 mg, lamivudine 300 mg and dolutegravir 50 mg orally once daily, with adjustment for kidney function and pregnancy as advised by the HIV service.

• Presumptive STI treatment: ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 7 days (azithromycin 1 g orally as a single dose if pregnant), plus metronidazole 2 g orally as a single dose.

• Hepatitis B vaccine if not immune, and tetanus toxoid if there is a wound and immunisation is not up to date.

• Vomiting within 2 hours of an oral dose: repeat the dose; give an antiemetic if needed.

Follow up. Review at 1 to 2 weeks for adherence, side effects and results; at 4 to 6 weeks for pregnancy test, STI results and psychological state; at 3 months for HIV testing; and at 6 months for final testing and mental health review.

Documentation. Record the history, findings, injuries and treatment given in a legible record, and complete any medico-legal forms required by law, with consent for release.

Support. Offer counselling, safe housing, protection and legal advice, and link to a violence response service.

Pregnancy after assault. Offer options counselling, antenatal care or safe abortion care as the law allows, and mental health support.

Injury. Treat lacerations, assess for perforation or internal injury, and refer for surgery if needed.

Post-exposure prophylaxis intolerance. Treat nausea with an antiemetic and continue the regimen; do not stop without clinical advice.

Psychological sequelae. Screen for depression, post-traumatic stress and suicidal thoughts at each visit and refer.

Red flags. Heavy bleeding, severe pain, suicidal thoughts, signs of sepsis, a child survivor.

Referral and escalation. Refer injuries, pregnancy, mental health crisis and child protection concerns immediately.