Post Rape Care

The integrated medical, psychological and forensic care of a survivor of sexual violence. The three objectives run in parallel and none may be sacrificed for another: treat injuries and prevent infection and pregnancy, collect and preserve evidence, and provide psychological support with onward linkage.

The governing principle

The survivor is a patient first. Clinical care is never delayed for forensic collection, and the survivor's consent governs every step including examination, specimen collection, photography and disclosure to police. Consent must be documented on the consent section of the standard form, and the survivor may decline any component while accepting others, including declining police involvement while accepting treatment.

Time windows that determine what is offered

• Under 72 hours: full package including post exposure prophylaxis against HIV, which is only effective if started within this window and is most effective the earlier it is given.
• Under 120 hours, that is 5 days: emergency contraception remains effective.
• Beyond 72 hours: post exposure prophylaxis is no longer indicated, but all other components remain, including emergency contraception up to 120 hours, sexually transmitted infection prophylaxis, hepatitis B vaccination, tetanus, human papillomavirus vaccination, counselling and forensic documentation. Presentation beyond 72 hours is common and such survivors must not be turned away or told that nothing can be done.

Documentation set

A complete record typically comprises the informed consent form, the standard post rape care form completed in triplicate with a clinical part and a treatment part, the police medical examination form, the entry in the post rape care register, the trauma counselling record and the psychological assessment. Incomplete documentation is the commonest reason prosecutions fail, and completing the forms accurately is a clinical duty rather than an administrative one.

Specimen handling

All clothing and physical specimens go into labelled brown paper bags, never plastic. Plastic retains moisture and promotes bacterial and fungal growth, which degrades deoxyribonucleic acid and destroys the evidential value of the sample. Specimens are stored in a secure locked cupboard until collected by the police, and the chain of custody must be recorded with each transfer signed and dated.

Presentation

Survivors present across an enormous range, from acutely injured and in shock to physically unharmed with profound psychological distress. Absence of physical injury is common and does not indicate that assault did not occur, and this must be stated explicitly in the documentation so that it is not misread later as evidence of consent.

Assessment priorities

• Life threatening injury first. Airway, breathing, circulation, disability and exposure, with resuscitation as for any trauma patient. Severe genital and anal trauma with haemorrhage, intra abdominal injury from penetrating trauma, head injury and strangulation injury all take precedence over everything else.
• Strangulation is specifically sought: neck pain, hoarseness, dysphagia, subconjunctival haemorrhage, petechiae above the neck, incontinence and any loss of consciousness. Non fatal strangulation carries a risk of delayed carotid dissection and laryngeal injury and requires imaging and observation.
• General examination for injuries in a systematic head to toe sequence, documenting each injury by site, size, shape, colour and type.
• Genital and anal examination, performed once, thoroughly, with a chaperone of the same sex as the survivor and with continuous explanation.

History

Taken once, in a private setting, in the survivor's own words and recorded verbatim where possible, avoiding repeated retelling which is retraumatising.

• Date, time and place of the assault.
• Nature of the assault: vaginal, anal, oral penetration; digital or object penetration; ejaculation; condom use.
• Number of assailants and whether known.
• Use of weapons, restraints, drugs or alcohol.
• Loss of consciousness or memory gaps, which raise the possibility of drug facilitated assault.
• Actions since the assault: washing, bathing, douching, urinating, defecating, changing clothes, eating and drinking, all of which affect specimen yield.
• Last consensual intercourse, which matters for interpretation of deoxyribonucleic acid findings.
• Menstrual and contraceptive history, last menstrual period.
• Past medical history, medications, allergies, HIV status, hepatitis B vaccination status and tetanus status.

Features requiring particular attention

• Children and adolescents, in whom the examination technique, the specimen approach and the safeguarding obligations differ, and in whom paediatric and child protection services must be involved from the outset.
• Male survivors, who are under recognised, under served and frequently not asked.
• Survivors with disability, who are at markedly increased risk and who may require additional communication support.
• Pregnancy at presentation.
• Repeat or ongoing abuse within a household, which requires a safety plan before discharge.

Examination and specimen collection

Collected as the examination proceeds rather than as a separate exercise, so the survivor is examined only once.

• High vaginal swab, endocervical swab, and swabs from any other site of penetration or contact, for spermatozoa, seminal fluid and deoxyribonucleic acid.
• Anal and oral swabs where indicated by the history.
• Swabs of any bite marks, licked areas or dried secretions on the skin, taken with a slightly moistened swab.
• Fingernail clippings or scrapings where the survivor scratched the assailant.
• Combed pubic hair and any foreign hairs.
• Clothing worn during and immediately after the assault, each item bagged separately in labelled brown paper.
• Photography of injuries with a scale, with explicit consent.
• Air dry all swabs before packaging, and label each with the survivor's details, the site, the date and the time.

Laboratory investigations

• HIV testing with pre test and post test counselling. Establish baseline status, which determines whether post exposure prophylaxis is appropriate and provides a medicolegal baseline. A survivor who declines testing may still be offered prophylaxis in some protocols, but testing should be encouraged with careful counselling.
• Hepatitis B surface antigen and surface antibody where available.
• Syphilis serology.
• Full blood count, and renal and liver function as a baseline before starting antiretroviral drugs.
• Pregnancy test in females of reproductive age.
• Urinalysis and microscopy.
• Nucleic acid amplification testing for gonorrhoea and chlamydia where available, recognising that a positive result may reflect pre existing infection.
• Toxicology on blood and urine where drug facilitated assault is suspected, taken as early as possible since many agents are cleared within 12 to 24 hours.

Repeat and follow up testing

• HIV testing at 4, 12 and 24 weeks.
• Full blood count, alanine aminotransferase and creatinine at 2 weeks for those on prophylaxis.
• Pregnancy test at 4 weeks.
• Syphilis serology at 6 and 12 weeks.

Immediate priorities

Resuscitate and treat injuries. Suture lacerations, arrange surgical or gynaecological review for significant genital, anal or intra abdominal trauma, and provide adequate analgesia. Do not defer treatment for forensic collection.

HIV post exposure prophylaxis, within 72 hours

Start as soon as possible, ideally within hours. Each hour of delay reduces efficacy, and the first dose should be given before laboratory results return.

• Preferred regimen: tenofovir 300 mg with lamivudine 300 mg as a single fixed dose combination tablet once daily, plus dolutegravir 50 mg once daily, which current World Health Organization guidance recommends as the preferred third agent for post-exposure prophylaxis given its tolerability and once-daily dosing. Continue for 28 days.
• Where tenofovir is contraindicated by renal impairment, zidovudine 300 mg twice daily may be substituted. Do not delay the first dose while waiting for renal function results.
• Where dolutegravir is unavailable, a ritonavir-boosted protease inhibitor such as atazanavir 300 mg with ritonavir 100 mg once daily, or lopinavir with ritonavir, is an alternative third agent.
• Paediatric dosing is weight based and should be prescribed from a current paediatric dosing chart.
• Give the first dose immediately in the department, observed.
• Adherence over 28 days is the principal determinant of efficacy and is poor without support. Provide a full 28 day supply where possible rather than a starter pack, arrange adherence counselling, and give clear written instructions.
• Anticipate and pre empt adverse effects: nausea, which is the commonest reason for discontinuation and for which an antiemetic such as metoclopramide 10 mg or ondansetron 4 to 8 mg should be co prescribed; headache; fatigue; and jaundice with atazanavir, which is benign unconjugated hyperbilirubinaemia and which must be explained in advance or the survivor will stop the drug.
• Review at 7, 14 and 28 days.

Emergency contraception, within 120 hours

• Levonorgestrel 1.5 mg orally as a single dose, or two 0.75 mg tablets taken together. Most effective the earlier it is given, with declining efficacy across the 120 hour window.
• Ulipristal acetate 30 mg as a single dose is more effective than levonorgestrel between 72 and 120 hours where available.
• A copper intrauterine device inserted within 5 days is the most effective method with a failure rate under 1 percent, and is appropriate for survivors who accept it, though many will not wish for an intrauterine procedure after sexual assault and this must be handled sensitively.
• Give an antiemetic if the survivor vomits within 2 hours of the dose, and repeat the dose.
• Emergency contraception does not disrupt an established pregnancy and is not an abortifacient, which should be explained where beliefs make this a concern.
• Discuss ongoing contraception and arrange follow up pregnancy testing at 4 weeks.

Sexually transmitted infection prophylaxis

Given presumptively rather than awaiting results.

• Ceftriaxone 250 to 500 mg intramuscularly as a single dose, or cefixime 400 mg orally as a single dose, for gonorrhoea.
• Azithromycin 1 g orally as a single dose for chlamydia, or doxycycline 100 mg twice daily for 7 to 14 days.
• Metronidazole or tinidazole 2 g orally as a single dose for trichomoniasis and bacterial vaginosis. This may be deferred and taken at home if the survivor has consumed alcohol, given the disulfiram like reaction, or if emergency contraception has just been given and nausea is a concern.
• An alternative combination is doxycycline 100 mg twice daily for 14 days plus ciprofloxacin 500 mg as a single dose plus tinidazole 2 g as a single dose.
• Counsel about the total pill burden, which is substantial when combined with post exposure prophylaxis, and stagger doses where nausea is limiting.

Hepatitis B

• If not previously vaccinated and not known to be surface antigen positive, give hepatitis B vaccine 1 mL intramuscularly at 0, 1 and 6 months, with the first dose ideally within 14 days.
• Hepatitis B immunoglobulin within 14 days in addition to vaccine where the assailant is known or strongly suspected to be infected and the survivor is unvaccinated.

Tetanus

Tetanus toxoid 0.5 mL intramuscularly unless the survivor has received three or more doses previously with the last within 5 years. Add immunoglobulin for contaminated or penetrating wounds in an incompletely immunised survivor.

Human papillomavirus vaccination

Offer to females aged 9 to 26 years and males aged 9 to 21 years. Bivalent vaccine 0.5 mL at 0, 1 and 6 months, or the nonavalent vaccine at 0, 2 and 6 months. Two doses suffice if the first is given before the fifteenth birthday.

Psychological care

• Immediate voluntary counselling before discharge, which is a required component rather than an optional extra.
• Trauma counselling at 2, 4, 6 and 12 weeks.
• Adherence counselling alongside, since the two are practically linked.
• Screen for acute stress reaction, suicidal ideation and pre existing mental illness. Survivors are at high risk of post traumatic stress disorder, depression and self harm, and a proportion will need urgent psychiatric input.
• Explain the range of normal reactions, since survivors frequently believe their responses indicate that they are losing their mind.
• Do not use single session psychological debriefing, which does not prevent post traumatic stress disorder and may worsen it. Structured trauma focused therapy delivered over subsequent weeks is what helps.

Discharge and safety

• Confirm both parts of the post rape care form are complete. Attach the designated copy to the file, give the survivor their copy, and retain the register copy.
• Confirm the survivor understands the drug regimen, with written instructions.
• Return belongings in a labelled brown paper bag.
• Provide a discharge summary listing every follow up date.
• Assess safety before discharge. Where the assailant lives in the household or the survivor is at ongoing risk, involve social services, a gender based violence recovery centre or a shelter before the survivor leaves. Sending a survivor back to the place of assault is a failure of care.
• Give the contact details and appointment for the nearest gender based violence recovery centre, ideally within one week.
• Refer to HIV services if the baseline test is positive, and to antenatal or termination services as appropriate and lawful if pregnancy results.

Follow up schedule

• Day 7, 14 and 28 for post exposure prophylaxis adherence, tolerance and blood monitoring.
• Week 2: full blood count, alanine aminotransferase and creatinine.
• Week 4: pregnancy test, HIV test, completion of prophylaxis.
• Weeks 2, 4, 6 and 12: trauma counselling.
• Weeks 4, 12 and 24: HIV testing.
• Months 1 and 6: subsequent hepatitis B and human papillomavirus vaccine doses.

Clinician obligations and pitfalls

• Never write an opinion on whether rape occurred. Document findings objectively; the legal determination is not a medical one.
• Never record the absence of injury as evidence against assault.
• Never delay treatment for forensic collection, and never delay post exposure prophylaxis for test results.
• Never examine a survivor without a chaperone.
• Never place specimens in plastic.
• Recognise vicarious trauma in staff providing this care and ensure supervision and support, since burnout in this service is high and directly degrades the care survivors receive.