Sexual Violence

Any sexual act or attempted sexual act committed against a person's will through force, coercion, or exploitation of an inability to consent. It is a significant public health and clinical concern affecting individuals across all demographics.

The clinical response covers acute medical and forensic assessment, management of physical and psychological consequences, and sensitive support and signposting to specialist and advocacy services.

A trauma-informed, patient-centred approach is essential at every stage of clinical contact, given the profound vulnerability and potential for further psychological harm inherent to this clinical context.

Principles of trauma-informed care

• A trauma-informed approach recognises that the clinical encounter can either support recovery or compound existing trauma.
• Core principles are:
  • Ensure the individual's safety and comfort throughout the assessment.
  • Maximise their sense of choice and control over each step, including explicit consent for each component of examination or forensic sampling.
  • Be transparent about what each step involves and why.
  • Avoid any language or approach that could be perceived as judgmental, or that implies any degree of responsibility on the part of the individual disclosing the assault.
• Wherever clinically and legally feasible, let the survivor's own stated priorities and wishes lead care. Some individuals prioritise immediate medical concerns. Others prioritise forensic evidence collection to support potential future reporting.
• Others primarily seek emotional support, without wishing to pursue extensive medical intervention or formal reporting at that time. Each approach is valid and appropriate, and the clinical team should support rather than direct it.
• Specialist sexual assault referral centres, where available, provide integrated, trauma-informed forensic, medical, and psychological support delivered by specifically trained practitioners. They are the optimal setting for full care where accessible.
• General emergency and primary care services must remain equipped to provide initial assessment, support, and referral where a specialist service is not immediately available or accessible.

• Presentation varies enormously.
• Acute presentation shortly after an assault is when forensic evidence collection and acute medical intervention, including emergency contraception and post-exposure prophylaxis, are most relevant and time-sensitive.
• Delayed disclosure sometimes occurs months or years after the event. The clinical focus then shifts substantially toward psychological support and management of longer-term physical or psychological sequelae.
• Physical injury, where present, ranges from absent or minimal to significant genital, anal, or other bodily trauma requiring specific medical attention.
• Never use the absence of visible injury to question or doubt the veracity of a disclosure. The great majority of sexual assaults do not result in visible physical injury.
• Psychological presentations are highly variable. They may include acute distress, dissociation, or an outwardly calm or flat affect.
• A calm or flat affect should never be interpreted as evidence against the veracity of a disclosure, given the well recognised, wide variation in individual psychological response to trauma.
• With delayed presentation, symptoms may be consistent with post-traumatic stress disorder, depression, or anxiety.
• Disclosure may be direct, with the individual explicitly stating they have experienced sexual violence. It may be indirect, through a related physical or psychological symptom without explicit initial disclosure of the underlying cause.
• Clinicians should stay aware of this possibility and create an environment conducive to disclosure where clinically relevant indicators are present.

• Wherever possible, practitioners with specific training in this area should assess recent sexual assault, ideally within a specialist sexual assault referral centre setting.
• Explain clearly the components of assessment (medical history, examination, and forensic evidence collection). Obtain explicit consent for each component. The individual may decline any element while still accessing the remaining components of care.
• Forensic evidence collection applies where the individual consents and the timeframe since the assault makes it potentially relevant. It is generally most valuable within seven days of the assault, though this window varies with the type of evidence and local forensic protocols.
• An appropriately trained practitioner should collect evidence following established forensic protocols, with careful attention to chain of custody procedures.
• Evidence collection does not obligate the individual to make a formal report to law enforcement. It can be undertaken and stored for potential future use should the individual later decide to pursue reporting.
• Acute clinical assessment includes assessment for physical injury, with genital, anal, and general bodily examination as clinically indicated and consented to. It also includes assessment of pregnancy risk and sexually transmitted infection risk.
• Ongoing, sensitive assessment of psychological impact is an important component of full care and extends well beyond the initial acute presentation.
• This includes screening for acute distress and dissociation. At appropriate follow-up intervals it includes screening for symptoms of post-traumatic stress disorder, depression, and anxiety.

• Emergency contraception, where pregnancy risk is relevant, should be offered and discussed, together with baseline pregnancy testing where appropriate to the clinical timeframe.
• Offer post-exposure prophylaxis for HIV, with appropriate screening and, where indicated, prophylactic treatment for other sexually transmitted infections. Base this on the circumstances of the assault and relevant local protocols. Review and address hepatitis B vaccination status where relevant.
• Manage any identified physical injury by standard clinical principles for the injury pattern present.
• Refer promptly to the relevant specialist service (including gynaecology, colorectal surgery, or plastic surgery) where significant genital, anal, or other injury needs specialist assessment or intervention.
• Psychological support is an essential, integral component of ongoing care. It includes immediate, supportive crisis intervention at the point of initial presentation.
• Give clear information about, and facilitate referral to, specialist counselling and psychological support services. Where relevant, provide specific evidence-based treatment for post-traumatic stress disorder or other identified psychological sequelae.
• Give clear, non-directive information about the individual's options for reporting to law enforcement, including the local process and what it would involve. Apply no pressure toward any particular course of action. Respect the individual's autonomy and right to decide according to their own circumstances and readiness.
• Connect the individual with specialist advocacy and support organisations. These provide ongoing practical, emotional, and, where relevant, legal support beyond the immediate clinical encounter.
• Give clear, accessible information on how to access further support or care in future, should the individual's needs or readiness to engage with specific aspects of support evolve. This underpins compassionate, individualised care for survivors of sexual violence.