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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Sexual assault assessment and referral

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Treat immediate threats before forensic processes

Airway compromise after strangulation, major bleeding, head injury, loss of consciousness, severe abdominal or genital trauma, intoxication, acute suicidality or danger from a perpetrator requires emergency intervention.

Action: Use ABCDE care, summon emergency and safeguarding support, preserve evidence only where compatible with lifesaving treatment and consent, and contact the regional SARC early so clinical and forensic pathways are coordinated.

Overview

Provide immediate trauma-informed medical care, preserve choice and consent, recognise occult injury and safeguarding risk, and coordinate timely SARC, forensic, pregnancy and infection interventions.

Sexual assault care begins with safety, dignity and choice. Introduce your role, ask how the person wishes to be addressed and whether they want a support person or interpreter who is independent of any suspected perpetrator. Use a private environment and explain confidentiality and its safeguarding limits. Acknowledge that the assault was not their fault. Avoid repeated detailed narrative-taking; establish only timing, types and sites of contact, condom or ejaculation information, injuries, strangulation, loss of consciousness, drug or alcohol exposure, pregnancy possibility and immediate danger needed for care.

Perform an ABCDE and mental-state assessment before considering forensic evidence. Non-fatal strangulation can cause delayed airway oedema, vascular injury and neurological complications without prominent neck marks; voice, swallowing, breathing, vision, headache, memory and focal symptoms matter. Examine and treat bleeding, head injury, abdominal pain, fractures and genital or anal trauma according to urgency. Assess intoxication, self-harm, suicide and capacity. Emergency treatment proceeds even if it alters evidence, with contemporaneous documentation of why.

Practice

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Obstetrics and gynaecologyOriginal SBA

Access without police reporting

An adult presents 48 hours after sexual assault, wants medical and forensic help, but does not want to report to police now. What is the most appropriate response?

Choose one answer, then submit
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NHS England sexual assault and abuse services
  • Forensic Science Regulator sexual offence examination guidance
  • BASHH post-exposure prophylaxis guideline
  • NHS emergency contraception guidance
  • NHS Specialist Pharmacy Service emergency contraception during breastfeeding guidance
  • NHS Specialist Pharmacy Service and CoSRH ulipristal emergency contraception PGD
  • GOV.UK support after rape or sexual assault

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

Contact the local SARC as early as possible. A SARC can coordinate forensic medical examination, clinical care, evidence storage, advocacy and onward referral without requiring an immediate police report. Do not conduct a forensic genital examination or collect ad hoc evidential swabs unless trained and operating within the accredited pathway. Record spontaneous statements accurately, preferably in quotation marks, objective injuries, times, people present, actions and consent. If the person wants evidence preserved, follow SARC advice for clothing and samples; do not imply that showering, eating or changing clothes makes attendance pointless.

Consent is active and itemised. Explain the purpose, possible discomfort and destination of each photograph, swab, blood sample or examination. Check understanding and capacity, offer breaks and stop immediately when requested. A patient can consent to medical treatment but decline forensic samples or police disclosure. For a child, a person without relevant capacity or an adult at risk, involve specialist safeguarding teams and follow statutory duties while sharing only necessary information. Never use a family member implicated in control as interpreter.

Address pregnancy risk promptly. Offer a urine or serum pregnancy test while explaining that it cannot detect a pregnancy from a very recent assault. The copper IUD is the most effective emergency contraception and may be inserted within five days after the first unprotected intercourse in a cycle or within five days of the earliest estimated ovulation, whichever is later, when clinically suitable. Oral ulipristal 30 mg is effective up to 120 hours and levonorgestrel 1.5 mg is licensed up to 72 hours; take as soon as possible. Check weight, enzyme inducers and recent or ongoing progestogen because these can change selection and follow-on contraception. Current FSRH advice does not require interruption of breastfeeding after a single ulipristal dose.

Assess infection risk by exposure site, trauma, ejaculation, source information and local epidemiology. HIV PEP is a risk-based intervention, not automatic: when indicated it starts immediately, ideally within 24 hours and no later than 72 hours, and continues for 28 days with specialist review. Assess hepatitis B immunisation status and source risk for vaccine and possible immunoglobulin. Offer baseline chlamydia, gonorrhoea, trichomonas, HIV, syphilis and hepatitis testing according to exposure, then schedule repeat tests for window periods. Avoid routine blanket antimicrobial prophylaxis when the SARC pathway instead supports testing and targeted treatment.

Discharge only with a safe contact plan. Provide written information that is safe for the person to carry, a direct SARC or independent sexual violence adviser route, injury and strangulation safety-netting, medicine instructions and follow-up dates. Discuss where they will go, who has access to them and whether digital or location tracking creates danger. Document police involvement as the person's choice unless a specific safeguarding or public-protection duty applies. Revisit sleep, intrusive memories, panic, low mood and suicide risk over time without pathologising an expected acute trauma response.

Key points

  • Believe and validate the disclosure without asking the person to prove it; use their words, avoid blame and ask only what is needed for immediate clinical decisions.
  • Consent is separate for history, examination, photography, samples, forensic evidence, treatment and information sharing; the person can pause or withdraw from any part.
  • A sexual assault referral centre can provide medical, forensic and advocacy care whether or not the person reports to police, and many services accept self-referral.
  • Stabilise injury, strangulation, intoxication and mental-health crisis first; forensic value never justifies delaying lifesaving or urgent clinical treatment.
  • Contact the SARC promptly because forensic sampling windows depend on assault type, site, timing and local capability; washing or changing clothes does not remove the right to assessment.
  • Offer pregnancy testing and emergency contraception: a copper IUD is most effective, ulipristal acetate 30 mg is used up to 120 hours and levonorgestrel 1.5 mg is licensed up to 72 hours after exposure.
  • Assess HIV PEP immediately and start when indicated as soon as possible, ideally within 24 hours and no later than 72 hours, for a 28-day course under BASHH guidance.
  • Assess hepatitis B vaccination and immunoglobulin need, baseline STI and blood-borne-virus testing, and follow-up windows without making empirical antibiotics automatic for every survivor.
  • Offer an independent sexual violence adviser, psychological support, safety planning and a named follow-up route while preserving control over police involvement wherever law permits.

Aetiology

01

Non-consensual sexual contact

Assault includes sexual acts without freely given agreement, including when coercion, threat, intoxication, unconsciousness or incapacity prevents consent.

02

Associated physical violence

Blunt injury, penetration, strangulation, restraint and drug facilitation can produce concurrent internal, neurological and systemic medical harm.

03

Ongoing coercive context

Intimate-partner abuse, trafficking, exploitation and digital surveillance can continue after the incident and shape safe communication and discharge.

Pathophysiology

  1. 1
    Tissue injury

    Blunt force, friction and penetration may cause abrasions, lacerations or internal injury, although absence of injury does not imply consent.

  2. 2
    Hypoxic and vascular insult

    Neck compression can obstruct airway, venous return or arterial flow, producing delayed oedema, stroke or neurological injury without obvious bruising.

  3. 3
    Exposure transmission

    Mucosal contact, trauma and body-fluid exposure create pathogen and pregnancy risk determined by site, act, timing and source factors.

  4. 4
    Trauma response

    Acute autonomic arousal, dissociation, sleep disruption and intrusive memories are common adaptive responses that can later develop into persistent psychological illness.

Clinical features and red flags

Immediate medical instability

Airway symptoms, altered consciousness, haemodynamic change, major bleeding, severe pain or neurological deficit takes priority over forensic examination.

Occult strangulation injury

Voice, swallowing, breathing, visual, memory or focal neurological change after neck compression can signal serious injury despite normal-looking skin.

Time-sensitive exposure

HIV risk within 72 hours and pregnancy risk within five days create expiring prevention opportunities requiring same-day decisions.

Impaired consent

Intoxication, sedation, cognitive impairment, acute distress or coercive presence may prevent valid consent for some steps and requires reassessment or lawful safeguarding action.

Ongoing danger

Threats, stalking, trafficking, coercive control, child exposure or unsafe accommodation makes discharge planning a safeguarding intervention rather than a routine handout.

Red flags requiring action

  • Voice change, dysphagia, dyspnoea, neck swelling, petechiae, neurological deficit or loss of consciousness after strangulation needs urgent emergency assessment despite few external marks.
  • Haemodynamic change, uncontrolled bleeding, severe abdominal pain, peritonism, head injury, suspected internal injury or inability to pass urine requires acute hospital care.
  • Intoxication, reduced consciousness, overdose, acute psychosis or suicidal intent requires immediate safety and capacity assessment before non-urgent examination.
  • Ongoing access by the alleged perpetrator, threats, coercive control, trafficking, child sexual abuse or an adult-at-risk concern activates safeguarding procedures.
  • A substantial possible HIV exposure approaching 72 hours or pregnancy risk within the emergency-contraception window needs same-day specialist action.

Investigations

  1. 01
    Injury-directed emergency assessmentFirst step
    Why
    Identify airway, vascular, neurological, abdominal, genital and musculoskeletal harm that needs urgent treatment.
    Interpretation and limitations
    Normal external findings do not exclude strangulation or internal injury; imaging and specialist examination follow symptoms, mechanism and emergency protocols.
  2. 02
    Forensic samples through an accredited SARC pathway
    Why
    Collect and preserve potential evidential material with informed consent and an auditable chain of custody.
    Interpretation and limitations
    Sample value depends on site, act and elapsed time; trained forensic advice is required, and negative or absent evidence does not disprove assault.
  3. 03
    Pregnancy test
    Why
    Identify an existing pregnancy and guide emergency contraception and medicine decisions.
    Interpretation and limitations
    A negative test soon after assault cannot exclude conception from that event, so emergency contraception should not await a later positive result.
  4. 04
    Exposure-site STI NAAT
    Why
    Test genital, rectal and pharyngeal sites for chlamydia, gonorrhoea and trichomonas according to contact.
    Interpretation and limitations
    Baseline positives may predate the assault and should not be used to judge credibility; early negatives may require repeat testing after a diagnostic window.
  5. 05
    HIV, syphilis and hepatitis serology
    Why
    Establish baseline status and plan repeat blood-borne-virus testing after relevant exposure windows.
    Interpretation and limitations
    A negative baseline cannot exclude recent acquisition; do not delay indicated HIV PEP while waiting for source or survivor serology.
  6. 06
    Toxicology within a forensic pathway
    Why
    Investigate suspected drug-facilitated assault using time-critical blood, urine or other validated specimens.
    Interpretation and limitations
    Collection timing, consent and chain of custody are crucial; routine hospital toxicology may not detect many agents and a negative result does not exclude incapacitation.

Differential diagnosis

01

Accidental or consensual injury

Medical care addresses injury regardless of mechanism, while consent history and forensic interpretation remain the remit of trained practitioners.

02

Spontaneous genital bleeding

Menstruation, pregnancy complications, cervical disease and vulval dermatosis can coexist with assault and require independent clinical evaluation.

03

Substance-related illness

Voluntary or involuntary alcohol and drug exposure can cause reduced consciousness, aspiration, injury, amnesia and impaired capacity requiring emergency treatment.

04

Acute mental-health crisis

Panic, dissociation, psychosis, self-harm and suicidal intent require proportionate assessment while avoiding dismissal of the disclosure as psychiatric.

05

Pre-existing infection

A baseline STI may predate the assault, so microbiological results cannot establish the timing of acquisition or whether consent occurred.

Management

01Immediate careStabilise and create safetyFirst stepA person discloses recent or historical sexual assault in any healthcare setting.+
  1. 1Move to privacy, assess immediate danger, ABCDE, strangulation, injury, intoxication, suicide risk, capacity and safeguarding needs.
  2. 2Treat life-threatening problems first, documenting objective findings and spontaneous words without repeated investigative questioning.
  3. 3Contact emergency specialists and the regional SARC early, agreeing a safe advocate, interpreter and communication method with the person.
02Consent and evidencePreserve choice and forensic qualityClinical or forensic examination, samples, photography or information sharing is being considered.+
  1. 1Explain each component separately, its purpose, possible discomfort, storage and recipients, and obtain specific informed consent.
  2. 2Use the trained SARC forensic pathway and chain-of-custody process; avoid ad hoc internal examinations or swabs that duplicate or compromise care.
  3. 3Pause or stop on request, and make clear that declining police involvement or having washed does not remove access to medical and advocacy support.
03Prevention and follow-upAddress expiring and delayed risksImmediate stabilisation is complete and exposure-specific prevention and continuity are needed.+
  1. 1Offer the most effective suitable emergency contraception promptly and assess HIV PEP before 72 hours, with hepatitis B prophylaxis according to risk and immunisation status.
  2. 2Take baseline exposure-site and blood-borne-virus tests and schedule repeat testing, pregnancy testing and medicine review at explicit dates.
  3. 3Provide ISVA or SARC follow-up, injury and mental-health safety-netting, contraception continuity and a discharge destination that has been assessed for safety.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Provides oral emergency contraception when a copper IUD is declined, unavailable or unsuitable within the five-day window.

Ulipristal acetate

Take 30 mg orally as one dose as soon as possible and within 120 hours of unprotected exposure.

Check enzyme-inducing medicines, severe asthma treated with oral glucocorticoids and recent progestogen. A single dose does not require interruption of breastfeeding; wait five days before restarting progestogen-containing contraception and use method-specific additional precautions.

Provides oral emergency contraception when selected after comparing timing, interactions, weight and follow-on contraceptive needs.

Levonorgestrel emergency contraception

Take 1.5 mg orally as one dose as soon as possible and within 72 hours of unprotected exposure.

Effectiveness falls with time; enzyme inducers and higher weight can alter dosing or favour a copper IUD, and vomiting may require redosing.

Complications

01

Unrecognised internal injury

Occult head, neck, abdominal or genital trauma can worsen after discharge without mechanism-aware assessment and explicit safety-netting.

02

Pregnancy or infection

Missed emergency contraception, HIV PEP, hepatitis prevention or follow-up testing can allow preventable pregnancy or transmitted infection.

03

Psychological morbidity

Post-traumatic stress, depression, anxiety, substance use, sexual difficulties and suicidality can emerge or persist after the acute event.

04

Forensic and trust harm

Poor consent, repeated questioning, victim-blaming or broken evidence handling can retraumatise the person and undermine later justice choices.

Monitoring and follow-up

  • Arrange early review of injuries, strangulation symptoms, sleep, acute stress, mood, suicide risk and safety from the alleged perpetrator.
  • Confirm completion and tolerability of a 28-day HIV PEP course when prescribed, with renal, liver and HIV testing under the specialist protocol.
  • Schedule repeat pregnancy testing after a negative early test and provide a clear pathway for any positive result and reproductive choice.
  • Repeat STI and blood-borne-virus testing at exposure-appropriate windows and act on positive results through confidential partner and specialist care.
  • Review emergency-contraception outcome and establish ongoing contraception, accounting for the delay in restarting hormonal methods after ulipristal.
  • Maintain SARC or ISVA contact and reassess safeguarding, housing, digital security and psychological needs without requiring police engagement.

Special situations

Medical care is not conditional

A person can receive treatment, a forensic examination and evidence storage without deciding immediately whether to report to police.

Consent is granular

Agreement to one swab or photograph does not authorise another examination, information disclosure or police transfer; each decision remains revocable.

Few marks can hide harm

Strangulation and internal genital injury may have minimal external signs, so symptoms and mechanism determine urgent assessment.

Baseline tests do not date infection

An STI detected immediately after assault may predate the event and should never be used to infer consent or credibility.

Evidence windows vary

SARC clinicians match each sample to act, body site and elapsed time; a single universal cut-off can wrongly deny useful assessment.

Common pitfalls

  1. 01

    Taking a long investigative narrative repeatedly when only brief facts are needed for immediate care and referral.

  2. 02

    Making police reporting a condition of SARC, forensic, emergency-contraception or infection-prevention access.

  3. 03

    Performing an internal forensic examination or collecting evidential swabs without training, consent and chain-of-custody arrangements.

  4. 04

    Reassuring after neck compression because no bruising is visible while ignoring voice, swallowing or neurological symptoms.

  5. 05

    Delaying HIV PEP for source results or allowing the 72-hour threshold to pass during routine referral.

  6. 06

    Assuming a negative immediate pregnancy or STI test excludes consequences of the recent assault.

  7. 07

    Sending written material or leaving messages without checking whether a perpetrator monitors the person's phone, post or location.

Content changes
Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom