Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

≤72 hours since assault: pre-pubertal children

1st line – safety assessment and counselling

Back
ACUTE
|
≤72 hours since assault: pre-pubertal children
1st line – 

safety assessment and counselling

In all cases of sexual abuse or assault, the safety of the child should be ensured via reporting (which may be mandatory) and referral to appropriate agencies (e.g., child protective services or law enforcement). Physical injury should be treated as appropriate. All sexually abused children should be offered psychological counselling.[66]

Consider – HIV post-exposure prophylaxis

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ACUTE
|
≤72 hours since assault: pre-pubertal children
Consider – 

HIV post-exposure prophylaxis

Additional treatment recommended for SOME patients in selected patient group

HIV post-exposure prophylaxis (PEP) should be considered for all patients.

Consultation with an infectious disease specialist is recommended for children who will be receiving PEP.

See Post-exposure HIV prophylaxis (Management approach).

Consider – hepatitis B vaccine ± hepatitis B immunoglobulin

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ACUTE
|
≤72 hours since assault: pre-pubertal children
Consider – 

hepatitis B vaccine ± hepatitis B immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

Hepatitis B vaccination should be considered in all patients unvaccinated against hepatitis B virus.[52][53]​ Consult local immunisation schedules for guidance on doses and schedules.​

​Vaccination is most effective if administered within 24 hours of exposure. There is limited evidence to guide the maximum interval for vaccination after exposure, but the vaccine is unlikely to be effective >14 days after sexual exposure.[70]

If the assailant is known HBsAg positive, hepatitis B immunoglobulin should be administered, preferably within 24 hours of contact.[70]​​

Consider – human papillomavirus vaccine

Back
ACUTE
|
≤72 hours since assault: pre-pubertal children
Consider – 

human papillomavirus vaccine

Additional treatment recommended for SOME patients in selected patient group

Should be considered in males and females aged 9-26 years who are victims of sexual abuse or assault and have not initiated or completed immunisation.[52]​ Consult local immunisation schedules for guidance on doses and schedules.

Although the vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against virus types not yet acquired.[71]

Consider – STI prophylaxis or treatment

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ACUTE
|
≤72 hours since assault: pre-pubertal children
Consider – 

STI prophylaxis or treatment

Additional treatment recommended for SOME patients in selected patient group

As the risk of a child acquiring an STI is generally low, antibiotic prophylaxis is generally not recommended in pre-pubertal children.[52][53]​ Depending on the type of abuse and other circumstances, such as whether violence was involved and the local STI prevalence, prophylactic treatment may be considered only after collection of all specimens for diagnostic tests.[52][53]

STI treatment depends on the causative organism. See Genital tract chlamydia infection (Management approach), Gonorrhoea infection (Management approach), Vaginitis (Management approach), Genital warts (Management approach), Herpes simplex virus infection (Management approach), and Syphilis infection (Management approach).

≤72 hours since assault: adolescent or adult

1st line – safety assessment and counselling

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
1st line – 

safety assessment and counselling

In all cases of sexual abuse or assault, the safety of the adolescent or adult should be ensured via reporting (which may be mandatory) and referral to appropriate agencies (e.g., child protective services or law enforcement). Physical injury should be treated as appropriate. All sexually abused or assaulted adolescents and adults should be offered psychological counselling.[66]​ Evidence from one Cochrane review suggests that survivors of rape, sexual violence, and sexual abuse during adulthood may experience significant reductions in post-traumatic stress disorder and depressive symptoms following psychosocial interventions, compared to those in control groups.[67]

Plus – STI prophylaxis (chlamydia, gonorrhoea, trichomonas)

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ACUTE
|
≤72 hours since assault: adolescent or adult
Plus – 

STI prophylaxis (chlamydia, gonorrhoea, trichomonas)

Treatment recommended for ALL patients in selected patient group

Females should be given an empirical antimicrobial regimen for chlamydia, gonorrhoea, and trichomoniasis; males should be given an empirical antimicrobial regimen for chlamydia and gonorrhoea.[52] See Genital tract chlamydia infection, Gonorrhoea infection, and Vaginitis.

Consider – HIV post-exposure prophylaxis

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
Consider – 

HIV post-exposure prophylaxis

Additional treatment recommended for SOME patients in selected patient group

HIV post-exposure prophylaxis should be considered for all patients. See Post-exposure HIV prophylaxis (Management approach).

Consider – hepatitis B vaccine ± hepatitis B immunoglobulin

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
Consider – 

hepatitis B vaccine ± hepatitis B immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

Hepatitis B vaccination should be considered in all patients unvaccinated against hepatitis B virus.[52][53]​ Consult local immunisation schedules for guidance on doses and schedules.

Vaccination is most effective if administered within 24 hours of exposure.​ There is limited evidence to guide the maximum interval for vaccination after exposure, but the vaccine is unlikely to be effective >14 days after sexual exposure.[70]

If the assailant is known HBsAg positive, hepatitis B immunoglobulin should be administered preferably within 24 hours of contact.​[70]

Consider – human papillomavirus vaccine

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
Consider – 

human papillomavirus vaccine

Additional treatment recommended for SOME patients in selected patient group

Should be considered in males and females aged 9-26 years who are victims of sexual abuse or assault and have not initiated or completed immunisation.[52]​ Consult local immunisation schedules for guidance on doses and schedules.

Although the vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against virus types not yet acquired.[71]

Consider – emergency contraception

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
Consider – 

emergency contraception

Additional treatment recommended for SOME patients in selected patient group

Females should be evaluated for pregnancy and offered emergency contraception. Oral emergency contraception should be initiated as soon as possible to maximise efficacy.[72]​ Levonorgestrel can be taken up to 72 hours after sexual contact, while ulipristal can be taken up to 120 hours after sexual contact.[73]​ Oral emergency contraception may be less effective in women with overweight or obesity. Levonorgestrel appears to be less effective in women with a body mass index (BMI) ≥25 kg/m².[73]​ Evidence on the impact of BMI on ulipristal is mixed, so it is sometimes the preferred option for women with a BMI >26 kg/m² or weight >70 kg.[74]​ A pregnancy test is not necessary before prescription for oral emergency contraception is provided.[38][72]​​​[75]​​ Oral contraception is unlikely to be effective if taken after ovulation.

The copper intrauterine device (IUD) is the most effective emergency contraceptive and can be inserted up to 120 hours after the assault.[73]​ It retains its high efficacy over the full 120-hour window.[72] The effectiveness of the copper IUD is not affected by body weight or BMI, and so it should be considered as an alternative to oral emergency contraception in women with obesity.[73][74]​​​ The IUD should not be considered as an option if the patient is pregnant. See Contraception.

If menses are delayed by 1 week or more after the expected time, a pregnancy test should be performed.[16]

Primary options

levonorgestrel: 1.5 mg orally as a single dose up to 72 hours after sexual contact

OR

ulipristal: 30 mg orally as a single dose up to 120 hours after sexual contact

Consider – STI treatment

Back
ACUTE
|
≤72 hours since assault: adolescent or adult
Consider – 

STI treatment

Additional treatment recommended for SOME patients in selected patient group

Treatment depends on the causative organism. See Genital tract chlamydia infection (Management approach), Gonorrhoea infection (Management approach), Vaginitis (Management approach), Genital warts (Management approach), Herpes simplex virus infection (Management approach), and Syphilis infection (Management approach).

>72 hours since assault: pre-pubertal children

1st line – safety assessment and counselling

Back
ACUTE
|
>72 hours since assault: pre-pubertal children
1st line – 

safety assessment and counselling

In all cases of sexual abuse or assault, the safety of the child should be ensured via reporting (which may be mandatory) and referral to appropriate agencies (e.g., child protective services or law enforcement). Physical injury should be treated as appropriate. All sexually abused children should be offered psychological counselling.[66]

Consider – hepatitis B vaccine ± hepatitis B immunoglobulin

Back
ACUTE
|
>72 hours since assault: pre-pubertal children
Consider – 

hepatitis B vaccine ± hepatitis B immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

Hepatitis B vaccination should be considered in all patients unvaccinated against hepatitis B virus.[52][53]​ Consult local immunisation schedules for guidance on doses and schedules.

There is limited evidence to guide the maximum interval for vaccination after exposure, but the vaccine is unlikely to be effective >14 days after sexual exposure.[70]

If the assailant is known HBsAg positive, hepatitis B immunoglobulin should be administered, preferably within 24 hours of contact.[70]​​

Consider – human papillomavirus vaccine

Back
ACUTE
|
>72 hours since assault: pre-pubertal children
Consider – 

human papillomavirus vaccine

Additional treatment recommended for SOME patients in selected patient group

Should be considered in males and females aged 9-26 years who are victims of sexual abuse or assault and have not initiated or completed immunisation.[52]​ Consult local immunisation schedules for guidance on doses and schedules.

Although the vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against virus types not yet acquired.[71]

Consider – STI treatment

Back
ACUTE
|
>72 hours since assault: pre-pubertal children
Consider – 

STI treatment

Additional treatment recommended for SOME patients in selected patient group

Treatment depends on the causative organism. See Genital tract chlamydia infection (Management approach), Gonorrhoea infection (Management approach), Vaginitis (Management approach), Genital warts (Management approach), Herpes simplex virus infection (Management approach), Syphilis infection (Management approach), and HIV infection (Management approach).

>72 hours since assault: adolescent or adult

1st line – safety assessment and counselling

Back
ACUTE
|
>72 hours since assault: adolescent or adult
1st line – 

safety assessment and counselling

In all cases of sexual abuse or assault, the safety of the adolescent or adult should be ensured via reporting (which may be mandatory) and referral to appropriate agencies (e.g., child protective services or law enforcement). Physical injury should be treated as appropriate. All sexually abused adolescents and sexually assaulted adults should be offered psychological counselling.[66]​ Evidence from one Cochrane review suggests that survivors of rape, sexual violence, and sexual abuse during adulthood may experience significant reductions in post-traumatic stress disorder and depressive symptoms following psychosocial interventions, compared to those in control groups.[67]

Consider – hepatitis B vaccine ± hepatitis B immunoglobulin

Back
ACUTE
|
>72 hours since assault: adolescent or adult
Consider – 

hepatitis B vaccine ± hepatitis B immunoglobulin

Additional treatment recommended for SOME patients in selected patient group

Hepatitis B vaccination should be considered in all patients unvaccinated against hepatitis B virus.[52][53]​ Consult local immunisation schedules for guidance on doses and schedules.

There is limited evidence to guide the maximum interval for vaccination after exposure, but the vaccine is unlikely to be effective >14 days after sexual exposure.[70]

If the assailant is known HBsAg positive, hepatitis B immunoglobulin should be administered, preferably within 24 hours of contact.[70]​​

Consider – human papillomavirus vaccine

Back
ACUTE
|
>72 hours since assault: adolescent or adult
Consider – 

human papillomavirus vaccine

Additional treatment recommended for SOME patients in selected patient group

Should be considered in males and females aged 9-26 years who are victims of sexual abuse or assault and have not initiated or completed immunisation.[52]​ Consult local immunisation schedules for guidance on doses and schedules. 

Although the vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against virus types not yet acquired.[71]

Consider – emergency contraception

Back
ACUTE
|
>72 hours since assault: adolescent or adult
Consider – 

emergency contraception

Additional treatment recommended for SOME patients in selected patient group

Females of reproductive age should be evaluated for pregnancy and offered emergency contraception if presenting within 120 hours of the sexual assault. Oral emergency contraception should be initiated as soon as possible to maximise efficacy.[72]​ Levonorgestrel can be taken up to 72 hours after sexual contact, while ulipristal can be taken up to 120 hours after sexual contact.[73]​ Oral emergency contraception may be less effective in women with overweight or obesity. Levonorgestrel appears to be less effective in women with a body mass index (BMI) ≥25 kg/m².[73]​ Evidence on the impact of BMI on ulipristal is mixed, so it is sometimes the preferred option for women with a BMI >26 kg/m² or weight >70 kg.[74]​ A pregnancy test is not necessary before prescription for oral emergency contraception is provided.[38][72]​​​[75]​​​ Oral contraception is unlikely to be effective if taken after ovulation.

The copper intrauterine device (IUD) is the most effective emergency contraceptive and can be inserted up to 120 hours after the assault.[73]​ It retains its high efficacy over the full 120-hour window.[72] The effectiveness of the copper IUD is not affected by body weight or BMI, and so it should be considered as an alternative to oral emergency contraception in women with obesity.[73][74]​​​ The IUD should not be considered as an option if the patient is pregnant. See Contraception.

If menses are delayed by 1 week or more after the expected time, a pregnancy test should be performed.[16]

Primary options

ulipristal: 30 mg orally as a single dose up to 120 hours after sexual contact

OR

levonorgestrel: 1.5 mg orally as a single dose up to 72 hours after sexual contact

Consider – STI treatment

Back
ACUTE
|
>72 hours since assault: adolescent or adult
Consider – 

STI treatment

Additional treatment recommended for SOME patients in selected patient group

Treatment depends on the causative organism. See Genital tract chlamydia infection (Management approach), Gonorrhoea infection (Management approach), Vaginitis (Management approach), Genital warts (Management approach), Herpes simplex virus infection (Management approach), Syphilis infection (Management approach), and HIV infection (Management approach).

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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