Infectious DiseasesTier 2Approach to a presentation

Patients presenting following recent sexual assault

Red flags

Acute physical injury requiring emergency assessment/treatment, and psychological distress/risk of self-harm - both should be assessed and addressed before or alongside the forensic/infectious diseases aspects of the consultation
Non-consensual nature and potential ongoing safety risk (from the perpetrator) require safety planning as part of the initial assessment

Differential by mechanism

This is a presentation requiring a trauma-informed, patient-led approach rather than a differential diagnosis exercise - the "differential" here is understanding the range of medical, forensic, psychological, and safety needs the patient may have, which the patient should guide the pace and scope of addressing

Focused history

Time since assault (affects forensic evidence collection window and time-critical prophylaxis decisions - HIV PEP most effective when started promptly, emergency contraception time-windows), nature of the assault (relevant to specific injury and infection risk assessment), and the patient's stated priorities and wishes should guide the consultation structure
History-taking should be trauma-informed - patient-led pace, avoiding repetition of distressing detail where possible, and clear explanation of each step and its purpose before proceeding

Focused examination

Examination should be conducted with the patient's informed consent for each component, ideally by clinicians trained in forensic examination where forensic evidence collection is desired by the patient, and should prioritise addressing acute injuries requiring treatment
The patient retains the right to decline any part of the examination, forensic collection, or police involvement - autonomy and consent are central throughout

Investigation strategy

STI screening and prophylaxis: baseline STI testing plus consideration of empirical prophylactic antibiotics for common STIs and HIV PEP (per current guidelines, started as soon as possible - efficacy diminishes with delay) based on assault characteristics and time since assault
Emergency contraception where pregnancy risk applies, time-sensitive and should be offered proactively
Hepatitis B immunisation/immunoglobulin consideration based on vaccination status and assault characteristics
Forensic evidence collection (if within the relevant time window and desired by the patient) coordinated with appropriately trained services

Management

Psychological support and follow-up - referral to specialist sexual assault services, counselling, and follow-up STI/blood-borne virus testing at appropriate intervals (accounting for window periods) should be arranged before the patient leaves
Police reporting is the patient's choice, not a requirement for receiving medical care, and should be presented as an option rather than a default step

Traps

Making forensic examination or police reporting a precondition of medical care - these are separate, patient-directed choices

Rushing through the consultation without addressing psychological safety first - acute distress needs acknowledgement before moving into forensic/infectious diseases logistics

Missing time-critical prophylaxis windows (HIV PEP, emergency contraception) by not addressing them proactively early in the consultation

Talk track

"I want you to know that you're in control of what happens in this appointment - we can go at whatever pace feels right for you, and you don't have to do or decide anything you're not ready for. I'll talk you through the medical care, testing, and any prophylactic treatment we'd recommend, and the choice about police involvement and forensic examination is entirely yours."

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