Sexual Assault

Sexual assault is common — an estimated ~18% of Australian women and ~4.7% of men report sexual assault since age 15, with transgender and gender-diverse people affected at markedly higher rates. A disclosure of recent assault is an opportunity to address forensic, medical, safety and psychosocial needs together — the response matters as much as the content.

Red flags — act immediately

• Signs of strangulation (external signs, hoarse voice, loss of consciousness, incontinence)
• Profuse bleeding
• Head injury

Definitions

A person is forced or coerced into sexual acts against their will, or a child is exposed to sexual acts. Includes any sexual behaviour that makes them feel threatened, intimidated or frightened.

Consider possible sexual assault if: a request for emergency contraception; sexual/genital health concerns; a history of physical assault, being drugged, or domestic violence; the patient is unconscious or injured.

Immediate priorities

1. Safety first — is the person currently safe? Address acute injuries and distress; escalate to ED for serious injury.
2. Believe and support — a calm, non-judgemental, patient-led response. Explain options without pressure; let the patient set the pace and choices. Suggested opener: “I’m sorry this has happened to you. So I can help you, I need to ask a few questions.”
3. Offer referral to a specialist Sexual Assault Service — most GPs’ role is first-response support and referral, not the forensic exam itself.

Assessment

Not usually necessary to go into much detail, but some history is needed: how long ago; concerning symptoms; gaps in memory; whether pressure was applied to the neck; brief who/when/where/context; pregnancy risk (menstrual/ contraceptive history); type of assault (vaginal, oral, anal, other physical injuries); need for STI prophylaxis.

Forensic considerations (time-sensitive)

• A forensic medical examination is patient-led and optional — it can proceed whether or not the person has decided to involve police (reporting is entirely the patient’s choice).
• Time-sensitive: forensic evidence is best collected as soon as possible — jurisdictions commonly allow up to ~7 days, with best yield <72 hours — so refer promptly even if the patient is undecided.
• Do not perform a genital examination yourself if a forensic examination is planned, unless you are trained in forensic examination.
• If they may want an exam, gently advise trying not to shower/wash, change clothes, brush teeth, or eat/drink (if oral assault) — and to keep clothing (e.g. in a paper bag for DNA testing). Never make this a condition of care.
• Document physical injuries factually, without assumptions — records may become legal evidence.

Medical management

• Attend to injuries and pain.
• Contact the Sexual Assault Service for support and forensic examination (within 7 days) — they help the patient decide on police involvement and provide a support worker.
• Emergency contraception:
  • Ulipristal (EllaOne) 30 mg stat, up to 5 days post-event (hormonal contraception can’t start until 5 days after UPA — use barrier methods meanwhile).
  • Levonorgestrel 1.5 mg stat, up to 3 days post-event.
  • Copper IUD if ovulation may have occurred — the most effective option and covers the widest window.
• Pregnancy test as a baseline where relevant.

Legal, documentation & reporting

• Mandatory reporting applies for children and young people (<18 years in this jurisdiction; thresholds vary by state/territory) and where there’s a child-protection concern.
• For competent adults, reporting to police is the patient’s decision — support either choice.
• Check patient safety before they leave the practice.

Psychosocial follow-up

• Manage psychological trauma — arrange contact with counselling services (sexual assault service, psychologist). Assess for ongoing risk from the perpetrator and co-occurring domestic/family violence — see Domestic/Family Abuse and Violence.
• Provide crisis-line details — 1800RESPECT (1800 737 732), 24/7.

Follow-up testing schedule (RACGP White Book)

Timing	What to do
2–3 days	Assess injury healing if relevant
2 weeks	Test results, pregnancy testing, healing, coping; follow-up testing for HIV, chlamydia, gonorrhoea, trichomonas (per local prevalence/practice)
3 months	Follow-up serology: HIV, hepatitis B, syphilis
6 months	Follow-up hepatitis C serology, if it was considered a risk and tested initially

Examine and swab all sites at risk of infection from the assault, as appropriate.

From the RACGP White Book (Abuse and violence) and ASHM’s Australian STI Management Guidelines.