EM · Sexual assault and intimate partner violence
Sexual assault and intimate partner violence in the emergency department
Also known as Sexual assault · Rape · Sexual violence · Intimate partner violence · Domestic violence · Forensic medical examination · Sexual assault kit · Trauma-informed care · Post-exposure prophylaxis after sexual assault · Danger assessment
Sexual assault and intimate partner violence in the emergency department — the trauma-informed approach that governs the entire encounter, the patient-centred consent that runs throughout, the time-windowed forensic examination (the sexual assault kit and the chain of custody within 72 hours), the STI prophylaxis (ceftriaxone 500 mg IM, doxycycline 100 mg twice daily for 7 days, metronidazole 500 mg twice daily for 7 days), the HIV post-exposure prophylaxis within 72 hours, and the emergency contraception (levonorgestrel 1.5 mg PO or ulipristal 30 mg PO), the safety assessment and safety planning, the mandatory reporting considerations, and the differential distinguished from intimate partner violence. ACEM-primary, globally tagged.
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- Consent, capacity and the medico-legal framework in the emergency department
- Mandatory reporting and child protection in the emergency department
- Breaking bad news and communication in the emergency department — the SPIKES framework
- Deliberate self-harm and suicide risk assessment
- Antepartum haemorrhage
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- A patient may decline any or every part of the examination, prophylaxis, and police involvement — consent is ongoing and may be withdrawn at any time, and the patient's autonomy is central after an experience in which it was overridden
- The forensic examination yields the most evidence within 72 hours of the assault — beyond the window, examination for injury, STI screening and prophylaxis still apply but forensic yield falls
- Strangulation by an intimate partner is a lethality marker — a non-fatal strangulation event carries over seven-fold odds of completed homicide and demands a structured airway, neurological and vascular assessment regardless of how well the patient looks
- HIV post-exposure prophylaxis must be started within 72 hours of the assault, ideally much sooner, as a 28-day three-drug regimen — the window missed is the chance lost
- Coercive control, isolation, and the partner who insists on staying and answering for the patient are hallmarks of intimate partner violence — screen when the patient is alone
- Drug-facilitated sexual assault presents with amnesia for the event and a delayed, distressed presentation — send a urine toxicology screen early, before the substances clear
Meet the patient
A 23-year-old woman presents at 4am, ten hours after being assaulted by an acquaintance. She is composed, guarded, and has chosen to come in. Your first job is not the examination — it is privacy, a same-sex chaperone and clinician if she wishes, a support person of her choosing, and consent taken at every step. She may decline any or every component, and that is her right.[1]
The encounter that took her control is not followed by a clinician who takes it again. Two questions frame the next hour in every assault presentation: am I preserving her autonomy and the evidence at the same time? (consent, the kit, the chain of custody) and which time-critical windows are still open? (forensic yield and HIV PEP within 72 hours, emergency contraception within 120 hours).[1]
She decides what happens; you make sure nothing time-critical is lost while she decides. Hold those two questions and everything below slots into place.[1]
References9ShowHide
- [1]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021 MMWR Recomm Rep, 2021.PMID 34292926
- [2]Tanner MR, O'Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025 MMWR Recomm Rep, 2025.PMID 40331832
- [3]Silverstein M, Wong JB, Davis EM, et al. Screening for Intimate Partner Violence and Caregiver Abuse of Older or Vulnerable Adults: US Preventive Services Task Force Recommendation Statement JAMA, 2025.PMID 40553450
- [4]Brown T, Ashworth H, Bass M, et al. Trauma-informed Care Interventions in Emergency Medicine: A Systematic Review West J Emerg Med, 2022.PMID 35679503
- [5]Shen J, Che Y, Showell E, et al. Interventions for emergency contraception Cochrane Database Syst Rev, 2019.PMID 30661244
- [6]Ziola EA, Gimenez MA, Stevenson AP, et al. The Role of Emergency Medicine in Intimate Partner Violence: A Scoping Review of Screening, Survivor Resources, and Barriers Trauma Violence Abuse, 2024.PMID 39049479
- [7]Yang DH, Sherak R, Chin M, et al. An Electronic Health Record-Integrated Clinical Pathway Improves Care of Sexual Assault Survivors Acad Emerg Med, 2026.PMID 41147845
- [8]Glass N, Laughon K, Campbell J, Block CR, Hanson G, Sharps PW, Taliaferro E. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med, 2008.PMID 17961956
- [9]Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse, 2007.PMID 17596343