Sexual Violence: Survivor-Centred Emergency Assessment, Care and Referral

Learning objectives

• Define sexual violence and explain the immediate medical, psychological, reproductive, infectious and safety consequences.
• Use WHO first-line support (LIVES) and trauma-informed communication from first contact to discharge.
• Perform ABCDE, injury assessment, pregnancy/STI/HIV risk assessment and suicide/safeguarding screening.
• Describe emergency contraception, HIV PEP, STI/hepatitis B/tetanus care, wound management and referral.
• Document objectively, preserve evidence with consent, maintain confidentiality and coordinate multidisciplinary follow-up.

Definition and forms of sexual violence

Sexual violence includes any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts directed against a person’s sexuality using coercion, intimidation, force, abuse of power, incapacity or inability to consent. It may occur in or outside intimate relationships and can affect women, men, children, adolescents, people with disabilities and people of any sexual orientation or gender identity.

Examples include rape, attempted rape, sexual assault, unwanted touching, forced sexual acts, sexual exploitation, trafficking, forced marriage, reproductive coercion, technology-facilitated sexual abuse and abuse of a child. The emergency response is based on safety, health needs and consent—not on the survivor’s clothing, relationship, previous sexual activity, alcohol use or decision to report.

Potential consequences

First contact: privacy, safety and consent

1. Move the survivor to a private, quiet, secure space away from the alleged perpetrator, relatives who may pressure them and unnecessary observers.
2. Introduce yourself, explain your role and ask how the person wishes to be addressed. Offer a trained interpreter, chaperone and support person chosen by the survivor when safe.
3. Explain that medical care, evidence collection, reporting and counselling are separate choices. Obtain consent before history, examination, photographs, specimens, treatment and information sharing.
4. Ask only what is needed for immediate care first. Do not conduct an investigative interrogation or ask “why” questions that imply blame.
5. Assess whether the survivor is safe to return home. If the alleged perpetrator or a dangerous household member has access, involve safeguarding/protection services.

WHO LIVES first-line support

ABCDE emergency assessment

A — Airway

• Assess voice change, difficulty swallowing, neck pain, facial injury and strangulation. Airway swelling can worsen after a delay.
• Call for advanced airway help if there is respiratory distress, cyanosis, reduced consciousness or suspected neck injury.

B — Breathing

• Measure respiratory rate and SpO₂; look for chest trauma, aspiration, poisoning or strangulation-related hypoxia.
• Give oxygen for hypoxaemia/distress, provide ventilation support as trained and monitor closely after strangulation even when initial findings are mild.

C — Circulation

• Assess pulse, BP, capillary refill, skin, bleeding, abdominal tenderness and shock. Control external haemorrhage with gentle direct pressure.
• Establish IV access for major injury, bleeding, severe pain, poisoning or shock; take blood tests/crossmatch as clinically indicated.
• Give isotonic fluid or blood products according to the trauma/haemorrhage protocol, while preserving evidence and dignity.

D — Disability

• Record AVPU/GCS, pupils, glucose, seizures, head injury, intoxication and suicidal thoughts.
• Do not assume altered behaviour is consent, intoxication or “hysteria”; treat hypoxia, hypoglycaemia, head injury, overdose and shock.

E — Exposure and examination

• Expose only the area being examined, use warm coverings and explain each step. Look for bruises, ligature marks, tears, burns, bite marks and other injuries.
• Examine genital/anal areas only with consent and trained staff; emergency stabilisation always takes priority.

Essential history without re-traumatisation

• Time and safety: When did it happen? Is the alleged perpetrator nearby or threatening the survivor now?
• Exposure: What type of contact occurred, including vaginal, anal or oral exposure, ejaculation, condom use, mucosal injury, force, weapons, restraint or drug/alcohol facilitation? Ask neutrally and accept “I don’t know.”
• Symptoms: Pain, bleeding, dysuria, discharge, abdominal pain, headache, neck pain, breathing/voice change, vomiting or loss of consciousness.
• Pregnancy: Last menstrual period, contraception, pregnancy possibility, pregnancy intention and previous pregnancy.
• Medical history: HIV status, medicines, allergies, hepatitis B vaccination, tetanus status, bleeding disorders, diabetes, mental health and current treatment.
• Evidence: Has the survivor bathed, changed clothes, urinated, eaten, brushed teeth or washed the mouth? Ask sensitively; do not blame or withhold care if these occurred.
• Support: Who can safely accompany the survivor? What are their immediate safety, shelter, transport, financial and child-care needs?

Injury examination and treatment

1. Perform a head-to-toe examination with consent, documenting size, shape, colour, location, tenderness and function of each injury.
2. Assess strangulation carefully: voice change, neck pain, swallowing difficulty, petechiae, facial swelling, neurological symptoms or loss of consciousness require urgent senior review and observation/imaging.
3. Clean and close wounds according to trauma principles; assess tetanus status and provide prophylaxis when indicated.
4. Provide analgesia, antiemetics, wound care and treatment of fractures/burns. Avoid unnecessary genital cleansing before forensic examination if the survivor wants evidence collection.
5. Consider intoxication, drug-facilitated assault and overdose; maintain airway, check glucose and obtain toxicology only with consent/policy.

Pregnancy prevention and pregnancy care

• Offer emergency contraception as soon as possible when pregnancy is possible and not desired. WHO post-rape care indicators recognise emergency contraception for survivors who present within five days; follow the locally available option and product instructions.
• Perform pregnancy testing when appropriate, remembering a very early test may be negative. Arrange repeat testing and follow-up if menstruation is delayed.
• If pregnancy results from assault, provide non-directive counselling, obstetric care, psychosocial support and information on legally available options under Ugandan law.
• Do not withhold contraception or HIV/STI care because the survivor is considering reporting, abortion care or continuing the pregnancy.

HIV, STI and hepatitis prevention

Forensic evidence and documentation

• Explain the purpose, process and limits of forensic examination; obtain specific consent for each specimen and photograph. The survivor may accept medical care but decline evidence collection.
• Document the survivor’s words in quotation marks where possible, including uncertainty; record date/time, who was present, findings, treatment, referrals and consent/refusal.
• Use body maps and objective descriptions; avoid conclusions such as “mucosa proves rape” or “no injury means no assault.” Absence of injury does not disprove sexual violence.
• Preserve clothing/specimens in labelled paper bags according to local chain-of-custody policy. Record collector, date/time, seal and transfer; never leave evidence unattended.
• Do not delay life-saving care for evidence collection. If the survivor has washed or changed, provide care and document what was reported.
• Share information only with consent or when a specific legal safeguarding duty applies; follow Ugandan policy for children, imminent danger and mandatory reporting.

Mental health, suicide and safeguarding

• Ask directly and privately about fear, dissociation, self-harm thoughts, suicide plan, access to means, threats and ability to remain safe.
• Provide psychological first aid, grounding, calm communication and a safe companion; avoid forced detailed recounting.
• Urgently involve mental-health and safeguarding teams for suicidal intent, psychosis, severe dissociation, child abuse, trafficking, disability-related dependence or ongoing perpetrator access.
• Make a written safety plan: safe place, emergency contacts, transport, phone privacy, medication/means safety and follow-up appointment.

Children and adolescents

• Prioritise immediate safety, safeguarding and child-protection referral. Use age-appropriate language and explain confidentiality limits before disclosure.
• Obtain assent from the child and consent from the legally appropriate guardian according to Ugandan law and facility policy; do not force the child to face the alleged perpetrator.
• Use trained paediatric/forensic staff. Avoid repeated interviews and unnecessary examinations; coordinate a single multidisciplinary approach.
• Assess injuries, pregnancy risk, STI/HIV exposure, tetanus/hepatitis B, developmental needs, school safety and caregiver reliability.

Discharge, referral and follow-up

1. Confirm that injuries are treated, vital signs stable, pain controlled, pregnancy/PEP/STI options explained and the survivor understands medicines.
2. Provide written dates for PEP refills, repeat HIV/STI/pregnancy tests, hepatitis B doses, wound review and mental-health follow-up.
3. Link to a trained counsellor, social worker, GBV protection service, legal/forensic service and safe shelter when desired.
4. Arrange safe transport and a confidential contact method. Do not call a number that the alleged perpetrator monitors.
5. Give return precautions: heavy bleeding, worsening pain, fever, vomiting, rash/medicine reaction, breathlessness, suicidal thoughts, new neurological symptoms or unsafe home situation.

Nursing and EMT responsibilities

• Use a private survivor-centred room; limit staff access and protect records from unnecessary disclosure.
• Maintain a calm, non-judgemental tone; offer choices and explain delays, examinations, medicines and referrals.
• Monitor airway, circulation, pain, bleeding, neurological status, sedation, allergic reaction and psychological distress.
• Double-check PEP/STI/EC medicines, allergies, pregnancy status, renal/hepatic considerations and follow-up schedule.
• Document objective findings and every consent/refusal; preserve chain of custody where evidence is collected.
• Use team debriefing and supervision after difficult cases while maintaining survivor confidentiality.

Clinical scenarios

Common errors to avoid

• Blaming the survivor, asking “why” questions, doubting disclosure or making care dependent on police reporting.
• Missing strangulation, head injury, pregnancy, HIV exposure, poisoning, severe bleeding or suicide risk.
• Performing an examination or taking specimens without informed consent or an appropriate chaperone.
• Assuming no visible injury means no assault or that a survivor who washed has no right to care/evidence discussion.
• Failing to start time-sensitive HIV PEP/EC because test results or a police form is unavailable.
• Discharging to an unsafe home or sharing confidential information with a person who may be involved.

Revision questions

1. What does LIVES stand for, and why is it appropriate for every survivor?
2. List the immediate medical priorities after sexual violence.
3. Why must strangulation be treated as an emergency even when external marks are absent?
4. What are the time-sensitive options for pregnancy and HIV prevention?
5. Which documentation and chain-of-custody principles protect the survivor and the case?
6. How should the approach differ for a child or adolescent survivor?
7. Write an SBAR handover for Scenario 2.

Key takeaways

References for further study

• WHO. Clinical management of rape and intimate partner violence, 2024 training package.
• WHO. Responding to intimate partner violence and sexual violence against women: clinical and policy guidelines.
• CDC. Sexual Assault and Abuse and STIs: STI Treatment Guidelines.
• CDC. HIV Post-Exposure Prophylaxis — start as soon as possible and within 72 hours.
• Follow current Uganda Ministry of Health GBV/clinical management of rape, child-protection, forensic and PEP/EC protocols.