🩹 Sexual Assault Post-Exposure Prophylaxis Simulator

Trauma-Informed Reception & Patient Autonomy

The first minutes of care set the tone for everything that follows. A trauma-informed approach means the clinical team's first job is not to collect evidence or start medication — it is to restore a sense of safety and control to someone whose sense of control was just violated. Every subsequent clinical option is offered, explained, and left entirely to the patient to accept or decline, at their own pace, with no pressure and no judgment.

• 100% patient choice: Patient decisions (no intervention is ever mandatory)
• At first contact: Advocate offered (hospital- or community-based programs)
• Up to ~120 h: Evidence collection window (jurisdiction-dependent; still worth discussing later)
• 700+: SANE-trained programs (US) (specialized sexual assault nurse examiner programs)

Creating physical and psychological safety

The reception process is designed around a simple principle: minimize additional harm. Practical steps include:

• A private room, away from the general waiting area, with a door that closes • Introduction of every team member and their role before anything else happens • An explicit statement, early and often: "Nothing has to happen here that you don't want to happen" • Offering food, water, a blanket, and time — there is rarely a true medical emergency that requires rushing a conversation • Asking permission before any physical contact, including something as routine as taking a blood pressure cuff

Many programs offer to contact a trained sexual assault advocate (hospital-based or through a community rape crisis center) who can stay with the patient throughout the visit, explain options in plain language, and simply provide company. The advocate is not part of the medical or legal team — their sole role is support.

Separating medical care, forensic evidence collection, and law enforcement

A recurring point of confusion — and a common reason survivors avoid seeking care — is the assumption that a hospital visit automatically triggers a police report. It does not. Three separate tracks exist, and a patient can choose any combination of them:

1. Medical care: prophylaxis, injury treatment, counseling referral — always available regardless of any other choice 2. Forensic evidence collection (a "SANE exam" or "rape kit"): can be performed and stored even if the patient has not decided whether to report; many jurisdictions allow anonymously stored kits for a defined period so the decision to report can be made later 3. Reporting to law enforcement: entirely optional, can happen immediately, later, or never

Explaining this separation clearly, early, and without pressure is itself a core piece of the "prophylaxis" being described in this simulator — it prophylaxes against the secondary harm of feeling railroaded into decisions.

A useful phrase used in many trauma-informed protocols: "You are the expert on what you need right now." Clinicians present options; they do not prescribe a single correct path through this visit.

Baseline assessment before any prophylaxis decision

Before offering specific prophylaxis, the clinical team typically gathers a focused history and baseline labs — again, all with the patient's consent and explained purpose:

• Time elapsed since the assault (drives urgency of HIV PEP and EC discussions) • Baseline pregnancy test, when relevant to the patient's anatomy and history • Baseline STI and HIV testing, understanding results will not be back same-day and do not delay same-day prophylaxis • Hepatitis B immunization status • Tetanus status if there are wounds • Allergies and current medications, to screen for interactions before any prescription

None of this requires recounting assault details beyond what is clinically necessary — the exam and interview are kept as brief and non-repetitive as possible, and the patient can pause or stop at any point.

Empiric STI Prophylaxis — Covering the Common Bacterial Infections

Because waiting for STI test results would mean days of uncertainty, standard protocols offer empiric ("presumptive") antibiotic treatment covering the three most common bacterial infections associated with sexual assault: chlamydia, gonorrhea, and trichomoniasis. This is typically offered regardless of the specific exposure details, because it is safe, well-tolerated, and closes a window of risk immediately — while remaining, like everything else, the patient's choice to accept.

• 3 pathogens: Empiric coverage (chlamydia, gonorrhea, trichomonas)
• Ceftriaxone 500 mg IM: Gonorrhea coverage (single dose)
• Doxycycline 100 mg BID ×7d: Chlamydia coverage (or single-dose alternative if adherence is a concern)
• Offered: Hepatitis B vaccination (if not previously immunized; series can start today)

Why empiric treatment, not test-and-treat

Standard guidance (e.g., CDC sexual assault treatment recommendations) favors offering empiric antibiotic prophylaxis at the initial visit rather than waiting for culture or NAAT results, for several reasons:

• Baseline STI tests reflect infections acquired before the assault, not from it — results take days and cannot inform same-visit decisions anyway • Follow-up visits are not guaranteed; treating empirically at the one visit a patient is certain to attend maximizes protection • The medications used are well-tolerated, with a long track record of safety • Patients who prefer to wait for test results and treat only if positive can absolutely choose that path instead — this is discussed, not assumed

The typical medication package

A commonly used empiric regimen (doses vary slightly by current national guidance and should always be confirmed against the latest local protocol):

• Ceftriaxone 500 mg intramuscularly, single dose — covers Neisseria gonorrhoeae • Doxycycline 100 mg orally twice daily for 7 days — covers Chlamydia trachomatis (an azithromycin 1 g single dose alternative exists for patients who cannot complete a 7-day course) • Metronidazole or tinidazole 2 g orally, single dose — covers Trichomonas vaginalis • Hepatitis B vaccination (if not previously immunized), with the first dose given today and follow-up doses scheduled • HPV vaccination discussed and offered to eligible patients, following standard age-based guidance

All medications are explained individually — what each treats, common side effects, and that the patient may accept some, all, or none of them.

Pregnancy and interaction screening before dosing

Before dispensing, the team confirms the medications are safe for this specific patient: checking for drug allergies, verifying pregnancy status where relevant (metronidazole and doxycycline require pregnancy-aware dosing decisions), and screening for interactions with any current medications. Side effects are reviewed candidly — mild nausea or a metallic taste with metronidazole, sun sensitivity with doxycycline — so the patient can make an informed choice rather than being surprised later.

"Empiric" does not mean "automatic." Even though this package is routinely offered, a patient can decline any single component — for example, accepting the antibiotics but declining the hepatitis B vaccine today — without affecting eligibility for any other part of care.

HIV Post-Exposure Prophylaxis — A Time-Sensitive, Collaborative Decision

Unlike the empiric STI package, HIV post-exposure prophylaxis (PEP) is offered based on an individualized assessment of exposure risk, discussed openly with the patient. It follows the same time-sensitive, 28-day, three-drug regimen principles used in any other HIV PEP scenario (e.g., occupational needle-stick exposure) — the biology of the exposure window does not change based on its context, but the decision of whether to start, and whether to complete, always rests with the patient.

• 28 days: Regimen length (3-drug antiretroviral course)
• ≤ 72 hours: Optimal start window (sooner is meaningfully better; ideally within hours)
• TDF/FTC + INSTI: Typical regimen (e.g., tenofovir/emtricitabine + raltegravir or dolutegravir)
• Patient's choice: Completion decision (can pause or stop anytime; reassessed at follow-up)

Assessing exposure risk without demanding a full narrative

Clinicians estimate HIV transmission risk using factors the patient is willing to share — type of exposure, whether the assailant's HIV status is known, and time elapsed — without requiring a detailed recounting of the assault itself. The conversation is framed around what changes the medical recommendation, not around building a complete narrative. When any uncertainty exists about exposure risk, most protocols default to offering PEP, since the cost of a 28-day course is far lower than the cost of a missed prevention opportunity, and the patient can still decline.

Why the clock matters — and why "too late" is rarely the full story

HIV PEP works by suppressing viral replication before the virus can establish permanent infection in the body — a window that closes gradually, not abruptly:

• Ideal: initiated within 1–2 hours of exposure • Still strongly recommended: within 72 hours, the generally accepted outer limit for starting PEP with good expected benefit • Beyond 72 hours: guidelines shift to an individualized discussion rather than a routine recommendation — some clinicians and patients may still choose to proceed depending on specific risk factors, since the marginal benefit, while reduced, is not necessarily zero

This is why the hours-elapsed conversation happens early and is revisited without judgment — a patient who took time to feel safe enough to seek care has done nothing wrong, and the team's job is to give the clearest possible picture of the current window, not to create urgency or guilt.

What the 28-day course actually involves

A typical modern regimen pairs two nucleoside/nucleotide reverse transcriptase inhibitors with a third agent, most often an integrase strand transfer inhibitor for its tolerability:

• Backbone: tenofovir disoproxil fumarate + emtricitabine (often as a single combined pill) • Third agent: raltegravir (twice daily) or dolutegravir (once daily) are common choices, selected based on interactions, pregnancy status, and patient preference • Full course: 28 consecutive days, with a follow-up visit typically around week 1–2 to check tolerability and adherence, and again at completion • Side effects are usually mild (nausea, fatigue, headache) and are discussed proactively so they do not become a surprise reason to stop

The patient can start the course today, decline it entirely, or take a starter pack home to decide within the window — flexibility that keeps the door open without forcing an immediate yes-or-no.

HIV testing is repeated during and after the PEP course (commonly around baseline, 6 weeks, 3 months, and sometimes 6 months) both to check for infection and to confirm the medication itself has not caused issues — this is explained as part of the same continuous relationship, not a one-time transaction.

Emergency Contraception — Time-Sensitive, Always Optional

For patients who may be at risk of pregnancy as a result of the assault, emergency contraception (EC) is offered as part of the standard care package. As with every other component of this visit, EC is presented as an option, not a default — some patients are not at risk of pregnancy, are already using effective contraception, or simply prefer not to take it, and all of those preferences are respected without further questioning.

• ≤ 72 h (reduced to 120 h): Levonorgestrel window (single 1.5 mg dose; more effective the sooner it is taken)
• ≤ 120 h: Ulipristal acetate window (single 30 mg dose; maintains effectiveness later in the window)
• ≤ 120 h: Copper IUD (most effective EC method overall; also ongoing contraception)
• Always offered: Pregnancy risk discussion (regardless of prior contraceptive history)

The available options, side by side

Several EC methods exist, and the choice depends on time elapsed, patient preference, medical history, and access:

• Levonorgestrel (a progestin-only pill, available over the counter in many places): most effective when taken as soon as possible, generally within 72 hours, with effectiveness declining notably thereafter • Ulipristal acetate (a prescription selective progesterone receptor modulator): maintains more consistent effectiveness across the full 120-hour window, making it a preferred choice when more time has elapsed • Copper intrauterine device (IUD): the most effective EC option available, placed by a clinician within 120 hours, with the added benefit of providing ongoing highly effective contraception afterward if the patient wants it

All three are explained without steering the patient toward one over another — the "best" option is the one that fits the individual patient's circumstances and comfort.

Effectiveness is a gradient, not a cliff

A common misconception is that EC "stops working" at a hard cutoff. In reality, effectiveness declines gradually the longer the wait, which is why the conversation is framed around "sooner is better, but it is still worth discussing" rather than a strict pass/fail line:

• Taken within the first 24 hours: EC methods are at their most effective • Taken between roughly 24–72 hours: levonorgestrel remains reasonably effective; ulipristal acetate remains highly effective • Taken between 72–120 hours: levonorgestrel effectiveness drops meaningfully; ulipristal acetate and the copper IUD remain the more reliable choices

This nuance matters clinically: a patient presenting at hour 80 has not "missed the window" — they simply have fewer, still-real options, and deserve the same unhurried conversation as a patient presenting at hour 2.

A baseline pregnancy test is typically offered before EC (a pre-existing pregnancy would change the conversation entirely), but a positive baseline test does not imply the pregnancy resulted from the assault — this distinction is handled sensitively and without assumption.

Respecting a decline, and leaving the door open

Patients may decline EC for many valid reasons — personal or religious beliefs, use of another reliable contraceptive method, or simply not wanting any additional medication today. A decline is documented respectfully and does not close off the option: if the patient changes their mind within the effective window, they can call or return, and the clinical team keeps that door explicitly open at every follow-up contact rather than treating today's decision as final.

Follow-Up Care Coordination — Care Continues Beyond the First Visit

A single emergency visit cannot address everything a survivor may need in the weeks and months that follow. Before discharge, the clinical team works with the patient to schedule follow-up STI and HIV testing, arrange a mental health support referral, and connect them — at their own pace and by their own choice — to advocacy and legal resources. The visit ends not with a discharge summary alone, but with a concrete, patient-directed plan for what comes next.

• 6 wk / 3 mo / 6 mo: HIV retesting schedule (baseline plus interval follow-up testing)
• ~2 weeks: STI retest interval (to confirm clearance or detect new findings)
• Offered at every visit: Mental health referral (trauma-focused counseling and therapy)
• RAINN 800.656.4673: 24/7 national hotline (confidential support, any time, any stage)

The follow-up testing schedule

Because certain infections are not detectable immediately, a structured retesting schedule is arranged:

• STI retesting: typically around 2 weeks, to catch infections not covered by empiric treatment or not yet detectable at the initial visit • HIV testing: repeated at intervals such as 6 weeks, 3 months, and sometimes 6 months, both to monitor for seroconversion and, if PEP was started, to confirm the medication course's outcome • Hepatitis B and C serology: follow-up testing scheduled according to baseline immunity and exposure risk • Pregnancy follow-up: a repeat test is offered a few weeks out if there is any remaining uncertainty

Appointments are scheduled before the patient leaves whenever possible, with clear, written instructions the patient can reference later, since memory for details is understandably affected by acute stress.

Mental health support as a standing offer, not a one-time referral

Psychological impact after a sexual assault varies enormously between individuals and does not always appear immediately. Rather than a single referral handed over at discharge, trauma-informed programs treat mental health support as a standing, renewable offer:

• Same-day connection to a crisis counselor or advocate, if the patient wants to talk before leaving • A warm hand-off (a direct introduction, not just a phone number) to trauma-focused counseling services when possible • Explicit permission to use the referral now, later, or never — and to change that answer at any future contact • Information for support people (partners, family, friends) when the patient wants them involved, without ever requiring it

Advocacy, legal information, and staying connected on the patient's terms

Patients are given clear, non-pressuring information about advocacy and legal resources available to them:

• Local rape crisis centers and victim advocacy organizations, which can support a patient regardless of whether they choose to report to police • The National Sexual Assault Hotline operated by RAINN (800.656.4673), available 24/7, confidential, and usable at any point — today, next week, or months from now • Plain-language information about legal options and evidence preservation timelines, presented without any expectation that the patient will act on it • A named contact or callback line at the treating facility, so the patient is never left wondering who to reach out to if new questions arise

The visit closes the way it opened: reaffirming that the patient remains in control of every decision from this point forward, and that support remains available whether they take it today or months down the line.

Care coordination succeeds not when every box is checked, but when the patient leaves with a clear, low-pressure map of what is available to them — knowing that accepting help later is just as valid as accepting it today.