Initial Consultation in a Sexual Health Setting

The limits of confidentiality should be made clear early in the consultation.  When an individual is deemed to have capacity, information may be shared in the absence of consent only if there is concern for the safety or wellbeing of a child, other vulnerable individuals or is in the public interest, or required by law. This acknowledges one of the cornerstones of medical ethics in respecting an individual’s autonomy and right to make their own decisions regardless of the view of the professional.

Young person (13, 14 and 15 years of age and young people looked after or accommodated age 16 and 17)  

Disclosure by a young person of sexual violence should follow local safeguarding procedures. Please carry out a young person’s risk assessment, discuss any immediate concerns with senior clinician or safeguarding / child protection lead within your service.

Self referral for a FME is not available for any young person (13, 14, 15 and those who are looked after / accommodated 16 and 17). Evidence can only be gathered through the Police Referral route.

All cases involving a young person should be discussed with both senior clinician and  safeguarding / child protection lead within your service. It would be normal practice to also discuss with local Child Protection services since there may be previous or existing concerns over the welfare of the young person or other family members. Following local procedures information may need to be shared with social services or police.

If a young person who does not wish Police Involvement it would not be normal practice for the Sexual Health Service to contact the Police directly unless there were serious / immediate concerns over safety of young person or another person. It would be normal practice to be engaging with social work and the local Child Protection Services.

Sexual activity (recent or historic) which took place under age of 13 should always be discussed  with senior clinician or safeguarding / child protection lead within your service.

See section Appendix 2 of  BASHH National guideline for the management of individuals disclosing sexual violence in sexual health services (2022)) for more information on Confidentiality and Information sharing in young people

Adults at risk

Adults may be unable to protect themselves from harm because of a learning disability, mental ill-health, substance use or a physical disability. If an adult discloses sexual violence and there are any concerns about their capacity to protect themselves from harm, then information may need to be shared with social care or the police.

Professionals should be aware of the possibility of coercive control influences the level of duress which, in the context of current or escalating sexual violence, may impede the individual’s ability to make a decision freely.

Gender based violence disclosures should be discussed within the multi-disciplinary team (MDT) and may include a medical defence organisation. Clearly document the subsequent decision-making processes.

Please discuss any immediate concerns with senior clinician.

For ongoing input / advice, please refer patient to the local adult protection team.

See section Appendix 2 of  BASHH National guideline for the management of individuals disclosing sexual violence in sexual health services (2022)) for more information on Confidentiality and Information sharing in adultts.

The following details should be taken during the consultation:

• Date, Time and Location of the assault
• Ascertain whether the patient wishes referral to the police and sensitively enquire about the reason for their reservation.
• Assailant details including gender, number of assailants, whether known to the patient, any known risk factors that may increase blood borne virus transmission, additional details such as ethnicity is helpful if wishing to share information with police.
• Nature of the assault – specifically ask which anatomical sites were involved in the assault including oral, vaginal, anal and use of objects and physical violence. Also ask whether a condom was used and if ejaculation occurred.
• Last Menstrual Period, contraceptive use and last consensual sexual intercourse
• Medical and drug history including allergies
• Ask if they are injured and any symptoms since the assault being mindful that it is more common to have an absence of genital injuries following sexual assault. They may have non genital injuries or no physical injuries at all.

Accurate and timely documentation is essential.  Clinical notes may form a part of the evidence in the criminal justice process should the patient choose to involve the police at a later stage, particularly if you are one of the first people to be informed about the assault.  Keep the history clear and concise without abbreviations, as inconsistencies between your history and the patient‘s statement could discredit their account of events.  As potentially one of the first people to become aware of the incident you may be asked about what they said to you during the disclosure if they later involve police. The account should be documented verbatim using punctuation for the patient’s own words with clarification of any slang or colloquial terms used.

• Urgent medical care always comes before forensic capture e.g. refer to the Emergency Department if head injury
• Assess risk of pregnancy/ and offer emergency contraception as appropriate
• Medical history
• Allergies
• Assess for PEPSE if within 72 hours
• Previous hepatitis B vaccination –offer if presents within 7 days of the assault
• Current use of PrEP
• Past and recent mental health well being
• Current and previous suicide attempts and self harm

Genital Examination (Good Practice Point)    

If the patient has chosen to be referred for a forensic medical examination (FME), in order to preserve DNA evidence, a physical examination should not be performed in the sexual health clinic unless there is an urgent indication for examination e.g. serious injury/ bleeding etc. Collaborate with patient on balancing their priorities and medical emergencies against forensic capture.  If the patient prioritises reduction of pregnancy risk via insertion of a copper IUD as emergency contraception over forensic capture, then their informed decision should be respected.

Patients not referred for a FME who present with injuries or genital symptoms should be offered a genital examination.  Those without injuries or symptoms, with consideration of incubation periods, can be offered an examination or self-taken sampling for STIs. Offer a chaperone, offer gender choice of both examiner and chaperone, explain every step of the examination process before the patient undresses, and advise that they may withdraw their consent to examination at any point.  Agreeing beforehand how the individual will tell you or indicate if they want to stop can help individuals feel safe and empowered. Asking the patient if there are any specific actions that could remind them of the assault and offering them alternatives may help minimise the risk of re-traumatisation.  Triggers might include being touched in a particular place on their body, or with a particular pressure, or using particular words or phrases, for example the phrase, “Just relax”.

During the examination the examiner and chaperone should carefully observe the patient looking for any signs of hyper or hypo stimulation, for example distress or dissociation. Dissociation is a sense of being disconnected from the here and now and can occur after traumatic events.  If there are any signs of distress or re-traumatisation, address any identified triggers and re-affirm consent to continue with the examination, asking for permission to continue and terminating the examination if requested.  Grounding techniques such as use of their name and affirmation of current safety may be more effective at reassuring safety at that moment than distraction and detachment from the examination.

If female genital mutilation (FGM) is identified, discuss with patient when and where this occurred and discuss with senior clinician since it may require reporting.  

Observation of injuries: In those not attending or declining SARC involvement, if asymptomatic, offer a full sexual health testing with self taken swabs after appropriate incubation periods. If symptomatic, carry out focussed examination.

Remember, if a patient has chosen to be referred to a SARC for a forensic medical examination as a self-referral or with police engagement, genital examination is unnecessary in a sexual health setting.

Consider immediate safety issues particularly in cases of domestic violence or sexual assault where the assailant (or their family & friends) may know the patient’s address or if threatening/ intimidating behaviour. Consider completing risk indicator checklist (RIC) to identify high risk domestic violence and establish if a Multi-Agency Risk Assessment Conference (MARAC) is required, available via the following link;

http://safelives.org.uk/sites/default/files/resources/Dash%20without%20guidance.pdf.

Non-Fatal Strangulation (NFS):

Where domestic abuse is disclosed, a Risk Indicator Checklist will provide the opportunity to enquire about the use of non-fatal strangulation (NFS). Where the perpetrator is not an intimate partner it is important to recognise the potentially fatal significance and delayed consequences if strangulation is disclosed as part of the incident. Victims of NFS being seven times more likely to go on to be fatally injured. Since, 2022 non-fatal strangulation is a stand-alone offence in England and Wales. It significance is acknowledge by the
Scottish Criminal Justice System and will be investigated and may be prosecuted under different legislation locally. The Institute for addressing strangulation (IFAS) provides additional information.

See Options for Information sharing with the Police

Prophylaxis against for HIV
If the patient presents within 72 hours of sexual assault, then a risk assessment for acquisition of HIV should be performed. Please see UK Guideline for the use of HIV Post-Exposure Prophylaxis 2021 

Clinicians should bear in mind that transmission of HIV is likely to be increased by physical genital injury, current STI, presence of bleeding or by multiple assailants or repeated assaults.

Decisions about the need for PEP in the setting of people on PrEP but with less than optimal PrEP adherence depends on length of time since the last dose of PrEP and the site of exposure. Please see Section 10.3 Please see UK Guideline for the use of HIV Post-Exposure Prophylaxis 2021 

If the patient is already taking daily Pre-exposure Prophylaxis (PrEP) with tenofovir/emtricitabine, then PEPSE is not required, provided they are taking this correctly, have not missed any doses and continue to take for at least 48 hours following the assault.

Indications for PEP are:

Anal sex: If the only exposure has been though anal sex and for people on daily PrEP, where fewer than 4 pills have been taken in the last 7 days. Or for people on event-based PrEP, PEP is indicated where PrEP has not been taken as recommended.

Vaginal: Where the potential HIV exposure is through vaginal sex and PrEP adherence has been suboptimal, PEP should be considered if more than 48 hours have elapsed since last dosing or if fewer than six tablets have been taken within the previous 7 days.

Frontal or neovaginal sex: Where the potential exposure to HIV is through frontal sex in transmen or through neovaginal sex in trans women, then PEP should be considered if more than 48 hours have elapsed since last dosing or if fewer than six tablets have been taken within the previous 7 days.

Prophylaxis against Hepatitis B

• Hepatitis B vaccine should be offered early, preferably within 24 hours. As post-exposure prophylaxis there is little evidence to support its effectiveness beyond 7 days.
• Delivery of later vaccine beyond the seven days is unlikely to be effective as post exposure prophylaxis however is not likely to cause harm. There may be other indications for offering the vaccine to patients in line with current public health guidance to consider.
• All three schedules are likely to have similar effectiveness as PEP but the accelerated (four doses at 0, 1, 2, and 12 months); or ultra-rapid (four doses at 0, 7– 10 days, 21 days, and 12 months) are preferred because of higher completion rates in addition to rapid development of immunity in those at ongoing risk and where compliance is an issue. 
• The adult dose (20mcg /1ml) is licensed for use in those 16 years or over. A licensed lower paediatric dose (10mcg / 0.5ml) of Engerix® is used in children aged 15 years and younger on three-dose regimen. Adolescents aged 11-15 who are not likely to attend for three doses and are at low immediate risk can be offered a two-dose regimen using the adult 20 mcg preparation. This two-dose schedule of a vaccine containing adult strength hepatitis B at zero and six months provides similar protection to three doses of the childhood hepatitis B vaccines. 
• As vaccine alone is highly effective, the use of HBIG in addition to vaccine is only recommended in high-risk situations or in a known non-responder to vaccine. Vaccine should be simultaneously offered. Further details on the indications and use of HBIG are available from Public Health England Guidance.

Prophylaxis against Hepatitis A
Post exposure vaccination for Hepatitis A following sexual assault would only be recommend if within two weeks of a contact of a confirmed case or one week after onset of jaundice in the index case.

If rapid protection against hepatitis A is required for adults, for example following exposure or during outbreaks, then a single dose of monovalent vaccine is recommended. In children under 16 years, a single dose of Ambirix® may also be used for rapid protection against hepatitis A. Both vaccines contain the higher amount of hepatitis A antigen and will therefore provide hepatitis A protection more quickly than Twinrix

Opportunistic vaccination against Hepatitis A 

The following groups should be opportunistically offered a single dose of adult monovalent hepatitis A vaccine, where available, unless they have documented evidence of two doses of hepatitis A vaccination or of previous hepatitis A illness.

• GBMSM (Gay, Bisexual, Men who have sex with men)
• PWID (People who inject drugs)
• People involved in transactional sex
• Transgender women who have anal sex
• People who are positive for HIV, HCV, HBV.

The Use of Combined Hep A/B Vaccine e.g.Twinrix is off label for use as post exposure prophylaxis. For those eligible and at ongoing risk give separate vaccines where possible. Although off-label, prescribers can use Twinrix if deemed suitable i.e. will refuse two vaccine.

Twinrix is available for use in those being provided both Hepatitis A and B vaccines where the risk of exposure is not as high or ongoing risk where pre exposure vaccination would be routinely recommended.

Human Papilloma Virus (HPV) vaccination

HPV vaccination is not routinely given post sexual assault to those disclosing sexual violence in the acute, post sexual assault setting. We would recommend instead that all survivors are questioned with respect to their HPV vaccination history and all those who are currently eligible for the HPV vaccination as per current UK guidelines are advised and signposted to commence (or complete any incomplete) HPV quadrivalent vaccination courses.

Emergency contraception
If no ongoing contraception in place, offer emergency contraception if indicated. If an IUD is recommended as per Emergency Contraception Guideline ideally wait until after the forensic exam and offer an emergency hormonal method in the interim. Also offer emergency contraception as a precautionary measure if there are concerns about bodily fluids when assault was by penetration by an object or a digit.

A pregnancy test (PT) will be positive at 3 weeks post risk (and sometimes earlier than this)

If a pregnancy test is positive, discuss options which include:

• Continuing with the pregnancy
• Termination of pregnancy
• Paternity testing 
• Using products of conception as evidence

If the patient continues with a pregnancy, contact their GP or Antenatal Clinic and share relevant information about the assault, with the patient’s consent. This may include discussion on the option of obtaining a DNA profile from the baby at some time following delivery. 

If the patient does not wish to continue the pregnancy, refer to local abortion services. Products of conception may be used as DNA evidence. If this is consented to, abortion services will liaise with Police Scotland on the available options. 

STI Testing

Patients should be offered opportunities to test at the end of the incubation period for each STI. Offer testing in all cases where there is a risk of infection, including assault by penetration by an object or a digit if there is any possible risk STI transmission This includes NAAT for CT/GC, bloods for HIV/syphilis/Hep B and Hep C. If the sexual assault was oral/anal penetration, NAATs should also be taken from these sites.

*If there is concern about bodily fluids on penetrating digit or object 

If a site is sexually naive, please consider sending a chain of evidence form if patient has reported or is considering reporting.

The additional complication of contact tracing suspects is introduced when a patient tests positive for an STI. Undertaking this public health responsibility, whilst retaining patient confidentiality can be complicated and require documentation of discussion with senior colleagues.

Prophylaxis against Bacterial Sexual Transmitted Infections

Prophylactic antibiotics for STI risk would not normally be indicated. A pragmatic approach may have to be taken whilst balancing against unnecessary antibiotic prescribing if there is a possibility of not re-attending.

Offering testing after incubation would be the preferred recommendation.

Consider the use of prophylactic antibiotics if patient presents within the 2 week incubation period and is unlikely to re-attend or if patient is symptomatic of a bacterial STI and Emergency Contraception copper coil insertion is being carried out.

At the time of writing, the recommended first line regimens for adults are:
• Chlamydia: Doxycycline 100mg twice daily for 7 days
• Gonorrhoea: Ceftriaxone 1g intramuscular single dose
• Trichomonas: Metronidazole 400mg twice daily for 7 days (or metronidazole 2g oral
single dose in non-pregnant women)