Humanitarian and conflict · WHO, UNFPA and UNHCR guidance
Clinical care after sexual violence
A survivor of sexual violence who reaches a health worker has taken a brave step. What happens next should leave them safer, respected and in control. Good clinical care is mostly about listening and choice, plus a few time-critical treatments that prevent pregnancy, HIV and other infections.
- For doctors, clinical officers, midwives and nurses in humanitarian settings
- Reviewed October 2026
Survivor-centred care
- The survivor decides. Every examination, test, treatment and referral is offered, explained and agreed to; they can decline any part.
- Privacy and confidentiality: a private room; nothing is shared with anyone who does not need to know.
- Safety: think about their safety in the clinic and when they leave.
- Dignity and no judgement: they are not to blame.
- A female health worker who speaks the same language is best. If that is not possible, offer a female companion or a person of their choice.
- Male survivors need the same care, vaccinations and STI treatment.
What you do not need to doYou do not need to solve their problems, persuade them to leave a violent relationship, persuade them to go to the police or courts, or ask detailed questions that make them relive what happened.
Source: WHO, UNFPA, UNHCR 2020, part 2
First-line support: LIVES
First-line support is the most helpful care you can give, and it fits with psychological first aid.
- Listen
- Listen closely, with empathy and without judging.
- Inquire about needs and concerns
- Ask about and respond to emotional, physical, social and practical needs (for example childcare).
- Validate
- Show that you understand and believe them, and that they are not to blame.
- Enhance safety
- Discuss a plan to protect them from further harm.
- Support
- Help them to reach information, services and social support.
Thank you for telling me. What happened was not your fault. You decide what happens next, and I will explain each step before we do anything.
Source: WHO, UNFPA, UNHCR 2020, part 2
The steps of a consultation
- Listen, ask about needs and concerns, and validate (LIVES).
- Get informed consent for each part of the examination and care. Explain in advance any mandatory reporting rules: what must be reported and to whom.
- Take a history, without pressing for detail beyond what is needed for care.
- Examine only with consent, and only as needed. Document findings carefully. Collect forensic evidence only if you are trained, the survivor agrees and the evidence can be used.
- Provide treatment (see the time limits below).
- Enhance safety and refer for other support: protection, psychosocial, legal, shelter.
- Assess mental health and offer psychosocial support.
- Arrange follow-up.
Life-threatening problems firstRefer immediately for emergency care if there is extensive injury, difficulty speaking or walking, breathing difficulty, one-sided joint swelling, or fever and signs of sepsis.
Source: WHO, UNFPA, UNHCR 2020, part 3
Treatment and the time limits that matter
Treatment depends on how long ago the incident happened. Encourage the community to come as soon as possible, within 72 hours, to prevent HIV and pregnancy.
| Treatment | Time limit | Key points |
|---|---|---|
| HIV post-exposure prophylaxis (PEP) | As soon as possible and no later than 72 hours | Taken for 28 days. Choice of medicines follows the national guideline. Not offered after 72 hours. |
| Emergency contraception (EC) pills | Up to 120 hours (5 days); most effective straight away and within 72 hours | No pregnancy test is needed first. EC does not cause abortion and does not harm an existing pregnancy. |
| Copper IUD as emergency contraception | Up to 5 days | More effective than EC pills and gives ongoing contraception. Not if already pregnant. Give full STI treatment if an IUD is inserted. |
| Presumptive STI treatment | At the first visit | Antibiotics for chlamydia, gonorrhoea and syphilis following the national protocol; single oral doses where possible. |
| Tetanus | At the first visit, whenever they present | Vaccinate if not fully vaccinated; consider tetanus immunoglobulin for major, dirty wounds. |
| Hepatitis B vaccine | First dose at the first visit | If never vaccinated: further doses as the national schedule. No need if fully vaccinated. |
| Wound care | At the first visit | Clean wounds; suture clean wounds within 24 hours; do not suture very dirty wounds. |
Source: WHO, UNFPA, UNHCR 2020, part 3, step 5
Emergency contraception pills
The WHO, UNFPA and UNHCR guide lists three regimens:
- Ulipristal acetate 30 mg, single dose
- Levonorgestrel 1.5 mg, single dose (or two 0.75 mg tablets together)
- Combined estrogen-progestogen pills (100 micrograms ethinylestradiol with 0.5 mg levonorgestrel), repeated 12 hours later: less effective and more nausea
- If she vomits within 2 hours of taking EC pills, she should take another dose as soon as possible.
- If she was taking an enzyme-inducing medicine (for example rifampicin or efavirenz) before the incident, she needs a double dose of EC pills.
- Spotting in the following days is common. She should return if her next period is more than a week late.
- Using EC is her choice alone.
Source: WHO, UNFPA, UNHCR 2020, part 3, step 5
HIV post-exposure prophylaxis
- Taking PEP is the survivor's decision. Explain that it lowers, but does not remove, the chance of HIV; it must be taken once or twice daily for 28 days; about half of people get side-effects such as nausea, tiredness or headache, which usually settle within days.
- PEP is not recommended if the survivor is already living with HIV (refer for treatment straight away), or if the perpetrator is known not to have HIV. If in doubt, offer it.
- Choose the regimen from the national guideline. Do not use nevirapine for PEP.
- Offer HIV counselling and testing at the first visit, but test only with consent and where PEP and HIV treatment are available.
- Retest at 3 and/or 6 months, with consent.
Source: WHO, UNFPA, UNHCR 2020, part 3, step 5 and annex 9
If the survivor comes after 72 hours
- First-line support, safety and mental health care are just as important.
- Between 72 and 120 hours: EC pills still reduce the chance of pregnancy, and a copper IUD is an option up to 5 days.
- PEP is no longer offered. Refer for HIV testing and counselling, usually 3 to 6 months after the incident.
- Vaccinate against tetanus if not fully vaccinated, and start hepatitis B vaccination if needed.
- Treat STIs following local protocols if there are symptoms or a positive test.
- If she is pregnant, discuss her options and the services available, including those for an unintended pregnancy, to the full extent of the law.
Source: WHO, UNFPA, UNHCR 2020, part 3, step 5, section B
Follow-up
| When | What to check |
|---|---|
| 2 weeks | Injuries healing; STI treatment completed; PEP adherence; pregnancy test if she was at risk, and discuss options if pregnant; first-line support and mental health |
| 1 month | Second hepatitis B dose if needed; STI symptoms and tests if available; mental health (refer for depression, PTSD or suicidal thoughts) |
| 3 months | Offer HIV testing with counselling; retest for syphilis if a laboratory is available; mental health |
| 6 months | Offer HIV testing if not done; third hepatitis B dose if needed; mental health |
If the survivor cannot come back, give the information they need to continue care at another facility.
Source: WHO, UNFPA, UNHCR 2020, step 8, table 3.4
Children and adolescents
- Use LIVES adapted for children: believe the child, reassure them they are not at fault, speak in words they understand, and go at their pace. Do not make them repeat their story to different people.
- Ask the child who they would like to be present, and respect their wishes. Ask whether they would prefer to speak with a female or male trained worker.
- Never examine a child against their will unless it is necessary for medical care. Parents or guardians usually give consent, but seek the child's or adolescent's own consent where that is in their best interests, and follow national law and child protection procedures.
- Medicine choices and doses differ for children: follow the guide's child annexes and your national protocol, and refer early if you are not trained.
Source: WHO, UNFPA, UNHCR 2020, part 6
Getting the clinic ready
- A private space, available 24 hours a day, 7 days a week, and a written protocol.
- Post-rape treatment kits (reproductive health kit 3), EC pills, PEP, STI treatment, tetanus and hepatitis B vaccine in stock.
- Trained staff, including female staff and interpreters.
- A referral list for protection, psychosocial, legal and safe shelter services.
- Confidential records, stored securely.
- Support for staff: this work is stressful, and staff can develop burnout or vicarious trauma.
Source: WHO, UNFPA, UNHCR 2020, part 1; IAWG MISP 2018
Sources
- World Health Organization, UNFPA and UNHCR. Clinical management of rape and intimate partner violence survivors: developing protocols for use in humanitarian settings. 2020 (ISBN 978-92-4-000141-1).
- Inter-Agency Working Group on Reproductive Health in Crises (IAWG). Minimum Initial Service Package (MISP) reference sheet, Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings. 2018.
- Sphere Association. The Sphere Handbook, fourth edition (standard 2.3.2: sexual violence and clinical management of rape). 2018.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.