Sexual violence in a humanitarian crisis: the first 72 hours

In a clinic set up in a settlement of displaced people, a young woman arrives accompanied by a friend. She says she came because of a headache and does not look at the health professional. After a few minutes, in a private room, she quietly says that she was assaulted two days earlier, when she was gathering firewood outside the settlement. She did not shower right away, she is afraid of becoming pregnant and she does not know whether she wants to tell anyone. The first reaction of the person attending may be to ask many questions about what happened. The scene is fictional and was written for teaching. This text uses that picture as a setting for clinical reasoning: how to offer first support, why the time since the assault decides part of the approach, what to offer in the first seventy-two hours and how to organize follow-up.

NEXO is a daily medical diagnosis game: one clinical case a day, up to six progressive clues, and ICD-10 proximity feedback across five levels.

The text is not a care protocol for survivors. Prophylaxis, vaccines, evidence collection and notification follow national guidelines, local laws and practical training. The interest here is the reasoning: how a vague complaint can hide an urgent situation, why consent organizes every step and which time windows cannot be missed. If you play the case of the day in NEXO, you will recognize the move: sometimes the most important clue is not the complaint the person brought.

Key points

• In humanitarian crises, about one in five refugee or displaced women reports sexual violence, and the real number is probably higher.
• First support, with listening, questions about needs, validation, safety and referral, is the most useful care one can give.
• HIV prophylaxis should start as soon as possible, ideally within twenty-four hours and at most within seventy-two hours, with a full twenty-eight-day prescription.
• Emergency contraception can be offered up to one hundred and twenty hours later, but it works better the sooner it is given.
• Every part of the care depends on the person's consent, including the examination and the collection of evidence.

Why sexual violence in crisis is a setting for reasoning

Humanitarian crises increase the risk of sexual violence and, at the same time, make access to care harder. Vu and colleagues reviewed studies with refugee or displaced women in complex humanitarian emergencies and estimated that about one in five reported sexual violence (Vu and colleagues, 2014). The authors note that this number probably underestimates reality, because of the many barriers to telling what happened. The World Health Organization published, with other United Nations agencies, a guide for the clinical care of survivors of rape and of intimate partner violence in humanitarian settings (World Health Organization, 2020).

What the scene teaches

In the opening scene, the initial complaint is a headache. The violence only appears because the professional created a private setting and did not rush the conversation. The most important information for the approach is time: two days later, there is still time for HIV prophylaxis and for emergency contraception, but the window is closing. The post about signs, symptoms and history shows how the history changes the weight of a vague complaint.

The consequences go beyond the body

The World Health Organization guide notes that sexual violence can cause injuries, unwanted pregnancy, sexually transmitted infections, including HIV, and mental health problems such as depression, post-traumatic stress and suicidal behavior (World Health Organization, 2020). Dworkin and colleagues reviewed decades of studies and found that people who have suffered sexual violence are at higher risk of all the mental disorders assessed, with stronger associations for post-traumatic stress and suicidal behavior (Dworkin and colleagues, 2017).

First support

The World Health Organization guide describes psychological first aid as the most useful care one can offer (World Health Organization, 2020). It has five elements: listening attentively, asking about needs and concerns, validating by showing that the person is believed and that it is not her fault, increasing safety, and supporting with information and referral. The guide notes that this type of support follows the principles of psychological first aid and can save lives, especially in an emergency.

What not to do

The guide recommends choosing a private place, where no one can see or hear the conversation, and ensuring that what is said will not be repeated to anyone who does not need to know (World Health Organization, 2020). It also recommends not pressuring the person to talk and not asking detailed questions that force her to relive the violence. The professional does not need to solve all the problems or convince the person to make decisions. In the opening scene, asking what she needs right now is more useful than asking for details of what happened.

Who provides the care

The guide recommends that, whenever possible, a female professional who speaks the same language as the survivor provides the care and that, if this is not possible, a companion of the person's choosing or another female professional be present (World Health Organization, 2020). The guide also notes that men and boys also suffer sexual violence, that they often disclose even less because of shame and stigma, and that they need the same vaccines and treatments.

Consent at every step

The World Health Organization guide notes that informed consent is required for the examination and for each procedure, and that the person may refuse any part, even after having agreed at the start (World Health Organization, 2020). The document suggests explaining each step, such as the examination, the collection of evidence and the release of information to the police, and asking separately whether the person accepts each one. When notification is mandatory, the professional must first explain what needs to be reported and to whom.

Treating even without an examination

The guide recommends that anyone who does not accept or cannot complete the physical examination receive treatment based on a careful history (World Health Organization, 2020). The document also states that the so-called virginity test has no medical or scientific validity and should never be performed. For clinical reasoning, refusal of the examination does not change the indication for prophylaxis and emergency contraception.

Forensic evidence

The guide notes that, if the person wants evidence to be collected, she should seek care as soon as possible, without bathing or changing clothes, and that after seventy-two hours the collection of evidence becomes limited (World Health Organization, 2020). Collection follows the local protocol and only happens with consent. The guide also notes that the examination remains important after that period, to document and treat injuries and to reassure the person when there is no physical harm.

Those who arrive after seventy-two hours

The World Health Organization guide notes that many survivors arrive after seventy-two hours and that care remains important (World Health Organization, 2020). The document recommends assessing the size and color of bruises and scars, complications such as deafness, fractures and abscesses, signs of pregnancy and mental state, including isolation, depression and suicidal thoughts. Even when no injuries are expected, the person may feel she has been harmed, and a careful examination followed by the explanation that there is no physical harm can bring great relief and be the main reason for the visit.

What the community needs to know

The guide recommends informing the community about the available services, where to find them at any hour and why it is worth seeking care in the first seventy-two hours, to prevent HIV and pregnancy and for the collection of evidence when available (World Health Organization, 2020). The document also recommends that the community know that the service treats survivors with dignity, protects their safety and respects privacy and confidentiality. For clinical reasoning, the time window only works if the person knows it exists.

Injuries that require hospital care

The World Health Organization guide recommends immediately referring anyone with serious or life-threatening conditions for emergency treatment (World Health Organization, 2020). The document cites extensive injuries to the genital or anal region, the head, the chest or the abdomen, neurological deficits, shortness of breath, swelling of joints on one side of the body, fever and sepsis. It also recommends looking, on examination, for signs of strangulation, such as small blood spots in the eyes and marks on the neck, and eardrums perforated by slaps.

HIV prophylaxis: the shortest clock

The World Health Organization recommends offering HIV post-exposure prophylaxis as soon as possible, ideally within the first twenty-four hours and at most up to seventy-two hours after exposure (World Health Organization, 2024). The guideline considers rapid access the most important factor for effectiveness. It recommends three-drug regimens, preferably, and cites the combination of tenofovir, lamivudine and dolutegravir in a single tablet as an option that reduces the number of tablets.

A full prescription, not a starter pack

The World Health Organization recommends handing over the full twenty-eight-day prescription at the first assessment and does not recommend starter packs with only a few days of medication (World Health Organization, 2024). Ford and colleagues reviewed studies and found fewer refusals and more people completing treatment when the full prescription was given from the start, and they observed that more than a quarter of those who received a starter pack did not come back for the rest (Ford and colleagues, 2015). In humanitarian crises, with displacement and difficulty returning to the clinic, this detail matters even more.

Adherence is the weak point

Chacko and colleagues reviewed studies on HIV prophylaxis after sexual violence and found that only about forty percent of people completed treatment (Chacko and colleagues, 2012). Ford and colleagues found a similar result in a larger review, with the lowest completion rates among victims of sexual violence and adolescents (Ford and colleagues, 2014). The World Health Organization guide recommends talking about side effects, about how to remember doses and about what to do when a dose is missed (World Health Organization, 2020).

When prophylaxis does not apply

The guide notes that prophylaxis is not indicated when the survivor already lives with HIV, in which case she should be referred for treatment, or when it is known that the aggressor does not have HIV, and that, when in doubt, prophylaxis should be offered (World Health Organization, 2020). The document describes situations of higher risk, such as penetration, blood or wounds, loss of consciousness, multiple aggressors or an aggressor who uses injectable drugs. The decision to take prophylaxis belongs to the survivor.

Emergency contraception

The World Health Organization guide recommends offering emergency contraception to every woman who has been raped, up to one hundred and twenty hours later, noting that it is more effective the sooner it is used (World Health Organization, 2020). The document describes ulipristal acetate and levonorgestrel pills and the copper intrauterine device, which can be placed up to five days later and is more effective than the pills. The guide notes that no pregnancy test is needed beforehand and that the pills do not interrupt an existing pregnancy.

What the evidence compares

Shen and colleagues reviewed the trials on emergency contraception and concluded that levonorgestrel is more effective than the old combined hormone regimen and that ulipristal may be more effective than levonorgestrel (Shen and colleagues, 2019). The authors also found that the copper intrauterine device may be associated with more abdominal pain than the pills. Glasier and colleagues directly compared ulipristal and levonorgestrel in a randomized trial with meta-analysis and concluded that ulipristal is an effective alternative that can be used up to five days after intercourse, with fewer pregnancies than levonorgestrel in the combined analysis (Glasier and colleagues, 2010). The World Health Organization guide notes that the pills, antibiotics and HIV prophylaxis can be taken together, and that if the woman vomits within two hours after the pill, she should take another dose (World Health Organization, 2020).

Infections, hepatitis B and tetanus

The World Health Organization guide recommends presumptive treatment of chlamydia, gonorrhea and syphilis at the first visit, preferably with single oral doses, according to the national protocol (World Health Organization, 2020). The document recommends offering hepatitis B vaccine, especially in places where infection is common, testing first when possible and vaccinating when it is not. It also recommends preventing tetanus when there are wounds on the skin or mucous membranes, according to vaccination history. The sexually transmitted infection guidelines from the United States Centers for Disease Control and Prevention also recommend empiric treatment after sexual violence, covering gonorrhea and chlamydia and, in women, trichomoniasis, as well as hepatitis B vaccine and human papillomavirus vaccine for those who have not been vaccinated (Workowski and colleagues, 2021). The document notes that the effectiveness of these regimens in preventing infections after sexual violence has not been evaluated.

Time windows: a table for care

The table below summarizes, in a teaching format, the main interventions and time windows described in the guidelines cited. It simplifies a complex topic and does not replace national guidelines, local protocols or practical training.

Intervention	Time window	What weighs in the decision
HIV prophylaxis	Ideally within twenty-four hours, at most seventy-two	Full twenty-eight-day prescription and support for adherence
Emergency contraception	Up to one hundred and twenty hours, better the sooner the better	Pill or copper device, according to choice
Forensic evidence	Most useful in the first seventy-two hours	Only with consent and according to local protocol
Sexually transmitted infections	At the first visit	Presumptive treatment according to national protocol
Hepatitis B and tetanus	At the first visit	Vaccination history
Initial support and mental health	At every visit	Safety, suicide risk and referral

Follow-up and mental health

The World Health Organization guide recommends follow-up visits two weeks, one month, three months and six months after the first visit (World Health Organization, 2020). At these visits, the professional checks the healing of lesions, adherence to prophylaxis, the need for a pregnancy test, the next doses of hepatitis B vaccine and tests for HIV and syphilis. The guide acknowledges that, in crises with continuous displacement, long-term follow-up may not be possible, and recommends at least one return visit in the first three months and all essential care at the first visit.

Mental health at each return visit

The guideline recommends continuing the first support and assessing emotional state at every visit, with attention to depression, post-traumatic stress, self-harm, suicide and unexplained physical complaints (World Health Organization, 2020). Dworkin and colleagues found larger mental health effects when the violence involved strangers, weapons or physical injuries (Dworkin and colleagues, 2017). For the clinician, asking about sleep, mood and thoughts of death is part of the care, not a subject for later. Roberts and colleagues reviewed early psychological interventions after trauma and found no important difference compared with usual care when the intervention was offered to everyone, without symptom screening (Roberts and colleagues, 2019). Among people who already had symptoms of traumatic stress, trauma-focused cognitive behavioral therapy had the strongest evidence of benefit. For the clinician, this reinforces tracking symptoms at every follow-up and referring those who continue to suffer.

Safety and referral

The guideline recommends assessing the immediate risk of further violence and helping the person make a safety plan, as well as referring them to social, legal and psychological support when they want it (World Health Organization, 2020). The document also notes that professionals can develop burnout and indirect trauma and need to take care of themselves. The post on the SPIKES protocol for communicating bad news and the post on affective bias help to think about how the professional's emotion enters the care.

The biases that get in the way of care

Care for sexual violence rarely fails for lack of knowledge. It usually fails because of predictable habits and biases:

1. Accepting the vague complaint without creating room for another story.
2. Asking detailed questions before offering support and treatment.
3. Missing the prophylaxis window while waiting for tests or legal decisions.
4. Handing over a starter pack of a few days instead of the full prescription.
5. Forgetting mental health and follow-up after the first visit.

Croskerry describes anchoring and premature closure among the most frequent cognitive errors in diagnosis (Croskerry, 2003). The post on the diagnostic pause shows how a short moment of checking helps to notice what was left out. The post on heuristics in clinical reasoning helps to recognize when the first complaint anchors the whole visit.

What to ask

Some questions organize the care, always with care and without pressure:

• Is there a private and safe place to talk?
• How much time has passed since the violence?
• What does the person need now and what are they worried about?
• Does she accept the exam, the collection of evidence and each treatment offered?
• Has she already received the hepatitis B and tetanus vaccine? Is she pregnant or was she using any contraceptive method?
• Is she at risk of further violence or does she have thoughts of hurting herself?

Back to the scene

In the opening scene, the professional who organizes the reasoning offers first support, without pressure. She explains that, two days later, there is still time to prevent HIV and pregnancy. With the young woman's consent, she offers HIV prophylaxis with the full twenty-eight-day prescription, emergency contraception, presumptive treatment of infections and the hepatitis B vaccine. She asks whether she wants an exam and collection of evidence and respects the answer. They talk about safety, about how to remember the doses, and she schedules the follow-up in two weeks. The reasoning starts with listening and with the clock, not with the headache complaint.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues. You propose a diagnosis by searching for the ICD-10 code and receive feedback on proximity in five levels, which shows whether the guess landed on the exact code, the same category, the same group, the same chapter or a different chapter. This format connects with the theme of this text: the initial complaint may not be the main problem.

To use the case of the day as training, try three habits. Before each guess, ask whether the complaint brought in could hide another story. When time matters, ask which treatment window is still open. After the result, note which clue would have anticipated the diagnosis.

Three exercises with cases

Look for the story behind the complaint. In each case, ask what situation could explain a vague complaint.

Watch the clock. When you reach a diagnosis, list the interventions that depend on time and their deadlines.

Plan the follow-up. Reread a case asking what needs to be checked in the following weeks and months.

The post on learning based on clinical cases shows how cases help fix patterns that rarely appear in daily practice.

The limits on using the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information under curation and creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

How late can HIV prophylaxis start?

As early as possible, ideally within the first twenty-four hours and no later than seventy-two hours after exposure.

For how long is prophylaxis taken?

For twenty-eight days. The recommendation is to hand over the full prescription at the first visit.

How late does emergency contraception work?

It can be offered up to one hundred and twenty hours later, but it works better the sooner it is given. The copper intrauterine device is the most effective option.

Is an examination or evidence collection mandatory?

No. Each step depends on the person's consent, and anyone who declines the examination should receive treatment based on the history.

What if the person arrives after seventy-two hours?

HIV prophylaxis is no longer indicated, but emergency contraception can be offered up to one hundred and twenty hours, and injuries, infections, vaccines and mental health still need care.

When are the follow-up visits?

Two weeks, one month, three months and six months later, or at least one visit in the first three months when long-term follow-up is not possible.

Final checklist

• I offered support first in a private place, without pressure.
• I asked how long ago the violence happened.
• I asked for consent at each step of the care.
• I offered HIV prophylaxis with a full prescription and emergency contraception within the time windows.
• I treated infections presumptively and offered vaccines.
• I assessed safety and mental health and scheduled the follow-up.

Want to practice reasoning with progressive clues? Play the case of the day.

References

1. Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis. Sex Transm Infect. 2012. PMID 22332148.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003. PMID 12915363.
3. Dworkin ER, Menon SV, Bystrynski J, Allen NE. Sexual assault victimization and psychopathology: a review and meta-analysis. Clin Psychol Rev. 2017. PMID 28689071.
4. Ford N, Irvine C, Shubber Z, et al. Adherence to HIV postexposure prophylaxis: a systematic review and meta-analysis. AIDS. 2014. PMID 25493598.
5. Ford N, Venter F, Irvine C, et al. Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review. Clin Infect Dis. 2015. PMID 25972501.
6. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010. PMID 20116841.
7. World Health Organization. Clinical management of rape and intimate partner violence survivors: developing protocols for use in humanitarian settings. 2020. Document.
8. World Health Organization. Guidelines for HIV post-exposure prophylaxis. 2024. Document.
9. Roberts NP, Kitchiner NJ, Kenardy J, et al. Early psychological intervention following recent trauma: a systematic review and meta-analysis. Eur J Psychotraumatol. 2019. PMID 31853332.
10. Shen J, Che Y, Showell E, et al. Interventions for emergency contraception. Cochrane Database Syst Rev. 2019. PMID 30661244.
11. Vu A, Adam A, Wirtz A, et al. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014. PMID 24818066.
12. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021. PMID 34292926.