๐ Key Information Summary
- Intimate partner violence (IPV) affects approximately 1 in 4 Australian women and 1 in 14 men over their lifetime; it is the leading contributor to illness, disability and death in women aged 18โ44.
- Screening for IPV should be considered in all primary-care encounters using validated tools (e.g., HITS, PVS, AAS) โ but only when the patient can be seen safely and confidentially, without the perpetrator present.
- Barriers to disclosure include fear of retaliation, shame, financial dependence, immigration status, cultural factors and prior negative healthcare experiences; clinicians must create a safe, non-judgemental environment.
- The cycle of violence โ tension building, acute violence, reconciliation/honeymoon โ explains why victims may return to abusive relationships; understanding this pattern is essential to compassionate management.
- A safety plan should be offered to every patient experiencing IPV, including emergency contacts, safe locations, essential documents and an escape strategy.
- After a recent sexual assault, the primary clinician's first role is medical stabilisation, informed consent, forensic evidence collection (within 72 hours via a Sexual Assault Forensic Examination), and provision of post-exposure prophylaxis.
- STI prophylaxis post-assault should include empirical treatment for chlamydia (azithromycin 1 g PO stat or doxycycline 100 mg PO BD for 7 days), consideration of gonorrhoea (ceftriaxone 500 mg IM stat), and offer of HIV PEP within 72 hours of exposure.
- Emergency contraception (levonorgestrel 1.5 mg PO stat within 72 hours, or ulipristal 30 mg within 120 hours) should be offered to all women of reproductive potential after assault.
- Hepatitis B vaccination should be commenced if the patient is non-immune; hepatitis B immunoglobulin is indicated for unvaccinated patients exposed to HBV-positive or unknown-status perpetrators.
- Follow-up at 1โ2 weeks and again at 3 months is mandatory for STI screening, psychological support (including trauma-informed care), vaccination completion and safety reassessment.
- Aboriginal and Torres Strait Islander women experience IPV at 3.1 times the rate of non-Indigenous women; culturally safe, trauma-informed, community-led responses are essential.
- Mandatory reporting obligations vary by Australian state and territory โ clinicians must know their local legislation, particularly regarding children exposed to family violence.
Introduction & Australian Epidemiology
Intimate partner violence (IPV) encompasses physical, sexual, psychological and economic abuse perpetrated by a current or former intimate partner. Sexual assault refers to any sexual act performed without consent, including completed or attempted penetration, unwanted sexual touching and coercive sexual contact. Both are significant public health and clinical problems that present frequently โ yet often unrecognised โ in Australian general practice, emergency departments and specialist clinics.
The Australian Institute of Health and Welfare's 2024 Family, Domestic and Sexual Violence report estimates that approximately 2.2 million Australians have experienced physical or sexual violence from a partner since the age of 15, with women disproportionately affected. IPV is the leading cause of homelessness for women and children, and the single greatest contributor to the burden of disease in women aged 18โ44 โ exceeding tobacco use, obesity and hypertension.
| Statistic | Value | Source |
|---|---|---|
| Women who have experienced IPV (lifetime, age โฅ15) | 1 in 4 (~23%) | AIHW 2024; ABS PSS 2021โ22 |
| Men who have experienced IPV (lifetime, age โฅ15) | 1 in 14 (~7%) | ABS PSS 2021โ22 |
| Women killed by a current/former partner (2022โ23) | ~1 per week nationally | AIC Homicide Monitoring |
| Sexual assaults recorded by police (2022โ23) | ~31,000 (under-reported) | ABS Recorded Crime |
| Aboriginal & Torres Strait Islander women โ IPV rate vs non-Indigenous | 3.1ร higher | AIHW 2024 |
| Economic cost of IPV to Australia (annual) | billion (estimated) | KPMG / NAL 2023 |
Clinical significance: The majority of IPV and sexual assault survivors never present with a primary complaint of violence. They more commonly present with chronic pain, somatic symptoms, depression, anxiety, substance misuse, injuries with inconsistent explanations, or frequent attendance. Recognition is the critical first step.
GPs are uniquely positioned to identify and respond to IPV because of their ongoing therapeutic relationship, continuity of care and holistic understanding of the patient's social context. The RACGP's White Book (Abuse and Violence โ Working with our Patients in General Practice) provides a comprehensive framework for Australian general practice.
Identifying IPV & Barriers to Communication
Clinical Indicators โ When to Suspect IPV
There is no single pathognomonic sign. Clinicians should maintain a high index of suspicion when encountering the following patterns:
Physical & Injury Indicators
- Injuries inconsistent with the patient's explanation or delayed presentation
- Multiple bruises in various stages of healing โ especially face, neck, torso, upper arms
- Bilateral or defensive-pattern injuries (forearms, hands)
- Burns (cigarette, immersion), bite marks, alopecia from hair-pulling
- Head and neck injuries, ruptured tympanic membrane
- Genital or breast trauma without adequate mechanism
Behavioural & Psychosocial Indicators
- Anxiety, depression, PTSD symptoms, suicidality or self-harm
- Substance misuse โ alcohol, pharmaceutical opioids, benzodiazepines
- Frequent presentations with vague somatic complaints (chronic pelvic pain, headache, IBS)
- Partner insists on accompanying patient to consultation or controls communication
- Patient appears fearful, hypervigilant or overly deferential to partner
- Social withdrawal, missed appointments, non-adherence to treatment
- Unexplained financial stress or restricted access to money
Screening Tools for Australian Practice
Universal screening (asking all patients) versus targeted screening (asking only when indicators are present) remains debated. The RACGP recommends that clinicians ask about IPV when there are clinical indicators or when safe to do so. The following validated instruments are recommended for use in Australian primary care:
| Tool | Items | Setting | Notes |
|---|---|---|---|
| HITS (Hurt, Insult, Threaten, Scream) | 4 items | General practice | Validated in Australian primary care; score โฅ10 suggests abuse |
| PVS (Partner Violence Screen) | 3 items | Emergency / GP | Quick; includes safety question |
| AAS (Abuse Assessment Screen) | 5 items | Antenatal / women's health | Specifically designed for pregnant women |
| WAST (Woman Abuse Screening Tool) | 8 items | General practice | Two-question short form available |
| IRIS (Identification and Referral to Improve Safety) | 2โ3 items | GP (training model) | Evidence-based UK model adapted for Australian context |
How to Ask โ Conversational Framework
Recommended opening statements (adapt to context):
- "Because violence is so common in many people's lives, I now ask all my patients about it โ is that OK?"
- "Is there anyone at home who hurts you or makes you feel unsafe?"
- "Do you ever feel frightened by what your partner says or does?"
- "Has anyone forced you to do something sexually that you didn't want to do?"
Barriers to Disclosure
Multiple barriers prevent patients from disclosing abuse. Understanding these barriers enables clinicians to create a safer disclosure environment:
| Barrier Category | Specific Barriers | Clinician Response |
|---|---|---|
| Fear | Retaliation by perpetrator; fear of child removal; fear of police involvement; escalation of violence | Assure confidentiality within legal limits; emphasise patient autonomy; safety planning |
| Shame & self-blame | Internalised stigma; belief that abuse is deserved; cultural norms around family privacy | Normalise the conversation; affirm that abuse is never the victim's fault; use non-judgemental language |
| Practical dependence | Financial control; housing insecurity; immigration visa dependence; caring responsibilities | Refer to social work; link with housing, financial and legal support services; explore visa protections |
| Previous negative healthcare experiences | Not believed; feeling judged; forced police reporting; lack of follow-up | Acknowledge past experiences; explain what you can and cannot do; build trust over multiple consultations |
| Cultural & linguistic factors | Lack of interpreter access; patriarchal norms; LGBTQIA+ stigma; Indigenous cultural shame | Use professional interpreters (never family); culturally specific services; LGBTQIA+-affirming practice |
| Lack of recognition | Patient may not identify coercive control, psychological abuse or technology-facilitated abuse as violence | Psychoeducation about power and control dynamics; validate non-physical forms of abuse |
Safety first: Never ask about IPV when the suspected perpetrator is present in the room or waiting area. Ensure the consultation occurs in a private setting. Document findings securely โ consider using a coding system in the medical record (e.g., a neutral-sounding diagnosis code) rather than explicit terms that could provoke violence if the record is accessed by the perpetrator.
Documentation Principles
- Use the patient's own words (in quotation marks) wherever possible.
- Document objective findings: examination results, photographs (with consent), body maps.
- Record the patient's current safety status and any safety planning discussed.
- Note referrals made and follow-up plans.
- Be aware that clinical records may be subpoenaed โ write factually and avoid speculation.
- In some jurisdictions, coded entries can protect the patient if records are accessed by the abuser.
Cycle of Violence & Management Strategy
The Cycle of Violence
Lenore Walker's cycle of violence model (1979) describes three recurring phases that characterise many abusive relationships. Understanding this cycle is essential to explaining why patients may remain in, or return to, violent relationships โ a phenomenon that is often incomprehensible to those unfamiliar with IPV dynamics.
1
Tension-Building Phase
Increasing verbal abuse, criticism, controlling behaviour and minor physical aggression. The victim attempts to de-escalate by being compliant, avoiding triggers and managing the abuser's mood. Stress and anxiety mount. Duration: weeks to months.
2
Acute Violence Phase
The explosive episode of physical, sexual or severe psychological violence. This is the most dangerous period and the most likely time for serious injury or homicide. The victim has no control over the outcome. Duration: minutes to hours (may be prolonged).
3
Reconciliation / "Honeymoon" Phase
The abuser expresses remorse, promises change, is attentive and loving, minimises or denies the violence, or blames the victim. The victim, exhausted and hopeful, may forgive and return. Over time, this phase may shorten or disappear entirely as the cycle repeats and escalates.
Escalation risk: The cycle tends to become shorter and more violent over time. The most lethal period is often when the victim attempts to leave โ the "separation assault." This must be factored into safety planning.
Power and Control โ The Duluth Model
Beyond the cycle, the Duluth Model conceptualises IPV as a pattern of coercive control encompassing multiple tactics: intimidation, emotional abuse, isolation, minimising/denying/blaming, using children, economic abuse, male privilege (or equivalent power dynamics in LGBTQIA+ relationships), and coercion/threats. Clinicians should be aware that physical violence is only one dimension of abuse โ coercive control (now legislated as an offence in Queensland, Victoria, Tasmania, New South Wales, South Australia and the ACT) may be the predominant pattern.
Clinical Management Strategy
The clinician's role is not to "rescue" the patient or insist on leaving, but to provide non-judgemental support, information and referral while respecting the patient's autonomy. Forced action can increase danger.
1
Acknowledge & Validate
"I believe you." "This is not your fault." "You don't deserve this." Simple affirmations can be transformative for someone who has never been heard.
2
Assess Immediate Safety
Use the Danger Assessment Tool (Campbell) or similar lethality screening. Ask about access to weapons, strangulation history, threats to kill, stalking, escalation of violence, pregnancy and perpetrator's substance use. Strangulation is the strongest predictor of future intimate partner homicide.
3
Medical Assessment & Treatment
Full examination with consent. Document injuries. Treat acute injuries. Screen for mental health conditions (PHQ-9, GAD-7, PC-PTSD-5). Offer referral to a forensic medical examination if the assault was recent.
4
Safety Planning
Collaboratively develop a personalised safety plan. This may include: identifying safe rooms (rooms with exits, avoiding kitchens/bathrooms where weapons may be accessible); packing an emergency bag; securing important documents; identifying a code word with trusted contacts; planning escape routes; safe storage of evidence.
5
Referral Pathway
Provide referrals to specialist DV services, counselling (trauma-informed), legal aid (apprehended violence orders / family violence intervention orders), housing services and financial support. Always obtain consent before making referrals โ uncontrolled referral can escalate danger.
6
Ongoing Support
Schedule follow-up. Document the safety plan. Continue non-judgemental support regardless of the patient's decisions. Leaving is a process, not a single event โ it takes an average of 7 attempts.
Key Australian Referral Resources
| Service | Contact | Scope |
|---|---|---|
| 1800RESPECT | 1800 737 732 (24/7) | National sexual assault, DV and family violence counselling |
| Lifeline | 13 11 14 (24/7) | Crisis support and suicide prevention |
| MensLine Australia | 1300 78 99 78 | Counselling for men (victims and perpetrators) |
| QLife | 1800 184 527 | LGBTQIA+ peer support and referral |
| State/territory DV crisis lines | Varies (see 1800RESPECT for routing) | Crisis accommodation, court support, safety planning |
| Legal Aid (each state/territory) | legalaid.gov.au | Free legal advice, AVO/FVIO applications, family law |
Mandatory Reporting & Legal Obligations
Jurisdiction-specific mandatory reporting: In most Australian states and territories, mandatory reporting of child abuse applies to medical practitioners. Exposure to family violence constitutes child abuse in many jurisdictions. There is no general mandatory reporting obligation for adult IPV victims in any Australian jurisdiction, with the limited exception of gunshot wounds and certain injury patterns in some states. Clinicians must be familiar with their state or territory legislation:
- NSW: Children and Young Persons (Care and Protection) Act 1998 โ mandatory reporting of children at risk of significant harm.
- VIC: Children, Youth and Families Act 2005 โ mandatory reporting; also Family Violence Protection Act 2008.
- QLD: Child Protection Act 1999 โ mandatory reporting.
- WA: Children and Community Services Act 2004 โ mandatory reporting.
- SA: Children and Young People (Safety) Act 2017 โ mandatory reporting.
- TAS: Children, Young Persons and Their Families Act 1997 โ mandatory reporting.
- NT: Care and Protection of Children Act 2007 โ mandatory reporting.
- ACT: Children and Young People Act 2008 โ mandatory reporting.
Recent Sexual Assault: Clinical Approach
Definition & Scope
Sexual assault encompasses any sexual act committed without consent, including vaginal, anal or oral penetration with a penis, object or digit; attempted penetration; non-penetrative sexual acts (touching, kissing); and exposure to sexual acts. In Australian law, consent must be affirmative, voluntary and ongoing. Under recent legislative reforms in NSW (2022), Victoria, Tasmania, SA and the ACT, a person who does not say or do anything to indicate consent is taken not to have consented.
Most sexual assaults in Australia are perpetrated by someone known to the victim โ approximately 80% of female victims and 60% of male victims. Stranger assaults represent a minority of presentations.
Initial Clinical Approach โ The SAFE Framework
S
Safety & Support
Ensure the patient is in a safe environment. Offer a support person (friend, family, victim advocate) if desired. Do not leave the patient alone without their consent. Provide blankets, water, a quiet room. Offer a same-gender clinician if the patient requests one.
A
Assessment (Medical)
Primary survey: ABCs, vital signs, GCS. Identify and manage life-threatening injuries first. Secondary survey: head-to-toe examination for injuries, with documentation using body maps and photographs (with consent). Genital examination is performed with patient consent โ a chaperone should be offered.
F
Forensic Evidence Collection
Ideally performed within 72 hours (up to 120 hours or longer for some evidence types). Refer to a Sexual Assault Forensic Examination (SAFE) service or trained forensic examiner. If no specialist service is available, a trained GP or ED clinician can collect samples using a Sexual Assault Investigation Kit (SAIK). Chain of custody documentation is critical.
E
Emotional Support & Follow-Up Planning
Provide crisis counselling or arrange referral to 1800RESPECT or a Sexual Assault Service. Explain all management options. Arrange follow-up at 1โ2 weeks and 3 months. Provide written information (discharge summary). Assess suicide risk โ the period immediately post-assault carries elevated risk.
Consent & Patient Autonomy
Core principles:
- The patient has the right to accept or refuse any part of the clinical assessment, forensic examination or treatment โ including police reporting.
- Informed consent must be obtained for every step. Explain what each intervention involves, why it is recommended and what will happen to any samples collected.
- In most Australian jurisdictions, clinicians are not obligated to report adult sexual assaults to police without the patient's consent (exceptions apply for minors, persons with cognitive impairment, and certain weapon-related injuries).
- Forensic samples can be collected and stored (with patient consent) for a defined period, allowing the patient time to decide about police involvement โ this is called a "report without investigation" or "anonymous report" model in most jurisdictions.
Forensic Evidence Collection โ Time Windows
| Evidence Type | Optimal Window | Maximum Window | Notes |
|---|---|---|---|
| Body swabs (skin, hair) | Within 72 hours | Up to 7 days (with clinical justification) | Do not bathe or change clothes before collection if possible |
| Penile/genital/anorectal swabs | Within 72 hours | Up to 7 days | DNA evidence degrades rapidly |
| Clothing & foreign fibres | As soon as possible | Indefinite if stored correctly | Place each item in a separate paper bag |
| Blood alcohol / toxicology | Within 12โ24 hours | ~36 hours (alcohol); varies for drugs | Document time of last drink/ingestion; urine toxicology extends window |
| Urine sample | Within 72 hours | Up to 7 days (for drug detection) | Also used for pregnancy testing and STI screening |
| Nail scrapings / clippings | Within 72 hours | Up to 7 days | DNA from assailant under fingernails |
Emergency Contraception
Levonorgestrel
Postinor-2ยฎ, NorLevoยฎ, Levonelleยฎ ยท Emergency contraceptive
Adult dose
1.5 mg PO as a single dose โ within 72 hours of assault (most effective within 24 hours); efficacy reduced if BMI >30
Paediatric dose
Same dose as adult (post-pubertal)
Route
Oral
Renal adjustment
None required
Hepatic adjustment
Use with caution โ avoid in severe hepatic impairment
PBS status
Not PBS (available OTC at pharmacies; provided free at sexual assault services)
Ulipristal acetate
EllaOneยฎ ยท Selective progesterone receptor modulator
Adult dose
30 mg PO as a single dose โ within 120 hours (5 days) of assault; effective regardless of BMI
Paediatric dose
Not recommended <15 years (limited data)
Contraindications
Pregnancy (confirmed); severe asthma treated with oral corticosteroids
Drug interactions
Avoid with hormonal contraception for 5 days after use; may reduce efficacy of hormonal methods
PBS status
Not PBS (available OTC; provided free at sexual assault services)
An intrauterine device (copper IUD) inserted within 120 hours of assault is the most effective form of emergency contraception (failure rate <1%) and provides ongoing contraception. Offer this option where clinical services are available and the patient consents. This must be performed by a trained clinician.
Post-Exposure Prophylaxis for HIV (HIV PEP)
HIV PEP must be initiated within 72 hours of sexual assault โ ideally within 24 hours. Delay beyond 72 hours renders PEP ineffective. Refer to the local Sexual Health Service or infectious diseases team if PEP is indicated.
- Indication: Penetrative assault (vaginal or anal) by a perpetrator of unknown or HIV-positive status, particularly with mucosal trauma, concurrent STI, or known high-risk behaviours of the perpetrator.
- Regimen (Australian PEP guidelines): Tenofovir disoproxil 300 mg / emtricitabine 200 mg (Truvadaยฎ) PO ON + dolutegravir 50 mg PO ON for 28 days.
- Renal impairment (eGFR <50): Adjust tenofovir dose โ consult infectious diseases.
- PBS status: Authority Required โ PEP can be initiated before authority approval in emergencies.
- Follow-up: HIV baseline test (4th-generation Ag/Ab) at presentation; repeat at 4โ6 weeks and 12 weeks post-exposure. Hepatitis B, hepatitis C baseline and follow-up serology.
STI Testing/Prophylaxis Post-Assault & Ongoing Care
Baseline STI Testing (at Presentation)
The following baseline tests should be offered to all patients presenting after sexual assault, irrespective of the type of assault:
Essential
Nucleic acid amplification test (NAAT) โ Chlamydia trachomatis
First-void urine, vulvovaginal swab, rectal swab, or pharyngeal swab depending on exposure site. NPS MedicineWise preferred. Available in all Australian laboratories.
Essential
NAAT โ Neisseria gonorrhoeae
Multi-site testing (pharyngeal, rectal, urogenital) based on exposure. Culture recommended if pharyngeal or rectal (to guide treatment given increasing resistance). MBS item 69316.
Essential
HIV โ 4th-generation Ag/Ab assay
Baseline at presentation. Repeat at 4โ6 weeks and 12 weeks. MBS item 69348.
Essential
Syphilis โ RPR/VDRL + specific treponemal serology
Baseline and 3 months. Increasing incidence in Australia. MBS item 69384/69385.
Essential
Hepatitis B โ HBsAg, anti-HBs, anti-HBc
Baseline serology. If non-immune, commence vaccination. If unknown perpetrator or HBV-positive, administer hepatitis B immunoglobulin (HBIG) within 72 hours. MBS item 69344.
Essential
Hepatitis C โ anti-HCV
Baseline and 3 months (PCR if high risk). Transmission risk via sexual assault is low but not zero, particularly with mucosal trauma. MBS item 69358.
Available
Pregnancy test โ serum ฮฒ-hCG or urine hCG
All women of reproductive potential. Baseline and repeat at 2 weeks if emergency contraception was given.
Available
Trichomonas vaginalis โ NAAT or wet mount
Consider if vaginal discharge or dysuria present. Available through most sexual health laboratories.
Empirical STI Prophylaxis
Prophylactic antibiotics should be offered to all patients after sexual assault, even if baseline tests are pending. The following regimen is recommended per the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) guidelines:
Azithromycin
Zithromaxยฎ ยท Macrolide ยท Chlamydia prophylaxis
Adult dose
1 g PO as a single dose
Paediatric dose
>45 kg: 1 g PO stat; <45 kg: 20 mg/kg PO stat (max 1 g)
Route / frequency
Oral, single dose
Duration
Single dose (stat)
Renal adjustment
None required
Hepatic adjustment
Use with caution in severe impairment โ risk of cholestatic hepatitis
PBS status
โ PBS General Benefit
Doxycycline (alternative to azithromycin)
Doxyยฎ ยท Tetracycline ยท Chlamydia prophylaxis
Adult dose
100 mg PO BD for 7 days
Paediatric dose
>8 years: 2 mg/kg PO BD (max 100 mg BD) for 7 days; avoid <8 years
Route / frequency
Oral, twice daily
Duration
7 days
Renal adjustment
None required
Hepatic adjustment
Avoid in severe hepatic impairment
PBS status
โ PBS General Benefit
Ceftriaxone
Rocephinยฎ ยท 3rd-generation cephalosporin ยท Gonorrhoea prophylaxis
Adult dose
500 mg IM as a single dose (increase to 1 g IM if body weight โฅ90 kg or pharyngeal exposure)
Paediatric dose
25โ50 mg/kg IM stat (max 500 mg in <45 kg; use 500 mg in โฅ45 kg)
Route / frequency
Intramuscular, single dose
Duration
Single dose (stat)
Renal adjustment
None required
Hepatic adjustment
Use with caution โ monitor LFTs if hepatic impairment
PBS status
โ PBS General Benefit
Metronidazole (anaerobic cover)
Flagylยฎ ยท Nitroimidazole ยท Considered if vaginal/anal exposure
Adult dose
2 g PO as a single dose OR 400 mg PO BD for 7 days (if treating trichomoniasis)
Paediatric dose
15 mg/kg/day PO divided BD for 7 days (max 400 mg BD)
Route / frequency
Oral
Duration
Single dose (stat) or 7 days
Renal adjustment
None required for single dose; reduce by 50% in severe renal impairment for prolonged courses
Hepatic adjustment
Reduce dose by 50% in severe hepatic impairment
PBS status
โ PBS General Benefit
Hepatitis B Post-Exposure Management
| Patient HBV Status | Perpetrator Status | Management |
|---|---|---|
| Previously vaccinated (anti-HBs โฅ10 IU/L) | Any | No further action required |
| Unvaccinated or non-immune | HBV-positive or unknown | Hepatitis B immunoglobulin (HBIG) 400 IU IM within 72 hours + commence HBV vaccination schedule (0, 1, 6 months) |
| Unvaccinated | HBV-negative (documented) | Commence HBV vaccination โ can be given as part of catch-up schedule |
Follow-Up Schedule
Presentation (Day 0)
Medical stabilisation. Informed consent for forensic examination. Baseline STI screen (NAAT for chlamydia/gonorrhoea, HIV 4th-gen Ag/Ab, syphilis, hepatitis B/C serology, pregnancy test). Empirical STI prophylaxis. Emergency contraception. HIV PEP if indicated (within 72 hours). Hepatitis B immunoglobulin + vaccine if non-immune. Safety assessment and crisis support. Document and refer to Sexual Assault Service.
1โ2 weeks
Review STI results. Review HIV PEP adherence and tolerability if commenced. Psychological wellbeing check (PHQ-2, safety screen). Referral for ongoing counselling if not already in place. Address any ongoing medical concerns. Confirm contraception status. Hepatitis B vaccine dose 2 if commenced.
6 weeks
HIV 4th-generation Ag/Ab repeat (if PEP taken, test 4โ6 weeks after PEP completion). Hepatitis C antibody if risk factors present. Syphilis serology. Psychological assessment โ screen for PTSD (PC-PTSD-5), depression (PHQ-9), anxiety (GAD-7).
3 months (12 weeks)
Final HIV test (12 weeks post-exposure). Hepatitis C antibody repeat (if applicable). Syphilis serology repeat. Final STI screen if indicated. Psychological review and referral for ongoing treatment if needed. Hepatitis B vaccine dose 3 (month 6). Confirm seroconversion post-vaccination (anti-HBs at month 7).
6โ12 months (if indicated)
Ongoing psychological support. Hepatitis B seroconversion check if deferred. Repeat STI screening if new sexual contacts or ongoing risk. Long-term safety reassessment for those still in abusive situations.
Ongoing Care โ Psychological & Psychosocial
The long-term health impacts of IPV and sexual assault are substantial. Australian studies report significantly elevated rates of:
- Major depressive disorder (OR 2.0โ3.5)
- Post-traumatic stress disorder (OR 3.0โ6.0)
- Anxiety disorders (OR 2.0โ4.0)
- Substance use disorders (OR 1.5โ3.0)
- Chronic pain syndromes โ fibromyalgia, chronic pelvic pain, chronic headache
- Gastrointestinal conditions (IBS, functional dyspepsia)
- Reproductive health complications โ unplanned pregnancy, STIs, chronic pelvic inflammatory disease
- Suicidality โ lifetime suicide attempts are 3โ9 times more common among IPV survivors
Clinicians should offer a trauma-informed approach in all subsequent healthcare encounters. This includes: recognising the impact of trauma; avoiding retraumatisation during examinations; offering patient choice and control; providing clear explanations; and using collaborative, strengths-based language.
Medicare-funded counselling: Under a Mental Health Treatment Plan (MHTP, MBS item 721), patients are eligible for up to 10 individual and 10 group psychological therapy sessions per calendar year (via referral to a psychologist, social worker or occupational therapist). Additional sessions may be available through state-funded Sexual Assault Services at no cost to the patient.
Special Populations
Pregnancy
IPV often escalates during pregnancy โ antenatal screening with the AAS tool is recommended at first antenatal visit and each trimester.
Physical abuse during pregnancy is associated with placental abruption, preterm birth, low birth weight and maternal/fetal death.
Emergency contraception is not applicable if pregnancy is confirmed, but termination of pregnancy should be discussed as an option if desired (available in all Australian states and territories under recent legislative reforms).
Azithromycin โ considered safe in pregnancy (Category B1); preferred over doxycycline for chlamydia prophylaxis.
Ceftriaxone โ safe in pregnancy for gonorrhoea prophylaxis.
HIV PEP โ tenofovir/emtricitabine + dolutegravir can be used in pregnancy; consult infectious diseases.
Involve obstetric social work early. Perinatal mental health services should be linked in for all affected pregnant patients.
Paediatrics & Adolescents
Children exposed to family violence (even without direct physical harm) are at increased risk of developmental delay, behavioural problems, mental health conditions and intergenerational violence.
Adolescents may experience dating violence โ the ABS reports ~20% of young Australians aged 18โ24 have experienced violence from a dating partner.
Sexual assault in children requires specialist paediatric forensic examination (via child protection units). Mandatory reporting applies in all jurisdictions.
Azithromycin โ dose: 20 mg/kg PO stat (max 1 g) for chlamydia.
Ceftriaxone โ dose: 25โ50 mg/kg IM stat (max 500 mg) for gonorrhoea.
HIV PEP โ use paediatric formulations; consult infectious diseases/paediatric HIV specialist.
Emergency contraception โ levonorgestrel 1.5 mg PO stat (same adult dose, post-pubertal); copper IUD if โฅ16 years and suitable facility available.
Involve multidisciplinary child protection teams. Consider the child's developmental stage when explaining procedures. Always obtain appropriate consent (Gillick competence for mature minors).
Elderly Patients
Elder abuse (physical, psychological, financial, neglect) by intimate partners or adult children is a significant and under-recognised form of family violence in Australia โ estimated to affect 2โ14% of older Australians.
Presentation may mimic frailty, falls or cognitive decline. Clinicians should be alert to unexplained injuries, malnutrition, dehydration, medication mismanagement and social withdrawal.
Patients with cognitive impairment may be unable to give a clear history โ corroborate with collateral from trusted sources.
HIV PEP โ tenofovir requires renal dose adjustment (eGFR monitoring). Avoid in eGFR <30; use alternative regimen.
Mandatory reporting of elder abuse varies by jurisdiction. The Australian Law Reform Commission's 2017 report recommended a national approach, but legislation remains state-based. Contact Older Persons Advocacy Network (OPAN) on 1800 700 600.
Renal Impairment
Tenofovir disoproxil โ contraindicated in eGFR <30 mL/min; dose reduction for eGFR 30โ50. Use tenofovir alafenamide (TAF)-based PEP regimen under specialist guidance.
Metronidazole โ reduce dose by 50% in severe renal impairment.
Azithromycin, ceftriaxone, doxycycline โ no dose adjustment required.
Monitor renal function during PEP. Consult infectious diseases for complex cases.
Hepatic Impairment
Dolutegravir โ no dose adjustment in mild-moderate hepatic impairment; caution in Child-Pugh C.
Azithromycin โ caution in severe hepatic impairment (cholestatic hepatitis risk).
Metronidazole โ reduce dose by 50% in severe hepatic impairment; risk of encephalopathy.
Paracetamol โ used for pain management; max 2 g/day in severe hepatic impairment (standard 4 g/day otherwise).
Hepatotoxicity monitoring during PEP โ baseline and 4-week LFTs recommended.
Immunocompromised
HIV PEP is essential in this population โ even lower-risk exposures should trigger a low threshold for PEP initiation.
Hepatitis B and hepatitis C transmission risk is higher โ ensure HBV vaccination and HBIG as indicated.
Herpes simplex virus (HSV) โ consider aciclovir prophylaxis if there is a history of genital herpes and significant mucosal exposure.
HPV vaccination โ if non-immune and not previously vaccinated, offer catch-up HPV vaccination (Gardasil 9ยฎ) โ funded under NIP for individuals aged 12โ25; available (non-PBS) for older individuals.
Refer to infectious diseases for comprehensive post-exposure management. CD4 count and viral load monitoring if HIV-positive patient is exposed to assault.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Family violence is one of the most pressing health and social issues facing Aboriginal and Torres Strait Islander communities. According to the AIHW (2024), Aboriginal and Torres Strait Islander women are 3.1 times more likely to experience physical violence from a partner and 5 times more likely to be victims of homicide (most commonly by a current or former partner) compared with non-Indigenous women. Aboriginal and Torres Strait Islander men also experience higher rates of family violence as both perpetrators and victims.
Violence in Indigenous communities cannot be understood outside the context of colonisation, intergenerational trauma, the Stolen Generations, systemic racism, socioeconomic disadvantage, overcrowded housing, and the disruption of cultural and kinship structures. Trauma-informed, culturally safe, community-led approaches are essential.
Key practice points for all clinicians:
- Engage Aboriginal and Torres Strait Islander health workers in the care team wherever possible.
- Use culturally appropriate screening tools and conversation approaches โ avoid direct, blunt questioning if culturally inappropriate.
- Prioritise establishing trust and rapport over rapid disclosure โ relationship-based practice is central to Indigenous healthcare.
- Be aware of the historical context of forced child removal and its ongoing impact on trust in government services, including health services.
- Refer to local ACCHO-based family support programs and FVPLS where available.
- Recognise that healing from intergenerational trauma requires a holistic approach addressing social, emotional, cultural and spiritual wellbeing โ the "social and emotional wellbeing" (SEWB) framework.
๐ References
- 1. Australian Institute of Health and Welfare (AIHW). Family, Domestic and Sexual Violence in Australia: Continuing the National Story 2024. Canberra: AIHW; 2024.
- 2. Australian Bureau of Statistics (ABS). Personal Safety Survey, Australia, 2021โ22. Cat. No. 4906.0. Canberra: ABS; 2023.
- 3. The Royal Australian College of General Practitioners (RACGP). Abuse and Violence: Working with our Patients in General Practice (White Book). 4th edn. Melbourne: RACGP; 2014.
- 4. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Post-Exposure Prophylaxis (PEP) Guidelines โ Expert Reference Group Consensus Statement. Sydney: ASHM; 2023.
- 5. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Sexual Assault Prophylaxis Guidelines. Sydney: ASHM; 2021.
- 6. Campbell JC, Webster DW, Glass N. The danger assessment: validation of a lethality risk assessment instrument for intimate partner femicide. J Interpers Violence. 2009;24(4):653โ674.
- 7. Walker LE. The Battered Woman. New York: Harper & Row; 1979.
- 8. Australian Government Department of Social Services. National Plan to End Violence against Women and Children 2022โ2032. Canberra: Australian Government; 2022.
- 9. National Aboriginal Community Controlled Health Organisation (NACCHO). Social and Emotional Wellbeing Framework: A National, Culturally Validated Framework for Aboriginal and Torres Strait Islander People. Canberra: NACCHO; 2020.
- 10. Organisation Mondiale de la Santรฉ (WHO). Responding to Intimate Partner Violence and Sexual Violence against Women: WHO Clinical and Policy Guidelines. Geneva: WHO; 2013.
- 11. Feder G, Ramsay J, Dunne D, et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess. 2009;13(16):iiiโiv, 1โ113.
- 12. Aboriginal and Torres Strait Islander Healing Foundation. Restoring the Soul of Our Communities โ Healing in Aboriginal and Torres Strait Islander Communities. Canberra: Healing Foundation; 2022.
- 13. Council of Australian Governments (COAG) Advisory Panel on Reducing Violence against Women and their Children. Final Report to the Council of Australian Governments. Canberra: COAG; 2016.
- 14. Hegarty K, Bush R, Sheehan M. The Composite Abuse Scale: further development and assessment of reliability and validity of a multidimensional partner abuse measure in clinical settings. Violence Vict. 2005;20(5):529โ547.
- 15. Australian Institute of Criminology (AIC). National Homicide Monitoring Program: Homicide in Australia 2022โ23. Statistical Report No. 44. Canberra: AIC; 2024.