Unmet Health Care Needs Among Children Evaluated for Sexual Assault FREE

A reported 1.2 in 1000 children in the United States were sexually abused in 2000 through 2002.¹ Many of these children underwent a medical examination after sexual assault, with the 2-fold purpose of ensuring the health of the child and documenting any injuries or other evidence that may support the allegation. Because access to health care remains a major problem for children in the United States, with approximately 9% being uninsured in the first half of 2004,² many children seen for a sexual assault evaluation may have had limited prior contact with the health care system. Furthermore, children from abusive households are at potentially greater risk for inadequately addressed health needs than is the general pediatric population. While extensive literature exists concerning the incidence of forensic findings in children examined after an allegation of sexual assault, contemporary studies that examine the prevalence of unmet health care needs in this population are unavailable. The primary objective of this study was to determine in a population of children examined after alleged sexual assault the number who had other health care needs that warranted intervention at the time of the sexual assault evaluation.

The secondary objective of this study was to determine the prevalence of forensic evidence of sexual assault in our population. Many children seen for a sexual abuse evaluation are brought by parties whose primary interest is the detection and preservation of forensic evidence. The reported incidence of such findings, however, is low. In their study of 2384 children seen at a tertiary referral center for alleged sexual assault, Heger et al³ found that less than 4% had forensic evidence and only 0.6% had a sexually transmissible disease, even though approximately two thirds reported penetration of the vagina or anus. Studies by Adams et al,⁴ Kellogg et al,⁵ and Bowen and Aldous⁶ support these findings. The recovery of laboratory evidence in acute rape settings is also likely to be low in children, although, to our knowledge, only one published study to date has addressed this question and modern DNA amplification techniques were not used in the analysis of the samples.⁷ We compared the prevalence of unmet health care needs with the prevalence of forensic findings in our population of children examined after an alleged sexual assault.

Institutional review board approval for this study was obtained from the University of Texas Health Sciences Center Committee for the Protection of Human Subjects. This was a retrospective review of medical records from a clinic located in a child advocacy center, which is a tertiary referral center for sexually abused children. The mission of the clinic is to provide comprehensive health care for sexually abused children; therefore, for all children seen at the clinic a complete medical history was obtained, and a physical examination was performed and the results recorded on a detailed standardized form. The medical examinations were performed by 3 board-certified pediatricians (R.G., S.L., and M.M.) specializing in sexual assault. Videocolposcopy was routinely used for the anogenital portion of the examination. Laboratory specimens for sexually transmissible infections were collected when the patient history or physical findings suggested that there was a risk for disease according to the Centers for Disease Control and Prevention 2002 sexually transmitted diseases treatment guidelines.⁸ For children who had been assaulted within the previous 72 hours, additional specimens for forensic laboratory evaluation (rape evidence collection) were collected and turned over to law enforcement personnel for processing. The clinic physicians (R.G., S.L., and M.M.) conducted monthly peer review of medical records according to clinic policy.

The medical records of all sexual assault evaluations performed during the study period (December 1, 2003, through April 30, 2004) were reviewed. Three of us (R.G., L.G., and K.B.) abstracted the data for this study, with oversight of all abstraction by the lead author (R.G.). Basic demographic information, referral source, time since the alleged assault, history of prior sexual contact, anogenital findings, laboratory test results, and nonforensic diagnoses (medical and psychological) were abstracted from each medical record. Only diagnoses that were judged by the physician to require intervention at the time of the evaluation were recorded.

Both the physical findings at examination and the results of laboratory tests for sexually transmissible diseases were considered in determining the evidence for sexual abuse. The criteria published by Adams⁹ in 2004 were used to categorize the children’s anogenital examination findings and the likelihood of abuse. An additional category, “probable sexual contact,” was also included for patients whose findings did not fall within one of the Adams categories but for whom sexual contact was considered by the authors to be the most likely cause.

Four hundred seventy-three children (81% girls) were brought to the advocacy center for a sexual assault examination during the study period. The children ranged in age from 2 months to 17 years; 157 children (33%) were 13 years or older. Two hundred fifty-nine children were referred for examination by Children’s Protective Services, 210 children were referred by law enforcement personnel, and the remaining 4 children were referred directly by their medical providers. Nine children received incomplete evaluations: no medical history was available and no medical evaluation was performed in 1 child with autism; a complete medical history was obtained in 2 children, but all components of the physical examination were refused; and 6 children gave a medical history but consented to only part of the medical examination or laboratory testing. A rape evidence collection kit was used in 22 children.

A medical or psychological diagnosis that warranted intervention by the examiner was made in 123 children (26% of the total who underwent at least a partial medical evaluation) (95% confidence interval, 22%-30%) (Table 1). Six children had medical diagnoses that could be attributed to sexual abuse, and 18 children had a psychological diagnosis. Thirty-nine children (representing 8% of the total evaluated) (95% confidence interval, 6%-11%) had a diagnosis with the potential to result in significant morbidity if not immediately addressed, including anemia, exacerbation of asthma, Chlamydia infection, depression without suicidal ideation, gonorrhea, menometrorrhagia, metrorrhagia, pelvic inflammatory disease, perforated tympanic membrane, pregnancy, secondary amenorrhea, self-mutilation, splenomegaly, suicidal ideation, suspected fistula, suspected pathologic heart murmur, suspected premature adrenarche, suspected pseudocyesis, and urinary tract infection. In contrast, 44 children (9% of those who underwent at least a partial anogenital examination) (95% confidence interval, 7%-12%) had physical or laboratory findings that potentially or definitively supported the allegation of sexual assault (Table 2).

Fourteen of 22 children who underwent rape evidence collection were in the group of 44 children with evidence supportive of the allegation of sexual assault. The remaining 8 children who underwent rape evidence collection had no or only nonspecific physical findings to support the allegation of sexual abuse and no diagnosis of a sexually transmissible disease. Results of forensic analyses of the evidence kits were unavailable.

Medical diagnoses significantly outnumbered forensic findings in our population (26% vs 9%), and the number of children with a serious diagnosis was almost the same as the number with assault-related findings (8% vs 9%). These results indicate that sexually abused children are at high risk for unmet health care needs. This study was conducted in the southern United States, where the proportion of children with inadequate access to health care is greater than in some other parts of the United States.¹⁰ The number of children in our study with unmet health care needs might, therefore, have been different had it been conducted in another region of the United States.

Twenty-two of the children in our study underwent rape evidence collection as part of the medical evaluation, and of these, 8 children had no physical findings or laboratory diagnosis to support the allegation of sexual abuse. Rape kits are processed by police laboratories only when requested by the judicial system. Because this process often takes months or even years in pediatric cases, an attempt to learn the outcome of these 8 kits was not made. However, even if all 8 kits contained evidence of sexual assault, the number of children with forensic evidence would have been only 11% (52 children) of the total, which is significantly lower than the number with unmet health care issues.

Our results should be of interest to medical providers, Children’s Protective Services workers, foster families, and others who must be vigilant for the potential health care needs of sexually abused children. Our results also have implications for medical facilities that provide sexual assault evaluations for children. Many centers rely on nonphysician health care providers who are not independently licensed to perform sexual assault evaluations. While many of the diagnoses recorded during the study were nonemergent, that the number of children with serious diagnoses was almost the same as the number with forensic evidence indicates that this population requires comprehensive medical care in addition to having their forensic concerns addressed. Institutions that rely on extended care providers must provide careful medical oversight of sexual assault evaluations in children.

Our data also point to the need for systems that provide services to sexually abused children to carefully consider how best to meet the ongoing health care needs of this vulnerable population. We are unable to discern from our data the number of children in our population who had received inadequate medical care compared with the number who were receiving good care but happened to have an acute need on the day that we examined them. However, the high prevalence of unmet medical and psychological needs in our population suggests that at least a proportion of these children lack a “medical home.” Because of their interdisciplinary design, advocacy centers that provide ongoing comprehensive medical care in addition to initial sexual assault evaluations are one solution to this problem. Ideally, the community outreach efforts of such centers can then facilitate communication with primary care physicians and, thus, provide for more permanent medical homes for these children.

Children seen for medical evaluations after alleged sexual assault are a population at risk for inadequately met health care needs, yet the systems in place to care for them are sometimes focused on the collection and documentation of potential forensic evidence rather than on medical care. To our knowledge, this study is the first to document the health care needs of this population. Unmet health care needs can be substantial in this population at high risk and should be considered in the structuring of systems designed to provide medical services for sexually abused children.

Correspondence: Rebecca Girardet, MD, University of Texas at Houston School of Medicine, 6431 Fannin St, MSB 3.156B, Houston, TX 77030 (Rebecca.g.girardet@uth.tmc.edu).

Accepted for Publication: June 29, 2005.

Acknowledgment: Data from the National Child Abuse and Neglect Data System Child File, 2002, were provided by the National Data Archive on Child Abuse and Neglect at Cornell University, Ithaca, NY, and are used with permission. Data were originally collected under the auspices of the Children’s Bureau, Administration on Children, Youth and Families, Administration for Children and Families, US Department of Health and Human Services, Washington, DC.