Physicians and nurses working in the ED are often the first to recognize sings of sexual abuse and identify children currently being abused. Although these emergency medicine professionals can serve medical, criminal justice, and protective roles in caring for such vulnerable patients, data are limited on the frequency with which children are admitted to the ED for sexual abuse. To observe patterns among children admitted to the ED for sexual abuse across the US and examine important subgroup characteristics based on demographic and primary payer data, Jesse J. Helton, PhD, and colleagues analyzed data from the Nationwide Emergency Department Sample of the Healthcare Cost and Utilization Project from January 2010 to December 2016, publishing their results in JAMA Pediatrics.

The team created a dichotomous sexual abuse variable based on ICD-9 and -10 diagnostic codes, calculated the number of all ED admissions for child sexual abused by year, and used national population data from the US Census Bureau to calculate rates of sexual abuse per 100,000 children younger than 18. The frequency of all children admitted to the ED each year was also examined by sex, age, and primary payer, which allowed Dr. Helton and colleagues to observe patterns among key subgroups of the sample.

Trends Unique to the ER

Among more than 190 million children admitted to EDs in the US during the 16-year study period, nearly 47,000 were admitted for confirmed sexual abuse, 85.14% of whom were girls, 44.75% were aged 12-17, and 55.91% were insured through a primary payer on Medicaid or Medicare. From 2010 to 2016, ED admissions for child sexual abuse increased from 5,138 to 8,818, or from 6.93 to 11.97 admissions per 100000 children younger than 18 (Figure).

“By far, the most important finding from our study is the increasing rate of child sexual abuse cases seen in the ED over time,” explains Dr. Helton, “which is the opposite of the trend we see in sexual abuse investigations nationally, with which we’ve seen a precipitous drop since the mid-1990s. As overall rates of child sexual abuse are decreasing, the rates in ERs are increasing.”

The researchers speculate that the increased rate may be associated with increases in the number of adolescents admitted to the ED during the study period, which grew from 44.77% in 2010 to 57.36% in 2016, or from 8.02 to 20.20 ED admissions per sexual abuse per 100,000 adolescents in the US. Dr. Helton adds that the sex differences seen in the study are historically consistent as well as consistent with difference in the general population. “The increase in cases over time is almost completely driven by adolescent girls,” he adds.

Important Implications

Dr. Helton notes that, while the paper is the first to show an upward trend in child sexual abuse cases over time in the ED, the findings should not be generalized to all children in the US outside the ED. “When we’ve talked with emergency physicians, they have anecdotally confirmed this increase in number of youth coming to the ER for sexual abuse,” he says. “There has also been a more concerted effort in the last 5-10 years to make sure all those who work in the ED are aware of how to handle children who have been sexually abused.”

The findings indicate a need for additional research to answer several key questions, according to Dr. Helton:

  • Are EDs, especially in rural areas, equipped to handle sexual abuse?
  • Are social workers available in the ED, are referrals provided to follow-up care, and how involved is child protective services?
  • Are emergency physicians and nurses trained well enough to identify these potential victims?
  • Are EDs administering the correct type of medical services, such as testing for STIs and mental healthcare?

In the meantime, Dr. Helton hopes hospitals ensure their ERs have everything needed to handle pediatric sexual abuse cases. “From sexual assault nurse examiners to social workers, a child who presents to the ED with sexual abuse deserves a continuum of care, from physical examination and treatment to emotional and social support to heal,” he adds.