Sexual Assault, Behavioral Health & Emergency Medicine: 3 Perspectives on New Research

Nearly 2 million adolescents in the United States have been sexually abused, and each year thousands of children and adolescents are the victims of sexual assault. The emergency department (ED) is often the first place these youth seek care. Mental health services, such as therapy and psychiatric hospitalization, can help victims cope with issues related to post-traumatic stress disorder (PTSD), anxiety, and depressive disorders that follow sexual assault, but it is critical that we link youth to these services as quickly as possible after their initial ED visit.

Unfortunately, even when ED physicians make referrals to mental health services for patients who have experienced sexual assault, prior research has demonstrated few youth attend these follow-up appointments. We also know that, in general, patients who come to the ED with a behavioral health concern are likely to return with similar complaints. So, it’s quite possible that victims of sexual assault who have pre-existing mental health issues may be at a particularly high risk of returning to the ED after the assault, though to date this has just been anecdotal.

Therefore, we designed a study to investigate how frequently youth who have been sexually abused return to the ED for a behavioral health issue. What we learned at our own hospital—which has a dedicated sexual assault response team and cares for approximately 100 pediatric victims of sexual assault annually—was shocking. Among the 192 patients in our study, 25% returned to the ED for a behavioral health issue, including suicidal ideation, attempted suicide, depression, anxiety and aggression. Interestingly, though, we found that if a patient had a behavioral health concern or diagnosis at the time of their first assault evaluation, this did not increase their likelihood of returning to the ED. This suggests that adolescents who are victims of sexual assault are at such high risk for subsequent behavioral health issues that a prior history isn’t a key risk factor.

It’s important to note that our sample size was small, so a larger study could find a relationship. In any case, we believe we uncovered a sub-group of patients that require more care, supervision, education and protection than they may be receiving.

The findings of this study—although small and from a single health care system—are a clear reminder that we aren’t doing enough to address the concerns of teen sexual assault victims during their initial trip to the ED and/or at future visits. Let’s delve into three perspectives on why this could be the case and how we can address this problem.

The need to develop appropriate, simple follow-up care plans – Cynthia Mollen, MD, MSCE

In the ED, a key component of any care we provide is connecting our patients to follow-up services. We know that there is a limit to the amount of information any patient or family can absorb, particularly during a time of high stress, and EDs are not set up to provide counseling or initiate long-term medication for depression or anxiety, for example. Therefore, the most important step for an ED provider is ensuring patients have a follow-up care plan for when they leave. This could simplify a process that families can find confusing, time-consuming, and at times frustrating, depending on available resources in their community.

Developing follow-up care plans becomes particularly important for ED providers who care for sexually assaulted youth. Given their vulnerability and their chances of experiencing future behavioral health issues, follow-up care plans for these youth should be appropriate and simple to ensure they receive psychiatric follow-up. This could include building a relationship with a local behavioral health specialist, developing a phone follow-up system to check-in on patients or using the electronic medical record to share information with the patient’s other health care providers.

The need to improve access to outpatient behavioral health resources – Wes Geddings, MD

The strain on EDs nationwide continues to increase as the number of children and teens who present for behavioral health concerns rises annually. An important subgroup of these youth are those who have experienced sexual assault. The weight of this increase ripples through the ED to all levels of psychiatric care, leading to overwhelmed inpatient psychiatric hospitals, which can provide close, 24/7 observation to maintain a patient’s safety. However, due to limitations in providing individualized treatment plans and a lack of inpatient hospital beds, ED providers are more and more having to refer this vulnerable patient population for outpatient behavioral health care.

Outpatient behavioral health resources can range from seeing an individual therapist on a weekly basis all the way to engaging in a partial hospitalization program with daily group and individual therapy, and anything in between. Unfortunately, patients and families often encounter difficulty in accessing these outpatient settings, with barriers ranging from navigating their insurance (as some services are only provided by certain plans) to finding appropriate resources in a timely fashion. The quickest interventions, which include inpatient hospitalization and, to a lesser extent, partial hospitalization, tend to be more restrictive and less individualized. However, patients will frequently use these options as bridges to more personalized therapy and psychiatric treatment, especially if they are having difficulties getting outpatient care.

The trend of youth visiting the ED for behavioral health concerns is likely to continue in the coming years, including for victims of sexual assault. Without improvement in outpatient resources, such as increasing the number of providers available and services covered by all insurance plans, providers and families can continue to expect inpatient behavioral health hospitals to feel the overwhelming strain of too many patients with too few treatment options.

Dr. Geddings is an attending physician in the Department of Child and Adolescent Psychiatry and Behavioral Science at the Children’s Hospital of Philadelphia.

The need to increase awareness of existing integrated, trauma-focused care solutions – LTC Brian Brennan, MD

As stated earlier, victims of child sexual abuse and assault are at a significantly higher risk of serious and, oftentimes, debilitating mental health disorders, as well as chronic physical ailments. The matter of coordinating the long-term care needs of these youth has long been a source of frustration for busy and ill-equipped EDs and primary care offices.

The solution to this problem in many counties has been to establish and utilize Child Advocacy Centers (CACs). CACs function as centralized locations wherein police, child protective services, victim advocates and medical personnel work in concert to provide these children and their families with needed resources and facilitate investigations. In many CACs, trauma-focused mental health services are available for both the victim and the family. These services are recommended and coordinated by the child’s assigned victim advocate, who is typically a social worker designated to help guide the family through these stressful times. In CACs without embedded mental health providers, victim advocates are able to offer guidance and support to families in order to locate appropriate trauma-focused mental health services in the community. Though most child protective services agents and police officers are aware of the existence of CACs in their community, it is helpful for medical providers treating these children to shepherd their families to their community CAC as well.

Dr. Brennan is a third year Child Abuse Pediatrics fellow at the Children’s Hospital of Philadelphia. 

The Need to Work Together

In summary, victims of sexual assault are at high risk for ongoing mental health issues, including depression, anxiety and PTSD. Despite a clear need for ongoing mental health care, many of these patients unfortunately lack access to adequate support and resources in our current medical system due to a limited number of trained providers and outpatient programs. Providers and health system administrators need to identify feasible collaborations to improve access to care and resources for these patients. We must also continue to seek evidence-informed solutions to provide the best care possible to these vulnerable youth.

Instead of approaching this crisis from siloed platforms, we can start by engaging local advocates, and emphasizing the importance of prioritizing funding to connect sexual assault victims to appropriate resources. Furthermore, we need to raise awareness of the behavioral health and public health crises facing sexual assault victims. In doing so, we hope to encourage connectivity and collective problem solving across various disciplines, institutions and communities, enabling stakeholders to devise creative solutions to a crisis that has reached a tipping point in our fractured health care system.

Elizabeth Robinson completed this study with the guidance of Dr. Cynthia Mollen and Tara Ketterer as part of her senior thesis as an undergraduate at Bryn Mawr College. She is currently researching Type 1 Diabetes at Columbia University.