Preadolescents and adolescents who are enrolled in Medicaid and seek reproductive health services have an elevated likelihood of being abused or engaging in criminal behavior, both before and after their reproductive health visits, according to a recent cross-sectional analysis of Alaskan public health databases.1 The study revealed that female Medicaid enrollees aged 10–15 who sought pregnancy care, abortions or contraceptives had more than double the odds of other Medicaid enrollees in the same age-group of being victims of sexual abuse by a caregiver during the five-year study period. They also had increased risks of physical abuse and referral to the juvenile justice system for theft and other criminal offenses.
Prior research has shown that adolescents who have been physically or sexually abused are at risk for pregnancy. To explore whether clinicians who provide reproductive health care to young female patients should screen them for abuse and exposure to violence, the researcher conducted a cross-sectional analysis of several Alaskan databases: a data file of all females who were enrolled in Medicaid at any point in 1999–2003 and who were 10–15 years old on December 31 of any study year; a database of all females in that age-group who were referred to the state's child protective services unit for investigation of physical or sexual abuse by a primary caregiver in 1999–2003; a similar database for referrals to the state's juvenile justice system; and a database of births to Alaskan residents. By linking the databases, the investigator was able to determine whether young women for whom Medicaid claims for reproductive health services (contraceptive management, pregnancy or pregnancy termination) had been submitted had also been the victim of suspected or documented abuse or had been referred for criminal offenses. Odds ratios for these outcomes were calculated using logistic regression.
A total of 21,350 females aged 10–15 were enrolled in Alaska's Medicaid program at some point during the study period. Billing records indicated that 2% of these young women had been pregnant (about half of whom had a documented or suspected abortion) and 3% had sought contraceptive services. (Pregnancy tests were not included in the analysis because these tests are sometimes done for medical reasons, such as presurgical evaluation.) Fourteen percent of the Medicaid enrollees were referred to child protective services between 1999 and 2003, and 4% were the victims of physical or sexual abuse. The juvenile justice system received one or more referrals for 9% of enrollees; 60% of these young women were referred for theft, 30% for assault or other violent offenses, 12% for drugs or alcohol and 12% for other reasons. Of the 841 young women who had a reproductive health claim, 39% were referred to child protective services and 31% to the juvenile justice system during the study period.
In logistic regression analyses that controlled for age at Medicaid enrollment, length of enrollment, Alaska Native status and Anchorage residence, young women with a reproductive health claim were more likely than other Medicaid enrollees to be referred for any reason to child protective services (odds ratio, 2.9) or to have experienced physical (1.6) or sexual abuse (2.3) during the study period. The odds of physical abuse were especially elevated among young women who had an abortion (2.3); those who had received pregnancy care had particularly high odds of sexual abuse (3.2). One-fourth of referrals for physical or sexual abuse were made within the month preceding or following the young women's first claim for reproductive health services; 60% were made within six months before or after the claim.
Young women with reproductive health claims were also more likely than other Medicaid enrollees to be referred to the juvenile justice system for any criminal offense (odds ratio, 2.9), for a violent offense (3.1) or for theft (2.4).2 Odds ratios were slightly higher among individuals who desired contraceptive management (2.5–3.0) than among those who sought services for pregnancy (2.1–2.6) or abortion (2.1–2.5). Twenty-five percent of referrals were made within three months of young women's first reproductive health claim, and 63% were made within 12 months.
These findings may not be generalizable to preadolescents and adolescents who are ineligible for Medicaid, the researcher notes, because poverty may increase a young woman's risk of abuse, criminal activity and early sexual initiation. In addition, the findings may not apply to states that differ from Alaska in their ethnic makeup and provision of services.
Many cases of criminal behavior and abuse occurred well before or after young women sought reproductive health care, suggesting that "sexual activity in this cohort often occurred within a general context of ongoing social disruption," the researcher notes. Nonetheless, the findings suggest that health care providers "should have a high index of suspicion" when a female Medicaid recipient younger than 16 presents for reproductive health services. "Clinicians providing care to this population should consider routine screening for sexual activity and experience of violence and should adhere to mandatory reporting laws when child maltreatment is suspected or identified," he advises.—P. Doskoch
1. Gessner BD, Reproductive health, criminal activity, and abuse among 10- to 15-year-old females enrolled in Medicaid, Obstetrics & Gynecology, 2006, 108(1):111–118.2. Errata, Obstetrics & Gynecology, 2006, 108(4):1035.
2. Errata, Obstetrics & Gynecology, 2006 108(4):1035