Abstract
Objectives. To report trends in sexual violence (SV) emergency department (ED) visits in the United States.
Methods. We analyzed monthly changes in SV rates (per 100 000 ED visits) from January 2017 to December 2019 using Centers for Disease Control and Prevention’s National Syndromic Surveillance Program data. We stratified the data by sex and age groups.
Results. There were 196 948 SV-related ED visits from January 2017 to December 2019. Females had higher rates of SV-related ED visits than males. Across the entire time period, females aged 50 to 59 years showed the highest increase (57.33%) in SV-related ED visits, when stratified by sex and age group. In all strata examined, SV-related ED visits displayed positive trends from January 2017 to December 2019; 10 out of the 24 observed positive trends were statistically significant increases. We also observed seasonal trends with spikes in SV-related ED visits during warmer months and declines during colder months, particularly in ages 0 to 9 years and 10 to 19 years.
Conclusions. We identified several significant increases in SV-related ED visits from January 2017 to December 2019. Syndromic surveillance offers near-real-time surveillance of ED visits and can aid in the prevention of SV.
The Centers for Disease Control and Prevention (CDC) defines sexual violence (SV) as a sexual act that is committed or attempted by another person without freely given consent of the victim or against someone who is unable to consent or refuse.1 SV is a significant and preventable public health issue. Nearly 52.2 million women and 27.6 million men in the United States have experienced some form of contact SV (i.e., rape, being made to penetrate someone else, sexual coercion, or unwanted sexual contact) in their lifetime.2 SV is associated with multiple negative health impacts and costs to society,3,4 with a recent study suggesting an estimated lifetime economic burden of $3.1 trillion for rape.5
Monitoring SV temporal and demographic trends is important for informing prevention and response efforts, yet because of the limitations of current data collection systems and other methodological challenges, national data on this topic are rarely reported in a timely manner. This lag time challenges timely monitoring and response for populations currently at risk of SV that are urgently in need of prevention programs. Using data from CDC’s National Syndromic Surveillance Program (NSSP), we examined SV-related emergency department (ED) visits in the United States from January 1, 2017, through December 31, 2019, according to sex and age groups.
METHODS
NSSP’s BioSense Platform launched in 2003 to establish a national public health surveillance system for early detection and assessment of potential bioterrorism-related illness. It has expanded to track infectious diseases and injuries. The cloud-based BioSense Platform is a secure, integrated health information system with standardized tools and procedures that allows public health officials to collect, analyze, and share syndromic data. Syndromic data from hospitals that voluntarily participate include data from several sources, including patient encounter data from EDs, urgent care, ambulatory care, and inpatient health care settings, as well as pharmacy and laboratory data. Health officials can analyze syndromic data in near real time to monitor and detect events, diseases, or outbreaks of public health significance. These data improve awareness of health threats over time and across regional boundaries, which can then inform response efforts (see https://www.cdc.gov/nssp/overview.html#bioSense).
We used NSSP data derived from participating states and jurisdictions to monitor trends in SV-related ED visits among all age groups from January 1, 2017, through December 31, 2019. ED visits are determined by facilities that are categorized as “emergency” and exclude patients designated as only inpatient or only outpatient. Forty-seven states participate in NSSP by contributing demographics, chief complaint data, and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM; Hyattsville, MD: National Center for Health Statistics; 2000) diagnostic codes, which covers approximately 73% of ED visits in the United States.6,7 Availability and completeness of data vary across participating EDs with chief complaint text and discharge diagnosis codes missing in 12% and 38% of ED visits in NSSP, respectively. NSSP coverage has been increasing over time; the latest details on coverage can be found at https://www.cdc.gov/nssp/overview.html. NSSP data were analyzed using the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) platform.
A CDC-developed syndrome definition was validated and used to assess SV-related ED visits. The SV syndrome definition used in this report was uploaded to ESSENCE and labeled Sexual Violence V2. It was developed and refined after coauthors developed Sexual Violence V1 in collaboration with the Washington State Health Department. The definition allowed for querying patients’ chief complaint history, discharge diagnosis, and admission reason code and description fields for a combination of terms frequently used in SV visits and Boolean operators (e.g., sexual assault, rape, forced sex, or SANE exam), as well as SV-related ICD-10-CM codes (Table 1, available as a supplement to the online version of this article at http://www.ajph.org). The definition also contained exclusions such as terms that are spelled similar to SV-related terms, but are not related to an SV incident (e.g., grape or scrape). Finally, the ICD-10-CM diagnosis code Z62.810 (history of physical or sexual abuse in childhood) was originally included in the syndrome definition but ultimately was removed because a determination was made to only include visits in which the patient was seeking medical care immediately following a SV-related event.
TABLE 1—
Trends and Changes in Monthly Rates for Emergency Department Visits Related to Sexual Violence Overall and by Sex—National Syndromic Surveillance Program: United States, January 2017–December 2019
| % Change January 2017–December 2019b | Average MPC (95% CI) | Trend 1a January 2017–July 2017, MPCc (95% CI) |
Trend 2a July 2017–January 2018, MPCc (95% CI) |
Trend 3a January 2018–July 2018, MPCc (95% CI) |
Trend 4a July 2018–January 2019, MPCc (95% CI) |
Trend 5a January 2019–July 2019, MPCc (95% CI) |
Trend 6a July 2019–December 2019, MPCc (95% CI) |
|
| Overall | 26.58 | 1.03 (0.18, 1.90) | 7.17 (4.92, 9.48) | –5.70 (–7.39, –2.69) | 6.53 (4.11, 9.02) | –4.08 (–6.16, –1.96) | 5.89 (3.66, 8.16) | –4.24 (–6.17, –2.27) |
| Sex | ||||||||
| Female | 26.87 | 1.04 (0.11, 1.97) | 7.48 (5.01, 10.00) | –5.42 (–7.93, –2.85) | 6.88 (4.25, 9.58) | –4.49 (–6.73, –2.20) | 6.37 (3.95, 8.85) | –4.53 (–6.62, –2.41) |
| Male | 0.90 (–0.42, 2.23) | 5.74 (2.39, 9.19) | –5.12 (–8.56, –1.54) | 7.05 (1.74, 12.63)d | –1.82 (–4.19, 0.62) d | 3.88 (0.62, 7.25) | –2.90 (–5.84, 0.13) |
Note. CI = confidence interval; ED = emergency department; MPC = monthly percent change. Monthly rate per 100 000 ED visits. Rates calculated as number of ED visits related to sexual violence divided by the total number of ED visits for each month and multiplied by 100 000. Data current as of July 1, 2020.
Joinpoint regression determines the number of linear segments needed to describe a trend and identifies points (i.e., Joinpoints) in which linear trends change. The Joinpoint is included in each adjoining linear segment.
Any percent change not reported indicates the trend line for that stratum was not significant.
Joinpoint reports annual percent change, but the unit of time in this analysis is 1 month, so this has been modified to MPC.
The time period for trend 3 in males is January 2018–June 2018, and the time period for trend 4 in males is June 2018–January 2019.
We computed monthly SV rates (per 100 000 ED visits) overall and stratified by sex and age group. We calculated rates for each stratum by providing the Joinpoint Regression Program8 with the numerator (i.e., the number of SV-related ED visits per month) and the denominator (i.e., the total number of ED visits per month). Joinpoint then produced a rate by dividing the numerator by the denominator and multiplying by 100 000. Trends were characterized in terms of monthly percentage change (MPC) estimates by trend segment as well as average monthly percent change estimates for the overall study period and for each stratum. We calculated all reported percent changes using the modeled average MPC; thus, all percent changes reflect modeled increases or decreases. We selected log-transform and Poisson variance options in Joinpoint. Under this approach, Joinpoint uses the numerators to construct a separate weight for each data point and then conducts a weighted least squares regression.
RESULTS
Approximately 298 million ED visits were captured by NSSP from January 2017 to December 2019; 196 948 of those met the syndrome definition criteria as an SV-related visit (an overall rate of about 66 per 100 000 ED visits). There were several fluctuations during the 3-year time period, which reflect significant changes in the rates of SV-related ED visits over time. From January 2017 to July 2017, the MPC significantly increased (7.17%), significantly decreased from July 2017 to January 2018 (–5.70%), significantly increased from January 2018 to July 2018 (6.53%), significantly decreased again from July 2018 to January 2019 (–4.08%), significantly increased from January 2019 to July 2019 (5.89%), and significantly declined from July 2019 to December 2019 (–4.24%; Figure 1 and Table 1).
FIGURE 1—
Overall Monthly Rates of Emergency Department Visits for Sexual Violence—National Syndromic Surveillance Program Data: United States, January 2017–December 2019
Note. ED = emergency department; SV = sexual violence. Monthly rate per 100 000 ED visits. Rates calculated as number of SV-related ED visits divided by the total number of ED visits for each month and multiplied by 100 000. Data current as of July 1, 2020.
Trends Stratified by Sex
From January 2017 to December 2019, there were 173 244 SV-related ED visits by females. Females experienced a significant positive trend in SV-related ED visits over the entire time period (1.04% per month; Figure 2 and Table 1). Rates of female SV-related ED visits showed a sharp, significant increase (7.48%) from January 2017 to July 2017, significantly decreased from July 2017 to January 2018 (–5.42%), significantly increased from January 2018 to July 2018 (6.88%), significantly declined from July 2018 to January 2019 (–4.49%), significantly increased from January 2019 to July 2019 (6.37%), and significantly declined from July 2019 to December 2019 (–4.53%; Figure 2 and Table 1).
FIGURE 2—
Monthly Rates of Emergency Department Visits for Sexual Violence by Sex—National Syndromic Surveillance Program Data: United States, January 2017–December 2019
Note. ED = emergency department; SV = sexual violence. The geometric shapes represent observed rates and the solid lines indicate modeled rates. Monthly rates per 100 000 ED visits. Rates calculated as number of SV-related ED visits divided by the total number of ED visits for each month by sex and multiplied by 100 000. Data current as of July 1, 2020.
During the study period, males accounted for 23 071 of SV-related ED visits. Male SV-related ED visits showed a nonsignificant positive trend from January 2017 to December 2019 (0.90% per month; Figure 2 and Table 1). However, male rates of SV-related ED visits showed several fluctuations, some of which were significant changes. From January 2017 to July 2017, the MPC significantly increased (5.74%), significantly decreased from July 2017 to January 2018 (–5.12%), significantly increased again from January 2018 to June 2018 (7.05%), did not change significantly from June 2018 to January 2019 (–1.82%), significantly increased from January 2019 to July 2019 (3.88%), and did not change significantly from July 2019 to December 2019 (–2.90%; Figure 2 and Table 1).
Trends Stratified by Age Group
When stratified by age group, there were significant increases in SV-related ED visits for certain age groups for the overall period (Figure 3 and Table B, available as a supplement to the online version of this article at http://www.ajph.org). From January 2017 to December 2019, SV-related ED visits significantly increased for persons aged 20 to 29 years (30.67%) and 50 to 59 years (55.57%; Figure 3 and Table B). Nearly all age groups observed substantial fluctuations during the 2-year time period, with several significant linear segments (Table B). All age groups showed a common pattern of increasing rates, followed by leveling off or decreasing rates, an increase in rates, a decrease or leveling off, another increase, and ended with a decline in rates at the end of the time period. Throughout the 3-year time period, those aged 10 to 19 years had the highest rates of SV-related ED visits.
FIGURE 3—
Monthly Rates of Emergency Department Visits for Sexual Violence by Age Group—National Syndromic Surveillance Program Data: United States, January 2017–December 2019
Note. ED = emergency department; SV = sexual violence. The geometric shapes represent observed rates and the colored lines indicate modeled rates. Monthly rates per 100 000 ED visits. Rates calculated as number of SV-related ED visits divided by the total number of ED visits for each month by age group and multiplied by 100 000. Data current as of July 1, 2020.
Trends Stratified by Age Groups and Sex
Several trends emerged when we stratified SV-related ED visits by sex and age groups (Figures A and B, available as supplements to the online version of this article at http://www.ajph.org). For females, significant increases for the overall period were observed for persons aged 20 to 29 years (32.47%) and 50 to 59 years (57.33%; Figure A and Table B). For males, there were significant overall increases in SV-related ED visits for persons aged 10 to 19 years (15.80%), 20 to 29 years (31.87%), 40 to 49 years (49.04%), and 60 years or older (32.77%; Figure B and Table B). Continuing the trend detected in all other strata, we observed substantial fluctuations during the 3-year time period, with several significant linear segments (Table B). Of the strata that had 6 linear segments (which were all female age groups except 1), all showed a common pattern of increasing rates, followed by leveling off or decreasing rates, an increase in rates, a decrease or leveling off, another increase, and a decline in rates at the end of the time period. For females, those aged 10 to 19 years had the highest rates of SV-related ED visits throughout the 3-year time period; for males, those aged 0 to 9 years had the highest rates of SV-related ED visits, followed by those aged 10 to 19 years.
DISCUSSION
Using syndromic surveillance data from CDC’s NSSP, we examined SV-related ED visits from January 2017 to December 2019. In all of the strata examined, SV-related ED visits displayed positive trends during the 3-year time period. Females had higher rates of SV-related ED visits than males. This is consistent with other national studies that have reported that 1 in 5 females reported experiencing completed or attempted rape and 1 in 14 males reported experiencing completed or attempted forced penetration in their lifetime.2 When combined, males and females aged 10 to 19 years had the highest overall rates of SV-related ED visits.
Significant increases in SV-related ED visits were observed for females aged 20 to 29 years and 50 to 59 years. Females aged 50 to 59 years showed the highest increase (57.33%) in SV-related ED visits, compared with other female age groups and all male age groups. Females aged 10 to 19 years had the highest overall rates of SV-related ED visits. This is also consistent with the National Intimate Partner and Sexual Violence Survey, which found that, among female victims of rape, 43.2% reported that it first occurred before age 18 years, with 30.5% reporting that their first victimization occurred between the ages of 11 and 17 years.2
For males, there were significant increases in SV-related ED visits for those aged 10 to 19 years, 20 to 29 years, 40 to 49 years, and 60 years or older. Contrary to the age trends for females, among males, the group aged 0 to 9 years had the highest rates of SV-related ED visits, followed by those aged 10 to 19 years. The recent National Intimate Partner and Sexual Violence Survey report found that, among male victims of rape, more than half (51.3%) reported first being raped before age 18 years, with 25.3% reporting that their first victimization occurred between the ages of 11 and 17 years and 26.0% at age 10 years or younger.2
Consistently, in all strata examined, SV-related ED visits displayed positive trends from January 2017 to December 2019; 10 out of the 24 observed positive trends were statistically significant increases. Joinpoint accounts for the variance in trends, and some observed trends had wide confidence intervals, which may explain why some increases were not significant. Nonetheless, the general trend of increasing SV-related ED visits is inconsistent with decreasing crime reports for rape or SV,9 but it aligns with an increasing trend among injured female victims of rape and sexual assault who seek treatment for their injuries in a hospital, doctor’s office, or ED (65% of females in 1994–1998 compared with 80% of females in 2005–2010).10 Thus, the number of victims who seek medical treatment as a result of SV is only a small portion of all SV victims. In the fall of 2017, #metoo became a viral hashtag across social media, bringing SV to the forefront of the national conversation.11 As a result, victims may have felt more comfortable disclosing their SV experience and seeking help for their injuries. It is also worth noting that the present findings represent a snapshot of a select 3-year time period, but the longer-term trends could look quite different if more years of data were included in the analysis.
Another interesting trend that emerged when we examined the strata with the highest rates by sex and age group was the spike in SV-related ED visits during warmer months once school is out of session and the decline during the school year and winter months. Particularly for females aged 0 to 9 years and 10 to 19 years, this trend corresponds with the academic calendar (males aged 0 to 9 years also exhibited this trend; see Figures A and B). This seasonal pattern is also consistent with the trend in serious violent victimization rates, which includes rape and sexual assault, robbery, and aggravated assault.12 Although increased temperatures during summer months have been associated with increased crimes and aggression,13 given the age range most impacted, these findings may be attributable to being out of school. School can provide a protective environment and supervision of children. These findings suggest the need to strengthen protective environments and for closer supervision during summer months for children. Quality childcare settings that are licensed and accredited promote positive and supportive relationships and experiences and ensure that the environment is safe, nurturing, and stimulating.14
The results indicate that females aged 0 to 9 years and 10 to 19 years have the highest rates of SV-related ED visits overall; within males, the same age groups (0–9 and 10–19 years) also displayed the highest rates of SV-related ED visits, although females are impacted at a much higher rate than males (Figures A and B). Sexual abuse during childhood is an adverse childhood experience with lasting negative impacts.15 For boys in particular, self-reporting sexual victimization is complicated by the fact that the perpetrator may be of the same sex, adding to the stigma of being a victim. Being a male victim of SV is incompatible with the norms of masculinity and may create a sense of shame, embarrassment, and emasculation.16 In turn, male victims may be less likely to disclose, resulting in severe underreports of SV for this population.17 Therefore, it is important for nurses and health care providers to develop trust and engage patients in a therapeutic discussion that will reduce fear and encourage disclosure of sexual abuse.17 A recent study found that the number of ED admissions for child sexual abuse more than doubled from 2010 to 2016, with girls experiencing the highest rate of ED admissions.18 In summary, the results offer evidence for the importance of primary prevention of child sexual abuse and adverse childhood experiences. Comprehensive approaches that focus on creating safe, stable, nurturing relationships and environments allow children to thrive and achieve their full potential and prevent adverse childhood experiences from occurring.19
Limitations
This study had some limitations, particularly around the use of syndromic surveillance data. First, the number of ED visits in ESSENCE may vary at any point in time because facilities might have a lag in reporting their information to ESSENCE, and hospital participation may vary by month. To control for this, instead of using ED visit counts, we calculated monthly SV rates. However, SV-related ED trends may be partially accounted for by changes in the total number of ED visits per month or characteristics of the participating hospital populations.
Next, while the syndrome definition for SV includes terms and ICD-10-CM codes, there is the potential to unintentionally omit SV terms or ICD-10-CM codes that participating hospitals use that would result in an underestimate. Underestimating SV-related ED visits may also occur because of the availability or missingness of ICD-10-CM diagnostic codes and quality of the chief complaint data. Completeness of ICD-10-CM diagnostic codes has been increasing over time, which could influence the observed trends. However, to test this potential concern, we conducted additional analyses. Using the SV syndrome definition, we queried the chief complaint fields separately from the discharge diagnosis fields. When we overlaid the 2 trend lines for the same period of time, the patterns mirrored each other. The similarity in trends offers confidence that the increase in SV-related ED visits is not attributable to the increasing completeness of ICD-10-CM diagnostic codes but represents a true increase in SV-related ED visits for the examined time period.
When one is using this study to inform prevention programs and interventions in the broader population, the results should be cautiously interpreted. Despite several strata showing increasing trends, it is worth emphasizing that the results show trends for the proportion of ED visits that are SV-related visits. Thus, the same strata that showed high rates of SV-related ED visits (when stratified by sex and age group it was females aged 10 to 19 years and males aged 0 to 9 years; see Figures A and B) in our study may not be the highest risk in the general population for experiencing SV. This is attributable in part to the fact that other males or females of differing age groups may be seeking medical care for non–SV-related reasons at a higher rate,20 which would make their rates of SV-related ED visits appear lower. To that end, rates derived from syndromic surveillance should not replace prevalence estimates generated by other data sources. Instead, they should be used in conjunction with other data to verify trends. Moreover, syndromic surveillance only captures individuals who seek medical care as a result of an injury; thus, it only represents a portion of all individuals that are victims of SV.
In a related vein, the current findings are not generalizable to areas not participating in NSSP. It should also be noted that certain populations are difficult to identify. For example, it is challenging to report on racial and sexual minorities because of the way in which data are collected and recorded and the lack of completeness in data fields that offer this information. Future coding and system improvements to enhance the completeness and validity of fields that potentially capture information about a patient’s race and sexual orientation could enhance surveillance of SV victims seeking medical care and improve targeted interventions.
It is worth noting why we did not include data during the COVID-19 pandemic in the present analysis. During COVID-19, there was an unprecedented decrease in the number of ED visits of approximately 42% from early in the pandemic compared to the same time period in 2019.21 As a result, the denominator (i.e., total ED visits per month) in the present analysis would drastically change and skew the rates of SV-related ED visits. To adequately unpack this complex time period, future studies should examine SV-related ED visits during COVID-19 and compare the rates and counts with the same time period in 2019. Finally, the present results provide a broad picture of SV-related ED visits using a national public health surveillance system, but local and state context is needed to identify clusters or hot spots and inform response efforts in near real time.6,7
Public Health Implications
SV is preventable. The CDC developed a technical package, STOP SV, which highlights several strategies with the best available evidence.22 EDs provide important treatment and referral services for those seeking care after an assault, but communities and health care providers can be engaged in prevention efforts at all stages. In addition, the results of the present analysis, which showed several significant increases (and nonsignificant positive trends) in rates of ED visits for SV across multiple age groups, underscores the need for prevention strategies that consider risk across the life span. Furthermore, our analysis found large significant increases in men aged 60 years or older and women aged 50 to 59 years, yet there is a dearth of research on SV in older individuals, particularly older men. More research is needed on this population, as they are vulnerable and may require different prevention approaches.
Our study demonstrated that syndromic surveillance can be a valuable data source to monitor national SV trends. Syndromic surveillance data at the local level can be useful for those working in SV prevention by helping identify which populations are most in need of services, where to target prevention efforts, and what services survivors need. For example, this analysis showed that, among males, those aged 0 to 9 years had the highest rates of SV-related ED visits (Figure B), suggesting that hospitals may need to strengthen pediatric SV services. In addition, once community-level prevention services have been established, syndromic surveillance can assist in evaluating those services to determine if rates decrease after intervention.
The results of the present study suggest a seasonality in SV-related ED visits, especially in the younger population. Hospitals can examine staffing and resources to be prepared for the surge in SV-related visits during these high-volume months. Emergency physicians should also have awareness of the increased SV in youths during summer months and consider asking youths about SV, as many victims do not exhibit physical signs of an assault.23
Given that the age groups with the highest rates of SV-related ED visits among each sex were males aged 0 to 9 years and females aged 10 to 19 years, it is critically important to link patients with SV injuries and their families to victim advocates and therapeutic providers. Treatment programs can help children acknowledge and identify inappropriate sexual behavior, process trauma symptoms, learn sexual behavior rules and self-control techniques, and provide sex education, which may prevent sexual behavior problems.24–28 The high rates of ED visits for SV found in younger individuals also suggests that the SV-related ED visit examined in this study may not be the first SV victimization for some older victims, so these victims may need additional assistance.
Conclusions
The present study provides the first examination of SV-related ED visits using syndromic surveillance data from across the nation. Capturing these visits is an important element in measuring the scope of SV victimization, particularly because these survivors may choose to not report their victimization to law enforcement or self-report it in surveys. Thus, syndromic data capture victimization experiences that can be used to further inform surveillance efforts and aid in the prevention of sexual violence.
ACKNOWLEDGMENTS
We thank the jurisdictions participating in the CDC National Syndromic Surveillance Program.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
HUMAN PARTICIPANT PROTECTION
Because this study used de-identified information from an existing surveillance system, it was determined to be nonresearch and, thus, did not require CDC institutional review board review.
Footnotes
See also Waechter, p. 339.
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