When victims of rape or sexual assault seek emergency medical attention after an assault, they can be saddled with hundreds or even thousands of dollars in medical bills, a new study published this week in the New England Journal of Medicine found it.
These accounts can further traumatize victims, the study authors warn, and dissuade others from seeking professional help. It is estimated that only a fifth of victims of sexual violence seek medical help after an attack.
Researchers at Harvard analyzed a nationwide dataset of more than 35 million emergency room visits in 2019, the most recent year such information was available. She looked specifically at visits where doctors took into account codes related to post-assault care, and found more than 112,000 such patients. Nearly 90 percent of those patients were women and 38 percent were children under the age of 18.
When victims of sexual assault go to the emergency room, there are two types of care they typically receive. The first is a forensic assault investigation, or more informally, a “rape kit.” That’s where a medical professional collects evidence from a victim, such as performing a pelvic, rectal, or throat exam, taking samples for a DNA test, and looking for sperm or other evidence of violent injury.
Under the Violence Against Women Act (VAWA) of 1994, the cost of a forensic examination is paid for through public funds, and while survivors are sometimes incorrectly billed, the federal law prohibits victims from the cost of collecting evidence.
But VAWA doesn’t cover the second category of care — which is therapeutic care, or whatever is medically necessary for a person’s health after a seizure.
“So, for example, doctors often give their victims preventive medication for STDs, such as antibiotics to prevent syphilis, gonorrhea, or HIV medication if that’s a possibility,” said Stephanie Woolhandler, one of the study’s lead authors. Emergency room doctors can also provide victims with emergency contraception if pregnancy is a problem, and in other cases, victims may have vaginal or rectal cuts that need to be stitched up, other injuries, or broken bones.
The researchers’ findings on the cost of such care are sobering. Uninsured victims, who numbered more than 17,000 in 2019, faced out-of-pocket costs average $3,673.
For all approximately 112,800 patients seen for sexual assault who visited the ER that year, the cost averaged $3,551, with even higher averages for pregnant patients ($4,553). Insured patients had lower cash bills, but how much lower depends on the structure of their insurance plan. Preliminary investigation suggests that even those with private insurance paid an average of about 14 percent of their bill, about $500. “That could be a huge sum of money, given that a disproportionate share of victims of sexual assault are low-income women and girls.” , Woolhandler told cafemadrid.
The findings, published less than three months after the Supreme Court decision was overturned, roe v. wadingcome when states move to limit not only access to abortion but other basic sexual health care treatments, such as emergency contraception and medications used to control miscarriages.
Samuel Dickman, an abortion provider and lead study author, told cafemadrid that when he provided care in Texas (he moved to Montana in May), he personally met patients who came in after sexual assaults, who were then vulnerable to catastrophic medical bills. “Texas has the highest uninsured rate in the country, and this study is a start to quantifying that vulnerability,” he said.
However, the vulnerability is not limited to the uninsured. Dickman recalls one of his former patients who was raped and became pregnant, seeking an abortion. “She was on Medicaid, and under the Hyde amendment, rape victims should have had that procedure, but Texas made it so hard that we wanted this victim to pay more than $1,000 out of pocket,” he said. “Those charges were just shocking to her, and on top of just being raped, it was honestly haunting.”
What reform might look like?
The study authors urge policies that provide affordable access to all essential medical services — including abortion and emergency contraception — “for rape survivors and for anyone who needs that care,” Dickman said.
An option they propose in their paper to help survivors of sexual violence would be to extend VAWA to therapeutic services, not just evidence gathering. Woolhandler told cafemadrid that would be “a step in the right direction” but ultimately more comprehensive reforms, including universal health coverage, are needed to remove barriers.
“Sexual health care is health care and we, like other developed countries, should make all health care free at the time of use,” Woolhandler added. “In a post-roe world, an unwanted pregnancy can mean an unwanted birth, and that’s why the government has the power to force you as someone with a vagina to bear all the consequences of your assault, not just a $500 or $3,000 medical bill, but you have to also carry this child. It’s downright outrageous.”
Paying more attention to survivors’ privacy issues, the study authors insist, is also paramount to making sure victims feel they can get the care they need. “Emergency room charges may discourage reporting rape and seeking medical care for both the short and long-term consequences of sexual assault,” the NEJM study states:. “Incurring such costs can further harm survivors — even those with full insurance coverage — by serving to disclose a potentially stigmatizing event to parents, partners or employers.”
Dickman said there is no reason why we couldn’t have a system where each individual has their own insurance card that entitles them to private care. “I have seen insured patients say they will pay for their care out of pocket, even if it means skipping rent or groceries because they have that kind of disclosure to their family or employer about abortion or sexual assault,” he said. you’re a minor seeking emergency care, chances are the primary insurance holder will get a list of what services you received, and very likely, that person could be the person who committed the attack. “
Woolhandler said some privacy concerns stem from private insurance, because insurers have a right to know what procedures have been performed and what diagnoses have been made. “Part of the problem with single payers is that hospitals don’t send bills,” she said. “In Canada, hospitals get a lump sum that they use to pay for all their surgeries; presumably there’s a file in the hospital about who you are and your… [medical] hospital, but it does not have to leave the hospital.”
“We shouldn’t tie people to their jobs or their relatives in terms of medical care,” Dickman added. “It’s just a crazy way to structure a system.”