Sexual assault, pregnancy, and other unique needs are often overlooked by a cursory and underfunded system. Poor physical health also increases girls' risk of recidivism.
The first twelve years of Jessica's life have not been easy.
She sits at a plastic table in the girls unit of The Bernalillo County Juvenile Detention and Youth Services Center in Albuquerque, New Mexico, with eight other girls, crammed onto benches nailed to the metal table frame. The girls are in the middle of activity period, answering a questionnaire on female relationships intended to help them bond with one another.
The room is surrounded on three sides by dormitory cells -- locked cinderblock rooms, each with a single window and a low cement bunk.
The other girls chatter away about the drama between girls in high school, but Jessica keeps mostly to herself, chiming in at one point to tell them, "I'm not even in high school yet."
With a broad face and a stocky build, Jessica is large for 12-year-old, the extra padding of early childhood visible even under the detention center's uniform of a baggy blue t-shirt and sweatpants. Her hands are red and chapped from the facility's allotted soap, dispensed from industrial-sized plastic jugs in the group shower. Her head is shaved down to a light brown fuzz; if she weren't sitting in the girls' unit, she might easily be mistaken for a boy.
Jessica (who asked us not to use her last name) has been here for about a month, booked on battery charges.
Like many of the 641,000 girls aged 11-17 who enter the juvenile justice system each year, Jessica has been the victim of sexual assault.
Incarcerated girls like Jessica are "one of the most vulnerable and unfortunately invisible populations in the country," and up to 90 percent have experienced physical, sexual, or emotional abuse, according to Catherine Pierce, a senior advisor at the federal government's Office of Juvenile Justice and Delinquency Prevention.
The health statistics are particularly grim: 41 percent of girls in detention have signs of vaginal injury consistent with sexual assault, up to a third have been or are currently pregnant, eight percent have had positive skin tests for tuberculosis and 30 percent need glasses but do not have them, according to research from the National Girls Health and Justice Institute.
For many incarcerated girls, detention may be the only time they interact with the health care system. But the health care provided to children, and girls in particular, in juvenile detention is often ill-equipped to deal with their complex health needs.
A 2004 study in the journal Pediatrics found that fewer than half of facilities surveyed were compliant with recommended health screening and assessments, and few met even minimum levels of care.
"I don't think detention facilities really understand enough about [girls'] history of victimization," says Pierce. "We have a lot of work to do."
Over the past decade, Leslie Acoca, who founded and directs the National Girls Health and Justice Institute, has visited dozens of juvenile detention centers across the country, researching the health care given to girls in the facilities. Her work has yielded a surprising finding: poor physical health seems to increase girls' risk of recidivism. In other words, girls who have health problems are more likely to reoffend and end up back in the criminal justice system.
Acoca is a psychologist who became interested in the treatment of girls in detention while serving as an expert witness in a California courtroom 12 years ago. As Acoca explains it, a young woman hobbled into the courtroom eight months pregnant and fully shackled at her feet, wrists and belly. Acoca stood up and asked the judge why the girl was bound in that way, to which the judge replied that the young woman was a flight risk.
"Have you ever been pregnant?" Acoca asked the male judge; she was promptly escorted out of the courtroom.
Since then, Acoca has been on a one-woman crusade to improve the conditions for girls in detention. Girls are the fastest growing sector of the juvenile justice population, yet the screening and treatment tools, for the most part, were designed for boys. Acoca worries that girls' unique physical and mental health issues are therefore "not being picked up early or accurately enough," even by the most experienced nurses.
The standard health question at the Bernalillo center about sexual abuse, for instance, is whether a girl has been raped in the past five days. A "yes" to that question could trigger an investigation, but it would do little to identify a history of sexual abuse that occurred earlier and may be a factor in a girls' mental health issues.
When Jessica first entered the facility, brought in by police in handcuffs, she was given basically the same treatment as if she were a boy.
First, she was given a full pat-down to check for contraband, like drugs or weapons. After showering and putting on her uniform, Jessica was given a brief health screening to ensure that she didn't need emergency medical services before being booked. The screen lasts about 15 minutes and is given by the facility's staff nurse in a small room attached to the intake area.
The door remains open for security purposes, with guards and new residents passing by. Without privacy, Acoca says, girls are unlikely to reveal important health information, especially when they have previously been victimized.
Jessica was weighed, measured, vital signs taken, and the nurse briefly evaluated her physical and mental state, noting her judgment, affect, speech and mood. Next, she was asked a series of about 35 questions from the facility's medical intake form, including a list of her current medications, whether she had taken alcohol or drugs in the last 24 hours, was feeling suicidal or if she had a history of self-destructive behavior.
There are a handful of questions given only to females: Are you pregnant? If so, have you started prenatal care? What form of birth control do you use?
The Albuquerque facility is among the 15 to 17 percent of the country's 3,500 juvenile justice detention centers that test all girls for pregnancy on admission, according to the 2004 Juvenile Facilities Census. Almost one quarter of facilities do not offer access to obstetric services.
"There are many stories about girls whose pregnancies aren't identified, who then have miscarriages on the unit," Acoca says. "Every teen pregnancy must be considered high risk." A study published in the Western Journal of Medicine in 1995 found that 60 percent of facilities reported at least one obstetric complication.
In some facilities, Acoca says girls are asked questions about sexual assault in front of male residents. "These are girls with a history or rape and assault and their boundaries might not be well established," she explains. In many facilities, she adds, the staff nurses are trained to deal with adult men, not young girls.
The screening process is a missed opportunity, argues Acoca. "Detention may be the only chance [these girls] get to see a doctor, physician's assistant or a nurse who asks them questions about their health," making it an ideal time to provide needed services. It's also a chance to create a health record for the girls that can travel with them outside of the facility, and to link them with clinics and providers in the community when they leave.