Women's Health in Juvenile Detention: How a System Designed for Boys Is Failing Girls

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."

Girls at the Bernalillo County Juvenile Detention and Youth Services Center line up for their gym class. [Jenny Gold/KHN]

---

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.

Leslie Acoca, who founded and directs the National Girls Health and Justice Institute, gives a Girls Health Screen to Reylene. [Jenny Gold/KHN]

---

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.

Acoca's Girls Health Screen app, given on an iPad.

---

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.

A study in the Journal of Adolescent Health in 1998 found that only half of all youth in detention had received medical care in the previous year, and one-third could identify a regular source of care. Fewer than half of families showed interest in the health care deemed important for their children by facility staff.

Acoca believes she has created a tool that will vastly improve the situation--a validated health questionnaire specifically for girls that would replace the current intake procedure in detention centers. The Girls Health Screen consists of 132 questions that would be asked of all girls upon arrival in a detention facility. The screen can be given by a nurse or the girls can fill it out on their own on a computer.

And the Bernalillo County Juvenile Detention and Youth Services Center, one of the better facilities in the country and a model site for the Annie E. Casey Foundation's Juvenile Detention Alternatives Initiative, agreed to a pilot test of the Acoca's health screen. The county also been a pioneer in accommodating the growing number of girls in the criminal justice system. It's home to one of just two girls-only courts in the country, and it also runs a girls-only probation unit.

***

Of the 30 girls at the facility who took the Girls Health Screen in the pilot, 12 were identified as needing immediate medical care; 23 were identified as needing medical care within 24 hours. All of them had previously been through the center's standard health screening procedure.

Jessica, for example, had already been in detention for a month when she was given the GHS, and yet her responses were troubling. She admitted feeling hopeless about her life, a response that would trigger an immediate intervention because it is considered an indication of depression and a risk factor for suicide. She had not yet told anyone in the facility about those feelings, she said. Jessica also admitted to regularly using drugs and alcohol and said she had severe cramping during her menstrual period, which she had not yet told the nurse.

Another resident, Reylene, who was 17 at the time, described during the GHS that her whole left breast was red and scarred with recent burns, an injury had occurred when she was passed out at a party. Reylene, who was in detention on charges of larceny and breaking and entering, said she had lied to the nurse during her standard intake about those injuries.

The girls in detention are hesitant to trust people, she explained. "We've been through a lot and we don't want to put nothing on blast. We just want to keep it to ourselves," Reylene said. "Sometimes it feels hard to say things to people you don't know," but it's easier to write it down, she added.

Since the average length of stay in the Albuquerque facility is only 15 days, and many kids become repeat offenders, it's important that their health records be able to be accessed within the facility, by community providers, and by the girls themselves. "Girls empower themselves with information," Acoca says.

The nurses and case workers at the facility, however, are less than enthusiastic about the screen. Nurse Veronica Crespin, says she doesn't believe the facility is missing urgent needs under their current system. The medical needs that Acoca identified as urgent, Crespin argued, likely had already been noted in the standard screening procedure. Reylene's burns had been observed, for instance, even though Reylene was evasive about how she got them.

In addition, Acoca's screen takes at least twice as long, she said, and the facility staff is already stretched thin. "Most of the time it's one nurse per shift and there are multiple intakes. It's constant and something is always going on," she says.

***

The real problem, Crespin says, is not what goes on inside the facility, where girls have access to medical care and are essentially a captive audience for providers and health educators, but rather what happens one they leave and return to the community. While many of the girls qualify for Medicaid or other forms of insurance, they simply do not seek medical care.

"I'm not sure if it's transportation or non-compliance," Crespin says. "Often they're released with their meds," and then return with the same pack, never having taken them. "We do go over the meds with the family when they're discharged, but sometimes they don't comply," she says.

Roberta Muro, who runs the girls' probation unit, also blames the gap in communication between detention and probation officers, who are in charge of the girls once they leave. "We don't have the mechanisms in place to get permission" for detention to share sensitive health information with the probation team, she explains. And because the detention center is run by the county, while the probation unit is run by the state, getting through the bureaucracy can be difficult.

Without that information, Muro says, probation officers often don't know what to follow up on, or whether the girls need help finding health care in the community. "Maybe she's not going to school because she has issues we don't know about. Maybe detention sent her home with antibiotics, but she can't afford it and no one follows up," Muro explains. "The more we know, the more we can help."

The girls often have insurance but need help using it, she adds. If they have a sore throat, for example, they may not have a primary care provider to visit; instead they may go to an ER "and then get fed up and leave." She says probation officers could help them access care at clinics instead, saving the health care system money in the process.

In most counties and states, the minute a child on Medicaid enters detention, their insurance coverage is suddenly cut off. The costs of any medical services during detention therefore fall entirely to the states. Acoca worries that this creates a disincentive for many facilities to identify health needs. New Mexico, however, has a law that allows kids to keep their Medicaid coverage for the first 60 days in detention. That means the federal government picks up a share of the health costs, since Medicaid is a joint state and federal program.

Muro hopes the Girls Health Screen would help close the gap between detention and probation. While Albuquerque doesn't have an electronic records system (the pilot was a paper version), if both could access an electronic version of a girl's answers, she says, the probation unit can follow up seamlessly, making sure a girl continues her birth control, for example, or completes her course of antibiotics.

"As we put the blocks together, they can start caring about themselves and feeling better," she says. "It's a chicken and egg thing--do you treat the trauma, the drug abuse, the medical issues? A lot of people don't understand-- you have to treat it all at once."

***

Albuquerque has not shied away from the challenge as Muro frames it. Judge John Romero, presiding judge of Bernalillo County's children's court, has been instrumental in making Albuquerque a gender-specific correctional system. Girls, he explains, tend to be among the least popular populations to work with in detention, considered more sensitive, dramatic and difficult than their male counterpoints. Romero recalls a seminar he once attended for youth correctional officers that was irreverently called "I'll Take Ten of Your Boys if You Take One of My Girls."

"The prevailing notion was that girls are more difficult than boys," he explains. "Well, yes they're more difficult if you don't try to meet them where they are, if you don't focus on relationship-building initially rather than 'how do we fix the problem,' and if you don't develop trust between the girls and those that are in the trenches working with them."

Girls tend to enter detention at earlier ages than boys and be held for less serious violations, such as violating probation or running away, rather than more serious violent offenses. Yet, on average, girls stay in detention longer than boys.

Romero says that's in part because of "the male inclination to put a fence or hedge around a dainty little girl." If a judge sees a young girl participating in behaviors, such as sex or drugs, where someone could take advantage of her, he may be inclined to put her in detention for safety.

When he adjudicated girls' cases, he began asking himself "If she were a boy, would I hold her?" The reality, he explains, is that girls are not always safer in detention, where there may also be predators.

Romero also noticed that there were fewer rehabilitation and community programs for girls than boys that serve as alternatives to detention, such as group homes and drug treatment programs. Albuquerque had a non-punitive court for boys, for example, which offered support for them to avoid detention, but there was no equivalent program for girls. Seven years ago, Romero started one himself.

Bernalillo's willingness to try Acoca's screen is another sign of its intention to try to handle girls in detention differently than boys.

***

For the girls who take the screen, Acoca hopes it will do more than just improve their access to healthcare; she hopes it will also bolster their self-esteem.

And she seems to be having some success. Amanda, 16, and in detention for failing to appear in court, also took the GHS at the Albuquerque facility. In a sweet and shy voice, she explained that while at first the questions seemed "pretty weird, like taking a quiz out of nowheres," it made sense as she thought about it. "You guys want to know about girls' health. And it felt like I was just a little bit important to put a dent in something big. Like it could change how you look at girls."

Acoca hopes to implement the Girls Health Screen in Albuquerque on a permanent basis. Meanwhile, Los Angeles County in California has begun using the screen as part of a collaboration including the County Department of Health Services, the Department of Probation, the L.A. Department of Mental Health and the courts. Phase one of the implementation began this summer in the all-girls Camp Scutter. Six other counties in California are also considering whether to adopt it.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. This story was produced in collaboration with NPR.