Temporal trends and outcomes of hospitalization for patients with confirmed sexual abuse in the United States

Sexual abuse is a significant health problem in the United States.1, 2 Sexual abuse is more frequently reported in female compared to male individuals and nearly one in four female individuals have experienced attempted or completed sexual violence during one's lifetime.2 Previous studies have examined premature adult death among early-life sexual and physical abuse survivors,3 and immediate mortality following sexual abuse in female individuals has been relatively understudied.4 The objective of this study was to assess (i) temporal trends of hospitalization for confirmed female sexual abuse and (ii) in-hospital mortality rate following the hospitalization for confirmed female sexual abuse. This serial cross-sectional study queried the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project National Inpatient Sample.5 The study population included any hospital admissions with available information for sex and mortality from 2016 to 2022. Exposure was a diagnosis of confirmed sexual abuse and physical abuse in both female and male patients. The WHO's International Classification of Disease Tenth Revision Clinical Modification code was used to identify the confirmed sexual abuse, including rape and sexual assault (T74.2), and confirmed physical abuse (T74.1).6 The main outcome measure was the mortality occurred during the index hospitalization for confirmed sexual abuse. A multivariable generalized linear model was created to identify the independent characteristics associated with in-hospital mortality following hospitalization for confirmed sexual abuse. To avoid over-adjusting and possible multicollinearity, pre-selected, stringent study covariates in the modeling included age, race and ethnicity, substance use disorder, and concurrent diagnosis of confirmed physical abuse, adopted and modified from prior investigation.4 Temporal trend of incidence rate of hospitalization for patients with confirmed sexual / physical abuse was evaluated with linear segmented regression model (year-quarter increments). Sensitivity analysis included the evaluation of temporal trend of hospitalization for confirmed physical abuse without sexual abuse. Clinical demographics were evaluated per sex and abuse types. The University of Southern California Institutional Review Board deemed this study exempt due to the use of publicly available, deidentified secondary data (registration no. HS-16-00481; informed consent, not required). Among 240 722 468 hospital admissions for national estimates from 2016 to 2022, 14 080 hospital admissions had a diagnosis of confirmed sexual abuse for female individuals. The median age was 27 (interquartile range [IQR]: 17–40) years. Combined physical and sexual abuse was reported in 5.2%. In-hospital morbidities included respiratory failure (4.6%), cardiac failure including arrest (4.1%), intubation (3.1%), hypotension (2.9%), shock (1.5%), and cerebrovascular accident (1.3%). During the same study period, the hospitalizations for male sexual abuse were approximately one eighth of female sexual abuse (n = 1860). The ratio of in-hospital mortality during the index hospitalization among female patients hospitalized with confirmed sexual abuse was 0.4% (95% confidence interval [CI]: 0.3–0.5). Among those who had in-hospital fatality, the median time from hospitalization to death was 4.5 (IQR: 3–11) days. In multivariable analysis, addition of physical abuse to sexual abuse had the largest effect for in-hospital mortality (2.7% vs. 0.2%, adjusted-incidence rate ratio 12.70, 95% CI: 7.19–22.44, P < 0.001). Age >30 years was associated with more than three-fold increase in-hospital mortality (0.6% vs. 0.2%, adjusted-incidence rate ratio 3.65, 95% CI: 1.97–6.79, P < 0.001). In a 7-year period, female sexual abuse hospitalization increased nearly three-fold, from 2.9 to 8.4 per 100 000 hospitalizations (P-trend < 0.001), while male sexual abuse hospitalizations increased from 0.6 to 1.2 per 100 000 hospitalizations (P-trend < 0.001) (Figure 1). Female sexual abuse hospitalization exceeded female physical abuse during the COVID-19 pandemic (Figure 1). The overall difference between female and male hospitalizations widened (Figure 1). Prevalence of mental health conditions in female sexual abuse patients were overall higher compared to other groups, and nearly one in eight (12.5%) were unhoused status (Table S1). This nationwide assessment described grand overview statistics of morbidity (respiratory failure, cardiac failure including arrest, intubation, hypotension, shock, and cerebrovascular accident) and in-hospital mortality for female patients who required hospitalization following confirmed sexual abuse. These data also suggest that number of female patients who require hospitalization following sexual abuse may be gradually increasing in the United States in recent years. The recent widening gap between the female and male sexual abuse hospitalization is a major concern. Key limitations of the study included lack of information on details of sexual abuse (reason, past episode, and severity), indication for hospitalization, cause of death, and post-discharge data. Analysis of only inpatient data also limits the interpretation. Increasing hospitalizations of sexual abuse may be due to the increase in reporting or capturing in administrative coding. Despite these limitations, the results of current investigation highlight importance of informing sexual abuse prevention efforts.2 Conceptualization: D.S.M.; Data curation: K.M.; Formal analysis: K.M.; Funding acquisition: K.M.; Investigation: all authors; Methodology: K.M.; Project administration: K.M.; Resources: C.J.D., S.S.C., N.M.C.; Software: K.M.; Supervision: S.S.C., K.M., N.M.C.; Validation: K.M.; Visualization: K.M.; Writing—original draft: D.S.M., K.M.; Writing—review and editing: all authors. Ensign Endowment for Gynecologic Cancer Research (K.M.). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. None. The manuscript's corresponding author (K.M.) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The National Inpatient Sample is developed for the Healthcare Cost and Utilization Project that is sponsored by the Agency for Healthcare Research and Quality, and the program is the source of the de-identified data used; race/ethnicity was grouped by the program; and the program has not verified and is not responsible for the statistical validity of the data analysis or the conclusions derived by the study team. The data on which this study is based are publicly available upon request at Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/nissoverview.jsp. Table S1. Clinical demographics per sex and abuse type. 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