Urban and rural differences in healthcare access among survivors of child sexual abuse: a nationwide survey

Child sexual abuse (CSA) is associated with poorer healthcare access in adulthood, but evidence remains limited on whether this association differs between urban and rural settings. We analyzed data from the 2023 Japan COVID-19 and Society Internet Survey (JACSIS), including 27,699 adults aged 18–79 years. Participants reported CSA before age 18 using behavior-specific items and two direct screening questions. We assessed adult healthcare access barriers, including missed scheduled visits, inability to obtain unplanned care, postponed surgery, and absence of a usual source of care. We used inverse probability of treatment weighting and weighted logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs), and we tested CSA-by-urbanicity interaction terms. CSA prevalence was 9.3%. Adults with a history of CSA had higher odds of missed scheduled visits (aOR 1.76, 95% CI 1.52–2.04), inability to obtain unplanned care (aOR 2.36, 95% CI 2.00–2.78), hospitalization postponed (aOR 3.25, 95% CI 2.42–4.37), surgery postponed (aOR 4.01, 95% CI 3.05–5.29), and non-surgical treatment postponed (aOR 3.15, 95% CI 2.40–4.12). Preventive care not received did not differ significantly. CSA was also associated with higher odds of having no usual source of care (aOR 1.67, 95% CI 1.54–1.82). Urbanicity significantly modified associations for missed scheduled visits (urban: aOR 1.97, 95% CI 1.64–2.37; rural: aOR 1.44, 95% CI 1.12–1.85; p for interaction = 0.04) and preventive care not received (urban: aOR 1.01, 95% CI 0.88–1.15; rural: aOR 0.82, 95% CI 0.70–0.95; p for interaction = 0.04). CSA survivors face substantial barriers to care. The stronger association with missed appointments in urban settings suggests that provider density alone does not ensure access. Trauma-informed care models may help reduce avoidance behaviors, particularly in high-volume urban practices.