For the growing number of teenage girls who are incarcerated each year, detention may be the only time they get health care.
But the care provided to girls in juvenile detention is often a poor match for their needs.
One reason: It's a system that was designed for boys.
Girls in detention are "one of the most vulnerable and unfortunately invisible populations in the country," says Catherine Pierce, a senior adviser at the federal government's Office of Juvenile Justice and Delinquency Prevention.
Up to 90 percent of these girls have experienced physical, sexual or emotional abuse, Pierce says.
Their health statistics are particularly grim: 41 percent have signs of vaginal injury consistent with sexual assault; up to a third have been or are currently pregnant; 8 percent have had positive skin tests for tuberculosis; and 30 percent need glasses but don't have them, according to research from the National Girls Health and Justice Institute.
Reylene, who asked that her full name not be used, was 17 a few months ago when she arrived in handcuffs at the Bernalillo County Juvenile Detention and Youth Services Center in Albuquerque, N.M., after being arrested for larceny and breaking and entering.
She received much the same treatment as if she were a boy.
First, Reylene was given a full pat-down to check for contraband, like drugs or weapons. After showering and putting on her uniform, she was given a brief health screening to make sure that she didn't need emergency medical services before being booked.
The screening 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, girls are unlikely to reveal important health information, especially when they have previously been victimized, says Leslie Acoca, a psychologist and researcher who has studied the health care of girls in detention for more than a decade.
Reylene was weighed and measured, and had her vital signs taken. The nurse briefly evaluated her physical and mental state, noting her judgment, speech and mood. Next, the nurse 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 past 24 hours, was feeling suicidal, or if she had a history of self-destructive behavior.
There are a handful of questions given only to girls: Are you pregnant? If so, have you started prenatal care? What form of birth control do you use?
During the screen, however, Reylene didn't mention a major health issue: painful red burns across her breasts.
"Usually I'm pretty straightforward, but, like, I lied to [the nurse] when I first came in here, about my burns," says Reylene, who explains that she doesn't know exactly what happened because she was passed out when she was burned.
The nurse saw the burns through her tank top, but Reylene was evasive because she didn't want them to be investigated. "If we're in the detention center ... we don't know who to trust, because we're vulnerable," she says.
Reylene says she had to ask several times for ointment.
Acoca wants to improve the situation faced by girls like Reylene. She's developed a tool that she believes will vastly improve the situation — a 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.
The Bernalillo center recently agreed to try out the Girls Health Screen. Of the 30 girls at the facility who participated in the pilot, 12 were identified as needing immediate medical care, and 23 as needing medical care within 24 hours. Some of these health issues had been missed when the girls went through the center's standard health screening procedure.
Acoca says that if Reylene had taken the Girls Health Screen on a computer, the burns would have triggered an immediate medical response.
"There would be a little flag that would go, 'Ding, ding, ding! Ointment for burns!' " Acoca says.
But Veronica Crespin, one of the nurses at the facility, says that Acoca's screen takes too long and finds problems they already knew about. And they don't have the staff.
"It's just very busy. Most of the time it's one nurse per shift. And there's multiple intakes," Crespin says
Acoca argues it's worth it to make the time. Her research 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.
The Albuquerque center hasn't decided yet whether to adopt Acoca's health screen. But Los Angeles County began using it in June, and six other California counties are considering it.
Jenny Gold is a reporter with Kaiser Health News, an independent, nonprofit news service supported by The Kaiser Family Foundation. The Kaiser Family Foundation also helps fund Leslie Acoca's research.
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America's juvenile justice system was designed for boys and that can make life difficult for girls when they're locked up. For one, their health needs, especially after sexual, physical, or emotional abuse, are often overlooked. We have a story now about one woman's efforts to change the system and make it more sensitive to those needs.
Reporter Jenny Gold visited the main juvenile detention center in Albuquerque and sent this report.
JENNY GOLD: In the intake area of the Bernalillo County Juvenile Detention Center, a guard is patting down a 16-year-old girl brought in for breaking parole. She's shackled at the wrist and ankles with pink cuffs.
UNIDENTIFIED WOMAN: So what I'm going to do is just going to go ahead and pat you down and see if anything is on you, OK? Spread your legs for me, please. Thank you.
GOLD: After the search is over, a staff nurse gives a girl a brief medical exam. Nurse Veronica Crespin asks the girls a series of 35 questions to find out whether they're sick or hurt.
VERONICA CRESPIN: Basically we, you know, go through if they were injured during the arrest, any drugs and alcohol, any history of rape within the last five days, any suicide ideation.
GOLD: She takes the girl's vital signs, asks her about birth control and gives her pregnancy test. It takes about 15 minutes. There's no physical exam. The door to the room remains open. A girl is often asked sensitive questions in front of male staff members or boys waiting to be screened. So is it any wonder that they often lie about their health?
REYLENE: If we're in the detention center, like, it's kind of like we don't know who to trust because we, we're vulnerable.
GOLD: That's Reylene. She was 17 when I talked to her a couple of months back. She didn't want us to use her full name.
REYLENE: Like, for example, if someone is being abused and they have marks and they can be treated for it, they're not going to want to say anything because they don't know what's going to happen when they get out.
GOLD: She's in detention this time for larceny and breaking and entering.
REYLENE: Usually I'm pretty straightforward. But, like, I lied to her, like, when I first came in here about, like, my burns and stuff.
GOLD: Reylene had severe burns across her chest.
REYLENE: My whole left breast is, like, scarred. And then, like, some of them are healing and the other ones are, like, really read.
GOLD: Reylene says she had asked several times for ointment, even though the nurse saw the burns during her medical screen. She was reluctant to talk about them.
REYLENE: I told her that I didn't know it was because I didn't want her to, like, investigate it or something. I knew what it was but I wasn't completely sure, because I was, like, passed out when it happened. But...
GOLD: Reylene's story is typical of girls in detention, and that presents a problem for people who run the juvenile justice system. They can't tackle the complex problems - addiction, trauma, mental and physical illness - if they don't know about them.
Bernalillo officials are trying a new approach. It was developed by Leslie Acoca, a psychologist and advocate who researches health care for girls in detention. Acoca says it's important to do more thorough exams because this may be the only time girls on the fringes encounter the health care system.
LESLIE ACOCA: If we don't ask these questions, who will, and at what point in their lives? And how sick do they have to get?
GOLD: An unpublished study Acoca conducted with the Children's Hospital of Philadelphia found that 41 percent of 148 girls given detailed physical exams had signs of vaginal injury consistent with sexual assault or violent sex. Up to a third had been pregnant. And that's just the beginning, she says.
ACOCA: Issues like self-harming, hopelessness, anxiety, those things are not being picked up accurately or early enough.
GOLD: A separate study showed that fewer than half of facilities surveyed are following national health screening guidelines, and almost all of those tests were designed with boys in mind.
So Acoca set out to design a new screening test. It has 132 written questions about health, medical history, and self-esteem. It takes 13 to 45 minutes to do, depending on a girl's reading ability. And it's meant to be given with a full physical. Reylene agreed to answer some of the questions out loud with Acoca.
ACOCA: Have you passed out or lost consciousness in the past two weeks?
ACOCA: You have. Do you think you use too much alcohol or drugs?
GOLD: If Reylene's first test had been like this, but on a computer, Acoca says the burns on her chest would have triggered an immediate medical response.
ACOCA: There would be little flag that would go ding-ding-ding.
GOLD: Of the 30 girls who took the test in Albuquerque, 12 were identified as needing immediate medical attention. But Nurse Veronica Crespin says the test finds problems they already knew about. It's too long and they don't have the staff.
CRESPIN: It's just very busy. You know, most of the time it's one nurse per shift and there's multiple intakes. You know, on any given day, it's just constant.
GOLD: Acoca says they have to make time. Research Acoca published in 2000 with the National Council on Crime and Delinquency found that poor physical health increases girls' risk of landing back in detention or jail. Catherine Pierce works at the juvenile division of the U.S. Department of Justice.
CATHERINE PIERCE: I think that many facilitates really don't understand the extent of girls health needs and how complex they are.
GOLD: She says Acoca's screen is a valuable tool.
PIERCE: As many as 90 percent of incarcerated girls have histories of sexual and physical and emotional abuse, and that is stunning and it makes girls very vulnerable.
GOLD: Just being asked the questions seemed to have an impact on some girls, like 16-year-old Amanda.
AMANDA: At first I thought it was weird, like just taking a quiz out of nowhere. But then when I thought about it, it made sense. They just want to know about girls' health. And so, it felt as if I was a little bit important to put a dent into something that could be big.
GOLD: The day I visited, Amanda was released back into her mother's care. The other girls looked on enviously as she left, imagining the day when they'd get out too.
UNIDENTIFIED WOMAN #1: I can't wait. I'm so excited to go home.
UNIDENTIFIED WOMAN #2: When I get out, I'm going to Panda Express.
UNIDENTIFIED WOMAN #3: Dude, when I get out I want to go eat some bomb Chinese food.
UNIDENTIFIED WOMAN #4: Yeah. It's like...
GOLD: At this moment, they could be any group of girls just hanging out. Acoca says she's amazed at their resilience.
ACOCA: We'd watch them play baseball in the gym, and do pushups, and laugh like little girls. When you take them off street, you don't see an offender, you see a child.
GOLD: A child, she hopes, with better medical care, might not end up back here. The Albuquerque center hasn't decided yet whether to adopt Acoca's health screen. But Los Angeles County began using it in June and six other California counties are considering it.
For NPR News, I'm Jenny Gold
SIEGEL: Jenny Gold is a reporter with Kaiser Health News, a nonprofit news service.
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