Background
Women consistently show a higher rate of CSA than men. Research suggests that one in three to four females and one in six to eight males have been sexually abused by age 18 (Finkelhor et al., 1990; Holz, 1994). Evidence and anecdotal reports suggest that many survivors use a disproportionate share of health care resources, often without solving the underlying problem.

Purpose and Objectives
The purpose of this study was to determine the cost of health services used by survivors of child sexual abuse, whether insured health care services helped in the healing process and whether there are other means of providing healing which fall outside insured health care services.

The study asked survivors to review their health care services costs for a ten, and in some cases eleven-year period; "tell their story" about the medical interventions in focus groups and in one-on-one interviews with the principal investigator; judge whether the medical system helped their healing process; identify what other services helped them in their healing journey and make recommendations about appropriate care for women survivors of CSA.

Research Questions

• The research reported here examined the following questions:
• How much did it cost to provide insured health care services to twelve women survivors of childhood sexual abuse?
• Did the insured health care services help in the healing process?
• What other services, other than insured health care services, helped in the healing journey?

Health care service costs were analyzed and compared to appropriate benchmarks, adjusted where possible for age and gender. Qualitative data on the CR-survivor's experience with health care services and their recommendations for improvements were gathered from interviews and focus groups. The PI analyzed the information using theme and content analysis methods.

Main Findings
The cost of insured health care services for the 12 CR-survivors was 4.1 times the population average after adjusting for age and gender. The average annual cost of publicly funded health care expenditures per CR-survivor was $4,387 as compared to $1,081 for the population average.

The adjusted utilization-to-benchmark ratios showed that, on average, the cost of medical services used by CR-survivors was 3.7 times the population average. The average costs of hospitalization for CR-survivors were 3.8 times the population average and 76% of the cost of hospitalization was spent on psychiatric care. The average cost of medications prescribed to the CR-survivors was 9.4 times the population average and the cost of their emergency visits was 1.5 times the population average.

The CR-survivors reported that some of the positive consequences of insured health care services included various stabilizing effects such as control of symptoms and the ability to function in society. They reported that the negative consequences of health care services included failure of health care providers to detect CSA which may have led to a diagnosis which overlooked the underlying cause, excessive use of psychotropic drugs, and continued fragmentation of various helping systems including health care, social services, and justice.

The cost comparison for community-based services was hard to measure in part because they are not publicly funded and therefore it is difficult to access the costs. But what we do know is that local estimates indicate the average cost in a Saskatoon hospital is $583.00 per day; it costs $47.00 for a half-hour with a family doctor and $72.00 for a specialist. By comparison, community-based, publicly funded counseling costs an average of $40.00 -$50.00 an hour. The estimated cost to run a fulltime (24 hrs. per day, seven days per week) holistic healing centre focused exclusively on healing from child sexual abuse with eight beds is $205.48 per bed per day.1

Implications
The consequences of CSA are costly in both personal and financial terms. The increased health care services costs associated with CSA, along with the requests of the CR-survivors for more and easier access (availability) to alternative means of healing call for the establishment of other services and treatment aimed at sustained inner healing, not merely the remediation of symptoms.

While existing information does not allow a reliable estimate of the proportion of the provincial health care budget attributable to unresolved CSA, we can extrapolate the provincial cost based on provincial population number. The population of Saskatchewan is approximately 1 million, half of which is female. Using Finkelhor's (1990)2 findings that as many as one in four women are victims of sexual abuse we can estimate the yearly cost to the medical system in dealing with the CSA of women to be approximately $54,837,5003.

Recommendations
The CR-survivors recommend that:

1. The Government of Saskatchewan ensure that education on the prevalence, impact, gendered differences and cost of childhood sexual abuse be part of the health care and human service professional educational training. The professional groups include Medicine, Nursing, Physical Therapy, Dentistry, Pharmacy, Allied Health Science Programs, Social Work, Complementary care programs, Law, Education, Theology, and Psychology.
2. Health care and human service professionals include the concept of violence, in particular childhood sexual abuse, as an integrated diagnostic concept in the assessment of clients;
3. Health care and human service professionals pay particular attention to the symptoms associated with CSA which often lead to costly misdiagnosis;
4. The Government of Saskatchewan fund the development and distribution of a public information package with an educational poster and pamphlets to all health, social services, justice and education providers in the province. The information package should include information on the prevalence, impact, gendered differences and cost of childhood sexual abuse, the public's role in eliminating this crime and the steps to be taken if one suspects it is taking place. In particular:
   • Such material be made accessible and available to children, professionals and the general public;
   • Such material make reference to a child's right, under provincial, federal and international law (The United Nations Convention on the Rights of the Child) to protection from abuse and the duty of society to protect children;
5. Professionals who work with and on behalf of CSA survivors be accredited by their professional bodies and governed by a professional Codes of Ethics.
6. The Saskatchewan Departments of Health, Social Services, Justice and Education actively address broad social and economic factors relating to prevention of and healing from CSA and work together on integrated collaborative solutions and services while being cognitive of the gender differences. In particular:

   A multi-sectoral initiative be undertaken to fund and host a national conference on the prevalence, impact and cost of child sexual abuse, its gendered differences and the prevention, detection and treatment of CSA, including complementary/alternative care.

7. Saskatchewan Government and Saskatchewan Health, establish a committee to assess the potential of selected complementary therapies for improving health outcomes and reducing health care costs in the treatment of symptoms resulting from childhood trauma, and to make appropriate recommendations concerning the inclusion of selected complementary therapies as publicly insured health services for trauma survivors. The committee should include representatives from Saskatchewan Health, Department of Social Services, and trauma survivors;
8. Saskatchewan provincial funding and budgetary commitments be provided for community-based agencies to provide comprehensive, holistic healing services to survivors of CSA;
9. Complementary/Alternative care workers be licensed under a professional act which will require adherence to a Code of Ethics.
   
   The authors of this Report further recommend that:
   
   
10. Participatory action research continue to be funded by Health Canada; such research can make use of the substantial body of knowledge possessed by CSA survivors and could serve as the basis for designing programs of prevention, early detection, and treatment of CSA.
11. Health Canada and other funders provide funding for research into complementary and alternative medical care.

Interventions which are targeted towards deep, authentic, inner healing, such as healing centres in the community, could have major positive human and societal consequences and result in significant reductions in costs associated with the health care, social services, and justice systems. With appropriate reallocation of resources all survivors of CSA are more likely to have access to the help they need.