Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, Levitt CJ, Shapiro RA, Moles RL, Starling SP. Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology. 2016; 29 (2) : 81-87 Review..
Keywords: Child sexual abuse,Differential diagnosis,Expert opinion,Expert testimony,Medical history taking,Peer review,Sexually transmitted infections
The medical evaluation is an important part of the clinical and legal process …
The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.
Religious objections to medical care. American Academy of Pediatrics Committee on Bioethics.. Pediatrics. 1997; 99 (2) : 279-81.
Keywords: Child, Child Advocacy, Child Welfare/*legislation & jurisprudence, Humans, Organizational Policy, Pediatrics, *Religion and Medicine, Societies, Medical, United States
Parents sometimes deny their children the benefits of medical care because of …
Parents sometimes deny their children the benefits of medical care because of religious beliefs. In some jurisdictions, exemptions to child abuse and neglect laws restrict government action to protect children or seek legal redress when the alleged abuse or neglect has occurred in the name of religion. The American Academy of Pediatrics (AAP) believes that all children deserve effective medical treatment that is likely to prevent substantial harm or suffering or death. In addition, the AAP advocates that all legal interventions apply equally whenever children are endangered or harmed, without exemptions based on parental religious beliefs. To these ends, the AAP calls for the repeal of religious exemption laws and supports additional efforts to educate the public about the medical needs of children.
Culturally effective pediatric care: education and training issues. American Academy of Pediatrics Committee on Pediatric Workforce.. Pediatrics. 1999; 103 (1) : 167-70.
Keywords: *Cultural Diversity, Culture, *Delivery of Health Care, Education, Medical, Continuing/methods, Education, Medical, Undergraduate/methods, Internship and Residency/methods, Pediatrics/*education, United States
This policy statement defines culturally effective health care and describes …
This policy statement defines culturally effective health care and describes its importance for pediatrics. The statement also defines cultural effectiveness, cultural sensitivity, and cultural competence and describes the importance of these concepts for training in medical school, residency, and continuing medical education. The statement is based on the premise that culturally effective health care is important and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the expressed purpose of addressing cultural competence and/or cultural sensitivity, and 2) educational components on cultural competence and/or cultural sensitivity that are incorporated into medical school, residency, and continuing medical education curricula.
Berson NL, Herman-Giddens ME, Frothingham TE. Children's perceptions of genital examinations during sexual abuse evaluations.. Child Welfare. 1993; 72 (1) : 41-9.
Keywords: *Attitude to Health, Child, Child Abuse, Sexual/diagnosis/*psychology, *Child Welfare, Child, Preschool, Female, Humans, Internal-External Control, *Patient Care Team, Patient Participation/psychology, Physical Examination/*psychology
Children's reactions to the medical evaluation of sexual abuse and the methods …
Children's reactions to the medical evaluation of sexual abuse and the methods that enhance their coping ability have not been well addressed in the literature. For many children, a genital examination can be highly stressful, and may even trigger memories of the sexual abuse itself. Stress can be reduced by preparing the child for the examination, by giving the child greater control, and by debriefing the child (and parents) afterward. Research is needed to develop the most effective techniques for reducing children's stress during a genital examination.
Christian CW, Crawford-Jakubiak JE, Flaherty EG, Leventhal JM, Lukefahr JL, Sege RD. The evaluation of suspected child physical abuse. Pediatrics. 2015; 135 (5) : e1337-e1354.
Child physical abuse is an important cause of pediatric morbidity and mortality …
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Jenny C, Crawford-Jakubiak JE. The evaluation of children in the primary care setting when sexual abuse is suspected.. Pediatrics. 2013; 132 (2) : e558-67.
Keywords: Adolescent, Child, Child Abuse, Sexual/*diagnosis/legislation & jurisprudence/psychology/therapy, Cooperative Behavior, Cross-Sectional Studies, Female, Follow-Up Studies, Humans, Interdisciplinary Communication, Interview, Psychological, Male, *Mandat
This clinical report updates a 2005 report from the American Academy of …
This clinical report updates a 2005 report from the American Academy of Pediatrics on the evaluation of sexual abuse in children. The medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.
Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Care Providers. Chicago: Department of Adolescent Health, American Medical Association [AMA]. 1994..
Keywords: Adolescents; Health; Health Care; Cultural Pluralism; Health Care for Newborns and Minors;
Drummond R, Gall JA. Evaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect.. Journal of Forensic and Legal Medicine. 2017; 46 : 37-45.
Keywords: Adolescent, Age Factors, Australia, Child, Child Abuse/*diagnosis/*legislation & jurisprudence, Child, Preschool, Female, Forensic Medicine/*legislation & jurisprudence, Humans, Male, Medical History Taking/*statistics & numerical data, Retrospective S
BACKGROUND: Suspected child physical abuse, sexual abuse and neglect are not …
BACKGROUND: Suspected child physical abuse, sexual abuse and neglect are not uncommon presentations. As part of the assessment of these cases, a forensic medical history may be taken. This forensic history is used not only to determine the steps necessary to address the child's wellbeing but also to direct the forensic examination. Currently, there is no clear consensus on whether or not a forensic medical history should consistently be considered an integral element within the paediatric forensic evaluation. This study examines the value derived by the medical practitioner taking a forensic medical history rather than relying on hearsay evidence when a child presents for an assessment. METHODS: A retrospective review of paediatric cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 2014 and 2015 was undertaken. 274 forensic case reports were reviewed and the data was entered into an Excel spread sheet and analysed using chi squared tests within STATA(®). RESULTS: With increasing age of the child, a forensic medical history is significantly more likely to be taken. Additional information is made available to the medical practitioner what would otherwise have been provided if the medical practitioner relied only on the interview conducted by the police. Discrepancies observed between the official third parties (police or child protection) report of what a child has said and what the child says to the medical practitioner decrease with age, as do discrepancies observed between the child's version of events and a third party's (eg. parents, caregivers, friends) version of events. CONCLUSIONS: The study showed that by taking a forensic medical history from the child additional information can be obtained. Further, that there is a value in the examining medical practitioner taking a forensic medical history from children in cases of child physical and sexual abuse and neglect.
Dubowitz H, Finkel M, Feigelman S, Lyon T. Initial Medical Assessment of Possible Child Sexual Abuse: History, History, History.. Academic Pediatrics. 2024; 24 (4) : 562-569.
Keywords: Humans, *Child Abuse, Sexual/diagnosis, *Medical History Taking, Child, Primary Health Care, Physical Examination
Primary care professionals (PCPs) can play a valuable role in the initial …
Primary care professionals (PCPs) can play a valuable role in the initial assessment of possible child sexual abuse (CSA), an all too prevalent problem. PCPs, however, are often reluctant to conduct these assessments. The goal of this paper is to help PCPs be more competent and comfortable playing a limited but key role. This is much needed as there may be no need for further assessment and also because of a relative paucity of medical experts in this area. While some children present with physical problems, the child's history is generally the critical information. This article therefore focuses on practical guidance regarding history-taking when CSA is suspected, incorporating evidence from research on forensic interviewing. We have been mindful of the practical constraints of a busy practice and the role of the public agencies in fully investigating possible CSA. The approach also enables PCPs to support children and their families.
Giardino AP, Finkel MA, Giardino ER, Seidl T, Ludwig S. Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. California: Sage Publications. 1992; 16-28.
Keywords: The purpose of this manual is to serve as a reference guide for health care professionals called upon to evaluate children suspected of being sexually abused.
The manual may be useful for various health care team members, including …
The manual may be useful for various health care team members, including clinical social workers, psychologists and psychiatrists, child protective service workers, and law enforcement personnel. It provides background information on child sexual abuse in order to increase the awareness of health care professionals; to facilitate their consideration of sexual abuse in differential diagnoses, given specific and nonspecific signs and symptoms; to reassure health professionals in their roles as care providers and child advocates; and to provide a reference on how to proceed with medical and psychological assessment. Sections of the manual cover the scope of child sexual abuse, sexual abuse evaluation, interview and history procedures, physical examinations and laboratory specimens, the differential diagnosis of anogenital findings, sexually transmitted diseases, and mental health evaluation. References, tables, figures, and photographs
Hartog J, Hartog EA. Cultural aspects of health and illness behavior in hospitals.. Western Journal of Medicine. 1983; 139 (6) : 910-6.
Keywords: Communication, *Culture, Diet, Hospitals, Humans, Pain/psychology, Religion and Medicine, *Sick Role
Health care attitudes reflect the basic world view and values of a culture, …
Health care attitudes reflect the basic world view and values of a culture, such as how we relate to nature, other people, time, being, society versus community, children versus elders and independence versus dependence. Illness behavior determines who is vulnerable to illness and who agrees to become a patient-since only about one third of the ill will see a physician. Cultural values determine how one will behave as a patient and what it means to be ill and especially to be a hospital patient. They affect decisions about a patient's treatment and who makes the decisions. Cultural differences create problems in communication, rapport, physical examination and treatment compliance and follow through. The special meaning of medicines and diet requires particular attention. The perception of physical pain and psychologic distress varies from culture to culture and affects the attitudes and effectiveness of care-givers as much as of patients. Religious beliefs and attitudes about death, which have many cultural variations, are especially relevant to hospital-based treatment. Linguistic and cultural interpreters can be essential; they are more available than realized, though there are pitfalls in their use. Finally, one must recognize that individual characteristics may outweigh the ethnic and that a good caring relationship can compensate for many cultural missteps.
Heger AH, Emans SJ, Muram D. Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas. 2nd Edition. Oxford University Press. 2003; 41-55.
Physicians examining children for suspected sexual abuse often do not have the …
Physicians examining children for suspected sexual abuse often do not have the training they need to make a skilled diagnosis. This comprehensive resource provides step-by-step guidance on interviewing and clinically evaluating possible child sexual abuse cases, and includes sixty-three pages of color photographs that document sexual abuse injuries, and offer comparisons to accidental injuries as well as normal anatomical variations.
Huff RA & Kline MV. Promoting Health in Multicultural Populations: A Handbook for Practitioners. London: Sage Publication. 1999..
Promoting Health in Multicultural Populations will prove an excellent shelf …
Promoting Health in Multicultural Populations will prove an excellent shelf reference for health and human service providers and scholars, and a valuable text for students in a wide variety of professional disciplines, including public health and other arenas of health care, social work, and medical sociology and anthropology.
Kraut AM. Healers and strangers. Immigrant attitudes toward the physician in America--a relationship in historical perspective.. JAMA. 1990; 263 (13) : 1807-11.
Keywords: *Attitude to Health, *Culture, Emigration and Immigration/*history, Ethnicity, History, 19th Century, History, 20th Century, Humans, Medicine, Chinese Traditional, Medicine, Traditional, *Physician-Patient Relations, Physicians/supply & distribution, Q
The current wave of immigration to the United States--mostly Asians and Latin …
The current wave of immigration to the United States--mostly Asians and Latin Americans--may well be the largest in the 20th century. Many newcomers practice habits of health and hygiene deficient by American standards. Some prefer the shaman to the physician and traditional herb remedies to modern medical therapies. Physicians find themselves practicing at an invisible border separating them from their foreign-born patients, where differences of language and culture can lead to misunderstanding and frustration, impeding a physician's ability to gain cooperation with prescribed therapy. Similar issues faced physicians at the turn of the century. Newly arrived Italians, East European Jews, and Chinese were often ambivalent toward physicians and their therapies. Quacks further undermined the physician's credibility among immigrants. Today, some physicians try collaborating with shamans and herbalists to accommodate patients' cultural preferences. Respect for the customs and taboos of immigrant patients pays dividends in physician effectiveness and efficiency.
Lazebnik R, Zimet GD, Ebert J, Anglin TM, Williams P, Bunch DL, Krowchuk DP. How children perceive the medical evaluation for suspected sexual abuse.. Child Abuse & Neglect. 1994; 18 (9) : 739-45.
Keywords: Adolescent, *Attitude to Health, Child, Child Abuse, Sexual/*diagnosis/*psychology, Child, Preschool, Cross-Sectional Studies, Fear, Female, Humans, Male, Pain/etiology, Physical Examination/adverse effects/*psychology, Physician-Patient Relations, *Ps
This study investigated how 99 children who were examined for suspected sexual …
This study investigated how 99 children who were examined for suspected sexual abuse (SSA) perceived their own medical evaluation experiences. Each child was interviewed about the degree of pain and fear associated with the experience, the kindness of the doctor, general fear of doctor visits, and degree of fear associated with a hypothetical second examination. The majority of children did not perceive their SSA examination to be strongly negative. However children did report greater fear associated with the SSA evaluation compared to an ordinary doctor visit. Using multiple regression, general fear of doctor visits and fear and pain associated with the SSA examination contributed to the prediction of intensity of fear about a hypothetical second SSA evaluation. Perceived kindness of the doctor, patient sex and age, and physician sex and age did not contribute to the regression equation. The relatively low reported rate of intense distress associated with medical evaluation of SSA suggests that fear and pain can be minimized and effectively managed for many children. The results of the regression analysis suggest that previous negative medical experiences may play an important role in determining how a child interprets the experience of an SSA medical evaluation.
Levitt CJ. The medical examination in child sexual abuse: A balance between history and exam. Journal of Child Sexual Abuse. 1992; 1 (4) : 113-121.
In many cases, children reporting sexual abuse will not present specific …
In many cases, children reporting sexual abuse will not present specific physical symptoms; where such findings are present, they are likely to be subtle bruises or abrasions. The efforts of professional medical groups to establish consensus on the range of possible findings and their meanings have been hampered by the difficulty of finding valid experimental populations for child sexual abuse. The colposcope has been instrumental in providing a basis for standardization of examinations and interpretation of findings. However, the quality of an examination is only as good as the practitioner and technique used, particularly with regard to hymenal findings. The physician must be aware that the ability of the State to prosecute a child sexual abuse case often rests upon the quality of the medical history and manner in which it is presented. Therefore, the examination must include a physical evaluation as well as an opportunity for the physician to question the child regarding possible experiences of abuse. 15 references
Lipson JG, Dibble S & Minarik PA. Culture & Nursing Care: A Pocket Guide. San Francisco, CA: UCSF Nursing Press. 1996..
Lorenc T, Lester S, Sutcliffe K, Stansfield C, Thomas J. Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews.. BMC Public Health. 2020; 20 (1) : 657.
Keywords: Adolescent, Adult, Adverse Childhood Experiences/*statistics & numerical data, Aged, Aged, 80 and over, Child, Child Abuse/*psychology/statistics & numerical data/*therapy, Child, Preschool, Female, Humans, Male, Middle Aged, *Resilience, Psychological
BACKGROUND: Adverse Childhood Experiences (ACEs) such as abuse, neglect or …
BACKGROUND: Adverse Childhood Experiences (ACEs) such as abuse, neglect or household adversity may have a range of serious negative impacts. There is a need to understand what interventions are effective to improve outcomes for people who have experienced ACEs. METHODS: Systematic review of systematic reviews. We searched 18 database sources from 2007 to 2018 for systematic reviews of effectiveness data on people who experienced ACEs aged 3-18, on any intervention and any outcome except incidence of ACEs. We included reviews with a summary quality score (AMSTAR) of 5.5 or above. RESULTS: Twenty-five reviews were included. Most reviews focus on psychological interventions and mental health outcomes. The strongest evidence is for cognitive-behavioural therapy for people exposed to abuse. For other interventions - including psychological therapies, parent training, and broader support interventions - the findings overall are inconclusive, although there are some positive results. CONCLUSIONS: There are significant gaps in the evidence on interventions for ACEs. Most approaches focus on mitigating individual psychological harms, and do not address the social pathways which may mediate the negative impacts of ACEs. Many negative impacts of ACEs (e.g. on health behaviours, social relationships and life circumstances) have also not been widely addressed by intervention studies.
Monteleone JA, Brodeur AE. Child Maltreatment: A Clinical Guide and Reference. St Louis, MO: GW Medical Publishing. 1994; 170-189.
Although the information is presented from a medical perspective, it can also …
Although the information is presented from a medical perspective, it can also be useful for social service workers, attorneys, law enforcement workers, State agencies, and others involved with abused children. The first volume is a clinical guide and reference. It begins with a discussion of the identification, interpretation, and reporting of injuries to children, followed by a chapter on the radiology of child abuse. A chapter addresses each of the following types of injuries: thoracoabdominal, ophthalmic, head injuries, and burns. Four chapters on sexual abuse include an overview of sexual abuse, the physical examination, the victim interview, and sexually transmitted diseases in abused children. Other chapters related to abuse injuries focus on multiple personality disorder, poisoning, the Munchausen syndrome by proxy, neglect and abandonment, emotional abuse, and the cycle of abuse. Other chapters address the review process, legal issues, the role of the medical examiner in fatal child abuse, expert medical testimony in child abuse cases, and the prevention of child abuse. The second volume is a comprehensive photographic reference for identifying potential child abuse. The photographs are presented under sections on physical abuse, radiologic investigations, sexual abuse cases, cases involving the police, forms of neglect, and drawings by victims of abuse.
Myers JEB. Role of physician in preserving verbal evidence of child abuse.. Journal of Pediatrics. 1986; 109 (3) : 409-11.
Keywords: Child, *Child Abuse, Humans, Jurisprudence, *Physician's Role, *Role
O'Brien JS. Interviewing Techniques. In: Olshaker JS, ed. Forensic Emergency Medicine Philadelphia: Lippincott, Williams, & Wilkins. 2001; : 55-61.
Olson LM, Campbell KA, Cook L, Keenan HT. Social history: A qualitative analysis of child abuse pediatricians' consultation notes.. Child Abuse & Neglect. 2018; 86 : 267-277.
Keywords: Brain Injuries, Traumatic/etiology, Child, Child Abuse/*diagnosis/statistics & numerical data, Child, Preschool, Female, Fractures, Bone/etiology, Humans, Inpatients, Male, *Medical History Taking, Parenting, Pediatricians/statistics & numerical data, Phy
BACKGROUND: Child abuse pediatricians (CAPs) are often consulted for injuries …
BACKGROUND: Child abuse pediatricians (CAPs) are often consulted for injuries when child physical abuse is suspected or when the etiology of a serious injury is unclear. CAPs carefully evaluate the reported mechanism of the child's injury and the medical findings in the context of the child's family and social setting to identify possible risk and protective factors for child abuse and the need for social services. It is unknown what population risk indicators along with other social cues CAPs record in the social history of the consultation notes when assessing families who are being evaluated for child physical abuse. PARTICIPANTS AND SETTING: Thirty-two CAPs representing 28 US child abuse programs. METHODS: Participants submitted 730 completed cases of inpatient medical consultation notes for three injury types: traumatic brain injury, long bone fracture, and skull fracture in hospitalized children 4 years of age and younger. We defined a priori 12 social cues using known population risk indicators (e.g., single mother) and identified de novo 13 negative (e.g., legal engagement) and ten positive social cues (e.g., competent parenting). Using content analysis, we systematically coded the social history for the social cues. RESULTS: We coded 3,543 cues resulting in a median of 7 coded cues per case. One quarter of the cues were population indicators while half of the cues were negative and one quarter positive. CONCLUSIONS: CAPs choose a wide variety of information, not always related to known population risk indicators, to include in their social histories.
Reece RM & Ludwig S, eds. Child Abuse: Medical Diagnosis and Management (2nd Ed.). Baltimore: Lippincott, Williams and Wilkins. 2001..
Reece RM. Child abuse. The Pediatric Clinics of North America. 1990; 37 (4) : 943-954.
Seidl T. Special Interviewing Techniques. In: Ludwig S & Kornberg AE eds. Child Abuse: A Medical Reference (2nd ed.) New York: Churchill Livingstone. 1992; : 279-293.
Steinmetz M. Interviewing children: Balancing forensic and therapeutic techniques. National Resource Center on Child Sexual Abuse News. 1995; 4 (3) : 1-4.
Summit RC. The child sexual abuse accommodation syndrome.. Child Abuse & Neglect. 1983; 7 (2) : 177-93.
Keywords: Adaptation, Psychological, Attitude, Child, *Child Abuse, Child Development, Child Reactive Disorders/*psychology, Cross-Sectional Studies, Female, Humans, Incest, Male, Rape, Set, Psychology, *Sex Offenses
Child victims of sexual abuse face secondary trauma in the crisis of discovery. …
Child victims of sexual abuse face secondary trauma in the crisis of discovery. Their attempts to reconcile their private experiences with the realities of the outer world are assaulted by the disbelief, blame and rejection they experience from adults. The normal coping behavior of the child contradicts the entrenched beliefs and expectations typically held by adults, stigmatizing the child with charges of lying, manipulating or imagining from parents, courts and clinicians. Such abandonment by the very adults most crucial to the child's protection and recovery drives the child deeper into self-blame, self-hate, alienation and revictimization. In contrast, the advocacy of an empathic clinician within a supportive treatment network can provide vital credibility and endorsement for the child. Evaluation of the responses of normal children to sexual assault provides clear evidence that societal definitions of "normal" victim behavior are inappropriate and procrustean, serving adults as mythic insulators against the child's pain. Within this climate of prejudice, the sequential survival options available to the victim further alienate the child from any hope of outside credibility or acceptance. Ironically, the child's inevitable choice of the "wrong" options reinforces and perpetuates the prejudicial myths. The most typical reactions of children are classified in this paper as the child sexual abuse accommodation syndrome. The syndrome is composed of five categories, of which two define basic childhood vulnerability and three are sequentially contingent on sexual assault: (1) secrecy, (2) helplessness, (3) entrapment and accommodation, (4) delayed, unconvincing disclosure, and (5) retraction. The accommodation syndrome is proposed as a simple and logical model for use by clinicians to improve understanding and acceptance of the child's position in the complex and controversial dynamics of sexual victimization. Application of the syndrome tends to challenge entrenched myths and prejudice, providing credibility and advocacy for the child within the home, the courts, and throughout the treatment process. The paper also provides discussion of the child's coping strategies as analogs for subsequent behavioral and psychological problems, including implications for specific modalities of treatment.
Cross-cultural medicine (Special Issue). The Western Journal of Medicine. 1992; 157 (3) : 247-373.
Keywords: *Cross-Cultural Comparison, *Health Services Needs and Demand, Humans, United States
