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The Need For A Comprehensive Public Health Approach To Preventing Child Sexual Abuse
The Need For A Comprehensive Public Health Approach To Preventing Child Sexual Abuse
Lifetime exposure to child sexual abuse (CSA) and other forms of sexual harm
Elizabeth J. Letourneau, PhDa
William W. Eaton, PhDa (e.g., sexual exposure, sexual harassment, and Internet sex talk) affect approxi-
Judith Bass, PhDa mately 10% of a nationally representative sample of U.S. children aged 0–17
Frederick S. Berlin, MDb years, including 12% of girls and nearly 8% of boys.1 Such exposure significantly
Stephen G. Moore, MDc increases the likelihood of subsequent sexual and nonsexual revictimization for
boys and girls and subsequent sexual offending for boys.2
CSA is among 24 global risk factors identified by the World Health Organi-
zation that substantively affect the global burden of disease, contributing an
estimated 0.6% to the global burden of disease, or 9 million years of healthy life
lost.3 Unipolar depression, human immunodeficiency virus/acquired immuno-
deficiency syndrome, alcohol use disorders, violence, and self-inflicted injuries
are among the leading contributors to the global burden of disease4 for which
CSA is a risk factor.5–7 Other studies have shown that CSA is associated with
unsafe sexual behaviors, alcohol use, and obesity,6–8 which also contribute to
the burden of disease.3
A separate evaluation of the disability and costs associated with 11 serious
mental health disorders identified four disorders with the highest disability
weights and with costs of $$70.0 billion, including schizophrenia, bipolar dis-
order, drug abuse/dependence, and major depressive disorder.9 CSA is a risk
factor for each of these disorders or their defining symptoms.6,10 Clearly, CSA
extracts a considerable toll on its victims and society.
The benefits of effective and widely adopted prevention programs for CSA
are, therefore, sizable, and it is not surprising that numerous efforts have been
made to encourage the development and evaluation of primary prevention
programs during the past 30 years. What is surprising are the outright failures
and significant limitations of these efforts.11–18 While some advances have been
noted,13,17,19 many existing primary prevention programs still suffer from a lack
of rigorous evaluation, limited implementation settings, ineffective program
content, and insufficient skills practice. Many current programs also fail to
target parents and other adults who might protect children, and few if any
a
Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
b
Johns Hopkins University, School of Medicine, Baltimore, MD
CarDon & Associates, Inc., Bloomington, IN
c
Address correspondence to: Elizabeth J. Letourneau, PhD, Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health,
624 N. Broadway, HH831, Baltimore, MD 21205; tel. 410-955-9913; fax 410-614-7469; e-mail <[email protected]>.
©2014 Association of Schools and Programs of Public Health
programs target potential offenders or bystanders. CSA is more than a single-agency issue, and hundreds
Funding for prevention programming is precarious, of organizations, agencies, and individuals have worked
and funding for rigorous program evaluation of such toward the prevention of CSA.17,29 Like CDC, many
prevention services appears to be nearly nonexistent. leaders in the field have publicized calls for a more
A recent review of public health agencies in all 50 uniform and coordinated approach to the study and
states and the District of Columbia indicated that 71% prevention of CSA, either as a stand-alone initiative14 or
offered programs targeting intimate partner violence within the context of broader public health approaches
whereas only 20% offered CSA prevention programs,20 aimed at preventing sexual violence,19,30,31 violence,32 or
demonstrating the low value placed on CSA prevention child abuse and neglect.33 These efforts have not yet
relative to other prevention foci. resulted in a coherent and coordinated public policy,
There are additional indicators that the topic of CSA suggesting that CSA might be policy resistant.34
remains largely absent from the broader discussions
of child maltreatment, sexual violence, and sexual Policy resistance
health. In 2013, the U.S. Preventive Services Task Policy resistance is “the tendency for interventions to
Force published a meta-analysis evaluating the effects be defeated by the system’s response to the interven-
of early prevention programming on reducing child tion itself”34 and occurs when specific interventions
maltreatment, but no evaluation of intervention effects designed to promote public health fail to achieve their
on CSA victimization or perpetration was included.21 intended effects or even make the targeted problem
Numerous entities promote sexual health education as worse. Phenomena that are complex, poorly under-
one way of preventing sexual violence against adults stood, and engender strong emotional and defensive
and adolescents, but mention of CSA prevention is responses are likely to be policy resistant. An example
lacking.22–28 is the over-prescription of antibiotics for viral respira-
We describe previous calls for the development of tory infections in young children, a procedure that
a public health approach to the prevention of CSA; increases the risk for antibiotic resistance but persists
consider how the concept of policy resistance might due to diagnostic complexity, fear of litigation, per-
account, in part, for the failure of these efforts; note ceived pressure from parents, and the desire to reduce
advances that signal hope for policy change; and make patient discomfort.35 Likewise, CSA is complex and
additional suggestions for achieving this important poorly understood and engenders strong emotional
public health goal. and defensive responses. Policy resistance can inter-
fere with any or all four components of a basic public
health approach: surveillance, identification of risk and
Previous Calls for a Public Health
protective factors, development and evaluation of inter-
Policy for CSA Prevention
ventions, and intervention implementation.36 In the
In 1991, the Centers for Disease Control and Preven- following subsections, we examine how CSA complexity
tion (CDC) created the Division of Violence Prevention and the strong emotional and defensive responses it
within the Injury Center. The mission of this Division engenders have particularly impeded the identification
is to help society conceptualize interpersonal violence of risk and protective factors and the development and
as a preventable public health problem, to ground evaluation of prevention interventions.
prevention policies in science, and to evaluate and
disseminate effective policies. Among the Division’s Complexity
priorities is the prevention of CSA; however, in 1999, CSA represents a complex human phenomenon involv-
CDC acknowledged that CSA had “not received suf- ing a series of behaviors between at least two people,
ficient attention as a public health problem.” To with those behaviors influenced by both risk and
address this oversight, CDC convened experts who protective factors. While protective factors are poorly
proposed dozens of recommendations designed to understood, there is a more substantive scientific lit-
address CSA prevention from a comprehensive public erature identifying risk factors, which can vary widely
health perspective.15 CDC followed up on several of along numerous dimensions. As shown in the Figure,
these recommendations, most notably by supporting two of the dimensions along which risk factors for
national and international CSA surveillance efforts, victimization and perpetration vary are (1) life-course
but the great majority of the recommendations remain period, from in-utero through adulthood, and (2) level
unmet, including the recommendation to develop a at which the risk factor occurs, including individual,
national CSA prevention agenda. intimates (i.e., family and friends), larger communities
The development of a public health policy to prevent (e.g., neighborhoods and schools), and society (e.g.,
Figure. Depiction of how risk factors for child sexual abuse victimization and perpetration might vary across the
life course and levels at which factors occur
Agency
Life stage
(e.g., by introducing skepticism about a victim’s report might have contributed to a laser-like focus on vic-
or shifting blame to the victim). These portrayals timization to the exclusion of perpetration. Similarly,
encourage two types of responses to CSA. One is to many clinicians and researchers treating and studying
view all CSA perpetrators as monsters who are nothing sex offenders have led an insular existence, perceiving
like ourselves. The second is to ignore the problem. hostility from outsiders who view them as sex offender
Both responses were aptly illustrated by the recent case apologists insensitive to the needs and rights of vic-
of Penn State Assistant Football Coach Jerry Sandusky. tims.43 What might have developed as a unified field
For years, evidence that Sandusky was sexually abus- instead became two distinct victimization and perpetra-
ing children was largely ignored,39 perhaps because he tion fields, complete with separate professional societies
was too popular or too powerful to be viewed as a sex (e.g., American Professional Society on the Abuse of
offender and because his victims were easily dismissed Children vs. Association for the Treatment of Sexual
as troubled young people. Following his conviction for Abusers) that support separate research journals (e.g.,
sexual crimes against 10 boys, Sandusky was vilified as a Child Maltreatment vs. Sexual Abuse: A Journal of Research
monster (a recent Internet search for “Sandusky” and and Treatment), separate funding sources operating
“monster” resulted in approximately 1,730,000 results). within separate governmental agencies (e.g., National
The perception of offenders as monsters might Child Traumatic Stress Initiative under the Depart-
make it more difficult for people to acknowledge ment of Health and Human Services vs. Office of Sex
that someone they know and love could be abusing Offender Sentencing, Monitoring, Apprehending,
a child. Neither denying abuse nor unduly maligning Registering, and Tracking [SMART Office] under the
perpetrators encourages open discussion of CSA or Department of Justice), and separate policy centers
its prevention, contributing to policy resistance and (e.g., Office for Violence Against Women vs. Center
possibly reducing the appetite of policy makers for for Sex Offender Management). This division of labor,
funding prevention intervention development and resources, and funding has almost certainly slowed
evaluation projects. the pace of scientific discovery and interfered with
the development of a unified, coherent approach to
Reactive legislation. The “monster” frame of offenders,
addressing and preventing CSA.
coupled with the complexity of CSA, can contribute
to the perception that CSA is “the result of forces
outside ourselves, forces largely unpredictable and Signs of Readiness for a Comprehensive
uncontrollable.”34 Yet, policy makers are expected to Public Health Prevention Policy
do something about sex offenders,40 with one result
The barriers contributing to CSA prevention policy
being nearly two decades of competition among policy
resistance have been entrenched for decades; hence, it
makers to enact ever-harsher consequences. Modern
may be difficult to convince policy makers and the pub-
sex crime policies include indefinite post-incarceration
lic of the need to expand beyond existing approaches
civil commitment, lifetime sex offender registration,
and to allocate resources to CSA prevention efforts. We
lifetime online public notification, and expansive
believe, however, that recent developments signal the
sex offender residency restrictions.41 Although these
potential success of a renewed effort toward this goal.
policies have not been convincingly linked to improve-
ments in child or community safety, they are nearly
Complexity
universally supported and give the appearance that
Several developments seem poised to reduce the
legislators are doing everything that can be done.
complexity and improve the scientific understanding
The resulting complacency is likely to contribute to a
of CSA, including recent federal research support
general disinclination toward more challenging and
for identifying adolescent and adult sex offender risk
seemingly less active prevention strategies.
and protective factors (e.g., via grants issued by the
Balkanized professional fields. Emotional and defensive SMART Office44), improvements in CSA surveillance
responses to CSA also likely contributed to the bal- (e.g., nationally via a joint effort of CDC and the
kanization of research, policy, and practice regarding Office of Juvenile Justice, Delinquency and Preven-
the fields of study on CSA victimization and perpetra- tion45 and internationally via CDC in partnership with
tion. Early victim advocates struggled against wide- UNICEF46), and an increased focus on CSA by the
spread denial that sexual abuse, including CSA, was National Institutes of Health (e.g., via a new branch
a serious problem, and then subsequently struggled within the National Institute of Child Health and
against backlash concerns about false allegations and Human Development47).
false memories.17,42 Their fight to be taken seriously
on CSA surveillance and epidemiology and hood sexual abuse: results from a prospective study. J Interpers
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