Child Sexual Abuse: A Public Health Perspective

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Child Sexual Abuse A Public Health Perspective

• Elizabeth J. Letourneau
• Moore Center for the Prevention of Child Sexual
  Abuse
• Johns Hopkins Bloomberg School of Public Health
• eletourn_at_jhsph.edu
• http//jhsph.edu/childsexabuse

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CSA from a Public Health Perspective

• Self-disclosure
• Clinical psychologist by training
• Sex offender research since 1988
• Sex crime policy research since 2004
• Public health research since 2011
• So, I dont know much (about public health) but I
  know I love you (NOTA)
• http//www.youtube.com/watch?viNX1JLRSiyg
• With apologies to Fergus McNeil for stealing his
  idea

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Outline

• Is CSA preventable?
• If so, why dont we focus on prevention?
• How can we achieve a prevention-focused, public
  health perspective from which to address CSA?

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CSA from a Public Health Perspective

• Show of hands, please
• Is child sexual abuse preventable?

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Is CSA Preventable?

• Mortality and burden of disease attributable to
  selected factors that have
• global spread
• known/estimable population distributions
• for which the means to reduce them are known
• Among the 24 risk factors is child sexual abuse,
  to which is attributed 9,000,000
  disability-adjusted life years (DALYs) for 2004

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Is CSA Preventable?

• Several strands of violence prevention and
  treatment outcome research support the hypothesis
  that CSA can be prevented, including research on
• Child and adult sexual abuse prevention
• Nonsexual violence prevention
• Treatment outcome for high risk or offending
  behaviors

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Violence Prevention Research

• Prevention programs that target children focus on
  3 Rs
• Recognize potentially abusive situations
• Resist abusive overtures
• Report previous/ongoing abuse
• The evidence of program effectiveness
• Increase knowledge about CSA prevention concepts
• Increase self-protection skills
• Retain knowledge skills longer if parents were
  included in programming
• Unknown whether these child-focused prevention
  programs actual reduce risk of CSA

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Violence Prevention Research

• Prevention programs that target adults typically
  teach women skills for detecting, avoiding or
  minimizing the potential for sexual violence
• Only 8 of prevention programs focus on men as
  potential perpetrators
• Nearly all programs focus on college students
• Meta-analytic results indicate significant,
  average effects
• Rape attitudes
• Rape knowledge
• Behavioral intent to sexually assault
• Incidence of sexual assault

Anderson Whiston (2005). Sexual assault
education programs A meta-analytic examination
of their effectiveness. Psychology of Women
Quarterly, 29, 374-388.
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Violence Prevention Research

• Recently, peer perpetrated CSA has declined more
  than adult perpetrated CSA
• Between 2003 2008 peer CSA declined by 50
• Between 2003 2008 adolescent bullying declined
  by 33
• Finklehor suggests that bullying prevention
  programming may prevent adolescent-perpetrated
  sexual harm

Child sexual assault 2003 2008
By a known adult 0.3 0.2
By a nonspecified adult 0.3 0.3
By a peer 1.2 0.6
Bullying 21.7 14.8
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Violence Prevention Research

• Prevention of child physical abuse demonstrated
  across numerous evaluation studies
• Individual or case-level prevention demonstrated
  by home visitation programs (see Sweet
  Appelbaum, 2004 meta-analysis)
• Population-level prevention demonstrated by the
  Triple P System (see Prinz et al., 2008 outcome
  paper)

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Treatment Outcome Research

• Treatment Reduces Risk of Future Sexual Harm

Children with severe sexual behavior problems
treated with family-focused CBT were no more
likely to commit a future sexual offense than
children treated for anxiety disorders at the
same clinic
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Treatment Outcome Research
Three RCTs support family-based treatment for
juveniles who sexually offend
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Is CSA Preventable?

• In combination the available research suggests
• Widely adopted, effective prevention programs can
  meaningfully reduce incidence and prevalence of
  abuse
• Involvement of parents improves prevention
• Potential offenders and bystanders can be
  influenced
• Effective treatment of at-risk youth and youth
  who have offended reduces future perpetration
• All of which supports the hypothesis that CSA is
  preventable

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Barriers to a Prevention Focus

• Preventing child sexual abuse before it occurs
  would be more humane and more clinically and cost
  effective than waiting to address the effects of
  abuse after it has occurred
• So, why havent we achieved greater progress
  towards CSA prevention?
• Traditional focus on CSA as a social problem
  requiring a criminal justice solution
• Policy resistance

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Traditional Perspective of CSA

• Social Problem

• Criminal Justice Solution

Photograph Murdo Macleod for the Guardian
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What Has Been Achieved Under This Perspective?

• Social Problem

• Criminal Justice Solution

• A new safety net of shelters for women and
  children
• Increased awareness among public, policy makers
• EBT for CSA victims
• EBT for CSA perpetrators

• Clear demarcation of adult sex with children as
  illegal
• Increased salience of consequences, e.g.,
• Wide-ranging attempts to address highest risk sex
  offenders

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Finklehor, D., Jones, L. (2012). Have sexual
abuse and physical abuse declined since the
1990s? http//cola.unh.edu/sites/cola.unh.edu/file
s/research_publications/CV267.pdf
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What are the Limitations of this Perspective?

• Directs investigation towards individual-level
  vulnerabilities with concomitant failure to
  identify community and societal-level risk
  factors
• Directs majority of resources towards
  after-the-fact, making the best of a bad
  situation responses
• Low value placed on CSA prevention relative to
  other prevention foci. For example
• 71 of U.S. states fund violence prevention of
  some sort
• 20 specifically fund CSA prevention programs

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Policy Resistance

• Occurs when specific interventions designed to
  promote public health fail to achieve intended
  effects or make the problem worse.
• Occurs with phenomena that are complex, poorly
  understood, and engender strong emotional and
  defensive responses
• Example over-prescription of antibiotics for
  viral respiratory infections in young children,
  an ineffective and costly procedure that
  increases risk for developing antibiotic
  resistance but that endures due to
• diagnostic uncertainty
• perceived pressure from parents
• desire to address distress in young patients.

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Policy Resistance

• CSA is complex, poorly understood and engenders
  strong emotional and defensive responses.
• With respect to complexity, risk factors that
  influence victimization and perpetration vary
  widely by agency and age.

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Complex, Poorly Understood Risk Factors
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Strong Emotion

• Monster media frame promotes angry and fearful
  reactions by
• presenting rare and extreme cases as if they were
  commonplace
• replacing predictability with randomness

• Victim-blaming media frame introduces skepticism
  about victims reports and/or shifts blame to
  victims

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Defensive Responses

• Victim Advocacy

• Offender Management

• Early victim advocates
• struggled against widespread denial that sexual
  abuse, including CSA was a serious problem
• And against backlash concerns about false
  allegations and false memories
• Their fight to be taken seriously might have
  contributed to a singular focus on victimization
  and the exclusion of issues relevant to
  perpetration

• Professionals treating and studying sex offenders
• have led an insular existence
• perceive hostility from outsiders who view them
  as sex offender apologists insensitive to the
  needs and rights of victims
• As evidenced by recent firing of ATSA member for
  espousing a balanced approach to civil commitment

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Barriers to Knowledge Sharing

• Thus, what might have developed as a unified
  field addressing CSA prevention instead became
  balkanized, with two distinct victimization and
  perpetration fields, complete with
• Separate professional societies
• American Professional Society on the Abuse of
  Children vs. Association for the Treatment of
  Sexual Abusers)
• Separate research journals
• Child Maltreatment vs. Sexual Abuse A Journal of
  Research and Treatment
• Separate funding sources operating within
  separate agencies
• Separate policy centers
• Office for Victims of Crime vs. Center for Sex
  Offender Management

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What Do the Experts Recommend to Achieve a Public
Health Approach to CSA Prevention? What Experts?

• CDC
• McMahon Pruett (1999, SAJRT)
• Mercy (1999, SAJRT)
• World Health Organization (2002)
• World Report on Violence and Health
• Keith Kaufman (2010)
• The Prevention of Sexual Violence A
  Practitioners Sourcebook

• International Centre on Missing and Exploited
  Children (2012)
• Global Health Coalition 2014 Prevention and
  Awareness Plan
• Institute of Medicine/National Research Council
  (2013)
• New Directions in Child Abuse and Neglect
  Research

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What Do the Experts Recommend to Achieve a Public
Health Approach to CSA Prevention?
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Develop a National Research Agenda

• Convene senior leadership from all federal
  agencies with a stake in CSA to create, implement
  and monitor a national action plan
• Develop international standards for definitions
  of and data collection on CSA to facilitate and
  enhance international comparison
• Increase collaboration among non-governmental
  agencies and organizations with a stake in CSA
  prevention
• Evidence that this is taking place Traditional
  offender and victim joining one anothers
  boards, inviting one another to meetings,
  obtaining one anothers perspectives and buy-in

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Increase Accountability

• National Research Agenda should include specific
  objectives, strategies, assigned
  responsibilities, a timetable, and an evaluation
  mechanism
• For all CSA-related legislation, require
  implementation research reviews in future
  reauthorization discussions
• Create mechanisms to evaluate state/federal
  efforts to reduce CSA and publicize results,
  e.g.,
• Trafficking in Persons (TIP) Report
• Annie E. Casey Kids Count Report

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Promote Research

• Increase federal and state/provincial funding
• Fund research and education centers of excellence
• Create career development incentives to develop
  and sustain a cadre of CSA researchers
• How???
• Reallocate a percent of criminal justice
  expenditures to prevention?

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Increase General Knowledge

• Educate the media to improve reporting on CSA
• Evidence that this is already working
• Integrate CSA prevention into social and
  educational policies
• E.g., include a CSA focus in existing
  anti-bullying programs
• Empower people to respond to all sexually
  problematic behaviors, not just major offenses
• E.g., community-based prevention efforts aimed at
  all adults

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Focus on Primary Prevention

• Develop, test and execute social norms approach
  to foster environments that resist and intervene
  to prevention CSA
• Target primary prevention towards parents,
  bystanders, adults attracted to children, teens
  attracted to children and invest in program
  development, evaluation, and dissemination
• E.g., Dunkelfeld Prevention Project
• Identify risk factors, especially at societal
  level
• Identify promotive factors at any level
• E.g., Vancouver Longitudinal Cohort Study