Sexual Abuse as a Public Health Problem

Adopted by the ATSA Executive Board of Directors on September 9, 2000

BACKGROUND:

Sexual abuse against persons of all ages represents a serious national problem that cannot be solved solely through the criminal justice system. The public health approach, which focuses on prevention before an act occurs, offers a framework that complements the criminal justice approach. The criminal justice system may offer deterrence, incarceration, rehabilitation, and restitution. Efforts to foster community safety within this model occur mostly after the commission of a crime. To complement criminal justice, the public health model strives to prevent the occurrence of crimes through the identification of critical risk factors and the development of interventions to address these factors. The public health model offers a broad array of opportunities to influence individuals, families, communities, and society.

Public health may be defined as what society does to assure that conditions exist in which people can be healthy. Violence is a condition that puts people at risk of both injury and death. The Centers for Disease Control and Prevention (CDC) and the World Health Assembly have declared violence a public health priority (Foege, Rosenberg, & Mercy, 1995; World Health Assembly, 1996). Though considering sexual abuse as a public health issue is a relatively recent approach, it clearly offers the potential to reduce the number of violent sexual offenders encountered by the criminal justice system, as well as to diminish the number of sexual offenders in the general population. In this manner, it diminishes the risk of sexual victimization in the community.

The public health approach addresses causes beyond identifying offenders and victims. It allows us to learn about and to change other causes such as: individual and parental skills deficits, family dysfunction, negative peer influences, adverse community living conditions, and inappropriate social messages (Powell, Dahlberg, Friday, Mercy, Thornton, & Crawford, 1996). Public health also collaborates with important segments of society such as parents, caregivers, community members, professionals, and the media (Prothrow-Stith, 1995).

Until now, much of the effort in the area of sexual abuse has focused on after-the-fact interventions to address the offender's crime and the victim's trauma. The burden of disclosure and prevention of further abuse has traditionally been placed on the victim. Public health efforts prod us to shift our focus from intervention and treatment following an assault to an additional focus on primary prevention, that is, the prevention of sexual abuse before it occurs. Public health, like criminal justice, also challenges society to accept responsibility for stopping sexual abuse by changing norms and voicing objections to such violence.

RECOMMENDATIONS:

1.- The Association for the Treatment of Sexual Abusers recognizes sexual abuse as a public health issue.

Recent national surveys have demonstrated that sexual abuse is a widespread problem among women and children in the United States (Tjaden & Thoennes, 1998: Kilpatrick, Edmunds, & Seymour, 1992; Sedlak & Broadhurst, 1996). For example, the National Violence Against Women Survey estimates that 18% of all adult women surveyed have experienced a completed or attempted rape at some time during their lives (Tjaden & Thoennes, 1998). Of these women, 22% experienced their first rape or attempted rape before age 12 and 32% were raped first between 12 and 17 years of age. Using data from Child Protective Service workers and a survey of a nationally representative sample of community professionals, the third National Incidence Survey (NIS-3) estimated that over 300,000 children were sexually abused in 1993 (Sedlak & Broadhurst, 1996). Though not universal, the effects of sexual abuse include injuries (Kilpatrick, Edmunds, & Seymour, 1992), sexually transmitted diseases (Lindegren et al., 1998), unwanted pregnancies (Holmes, Resnick, Kilpatrick, & Best, 1996), HIV-risk behavior (Bensley, Van Eenwyk, & Simmons, 2000), depression and subsequent substance abuse (Holmes & Slap, 1999), post-traumatic stress disorder (Cuffe et al., 1998), and suicide attempts (Brener et al., 1999; Bryant & Range, 1995). Family members are also often traumatized when a loved one is victimized by sexual abuse (Newberger, Gremy, Waternaux, & Newberger, 1993; Manion et al., 1996). Given the magnitude of the problem and its physical and mental health impact, ATSA recognizes sexual abuse as an important public health problem.

2.- The Association for the Treatment of Sexual Abusers supports the development of a national public health surveillance system for sexual abuse that includes reported, as well as unreported cases of sexual abuse.

Public health surveillance involves the ongoing, systematic collection, analysis, and interpretation of information on a public health problem that is closely integrated with the timely dissemination of these data to those responsible for preventing or controlling the injury (Thacker & Berkelman, 1988). ATSA supports the development of a national public health surveillance system for sexual abuse that includes officially reported as well as unreported cases of sexual abuse. The inclusion of unreported cases is of critical importance since estimates suggest that only three percent of all cases of child sexual abuse (Finkelhor & Dziuba-Leatherman, 1994) and 16% to 36% of all rapes, including rapes of children, are ever reported to police (Kilpatrick, Edmunds, & Seymour, 1992; U.S. Department of Justice, 1997). Further, research suggests that reported cases of childhood rape are different from unreported cases of childhood rape. Specifically, reported cases are more likely to involve strangers (Hanson et al., 1999) and the perception of life threat or physical injury (Saunders et al., 1999) than are unreported cases.

3.- The Association for the Treatment of Sexual Abusers encourages researchers to conduct studies and publish data to increase understanding of risk factors related to sexual abuse perpetration and victimization.

ATSA encourages researchers to conduct studies and publish data examining risk factors related to sexual abuse perpetration and victimization. Public health scientists believe that ill health or unhealthy behaviors, including violence, are not randomly distributed in the population. They are interested in conducting analyses on risk factors to find out the reasons for this nonrandom distribution. Risk factor research focuses on understanding what factors place an individual at higher risk for an unhealthy behavior such as sexual deviance or an unhealthy consequence such as sexual victimization. The intent of such research is not to blame the victim but rather to find out whether particular situations or behaviors put persons at greater risk for victimization.

Identification of a risk factor indicates that development of sexually aggressive behaviors (or becoming a victim of sexual abuse) is statistically more likely if there is exposure to a particular factor (e.g., attitudes while growing up that support abuse toward women). It does not, however, ensure that those with such an exposure will invariably develop the sexually aggressive behaviors (or invariably become victims of sexual aggression). Given that sexual abuse is a complex problem, it is likely that risk factors are multidimensional in nature and involve a variety of individual, family, community, and societal risk factors (Ryan, 2000; Elliott, 1994; Wurtele, 1999).

4.- The Association for the Treatment of Sexual Abusers supports the development of primary prevention and early intervention programs based on risk factor and related research.

ATSA’s position is that primary prevention programs should target modifiable risk factors identified by research. Since it is generally easier to alter developing behaviors as compared to behaviors that are ingrained, ATSA also supports the development of early intervention programs. In developing interventions of this nature, it is recognized that research describing the nuances of the sexual offence process (i.e., “grooming” process) will be particularly relevant (Kaufman, Hilliker, & Daleiden, 1996; Kaufman et al., 1998). Evaluation of prevention programs targeting various segments of society (e.g., sexual abusers, parents, teachers, caregivers) not traditionally targeted as sexual abuse prevention agents is also critical to the eventual success of a public health approach (Chasen-Taber & Tabachnick, 1999).

References

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Chasen-Taber, L., & Tabachnick, J. (1999). Evaluation of a child sexual abuse prevention program. Sexual Abuse: A Journal of Research and Treatment, 11, 279-292.

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