Sexual Abuse as a Public Health Problem

Adopted by the ATSA Executive Board of Directors on May 26, 2011

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BACKGROUND:

Sexual abuse is a serious national problem that cannot be solved solely by responding to abuse after it has been perpetrated. While the criminal justice and related systems may offer deterrence, incarceration, rehabilitation, and restitution, these efforts to foster community safety are implemented only after the detection and commission of a crime. After-the-fact interventions address the offender's crime and the victim's trauma with the burden of disclosure and prevention of further abuse placed on the victim. A complementary approach to prevent sexual abuse from being perpetrated in the first place is necessary. Public health prevention efforts encourage us to shift our focus from intervention and treatment following an assault to primary prevention, that is, the prevention of sexual abuse before it is perpetrated.

Recent national surveys have demonstrated that sexual abuse is a widespread problem in the United States (Whitaker et al., 2008; Jewkes et al., 2002; Tjaden & Thoennes, 1998 & 2000). For example, the National Violence Against Women Survey, research cosponsored in the United States by the National Institute of Justice and the Centers for Disease Control and Prevention, reported that 18% of all adult women surveyed had experienced a completed or attempted rape at some time during their lives (Tjaden & Thoennes, 2000). Later research confirmed these numbers: a nationally representative survey completed in the United States showed that 18.5% of women have experienced forced sex in their lifetime and 5.8% of men reported experiencing forced sex at some time in their lives (Black et al., as reported in National Center for Injury Prevention and Control, 2009). 60.4% of female and 69.2% of male victims were first raped before age 18 (Basile et al., 2007). Using data from Child Protective Service workers and a survey of a nationally representative sample of community professionals, the Fourth National Incidence Study of Child Abuse and Neglect (NIS-4) estimated that 135,300 children were sexually abused in the United States in 2005 (Sedlak et al., 2010). These rates take on added significance when compared to rates of other major public health concerns. For example, the United States Centers for Disease Control and Prevention (CDC) estimate that more than 1 million people in the United States, about 0.3% of the population, are living with HIV, 75% of whom are men and 25% of whom are women (CDC, 2010).

In 1995, the American Medical Association declared sexual abuse a “silent-violent epidemic” (AMA Press Release, 1995). The CDC and the World Health Assembly have both declared violence prevention a public health priority (Foege, Rosenberg, & Mercy, 1995; World Health Assembly, 1996). There is also widespread recognition that the prevention of child sexual abuse is a critical public health concern. Child sexual abuse is known to increase the risk of a wide range of behavioral issues, mental health disorders and adjustment difficulties in childhood and later in adult life (Dong, et al., 2002).

Public health approaches to problems like sexual abuse move beyond ensuring the health of individuals; it addresses the health of an entire population (CDC, 2004). Sexual violence is a widespread problem that affects not just the victim, but the offender and the families and communities around both of them; it is just the sort of social issue to be targeted by a public health prevention approach which emphasizes prevention before sexual violence occurs. A public health focus on prevention has the potential to diminish the number of sexual offenders in the general population and to diminish sexual victimization in the community.

The public health model strives to prevent harm through identifying and reducing “risk factors” that may contribute to the perpetration of, and victimization by, sexual abuse. It also identifies and enhances the “protective factors” that may prevent the development of sexually abusive behaviors and vulnerability to victimization. Modification and reduction of risk factors for sexually abusive behavior may include addressing 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). Enhancing protective factors to increase our ability to prevent victimization and perpetration may include incorporating into school curricula interpersonal skills-building training for boys and young men or the implementation of mass campaigns that target communities with information about the importance of consent in sexual encounters (Finkelhor, 2009), and the laws regarding sexual assault.

It is important to note that only a small number of public health prevention programs have been evaluated adequately enough to determine their effectiveness and offer recommendations for widespread implementation (Institute of Medicine as quoted in National Center for Injury Prevention and Control, 2009). The CDC, along with other federal agencies in the United States, call for “rigorous research with direct implications for achieving health impact” (National Center for Injury Prevention and Control, 2009) in the public health prevention of sexual abuse.

The field of public health commonly collaborates with key community partners such as parents, caregivers, educators, institutions, nonprofit organizations, the media, and others for optimal success in preventing violence (Prothrow-Stith, 1995; Rattray, Brunner, & Freestone, 2002). The utilization of an ecological model for the development of sexual violence prevention strategies is considered ideal: this public health framework takes into consideration the interplay of the individual, relationship, social, political, cultural, and environmental factors that all have a role in promoting and preventing sexual violence (Krug et al., 2002). The ecological model encourages addressing not just individuals’ risk factors for perpetration of sexual abuse, but the norms, beliefs, and social and economic systems that may allow for and promote sexual violence (CDC, 2004). Public health challenges society to accept responsibility for stopping sexual abuse by changing norms both within relationships and within communities, and voicing objections to such violence.

RECOMMENDATIONS:

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

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 or perpetrates 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 12% of all cases of child sexual abuse (Hanson et al., 1999) 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. Surveillance data that broadens the view of both victim and perpetrator will have an impact on the shifting of norms that influence policy.

3. The Association for the Treatment of Sexual Abusers encourages researchers to conduct studies and publish data to increase understanding of risk factors and protective factors related to sexual abuse perpetration and victimization, and recommends that such efforts be funded.

ATSA encourages funding for researchers to conduct studies and publish data examining risk factors and protective 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. These scientists are interested in conducting analyses on risk factors to find the reasons for this nonrandom distribution and the protective factors that might mitigate the expression of violence. Risk factor research focuses on understanding what factors place an individual at higher risk for unhealthy behaviors such as sexual deviance or unhealthy consequences such as sexual victimization. The intent of such research is to find out whether particular situations or behaviors put persons at greater risk for victimization or perpetration.

Identification of a risk factor indicates that developing 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). Identification of a protective factor indicates that developing sexually aggressive behaviors or becoming a victim may be less likely when exposed to a particular factor (e.g., violence and exposure to sexual materials in the home). The presence of any one protective or risk factor does not predict definitively the development of sexually aggressive behaviors or the likelihood of victimization by sexual aggression. Given that sexual abuse is a complex problem, it is likely that risk factors and protective factors are multidimensional in nature and involve a variety of individual, family, community, and societal risk/protective 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 and protective 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 than behaviors that are ingrained, ATSA also supports the development of universal and early intervention programs. Points of intervention may focus on the development of appropriate social and emotional skills as well as family, community and cultural factors that may contribute to the development of sexual offending (Whitaker et al., 2008). In developing interventions of this nature, ATSA recognizes that research describing the nuances of the sexual offence 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).

5. The Association for the Treatment of Sexual Abusers supports the U.S. Centers for Disease Control and Prevention and other federal agencies in the United States in their pursuit of rigorous research to evaluate the effectiveness of programs designed to prevent the perpetration of, and victimization by, sexual abuse, and to ensure that these programs have no iatrogenic effects that may impede the prevention of sexual violence.

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