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Child Sexual Abuse: A Public Health Perspective


Child Sexual Abuse: A Public Health Perspective. ... Child and adult sexual abuse prevention . ... average effects: Rape attitudes. – PowerPoint PPT presentation

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Title: Child Sexual Abuse: A Public Health Perspective

Child Sexual Abuse A Public Health Perspective
  • Elizabeth J. Letourneau
  • Moore Center for the Prevention of Child Sexual
  • Johns Hopkins Bloomberg School of Public Health
  • http//

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//
  • With apologies to Fergus McNeil for stealing his

  • 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?

CSA from a Public Health Perspective
  • Show of hands, please
  • Is child sexual abuse preventable?

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

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

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

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.
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
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

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
Treatment Outcome Research
Three RCTs support family-based treatment for
juveniles who sexually offend
Is CSA Preventable?
  • In combination the available research suggests
  • Widely adopted, effective prevention programs can
    meaningfully reduce incidence and prevalence of
  • Involvement of parents improves prevention
  • Potential offenders and bystanders can be
  • Effective treatment of at-risk youth and youth
    who have offended reduces future perpetration
  • All of which supports the hypothesis that CSA is

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

Traditional Perspective of CSA
  • Social Problem
  • Criminal Justice Solution

Photograph Murdo Macleod for the Guardian
What Has Been Achieved Under This Perspective?
  • Social Problem
  • Criminal Justice Solution
  • A new safety net of shelters for women and
  • Increased awareness among public, policy makers
  • EBT for CSA victims
  • EBT for CSA perpetrators
  • Clear demarcation of adult sex with children as
  • Increased salience of consequences, e.g.,
  • Wide-ranging attempts to address highest risk sex

Finklehor, D., Jones, L. (2012). Have sexual
abuse and physical abuse declined since the
1990s? http//
What are the Limitations of this Perspective?
  • Directs investigation towards individual-level
    vulnerabilities with concomitant failure to
    identify community and societal-level risk
  • 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

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.

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.

Complex, Poorly Understood Risk Factors
Strong Emotion
  • Monster media frame promotes angry and fearful
    reactions by
  • presenting rare and extreme cases as if they were
  • replacing predictability with randomness
  • Victim-blaming media frame introduces skepticism
    about victims reports and/or shifts blame to

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
  • 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

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

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
  • New Directions in Child Abuse and Neglect

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

Increase Accountability
  • National Research Agenda should include specific
    objectives, strategies, assigned
    responsibilities, a timetable, and an evaluation
  • 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,
  • Trafficking in Persons (TIP) Report
  • Annie E. Casey Kids Count Report

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?

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

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
  • Identify promotive factors at any level
  • E.g., Vancouver Longitudinal Cohort Study