The Need For A Comprehensive Public Health Approach To Preventing Child Sexual Abuse

Reports and Recommendations
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, years, including 12% of girls and nearly 8% of boys.1 Such exposure
MDb Stephen G. Moore, significantly increases the likelihood of subsequent sexual and nonsexual
MDc 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
c
CarDon & Associates, Inc., Bloomington, IN
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 <eletourn@jhsph.edu>.
©2014 Association of Schools and Programs of Public Health
Preventing Child Sexual Abuse  223
222  Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129
programs target We describe previous CSA prevention from a CSA is more than a
potential offenders or calls for the comprehensive public single-agency issue, and
bystanders. Funding development of a health perspective.15 hundreds of
for prevention public health CDC followed up on organizations, agencies,
programming is approach to the several of these and individuals have
precarious, and prevention of CSA; recommendations, worked toward the
funding for rigorous consider how the most notably by prevention of CSA.17,29
program evaluation of concept of policy supporting national Like CDC, many
such prevention resistance might and international CSA leaders in the field
services appears to be account, in part, for the surveillance efforts, but have publicized calls
nearly nonexistent. A failure of these efforts; the great majority of the for a more uniform
recent review of public note advances that recommendations and coordinated
health agencies in all signal hope for policy remain unmet, approach to the study
50 states and the change; and make including the and prevention of CSA,
District of Columbia additional suggestions recommendation to either as a stand-alone
indicated that 71% for achieving this develop a national CSA initiative14 or within the
offered programs important public health prevention agenda. context of broader
targeting intimate goal. The development of public health
partner violence a public health policy approaches aimed at
whereas only 20% to prevent preventing sexual
PreviouS
offered CSA prevention violence,19,30,31
CAllS for A
programs,20 violence,32 or child
PubliC
demonstrating the low abuse and neglect.33
HeAlTH
value placed on CSA These efforts have not
PoliCy for
prevention relative to yet resulted in a
CSA
other prevention foci. coherent and
PreveNTioN
There are additional coordinated public
indicators that the topic In 1991, the Centers policy, suggesting that
of CSA remains largely for Disease Control and CSA might be policy
absent from the Preven- tion (CDC) resistant.34
broader discussions of created the Division of
child maltreatment, Violence Prevention P
sexual violence, and within the Injury o
sexual health. In 2013, Center. The mission of l
the U.S. Preventive this Division is to help i
Services Task Force society conceptualize c
published a meta- interpersonal violence y
analysis evaluating the as a preventable public
effects of early health problem, to r
prevention ground prevention e
programming on policies in science, and s
reducing child to evaluate and i
maltreatment, but no disseminate effective s
evaluation of policies. Among the t
intervention effects on Division’s priorities is a
CSA victimization or the prevention of CSA; n
perpetration was however, in 1999, CDC c
e
included.21 acknowledged that
Policy resistance is “the
Numerous entities CSA had “not received
tendency for
promote sexual health suf- ficient attention
interventions to be
education as one way as a public health
defeated by the
of preventing sexual problem.” To address
system’s response to the
violence against adults this oversight, CDC
intervention itself”34
and adolescents, but convened experts who
and occurs when specific
mention of CSA proposed dozens of
interventions designed
prevention is lacking.22– recommendations
28 to promote public
designed to address
health fail to achieve
their intended effects C
or even make the o
targeted problem m
worse. Phenomena that p
are complex, poorly l
understood, and e
engender strong x
emotional and i
defensive responses are t
likely to be policy y
resistant. An example is CSA represents a
the over-prescription of complex human
antibiotics for viral phenomenon involv-
respiratory infections ing a series of behaviors
in young children, a between at least two
procedure that people, with those
increases the risk for behaviors influenced
antibiotic resistance but by both risk and
persists due to protective factors.
diagnostic complexity, While protective factors
fear of litigation, per- are poorly understood,
ceived pressure from there is a more
parents, and the desire substantive scientific
to reduce patient lit- erature identifying
discomfort.35 Likewise, risk factors, which can
CSA is complex and vary widely along
poorly understood and numerous dimensions.
engenders strong As shown in the Figure,
emotional and two of the dimensions
defensive responses. along which risk
Policy resistance can factors for victimization
inter- fere with any or and perpetration vary
all four components of are (1) life-course
a basic public health period, from in-utero
approach: surveillance, through adulthood, and
identification of risk (2 ) level at which the
and protective factors, risk factor occurs,
development and including individual,
evaluation of inter- intimates (i.e., family
ventions, and and friends), larger
intervention communities (e.g.,
implementation.36 In neighborhoods and
the following schools), and society
subsections, we (e.g.,
examine how CSA
complexity and the
strong emotional and
defensive responses it
engenders have
particularly impeded
the identification of risk
and protective factors
and the development
and evaluation of
prevention
interventions.
224  Reports and Recommendations
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

norms and social E Preventing
promotes angry Child
and Sexual Abuse  225
policies). Most m fearful reactions (e.g.,
etiological research has o by presenting rare and
focused on factors that ti extreme cases as if they
occur in adolescence o were commonplace and
or adulthood and at the n by replacing
individual level. Little a predictability with ran-
research has addressed l/ domness) and a second
community or societal- d that promotes victim
level risk factors, and e blaming
even less research has f
addressed genetic or e
epi- genetic risk factors. n
Moreover, there remain si
significant gaps as to v
e
how factors combine to
r
promote or inhibit risk
e
across the life course.
s
More effectively p
delineating risk and o
protective factors, and n
how these factors inter- s
act to influence CSA e
victimization and s
perpetration, will be In addition to
critical to reducing the complexity, CSA
complexity of this issue, engenders strong
ameliorating its policy emotional reactions that
resistance, and curtail an objective
contributing to the discussion of its
science on why CSA prevention, causes, and
occurs and to whom. consequences.37 There
Such knowledge is are several ways in
essential to the which these
development of emotional/defensive
effective interventions, responses manifest,
which to date tend to including
focus on a limited counterproductive
subset of individual- fram- ing of issues by
level risk factors. the media, legislation
that is reactive to
events but not effects,
and unproductive
divisions between
professional fields
focused on
victimization and
perpetration.
Media frames. An
evaluation of media
coverage 38 suggested
two “frames” (or social
constructions) for
engaging audience
members with sex
crime stories: one that


(e.g., by introducing of policy makers for CSA Preventing
also Child Sexual
likely might Abuse  have 227
skepticism about a funding prevention contributed to the bal- contributed to a laser-
victim’s report or intervention kanization of research, like focus on vic-
shifting blame to the development and policy, and practice timization to the
victim). These evaluation projects. regarding the fields of exclusion of
portrayals encourage study on CSA perpetration. Similarly,
Reactive legislation. The victimization and
two types of responses many clinicians and
“monster” frame of perpetration. Early
to CSA. One is to view researchers treating and
offenders, coupled with victim advocates
all CSA perpetrators as studying sex offenders
the complexity of struggled against wide-
monsters who are have led an insular
CSA, can contribute to spread denial that
nothing like ourselves. existence, perceiving
the perception that sexual abuse,
The second is to hostility from outsiders
CSA is “the result of including CSA, was a
ignore the problem. who view them as sex
forces outside ourselves, serious problem, and
Both responses were offender apologists
forces largely then subsequently
aptly illustrated by the insensitive to the needs
unpredictable and struggled against
recent case of Penn and rights of victims.43
uncontrollable.”34 Yet, backlash concerns
State Assistant Football What might have
policy makers are about false allegations
Coach Jerry Sandusky. developed as a unified
expected to do and false memories.17,42
For years, evidence field instead became
something about sex Their fight to be taken
that Sandusky was two distinct victimization
offenders,40 with one seriously
sexually abusing and perpetration fields,
result being nearly two
children was largely complete with separate
decades of competition
ignored,39 perhaps professional societies
among policy makers to
because he was too (e.g., American
enact ever-harsher
popular or too powerful Professional Society on
consequences. Modern
to be viewed as a sex the Abuse of Children
sex crime policies
offender and because vs. Association for the
include indefinite post-
his victims were easily Treatment of Sexual
incarceration civil
dismissed as troubled Abusers) that support
commitment, lifetime
young people. separate research
sex offender
Following his journals (e.g., Child
registration, lifetime
conviction for sexual Maltreatment vs. Sexual
online public
crimes against 10 boys, Abuse: A Journal of
notification, and
Sandusky was vilified as Research and Treatment),
expansive sex offender
a monster (a recent separate funding
residency restrictions.41
Internet search for sources operating
Although these policies
“Sandusky” and within separate
have not been
“monster” resulted in governmental agencies
convincingly linked to
approximately 1,730,000 (e.g., National Child
improvements in child
results). Traumatic Stress
or community safety,
The perception of Initiative under the
they are nearly
offenders as monsters Depart- ment of Health
universally supported
might make it more and Human Services
and give the
difficult for people to vs. Office of Sex
appearance that
acknowledge that Offender Sentencing,
legislators are doing
someone they know Monitoring,
everything that can be
and love could be Apprehending,
done. The resulting
abusing a child. Registering, and
complacency is likely to
Neither denying abuse Tracking [SMART
contribute to a general
nor unduly maligning Office] under the
disinclination toward
perpetrators Department of Justice),
more challenging and
encourages open and separate policy
seemingly less active
discussion of CSA or centers (e.g., Office for
prevention strategies.
its prevention, Violence Against
contributing to policy Balkanized professional Women vs. Center for
resistance and possibly fields. Emotional and Sex Offender
reducing the appetite defensive responses to Management). This
228  of
division Reportslabor,and Recommendations
support for identifying
resources, and adolescent and adult
funding has almost sex offender risk and
certainly slowed the protective factors (e.g.,
pace of scientific via grants issued by the
discovery and SMART Office44),
interfered with the improvements in CSA
development of a surveillance (e.g.,
unified, coherent nationally via a joint
approach to addressing effort of CDC and the
and preventing CSA. Office of Juvenile
Justice, Delinquency
and Preven- tion45 and
SigNS of
internationally via CDC
reAdiNeSS for A
in partnership with
ComPreHeNSive
UNICEF46), and an
PubliC
HeAlTH increased focus on
PreveNTi CSA by the National
oN Institutes of Health
PoliCy (e.g., via a new branch
within the National
The barriers Institute of Child
contributing to CSA Health and Human
prevention policy Development47).
resistance have been
entrenched for decades;
hence, it may be
difficult to convince
policy makers and the
public of the need to
expand beyond existing
approaches and to
allocate resources to
CSA prevention efforts.
We believe, however,
that recent
developments signal
the potential success of
a renewed effort toward
this goal.
C
o
m
p
l
e
x
i
t
y
Several developments
seem poised to reduce
the complexity and
improve the scientific
understanding of CSA,
including recent
federal research

230
E  Reports and Recommendations
Given the strong t health policies aimed
m influence of the media i at prevention.
o on percep- tions about o
ti CSA,40 it is encouraging n
o that several recent Since 1990, there has
n articles in major news been an unprecedented
a publications have increase in sex crime
l/ moved beyond titillating legislation, often in
d descriptions of CSA response to extreme
e cases to more nuanced cases.53,54 There are
f discussion of CSA. recent signs that states
e Recent articles have are taking a more
n measured approach
addressed “the science
si before implementing
of sex abuse,”48
v or revising sex crime
debated restrictions on
e policies. For example,
r sex offenders,49 and
addressed the etiology 35 states still have not
e
of pedophilia.50 These complied with the
s
publications represent sweeping requirements
p
an important of the Adam Walsh
o
development in how Child Protection and
n
s CSA is portrayed to the Safety Act of
e public, as a problem 2006, which include
s whose etiology might longer minimum
Improving the science be understood by, registration and online
of CSA should among other things, notification durations,
contribute to less biased brain research, and more frequent
and more thoughtful that might be reregistra- tion, and
discourse on this addressed with collection of more
topic, further interventions that personal information
contributing to a move beyond criminal than previously
reduction in policy justice policies. Similar required.55 This lack of
resistance. Changes in changes in how CSA is compliance stands in
how the media frame reported in the media stark contrast to the
CSA, how legislators have been noted in the alacrity with which all
address CSA while United Kingdom.51 states enacted earlier
maintaining their Efforts have also been federal sex offender
constituents’ support, made to educate the registration and
and how professionals media on CSA notification mandates.56
in victimization and reporting.52 Relatedly, in the face of
perpetration fields wide- spread
bridge their divisions R condemnation, the Act
will also contribute to e was formally amended
less policy resistance. a to remove all juvenile
c public notification
M t requirements, the first
e i substantial reversal of
d v sex crime policy in
i e decades. That legislators
a are, with their
l constituencies’ consent,
f e willing to take their time
r g before enacting new
a i sex crime policies might
m s signal more openness
e l toward considering
s a alternative public

B fied approach to CSA Preventing
adoption, and deliveryChild Sexual Abuse  231
a prevention. of the most effective
l interventions.36
k Reducing the policy
a TowArd A
resistance of CSA
n PubliC
prevention through
i HeAlTH
science and concerted
z APProACH
efforts targeting stake-
e To CSA
holders in the media,
d PreveNTioN
government, and
Traditionally, CSA has professional
p been viewed as a social organizations is a
r problem best necessary but
o addressed through insufficient step toward
f clinical intervention attaining a national
e and criminal redress. agenda focused on the
s
There have been primary prevention of
s
undeniable gains CSA. Additional steps
i
under this perspective, recommended by
o
n including the experts15,19,30–33 include
a development of the following:
l effective interventions 1. The need to
targeting the treatment convene senior
needs of victims58 and leadership from
f
i offenders, particularly all federal
e juvenile offenders;59,60 agencies with a
l increased penalties for stake in CSA to
d adults convicted of sexu- create a national
s ally abusing children;13 action plan for
Evidence of increased and the development prevention.
collaboration between of tools that more Account- ability
CSA victimization and accurately assess for achieving the
perpetration groups offender recidivism goals of this plan
tends to be more risk.61 must be
anecdotal. However, Yet, these approaches, established and
there are two concrete while necessary, are should include
indicators of such. First, fundamentally measurable
the Office on Violence reactive, attempting to objectives,
Against Women make the best of a assigned
recently awarded bad situation. By responsibilities,
funding to the Center comparison, the public timetables, and
for Sex Offender health framework is evaluation
Management for a fundamentally oriented mechanisms.
project expressly toward prevention. In
2. Increasing
designed to build the context of
federal, state,
collaboration between empirical rigor and
and
victim advocacy and multidisciplinary col-
foundational
sex offender treatment laboration, prevention
funding for
communities.57 Second, can be achieved
CSA-related
the SMART Office through defining and
research, with a
recently funded a surveying the scope of
focus
prevention-focused public health problems;
fellowship position.44 formally evaluating
These public efforts to intervention and
improve collaboration effectiveness; and
bode well for the supporting the
future of a more uni- dissemination,

on CSA long-term efforts to Preventing
sustainable Child Sexual
resources, hoodAbuse 233
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Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

Public Health Reports / May–June 2014 / Volume 129

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