Child Sexual Abuse: A Public Health Perspective

1. 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@jhsph.edu http://jhsph.edu/childsexabuse

2. 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 don’t know much (about public health) but I know I love you (NOTA) • http://www.youtube.com/watch?v=iNX1JLRSiyg • With apologies to Fergus McNeil for stealing his idea

3. Outline • Is CSA preventable? • If so, why don’t we focus on prevention? • How can we achieve a prevention-focused, public health perspective from which to address CSA?

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

5. 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

6. 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 Is CSA Preventable?

7. 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

8. 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.

9. 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

10. 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)

11. 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

12. Treatment Outcome Research Three RCTs support family-based treatment for juveniles who sexually offend

13. 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 Is CSA Preventable?

14. 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 haven’t we achieved greater progress towards CSA prevention? • Traditional focus on CSA as a social problem requiring a criminal justice solution • Policy resistance

15. Traditional Perspective of CSA Social Problem Criminal Justice Solution Photograph: Murdo Macleod for the Guardian

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

17. Finklehor, D., & Jones, L. (2012). Have sexual abuse and physical abuse declined since the 1990s? http://cola.unh.edu/sites/cola.unh.edu/files/research_publications/CV267.pdf

18. 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

19. 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.

20. 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.

21. Complex, Poorly Understood Risk Factors

22. 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

23. Defensive Responses Victim Advocacy Offender Management 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 • 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

24. 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

25. 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 Practitioner’s 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

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

27. 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 another’s boards, inviting one another to meetings, obtaining one another’s perspectives and buy-in

28. 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

29. 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?

30. 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

31. 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 andinvest in program development, evaluation, and dissemination • E.g., Dunkelfeld Prevention Project • Identify risk factors, especially at societal level • Identify promotive factorsat any level • E.g., Vancouver Longitudinal Cohort Study