Reports and Recommendations
The Need for a Comprehensive Public Health Approach to Preventing Child Sexual Abuse
Elizabeth J. Letourneau, PhDa William W. Eaton, PhDa Judith Bass, PhDa Frederick S. Berlin, MDb Stephen G. Moore, MDc
Lifetime exposure to child sexual abuse (CSA) and other forms of sexual harm (e.g., sexual exposure, sexual harassment, and Internet sex talk) affect approximately 10% of a nationally representative sample of U.S. children aged 0–17 years, including 12% of girls and nearly 8% of boys.1 Such exposure significantly increases the likelihood of subsequent sexual and nonsexual revictimization for boys and girls and subsequent sexual offending for boys.2 CSA is among 24 global risk factors identified by the World Health Organization 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 immunodeficiency 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 disorder, 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
Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
a
Johns Hopkins University, School of Medicine, Baltimore, MD
b
CarDon & Associates, Inc., Bloomington, IN
c
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 . ©2014 Association of Schools and Programs of Public Health
222
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 223
programs target potential offenders or bystanders. Funding for prevention programming is precarious, and funding for rigorous program evaluation of such prevention services appears to be nearly nonexistent. A recent review of public health agencies in all 50 states and the District of Columbia indicated that 71% offered programs targeting intimate partner violence whereas only 20% offered CSA prevention programs,20 demonstrating the low value placed on CSA prevention relative to other prevention foci. There are additional indicators that the topic of CSA remains largely absent from the broader discussions of child maltreatment, sexual violence, and sexual health. In 2013, the U.S. Preventive Services Task Force published a meta-analysis evaluating the effects of early prevention programming on reducing child maltreatment, but no evaluation of intervention effects on CSA victimization or perpetration was included.21 Numerous entities promote sexual health education as one way of preventing sexual violence against adults and adolescents, but mention of CSA prevention is lacking.22–28 We describe previous calls for the development of a public health approach to the prevention of CSA; consider how the concept of policy resistance might account, in part, for the failure of these efforts; note advances that signal hope for policy change; and make additional suggestions for achieving this important public health goal. Previous Calls for a Public Health Policy for CSA Prevention In 1991, the Centers for Disease Control and Prevention (CDC) created the Division of Violence Prevention within the Injury Center. The mission of this Division is to help society conceptualize interpersonal violence as a preventable public health problem, to ground prevention policies in science, and to evaluate and disseminate effective policies. Among the Division’s priorities is the prevention of CSA; however, in 1999, CDC acknowledged that CSA had “not received sufficient attention as a public health problem.” To address this oversight, CDC convened experts who proposed dozens of recommendations designed to address CSA prevention from a comprehensive public health perspective.15 CDC followed up on several of these recommendations, most notably by supporting national and international CSA surveillance efforts, but the great majority of the recommendations remain unmet, including the recommendation to develop a national CSA prevention agenda. The development of a public health policy to prevent
CSA is more than a single-agency issue, and hundreds of organizations, agencies, and individuals have worked toward the prevention of CSA.17,29 Like CDC, many leaders in the field have publicized calls for a more uniform and coordinated approach to the study and prevention of CSA, either as a stand-alone initiative14 or within the context of broader public health approaches aimed at preventing sexual violence,19,30,31 violence,32 or child abuse and neglect.33 These efforts have not yet resulted in a coherent and coordinated public policy, suggesting that CSA might be policy resistant.34 Policy resistance Policy resistance is “the tendency for interventions to be defeated by the system’s response to the intervention itself”34 and occurs when specific interventions designed to promote public health fail to achieve their intended effects or even make the targeted problem worse. Phenomena that are complex, poorly understood, and engender strong emotional and defensive responses are likely to be policy resistant. An example is the over-prescription of antibiotics for viral respiratory infections in young children, a procedure that increases the risk for antibiotic resistance but persists due to diagnostic complexity, fear of litigation, perceived pressure from parents, and the desire to reduce patient discomfort.35 Likewise, CSA is complex and poorly understood and engenders strong emotional and defensive responses. Policy resistance can interfere with any or all four components of a basic public health approach: surveillance, identification of risk and protective factors, development and evaluation of interventions, and intervention implementation.36 In the following subsections, we 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. Complexity CSA represents a complex human phenomenon involving a series of behaviors between at least two people, with those behaviors influenced by both risk and protective factors. While protective factors are poorly understood, there is a more substantive scientific literature identifying risk factors, which can vary widely along numerous dimensions. As shown in the Figure, two of the dimensions along which risk factors for victimization and perpetration vary are (1) life-course period, from in-utero through adulthood, and (2) level at which the risk factor occurs, including individual, intimates (i.e., family and friends), larger communities (e.g., neighborhoods and schools), and society (e.g.,
Public Health Reports / May–June 2014 / Volume 129
224 Reports and Recommendations
Agency
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
Life stage
norms and social policies). Most etiological research has focused on factors that occur in adolescence or adulthood and at the individual level. Little research has addressed community or societal-level risk factors, and even less research has addressed genetic or epigenetic risk factors. Moreover, there remain significant gaps as to how factors combine to promote or inhibit risk across the life course. More effectively delineating risk and protective factors, and how these factors interact to influence CSA victimization and perpetration, will be critical to reducing the complexity of this issue, ameliorating its policy resistance, and contributing to the science on why CSA occurs and to whom. Such knowledge is essential to the development of effective interventions, which to date tend to focus on a limited subset of individual-level risk factors.
Emotional/defensive responses In addition to complexity, CSA engenders strong emotional reactions that curtail an objective discussion of its prevention, causes, and consequences.37 There are several ways in which these emotional/defensive responses manifest, including counterproductive framing of issues by 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 coverage38 suggested two “frames” (or social constructions) for engaging audience members with sex crime stories: one that promotes angry and fearful reactions (e.g., by presenting rare and extreme cases as if they were commonplace and by replacing predictability with randomness) and a second that promotes victim b laming
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 225
(e.g., by introducing skepticism about a victim’s report or shifting blame to the victim). These portrayals encourage two types of responses to CSA. One is to view all CSA perpetrators as monsters who are nothing like ourselves. The second is to ignore the problem. Both responses were aptly illustrated by the recent case of Penn State Assistant Football Coach Jerry Sandusky. For years, evidence that Sandusky was sexually abusing children was largely ignored,39 perhaps because he was too popular or too powerful to be viewed as a sex offender and because his victims were easily dismissed as troubled young people. Following his conviction for sexual crimes against 10 boys, Sandusky was vilified as a monster (a recent Internet search for “Sandusky” and “monster” resulted in approximately 1,730,000 results). The perception of offenders as monsters might make it more difficult for people to acknowledge that someone they know and love could be abusing a child. Neither denying abuse nor unduly maligning perpetrators encourages open discussion of CSA or its prevention, contributing to policy resistance and possibly reducing the appetite of policy makers for funding prevention intervention development and evaluation projects. Reactive legislation. The “monster” frame of offenders, coupled with the complexity of CSA, can contribute to the perception that CSA is “the result of forces outside ourselves, forces largely unpredictable and uncontrollable.”34 Yet, policy makers are expected to do something about sex offenders,40 with one result being nearly two decades of competition among policy makers to enact ever-harsher consequences. Modern sex crime policies include indefinite post-incarceration civil commitment, lifetime sex offender registration, lifetime online public notification, and expansive sex offender residency restrictions.41 Although these policies have not been convincingly linked to improvements in child or community safety, they are nearly universally supported and give the appearance that legislators are doing everything that can be done. The resulting complacency is likely to contribute to a general disinclination toward more challenging and seemingly less active prevention strategies. Balkanized professional fields. Emotional and defensive responses to CSA also likely contributed to the balkanization of research, policy, and practice regarding the fields of study on CSA victimization and perpetration. Early victim advocates struggled against widespread denial that sexual abuse, including CSA, was a serious problem, and then subsequently struggled against backlash concerns about false allegations and false memories.17,42 Their fight to be taken seriously
might have contributed to a laser-like focus on victimization to the exclusion of perpetration. Similarly, many clinicians and researchers treating and studying sex offenders have led an insular existence, perceiving hostility from outsiders who view them as sex offender apologists insensitive to the needs and rights of victims.43 What might have developed as a unified field instead became two distinct victimization and perpetration fields, complete with separate professional societies (e.g., American Professional Society on the Abuse of Children vs. Association for the Treatment of Sexual Abusers) that support separate research journals (e.g., Child Maltreatment vs. Sexual Abuse: A Journal of Research and Treatment), separate funding sources operating within separate governmental agencies (e.g., National Child Traumatic Stress Initiative under the Department of Health and Human Services vs. Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking [SMART Office] under the Department of Justice), and separate policy centers (e.g., Office for Violence Against Women vs. Center for Sex Offender Management). This division of labor, resources, and funding has almost certainly slowed the pace of scientific discovery and interfered with the development of a unified, coherent approach to addressing and preventing CSA. Signs of Readiness for a Comprehensive Public Health Prevention Policy The barriers contributing to CSA prevention policy 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. Complexity Several developments seem poised to reduce the complexity and improve the scientific understanding of CSA, including recent federal research support for identifying adolescent and adult sex offender risk and protective factors (e.g., via grants issued by the SMART Office44), improvements in CSA surveillance (e.g., nationally via a joint effort of CDC and the Office of Juvenile Justice, Delinquency and Prevention45 and internationally via CDC in partnership with UNICEF46), and an increased focus on CSA by the National Institutes of Health (e.g., via a new branch within the National Institute of Child Health and Human Development47).
Public Health Reports / May–June 2014 / Volume 129
226 Reports and Recommendations
Emotional/defensive responses Improving the science of CSA should contribute to less biased and more thoughtful discourse on this topic, further contributing to a reduction in policy resistance. Changes in how the media frame CSA, how legislators address CSA while maintaining their constituents’ support, and how professionals in victimization and perpetration fields bridge their divisions will also contribute to less policy resistance. Media frames Given the strong influence of the media on perceptions about CSA,40 it is encouraging that several recent articles in major news publications have moved beyond titillating descriptions of CSA cases to more nuanced discussion of CSA. Recent articles have addressed “the science of sex abuse,”48 debated restrictions on sex offenders,49 and addressed the etiology of pedophilia.50 These publications represent an important development in how CSA is portrayed to the public, as a problem whose etiology might be understood by, among other things, brain research, and that might be addressed with interventions that move beyond criminal justice policies. Similar changes in how CSA is reported in the media have been noted in the United Kingdom.51 Efforts have also been made to educate the media on CSA reporting.52 Reactive legislation Since 1990, there has been an unprecedented increase in sex crime legislation, often in response to extreme cases.53,54 There are recent signs that states are taking a more measured approach before implementing or revising sex crime policies. For example, 35 states still have not complied with the sweeping requirements of the Adam Walsh Child Protection and Safety Act of 2006, which include longer minimum registration and online notification durations, more frequent reregistration, and collection of more personal information than previously required.55 This lack of compliance stands in stark contrast to the alacrity with which all states enacted earlier federal sex offender registration and notification mandates.56 Relatedly, in the face of widespread condemnation, the Act was formally amended to remove all juvenile public notification requirements, the first substantial reversal of sex crime policy in decades. That legislators are, with their constituencies’ consent, willing to take their time before enacting new sex crime policies might signal more openness toward considering alternative public health policies aimed at prevention.
Balkanized professional fields Evidence of increased collaboration between CSA victimization and perpetration groups tends to be more anecdotal. However, there are two concrete indicators of such. First, the Office on Violence Against Women recently awarded funding to the Center for Sex Offender Management for a project expressly designed to build collaboration between victim advocacy and sex offender treatment communities.57 Second, the SMART Office recently funded a prevention-focused fellowship position.44 These public efforts to improve collaboration bode well for the future of a more unified approach to CSA prevention. Toward a Public Health Approach to CSA Prevention Traditionally, CSA has been viewed as a social problem best addressed through clinical intervention and criminal redress. There have been undeniable gains under this perspective, including the development of effective interventions targeting the treatment needs of victims58 and offenders, particularly juvenile offenders;59,60 increased penalties for adults convicted of sexually abusing children;13 and the development of tools that more accurately assess offender recidivism risk.61 Yet, these approaches, while necessary, are fundamentally reactive, attempting to make the best of a bad situation. By comparison, the public health framework is fundamentally oriented toward prevention. In the context of empirical rigor and multidisciplinary collaboration, prevention can be achieved through defining and surveying the scope of public health problems; formally evaluating intervention and effectiveness; and supporting the dissemination, adoption, and delivery of the most effective interventions.36 Reducing the policy resistance of CSA prevention through science and concerted efforts targeting stakeholders in the media, government, and professional organizations is a necessary but insufficient step toward attaining a national agenda focused on the primary prevention of CSA. Additional steps recommended by experts15,19,30–33 include the following: 1. The need to convene senior leadership from all federal agencies with a stake in CSA to create a national action plan for prevention. Accountability for achieving the goals of this plan must be established and should include measurable objectives, assigned responsibilities, timetables, and evaluation mechanisms. 2. Increasing federal, state, and foundational funding for CSA-related research, with a focus
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 227
on CSA surveillance and epidemiology and on the development, rigorous evaluation, and dissemination of effective CSA prevention interventions. 3. Growing a cadre of multidisciplinary scientists with expertise in CSA by, for example, creating career development incentives and funding educational and research centers. 4. Increasing general and accurate knowledge about CSA by, for example, integrating CSA prevention into social and educational policies and educating the media to improve reporting on CSA. To realize these recommendations will require strong backing by highly placed leaders who can allocate resources and funding. President Barack Obama has stated that the “fight against human trafficking is one of the great human rights causes of our time.”62 Vice President Joseph Biden has called long-term efforts to address domestic violence “the single most important cause of my life.”63 Their efforts have helped initiate and maintain strong interest in and resources for addressing these two types of violence. Similar dedication from highly placed leaders is needed to spur the development of a national agenda to prevent CSA. Conclusions There are many reasons to champion a comprehensive public health approach to CSA prevention. Most fundamentally, it is simply more humane to prevent CSA than to address abuse after it occurs. The public health approach emphasizes the importance of such prevention within the context of scientific rigor, rational discourse, and multidisciplinary collaboration. Achieving a national public health approach to CSA prevention will require a sustained focus on further reducing CSA policy resistance, encouraging national leadership, and identifying sustainable resources, all of which appears to be within reach. References 1. Finkelhor D, Turner H, Ormrod R, Hamby SL. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics 2009;124:1411-23. 2. Ogloff JRP, Cutajar MC, Mann E, Mullen P. Child sexual abuse and subsequent offending and victimisation: a 45 year follow-up study. Trends Issues Crime Criminal Just 2012;440:1-6. 3. Mathers C, Stevens G, Mascarenhas M. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization; 2009. 4. Mathers C, Boerma T, Fat DM. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. 5. Noll JG, Horowitz LA, Bonanno GA, Trickett PK, Putnam FW. Revictimization and self-harm in females who experienced child-
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23. 24.
25.
26.
27. 28. 29. 30.
Public Health Reports / May–June 2014 / Volume 129
hood sexual abuse: results from a prospective study. J Interpers Violence 2003;18:1452-71. Molnar BE, Buka SL, Kessler RC. Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey. Am J Public Health 2001;91:753-60. Putnam FW. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-78. Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: a prospective study. Pediatrics 2007;120:e61-7. Eaton WW, Martin SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P. The burden of mental disorders. Epidemiol Rev 2008;30:1-14 Cutajar MC, Mullen PE, Ogloff JR, Thomas SD, Wells DL, Spataro J. Schizophrenia and other psychotic disorders in a cohort of sexually abused children. Arch Gen Psychiatry 2010;67:1114-9. Putnam F. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-78. Basile KC. Implications of public health for policy on sexual violence. Ann N Y Acad Sci 2003;989:446-63. Finkelhor D. The prevention of childhood sexual abuse. Future Child 2009;18:169-94. Freyd JJ, Putnam FW, Lyon TD, Becker-Blease KA, Cheit RE, Siegel NB, et al. Psychology. The science of child sexual abuse. Science 2005;308:501. McMahon PM, Puett RC. Child sexual abuse as a public health issue: recommendations of an expert panel. Sex Abuse 1999;11:257-66. Mercy JA. Having new eyes: viewing child sexual abuse as a public health problem. Sex Abuse 1999;11:317-22. Plummer CA. Prevention of child sexual abuse: a survey of 87 programs. Violence Vict 2001;16:575-88. Wurtele SK. Preventing sexual abuse of children in the twenty-first century: preparing for challenges and opportunities. J Child Sex Abus 2009;18:1-18. Kaufman KL. Future directions for the prevention of sexual violence. In: Kaufman KL. The prevention of sexual violence: a practitioners sourcebook. Holyoke (MA): K.L. Kaufman; 2010. p. 489-501. Centers for Disease Control and Prevention (US). Findings from the 2009 child maltreatment prevention environmental scan of state public health agencies. Atlanta: CDC; 2010. Selph SS, Bougatsos C, Blazina I, Nelson HD. Behavioral interventions and counseling to prevent child abuse and neglect: a systematic review to update the US Preventive Services Task Force recommendation. Ann Intern Med 2013;158:179-90. World Health Organization. Education and treatment in human sexuality: the training of health professionals. Report of a WHO meeting. World Health Organ Tech Rep Ser 1975;(572):5-33. World Health Organization. Defining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva. Geneva: WHO; 2006. Department of Health and Human Services (US). The Surgeon General’s call to action to promote sexual health and responsible sexual behavior. Washington: Office of the Surgeon General (US); 2001. Department of Health and Human Services (US), Centers for Disease Control and Prevention, Health Resources and Services Administration. CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment, May 8–9, 2012, Atlanta, Georgia: record of the proceedings. Atlanta: CDC; 2012. Robinson SJ, Stellato A, Stephens J, Kirby S, Forsythe A, Ivankovixh MB. On the road to well-being: the development of a communication framework for sexual health. Public Health Rep 2013;128 Suppl 1:43-52. Nystrom RJ, Duke JEA, Victor B. Shifting the paradigm from teen pregnancy prevention to youth sexual health. Public Health Rep 2013;128 Suppl 1:89-95. Ivankovich MB, Fenton KA, Douglas JM Jr. Considerations for national public health leadership in advancing sexual health. Public Health Rep 2013;128 Suppl 1:102-10. Baker K. Preventing child sexual abuse: a national resource directory and handbook. Enola (PA): National Sexual Violence Resource Center; 2005. Prentky RA, Janus ES, Seto MC. Sexually coercive behavior: understanding and management. New York: The New York Academy of Sciences; 2003.
228 Reports and Recommendations
31. Robinson LO. Sex offender management: the public policy challenges. Ann N Y Acad Sci 2003;989:1-7. 32. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002;360:1083-8. 33. Institute of Medicine. New directions in child abuse and neglect research. Washington: National Academies Press; 2013. 34. Sterman JD. Learning from evidence in a complex world. Am J Public Health 2006;96:505-14. 35. Wang EE, Einarson TR, Kellner JD, Conly JM. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999;29:155-60. 36. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for preventing violence. Health Aff (Millwood) 1993;12:7-29. 37. Quinn JF, Forsyth CJ, Mullen-Quinn C. Societal reaction to sex offenders: a review of the origins and results of the myths surrounding their crimes and treatment amenability. Dev Behav 2004;25:215-32. 38. Dowler K. Sex, lies, and videotape: the presentation of sex crime in local television news. J Crim Just 2006;34:383-92. 39. Freeh Sporkin & Sullivan. Report of the special investigative counsel regarding the actions of the Pennsylvania State University related to the child sexual abuse committed by Gerald A. Sandusky. Washington: Freeh Sporkin & Sullivan; 2012. 40. Sample LL, Kadleck C. Sex offender laws: legislators’ accounts of the need for policy. Crim Just Policy Rev 2008;19:40-62. 41. Letourneau EJ, Levenson JS. Preventing sexual abuse: community protection policies and practice. In: Myers JEB, editor. The APSAC handbook on child maltreatment. 3rd ed. Thousand Oaks (CA): Sage; 2010. p. 325-36. 42. Myers JEB. Child protection in America: past, present, and future. New York: Oxford University Press; 2006. 43. Andrew RP. Child sexual abuse and the state: applying critical outsider methodologies to legislative policymaking. UC Davis Law Rev 2006;39:1851-77. 44. Office of Justice Programs (US), Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. Funding opportunities [cited 2014 Jan 8]. Available from: URL: http:// www.smart.gov/funding.htm 45. Finkelhor D, Turner H, Hamby S. Questions and answers about the National Survey of Children’s Exposure to Violence. Washington: Department of Justice (US), Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention; 2011. 46. United Nations Children’s Fund, Centers for Disease Control and Prevention (US), and Muhimbili University of Health and Allied Sciences. Violence against children in Tanzania: findings from a national survey, 2009. Dar es Salaam (Tanzania): United Republic of Tanzania; 2011. Also available from: URL: http://www.unicef .org/media/files/violence_against_children_in_tanzania_report .pdf [cited 2014 Jan 8]. 47. National Institute for Child Health and Human Development (US). The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) announces the creation of two new branches to better facilitate NICHD research priorities. Bethesda (MD): National Institutes of Health (US); 2012. Also available from: URL: http://grants.nih.gov/grants/guide/notice-files /not-hd-12-035.html [cited 2014 Jan 8].
48. Aviv R. The science of sex abuse: is it right to imprison people for heinous crimes they have not yet committed? The New Yorker 2013 Jan 14 [cited 2014 Jan 3]. Available from: URL: http://www .newyorker.com/reporting/2013/01/14/130114fa_fact_aviv 49. Too many restrictions on sex offenders, or too few? The New York Times 2013 Feb 20 [cited 2014 Jan 3]. Available from: URL: http://www.nytimes.com/roomfordebate/2013/02/20 /too-many-restrictions-on-sex-offenders-or-too-few 50. Zarembo A. Many researchers taking a different view of pedophilia. Los Angeles Times 2013 Jan 14 [cited 2013 Jan 15]. Available from: URL: http://www.latimes.com/news/local/la-me-pedophiles20130115,0,197689.story 51. Hanvey S. Is a confidential service for sex offenders viable in the UK? Presentation at the NOTA International Conference 2013 Sep 25–27; Cardiff, Wales. 52. Journalism Center on Children & Families. Beyond the headlines: covering child sexual abuse. College Park (MD): Phillip Merrill College of Journalism; 2014. Also available from: URL: http:// www.journalismcenter.org/resource/beyond-headlines/beyondheadlines [cited 2014 Jan 8]. 53. Federal Strategy Consulting. U.S. laws and agency policies and pending federal legislation pertaining to the prevention of child sexual abuse. Brooklyn (NY): Ms. Foundation for Women; 2012. 54. Wright RG. Sex offender post-incarceration sanctions: are there any limits? N Engl J Crim Civil Confinement 2008;34:17-50. 55. Office of Justice (US), Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. Requests for reallocation of Byrne JAG funding penalty. Washington: Department of Justice (US); 2012. Also available from: URL: http://www.ojp .usdoj.gov/smart/smartwatch/12_spring/pfv.html [cited 2014 Jan 8]. 56. Logan WA. Knowledge as power: criminal registration and community notification laws in America. Stanford (CA): Stanford Law Press; 2009. 57. Center for Sex Offender Management. CSOM and partners funded by OVW to build collaboratives among advocacy and treatment communities [cited 2014 Jan 8]. Available from: URL: http://www .csom.org/news/index.html 58. Chadwick Center for Children & Families. Closing the quality chasm in child abuse treatment: identifying and disseminating best practices. San Diego: Chadwick Center for Children & Families; 2004. 59. Letourneau EJ, Henggeler SW, Borduin CM, Schewe PA, McCart MR, Chapman JE, et al. Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. J Fam Psychol 2009;23:89-102. 60. Letourneau EJ, Henggeler SW, McCart MR, Borduin CM, Schewe PA, Armstrong KS. Two-year follow-up of a randomized effectiveness trial evaluating MST for juveniles who sexually offend. J Fam Psychol 2013;27:978-85. 61. Janus ES, Prentky RA. Forensic use of actuarial risk assessment with sex offenders: accuracy, admissibility and accountability. Am Crim Law Rev 2003;40:1443-99. 62. The White House (US). End human trafficking [cited 2014 Jan 8]. Available from: URL: http://www.whitehouse.gov/issues /foreign-policy/end-human-trafficking 63. Balluck K. Biden: domestic violence “the single most important cause of my life.” The Hill 2013 May 2.
Public Health Reports / May–June 2014 / Volume 129
The Need for a Comprehensive Public Health Approach to Preventing Child Sexual Abuse
Elizabeth J. Letourneau, PhDa William W. Eaton, PhDa Judith Bass, PhDa Frederick S. Berlin, MDb Stephen G. Moore, MDc
Lifetime exposure to child sexual abuse (CSA) and other forms of sexual harm (e.g., sexual exposure, sexual harassment, and Internet sex talk) affect approximately 10% of a nationally representative sample of U.S. children aged 0–17 years, including 12% of girls and nearly 8% of boys.1 Such exposure significantly increases the likelihood of subsequent sexual and nonsexual revictimization for boys and girls and subsequent sexual offending for boys.2 CSA is among 24 global risk factors identified by the World Health Organization 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 immunodeficiency 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 disorder, 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
Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
a
Johns Hopkins University, School of Medicine, Baltimore, MD
b
CarDon & Associates, Inc., Bloomington, IN
c
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 . ©2014 Association of Schools and Programs of Public Health
222
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 223
programs target potential offenders or bystanders. Funding for prevention programming is precarious, and funding for rigorous program evaluation of such prevention services appears to be nearly nonexistent. A recent review of public health agencies in all 50 states and the District of Columbia indicated that 71% offered programs targeting intimate partner violence whereas only 20% offered CSA prevention programs,20 demonstrating the low value placed on CSA prevention relative to other prevention foci. There are additional indicators that the topic of CSA remains largely absent from the broader discussions of child maltreatment, sexual violence, and sexual health. In 2013, the U.S. Preventive Services Task Force published a meta-analysis evaluating the effects of early prevention programming on reducing child maltreatment, but no evaluation of intervention effects on CSA victimization or perpetration was included.21 Numerous entities promote sexual health education as one way of preventing sexual violence against adults and adolescents, but mention of CSA prevention is lacking.22–28 We describe previous calls for the development of a public health approach to the prevention of CSA; consider how the concept of policy resistance might account, in part, for the failure of these efforts; note advances that signal hope for policy change; and make additional suggestions for achieving this important public health goal. Previous Calls for a Public Health Policy for CSA Prevention In 1991, the Centers for Disease Control and Prevention (CDC) created the Division of Violence Prevention within the Injury Center. The mission of this Division is to help society conceptualize interpersonal violence as a preventable public health problem, to ground prevention policies in science, and to evaluate and disseminate effective policies. Among the Division’s priorities is the prevention of CSA; however, in 1999, CDC acknowledged that CSA had “not received sufficient attention as a public health problem.” To address this oversight, CDC convened experts who proposed dozens of recommendations designed to address CSA prevention from a comprehensive public health perspective.15 CDC followed up on several of these recommendations, most notably by supporting national and international CSA surveillance efforts, but the great majority of the recommendations remain unmet, including the recommendation to develop a national CSA prevention agenda. The development of a public health policy to prevent
CSA is more than a single-agency issue, and hundreds of organizations, agencies, and individuals have worked toward the prevention of CSA.17,29 Like CDC, many leaders in the field have publicized calls for a more uniform and coordinated approach to the study and prevention of CSA, either as a stand-alone initiative14 or within the context of broader public health approaches aimed at preventing sexual violence,19,30,31 violence,32 or child abuse and neglect.33 These efforts have not yet resulted in a coherent and coordinated public policy, suggesting that CSA might be policy resistant.34 Policy resistance Policy resistance is “the tendency for interventions to be defeated by the system’s response to the intervention itself”34 and occurs when specific interventions designed to promote public health fail to achieve their intended effects or even make the targeted problem worse. Phenomena that are complex, poorly understood, and engender strong emotional and defensive responses are likely to be policy resistant. An example is the over-prescription of antibiotics for viral respiratory infections in young children, a procedure that increases the risk for antibiotic resistance but persists due to diagnostic complexity, fear of litigation, perceived pressure from parents, and the desire to reduce patient discomfort.35 Likewise, CSA is complex and poorly understood and engenders strong emotional and defensive responses. Policy resistance can interfere with any or all four components of a basic public health approach: surveillance, identification of risk and protective factors, development and evaluation of interventions, and intervention implementation.36 In the following subsections, we 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. Complexity CSA represents a complex human phenomenon involving a series of behaviors between at least two people, with those behaviors influenced by both risk and protective factors. While protective factors are poorly understood, there is a more substantive scientific literature identifying risk factors, which can vary widely along numerous dimensions. As shown in the Figure, two of the dimensions along which risk factors for victimization and perpetration vary are (1) life-course period, from in-utero through adulthood, and (2) level at which the risk factor occurs, including individual, intimates (i.e., family and friends), larger communities (e.g., neighborhoods and schools), and society (e.g.,
Public Health Reports / May–June 2014 / Volume 129
224 Reports and Recommendations
Agency
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
Life stage
norms and social policies). Most etiological research has focused on factors that occur in adolescence or adulthood and at the individual level. Little research has addressed community or societal-level risk factors, and even less research has addressed genetic or epigenetic risk factors. Moreover, there remain significant gaps as to how factors combine to promote or inhibit risk across the life course. More effectively delineating risk and protective factors, and how these factors interact to influence CSA victimization and perpetration, will be critical to reducing the complexity of this issue, ameliorating its policy resistance, and contributing to the science on why CSA occurs and to whom. Such knowledge is essential to the development of effective interventions, which to date tend to focus on a limited subset of individual-level risk factors.
Emotional/defensive responses In addition to complexity, CSA engenders strong emotional reactions that curtail an objective discussion of its prevention, causes, and consequences.37 There are several ways in which these emotional/defensive responses manifest, including counterproductive framing of issues by 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 coverage38 suggested two “frames” (or social constructions) for engaging audience members with sex crime stories: one that promotes angry and fearful reactions (e.g., by presenting rare and extreme cases as if they were commonplace and by replacing predictability with randomness) and a second that promotes victim b laming
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 225
(e.g., by introducing skepticism about a victim’s report or shifting blame to the victim). These portrayals encourage two types of responses to CSA. One is to view all CSA perpetrators as monsters who are nothing like ourselves. The second is to ignore the problem. Both responses were aptly illustrated by the recent case of Penn State Assistant Football Coach Jerry Sandusky. For years, evidence that Sandusky was sexually abusing children was largely ignored,39 perhaps because he was too popular or too powerful to be viewed as a sex offender and because his victims were easily dismissed as troubled young people. Following his conviction for sexual crimes against 10 boys, Sandusky was vilified as a monster (a recent Internet search for “Sandusky” and “monster” resulted in approximately 1,730,000 results). The perception of offenders as monsters might make it more difficult for people to acknowledge that someone they know and love could be abusing a child. Neither denying abuse nor unduly maligning perpetrators encourages open discussion of CSA or its prevention, contributing to policy resistance and possibly reducing the appetite of policy makers for funding prevention intervention development and evaluation projects. Reactive legislation. The “monster” frame of offenders, coupled with the complexity of CSA, can contribute to the perception that CSA is “the result of forces outside ourselves, forces largely unpredictable and uncontrollable.”34 Yet, policy makers are expected to do something about sex offenders,40 with one result being nearly two decades of competition among policy makers to enact ever-harsher consequences. Modern sex crime policies include indefinite post-incarceration civil commitment, lifetime sex offender registration, lifetime online public notification, and expansive sex offender residency restrictions.41 Although these policies have not been convincingly linked to improvements in child or community safety, they are nearly universally supported and give the appearance that legislators are doing everything that can be done. The resulting complacency is likely to contribute to a general disinclination toward more challenging and seemingly less active prevention strategies. Balkanized professional fields. Emotional and defensive responses to CSA also likely contributed to the balkanization of research, policy, and practice regarding the fields of study on CSA victimization and perpetration. Early victim advocates struggled against widespread denial that sexual abuse, including CSA, was a serious problem, and then subsequently struggled against backlash concerns about false allegations and false memories.17,42 Their fight to be taken seriously
might have contributed to a laser-like focus on victimization to the exclusion of perpetration. Similarly, many clinicians and researchers treating and studying sex offenders have led an insular existence, perceiving hostility from outsiders who view them as sex offender apologists insensitive to the needs and rights of victims.43 What might have developed as a unified field instead became two distinct victimization and perpetration fields, complete with separate professional societies (e.g., American Professional Society on the Abuse of Children vs. Association for the Treatment of Sexual Abusers) that support separate research journals (e.g., Child Maltreatment vs. Sexual Abuse: A Journal of Research and Treatment), separate funding sources operating within separate governmental agencies (e.g., National Child Traumatic Stress Initiative under the Department of Health and Human Services vs. Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking [SMART Office] under the Department of Justice), and separate policy centers (e.g., Office for Violence Against Women vs. Center for Sex Offender Management). This division of labor, resources, and funding has almost certainly slowed the pace of scientific discovery and interfered with the development of a unified, coherent approach to addressing and preventing CSA. Signs of Readiness for a Comprehensive Public Health Prevention Policy The barriers contributing to CSA prevention policy 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. Complexity Several developments seem poised to reduce the complexity and improve the scientific understanding of CSA, including recent federal research support for identifying adolescent and adult sex offender risk and protective factors (e.g., via grants issued by the SMART Office44), improvements in CSA surveillance (e.g., nationally via a joint effort of CDC and the Office of Juvenile Justice, Delinquency and Prevention45 and internationally via CDC in partnership with UNICEF46), and an increased focus on CSA by the National Institutes of Health (e.g., via a new branch within the National Institute of Child Health and Human Development47).
Public Health Reports / May–June 2014 / Volume 129
226 Reports and Recommendations
Emotional/defensive responses Improving the science of CSA should contribute to less biased and more thoughtful discourse on this topic, further contributing to a reduction in policy resistance. Changes in how the media frame CSA, how legislators address CSA while maintaining their constituents’ support, and how professionals in victimization and perpetration fields bridge their divisions will also contribute to less policy resistance. Media frames Given the strong influence of the media on perceptions about CSA,40 it is encouraging that several recent articles in major news publications have moved beyond titillating descriptions of CSA cases to more nuanced discussion of CSA. Recent articles have addressed “the science of sex abuse,”48 debated restrictions on sex offenders,49 and addressed the etiology of pedophilia.50 These publications represent an important development in how CSA is portrayed to the public, as a problem whose etiology might be understood by, among other things, brain research, and that might be addressed with interventions that move beyond criminal justice policies. Similar changes in how CSA is reported in the media have been noted in the United Kingdom.51 Efforts have also been made to educate the media on CSA reporting.52 Reactive legislation Since 1990, there has been an unprecedented increase in sex crime legislation, often in response to extreme cases.53,54 There are recent signs that states are taking a more measured approach before implementing or revising sex crime policies. For example, 35 states still have not complied with the sweeping requirements of the Adam Walsh Child Protection and Safety Act of 2006, which include longer minimum registration and online notification durations, more frequent reregistration, and collection of more personal information than previously required.55 This lack of compliance stands in stark contrast to the alacrity with which all states enacted earlier federal sex offender registration and notification mandates.56 Relatedly, in the face of widespread condemnation, the Act was formally amended to remove all juvenile public notification requirements, the first substantial reversal of sex crime policy in decades. That legislators are, with their constituencies’ consent, willing to take their time before enacting new sex crime policies might signal more openness toward considering alternative public health policies aimed at prevention.
Balkanized professional fields Evidence of increased collaboration between CSA victimization and perpetration groups tends to be more anecdotal. However, there are two concrete indicators of such. First, the Office on Violence Against Women recently awarded funding to the Center for Sex Offender Management for a project expressly designed to build collaboration between victim advocacy and sex offender treatment communities.57 Second, the SMART Office recently funded a prevention-focused fellowship position.44 These public efforts to improve collaboration bode well for the future of a more unified approach to CSA prevention. Toward a Public Health Approach to CSA Prevention Traditionally, CSA has been viewed as a social problem best addressed through clinical intervention and criminal redress. There have been undeniable gains under this perspective, including the development of effective interventions targeting the treatment needs of victims58 and offenders, particularly juvenile offenders;59,60 increased penalties for adults convicted of sexually abusing children;13 and the development of tools that more accurately assess offender recidivism risk.61 Yet, these approaches, while necessary, are fundamentally reactive, attempting to make the best of a bad situation. By comparison, the public health framework is fundamentally oriented toward prevention. In the context of empirical rigor and multidisciplinary collaboration, prevention can be achieved through defining and surveying the scope of public health problems; formally evaluating intervention and effectiveness; and supporting the dissemination, adoption, and delivery of the most effective interventions.36 Reducing the policy resistance of CSA prevention through science and concerted efforts targeting stakeholders in the media, government, and professional organizations is a necessary but insufficient step toward attaining a national agenda focused on the primary prevention of CSA. Additional steps recommended by experts15,19,30–33 include the following: 1. The need to convene senior leadership from all federal agencies with a stake in CSA to create a national action plan for prevention. Accountability for achieving the goals of this plan must be established and should include measurable objectives, assigned responsibilities, timetables, and evaluation mechanisms. 2. Increasing federal, state, and foundational funding for CSA-related research, with a focus
Public Health Reports / May–June 2014 / Volume 129
Preventing Child Sexual Abuse 227
on CSA surveillance and epidemiology and on the development, rigorous evaluation, and dissemination of effective CSA prevention interventions. 3. Growing a cadre of multidisciplinary scientists with expertise in CSA by, for example, creating career development incentives and funding educational and research centers. 4. Increasing general and accurate knowledge about CSA by, for example, integrating CSA prevention into social and educational policies and educating the media to improve reporting on CSA. To realize these recommendations will require strong backing by highly placed leaders who can allocate resources and funding. President Barack Obama has stated that the “fight against human trafficking is one of the great human rights causes of our time.”62 Vice President Joseph Biden has called long-term efforts to address domestic violence “the single most important cause of my life.”63 Their efforts have helped initiate and maintain strong interest in and resources for addressing these two types of violence. Similar dedication from highly placed leaders is needed to spur the development of a national agenda to prevent CSA. Conclusions There are many reasons to champion a comprehensive public health approach to CSA prevention. Most fundamentally, it is simply more humane to prevent CSA than to address abuse after it occurs. The public health approach emphasizes the importance of such prevention within the context of scientific rigor, rational discourse, and multidisciplinary collaboration. Achieving a national public health approach to CSA prevention will require a sustained focus on further reducing CSA policy resistance, encouraging national leadership, and identifying sustainable resources, all of which appears to be within reach. References 1. Finkelhor D, Turner H, Ormrod R, Hamby SL. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics 2009;124:1411-23. 2. Ogloff JRP, Cutajar MC, Mann E, Mullen P. Child sexual abuse and subsequent offending and victimisation: a 45 year follow-up study. Trends Issues Crime Criminal Just 2012;440:1-6. 3. Mathers C, Stevens G, Mascarenhas M. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization; 2009. 4. Mathers C, Boerma T, Fat DM. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. 5. Noll JG, Horowitz LA, Bonanno GA, Trickett PK, Putnam FW. Revictimization and self-harm in females who experienced child-
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23. 24.
25.
26.
27. 28. 29. 30.
Public Health Reports / May–June 2014 / Volume 129
hood sexual abuse: results from a prospective study. J Interpers Violence 2003;18:1452-71. Molnar BE, Buka SL, Kessler RC. Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey. Am J Public Health 2001;91:753-60. Putnam FW. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-78. Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: a prospective study. Pediatrics 2007;120:e61-7. Eaton WW, Martin SS, Nestadt G, Bienvenu OJ, Clarke D, Alexandre P. The burden of mental disorders. Epidemiol Rev 2008;30:1-14 Cutajar MC, Mullen PE, Ogloff JR, Thomas SD, Wells DL, Spataro J. Schizophrenia and other psychotic disorders in a cohort of sexually abused children. Arch Gen Psychiatry 2010;67:1114-9. Putnam F. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-78. Basile KC. Implications of public health for policy on sexual violence. Ann N Y Acad Sci 2003;989:446-63. Finkelhor D. The prevention of childhood sexual abuse. Future Child 2009;18:169-94. Freyd JJ, Putnam FW, Lyon TD, Becker-Blease KA, Cheit RE, Siegel NB, et al. Psychology. The science of child sexual abuse. Science 2005;308:501. McMahon PM, Puett RC. Child sexual abuse as a public health issue: recommendations of an expert panel. Sex Abuse 1999;11:257-66. Mercy JA. Having new eyes: viewing child sexual abuse as a public health problem. Sex Abuse 1999;11:317-22. Plummer CA. Prevention of child sexual abuse: a survey of 87 programs. Violence Vict 2001;16:575-88. Wurtele SK. Preventing sexual abuse of children in the twenty-first century: preparing for challenges and opportunities. J Child Sex Abus 2009;18:1-18. Kaufman KL. Future directions for the prevention of sexual violence. In: Kaufman KL. The prevention of sexual violence: a practitioners sourcebook. Holyoke (MA): K.L. Kaufman; 2010. p. 489-501. Centers for Disease Control and Prevention (US). Findings from the 2009 child maltreatment prevention environmental scan of state public health agencies. Atlanta: CDC; 2010. Selph SS, Bougatsos C, Blazina I, Nelson HD. Behavioral interventions and counseling to prevent child abuse and neglect: a systematic review to update the US Preventive Services Task Force recommendation. Ann Intern Med 2013;158:179-90. World Health Organization. Education and treatment in human sexuality: the training of health professionals. Report of a WHO meeting. World Health Organ Tech Rep Ser 1975;(572):5-33. World Health Organization. Defining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva. Geneva: WHO; 2006. Department of Health and Human Services (US). The Surgeon General’s call to action to promote sexual health and responsible sexual behavior. Washington: Office of the Surgeon General (US); 2001. Department of Health and Human Services (US), Centers for Disease Control and Prevention, Health Resources and Services Administration. CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment, May 8–9, 2012, Atlanta, Georgia: record of the proceedings. Atlanta: CDC; 2012. Robinson SJ, Stellato A, Stephens J, Kirby S, Forsythe A, Ivankovixh MB. On the road to well-being: the development of a communication framework for sexual health. Public Health Rep 2013;128 Suppl 1:43-52. Nystrom RJ, Duke JEA, Victor B. Shifting the paradigm from teen pregnancy prevention to youth sexual health. Public Health Rep 2013;128 Suppl 1:89-95. Ivankovich MB, Fenton KA, Douglas JM Jr. Considerations for national public health leadership in advancing sexual health. Public Health Rep 2013;128 Suppl 1:102-10. Baker K. Preventing child sexual abuse: a national resource directory and handbook. Enola (PA): National Sexual Violence Resource Center; 2005. Prentky RA, Janus ES, Seto MC. Sexually coercive behavior: understanding and management. New York: The New York Academy of Sciences; 2003.
228 Reports and Recommendations
31. Robinson LO. Sex offender management: the public policy challenges. Ann N Y Acad Sci 2003;989:1-7. 32. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002;360:1083-8. 33. Institute of Medicine. New directions in child abuse and neglect research. Washington: National Academies Press; 2013. 34. Sterman JD. Learning from evidence in a complex world. Am J Public Health 2006;96:505-14. 35. Wang EE, Einarson TR, Kellner JD, Conly JM. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999;29:155-60. 36. Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for preventing violence. Health Aff (Millwood) 1993;12:7-29. 37. Quinn JF, Forsyth CJ, Mullen-Quinn C. Societal reaction to sex offenders: a review of the origins and results of the myths surrounding their crimes and treatment amenability. Dev Behav 2004;25:215-32. 38. Dowler K. Sex, lies, and videotape: the presentation of sex crime in local television news. J Crim Just 2006;34:383-92. 39. Freeh Sporkin & Sullivan. Report of the special investigative counsel regarding the actions of the Pennsylvania State University related to the child sexual abuse committed by Gerald A. Sandusky. Washington: Freeh Sporkin & Sullivan; 2012. 40. Sample LL, Kadleck C. Sex offender laws: legislators’ accounts of the need for policy. Crim Just Policy Rev 2008;19:40-62. 41. Letourneau EJ, Levenson JS. Preventing sexual abuse: community protection policies and practice. In: Myers JEB, editor. The APSAC handbook on child maltreatment. 3rd ed. Thousand Oaks (CA): Sage; 2010. p. 325-36. 42. Myers JEB. Child protection in America: past, present, and future. New York: Oxford University Press; 2006. 43. Andrew RP. Child sexual abuse and the state: applying critical outsider methodologies to legislative policymaking. UC Davis Law Rev 2006;39:1851-77. 44. Office of Justice Programs (US), Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. Funding opportunities [cited 2014 Jan 8]. Available from: URL: http:// www.smart.gov/funding.htm 45. Finkelhor D, Turner H, Hamby S. Questions and answers about the National Survey of Children’s Exposure to Violence. Washington: Department of Justice (US), Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention; 2011. 46. United Nations Children’s Fund, Centers for Disease Control and Prevention (US), and Muhimbili University of Health and Allied Sciences. Violence against children in Tanzania: findings from a national survey, 2009. Dar es Salaam (Tanzania): United Republic of Tanzania; 2011. Also available from: URL: http://www.unicef .org/media/files/violence_against_children_in_tanzania_report .pdf [cited 2014 Jan 8]. 47. National Institute for Child Health and Human Development (US). The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) announces the creation of two new branches to better facilitate NICHD research priorities. Bethesda (MD): National Institutes of Health (US); 2012. Also available from: URL: http://grants.nih.gov/grants/guide/notice-files /not-hd-12-035.html [cited 2014 Jan 8].
48. Aviv R. The science of sex abuse: is it right to imprison people for heinous crimes they have not yet committed? The New Yorker 2013 Jan 14 [cited 2014 Jan 3]. Available from: URL: http://www .newyorker.com/reporting/2013/01/14/130114fa_fact_aviv 49. Too many restrictions on sex offenders, or too few? The New York Times 2013 Feb 20 [cited 2014 Jan 3]. Available from: URL: http://www.nytimes.com/roomfordebate/2013/02/20 /too-many-restrictions-on-sex-offenders-or-too-few 50. Zarembo A. Many researchers taking a different view of pedophilia. Los Angeles Times 2013 Jan 14 [cited 2013 Jan 15]. Available from: URL: http://www.latimes.com/news/local/la-me-pedophiles20130115,0,197689.story 51. Hanvey S. Is a confidential service for sex offenders viable in the UK? Presentation at the NOTA International Conference 2013 Sep 25–27; Cardiff, Wales. 52. Journalism Center on Children & Families. Beyond the headlines: covering child sexual abuse. College Park (MD): Phillip Merrill College of Journalism; 2014. Also available from: URL: http:// www.journalismcenter.org/resource/beyond-headlines/beyondheadlines [cited 2014 Jan 8]. 53. Federal Strategy Consulting. U.S. laws and agency policies and pending federal legislation pertaining to the prevention of child sexual abuse. Brooklyn (NY): Ms. Foundation for Women; 2012. 54. Wright RG. Sex offender post-incarceration sanctions: are there any limits? N Engl J Crim Civil Confinement 2008;34:17-50. 55. Office of Justice (US), Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. Requests for reallocation of Byrne JAG funding penalty. Washington: Department of Justice (US); 2012. Also available from: URL: http://www.ojp .usdoj.gov/smart/smartwatch/12_spring/pfv.html [cited 2014 Jan 8]. 56. Logan WA. Knowledge as power: criminal registration and community notification laws in America. Stanford (CA): Stanford Law Press; 2009. 57. Center for Sex Offender Management. CSOM and partners funded by OVW to build collaboratives among advocacy and treatment communities [cited 2014 Jan 8]. Available from: URL: http://www .csom.org/news/index.html 58. Chadwick Center for Children & Families. Closing the quality chasm in child abuse treatment: identifying and disseminating best practices. San Diego: Chadwick Center for Children & Families; 2004. 59. Letourneau EJ, Henggeler SW, Borduin CM, Schewe PA, McCart MR, Chapman JE, et al. Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. J Fam Psychol 2009;23:89-102. 60. Letourneau EJ, Henggeler SW, McCart MR, Borduin CM, Schewe PA, Armstrong KS. Two-year follow-up of a randomized effectiveness trial evaluating MST for juveniles who sexually offend. J Fam Psychol 2013;27:978-85. 61. Janus ES, Prentky RA. Forensic use of actuarial risk assessment with sex offenders: accuracy, admissibility and accountability. Am Crim Law Rev 2003;40:1443-99. 62. The White House (US). End human trafficking [cited 2014 Jan 8]. Available from: URL: http://www.whitehouse.gov/issues /foreign-policy/end-human-trafficking 63. Balluck K. Biden: domestic violence “the single most important cause of my life.” The Hill 2013 May 2.
Public Health Reports / May–June 2014 / Volume 129
