Letters
Table. Results of Logistic Regression Analyses Predicting Obesity Status at Age 19 Years From Baseline Weight Labelinga Source of Labeling, OR (95% CI) Predictor
Model 1: Anyone
Model 2: Family
Baseline BMI
1.70 (1.61-1.80)
1.70 (1.61-1.80)
Model 3: Nonfamily 1.72 (1.62-1.82)
Race
1.31 (0.93-1.84)
1.30 (0.93-1.82)
1.32 (0.94-1.86)
Parental education
0.73 (0.58-0.93)
0.73 (0.58-0.93)
0.75 (0.59-0.95)
Household income
0.76 (0.64-0.89)
0.76 (0.64-0.89)
0.74 (0.63-0.88)
Age at menarche
1.01 (0.91-1.12)
1.00 (0.90-1.11)
1.01 (0.91-1.13)
Baseline labeling
1.66 (1.20-2.30)
1.62 (1.18-2.22)
1.40 (1.01-1.94)
the source of labeling and 1.40 when nonfamily members were the source. These effects were not modulated by race.
Abbreviations: BMI, body mass index; OR, odds ratio. a
The pattern of results was the same when modeling both weight labeling and BMI as continuous variables; these full results are available from the authors.
COMMENT & RESPONSE
Understanding Sexual Violence Perpetration
5. Mustillo SA, Budd K, Hendrix K. Obesity, labeling, and psychological distress in late-childhood and adolescent black and white girls: the distal effects of stigma. Soc Psychol Q. 2013;76(3):268-289. doi:10.1177/0190272513495883.
To the Editor It seems unlikely that the 9% of adolescents reported by Ybarra and Mitchell1 to have coerced sex, or to have attempted or completed rape, made a conscious decision to commit a felony. It is more likely that they made excuses for their behavior because they had not fully understood the lesson that any penetration of the body of a girl (or boy) without free consent is rape—consent being valid only if she or he is capable of giving consent. Somehow, they convinced themselves that the rules did not apply to them. This ignorance is not surprising because study after study has found that most people define rape using a stereotypical script in which a sober girl is injured resisting a stranger.2 Scenarios that deviate from this script are often thought to be legal—although perhaps not good—behavior. Even victims doubt that rape occurred if the event deviated from the societal script.3 As soon as a perpetrator knows the victim, or if the victim has used alcohol or drugs, society’s script is less critical of behavior that can still legally be considered rape. Fortunately, it is possible to get adolescents to rethink their scripts for acceptable behavior. In Canada, an educational program for high school freshmen was associated with reduced dating violence (sexual assault was not assessed separately).4 In California, a coach-led program for high school athletes was associated with reduced sexually aggressive behavior.5 More important, after the program, student athletes engaged in less negative bystander behavior such as laughing, going along with abusive behavior, or saying nothing. Bystander behavior is important because, as shown by a Facebook posting in Steubenville, Ohio, one motivation for rape is to exhibit one’s prowess to bystanders. And changing bystander behavior brings us back to the importance of societal scripts. We do not typically think of our daily lives as bystander activity that helps shape the societal script for rape. However, common jokes, different types of entertainment, and casual conversations frequently reinforce myths that undermine the seriousness of rape. We should apply the lessons learned from high school students to rethink the actions that we as the adults in society call rape. This is not a negative action leading to censorship but rather an affirmative action to rethink our collective script so that everyone is aware that forced or coerced sex is never acceptable—even between friends who have been drinking.
6. Callahan D. Children, stigma, and obesity. JAMA Pediatr. 2013;167(9):791-792.
William H. Goodson III, MD
Discussion | Being labeled “too fat” in childhood was associated with higher odds of having an obese BMI nearly a decade later. Importantly, this relationship was independent of initial BMI and thus not attributable simply to participants’ objective weight at baseline. These data provide novel evidence that the relationship between weight stigma and weight gain may begin early in life; these findings also demonstrate that this relationship can emerge even for a seemingly innocuous facet of stigma (ie, labeling). Weight stigma may contribute to weight gain by increasing obesogenic stress processes and triggering weight-promoting coping behaviors like overeating; future research should examine these potential mechanisms. Conclusions | Given our findings, and the broader literature suggesting weight stigma adversely affects the well-being of overweight children,2 advocating for weight stigma as public health policy seems unproductive.6 Researchers, public health officials, and clinicians should consider nonstigmatizing approaches to improving the health and well-being of overweight children. Jeffrey M. Hunger, MA A. Janet Tomiyama, PhD Author Affiliations: University of California, Santa Barbara (Hunger); University of California, Los Angeles (Tomiyama). Corresponding Author: A. Janet Tomiyama, PhD, Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA 90095 ([email protected]). Published Online: April 28, 2014. doi:10.1001/jamapediatrics.2014.122. Conflict of Interest Disclosures: None reported. 1. Vartanian LR, Smyth JM. Primum non nocere: obesity stigma and public health. J Bioeth Inq. 2013;10(1):49-57. 2. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007;133(4):557-580. 3. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013;8(7):e70048. 4. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363-385. doi:10.1146/annurev.soc.27.1.363.
580
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Letters
Author Affiliation: California Pacific Medical Center Research Institute, San Francisco. Corresponding Author: William H. Goodson III, MD, California Pacific Medical Center Research Institute, 2100 Webster St, Ste 401, San Francisco, CA 94118 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134. 2. Untied AS, Orchowski LM, Mastroleo N, Gidycz CA. College students’ social reactions to the victim in a hypothetical sexual assault scenario: the role of victim and perpetrator alcohol use. Violence Vict. 2012;27(6):957-972. 3. Littleton HL, Axsom D, Breitkopf CR, Berenson A. Rape acknowledgment and postassault experiences: how acknowledgment status relates to disclosure, coping, worldview, and reactions received from others. Violence Vict. 2006;21(6):761-778. 4. Wolfe DA, Crooks C, Jaffe P, et al. A school-based program to prevent adolescent dating violence: a cluster randomized trial. Arch Pediatr Adolesc Med. 2009;163(8):692-699. 5. Miller E, Tancredi DJ, McCauley HL, et al. One-year follow-up of a coach-delivered dating violence prevention program: a cluster randomized controlled trial. Am J Prev Med. 2013;45(1):108-112.
To the Editor The article “Prevalence Rates of Male and Female Sexual Violence Perpetrators in a National Sample of Adolescents”1 recently published in JAMA Pediatrics documents that both males and females can be perpetrators or victims of sexual violence; however, both the methods used and the interpretation of the findings ignore the important influence of gender, particularly in the etiology underlying sexual violence perpetration. First, although the authors have stratified their findings by gender, there is no discussion provided to explain how findings would be expected to vary by gender (or by biological factors related to male or female sex, although less plausible). However, presenting findings separately for males and females implies an expectation of the role of gender (and/or sex) to afford significant differences in findings. Increasingly, studies such as this one by Ybarra and Mitchell1 have reported that females are perpetrating dating and/or sexual violence in similar proportions as males.2 Collectively, these works imply that such violence perpetration is not differentiated by gender. However, numerous other studies have presented empirical findings highlighting that such conclusions are a result of limitations in measurement, primarily by using measures that do not consider relevant differences by gender in the motivations, context, or consequences of abuse.3 Namely, differences exist in the reporting of violence by gender. Male-perpetrated violence, particularly sexual violence, including pressure or coercion, is a highly stigmatized behavior and likely underreported in a way that is not comparable to female reports of violence perpetration. Furthermore, males and females perpetrate violence and abuse for different reasons that are influenced by gender. The majority of male-perpetrated violence, particularly against females, is gender-based violence; regardless of the gender of the victim, male-perpetrated sexual violence has been linked to gender norms that promote male dominance and control, as demonstrated by a recently published multicountry study on rape perpetration.4 We have seen this as a significant findjamapediatrics.com
ing across every study on the topic, and this has arisen from practical evidence on the ground.4,5 In contrast to these findings among males, there are no societal-level gender norms or other societal-level factors that are influencing populations of females to perpetrate sexual violence in the same way. In summary, the role and basis of gender in violence perpetration is important to consider when developing research questions, measuring violence perpetration, and interpreting findings. These distinctions by gender are critical to inform future research and prevention efforts. Elizabeth Reed, ScD, MPH Jhumka Gupta, ScD, MPH Jay G. Silverman, PhD Author Affiliations: Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla (Reed, Silverman); Department of Chronic Disease Epidemiology, Division of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Gupta). Corresponding Author: Elizabeth Reed, ScD, MPH, Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134. 2. Reed E, Raj A, Miller E, Silverman JG. Losing the “gender” in gender-based violence: the missteps of research on dating and intimate partner violence. Violence Against Women. 2010;16(3):348-354. 3. Molidor C, Tolman RM, Kober J. Gender and contextual factors in adolescent dating violence. Violence Against Women. 1998;4(2):180-194. 4. Jewkes R, Fulu E, Roselli T, Garcia-Moreno C; UN Multi-country Cross-sectional Study on Men and Violence research team. Prevalence of and factors associated with non-partner rape perpetration: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific. Lancet Global Health. 2013;1(4):e208-e218. doi:10.1016/S2214-109X(13) 70069-X. 5. Tilley DS, Brackley M. Men who batter intimate partners: a grounded theory study of the development of male violence in intimate partner relationships. Issues Ment Health Nurs. 2005;26(3):281-297.
In Reply We agree with Reed et al that sexual violence perpetration is gendered. Indeed, this is the story that emerges from our study: although females and males perpetrate sexual assaults at equivalent rates, males are overrepresented in coercive sex and in attempted and completed rapes.1 Among those who have attempted or completed rape, female perpetrators tend to initiate this behavior at an older age than male perpetrators. Accordingly, there are some differences in the type of victims female and male perpetrators describe. We posit in our study1 that these data point to etiological differences in the emergence of sexual violence between males and females. As an epidemiological study, the main aim was to report prevalence rates. We certainly hope that the findings will invigorate future studies that are designed to better illuminate cultural and gender differences that may help contextualize the rates that we observed. We are concerned by the suggestion that contextual factors could somehow explain (ie, excuse) female perpetration. We are particularly perplexed by the assertion that it may be more culturally acceptable for females to report perpetration of sexual JAMA Pediatrics June 2014 Volume 168, Number 6
Copyright 2014 American Medical Association. All rights reserved.
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581
Letters
violence. Although previous studies have noted gender norms that promote male dominance and control as key factors, it must be acknowledged that these studies (including the recently published multicountry study2) only include men in their measures of perpetrators. We lack similar theories for females because they have largely been excluded from the perpetration research. As noted by Righthand and Welch,3 research on females who have committed sex offenses is rare. They suggest that “[t]he incidence of sex offending may be underestimated for female juveniles even more than for males, perhaps because of a societal reluctance (and even a reluctance among professionals) to acknowledge that girls are capable of committing such offenses.”3(p14) Thus, societal norms do encourage female perpetration, just in different ways than male perpetration. Until we acknowledge that women can be violent, we will not be able to develop gender-appropriate prevention programs that reduce rates of perpetration for men and women. We appreciate Dr Goodson’s observation that it is unlikely that all teenage perpetrators of sexual violence are making a conscious decision to commit a felony. Motivations certainly vary considerably. Future research could focus on illuminating this aspect of the perpetration. At the same time, sexual violence is sexual violence, regardless of motivation. Prevention programs that address this behavior are critical. Whether the motivation behind the violence was insidious or not, the data suggest that perpetrators often do not take responsibility for their actions and that many blame the victim to some extent. Taking responsibility for one’s actions may very well be related to the motivation behind the violence, and this combination could be a useful focus within prevention programs. The research on programs that focus on rethinking scripts for acceptable behavior is encouraging.4,5 And, as suggested in the implications of our study,1 we agree that bystander intervention could play a crucial role in both helping victims and identifying perpetrators. Michele L. Ybarra, MPH, PhD Kimberly J. Mitchell, PhD Author Affiliations: Center for Innovative Public Health Research, San Clemente, California (Ybarra); Crimes Against Children Research Center, University of New Hampshire, Durham (Mitchell). Corresponding Author: Michele L. Ybarra, MPH, PhD, Center for Innovative Public Health Research, 555 El Camino Real, Ste A347, San Clemente, CA 92672-6745 (michele@innovativepublichealth).
Survival at a Gestational Age of 24 Weeks in the Netherlands To the Editor Verhagen and Janvier1 have described the processes involved in the medical care of neonates who died. Although their article is highly relevant, we would like to comment on one aspect of it. They state that “[s]urvival for those born at 24 weeks…is as low as zero in some centers in the Netherlands.”1(p988) It is important to note that, in the Netherlands, views on the medical care of extremely preterm neonates have developed over time. Since September 2010, obstetricians and neonatologists nationwide agreed on offering parents active resuscitation for neonates from a gestational age of 24 weeks onwards. Since then, in the Netherlands, the mortality rate among neonates with a gestational age from 24 weeks and 0 days to 24 weeks and 6 days has decreased to between 45% and 50% in the neonatal intensive care units (data from the Netherlands Perinatal Registry), which is well in accordance with the rates in other European countries actively resuscitating neonates with such a low gestational age.2 Data on long-term morbidity are as yet unavailable but are being collected.3 In addition, data on perinatal deaths are collected to provide insight into the relevant ethical aspects of medical care at the limits of viability raised by Verhagen and Janvier.1 Floris Groenendaal, MD, PhD Rene Kornelisse, MD, PhD Chantal Hukkelhoven, PhD Author Affiliations: Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands (Groenendaal); Erasmus Medical Center, Rotterdam, the Netherlands (Kornelisse); Netherlands Perinatal Registry, Utrecht, the Netherlands (Hukkelhoven). Corresponding Author: Floris Groenendaal, MD, PhD, Department of Neonatology, University Medical Center Utrecht, PO Box 85090, Room KE 04.123.1, 3584 EA Utrecht, the Netherlands ([email protected]). Conflict of Interest Disclosures: None reported. 1. Verhagen AAE, Janvier A. The continuing importance of how neonates die. JAMA Pediatr. 2013;167(11):987-988.
Conflict of Interest Disclosures: None reported.
2. Costeloe KL, Hennessy EM, Haider S, Stacey F, Marlow N, Draper ES. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ. 2012;345:e7976.
1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134.
3. de Kluiver E, Offringa M, Walther FJ, Duvekot JJ, de Laat MW. Perinatal policy in cases of extreme prematurity; an investigation into the implementation of the guidelines [in Dutch]. Ned Tijdschr Geneeskd. 2013;157(38):A6362.
2. Jewkes R, Fulu E, Roselli T, Garcia-Moreno C; UN Multi-country Cross-sectional Study on Men and Violence research team. Prevalence of and factors associated with non-partner rape perpetration: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific. Lancet Global Health. 2013;1(4):e208-e218. doi:10.1016/S2214-109X(13) 70069-X. 3. Righthand S, Welch C. Juveniles Who Have Sexually Offended: A Review of the Professional Literature. https://www.ncjrs.gov/pdffiles1/ojjdp/184739.pdf. Revised January 19, 2001. Accessed April 14, 2014. 4. Wolfe DA, Crooks C, Jaffe P, et al. A school-based program to prevent adolescent dating violence: a cluster randomized trial. Arch Pediatr Adolesc Med. 2009;163(8):692-699.
582
5. Miller E, Tancredi DJ, McCauley HL, et al. One-year follow-up of a coach-delivered dating violence prevention program: a cluster randomized controlled trial. Am J Prev Med. 2013;45(1):108-112.
In Reply In their letter, Groenendaal and coauthors inform us about recent changes in attitudes and practice regarding the care of extremely preterm babies in the Netherlands resulting in optional active resuscitation for neonates from a gestational age of 24 weeks onwards. That is important news. We hope that they will soon publish these data internationally in a detailed manner and include the descriptions of medical care and the decisions that preceded the death or
JAMA Pediatrics June 2014 Volume 168, Number 6
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Table. Results of Logistic Regression Analyses Predicting Obesity Status at Age 19 Years From Baseline Weight Labelinga Source of Labeling, OR (95% CI) Predictor
Model 1: Anyone
Model 2: Family
Baseline BMI
1.70 (1.61-1.80)
1.70 (1.61-1.80)
Model 3: Nonfamily 1.72 (1.62-1.82)
Race
1.31 (0.93-1.84)
1.30 (0.93-1.82)
1.32 (0.94-1.86)
Parental education
0.73 (0.58-0.93)
0.73 (0.58-0.93)
0.75 (0.59-0.95)
Household income
0.76 (0.64-0.89)
0.76 (0.64-0.89)
0.74 (0.63-0.88)
Age at menarche
1.01 (0.91-1.12)
1.00 (0.90-1.11)
1.01 (0.91-1.13)
Baseline labeling
1.66 (1.20-2.30)
1.62 (1.18-2.22)
1.40 (1.01-1.94)
the source of labeling and 1.40 when nonfamily members were the source. These effects were not modulated by race.
Abbreviations: BMI, body mass index; OR, odds ratio. a
The pattern of results was the same when modeling both weight labeling and BMI as continuous variables; these full results are available from the authors.
COMMENT & RESPONSE
Understanding Sexual Violence Perpetration
5. Mustillo SA, Budd K, Hendrix K. Obesity, labeling, and psychological distress in late-childhood and adolescent black and white girls: the distal effects of stigma. Soc Psychol Q. 2013;76(3):268-289. doi:10.1177/0190272513495883.
To the Editor It seems unlikely that the 9% of adolescents reported by Ybarra and Mitchell1 to have coerced sex, or to have attempted or completed rape, made a conscious decision to commit a felony. It is more likely that they made excuses for their behavior because they had not fully understood the lesson that any penetration of the body of a girl (or boy) without free consent is rape—consent being valid only if she or he is capable of giving consent. Somehow, they convinced themselves that the rules did not apply to them. This ignorance is not surprising because study after study has found that most people define rape using a stereotypical script in which a sober girl is injured resisting a stranger.2 Scenarios that deviate from this script are often thought to be legal—although perhaps not good—behavior. Even victims doubt that rape occurred if the event deviated from the societal script.3 As soon as a perpetrator knows the victim, or if the victim has used alcohol or drugs, society’s script is less critical of behavior that can still legally be considered rape. Fortunately, it is possible to get adolescents to rethink their scripts for acceptable behavior. In Canada, an educational program for high school freshmen was associated with reduced dating violence (sexual assault was not assessed separately).4 In California, a coach-led program for high school athletes was associated with reduced sexually aggressive behavior.5 More important, after the program, student athletes engaged in less negative bystander behavior such as laughing, going along with abusive behavior, or saying nothing. Bystander behavior is important because, as shown by a Facebook posting in Steubenville, Ohio, one motivation for rape is to exhibit one’s prowess to bystanders. And changing bystander behavior brings us back to the importance of societal scripts. We do not typically think of our daily lives as bystander activity that helps shape the societal script for rape. However, common jokes, different types of entertainment, and casual conversations frequently reinforce myths that undermine the seriousness of rape. We should apply the lessons learned from high school students to rethink the actions that we as the adults in society call rape. This is not a negative action leading to censorship but rather an affirmative action to rethink our collective script so that everyone is aware that forced or coerced sex is never acceptable—even between friends who have been drinking.
6. Callahan D. Children, stigma, and obesity. JAMA Pediatr. 2013;167(9):791-792.
William H. Goodson III, MD
Discussion | Being labeled “too fat” in childhood was associated with higher odds of having an obese BMI nearly a decade later. Importantly, this relationship was independent of initial BMI and thus not attributable simply to participants’ objective weight at baseline. These data provide novel evidence that the relationship between weight stigma and weight gain may begin early in life; these findings also demonstrate that this relationship can emerge even for a seemingly innocuous facet of stigma (ie, labeling). Weight stigma may contribute to weight gain by increasing obesogenic stress processes and triggering weight-promoting coping behaviors like overeating; future research should examine these potential mechanisms. Conclusions | Given our findings, and the broader literature suggesting weight stigma adversely affects the well-being of overweight children,2 advocating for weight stigma as public health policy seems unproductive.6 Researchers, public health officials, and clinicians should consider nonstigmatizing approaches to improving the health and well-being of overweight children. Jeffrey M. Hunger, MA A. Janet Tomiyama, PhD Author Affiliations: University of California, Santa Barbara (Hunger); University of California, Los Angeles (Tomiyama). Corresponding Author: A. Janet Tomiyama, PhD, Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA 90095 ([email protected]). Published Online: April 28, 2014. doi:10.1001/jamapediatrics.2014.122. Conflict of Interest Disclosures: None reported. 1. Vartanian LR, Smyth JM. Primum non nocere: obesity stigma and public health. J Bioeth Inq. 2013;10(1):49-57. 2. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007;133(4):557-580. 3. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013;8(7):e70048. 4. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363-385. doi:10.1146/annurev.soc.27.1.363.
580
JAMA Pediatrics June 2014 Volume 168, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
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Letters
Author Affiliation: California Pacific Medical Center Research Institute, San Francisco. Corresponding Author: William H. Goodson III, MD, California Pacific Medical Center Research Institute, 2100 Webster St, Ste 401, San Francisco, CA 94118 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134. 2. Untied AS, Orchowski LM, Mastroleo N, Gidycz CA. College students’ social reactions to the victim in a hypothetical sexual assault scenario: the role of victim and perpetrator alcohol use. Violence Vict. 2012;27(6):957-972. 3. Littleton HL, Axsom D, Breitkopf CR, Berenson A. Rape acknowledgment and postassault experiences: how acknowledgment status relates to disclosure, coping, worldview, and reactions received from others. Violence Vict. 2006;21(6):761-778. 4. Wolfe DA, Crooks C, Jaffe P, et al. A school-based program to prevent adolescent dating violence: a cluster randomized trial. Arch Pediatr Adolesc Med. 2009;163(8):692-699. 5. Miller E, Tancredi DJ, McCauley HL, et al. One-year follow-up of a coach-delivered dating violence prevention program: a cluster randomized controlled trial. Am J Prev Med. 2013;45(1):108-112.
To the Editor The article “Prevalence Rates of Male and Female Sexual Violence Perpetrators in a National Sample of Adolescents”1 recently published in JAMA Pediatrics documents that both males and females can be perpetrators or victims of sexual violence; however, both the methods used and the interpretation of the findings ignore the important influence of gender, particularly in the etiology underlying sexual violence perpetration. First, although the authors have stratified their findings by gender, there is no discussion provided to explain how findings would be expected to vary by gender (or by biological factors related to male or female sex, although less plausible). However, presenting findings separately for males and females implies an expectation of the role of gender (and/or sex) to afford significant differences in findings. Increasingly, studies such as this one by Ybarra and Mitchell1 have reported that females are perpetrating dating and/or sexual violence in similar proportions as males.2 Collectively, these works imply that such violence perpetration is not differentiated by gender. However, numerous other studies have presented empirical findings highlighting that such conclusions are a result of limitations in measurement, primarily by using measures that do not consider relevant differences by gender in the motivations, context, or consequences of abuse.3 Namely, differences exist in the reporting of violence by gender. Male-perpetrated violence, particularly sexual violence, including pressure or coercion, is a highly stigmatized behavior and likely underreported in a way that is not comparable to female reports of violence perpetration. Furthermore, males and females perpetrate violence and abuse for different reasons that are influenced by gender. The majority of male-perpetrated violence, particularly against females, is gender-based violence; regardless of the gender of the victim, male-perpetrated sexual violence has been linked to gender norms that promote male dominance and control, as demonstrated by a recently published multicountry study on rape perpetration.4 We have seen this as a significant findjamapediatrics.com
ing across every study on the topic, and this has arisen from practical evidence on the ground.4,5 In contrast to these findings among males, there are no societal-level gender norms or other societal-level factors that are influencing populations of females to perpetrate sexual violence in the same way. In summary, the role and basis of gender in violence perpetration is important to consider when developing research questions, measuring violence perpetration, and interpreting findings. These distinctions by gender are critical to inform future research and prevention efforts. Elizabeth Reed, ScD, MPH Jhumka Gupta, ScD, MPH Jay G. Silverman, PhD Author Affiliations: Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla (Reed, Silverman); Department of Chronic Disease Epidemiology, Division of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut (Gupta). Corresponding Author: Elizabeth Reed, ScD, MPH, Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134. 2. Reed E, Raj A, Miller E, Silverman JG. Losing the “gender” in gender-based violence: the missteps of research on dating and intimate partner violence. Violence Against Women. 2010;16(3):348-354. 3. Molidor C, Tolman RM, Kober J. Gender and contextual factors in adolescent dating violence. Violence Against Women. 1998;4(2):180-194. 4. Jewkes R, Fulu E, Roselli T, Garcia-Moreno C; UN Multi-country Cross-sectional Study on Men and Violence research team. Prevalence of and factors associated with non-partner rape perpetration: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific. Lancet Global Health. 2013;1(4):e208-e218. doi:10.1016/S2214-109X(13) 70069-X. 5. Tilley DS, Brackley M. Men who batter intimate partners: a grounded theory study of the development of male violence in intimate partner relationships. Issues Ment Health Nurs. 2005;26(3):281-297.
In Reply We agree with Reed et al that sexual violence perpetration is gendered. Indeed, this is the story that emerges from our study: although females and males perpetrate sexual assaults at equivalent rates, males are overrepresented in coercive sex and in attempted and completed rapes.1 Among those who have attempted or completed rape, female perpetrators tend to initiate this behavior at an older age than male perpetrators. Accordingly, there are some differences in the type of victims female and male perpetrators describe. We posit in our study1 that these data point to etiological differences in the emergence of sexual violence between males and females. As an epidemiological study, the main aim was to report prevalence rates. We certainly hope that the findings will invigorate future studies that are designed to better illuminate cultural and gender differences that may help contextualize the rates that we observed. We are concerned by the suggestion that contextual factors could somehow explain (ie, excuse) female perpetration. We are particularly perplexed by the assertion that it may be more culturally acceptable for females to report perpetration of sexual JAMA Pediatrics June 2014 Volume 168, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
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Letters
violence. Although previous studies have noted gender norms that promote male dominance and control as key factors, it must be acknowledged that these studies (including the recently published multicountry study2) only include men in their measures of perpetrators. We lack similar theories for females because they have largely been excluded from the perpetration research. As noted by Righthand and Welch,3 research on females who have committed sex offenses is rare. They suggest that “[t]he incidence of sex offending may be underestimated for female juveniles even more than for males, perhaps because of a societal reluctance (and even a reluctance among professionals) to acknowledge that girls are capable of committing such offenses.”3(p14) Thus, societal norms do encourage female perpetration, just in different ways than male perpetration. Until we acknowledge that women can be violent, we will not be able to develop gender-appropriate prevention programs that reduce rates of perpetration for men and women. We appreciate Dr Goodson’s observation that it is unlikely that all teenage perpetrators of sexual violence are making a conscious decision to commit a felony. Motivations certainly vary considerably. Future research could focus on illuminating this aspect of the perpetration. At the same time, sexual violence is sexual violence, regardless of motivation. Prevention programs that address this behavior are critical. Whether the motivation behind the violence was insidious or not, the data suggest that perpetrators often do not take responsibility for their actions and that many blame the victim to some extent. Taking responsibility for one’s actions may very well be related to the motivation behind the violence, and this combination could be a useful focus within prevention programs. The research on programs that focus on rethinking scripts for acceptable behavior is encouraging.4,5 And, as suggested in the implications of our study,1 we agree that bystander intervention could play a crucial role in both helping victims and identifying perpetrators. Michele L. Ybarra, MPH, PhD Kimberly J. Mitchell, PhD Author Affiliations: Center for Innovative Public Health Research, San Clemente, California (Ybarra); Crimes Against Children Research Center, University of New Hampshire, Durham (Mitchell). Corresponding Author: Michele L. Ybarra, MPH, PhD, Center for Innovative Public Health Research, 555 El Camino Real, Ste A347, San Clemente, CA 92672-6745 (michele@innovativepublichealth).
Survival at a Gestational Age of 24 Weeks in the Netherlands To the Editor Verhagen and Janvier1 have described the processes involved in the medical care of neonates who died. Although their article is highly relevant, we would like to comment on one aspect of it. They state that “[s]urvival for those born at 24 weeks…is as low as zero in some centers in the Netherlands.”1(p988) It is important to note that, in the Netherlands, views on the medical care of extremely preterm neonates have developed over time. Since September 2010, obstetricians and neonatologists nationwide agreed on offering parents active resuscitation for neonates from a gestational age of 24 weeks onwards. Since then, in the Netherlands, the mortality rate among neonates with a gestational age from 24 weeks and 0 days to 24 weeks and 6 days has decreased to between 45% and 50% in the neonatal intensive care units (data from the Netherlands Perinatal Registry), which is well in accordance with the rates in other European countries actively resuscitating neonates with such a low gestational age.2 Data on long-term morbidity are as yet unavailable but are being collected.3 In addition, data on perinatal deaths are collected to provide insight into the relevant ethical aspects of medical care at the limits of viability raised by Verhagen and Janvier.1 Floris Groenendaal, MD, PhD Rene Kornelisse, MD, PhD Chantal Hukkelhoven, PhD Author Affiliations: Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands (Groenendaal); Erasmus Medical Center, Rotterdam, the Netherlands (Kornelisse); Netherlands Perinatal Registry, Utrecht, the Netherlands (Hukkelhoven). Corresponding Author: Floris Groenendaal, MD, PhD, Department of Neonatology, University Medical Center Utrecht, PO Box 85090, Room KE 04.123.1, 3584 EA Utrecht, the Netherlands ([email protected]). Conflict of Interest Disclosures: None reported. 1. Verhagen AAE, Janvier A. The continuing importance of how neonates die. JAMA Pediatr. 2013;167(11):987-988.
Conflict of Interest Disclosures: None reported.
2. Costeloe KL, Hennessy EM, Haider S, Stacey F, Marlow N, Draper ES. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ. 2012;345:e7976.
1. Ybarra ML, Mitchell KJ. Prevalence rates of male and female sexual violence perpetrators in a national sample of adolescents. JAMA Pediatr. 2013;167(12):1125-1134.
3. de Kluiver E, Offringa M, Walther FJ, Duvekot JJ, de Laat MW. Perinatal policy in cases of extreme prematurity; an investigation into the implementation of the guidelines [in Dutch]. Ned Tijdschr Geneeskd. 2013;157(38):A6362.
2. Jewkes R, Fulu E, Roselli T, Garcia-Moreno C; UN Multi-country Cross-sectional Study on Men and Violence research team. Prevalence of and factors associated with non-partner rape perpetration: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific. Lancet Global Health. 2013;1(4):e208-e218. doi:10.1016/S2214-109X(13) 70069-X. 3. Righthand S, Welch C. Juveniles Who Have Sexually Offended: A Review of the Professional Literature. https://www.ncjrs.gov/pdffiles1/ojjdp/184739.pdf. Revised January 19, 2001. Accessed April 14, 2014. 4. Wolfe DA, Crooks C, Jaffe P, et al. A school-based program to prevent adolescent dating violence: a cluster randomized trial. Arch Pediatr Adolesc Med. 2009;163(8):692-699.
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5. Miller E, Tancredi DJ, McCauley HL, et al. One-year follow-up of a coach-delivered dating violence prevention program: a cluster randomized controlled trial. Am J Prev Med. 2013;45(1):108-112.
In Reply In their letter, Groenendaal and coauthors inform us about recent changes in attitudes and practice regarding the care of extremely preterm babies in the Netherlands resulting in optional active resuscitation for neonates from a gestational age of 24 weeks onwards. That is important news. We hope that they will soon publish these data internationally in a detailed manner and include the descriptions of medical care and the decisions that preceded the death or
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