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 approxi-
mately 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 Organi-
zation that substantively affect the global burden of disease, contributing an
estimated 0.6% to the global burden of disease, or 9 million years of healthy life
lost.3 Unipolar depression, human immunodeficiency virus/acquired immuno-
deficiency syndrome, alcohol use disorders, violence, and self-inflicted injuries
are among the leading contributors to the global burden of disease4 for which
CSA is a risk factor.5–7 Other studies have shown that CSA is associated with
unsafe sexual behaviors, alcohol use, and obesity,6–8 which also contribute to
the burden of disease.3
A separate evaluation of the disability and costs associated with 11 serious
mental health disorders identified four disorders with the highest disability
weights and with costs of $$70.0 billion, including schizophrenia, bipolar dis-
order, drug abuse/dependence, and major depressive disorder.9 CSA is a risk
factor for each of these disorders or their defining symptoms.6,10 Clearly, CSA
extracts a considerable toll on its victims and society.
The benefits of effective and widely adopted prevention programs for CSA
are, therefore, sizable, and it is not surprising that numerous efforts have been
made to encourage the development and evaluation of primary prevention
programs during the past 30 years. What is surprising are the outright failures
and significant limitations of these efforts.11–18 While some advances have been
noted,13,17,19 many existing primary prevention programs still suffer from a lack
of rigorous evaluation, limited implementation settings, ineffective program
content, and insufficient skills practice. Many current programs also fail to
target parents and other adults who might protect children, and few if any

a
Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
b
Johns Hopkins University, School of Medicine, Baltimore, MD
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 <eletourn@jhsph.edu>.
©2014 Association of Schools and Programs of Public Health

222    Public Health Reports  /  May–June 2014 / Volume 129


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 Preven-
tion (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 suf-
ficient 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
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Preventing Child Sexual Abuse   223
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 interven-
tion 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 under-
stood, and engender strong emotional and defensive
responses are likely to be policy resistant. An example
is the over-prescription of antibiotics for viral respira-
tory infections in young children, a procedure that
increases the risk for antibiotic resistance but persists
due to diagnostic complexity, fear of litigation, per-
ceived 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 inter-
fere with any or all four components of a basic public
health approach: surveillance, identification of risk and
protective factors, development and evaluation of inter-
ventions, 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 involv-
ing 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 lit-
erature 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.,
224    Reports and Recommendations

Figure. Depiction of how risk factors for child sexual abuse victimization and perpetration might vary across the
life course and levels at which factors occur
Agency

Life stage

norms and social policies). Most etiological research Emotional/defensive responses

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 epi-
genetic 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 inter-
act 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.
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 fram-
ing 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 ran-
domness) and a second that promotes victim b ­ laming

Public Health Reports  /  May–June 2014 / Volume 129


(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 abus-
ing 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 improve-
ments 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 bal-
kanization of research, policy, and practice regarding
the fields of study on CSA victimization and perpetra-
tion. Early victim advocates struggled against wide-
spread 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
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Preventing Child Sexual Abuse   225
might have contributed to a laser-like focus on vic-
timization 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 vic-
tims.43 What might have developed as a unified field
instead became two distinct victimization and perpetra-
tion 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 Depart-
ment 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 pub-
lic 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 Preven-
tion45 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).
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 con-
tribute to less policy resistance.
Media frames
Given the strong influence of the media on percep-
tions 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 pedo-
philia.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 reregistra-
tion, 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 wide-
spread 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.
Public Health Reports  /  May–June 2014 / Volume 129
Balkanized professional fields
Evidence of increased collaboration between CSA vic-
timization 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 uni-
fied approach to CSA prevention.
Toward a Public Health Approach
to CSA Prevention
Traditionally, CSA has been viewed as a social prob-
lem 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 offend-
ers;59,60 increased penalties for adults convicted of sexu-
ally abusing children;13 and the development of tools
that more accurately assess offender recidivism risk.61
Yet, these approaches, while necessary, are fundamen-
tally 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 col-
laboration, prevention can be achieved through defin-
ing 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 stake-
holders 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. Account-
ability 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

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 allo-
cate 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 comprehen-
sive 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, ratio-
nal 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.
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