Developing Sexual Violence Prevention Strategies by Bridging Spheres of Public Health

Introduction

The Centers for Disease Control and Prevention (CDC) defines sexual violence (SV) as any sexual act that is committed against someone who does not consent or is unable to consent or refuse. ¹ The perpetration of SV includes completed nonconsensual sex acts (e.g., rape), attempted nonconsensual sex acts, abusive sexual contact (e.g., unwanted touching), and noncontact sexual abuse (e.g., threatened SV, exposure to exhibitionism, verbal sexual harassment). ¹ The physical and mental health consequences of SV, in addition to the economic burden, indicate that SV is a major public health concern that requires immediate and decisive action. ^2,3 Victims of SV experience serious negative health outcomes. For instance, research has shown that victims may experience long-term physical health problems (e.g. chronic pain ⁴ ); emotional distress (e.g. posttraumatic stress disorder [PTSD], ⁵ depression, ⁶ or panic attacks ⁷ ); and are at risk for engaging in risky health behaviors, including sexual risk behaviors ⁸ and drug abuse. ⁹

Nationally, approximately 1 in 6 women and 1 in 33 men report experiencing an attempted or completed rape at some point in their lifetime ¹⁰ ; many rapes, however, occur among college populations. ¹¹ Females aged 16–19 are four times more likely than the general population to be victims of rape, attempted rape, or sexual assault. ¹² This peak in risk for SV victimization during midadolescence to late adolescence suggests early adolescence is a key time for prevention. Additionally, adolescence is a time marked by significant physical, psychological, and sexual growth. ¹³ During this impressionable time, youth initiate a constellation of interconnected risk behaviors. For example, by the end of high school, approximately 48% of adolescents report having had sexual intercourse with one partner and 15% with four or more sexual partners. ¹⁴ Whereas adolescents represent only one fourth of the sexually experienced population, it is estimated that 15–24-year-olds acquire nearly 50% of all new sexually transmitted diseases (STDs). ¹⁵ The risks for HIV and teen pregnancy are also high during adolescence, particularly for minority youth. ^16,17 In addition, SV often co-occurs with and is associated with other negative health outcomes or health risk behaviors. For example, young adults who experienced sexual abuse as a child may be more likely to engage in high-risk sexual behaviors, such as engaging in sexual intercourse with strangers and having multiple sexual partners, which can lead to negative health outcomes, such as pregnancy before age 18 and contracting HIV and STDs. ¹⁸ Male perpetrators of SV are also more likely to report high-risk sexual behaviors, including inconsistent or no condom use during sexual intercourse. ¹⁹

Risk Factors for SV Perpetration

Given the negative health consequences associated with SV perpetration and victimization, efforts to prevent these behaviors are critical to public health. In order to prevent SV perpetration, however, we must first understand the circumstances and factors that influence its occurrence. The CDC addresses SV by using a public health approach, which is a four-stage model that investigates the underlying causes of SV and strengthens resources for the effective implementation and dissemination of evidence-based prevention approaches. ^20,21 The steps include (1) defining the breadth and magnitude of the problem, (2) identifying risk and protective factors associated with SV, (3) developing and evaluating prevention approaches, and (4) assuring widespread dissemination and adoption of evidence-based approaches. The public health model allows for the integration and cumulative effect of multiple levels (e.g., individual, peer, community, and societal level) and contexts of the social ecology, which asserts that individuals, peers, communities, and societies all exhibit modifiable risk factors that influence the incidence of SV, ²⁰ to establish a comprehensive research approach. ²²

Many of the individual, peer, community, and societal level risk factors for SV perpetration identified in the literature are shared with other negative health outcomes. This report focuses on the individual and peer level sexual risk factors that are associated with both SV perpetration and negative sexual health outcomes. Although there may be common risk factors for SV and sexual risk behaviors, it is important to note that SV is not a sexual risk behavior in and of itself (i.e., sexually aggressive behavior is not the same as risky sexual behavior). Rather, these unique forms of unhealthy sexual behavior ²³ may be influenced by a similar set of risk factors that, in some cases, may cause an increased risk for individuals to engage in both SV and risky sexual behaviors. Given that other fields (i.e., HIV/STDs and teen pregnancy prevention) have been able to impact some of these shared risk factors using effective prevention programs, SV prevention programs may benefit by addressing these same factors.

The risk factor literature acknowledges several distinct sets of risk factors, including developmental experiences; attitudes, beliefs, and norms; and situational or contextual factors, that are commonly associated with SV perpetration and sexual risk behaviors. Early initiation of sexual intercourse is an example of a developmental experience that is a risk factor for both SV perpetration and negative sexual health outcomes, such as unintended pregnancy and HIV/STD transmission. ^24,25 The literature suggests that early initiation of sexual intercourse is associated with SV during adolescence and well into adulthood. College men who reported forcing a woman to have sex also reported that their first sexual experience occurred at a younger age and reported having more frequent sexual experiences during childhood than nonperpetrators. ²⁶ Koss and Dinero ²⁷ found that men who reported sexually aggressive acts were more likely to have become sexually active at an earlier age and reported more childhood sexual experiences (both forced and voluntary) than their less sexually aggressive counterparts.

Attitudes, beliefs, and norms are also predictors of SV and sexual risk behaviors and include such factors as traditional sex role adherence. ^28,29 Traditional gender roles are the perceived norms attributed to men or women in a given society. For example, in many cultures girls are socialized to be submissive and docile, and boys are encouraged to be sexually aggressive and dominant. ³⁰ Murnen and Kohlman ³¹ found that sexual stereotyping, “the extent to which individuals believe that women and men should have separate and traditional roles in society,” ³² was significantly associated with SV perpetration in several studies. The field of HIV/AIDS has been discussing a framework that acknowledges sexual risk behavior within a context of traditional gender roles and other contextual factors, as current behavioral approaches to HIV prevention have largely ignored these factors when developing approaches to prevent and reduce risk of infection. ^33,34

Lastly, situational and contextual factors, which occur at the outer levels of the social ecology and can include peer group acceptance of and support for SV, ^29,35 are also considered to be risk factors for perpetration. Peers' behavior tends to be correlated with adolescents' choices and actions in many behavior areas. ³⁶ Similar to other risk behaviors during adolescence, a period when peer behavior has a significant amount of influence on the actions of individuals, such as with inconsistent use of condoms ³⁷ and alcohol use, ³⁸ peer influence also plays a role in predicting SV. In fact, social norms theory indicates that people behave in a manner they perceive to be consistent with their peers' behavior. ³⁹ Further, Kinsman et al. ⁴⁰ demonstrated support of social norms theory by finding that students who initiated sexual intercourse at an early age were more likely to perceive that many of their peers were also engaging in sexual activity at a young age. Similarly, this is true for other adolescent sexual behaviors; youth who perceived that most of their peers had sex also reported intentions to have sex ⁴⁰ and to initiate sexual activity early. ⁴¹ These intentions were associated with youths' subsequent reports of sexual activity. ⁴²

Understanding adolescent sexual development is an important entry point into the discussion about the overall health of adolescents. The risk factors discussed here—attitudes, beliefs, and norms about sex and early initiation of sex—also pose a risk for unhealthy and risky sexual behavior, such as behaviors that can lead to the contraction of STDs/HIV and unintended pregnancy. ⁴³

Opportunities for Cross-Cutting Approaches to Prevention

Currently, there are few effective SV prevention programs that address multiple risk factors across the social ecology. Strides have been made in developing, implementing, and rigorously evaluating SV prevention programs with high school populations, ^44,45 but because of institutional and state mandates for rape prevention in colleges, current work focuses primarily on program development and implementation with college populations. It is important to note that some of the risk factors targeted by these programs appear to be shaped before entering college. Specifically, because peer support for certain activities, such as SV, and peer influence on sexual activity can occur at a young age, it is important that these risk factors for SV perpetration be addressed when they are being shaped—in early adolescence.

Such fields as HIV/STD prevention have a large evidence base supporting their prevention efforts. For instance, it is widely known that one of the reasons for increased STD rates among adolescents and young adults aged 15–24 is that this population often exhibits risky sexual behavior. ⁴⁶ Prevention efforts targeting risky sexual behavior through education about condom use have had an impact on reducing the associated risk of contracting STDs in this population. ^47,48 Thus, although the evidence base for SV prevention is still growing, the SV field stands to benefit from the knowledge of our neighbors in public health, specifically HIV/STD and teen pregnancy prevention. Current programs ⁴⁷ that are aimed at reducing sexual risk behaviors and increasing protective factors against HIV/STD and pregnancy in high school populations could be modified to include messages that simultaneously target SV perpetration. The core components of effective SV prevention programs could be integrated into effective prevention strategies from other health areas. Research in SV continues to explore these mechanisms of change.

Furthermore, SV prevention programs targeting college-aged men have shown changes in participants' attitudes and beliefs; however, attitude change does not guarantee behavior modification (i.e., subsequent refusal to engage in sexually aggressive behavior). ^{49 –51} This fact implies that a cross-cutting approach to SV prevention may be necessary in order to successfully prevent SV. A cross-cutting approach would allow for program developers to address risk factors at multiple levels of the social ecology and to use what we know works from other health fields, including teen pregnancy and HIV/STD prevention programs, which often advocate prevention strategies that can impact SV as well. It is also imperative to continually evaluate such programs for effectiveness in multiple populations as well as for multiple health outcomes. An additional gain from steps in this direction is that a more comprehensive approach, which bundles evidence-based prevention strategies to address multiple outcomes, may reduce the burden on schools and communities.

Conclusions

The aspirational goal of primary prevention of SV is to stop SV before it begins, thereby eliminating both victimization and perpetration. Prevention efforts may be more effective if they are implemented at multiple levels by targeting risk factors at each level of the social ecology, as well as risk factors shared by SV and other risky behaviors and negative health outcomes. A logical next step is to further explicate the intersection between SV and other aspects of sexual health and healthy sexual development in order to develop programs and adapt evidence-based strategies to prevent SV or to develop comprehensive prevention approaches that reduce multiple negative outcomes and have widespread preventive effects. Expanding our conceptualization and incorporating the lessons learned from other areas of public health hold promise for improving approaches to SV prevention.