Primary Versus Secondary Prevention Effects of a Gender-Transformative Sexual Violence Prevention Program Among Male Youth: A Planned Secondary Analysis of a Randomized Clinical Trial

Abstract

Engaging adolescent males is a promising violence prevention strategy. This study explored primary versus secondary prevention effects of a gender-transformative program (i.e., Manhood 2.0) versus job-readiness training on multiple forms of violence perpetration. Adolescent males, ages 13 to 19 years, were recruited through youth-serving organizations in Pittsburgh, PA, between July 27, 2015, and June 5, 2017, to participate in an unblinded community-based cluster-randomized trial in 20 neighborhoods. The intervention curriculum, Manhood 2.0, focused on challenging norms that foster gender-based violence and building bystander skills. The control program was job-readiness training. We completed a planned secondary analysis of surveys from baseline and 9 months post intervention (follow-up), wherein we stratified participants based on any sexual violence/adolescent relationship abuse (SV/ARA) at baseline and examined risk of perpetration of SV/ARA, incapacitated sex, sexual harassment, cyber sexual abuse, peer violence, bullying, and homophobic teasing at follow-up. Among 866 participants, mean age was 15.6 years, 70% identified as Black, 6% as Hispanic, and 6% as multiracial. In both the Manhood 2.0 intervention group and job-readiness control groups, youth who reported SV/ARA at baseline were significantly more likely to report any form of SV/ARA, incapacitated sex, sexual harassment, cyber sexual abuse, bullying, and homophobic teasing at follow-up. Among participants who reported no SV/ARA perpetration at baseline, participating in the Manhood 2.0 intervention program was associated with increased risk of SV/ARA at follow-up compared to participating in the job-readiness control program. Among participants who reported SV/ARA perpetration at baseline, participating in the Manhood 2.0 intervention group was associated with lower risk of peer violence at follow-up. Synergizing gender-transformative approaches with job-readiness training may offer opportunities for crosscutting prevention programming to address multiple forms of violence.

Keywords

prevention sexual assault adolescents sexual harassment youth violence

Sexual violence (SV) is pervasive, with 1 in 3 U.S. women and nearly 1 in 5 men experiencing sexual violence in their lifetime (Smith et al., 2018). Among U.S. high-school aged adolescents in 2019, 13% of females reported past year sexual dating violence and 9% reported physical dating violence, with males reporting rates of 4% and 7%, respectively (Underwood et al., 2019). Adolescent relationship abuse (ARA), defined as physical, sexual, or emotional abuse by a partner, often co-occurs with non-partner SV. Experiences of SV and ARA are associated with physical and mental health sequelae including depression, substance use, sexually transmitted infections, and unintended pregnancy (Exner-Cortens et al., 2013; World Health Organization, 2013).

Youth who perpetrate one form of violence are more likely to perpetrate other forms of violence, such that sexual violence, bullying, and peer violence perpetration often co-occur (Culyba et al., 2019; Wilkins et al., 2014). Root causes of violence perpetration, including systematic disinvestment in communities, can lead to multiple forms of violence perpetration. Among youth in lower resource urban settings, research has demonstrated links between neighborhood disadvantage, violence exposure, and multiple types of violence perpetration (e.g., sexual/relationships violence, peer violence, weapon violence, bullying, homophobic teasing perpetration) (Culyba et al., 2019; Elgar et al., 2009; Khetarpal et al., 2021; Miller, Culyba et al., 2020; Miller et al., 1999; Pinchevsky & Wright, 2012). Understanding common root causes and co-occurrence patterns is important for interventions to prevent violence.

The Centers for Disease Control and Prevention Connecting the Dots framework urges researchers and practitioners to examine crosscutting risk and protective factors to inform interventions designed to address root causes of multiple forms of violence perpetration (Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016; Wilkins et al., 2014). Researchers and advocates highlight the urgent need for crosscutting programs that address intersections between violence exposure and use of violence among youth experiencing marginalization in urban lower resource neighborhoods (D’Inverno & Bartholow, 2021; Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016; Kingston et al., 2021; Rich & Grey, 2005).

Theory of Gender and Power (Connell, 1987) draws attention to the ways in which use of violence especially among young men can be understood in the context of gender inequitable attitudes and adherence to rigid masculinity norms. Gender inequitable attitudes have been linked to multiple forms of violence perpetration including youth violence, bullying, dating abuse, and sexual harassment (Miller, Culyba et al., 2020). Among young men, rigid, heteronormative gender norms are associated with bullying, homophobic teasing, and violence against women and sexual and gender minorities (DeGue et al., 2013; Espelage et al., 2000, 2001; Kalichman et al., 2007; McCauley et al., 2014; Miller et al., 2011).

Preventing SV and ARA requires comprehensive approaches that address gender inequitable attitudes and modify perpetrator behavior (DeGue et al., 2014). Prior research demonstrates how violence perpetration often occurs in the context of peers who demonstrate gender inequitable attitudes, hold bias-based prejudices including homophobia, and condone abuse perpetration (Espelage et al., 2000, 2001, 2008; McMahon et al., 2011; Reed et al., 2008, 2011; Verma et al., 2006). Violence prevention requires addressing youths’ own inequitable attitudes and behaviors as well as attitudes fostered through the peer environment.

Research in domestic and international settings highlights addressing gender inequity and promoting gender equitable relationship norms as important violence prevention strategies (Amin & Chandra-Mouli, 2014; Barker et al., 2007; Casey et al., 2018; Dworkin et al., 2013). Key approaches include critical analysis of how gender norms are shaped and reinforced. Additionally, research demonstrates the importance of challenging behaviors considered precursors to sexual and partner violence perpetration including sexual harassment, homophobic teasing, and bullying (Espelage et al., 2018; Rinehart & Espelage, 2016). Gender-transformative approaches focused on development of healthy masculinities, including masculinity norms that promote gender equity and respectful sexual behaviors, coupled with bystander skills development, are a promising approach to reducing SV and ARA perpetration, and may also create crosscutting prevention across multiple forms of violence (Casey et al., 2018; DeGue et al., 2014; Lundgren & Amin, 2015; McCarthy et al., 2018; Miller, Culyba et al., 2020; Weber et al., 2019).

There has been increasing attention on tailored intervention approaches that differentiate curricular content based on whether or not teens have been previously exposed to violence (Basile et al., 2016; Niolon et al., 2017). This approach suggests that interventions that focus on prevention of violence among youth who have never engaged in violence (primary prevention) may require different strategies compared to interventions that focus on prevention of future violence among youth with prior histories of violence involvement (secondary prevention). However, relatively few studies have examined primary versus secondary effects of prevention programming to understand whether this tailored approach is warranted.

Our team conducted a community-based cluster-randomized trial among adolescent males to evaluate the effectiveness of a gender-transformative program, Manhood 2.0, compared to job-readiness training in reducing participants’ self-reported SV and ARA perpetration (Abebe et al., 2018). We found that the combined primary endpoint of any self-reported SV/ARA at 9-month follow-up decreased in both study arms and that there was no evidence of an intervention effect for the primary outcome (Miller, Jones, et al., 2020).

Motivated to explore how previous involvement in SV and ARA perpetration may impact the effectiveness of gender-transformative intervention approaches on perpetration of multiple forms of violence, we conducted a planned secondary analysis of the trial data. Viewed through a public health lens, this analysis examined primary versus secondary prevention effects by examining effectiveness of Manhood 2.0 versus job-readiness training among participants who did not (primary prevention) versus did (secondary prevention) report having used SV/ARA at baseline across multiple sexual violence, peer violence, and bullying perpetration outcomes.

Methods

This community-based cluster-randomized trial among adolescent males evaluated the effectiveness of a gender-transformative program, Manhood 2.0, compared to job-readiness training in reducing participants’ self-reported SV and ARA perpetration. The current study reports results of a planned secondary analysis to examine differential effects of programming on perpetration of multiple forms of violence (i.e., sexual violence, bullying, peer violence) based on participants’ baseline perpetration of SV/ARA. We chose a priori to stratify the sample based on prior perpetration of any form of SV/ARA (including adolescent relationship abuse, sexual violence, incapacitated sex, sexual harassment, or cyber sexual abuse perpetration) to broadly capture youth who had versus had not participated in a range of behaviors linked with SV/ARA. This stratification was in keeping with the primary trial outcome and is aligned with calls to examine tailored primary versus secondary prevention approaches.

Intervention

The intervention, Manhood 2.0, is an 18-hour gender-transformative sexual violence prevention curricula adapted from Program H, a widely implemented and adapted curriculum originally developed in Latin America and since implemented and evaluated in more than 10 settings. The curriculum is organized around three primary themes: (1) gender, masculinity, and power; (2) violence, romantic relationships, and bystander interventions; and (3) sexual and reproductive health. The content includes healthy relationships and sexuality, reflecting on gender norms, and practicing bystander interventions in response to negative peer behavior. Curricular adaptations for Manhood 2.0 included content focused on racial justice, intersectionality, social media, pornography, female-controlled contraception, and bystander intervention skills and have been previously described (Abebe et al., 2018).

The control is a frequently used job-readiness training program that covers career options, goal setting, and interview skills (YouthWorks. JumpStart Success: Work Readiness and Career Exploration Training). Curriculum implementation focused on the first six of the full nine modules and covered goal setting, future orientation, resume development, interview skills, and workplace expectations.

Program implementation for both the intervention and control curricula relied on community partnerships and youth development infrastructure within participating organizations. Curricula were delivered by community leaders in community-based settings (e.g., community centers, YMCAs, libraries, churches) in 6 once or twice weekly 3-hour sessions to 45 unique intervention groups and 41 unique control groups (8–12 youth per group) from July 2015 to August 2017. Further details on the curricula and implementation protocol have been described (Abebe et al., 2018).

Study Sample

Twenty neighborhoods with high levels of racial segregation, poverty, and community violence in Pittsburgh, PA were selected as clusters (n = 21 clusters), enrolled by the study PI (EM), and randomly allocated (1:1) by the study statistician (KZA) to intervention or control groups (Abebe et al., 2018). Participants included self-identified adolescent males between the ages 13 and 19, who were recruited by community organizations and respondent-driven sampling from July 2015 to June 2017, to participate in their neighborhood’s program. Participants were recruited after randomization and were aware of the site’s allocation. The study procedures were approved by the University of Pittsburgh Institutional Review Board with a waiver of parental permission and a waiver of written documentation of assent/consent. Research assistants reviewed verbal assent/consent with participants at enrollment. Further details of the study design are described elsewhere (Miller, Jones, et al., 2020).

Study Procedures

Participants completed baseline surveys in-person on tablets at community sites before the first session. Follow-up surveys were completed at the end of programming, and approximately 3 months and 9 months after programming, either in-person or remotely. Surveys were anonymous and linked by a youth-generated secret code across time points (Ripper et al., 2017). The current analysis includes baseline and 9-month follow-up (referred to as follow-up henceforth) survey data. Participants received up to $100 remuneration.

Measures

A full description of the survey measures has been previously published (Abebe et al., 2018). Participants self-reported age, race/ethnicity, school status (in school, graduated, dropped out), and caregiver educational attainment on baseline surveys.

ARA perpetration was measured with 10 binary items (e.g., “Have you done any of the following to someone you were going out with . . . physically hurt them (like shoving, grabbing, slapping, punching, or choking?”) and modeled as any lifetime (baseline) and past 9 months (follow-up) perpetration (Cronbach’s alpha .88) (Miller et al., 2012).

SV perpetration items assessed both partner sexual violence (e.g., “Have you . . . used physical force or threats to make someone you were going out with or hooking up with have sex?,” two binary items) and non-partner sexual violence (e.g., “Have you insisted that someone you were not going out with or hooking up with have sex (vaginal, oral or anal sex) when they didn’t want to, without using force or threats?,” two binary items), modeled as a composite of any lifetime (baseline) and past 9 months (follow-up) sexual violence (Cronbach’s alpha .64) (Tancredi et al., 2015).

Incapacitated sex was measured with two binary items (e.g., “Have you done something sexual with someone when they were too drunk or high to stop you (this can include kissing, touching, fingering them, or having intercourse?”), modeled as any lifetime (baseline) and past 9 months (follow-up) (Cronbach’s alpha .48) (Dartnall & Jewkes, 2013; Koss & Gidycz, 1985).

Sexual harassment perpetration was assessed with five items (e.g., “How often have you done the following things to someone when they did not want you to . . . made unwelcome sexual comments, jokes, gestures, or looks?,” four-point Likert frequency scale from 0 = never to 3 = every or almost every day), modeled as never versus any lifetime (baseline) and past 9 months (follow-up) (Cronbach’s alpha .79) (AAUW Educational Foundation Sexual Harassment Task Force, 2004; Espelage & Holt, 2007).

Cyber sexual abuse included three items (e.g., “How often did you . . . ask them to do something sexual that they did not want to do . . . using mobile apps, social networks, texts, or other digital communication?,” four-point Likert frequency scale from 0 = never to 3 = every or almost every day), modeled as never versus any lifetime (baseline) and past 9 months (follow-up) (Cronbach’s alpha .78) (Bennett et al., 2011; Dick et al., 2014; Ybarra et al., 2007).

A prespecified composite measure, any SV/ARA, was defined among participants who reported any instance of adolescent relationship abuse, sexual violence, incapacitated sex, sexual harassment, or cyber sexual abuse perpetration. This composite SV/ARA measure served as the primary outcome of the RCT and as the stratification variable in the current analyses (Abebe et al., 2018).

Peer violence was assessed with three items (“In the past 9 months . . . (1) how many times were you in a physical fight?, (2) how many times have you threatened to injure someone with a weapon such as a gun, knife, or club?, (3) how many times have you physically injured someone with a weapon such as a gun, knife, or club?,” five-point frequency scale from 0 = 0 times to 4 = 10 or more times), modeled as never versus at least once in past 9 months (baseline and follow-up) (Cronbach’s alpha .59) (Centers for Disease Control and Prevention).

Bullying included three items (e.g., “In the past 3 months, how often did you do the following to someone. . . (1) make fun of someone or call them names in a hurtful way, or spread rumors about them, (2) push, shove, trip or spit on someone, (3) exclude someone form activities on purpose?,” four-point frequency scale from 0 = never to 3 = every day or almost every day), modeled as never versus any past 3 months (baseline and follow-up) (Cronbach’s alpha .68) (Espelage & Holt, 2001).

Homophobic teasing was assessed with five items (e.g., “How many times in the past 3 months have you said words like homo or gay to the following person. . . (1) to a friend?, (2) to someone you did not know well?, (3) to someone you did not like?, (4) to someone you did not think was gay or lesbian, (5) to someone you thought was gay or lesbian?,” four-point frequency scale from 0 = never to 3 = every day or almost every day), modeled as any past 3 months (baseline and follow-up) (Cronbach’s alpha .84) (Poteat & Espelage, 2005).

Statistical Analysis

We compared distributions of demographic factors by baseline perpetration status (i.e., any SV/ARA) using Fisher’s exact tests. Next, we compared the prevalence of recent perpetration by intervention arm (Manhood 2.0 vs. job-readiness training), timepoint (baseline and follow-up), and baseline perpetration status (any SV/ARA). We described the within-group change in the prevalence of each form of violence perpetration in the Manhood 2.0 and job-readiness intervention groups using McNemar’s test.

Third, we modeled the relative risk of perpetration of each form of violence by study arm in strata defined by baseline perpetration status (any SV/ARA). To assess whether the relative risks of violence perpetration associated with the study intervention differed by baseline perpetration status, generalized estimating equations were used to estimate the prevalence of violence perpetration as a function of study arm, baseline perpetration status, and the interaction. Additionally, relative risks were estimated within each strata defined by baseline perpetration status. All models adjusted for age and race and accounted for clustering by site. A similar approach was used to model the relative risk of loss to follow-up by study arm in strata defined by baseline perpetration status. Analysis was conducted using PROC GENMOD in SAS software, version 9.4 (SAS Institute, Cary NC) from January 2020 to May 2022.

Results

The trial included 866 participants, 465 in the intervention group across 11 clusters, and 401 in the control group across 10 clusters. All participants completed the baseline survey. At 9-month follow-up, 334 participants in the intervention group (72%) and 301 participants in the control group (75%) completed follow-up surveys. Mean participant age was 15.5 years, 70% identified as Black or African American, 6% as Hispanic, and 6% as multiracial (Table 1). Most participants (85%) were currently in school. Nearly half of the participants (44%) reported their caregiver did not complete high school.

Table 1.

Participant Characteristics by Baseline Perpetration of Sexual Violence or Relationship Abuse.

	Overall (n=866)	No Sexual Violence or Relationship Abuse Reported at Baseline (n=344)	Any Sexual Violence or Relationship Abuse Reported at Baseline (n=509)
	n (%)	n (%)	n (%)	p ^a
Arm
Control	401 (46.3)	181 (52.6)	213 (41.8)
Intervention	465 (53.7)	163 (47.4)	296 (58.2)	.002
Age
13–14 years	280 (32.4)	120 (35.0)	157 (30.8)
15–16 years	339 (39.2)	122 (35.6)	209 (41.1)	.25
17–19 years	245 (28.4)	101 (29.4)	143 (28.1)
School status
In school	735 (91.3)	298 (91.4)	433 (91.2)
Graduated	28 (3.5)	13 (4.0)	15 (3.2)	.67
Did not complete HS	42 (5.2)	15 (4.6)	27 (5.7)
Race
Black or African American	610 (74.7)	238 (73.2)	369 (75.6)
White	29 (3.6)	11 (3.4)	18 (3.7)
Hispanic	53 (6.5)	16 (4.9)	37 (7.6)	.09
Multiracial	55 (6.7)	25 (7.7)	30 (6.1)
Other	70 (8.6)	35 (10.8)	34 (7.0)
Caregiver education level
Did not complete high school	378 (47.1)	151 (47.6)	225 (46.6)
Completed high school or GED	149 (18.6)	62 (19.6)	87 (18.0)	.43
Some college	66 (8.2)	30 (9.5)	36 (7.5)
College degree or higher	209 (26.1)	74 (23.3)	135 (28.0)

p value from Fisher’s exact test.

Table 2 presents perpetration of violence by group and timepoint. At baseline, 64.5% of participants in the intervention group and 51.4% of participants in the control group reported perpetrating any sexual violence or adolescent relationship abuse. Among SV/ARA subdomains at baseline, sexual harassment was most reported (53.0% of intervention group and 46.1% of control group). Approximately one in four participants reported ARA perpetration (23.3% of intervention group and 22.8% of control group) and cyber sexual abuse (26% of intervention group and 25.3% of control group). Peer violence, bullying, and homophobic teasing were frequently reported among both groups (75.1%, 66.2%, and 82.0%, respectively, in the intervention group and 66.6%, 62.6%, and 73.6%, respectively, in the control group).

Table 2.

Perpetration of Violence by Trial Arm and Timepoint.

		Intervention Arm					Control Arm
		Baseline		Follow-up			Baseline		Follow-up
		n	col%	n	col%	p ^a	n	col%	n	col%	p ^a
Any form of sexual violence or adolescent relationship abuse	yes	296	64.5	173	52.1	.0001	213	54.1	124	42.6	.001
	no	163	35.5	159	47.9		181	45.9	167	57.4
Adolescent relationship abuse	yes	104	23.3	45	14.4	.0003	86	22.8	36	13.1	.001
Adolescent relationship abuse	no	343	76.7	267	85.6		292	77.2	238	86.9
Sexual violence	yes	33	7.3	44	13.3	.001	30	7.7	30	10.5	.26
Sexual violence	no	422	92.7	287	86.7		359	92.3	257	89.5
Incapacitated sex	yes	54	11.9	38	11.5	.80	43	11.2	21	7.4	.06
Incapacitated sex	no	398	88.1	292	88.5		340	88.8	262	92.6
Sexual harassment	yes	239	53.0	137	41.6	.006	176	46.1	101	35.2	.001
Sexual harassment	no	212	47.0	192	58.4		206	53.9	186	64.8
Cyber sexual abuse	yes	118	26.0	87	26.3	.92	99	25.3	49	17.0	.02
Cyber sexual abuse	no	336	74.0	244	73.7		292	74.7	240	83.0
Peer violence	yes	334	75.1	175	53.2	<.0001	253	66.6	160	56.9	.003
Peer violence	no	111	24.9	154	46.8		127	33.4	121	43.1
Bullying	yes	300	66.2	181	54.7	.081	244	62.6	132	45.2	<.0001
Bullying	no	153	33.8	150	45.3		146	37.4	160	54.8
Homophobic teasing	yes	374	82.0	255	77.5	.09	287	73.6	195	67.2	.07
Homophobic teasing	no	82	18.0	74	22.5		103	26.4	95	32.8

p values come from a McNemar’s test. As this is a paired test of comparisons, p value comparisons were restricted to participants who had baseline and follow-up survey data for each type of violence.

Examining changes in the prevalence of violence perpetration from baseline to follow-up, SV/ARA perpetration decreased significantly across both groups (Table 2). Among the intervention group, the reported prevalence of perpetrating any sexual violence or adolescent relationship abuse was 52.1% at follow-up compared to 64.5% at baseline (p < .001). Among the control group, prevalence of any SV/ARA at follow-up was 42.6% compared to 54.1% at baseline (p < .01). Both groups also reported significant decreases in sexual harassment (p intervention <.01, p control < .01) and peer violence (p intervention <.0001, p control < .01). Sexual violence prevalence increased in both groups, with results reaching statistical significance in the intervention group (p < .01). Cyber sexual abuse decreased significantly among control participants (p < .05).

Table 3 reports the prevalence of multiple forms of violence perpetration at follow-up among participants who did versus did not report any SV/ARA perpetration at baseline. In both the intervention and control groups, those who reported SV/ARA at baseline were significantly more likely to report any form of SV/ARA at follow-up (intervention group: 61.5% of the subgroup who reported SV/ARA at baseline reported SV/ARA at follow-up vs. 34.8% of those who did not report SV/ARA at baseline, p < .0001; control group: 59.6% of the subgroup who reported SV/ARA at baseline reported SV/ARA at follow-up vs. 22.2% of those who did not report SV/ARA at baseline, p < .0001). Similar patterns emerged across all forms of violence perpetration. Those in both the intervention and control groups who reported SV/ARA at baseline were significantly more likely to report incapacitated sex (p intervention <.05, p control <.01), sexual harassment (p intervention <.0001, p control <.0001), cyber sexual abuse (p intervention <.05, p control <.01), bullying (p intervention <.001, p control <.0001), and homophobic teasing (p intervention <.01, p control <.05) at follow-up, and those in the control group were also more likely to report peer violence (p <.0001), compared to youth who did not report SV/ARA at baseline.

Table 3.

Prevalence of Violence at Follow-up by Baseline Perpetration Status.

		Intervention Arm					Control Arm
		− For Baseline Sexual Violence/Abuse		+ For Baseline Sexual Violence/Abuse			− For Baseline Sexual Violence/Abuse		+ For Baseline Sexual Violence/Abuse
Perpetration at follow-up		n	col%	n	col%	p diff^a	n	col%	N	col%	p diff^a
Any form of sexual violence or adolescent relationship abuse	yes	40	34.8	131	61.5	<.0001	28	22.2	96	59.6	<.0001
	no	75	65.2	82	38.5		98	77.8	65	40.4
Adolescent relationship abuse	yes	5	4.5	39	18.8	.0003	9	7.5	27	18.0	.01
Adolescent relationship abuse	no	105	95.5	168	81.2		111	92.5	123	82.0
Sexual violence	yes	6	5.2	37	17.5	.002	7	5.6	23	14.5	.02
Sexual violence	no	109	94.8	175	82.5		117	94.4	136	85.5
Incapacitated sex	yes	7	6.1	31	14.7	.02	3	2.4	18	11.5	.005
Incapacitated sex	no	108	93.9	180	85.3		120	97.6	138	88.5
Sexual harassment	yes	30	26.3	106	50.2	<.0001	20	16.0	81	51.3	<.0001
Sexual harassment	no	84	73.7	105	49.8		105	84.0	77	48.7
Cyber sexual abuse	yes	21	18.4	64	30.0	.02	12	9.5	37	23.3	.003
Cyber sexual abuse	no	93	81.6	149	70.0		114	90.5	122	76.7
Peer violence	yes	55	48.2	117	55.5	.24	51	41.8	107	69.0	<.0001
Peer violence	no	59	51.8	94	44.5		71	58.2	48	31.0
Bullying	yes	47	41.2	131	61.5	.0005	41	32.3	91	56.9	<.0001
Bullying	no	67	58.8	82	38.5		86	67.7	69	43.1
Homophobic teasing	yes	76	67.9	175	82.2	.005	76	60.8	117	73.1	.03
Homophobic teasing	no	36	32.1	38	17.8		49	39.2	43	26.9

p values come from a Fisher’s exact test.

Last, we assessed whether the relative risk of perpetration of each form of violence associated with the study intervention differed by baseline perpetration status (any SV/ARA, Table 4). Results demonstrated significant interactions between baseline SV/ARA perpetration, intervention arm, and time for two outcomes: any SV/ARA and peer violence (both p interaction < .05). Among participants who reported no SV/ARA perpetration at baseline, participating in Manhood 2.0 was associated with increased risk of any reported SV/ARA at follow-up compared to participants in the control group (RR 1.57, 95% CI [1.06, 2.32]). In contrast, among participants who reported SV/ARA at baseline, participating in the intervention group was associated with lower risk of peer violence (RR 0.76, 95% CI [0.63, 0.92]) at follow-up compared to the control group. The remainder of the models did not demonstrate significant interactions between study arm and other forms of violence perpetration over time. Additionally, there were no significant associations between intervention arm and loss to follow-up among youth who did and did not endorse SV/ARA at baseline (Appendix A).

Table 4.

Relative Risk of Perpetration at Follow-Up by Intervention Arm in Strata Defined by Baseline Perpetration of Sexual Violence or Relationship Abuse, Adjusted for Age and Race.

	No Reported Perpetration at Baseline (n = 344)	Reported Perpetration at Baseline (n = 509)
Type of Violence Perpetration	RR [95% CI]^a	RR [95% CI]^a	p interaction^b
Any form of sexual violence or adolescent relationship abuse	1.57 [1.06, 2.32]	0.98 [0.86, 1.13]	.03
Adolescent relationship abuse	0.61 [0.20, 1.86]	1.02 [0.65, 1.58]	.49
Sexual violence	1.03 [0.68, 1.57]^c	1.17 [0.73, 1.87]	.89
Incapacitated sex	1.92 [0.82, 4.48]	1.21 [0.62, 2.36]	.20
Sexual harassment	1.54 [0.95, 2.49]	0.95 [0.78, 1.14]	.09
Cyber sexual abuse	1.82 [1.03, 3.19]	1.25 [0.89, 1.74]	.17
Peer violence	1.21 [0.91, 1.62]	0.76 [0.63, 0.92]	.03
Bullying	1.33 [0.94, 1.87]	1.08 [0.93, 1.26]	.42
Homophobic teasing	1.18 [0.99, 1.41]	1.12 [1.03, 1.21]	.74

RR are drawn from adjusted models stratified on baseline perpetration status and reflect relative risk associated with being in the intervention arm. Models were adjusted for age and race.

p values are drawn from models that include interaction terms.

The stratified model for no baseline SV/ARA did not run so this estimated RR comes from the unstratified model with the interaction term in it.

Discussion

In a planned secondary analysis of a cluster-randomized trial among adolescent males in neighborhoods with concentrated disadvantage, we explored the effectiveness of a gender-transformative curriculum compared to job-readiness training for primary versus secondary prevention of SV/ARA and multiple forms of violence. Among participants who reported no SV/ARA perpetration at baseline (i.e., primary prevention analysis), participating in Manhood 2.0 was associated with increased risk of any reported SV/ARA at follow-up compared to participants in the control group. Among participants who reported SV/ARA at baseline (i.e., secondary prevention), participating in the intervention group was associated with lower risk of peer violence at follow-up compared to the control group.

Participants in both intervention and control groups reported increased SV perpetration at follow-up, with a more pronounced increase in the intervention group. Importantly, there are multiple risk and protective factors across the social ecology that influence the use of sexual violence including at the individual level (e.g., age, developmental maturation, substance use), interpersonal level (e.g., peer influence, family relationships), community level (e.g., school connectedness, access to programs and opportunities), and societal level (e.g., social norms, economic policies) (Krug et al., 2002). Increased self-reported SV perpetration could be due to increased perpetration and, especially in the intervention group, could also represent increased recognition of abusive behaviors because of participating in the Manhood 2.0 program. In the primary trial analysis (Miller, Jones, et al., 2020), we did find that recognition of abuse increased significantly among intervention participants from baseline to follow-up. There was no significant increase in recognition of abuse among control participants. In intensity-adjusted analyses, participating in Manhood 2.0 was associated with increased recognition of abuse compared to participating in the control intervention. This may, in part, explain the increase in reported sexual violence among Manhood 2.0 participants at follow-up. Differences in reporting intervals between baseline (lifetime) and follow-up (past 9 months) may also contribute to the reporting patterns observed herein. Age can also play an important role in sexual violence perpetration, with older youth reporting higher rates of perpetration compared to younger youth. As youth completed the follow-up survey 9 months after program completion, this could be a contributor to the increased rates overall. We did not identify any age differences between the intervention and control groups to suggest differential age effects across the two groups.

In a recent systematic review examining the efficacy of interventions to prevent dating violence among adolescents, pooled estimates demonstrated statistically significant reductions in physical dating violence perpetration; while estimates for SV perpetration showed similar directionality, prevention programming was not associated with significant reductions in SV perpetration (Piolanti & Foran, 2021). The authors also noted iatrogenic effects in several randomized studies, including increases in physical/sexual dating violence and sexual harassment (Piolanti & Foran, 2021). Taken together, this creates an important moment for reflection and a need to pause and critically examine this signal to ensure we are not inadvertently doing harm with our SV/ARA intervention approaches, as well as the need to formulate hypotheses as to why prevention programming might be contributing to increases in SV perpetration (Ragavan & Miller, 2021).

In keeping with prior literature, we identified co-occurrence of multiple forms of violence over time. In both the intervention and control groups, those who reported SV/ARA at baseline were significantly more likely to report any form of SV/ARA at follow-up and were significantly more likely to report incapacitated sex, sexual harassment, cyber sexual abuse, bullying, and homophobic teasing at follow-up, compared to youth who did not report SV/ARA at baseline. Shared risk and protective factors across the social ecology, including individual, interpersonal, contextual, and structural factors likely contribute to these associations (Wilkins et al., 2014). These findings reinforce the need to address violence co-occurrence in intervention programming and evaluate the effectiveness of programs in reducing multiple forms of violence (Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016). The findings also suggest the need for violence prevention programs that address these multiple levels of antecedents and causal factors, which likely implies interventions beyond group education, including for example, income supports to economically fragile households, substance use prevention and counseling, individual and/or family therapy, community coordinated response models, among others.

Among adolescent males residing in neighborhoods made vulnerable by systemic racism and structural inequities, there is a need for multilevel interventions that uplift the strengths of diverse young people while addressing interpersonal and structural drivers of multiple forms of violence perpetration. The control job-readiness training curricula focused on resume development, interview skills, and workplace expectations. While not a structural intervention, it did include curricular elements designed to position youth to pursue job opportunities. Especially among youth in neighborhoods with high rates of poverty, this type of programming could contribute to economic security, which is inversely associated with violence victimization and perpetration (Breiding et al., 2017; Gibbs et al., 2020). In the current study, we did not collect data on economic security across timepoints, and this is an important factor to consider in future studies of violence interventions.

Findings herein create opportunities to rethink the need for different interventions for those already engaged in SV/ARA (Basile et al., 2016; Niolon et al., 2017). Rigorous examination of primary versus secondary prevention effects using methods similar to those employed herein can help to evaluate whether this tailored approach is justified. For teens residing in oppressed neighborhoods who are exposed to and involved in multiple forms of violence, structural interventions broadly applied may be most impactful. Programming that couples gender-transformative approaches with structural interventions may offer important opportunities. Future work should examine combined effects of gender-transformative curricula with job-readiness training across multiple forms of violence.

Limitations

The study was conducted among adolescent males in urban racially segregated neighborhoods in a single mid-sized city who chose to participate in a program about healthy masculinity or job readiness. Results may not generalize to other geographic contexts or populations. In keeping with many studies on interpersonal violence, all outcomes were self-reported and as such are subject to reporting bias (Smith et al., 2018). The use of anonymous surveys linked by a participant secret code was designed to mitigate this. Unmeasured confounding could affect associations between intervention and violence. Despite robust efforts to promote retention (Abebe et al., 2018), retention of the community-based cohort was challenging, and loss to follow-up could impact findings.

Conclusion

This planned secondary analysis of a community-based cluster-randomized trial compared the effectiveness of a gender-transformative SV prevention program versus job-readiness training on multiple forms of violence among adolescent males who did versus did not report SV/ARA perpetration at baseline. Findings demonstrate significant reductions in multiple forms of violence perpetration over time among participants in both groups, with differences in primary versus secondary prevention effects across the two curricula. Findings highlight the need for multifaceted curricula that address interconnected forms of violence. Programs that combine job skills-building with gender equity-focused approaches to sexual health and bystander interventions may offer synergistic protection against multiple forms of violence. Research should explore whether job-readiness programs and other youth programs that involve creating structured, pro-social interactions with youth workers are, like gender-transformative programs explicitly focusing on violence prevention, useful to reduce violence by the fact of creating positive relations and modeling with young people. Youth workers who model positive, dialogic interactions, active listening, and appreciation for the lived experiences of youth may in and of themselves—without explicit content on violence prevention—contribute to reductions in violence among some young people. More research would be useful to measure and qualitatively understand these interactions in combination with group education models that have violence prevention or gender-transformative content.

Supplemental Material

sj-docx-1-jiv-10.1177_08862605231179717 – Supplemental material for Primary Versus Secondary Prevention Effects of a Gender-Transformative Sexual Violence Prevention Program Among Male Youth: A Planned Secondary Analysis of a Randomized Clinical Trial

Supplemental material, sj-docx-1-jiv-10.1177_08862605231179717 for Primary Versus Secondary Prevention Effects of a Gender-Transformative Sexual Violence Prevention Program Among Male Youth: A Planned Secondary Analysis of a Randomized Clinical Trial by Alison J. Culyba, Barbara Fuhrman, Gary Barker, Kaleab Z. Abebe and Elizabeth Miller in Journal of Interpersonal Violence

Footnotes

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Declaration of Conflicting Interests

The author(s) declared a potential conflict of interest (e.g., a financial relationship with the commercial organizations or products discussed in this article) as follows: Drs. Culyba, Abebe, and Miller reported receiving grants from the National Institutes of Health during the conduct of this study. Dr. Miller reported receiving grants from the Centers for Disease Control and Prevention and royalties for writing content for UptoDate.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This study was supported by grant No. U01CE002528 from the Centers for Disease Control and Prevention (CDC) (PI: Miller) and by NIH/NICHD grant No. K23 HD098277-01 (PI: Culyba).

Role of the Funder/Sponsor

The CDC did not participate in the design and conduct of the study or collection, management, analysis, and interpretation of the data.

Trial Registration

ClinicalTrials.gov Identifier: NCT02427061

ORCID iDs

Alison J. Culyba

Elizabeth Miller

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Alison Culyba, MD, PhD, MPH, is an Assistant Professor of Pediatrics in the Division of Adolescent and Young Adult Medicine at the University of Pittsburgh. Her research focuses on strengths-based approaches to violence prevention and translation into community-based interventions. She also directs the Empowering Teens to Thrive hospital-based violence intervention program at UPMC Children’s Hospital of Pittsburgh.

Barbara Fuhrman, PhD, is a Senior Research Scientist in the Division of Adolescent and Young Adult Medicine at the University of Pittsburgh whose research focuses on innovative approaches to modeling risk and protective behaviors and adolescent health outcomes.

Gary Barker, PhD, is the CEO and co-founder of Equimundo and an international leader in engaging men and boys in gender equality and positive masculinities. His research focuses on men’s attitudes and behaviors related to violence, fatherhood, and positive masculinities and research-informed translation into programs and policies.

Kaleab Z. Abebe, PhD, is an Associate Professor of Medicine, Biostatistics, and Clinical and Translational Science and Director of the Center for Clinical Trials and Data Coordination at the University of Pittsburgh. Dr. Abebe’s collaborative research focuses on design, conduct, and analysis of multicenter, randomized, controlled trials.

Elizabeth Miller, MD, PhD, is Division Director of Adolescent and Young Adult Medicine, Edward R. McCluskey Chair in Pediatric Medical Education, and Professor of Pediatrics at the University of Pittsburgh. Her research focuses on addressing interpersonal violence prevention among adolescents and young adults in clinical and community settings.

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