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A prevention-first approach to child sexual abuse

Rescues and arrests make headlines, but we need to put more resources into stopping these crimes before they happen

By Dr. Elizabeth J. Letourneau

4:04 PM EDT, August 6, 2013

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The recent FBI raid that arrested three men in Maryland as part of Operation Cross Country that netted 150 alleged pimps in 76 cities illustrates significant governmental efforts in detecting and arresting sex offenders, including pimps and buyers.

But child sexual abuse (CSA), which includes the sexual exploitation of children and juvenile prostitution, is a complex problem that requires a much more comprehensive approach that moves beyond rescues and raids. Rather, we need to invest in a public health approach that emphasizes the importance of primary prevention as well as criminal justice interventions and post-abuse services and treatment. A public health framework would also bring more scientific integrity to the issue of child sex trafficking.

While more research is needed, it is clear from the available data that youths at risk of various forms of sexual exploitation are characterized by a host of vulnerabilities that could be addressed before abuse occurs if we funded the development and testing of effective prevention programs. But, in general, we do not put resources into prevention efforts at anywhere near the level of after-the-fact criminal justice interventions. Making the best of a bad situation is poor policy; we need to develop a prevention mindset.

Good prevention policy would fund the development of effective programs that target vulnerable families, vulnerable youths, and vulnerable settings. At the family level, among the factors that increase risk for CSA and other negative outcomes are young and single parents and parental substance abuse. Fortunately, there are evidence-based interventions that effectively address many of the problems associated with these family factors. For example, nurse home visiting programs that target young parents reduce the risk of physical abuse and neglect; and contingency management helps drug-addicted parents abstain. These and other evidence-based programs should be more broadly available. However, we also need research to determine whether existing programs reduce a child's risk for future CSA, or whether adaptations or new interventions are needed.

At the youth level, factors that increase risk for CSA and other negative outcomes include associating with delinquent peers, school problems, and substance abuse. Again, evidence-based interventions should be more widely disseminated to address these problems. Multisystemic therapy is a parent-focused intervention proved to reduce youth delinquency, improve school outcomes and, importantly, reduce the sexual re-offense rates of youths who have perpetrated sexual harm against peers and younger children. Such interventions should be more broadly available to adolescents who have sexually offended, and additional interventions are needed. Given that about 40 percent of CSA perpetrators are themselves adolescents, and that adolescents are sometimes used to recruit peers into prostitution and trafficking, developing effective primary prevention interventions should be a priority.

At the settings level, among the factors that increase risk of CSA and other negative outcomes are residing in congregate care settings, residing in foster care settings, and being homeless/runaway. As above, there are some proven strategies. Avoiding or greatly limiting time in congregate care is essential; for youths who need foster care, specialized therapeutic techniques such as multidimensional-treatment foster care reliably improves many outcomes, including youths' ability to return and remain home and avoid delinquency. Yet, again, it remains unknown whether youths who receive such multidimensional treatment are at lower risk of CSA, prostitution or trafficking or whether more specialized interventions are needed to address foster care concerns.

David Finkelhor, a nationally and internationally respected sociologist, has studied CSA and the related areas of juvenile prostitution and sex trafficking for decades. He recently noted that "Arrests make great publicity. But it is only through a multidisciplinary, comprehensive mobilization of dedicated child welfare, social service, mental health, drug rehabilitation, [and] educational systems — working together with law enforcement — that we will find a solution to young people being sold or selling sex for money and survival." To this multidisciplinary list, I would add the mobilization of parents, who wield substantial and ongoing influence over their children's risk of CSA and other negative outcomes, as well as their children's likelihood of engaging in sexually risky behaviors and who, if given the proper help and tools, are the most likely "stakeholders" of all to impact the lives of young people.

The primary prevention of child sexual abuse is both desirable and achievable. However, developing, rigorously testing, and disseminating evidence-based interventions requires long-term dedication to a public health approach, with significant resources and substantial collaboration.

Dr. Elizabeth J. Letourneau is director of the Moore Center for the Prevention of Child Sexual Abuse, Johns Hopkins Bloomberg School of Public Health (www.jhsph.edu/childsexabuse). Her email is eletourn@jhsph.edu.