Primary and Secondary Prevention of Child Sexual Abuse Notes
Introduction
Child Sexual Abuse (CSA) is a significant global issue with prevalence rates:
Girls: 18-20%
Boys: 8%
Based on meta-analyses of over 9.9 million participants across six continents.
A United Nations Children’s Fund (2014) report indicated that over 120 million girls worldwide have been sexually victimized.
CSA prevalence varies with the severity of the sexual activity.
Adolescents aged 15–17 reported higher rates of sexual victimization by juvenile perpetrators.
Preventing CSA is a societal priority due to high prevalence rates and severe short- and long-term consequences.
Personal consequences for the victim:
Physical effects (injury, chronic pain, STIs, sexual dysfunction).
Mental illness (depression, PTSD, suicide attempts, substance abuse).
Emotional and interpersonal issues (difficulty forming relationships).
Financial consequences:
Estimated annual cost of CSA in the US: 124 billion USD
Australia: 3.9 billion AUD
UK: 3.2 billion GBP
Preventative Approaches to CSA
Societal shift towards preventative approaches is needed to address risk factors before victimization occurs.
Effective prevention initiatives can reduce the number of children victimized and associated costs.
Widespread public messages about CSA prevalence and consequences can lead to fear and hatred toward those at risk of perpetrating abuse.
Prevention initiatives may be misconstrued by the media, public, and policymakers as protecting offenders rather than victims.
Misunderstandings and misrepresentations can thwart prevention attempts.
Primary, Secondary, and Tertiary Prevention
Effective prevention requires interventions at primary, secondary, and tertiary levels, adopted from public health.
Primary prevention: Wide-scale initiatives aimed at the general public before sexual violence occurs.
Examples: general crime deterrence, public education, adequate sex education in schools.
Secondary prevention: Targeted interventions for those at-risk of engaging in CSA.
Examples: anonymous helplines for individuals with sexual interest in children, addressing issues that increase the risk of offending.
Tertiary prevention: Reactionary approach after a sexual offence to prevent sexual recidivism.
Examples: treatment programs for those who have engaged in CSA.
Historically, secondary prevention initiatives have received less attention and resources compared to primary and tertiary initiatives.
Meta-analysis found sexual recidivism rates under 14%, lower than recidivism rates for property, drug, public order, and violent offenders.
Up to 95% of sexual offences against children are committed by first-time offenders.
Men may struggle with their sexual thoughts and urges for 5–10 years before committing an offence.
The article focuses on secondary prevention initiatives, which may require primary-level interventions to address stigma and misunderstandings about paedophilia.
Sexual Interest vs. Sexual Behavior
Distinction between sexual interests and sexual behaviors is vital for designing CSA prevention strategies.
Adults with persistent sexual interest in children, who have acted on this interest or suffered distress from it, may meet the diagnostic criteria for Paedophilic Disorder.
People with Paedophilic Disorder do not choose to have this disorder, and most prefer non-criminal sexual desires.
Individuals are responsible for their sexual behaviors, not their sexual interests.
Not all individuals with Paedophilic Disorder will sexually abuse a child.
Paedophilic Disorder classifications: exclusive, non-exclusive, or incest-only type.
Exclusive subgroup: fixated and longstanding sexual interest in children, established during puberty.
Child sexual abuse (contact and non-contact) is a sexual behavior committed by someone who may or may not have a sexual interest in children.
Approximately 50% of men convicted of CSA do not meet the diagnostic criteria for paedophilia.
Motivations for Child Sexual Abuse
Understanding distinct underlying motivations is necessary for designing effective treatment interventions.
Term ‘minor-attracted people’ (MAP) describes individuals who are both sexually attracted to and/or affectionate toward children.
Both MAP and non-MAP engage in CSA, indicating that motivations are not clear-cut.
CSA is almost always associated with non-sexual motivations.
Effective prevention initiatives and treatment strategies for MAP and non-MAP require a thorough understanding of pertinent motivations.
For MAP, sexual attraction to children is likely an inherent part of the motivation to engage in CSA.
Other underlying motivators for MAP:
Abuse in childhood.
Cognitive distortions and abuse-supportive attitudes.
Desire for intimacy and emotional gratification.
Use of maladaptive coping mechanisms.
Life stressors can act as a catalyst for the transition from sexual interest to sexual behavior.
Underlying motivations endorsed by those with and without a sexual interest in children:
Lack of sexual knowledge.
Personal abuse during childhood.
Social skills and relationship difficulties.
Substance abuse or other mental health issues.
Attempts to use children to satisfy perceived emotional or sexual needs.
Explanations for why someone without a sexual interest in children may engage in CSA:
General anti-social orientation.
Sexual interest in coercion.
Attitudes accepting of sex between adults and children.
Indiscriminate or opportunistic sexual behaviors.
Opportunistic offences may result from the inability to establish relationships with age-appropriate adults.
Repressing pro-social sexual desires due to restrictive environments may result in illegal sexual behaviors, including sexual contact with children.
Repressing a healthy homosexual orientation can lead individuals to engage in CSA because they perceive boys as being more accessible and less judgmental.
Individuals with disabilities
Individuals with intellectual and developmental disabilities are no more likely to commit sexual offences and are more likely to be victims of crime.
They may seek sexual contact with a child because their opportunities for sexual expression are restricted.
The counterfeit deviance hypothesis suggests that it is important to determine whether deviant sexual behaviors are an inappropriate expression of healthy sexual desires or evidence of an underlying paraphilia.
Features of developmental disorders such as autism spectrum disorder (ASD) may inadvertently contribute to offending behaviors.
Accurate diagnosis is important for designing treatment programs that are responsive to individuals’ specific needs.
Public Health Approach to Child Sexual Abuse
CSA is a 100% preventable public health problem.
A public health approach involves making relevant treatment and services widely available and encouraging those at risk of offending to seek treatment before an offence has occurred.
Key prevention strategies include community-based prevention programmes, pharmacological treatments, support for individuals wishing to change their unwanted sexual thoughts, treatment interventions that address trauma, and greater access to mental health services.
Prevention initiatives need to make the public and at-risk individuals aware that effective treatment exists and ensure that these services are accessible.
Accessibility involves creating a social environment in which individuals with problematic sexual interests feel safe enough to seek help.
A successful public health approach requires strategies for reducing the stigma of ‘paedophilia’ and mental health treatment.
A widespread marketing campaign is needed to change the social and political climate.
Self-efficacy (an individual’s belief that they are in control of their own behaviors) may play a role in MAPs ability to change their sexual interest.
Public education campaigns should avoid perpetuating myths and stereotypes, and spreading information that is not empirically founded, as this may reduce MAPs motivation to seek treatment.
Examples of Secondary Prevention Initiatives
Stop it Now! (originated in the US in 1992 and has expanded to include affiliate sites in the UK & Ireland, Wales, the Netherlands, and Scotland).
Prevention Project Dunkelfeld (PPD), a Berlin-based research project that started in 2005 and has developed into the Prevention Network, with 12 treatment providers across Germany.
Both initiatives provide confidential support to those concerned about their sexual interests or behaviors and provide information to the general public regarding their role in helping prevent CSA.
Multiple German institutions have provided therapeutic services for MAP since the 1960s.
Sexual Behaviours Clinic Prevention Study
Established in Ottawa (Canada) in 1983, The Royal’s Sexual Behaviours Clinic (SBC) has provided assessment and treatment to over 4600 people.
The SBC’s Prevention Study aims to increase awareness of preventative treatments and encourage at-risk individuals to ask for help before offending, using a website (www.sexualbehavioursclinic.ca) to provide information and recruit participants.
Study participants complete questionnaires about their mental health, coping mechanisms, and sexual interests/behaviors at baseline and 6 months post-baseline, and are given the voluntary option of receiving treatment in the SBC.
The SBC maintains no wait list, and participants are typically able to begin receiving specialized psychiatric treatment within 1 week of their initial research appointment.
The SBC makes no distinction between those with ‘exclusive’ and ‘non-exclusive’ paedophilia, since treatment is focused on decreasing sexual interest in children and increasing sexual interest in adults.
The SBC programme and Prevention Study are evidence that interventions exist, yet the study is currently restricted primarily to Eastern Ontario due to a lack of available resources.
The research team has received requests for treatment from individuals in other Canadian provinces and internationally, indicating an international need for this type of prevention programme.
A nationwide response to CSA is unfeasible without government funding and support, which is lacking in Canada compared to Germany and the UK.
The Safer Living Foundation Prevention Project
The Safer Living Foundation (SLF) is a registered charity, established in 2014 as a joint venture between Whatton prison, Nottingham Trent University, the National Probation Trust (Nottinghamshire), and Nottinghamshire Police.
Its charitable objectives are to promote the protection of people from sexual crime and promote the rehabilitation of persons who have committed or are likely to commit sexual offences.
The SLF set up a project (The Aurora Project) that provides a free treatment service for individuals who are concerned that they may sexually offend.
The service was set up with input from a long-running service user group at Whatton prison, utilizing both the current evidence base together with the ‘lived experience’ of people who have committed sexual offences.
The project runs in a specialist treatment centre in Nottingham city centre, managed by a multi-disciplinary team of treatment facilitators, psychologists, and psychiatrists.
The project offers a group-based intervention using third wave CBT methods, such as Acceptance and Commitment Therapy (ACT) and Compassion Focused Therapy (CFT), and addresses the dynamic risk and protective factors associated with sexual offending.
The service also offers individual support and/or medication to manage sexual arousal for those clients who are sexually preoccupied.
Demand for Prevention Services
The expansion of the Stop it Now! and Prevention Project Dunkelfeld (PPD) programmes, the emergence of new prevention initiatives, and the volume at which these programmes are being used are indicative of increased demand for preventative services that address CSA.
From 2002 to 2017, the Stop it Now! UK & Ireland Helpline received upwards of 60,000 calls, over 40% of which were made by MAP, and demand was so high that an average of 2199 calls went unanswered each month from 2013–2014.
Within the first 15 months of operation, the Stop it Now! Netherlands helpline was contacted by 254 individuals.
In 2016, the Stop it Now! Scotland website was accessed by 1530 people, and the helpline received over 100 calls.
Of the 476 individuals who contacted PPD within the first 18 months, 43% elected to be assessed for treatment.
91% of convicted sex offenders said they would consider using a preventative service in the future if needed, and 61% said they would have previously used a preventative service had it been available or known to them.
A recent media campaign targeting users of online child sexual abuse images received approximately 2 million hits over 8 months from people concerned about their behaviors.
Police in the UK have been supportive of secondary prevention initiatives that aim to address these behaviors before involvement with the criminal justice system.
These initiatives may be a crucial part of addressing the problem of online sexual offending, as the sheer volume of online child sexual abuse images and the difficulty in apprehending all these perpetrators means that ‘We are not going to be able to arrest our way out of it’.
Benefits of Primary and Secondary Prevention
Preventing children from becoming victims of sexual abuse.
Helping people who may be at risk of offending get appropriate treatment.
Saving the criminal justice system time and resources.
Reducing the strain on the healthcare system.
Strengthening protective factors that reduce the risk of CSA.
Social support has been consistently identified as a protective factor.
Potential and actual sexual offenders often experience intense feelings of alienation and social isolation.
Professionals have found that providing a safe space for disclosure can have a preventative function.
Callers to the Stop it Now! Helpline reported improved emotional, psychological, and physical health, as well as reductions in their feelings of social isolation.
There was strong support for the belief that using the Stop it Now! helpline can help protect children that may be at risk of sexual abuse.
Improved emotional functioning, fewer cognitive distortions, greater understanding and control of sexual interests, behaviors, and risk factors, and the development of new coping mechanisms have been reported.
Personal well-being and improved quality-of-life can result in desistance and improved ability to self-manage behaviors.
Economic Benefits of Prevention
The estimated cost of CSA in the UK is £3.2 billion per year, and estimates are even higher in the US.
Cost-benefit analyses of tertiary services indicate that treating these individuals leads to significantly more savings than expenses.
Early results support the hypothesis that cost-benefit analyses of primary and secondary prevention initiatives would result in similar outcomes.
An economic analysis of the Stop it Now! UK & Ireland Helpline estimated that savings to taxpayers would be approximately 818,400 per year
Another UK-based prevention initiative has estimated that it would cost the government close to £126 million if all 1936 of their expected clients in 2018 were sentenced to a period of imprisonment, compared to £735,000 per year to treat all expected clients.
The full economic benefits of a prevention approach are incalculable, as there is no way to accurately determine the cost of the harm and suffering experienced by victims of CSA.
Governments should more carefully consider cost-benefit ratios when deciding whether to devote resources toward tertiary interventions vs primary and secondary prevention initiatives.
Barriers to Primary and Secondary Prevention
Practical, ethical, and systemic barriers have hindered the availability and accessibility of primary and secondary prevention initiatives.
A lack of knowledge about available treatments may be a larger barrier to accessing these services than a lack of personal motivation for treatment.
Guilt, shame, and stigma can prevent even those who are motivated for treatment from voluntarily seeking help.
Individuals were deterred from seeking treatment as they were unaware of how to identify or access relevant services.
Some individuals were hesitant to search for available services online or disclose their sexual issues to a healthcare provider due to uncertainty of the legal consequences.
Barriers to treatment included participants’ concerns they would be arrested or labelled as a sexual deviant, as well as concerns about privacy and anonymity.
Internal barriers included denial and minimization of sexual problems, refusal to acknowledge the harmful effects of illegal sexual behaviors, fears concerning disclosure, and shame and guilt related to sexual interests and/or behaviors.
External barriers included a lack of knowledge about existing treatment options and referral sources, as well as the limited availability of applicable resources.
Professionals’ unease with the use of secondary prevention initiatives may relate to the ethical ‘gray area’ regarding the degree to which it is a healthcare provider’s duty to probe someone who is not already involved with the legal system for information about potential offending behaviors.
Even if clinicians are available, the cost of private counselling sessions can make this option unfeasible for some.
Overcoming Barriers and Future Directions
Reducing the stigma toward MAP, especially those who have never acted on this sexual interest, is an essential step toward eradicating the barriers that deter at-risk individuals from seeking help.
Widespread education on problematic sexual interests and behaviors is needed, both for professionals working in the health and criminal justice fields, as well as the general public.
The media’s role in altering the social landscape cannot be overlooked.
Clinicians and researchers should avoid ‘generalized and absolute statements about the immutability of a sexual interest in children’, as they may reduce the self-efficacy of MAP to change their sexual interests while simultaneously increasing public stigma.
Treatment providers should be cognizant that treatment interventions may need to be adjusted based on the exclusivity of sexual interest in children.
Hearing from others who had been successfully treated and were now living healthy and productive lives in the community would have the largest impact on individuals’ decision to access services.
Possible strategies that have been suggested for mitigating ethical barriers include providing comprehensive and explicit explanations to both treatment providers and service users regarding what information would be asked, whether the sessions would be recorded, and what information falls under local mandatory reporting laws.
Finding an appropriate balance between protecting public safety and maintaining the therapeutic relationship is crucial to the success of secondary prevention initiatives.
Recommendations for Programme Development and Implementation
The design of effective primary and secondary prevention initiatives depends on many factors, including the specific goals of the programme, targeted populations, available funding, programme location, and service delivery methods.
Decisions regarding programme development and implementation should be thoroughly informed and evidence-based whenever possible.
Treatment interventions should be tailored to address clients’ individual needs, and the use of ‘one size fits all’ treatment strategies should be avoided.
Programmes should provide a range of possible treatment options, such as psychotherapy, assistance finding housing or employment, and medications to reduce sexual arousal or treat other psychiatric illnesses.
Ideally, prevention programmes will employ a multi-disciplinary staff equipped to meet the diverse needs of their clientele, including at least one psychiatrist who has the necessary training to administer and monitor medications and diagnose Paedophilic Disorder.
If programmes are unable to employ a multi-disciplinary staff, collaborations between multiple community organizations are encouraged.
Programme development will also require decisions regarding clinical practices, including whether treatment interventions will differ for individuals considered to have an exclusive vs non-exclusive sexual interest in children.
Important decisions will also need to be made with regard to promotional strategies.
Successful advertising campaigns are crucial to the success of prevention initiatives.
Criteria necessary when developing a campaign to recruit MAP into treatment include showing empathy, avoiding discrimination, reducing fear of legal repercussions, ensuring confidentiality and anonymity, and decreasing feelings of guilt and shame.
Resources considered most important by sexual offenders themselves include free counselling, free group treatment, the existence of a helpline, free online counselling, and self-help books.
Decisions about advertising strategies may need to account for differences based on programme location.
Effective prevention initiatives will likely require significant media engagement and close attention to public relations.
Organizations and professionals working in the field of prevention should help to shape public messages through proactive engagement with the media and the dissemination of important information.
Conclusions
Emotional reactions to CSA have been allowed to dictate the way that society addresses the issue, often leading to ineffective solutions.
Media-fuelled fears and over-simplified characterizations of sexual offenders can result in tertiary legal strategies that are not evidence-based and may actually increase the risk of sexual recidivism.
The stigma, hatred, and disgust towards those who sexually abuse children becomes inherently associated with MAP, regardless of whether they’ve acted on their sexual interest.
Misunderstandings of the law and fears about ‘thought police’ can prevent individuals from seeking treatment before they offend.
Society must prioritize evidence-based strategies to ensure the safety and well-being of children, including those at the primary and secondary levels.
The ability of primary and secondary prevention initiatives to circumvent even initial sexual offences is life-changing, and individuals at-risk of engaging in CSA should not have to wait until after they’ve offended to be given access to treatment.