Sexual Violence in America: Public Funding and Social Priority

Abstract

We compared lifetime risk, annual incidence, and annual economic burden of sexual violence with other major public health issues in the United States: cardiovascular disease, cancer, diabetes, and HIV/AIDS.

With public funding data from 2013, we examined how much public funding is allocated to these public health issues as a proxy of the social priority of addressing each of them.

Although sexual violence is as prevalent as and more costly than are these other major public health issues, it receives a fraction of the public funds that they receive.

Before 1995–1996, when the Centers for Disease Control and Prevention (CDC) and the National Institute of Justice conducted the National Violence Against Women Survey,¹ no nationally established mechanism for routine identification, recording, and monitoring of sexual violence existed.² Because of the complexity of the violence landscape, lifetime risk and annual incidence rates of gender-based violence varied widely between studies predicated on geographical region, how violence was defined, the population under examination, and the methodology used to collect data.³

Currently, the CDC partners with the National Institute of Justice to assess experiences of intimate partner violence, sexual violence, and stalking via the National Intimate Partner and Sexual Violence Survey (NISVS). The NISVS is an ongoing, yearlong survey that uses random digit dial to all landlines and cell phones. Respondents surveyed are noninstitutionalized English- and Spanish-speaking US adults (aged 18 years and older) in all 50 states and the District of Columbia. In 2011, 14 155 interviews were started and 12 727 interviews were completed; 54% of the respondents were women.

According to the NISVS,¹ almost 1 in 5 women in the United States (19.3%) has been raped at least once in her life, including completed and attempted forced penetration. The vast majority (78.7%) of women reported that their first rape occurred before they were aged 25 years, and 40.4% were raped before aged 18 years. This suggests that a significant proportion of the rape in America can be classified as child sexual abuse. In the last 12 months of the survey, 1.6% of women reported being raped by any perpetrator. Additionally, almost 1 in 2 women (43.9%) reported experiencing at least 1 episode of sexual violence other than rape or attempted rape at some point in her life, and more than 1 in 20 women (5.5%) reported experiencing sexual violence other than rape or attempted rape in the last 12 months of the survey.¹ Because there was a population of 118.89 million women aged 18 years and older in the United States in 2011,⁴ the NISVS results indicate that approximately 1.9 million women are raped and 6.54 million women experience sexual violence other than rape annually.

The NISVS also collects data on male victims, of whom 1.7% report being raped (completed and attempted forced penetration) at least once in their lives. Also, 23.4% of men report experiencing at least 1 episode of sexual violence other than rape or attempted rape at some point in their lives, and 5.1% of men reported experiencing sexual violence other than rape or attempted rape within the last 12 months of the survey.¹ There was an insufficient case count of men reporting rape in the preceding 12 months to produce a statistically reliable prevalence estimate on this measure.¹ Because there was a population of 112.3 million men aged 18 years and older in the United States in 2011,⁴ the NISVS results indicate that approximately 5.73 million men experience sexual violence other than rape annually.

IMPACT AND BURDEN—VICTIM HEALTH

Exposure to violence is a significant contributing factor to chronic diseases, and individuals with chronic health problems generate a larger financial burden on the health care system.⁵ In a study comparing health plans, battered women generated approximately 92% more costs per year than did nonbattered women, with mental health services accounting for most of the costs.⁶ According to the NISVS,¹ just under 3 in 10 women (27.3%) reported at least 1 negative social impact related to experiencing rape or sexual violence, such as concern for ongoing safety, requiring professional health care, utilizing victim advocate and legal services, contacting a crisis hotline, and missing work or school. Women who experience sexual violence are also at increased risk for numerous health problems, including trauma- and stress-related disorders, gastrointestinal disorders, reproductive system disorders, autoimmune diseases, obesity and diabetes, and sexually transmitted infections.⁷

Numerous studies have corroborated the negative impact of sexual violence. Women who experience childhood sexual abuse or sexual violence are at greater risk for mental health problems (e.g., chronic stress,⁸ depression, posttraumatic stress disorder, and other anxiety-spectrum disorders⁹), physical health problems (e.g., increased friability of vaginal tissue,¹⁰ increased risk of vaginal bleeding during pregnancy,¹¹ low infant birth weight¹²), and immune dysfunction and infectious diseases (e.g., long-term immune system dysfunction and chronic inflammation as indicated by increased C-reactive protein and interleukin-6,¹³ increased CD4+ cells in the cervical epithelium,¹⁴ changes to the vaginal and cervical mucosa that can increase the risk of HIV transmission,¹⁵ an inflammatory cascade and dysregulation of the hypothalamic–pituitary–adrenal axis that can increase HIV susceptibility and disease progression¹⁶).

STUDY PURPOSE

Because of the strong connection between sexual violence and subsequent health outcomes, in 1996 the World Health Organization encouraged member states to view violence as a public health issue rather than a justice issue.^17,18

We compared lifetime risk, annual incidence, and annual economic burden of sexual violence to other major public health issues in the United States: cardiovascular disease, cancer, diabetes, and HIV/AIDS. We chose the first 2 because they are the most expensive medical conditions in the United States, the third because of its high annual incidence, and the fourth because, like violence, its spread requires interpersonal interaction (i.e., something that one person gives to or does to another person). We then examined how much annual public funding is allocated to each of these public health issues as a proxy of the social priority of addressing each of them.

METHODS

We conducted a literature and Internet search to find recent US lifetime risk estimates for each of the targeted public health issues: cardiovascular disease (myocardial infarction, coronary insufficiency, angina, stroke, claudication),¹⁹ cancer diagnosis,²⁰ diabetes diagnosis,²¹ contraction of HIV/AIDS,²² and rape and sexual violence other than rape.¹

We then investigated annual US incidence estimates for each of the targeted public health issues: cardiovascular disease (heart attack and stroke),^23,24 cancer diagnosis,²⁵ diabetes diagnosis,²⁶ contraction of HIV/AIDS,²⁷ and rape and sexual violence other than rape.¹ For rape and sexual violence other than rape, we used past year prevalence rates as reported in the NISVS.¹

For economic impact and burden, we compared the estimated annual economic burden of cardiovascular disease,²⁸ cancer,²⁵ diabetes,²⁹ HIV/AIDS,³⁰ and rape and sexual violence other than rape in the United States.¹ These included existing estimates of direct costs (e.g., hospital and health care expenses, medications) as well as indirect costs (e.g., loss of income, caregiver costs).

We investigated the annual amount of US public funding allocated to researching cardiovascular disease, cancer, diabetes, and HIV/AIDS for the year 2013,^31,32 and we compared that to the annual amount of US public funding allocated to researching rape and sexual violence other than rape for the year 2013.^31,33,34 For the rape and sexual violence category, we also included all public funds allocated to addressing, preventing, and supporting victims of violence in general.

To determine public funding as a function of economic burden, we calculated the ratio of public funding to disease burden for cardiovascular disease, cancer, diabetes, HIV/AIDS, and rape and sexual violence other than rape as a proxy of the social priority of addressing each of these public health concerns in the United States. To make a direct economic comparison, we used a consumer price index inflation calculator to adjust all financial values to 2013 dollars.

RESULTS

We carried out 4 comparisons between cardiovascular disease, cancer, diabetes, HIV/AIDS, and rape and sexual violence other than rape: (1) lifetime risk and annual incidence, (2) economic impact and burden, (3) public funding, and (4) public funding as a function of economic burden.

Lifetime Risk and Annual Incidence

Lifetime risk estimates for cardiovascular disease (myocardial infarction, coronary insufficiency, angina, stroke, claudication) from aged 50 years (as of 1971–2002),¹⁹ cancer diagnosis (as of 2009–2011),²⁰ diabetes diagnosis (as of 2000–2011),²¹ contraction of HIV/AIDS (as of 2004–2005),²² and experience of rape and sexual violence other than rape (as of 2011)¹ are shown in Figure 1. Lifetime risk rates for sexual violence (other than rape and attempted rape) among women were very similar to lifetime risk rates for cardiovascular disease, cancer, and diabetes. Lifetime risk rates for rape and attempted rape among women were approximately 50% of the lifetime risk rates for cardiovascular disease, cancer, and diabetes but 27 times higher than were lifetime risk rates for the contraction of HIV/AIDS.

FIGURE 1—

Lifetime percentage risk of experiencing sexual violence, cardiovascular disease (myocardial infarction, coronary insufficiency, angina, stroke, claudication), cancer diagnosis, diabetes diagnosis, and contraction of HIV/AIDS: United States, 2013.

Figure 2 includes estimates of annual US incidence rates for cardiovascular disease and specifically heart attack or stroke (men and women combined; for 2015),^23,24 cancer diagnosis (men and women; for 2014),²⁵ diabetes diagnosis (men and women; for 2012),²⁶ contraction of HIV/AIDS (men and women; for 2010),²⁷ sexual violence other than rape (men and women; for 2011),¹ and rape (women only; for 2011).¹ The estimated annual incidence of experiencing sexual violence other than rape was approximately 8 times higher than the annual incidence of cardiovascular disease, cancer diagnosis, and diabetes diagnosis, and it was 259 times higher than the annual incidence of contracting HIV/AIDS. Furthermore, the annual incidence of rape or attempted rape among women alone (the NISVS did not provide this estimate for men) was higher than the annual incidence of cardiovascular disease, cancer, diabetes, and HIV/AIDS among men and women.

FIGURE 2—

Annual incidence of sexual violence (women only), cardiovascular disease (heart attack and stroke), cancer diagnosis, diabetes diagnosis, and contraction of HIV/AIDS (men and women combined) in millions of people: United States, 2013.

Economic Impact and Burden

Cohen and Piquero³⁵ divide the costs of victimization into

1. victim impact and costs;

2. medical system costs;

3. criminal justice system investigation, arrest, adjudication, incarceration, parole, and probation;

4. lost earnings of both the victim and perpetrator; and

5. willingness to pay to prevent future violence (prevention expenditures for personal security, avoidant behaviors to safeguard against victimization, third-party costs of insurance, and government welfare programs).

Including all these categories, DeLisi³⁶ estimated that each rape imposed US $448 532 in victim, justice, and offender productivity and willingness to pay costs in 2008. Multiplying this figure by our estimate of 1.9 million annual rapes¹ gives a total direct and indirect cost of $851.87 billion in 2008 US dollars or $921.72 billion in 2013 US dollars. Importantly, this value does not account for the economic burden of sexual violence excluding rape and attempted rape experienced by an estimated 12.3 million women and men each year.¹ The annual economic burden of rape or attempted rape compared with cardiovascular disease, cancer, diabetes, and HIV/AIDS are shown in Figure 3 (dark gray bars).

FIGURE 3—

Annual public funding for addressing, researching, or preventing sexual violence, cardiovascular disease, cancer, diabetes, and HIV/AIDS: United States, 2013.

Note. Left vertical axis (black bars): annual economic burden of sexual violence (rape or attempted rape only), cardiovascular disease, cancer, diabetes, and HIV/AIDS. Right vertical axis (white bars): public research and program funding for all violence (i.e., sexual violence, youth violence, violence prevention, child abuse or neglect), cardiovascular disease (heart disease and stroke), cancer, diabetes, and HIV/AIDS. Percentage of annual public spending to annual economic burden for violence, cardiovascular disease (including heart disease and strokes), cancer, diabetes, and HIV/AIDS is included above each set of bars.

The total direct and indirect cost of cardiovascular disease in the United States for 2010 was estimated at $503.20 billion.²⁸ Heidenreich et al.³⁷ estimated the direct and indirect costs of cardiovascular disease (i.e., coronary heart disease, hypertensive disease, stroke, heart failure) in the United States at $290.70 billion in 2010. We included the highest estimate in our results analysis, which was equivalent to $537.59 billion in 2013 US dollars.

The American Association for Cancer Research estimates that the overall costs of cancer to the United States in 2009 was $216.60 billion: $86.60 billion for direct health expenditures and $130.00 billion for indirect mortality costs, such as lost productivity stemming from premature death.²⁵ This was equivalent to $235.20 billion in 2013 US dollars. The total costs of diagnosed diabetes in the United States was $245.00 billion in 2012, consisting of $176.00 billion for direct medical costs and $69.00 billion in reduced productivity.²⁹ This was equivalent to $248.59 billion in 2013 US dollars. The total costs associated with new HIV infections in the United States in 2002 was $36.40 billion, including $6.70 billion in direct medical costs and $29.70 billion in productivity losses.³⁰ This was equal to $47.14 billion in 2013 US dollars.

Rape and attempted rape among only women in the United States had 1.7 times the annual economic impact of cardiovascular disease, 3.9 and 3.7 times the annual economic impact of cancer and diabetes, respectively, and 19.6 times the annual economic impact of HIV/AIDS among both men and women in the United States (Figure 3, dark gray bars).

Public Funding

Through programs at the CDC, Department of Justice (DOJ), and National Institutes of Health (NIH), public funding directed at sexually based violence amounted to $822.4 million in 2013. This total is broken down as follows: (1) DOJ, Office on Violence Against Women—$412.5 million in 2013³³ spread across 24 programs³⁴ (these programs mostly adhere to the administration of justice and strengthening of services to victims, rather than attempting to reduce the risk and perpetration of initial violence against women); (2) CDC, National Center for Injury Prevention and Control, Division of Violence Prevention, Injury Prevention and Control—Intentional Injury Program ($88.4 million in 2013) and Injury Control Research Centers ($9.5 million in 2013)³¹; and (3) NIH research across general violence, violence against women, youth violence, youth violence prevention, and child abuse and neglect research—$312.0 million in 2013.³²

According to the research, condition, and disease categorization (RCDC) system, in 2013, the NIH had an approximate annual budget of $137.000 million for violence, $31.000 million for violence against women, $70.000 million for youth violence, $26.000 million for youth violence prevention, and $30.000 million for child abuse and neglect research.³² Although $1.172 billion was allocated for basic behavioral and social science and $3.535 billion was allocated for behavioral and social science, we searched the research project titles listed under these 2 categories (14 581 in total) to determine the proportion of behavioral and social science funds allocated for gender-based violence. We found 83 projects with at least 1 of the words “violence,” “rape,” or “assault” in the title, with total funding of $18.000 million in 2013—just 0.38% of the total funding in these 2 categories.³²

Furthermore, the RCDC includes a funding category called “Women’s Health,” with 2013 funding of $3.745 billion.³² According to a RCDC footnote, this category covers studies that break results down by gender or ethnicity—that is, any study that tracked results between males and females. Furthermore, the note states: “The databases used to track gender/ethnicity are complex and are not currently compatible with the RCDC system.” Thus, we did not include any dollar values from this category in our NIH funding estimate for 2013.³²

In 2013, the NIH allotted $1.96 billion for research into cardiovascular disease, $5.27 billion for cancer, $1.01 billion for diabetes, and $2.90 billion for HIV/AIDS.³² That same year, the CDC allocated $52.10 million for heart disease and stroke prevention, $330.20 million for cancer prevention and control, $61.00 million for diabetes prevention, and $740.90 million for domestic HIV/AIDS prevention and research.³¹

The annual public funding allocated for addressing, researching, or preventing sexual violence, cardiovascular disease, cancer, diabetes, and HIV/AIDS is shown in Figure 3 (white bars).

Public Funding as Function of Economic Burden

To gain a proxy of the social priority of addressing each public health issue, we calculated the percentage of annual public funding to annual economic burden for sexual violence, cardiovascular disease, cancer, diabetes, and HIV/AIDS. To determine the most conservative figures, we included all public funding for violence across the DOJ, the CDC, and the NIH in this calculation, including funding for youth violence and child maltreatment. Furthermore, we included only the estimated economic burden associated with rape and attempted rape ($921.72 billion).

HIV/AIDS had the greatest ratio of annual public spending to economic burden, at 7.72% (Figure 3). Violence in general had the lowest ratio of annual public spending to economic burden, at 0.09%. Critically, the economic burden number used in this ratio was restricted to rape and attempted rape of women and did not account for rape and attempted rape of men, sexual violence excluding rape and attempted rape, child maltreatment, and other forms of violence. If the economic burden of these forms of violence were included, the ratio of annual public spending would be significantly lower.

DISCUSSION

Every year, between 12 and 14 million men, women, boys, and girls are victims of rape or sexual violence in the United States.^1,4 This figure is approximately 2.5 times the annual incidence of cardiovascular disease, cancer diagnosis, diabetes diagnosis, and contraction of HIV/AIDS combined.^23–27 The immediate and long-term negative health impacts of violence victimization are significant and well documented, leading the World Health Organization to encourage member states to view violence as a public health issue rather than a justice issue.^17,18 We estimated that in the United States rape and attempted rape alone have an impact that is 1.7 times the annual economic impact of cardiovascular disease, 3.9 and 3.7 times the annual economic impact of cancer and diabetes, respectively, and 19.6 times the annual economic impact of HIV/AIDS.

Despite this higher economic burden, total public funding across the CDC, the DOJ, and the NIH to address all forms of violence (i.e., rape, nonrape sexual violence, youth violence, youth violence prevention, child maltreatment) is approximately 42% of the amount both the NIH and the CDC direct to cardiovascular disease, 15% of the amount they direct to cancer, 81% of the amount they direct to diabetes, and 23% of the amount they direct to HIV/AIDS. In 2013, funding to conduct research on all forms of violence was a tiny fraction of total NIH funding (0.001%) compared with the percentage of total NIH funding for cardiovascular disease (6.70%), cancer (17.99%), diabetes (3.44%), and HIV/AIDS (9.89%).³²

Dividing the total annual economic burden by the total public funding (CDC, DOJ, NIH, where appropriate) provides a rough proxy of the social priority of addressing each of these public health concerns. This analysis reveals that all forms of violence—not only sexual violence—receive just 0.09% of the estimated annual economic burden of rape and attempted rape. This is a fraction of the ratio of annual public funds to economic burden allocated for cardiovascular disease (0.37%), cancer (2.38%), diabetes (0.41%), and HIV/AIDS (7.72%).

Approximately half (50.2%) of public funding to address violence in the United States is allocated through the DOJ. This indicates that violence against women continues to be significantly viewed from the paradigm of justice, which is primarily a matter for state laws and state resources, whereas funding for medical research is overwhelmingly federal. Thus, violence prevention is often wrapped up in state budget processes for the criminal justice system, which is notoriously underfunded.

A focus on justice is important for tracking violence, capturing perpetrators, holding perpetrators accountable, and protecting existing victims from revictimization. Because of low arrest rates for sexual assault, increasing the criminal justice system response and prosecuting perpetrators is a critical step in addressing revictimization.³⁸ Although the CDC is more focused on preventing violence than is the DOJ (e.g., through initiatives such as their Rape Prevention and Education program), the level of public funding it allocates to these programs, at $97.88 million, remains a small fraction of the $412.50 million in public funds the DOJ directs to mostly postviolence support-based programs allocated through its Office on Violence Against Women.³³

Limitations

There are numerous limitations to this study. First, we drew all the data from secondary sources, making it impossible to compare public health data from the same year. We carried out extensive searches in an attempt to include the most recent available data, but we may not have succeeded in doing so. To make meaningful financial comparisons, we transformed all dollar figures into 2013 amounts using the US Bureau of Labor Statistics online consumer price index inflation calculator.

There are conceptual challenges in comparing violence to cardiovascular disease, cancer, and diabetes. Notwithstanding different etiologies and courses, they are fundamentally different in experience. Violence is necessarily an interpersonal phenomenon, whereas cardiovascular disease, cancer, and diabetes are individually experienced diseases. To at least partially address this concern, we included HIV/AIDS in the analysis for comparison with a public health problem with an interpersonal component (i.e., HIV/AIDS is something that 1 person gives to another person). Certainly, we could have included other public health issues (e.g., influenza, hepatitis, anxiety disorders) in our analysis, but such an exhaustive comparison was beyond the scope of this study.

Finally, the fundamental differences between violence and cardiovascular disease, cancer, diabetes, and, to a lesser extent, HIV/AIDS prompts the question of what increased spending to address the violence problem would look like. With AIDS, scientists and policymakers realize that finding a vaccine might cure the disease among those who have it and certainly would eliminate its scourge from future generations. How do we eliminate the scourge of violence without an equivalent vaccine template? As is the process with infectious diseases, perhaps the answer lies in researching and understanding the underlying causes of violence so that effective prevention programs can be engineered and implemented. First, a paradigm shift in how we view violence—from that of a justice issue to a public health issue—may be needed.

Conclusions

Nearly 2 decades after the World Health Organization declared violence a public health rather than a justice issue, the United States continues to allocate public funds for addressing violence as much from a justice paradigm as from a public health paradigm. Even when justice expenditures for addressing violence are included with health research expenditures, public funds allocated to sexual violence are a fraction of those allocated to other major public health issues, such as cancer, cardiovascular disease, and diabetes, despite the similar incidence, prevalence, and economic burden between them.

The reasons for this disparity are complex and beyond the scope of this study. Our goal was to highlight the ongoing disparity, promote further discussion of the best way forward in addressing sexual violence and its many poor health outcomes, and advocate further funding to examine the factors associated with violence with the goal of prevention rather than intervention.