A Comprehensive Approach to Sexual Violence Prevention

Sexual violence is a widespread problem that is associated with negative health outcomes throughout life.¹ Recent national data reveal that, among women reporting a history of rape, 40% were first raped before 18 years of age and 38% between 18 and 24 years of age.¹ The college years may be a particularly vulnerable time for women, given the increase in partying and alcohol use. One study showed that 20% of undergraduate women were victims of sexual violence since beginning college.² Nevertheless, sexual violence is a preventable public health problem.

In this issue of the Journal, Senn et al.³ report the results of a randomized, controlled trial of an intervention designed to reduce the incidence of sexual violence victimization among first-year female university students in Canada. They found that an enhanced sexual assault resistance program led to reductions in the risk of completed rape and attempted rape and, to a lesser degree, attempted coercion and nonconsensual sexual contact over a 1-year follow-up period. The researchers calculated that for every 22 women enrolled, the intervention would prevent one additional completed rape within 1 year after participation. Their study has numerous strengths consistent with principles of effective prevention,⁴ including a rigorous design, assessment of several types of sexual violence, and an intervention informed by theory⁵ and administered in multiple sessions with the use of varied teaching methods. Its primary weakness is that it places the onus for prevention on potential victims, possibly obscuring the responsibility of perpetrators and others. What happens when women who complete the intervention cannot successfully resist rape?

With a public health approach, the most efficient way to have a population-level effect on violence is through a focus on primary prevention with potential perpetrators as part of a comprehensive, multilevel approach.^{6, 7} With the spotlight currently focused on sexual violence on college campuses in both the United States and Canada, it may be tempting to focus all attention on the college-age group for prevention efforts. But prevalence data paint a different picture — we must start younger.

The social–ecologic model is a useful framework for understanding and preventing violence. This model suggests that contributing factors for violence exist not only at the individual level but also within the context of relationships, communities, and the larger society.⁶ To prevent sexual violence, we must develop strategies at all of these ecologic levels. Research has suggested promising approaches for adolescent and college populations beyond the individual level.⁷ For example, in one study, rates of sexual harassment and stalking victimization and perpetration were lower at a college with a bystander-training program than at two colleges without such a program.⁸ Another study assessed the effects of a program to prevent dating violence among male high-school athletes that involved training high-school coaches to model respectful and healthy relationships. The intervention had no sustained effects on the primary outcomes (intention to intervene when witnessing abusive behaviors, recognition of abusive behaviors, and gender-equitable attitudes) but did reduce negative bystander behaviors (i.e., supporting peers' abusive behavior) and rates of perpetration of dating violence (including sexual violence) by the athletes at the 1-year follow-up.⁹

At the school level, a prevention program in New York City included a building-level intervention that used hotspot mapping to identify unsafe areas in middle schools and increase staff monitoring; in a randomized trial involving many middle schools, the intervention reduced sexual violence perpetration and victimization.¹⁰ At the broader community level, given observations that the number of on-premises alcohol outlets in a defined geographic area was positively associated with police-reported rates of rape,¹¹ alcohol policies related to outlet density and other areas warrant consideration among approaches to reduce sexual violence.¹² Rigorous evaluation of all the promising strategies described here and others is required to increase the evidence base for prevention.⁷

Empowering women to resist violence and protect themselves, as described by Senn et al., is a positive and sensible part of sexual violence prevention, and there is a long history behind these kinds of approaches.⁶ However, women-focused approaches used in isolation for prevention not only deflect responsibility from potential perpetrators, but also represent only a partial solution. We can have a greater effect through combined efforts that also focus on potential perpetrators, bystanders, and broader community-level influences.

There are no easy solutions to this problem. Quick, single-session sexual violence interventions are not effective and may actually be harmful.⁷ Senn et al. describe an effective individual-level intervention for women in college. Approaches such as theirs, although limited by themselves, can be part of a comprehensive multilevel approach, including a focus on younger ages and potential perpetrators, to address this public health crisis.