Prevention of Sexual Violence in America: Where Do We Stand?

With an annual cost of approximately $1.03 trillion ($921.72 billion in 2013 dollars),¹ rape is one of the most expensive public health problems in the United States. If sexual violence other than rape is included, the number of victimizations increases from approximately 2 million to 12 million annually, and the associated cost is in trillions of dollars, making sexual violence the most expensive enduring public health problem. Although the COVID-19 pandemic has cost an estimated $16 trillion to date, this will theoretically be a one-time cost. Once 70% of the population has become immune, either through infection or vaccination, illness is predicted to drop significantly because of herd immunity. Sexual violence, by contrast, is persistent and pervasive, and the costs outlined do not even account for its emotional impact.

Prevention is one of the pillars of public health. Primary prevention—the avoidance of biological, social, and environmental factors that cause illness and disease—is the ultimate goal of every public health professional, policymaker, and frontline health worker treating patients or, in this case, victims of sexual violence. The most significant historical advancements in human health have resulted from primary prevention efforts. Improvement in providing clean water and sanitization, decreased microbial contamination of food, vaccine development, and reduction in tobacco use are a few examples.

When it comes to the prevention of sexual violence, the United States has a very long way to go. There are a number of potential explanations for the slow progress.¹ Despite the World Health Organization’s 1996 call to view violence as a public health issue rather than a criminal justice issue, sexual violence continues to be addressed primarily as a justice concern.¹ There are a number of sociocultural and historical factors driving this justice emphasis that are beyond the scope of this editorial. Investigating crimes and prosecuting offenders is important, but given the potentially enduring impact of sexual violence on victims, prevention is more important.²

Sexual violence disproportionally affects the most vulnerable in society: children, women, and lesbian, gay, bisexual, transgender, and queer or questioning individuals. There is abundant evidence that there is an unequal distribution of resources between men and women in the United States²; those with more resources tend to have more power, and those with more power are less likely to be victimized than those with less power. Thus, sexual violence victimization might reflect differences between the empowered and the vulnerable rather than males and females per se. Until society addresses these power differentials regardless of gender, sexual violence will likely persist.³

In a world of limits, difficult decisions must be made when allocating funding and other resources. Although there is no widely accepted methodology for how to do this, public health experts condone an approach that considers the prevalence, incidence, and economic burden of diseases when allocating resources.³ Waechter and Ma¹ make the case for greater resource allocation to examine the prevention of sexual violence, given its outsized burden on the population.⁴ The evidence base for the effective prevention of sexual violence is lacking, hampering efforts to implement widespread primary prevention programs. The reasons for this lack of evidence are complex, but limited funding to carry out basic research to understand the mechanisms behind sexual violence perpetration and how to effectively prevent it is a significant factor. The methodological pathway for this work has been provided by the Centers for Disease Control and Prevention (CDC). Key components of prevention include the following:

1. awareness and education,

2. research,

3. surveillance at all levels,

4. hazard evaluation,

5. improvement of the public health system, and

6. proactive behavior by individuals.

The article in this issue of AJPH titled “Monitoring Sexual Violence Trends in Emergency Department Visits Using Syndromic Data From the National Syndromic Surveillance Program—United States, January 2017–December 2019” (D’Inverno et al., p. 485) contributes to the prevention effort by providing a novel way to monitor sexual violence via emergency department (ED) visits as reported by the CDC’s National Syndromic Surveillance Program (NSSP). The authors report a positive trend of sexual violence–related ED visits across the three years of the study and significantly higher rates of sexual violence perpetrated against females than against males, consistent with existing surveillance data.

An interesting finding from the mapping of these NSSP data is a consistent spike seen in ED visits during the warmer months when school is out of session and a consistent decrease in ED visits during colder months when school is in session. If confirmed, this finding provides important insight regarding the potentially protective factor played by schools and provides an evidence-based target for prevention programs and monitoring during the summer months. Although the study provides a way to capture more timely data of sexual violence victimization in the United States, it does have limitations. It includes data only from sexual violence cases that are reported to EDs, and it is likely that only a fraction of sexual violence victimization is reported via this route.⁴

Further, the seasonal effect of sexual violence reporting may reflect reporting bias rather than victimization per se—that is, people may be less likely to report victimization when winter travel to hospitals and EDs is more challenging. When schools are in session, students may be more likely to report sexual violence victimization to school or campus authorities rather than EDs. Sexual assault in schools and on campuses might also differ significantly from those that occur away from school and campuses in the summer, leading to the change in ED reporting. Thus, rates of sexual violence victimization derived from syndromic surveillance should be used in conjunction with other data sources to verify trends in a timely manner, given the near real-time compilation of these data.

In the meantime, the public health community must continue to champion a sexual violence prevention paradigm. Pioneering work in this field, including Risk Reduction,⁵ the Violence Prevention Model (Katz), and bystander intervention,⁶ have culminated in the CDC STOP Sexual Violence Technical Package.⁷ This package promotes social norms that protect against violence, teaches skills to prevent sexual violence, provides opportunities to empower and support those most likely to experience sexual violence victimization, creates protective environments, and supports victims and survivors to lessen harms. It is a practical approach that acknowledges the interaction of individual factors between intimate partners in a community and societal context. It is an excellent starting point that draws on existing evidence about the underlying causes of sexual violence.

The next step is to increase funding and resources to carry out large-scale intervention studies that draw on existing knowledge to reduce the incidence of (i.e., prevent) sexual violence. Given its human impact and cost, randomized control trials of more than 43 000 participants, as was recently achieved in just one COVID-19 phase III vaccine trial, should be commonplace in the field of sexual violence prevention. Longitudinal studies tracking the effectiveness of prevention programs over time and how to boost their efficacy should also be commonplace. Simultaneously, increased funding and resources should be allocated to basic research to identify other factors that contribute to power differentials and sexual violence perpetration, the improvement of existing intervention models, and the piloting of novel interventions. The speed with which the evidence base for large-scale prevention accumulates will be determined by the resources we devote to researching the problem. We are getting there, but there is much more work to do.