You Asked: What Can We Do to Stop Rape?

A reader asks what we can do to stop rape. This question is very important to me having spent nearly 20 years treating child and adolescent victims of sexual assault and abuse.  It's also timely because April is Sexual Assault Awareness and Prevention Month. And awareness is the first step in preventing rape.

Let's start with some basic facts and then look at prevention. Sexual assault is any type of sexual activity (including rape) in which the victim is forced, threatened, doesn't consent, or is not capable of giving consent. Regardless of the victim's statements or actions, it is sexual assault if she or he is too young, drunk, drugged, or mentally impaired to legally consent to sex.

According to the most comprehensive, representative survey in the United States--the National Violence Against Women Survey:

• 1 of every 6 women (17.6%) and 1 of every 33 men (3%) have been raped at some time in their lives.
• The majority of the victims were younger than 18 years old when they were raped (females - 54%; males - 71%).
• Most disturbingly, many victims were less than 12 years old when they were raped (girls - 21.6%; boys - 48%).
• Girls under the age of 12 were most likely to be victimized by relatives. The girls ages 12 to 17 were more likely to be victimized by intimates and acquaintances. Women were more likely to be raped by intimates.
• Boys and men are more likely to be raped by acquaintances at all ages.

There are three basic approaches to preventing rape. The most common places the burden on potential victims to protect themselves. Some of the safety precautions are the same as for other violent crimes: Keep doors and windows locked (at home and in the car); don't open the door or go somewhere with strangers; and don't walk alone in isolated places (daytime or night). Although these actions can help prevent stranger rapes, most sexual assaults (80%) are committed by someone the victim knows--a boyfriend or girlfriend, relative, friend or acquaintance.

The following tips from the National Child Traumatic Stress Network's "Preventing Acquaintance Rape-A Safety Guide for Teens" apply also to young adults:

• Expect respect and keep away from people who don’t show you respect.
• Be clear about your limits: let the other person know what you want and don’t want to do. You have the right to change your mind, to say “no,” or to agree to some sexual activities and not to others.
• Don’t allow a person to touch you if it makes you uncomfortable. If your limits are reached or you sense danger, speak your mind and act immediately. Make a scene if necessary.
• Avoid excessive drinking or drugs. They reduce your ability to think and communicate clearly. Being drunk or high does not give anyone permission to assault you.
• Pour your own beverage and keep it in sight. Date rape drugs can be put into drinks and are often undetectable.
• Don’t hang out in places that keep you isolated from others. Although you may feel you can take care of yourself, it is always wise to be careful.
• Trust your instincts. If you feel that a person is not trustworthy or a situation is unsafe, leave.
• Have a back-up plan. For example, if you’re going out to a party in a different neighborhood, make sure someone you trust knows where you’re going. Have a person you can call to come and get you if you need to leave without your original ride.

A second prevention approach is to reach teen boys and young men before they commit rape. Men Can Stop Rape is one organization dedicated to this effort. Their program, Men of Strength (MOST) Club, is considered the premier primary prevention program for male youth in the country. It provides high school age and college age young men with a structured and supportive space to learn about healthy masculinity and redefine male strength.

The third approach is through law enforcement. Unfortunately, only 39% of rapes and sexual assaults are ever reported to the police. Partly due to the difficulty of investigating and prosecuting these crimes, only 16% of reports result in a perpetrator serving time in prison. Factoring in unreported rapes, only 6% of rapists end up in prison. The rest are free to repeat their crimes. One way to increase convictions is for more police and prosecutors to receive specialized training in sex crimes. Media attention and community pressure can help push local authorities into pursuing this training if they have not already done so.

So what can you do? Continue to educate yourself. Help raise awareness. Teach potential victims ways to protect themselves. Educate potential perpetrators through men's antiviolence programs. If you are a parent, talk to your children and teens about safety and healthy dating relationships. Encourage victims to report rape, and support them through the difficult process of investigation and prosecution. Donate time and money to your local rape crisis/sexual assault center--most are under-funded and under-staffed. (To find a center in your area, see RAINN's listing of state coalitions against sexual assault.) If you are a college student, get involved by supporting (or starting) a campus program to help victims and raise awareness among students.

To start raising awareness, watch the following video from RAINN and then e-mail it to everyone you know that could benefit. You can also link to it or embed it on your blog or website.

Child Abuse is the Primary Cause of Infant Homicides

Child abuse of any sort is difficult to understand, but the homicide of infants by caretakers is beyond most people's imagination. A new study sheds some light on who commits these acts.

Fujiwara, T., Barber, C., Schaechter, J., & Hemenway, D. (2009). Characteristics of Infant Homicides: Findings From a U.S. Multisite Reporting System PEDIATRICS, 124 (2) DOI: 10.1542/peds.2008-3675

The study reports on 72 cases drawn from the National Violent Injury Statistics System. The system was developed to provide detailed information from multiple sources--death certificates, coroner/medical examiner reports, police reports, and crime laboratories--to be used for public health research. The purpose of this study was to describe features of different types of infant homicide (under age 2) to inform prevention efforts.

Three-quarters of infant homicides were due to beating/shaking by a caretaker (Type 1). The perpetrator was most often the father (43%) or the mother's boyfriend (30%). In almost all cases, emergency medical treatment was sought by either the abuser or another household member. The authors conclude that Type 1 homicides are impulsive and largely unintentional in nature. However, in most cases there was evidence of prior physical abuse. Their recommendations for prevention are early identification of child abuse and education directed at male caretakers.

In contrast, most Type 2 homicides were committed by women (69%), were intentional, and no medical treatment was sought. The deaths were related to domestic violence, psychosis, other crime, or occurred within 24 hours of birth. There were too few cases of each kind to draw conclusions useful for prevention. A larger study would be needed.

Of note, nearly half of the Type 1 homicides were caused by shaking. Young adult males with little or no experience can find it difficult to care for a baby that continually cries. Some will shake a baby out of frustration and anger to stop it crying without realizing the damage shaking will cause. Not all shaken babies die, but survivors' injuries may include severe brain damage, blindness, learning disabilities, and physical impairments.

One hospital-based prevention education program directed at both parents has been successful in reducing the number of cases, and the program has been replicated elsewhere (Upstate New York Shaken Baby Syndrome Education Program). The basic elements of this and other prevention education are to raise awareness of injuries caused by shaking and teach caretakers how to soothe a crying baby and cope with their own frustration.

For more information: The National Center on Shaken Baby Syndrome

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This post was featured in Grand Rounds Vol. 5 No. 51, comes to Paramedicine! « Medic999

Ten Common Causes of Child Trauma Due to Violence

I started this post several weeks ago to answer the question "What are the most common causes of child trauma?" It was much harder than I expected. The task of reviewing statistics wasn't just comparing apples to oranges. It was, instead, like comparing the ingredients of a fruit salad. The statistics varied greatly, in part, due to differences in research design:

• Some studies reported how many children experienced traumatic events in one year while others reported lifetime experience (incidence vs prevalence).
• Some included only children or adolescents while others asked adults to report on their entire childhood.
• Most focused on one type of trauma (for example child sexual abuse) rather than a wider range of traumatic experiences.
  
• Most weren't large enough or representative enough of the entire nation to draw firm conclusions. (Unfortunately, few researchers are able to obtain the funding needed to conduct large, representative studies.)
• Those that relied on victim reports to child welfare or law enforcement weren't able to estimate the number of victims who had not reported.
  

There are several ways to estimate how many children have experienced trauma. One way is to ask about a short period of time (incidence) rather than a person's entire childhood (prevalence). Some advantages of this approach is that it relies less on memory, and it is easier to compare different ages. Otherwise, when asked if an event has ever occurred, more teenagers are likely to report an experience than younger children simply because they've had more years for it to have happened.

A disadvantage is that the results do not reflect the full magnitude of a problem which is often better represented by an estimate of prevalence. For example, a familiar childhood statistic such as "one out of four girls experience sexual victimization before age 18" will be higher than the number of girls victimized in one year. Still, the advantages can outweigh the disadvantages when comparing rates across various traumatic experiences within different age groups, and a one-year snapshot of new cases can be more useful for current policy and service delivery.

My list is limited to child trauma caused by violence because there has been more research done for it than for other traumas (such as disaster or accidental injury). I selected a single study that included a wide range of violence-related victimizations by David Finkelhor and colleagues designed to address many of the issues listed above.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby S. L. (2005). The Victimization of Children and Youth: A Comprehensive, National Survey Child Maltreatment, 10 (1), 5-25 DOI: 10.1177/1077559504271287


Their study included:

• a large, nationally representative sample of children ages 2 to 17
• younger children (through interviews with their parents)
  
• a comprehensive list of child abuse and other victimization experiences
• examined the number of victims for each trauma during one year
• relied on direct reports rather indirect statistics collected by reporting agencies
• reported how many children experienced multiple traumas

Of the 34 different direct and indirect victimizations included in the study, I've selected the top ten I believe best fit the criteria needed to diagnose PTSD. I converted population rates (number per 1000) to percentages more familiar to most readers. I've also included the definition of each trauma used in the study.

1. Bullying - 22% - A peer picked on child (for example, by chasing, grabbing hair or clothes, or making child do something he or she did not want to do).

2. Assault with injury - 10% - Someone hit or attacked child, and child was physically hurt when this happened. (Hurt means child felt pain the next day, or had a bruise, a cut that bled, or a broken bone.) No weapon was used.

3. Assault with a weapon - 8% - Someone hit or attacked child on purpose with something that would hurt (like a stick, rock, gun, knife or other thing).

4. Exposure to shooting, bombs, riots - 6%
Child was in a place (in real life) where child could see or hear random shootings, terror bombings, or riots.

5. Non-sexual genital assault - 5% - A peer tried to hurt child's private parts on purpose by hitting or kicking.

6. Robbery by nonsibling- 4% - A nonsibling (peer or adult) used force to take something away from child that child was carrying or wearing.

7. Physical abuse by caregiver - 4%
An adult in child's life hit, beat, kicked, or physically abused child in any way.

8. Witness domestic violence - 4% - Child saw one parent get hit (for example, slapped, hit, punched, or beat up) by another parent, or parent's boyfriend or girlfriend.

9. Sexual assault - 3% - Someone touched child's private parts when unwanted, make child touch their private parts, or forced child to have sex. Or attempted any of these acts.

10. Murder of someone close - 3% - Someone close to child (for example, family member, friend, or neighbor) was murdered.

There are some surprises here. Bullying was the most common. Significant numbers of children in the United States have been exposed to shootings, bombs, or riots. Many children have had someone close to them murdered though perhaps this shouldn't be surprising given the U.S.'s high murder rate.

In this article, I've focused on the number of children in the United States who experience trauma related to violence. In future articles, I will address other forms of child trauma such as disaster or serious accidents. I will also, from time to time, provide an in-depth look at items in the list including what is known about rates of PTSD and other negative consequences.
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This post was featured in Doc Gurley » Grand Rounds, Vol. 5, No. 44: Mystery!