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Non-Victim-Focused Actions for Sexual Violence Using WHO’s Framework on the Determinants of Health

  • crockaltenhof1
  • Nov 7, 2023
  • 6 min read

Sexual violence is a complex construct with deep, widespread roots through generations of our culture making it difficult to pinpoint the causes. In Canada, its meaning is defined by the criminal codes. A simple definition from the Centers for Disease Control and Prevention is any sexual act that is committed against someone who does not consent or is unable to consent or refuse (Basile & Saltzman, 2002). Sexual violence has been long described as a significant public health problem (DeGue et al., 2012; Vivolo et al., 2010) and victims often experience long-term physical (chronic pain), gynecological (injuries, pregnancy complications, sexually transmitted infections), gastrointestinal, mental (depression, anxiety, panic attacks, suicidal behaviour, posttraumatic stress disorder), substance abuse, sexual health problems, and engaging in risky sexual behaviours (CDC, 2016; DeGue et al., 2012; Vivolo et al., 2010). Sexual assault is also the only form of violence in Canada that is not declining (Statistics Canada, 2015). In Canada, 30% of women and eight percent of men have experienced sexual assault since the age of 15 (Statistics Canada, 2021). This does not include intimate partner or childhood sexual assault. For these reasons, it is important to address the issue on multiple levels to help sexual violence stop. The determinants of heath focus on causes so that problems can be prevented. Thus, focusing on causes of sexualized violence should help create strategies to prevent it.

Many interventions, even institutional ones, are victim-focused and on the individual level (DeGue et al., 2012; Vivolo et al., 2010), teaching strategies to prevent sexual assault, empowering minorities to make safe choices (CDC, 2016) or providing medico-legal services after an assault (Peacock, 2022). Even when programs are not directed at victims, such as the few that encourage bystanders to speak up (Basile et al., 2022), still concentrate on preventing sexual assaults from being completed but not on preventing them from being attempted. Considering that many key risk factors such as exposure to violence, traditional gender roles, and hyper-masculinity are learned at a young age and over time, programs for teenagers and adults have minimal impact because they are provided after risk factors have been fully engrained (Vivolo et al., 2010). Gender norm programs are more successful (Basile et al., 2022) but the number of interventions that are perpetrator-focused and at the community or societal levels is low.

Most countries rely solely on the legal system to deal with perpetrators. Evidence shows that the court process often retraumatizes victims, and there is little evidence to show that the possibility of a harsh punishment deters violence. A stay in prison where violence and rape are common may seem retributive but upon release perpetrators are often (more) traumatized and well-schooled in toxic masculinity (Peacock, 2022). Considering all the risk factors, this punitive strategy may increase recidivism.

“In order to prevent sexual violence perpetration…we must first understand the circumstances and factors that influence its occurrence” (Vivolo et al., 2010). There are both risk and protective factors for perpetration (CDC, 2023; Vivolo et al., 2010). These upstream or causal factors are the ones that need to be impacted to decrease sexual violence and should be approached from all levels: individual and relationships, community, public policy, and globally.

The World Health Organization’s (WHO) Conceptual Framework for Action on the Social Determinants of Health (Solar O, 2010) is complex and involves two steps (see Figure 1a and 1b). I chose to focus on the step that involves the health inequities.

The framework includes, but moves beyond, the social-ecological model (Figure 1a). The Canadian Council on Social Determinants of Health (2015) reviewed 36 models, and the WHO model (Solar O, 2010) was one of seven showcased models for several reasons.



First, it includes all three categories of frameworks: explanatory (provides a basic explanation of the concept of social determinants of health), interactive (shows relationships between the determinants of health), and action-oriented (includes decision-making and policy-making processes and/or evaluation of interventions).

Second, the framework is multi-level, involving individual, community, societal, and global levels. Policy development is emphasized at each level to limit the social imbalances that cause health inequities: social stratification from the unequal distribution of power, prestige, and resources among groups in society; exposures and vulnerabilities of disadvantaged people to factors that harm health; and the unequal consequences of illness (Solar O, 2010). It calls for a holistic approach, and a primary prevention focus--a good model for sexual violence prevention because most current programs concentrate on tertiary prevention.

Third, it is a multi-sphere approach using social and environmental determinants. “The social-ecological model is used [for prevention] because sexual violence is complex” (Washington Coalition of Sexual Assault Programs, 2022).

Finally, it emphasizes intersectoral action (Canadian Council on Social Determinants of Health, 2015). Also known as a cross-cutting approach, many agree that this type of intervention is necessary for sexual violence prevention strategies (Vivolo et al., 2010; Wilkins et al., 2014). A cross-cutting approach is one where multiple organizations whose different mandates have similar risk or protective factors, work together to reduce the risks. Decades of research and program evaluations have shown that different forms of violence are strongly interconnected with common risk and protective factors, and mental, emotional, physical, and social consequences that contribute to similar chronic health issues. Furthermore, perpetrators are likely to be violent in multiple contexts (toward peers and partners; physically and sexually) and victims of violence often experience other forms of violence and are more likely to become perpetrators of violence (Wilkins et al., 2014). An example of a cross-cutting approach is: violence in the media is a common risk factor for sexual violence, youth violence, bullying, and suicide (Wilkins et al., 2014). Therefore, a sexual assault centre, a justice centre teaching about physical violence, a school with a bullying program, and a health organization that offers suicide prevention workshops could partner to educate about the effects of violence in the media or advocate for more stringent age minimums on violent movies.

I have curated and listed many of the risk factors for perpetrating sexual violence (see Figure 2). Finally, because much of the current programming for sexual violence is victim-focused, I have recreated the health inequities portion of the framework with programs and policy-focused ideas to address sexual violence in a non-victim-focused manner, leaning toward upstream interventions with a focus on policy (see Figure 3.) Sexual violence will not go away soon, but with policy development on multiple levels, addressing upstream causes and early childhood interventions, taking a cross-cutting approach, and assuming successful programs, we may be able to initiate a decrease. Given that a strong risk factor is copying peer behaviour during adolescence, I anticipate seeing a faster decrease in about ten years, when the children of families who were impacted successfully become teens and start influencing peers to behave in sexually positive manners.







References

  • Basile, K. C., DeGue, S., Jones, K., Freire, K., Dills, J., Smith, S. G., & Raiford, J. L. (2016). Sexual Violence Prevention Resource for Action: A compilation of the best available evidence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/SV-Prevention-Resource_508.pdf

  • Basile, K. C., & Saltzman, L. E. (2002). Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements, 1–94. https://doi.org/10.1037/e721362007-001

  • Basile, K. C., Smith, S. G., Kresnow, M.-J., Khatiwada, S., & Leemis, R. W. (2022). The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Sexual Violence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/nisvs/nisvsReportonSexualViolence.pdf

  • Canadian Council on Social Determinants of Health. (2015). A Review of Frameworks on the Determinants of Health. 1–76. https://nccdh.ca/images/uploads/comments/CCSDH_A-review-of-frameworks-on-the-determinants-of-health_EN.pdf

  • Centers for Disease Control and Prevention. (2023, May 12). Risk and Protective Factors for Sexual Violence. Violence Prevention. https://www.cdc.gov/violenceprevention/sexualviolence/riskprotectivefactors.html

  • CDC. (2023, July 23). Prevention Strategies: Sexual Violence Prevention. Center for Disease Control. https://www.cdc.gov/violenceprevention/sexualviolence/prevention.html

  • DeGue, S., Simon, T. R., Basile, K. C., Yee, S. L., Lang, K., & Spivak, H. (2012). Moving Forward by Looking Back: Reflecting on a Decade of CDC’s Work in Sexual Violence Prevention, 2000-2010. Journal of Women’s Health (15409996), 21(12), 1211–1218. https://doi.org/10.1089/jwh.2012.3973

  • Department of Justice Canada. (2017, January 10). The Impact of Trauma on Adult Sexual Assault Victims: PART I – The Traumatic Impact of Sexual Assault on Victims. https://www.justice.gc.ca/eng/rp-pr/jr/trauma/p2.html

  • Peacock, D. (2022). Moving Beyond a Reliance on Criminal Legal Strategies to Address the Root Causes of Domestic and Sexual Violence. Violence Against Women, 28(8), 1890–1907. https://doi.org/10.1177/10778012221086002

  • Solar O, I. A. (2010). A Conceptual Framework for Action on the Social Determinants of Health: Social determinants of health discussion paper 2 (Policy and Practice). World Health Organization. https://www.who.int/publications-detail-redirect/9789241500852

  • Statistics Canada. (2015, November 23). Criminal victimization in Canada, 2014. https://www150.statcan.gc.ca/n1/pub/85-002-x/2015001/article/14241-eng.htm#a2

  • Statistics Canada. (2021, August 25). Criminal victimization in Canada, 2019. https://www150.statcan.gc.ca/n1/pub/85-002-x/2021001/article/00014-eng.htm

  • Statistics Canada. (2019, December 5). Gender-based violence and unwanted sexual behaviour in Canada, 2018: Initial findings from the Survey of Safety in Public and Private Spaces. The Daily. https://www150.statcan.gc.ca/n1/daily-quotidien/191205/dq191205b-eng.htm

  • ValorUS. (2019, January 30). Applying a public health approach to preventing sexual and domestic violence. https://www.youtube.com/watch?v=vDsbsOZMP9I

  • Vivolo, A. M., Holland, K. M., Teten, A. L., & Holt, M. K. (2010). Developing Sexual Violence Prevention Strategies by Bridging Spheres of Public Health. Journal of Women’s Health (15409996), 19(10), 1811–1814. https://doi.org/10.1089/jwh.2010.2311

  • Washington Coalition of Sexual Assault Programs. (2022). The Social Ecological Model. Prevention. https://www.wcsap.org/prevention/concepts/social-ecological-model

  • Wilkins, N., Tsao, B., Hertz, M., Davis, R., & Klevens, J. (2014). Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence. Centers for Disease Control and Prevention and Prevention Institute. https://www.cdc.gov/violenceprevention/pdf/connecting_the_dots-a.pdf

 
 
 

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