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Putting It All Together: An Analysis of Sexual Violence from a Public Health Lens

  • crockaltenhof1
  • Dec 5, 2023
  • 8 min read



Sexual violence is all too common but most of the public do not realize it.  It often goes unreported and unmentioned even with close family or friends. It is the only violent crime in Canada that is increasing rather than decreasing. Anyone can be sexually assaulted but women and marginalized populations (homelessness, non-binary, Indigenous, black, other people of colour, disabled) are at higher risk. Intersectionality increases the risk.  One in three women have been sexually assaulted in their lifetime.  We are products of ‘rape culture’ when the “prevailing societal attitudes justify, tolerate, normalize and minimize sexual violence against women” (Baker, 2014). Although there are laws criminalizing sexual assault, they are not well-understood in the legal community and mistakes are made in cases, and the public are calling for lawyers and judges to undertake mandatory training prior to working on sexual assault cases. Most ‘prevention’ programs in society perpetuate our rape culture by assuming it will happen and educating potential victims to avoid being raped. A strong public health approach needs to be enacted to delve into and combat the risk factors and prevailing myths and beliefs in our society.


Like its 1946 definition, the World Health Organization (WHO) describes sexual health as “a state of complete physical, mental and social [sexual] well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946, p.1) adding that it must be positive, respectful, pleasurable, safe, and free of discrimination, coercion, and violence (“Education and Treatment in Human Sexuality: The Training of Health Professionals. Report of a WHO Meeting.,” 1975). Therefore, the presence or the constant threat of sexual violence is not healthy.

Sexual violence is any form of sexual contact committed against someone who does not consent or is unable to consent or refuse (Basile & Saltzman, 2002). It includes harassment and unwanted touching or activity, and can be in person or online (Howard, 2022). Victims often experience long-term problems: physical (chronic pain), gynecological (injuries, pregnancy, sexually transmitted infections), gastrointestinal, mental (depression, anxiety, panic attacks, suicidal behaviour, posttraumatic stress disorder), substance abuse, sexual health, or engage in risky sexual behaviours (DeGue et al., 2012; Vivolo et al., 2010). Its deep, widespread roots extend throughout generations of cultures and religions around the world.

In Canada, sexual assault is the only form of violence that is not declining (Statistics Canada, 2015). Thirty percent of women and eight percent of men have experienced sexual assault since the age of 15 (Statistics Canada, 2021). These numbers do not include intimate partner or childhood sexual assault. Sexual violence is a significant public health problem (DeGue et al., 2012; Vivolo et al., 2010) and must be addressed on multiple levels to eliminate it.

The determinants of heath represent core factors that affect health or illness. The social determinants of health (SDOH) are the nonmedical factors that influence health or illness (Centers for Disease Control and Prevention, 2022). Although most people think the opposite, the SDOH are more impactful to individual and population health than actual healthcare (Venkatapuram, 2022). This is evident even within the professional community by the prevalence of the biomedical model usage and programs that provide care for victims after an assault. A stronger attention to the root causes of sexualized violence would have more impact. There are many spheres of influence in our culture that we can address to prevent violence. We can create programs and policy from a social-ecological model, from a health lens, and from a legal lens.

Current prevention programs (DeGue et al., 2012; Vivolo et al., 2010) are provided at the individual level, teaching females strategies to prevent sexual assault or ‘make better choices’. Most perpetrators are male, but very few programs are directed at preventing male perpetration of sexual violence. Our victim-blaming culture is evident in our programming.

Key risk factors for victims and perpetrators are an early exposure to violence, traditional gender roles, and hyper-masculinity (male aggressiveness and dominance). Basile et al., (2022) also noted that there are also few programs for sexual violence prevention addressing those social determinants of health. Although mid-level spheres of education and awareness, such as challenging gender norms, have proven to more successful, they are not common.

In the broader macro-level sphere, many institutions have adopted policies regarding workplace violence and sexual harassment. There has been a paradigm shift in this area, but instances are still prevalent, just more covert (Mazaheri & Zonas, 2023). We need to do more. Most institutional programs still provide medico-legal services to individuals for care and follow-up, not prevention.

The World Health Organization (WHO) framework for action on the social determinants of health (Solar O, 2010) contains three categories of frameworks: explanatory, interactive, and action-oriented; and emphasizes policy development to limit social imbalances which cause health inequities. It calls for a holistic approach and a primary prevention focus.  It is a fitting model to address the gaps in current sexual violence prevention methods which rely on secondary and tertiary prevention.

Common risk factors for sexual violence include normalizing aggressive behaviours, family violence or any form of abuse, emotionally unsupportive family environment, early sexual initiation, and poverty. On a larger scale, societal norms that support gender stereotypical roles and weak laws and policies all contribute to sexual violence being tolerated by society. Protective factors include quality conflict resolution in the family, emotional connectedness, and empathy for others.

The WHO framework emphasizes intersectoral action with agencies that have similar risk factors even though having different mandates (Canadian Council on Social Determinants of Health, 2015). Many agree that this cross-cutting intervention is necessary for sexual violence prevention strategies (Vivolo et al., 2010; Wilkins et al., 2014). Much research has shown that different forms of violence are interconnected with common risk and protective factors that contribute to similar chronic health issues. Furthermore, perpetrators are frequently violent in multiple contexts, victims often experience several forms of violence, and are more likely to become perpetrators (Wilkins et al., 2014). Outcomes are better when multiple agencies work together to reduce risk factors.

Violence is unique from most other health issues because it is also a crime. There are more barriers to overcome if a victim of a sexual assault wants to proceed through the justice system. The poor treatment and stress on victims from police and legal personnel impact health and healing. Along with ‘rape culture’ and victim-blaming beliefs in our society, western legal systems also favour the perpetrator (the ‘accused’ in the legal system) as they are considered innocent until proven guilty, and the burden of proof is with the victim or ‘complainant’. Furthermore, sexual activity is usually a private activity so most sexual assaults go unwitnessed, making it difficult for the victim to prove. Many victims never finish the process. Research shows that only five percent report their sexual assault to police (Department of Justice Canada, 2017) and of those, only seven percent result in convictions (McMahon, 2016).

There are many problematic areas and trends in sexual assault cases in recent years.

  • Even well-educated professionals do not necessarily have the education or insight into their belief system about sexual violence. In 2014, a federal court judge asked a victim “Why couldn’t you just keep your knees together?” (Tunney, 2020).

  • The rough sex defense (Craig 2022) has greatly increased in the last decade. This is where the accused claims the complainant consented to being punched, strangled, and otherwise harmed.

  • Capacity to consent is not understood and judges are unlikely to find that complainants were incapacitated regardless of obvious signs (inability to walk or talk, vomiting, bladder incontinence), unless they were unconscious, which still requires proof (Craig, 2020).

  • The details of section 276 of the criminal code, known as the ‘rape shield’ law, are not well-understood, so a victim’s irrelevant previous sexual behaviour is sometimes allowed in court (Craig, 2016, 2017).

  • Defense attorneys take advantage of the lack of knowledge and purposefully use prohibited strategies to discredit the victim (a tactic known in the legal world as ‘whacking’), hoping neither prosecution nor judge objects (Tremonti, 2016).

Returning to the social determinants of health, policies are also needed in the legal arena to require sexual assault, sexual assault law, and trauma-informed education for police, lawyers, and judges who participate in the legal process. In the Appendix, the health inequities portion of the WHO framework was used to illustrate more sexual violence prevention possibilities from a non-victim-focused manner (Rock-Altenhof, 2023) that may be more successful than currently existing ones.

Conclusion

Sexual violence is considered a significant public health problem. It includes non-consensual verbal sexual harassment up to penetrative assaults and can be in person or online. Victims often experience long-term mental and physical health problems from unwanted sexual events, but most curricula to address prevention focuses on changing the behaviour of potential victims. There are few programs that intervene at an age before ‘rape culture’ can be engrained in young minds. Likewise, few programs address social determinants of health at mid and broad levels where more positive outcomes can be achieved. Quality education and policies addressing social determinants of health, must be implemented broadly, at the macro level, to successfully reduce the amount of sexual violence in our society.

References

Appendix



 
 
 

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