Sexual Violence Prevention: Resource for Action (A Compilation of the Best Available Evidence)

Feb 12

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🔹 Why are we republishing this? Due to recent federal policy changes, some CDC materials on sexual and reproductive health have been removed or altered. We are committed to ensuring that evidence-based, medically accurate resources remain publicly available.

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- Kathleen C. Basile, PhD
- Sarah DeGue, PhD
- Kathryn Jones, MSW
- Kimberley Freire, PhD
- Jenny Dills, MPH
- Sharon G. Smith, PhD
- Jerris L. Raiford, PhD
2016
Division of Violence Prevention
National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta, Georgia
Acknowledgements
We would like to thank the following individuals who contributed in specific ways to the development of this Prevention Resource. We give special thanks to Linda Dahlberg for her vision, guidance, and support throughout the development of this resource. We thank Division, Center, CDC leadership, and members of CDC Division of Violence Prevention’s Intimate Partner and Sexual Violence Workgroup for their careful review and helpful feedback on
earlier iterations of this document. We thank Alida Knuth for her formatting and design expertise. Last but definitely not least, we extend our thanks and gratitude to all the external reviewers for their helpful feedback, support and encouragement for this document.
Mark Bergeron-Naper
Massachusetts Department of Public Health
Carrie Bettinger-Lopez
White House, Office of the Vice President
Andrea Bright
Missouri Department of Health and Senior Services
Amalia Corby-Edwards
American Psychological Association
Andrea Hamor Edmondson
Oklahoma State Department of Health
Craig Fisher
American Psychological Association
Donna Greco
National Sexual Violence Resource Center
Jennifer Grove
National Sexual Violence Resource Center
Sandra Henriquez
California Coalition Against Sexual Assault
Rosie Hidalgo
White House, Office of the Vice President
Darlene Johnson
U.S. Department of Justice, Office of Violence Against Women
David Lee
California Coalition Against Sexual Assault
Kat Monusky
Washington Coalition of Sexual Assault Programs
Rebecca K. Odor
U.S. Department of Health and Human Services, Administration for Children and Families, Family Violence Prevention and Services Program
Lisa Fujie Parks Prevention Institute
Jen Przewoznik
North Carolina Coalition Against Sexual Assault
Karen Stahl
National Sexual Violence Resource Center
Kiersten Stewart
Futures Without Violence
Caira M. Woods
White House, Office of the Vice President
The experts above are listed with their affiliations at the time this document was reviewed.
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. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Note: The title of this document was changed in July 2023 to align with other Prevention Resources being developed by CDC’s Injury Center. The document was previously cited as “STOP SV: A Technical Package to Prevent Sexual Violence.”

Overview

and women; creating protective environments; and supporting victims/survivors to lessen harms. The strategies represented in this resource include those with a focus on preventing SV from happening in the first place as well as approaches to lessen the immediate and long-term harms of SV. Though the evidence for SV is still developing and more research is needed, the problem of SV is too large and costly and has too many urgent consequences to wait for perfect answers. There is a compelling need for prevention now and to learn from the efforts that are undertaken. Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health care, social services, business/labor, and government can bring about the successful implementation of this resource.

What is a Prevention Resource?

A Prevention Resource, formerly known as a technical package, is a compilation of a core set of strategies to achieve and sustain substantial reductions in a specific risk factor or outcome.1 CDC’s Prevention Resources help communities and states prioritize prevention activities based on the best available evidence. This resource has three components. The first component is the strategy or the preventive direction or actions to achieve the goal of preventing SV. The second component is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through programs, policies, and practices. The evidence for each of the approaches in preventing SV or its associated risk factors is included as the third component. This resource is intended to guide and inform prevention decision-making in communities and states.

Preventing Sexual Violence is a Priority

SV is a serious public health problem that affects millions of people each year. SV involves a range of acts including attempted or completed forced or alcohol/drug facilitated penetration (i.e., rape), being made to penetrate someone else, verbal (non-physical) pressure that results in unwanted penetration (i.e., sexual coercion), unwanted sexual contact (e.g., fondling), and non-contact unwanted sexual experiences (e.g., verbal harassment, voyeurism).2

SV is highly prevalent. Approximately 1 in 5 women (19.3%) in the United States have experienced rape or attempted rape in their lifetime and 43.9% have experienced other forms of SV. For instance, 12.5% have experienced sexual coercion, 27.3% have experienced unwanted sexual contact, and 32.1% have experienced non-contact unwanted sexual experiences.3 Although national prevalence studies indicate that women carry the greatest burden of SV over their lifetimes, men are also impacted by SV. Approximately 1 in 15 men (6.7%) have been made to penetrate someone at some point during their lives, 5.8% have experienced sexual coercion, 10.8% have experienced unwanted sexual contact, and 13.3% have experienced non-contact unwanted sexual experiences.3

As with other forms of violence, some racial/ethnic and sexual minority groups are disproportionately impacted by SV. Lifetime estimates of rape or attempted rape of women range from 32.3% among multiracial women, 27.5% among American Indian/Alaska Native women, 21.2% among Black women, 20.5% among non-Hispanic white women, to 13.6% among Hispanic women. Among men, 39.5% of multiracial men, 26.6% of Hispanic men, a quarter of American Indian/Alaska Native (24.5%) and Black men (24.4%), and 22.2% of non-Hispanic white men have also experienced some form of SV in their lifetime.3 Furthermore, among sexual minorities, 46.1% and 13.1% of bisexual and lesbian women, respectively, have experienced rape at some point in their lives, and 74.9% and 46.4%, respectively, have experienced other forms of SV in their lifetime. Among men, 47.2% bisexual men and 40.2% gay men have experienced some form of SV other than rape in their lifetime.4

SV starts early in the lifespan. Among women reporting a history of completed rape, 40% first experienced it before age 18, with more than
28% indicating they were first raped between the ages of 11 and 17; among men who were made to penetrate someone, 71% first experienced this
before the age of 25, and 21.3% experienced this before the age of 18.3
While adolescence seems to be a period of high risk, college may also be a particularly vulnerable time. In a large, cross-sectional survey of campus sexual assault, 20% of the undergraduate women indicated that they had been a victim of SV since beginning college.5

SV is associated with several risk and protective factors. Risk for SV perpetration is influenced by a range of factors, including characteristics of the individual and their social and physical environments. These factors interact with one another to increase or decrease risk for SV over time and within specific contexts. Examples of key risk factors for SV perpetration include a history of child physical abuse, exposure to parental violence, involvement in delinquent behavior, acceptance of violence, hyper-masculinity, traditional gender role norms, excessive alcohol use, early sexual initiation and sexual risk-taking behavior (e.g., sex without a condom), and association with sexually-aggressive peer groups.6 Poverty or low socioeconomic status,7 gender inequality,8 exposure to community crime and violence, social norms supportive of SV and male sexual entitlement, and weak laws and policies related to SV are also risk factors for SV perpetration.6,9 Less is known about protective factors—that is, factors that decrease or buffer the risk for SV. However, the evidence suggests that greater empathy, emotional health
and connectedness, academic achievement, and having parents who use reasoning to resolve family conflicts are associated with a lower risk of SV perpetration.6

SV is connected to other forms of violence. Research has demonstrated that experiences with SV are related to experiencing other types of violence. For example, girls who have been sexually abused are more likely to suffer physical violence and sexual violence re-victimization, and be a victim of intimate partner violence later in life.10 In addition, perpetrating bullying in early middle school is associated with subsequent sexual harassment perpetration.11 Adolescents who have experienced forced intercourse at some point in their life are more likely than those who have not been forced to have intercourse to have thoughts of suicide.12 The overlap and co-occurrence of SV and other types of violence may reflect the presence of shared risk factors across the multiple violent behaviors and experiences. As such, approaches that address multiple forms of violence and/or risk factors that are shared across the types of violence may be an effective and efficient way to prevent violence.

The health and economic consequences of SV are substantial. SV victimization may result in injuries that
are physical (e.g., bruising, genital trauma) or psychological (e.g., depression, anxiety, suicidal thoughts).13 The consequences of SV may also be chronic; some victims experience re-occurring gynecological, gastrointestinal, and sexual health problems.13 Victims may also suffer from post-traumatic stress disorder.13 SV is also associated with risk behaviors (e.g., smoking, excessive alcohol use) for chronic disease and medical conditions (e.g., high cholesterol, increased risk of a heart attack).14 In addition, sexual abuse in childhood and forced sexual initiation in adolescence
are associated with increased HIV- and STD-related risk-taking behaviors, including sex with multiple partners, sex with unfamiliar partners, sex with older partners, alcohol-related risky sex, anal sex, and low rates of condom use,9, 15-17 as well as HIV infection in adult women.18 Other negative consequences of SV victimization include decreased self- esteem and disruptions to daily routine.19 Readjustment after victimization can be challenging and influences recovery time. Victims may have difficulty in their personal relationships, in returning to work or school, and in regaining a sense of normalcy.13

To have the greatest impact on SV prevention, we must take advantage of the best available evidence and focus on the strategies and approaches most likely to impact SV.

Society incurs significant costs associated with the long-term physical and mental health consequences of sexual victimization.20-22 SV victims exceed non-victims in the average number and cost of medical care visits.23 Beyond medical costs, there are productivity costs and other long-term costs to victims and their families such as pain and suffering, trauma, disability, and risk of death. For example, findings from one state estimated the total cost of SV
in 2009 to be $4.7 billion, or about $1,580 per resident.24 This estimate included quality of life, work loss, medical (including mental health), and criminal justice costs. In a qualitative study of SV survivors, Loya25 found that SV and the trauma resulting from it can have an impact on the survivor’s employment in terms of time off from work, diminished performance, job loss, or being unable to work. These impacts disrupt earning power and have a long-term effect on the economic well-being of SV survivors.

SV can be prevented. Public health underscores the importance of primary prevention, or preventing SV before it occurs.26,27 A comprehensive approach with preventive interventions at multiple levels of the social ecological model (i.e., individual, relationship, community, and societal) is critical to having a population level impact on SV. Compared to other types of violence (e.g., youth violence) and other public health topics (e.g., HIV prevention), the evidence base for SV prevention is less developed. We must continue to build the evidence base of what works to prevent SV by investing in rigorous evaluation of promising prevention approaches. In the meantime, we must act on the evidence that does exist. There is evidence that some approaches, such as brief, one-session educational programs aimed at raising awareness and knowledge about SV, do not work to prevent SV perpetration.28 To have the greatest impact on SV prevention, we must take advantage of the best available evidence and focus on the strategies and approaches most likely to impact SV.

Assessing the Evidence

This Prevention Resource includes programs, practices, and policies with evidence of impact on SV victimization, perpetration, or risk factors for SV. To be considered for inclusion in the Prevention Resource, the program, practice, or policy selected had to meet at least one of these criteria: a) meta-analyses or systematic reviews showing impact on SV victimization or perpetration; b) evidence from at least one rigorous (e.g., randomized controlled trial [RCT] or quasi- experimental design) evaluation study that found significant preventive effects on SV victimization or perpetration; c) meta-analyses or systematic reviews showing impact on risk factors for SV victimization or perpetration, or d) evidence from at least one rigorous (e.g., RCT or quasi-experimental design) evaluation study that found significant impacts on risk factors for SV victimization or perpetration. Finally, consideration was also given to the likelihood of achieving beneficial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or with particular subgroups; and feasibility of implementation in a U.S. context if the program, policy, or practice has been evaluated in another country.

Within this resource, some approaches do not yet have research evidence demonstrating impact on rates of SV victimization or perpetration but instead are supported by evidence indicating impacts on risk factors for SV (e.g., rape-supportive peers, risky sexual behavior). In terms of the strength of the evidence, programs that have demonstrated effects on SV outcomes (reductions in perpetration or victimization) provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of community and societal level approaches on SV outcomes. Thus, approaches in this resource that have effects on risk factors reflect the developmental nature of the evidence base and the use of the best available evidence at a given time.

It is also important to note that there is often significant heterogeneity among the programs, policies, or practices
that fall within one approach or strategy area in terms of the nature and quality of the available evidence. Not all programs, policies, or practices that utilize the same approach (e.g., bystander training, empowerment-based training) are equally effective, and even those that are effective may not work across all populations. Very few evaluations have looked at diverse populations (e.g., racial/ethnic or sexual minorities).

It is also important to note that few programs have been designed for diverse populations, so tailoring programs
and more evaluation may be necessary to address different population groups. The examples provided are not intended to be a comprehensive list of evidence-based programs, policies, or practices for each approach, but rather illustrate models that have been shown to impact SV victimization or perpetration or have beneficial effects on risk factors for SV.

In practice, the effectiveness of the programs, policies and practices identified in this resource will be strongly dependent on the quality of their implementation and the communities in which they are implemented. Implementation guidance to assist practitioners, organizations and communities will be developed separately.

Context and Cross-Cutting Themes

The strategies and approaches in this resource represent different levels of the social ecology with efforts not only intended to impact individual behaviors, but also the relationships, families, schools, communities, and social structures that influence risk and protective factors for SV and ultimately SV behaviors (see box below). Strategies
and the approaches within them are intended to work in combination and reinforce each other to influence both individual and environmental factors related to SV. While individual skills are important and research has shown some skill-based programs to be useful for reducing SV, approaches addressing relationships, schools, communities and larger social forces are equally important for a comprehensive approach that can have the greatest public health impact.

The example programs, policies, and practices have been implemented within particular contexts. Each community and organization working on SV prevention across the nation brings its own social and cultural context to bear on the selection of strategies and approaches that are most relevant to its populations and settings. Practitioners in the field may be in the best position to assess the needs and strengths of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their context.

One important feature of the Prevention Resource is the complementary, but potentially synergistic impact of the strategies and approaches. The strategies and approaches delineate prevention efforts that impact various SV- related outcomes. The strategies are not mutually exclusive categories, but each has an immediate focus. The strategy Create Protective Environments, for example, may ultimately impact SV social norms, but the immediate focus of this strategy is to change school, workplace and community environmental factors. Similarly, the approaches within any one strategy sometimes have components that cross other strategies. For example, Mobilizing Men and Boys as Allies, an approach in the Promote Social Norms that Protect against Violence strategy, includes fostering healthy dating relationships which is also found in some of the approaches under the Teach Skills to Prevent SV strategy.

The strategies and approaches in this resource may impact other forms of violence,29 which reflects the interconnectedness and overlap between SV risk and protective factors and risk and protective factors for other forms of violence. For example, a program within Bystander Approaches has not only been shown to reduce SV, but also dating violence and stalking.30 In addition, the approach Teaching Healthy, Safe Dating and Intimate Relationship Skills to Adolescents includes an example program that has shown reductions in SV and also peer victimization and weapon carrying behavior.31 Further, some of the approaches in this resource address early exposures to violence which is a risk factor for later SV perpetration. For example, Treatment for at-Risk Children and Families to Prevent Problem Behavior reflects the strong connection between early witnessing or experiences of violence (e.g., child abuse and neglect) and SV.6 Programs described under this approach are intended to promote training, therapy, and other supports early in life that can impact risk for SV in adolescence and adulthood.

SV prevention has always centered on issues related to gender, and gender equality is central to SV prevention. In the context of health and SV prevention, gender equality refers to equal rights, responsibilities and opportunities that enable all individuals to achieve their full rights and potential to be healthy, contribute to health development, and benefit from the results.*,33,34 While most gender-based strategies are defined by male and female identities, it is important to recognize and affirm identities that do not necessarily fit into binary male or female sex categories.33 Many in the field, particularly in the global context, refer to SV as a form of gender-based violence (GBV). In this resource, the strategy Provide Opportunities to Empower and Support Girls and Women directly addresses gender equality through specific approaches intended to, for example, improve the social and economic status of girls and women. Gender, however, cuts across all strategies included in the resource and is represented by approaches that influence both male and female gender norms, and other risk and protective factors. For example, the approach Mobilizing Men and Boys as Allies in preventing SV perpetration is intended to foster healthy, positive norms about masculinity, gender and violence. In addition, approaches included under other strategies focus on environmental factors that influence social norms related to violence, including gender norms.

The strategies and approaches in this resource address prevention across the lifespan. Addressing SV over the lifespan requires particular attention to children’s critical developmental years and the connections between childhood victimization experiences and health and well-being later in life. The experience of violence early in life is not only traumatic in childhood, but manifests in poor mental and physical health outcomes, as well as increased risk for

SV victimization or perpetration later in life. Approaches that promote safe, stable and nurturing relationships and environments for children and their families35 are important foundational steps in a comprehensive SV prevention effort. Indeed, many of the strategies and approaches in this resource are focused on children and youth given that SV tends to happen early in life for victims.

* Some gender-based initiatives use the term gender equity, which is related to, but not necessarily a synonym for gender equality. Gender equity refers to “fairness of treatment for women and men, according to their respective needs. This may include equal treatment or treatment that is different but which is considered equivalent in terms of rights, benefits, obligations and opportunities.”32 We use the term gender equality in the resource to be consistent with the literature we are citing.

Several approaches in the resource focus on preventing SV perpetration. This is in keeping with CDC’s emphasis on promoting prosocial behavior and creating the context for non-violent behavior, relationships, and norms to prevent SV. Preventing behavioral patterns of aggression and violence, particularly from taking shape in the first place, is an important step toward achieving population-level reductions in rates of SV. Other approaches in this resource focus on treatment or risk reduction for SV victimization. For example, Treatment for Victims of SV, an approach in the Support Victims/Survivors to Lessen Harms strategy, is exclusively focused on helping victims after victimization occurs. Empowerment Based Training is one approach under the Teach Skills to Prevent SV strategy that focuses on reduction of risk for SV victimization. Similarly, approaches within the Provide Opportunities to Empower and Support Girls and Women strategy aim to strengthen economic supports, leadership, and opportunities for girls and women to reduce risk for SV victimization. These approaches can serve as a useful and effective complement to efforts focused on the prevention of perpetration, particularly when implemented as part of a comprehensive, multifaceted prevention effort. It is critical that any program, practice, or policy focused specifically on reducing risk for victimization avoid placing any responsibility, implied or explicit, for potential victimization on participants.

Implementing this resource will require the engagement and investment of multiple sectors. The resource includes strategies where public health agencies are well positioned to bring leadership and support to implementation efforts. It also includes strategies where public health can serve as an important collaborator (e.g., strategies addressing community and societal level risks), but where leadership and commitment from other sectors such as business/labor is critical to implement a particular policy or program (e.g., workplace policies). The role of various sectors in the implementation of a strategy or approach is described further in the section on Sector Involvement.

In the sections that follow, the strategies and approaches with the best available evidence for preventing SV are described.

Many of the strategies and approaches in this resource are focused on children and youth given that SV tends to happen early in life for victims.

Promote Social Norms that Protect Against Violence

Rationale

Changing social norms that accept or allow indifference to violence is necessary to prevent SV. Norms are group- level beliefs and expectations about how members of the group should behave. The group can be large or small, ranging from the cultural norms of an entire country to those of a small sub-population. Gender norms define appropriate behaviors for men and women, and girls and boys, in terms of roles, behavior, and how to relate to one another. Restrictive gender norms (i.e., rigid ideas about the appropriate roles and behavior of men and women) can serve to support or condone violent behavior in intimate and other relationships. Studies show that individuals and communities adhering to restrictive and harmful social norms are more likely to perpetrate physical, sexual, and emotional violence against women.6,9

Approaches

The following approaches seek to change social norms in ways that protect against SV.

Bystander Approaches. These types of approaches engage individuals to change social norms and provide leadership around preventing SV. These types of approaches engage people, often youth, with the purpose of promoting social norms that protect against violence. They are also used to motivate people to promote protective norms through providing peer leadership around preventing SV and to help when they see behavior that puts others at risk and take appropriate steps to safely and effectively intervene. Bystander approaches have typically been evaluated in high school and college settings.

Mobilizing Men and Boys as Allies. These approaches provide an opportunity to encourage men and boys to be allies in preventing sexual and relationship violence by demonstrating their role in preventing violence and supporting victims while also teaching skills and reinforcing norms that reduce their own risk for future perpetration. Such approaches work by fostering healthy, positive norms about masculinity, gender, and violence among individuals with potential for these social norms to spread through their social networks. Approaches focused on male audiences can be implemented in targeted peer groups, such as sports teams or fraternities, or can recruit men from high schools, colleges, or community-based organizations for participation. Some programs for youth utilize adult male implementers who can serve as strong role models for healthy, positive definitions of masculinity.

Potential Outcomes

Reductions in acceptability of SV
Increases in favorable beliefs towards safe communities
Increases in favorable attitudes towards women and girls
Increases in recognition of abusive behavior towards men, women, and children
Increases in bystander behavior to prevent violence against men, women, and children
Reductions in negative bystander behavior
Reductions in the perpetration of SV
Reductions in the perpetration of related forms of violence (e.g., stalking, dating violence, intimate partner violence)
Reductions in peer support for violence

Evidence

There is some evidence suggesting that bystander approaches and approaches that mobilize men and boys as allies can prevent SV perpetration.

Bystander Approaches. Experimental evaluations show that programs such as Bringing in the Bystander and Green Dot can empower young people to intervene in their peer groups by speaking up against sexist language or behaviors that promote violence, reinforcing positive social norms, and offering help or support in situations where violence may occur or has occurred.36-38 Evidence suggests that these programs can increase positive bystander intervention behaviors (e.g., stepping in to help or speaking up) and increase participants’ confidence in their own ability to intervene to prevent violence. Evaluations of Bringing in the Bystander show increases in self-efficacy and intentions to engage in bystanding among college students36 and bystander behaviors that involve helping friends.39

An evaluation of Green Dot implemented with college students found the intervention campus had an 11% lower rate of sexual harassment and stalking victimization and a 19% lower rate of sexual harassment and stalking perpetration when compared to two non-intervention campuses.38 Another evaluation found that Green Dot substantially decreased SV, including sexual harassment, dating violence, and stalking in high schools, including a decrease in SV perpetration.30

Mobilizing Men and Boys as Allies. Several programs have been developed and implemented across the country and internationally that focus on engaging men and boys as allies, modeling positive masculinity, and changing social and peer-group norms related to relationships, violence, and sexuality, but few have yet been evaluated
and more evidence is needed to understand the effectiveness of these approaches.40 Coaching Boys into Men is

an example of a program with rigorous evaluation evidence that engages boys through high school athletics by providing coaches with training tools to model and promote respectful, non-violent, healthy relationships with their male athletes. Coaching Boys into Men has been shown to decrease negative bystander behavior (e.g., laughing at sexist jokes) and decrease dating violence perpetration, including physical, sexual, and emotional abuse, among male high school athletes.41, 42

Several programs have been developed and implemented that focus on engaging men and boys as allies, modeling positive masculinity, and changing social and peer-group norms related to relationships, violence, and sexuality.

Teach Skills to Prevent Sexual Violence

Rationale

Individual skill-based learning is an important component of a comprehensive approach to SV prevention. Several individual skills are associated with preventing SV, including social-emotional learning skills (e.g., empathy,
conflict management, and communication), healthy dating and intimate relationship skills, skills related to healthy sexuality, and empowerment skills. Building individual skills in these areas can help reduce both perpetration of and victimization from SV including sexual harassment, as well as bullying, dating violence, and other factors associated with SV (e.g., empathy, increased communication about sex).

Approaches

There are a number of approaches that utilize skills-building training to address SV perpetration, victimization or risk factors for SV. These include:

Social-emotional learning approaches. These approaches work in childhood and adolescence to enhance a core set of social and emotional skills including communication and problem-solving, empathy, emotional regulation, conflict management, and bystanding skills. In addition to providing information about violence, these approaches focus on changing the way children and adolescents think and feel about violence and provide opportunities to practice and reinforce skills. These approaches have typically been used in middle and high school settings.

Teaching healthy, safe dating and intimate relationship skills to adolescents. These programs strive to reduce
SV that occurs in the context of dating and intimate partner relationships. Such approaches can work to build communication and conflict resolution skills as well as expectations for caring, respectful, and non-violent behavior. Opportunities to practice and reinforce these skills are an important part of prevention programs that work. Although typically implemented with adolescent populations in school-based settings, these approaches and skills may also be useful with young adults.

Promoting healthy sexuality. These approaches focus on comprehensive sex education that addresses sexual communication, sexual respect, and consent. These approaches protect against SV by increasing awareness of risks and improving communication between parents and youth. They are also cross-cutting in that they often focus on sexual health (e.g., risk for HIV or STDs, pregnancy prevention) as well as empowering youth to reduce risk for SV and dating violence by encouraging sexual communication and healthy sexual behavior. Although these approaches focus on sexual health outcomes, they may also result in decreased risk for SV due to impacts on shared risk factors. Specifically these approaches focus on such things as delaying sexual initiation as well as reducing sexual risk-taking (e.g., sex without a condom, multiple sexual partners, and preference for impersonal sex) which are all risk factors for SV perpetration as well as for STDs and other negative sexual health outcomes.6

Empowerment-based training for women to reduce risk for victimization. These approaches focus on strengthening the ability of women to assess risk for violence in relationships and situations and empowering them
to act. They address potential emotional and physical barriers that may inhibit actions to reduce risk for sexual victimization, such as fear, internalized sex role norms, or physical size and strength. Empowerment-based approaches that focus on increasing participants’ self-efficacy to identify and reduce exposure to risky situations and people through intensive skills training have greater research and theoretical support than approaches focused primarily on physical self-defense training. Empowerment-based training approaches have typically been implemented and evaluated with college populations.

Potential Outcomes

Reductions in SV victimization and perpetration
Reductions in sexual harassment perpetration
Reductions in teen dating violence victimization and perpetration
Reductions in stalking victimization and perpetration
Reductions in homophobic teasing victimization
Increases in self-efficacy and intentions to engage in active bystanding behavior
Reductions in peer victimization
Reductions in weapon carrying
Reductions in sexual risk behaviors (e.g., sex without a condom, number of sexual partners)

Evidence

The current evidence suggests several approaches to teach skills that can lead to reductions in SV perpetration and victimization or their risk factors.

Social-emotional learning approaches. These types of approaches have demonstrated reductions in peer violence43 and may also prevent SV. One example is the Second Step: Student Success through Prevention program, which is a social-emotional skills based program for middle school students aimed at reducing bullying and SV perpetration. The program is delivered over 15 weeks by teachers and includes content related to bullying, problem-solving skills, emotion management, and empathy. Lessons are highly interactive and incorporate small-group and classroom discussions, activities, dyadic exercises, and individual work. A rigorous multi-site evaluation found that Second Step was associated with a 39% reduction in SV perpetration and a 56% reduction in homophobic teasing victimization in one of the two states where it was implemented; implementation differences between sites may account for the variation in effectiveness.44

Teaching healthy, safe dating and intimate relationship skills to adolescents. These approaches, often delivered in school settings, build the skills needed to support healthy, safe relationships. One example is the Safe Dates program, which focuses on teaching healthy relationship skills to adolescents, including positive communication, anger management, and conflict resolution. Safe Dates includes a 10-session curriculum focused on attitudes and behaviors associated with dating abuse and violence, as well as a play to set the stage for the program, a poster contest to reinforce concepts learned in the curriculum, and parenting materials. Results of a rigorous evaluation found that Safe Dates reduces physical and sexual violence perpetration and victimization within the dating context among 8th and 9th graders. Youth exposed to Safe Dates reported from 56% to 92% less dating violence victimization and perpetration compared to controls at follow-up. The effects of the Safe Dates program were sustained for four years after implementation.45 Additional research found that Safe Dates also reduced peer victimization and weapon carrying behavior among youth receiving the intervention one year after the intervention.31 The program has also been found to have similar effects for males and females and for racial minority and non-minority adolescents.45

Promoting healthy sexuality. Comprehensive sex education programs have been shown to reduce high risk sexual behavior,46 a clear risk factor for SV victimization and perpetration.6,47

Strong African American Families (SAAF) is a prevention program developed for rural African American parents and their preadolescent children. The program seeks to prevent adolescent problem behaviors, including early sexual involvement and risky sexual behavior, by focusing on protective parenting practices (e.g., parental involvement, limit setting, consistent discipline, monitoring, adaptive racial socialization, general communication, and specific parent-child communication and expectations around sexual behavior, alcohol, and substance abuse). A rigorous evaluation of SAAF found improvements in parenting practices among parents in the intervention group relative
to those in the control group.48 Long-term follow up assessments when youth were 17 years old (65 months from pre-test) demonstrated that changes in parenting practices mediated changes in sexual behavior among the youth. Intervention youth (vs. controls) had higher levels of self-pride and protective sexual norms, which in turn resulted in later onset of sexual behavior and engagement in fewer high-risk sexual behaviors.

Another example is the Safer Choices program which is a multi-component educational program focused on HIV, other STDs, and pregnancy prevention and designed to reduce sexual risk behaviors and increase protective behaviors among high school students.49 Safer Choices includes student, school staff and parental components. A rigorous evaluation of Safer Choices involving 3,869 ninth-grade students revealed that students in schools that received Safer Choices (compared to students in comparison group schools that received a standard HIV knowledge- based curriculum) showed reductions at 31 month follow up in several high-risk sexual behaviors (e.g., frequency of intercourse without a condom, number of sexual partners with whom students had intercourse without a condom).

Empowerment-based training for women to reduce risk for victimization. The Enhanced Assess, Acknowledge, Act program is a 12-hour victimization prevention program for college-aged women that provides education and skills training with the goal of being able to assess risk from acquaintances, overcome emotional barriers in acknowledging danger, and use verbal and physical strategies to reduce risk for violence. In a rigorous study of Canadian college women, participants were 50.4% less likely to have experienced a rape and/or attempted rape at one year follow-up than a control group. Risk of sexual coercion and other non-consensual sexual contact was also significantly lower in the intervention group.50

Comprehensive sex education programs have been shown to reduce high risk sexual behavior, a clear risk factor for SV victimization and perpetration.

Provide Opportunities to Empower and Support Girls and Women

Rationale

Empowering and supporting girls and women through education, employment, income supports and providing other opportunities (e.g., for leadership, civic participation) is important for reducing women and girls’ risk for SV. Studies show that gender inequality in education, employment, and income results in increased risk for SV.8,51 Poverty and
low income status have been directly linked to SV and sexual trafficking7,52 and are conceptually linked to vulnerability for abuse in that they force women and their children into situations that may put them at increased risk for SV, such as walking home alone, living in unstable and unsafe housing, limiting the time and opportunities parents have to supervise their children, or engaging in sex work out of financial necessity.53 Cross-national evidence indicates that rates of SV are lower in countries where women have higher educational and occupational status.54 Policies and programs that improve economic security and stability for women and provide women and girls with opportunities to strengthen their education, employment, and income outcomes can reduce the risk for SV victimization.

Approaches

Two approaches to empower and support girls and women in ways that can reduce their risk for SV include strengthening economic supports and increasing leadership opportunities.

Strengthening economic supports for women and families. This approach addresses poverty, economic security, and power imbalances between women and men. The economic security of families depends on women’s access to full and equal labor force participation, including having comparable salaries to men, income generating options, and work supports such as affordable quality child care through vouchers, lower cost child care, or cash-transfers to off-set the cost of quality, full-time child care. Provision of these types of supports to ensure women can remain in and contribute substantially to the workforce not only improves their economic conditions and promotes family stability, but also decreases gender inequality, which has been linked to risk for SV.8,54 Paid family and medical leave is also critical because it provides income replacement to workers for life events such as the birth of a child or a short- or long-term illness. When these life events arise, women and children can become vulnerable to financial, employment, and housing instability, increasing their risk for SV victimization.7,55

Strengthening leadership and opportunities for adolescent girls. Programs that build confidence, knowledge, and leadership skills in young women can lead to greater outcomes in education, employment, and community engagement, including political participation. Such programming ideally involves girls as leaders in planning, development, and implementation. Effective programs also support family involvement and provide opportunities for girls to connect with their cultural and community identities. Effective girls’ programming provides a safe space for girls to grow and connect while developing leadership skills and abilities.56 Such approaches may improve girls’ educational and occupational opportunities and contribute to the status and influence of women in society, potentially reducing risk for SV, given the links between gender inequality, low SES, educational and occupational status of women, and risk for SV.7,8,54

Potential Outcomes

Increases in economic stability for women
Increases in equitable education opportunities
Increases in gender equality and economic and occupational status of women
Decreases in poverty of women and children
Decreases in pay differentials between women and men
Increases in employment stability for women
Reductions in sexual violence victimization
Reductions in sexual harassment
Reductions in sexual trafficking
Increases in knowledge of gender norms and health
Increases in knowledge and skills for girls on healthy relationships, education and employment, and civic engagement
Increased leadership skills for girls and young women

Evidence

There are a number of policies and programs with evidence of impact on gender inequality and related risk factors for SV.

Strengthening economic supports for women and families. The majority of states have equal pay laws, although the laws themselves vary in terms of the populations covered, remedies available to employees, and the nature and extent to which comparable worth provisions are included.57,58 Comparable worth—which means equal pay for women and men for equivalent work—is determined by measuring the skill, working conditions, effort, and responsibility of positions, and determining pay rates based on these factors.59 Studies of the potential impact of a national comparable worth policy on earnings inequality show decreases in overall earnings inequality, inequality between women and men, and inequality among women.60,61 More recent findings from an analysis of the 2010-2012 Current Population Survey Annual Social and Economic supplement show potential impacts on women’s annual earnings, annual family income, and poverty rates even after controlling for labor supply, human capital, and labor market characteristics.62 These policies could have an impact on reducing SV by increasing economic stability of women and their families, given that economic inequality is a known risk factor for SV victimization.7

Adequate work supports such as affordable and good quality child care are essential to working parents, particularly single mothers. The evidence indicates that child care prices can significantly impede married mothers’ labor force participation.63 Family-friendly policies such as maternity benefits and paid family and medical leave can also contribute to economic security. Women with maternity benefits are more likely to return to their original employers.64 A related benefit is that mothers who are employed prior to child birth and who delay returning to work after giving birth experience fewer depressive symptoms than those who return to work earlier,65 which suggests the importance of maternity leave on the psychological well-being of mothers. While affordable child care and paid family leave policies have not been directly linked to reductions in SV, the literature suggests they are linked to mothers staying employed, which may be protective against SV victimization given the links in the literature between unemployment and SV.7

Income generating options such as Microfinance provide loans and savings opportunities to low-income households to improve the financial and social status of women and families.66 Microfinance typically includes incentives for repayment (e.g., access to future loans), and social supports such as borrower groups in which members collectively guarantee loans for each other. Loan and savings programs are sometimes combined with participatory multi- session training on topics that promote empowerment and influence women’s social status and health including domestic violence, gender norms, sexuality and HIV. Microfinance is supported by theories of sustainable living that hypothesize that individuals and families draw from multiple types of capital—including financial, social, human, natural and physical resources—to make a living and survive.53 Kim et al.67 and Pronyk et al.68 found that microfinance in combination with training on gender norms and health topics reduced participants experience with past-year physical and sexual intimate partner violence by half after two years in the program. Although microfinance has been mostly studied in low income countries, the application of sustainable living is relevant to the experiences of poor women living in the United States, and microfinance opportunities are viable options for increasing women’s household income. This is likely to protect against SV victimization given low income puts women at risk for SV.7 There are organizations providing this type of lending in the United States.

Strengthening leadership and opportunities for adolescent girls. These programs work by building confidence and leadership skills in young women as a way to influence their potential in education, employment, and community engagement. One example is Powerful Voices, a Seattle, Washington-based organization that provides opportunities for adolescent girls to develop individual leadership skills, while also seeking to address root issues for gender inequity through social justice. Powerful Voices offers several programs, including: Powerful Choices, a middle school curriculum for girls; girl justice training; Girlvolution Conference; community coalitions led by girls; and the Youth Employment Program for adolescent girls to build their marketability and job readiness. Evaluation results show that after participating in the program, the majority of girls had increased connection to their cultural identity and values, increased their ability to develop healthy relationships with peers and adults, received performance evaluations indicating “good” or “excellent” job skills, and had increased motivation to excel at school.69 While there is not empirical evidence linking this program to reductions in SV, it is expected that school success and improved job skills in adolescence will lead to reduced risk of poverty and low educational attainment which are known risk factors for SV victimization.7

Policies and programs that improve economic security and stability for women and provide women and girls with opportunities to strengthen their education, employment, and income outcomes can reduce the risk for SV victimization.

Create Protective Environments

Rationale

Creating protective community environments is a necessary step towards achieving population-level reductions
in SV. Communities can include any defined population with shared characteristics and environments, including schools, neighborhoods, cities, organizations (e.g., workplaces), or institutions. Approaches that operate by modifying characteristics of the community, rather than individuals within the community, are considered community-level approaches. Such approaches can involve, for example, changes to policies, institutional structures, or the social and physical environment in an effort to reduce risk characteristics and increase protective factors that affect the entire community. Characteristics of the social and physical environment can have a significant influence on individual behavior creating a context that can promote positive behavior or facilitate harmful behavior. Although the evidence base supporting community-level approaches to prevent SV is less developed than the individual- or relationship- level evidence base, it is growing.

Approaches

The current evidence suggests three approaches with promise for modifying community-level characteristics associated with SV to create protective environments. These include:

Improving safety and monitoring in schools. These approaches monitor and modify physical and social characteristics of the school environment to reduce SV by addressing areas where students feel less safe, to identify safe spaces and staff support for students, and to create an atmosphere of intolerance for harassment and violence. Although these approaches can have an impact on their own, they can be implemented in conjunction with other efforts to educate, teach skills, and change social norms related to sexual and relationship violence in schools. Such approaches have typically been used in middle and high school environments, but could be adapted for use on college campuses or other settings.

Establishing and consistently applying workplace policies. Workplace policies address risk factors for SV and create healthy organizational climates. These policies are designed to help employees and managers know what is expected of them with respect to standards of behavior and can prevent workplace bullying and sexual harassment. Research indicates that individual characteristics and organizational characteristics interact to create an environment in which sexual harassment is tolerated.70 Sexual harassment is a form of SV2 and it also creates conditions that are conducive to other forms of SV.71,72 Individual characteristics can be mitigated by changing the organizational culture and tolerance of sexual harassment.

Addressing community-level risks through environmental approaches. These approaches address aspects of neighborhood and other community settings
to make SV less likely. Such approaches address community-level risk factors by changing, enacting, or enforcing laws, regulations, or organizational policies (e.g., alcohol policies) or by changing the physical environment, economic or social incentives (or consequences) for behavior, or other characteristics of the community (e.g., ability to monitor and respond to problem behavior, increased social controls). Community-level environmental approaches have potential for population-level impact on SV outcomes, often at low cost for implementation.

Potential Outcomes

Reductions in perceived tolerance of sexual harassment and violence in communities
Reductions in sexual harassment
Reductions in excessive alcohol use at the community level
Increases in indicators of community connectedness
Increases in feelings of safety in one’s school, workplace, or neighborhood
Reductions in rates of SV at the community level
Reductions in bullying and other youth violence
Reductions in teen dating violence

Evidence

Current evidence provides some support for these types of approaches in reducing risk for SV.

Improving safety and monitoring in schools. Research has found that modifying the physical environment of schools to increase monitoring in areas perceived as unsafe can have a beneficial impact on rates of sexual harassment, other SV, and dating violence among students. Shifting Boundaries building-level intervention is an example of a school-based intervention that involves (a) revising school protocols for identifying and responding to dating violence and sexual harassment, (b) the use of temporary building-based restraining orders to reinforce respectful boundaries between victims and perpetrators, (c) a poster campaign, and (d) increasing staff monitoring based on “hotspot” mapping that students complete. Shifting Boundaries building-level intervention was found to reduce peer SV perpetration by 40% and sexual harassment perpetration by 34% among middle school students in New York City in a rigorous evaluation.73 Reductions were also found for peer SV victimization and SV victimization by a dating partner.

Establishing and consistently applying workplace policies. Proactive Sexual Harassment Prevention Policies and Procedures that include commitment from top management, zero tolerance, notification to applicants and new hires of harassment-free environments, regular organizational assessments, and consistent, specific training can reduce workplace SV behaviors. A national study of Canadian women74 found that proactive versus information-only policies were associated with fewer incidents of sexual harassment in the past 12 months. Women in workplaces with proactive sexual harassment policies were less likely to be physically threatened or to be the targets of unwanted sexual behavior or comments. Women also responded more assertively to unwanted sexual behavior when the workplace implemented policy, complaint procedures, and training to prevent sexual harassment. A more recent review of previously published workplace ethnographies found that having formal, written grievance procedures protected women from predatory harassment—the most threatening and well-defined form of sexual harassment.71

Addressing community-level risks through environmental approaches. Research suggests that changes to alcohol-related policies can reduce risk for SV at the community level.75 Excessive alcohol use interacts with other individual and community-level risk factors to increase the risk for SV perpetration. Also, the location and concentration of alcohol outlets in a community can have a negative impact on characteristics of the community, including perceived safety and social connections between individuals, which can in turn influence rates of violence. Alcohol policy approaches with the strongest evidence related to SV are those which work to reduce excessive alcohol use by increasing prices or reducing the density of outlets in a community. Research has found that higher alcohol prices are associated with lower rates of SV victimization in communities, while greater outlet density is linked to higher rates of SV.75

Support Victims/Survivors to Lessen Harms

Rationale

Violence victimization in childhood, adolescence, or adulthood can have long-term effects on the psychological well-being and functioning of survivors.12,13,76 Exposure to violence and other trauma in childhood can also increase risk for later SV perpetration and other problem behaviors in adolescence and adulthood.6 To lessen these harms, this strategy employs the use of evidence-based therapeutic and victim centered approaches that address the needs of survivors to improve their outcomes and reduce long-term risks for negative psychological and behavioral consequences. Approaches for youth, including those at risk for or who have engaged in sexual offending behaviors, often address the needs of the family as well to improve parent-child relationships and increase the supports available to youth and their parents in their homes and communities.

Approaches

The current evidence suggests the following three approaches:

Victim-centered services. These approaches include an array of formal services such as support groups, crisis intervention, medical and legal advocacy, and access to community resources to help improve outcomes for survivors and mitigate long-term negative health consequences. Services are based on the unique needs and circumstances of victims and survivors and coordinated among community agencies and victim-advocates.

Treatment for victims of SV. These approaches include a range of evidence-based psychological interventions that are conducted in therapeutic settings by licensed providers. Psychosocial interventions help address depression, fear and anxiety, problems adjusting to school, work or daily life and other symptoms of distress associated with experiencing SV. These types of interventions are associated with improved psychological health and long-term positive impact for victims/survivors of SV.77,78 Some programs are designed for specific populations of SV victims (i.e., child vs. adult).

Treatment for at-risk children and families to prevent problem behavior, including sex-offending. Many youth at risk for violence perpetration and other serious behavioral problems in childhood and adolescence have been exposed to violence in their homes or communities as witnesses or victims.79 These intensive therapeutic approaches address the individual, family, school and community factors associated with violence perpetration, including sexual offending among these high-risk and high-need youth. Importantly, these approaches also focus on strengthening parent-child relationships and parental outcomes, such as stress and depression, which influence parenting behaviors that may impact children’s risk for SV perpetration.

Potential Outcomes

Reductions in short- and long-term negative effects of SV victimization
Reductions in risk for later SV perpetration among victimized youth
Reductions in parental stress and depression and improvements in
parenting outcomes for parents of youth with behavioral problems
Improvements in parental limit setting, parent-child communication, and youth’s prosocial behavior
Reductions in problematic sexual behavior reoffending
Reductions in arrests for sexual crimes
Improvements in family cohesion and adaptability
Improvements in peer relations, including aggression
Improvements in academic performance
Improvements in access to services for SV survivors

Evidence

There is strong support for the value of victim-centered services and therapeutic approaches in reducing the short- and long-term impacts of SV. Examples of specific approaches with evidence include:

Victim-centered services. Rape Crisis Centers provide a safe, healing environment in which survivors can access resources and victim advocacy, and studies show that survivors consider the services received as healing and helpful.80 A study conducted in one state found that most victims accessing advocacy services reported high levels of information (62%), support provision (79%), and help in making decisions (54%).81 Victims who work with advocates had more positive experiences with both the medical and legal systems, including increased reporting and receipt of medical care, and decreased feelings of distress.82 Other types of services include Sexual Assault Response Teams and Sexual Assault Nurse Examiner programs. These are valuable and widely-used practices but currently have not been rigorously evaluated.

Treatment for victims of SV. There are a number of evidence-based treatments for victims of SV. One example is Trauma-focused Cognitive Behavioral Therapy (TF–CBT) which is a widely-used, evidence-based treatment for children, adolescents, and their non-offending parents/caregivers. The goals of TF–CBT are to address the negative effects of sexual abuse (e.g., post-traumatic stress disorder [PTSD], depression, anxiety, and emotional and behavioral problems). TF–CBT also enhances parents’ skills to respond to and support their children who have been victims.83 Multi-site randomized controlled trials have shown that TF–CBT can reduce symptoms of PTSD, depression, and behavioral problems in child victims of sexual abuse. Research also indicates that improvements are sustained for 6–12 months after treatment has concluded.84,85 Several psychological interventions, including exposure interventions and eye movement desensitization and reprocessing interventions, have also been shown to reduce psychological symptoms and improve functioning for survivors of SV.78 Two specific therapeutic modalities show particular promise given evidence of continued effects at long-term follow-up. Cognitive Processing Therapy (CPT) is an evidence-based psychological treatment that addresses PTSD symptoms among victims of trauma, including rape, using a trauma-specific adaptation of cognitive behavioral therapy. Prolonged Exposure Therapy (PET) is an evidence-based psychological treatment that addresses PTSD symptoms through the use of exposure therapy. PET has been used to treat victims of rape and other trauma, such as war veterans. Both CPT and PET were associated with sustained improvements in PTSD and depression symptoms at 6-year follow-up among adult rape victims in an RCT.86

Treatment for at-risk children and families to prevent problem behavior, including sex-offending. The evidence is also strong for therapeutic approaches that focus on high-risk children who may have been exposed to violence in their homes and communities and are at risk for violence perpetration and other serious behavioral problems. One example is the Children with Problematic Sexual Behavior Cognitive-Behavioral Treatment Program: School-Age Program (PSB–CBT). PSB–CBT is a family-oriented, cognitive-behavioral, psychoeducational, and supportive treatment group designed to reduce or eliminate incidents of sexual behavior problems. The program is an outpatient group treatment program for children ages 6 to 12 years and their parents or other caregivers. Treatment for the child focuses on acknowledging and identifying inappropriate sexual behavior, learning sexual behavior rules and self-control techniques, and sex education. Parents and caregivers receive information on developmentally normal and atypical childhood sexual behavior and are taught skills for preventing and responding to the child’s problematic sexual behavior. In a 10-year prospective study of children aged 5–12 with sexual behavior problems, significant reductions in re-offending were noted for the PSB–CBT treatment group when compared to a play therapy group (2% vs 10%), and the PSB–CBT group was reduced to baseline, general-clinic population levels that are very low.87 In other research, PSB–CBT has demonstrated improvements in child sexual behavior problems at post-treatment and/or follow-up.88,89

Multisystemic Therapy—Problem Sexual Behavior (MST–PSB) focuses on aspects of a youth’s ecology that are functionally related to problem sexual behavior and includes reduction of parent and youth denial about the sexual offenses and their consequences; promotion of the development of friendships and age-appropriate sexual experiences; and modification of the individual’s social perspective-taking skills, belief system, or attitudes that contributed to sexual offending. Families are provided family therapy; youth are provided individual therapy. Bourduin and colleagues90 found MST–PSB participants had fewer rearrests for sexual crimes compared with the control group, and 83% fewer arrests for sexual crimes at eight-year follow-up.91 In the same study they also found improvements in family relations, peer relations, and academic performance. In a randomized clinical trial with juvenile sex offenders, Letourneau and colleagues92 found MST–PBS participants had decreased sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements compared to juveniles in the usual sex offender specific treatment.

There is strong support for the value of victim-centered services and therapeutic approaches in reducing the short- and long-term impacts of SV.

Sector Involvement

Public health can play an important and unique role in addressing SV. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate SV prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing SV, the strategies and approaches outlined in this resource cannot be accomplished by the public health sector alone.

Other sectors vital to implementing the resource include, but are not limited to, education, government (local, state, and federal), social services, health services, business/labor, justice, housing, media, and organizations that comprise the civil society sector such as rape crisis centers, SV coalitions, faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing SV by impacting the various contexts and underlying risks that contribute to SV.

The strategies and approaches described in the resource are summarized in Appendix A along with the relevant sectors that are well positioned to lead implementation efforts. For example, the approaches and programs for
the first two strategies (Promoting Social Norms that Protect against Violence and Teach Skills to Prevent SV) are often delivered in educational settings, making education an important sector for implementation. Health departments across the country often work in partnership with school districts and community-based organizations to implement and evaluate prevention programs in school settings. Some of these programs may also be suitable for delivery in community settings. Through their work with community-based organizations, local and state health departments can also play a leadership role in implementing and evaluating these programs in other settings.

The business, education, and labor sectors, as well as government entities, are in the best position to establish and implement policies to advance strategies in the resource such as those focusing on Empowering and Supporting Girls and Women through education, employment, and income supports or Creating Protective Environments in workplaces and community settings. These strategies go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts
that make SV more likely to occur. Public health entities can play an important role by gathering and synthesizing information, working with other agencies within the executive branch of their state or local governments in support of policy and other approaches, and evaluating the effectiveness of measures taken.

Finally, the resource includes victim-centered services and a number of therapeutic approaches to Support Victims/ Survivors of SV. Rape crisis centers, SV coalitions, and other professionals who work with victims and survivors, in collaboration with justice, housing, social services, and the health care sector, are uniquely positioned to identify and deliver critical intervention support and victim-centered services in a manner that best meets the needs and circumstances of victims and survivors. The health care sector, working with victim advocates and in collaboration with justice and social services, is also uniquely positioned to address trauma and the long-term consequences of SV. In addition to having licensed providers trained to recognize and address trauma, the health care sector can also coordinate wrap-around behavioral health and social services to address the health consequences of SV and also the conditions that may put the patient at risk of repeated violence or perpetration (e.g., among children or adolescents with behavioral problems, including sexual offending).

Regardless of strategy, action by many sectors will be necessary for the successful implementation of this resource. In this regard, all sectors can play an important and influential role in helping accomplish the work to stop SV.

Monitoring and Evaluation

Monitoring and evaluation are necessary components of the public health approach to prevention. It is important to have timely and reliable data to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data are necessary for program implementation; planning, implementation, and assessment all rely on accurate measurement of the problem.

Surveillance data helps researchers and practitioners track changes in the burden of SV. Surveillance systems exist
at the federal, state, and local levels. It is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. At the federal and state level, the National Intimate Partner and Sexual Violence Survey (NISVS) and the Youth Risk Behavior Surveillance System (YRBSS) are examples of surveillance systems that provide data for SV. NISVS collects information on intimate partner violence, SV, and stalking victimization at both the state and national level, including data on characteristics of the victimization, demographic information on victims and perpetrators, impacts of the violence, first experiences of these types of violence, and health outcomes associated with the violence.93 YRBSS collects information on teen dating violence victimization (including physical and sexual), SV victimization, youth violence victimization (including bullying) and suicidal behavior among high-school aged youth. This information is available at the local, state, and national levels.94 In addition, there are data at the local level including school surveys, women’s health surveys, criminal justice data and other data that are important in local efforts to monitor the problem of SV.

It is also important at all levels (local, state, and federal) to address gaps in responses, track progress of prevention efforts and evaluate the impact of those efforts, including the impact of this resource. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce SV rates and risk and protective factors. Theories of change and logic models that identify short, intermediate, and long-term outcomes are an important part of program evaluation.

Much progress has been made in recent years to build the evidence-base for SV prevention through research. However, additional research is needed to expand the inventory of SV prevention strategies with known effectiveness. Prevention practitioners play a large role in building the evidence-base by evaluating programs
for impact on SV rates and risk and protective factors. The field will advance if research continues to evaluate the effectiveness of programs developed in the practice field, and identifies and tests new programs for high-need populations. Additionally, research is needed on the impact of community- and societal-level strategies, including policies, the application of social media, and community environmental change, to reduce rates of SV. Lastly, it will be important for researchers to test the effectiveness of combinations of the strategies and approaches included in the resource. Most existing evaluations focus on approaches implemented in isolation. However, there is potential to understand the synergistic effects within a comprehensive prevention approach. Additional research is needed to understand the extent to which combinations of strategies and approaches result in greater reductions in SV than individual programs, practices, or policies.

Conclusion

SV is a significant public health problem but it can be prevented. This Prevention Resource represents the best available evidence to address the problem of SV. This Prevention Resource includes a range of complementary strategies and approaches that ideally would be used in combination in a multi-level, multi-sector approach to prevent SV. It includes strategies and approaches that are in keeping with CDC’s emphasis on the primary prevention of perpetration, or stopping SV perpetration before it starts, as well as approaches to reduce risk for victimization and to lessen the short- and long-term harms of SV. The hope is that multiple sectors, such as public health, health care, education, justice, and social services will use this resource to prevent SV and its consequences.

Collectively, the strategies and approaches found in this resource represent CDC’s understanding of the best ways to prevent SV based on the current state of the evidence. As previously noted, the current state of the evidence is limited and must continuously be built through rigorous evaluation. Decisions on specific programs should be based on a thorough understanding of the evidence for a particular program, its applicability to the intended population and setting, and best practices for effective prevention.95,96 By continuing to invest in the evaluation of practice-based prevention programs and promising practices, researchers and funders can also help to expand our understanding of what works to prevent SV. Several innovative studies are currently in progress to uncover promising future directions for SV prevention work. As new programs, policies or practices are identified, evaluated, and shown to be effective, they will be added to this resource. Conclusion

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