Forensic Nursing and Primary Sexual Violence Prevention

Sexual violence remains today a worldwide public health issue despite healthy upward trends in preventative awareness. Forensic nurses are especially well-equipped to both understand and untangle these problems — perhaps more so than anyone else — considering that a large part of their work is dedicated to addressing victims of sexual violence at the convergence of law and medicine. In the United States alone 26 million women report experiencing an attempted or completed rape in their lifetimes, and on college campuses the numbers only get worse. In a call to action, Surgeon General C. Everett Koop held the Workshop on Violence and Public Health in October 1985, which formally gave fire and life to the healthcare industry’s role in sexual violence prevention. In fact, the term “forensic nursing” wasn’t even coined until 7 years later, in 1992, when a group of sexual assault nurses came together in St. Paul, Minnesota and birthed the industry.

A sexual assault occurs every two minutes in the United States, and plenty more cases go unreported due to privacy concerns and the fear associated with victimology. Until the early 1990s, anti-sexual violence efforts were responsive in nature, much like the role of forensic nurses. Targeted campaigns against such violence sought to heighten victim awareness and recuperation only after the fact. Unsatisfied with the status quo, national efforts adopted a promising strategy called “primary prevention.” These plans tackled sexual violence a priori, and since its adoption as the preferred approach sexual assaults have decreased by 60% in the United States.

Forensic nurses and other health care professionals have been instrumental in this reduction. Unlike others with direct and indirect exposure to victims and perpetrators of sexual crimes — sexual assault response teams (SART), mental health professionals, law enforcement officials and lawyers — forensic nurses typically find themselves in unique situations that position them to address primary prevention from within the trenches and beyond. By using various established models like the Spectrum of Prevention and the Ecological Model (two of the most widely recognized primary prevention models), societies and their major healthcare players can continue to affect positive change in sexual violence prevention.

What is Primary Prevention?

Primary prevention is an approach to addressing a problem of any kind before it occurs, whether it be related to traffic safety, substance abuse, or sexual violence. The Ecological Model and Spectrum of Prevention are flexible frameworks upon which professionals over many decades have built targeted strategies optimized for solving multi-layered problems. These two aforementioned models specifically emphasize the role of societal norms and environmental conditions in the occurrence of certain phenomena like sexual violence. To combat such enormous problems systematically, each model drives the development of a comprehensive strategy that simultaneously educates on an individual level and helps reform the norms and beliefs propagated into societies which contribute to the occurrence of sexual violence.
Further Reading

World Report on Road Traffic Injury Prevention — a World Health Organization (WHO) report that is particularly useful to see how the application of primary prevention model is applied macroscopically. World Report on Violence and Health — another WHO conference report with substantial information on actionable strategies that have proven effective against sexual violence prevention.

The Global Initiative on Primary Prevention of Substance Abuse

Primary Prevention of Substance Abuse — a unique workbook that demonstrates model overlap and the core principles of primary prevention

National Health Foundation’s Letter on Prevention

The Ecological Model

First presented in the World Health Organization’s World Report on Violence and Health, the ecological model addresses four levels of influence and the associated risk factors that lead to the occurrence of sexual violence (See the Center for Disease Control and Prevention’s full report for in-depth descriptions of each level):

1.Individual-Level Influences: Attitudes and beliefs that support sexual violence; impulsive and antisocial behavior; childhood history of sexual abuse or witnessing violence; drug and alcohol use

2. Interpersonal Relationship-Level Influences: Association with sexually aggressive peers; family environment that is emotionally unsupportive, physically violent or strongly patriarchal

3.Community-Level Influences: General tolerance of sexual assault; lack of support from police or judicial system; poverty; lack of employment opportunities; weak community sanction against perpetrators

4.Societal-Level Influences: Inequalities based on gender, race and sexual orientation, religious or cultural beliefs, economic and social policies

It is important to understand the causal risk factors influencing sexually violent behavior to better prepare a strategy to reform that behavior. The ecological model does exactly this: it develops a prevention strategy for each level of influence and also caters these interventions to specific audiences (an ‘intervention’ is an applied prevention strategy). For example, the CDC develops a prevention strategy for those in the population deemed at risk of sexual violence victimization or perpetration. The most comprehensive and effective strategy will engage each level and address all audiences, whether it is a universal audience, those at risk, or past offenders.

Here is an example of an action plan for forensic nurses that addresses a general audience at each level:

1. Individual Level: The forensic nurse can implement discussion groups among male hospital employees or community members to discuss notions of masculinity, promote healthy and respectful relationships, and discuss the man’s role in preventing sexual violence.

2.Relationship Level: The forensic nurse can implement discussion groups with male peer groups such as fraternities or athletic teams to reform group norms supporting and condoning sexual harassment and violence while teaching them to hold their peers accountable for malignant behavior.

3.Community Level: The forensic nurse can engage local youth and prepare them to lead change in their schools by spearheading classroom and school event discussions about the climate of tolerance for sexualized bullying.

4.Societal Level: The forensic nurse can reach out to and educate legislators regarding the importance of policies that promote the economic status of women and reduce workplace inequalities.

The Spectrum of Prevention

Developed by the Prevention Institute’s founder and director Larry Cohen, the Spectrum of Prevention describes six overlapping and complementary arenas for intervention and change (each level counts as an intervention).

1.Strengthening Individual Knowledge and Skills: Enhance an individual’s capability of preventing injury or illness and promote safety.

2.Promoting Community Education: Reach out to groups of people with information and resources to promote health and safety.

3.Educating Providers: Inform providers who will transmit skills and knowledge to others.

4.Fostering Coalitions and Networks: Convene groups and individuals for the broader goals and greater for the primary prevention of sexual violence.

5.Changing Organizational Practices: Adopt regulations and shape norms to improve health and safety.

6.Influencing Policies and Legislation: Develop strategies to change ordinances, laws and policies to influence outcomes.

The Spectrum aims to achieve far-reaching change by engaging individual behaviors as well as addressing the environments in which they occur. Larry Cohen intentionally developed the Spectrum to include a great deal of overlap between the categories. Officially referred to as ‘synergy’ when all categories are implemented in concert, this inter-relatedness builds momentum for change from the bottom level to the top. As the paper states, efforts to influence policy (level 6) will have greater success if public awareness and support is gathered (levels 1 and 2) while a variety of partnered groups in different sectors work in collaboration to effect their desired change. Ultimately, the comprehensive use of the Spectrum will exact normative change that will greatly decrease the instances of sexual violence.

The Role of Forensic Nurses