illustration of a man with his head bent down; behind him a small girl plays with a balloon

Reason versus Rage

Stopping child sexual abuse requires prevention—not just punishment

By Jim Duffy • Illustration by Dung Hoang

The sexual victimization of children is a subject so horrifying that it’s difficult even to address. As a society, we approach it from two extremes. Most of the time we avoid it. When forced to confront it, we run to the opposite extreme, flying into a rage, voices full of fury.

With that said, it’s time to face up to another fact: Rage is not an emotion associated with clear thinking and sound public policy. Child sexual abuse is not a subject that lends itself to the sort of rational, dispassionate decision making so essential to scientific practice. Instead, it’s a subject where the playing field seems always tilted toward punishment rather than prevention.

This is the challenge that the Bloomberg School’s Department of Mental Health is now taking up. William Eaton, PhD, the Sylvia and Harold Halpert Professor and chair of Mental Health, says the decision to do so is based not only on alarming numbers—80,000 confirmed cases annually, tens of thousands more unreported—but also on the devastating impact these incidents have on victims for decades after the crime.

“One thing that has come as a surprise to me is the way people with a history of being abused sexually as a child have a much higher risk going forward of so many major mental disorders,” Eaton says. He ticks off a list: depressive disorders, personality disorders, drug abuse, schizophrenia, suicide and more.

“This is one of the leading risk factors for the entire range of mental disorders,” Eaton says.

Worst of all, these crimes can fuel a brutal cycle, as victimized boys are at higher risk for becoming sex offenders themselves. Fred Berlin, MD, founder of the Johns Hopkins Sexual Disorders Clinic and director of the Sexual Behavior Consultation Unit, has seen this cycle play out in his four decades of work in this area as a psychiatrist at the School of Medicine. A mother whose son was victimized angrily confronted Berlin in a courtroom. “Years later I get a call from this same mother. Her son had now committed a sex offense, and she was wondering if there was something I could do to help. There is just so much tragedy in this.”

With the help of private donors, Eaton’s department has sought to bring public health expertise to bear on child sexual abuse. It established a partnership with Berlin and then in 2011 hired researcher Elizabeth J. Letourneau, PhD.

Letourneau and Berlin took time recently to discuss the road ahead as they seek to move prevention-based strategies and policies to the forefront. One big challenge: combating the myths that have come to dominate public discussion of the topic.

The work will not be easy—and it might be controversial at times. But Eaton is confident that the effort will have results. “We will never eliminate child sex abuse from the picture altogether,” he says, “but I believe there are opportunities out there to lower the rate of it—and perhaps lower it by a lot.”

Myth #1: Our social policies aim to prevent the incidence of child sexual abuse.

In recent years, researchers have set out to dig past the 80,000 annual cases confirmed by the U.S. Department of Health and Human Services and gauge the real extent of child sexual abuse in this country.

On the lower end of the spectrum, a review of 16 studies published in Child Abuse and Neglect estimated that 7 percent of boys and 14 percent of girls in this country are sexually victimized as minors. A Psychological Bulletin article that averaged the results of 23 studies estimated 17 percent of boys and 28 percent of girls were victims.

Such numbers signal a public health problem of the first order, especially considering the mental health problems victims might endure in later life, problems that spread to the lives of countless siblings, spouses, future children and sometimes even whole communities, as recently demonstrated by the child sexual abuse scandal at Penn State University.

Seated in her tidy office at Hampton House during an interview, Letourneau reviews the extent of this wreckage and makes the case that society’s current response to it is out of balance. On the one hand, there is the criminal justice system, where expensive policies are increasingly the norm—things like maintaining vast online databases of sex offenders and seeking extended civil commitment in specialized mental health facilities for some convicted offenders who have completed prison terms.

“We don’t put anything like those resources into prevention,” Letourneau says. “There’s virtually no money for this stuff. This is a field where it’s a big deal if the Centers for Disease Control puts out a single $1 million grant every couple of years for work on prevention.”

A few days later in his Mount Vernon office, Berlin says he shares Letourneau’s frustration on this front. His work with sex offenders has stirred occasional controversy over the years. Some have worried that his efforts to better understand offenders, their mental states and their behaviors might have the effect of destigmatizing—or “normalizing”—their abnormal behaviors, though Berlin has never suggested decriminalizing harmful sexual acts.

Questions have also arisen over his support for limited use of testosterone-reducing medications that induce “chemical castration.” In recent years, however, the use of such medications to help individuals maintain control of their sexual desires has gained increased acceptance.

“We cannot legislate this problem away, and we cannot punish it away, but that’s all we keep trying to do,” Berlin says. “That’s not the right approach here any more than it is with problems like alcoholism or drug addiction. We need a law enforcement component, yes, but this is a field that needs the surgeon general as well as the attorney general.”

Myth #2: Convicted sex offenders never stop being a risk to children.

Monsters exist, to be sure. But researchers who have studied this issue say that the serial-offender pedophiles who garner media attention are more the exception than the rule.

The Department of Justice regularly runs statistical comparisons of different categories of criminal offenders, and its data indicate that sex offenders have a comparatively low rate of recidivism.

Much of Letourneau’s research focuses on young offenders—boys between 12 and 14, who are at the peak age of risk for engaging in sexual misbehaviors with younger children. Such offenders don’t fit the “monster” profile.

“They are acting oftentimes out of a lack of knowledge and with a lack of adult supervision, or sometimes their behavior is basically experimental,” Letourneau says. “Rarely are they acting out of genuine sexual interest in children, though that can happen and we know it does happen on occasion. But in reality, the vast majority of these kids—something like 95 percent of them—are simply not going to re-offend.”

This trend in recidivism data applies to adults as well as children. One of Berlin’s research projects involves tracking outcomes for more than 400 adult male offenders diagnosed with pedophilia, a strong sexual preference for children. Over the first five years of the study, the recidivism rate for this group was less than 8 percent. Among the pedophiles who were generally cooperative with terms of treatment and parole or probation, the rate was less than 3 percent. Berlin’s team is now tracking this same group on a 15-year time frame, and preliminary data show no shift toward increasing rates of recidivism as years go by.

These numbers can be imprecise, given how many offenses in this category go unreported, but Letourneau expresses confidence in the quality of the research. “For younger offenders, if you follow them for 10 years, you’re going to have a very good understanding of how many are re-offending,” she says. “You might not know how often they’ve re-offended, but if they’re re-offending with any frequency over a 10-year period, at some point a victim will come forward. The same is true of adults. If you follow them out 20 years, you’ll have caught pretty much everyone who’s committing offenses.”

Moreover, she adds, rigorous, randomized controlled clinical trials have repeatedly demonstrated that even high-risk youth and—importantly—their families can succeed with treatment.

In essence, most sex offenders are not serial predators. Both Letourneau and Berlin believe that prevention strategies must include both treatment for convicted offenders and outreach to potential offenders.

This is a bridge that it took Kathy Headley a long time to cross. Victimized in her youth by a pedophile grandfather, the Indiana resident has joined with her siblings (including Stephen Moore, MD, MPH ’93) to fund Letourneau’s position for a three-year startup period—and perhaps beyond.

Headley and Moore spoke about the long-term impact on victims and their families at an April 27 symposium, “Child Sex Abuse: A Public Health Perspective” at the Bloomberg School.

“One of the things we were asking about in our meetings is whether there is any possible way of getting to offenders before they offend and ruin children’s lives—and ruin their own lives for that matter,” Headley says. “That’s been hard for me, to get past the feeling that you should just lock them up and keep them there. But I’ve come to see that if it helps keep one person from becoming a victim, then that’s what we have to do.”

Myth #3: Online offender registries help communities keep their children safe.

Google the topic of online sex-offender registries and you’ll arrive soon enough at this sort of proclamation: “Online sex- offender registries are an essential resource.”

Minnesota was the first state to launch a registry, in 1991. That move came in the aftermath of the disappearance of an 11-year-old Minnesota boy, Jacob Wetterling, who has never been found. Three years later, the feds upped the ante, requiring states to maintain online registries that are open to the public. That requirement is often called “Megan’s Law,” as it went on the books after the rape and murder of a 7-year-old New Jersey girl, Megan Kanka, whose killer was both a neighbor and a twice-convicted sex offender.

Today, different states handle these registry requirements in different ways. The most aggressive require registration for a broad range of offenses and keep even one-time offenders listed for life. Others limit registration to offenders deemed especially dangerous.

Letourneau worked previously at the Medical University of South Carolina, where she conducted a series of studies seeking to measure the impact of that state’s aggressive approach to registration. Early on, she measured whether the registry law achieved its primary goal of reducing the number of offenders who commit new sex crimes.

The answer was no. Recidivism rates showed no significant change as the state adopted its registration law and then again as the online registry went public.

Letourneau’s follow-up work on this topic is fascinating, demonstrating that the registry has had significant unintended consequences. First, she conducted a pair of studies showing that prosecutors changed their approach to juvenile sex crimes after the registry requirement went into effect.

The first study showed that prosecutors became less likely to move forward with sex-crime charges once the registry was in place—cases were simply dismissed or diverted. The second study concluded that when prosecutors did move forward on cases, they became more likely to permit defendants to plea bargain into the assault category and out of the sex-crime category.

In both cases, Letourneau’s hypothesis is that prosecutors came to regard lifelong registration as a draconian penalty that didn’t fit the crime in a significant number of cases with youthful offenders. One important concern she voices about this finding is that the offenders end up receiving no follow-up or treatment geared specifically to their actual crimes.

Letourneau next looked at the outcomes of cases involving adult offenders that went to jury trials after the registry was launched. These are the cases, she says, that prosecutors tend to regard as slam-dunk wins as they head to trial. But she found that conviction rates in these cases declined after the public online registry was established.

“I’ve had prosecutors and attorneys of all stripes tell me about cases where the jury was deliberating and they asked the judge, ‘Will he have to go on the registry? Or will he just face time?’ It’s a punishment that’s just so harsh—juries were modifying their behavior. So we’re now setting some of these guys free—they’re completely exonerated. It’s unbelievable, but we have a policy that increases the likelihood of letting adult sex offenders go.”

Letourneau plans to build on this work at Johns Hopkins. Studies of the impact of registration in other states have yielded varying results, an outcome likely related to the different approaches taken. She is preparing to compare the results of juvenile registry policies in three states—one that aggressively registers a wide swath of offenders (Texas), one that takes a middle-of-the-road approach by giving discretion to prosecutors and judges (Maryland), and one whose conservative approach reserves the registration requirement for a very few offenders judged to be high risks (Oklahoma).

Letourneau raises one other question surrounding offender registries that deserves more attention going forward: What impact does being on a public registry have on the lives of ex-offenders, especially the ones sincerely trying to steer clear of future trouble?

“It can be very difficult for known sex offenders to maintain stable living conditions and stable jobs while on these registries,” Letourneau says. “And when you don’t have stable living conditions and stable social connections, it makes it more difficult to re-integrate into society.”

Berlin feels that registries are a prime example of what’s wrong with the way society is dealing with child sex abuse. “The goal is right—we need to protect these children,” he says. “But we need to do it in a way that’s going to work, a way that’s based on data, a way that’s cost-effective. We’re not doing that. What we’re doing instead is reacting to the emotion of the moment, and as understandable as that emotion is, it’s just not the right way to go. Effective public policy should be based upon evidence about what works best.”

Myth #4: The Jerry Sandusky case at Penn State will drive society to develop better policies.

The media explosion set off last year by allegations of serial sexual abuse of young boys over the course of years by Jerry Sandusky, a former assistant football coach at Penn State University, has focused sustained attention on a topic that society might otherwise avoid. Peter Pelullo, the leader of a foundation devoted to supporting victims of child sex abuse, says he’s hopeful the case will help the public grasp the true costs of sexual abuse.

“This thing has just rocked the country,” he says. “It presents a great opportunity to really put the focus on these young boys—and especially on the fact that they’re going to be living with this for 40 or 50 or more years.”

A successful music-industry executive, Pelullo is a former victim himself. His book, Betrayal and the Beast, recounts his journey from being raped repeatedly at age 7 by older neighborhood children to his still-in-process recovery as a 50-something adult. In between, Pelullo battled multiple addictions and endured an inability to establish bonds of trust and intimacy.

In going public as an abuse victim, Pelullo launched his Let Go … Let Peace Come In Foundation. In March, the foundation reached an agreement with the Bloomberg School to help fund research by Letourneau, Eaton and other department colleagues aimed at preventing abuse.

“To truly study this as a public health issue, that’s something that just hasn’t been done,” Pelullo says. “It’s a mammoth task, considering that this is an area where we have a hard time just engaging in a conversation.”

If the focus stays on victims and how to help them, the Sandusky case might indeed turn out to be a positive. But as Letourneau points out, we’ve seen “monster” cycles play out before—and the results have not always been productive.

“These blowups always center on the most sensational type of offenses,” Letourneau says. “If these allegations against Sandusky are true, think about it this way: How many guys go out and set up a not-for-profit agency to serve as a feeder system to satisfy their urges?”

She rates it a one-in-a-hundred-million event. “We’re going to base policy on that?” she asks. “When you base it on the rarest, most unique, most bizarre case, you’re not going to get good policy.”

Berlin has a friend who once joked that no laws should ever be adopted in the immediate aftermath of any 60 Minutes broadcast. He feels the same way about cases like Penn State. “We tend to legislate in response to the emotion of such moments,” he says. “Let’s just say that in my opinion this does not ensure that we will get effective public policy based on data and careful thought.”

There’s another danger to this “monster” cycle as well. Since cases like these are often the only ways the general public and political leaders learn about child sexual abuse, they tend to fuel the misconception that all offenders are serial predators.

“The reality is, most offenders are people we know and even people we like,” Letourneau says. “They are people in our families, in our communities and in our social circles. What we’ve got to do as a society is figure out a way to talk about these offenders in a way that doesn’t always evoke the monster. We’ve got to get to a place where people can stand up and say, ‘I’m a little worried about my friend Jim. He’s having some troubles in his life right now, and I think he might be spending too much time with one of his young volunteers. I’m worried he might make a mistake, and I’d like to get him some help.’”

Berlin draws analogies here to alcoholism—a condition that not so many decades ago was regarded as a matter of personal weakness and shoved under the rug in family life and civic affairs. “If we ask the question, ‘Who is the person who gets involved sexually with children?’ It’s actually a lot like asking, ‘Who’s the drunk driver?’” he says. “There’s a tremendous spectrum. On one end is the chronic alcoholic who might always pose a threat to others. On the other end is the guy who wants to quit but needs help.”

Berlin surveys the landscape today and sees a balanced approach to alcoholism—one that encourages people to seek help and one that steers clear of blanket demonization while also delivering the needed criminal justice component. “With alcoholism today, we recognize that decent people can be struggling,” he says. “We see that Aunt Jane or Uncle Harry has a problem. We recognize that they could get in a car and kill somebody. But we also see them as human beings we care about and want to help.”

By contrast, the demonization of child sex offenders allows no room for such consideration.

“We hear all the time—if you are depressed or addicted or have anorexia, please come in so we can help you,” he says. “As I speak, there are some 16- or 17-year-olds out there who are privately aware of the fact that they’re sexually attracted to children. And because of how we’ve demonized people in this area, the last thing they’re going to do is raise their hand and ask for help—which is exactly what we should be encouraging them to do.”