Introduction

Public, political and professional concern about child sexual abuse (CSA) is widespread, and it attracts disproportionally more media than other forms of maltreatment (Hove et al., 2013). International studies have suggested a global prevalence of CSA of around 18 to 20% for girls and 8% for boys (Pereda et al., 2009; Stoltenborgh et al., 2011). It is a serious crime that has been associated with many adverse health, mental health, substance misuse, relationship difficulties and other issues in childhood, adolescence and adulthood (Cashmore & Shackel, 2013; Cutajar et al., 2010; Fisher et al., 2017; Ogloff et al., 2012; Trickett et al., 2011). It has also been associated with increased risk for experiencing or committing a range of offences, including sexual offences (Ogloff et al., 2012; Papalia et al., 2017). The adverse effects of CSA extend beyond the primary victim to the child’s non-implicated parents, siblings, other family members, and in some cases, to the community (Fisher et al., 2017; Quadara et al., 2016). Its economic impact on the community is considerable (Letourneau et al., 2018).

To avoid these adverse outcomes for children, families and communities, CSA must be stopped before it starts. There is agreement that we need a public health approach that is systematic and coherent and uses the services and knowledge that we have in order to do this (Higgins et al., 2019; Letourneau et al., 2014; McKibbin & Humphreys, 2020; Quadara, 2019; Smallbone, Marshall & Wortley, 2014; United Nations Children’s Fund, 2020).

Current approaches to CSA prevention are tertiary focused, disjointed, scattered and ‘siloed’ into victim or perpetrator services (Letourneau et al., 2014; McKibbin & Humphries, 2020; Quadara, 2019). They emphasise the reporting of CSA, forensic investigation, punishing individual offenders, public safety measures such as offender registration and removing children from harmful situations (Finkelhor, 2009; Parton, 2019). Treatment for those with a sexual interest or attraction to children is limited and rarely available outside the justice sector (Christofferson, 2019; United Nations Children’s Fund, 2020). While generally prudent (United Nations Children’s Fund, 2020), these responses are after the fact and, at best, minimally preventive.

To adopt a public health approach, we need to think differently—not in silos—and within a new paradigm. Such a paradigm requires we think differently about who the people are who offend, the children they harm, the situations in which the offences occur and the communities affected by the offending as well as the language we use. The language of ‘perpetrators’, ‘criminal justice’, ‘disease’, ‘victims’ needs to be replaced with a language that starts with a question about how to keep children safe and which recognises the epidemiological complexity and multiple causal pathways to offending and the diversity of those who offend.

So, what would a public health approach to preventing CSA actually look like? It would:

  1. 1.

    Reflect the diversity of individuals, families, and communities.

  2. 2.

    Integrate programs and services so they are not discrete or standalone but interconnected.

  3. 3.

    Utilise the substantial knowledge from research and service evaluations.

  4. 4.

    Recognise that providing programs at one level will have impact at other levels.

  5. 5.

    Provide services that can address the different needs of people by addressing the grave gaps in services to individuals, families and communities from interventions thus far.

  6. 6.

    Evaluate the effectiveness of preventive strategies and disseminate information about what works (Broadley & Goddard, 2015).

The focus of this paper is the subsystem—the component of the prevention system that focuses on preventing offending by concentrating on offenders and potential offenders.

A Typology of Prevention: A Whole of System Approach

The four stages of prevention are:

  1. 1.

    Primordial—policies and legislation aimed at improving underlying social and environmental conditions, including cultural understanding of childhood, to prevent or reduce exposure to risk factors associated with adversity.

  2. 2.

    Primary Prevention—measures aimed at a susceptible population or group to prevent CSA from occurring by reducing exposure to risk or reducing susceptibility.

  3. 3.

    Secondary Prevention—measures aimed at detecting risk of sexual abuse and taking preventive action before it happens.

  4. 4.

    Tertiary Prevention including Restorative Justice which facilitates individual and collective ‘healing’ (Kisling & Das, 2021).

Together these four stages aim to prevent CSA by reducing risk and also mitigate its consequences (Kisling & Das, 2021). All stages are necessary for a whole of system approach to prevention.

Thinking Differently: Using Systems Thinking

An integrated public health approach to preventing CSA can be thought of as a complex adaptive system that is made up of a number of interconnected subsystems and able to adapt and evolve in response to a changing environment (Chan, 2001; Checkland, 1999) (Fig. 1). Such a system must be able to address the variations in situations (e.g. family, friend, institution, public) for victims and those who are at risk of offending. It requires four foci: offenders, victims, situations and communities (Smallbone et al., 2014).

Fig. 1
figure 1

Using a public health approach to preventing CSA

Full size image

At the heart of systems thinking are interrelationships, perspectives and boundaries (Williams & Hummelbrunner, 2010). Interrelationships refer to the ways in which people, processes and objects interconnect and how those interconnections affect behaviour. Interrelationships are dynamic, context-sensitive, non-linear and often complex—small changes in conditions can have profound and widely divergent effects on system outcomes (the ‘butterfly effect’) (Vernon, 2017; Williams & Van t’Hof, 2016). Perspectives refer to how people ‘see’ or ‘frame’ a situation or issue and can greatly affect their responses to it. Acknowledging the reality of different perspectives requires that people recognise their own underlying assumptions or value judgements and allows alternative possibilities based on differing world views to be conceived (Checkland, 1999; Williams & Hummelbrunner, 2010). Boundaries differentiate between what is ‘in’ and what is ‘out’ of a system and affect where attention is directed and how resources are allocated. Boundaries can result in people or issues becoming marginalised and, when that occurs or perspectives and values clash, can lead to conflict and resistance to change (Checkland, 1999; Midgley & Pinzón, 2011; Midgley et al., 1998; Williams & Hummelbrunner, 2010).

The past effect of interrelationships, perspectives and boundaries on the prevention of CSA is neatly captured in the description of Letourneau and colleagues of siloed professional fields in researching and responding to CSA. These authors have suggested that the struggle of early victim advocates to be taken seriously ‘might have contributed to a laser-like focus on victimization to the exclusion of perpetration’ (Letourneau et al., 2014, p. 225). They further hypothesise that many clinicians and researchers working with sex offenders ‘have led an insular existence, perceiving hostility from outsiders who view them as sex offender apologists, insensitive to the needs and rights of victims. What might have developed as a unified field instead became two distinct victimization and perpetration fields, complete with separate societies…separate funding sources operating within separate government agencies…and separate policy centers…’ (Letourneau et al., 2014, p. 225).

This compartmentalisation has not been universal, for example, one of the first inquiries into child sexual abuse in Australia, the Child Sexual Abuse Task Force, recommended a coordinated and holistic approach to child sexual abuse that considered the therapeutic needs of all parties, including offenders, and incorporated primary, secondary and tertiary prevention strategies (Lawrence, 1987). The need for an integrated or holistic approach to CSA that responds to the needs of abused children, adults abused as children, multigenerational families and communities and also healing and treatment for adults and adolescents convicted of CSA, is well recognised internationally by First Peoples (Breckenridge & Flax, 2016; Cripps & McGlade, 2008; Healing Foundation, 2018). The Anishnabe peoples’ Hollow Water Community Holistic Circle Healing in Canada, and the Indigenous Healing Foundation’s work in Australia are examples of integrated approaches (Buller, 2004; Healing Foundation, 2018; Sawatsky, 2009).

A Focus on the Offender/Potential Offender Subsystem

A system to prevent a person at risk of sexually abusing a child from committing that first offence or preventing someone who has already offended from re-offending should be one of the key subsystems in a comprehensive public health system to stop CSA before it starts. Other logical subsystems could include:

  • A system to detect and prosecute CSA.

  • A system to prevent or mitigate the adverse effects of CSA victimisation.

  • A system to create child safe environments.

  • A system to prevent CSA in communities.

Although this paper’s focus is the offender/potential offender subsystem, it is important not to lose sight of the fact that this is just one of the interconnected subsystems in a fully-fledged public health approach to preventing CSA. This paper’s aim is to emphasise the importance of interconnection and perspective when planning prevention strategies whether it is at a national, state or local level with reference to existing programs and services.

Offender Diversity

Although about 90% of offenders are male (Cortoni et al., 2017; Finkelhor et al., 2009; Peter, 2009), they are diverse in many other respects making it clear that when it comes to prevention one size will not fit all.

  • CSA in a family environment by relatives, friends and neighbours is the most common (Bromfield et al., 2017; Children’s Commissioner for England, 2015; Richards, 2011; Seto et al., 2015; Smallbone & McKillop, 2016).

  • Intrafamilial offenders tend to be older than extrafamilial offenders, to score lower on variables reflecting antisocial tendencies and atypical sexual interests but to be more likely to have a history of family problems such as CSA, family abuse and neglect and poor parental attachment (Seto et al., 2015).

  • Intrafamilial and extrafamilial offence patterns differ around duration of abuse, number of victims and the age and gender of victims. Intrafamilial abuse is likely to be of longer duration but have a smaller number and younger victims compared with extrafamilial abuse. Boys are more likely to be abused by extrafamilial offenders (Australian Bureau of Statistics, 2017; Smallbone, Marshall & Wortley, 2014).

  • Children and adolescents commit an appreciable proportion of CSA—between 30 and 60%, according to a review of the available literature by El-Murr (2017). Exploratory and harmful sexual behaviour are common among children and young people of both genders (Larsson & Svedin, 2002; Mitchell & Ybarra, 2013).

  • CSA takes a number of forms including, sexual penetration, inappropriate touching, non-contact abuse and the production and possession of child pornography.

  • CSA occurs in a range of settings—domestic/family environment (e.g. relatives, friends, neighbours, babysitters), institutional (e.g. schools, residential settings, religious settings, sporting and social clubs), public spaces (e.g. swimming pools, playgrounds, shopping centres) and virtual (Smallbone & McKillop, 2016).

  • Most minor-attracted persons discover their attraction in puberty or before the age of 20, some 5–0 years before their arrest (Levenson et al., 2017; Schaefer et al., 2010.). Not all minor-attracted persons act on that attraction.

  • The vast majority of adults convicted of sexual crime, including CSA, do not go on to offend with another sexual crime (Hanson et al., 2018; Schmucker & Lösel, 2008). The sexual offence recidivism rate for juvenile sexual offenders is very low (Caldwell, 2016).

Identifying the target group for prevention initiatives is critical. The goal may be the same i.e. to prevent that first offence (or reoffence), but the strategies will differ depending, for example, on whether they are intended to reach adolescents or adults, the general community or particular communities within the wider community. Not only the most successful media/social marketing campaigns but arguably all types of intervention ‘begin by understanding the behaviour of their audience and engaging its members in developing the intervention’ (United Nations Children’s Fund, 2020, p.80).

Risk Factors

While there is limited research into risk factors associated with CSA perpetration by adolescents and adults (Letourneau et al., 2017), associations between perpetration and adverse childhood experiences such as sexual and physical abuse and neglect, parenting issues, exposure to family violence, substance misuse, socio-economic factors, exposure to pornography and rigid gender values and patriarchy have been found by some researchers (Quadara, 2019; Seto et al., 2015; Seto & Lulumiére, 2010). Reports on the CSA of First People children add the impact of colonialism on all aspects of First People’s lives and the resultant transgenerational trauma and unresolved grief as risk factors (Aboriginal Child Sexual Assault Taskforce, 2006; Robertson, 2000). Many of the same factors are associated with being a victim of CSA abuse, and of child maltreatment more generally, underlining the often-unhelpful nature of the victim/abuser binary (Letourneau et al., 2014; McKibbin & Humphreys, 2020).

Offender-Focused Prevention Initiatives

The offender-focused prevention initiatives outlined below should not be conceived as standalone solutions but as interconnected components of a coherent, integrated strategy to prevent the perpetration of CSA.

Primordial Prevention

Quadara (2020) has proposed some key determinants as underlying conditions that give rise to the above risk factors:

  • Children’s structural vulnerability relative to adults within the family, organisations, institutions and civil society.

  • Forms of masculinity and rigid gender attitudes that endorse men’s social dominance, sexual and other entitlement, authority and control.

  • Socio-economic disadvantage and inequality, including gender inequality and disadvantage.

  • Limited mechanisms for addressing psycho-social needs arising from the trauma associated with CSA, other forms of child abuse and neglect and exposure to family violence.

Primordial prevention would target these key determinants at a population level through government policies and programs and universal services. In Australia, the National Agreement on Closing the Gap, a partnership between all Australian governments and the Coalition of Aboriginal and Torres Strait Peak Organisations, is an example. Closing the Gap aims to enable Aboriginal and Torres Strait Islander people to achieve health, education, economic, social and emotional wellbeing and cultural outcomes equal to all Australians (Commonwealth of Australia, 2020). Other examples include National policies and programs to achieve the United Nations Sustainable Development Goal 5—‘achieve gender equality and empower all women and girls’. In Canada, the strengthening of spirituality, identity and healing in many Aboriginal communities, the development of Aboriginal programs in the areas of health, social services and economic development and opportunities for Aboriginal communities to reshape justice programs, have been suggested as a possible explanation for an apparent decline in the sexual abuse incident rate for Aboriginal children investigated by the Canadian child protection authorities (Collin-Vézina et al., 2009).

Primary Prevention

UNICEF’s review of the evidence to end child sexual abuse and exploitation found three approaches to primary prevention:‘(1) those aimed at mobilization to change social norms, attitudes and behaviour (most common); (2) situational prevention (altering the environmental and situational context that provide opportunities for abuse); and (3) prevention by reducing risks and vulnerabilities of children to victimisation…’ (United Nations Children’s Fund, 2020, p.76). It is the first of these with which this paper is concerned, although it is recognised that all three are necessary for effective prevention (United Nations Children’s Fund, 2020).

According to UNICEF, social marketing and media campaigns aimed at promoting awareness and understanding about child sexual abuse and exploitation have been ‘very much part of international, regional and national strategies for universal primary prevention…’ (United Nations Children’s Fund, 2020, p.78). More research is needed but there is evidence that multi-faceted campaigns using a range of methods can increase public awareness and understanding of CSA and, importantly, facilitate the public to take preventive action (Kemshall & Moulden, 2017; United Nations Children’s Fund, 2020).

Most people, including decision-makers, get their information about CSA through the media, but the media do not accurately portray the offenders, the victims or the dynamics of CSA (Kemshall & Moulden, 2017). The true picture of CSA is not in the public arena—most CSA occurs in the family environment, not in institutions or public spaces, is committed by someone known to the child who may be an adult or another child and can take a variety of forms. The perspective fostered by the media and high profile cases that people who harm children are ‘monsters’, highly dangerous, likely to re-offend and cannot be treated, is not supported by the evidence but has resulted in policies such as sex offender registration, community notification, residency restrictions and civil commitment being enacted in the USA and other countries (Levenson & D’Amora, 2007). It also discourages people who are worried about their thoughts, feelings and behaviour from seeking help (Brown et al., 2014; Levenson et al., 2017).

One of the primary challenges of operating a child sexual abuse prevention helpline is enabling adults concerned about themselves or others to overcome cultural and practical barriers to seeking help. People who have a sexual interest in children will be under no illusion about how society views this behaviour. There is barely a week without a mainstream media story about an online or offline sexual offence—and the commentary can be punitive and inflammatory. Consequently, the stigma associated with people who sexually abuse children is likely to prove an obstacle to raising awareness of the helpline. (Brown et al., 2014)

From a preventive perspective, it is important for people at risk of abusing a child and those who have already abused a child to take action to prevent any abuse from happening or to stop further abuse. However, the shame and stigma experienced by minor attracted persons, together with concerns about confidentiality, fears about the personal and legal consequences of disclosing, confusion about whether behaviour is CSA, lack of knowledge of where to go and issues of access and affordability are all barriers to help seeking (Levenson et al., 2017; Van Horn et al., 2015). A paradigm shift is needed in public education, media campaigns and resource allocation to encourage people at risk of abusing, and people who have abused to seek help when CSA has occurred or is at risk of occurring.

Sensitive well-developed social marketing campaigns to raise awareness of the dynamics of CSA and inform the public of available services that have at risk or undetected offenders as one target can be effective in mobilising those at risk of abusing a child and their family and friends to seek help to prevent abuse from occurring or to respond appropriately when it has occurred (Beier et al., 2015a and 2015b; Grant et al., 2019; Van Horn et al., 2015). However, to be fully effective, the messages need to be developed with input from the target group and, most critically, policies, programs, partnerships and resources need to be in place to ensure that suitable help is available when, where and for whom it is needed (Beier et al., 2015a; United Nations Children’s Fund, 2020). As an example of the interconnection between social marketing campaigns and the availability of services, the Australian National Strategy to Prevent and Respond to Child Sexual Abuse 2021–2030 has overtly recognised that before a national awareness campaign relating to children with harmful sexual behaviours can happen, measures to improve a country’s capacity to respond to harmful sexual behaviours must be in place (Commonwealth of Australia, 2021).

Secondary Prevention

Secondary prevention actively targets groups at risk of committing or experiencing CSA. Two programs offering early help to adults experiencing thoughts and feelings that place them at risk of harming a child and undetected adult offenders are prominent in this space:—Stop It Now! (Grant et al., 2019; Van Horn et al., 2015) and Prevention Project Dunkelfeld (Beier et al., 2015a). The Berlin Project (Beier et al., 2015b) offers help to potential and undetected juveniles preferentially attracted to children. However, Meiksans et al. (2017) have drawn attention to the lack of secondary prevention for children and young people more generally.

Stop It Now! provides a free, confidential and anonymous helpline for advice, support and information, a secure messaging service and online self-help for people concerned about their own or others’ sexual thoughts or behaviours towards children. The original model was developed in the USA, and Stop It Now! operates in the USA, the UK and Ireland, and the Netherlands (Brown et al., 2014; Grant et al., 2019; Van Horn et al., 2015). In Australia, Jesuit Social Services announced in June 2022 that it will run a 12-month privately funded pilot of Stop It Now!

Stop It Now! UK includes a disclaimer that information on the Stop It Now! website is not a substitute for professional advice and/or treatment, and Stop It Now! USA states that it does not provide therapy, although it does provide a limited listing of therapeutic resources. Stop It Now! Australia will be similar (Jesuit Social Services, 2019). Only Stop It Now! Netherlands offers direct access to free and confidential therapeutic services (Van Horn et al., 2015).

Uniquely, Germany has integrated prevention measures into the health care system. Prevention Project Dunkelfeld is a voluntary research and treatment program for potential and undetected offenders partially or exclusively attracted to prepubescent (paedophiles) or pubescent children (hebephiles). The project currently offers free confidential psychological, sexological and pharmacological services at 11 regional sites and aims to prevent CSA and use of child pornography (Beier et al., 2015a, 2021; Schaefer et al., 2010). The Berlin Project is a similar project for juveniles aged 12–18 years who have a sexual preference for prepubescent or early pubescent children (Beier et al., 2015b). A recent article by Beier and colleagues draws attention to the importance of political support.

The establishment of this kind of programme is not at all straightforward, it requires political support to ensure sustainability, but early financing is also possible through alternative concepts. In Germany, the programme was initially funded through the Volkswagen Foundation and received support from child protection NGOs and media agencies, who took on the important role of public relations. Political support followed (through the Federal Ministry of justice and Consumer Protection) and, finally, the integration into the health care system. (Beier et al., 2021, p.13)

The interconnections between media coverage, social marketing and the availability of free, confidential and accessible treatment have a demonstrable impact on the extent to which people who are at risk to abuse or who are concerned about their thoughts and feelings towards minors access help from Stop It Now!. In the USA and the UK where Stop It Now! has not run extensive promotional campaigns and does not provide direct access to free treatment services, the pattern of referrals and the proportion of those at risk of abusing a child who make contact is different from those of Stop It Now! Netherlands.

The most common source by which Stop It Now! UK users learnt about the helpline was police, media accounting for only a small proportion of contacts (Brown et al., 2014). This contrasts with Stop It Now! USA where 61% of callers heard about the helpline from internet/media; 9% were repeat contacts and the remainder heard about it from a variety of sources. In the Netherlands, the majority of callers found their way to the helpline through media campaigns, talk shows and newspapers. Media campaigns and news articles about the helpline appeared to considerably increase calls from ‘pedophilic’ men (Van Horn et al., 2015).

The helplines differ markedly in the extent to which they attract people at risk to abuse, the prime target for prevention. Both in the UK and the Netherlands, about half the helpline users were people who were concerned about their sexual feelings or behaviours towards children, but in the UK, 83% of contacts were made after the abuse had been committed, whereas in the Netherlands, more than half the helpline users made contact prior to actually offending (Van Horn et al., 2015). In the USA, only 12% of helpline contacts identified themselves as at risk to abuse or having already abused a child (Grant et al., 2019). A very much higher proportion of calls to Stop It Now! USA were from bystanders (family, friends or others who knew someone in the situation) than calls to Stop It Now! UK or the Netherlands. It has been suggested that the Netherlands’ confidentiality laws do not allow the disclosure of previous offending and that this makes the services more accessible to those at risk of abusing (Grant et al., 2019; Van Horn et al., 2015).

Both Dunkelfeld projects, which have been very successful in reaching people concerned about their own (or in the case of juveniles their child’s) behaviour and seeking help, were preceded by extensive and effective media campaigns that informed the target groups of the availability of free and confidential help and how to obtain it. The media campaigns were informed by input from known members of the target groups (Beier, 2009; Beier et al., 2015b).

Although largely funded through foundations, government support is essential for secondary prevention programs like Stop It Now! and Prevention Project Dunkelfeld to reach their preventive potential because of the policy/legislative environments in which they must operate. For example, in countries with mandatory reporting like Australia and the USA, the establishment of programs like Prevention Project Dunkelfeld is not feasible because no commitment to confidentiality is possible. Helplines like Stop It Now! allow for anonymity but for those at risk to abuse or undetected offenders for whom information and advice is not enough, mandatory reporting may be an insurmountable barrier to accessing in-person treatment, should this even be available and affordable.

Tertiary Prevention

Tertiary prevention responds to CSA after it has happened with the aim of preventing further incidents. Responses include prosecution and criminal penalties, sex offender registration, notification, residence restriction and treatment—which for adult offenders is limited and largely prison-based (Finkelhor, 2009; Quadara et al., 2015). For juveniles, tertiary prevention mostly focuses on ‘the minority of convicted offenders diverted to treatment programs or supervised on release in the community’ (United Nations Children’s Fund, 2020, p.153).

While prosecution and criminal penalties are considered to be prudent, sex offender registration, notification and residence restriction are judged to be ineffective as prevention mechanisms and possibly harmful to rehabilitation because of increased difficulties created around employment, accommodation and family relationships (Levenson & D’Amora, 2007; United Nations Children’s Fund, 2020). Sex offenders differ widely in terms of dangerousness and risk of recidivism. Much CSA occurs in the family environment, most offenders will not be re-arrested for CSA and many will benefit from treatment (Levenson & D’Amora, 2007).

Finkelhor et al. (2022) in their most recent update on trends in child maltreatment noted that the start of the ‘dramatic downturn trend’ in substantiated physical and sexual abuse rates in the USA in the 1990s coincided with ‘increases in the number of law enforcement and child protection personnel and more aggressive prosecution and incarceration policies’ (tertiary prevention) as well as growing public awareness of the problems (primary prevention), sustained economic improvement and the ‘dissemination of new treatments for family and mental health problems’ (primordial prevention) (Finkelhor et al., 2022. p. 3.). It seems likely that it was the primordial, primary and tertiary factors in combination rather than any individual factor which produced the change.

Treatment as Prevention

Although there is no definitive answer on the effectiveness of treatment for adults sexually attracted to pre-pubescent and pubescent children or for juveniles displaying harmful sexual behaviour, on balance it appears that treatment has preventive potential (Caldwell, 2016; Collaborative Outcome Data Committee, 2007; Hanson et al., 2018; Lösel & Schmucker, 2005; United Nations Children’s Fund, 2020).

For juvenile offenders, the United Nations Convention on the Rights of the Child obligates signatory states to use diversion and alternatives to custody to the greatest extent possible (United Nations Children’s Fund, 2020). The Australian National Strategy to Respond to Child Sexual Abuse 2021–2030, for example, has recognised the importance of treatment and ongoing support for juveniles displaying harmful sexual behaviour and will increase workforce capacity to prevent and respond to such behaviour. Shlonsky et al. (2017) conducted a rapid evidence assessment of the international data on the therapeutic treatment of children under ten displaying problem sexual behaviour and those aged 10–17 years exhibiting harmful sexual behaviour or prosecuted for CSA (offenders) but found few rigorous, high quality studies. They gave qualified support to the USA developed multi-systemic therapy (MST) as showing promise. From their assessment, they suggested that therapeutic treatment services for problematic or harmful sexual behaviours should be specialised, actively involve parents, use behavioural and/or cognitive techniques and be based on a holistic ecosystems approach.

Internationally, most treatment programs for adults have focused on convicted offenders and men in prison (United Nations Children’s Fund, 2020), although there are some community treatment programs such as de Waag Centre for outpatient forensic psychiatry in the Netherlands (Van Horn et al., 2015), Prevention Project Dunkelfeld in Germany (Beier, et al., 2015a, 2021) and the New Zealand Wellstop (Lambie & Stewart, 2012). For community treatment programs to be realistic, they need to be geographically accessible, affordable and timely.

In Australia, successful government-supported community-based treatment programs for adults that uniquely focused on CSA by family members were once available in New South Wales (Cedar Cottage) and Western Australia (SafeCare Inc/) but no longer operate due to legislative impediments. Cedar Cottage (1989–2012) provided a 2-year pre-trial diversion program for CSA offenders in a parental role who were willing to plead guilty to abusing a child in their care and were assessed as suitable for community-based sex offender treatment (Goodman-Delahunty & O’Brien, 2014). SafeCare Inc. (1989–2009) offered a two-year community-based CSA treatment program for men who accepted responsibility for abuse, left the family home, committed never to being alone with a child for the duration of treatment and would plead guilty if charged with sexually abusing a child. The SafeCare program was available to potential offenders, undetected or unadjudicated offenders and convicted offenders. The lack of programs like Cedar Cottage and SafeCare Inc. is a major gap in a public health approach to the prevention of CSA and arguably discourages potential or undetected familial offenders (and their families) who might wish to seek help from doing so (Goodman-Delahunty & O’Brien, 2014).

There is interconnection and overlap between secondary and tertiary prevention when treatment is community-based and accessible to those at risk to abuse, undetected offenders, unadjudicated offenders and convicted offenders. To be fully effective a secondary prevention helpline service like Stop It Now! needs to be able to refer individuals to treatment services whatever their offending status whenever referral is assessed as necessary. Prevention Project Dunkelfeld could be classified as tertiary prevention when treating undetected offenders. The boundaries between prevention levels cannot be rigid.

In some countries, a possible impediment to increasing treatment services for potential offenders and offenders be they adults or juveniles is the lack of training for professionals to work in the area. There needs to be high quality training at university level, more opportunities for professional development and for sharing experience and expertise.

Reintegration of the offender into the community and reconnection with family where this is safe and acceptable to family members, including victim/survivors, is further aspect of tertiary prevention. For some offenders, their families and communities, a restorative justice approach may be the way to achieve this.

Restorative Justice: Beyond Treatment to Healing

Restorative justice in a family context would bring together all parties affected by CSA, give everyone the opportunity to say how they felt, for the offender to clarify why the harm occurred, to listen to others about how they have been affected and to plan for future safety (Braithwaite, 2021; Ivec et al., 2012). A sensitive restorative justice process has potential to reduce the impact of CSA on all family members and cut across generational sequences of victimisation. Examples of restorative justice programs internationally include:

  • Circles of Support and Accountability (COSA), which originated in Canada in the 1990s and has since been implemented in several countries, is a community-based program based on restorative justice principles. COSA uses trained community volunteers supported by volunteer professionals to provide a circle of support for offenders with promising results (Azoulay et al., 2019).

  • Hollow Water First Nations Community Holistic Circle Healing is a Canadian cultural and community-based restorative justice approach which has been suggested by inquiries into CSA in Australian Aboriginal communities as an alternative sentencing model for offenders from Aboriginal communities (Aboriginal Child Sexual Assault Taskforce, 2006; Wild & Anderson, 2007).

  • Hidden Water is a restorative justice approach in the USA based on the indigenous practice of peacemaking circles and is founded on the belief that CSA harms not only the person directly impacted but also the whole web of connected relationships (https://hiddenwatercircle.org/).

Intergenerational CSA

The intergenerational nature of child sexual abuse both in the intrafamilial and extrafamilial contexts adds a complexity to the dimensions of primordial, primary, secondary and tertiary prevention. There is increasing recognition that childhood victimisation and trauma are associated with repeated victimisation or acting out and offending in different individuals. For example, Ogloff and colleagues’ research has shown that there is an increased risk of later offending or victimisation in those children with substantiated CSA (Ogloff et al., 2012). Thus, treatment for children of any gender who have experienced CSA is important to prevent the next generation of children being harmed.

Prevention approaches are not linear but circular. While therapy and treatment may be regarded as tertiary prevention, it may also be regarded as primary prevention when it is offered to offenders in order to prevent repeat offending as it protects potential future victims from the offender. Treatment for victims can also be regarded as primary, if it protects them from being re-abused or re-victimised in later life or becoming offenders themselves.

Conclusion

A public health approach to CSA prevention demands a policy framework that integrates the four levels of prevention—primordial, primary, secondary and tertiary—into a complex adaptive system made up of interconnected subsystems. Preventing potential offenders’ first offence or preventing re-offending is one of those subsystems. Internationally, initiatives exist at each level of prevention, but their implementation remains fragmented, and each initiative tends to be standalone and independent of others. The proposed policy framework integrates all the initiatives into a unified strategy to prevent CSA before it occurs. Greater priority is given to the earlier levels of prevention as these are the most productive in achieving the desired aim. The framework recognises that progressing through the levels of prevention is not linear but circular—that at each level, one is potentially also engaging in others. As an important example of the interconnectedness and circularity of these levels, the promising role of restorative justice is introduced as a component of tertiary prevention that provides opportunities for individual and collective healing with its potential for primordial and primary prevention.