A Royal gift to prevention efforts

In public health prevention, the vast majority of victories have resulted from changes to public policy (Porter, 2012). The dramatic reduction in incidence of cardiovascular mortality, for example, has been largely attributed to persistent trench warfare against the tobacco industry (Scarborough et al., 2009). This was a slow, step-by-step and bitterly fought victory, and a parallel war is beginning in the obesity sphere. The first salvos have been fired, with Mayor Bloomberg of New York City attempting to reduce serving sizes of sodas; as happened in the smoking campaign, the food industry has vigorously fought the policy in the courts. Again, as in the smoking wars, this war will likely last decades and will be fought across multiple jurisdictions and domains (Grynbaum, 2012).

What can be learnt from these battles is that the road between identifying a public health problem and enacting change to public policy is long, arduous and filled with barriers. One major barrier that must be overcome is the need to create sufficient acceptance and a sense of urgency amongst the general populace to stimulate enthusiasm and support for complex policy change.

Rarely, unintended gifts to prevention efforts fall into our laps. The recently announced Royal Commission into Institutional Responses to Child Sexual Abuse (2013) may be such an opportunity. Its scope is limited to an examination of how institutions that had a responsibility for the care of children responded and managed instances and allegations of child sexual abuse. It aims to investigate instances where systems failed to protect children in their custody. Its purpose is also to produce recommendations on ways to improve laws, practices and policies in order to prevent and better respond to institutional child sexual abuse. Its greatest impact, however, may be cultural.

Underpinning the success of anti-smoking campaigns was an increasing public recognition and acceptance of smoking’s deleterious health effects. Population-wide attitudinal change is needed to facilitate the implementation of any preventive initiatives (Rüsch et al., 2012). The Royal Commission will spotlight an area that has been in the shadows for decades, publicly vindicating victims and seeking redress. Given that victims have infrequently reported abuse to date, silence may have inadvertently facilitated further abuse. The voice provided by this Commission will certainly increase public awareness of abuse and hopefully allow victims a space to come forward and tell their stories.

Given the multitude of risk factors for all common psychiatric disorders, each contributing a small overall proportion of the variance, a key issue for prevention policy is quantifying the estimated population risk that may be averted if we were able to substantially reduce, or even eliminate, an individual risk factor. Molnar and colleagues (2001), using data from the National Comorbidity Survey, estimated that the population attributable risk of suicide attempt owing to childhood sexual abuse was between 11% and 14.5% in women and from 3.6% to 15% for men. Similarly, Chapman and colleagues (2004), in a cohort study of 9460 members of a health maintenance organisation, found that childhood emotional abuse was associated with an adjusted odds ratio of 2.7 (95% confidence interval (CI), 2.3–3.2) in women and 2.5 (95% CI, 1.9–3.2) in men for lifetime depressive disorders, with a robust dose–response relationship evident between the adverse child experience score and the probability of both recent and lifetime depressive disorders.

It scarcely needs to be mentioned that childhood sexual and physical abuse is a pervasive and noxious factor that both increases the risk of almost all adult mental disorders, from borderline personality to substance abuse, anxiety disorders, suicidal behaviour, depression, bipolar disorder and psychosis, and worsens the outcome of many of these disorders (Bendall et al., 2012; Ferguson et al., 1996). Sexual, physical and emotional abuse causes trans-generational damage, with victims tragically becoming more likely to be perpetrators (Bebbington et al., 2011; Hornor, 2010). Anything that can interrupt this noxious cascade will be a major victory in the nascent efforts to prevent psychiatric disorders (Jacka et al., 2012).

The Royal Commission presents a unique opportunity to shed light on child sexual abuse in Australia. Although not an explicit aim of the Commission, a potential outcome of this process is an effective public reinforcement of the undesirability of childhood sexual abuse and an increased understanding among the population of its impact on children. Increased public awareness and public vindication of victims will hopefully help to end a culture of silence that has perpetuated a continuing cycle of abuse. The mental health profession needs to embrace this Commission for the benefits it will serve to victims, their families, and to future generations who may be less likely to suffer abuse as a consequence. For these benefits, and for the potential unintended positive effects the Commission may have on reducing the population’s risk of major mental illnesses, our profession should be more vocal in publically supporting its work.