Lessons as a prevention intern: Eliminating sexual violence through school-based programs

Sexual violence is so prevalent that every 73 seconds another person in America is sexually assaulted. Motivated by this statistic, I chose to complete my senior practicum at the Sexual Assault Resource Center, which provides advocacy and support services, including crisis intervention and counseling, for survivors of sexual violence. My goals for my time with SARC included developing knowledge and skills related to being a trauma therapist, learning about how a nonprofit operates, and gaining an understanding of sex education and sexual violence prevention programs. As a Sexual Assault Advocate and Education and Prevention Intern at SARC, my primary responsibilities involved providing direct advocacy services to survivors, delivering educational workshops, and presenting prevention curriculum in schools. As a result of my participation, I became interested in researching school-based prevention strategies and programs aimed at reducing sexual violence, as well as their focus areas, strengths, and limitations. My research and practicum experience reframed the way I viewed prevention work, provided insight into effective prevention strategies, and reminded me of why I believe so strongly in early prevention education to reduce sexual violence.

Over the course of their lifetime, approximately 16% of men and 33% of women will experience some form of contact sexual violence (Truman & Langton, 2015). Sexual violence has significant negative physical and psychological effects on survivors (Hubach, et al., 2019;Miller, 2017;Shorey, et al., 2017). Because of the profound effects, prevention efforts are incredibly important. This thesis will explore sexual violence and sexual violence prevention in four sections. Section one will discuss the Sexual Assault Resource Center (SARC), an organization that provides assistance to survivors and works to prevent sexual violence in the community. Section two will discuss my internship at the SARC, including a description of my roles, responsibilities, and learning goals. Section three will review the existing literature on the topic of reducing sexual violence through school-based prevention programs. Finally, section four will discuss the work I did at the SARC and my reflections on the experience.

Organization and Population
This section discusses the history, mission, and services provided by the SARC where I completed my year-long practicum. It also will discuss the characteristics of the populations served by SARC, including the specific needs of the individuals and groups that receive services from the organization.
Organization. The SARC is an advocacy and support center located in Beaverton, Oregon. It was founded in 1977 by two sexual assault survivors with the goal of creating a caring and compassionate space for other survivors. SARC s mission is to promote social justice by eliminating sexual violence in [the] community through education, support, and advocacy (SARC, 2019). They accomplish this by providing free and confidential services to survivors of all types of sexual violence, regardless of age, gender, race, ethnicity, economic class, disability, or religion. SARC s philosophy is providing survivors with choice and autonomy, ensuring survivors feel heard, and honoring the survivor s resiliency.
SARC offers comprehensive services in the areas of crisis intervention, case management, and counseling services. The 24hour crisis support line provides resource referrals (e.g., counseling), de-escalation and grounding techniques, emotional support for survivors and their friends and family members, and arranges advocate accompaniment to medical exams or law enforcement reports. To further support survivors, case managers provide on-going emotional support, continued resource referrals (e.g., housing assistance), and assistance through the justice system. Additionally, SARC offers individual and group counseling services. To meet the needs of underserved populations who are disproportionately affected by sexual violence and face unique barriers in accessing services, SARC also offers a Latinx program and a program designed to support those who are incarcerated or justice-involved.
A second way SARC works to eliminate sexual violence is through community education. They do this by offering a nine-week Sexual Violence Prevention Program to schools in Washington and Multnomah counties that covers topics like features of healthy relationships, oppression, and rape culture, with the goal of addressing the root causes of sexual violence. In addition to school settings, SARC offers workshops, training, and outreach to a variety of agencies (e.g., law enforcement, Planned Parenthood) and settings (e.g., college campus, resource fairs).
In summary, SARC seeks to provide support and advocacy services to survivors of all forms of sexual violence and of all identities, while simultaneously working to reduce rates of sexual violence through community education and prevention work.
Population served. SARC serves an average of 2,000 clients a year. Recent data indicates an increase in the number of clients accessing services, with 1,629 clients being served in the first eight months of 2019. Those most likely to seek services at SARC are female (94%), White (37%), and are between the ages of 18 and 65 (85%). SARC also works with a large Hispanic/Latinx population (16%) in their Latinx program. SARC s Education and Prevention Program works with a variety of organizations in the community. SARC s prevention curriculum is taught in high schools. SARC also teaches prevention workshops and trainings to law enforcement, school personnel, and other social service agencies (e.g., Planned Parenthood). Three times a year, SARC offers a forty-hour advocacy training for potential volunteers that trains advocates on several trauma-related topics.
Needs of the population served. Oregon has rates of sexual violence that significantly exceed the national average (Smith et al., 2017;Women s Foundation of Oregon, 2015). According to one report, one million Oregon women and girls, representing nearly half of the state s female population, has experienced sexual violence (Women s Foundation of Oregon, 2015). Another study reports that 47.5% of women in Oregon, the highest rate in the nation, have experienced some form of contact sexual violence (Smith, et al., 2017).
In most cases, survivors of sexual assault choose not to pursue any post-assault care. Even though sexual violence has significant impacts, only 18% of survivors choose to seek medical attention or help from a social service agency following an assault (Kramer, et al., 2017). Cost of services and stigma are two of the biggest reason survivors do not seek care (Kramer, et al., 2017). Research suggests that intervention centers are most utilized and beneficial when they offer the following: a culture of caring, one stop shop, validation, survivor control and agency, and confidentiality (Kramer, et al., 2017). SARC s philosophy and approach aligns with these principles. All of SARC s services are confidential; their philosophy focuses on providing survivors with autonomy; and by providing comprehensive care, through crisis intervention, case management, and counseling services, SARC is essentially a one stop shop for survivors. Research indicates that most women (81%) and about a third of men (35%) report significant effects associated with sexual violence, including posttraumatic stress disorder (Truman & Langton, 2015). In 2018, over 85% of clients reported feeling safer and experiencing fewer symptoms of posttraumatic stress after accessing SARC services (SARC, 2019).
SARC also works to meet the needs of populations who experience increased risk and increased barriers to care, particularly people of color. Emerging research is reporting that women of color experience higher rates of sexual violence, face more barriers to accessing counseling or medical services, seek services less, and are less likely to report an assault, compared to white women (National Sexual Violence Resource Center, 2013;Smith, et al., 2017). Among the barriers identified in the literature are: cultural or linguistic issues, fear of isolation or lack of support from family and community, and lack of awareness about how to utilize services (National Sexual Violence Resource Center, 2013). Another barrier is reluctance or fear, primarily due to an agency s lack of bilingual or bicultural staff, concerns about an agency s connection with immigration, or lack of cultural values incorporated into advocacy work (National Sexual Violence Resource Center, 2013;Women of Color Network, 2006). The National Center for Cultural Competency created a framework for culturally-competent organizations. Using this information and data from a study on population needs, The National Sexual Violence Resource Center (2013) identified principles for working in culturally-responsive ways. These principles include: offering services and supports in clients preferred language and mode of delivery, translate and adapt written materials, offer interpretation services, value diversity, and adapt to cultural contexts of communities being served.
In the western U.S., where SARC is located, 28.6% of the population identifies as Latinx or Hispanic (National Sexual Violence Resource Center, 2013). SARC works to break down barriers for this population through its Latinx program. Through the Latinx program, survivors have access to advocacy, case management, and counseling services with bilingual and bicultural providers, who are extra attuned to the cultural needs and strengths of the population. All printed materials are also offered in English and Spanish, the two most used languages in the area. Furthermore, all survivors are asked their preferred language upon initial contact with an advocate. Translation and interpretation services are available for all services. SARC services are also completely separate from all other agencies, including government agencies, like law enforcement and immigration. Informing clients of their right to confidentiality and privilege is one of the first conversations that happens when they meet with an advocate. Another way SARC attempts to reduce barriers is by doing outreach events in settings that feel safe and familiar for survivors, for example a cultural center or church.
While there must be continuous education and work to break down systemic barriers, SARC attempts to provide support and advocacy services for all survivors of sexual assault in a culturally-responsive, trauma-informed way.

Practicum
In this section, I explain my position as a Sexual Assault Advocate and Education and Prevention Intern at the SARC, my roles and responsibilities, and the learning goals I developed for my time with the organization.

Roles and responsibilities. As a Sexual
Assault Advocate and Education and Prevention Intern at SARC, I delivered both direct advocacy services and community education and prevention services. In my role as a Sexual Assault Advocate, I was involved in frontline advocacy work with survivors, through in-person crisis response via hospital and law enforcement accompaniment. In my role as an Education and Prevention Intern, I created and delivered educational workshops for various community organizations, participated in outreach events, and delivered prevention curriculum in a local high school. Another part of my role at SARC was attending trainings relevant to the work being done by the organization and collaborating with staff and community partners during various committee meetings.
Additionally, a requirement of my position was participation in forty-hours of advocacy training on topics like trauma physiology, methods of listening, medical advocacy, stages of healing, and crisis intervention.
Based on my understanding of the position prior to beginning my internship at SARC, I established learning goals to guide my development of professional skills and knowledge about school-based prevention work during my practicum.
Learning goals. As shown in Figure 1, I outlined three learning goals, which included developing professional skills and knowledge towards becoming a trauma therapist, learning about the history and operation of nonprofits agencies, and gaining a thorough understanding of sex education and prevention programs. Each goal was associated with a set of objectives that I hoped to accomplish through specific activities during the year.
My first goal was to increase professional knowledge and skills related to my goal of becoming a trauma therapist. In order to accomplish this, I wanted to a. research education requirements and career paths, b. gain practical skills necessary to become a professional in the field, c. engage in trauma-related training and practice towards getting certified as an adolescent trauma therapist. My second goal was to learn more about how nonprofit organizations are structured and the services they provide to address sexual violence. To achieve this, I planned to (a) learn about the history of nonprofit agencies, (b) learn about how nonprofits function to provide necessary services, and (c) learn about SARC s services specifically for sexual assault survivors. My third learning goal was to gain a thorough understanding of the features of sex education and prevention programs within school-based settings by learning about (a) state and federal requirements for sex education and (b) the elements of effective sex education programs, as well as (c) participating and facilitating education, prevention, and outreach work.
While accomplishing my practicum hours, I was reminded of the prevalence of sexual violence, the significant impact on survivors, and the importance of prevention efforts. Because of this, I chose to conduct a literature review on how school-based education and prevention programs can prevent sexual violence.

Eliminating Sexual Violence Through School-based Prevention Programs
Sexual violence is defined as any sexual act that is committed against someone who does not consent or is unable to consent or refuse and can include penetration, unwanted touching, and noncontact sexual abuse (Vivolo, Holland, Teten, & Holt, 2010). According to recent estimates, 1 in 6 men and 1 in 3 women will experience sexual violence at some point in their life (Truman & Langton, 2015). College-aged individuals are at an increased risk of experiencing sexual violence, with college women three times as likely and college men 78% more likely to experience sexual assault than other women and men (Rape, Abuse & Incest National Network, 2015). As a public health issue, reducing sexual violence is focused on preventing associated risk factors and promoting protective factors (Santelli et al., 2018;Vivolo et al., 2010). One way this is accomplished is by focusing on education within school-based settings. School-based programs can be effective at changing attitudes towards sexual violence and reducing risk of sexual violence perpetration  and victimization (Banyard, et al., 2019;Charmaraman, Lee, & Erkut, 2012;Grossman, et al., 2014;Santelli et al., 2018;Vivolo et al., 2010). However, current school-based programs have many limitations and must overcome a number of barriers to become effective (Eisenberg, et al., 2013;Fagan & Catalano, 2012;Santelli et al., 2018).
Effects of sexual violence. Sexual violence has significant short-and long-term effect on both individuals and the larger society. In the U.S., the lifetime economic burden of rape is $3.1 trillion (Peterson, et al., 2017). That equates to approximately $127 billion annually, more than any other crime (Krebs, et al., 2007). Cost associated with sexual assault are approximately $240,776, while a robbery costs approximately $42,310 (McCollister, et al., 2010). These costs stem primarily from medical costs, lost productivity, and criminal justice activities (Peterson et al., 2017). Victims of violence experience direct costs associated with medical care or lost earnings. However, larger communities also absorb costs from these crimes. When the justice system gets involved, there are costs associated with legal services and incarceration, should a conviction be made. There are also costs associated with addressing survivor mental and physical health concern, treating addiction, and compensating for disparities in education and vocational abilities (Fagan & Catalano, 2012;Vivolo et al., 2010). Survivors of sexual violence are significantly more likely to engage in risk-taking behaviors such as binge drinking, risky sexual behaviors, and substance use and abuse (Hubach, et al., 2019;Vivolo. et al., 2010). Substance abuse and addiction has an increasing societal cost. Alcohol abuse costs the U.S. $249 billion annually and prescription drug abuse costs $78.5 billion annually (Gans, 2020). These costs are associated with lost employment, excess medical expenses, and correctional facilities or policing (Birnbaum, et al., 2011).
In addition to increased likelihood of engaging in risky behaviors, survivors of sexual violence are more likely to experience negative physical and mental health outcomes (Hubach, et al., 2019;Miller, 2017;Shorey, et al., 2010;Smith, et al., 2017). Societal costs are associated with an increase in emergency department visits and need for ongoing medical services. Survivors are significant more likely to experience chronic pain and chronic illness (e.g. irritable bowel syndrome, asthma, migraines ;Hubach, et al., 2019;Miller, 2017;Shorey, et al., 2010;Smith, et al., 2017). Compared to 14.7% of those without a history of sexual violence, 22.1% of sexual violence survivors experience asthma (Smith. et al., 2017). Similarly, 27.4% of survivors experience chronic headaches, compared to 15.6% of non-survivors (Smith, et al., 2017). Additionally, there are trends of sleep and activity disruption in those who have experienced sexual violence. Nearly 40% of survivors experience sleep problems and 33.6% report having significant activity limitations (Smith, et al., 2017). Because of this, survivor accrue significant amounts of medical costs, associated not only with injuries immediately after the assault, but several months or years later. Survivors also report an increase in symptoms associated with emotional distress, including suicidality, panic, depression, and posttraumatic stress disorder (Hubach, et al., 2019;Miller, 2017;Shorey, et al., 2010;Vivolo, et al., 2010).
Those who have experienced sexual violence also tend to have problems in intimate relationships, lower educational attainment, and underachievement at work (Fagan & Catalano, 2012;Vivolo, et al., 2010). This is linked with higher rates of housing instability and need for assistance programs.
As a result of the significant impacts, the Center for Disease Control and Prevention encourages preemptive rather than reactionary strategies for addressing sexual violence (Menning & Holtzman, 2015). With this is mind, recent research has found a number of preemptive approaches to countering sexual violence. Because the years 15 to 25, from adolescence through emerging adulthood, present the greatest risk for sexual violence among peers (Miller, 2017;Shorey, et al., 2017) and prevention efforts are most effective prior to initial exposure to violence (Degue, et al., 2014;Miller, 2017;Shorey, et al., 2017;Vivolo, et al., 2010), school-based prevention programs are one effective preemptive approach.

Components of Effective Schoolbased Prevention Programming
Effective prevention programs require a number of key features to successfully create change, mitigate risk factors, increase protective factors, reduce the likelihood of negative outcomes, and enhance the likelihood of positive outcomes (Nation, et al., 2003). Prevention programs should be a. theory-driven, relying on empirical evidence to offer b. comprehensive topics and c. affect outcomes as predicted. Programs must also be d. socio-culturally relevant to the population that is being addressed, e. offer sufficient dosage/duration to implement change immediately or long-term, and f. be offered at appropriate times to effect predictors associated with specific outcomes, including risk and protective factors. Programs that are successful will also have g. emphasize positive relationships, h. provide many ways of disseminating the information, and i. offered by well-trained staff. As stated above appropriate messaging, duration, and timing are key to the development and implementation of prevention programs (Nation et al., 2003).
Characteristics of the intended population, including cognitive abilities, developmental stage, sociocultural factors, and unique risk and protective factors, must be accounted for to increase the likelihood of improvement or change on the desired outcome (Banyard, et al., 2019;Fagan & Catalano, 2012). Prevention programs focused on eliminating sexual violence must take into account the developmental stage of the youth in order to reduce risk factors associated with increased sexual violence and increase protective factors that serve to reduce the prevalence of sexual violence. One way this is accomplished is by modifying the topics, goals, and approaches for elementary, middle, and high school students.
Elementary school. Primary prevention programs in elementary schools have the goal of reducing Adverse Childhood Experiences (ACEs), which are associated with sexual violence and perpetration later in life (Lundgren & Amin, 2015), and providing a foundational understanding of respect and safety. Given the age of the youth, topics at this developmental level focus on increasing knowledge about body safety and autonomy by using curriculum that addresses topics like safe and unsafe touch, identifying private parts of the body, introducing the concept of your body is your own, and what to do when feeling unsafe . Elementary-school-aged children learn these concepts best when they involve different methods, typically a combination of verbal instruction and play (Nation, et al., 2003;Walsh, et al., 2018). Comprehensive prevention strategies recognize that preventing childhood trauma is an effective strategy for preventing violence later in life (Smith, et al., 2017). For this reason, community programs that increase safety and stability for youth can dramatically reduce future sexual violence perpetration and victimization (Smith, et al., 2017). One way of doing this is offering programming, support, and interventions for parents and caretakers for youth who have been identified as at-risk (Lundgren & Amin, 2015). Programs that emphasize the creation of positive, healthy relationships and stability within homes, communities, and schools are also effective in reducing sexual violence later in life (Smith, et al., 2017).
In summary, prevention work at the elementary school level is primarily about reducing future perpetration and victimization through decreasing childhood trauma, neglect, and disruption, and increasing stability, safety, and healthy relationships.
Middle school. Prevention programs in middle school emphasize relevant and accurate medical information, consent, assertive communication, and delaying onset of first sexual encounters (Grossman, et al., 2014;Santelli, et al., 2018). Prevention programs at this developmental stage are rooted in social norms theory, highlighting the role of relationships with family members and peers as key factors that influence the knowledge, attitudes, and behaviors of youth (Miller, et al., 2012;Santelli, et al., 2018;Vivolo, et al., 2010).
While research indicates the importance of parental communication on topics related to sexual education and wellness, parents report feeling ill-equipped to have these conversations (Grossman, et al., 2014;Santelli, et al., 2018;Vivolo, et al., 2010). Programs, such as the nine-week Get Real developed by Planned Parenthood, offer information and resources to students, as well as activities aimed at facilitating conversations between youth and parents, on topics such as healthy and unhealthy relationships, sexuality, consent, and sexually transmitted diseases (Grossman, et al., 2014). An evaluation of the program reported the addition of a family component to the school-based sex education program reduced the likelihood of sexual violence later in life, by delaying initial sexual experience, reducing engagement in risky sexual behaviors, and promoting the development of skills needed for healthy intimate relationships (Grossman, et al., 2014;Santelli, et al., 2018;Vivolo, et al., 2010).
Social acceptance among peers at this developmental stage is key and offers some important ways to reduce risk factors associated with sexual violence (U.S. Department of Health and Human Services, 2019). Because of the importance of peer acceptance, adolescents are strongly influenced by their perception of peer behaviors. Programs that dispel myths about sexual behaviors (e.g., that everyone is having sex) and beliefs (e.g., that it is okay to pressure your partner into sex) among students can be effective in changing overall behaviors and beliefs (Miller, et al., 2012; U.S. Department of Health and Human Services, 2019). Bystander intervention training is used to promote accountability among peers, intervene when harmful or inappropriate behaviors, and change attitudes towards violence in general within schools (Menning & Holtzman, 2015;Miller, 2017;Miller, et al., 2012). This type of intervention gives students specific skills to intervene when they see something problematic and functions to shift what is seen as acceptable within a community.
In summary, middle school prevention programs highlight the importance of peers, social influences and larger school culture, as well as the protective factor of parents and family ability to communicate about sex, relationships, and consent.
High school. Prevention programs for high school students educate, provide skills, and change attitudes and behaviors associated with sexual violence. Effective efforts at the high school level utilize components such as comprehensive sex education, gender transformative programming, and the combination of primary prevention and risk reduction strategies (Charmaraman, et al., 2012;Grossman, et al., 2014;Menning & Holtzman, 2015;Santelli, et al., 2018).
Comprehensive sex education includes not only accurate medical information and resources, but also components related to developing refusal skills, exploring gender dynamics, and discussing features of sexual pleasure (Charmaraman, et al., 2012;Grossman, et al., 2014;Santelli, et al., 2018). The implementation of comprehensive sex education programs, when compared to other sexual education strategies, resulted in delayed onset of initial sexual experiences, higher rates of accurate knowledge about sexual health, and reduced rates of sexual violence (Charmaraman, et al., 2012;Grossman, et al., 2014;Santelli, et al., 2018).
Gender transformative programs, such as Coaching Boys into Men, address risk factors associated with sexual violence by challenging traditional gender roles, addressing the detrimental effects of toxic masculinity, and combatting acceptance of violence perpetrated by men towards women (Banyard, et al., 2019;Miller, et al., 2012;Santelli, et al., 2018;Vivolo, et al., 2010). In the program mentioned above, male high-school athletes have discussions facilitated by their coach on violence against women, respect, dating and sexual violence, and bystander behaviors (Miller, et al., 2012). Programs such as this one not only increase the recognition of abusive words and actions, but also result in less support of violence and assertion of male power, and an increase in gender equitable attitudes (Banyard, et al., 2019;Miller, et al., 2012).
The most effective prevention programs for reducing sexual violence at the high school level include not only primary prevention efforts (e.g., communication skills, social norms, peer attitudes) but also risk reduction strategies (e.g., self-defense, refusal skills; DeGue, et al., 2014;Menning & Holtzman, 2015). The Elemental program is a 6-hour training that includes both of these strategies. Completion of the program resulted in students feeling more prepared about how to handle threatening situations, fewer attitudes associated with sexual violence, and lowered risk for future sexual violence victimization or perpetration (Menning & Holtzman, 2015).
In summary, high school prevention programs are primarily focused on changing attitudes and behaviors around sexual violence, with the most effective programs including elements of comprehensive sex education, gender transformative programming, and the combination of primary prevention and risk reduction strategies.

Limitations of School-based Prevention Programming
While there are school-based programs that are effective at reducing sexual violence, many limitations related to implementation and content remain. Primary limitations at this time are: timing of program implementation, lack of consistency in programming, treatment of the issue of sexual violence, and barriers specific to implementing school-based programs (Banyard, et al., 2019;Eisenberg, et al., 2013;Menning & Holtzman, 2015;Santelli, et al., 2018;Vivolo, et al., 2010).

Timing prevention programs. For most
individuals, their first exposure to a sexual violence prevention program is when they enter college and, while rates of sexual violence increase in college, research shows that initial incidents of victimization and perpetration begin well before college (Miller, 2017;Shorey, et al., 2017;Vivolo, et al., 2010). According to Shorey and colleagues (2017), 10% to 20% of adolescents perpetrate sexual violence each year. Additionally, in a survey of middle school students, 50% reported perpetrating sexual harassment against a peer (Charmaraman, et al., 2012). Because prevention curriculum is most effective when received prior to initial experiences of perpetration or victimization, middle or high school are more beneficial times to implement such a program. (Banyard, et al., 2019;DeGue, et al., 2014;Miller, 2017;Shorey, et al., 2017).
Adolescence is a critical period for emotional, social, and sexual development, and characterized by an increase in sexual experiences, intimacy, and romantic relationships (Miller, 2017;Shorey, et al., 2017;Vivolo, et al., 2010). This development period is also key for regulation skills and building the capacity for empathy making it an important time to provide prevention programs that cover the effects of peer influences, social norms around gender, sexual attitudes, and environments that tolerate violence (Banyard, et al., 2019;Miller, et al., 2012). Implementing prevention programs while brain pathways are still malleable and at a time when peer influence is strong, increases the likelihood that the program will shape collective attitudes, and, as a result, shift individual values and behaviors (Banyard, et al., 2019;Miller, et al., 2012;Vivolo, et al., 2010).
Given trends indicating sexual violence is being perpetrated at younger and younger, prevention programs also need to be presented at earlier ages in order to be effective (DeGue, et al., 2014;Miller, 2017;Shorey, et al., 2017;Vivolo, et al., 2010).

Lack of accurate, consistent, and comprehensive sex education. Studies on
the availability and accessibility of schoolbased sexual education and sexual violence prevention programs indicated that the majority are poorly delivered, fear-based, or do not exist at all (Hubach, et al., 2019;Santelli, et al., 2018). When sexual violence is discussed in schools, it is often incorporated into the school s general sex education teachings. These programs vary widely by state, in terms of content, duration, and scope. Currently only 24 states and the District of Columbia require any form of sexual education be provided to students in schools (Planned Parenthood, 2019). Of those, only 17 states require that the program content be medically accurate (Guttmacher Institute, 2019; Planned Parenthood, 2019). The CDC (2019) reports less than 50% of high schools and only around 20% of middle schools cover essential components of sex education, which include topics like communication and decisionmaking skills (Planned Parenthood, 2019). Issues related to sexual violence such as consent, are only mandated by 8 states nationwide (Guttmacher Institute, 2019).
The lack of adequate information about sexual education and violence results in adolescents relying on ad hoc solutions that are more likely to lead to inaccurate information and increase risky sexual behaviors. (Santelli, et al., 2018). The adoption of medically accurate, comprehensive sex education has mitigating effects on sexual violence. Comprehensive sex education in middle school and high school has an overall negative association with sexual violence (Grossman, et al., 2014;Santelli, et al., 2018). Additionally, participation in comprehensive sex education programs was related with decreased involvement in risky sexual behaviors, delayed onset of initial sexual experiences, and built skills needed for healthy intimate relationships, all factors associated with a decrease in future sexual violence (Grossman, et al., 2014).
While middle and high school students are currently unlikely to receive comprehensive sexual education that also includes topics relating to sexual violence and consent, the incorporation of such education offers a promising means of reducing sexual violence.

Sexual violence as an individual-versussocietal issue. Many prevention programs
focus on individual level factors that contribute to sexual violence such as behaviors, thoughts, and attitudes of the perpetrator, and predictors of sexual violence among survivors. Looking at sexual violence on only an individual level is problematic because it promotes victim blaming, perpetuates misconceptions around sexual violence, and ignores the larger environments that support it.
The Social-Ecological Model takes the focus away from individuals to shed light on the ways that sexual violence is maintained, directly or indirectly, by larger systems (Menning & Holtzman, 2015).While individual-level factors focus on personal history or beliefs leading to sexual violence, community-level factors (e.g., school climate, sense of community, neighborhood influences) and societal-level factors (e.g., sexism, heterosexism, gender pay gap, gender stereotypes as biologically driven) are also major elements of sexual violence perpetration and victimization (Menning & Holtzman, 2015).
Research suggests that the most effective prevention program discuss and intervene at multiple levels (Menning & Holtzman, 2015;Santelli, et al., 2018;Vivolo, et al., 2010). In addition to addressing individual factors, through confronting individual attitudes and beliefs, program that addresses multiple levels of influence will incorporate elements relating to relationshiplevel factors (e.g., helping parents identify and address violent behaviors, bystander intervention training) and community-level factors (e.g., addressing school norms and attitudes related to sexual violence; Menning & Holtzman;Vivolo, et al., 2010). Effective primary prevention will also identify opportunities for structural changes that will help decrease community and societal level factors that contribute to sexual violence; evaluate and change policies that create a culture of consent and respect; and, search for early intervention strategies (Santelli, et al., 2018).
Barriers to implementing programs within schools. When comprehensive and effective prevention programs have been identified, there are barriers towards adoption and implementation. As mentioned previously, only 24 states mandate sexual education and of those, only 8 also require topics related to sexual violence be included. There are also additional barriers that include, denial of sexual behaviors and violence among youth, parental and administrative restrictions on the content of programming, structural barriers that make it difficult for teachers to cover topics related to comprehensive sex education, and restrictive policies at the district or state level (Eisenberg et al., 2013).
School-based prevention programs decrease sexual violence by increasing knowledge, building skills, and shifting attitudes, but can only be accomplished within a larger community that is knowledgeable, educated, and supports the implementation of comprehensive, accurate education and prevention programming within school settings (Fagan & Catalano, 2012;Menning & Holtzman, 2015).
This empirical review discussed the prevalence of sexual violence, the implementation of school-based prevention programs, and the limitations of school-based programming. Studies indicate that sexual violence is happening to students before they ever receive sexual violence prevention education (Miller, 2017;Shorey, et al., 2017;Vivolo, et al., 2010). Effective school-based prevention programs address risk factors associated with sexual violence, while offering developmentally appropriate topics and strategies (Banyard, et al., 2019;Fagan & Catalano, 2012). Properly implemented programs are associated with an increase in bystander behaviors, increases in gender equitable attitudes, decrease in support of violence, increase of healthy behaviors within intimate relationships, and an overall decrease in sexual violence perpetration and victimization (Grossman, et al., 2014;Miller, et al., 2012;Santelli, et al., 2018;Shorey, et al., 2017;Vivolo, et al., 2010). Unfortunately, there are a number of limitations that currently exist in offering effective, evidence-based sexual violence prevention programs in school. Some of these limitations are associated with timing of program implementation, lack of consistency in programming, treatment of the issue of sexual violence, and structural barriers (Banyard, et al., 2019;Eisenberg, et al., 2013;Menning & Holtzman, 2015;Santelli, et al., 2018;Vivolo, et al., 2010). Still, the findings that support school-based prevention programs are effective in reducing sexual violence, along with the push from national organizations, like the CDC, to combat sexual violence, suggest that there is movement towards resolution of those limitations.

Progress, Program, and Reflections
As a Sexual Assault Advocate and Education and Prevention Intern, I completed 40 hours of advocacy training and approximately 90 experiential hours with the SARC. To prepare for this experience, I developed three learning goals that focused on developing knowledge and skills related to being a professional in the psychology field; observing the way a violence prevention nonprofit organization functions; researching the components of effective school-based sexual violence prevention programs; and participating in outreach, education, and prevention events within the community. In this section, I share my progress, the objectives I was able to accomplish; provide a brief overview of SARC s education program and how it aligns with the previously discussed principles for effective prevention work; and provide overall reflections on my experience.

Progress and outcomes. During my time at
SARC, I was able to engage in a variety of educational experiences and prevention activities to meet a number of my learning goals.
1. My first learning goal was to develop knowledge and skills necessary to become a trauma therapist. The objectives associated with this goal were to research educational requirements and career paths, gain practical and professional skills, and engage in traumarelated training and practice. To accomplish these objectives, I completed a forty-hour advocacy training in order to get certified as a Sexual Assault Advocate. In this training, I learned about crisis intervention, medical advocacy, trauma stewardship, and the interplay of trauma and other oppressive systems. I also researched a number of graduate psychology programs and degrees and talked with multiple providers in psychology and social work fields. Finally, I gained professional skills through practicing professional communication, professionalism in the workplace, and collaborative work, as well as through participation in multiple professional development webinars on topics like preventing human trafficking and preventing violence in the Latinx youth population. 2. My second learning goal was to gain an understanding of nonprofit work. The objectives associated with this goal were to learn about the history of nonprofit domestic violence and sexual assault agencies, learn about how nonprofits function and operate, and learn about outcomes of nonprofits. To accomplish these objectives, I attended weekly staff meetings and monthly volunteer meetings. These meetings provided me with an understanding of the structure and function of nonprofit organizations. I also attended an intraorganizational Equity, Diversity, and Inclusion (EDI) committee meeting. This committee functions to ensure organizational practices are inclusive and equitable. This meeting allowed me to learn about the way nonprofits, especially those that serve vulnerable populations, work to meet the various needs of their clients. I learned about the purpose and importance of nonprofits and the roles different members play through staff interviews. I learned about client demographics, outcomes, and barriers; sources of organization funding; the organization history; and the structure of the organization through research, evaluation of statistics, and information from the director of the organization. 3. My third learning goal was to gain a thorough understanding of sex education and sexual violence prevention programs. The objectives associated with this goal were to learn about the elements of effective programs, learn about state and federal sex education requirements, and engage in education, prevention, and outreach work with SARC. To accomplish these objectives, I conducted thorough research and participated in a number of activities with SARC. I attended community engagement and outreach events, with the purpose of connecting people with SARC resources and educating people about the services available to them. I created handouts and resource sheets for these events (For example handouts, see Figure 2). I was also able to observe, present, and develop education and prevention workshops within the community. These trainings were directed at health agencies, college students, and high schoolers, and covered topics like teen dating violence, oppression, consent culture, and handling disclosures. I worked in one local high school presenting their sexual violence prevention curriculum. These weekly lessons involved advocate-led instruction, classroom discussions, and group activities on topics like communication, healthy relationships, and pornography. I was also able to conduct a thorough literature review on sexual violence and the effectiveness of a variety of school-based prevention programs.

SARC's prevention program.
After completing my research and practicum, I am able to connect the elements of effective school-based prevention work to SARC s youth education and prevention program. In many ways, SARC s program utilizes principles of effective prevention work. At the same time, SARC faces some of the barriers seen in other prevention programs. SARC s prevention curriculum was designed with the goal of addressing the root causes of sexual violence, through an analysis of healthy and unhealthy norms. Their curriculum is linked with state and federal standards, based on literature reviews and best practices, and meets Oregon s requirements stemming from Erin s Law and Healthy Teen Relationship Act (legislature regarding education on sexual abuse and teen dating violence). SARC also regularly updates their lessons to stay relevant and timely, and improve participant outcomes. SARC s high school curriculum is nine weeks long and is taught by SARC staff or interns during the students health period. Lessons are interactive and incorporate skill-based activities. The nine topics are: sexual violence, anti-oppression, gender and sexual orientation, healthy relations and sexuality (two weeks), media, pornography, victim blaming and victim empathy, and bystander interventions.
As an organization, SARC recognizes that there are multiple levels of intervention (primary, secondary, and tertiary). However, their education and prevention program focuses on primary prevention strategies. Primary prevention work is designed to prevent first-time perpetration and victimization. At SARC, this is done primarily through addressing attitudes, beliefs, and behaviors as they relate to relationships and sexual violence. SARC also recognizes the multiple levels of influence and considers risk and protective factors across all levels. On the individual level, SARC s program works to build healthy relationship skills and establish positive norms. On the relationship level, SARC teaches bystander intervention skills. On the community and societal level, SARC works with the school to promote a culture of safety and implementing policy changes.
There are many elements of SARC s prevention program that aligns with the principles for effective prevention work. Unlike many programs, SARC provides comprehensive education, looks at sexual violence as a holistic problem, and delivers timely curriculum. SARC teaches prevention curriculum in high schools. While sexual violence certainly can and does occur earlier than this, providing education in high school (as opposed to college) is a step towards more effective prevention work. As explained above, SARC uses the Social-Ecological Model to address the multiple facets of sexual violence. Through addressing root causes at multiple levels, SARC is able to create larger system change and shift cultural norms. Additionally, SARC s curriculum is designed to provide comprehensive sex education. One limitation of prevention work is the lack of comprehensive education, especially around topics like violence and pleasure. A primary way SARC promotes comprehensive education is through the use of an anonymous question box. Students are able to anonymously ask questions (on any topic) for the SARC staff to answer the following week.
During my experience, students asked questions about anatomy and bodily functions, sexual terminology, aspects of sexual pleasure, and clarification on violent acts. Because there were no rules or limitations on the question box, and the questions were never met with shame, students were able to ask about anything and receive medically accurate and stigma-free information. Comprehensive sex education was one of the most effective means of decreasing sexual violence and related beliefs among high school students (Charmaraman, et al., 2012;Grossman, et al., 2014;Santelli, et al., 2018). Another specific method SARC employs is the use of gender transformative and social norms strategies. Their curriculum does this by challenging existing beliefs, exploring the origins of those beliefs, and working to form new, healthier norms. Finally, SARC uses a variety of methods (e.g., videos, group activities) in the curriculum, as well as uses skills training to teach bystander intervention and communication skills. Both of these strategies are effective in reducing sexual violence (Menning & Holtzman, 2015;Miller, 2017;Miller, et al., 2012).
A main limitation of SARC s program is difficulties in building rapport with students. When students get to know SARC staff, they tend to open up more. However, because of the school schedule and number of SARC staff, students do not work with the same staff member every week. Continued change in facilitator hinders the ability to strengthen relationships, which is one of the factors of effective programs (Nation, et al., 2003). Another limitation of the program is the fact that the facilitators are not completely representative of those they are teaching. There were no male-identified facilitators or facilitators of color. I feel like this decreased student comfort in participating in some conversations. Many students at the school were also English-language learners and there were not always translators available. Not only was this a barrier to understanding the discussions, I feel like it was a barrier to connecting and rapport building.
While SARC faces barriers in effectively delivering prevention curriculum, SARC also follows many of the principles of effective prevention programs. It is evident that they really do base their program in evidence-based practices and literature reviews. As a facilitator, I noticed that the students were really engaged with the material and actively participated in the curriculum. Overall, the program appeared to be effective in shifting student beliefs about sexual violence, relationships, communication, and consent.

Reflections. Throughout my internship, I
learned about the importance of self-care when working in the trauma field; deepened my understanding of my own privilege and biases and what that means for working with survivors; and, strengthened my passion for sexual violence prevention.
One of my major takeaways from my time with SARC was the importance of selfcare within helping professions. SARC intentionally creates an environment that promotes self-care by having staff check-ins, doing group self-care activities during staff meetings, training advocates on trauma stewardship, and encouraging mental health days when needed. Working within this environment was useful in helping me acknowledge the potential emotional toll of participating in the crisis and healing of others, particularly if it activates my own trauma. My work with SARC supported me in becoming aware of the way this type of work impacts me and becoming more intentional about taking steps to prevent burnout, compassion fatigue, and being triggered. Throughout my internship, I learned to set boundaries around my time and energy; create my own self-care practice, which included my own therapy; recognize when I when I was being activated by the work I was doing; and, seek support from others. As I continue on my journey to become a trauma therapist, continued development of these skills and awareness are crucial to ensuring that I am able to be effective in my role.
I also learned the importance of considering personal privilege when working to treat or prevent trauma. Historically, many institutions and systems, including social services agencies, have been based in oppressive values, such as white supremacy. For those who have experienced marginalization or oppression may face increased barriers to accessing services or experiencing fear or distrust towards those systems, because of their historical inequality. It is important to find ways to reduce barriers to access and increase safety within these domains. As the provider, I hold the position of power in the relationship. It is important to work to fix that imbalance because the client is the expert on their own life. I must acknowledge that I do not understand their lived experience and remain humble and teachable, particularly in areas that I am less familiar work. I also hold multiple privileged identities. It is crucial that I am cognizant of that fact and the way that influences the way I interact with those I work with. Creating a safe and accessible space might mean adjusting things within myself. Understanding my privilege is also important because it makes me aware of the biases that I bring into a therapy or prevention practice. One lesson I learned at SARC was that my perception of others experiences may not be their reality. For example, as we were discussing barriers for service for a particular population, I learned that my beliefs were not accurate at all. I was informed by someone who identified with that identity that that belief was actually a really common misconception held by a lot of white individuals, but that it really does not represent their community. I also had an experience in the high school where a student of color pointed out that all of the instructors (who were teaching a lesson on oppression) were white. He didn t think that it was fair for us to teach about his experience. These experiences taught me the importance of listening to those with lived experience and remaining aware of how my privilege, especially as it relates to personal biases or historical structures of oppression, affects interactions with others. Acknowledgement that others may experience the same situations or events differently because of different lived experiences is also necessary to be able to hold space for those experiencing trauma. Additionally, these experiences taught me that connection-seeking in trauma work involves meeting others where they are at by stepping towards their culture, rather than continually asking them to come towards me. As a future mental health professional, I hope to remain mindful of my privilege, active in reducing barriers, and intentional in how I hold space for others.
Finally, my internship and research reminded me of why I believe so strongly in early prevention work. Society, in general, has the perception that students, particularly younger students, are not engaged in sex, much less engaged in sexual violence. Because of this, most people tend to avoid conversations about sex and violence with adolescents. However, research indicates that sexual violence is occurring in these young populations and both my research and internship experience would also indicate that students are actively seeking out these types of conversations. Student-led groups were the ones seeking presentations by SARC and the high school students I worked with were actively engaged in conversations about sexual violence, healthy relationships, and consent. Young people showed a genuine interest in being a part of these discussions and learning how to apply these concepts to their lives. From this, I took away the fact that there is a need and a desire for information at younger and younger ages, and that I have a responsibility to provide that when I am able. Sexual violence prevention can begin with a simple conversation-and young people are seeking out those conversations. While doing direct advocacy work with survivors, I saw firsthand the physical and psychological impact of sexual violence. These experiences affirmed my desire to become a trauma therapist, as I learned providing support to survivors in a survivor-led, shame-free way is critical to healing. At the same time, my simultaneous prevention work and research showed me that early intervention can have profound impacts on reducing the number of sexual violence incidents that occur. While my internship strengthened my desire to be a trauma therapist, it also reminded me that primary prevention work is an important aspect of my role, as well. Seeing the ways advocacy work promoted healing and prevention work promoted change, I was encouraged that this is the field for me.
In summary, during my internship at SARC I achieved many of the learning goals I set for myself by developing knowledge and skills related to becoming a trauma therapist, through engaging in trauma-related practice and trainings; learning about the structure and functions of nonprofits, through attending meetings and interviewing staff; and, gaining an understanding of sex education and prevention programs, through a thorough literature review and the facilitation of educational workshops and prevention curriculum with SARC. Furthermore, my time at SARC taught me about the importance of: self-care in helping professions, recognizing my privilege while doing trauma work, and having preventionrelated at an early age.

Conclusion
While working as a Sexual Assault Advocate and Education and Prevention Intern at the SARC, I was able to learn about the organization s history, mission and services; the population served by the organization; and, the specific needs of those who have experienced sexual violence. During my practicum, I participated in a variety of activities at SARC, which include attending staff and intraorganizational meetings, completing a forty-hour trauma training, engaging in outreach work, and delivering educational workshops and prevention curriculum within the community. As a result of my work at SARC, I became interested in prevention efforts for sexual violence and wanted to research the features of effective sexual violence prevention programs within schools, including their limitations and issues with their implementation. Through research, I found that while there are limitations within our current sex education and violence prevention systems, there are a number of effective school-based prevention components and programs that are linked with a reduction in sexual violence. My research and internship experiences highlighted the importance of having conversations about sex, consent, and healthy relationships at an early age; instilled hope that we can shift the prevalence and dynamics around sexual violence; and reinforced my goal of becoming a trauma therapist.