EFTA00024175

Exhibit B EFTA00024175 Ctc•ckl.e 4.pdzAco Review Manuscript TRAUMA. VIOLENCE & ABUSE 2019, Vol. 20(2) 260-283 Facilitators and Barriers to Child Sexual C The Author(s) 2017 Abuse (CSA) Disclosures: A Research Artock roust guidelines: sacepub comlioumalvptimoskin DOI, 10117711124838017697312 Update (2000-20 I 6) nals sagepuboornlhomakva OSAGE Ramona Alaggial , Delphine Collin-Vezina2, and Rusan Lateefl Abstract Identifying and understanding factors that promote or inhibit child sexual abuse (CSA) disclosures has the potential to facilitate earlier disclosures, assist survivors to receive services without delay, and prevent further sexual victimization. Timely access to therapeutic services can mitigate risk to the mental health of survivors of all ages. This review of the research focuses on CSA disdosures with children, youth, and adults across the life course. Using Kiteley and Stogdon's literature review framework. 33 studies since 2000 were identified and analyzed to extrapolate the most convincing findings to be considered for practice and future research. The centering question asked: What is the state of CSA disclosure research and what can be learned to apply to practice and future research? Using Braun and Clarke's guidelines for thematic analysis. five themes emerged: (I) Disclosure is an iterative, interactive process rather than a discrete event best done within a relational context; (2) contemporary disclosure models reflect a social—ecological, person-in-environment orientation for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CA disclosure; (3) age and gender significantly influence disclosure; (4) there is a lack of a life-course perspective; and (5) barriers to disclosure continue to outweigh facilitators. Although solid strides have been made in understanding CSA disclosures, the current state of knowledge does not fully capture a cohesive picture of dis. dosure processes and pathways over the life course. More research is needed on environmental. contextual, and cultural factors. Barriers continue to be identified more frequently than facilitators, although dialogical forums are emerging as important facil- itators of CSA disclosure. Implications for practice in facilitating CSA disclosures are discussed with recommendations for future research. Keywords sexual abuse, child abuse, cultural contexts Introduction the same time global trends from systematic reviews and meta- analyses have found concerning rates of CSA, with averages of Timely access to supportive and therapeutic resources for child 18-20% for females and of 8-10% for males (Pereda, Guilera, sexual abuse (CSA) survivors can mitigate risk to the health Fours, & Gomez-Benito, 2009). The highest rates found for and mental health well-being of children, youth, and adults. girls is in Australia (21.5%) and for boys in Africa (19.3%), Identifying and understanding factors that promote or inhibit with the lowest rates for both girls (11.3%) and boys (4.1%) CSA disclosures have the potential to facilitate earlier disclo- reported in Asia (Stoltenborgh, van Uzendoorn, Euser, & sures, assist survivors to receive services without delay, and Bakermans-Kranenburg, 20 I 1). These findings point to the potentially prevent further sexual victimization. Increased incongruence between the low number of official reports of knowledge on both the factors and the processes involved in CSA disclosures is timely when research continues to show high rates of delayed disclosures (Collin-VEzina, Sablonni, I Factor-Inwentash Faculty of Social Work. University of Toronto. Toronto. Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, Ontario. Canada 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, 2 Centre for Research on Children and Families. School of Social Work, McGill Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; University. Montreal. Qubec. Canada Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). Corresponding Author: Ramona Alaggia. Factor-Inwentash Chair in Children's Mental Health. Factor- Incidence studies in the United States and Canada report Inwentash Faculty of Social Work. University of Toronto. 246 Moor St West. decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Toronto, Ontatio, Canada M4K I W I. Turner, & Hamby, 2014; Trocme et al., 2005, 2008), while at ramonaalaggiaeutorortoca EFTA00024176 Alaggia et at 261 CSA to authorities and the high rates reported in prevalence disclosure research, through various mixed methods, to high- studies. For example, a meta-analysis conducted by Stolten- light the most convincing findings that should be considered for borgh, van LIzendoom, Euser, and Bakermans-Kranenburg future research, practice, and program planning. This review (2011) combining estimations of CSA in 217 studies published centered on the question: What is the state of CSA disclosure between 1980 and 2008 revealed rates of CSA to be more than research and what can be learned to apply to future research 30 times greater in studies relying on self-reports (127 in 1,000) and practice? By way of clarification, the term systematic than in official report inquiries, such as those based on data refers to a methodologically sound strategy for searching liter- from child protection services and the police (4 in 1,000) (Ju- ature on studies for knowledge construction, in this case the lian, Cotter, & Perreault, 2014; Statistics Canada 2013). In CSA disclosure literature, rather than intervention studies. The other words, while 1 out of 8 people retrospectively report years spanned for searching the literature were 2000-2016, having experienced CSA, official incidence estimates indicate building on previous reviews without a great deal of overlap. only 1 per 250 children. In a survey of Swiss child services, Retrieval of relevant research was done by searching interna- Maier, Mohler-Kuo, Landholt, Schnyder, and Jud (2013) fur- tional electronic databases: PsycINFO, PsycARTICLES, Edu- ther found 2.68 cases per 1,000 of CSA disclosures, while in a cational Resources Information Center, Canadian Research recent comprehensive review McElvaney (2015) details the Index, International Bibliography of the Social Sciences, Pub- high prevalence of delayed, partial, and nondisclosures in lished International Literature on Traumatic Stress, Sociologi- childhood indicating a persistent trend toward withholding cal Abstracts, Social Service Abstracts, and Applied Social CSA disclosure. Science Index and Abstracts. This review searched peer- It is our view that incidence statistics are likely an under- reviewed studies. A search of the gray literature (unpublished estimation of CSA disclosures, and this drives the rationale for literature such as internal agency documents, government the current review. Given the persistence of delayed disclosures reports, etc.) was beyond the scope of this review because with research showing a large number of survivors only dis- unpublished studies are not subjected to a peer-review process. closing in adulthood (Collin-Vezina et al., 2015; Easton, 2013; Keyword search terms used were child sexual abuse, childhood Hunter, 2011; McElvaney, 2015; Smith et al., 2000), these sexual abuse, disclosure, and telling. issues should be a concern for practitioners, policy makers, and A search of the 9 databases produced 322 peer-reviewed the general public (McElvaney, 2015). The longer disclosures articles. Selected search terms yielded 200 English publica- are delayed, the longer individuals potentially live with serious tions, I French study, and 1 Portuguese review. The search was negative effects and mental health problems such as depres- further refined by excluding studies focusing on forensic inves- sion, anxiety, trauma disorders, and addictions, without receiv- tigations, as these studies constitute a specialized legal focus on ing necessary treatment. This also increases the likelihood of interview approaches and techniques. As well, papers that more victims falling prey to undetected offenders. Learning focused exclusively on rates and responses to CSA disclosure more about CSA disclosure factors and processes to help were excluded, as these are substantial areas unto themselves, advance our knowledge base may help professionals to facil- exceeding the aims of the review question. Review articles itate earlier disclosures. were also excluded. Once the exclusion criteria were applied, Previous literature reviews examining factors influencing the search results yielded 33 articles. These studies were sub- CSA disclosure have served the field well but are no longer jected to a thematic analysis as described by Braun and Clarke current. Important contributions on CSA disclosures include (2006). This entailed (I) multiple readings by the three authors; Paine and Hansen's (2002) original review covering the liter- (2) identifying patterns across studies by coding and charting ature largely from the premillennium era, followed by London, specific features; (3) examining disclosure definitions used, Bruck, Ceci, and Shuman's (2005) subsequent review, which sample characteristics, and measures utilized; and (4) major may not have captured publications affected by "lag to print" findings were extrapolated. Reading of the articles was initially delays so common in peer-reviewed journals. These reviews conducted by the authors to identify general trends in a first are now dated and therefore do not take into account the level of analyses and then subsequently to identify themes plethora of research that has been accumulated over the past through a deeper second-level analyses. A table of studies was 15 years. Other recent reviews exist but with distinct contribu- generated and was continuously revised as the selection of tions on the dialogical relationalprocesses of disclosure (Reit- studies was refined (see Table 1). sema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood(McEl- vaney, 20I5). This literature review differs by focusing on CSA Key Findings disclosures in children, youth, and adults from childhood and First-level analysis of the studies identified key study charac- into adulthood—over the life course. teristics. Trends emerged around definitions of CSA disclosure, study designs, and sampling issues. First, in regard to defini- tions, the term "telling" is most frequently used in place of the Method term disclosure. In the absence of standardized questionnaires Kiteley and Stogdon's (2014) systematic review framework or disclosure instruments, telling emerges as a practical term was utilized to establish what has been investigated in CSA more readily understood by study participants. Several EFTA00024177 rig Table I. Ch d Sexua Abuse (CSA) D sc osure Stud es: 2000-2016. Study Purpose Des gn Samp e F nd ngs Summary Gagner and Co n- To exp ore d sc osure Phenomeno og ca 17 men ranged n age The major ty of the men n the study wa ted A part c pants had d sc osed and Vez na (2016) processes for ma e methodo ogy used to from 19 to 67— unt adu thood to d sc ose the r abuse. rece ved sery ces before v ct ms of CA ntery ew ma e CSA average age 47. w th negat ve stereotypes contr but ng part c pat ng n the study. Member sury vors. The Long Purpos ve samp rig to the r de ayed d sc osures. Negat ve check ng cou d not be done w th Intery ew Method strategy was used stereotypes contr buted to de ayed the part c pants to check themes. (LIM) gu ded data d sc osure w th try ng to forget. Break ng Sma but surf c ent s ze for a co ea on and so at on was c ted as a mot vator to qua tat ve nqu ry. Otherw se, ana yses. d sc osure a ong w th the a d of var ous h gh eve of r gor n estab sh ng forms of med a on d sc osure. Important trustworth ness of the data and contextua ssues such as negat ve ana ys s. Retrospect ve study stereotyp ng of ma es. sexua ty. and cou d mp y reca ssues v ct ms were noted. Soc a med a was seen as a fac tator of d sc osures Braze ton (2015) To exp ore the mean rig Co ect ve case study 17 Afr can Amer can CSA onset was arge y between the ages 5 One of few stud es to focus Afr can Amer can des gn w th us ng women n m d- fe and 9. No one ever ta ked to them about exc us ye y on Afr can Amer can women make of the r narrat ve wad t on between 40 and 63 sex, so they d dn't have anguage to women. Sma but stiff cent s ze traumat c exper ences (storyboard) for data who exper enced d sc ose. Barr en: fear of fam y for a qua tat ve nqu ry. Important w th CSA and how co ea on and am ys s. ntrafam a CSA_ breakdown and remova , not want ng to cu tura and contextua ssues they d sc osed across Qua tat ve Purpos ye. snowba ng tarn sh the fam y's name, and fear of were brought forward. the fe course ntery ew ng strategy retr but on by tam y members f they Retrospect ye study that may d sc osed. Pattern of st fed and have been affected by reca ssues. d sm ssed d sc osures dent f ed over the Use of a fe-course perspect ye as fe course. A 17 part c pants dent f ed a theoret ca ens for sp r tua ty as a pr mary source of understand ng CSA n the m dd e strength throughout the fe course to ater years of fe that shou d be cons dered n further nvest gat ons Co n-Vez na, Sab onn . To prov de a mapp ng of Qua at ve des gn us ng 67 ma e and fema e CSA Three broad categor es were dent fed as Ha f of the part c pants had not Pa mer, and M ne factors that prevent LIM. adu t sury vors (76% barr en to CSA d sc osure: Barr ers d sc osed the r CSA exper ences (20 I 5) CSA d sc osures dent f ed as fema e and from w th n- nterna zed v a m b am ng, before the age of 19. through an eco og ca 24% as ma e). Age mechan sms to protect onese f. and Retrospect ye aspect of the study ens from a samp e of ranges from 19 to 69 mmature deve opment at t me of abuse: cou d mp y reca ssues. A CSA adu t sury von. years (M = 44.9). barr en n re at on to others—v o ence pan c pants had d sc osed and Purpos ve samp ng and dysfuna on n the fam y, power rece ved counse ng at some strategy dynam a. awareness of the mpact of before part c pat ng n the study. to ng, and frag e soc a network; H gh eve of rgor n estab sh ng barr en n re at on to the soc a wor d trustworth ness of the data and abe ng, taboo of sexua ty, ack of ana ys s sery ces ava ab e. and cu ture or t me per od. Lec erc and Wort ey Study object yes Adu t ma e ch d sexua 369 adu t ma es who had D sc osure ncreased w th the age of the Offender generated data through (20 I 5) nvest gated the offenders were been cony cted of a v ct m: f penetrat on had occurred, f the se (-reports cou d be subject to factors that fac tate ntery ewed to sexua offense aga nst a v ct m was re aced to the offender, f the cogn t ve d stort ons— CSA d sc osures exam ne pred ctors of ch d aged between I v ct m was not v ng w th die offender at m n m sat on or exaggerat ons. (continued) EFTA00024178 Table I. (cont nued) Study Purpose Des gn Samp e F nd rags Summary v ct m d sc osure. and I7 years o d. the t me of the abuse, or f the v a m Penpect ves of offenders on Sem structured Major ty were Wh te. res sted dur ng the offense. Ma e v a ms vu nerab ty of v ct ms n re at on ntery ews based on uneducated, a most and v a ms from dysfuna ona to d sc osure cou d be mportant the QID ha f unemp oyed backgrounds were ess ke y to d sc ose nformat on to nform quest onna re. before the r arrest ntervent ons McE vaney and Cu hane To nvest gate the F e reports of ch dren Content ana ys s was Major ty of ch dren to d the r mothers The samp e s ze s sma but w (2015) teas b ty of us ng ch d seen for assessment n comp eted on 39 f es (43%) and peers (33%) f rst_ Three major toner bute to a arge mu t s te assessments as data a ch d sexua abuse (32 fema es and 7 themes were dent fed as nf uenc ng the study n Ire and. Serves as an sources of nforma un t n a ch dren's ma es) based on a d sc osure process: (I) fee ng d stressed. mportant exp oratory p of CSA d sc osure. To hosp ta were cod ng framework. (2) opportun ty to te . and (3) fears for br ng ng forward d sc osure assess f these reports rev ewed Parents were asked to se f. Add t ona themes of be ng be eyed. themes for cons dent on prov de substant ye consent to have the r shame/se f-b ame. and peer nf uence data on d sc osures ch d's f e rev ewed for were a so dent fed the study. V a ms assessed were 12-18 years of age Dumont, Messerschm tt Th s study a med to F e reports of ch dren 220 m nor v a rns- D sc osure processes were more cone ex The re at onsh p w th the V a, Bohu. and exp ore how the seen for assessment n 78.2% fema e v a ms. when t concerned sexua abuse perpetrator has a s gn f cant Rey-Sa mon (2014) re at onsh p between a ch d sexua abuse 41.8% aged between comm tted by ntrafam a perpetrator mpact on both t m ng and the perpetrator and un t n a ch dren's 14 and 18 (most 60% of the v a ms revea the facts rec p ent of d sc osure. w th the v ct m, espec a y hasp ta were preva ent age range). seven years after, and most often to ntrafam a abuses ess ke y to whether these rev ewed and 48.2% were nd v dua s outs de the fam y (78.6% of be d sc osed prompt y and w th n re at ons are abused by a fam y the d sc osures done at schoo): on the the tam y system ntrafam a or member contrary. extrafam a d sc osures take extrafam a, mpact p ace more spontaneous y and qu ck y: CSA d sc osure 80% of the v a ms revea the facts a few days after, most often to the r mother or peers Easton. Sa tzman. and Study focus was on Us ng qua tat ve content 460 men w th CSA Vast major ty of part c pants (94.6%) were At t me of the study. th s was the W 5 (2014) dent f cat on of ana ys s, researchers h stor es comp eted an sexua y abused by another ma e. argest qua tat ve data set to have barr en to CSA conducted a secondary anonymous, Internet- Durst on of sexua abuse broke down been ana yzed w th an exp c t d sc osure w th ma e ana ys s of on ne based survey. nto: 30.2% ess than 6 months. 32.3% 6 focus on adu t ma e sury vors' sury von survey data. the 2010 Recta ted from months to 3 years. and 34.3% more than percept ons of barr en to CSA Heath and We -Be ng sury yore 3 years. Ten years o d was average age of d sc osure. Because the samp e Survey. that nc uded organ zat ons. Age CSA onset Ten categor es of barr en was m ted n terms of the ow men w th se (-reported range of 18-84 years. were c ass fed nto three doma ns: (I) percentage of rac a m nor t es CSA h stor es w th an Two th rds of soc opo t ca: mascu n ty. m ted (9.3%). d sc osure d fferences open-ended tem on respondents reported resources; (2) nterpersona : m strust of based on race or ethn c ty were d sc osure barr ers c ergy-re ated abuse. others, fear of be ng abe ed "gay," safety not d scerned. The major ty of Major ty of and protect on ssues, past responses: abuse reported was by c ergy respondents were and (3) persona: ntema emot ons. wh ch m ght present a un que set Wh te see ng the exper ence as sexua abuse. of barr ers to d sc osure and sexua or enat on. (continued) EFTA00024179 Pt ' Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Easton (2013) Study purpose was to Cross-sect ona survey Purpos ve samp ng of O der age and be ng abused by a fam y Purpos ye samp ng of men from descr be ma e CSA des grt.E gbe 487 men from three member were both re ated to de ays n awareness ra s ng organ zat ons d sc osure processes part c pants were nat ona organ zat ons d sc osure. Most part c pants who to d may have attracted part cu ar us ng a fe span screened and devoted to ra s ng someone dur ng ch dhood d d not part c pants who had a ready approach exam n ng comp eted an awareness of CSA rece ve emot ona y support ve or d sc osed and rece ved he p. d fferences based on anonymous, Internet- among men. Age protect ve responses and the he pfu ness Part c pants needed to have age. A so. to exp ore based survey dur ng range: 19-84 years. of responses across the fe span was access to Internet wh ch wou d re at onsh ps between 2010. Measures used: Mean age for onset of m xed. De ays n te ng were s gn f cant have e m nated men n ower SES d sc osure attr butes Genera Menta Heath CSA was 10.3 years per ods oft me (over 20 years). groups and requ red prof c ency n and men's menta D stress Sca e and Approx mate y one ha f of the Eng sh wh ch wou d e m nate hea th Genera Assessment of part c pants f rst to d about the sexua certa n cu tura groups. However. Ind v dua Needs. abuse to a spouse/partner (27%) or a the samp ng strategy ga ned Quest ons re ated to menta hea th profess ona (20%): 42% of access to a predom nant y h dden CSA d sc osure and part c pants reported that the r most popu at on. Important c n ca supports were he pfu d scuss on was w th a menta recommendat ons are made w th nc uded hea th profess ona. However. unhe pfu an emphas son a fe-course focus responses caused most menta d stress. C n ca recommendat ons nc uded more of a fe-course perspect ve be adopted. understand ng mpact of unhe pfu responses and the mportance of expand ng networks for ma e sury von McE vaney. Greene. and Qua tat ve study asked Grounded theory Samp e of 22 young A theoret ca mode was deve oped that Modest but suff c ent samp e for an Hogan (2012) the centre research method study. peop 16 g r s and 6 conceptua zes the process of CSA exp oratory qua tat ve nqu ry. quest on: "How do Intery ews were boys: age range: 8-18 d sc osure as one of conta n ng the H gh eve of trustworth ness ch dren te ?" conducted. L ne-by- years: 22 ntery ewed secret (I) the act ve w thho d ng of the r gor. A subsamp e of random y Object ve was to ne open and ax a n ton between the secret on the part of the ch d; (2) the se ected transcr pts was deve op theory of how cod ng was conducted ages of 8 and 18. M xed exper ence of a "pressure cooker effect" ndependent y coded. Very young ch dren te of the r on verbat m samp e of some ref ect ng a conf ct between the w sh to ch dren and young adu is were CSA d sc osure transcr pts endur ng ntrafam a te and the w sh to keep the secret; and not captured n th s samp e. exper ences. Parents CSA, some (3) the conf d ng tse f wh ch often Transferab ty of f nd ngs can on y were ntery ewed. extrafam a CSA, and occurs n the context of a trusted be made to the age range samp ed two endured both re at onsh p. These were der ved from n the context of Ire and forms e even categor es that were deve oped through open and ax a cod ng Schonbucher, Ma er, To nvest gate the Data co ect on was Conven ence samp e of Less than one th rd of part c pants Two th rds of the samp e d d not Moh er-Kuo, Schnyder, process of CSA through face-to-face 26 sexua y v ct m zed mmed ate y d sc osed CSA to another d sc ose r ght away. Strengthen ng and Lando t (20 I 2) d sc osure w th qua tat ve ntery ews. ado escents. 23 g r s person. In most cases, rec p ents of both parent—ch d re at onsh ps may be ado escents from the Standard zed quest ons and 3 boys. Age range: mmed ate and de ayed d sc osure were one of the most mportant ways genera popu at on and measures were I5—I8 years. On ne to peers. More than one th rd of to ncrease d sc osure to parents. who had exper enced adm n stered on fam y advert cements and part c pants had never d sc osed the D sc osure to peers has been CSA. How many s tuat on. f yen were used to abuse to a parent. Part c pants reported found a common trend n other d sc osed, who d d soc odemograph c recru t youth from re uctance to d sc ose to parents so as (continued) EFTA00024180 Table I. (cant nued) Study Purpose Des gn Samp e F nd ngs Summary they d sc ose to, and data, sexua commun ty and not to burden them. Ear er d sc osures research and bears more what were the r v ct m sat on. genera . counse ng sery ces were re ated to extrafam a CSA, s ng e exam nat on mot yes for d Sc os ng and menta hea th. occurrence CSA, age of v ct m at abuse Sexua Assau t Modu e onset, and parents who were v ng of the Juven e together. H gher eves of reported gu t V ct m sat on and shame were re ated to de ayed Quest onna re was d sc osures. Peers were v ewed by th s used samp e as more re ab e con( darts Hunter (20 I I ) A m of th s study was to Narrat ve nqu ry Purpos ye samp ng was On y 5 out of 22 part c pants to d anyone De ayed d sc osure was common n deve op a fu er methodo ogy. Face-to- emp oyed. Samp e about the r ear y sexua exper ences as th s qua tat ve samp e. Most understand ng of CSA face n-depth cons sted of 22 ch dren. Fear, shame, and se f-b ame part c pants d d not make a d sc osures ntery ews were part c pants aged 25- were the man nh b ton to d sc osure. se ect ve d sc osure unt conducted w th 70 years: 13 women These factors are further dem ed adu thood. These f nd ngs support part c pants. Data and 9 men. Part c pants through subthemes. Te ng as a ch d and A agg a's (2004) mode of were ana yzed us ng were sexua y abused as an adu t was further expanded upon d sc osure but a so h gh ghts the Rosentha and F scher— at IS years or under us ng A agg a's (2004) framework mportance of fe stage. Modest Rosentha 's (2004) w th someone over ver fy ng behav on nd rect attempts to but suff c ent samp e s ze for a method. the age of It te and purposefu d sc osure as qua tat ve nqu ry. We -des gned categor es. Themat c ana ys s supported study w th dem ed ana ys s for that CSA d sc osure shou d be transferab ty off nd ngs conceptua zed and v ewed as a comp ex and fe ong process Schaeffer, Leventha , and Th s study a med to: (I) Study sought to f nd out f 191 ntery ews of CSA Reasons the ch dren dent fed for te ng An nnovat ve study to try to assess Asnes (2011) add d rect nqu ry process flues of v ct ms aged 3-18 over were c ass fed nto three doma ns: (1) f forma nvest gat ye ntery ews about the process of a d sc osure cou d be a -year per od were d sc osure as a resu t of nterna st mu can fac tate d sc osures of CA. ch d's CSA d sc osure; dent f ed n the used for the study. (e.g. the ch d had n ghtmares): (2) Data were based on a arge (2) determ ne f context of forens c Inc us on cr ter a d sc osure fac tated by outs de number of ntery ews. Dem ed ch dren w d scuff ntery ews. Forens c nc uded ch dren who of uences (e.g. the ch d was ana ys s produced dem ed process that ed them ntery ewers were made a statement quest oned): and (3) d sc osure due to f nd ngs support ng other study to te : and (3) descr be asked to ncorporate about CSA pr or to d rect ev dente of abuse (e.g., the ch d's f nd ngs on CSA d sc osure factors that ch dren quest ons about refers. reasons for abuse was w tnessed). The barr ers to dent fy that ed them "te ng" nto an te ng or wa t ng to d sc osure dent f ed fe nto f ve groups: to te about or caused ex st ng forens c te , and those who (I) threats made by the perpetrator them to de ay CSA ntery ew protoco spoke Eng sit. (e.g.. the ch d was to d she or he wou d d sc osure Intery ew content Part c pants were get n troub e f she or he to 4 (2) fears re ated to the ch dren who were (e.g.. the ch d was afra d someth ng bad ch dren's reasons for ntery ewed at a ch d wou d happen f she or he to d), (3) ack te ng or wa t ng was sexua abuse c n c. of opportun ty (e.g., the ch d fe t the extracted, transcr bed, 74% were ferna e and opportun ty to d sc ose never and ana yzed us ng 51% were Caucas an presented), (4) ack of understand ng grounded theory (e.g.. the ch d fa ed to recogn ze abus ye method of ana ys s behav or as unacceptab e), and (5) re at onsh p w th the perpetrator (e.g. the ch d thought the perpetrator was a fr end) (continued) EFTA00024181 I-, cr. Table I. (coin nued) P Study Purpose Des gn Samp e F nd ngs Summary A agg a (2010) The study a med to A qua tat ve Purpos ye samp ng was Themes fe nto four doma ns: (I) The study presents a comprehens ve dent fy factors phenomeno og ca emp oyed. Snowba nd v dua and deve opmenta factors, soc a —eco og ca ana ys s to CSA mped ng or promot ng des gn, LIM, was used samp ng was a so used deve opmenta factors as to whether d sc osure h gh ght ng the CSA d sc osures. to ntery ew adu t CSA to recru t more ma e they comprehended what was mu t faceted of uences. Of note, Overarch ng research sury von about the r sury von. 40 adu t happen ng, persona ty tra is a so had 42% had d sc osed the abuse quest on: What d sc osure exper ences sury von of CA were some bear ng on the r ab ty to te . and dur ng ch dhood: 26% had not nd v dua, to prov de ntery ewed: 36% men ant c pat ng not be ng be eyed; (2) d sc osed because they had nterpersona . retrospect ve accounts and 64% women. Age d sc osure nh b ted by fam y repressed the memory, or the env ronmenta . and of CSA d sc osure and range of 18-65 w th a character st cs such as rgdy fxed abuse had occurred n preschoo contextua nf uences mean ng-mak ng of mean age of 40.1 years. gender ro es w th dom nat ng fathers, years and they had d dal ty w th mpede or promote these exper ences. Average age of abuse chaos and aggress on. other forms of reca . The rema nder had CSA d sc osures. Themat c ana ys s was onset was 5.3 years ch d abuse, domest c v o ence. attempted some form of done through a soc a — o d. 36% of the samp e dysfunct ona commun cat on. and soc a d sc osure n nd rett ways dur ng eco og ca ens. was non-Wh te. so at on; (3) ne ghborhood and ch dhood. A retrospect ye D verse commun ty context. that s. ack of approach that cou d be affected by soc oeconom c nterest from ne ghbors and teachers not reca ssues backgrounds pursu ng troub ng behav or; and (4) cu tura and soc eta an tudes, med a messages and soc eta an tudes. fee ng unheard as k ds, gender soc a zat on for ma es. and cu tura an tudes of uenc ng parent's react ons. Purposefu d sc osure s h gher than reported n other stud es because of the samp ng attempts to purposefu y ocate d sc osers Fontes and P ummer Th s exam nat on of CSA Us ng pub shed terature Data cons sted of Cu tura and structura factors affect ng One of the few works that adds (2010) d sc osure exp ored wthc nca data, th s pub shed terature on CSA d sc osure are dent f ed n n-depth know edge to cu tun y the ways cu ture art c e conducted an d sc osure and cu ture deta Recommendat ons made nc ude contextua d sc osure affects processes of ana ys s to prov de a that was tr angu ated (I) d sc osure ntery ew ng shou d be ntery ew ng. Un que comb nat on CSA d sc osure and cu tura y competent wthc n ca case ta ored to the ch d's cu tura context. of teraturefnd ngswthcn ca report ng. both n the framework for CSA mater a (2) quest on ng shou d a so take nto mater a . Anecdota accounts may Un ted States and d sc osure quest on ng cons dent on age and gender factors. prec ude transferab ty of nternat ona y and (3) cu ture stands as an mportant f nd ngs. Oven adds to an factor n a cases n wh ch ch dren are mpover shed area of CSA cons der ng d sc os ng or be ng asked to d sc osure nformat on d sc ose. and not so e y n cases nwh ch ch dren are from not ceab e m nor ty groups. Presents a comprehens ye ntery ew framework ntegrat ng cu tura cons dent ons Ungar, Barter. Th s study exp ored Forms were comp eted Exam nat on of resu is Youth who have been abused or w tnesses Th s study h gh ghts that d sc osure McConne . Tutty, and d sc osure strateg es by youth fo ow ng from a nat ona sampe to abuse emp oy f ve d sc osure s an nteract ye ongo ng process. Fa rho m. (2009a) w th a nat ona sampe pan c pat on n abuse of 1,621 eva uat on strateg es: us ng se f-harm ng behav on F nd ngs end support to stud es of youth focus ng on prevent on forms where youth to s gna the abuse to others; not ta k ng that have dent f ed s mar y (continued) EFTA00024182 Table I. (cont nucd) Study Purpose Des gn Samp e F nd ngs Summary (I) What are the program ng by the anonymous y d sc osed at a about the abuse to prevent nteract ye modes of d sc osure h dden exper ences of Canad an Red Cross abuse exper ences. ntrus ve ntervent ons by others; such as those deta ed by A agg a abuse among Canad an (RespectED). Respondent's ages: 13 seek ng he p from peers; seek ng he p (2004) and Sta er and Ne son- youth? (2) What A ser es of focus groups and under (27%). 14- from nforma adu t supports: and Garde (2005). Th s m xed samp e mpact does and observat ons of IS (37%), 16-17 (25%). seek ng he p from mandated sery ce of youth who exper enced part c pat on n abuse the workshops were 18 and o der (4%), and prov den (soc a workers and po ce). d fferent forms of abuse and prevent on programs used to he p unknown (7%) Resu is suggest d sc osure s an v o ence exposure were have on youth to contextua ze the nteract ye process, w th expectat ons part c pants—not in ted to CSA express the r abuse f nd ngs. Eva uat on regard ng consequences to d sc osure. SW, / vors exper ences? (3) What forms were ana yzed Patterns of ncrementa y char ng abuse d sc osure barr en do from two v o ence exper ences are shaped by young youth face? (4) What prevent on programs: peop e's nteract ons w di peers, are young peop es (I) It's not your fau t educators, and careg vers. About three- d sc osure patterns? and (2) What's ove quarters of fema es prey ous y d sc osed: and (5) Who do they got to do w th It? s gn f cant y ess ma es d sc osed to ? Ungar, Tutty. McConne . Th s study exp ored Exp oratory des gn w th a Purposefu samp e of F nd ngs suggest h gh rates of h dden abuse, Innovat ve des gn of th s study Barter, and Fa rho m abuse d sc osure nonrepresentat ve 1,099 eva uat on forms w th ess than one quarter of youth prov des ns ght nto young (20096) strateg es w th a samp es. Qua tat ye comp eted fo ow ng report ng a d sc osure. 244 of the 1,099 peop es percept ons of d sc osure nat ona samp e of ana ys s of 1,099 Red Cross RespectED youth who d sc osed abuse on the r exper ences. H gh eve of r gor Canad an youth who eva uat on forms v o ence prevent on eva uat on forms dent fed spec f c w th trustworth ness of the data part c paced nvoence comp Ned fo ow ng programm rig nd v dua s they to d about the r abuse. ana ys s ensured through use of prevent on Red Cross RespectED de vered between D sc osure patterns vary w th boys, youth focus groups. ntery ews. programm ng. One of v o ence prevent on 2000 and 2003 youth aged I4-15, v ct ms of phys ca and observat ona data. The study the goa s of the study programm ng abuse, and those abused by a fan y resu is are somewhat m ted n was to document not de vered between member be ng most ke y to d sc ose to the th ckness of the descr pt ons t prey ous y dent f ed 2000 and 2003. Forms profess ona s or the po ce. One th rd of can offer because most of the data exper ences of abuse of anonymous abuse d sc osures were d rected toward are survey based. Reg ona and youth att tudes d sc osures by youth profess ona s and the east. 5% percent d fferences may not have been toward d sc osure of pan c pants of neg each, were d rected toward fr ends, p cked up. Scope of the study s abuse exper ences emot ona phys ca . parents. and others. Part c pants were broad and approach s treat ve and sexua abuse. most ke y to d sc ose sexua abuse to Twenty-seven parentsffam y. profess ona s. and the ntery ews and focus po ce/courts. w th fewer choos ng groups were a so done fr ends. to understand Out of a 1.099 part c pants, 225 ma es and contextua ssues and 779 fema es nd cated that they had been engage youth and abused. Out of those. 43 ma es and 180 program fac tators n fema es nd cated that they had d sc osed the nterpretat on of the abuse. Of those who had d sc osed, f nd ngs. A cod ng on y a port on of ma es and fema es structure was spec fed who they had d sc osed the deve oped for ana ys s abuse to c'VVh e 1.099 eva uat ons w th to synthes ze themes d sc osure statements were ana yzed. across data sources on y 22% made ment on of peop e to (continued) EFTA00024183 Table I. (cont nued) ao Study Purpose Des gn Samp e Fnd ngs Summary whom d sc osures occurred.") More fema es spec fed who they d sc osed to compare to ma es. The data show percept ons among youth of negat ve consequences fo ow rig d sc osure Pr cbc and Svcd n (2008) Th s study a med to Part c pants competed The samp e cons sted of Of the samp e, 1.505 g r s (65%) and 457 Th s study h gh ghted that sexua nvest gate d sc osure 65- tern quest onna re 4,339 h gh schoo boys (23%) reported CS& The abuse s arse y h dden from adu t rates and d sc osure that nc uded quest ons students n Sweden d sc osure rate was 81% (g r s) and 69% soc ety. espec a y from patterns and exam ne about background, (2,324 g r s and 2,0 I 5 (boys). G r s and boys d sc osed most profess ona s and the ega system. pred ctors of consensua sex. sexua boys). The mean age of often to a fr end of the r own age. Few However. t me apsed to nond sc osure n a abuse exper ences the part c pants was had d sc osed to profess ona s. and even d sc osure was not reported. samp e of ma e and (noncontact, contact 18.15 years. Th s study fewer had reported to the author t es. S nce fr ends appeared to be the fema e ado escents or penetrat rig abuse, used a subsamp e of There were h gher rates of d sc osure to man rec p ents of sexua abuse w th se (-reported nc ud ng peer abuse), 1,962 part c pants who a profess ona w th more severe abuse d sc osures, pract ce mp cat ons exper ences of sexua d sc osure of CSA, reported CSA and (contact abuse w th or w thout of th s cou d be to f nd ways to abuse own sexua abus ve who answered penetrat on) for g r s. but ower rates for g ye young peop e better behav or. sexua d sc osure quest ons boys The more severe the sexua abuse nformat on and gu dance about att tudes. and was, the ess key both g r s and boys how to support a sexua y abused exper ences w th had ta ked to the r mother, father. or a peer. A qua tat ve component to pornography and s b ng. G r s were ess ke y to d sc ose f the study wou d have prov ded a sexua exp o at on. they had exper enced contact sexua broader understand ng of The quest onna re abuse w th or w thout penetrat on. ess d sc osure processes. Study nc uded 6 mod( ed frequent abuse, abuse by a fam y m tat ons nc ude a s gn f cant terns from the SCL-90 member, or f they had perce ved the r amount of boys who d d not and 9 of 25 tems from parents as ess car rig and ess comp ete the quest ons regard rig the Parenta Bond ng overprotect ve and h gh y d sc osure on: the t m rig of Instrument_ The data overprotect ve. Boys were ess key to d sc osures (whether they were for g r s and boys were d sc ose f a fam y member abused them, de ayed or not) was not ana yzed separate y they were study ng a vocat ona program measured: poss b ty of reca b as (vs. an academ c program), ved w th w th retrospect ve stud es based both parents or had perce ved the r on se (-reports; and youth parents as ess car rig and not part c pants may not have overprotect ve. understood a the quest ons Ado escents who reported CA perce ved the r menta heath as poorer compared to ado escents w thout CS& Nond sc osers reported more symptoms on the Mena Heath Sca e than those who had d sc osed Sorso , K a-Keat ng, and Study focused on Ma e sun von of CA The samp e cons sted of Barr en to d sc osure were found to be S nce the vast major ty of men n the Grossman (2008) d sc osure cha ences were ntery ewed 16 ma e sury vors of operant n three nterre aced doma ns: samp e had not d sc osed n for ma e sury von of about the r d sc osure ch dhood sexua (I) persona (e.g.. ack of cogn t ve ch dhood, they may have been CSA to understand exper ences. Ana yt c abuse; I I Caucas an, 2 awareness. ntent ona avo dance, pred spored to dent fy ng three ssues: (I) To techn ques nc uded Afr can Amer can. I emot ona read ness. and shame); (2) barr ers to d sc osure more (continued) EFTA00024184 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary whom and n what grounded theory Puerto R can. I part re at ona (e.g.. fears about negat ve read y. Retrospect ve accounts contexts have they method of ana ys s for Nat ve Amer can, repercuss ons. so at on); and (3) are subject to reca ssues. d sc osed these cod ng and Afr can Cuban: age zoc ocu tura (e.g., ack of acceptance for Invest gators made s gn f cant exper ences? (2) What deve opment of range of 24-61 years; 9 men to exper ence or acknow edge efforts to gather a d verse samp e. do they have to say conceptua y c ustered dent fed themse yes v ct m zat on). H gh eve of r gor was executed about the r d sc osure matr ces. Part c pants as heterosexua, 5 as On y I of the 16 men n th s samp e n the dependab ty of the data exper ences? and (3) comp eted two n- homosexua, and 2 as d sc osed the fu extent of h s sexua and tent ve process of the What are the r depth, sem -structured b sexua abuse exper ences wh e he was st a nterpretat on of f nd ngs was percept ons of pos t ve ntery ews, ast ng ch d. The other men reported that they conducted and negat ye aspects of between 2 and 3 hr had not d sc osed. a though some the r d sc osure. each tak ng p ace reported attempts to to that were nc ud ng ncent ves approx mate y a week nd rect or ncomp ete. Seven other and barren? apart men d sc osed terra n exper ences or e ements of the r abuse, but concea ed others. By the t me of the study. many of these men had d sc osed the r past exper ences n a var ety of re at onsh nc ud ng those w th fam y members, partners. therap sts, and nfrequent y fr ends. Seven had on y m ted d scuts ons of the r sexua abuse Hershkow tz. Lanes, and The goa of the present A eged v a ms of sexua Th ny a eged v ct ms of D sc osure categor es were dent fed as Innovat ve des gn to gather Lamb (2007) study was to exam ne abuse and the r CSA: 18 boys and 12 fo ows: (I) de ayed 53% of the ch dren d sc osure data from young how ch d v ms of parents were g r s. Ch d samp e was de ayed d sc osure for between I week ch dren. Focus s on extrafam a extrafam a sexua ntery ewed. Ch dren 7- to I2-year-o ds w th and 2 years: (2) rec p ent of d sc osure: CA wh ch may d Her than abuse d sc osed the were ntery ewed an avenge age of 9.2 47% of ch dren f rst d sc osed to s b ngs d sc osure patterns of ntnfam a abuse exper ence us ng the NICHD years. Twenty mothers or fr ends, 43% f rst d sc osed to the r CSA. Two th rds of the parents Invest gat ve Intery ew and 10 fathers were parents. and I0% f rst d sc osed to reg stered unsupport ve Protoco by a so ntery ewed for a another adu t. 57% of the ch dren responses wit ch s h gh exper enced youth tota of 30 parent spontaneous y d sc osed abuse, but 43% nvest gators. ntery ews. A content d sc osed on y after they were Informat on on ana ys s was conducted prompted. 50% of the ch dren reported d sc osure processes on ch d and parent fee ng afn d or ashamed of the r was obta ned n the ntery ews parents' responses. Parents' react ons: f rst forma ntery ew, support ve (37%) and unsupport ve before any po ce (63%). There was a strong corre at on nvest gat on or ch d between pred cted and acwa parenta we fare ntervent on react ons suggest ng ch dren ant c pated the r parents' ke y react ons accurate y. D sc osure processes var ed depend ng on the ch dren's ages (e.g.. younger ch dren d sc osed to parents). sever ty and frequency of abuse, parents' expected react ons, suspects' dent t es, and strateg es used to foster secrecy rconunuedt EFTA00024185 •-•1 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary A agg a and K rshenbaum The object ves of the A qua tat ve Purpos ye samp ng was Four major themes emerged suggest ng Over ha f the part c pants had not (2005) current study were to phenomeno og ca emp oyed to recru t 20 that CSA d sc osure can be s gn f cant y d sc osed the abuse dur ng dent fy a broad range des gn—LIM—was adu t sun von comprom sed when certa n fam y ch dhood. Of the nond sc os ng of factors, nc ud ng used toe c t between the ages of condtons ex st (I) rg dy f xed, gender part c pants, s x d d not d sc ose fam y dynam cs that d sc osure and 65 who were ro es based on a patr archy-based fain y because they had repressed or corn bute to or exper ences: sexua y abused by a structure; (2) presence of fam y forgotten the memory. A most h nder a ch d's ab ty fac tators and fam y member. v o ence; (3) c osed, nd rect fam y one th rd w thhe d d sc osure to d sc ose CSA. barr en: and re evant Average age of commun cat on patterns; and (4) soc a ntent ona y. More data are c rcumstances. part c pants was 40.1 so at on of the fam y as a who e, or needed on ear y d sc osures to Intery ews were years: 60% of spec f c members, payed a part n CSA garner more nformat on on transcr bed verbat m. part c pants were v ct ms fee ng they had no one safe to fac atop of d sc osure. L ne-by- ne open fema e and 40% ma e. te . Fam y systems formu at ons through Retrospect ye approach mp es cod ng was conducted Avenge age of onset a fem n st ens are mportant n reca ssues. H gh eve of to capture fam y- eve of abuse was 6.7 years. understand ng ch dren and fam es at trustworth ness of the data and factors. Ax a and M xed c n ca and r sk of d sc osure barr en nterpretat ons were ach eyed se ect ve cod ng nonc n ca samp e. The through cred b ty. dependab ty. fac tated major ty had rece ved and conf rmab ty through d rect dent f at on of treatment for CSA at quotes themes some po nt n the r ves A au a (2005) The study purpose was Sury von of CSA were Purpos ve samp ng of Three themes emerged for men that One n a dearth of stud es that to qua at ve y exp ore ntery ewed about women and men. a ong nh b ted or prec p tated d sc osure for conduct gender ana ys s. dynam cs that mpede the r d sc osure w th those who reasons re ated to gender: (I) fear of Comparat ye ana ys s draws out or promote d sc osure exper ences us ng LIM. d sc osed dur ng the be ng v ewed as homosexua : (2) mportant pract ce mp cat ons. by exam n ng a range of Ana ys s of 30 abuse and those who profound fee ngs of st gmat zat on or Retrospect ve des gn of the study factors nc ud ng part c pant narrat ves d d not. I9 fema es and so at on because of the be of that boys wh ch mp es poss b e reca gender as a dynam c— was used for theme II ma es; 18-65 (mean are rare y v ct m zed; and (3) fear of ssues. Hgh eve of how d sc osures of deve opment regard ng 40.1) years who were becom ng an abuser, wh ch acted as a trustworth ness of the data and fema es and ma es are mpact of gender on sexua y abused by a prec p cant for d sc osure. Two nterpretat ons were ach eyed s m ar and d fferent. d sc osure. Intery ews fam y member or a predom nant themes w th fema e through cred b ty. dependab ty. and n what ways were transcr bed trusted adu t. Avenge part c pants re ated to d ff cu t es and conf rmab ty through d rect gender affects CSA verbat m for open. age of abuse onset was d sc os ng: (I) they fe t more conf cted quotes d sc osure ax a . and se ect ve 5.3 years, 36% were about who was respons b e for the abuse cod ng. Categor es and nonwh te, and 58% had and (2) they more strong y ant c paced subcategor es were not d sc osed dur ng be ng b amed and/or not be eyed co apsed and ref n ng ch dhood nto theme areas Co ngs, Gr ff ths. and Study exam ned patterns F e rev ews of a soc a 1.737 cases of CSA Content ma ys s dent fed two broad These resu tsft nto A agg a's (2004) Kuma o (2005). of d sc osure n a arge work and med a case reported n the North d mens ons of d sc osure: (I) agency: d sc osure framework. Through represent ve samp e f es for CSA v ct ms Durban area of ch d- n t aced d sc osure versus data ana ys s two raters coded of South Afr can CSA seen at the cr s s KwaZu u-Nata . South detect on by a th rd party and (2) d sc osure categor es us ng v ct ms. Two study center where a cases Afr ca, dur ng January tempon durst on: an event versus a author's d sc osure framework, object ves to: (I ) of CSA reported to 2001 to December process. These d sc osure d mens ons wh ch proved to be both exam ne how and the North Durban 2003. 1,614 grs and def ned four d screte categor es of exhaust ve and mutua y exc us ve (continued) EFTA00024186 Table I. (cone nued) Study Purpose Des gn Samp e F nd ngs Summary when CSA v ct ms po c ng area were 123 boys: average age d sc osure: (I) purposefu d sc osure w th the percentage of nternter d sc ose the r abuse referred dur ng the of v ct m zed ch dren (30% of cases), (2) nd rect d sc osure agreement at 98%. and (2) Ident fy factors per od of January 2001 was 9.9 years. 47% (9% of cases), (3) eyew tness detect on Genera zab ty of th s study s assoc ated w th to December 2003 reports were made (18% of cases), and (4) acc dents m ted to ch d o ents rece v ng a d fferent patterns of w th n 72 hr of the detect on (43% of cases). D sc osure cr s s assessment referred d sc osure abuse, 31% from 72 hr ndependent y pred cted by v a m's age. through a po ce report to I month, and 22% nature of the v ct m—perpetrator more than a month re at onsh p. offender's age. frequency of after the abuse abuse. and report ng atency. Mean age of purposefu d sc osures (10.67) was h gher than the mean age of nd rect d sc osures (5.84). Exp c t forms of d sc osure were ess ke y when the offender was a fam y member. Shorter report ng atency was more key w th repeated abuse Hcrshkow a, Horow Th s study a med to Large database of The camp e was Oven , 65% of the 26,446 ch dren made Oven f nd ngs nd cated that rates and Lamb (2005). dent fy character st cs suspected cases of compr sed of 26.446 of a egatons when ntery ewed. Rates of of d sc osure var ed systemat ca y of suspected ch d phys ca and sexua 3- to14-yearn d d sc osure were greater for sexua abuse depend ng on the nature of the abuse v a ms that are abuse nvest gated n a eged v ct ms of (71%) over phys ca abuse (61%). a eged offences. the re at onsh p assoc ated w th Isne between 1998 sexua and phys ca Ch dren of a ages were ess key to between a eged v a ms and d sc osure and and 2002 was ana yzed. abuse ntery ewed n d sc osela ege abuse when a parent was suspected perpetrators. and the nond sc osure dur ng Intery ews were a so Israe n the 5-year the suspected perpetrator. D sc osure age of the suspected v a ms. forma nvest gat ons conducted us ng per od from 1998 to rates ncreased as ch dren grew o der. Ana yses on y mo ved cases that standard zed NICHD 2002. 140 exper enced 50% w th 3- to 6-yearn ds. 67% of the 7- had come to the attent on of Invest gat ve Intery ew toned youth to I0-year-o ds. and 74% of the I I- to off c a agenc es. mak ng t d ff cu t Protoco . Arch va data nvest gators I4-year-o ds d sc osed abuse when to determ ne how many of abuse were ana yzed conducted ntery ews quest oned take p ace w thout ever tr gger ng any k nd of off c a nvest gat on Jensen. Gu brandsen, Th s study nvest gated Qua tat ve approach to 20 fam es w th a tota of None of the ch dren to d of abuse Ev dence for de ayed d sc osures. Moss ge, Re the t. and the context n wh ch data co ect on and 22 ch dren mmed ate y after t occurred. Ch dren The resu is nd ate that Tjers and (2005) ch dren were ab e to ana ys s was used. part c pated. A exposed to repet t ye abuse kept th s as a d sc osure s a fundaments y report the r ch d Therapeut c ntery ews ch dren had to d about secret for up to seven years: 17 to d d a og a process that becomes sexua abuse o the ch dren and exper ences that the r mothers f rst, 3 f rst to d a fr end. ess d ff cu t f ch dren perce ve exper ences: the r most y the r mothers created concerns for to d the r father, and I the r unc e. that there s an opportun ty to v ews as to what made were ana yzed through care-g vers about CSA. Major ty of remarks that ed to the ta k. a purpose for speak ng and a t d ff cu t to ta k about a qua tat ve approach. Ch dren's ages ranged susp con of CSA were made n connect on has been estab shed abuse: what he ped Fo ow-up ntery ews between 3 and 16 s tuat ons where someone engaged the to what they are ta k ng about. them n the d sc os ng were he d I year ater years (average age 7.5 ch d nada ogue about what was Strengthen ng parent ch d process: and the r years): 15 g r s and 7 bother ng them, resu t ng n a referra re at onsh ps s an mportant parent's percept ons of boys. Sexua y abused The ch dren fe t t was d ff cu t to f nd pact ce mp cat on the r d sc osure by someone n the s tuat ons conta n ng enough pr vacy and processes tam y or a c ose prompts that they cou d share the r person to the fam y exper ences. When the ch dren d d ICOtitinUed) EFTA00024187 Table I. (coot nued) Study Purpose Des gn Samp e F nd ngs Summary d sc ose they d d t n s wat ons where the top c of ch d sexua abuse was n some form addressed or act vated. where someone recogn zed the ch d's cues and probed further. They a so were sens t ve to others react ons, and whether the r d sc osures wou d be m s nterpreted. Seven of the ch dren perce ved negat ve consequences as major factors contr but ng to de ay ng d sc osure. They were pr mar y concerned about negat ve effects for the mother. The mothers sad they were a so sens t ve to the ch dren's fee ngs. If the r ch dren showed s gns of d stress and d d not want to ta k. the mothers wou d change the subject or not pursue the top c further Sta er and Ne son- The purpose of th s study Secondary ana ys s of Samp e cons seed of 34 F nd ngs are reported n three major Th s study prov ded a contextua Garde (2005) was to understand the qua tat ve focus group part c pants from four doma ns: (I ) se (-phase: where ch dren exam nat on of the ent re fu process of CSA data. Or g na project groups. Sess ons come to understand v ct m at on d sc osure process. c oser to the d sc osure and how cons seed of four focus ana yzed were nterna y (2) conf dant se ect on- po nt n t me when the abuse and th s unfo ded for groups conducted between 60 and 90 m n react on phase: where they se ect a t me, d sc osure occurred. Sma groups preado escent and w th n the context of ong: and otaped and p ace, and person to te and then of preado escent and ado escent ado escent g r s. ongo ng therapy for ater transcr bed for whether that person's react on was g r s who had sury ved sexua Exam ned what g r s who had content am ys s support ve or host e: and (3) abuse a so served as consu tants fac tated and exper enced CSA. consequences phase: good and bad that and were encouraged to share h ndered d sc osure Secondary am ys s cone nued to nform the r ongo ng the r know edge for the benef t of and subsequent cons seed of wr tten strateg es of te ng. The act ons and profess ona prate t oners consequences narrat ye summar es of react ons of adu is were s gn f cant and each secs on group ng nformed the g r s' dec s ons. The these conceptua y, consequences phase was further and exam n ng the r subd v ded nto four aspects: (I) nterconnectedness Boss p ng and news networks, (2) chang ng re at onsh ps, (3) nst tut om responses and the after fe of te ng. and (4) ns der and outs der commun t es A agg a (2004) The study sought to The study emp oyed Us ng purpos ye samp ng Through ana ys s of the ntery ew new Th s study expanded types of CSA exam ne nf uences LIM—a 24 adu t sun von of categor es of d sc osure were dent fed d sc osures to more fu y that nh b t or promote phenomeno og ca ntnfam a abuse to add to ex st ng types. Three understand how ch dren and ch dren's d sc osure of des gn. Intens ve between ages of 18 prey ous y dent f ed were conf rmed n adu is d sc ose. And under what CSA to address gaps n ntery ew ng that were and 65 (average age these data: acc denta purposefu . and c rcumstances. Ask ng peop e to know edge about how, 2 hr ong on average 41.2) were recru ted prompted!e c ted accounted for 42% of recount events that occurred n when, and under what generated data for a from agent es and one d sc osure patterns n the study samp e. ch dhood s suscept b e to c rcumstances v a ms themat c am ys s. The un vers ty: 57% ma e Over ha f the d sc osure patterns descr bed memory ft ure. espec a y when of CSA d sc ose ntery ew gu de was and 43% fema by the study samp e d d not f t these memor es were forgotten. (continued) EFTA00024188 Table I. (tont nued) Study Purpose Des gn Samp e F nd ngs Summary deve oped to probe average age of abuse prey ous y estab shed categor es. Three de ayed. or repressed and ater for nd v dua , onset was 6.5 years: add t ona d sc osure categor es recovered. D stop on and nterpersona . 42% of the part c pants emerged: behav ora and nd rect verba rev s on of events are a so env ronmenta . and had d sc osed the attempts. d sc osures ntent ona y potent a prob ems nreca . H gh cu tura factors abuse dur ng w thhe d. and d sc osures tr ggered by degree of trustworth ness of the of uenc ng CSA ch dhood: 58% recovered memor es data was ach eyed and quotes d sc osure d sc osed as adu is prov ded supported the categor es Cr sma, Basce , Pac. and The ma n goa s of th s In-depth to ephone The samp e was The ma n mped menu to d sc ose to a Th s study represented the f nd ngs Rom to (2004) study were to (anonymous) compr sed of 36 young fam y member were: fear of not be ng of a m xed samp e of sun von of understand ntery ews were peop e who be eyed, shame, and fear of at ng ch d sexua abuse and nt mate mped menu that conducted after exper enced sexua troub e to the fam y. The ma n partner v o ence. The study was prevent ado escents nformed consent was abuse n ado escence: mped menu for not seek ng sery ces conducted n Ita y and t s not from d sc os ng CSA exp a ned and 35 fema es and I ma c were: unaware of appropr ate sery ces. c ear what sexua abuse response and seek ng he p from obta ned. Three aged 12-17. Some of w sh to keep the secret. ack of tra n ng s an ab e. There may the r soc a network nvest gators the samp e awareness of be ng abused, m strust of have been a se ect on b as as the and/or the sery ces exper enced n exper enced sexua adu ts and profess ona s. and fear of the most d scat sf ed sury vors counse ng CSA v o ence n a dat ng consequences of d sc os ng sexua abuse. responded to the research ca counse ng conducted re at onsh p When they d d d sc ose to profess ona s. the ntery ews wh ch teens rece ved very m ted support as were recorded w th many profess ona s were not tra ned on perm ss on. Three sexua abuse and cou d not offer researchers appropr ate ntervent ons co v ct ms ndependent y scored the ntery ews accord ng to a cod ng framework Jonzon and L ndb ad Study purpose was to Adu t women report ng 122 adu t women Abuse character st a: abuse by mu t p e 68% de ayed d sc osure unt (2004) exp ore how abuse CSA by someone c ose between 20 and 60 perpetrators was more common than by adu thood. At the t me of the tra ts. openness, were ntery ewed years o d (average age a s ng e perpetrator. Age of onset was study, t was one of the f rst react ons to CSA us ng sem -structured of 41 years) report ng often before age of 7. w th an average stud es to focus on the nterp ay d sc osure. and soc a gu des together w th exposure to ch d durat on of 7 years. Severe y abused between soc a support networks support were re ated. quest onna res. Data sexua abuse by women had to ked to more of the r and d sc osure of ch d sexua D fferences based on on v a m zat on and someone c ose before soc a network. espec a y to abuse. The study resu u are sever ty of abuse. current soc a support the age of I8 and had profess ona s. D sc osures: 32% somewhat m ted by an t m ng and outcomes were retr eyed to d someone about at d sc osed dur ng ch dhood (before the overrepresentat on of severe y of d sc osure. soc a through the east one abuse event age of 18) w th an average of 21 years abused women. Retrospect ve support. and quest onna res, and 90% were Swed sh de ay. Women who had d sc osed n study and se f-report of pred a ng factors of data on d sc osure and subjects. Purpos ve ch dhood reported more nstances of nformat on cou d mp y reca pos t ve and negat ve react ons were samp ng strategy was phys ca abuse, mu t p e perpetrators. ssues and thus m ts the accuracy react ons were probed gathered through the used use of v o ence, and were more ke y to of the nformat on obta ned on ntery ews w th have confronted a perpetrator, and had abuse and d sc osure part c pants rece ved a negat ve f rst react on. Factors character st a. Cross-sect ona (continued) EFTA00024189 ;el Table I. (cont nued) a. Study Purpose Des gn Samp e F ndngs Summary s gn f cant y pred ct ng de ay were des gn does not a ow for def n te younger age at f rst event and no use of conc us ons of cause and effect on v o ence. D sc osure outcomes: of the 26 the re at onsh ps found women who to d n ch dhood dur ng a per od w th ongo ng abuse, IS women were cont nuous y abused after d sc osure Kogan (2004) The purpose of th s study Data were gathered from A subsamp e of 263 Ch dren under the age of 7 were at a Th s study exam ned factors was to dent fy factors a subsamp e of fema e ado escent fema es h gher r sk for de ayed d sc osures. nc ud ng d sc osures of USES n that of uence the ado escents that between 12 and 17 Part c pants whose USE occurred ch dhood and ado escence n a d sc osures made by part c pared n the years o d, mean age of between the ages of 7 and 13 were most nat ona y representat ye samp e fema e sury vors of NSA, wh ch cons sted 15.2 years o d, who key to te an adu t. Ado escents (14- of fema e ado escents who USE n ch dhood and of structured phone reported at east one 17) were more ke y to te on y peers part c pared n the NSA. Surveys ado escence. The ntery ews. USES exper ence of than ch dren aged 7-10 years. Ch dren for nvest gat ons of v ct m zat on pred tears of both the reported n the NSA unwanted sexua under II were more ke y to te an exper ences may be b ased due to t m ng of d sc osure were assessed us ng a contact n the NSA. adu t. but were at r sk for de ay ng underreport ng. Ado escents who and the rec pent of the mod f ed vers on of the Part c pant d sc osure beyond a month. Ch dren refused to report or d scuss an d sc osure were Inc dent C ass f cat on character st a. USE aged II-13 tended to d sc ose w th n a USE may represent a source of nvest gated Intent ew. They were character st a. and month. C oser re at onsh p to the systemat c b as and wou d make then asked a ser es of fam y contextua perpetrator or a fam y member was the resu ts genera zab e on y to quest ons about each attr butes were assoc ated w th de ayed d sc osure. ado escents who are w ng to ep sode of unwanted exp ored Immed ate d sc osure was more ke y d sc ose USE v a survey. A though sexua contact w th stranger perpetrat on. Fear for data may be retrospect ye, reca nc ud ng event ones fe dur ng and penetrat on were b as may have been m n m zed n character st a and assoc ated w th d sc osure to adu ts. th s study s nce part c pants were perpetrator Fam y factors nked to d sc osure were ado escents. and so the t me ag character st a (I) drug abus ng househo d member, between the USE and the wh ch made sury von more key to ntery ew were presumab y d sc ose more prompt y and (2) never shorter than a study of adu t v ng w th both parents was assoc ated part c pants reca ng CSA w th nond sc osure exper ences Goodman-Brown, The purpose of th s study Case f e rev ews of data Samp e cons sted of 218 64% d sc osed w th n a month and 29% Th s study represents a h gher rate Ede ste n. Goodman. was to nvest gate obta ned from dr dren referred to w th n 6 months. F ve var ab es for the of d sc osers w th n a month. Jones, and Gordon var ab es assoc ated prosecut on f es, as prosecutors' off ces mode were tested. (I) age: ch dren who These cases had been reported to (2003) w th de ay of we as from for a eged CSA. A were o der took onger to d sc ose and author t es and were n process of d sc osure of CSA and structured ntery ews ch dren n the samp e o der ch dren feared more negat ve prosecut on wh ch may exp a n test a mode for w th the ch dren's had d sc osed the r consequences to others than younger h gher rate of ear y d sc osures. factors that of uence caretaker and abuse n some manner. ch dren: (2) type of abuse: v ct ms of Lega samp e w th h gher rate of how qu ck y ch dren observat ons of ch d Ch dren ranged n age ntrafam a fam es took onger to extrafam a abuse (52%) may a so d sc ose sexua abuse ntery ews. Tn ned from 2 to I6 years at d sc ose—v ct ms of ntrafam a abuse account for ear er d sc osures. graduate students and the beg nn ng of abuse; feared greater negat ye consequences to Mode suggests that o der one v ct m advocate 3-16 years at the end others compared to v ct ms of ch dren, v ct ms of ntrafam a comp eted the Sexua of the abuse, and 4-16 extrafam a abuse: (3) fear of negat ve abuse: fe t greater respons b ty Assau t Prof e years at the t me of the consequences: ch dren who feared for the abuse, and perce v ng (continued) EFTA00024190 Table 1. (coot nued) Study Purpose Des gn Samp e F nd ngs Summary quest onna re for ch d n t a po ce report: negat ve consequences of d se osure negat ve consequences to character st cs. the 77% fema e. 70% took onger to d sc ose, ch dren who d sc os ng took onger to d sc on. abuse and the r Caucas an. 17% be eyed that the r d sc osure wou d We -des gned study w th h gh d sc osure. Ch dren's H span c. and I I% br ng harm to others took onger to eve of r gor. Produced a v ab e percept on of Mr can Amer can. d sc ose, fear of negat ye consequences mode of d sc osure for further respons b ty and fear Predom nant y m dd e to the se f or the perpetrator was nvest gat ons. However. of negat ve to ow SES. unre ated to t me of d sc osure. and g r s researchers were not ab e to consequences were Approx mate y 47% more than boys feared negat ye ntery ew ch dren d rect y probed. ntrafam a abuse consequences to others: (4) Perce ved Corre at ona ana yses respons b ty: ch dren who fe t greater were conducted w th respons b ty for the abuse took onger path ana yses to test to d sc ose and o der ch dren fe t more the hypothes zed respons b ty for the abuse: and (5) causa re at ons among gender was not s gn f cant y corre ated var ab es w th t me to d sc osure Sm th. Letourneau. The study focus was to Structured te ephone Two probab ty samp es. 288 (9%) reported exper enc ng at east The t me frame of th s survey may Saunders, K paw ck. gather data from a ntery ews that asted Wave I was a random one event that met the study's def n t on have had contextua mp cat ons. Resn ck and Best arge samp e of women approx mate y 35 m n samp e of 2.009 of ch dhood rape. The average age at the The major ty of ch d rapes (2000) about the ength of were used to co ect respondents se ected t me of the f rst rape was 10.9 years. Of reported by th s samp e occurred t me women who data us ng a computer- from stmt fed samp es the 288 women who reported a ch d pr or to the arge-sca e ch d were raped before age ass sted te ephone of def ned rape. 28% stated that they had never to d assau t prevent on educat on 18 de ayed d sc osure ntery ew system. A jur sd ct ons. anyone about th s sexua assau t unt programs that were begun n the who they d sc osed to. te ephone ntery ews Random d g ta d a rig spec f a y quer ed by the ntery ewer I 980s that teach ch dren that and var ab es that were conducted w th was used to so c t for th s study. 58% d d not d sc ose for assau is ( nc ud ng CSA) are pred cted d sc osure each quest on on a househo ds for seed over 1 year and up to 5 years post-rape. wrong and Thou d be d sc osed to w th n I month computer screen. The and un seed te ephone 27% d sc osed w th n a month. Among respons b e adu u. Th s survey cons sted of numbers. Second women who d sc osed pr or to the r nformat on may have nf uenced seven measures random samp e of NWS ntery ew c ose fr ends were the (and may current y be nf uenc ng) des gned toe ct 2.000 women between most common person to whom v a ms young women's d sc osure demograph c the ages of 18 and 34 made d sc °sures, fo owed by mothers patterns. For Wave I, compar son nformat on. Was se ected. Both and other mmed ate fam y members. of these data w th the popu at on psych atr c symptoms. Wave I and Wave 2 Fewer than 10% of ir a ms reported parameters obta ned from the substance use, and data were we ghted to mak ng the r nta dsc osure to soc a U.S. Census Bureau nd cated that v ct m zat on h story. conform to the 1989 workers or aw enforcement personne . the samp e c ose y matched the The present study Census stat st a On y 12% of ch d rape v ct ms stated demograph c attr butes of the reports on data from that the r assau is were reported to popu at on of U.S. women the demograph c and author t es at some po nt ch d rape v a m zat on quest ons Note. SCL-90 = Symptom Check List-90: SES = socioeconomic status: L N = ong interview method: CA = chi d sexua abuse: N CHD = Nationa nstitute of Chi d Heath and Human Deve opmenc USE = unwanted sexua experiences: NSA = Nationa Survey of Ado escents: NWS = Nationa Women's Study: Q DS = Questionnaire informattse sur es dE inquants sexeu s. EFTA00024191 276 TRAUMA, VIOLENCE, & ABUSE 20(2) examples of this usage were found in the research questions, being facilitated within a dialogical and relational context is interview guides, and surveys examined: "How and when do being more clearly delineated. people decide to tell others about their early sexual experiences Theme 2: Contemporary disclosure models reflect a with adults?" (Hunter, 2011, p. 161); "Some men take many social—ecological, person-in-environment perspective to years to tell someone that they were sexually abused. Please understand the complex interplay of individual, familial, describe why it may be difficult for men to tell about/discuss contextual, and cultural factors involved in CSA disclosure. the sexual abuse" (Easton, Saltzman, & Willis, 2014, p. 462). Subthemes include new categories of disclosure and a grow- "Participants were asked a series of open-ended questions to ing focus on previously missing cultural and contextual elicit a narrative regarding their experiences of telling. .." factors. (McElvaney, Greene, & Hogan, 2012, p. 1160). "Who was the Theme 3: Age and gender are strong predictors for delaying first person you told?" (Schaeffer, Leventhal, & Anes, 2011, p. disclosure or withholding disclosure with trends showing 346). fewer disclosures by younger children and boys. One sub- There was sound consistency between studies, defining dis- theme emerged that intrafamilial abuse/family-like relation- closure in multifaceted ways with uniform use of categories of ship of perpetrator has a bearing on disclosure delays or prompted, purposeful, withheld, accidental, direct, and indi- withholding. rect. However, defining the period of time that would delineate Theme 4: There is a lack of a cohesive life-course perspec- a disclosure as delayed varied widely across studies, wherein tive. One subtheme includes the lack of data within the 18- some studies viewed I week or I month as a delayed disclosure to 24-year-old emerging adult population. (i.e., Hershkowitz et al., 2007; Kogan, 2004; Schembucher, Theme 5: Significantly more information is available on Maier, Moher-Kuo, Schnyder, & Lamdolt, 2012). Other studies barriers than on facilitators of CSA disclosure. Subthemes simply reported average years of delay sometimes as long as of shame, self-blame, and fear are uniformly identified as from 20 to 46 years (Easton, 2013; Jonzon & Linblad, 2004; disclosure deterrents. Smith et al., 2000). Second, the number of qualitative studies has increased sig- nificantly over the last 15 years. This rise is in response to a Disclosure as an ongoing process: Iterative and interactive in nature. previous dearth of qualitative studies. Based on Jones's (2000) Disclosure is now generally accepted as a complex and lifelong observation that disclosure factors and outcomes had been well process, with current trends showing that CSA disclosures are documented through quantitative methods; in a widely read too often delayed until adulthood (Collin-Vezina et al., 2015; editorial, he recommended "Qualitative studies which are able Easton, 2013; Hunter, 2011). Knowledge building about CSA to track the individual experiences of children and their percep- disclosure has moved in the direction of understanding this as tion of the influences upon them which led to their disclosure of an iterative and interactive process rather than a discrete, one- information are needed to complement .. . " (p. 270). time event. Since the new millennium, disclosure is being Third, although a few studies strived to obtain representative viewed as a dynamic, rather than static, process and described samples in quantitative investigations (Hershkowitz, Horowitz, "not as a single event but rather a carefully measured process" & Lamb, 2005; Kogan, 2004; Smith et al., 2000), sampling was (Alaggia, 2005, p. 455). The catalyst for this view originates for the most part convenience based, relying on voluntary par- from Summit (I 983) who initially conceptualized CSA disclo- ticipation in surveys and consent-based participation in file sures as process based, although this notion was not fully reviews (Collings, Griffiths, & Kumalo, 2005; Priebe & Sve- explored until several years later. Examinations of Summit's din, 2008; Schembucher et al., 2012; Ungar, Barter, McConnell, (1983) groundbreaking proposition of the CSA accommodation Tutty, & Fairholm, 2009a). Therefore, generalizability of find- (CSAA) model produced varying results as to whether his five ings is understandably limited. The qualitative studies used stages of secrecy, helplessness, entrapment and accommoda- purposive sampling as is deemed appropriate for transferability tion, delayed, conflicted, and unconvincing disclosures, and of findings to similar populations. Some of those samples con- retraction or recantation, hold validity (for a review, see Lon- tained unique characteristics, since they were sought through don, Bruck, Ceci, & Shuman, 2005). However, the idea of counseling centers or sexual advocacy groups. These would be disclosure as a process has been carried over into contemporary considered clinical samples producing results based on disclo- thinking. sures that may have been delayed or problematic. This might Recently, McElvaney, Greene, and Hogan (2012) detailed a presumably produce data skewed toward bathers and bring process model of disclosure wherein they describe an interac- fonvard less information on disclosure facilitators. tion of internal factors with external motivators which they Through an in-depth, second-level analysis, this review liken to a "pressure cooker" effect, preceded by a period of identified five distinct themes and subthemes beyond the gen- containment of the secret. Moreover, this and other studies eral trends as noted earlier. strongly suggest disclosures are more likely to occur within a dialogical context—activated by discussions of abuse or pre- Theme 1: Disclosure is viewed as an ongoing process as vention forums providing information about sexual abuse opposed to a discrete event—iterative and interactive in (Hershkowitz et al., 2005; Jensen, Gulbrandsen, Mossige, nature. A subtheme was identified regarding disclosure as Reichelt, & Tjersland, 2005; Ungar et al., 2009a). The term EFTA00024192 Maggie et al. 277 dialogical simply means to participate in dialogue. Key dialo- In terms of environmental factors, one study revealed that gical vehicles identified in these studies were providing sexual neighborhood/community conditions can hinder disclosure abuse information through prevention programs, being asked when there is lack of school involvement in providing a sup- about sexual abuse, and being prompted to tell (McElvaney portive environment, such as in following up on troubling stu- et al., 2012; Ungar et al., 2009a). dent behavior (Alaggia, 2010). Additionally, a child victim's anticipation of a negative response to disclosure, especially that they may not be believed by others outside their family such as Contemporary models of CSA disclosure reflect a social cological neighbors or other community members, has shown to deter perspective. Knowledge on CSA disclosure has been steadily disclosure (Collin-Vezina et al., 2015). advancing toward a holistic understanding of the complex Cultural factors influencing CSA disclosure have been stud- interplay of individual, familial, contextual, and cultural fac- ied to a much lesser degree. Despite this, a few important tors (Alaggia & Kirshenbaum, 2005; Brazelton, 2015; Fontes studies examining critical sociocultural factors now exist for & Plummer, 2010). Where at one time factors examined and better understanding CSA disclosure within a cultural context identified were predominantly of intrapersonal factors of child (Brazelton, 2015; Fontes & Plummer, 2010). Among these victims, knowledge construction has shifted to fuller social— important contributions, Brazelton's (2015) research has deli- ecological, person-in-environment explanations (Alaggia, neated CSA disclosure processes as "shaped by relational, 2010; Collin-Vezina et al., 2015; Easton et al., 2014; Hunter, racial, socio-cultural, historical, and developmental factors" 2011; Ungar, Tutty, McConnell, Barter, & Fairholm, 2009b). (p. 182). In a unique study using culturally focused research Social-ecological explanations open up more opportunities to literature as data triangulated with clinical case material, cul- intervene in facilitating earlier disclosures. Alaggia (2010) pro- turally based belief systems in many cultures have been found poses an ecological mapping of what individual, interpersonal, to foster family climates that can silence children from disclos- environmental, and contextual influences impede or promote ing abuse (Fontes & Plummer, 2010). Taboos about sexuality, CSA disclosures based on analysis of in-depth interview data of patriarchal attitudes, and devaluation of women are among 40 adult survivors. Subsequently, based on a sample of 67 adult some of the cultural barriers that inhibit disclosure (Fontes & survivors, Collin-Vezina, Sablonni, Palmer, and Milne (2015) Plummer, 2010). identified three broad categories, closely aligned with an eco- Clearly, disclosure conceptualizations are being integrated logical framework that impede CSA disclosure: (1) barriers into a social—ecological model of individual and developmental from within, (2) barriers in relation to others, and (3) bathers factors, family dynamics, neighborhood, and community con- in relation to the social world which can be aligned to intra- text as well as cultural and societal attitudes toward better personal, interpersonal, and contextual factors. understanding disclosure barriers and facilitators (Alaggia, A summary of knowledge building using a social—ecologi- 2010), although more data are needed on cultural and contex- cal framework follows. Knowledge gained in the intrapersonal tual factors. domain includes expanded conceptualization of disclosure by building on previous categories of accidental, purposeful, and Age and gender as predictors of disclosure prompted disclosure to also include behavioral and indirect Age. Age is consistently found to be an influential factor in attempts to tell, intentionally withheld disclosure, and triggered CSA disclosure, making the life stage of the victim/survivor a and recovered memories (Alaggia, 2004). Categories of indi- critical consideration. Studies draw distinctions in age-groups rect behavioral disclosure patterns have been further verified in falling into either under or over 18 years of age. Eighteen years follow-up research by Hunter (2011), and through an extensive of age was the common age cutoff point that investigators chose file review that used Alaggia's (2004) disclosure framework to in order to distinguish child/youth populations from adult sam- analyze their data (Collings et al., 2005) for verification. ples. Sixteen of the studies drew on samples of children and Interpersonal factors have also emerged in regard to certain youth, while the other 15 studies sampled adults over the age family characteristics as disclosure barriers. Families with of 18, and a further two studies used mixed age-groups (refer to rigidly fixed gender roles, patriarchal attitudes, power imbal- Table I). Among the child and youth samples, the age ranges ances, other forms of child abuse and domestic violence, chao- spanned from preschool to late adolescence (3-17 years of age), tic family structure, dysfunctional communication, and social with varying methodological approaches implemented across isolation have been found to suppress disclosure (Alaggia age cohorts. For younger cohorts, file reviews and secondary Kirshenbaum, 2005; Collin-Vezina et al., 2015; Fontes & data analyses of CSA reports were typically undertaken. Ado- Plummer, 2010). In addition, relationship with perpetrator is lescents were most often given surveys. Sometimes children and a factor whereby research indicates that disclosure is made youth were interviewed as part of administering a survey or as a more difficult when the perpetrator is a family member or close follow-up (Crisma et al., 2004; Hershkowitz et al., 2005; Ungar to the family (Dumont, Messerschmitt, Vila, Bohu, & Rey- et al., 200%). In the majority of child and adolescent samples, Salmon, 20 I 4;Easton, 2013; Goodman-Brown et al., 2003; sexual abuse concerns were already flagged to investigative Hershkowitz et al., 2005; Priebe & Svedin, 2008; Schanbucher authorities. However, the work of Ungar, Barter, McConnell, et al., 2012). This is especially a barrier when the perpetrator Tutty, and Fairholm (2009a, 200%) is one exception, whereby lives with the victim (LeClerc & Wortley, 2015). their survey elicited new disclosures. EFTA00024193 278 TRAUMA, VIOLENCE, & ABUSE 20(2) Adult studies typically had a mean age between 40 and 50 for the abuse, resulting in no disclosure. Male participants in a years. Interviews were the main data collection method with a subsequent study also relayed that gender norms and stereotypes few exceptions using survey designs (i.e., Easton, 2013; Kogan, contributed to them concealing the abuse because they were 2004; Smith et al., 2000) and case file reviews (i.e., Collings abused by a woman (Gagnier & Collin-Vezina, 2016). In the one et al., 2005; Goodman-Brown et al., 2003). Results show a clear study that compared male and female disclosures, investigator trend toward increased likelihood of disclosure in older youth, found that men's fears ofbeing viewed as homosexual; profound and findings from adult samples showing a preponderance of feelings of stigmatization or isolation because of the belief that disclosures in adulthood, with the large majority of participants boys are rarely victimized; and fear ofbecoming an abuser acted of adults reporting never having had a sexual abuse complaint as disclosure barriers. Whereas females felt more conflicted about filed with investigative authorities as a child or an adolescent who was responsible for the abuse and more strongly anticipated (i.e., Hunter, 2011; Gagnier & Collin-Vezina, 2016; Sorsoli, being blamed and not believed (Alaggia, 2005). Kia-Keating, & Grossman, 2008; Ungar et al., 200%). With children and youth under the ages of 18 distinct Lack of a life-course perspective. Given that the study of CSA patterns emerged. First, accidental detection, rather than disclosure draws on age-groups ranging from samples of very purposeful disclosure, is more likely to occur with younger young children to retrospective studies of adult survivors, with children. For example, in one large-scale study of over significant developmental considerations, this area of study 1,737 file reviews, over half of the CSA-related cases were lacks an intentional cohesive life-course perspective. Most data identified through accidental and eyewitness detection (61%), are derived from either cross-sectional or retrospective designs, while less than one third were purposeful disclosures initiated with few longitudinal studies. There are a series of sound, yet by the child victim (Collings et al., 2005). A second pattern disconnected, studies focusing on specific age-groups of chil- which emerged is that rates of disclosure increase with age, dren and adolescents, along with adult retrospective studies. especially into adulthood, which is supported by persistent Thus, the available knowledge base does not allow for a cohe- findings of high rates of delayed disclosure reported later sive picture of CSA disclosure processes and pathways over the in the life course by adult survivors (Collings et al., 2005; life course to emerge. Collin-Vezina et al., 2015 ; Easton, 2013; Jonzon & Linblad, The life-course perspective has long been recommended as 2004; Kogan, 2004; Leclerc & Wortley, 2015; Sorsoli et al., a critical lens for the study of child abuse (Browning & Lau- 2008). While gender and relationship with the perpetrator are mann, 1997; Williams, 2003). For example, a life-course per- considerable factors in CSA disclosure, age is consistently a spective has been utilized to understand the immediate- and stronger predictor of disclosure (or nondisclosure) (Hershko- long-term effects of CSA on the developing child victim witz et al., 2005; Leclerc & Wortley, 2015). Third, younger (Browning & Laumann, 1997). Further, a life-course perspec- children who disclose are more likely to do so in an interview tive is important in terms of examining age of onset of CSA to situation or other environment that provides prompts or explain the differential effects of sexual victimization and questions about sexual abuse (Hershkowitz et al., 2005; developmental impacts in terms of understanding their ability McElvaney, Greene, & Hogan, 2014; Schaeffer et al., to disclose—effects that need to be understood within a devel- 2011), but this trend can also be seen in older youth (Ungar opmental context, especially for designing appropriate inter- et al., 2009a, 2009b). ventions for disclosure at critical transitions from early childhood through to adolescence and into adulthood. In addi- Gender. A number of studies have recently focused on CSA tion, important "turning points" in life may facilitate disclo- disclosures with male victims, since males have been an under- sures. For example, entry into adulthood given that delayed studied population (Alaggia, 2005; Easton, 2013; Easton et al., disclosure occurs more often in adulthood. Alaggia (2004, 2014; Gagnier & Collin-Vezina, 2016). Most investigations 2005) found that being in a committed relationship or the birth that sampled both sexes show females outweighing male parti- of children acted as facilitators for some survivors to disclose, cipants. Although women are at double the risk of being sub- especially to their spouses. These significant life events, as jected to CSA, the ratio of women to men in most disclosure contributing to disclosures, bear further examination. studies has not been representative. This finding may be indi- cative of male victims more likely delaying disclosing their Summary of barriers and facilitators. Research over the past 15 CSA experiences, leaving male disclosure in child and youth years continues to uncover barriers to CSA disclosure at a samples underrepresented (Hebert, Tourigny, Cyr, McDuff, & higher frequency than that of facilitators. As stated previously, Joly, 2009; Ungar et al., 2009b). this might be the result of sampling methods whereby partici- Easton, Saltzman, and Willis (2014) have been developing pants who volunteer for disclosure research may have had more gender-specific modeling of disclosure examining male disclo- negative disclosure experiences, especially since many report sures. Their proposed model groups male disclosures into barrier delays in disclosure. The following section outlines the major categories as determined by individual factors, interpersonal trends in both barriers and facilitators (see Table 2). issues, and factors that are sociopolitical in nature. These authors suggest that predominant gender norms around masculinity rein- Barriers. Age and gender were found to contribute to barriers force the tendency for male victims of CSA to blame themselves as covered in Theme 3. Disclosures generally increase with age EFTA00024194 Maggie et al. 279 Table 2. Factors Influencing Child Sexual Abuse Disclosures. Barriers Facilitators Age: The younger the child victim, the less likely they will purposefully Age: Disclosures Increase with age. especially in adulthood. disclose. Gender: Males may be less likely to disclose in childhood/adolescence, Gender. Slight trend toward females who are older (adolescent) to fear of being seen as homosexual and as a victim, females experience disclose before adulthood more self blame and anticipation of being blamed and/or not believed Relationship to perpetrator: If the perpetrator is a family member or in Relationship to perpetrator: If the perpetrator is not living with the a family like role. disclosure is less likely to happen victim, disclosure rates increase Internal: Shame, self blame, and fear are psychological barriers. In Dialogical context Opportunities to disclose through discussion. addition, fear of negative consequences on the family and for self therapeutic relationship, information sessions on sexuality, and safety inhibits disclosure sexual abuse prevention programs Family relations: families with a patriarchal structure, rigidly fixed Family relations: Supportive parent-child relationship. gender roles, dysfunctional communication. other forms of abuse Involvement of others: Eyewitnesses coming forward and reporting: (i.e.. domestic violence), and isolation inhibit disclosure detection through community members, professionals Environmental and cultural context Lack of discussion about sexuality; Environmental and cultural context: Promotion of open discussion of passive acceptance that unwanted sexual experiences are inevitable; sexuality; community member involvement not wanting to bring shame to the family by admitting sexual abuse; lack of involvement from neighbors. school personnel; and stigma perpetuated by societal perceptions as children gain more developmental capacity, understanding between men and women, parents and children, presence of of sexual abuse as victimization, and increased independence. other forms of child abuse and/or domestic violence, chaotic Males are somewhat less likely to disclose, but this is often in family structure, dysfunctional communication, and social iso- interaction with other factors in the environment such as soci- lation have been found to suppress disclosure (Alaggia & Kir- etal attitudes that promote hypermasculinity as desirable, atti- shenbaum, 2005; Collin-Vezina et al., 2015; Fontes & tudes that perpetuate negative views of boys and men who are Plummer, 2010). In regard to broader environmental factors, victims, and homophobic attitudes (Alaggia, 2010; Easton disclosure can be hindered when involved and supportive com- et al., 2014; Gagnier & Collin-Vezina, 2016). munity members are not available, or not trained in sensitive Victims of intrafamilial abuse when the offender is a parent, responses, or when child victims anticipate not being believed caregiver, significant family member, or someone in a family- by neighbors and other people outside the family (Alaggia, like role are less likely to disclose immediately or at all in 2010; Collin-Vezina et al., 2015). Further, barriers in relation childhood/adolescence because of obvious power differentials to the social world were identified as stigmatization, the neg- and dependency needs (Collings et al., 2005; Dumont et al., ative labeling of sexual abuse victims, and taboos surrounding 2014; Hershkowitz et al., 2005; Kogan, 2004; Leclerc & Wort- sexuality and talking about sex as driven by cultural norms ley, 2015; Paine & Hansen, 2002; Schaeffer et al., 2011). (Collin-Vezina et al., 2015; Fontes & Plummer, 2010). Further, the perpetrator residing with their victim(s) Identification of cultural barriers is important recent contri- increases the likelihood of no disclosure (Leclerc & Wortley, bution to understanding disclosure processes—and in particular 2015). to the obstacles. Findings related to cultural barriers included Internalized victim-blaming, mechanisms to protect oneself themes of children's voices not being heard leading to silen- (such as minimizing the impact of the abuse), and developmen- cing, the normalization of the sexualization and objectification tal immaturity at the onset of abuse constituted internal bar- of girls and women, and the perpetuation of hypermasculinity riers. Further, shame, self-blame, and fear have been identified in men—all acting as barriers in terms of stigma to disclosure as significant factors deterring disclosure (Collin-Vezina et al., (Alaggia, 2005, 2010; Easton et al., 2014). Brazelton (2015) 2015; Crisma et al., 2004; Goodman-Brown et al., 2003; Hun- similarly found that lack of discussions about sex, young age at ter, 2011; Kogan, 2004; McElvaney & Culhane, 2015; McEl- the onset of sexual abuse, therefore not having the language to vaney et al., 2014). However, aspects of shame, self-blame and express what was happening to them, and preserving the family fear, and have not been fully explored in research. Since these good name by not talking about abuse in the family were also are strong predictors of disclosure suppression, they bear fur- barriers to disclosure. ther examination in future research to understand more fully Finally, it may be the case that more barriers continue to be how they operate in disclosure processes. identified over facilitators of CSA disclosure perhaps because In terms of interpersonal and environmental factors, family of the methods employed in studies—particularly those draw- dynamics can play a part in deterring disclosure. As previously ing on adult populations who delayed disclosure. These sam- mentioned, families characterized by rigidly defined gender ples may not be representative of the overall population of CSA roles, patriarchal attitudes that perpetuate power imbalances victims, since they may have had more negative disclosure EFTA00024195 280 TRAUMA, VIOLENCE, & ABUSE 20(2) experiences, consequently more readily identifying barriers. (3) age and gender are significant disclosure factors; (4) there On the other hand, these findings may speak to the actual is a lack of a life-course perspective; and (5) barriers to disclo- imbalance between facilitating factors and barriers for disclo- sure continue to outweigh facilitators. Based on these themes, a sure, the latter carrying more weight in the victims/survivors' number of conclusions are drawn from this review. First, dis- experiences, thus, explaining the high rates of disclosures closure as a process is emphasized throughout contemporary delayed until adulthood. research. Advances have been made in understanding these complex processes. However, the disclosure process over Facilitators. Although fewer disclosure facilitators are identi- time—for example, how the first detection of CSA or attempts fied in this review, very important facilitators were nonetheless to disclose in childhood impact later disclosures—are not well uncovered—ones that should be noted for professionals in this understood. This is the result of the absence of a cohesive life- field of practice. Internal factors that facilitate disclosures course perspective in investigations, although age consistently include symptoms that become unbearable, getting older with surfaces as significantly influencing CSA disclosure. Using a increased developmental efficacy, and realizing that an offence life-course perspective through the use of longitudinal studies was committed (Collin-Vezina et al., 2015; Crisma et al., 2004; is recommended. Easton, 2013; Hershkowitz et al. 2007; McElavaney, Greene, The use of varied methodological designs, depending on the & Hogan, 2014; Schaeffer et al., 2011). Circumstantial facil- developmental stage of the victims/survivors, influences the itators are those where the child discloses because there has data generated and subsequent findings. For example, most been evidence provided, eye-witnessing has occurred, and a studies on children and youth are based on file reviews of cases report has been made. Environmental factors include settings that have been brought to the attention of authorities, or sur- that provide opportunities such as counseling, interviews, veys, with only a few studies using interviewing of younger information sessions and educational forumsAvorIcshops, and children. Therefore, there is less information available on pro- prevention programs for children and youth to disclose. cess issues with children and youth. In contrast, research on To elaborate, dialogical contexts about CSA for children adult populations largely favors the use of qualitative interview and youth can provide opportunities for discussion that may methods for retrospective inquiry producing important process facilitate disclosures (Jensen et al., 2005). The research shows findings. In addition, investigations have not yet captured the creating open dialogue in relationship contexts, to offset the disclosure experiences of adults in the "emerging adult" stage power and influence of the perpetrator, can facilitate earlier given that adult studies have failed to recognized that the age disclosure. Among disclosure facilitators is being asked about range of 18-24, which is now considered a developmental abuse and given the opportunity to "tell" (McElavaney et al., phase defined by neurobiological developmental uniqueness. 2014); workshops on abuse and sexual abuse, in particular, can As well, late adulthood has not been given attention as shown facilitate disclosures (Ungar et al., 2009b); and using culturally by the absence of participants representing this age-group in sensitive probes and questions (Fontes & Plummer, 2010). In current research (70+). With a swelling geriatric population in Gagnier and Collin-Vezina's (2016) study, positive disclosure North America, issues of historic CSA can be expected to experiences were described by participants as those where they surface and, with that, new disclosures. This trend is also antici- felt that they had been listened to, were safe, were believed, and pated due to attitudinal shifts that have presumably occurred were not judged by the person they disclosed to. Further, family over the last two generations about revealing such traumas and members and friends (peers) of the child victim can act as key changing views about discussing sexual victimization. supports to creating an open relational context and fostering Interview guides used in a number of studies intentionally positive responses (Jensen et al., 2005; Priebe & Svedin, 2008; probed for facilitators, producing notable findings. For exam- Schonbucher et al., 2012; Ungar et al., 20096). In particular, as ple, one such finding focuses on the importance of creating a children grow older, they are more likely to disclose to a peer, contextually supportive environment to promote disclosure as shown in a number of studies, and this is an important reality across the life course. These include developing therapeutic for counselors and educators to be aware of (Dumont et al., relational contexts for disclosure by providing information 2014; Kogan, 2004; Sclainbucher et al., 2012; Ungar et al., about sexuality, sexual abuse, prevention programming, and 2009b). by asking directly. Disclosures to professionals are positive outcomes of how therapeutic contexts work; however, for for- ensic purposes prompting such disclosures would be viewed as Discussion problematic in legal settings, seriously compromising testimo- Through examination of 33 studies published since the year nies for trial proceedings. This is one example that speaks to the 2000, this review identified five distinct themes regarding CSA structural barriers victims and survivors run up against time and disclosure: (1) Disclosure is best viewed as an iterative, time again. Facilitators that show evidence to promote disclo- interactive process rather than a discrete event done within sure in one domain (therapeutic) are seen to work against CSA a relational context; (2) contemporary models reflect a survivors in another domain—such as legal settings when per- social—ecological, person-in-environment framework for petrators face prosecution. Defense attorneys will use this as understanding the complex interplay of individual, familial, evidence that the disclosure was prompted, and therefore the contextual, and cultural factors involved in CSA disclosure; disclosure is potentially seen as not credible. Broadcasting of EFTA00024196 Alaggia et al. 281 the frequency of acquitted cases or rulings in favor of the survivors continue to be systemically and structurally perpetrator through media outlets, often sensationalized, disadvantaged in legal proceedings. become a further compounding barrier. Given the review find- • Health-care practitioners (i.e., child abuse pediatricians, ings, we conclude that barriers and facilitators to CSA disclo- family practice doctors, clinical nurse specialists, and sures are nuanced and clearly embedded within intrapersonal, public health nurses) should be made aware of the evi- interpersonal, environmental, contextual, and cultural dence in the CSA disclosure literature to create environ- domains—often interlocked in complex ways. ments for facilitating therapeutic disclosures. • Given that age is a stable predictor ofdisclosure of CSA, more studies are needed that make use of a life-course Limitations perspective. More longitudinal studies are needed to better identify trends over different life stages. Although comprehensive in nature with its life-course cover- • The emerging young adult as a developmental age group age, this review may be limited by its qualitative, thematic needs specific investigation. Neuroscience research has focus rather than providing an evaluative, quantitative account- established that ages 18-24 is a distinct developmental ing of CSA disclosures. However, because of the recent focus phase. Late adulthood is another life stage that deserves on disclosure processes, the authors chose a suitably compati- to be researched. ble approach—qualitative in nature. As well, a traditional • Gender needs to be more fully investigated in relation to checklist approach in rating the studies was not employed for impact on disclosure. Awareness that boys and girls interrater reliability, since two of the authors hold expertise in have unique challenges and barriers in disclosing CSA CSA disclosure research and are well versed with the literature. should be paramount for practitioners. This expertise, and through closely following a systematic • Intervention planning should take note that disclosures review framework (Kiteley & Stogdon, 2014), assures that a increase when perpetrators no longer reside with vic- thorough adjudication of the research literature was completed. tims, and this finding should be heeded by policy and law makers. • Shame, self-blame, and fear are intrapersonal factors Implications for Research and Practice that persistently emerge as barriers to CSA disclosures These review findings have implications that can be useful in and warrant more research to understand how to redress guiding future research and practice: these barriers for earlier disclosures. • Solid strides are being made in the use of a social—eco- Conclusion logical framework to underpin investigations in the CSA disclosure investigations. Research efforts and practice There are still a substantial number of children and youth considerations should continue in this vein. Investigat- who are subjected to sexual abuse, despite preventative ing environmental factors and contextual and cultural efforts. Just as concerning is the fact that many victims forces is understudied, necessitating more research in continue to suffer in silence as evidenced by the high num- these areas to more fully fill out understanding of CSA bers of delayed disclosure. These hidden cases should not be disclosure from a social—ecological perspective. overlooked, and these victims should not be forgotten. • There is good evidence that CSA disclosures are more Despite significant progress in bringing the issue of CSA likely to occur in a dialogical context—formal helping to the forefront, improving facilitation of disclosure and relationships but as well as other relationships such as increasing positive influences on disclosure processes are peers and trusted adults. Providing information and edu- still critical in order to protect current and future genera- cation on topics of sexuality in general, and sexual abuse tions of children and youth from the grave effects of sexual specifically, can help children and youth to disclose. violence. Further, the focus should not be simply on Raising awareness and prevention programs can pro- strengthening and shoring up intrapersonal resources of vic- mote disclosures of sexual violence committed against tims to disclose but rather to change environmental condi- children and youth. tions to create a more supportive and safer context for CSA • Goals of therapeutically supported disclosures (i.e., victims and survivors to disclose. through therapy) may need to take precedence over for- ensic approaches, if well-being of child victims and Declaration of Conflicting Interests adult survivors is to be made paramount. Legal pro- The author(s) declared no potential conflicts of interest with cesses may act to facilitate disclosures but can also act respect to the research, authorship, and/or publication of this as barriers because of the negative outcomes experi- article. enced in the court process. • Practitioners need to keep in mind that the legal system Funding is lagging far behind in knowledge uptake of recent The author(s) received no financial support for the research. author evidence on CSA disclosures so that victims and ship, and/or publication of this article. EFTA00024197 282 TRAUMA, VIOLENCE, & ABUSE 20(2) References Gagnier, C., & Collin Vezina, D. (2016). The disclosure experiences Alaggia, R. (2004). Many ways of telling: Expanding conceptualiza of male child sexual abuse survivors. Journal of Child Sexual tions of child sexual abuse disclosure. Child Abuse & Neglect, 28, Abuse, 25, 221 241. 1213 1227. Goodman Brown, T. B., Edelstein, R. S., Goodman, G. S., Jones, Alaggia, R. (2005). Disclosing the trauma of child sexual abuse: A D., & Gordon, D. S. (2003). Why children tell: A model of gender analysis. Journal ofLoss and Trauma, 10, 453 470. children's disclosure of sexual abuse. Child Abuse & Neglect, Alaggia, R. (2010). An ecological analysis of child sexual abuse dis 27, 525 540. closure: Considerations for child and adolescent mental health. When, M., Tourigny, M., Cyr, M., McDuff, P., & Joly, J. (2009). Journal of the Canadian Academy of Child and Adolescent Psy Prevalence of childhood sexual abuse and timing of disclosure in a chiatty Journal De ?Academie Canadienne De Psychiatric De representative sample of adults from Quebec. Canadian Journal of ?Enfant Et De ?Adolescent, 19, 32 39. Psychiatry, 54, 631 636. Retrieved from http://search.proquest. Alaggia, It., & Kirshenbaum, S. (2005). Speaking the unspeakable: com/docview/222860811?accountid= 14771 Exploring the impact of family dynamics on child sexual abuse Hershkowitz, I., Horowitz, D., & Lamb, M. E. (2005). Trends in disclosures. Families in Society, 86, 227 234. children's disclosure of abuse in Israel: A national study. Child Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Abuse & Neglect, 29, 1203 1214. Qualitative Research in Psychology, 3, 93. doi:10.1191/ Hershkowitz, 1., Lanes, O., & Lamb, M. E. (2007). Exploring the 1478088706qp063oa disclosure of child sexual abuse with alleged victims and their Brannon, J. F. (2015). The secret storm: Exploring the disclosure parents. Child Abuse & Neglect, 31, III 123. process of African American women survivors of child sexual Hunter, S. V. (2011). Disclosure of child sexual abuse as a life long abuse across the life course. Traumatology: An International Jour process: Implications for health professionals. The Australian and nal, 21, 181 187. New Zealand Journal ofFamily Therapy, 32, 159 172. Browning, C. R., & Laumann, E. O. (1997). Sexual contact between Jensen, T. K_, Gulbrandsen, W., Mossige, S., Reichelt, S., & Tjersland, children and adults: A life course perspective. American Socio O. A. (2005). Reporting possible sexual abuse: A qualitative study logical Review, 62, 540 560. on children's perspectives and the context for disclosure. Child Collings, S. J., Griffiths, S., & Kuntalo, M. (2005). Patterns of disclo Abuse & Neglect, 29, 1395 1413. sure in child sexual abuse. South African Journal ofPsychology, Jillian, B., Cotter, A., & Perreault, S. (2014). Police reported crime 35,270 285. statistics in Canada, 2013 (Catalogue number 85 002 X). Ottawa, Collin Vezina, D., Sablonni, D. L., Palmer, A. M., & Milne, L. (2015). ON: Statistics Canada. A preliminary mapping of individual, relational, and social factors Jones, D. P. H. (2000). Editorial: Disclosure of child sexual abuse. that impede disclosure of childhood sexual abuse. Child Abuse & Child Abuse & Neglect, 24, 269 271. Neglect, 43, 123 134. doi:10.10160.chiabu.2015.03.010 Jonzon, E., & Lindbald, F. (2004). Disclosure, reactions, and social Crisma, M., Bascelli, E., Paci, D., & Romito, P. (2004). Adolescents support: Findings from a sample of adult victims of child sexual who experienced sexual abuse: Fears, needs and impediments to abuse. Child Maltreatment, 9, 190 200. disclosure. Child Abuse & Neglect, 28, 1035 1048. Kiteley, It., & Stogdon, C. (2014). Literature reviews in social murk. Dumont, M., Messerscluniu, P., Vila, G., Bohu, D., & Rey Salmon, C. London, England: Sage. (2014). Is processus de revelation dans les agressions sexuelles Kogan, S. (2004). Disclosing unwanted sexual experiences: Results intrafamiliales et extrafamiliales sur mineurs. Annales Medico from a national sample of adolescent women. Child Abuse & Psychologiques, 172, 426 431. doi:10.1016/j.amp.2012.06.024 Neglect, 28, 147 165. Easton, S. D. (2013). Disclosure of child sexual abuse among adult Leclerc, B., & Wortley, It. (2015). Predictors of victim disclosure in male survivors. ClinicalSocial Work Journal,41,344 355. doi:10. child sexual abuse: Additional evidence from a sample of incar 1007/s10615 012 0420 3 cerated adult sex offenders. Child Abuse & Neglect, 43, 104 Ill. Easton, S. D., Saltzman, L. Y., & Willis,D. G. (2014). "Would you tell London, K., Bruck, M., Ceci, S. J., & Shuman, D. W. (2005). Disclo under circumstances like that?": Barriers to disclosure of child sure ofchild sexual abuse: What does the research tell us about the sexual abuse for men. Psychology of Men & Masculinity, 15, ways that children tell? Psychology, Public Policy, and Law, 11, 460 469. 194 226. Fallon, B., Van Wert, M., Troeme, N., MacLaurin, B., Sinha, V., McElvaney, R. (2015). Disclosure of child sexual abuse: Delays, Lefebvre, R., ... Goel, S. (2015). Ontario Incidence Study of non disclosure and partial Disclosure. What the research tells Reported Child Abuse and Neglect 2013 (OIS 2013). Toronto, us and implications for practice. Child Abuse Review, 24, ON: Child Welfare Research Portal. 159 169. Finkelhor, D., Shattuck, A., Turner, FL A., & Ilamby, S. L. (2014). McElvaney, R., & Culhane, M. (2015). A retrospective analysis of Trends in children's exposure to violence, 2003 to 2011. JAMA children's assessment reports: What helps children tell? Child Pediatrics, 168, 540 546. doi:10.1001/jamapediatrics.2013.5296 Abuse Review. doi:10.1002/car.2390. Fontes, L. A., & Plummer, C. (2010). Cultural issues in disclosures McElvaney, It., Greene, S., & Hogan, D. (2012). Containing the secret of child sexual abuse. Journal of Child Sexual Abuse, 19, of child sexual abuse. Journal of Interpersonal Violence, 27, 491 518. 1155 1175. EFTA00024198 Alaggia et al. 283 McElvaney, R., Greene, S., & Hogan, D. (2014). To tell or not to tell? Stoltenborgh, M., van Uzendoom, M. II., Fuser, E. M., & Balcemtans Factors influencing young people's informal disclosures of child Kranenburg, M. (2011). A global perspective on child sexual sexual abuse. Journal ofInterpersonal Violence, 29, 928 947. abuse: Meta analysis of prevalence around the world. Child Mal Maier, T., Mohler Kuo, M., Landholt, M. A., Schnyder, U., & Jud, A. treatment, 16, 79 101. doi:10.1177/1077559511403920 (2013). The tip of the iceberg. Incidence of disclosed cases ofchild Summit, R. C. (1983). The sexual abuse accommodation syndrome. sexual abuse in Switzerland: Results from a Nationwide Agency Child Abuse & Neglect, 7, 177 193. Survey. International Journal ofPublic Health, 58, 875 883. Tener, D., & Murphy, S. (2015). Adult disclosure of child sexual Paine, M. L., & Hansen, D. J. (2002). Factors influencing children to abuse. Trauma, Violence & Abuse, 16, 391 400. self disclose sexual abuse. Clinical Psychology Review, 22, Trocme, N., Fallon, B., MacLaurin, B., Daciuk, J., Felstiner, C., Black, 271 295. doi:10.1016/S0272 7358(01)00091 5 T., ... Cloutier, R. (2005). Canadian incidence study of reported Pereda, N., Guilera, G., Fonts, M., & Gomez Benito, J. (2009). The child abuse and neglect 2003: Major findings. Ottawa: Minister international epidemiology of child sexual abuse: A continuation of Public Works and Government Services Canada. of Finkelhor (1994). Child Abuse & Neglect, 33, 331. Retrieved Trocme, N., Fallon, B., MacLaurin, B., Sinha, V., Black, T., Fast, from http://search.proquest.com/docview/230158315? E., ... Holroyd, J. (2008). Characteristics of substantiated accountid= 14771 maltreatment. Canadian incidence study of reported child abuse Priebe, G., & Svedin, C. G. (2008). Child sexual abuse is largely and neglect: Major findings (Chapter 4). Retrieved from http:// hidden front the adult society: An epidemiological study of ado www.phac aspc.gc.ca/cm vee/public eng.php lescents' disclosures. Child Abuse & Neglect, 32, 1095 1108. Ungar, M., Baxter, K., McConnell, S. M., Tutty, L. M., & Fairholm, J. Reitsema, A. M., & Grietens, II. (2015). Is anybody listening? The (2009a). Patterns of abuse disclosure among youth. Qualitative literature on the dialogical process ofchild sexual abuse disclosure Social Work, 8, 341 356. reviewed. Trauma Violence Abuse. doi:10.1177/152483801 Ungar, M., Tutty, L. M., McConnell, S., Barer, K., & Fairholm, J. 5584368 (2009b). What Canadian youth tell us about disclosing abuse. Rosenthal, G., & Fisher Rosenthal, W. (2004). The analysis of narra Child Abuse & Neglect, 33, 699 708. tive biographical interviews in U Flick. In E. von Kardorff & I. Williams, L. M. (2003). Understanding child abuse and violence Steinke (Eds.), A Companion to Qualitative Research (pp. against women: A life course perspective. Journal ofInterpersonal 259 265). London, UK: Sage. Violence, 18,441 451. Schaeffer, P., Leventhal, J. M., & Asnes, A. G. (2011). Children's disclosures of sexual abuse: Learning from direct inquiry. Child Abuse & Neglect, 35, 343 352. doi:10.1016/j.chiabu.2011.01.014 Author Biographies Schtinbucher, V., Maier, T., Molder Kuo, M., Schnyder, U., & Land olt, M. A. (2012). Disclosure of child sexual abuse by adolescents: Ramona Alaggia, MSW, PhD, is an associate professor in social work A qualitative in depth study. Journal of Interpersonal Violence, and the Factor Inwentash Chair in Children's Mental Health at the 27, 3486 3513. doi:10.1177/0886260512445380 University of Toronto. Iler teaching and research focuses on gender Smith, D. W., Letoumeau, E. J., Saunders, B. E., Kilpatrick, D. G., and violence, sexual abuse disclosures, domestic violence exposure, and resilience processes. Resnick, H. S., & Best, C. L. (2000). Delay in disclosure of child hood rape: Results from a national survey. ChildAbuse & Neglect, Delphine Collin-Vezina, PhD, is an associate professor for School of 24,273 287. Retrieved from http://search.proquest.com/docview/ Social Work, McGill University and director for Centre for Research 70933344?accountid= 14771 on Children and Families. She holds the Nicolas Steinmetz and Gilles Sorsoli, L., Kia Keating, M., & Grossman, F. K. (2008). "I keep that Julien Chair in Social Pediatrics in Community and the Canada hush hush": Male survivors of sexual abuse and the challenges of Research Chair (Tier II) in Child Welfare. Her work focuses on disclosure. Journal of Counseling Psychology, 55, 333 345. doi: research and clinical topics related to child maltreatment, child sexual 10.1037/0022 0167.55.3.333 abuse, and trauma. Seller, K. M., & Nelson Gardell, D. (2005). "A burden in your heap": Rusan Lateef, MSW, is a social worker employed in the criminal Lessons of disclosure from female preadolescent and adolescent justice system with adult male offenders in Ontario, Canada. She survivors of sexual abuse. ChildAbuse & Neglect, 29, 1415 1432. specializes in the intersection of health and mental health, child sexual Statistics Canada. (2013). Police reported crime statistics in Canada. abuse disclosures, and she is a researcher on the "Make Resilience 2012 (Catalogue number 85 002 X). Retrieved from the Statistics Matter" project examining childhood exposure to domestic violence Canada website httplAvww.statcan.gc.ca/pub/85 002 x/2013001/ with Dr. Alaggia at the Factor Inwentash Faculty of Social Work, article/11854 eng.htm#n2 University of Toronto. EFTA00024199 Child Abuse Review Vol. 24: 159-169 (2015) Published online 9 May 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2280 Disclosure of Child Rosaleen McElvaney School of Nursing and Human Sexual Abuse: Delays, Sciences. Dublin City University, Dublin. Ireland Non-disclosure and Partial Disclosure. What the Research Tells Us and Implications for Practice This paper reviews the research on disclosure of child sexual abuse with specific reference to delays in disclosing, non-disclosure and partial disclosure of experiences of child sexual abuse. Findings from large-scale national probability studies highlight the prevalence of both non-disclosure and delays in disclosure, while findings from small-scale qualitative studies portray the complexity, diversity and individuality of experiences. The possible explanations regarding why children are reluctant to disclose such experiences have significant implications for addressing the issue of child sexual abuse from the perspectives of child protection, legal and therapeutic professionals. The importance of understanding `The importance of the dynamics of disclosure, in particular the needs of young people to maintain control over the disclosure process, the important role that peers play in this process, the responses understanding the of adults in both informal and formal networks, and the opportunities to tell, is key to dynamics of helping young people speak more promptly about their experiences of sexual abuse. Copyright O 2013 John Wiley & Sons, Ltd. disclosure' KEY PRACTITIONER MESSAGES: • Children typically delay disclosing experiences of abuse. • Asking children questions about their wellbeing gives them the opportunity to tell when they are ready. • The challenge is to find the right questions at the right time. • Peers can be the right people to ask these questions. • Adolescents need to know about how to ask and what to do if someone tells. 'Adolescents need to know about how to KEY WORDS: child sex abuse; disclosure; research to practice ask and what to do if someone tells' A n issue of increasing concern in recent years is the phenomenon of delayed disclosure of childhood sexual abuse and the need to understand the process of how children and adults disclose their experiences of child sexual abuse, given the implications for child protection, social justice and •Correspondence to: Rosaleen McElvaney. School of Nursing and Human Sciences. Dublin City University. Glasnevin, Dublin 9. Ireland. E-mail: rosaleen.mcelvaneygdcu.ie Copyright © 2013 John Wiley & Sons, Ltd. Accepted: 17 February 2013 EFTA00024200 160 McElvaney mental health outcomes. This paper reviews the research on disclosure patterns `This paper reviews of childhood sexual abuse, specifically delays in disclosure, non-disclosure the research on (as evident through adult retrospective studies) and partial disclosures, and discusses implications for practice. Literature searches of the online databases disclosure patterns of PSYCINFO and Social Sciences Citation Index, in addition to manual searches childhood sexual of texts published since 2000, were conducted using the search terms 'child abuse' sexual abuse', 'sex abuse' and 'disclosure'. The research to date on disclosure patterns is based on two sampling methodologies — studies of adults reporting retrospective experiences and studies of children. The former group of studies has the benefit of drawing on large-scale national probability samples which can be considered to be representative of the general population. The latter group with some small exceptions (predominantly adolescent studies) uses samples of young people who have disclosed sexual abuse but would not be considered as representative of all children who have been abused: 'children who decide to tell someone about being sexually abused and whose cases therefore come to court are not representative of sexually abused children in general' (Olafson and Lederman, 2006, p. 29). Patterns of Disclosure: Delays and Non-disclosure There is consensus in the research literature that most people who experience 'Most people who sexual abuse in childhood do not disclose this abuse until adulthood, and when experience sexual disclosure does occur in childhood, significant delays are common. Table 1 summarises two large-scale studies to highlight the extent of delays in disclosure abuse in childhood do and the percentage of those who did not disclose to anyone prior to the study. not disclose this Kogan (2004) examined the timing of disclosure of unwanted sexual abuse until adulthood' experiences in childhood or adolescence in a sub-sample (n = 263 adolescent women, aged 12 to 17) of the National Survey of Adolescents (Kilpatrick and Saunders, 1995) in the USA — a nationally representative study. Kogan's results can be summarised as follows: immediate disclosure (within 1 month) 43 per cent, delayed disclosure (less than 1 year) 31 per cent and non-disclosure (disclosed only during the survey) 26 per cent. Smith and colleagues (2000) examined a sub-sample (n = 288) of the National Women's Study in the USA (Resnick a al., 1993, cited in Smith et at, 2000) who had reported a childhood rape prior to the age of 18. Smith el al.'s findings can be summarised as follows: immediate disclosure (within 1 month) 27 per cent, delayed disclosure (more than a year) 58 per cent and non-disclosure (survey only) 28 per cent. Those who had never disclosed prior to the survey constitute comparable proportions in these two studies while the rates for immediate Table I. Panerns of disclosure delay and non-disclosure Kogan (2004) Smith a a). (2000) (n 263 adolescents) (n 288 adults) Told within 24 hours 24% 18% Told within 1 month 19% 9% Told within 1 year 12% 11% Delayed telling more than I year 19% 47% Never told before survey 26% 28% Copyright 0 2013 John Wiley & Sons, Ltd. Chid Abuse Rev. Vol. 24: 159 169 (2015) DOt 10.1002/ear EFTA00024201 Disclosure Patterns in Child Sexual Abuse 161 disclosure are higher in the adolescent study than in the adult study, a The rates for reassuring finding given the increased awareness of sexual abuse in society during the past 20 years. immediate disclosure Goodman-Brown and colleagues (2003) examined USA district attorney are lower in the files of 218 children. Their categories were slightly different from the previous adolescent study than two studies but in summary, immediate disclosers (within 1 month) constituted in the adult study' 64 per cent of the sample while 29 per cent disclosed within six months. This study is unusual insofar as the sample studied had reported their experience of abuse to the authorities and a prosecution was in progress. Goodman-Brown et at also pointed out that families who participated in this study were more likely to represent those children who experienced abuse by someone outside the family. Research has found that delays in disclosure are longer for those abused within the family (Sjoberg and Lindblad, 2002; Goodman-Brown et at, 2003; Kogan, 2004; Hershkowitz a at, 2005). Therefore, children who disclose more promptly may be overrepresented in legal samples. 'Children who disclose In Sweden, Priebe and Svedin (2008) conducted a national survey of 4339 more promptly may be adolescents, of whom 1962 reported some form of sexual abuse (65% of girls and 23% of boys). Details of the time lapse in disclosing were not available overrepresented in from this study. However, of those who had disclosed and answered the legal samples' questions on disclosure (n = 1493), 59.5 per cent had told no-one of their experiences prior to the survey. Of those who did disclose, 80.5 per cent mentioned a 'friend of my own age' as the only person who they had told. In this study, 6.8 per cent had reported their experiences to the social authorities or police. A further Swedish study of 122 women who had experienced childhood sexual abuse (Jonson and Lindblad, 2004) found that 32 per cent disclosed during childhood (before the age of 18) while the majority told in adulthood (68%). The delay was up to 49 years, with an average of 21 years (SD = 12.9). Of those who told in childhood, 59 per cent told only one person. In Ireland, the SAVI study (n = 3118, McGee et al., 2002) found that 47 per cent of those respondents who had experienced some form of sexual assault prior to age 17 had told no-one of this experience until the survey. McElvaney (2002) investigated delay in a legal sample of ten adults who had made formal complaints of childhood sexual abuse in Ireland and found delays ranging from 20 years to 50 years. `Delays ranging from Studies of children in the context of forensic/investigative interviews 20 years to 50 years' where children are interviewed by professionals due to concerns that the child has been sexually abused also point to high non-disclosure rates, particularly striking in cases where there is corroborative evidence that abuse has occurred — medical evidence (Lyon, 2007), or confessions from the abuser or videotaped evidence/witness reports (Sjoberg and Lindblad, 2002). Lyon (2007) reported his findings from a review of studies published between 1965 and 1993 of children diagnosed with gonorrhoea where the average disclosure rate among 579 children was 43 per cent (n = 250). In a study where the evidence for the abuse was available on videotape, children have denied abuse when interviewed by the police (Sjoberg and Lindblad, 2002). In summary, significant numbers of children do not disclose experiences of sexual abuse until adulthood and adult survey results suggest that significant Copyright ID 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOE 10.1002/car EFTA00024202 162 McElvaney proportions of adults have never disclosed such abuse, as evidenced by the `High numbers of high numbers of respondents disclosing to researchers for the first time. respondents Patterns of Disclosure — Partial Disclosure disclosing to researchers for the Information on how children disclose over time can be obtained from studies of children who participated in forensic/investigative interviews where first time' children are interviewed by professionals due to concerns that the child has been sexually abused. The issue of partial disclosures was highlighted by earlier studies such as those by DeVoe and Faller (1999) of five- to ten-year olds (i.e. making detailed informal disclosures that were not replicated in formal interviews) and Elliott and Briere (1994) of children aged eight to 15 years (i.e. disclosing only partial information until confronted with external evidence that led to more complete disclosures). More recently, investigators have examined the role of the interviewer and questioning styles in the forensic interview and how this impacts on children's disclosures and the level of detail provided in interview. Hershkowitz et at (2006) compared tapes of interviews with children who disclosed sexual abuse and those who did not (but about whom there was `substantial' reason to believe that they had been abused). They found that interviewers behaved `They found that differently with the two groups, using different types of prompts with children interviewers behaved who presented as somewhat uncooperative, offered fewer details and gave more uninformative responses at the beginning of the interview. It would differently with the appear that interviewers responded to less communicative children by two groups' increasing the proportion of closed questions which in turn led to children being less forthcoming. Lamb el al. (2002) have found that the use of a protocol that emphasises the use of prompts that elicit free narrative (e.g. 'tell me about that') as compared with closed questions (those requiring a yes/no response) has resulted in more detail and more accuracy in children's accounts. Although few studies exist that examine the phenomenon of disclosure in informal settings (when disclosure is made to a friend or family member), some qualitative studies have described this process. McElvaney (2008) quoted one teenage girl who described hinting to her mother prior to disclosing the experience: 'I didn't tell her what happened but I was saying things that made 'A parent described her think it made her think that it happened but I didn't tell her' (p. 127). A how her teenage son parent described how her teenage son told her over a period of days, keeping the most difficult parts of the story until last: told her over a period of days' 'Ile came out with like it came out over two or three days so you know.. _he'd say well I've something else to tell you... the bad stuff last... what hun him most and what he's saying what hurt him most' (p. 92) And finally, one young person described how she told her social worker: 'I couldn't tell her most things but I just gave things to her to read... I told her at first I told her bits of it and em then just the others. I finished writing and then I gave them to her... later I told her that it was the father as well.' (p. 93) This young person had been abused by both a father and son in a family with whom she was staying. Copyright O 2013 John Wiley & Sons, Ltd. Chid Abuse Rev. Vol. 24: 159 169 (2015) 10.1002/ear EFTA00024203 Disclosure Patterns in Child Sexual Abuse 163 In reviewing the literature on this subject, London and colleagues (2005) noted, `when children do disclose, it often takes them a long time to do so' "When children do (p. 204). disclose, it often takes them a long time to do Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure so" There are many influences on disclosure that have been identified in the research literature to help explain why it is that children delay disclosure, are reluctant to disclose, provide details of their experiences over time or do not disclose at all. Age has been identified as a significant predictor of disclosure in that younger children are less likely to disclose than older children. Children `Younger children are who are abused by a family member are less likely to disclose and more likely less likely to disclose to delay disclosure than those abused by someone outside the family (Smith than older children' a at, 2000; Goodman-Brown a at, 2003; Kogan, 2004). Children who do disclose during forensic interviews compared to children who do not disclose in such contexts (yet concerns remain that they have been abused) are more likely to have parents (particularly mothers) who are more supportive (Lawson and Chaffin, 1992). In Priebe and Svedin's (2008) study of young people, parental bonding (positive relationship with parent who was not overprotective) was identified as the most significant predictor of disclosure for both boys and girls. However, close relationships can also act as an inhibitor to disclosure. McElvaney (2008) found that many young people in her study were reluctant `Many young people to disclose due to concerns ofupsetting their parents while others were concerned in her study were about the consequences for others of their disclosure. One 13-year-old girl described her concern that if she told, her uncle would go to jail and her small reluctant to disclose cousins would be left without a father: due to concerns of upsetting their 'I didn't want them to grow up with no Dad and just looking at ... their other little friends having their Dad holding their hand I felt like I was taking their Dad away from them' (p. 130) parents' Gender has been found to influence disclosure in that boys appear to be more reluctant to disclose than girls (Goodman-Brown a at, 2003; Hershkowitz a at, 2005; Ungar a al., 2009a). Mental health difficulties on the part of the child have also been found to be relevant, particularly when children experience dissociative symptoms or other post-traumatic stress symptomatology (Priebe and Svedin, 2008). Some studies have found that the severity of abuse (e.g. penetrative abuse) predicts earlier disclosure while other studies have found no relationship between different types ofabuse and disclosure timing. Similarly, the relationship between the duration of abuse — one-off incidents of abuse compared with abuse that takes place over a significant period of time — and timely disclosure has been investigated with mixed findings. Fear of the consequences ofdisclosure has been `Fear of the identified as a predictor of delayed disclosure and this in turn is associated with consequences of the age of the child (Goodman-Brown a at, 2003). Older children are more cognitively competent in terms ofbeing able to reflect on and anticipate possible disclosure has been reactions to their disclosure. This can act then as an inhibitor to disclosure, identified as a although as noted above, most studies have found that older children are more predictor of delayed likely to disclose than younger children. Fears of not being believed have been disclosure' described by young people as inhibiting their disclosure and these fears are often Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024204 164 McElvaney justified. Hershkowitz a at (2007) interviewed children about their initial disclosures prior to formal interview and 50 per cent of the sample (n = 30) reported feeling afraid or ashamed of their parents' reaction. The authors reported that parents did show a tendency to blame their children and react angrily to the disclosure. Recent research has highlighted the need for children to be asked direct questions to facilitate their disclosure. Of those children who did disclose, significant proportions disclosed following prompts rather than it being initiated by the child (Kogan, 2004). Qualitative studies drawing on interviews with children that focus on the disclosure process are important in `Investigating the investigating the precise circumstances that led to disclosures for children. precise McElvaney (2008) found that parents' questioning of children was prompted by their concern about the young person's emotional distress. On occasion, circumstances that young people were communicating that something was not right in their world led to disclosures for but were not able to articulate this verbally. Signs of psychological distress children' were, however, evident and questions targeted at the reasons for this distress were identified by McElvaney as a factor that helped young people to tell. Thus, many children may not have told about their experiences of abuse because they were not asked. McGee a al. (2002) followed up a sample of their respondents who had disclosed childhood abuse for the first time in their survey. When asked why they had not disclosed prior to the survey, many respondents noted that it was because they had not been asked. Increasingly, `Significant research studies are finding that significant proportions of disclosure have proportions of been prompted by questions by caregivers, friends or others in the child's disclosure have been educational and social milieu that in themselves provide an opportunity for the young person to tell (Jensen et at, 2005; Hershkowitz a at, 2007; prompted by McElvaney et al., 2012). questions by Finally, some children need time to tell. Mudaly and Goddard (2006) quote caregivers, friends or a 13-year-old girl: `she (mother) helped by not making me, not rushing me to get it out, which, um, I think it's a really stupid idea to make kids get it others' out A.S.A.P.' (p. 91). Implications for Practice The consensus in the research literature at the present time is that disclosure is multi-determined, influenced by a complex range of factors that may influence each child in a different way. Large-scale national probability studies confirm that non-disclosure and delays in disclosure are significant problems facing society and in particular for those professionals tasked with safeguarding the wellbeing of children. Children's fears and anxieties in relation to telling need to be understood and contained by those in their environment so that early disclosure can be encouraged and facilitated. `The implications of The implications of these findings can be considered in interrelated these findings can be contexts: the legal context where action can only be taken if the child is able to give a clear, credible account of his/her experiences; child protection and considered in therapeutic contexts where a comprehensive account is required to enable child interrelated contexts' protection professionals to intervene and where the psychological sequelae can be addressed to minimise the long-term impact of the experiences; and family and community contexts where early disclosure needs to be encouraged, and Copyright O 2013 John Wiley & Sons, Ltd. Chid Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/ear EFTA00024205 Disclosure Patterns in Child Sexual Abuse 165 other family issues addressed in the aftermath of disclosure and where peers play an important role. Studies have confirmed the importance of professionals asking children and young people in a sensitive, open manner about possible experiences of abuse using non-leading questioning styles to minimise inaccurate accounts or contaminate children's narratives. It is clearly important for professionals to remain open to the possibility of abuse and further disclosure. It is equally important for professionals to be able to avoid persisting with questioning those children who are 'reluctant disclosers'. Similarly, professionals engaged with children in therapeutic work need to be open to the possibility of both initial and further disclosures. Contradiction in witness statements is a well-known feature of false statements 'Contradiction in and giving additional detail to original formal statements can be interpreted witness statements is within child protection, therapeutic and legal contexts as a contradiction of an earlier account. Listening to children's accounts of their experiences of disclosure a well-known feature helps us understand why it is that disclosure can be delayed and that when they do of false statements' feel ready to tell this is not an 'all or nothing' decision. As one young person in Staller and Nelson-Gardell's (2005) study noted, 'it's never finished, never' p. 1426. This understanding in turn helps us identify those circumstances and reactions that may encourage the child to disclose. The importance of asking children questions, thus giving them an opportunity to tell, has been identified. While parents, teachers and those in daily contact with children are often reluctant to question children, it is clear that many children do not disclose unless given this opportunity. Education 'Education and and increased awareness are needed on how to question children in an increased awareness appropriate manner. McElvaney (2008) noted that questions did not need to be about sexual abuse per se, but rather questions prompted by the young are needed on how to person's psychological distress, asking after the young people's wellbeing. question children in This questioning in effect acted as an external pressure for the young person an appropriate to tell his/her secret (McElvaney et al., 2012). In Ungar el at's (2009a) study manner' of Canadian youth, they found that young people used a range of disclosure strategies ranging from less direct strategies (such as risk-taking behaviours, not talking about the abuse) to direct strategies (such as seeking support from peers, turning to non-professional adult supports, disclosing to formal service providers), representing a process that relied heavily on others to 'build the bridges between the youth and formal care providers' (p. 352). The tendency to delay disclosing and the partial nature of many disclosures are not conducive to successful legal investigations and prosecutions. In addition, the knowledge base that exists within the legal sphere is limited if only a percentage of the children who experience sexual abuse engage with this system. The disproportionately high 'immediate disclosure' rate found in Goodman-Brown a al.'s (2003) legal sample compared to Kogan's (2004) community sample raises the question of the representation of delayed disclosers in the legal system. Are children who delay in disclosing less likely 'Are children who to engage with the legal system? Are delays in disclosing contributing to delay in disclosing decisions not to prosecute child sexual abuse crimes? In Ireland, the 1990s saw a significant increase in the numbers of complainants coming before the less likely to engage courts reporting experiences of childhood sexual abuse. Many of these cases with the legal system?' were referred to the higher courts for judicial review proceedings to establish whether the cases could proceed without prejudicing the accused given the Copyright 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024206 166 McElvaney delay in the complaint being made and giving due regard to the accused's right to a speedy trial. Psychological expert testimony was sought as part of these proceedings to explain the delay in disclosure in each individual case to enable the courts to adjudicate on whether the delay in reporting was reasonable (see McElvaney, 2002). This legal mechanism provided an opportunity to enhance the knowledge base within the legal profession as to the complexities involved in disclosing and formally reporting experiences ofchildhood sexual abuse for adults. While one might expect that the legal system would be more sympathetic to children's difficulties in making disclosures, it may also be the case that the belief that 'if the child was really sexually abused, why would they not tell?', as articulated by Summit (1983), still prevails. 'Concerns that In addition, concerns that engagement with the legal system will lead to further engagement with the psychological trauma need to be considered. A prospective longitudinal study conducted by Quas et al. (2005) indicated that the consequences of legal legal system will lead involvement change over the course of development and as a function of the to further child's reactions to and experiences during the legal case. The associations psychological trauma between legal involvement and outcomes varied with age. The authors suggested that although younger children may be at increased risk for some need to be considered' adverse outcomes such as mental health problems, older children may be at increased risk for other undesirable sequelae such as the negative attitudes of others toward them. Quas and Goodman's (2011) recent review notes that older children are more at risk in developing poor mental health outcomes. Thus, as noted earlier, young people's fears of the consequences of disclosure may well be justified. Raised awareness of both the prevalence of non-disclosure of sexual abuse and the importance of supporting children to disclose may go some way to addressing children's fears. 'Many young people One interesting finding in recent studies is that many young people who who delayed delayed disclosure to an adult had told a friend. McElvaney (2008) and Ungar et al. (2009b) identified peer influence as significant in encouraging disclosure disclosure to an adult among adolescents. There is some suggestion from the research that regardless had told a friend' of the age at the time of abuse, adolescence may be a 'critical period' for disclosure. It may be that targeting adolescents in general (rather than those at risk of abuse) may be a powerful prevention tool in encouraging early disclosure. Evaluations of child abuse prevention programmes have shown significant improvements in the levels of awareness of child abuse in children and young people (Rispers et al., 1997; Zwi el al., 2007). It may be that the increasing trend towards peer disclosure is a by-product of such educational and awareness-raising programmes. There is evidence that public awareness campaigns when implemented as part of a multi-dimensional strategy that involves targeting children, parents and communities (see Lalor and McElvaney, 2010, for a review of child abuse prevention programmes) are an effective tool in the prevention of child abuse. McElvaney et al. (2012) describe the importance for young people of containing the secret of abuse and their need for confidentiality following 'An adaptive strategy disclosure as representing an adaptive strategy on the part of the young person on the part of the to contain the experience and his/her emotional reaction to it. The conflict between wanting/needing to keep the secret and wanting/needing to tell is young person to mediated by what they term the 'pressure cooker effect'. Young people in their contain the experience' study described influences from within and without that led to a build up of pressure, ultimately leading to disclosure. They suggest that building up the Copyright (0 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) 10.1002/ear EFTA00024207 Disclosure Pattems in Child Sexual Abuse 167 pressure for young people by providing opportunities to tell may be needed to help young people tell more promptly. However, the lack of control that young people experience following disclosure remains an issue (Ungar et al., 2009b; Quayle a al., 2012). This highlights the need for dissemination of information directly to young people about the legal process, the possible consequences of disclosure, as well as ongoing developments in legal proceedings when young people and their families interface with the legal system. The more recent focus on investigating those strategies that children use in 'More recent focus on making disclosures rather than solely on identifying bathers to disclosure is investigating those perhaps more helpful in informing awareness-raising campaigns and professional interventions. The author is involved in a large-scale review of strategies that children's files in an assessment service to ascertain those factors that helped children use in children tell about their experiences of sexual abuse. A pilot study has making disclosures' suggested that this is an appropriate methodology for gathering data on children's experiences of informal disclosure, acknowledging the limitations of such an approach. Ungar a al. (2009a) describe the optimal conditions for disclosure as follows: being directly asked about experiences of abuse; having access to someone who will listen, believe and respond appropriately; having knowledge and language about what constitutes abuse and how to access help; having a sense of control over the process of disclosure both in terms of their 'Having a sense of anonymity (not being identified until they are ready for this) and confidentiality control over the (the right to control who knows); and effective responses by adults both in informal and formal contexts. process of disclosure Ungar etal. (2009b) support recent developments in prevention programmes both in terms of their that target supportive formal and informal caregivers in being better able to anonymity and detect the possibility of abuse and support disclosures rather than focusing on empowering children themselves in making disclosures. Their findings in confidentiality' relation to the importance of bridge building for young people to access formal supports are supported by Jensen et at's (2005) emphasis on the dialogical nature of disclosure, and the important role that trusted adults and peers play in the disclosure process through noticing signs of psychological distress and asking young people about their psychological wellbeing (Collings a al., 2005; Jensen et at, 2005; McElvaney et at, 2012). More emphasis is therefore needed on providing opportunities for children and young people to disclose. The challenge for professionals and those who care for children is how to do this in a way that protects children and promotes their wellbeing. References Collings SJ, Griffiths S, Kumalo M. 2005. Patterns of disclosure in child sexual abuse. South African Journal ofPsychology 35(2): 270 285. DeVoe ER, Faller KC. I 999.The characteristics of disclosure among children who may have been sexually abused. Child Maltreatment 4: 217 227. Elliott DM, Briere 1 1994. Forensic sexual abuse evaluations of older children: Disclosures and symptomatology. Behavioral Sciences & the Law 12: 261 277. Goodman Brown TB, Edelstein RS, Goodman GS, Jones DP14, Gordon DS. 2003. Why children tell: A model of children's disclosure of sexual abuse. Child Abuse & Neglect 27: 525 540. Hershkowitz I, Horowitz D, Lamb ME. 2005. Trends in children's disclosure of abuse in Israel: A national study. Child Abuse & Neglect 29(11): 1203 1214. Ilashkowitz I, O,bach Y, Lamb ME, Sternberg KJ, Ilorowitz D. 2006. Dynamics of forensic interviews with suspected abuse victims who do not disclose. ChildAbuse & Neglect 30: 753 769. Copyright 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024208 168 McElvaney llershkowitz I, Lanes O, Lamb ME. 2007. Exploring the disclosure of child sexual abuse with alleged victims and their parents. Child Abuse & Neglect 31: Ill 123. Jensen TK, Gulbrandsen W, Mossige S, Reichelt S, Tjersland OA. 2005. Reporting possible sexual abuse: A qualitative study on children's perspectives and the context for disclosure. Child Abuse ti Neglect 29(12): 1395 1413. Jonson E, Lindblad F. 2004. Disclosure, reactions and social support: Findings from a sample of adult victims of child sexual abuse. Child Maltreatment 9(2): 190 200. Kilpatrick DG, Saunders BE. 1995. The National Survey of Adolescents in the United States [Computer File]. Medical University of South Carolina [producer], 1999. Inter university Consortium for Political and Social Research [distributor], 2000: Ann Arbor, MI. Kogan SM. 2004. Disclosing unwanted sexual experiences: Results from a national sample of adolescent women. Child Abuse & Neglect 28: 147 165. Lalor K, McElvaney R. 2010. Child sexual abuse, links to later sexual exploitation/high risk sexual behavior, and prevention/treatment programs. Trauma, Violence & Abuse 11(4): 159 177. DOI: 10.1177/1524838010378299 Lamb ME, Orbach Y, Sternberg KJ, Esplin PW, Ilershkowitz I. 2002.The effects of forensic interview practices on the quality of information provided by alleged victims of child abuse. In Children's Testimony: A handbook of Psychological Research and Forensic Practice, Westen ILL, Davies GM, Bull R (eds). John Wiley & Sons Ltd: Chichester, England; 131 145. Lawson L, Chaffin, M. 1992. False negatives in sexual abuse disclosure interviews: Incidence and influence of caretaker's belief in abuse in cases ofaccidental abuse discovery by diagnosis of STD. Journal ofInterpersonal Violence 7(4): 532 542. London K, Bruck M, Ceci SJ, Shuman D. 2005. Disclosure ofchild sexual abuse: What does the research tell us about the ways that children tell? Psychologn Public Policy, and Law 11(1): 194 226. Lyon TD. 2007. False denials: Overcoming methodological biases in abuse disclosure research. In Child sexual abuse: Disclosure, delay and denial, M Pipe, M Lamb, Y Orbach, AC Cederborg (eds). Lawrence Erlbaum Associates: London; 41 62. McElvaney R. 2002. Delays in reporting childhood sexual abuse and implications for legal proceedings. In Sex and Violence: The Psychology of Crime and Risk Assessment, Farrington DP, Hollin CR, McMurran M (eds). Routledge: London; 138 153. McElvaney R. 2008. How children tell: containing the secret of child sexual abuse. Unpublished doctoral dissertation, Trinity College, Dublin. McElvaney R, Greene S, Hogan D. 2012. Containing the secret of child sexual abuse. Journal of Interpersonal Violence 27(6):I 155 1175. DOI: 10.1177/0886260511424503 McGee H, Caravan R, deBarra M, Byrne J, Conroy R. 2002. The SAVI Report: Sexual Abuse and Violence in Ireland. The Liffey Press: Dublin. Mudaly N, Goddard C. 2006. The truth is longer than a lie: Children's experiences of abuse and professional interventions. Jessica Kingsley Publishers: London. Olafson E, Lederman CS. 2006. The state of the debate about children's disclosure patterns in child sexual abuse cases. Juvenile and Family Court Journal 57(1): 27 40. Priebe G, Svedin CG. 2008. Child sexual abuse is largely hidden from the adult society: An epidemiological study of adolescents' disclosures. Child Abuse & Neglect 32: 1095 1108. Quas JA, Goodman GS. 2011. Consequences of criminal court involvement for child victims. Psychology, Public Policy and Law 18, 392 414 10.1037/a0026146 Quas JA, Goodman GS, Ghetti SA, Kristen W, Edelstein RR, Allison D, Cordon IM, Jones, DPI'. 2005. Childhood sexual assault victims: Long term outcomes after testifying in criminal court: VII. General discussion. Monographs oldie Societyfor Research in Child Development 70(2): 104 117. Quayle E, Jonsson L, LoafL. 2012. Online Behaviour related to Child Sexual Abuse: Preliminary Version. ROBERT Project. Available: http://www.innocenceindangendeffileadmin/user upload/ Downloads/ROBERT/Interview analysis PRELIMINARIpdf [18 June 2012]. Resnick HS., Kilpatrick DG., Dansky BS, Saunders BE, & Best CL. 1993. Prevalence ofcivilian trauma and posttraumatic stress disorder in representative national sample of women. Journal of Consulting and Clinical Psychology 61: 984 991. Rispers J, Aleman A, Goudena PP. 1997. Prevention of child sexual abuse victimization: A meta analysis of school programs. Child Abuse & Neglect 21: 975 987. Sjoberg RL, Lindblad F. 2002.Limited disclosure of sexual abuse in children whose experiences were documented by videotape. The American Journal ofPsychiatry 159: 312 314. Copyright ig> 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024209 Disclosure Pattems in Child Sexual Abuse 169 Smith DW, Letoumeau EJ, Saunders BE, Kilpatrick DG, Resnick, HS, Best CL. 2000. Delay in disclosure of childhood rape: Results from a national survey. Child Abuse & Neglect 24: 273 287. Staller KM, Nelson Gardell D. 2005. "A burden in your heart": Lessons of disclosure from female preadolescent and adolescent survivors of sexual abuse. Child Abuse & Neglect 29: 1415 1432. Summit R. 1983. The child sexual abuse accommodation syndrome. Child Abuse & Neglect 7(2): 177 193 Ungar M, Barter K, McConnell S, Tutty L, Fairholm I 2009a. Patterns of disclosure among youth. Qualitative Social Ifbrk 8(3): 341 356. DOI: 10.1177/1473325009337842. Ungar M, linty LM, McConnell S, Barter K, Fairholm J. 2009b. What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33: 699 708. Zwi KJ, Woolfenden SR, Wheeler DM, O'Brien TA, Tait P, Williams KW 2007. School based education programmes for the prevention ofchild sexual abuse (Review). Cochrane Database ofSystematic Review 3: CD004380. Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024210 nor EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 88flon CLINICAL RESEARCH ARTICLE Predictors of delayed disclosure of rape in female adolescents and young adults Iva A. E. Bicanicl ", Lieve M. Hehenkampl , Elise M. van de Puttee, Arjen J. van Wijk3 and Ad de Jongh3•4 'National Psychotraumacenter for Children and Youth, University Medical Center Utrecht, Utrecht The Netherlands; 2Department of Paediatrics, University Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Behavioral Sciences, ACTA, University of Amsterdam and VU University, Amsterdam, The Netherlands; °School of Health Sciences, Salford University, Manchester, United Kingdom Background: Delayed disclosure ofrape has been associated withimpaired mental health; it is, therefore, important to understand which factors are associated with disclosure latency. The purpose of this study was to compare various demographics, post rape characteristics, and psychological functioning of early and delayed disclosers (i.e., more than I week post rape) among rape victims, and to determine predictors for delayed disclosure. Methods: Data were collected using a structured interview and validated questionnaires in a sample of 323 help seeking female adolescents and young adults (12 25 years). who were victimized by rape, but had no reported prior chronic child sexual abuse. Results: In 59% of the cases, disclosure occurred within I week. Delayed disclosers were less likely to use medical services and to report to the police than early disclosers. No significant differences were found between delayed and early disclosers in psychological functioning and time to seek professional help. The combination of age category 12 17 years [odds ratio (OR) 2.05, confidence intervals (CI) 1.13 3.73], penetration (OR 2.36, CI 1.25 4.46), and closeness to assailant (OR 2.64, CI 1.52 4.60) contributed significantly to the prediction of delayed disclosure. Conclusion: The results point to the need of targeted interventions that specifically encourage rape victims to disclose early, thereby increasing options for access to health and police services. Keywords: Adolescents; young adults: rape: sexual assault: disclosure; latency to disclosure; posurauniatic stress disorder Responsible Editor: Rita Rosner, KU Eichstaett Ingolstadt. Germany. 'Correspondence to: Iva A. E. Bicanic, National Psychotrauma Center for Children and Youth, University Medical Center Utrecht, P.O. Box 85090, NL 3508 AB Utrecht, The Netherlands, Email: i.a.e.bicanio@rencutrecht.n1 For the abstract or full text in other languages, please see Supplementary files under Article Tools' Received: 31 August 2014; Revised: 30 Mardi 2015: Accepted: 13 April 2015; Published: 11 May 2015 revious studies have shown that disclosure of rape groups (De Haas, Van Berlo, Bakker, & Vanwesenbeeck, p to formal agencies, such as police or mental health services, is uncommon (Fisher, Cullen, & Turner, 2000; Wolitzky-Taylor et al., 2011), especially when the 2012; Tjaden & Thoennes, 2006), may not receive targeted mental health care and may not report the crime to the police (Ruch, Coyne, & Perrone, 2000). rape has been committed on a date or by an acquaintance For reasons of mental health and public safety, it is and involves the victim's use of drugs and/or alcohol important to understand the potential factors that are (Resnick et al., 2000; Wolitzky-Taylor et al., 2011). There is related to disclosure. Timing of disclosure may be a crucial evidence to suggest that victims believe that professionals factor, as early disclosers are more likely to utilize appro- will not be helpful to them because their rape experience priate medical care and report to the police than delayed does not match stereotypical conceptions of rape, such disclosers (Ahrens, Stansell, & Jennings, 2010; Ullman & as involving a stranger, a weapon, and severe injury Filipas, 2001). In contrast, adults who wait longer than (Patterson, Greeson, & Campbell, 2009; Resnick et al., month to disclose the rape are more likely to suffer 2000). Accordingly, adolescents and young adults, who from posttraumatic stress disorder (PTSD) and depres- are more at risk to be victimized by rape than other age sion compared to early disclosers (Ruggiero et al., 2004). European Jamul or Psychotraumatciagy 2015. I; 2015 lye A. E. Scant et al. inn an Open Access made clsktuted under the terms of the CeeaiWe Careens Andbution4.01nernanonsi License dThp://creatkeccnvensxxnelcensestby/4.04.ahmingthYd paniest000pyand fecistdbuielhematedal many medumor fennel. and lcueirix.ranseern. 8nd tuild unorahe materiel. for anypurecee. eAncommsciali.undei the condito trot at:peg:date ciech qvon.!hale 'ha lothelicenseIsprosided. and mat you /Ideate (Changeswere mace. Youmay do so in any reascoatie manner. but not in any way that worsts ioeosor &domes you or you, use. citation: Eutcpean Jounial cd Psychotraumatiogy 2015. 8: 25883 hnplidx.cbi.orp/10.3402/ept.y8.25883 (pan pa be 1w deem maul EFTA00024211 tva A. E. Scant et al. In addition, adolescents who disclose their rape experience interventions that increase victims' opportunities to at least I month after the incident took place are found receive timely post-rape services. to be at higher risk for major depressive disorder and delinquency (Broman-Fulks et al., 2007) compared to those Methods who disclosed within I month. Victim—assailant relationship is crucial in disclosure Subjects and data collection latency, with victims being at higher risk for delayed dis- Rape was defined as "an event that occurred without the closure if there is a close relation with the assailant (Kogan, victim's consent that involved the use or threat of force in 2004; Koss, 1988; Rickert, Wiemann, & Vaughan, 2005). vaginal, anal, or oral intercourse" (Tjaden & Thoennes, In contrast, delayed disclosure is less common in victims 2006). The definition includes both attempted and com- of a stereotypical rape, i.e., rape by a stranger including a pleted rape; the term "completed" referring to vaginal, weapon and injury (Smith et al., 2000). Victims of prior oral, anal, or multiple penetrations. Victims who disclosed sexual trauma are more likely to postpone disclosure of a within 1 week were defined as "early disclosers," whereas subsequent assault than those without prior victimization those who disclosed at least after 1 week were defined as (Smith et al., 2000; Ullman, 1996). This is in contrast with "delayed disclosers." This dichotomization of the variable the findings of Ahrens et al. (2010), who report no dif- "disclosure latency" was based on the study of Ahrens ference in rates of prior sexual trauma between early and et al. (2010) and the national standard criteria for admis- delayed disclosers. In addition, the victim's age appears sion to a Rape Centre in the Netherlands, i.e., a maximum to be an important variable in predicting disclosure. of 7 days post-rape. Evidence suggests that young children are at higher risk The study was conducted in the Dutch National for delayed disclosure than adolescents (Kogan, 2004; Psychotrauma Centre, which provides psychological ser- Schonbucher, Maier, Mohler-Kuo, Schnyder, & Landolt, vices for rape victims aged 12-25 years and their parents. 2012). Thus, various rape and victim-related character- Between May 2005 and December 2011, the centre re- istics have been found to be associated with timing of ceived 621 phone calls concerning alleged rape victims disclosure. from police authorities, mental health services, and self- The majority of the aforementioned studies included referrals. In 178 cases, the phone call did not result in college and adult female rape victims. It is important to admission at the centre because of age limitations, or examine rape disclosure latency in an age and sex group motivational reasons. In 108 cases, referrals were made to that is most at risk for rape victimization. There is only other institutions because the index trauma was chronic one prior quantitative study in adolescents (those aged childhood sexual abuse rather than rape in adolescence/ 12-17 years) that identified factors that might influence young adulthood. Of the 335 cases admitted to the centre, disclosure latency (Kogan, 2004). He found that identity 12 were not included in this study because of male gender, of the assailant, a familial relationship with the assailant, resulting in a final sample of 323 females with the index and a history of drug abuse in the household were related trauma being single rape. Referral sources for this final to the timing of disclosure. The results suggested that sample included the police (33.7%), mental health services a familial relationship with the assailant will postpone (40.7%). and self-referrals, i.e., victims or parents (25.6%). disclosure, whereas a history of drug abuse in the house- hold, albeit this seems counterintuitive, makes prompt Procedure disclosure more likely. This study had some limitations, During admission, all patients underwent a psychological including the fact that the interviews were conducted by assessment, consisting of 1) a structured interview for telephone and that the description of the relationship with obtaining demographic and post-rape characteristics and the assailant was limited. Therefore, in the present study, 2) self-report questionnaires to obtain information about we investigated a sample of female adolescent and young mental health functioning. Information from the inter- adult victims of rape who were admitted to a specialized view was transcribed onto a form designed for this mental health centre for victims of sexual assault. The first purpose. The following variables were obtained and aim of this study was to compare demographics, post-rape dichotomized or categorized for the purpose of the study: characteristics, and psychological functioning between early and delayed disclosers in this group. The second aim, Demographic and victim characteristics based on the exploratory findings of Kogan (2004), was to We asked patients about their current age, educational determine the predictors for delayed disclosure in adoles- level (lower, middle, or higher), and whether they were of cents and young adults, including age, prior trauma, and Dutch origin (i.e., in case of having parents born in the victim—assailant relationship using logistic regression Netherlands). Those between 12 and 17 years of age were analyses. Insight into the predictors for delayed disclosure defined as adolescents and those between 18 and 25 years for adolescents and young adults may reveal not only of age as young adults. We also asked whether the patient potential causal mechanisms but also possible targets for was living with their parent(s) (yes/no), and whether the 2 *we number molter ellnibn Disposal Claten: European Journal of Psychofnaumatdogy 2015. 6: 25883 htlp://thartorW10.3407Jept.v6.25BE3 EFTA00024212 Precictors of delayed disclosure of rape family structure was complete, i.e., whether the biological For the purpose of the study, only the total score was parents were living together (yes/no). Patients were then analysed. asked to confirm the presence of prior negative sexual experiences (yes/no), and whether they had a current Depression sexual relationship (yes/no). Children Depression Inventory (CDI; Kovacs, 1992; Timbremont & Braet, 2002) was used for participants Rape characteristics aged 12-17 years of age. The CDI is a 27-item ques- Information about date and time of the rape was ob- tionnaire, assessing cognitive, affective, and behavioural tained to calculate the time since rape at admission. Next, symptoms of depression. The Dutch CDI has a satisfac- patients were requested to describe the rape. Their re- tory internal consistency, with Cronbach's a ranging sponse was categorized into use of penetration (yes/no), between 0.71 and 0.89 (Timbremont & Braet, 2002). group rape (yes/no), use of physical violence (yes/no), and Behavioural problems use of threats verbally and/or with a weapon (yes/no). The Youth Self-Report (YSR; Achenbach & Rescorla, Also, information regarding the victim's relationship to 2001) was used for participants aged 12—I8 years. This the assailant was obtained. The assailant was defined as questionnaire evaluates the teenager's perception of be- a stranger when the victim had never been in contact with the assailant before the rape. Responses were used havioural and emotional problems. YSR has shown to be internally reliable (Cronbach's a's ranging from 0.71 to form a closeness category (yes in case of family, (boy) to 0.95), and convergent and discriminant validity is friend, or mentor). Patients were also asked about the reported to be satisfactory (Berube & Achenbach, 2006). (estimated) age of the assailant (categorized into 12-17 The YSR includes four broadband scales and nine years or > 18 years), and whether the victim had used narrow-band scales to assess behaviour problems. For alcohol prior to the rape (yes/no). the purpose of the study, only the total score on behaviour problems was included in the analyses. Post-rape characteristics Patients were asked when they first talked about the rape. General psychopathology The response was used to calculate the disclosure time The Symptom Checklist-90-R (SCL-90-R; Arrindell & and the help-seeking time. At the end of the interview, Ettema, 1986) was used for participants aged 12-25 years. patients were asked whether they had reported to the This is a 90-item self-report inventory to assess psycho- police after the incident (yes/no), and whether they had social distress. Patients were instructed to indicate the received any medical care after the incident (yes/no). amount they were bothered by each of the distress The study was performed in accordance with the symptoms during the preceding week. Patients rated 90 precepts and regulations for research as stated in the distress symptoms on a five-point Liken scale with Declaration of Helsinki, and the Dutch Medical Research being "not at all" and 5 being "extremely." The state- involving Humans Subjects Act concerning scientific ments are assigned to eight dimensions, reflecting various research. According to the Ethical Medical Committee types of psychopathology: anxiety, agoraphobia, depres- of the University Medical Centre Utrecht, this act was not sion, somatization, insufficiency, sensitivity, hostility, and applicable to the present study. Written informed consent insomnia. The Global Severity Index (GSI) can be used was obtained from both patients and parents. as a summary of the test and reflects the severity of all answered statements as a global measure of distress. Measures Cronbach's a has been found to range from 0.73 to 0.97. For the purpose of the study, only the GSI was analysed. Posttraumatic stress The Children's Responses to Trauma Inventory (CRTI; Data analyses Alisic, Eland, & Kleber, 2006) was used for participants To compare demographic and post-rape characteristics aged 12-18 years. This is a 34-item questionnaire asses- between the early and delayed disclosers, chi-square tests sing severity of PTSD symptoms according to DSM-IV. were used. To compare multiple continuous psychological Patients are asked to indicate to what extent a reaction scores, MANCOVA was used with "time since trauma" as to a traumatic event was present during the past week. a covariate to correct for the potential influence of time Scores range from I to 5, with higher scores indicating since trauma. more symptomatology. The four subscales: Intrusion, Delayed disclosure was used as a dependent variable. Avoidance, Arousal, and Other Child-Specific Reactions The strength of the univariate associations between each consist of 7, 11, 6, and 10 items, respectively. The reli- potential risk factor and delayed disclosure was estimated ability of this instrument is good to excellent (Cronbach's by calculating the odds ratio (OR) along with 95% a 0.92 for total score, 0.79 for Intrusion, 0.77 for confidence intervals (95% CI). To determine the strongest Avoidance, 0.71 for Arousal; Alisic & Kleber. 2010). risk factors for delayed disclosure, each potential risk Citation: Eurccean Jame) of Psychoireumacology 2015. 8: 25883 ritip://cbc.dol.mgn0.3402teipt.v8.25883 3 (pope rwmber no. oor noon puma* EFTA00024213 Na A. E. Blears° et al. factor identified in the univariate analyses with a sig- Table 2. Victim assailant relationship (N-323) in valid nificant OR (p <0.05) was entered as a predictor variable percentages into the multivariable model, using a stepwise forward logistic regression (LR) analysis with delayed disclosure as the outcome variable. The Hosmer—Lemeshow goodness- Stranger 94 29.5 of-fit chi-square was used to calculate how well the (Ex-)Boyfriend 32 10.0 data fit the model. For all statistical analyses, a p-value Friend 33 10.3 of <0.05 was considered statistically significant. Acquaintance 61 19.1 All statistical analyses were conducted using SPSS Person met during nightlife 30 9.4 (IBM SPSS Statistics for Windows, Version 20.0, IBM Second-degree relative 15 4.7 Corp., Armonk, NY). Person seen only once 15 4.7 Person from school 14 4.4 Results Person met on the intemet 12 3.8 Colleague 10 3.1 Socio-demographic characteristics Mentor 3 1.0 Socio-demographic characteristics of the sample are pre- sented in Table I. Victims' age ranged from 12 to 25 higher [4269) =24.297, p <0.001] compared to the gen- years, with a mean age of 16.7 years (SD =2.7) and a eral population (M=118.28, SD =32.38; Arrindell & median age of 16.1 years. Victims' mean age at time of Ettema, 1986). For the CDI, mean scores were in the rape was 14.3 years (SD =2.7) and a median age of 13.9 clinical range (M=17.2, SD =4.6) and rape victims years. Penetration occurred in 79.6% of the cases. None had significantly higher mean scores (1(230)=15,923, of the victims reported prior chronic child sexual abuse. p <0.001), in comparison to previously reported data of Data about victim—assailant relationship are presented in the general population of adolescent girls (Timbremont, Table 2. Victims first disclosed after a mean 20.8 weeks Braet, & Roelofs, 2008; M=9.01, SD =6.45). (SD =56.8, range 1-624 weeks), although 58.5% of the cases told within 1 week. First disclosure was to a friend Differences between early and delayed disclosers (45.8%), parent(s) (17.1%), (ex) boy-friend (9.4%), family Fifty-nine percent of the sample consisted of early dis- member (6.8%), professional (5.8%), or other adult closers (disclosure within I week). No significant differ- (15.2%). With regard to post-rape services, 53.8% of all ences in demographic characteristics were found between victims consulted a doctor for medical care and 51.4% early and delayed disclosers, except that there were reported to the police. On average, victims were admitted more delayed disclosers in the age category 12-17 years to the centre 59.8 weeks post-rape (SD =93.7, range compared to the early disclosers group (x2 (1) =6.96; 1-676). The mean GSI of the rape victims on the SCL-90- p = 0.008). For rape characteristics, significant differences R (Al = 209.7, SD = 61.8) was comparable with previously between groups were found for the use of penetration, reported data of psychiatric populations [M=203.55, with more victims of penetration in the delayed disclosers SD = 61.60; 4269) =1.629, p = 0.104] and was substantially group compared to the early disclosers group (x2 (I) = 5.37; p =0.02). Also, the delayed disclosers group pre- Table I. Demographic characteristics of rape victims sented more victims of verbal and/or weapon threats (N-323) in valid percentages than the early disclosers group (x2 (I)=5.35; p =0.02). Furthermore, among the delayed disclosers more victims N 44 identified the assailant as a close person compared to the Dutch origin° 274 84.8 early disclosers (x2 (I) =10.84; p =0.001). Alcohol was Education lever used more often in the early disclosers group compared Low 182 58.0 to the delayed disclosers group (x2 (I) =20.24;p <0.001). Medium 76 24.2 With respect to post-rape characteristics, a significantly High 56 17.8 smaller proportion of the delayed disclosers (15.9%) Parents divorced 102 31.9 utilized medical services following the rape compared Lives at parental home 273 85.3 to the early disclosers (30.3%; z2 (1)=5.32; p =0.02). Current relationship 81 26.5 Similarly, a significantly smaller proportion of the delayed Prior negative sex 46 14.8 disclosers (14.6%) compared to the early disclosers (34.3%) reported the rape to the police (x2 (I) =16.15; 'Dutch origin was defined as being a child from parents born in the Netherlands: °after 6 years of general primary school, at the p <0.001). The time since trauma at admission was sig- age of 12 years. students enter low (4 years). medium (5 years). nificantly lower for early disclosers (M=41.1 weeks, or high (6 years) secondary education level. SD =79.4) than for delayed disclosers (M =82.9 weeks, 4 Cuban: European Journal of Psychotraumatclogy 2016.6: 25883 htlp://dxartorW10.3407Jept.v6.25P83 woe norribt• nor to Minion ouposel EFTA00024214 Predictors of delayed disclosise of rape SD =103.3: 4314) =4.06, p <0.001). Mean and median delayed disclosers were less likely to use medical services time to seek help were 37.7 and 12.0 weeks, respectively. and to report to the police than early disclosers. Mean time to seek help did not differ between groups Furthermore, this study identified a number of factors (1(309)=2.54, p <0.48). Excluding outliers (M±3 SD, related to the timing of rape disclosure, showing that N = II) did not change the outcome of this analysis. Both delayed disclosers represented significantly more adoles- early and delayed disclosers scored in the highest level cents than young adults, significantly more victims of of psychological distress when compared to previously penetration than assault, significantly more victims who reported norm scores (CRTI, Alisic, Eland, Huijbregts, were threatened than not threatened, and significantly & Kleber, 2012; CDI, Timbremont et al., 2008; YSR, more victims who were close with the assailant. Achenbach & Rescorla, 2001; SCL-90, Arrindell & The finding that delayed disclosers are less likely to Ettema, 1986), but the MANCOVA results showed that utilize medical services and report to the police than early when comparing multiple continuous psychological disclosers is in line with previous studies in adult women scores, the overall psychological functioning (posttrau- (Ahrens et al., 2010; Ullman, 1996; Ullman & Filipas, matic stress, depression, behavioural problems, and gen- 2001). It suggests that disclosure latency is important for eral psychopathology) did not differ significantly between public health and safety, as delayed disclosure may not early and delayed disclosers (F(6,I98) = 0.88, p =0.51). only impede reception of proper medical care, such as Table 3 shows the ORs with 95% Cls for the associa- treating anogenital injuries and preventing the onset of tions between potential risk factors and delayed disclosure. STDs and unwanted pregnancy (Linden, 2011), but also Delayed disclosers, when compared to early disclosers, impede the forensic investigation and apprehension of the were significantly more likely to be in the age category assailant (Lacy & Stark, 2013). of 12-17 years (OR =2.10), to have experienced rape by Three variables were identified that successfully pre- a close person (OR = 2.35), to have been threatened dicted delayed disclosure: age category 12-17 years, verbally and/or with a weapon (OR =1.75), and to have penetration, and the assailant being a close person. The experienced penetration (OR = 1.99). Delayed disclosers finding that the victim's age significantly predicts disclo- were also found less likely to have used alcohol prior to sure latency is in line with previous research showing that the rape (OR = 0.22). None of the other factors were adolescents are at a greater risk for delayed disclosure found to be significant risk factors for delayed disclosure. when compared to their older counterparts (Kogan, 2004; Smith et al., 2000). Adolescents may be less able to over- Predicting delayed disclosure come the barriers to disclose, including factors such as A stepwise forward LR analysis was conducted to predict assailant tactics for maintaining secrecy, stigma that often delayed disclosure, using "age category," "close assailant," accompanies rape, and fear that their parents would "use of threats," and "penetration" as predictors. Victims' consequently limit their freedom (Crisma, Bascelli, Paci, alcohol use was not entered in the analysis because of & Romito, 2004). Also, as victims approach adulthood, missing values for 33.4% of the cases. The use of threats they may possess more information about their rights and was not a significant predictor in the model. A test of the options after victimization, and have more possibilities for full model against a constant-only model was statistically whom to disclose. In our study, most adolescents disclosed significant, indicating that the predictors (i.e., age cate- the rape event to peers, in line with prior research (Crisma gory 12-17 years, close assailant, penetration) reliably et al., 2004; Priebe & Svedin, 2008). distinguished between early and delayed disclosers (2 2 The use of penetration was found to make victims (3) = 23.09, p <0.000). There were no significant interac- more likely to postpone disclosure, opposite to the results tions between the predictors. Nagelkerke's R2 of 10.5% from Priebe and Svedin (2008), but in line with an older suggests only a modest association between the predic- study by Arata (1998), who found that more severe forms tors and delayed disclosure, although the model did show of sexual abuse were associated with less disclosure. an adequate fit to the data (Hosmer-Lemeshow x 2 (4) = Penetration may influence disclosure latency through 2.77, p <0.60). In total, 62% of the respondents were a variety of mechanisms. It could be argued that more categorized correctly, when using the three predictors severe rape, indicated by the use of penetration, is more that contributed significantly to the prediction of delayed likely to be accompanied by extensive coercive use of disclosure: age category 12-17 years (OR 2.05, CI 1.13- tactics to maintain the victim's silence, with fear of re- 3.73), penetration (OR 2.36, CI 1.25-4.46), and closeness prisal possibly contributing to the finding of delayed dis- to the assailant (OR 2.64, CI 1.52-4.60). closure (Kogan, 2004). Also, adolescents may think that social reactions in response to disclosure are more nega- Discussion tive in case of completed rape compared to assault. The results of this study show that, although no dif- Another factor that seems to make immediate dis- ferences were found between delayed and early disclosers closure of rape less likely is closeness to the assailant, in psychological functioning and time to seek help, as indicated by the assailant being a (boy)friend, family Citation: European Jcumal of Paychouaumacology 2015. 6: 25883 rittp:adidoicrono.34o2tetpt.y6258.83 5 (pope tuft. , ,or be moon puma* EFTA00024215 Iva A. E. Bicanic et al. lithie 3. Demographic and (post )rape characteristics by disclosure time (early vs. delayed disclosers) and odds ratios for delayed disclosure Early disclosure Delayed disclosure (N=185) (i.e., >1-week post-rape), N=131 Demographic and (post-)rape characteristics OR 95% CI Age category (years) 18 25 55 17.4 22 7.0 12 17 130 41.1 109 34.5 2.10 1.20 3.65' Dutch origin No 27 8.5 22 7.0 Yes 158 50.0 109 34.5 0.85 0.46 1.56 Living with parent(s) No 29 9.2 16 5.1 Yes 155 49.2 115 36.5 1.35 0.70 2.59 Complete family structure No 58 18.4 42 13.3 Yes 127 40.3 88 27.9 0.96 0.59 1.55 Current sexual relationship No 127 411 97 31.9 Yes 53 17.4 27 8.9 0.67 0.39 1A4 Prior negative sexual experience(s) No 152 49.4 110 35.7 Yes 32 10.4 14 4.5 0.61 0.31 1.19 Known assailant No 56 17.7 36 11.4 Yes 129 40.8 95 30.1 1.15 0.70 1.88 Close to assailant No 150 47.6 84 26.7 Yes 35 11.1 46 14.6 2.35 1.40 3.9r Group rape No 160 50.8 116 36.8 Yes 24 7.6 15 4.8 0.86 0.43 1.71 Age of assailant (years) 12 17 63 20.6 54 17.6 >18 117 38.2 72 23.5 0.72 0.45 1.14 Use of penetration No 46 14.7 19 6.1 Yes 136 43.5 112 35.8 1.99 1.10 3.60' Use of threats No 90 31.6 48 16.8 Yes 76 26.7 71 24.9 1.75 1.09 2.82' Use of physical violence No 130 42.6 82 26.9 Yes 51 16.7 42 13.8 1.31 0.80 2.14 Victim% alcohol use No 72 33.5 69 32.1 Yes 61 28.4 13 6.0 0.22 0.11 0.44' 'p <0.05. Seven participants were dropped from analyses due to missing disclosure time data. member, or mentor. This finding is consistent with pre- woman was to report this victimization to anyone (Koss, vious studies showing that the closer the relationship 1988; Rickert et al., 2005; Wolitzky-Taylor et al., 2011). between the victim and assailant, the less likely the young The dynamics of intrafamilial abuse is often proposed as 6 Crlaten: European Journal of Psycholraumatdogy 2016. 6: 25883 htlp://dxsttorW10.3607Jept.v6.25666 imp meow 101Mr OS*, wpm) EFTA00024216 Predictors of delayed disclosue of rape the explanation for delayed or non-disclosure (Kogan, generalizable to all rape victims, because the percentage 2004; Smith et al., 2000). In the present study, however, of victims that consulted a medical professional and only 5% of the assailants were identified as a family reported to the police was higher in our sample than in member. Most close relationships referred to (boy)friends, most studies (Hanson et al., 2003; Resnick et al., 2000; suggesting that a significant percentage of the sample Zinzow, Resnick, Bare, Danielson, & Kilpatrick, 2012). experienced peer-to-peer victimization. This type of vic- Perhaps, these differences could, at least partially, be timization is most likely to occur during adolescence, as explained by the fact that stranger rape, representing 30% compared to childhood or young adulthood, and greatly of our sample, leads to higher likelihood of help-seeking increases the risk of revictimization (Humphrey & White, and police reporting because of its association with higher 2000). Hence, victims of rape by peers may be a target acknowledgment of victim status (Resnick et al., 2000; group for interventions promoting early disclosure. Smith et al., 2000). The fact that this is a help-seeking Clearly, there are many variables working in tandem to sample is critical for the reasons cited in the discussion, affect the timing of victim's disclosure. A closer look at but also because the generalizability of these data to rape the final model, which identified three unique variables that victims who never tell anyone—perhaps the group most contributed significantly to the prediction of delayed dis- at risk—simply cannot be known. Besides these limita- closure, can help us to better understand the phenomenon tions, several strengths of the current study need to be of initial disclosure in adolescents and young adults. noted. One strength is the unique set of adolescents and Younger adolescent victims who are raped by a close per- young adults who presented at a mental health care son are more likely to delay disclosure than older victims centre after a single rape event, but who reported no prior of attempted rape by a stranger or acquaintance. Perhaps, chronic sexual abuse in childhood. For 85% of the they struggle with the notion that someone close to them sample, the index trauma was a first time rape. Moreover, performed such a violent act against them, which con- data were collected at a designated referral centre for fuses them about what might happen in terms of safety victims of rape and, therefore, the sample is likely to if they would disclose (or not). This finding is especially represent the clinical population of Dutch victims in the important in the light of the fact that approximately 80% age group of 12-25 years. of victims had some sort of relationship with their per- The findings of the current study, suggesting that petrator prior to the assault (Basile, Chen, Black, & delayed disclosers are less able to benefit from emergency Saltzman, 2007). With regard to rape types, it would medical care and evidence collection, have a number of intuitively seem that less severe forms of sexual assault practical implications. One of the strategies to enhance are associated with delayed disclosure and that completed victims' willingness to disclose within the first week post- rape would be easier to identify as clearly inappropriate rape may be sexual education campaigns in school and and wrong. Victims of completed rape, however, may be media, as being uninformed is one of the reasons for them more likely to experience negative psychological reac- not to disclose (Crisma et al., 2004). Education may tions, e.g., self-blame and avoidance coping. It is con- include medical information on rape-related pregnancy ceivable that they delay their disclosure as a result of and STDs, as well as the need for timely emergency rape-induced psychological distress (Starzynski, Ullman, contraception and prophylaxis, given that these concerns Filipas, & Townsend, 2005), not necessarily the severity appear to be facilitators of seeking medical help (Zinzow of the assault. et al., 2012). Also, practical information about DNA evi- Although the final model showed acceptable goodness dence and how to best protect it, e.g., related to shower- of fit, the percentage of explained variance of delayed ing, clothing, eating, and drinking, may increase the disclosure was modest. Thus. there must be other variables awareness of opportunities in the early-phase post-rape. predictive of delayed disclosure, such as the assailant's Moreover, facts about the potential psychological impact use of alcohol or weaker support systems, that we did not of rape, such as PTSD and revictimization, but also in- assess in this study. Besides this limitation, there are other formation about evidence-based treatments (Elwood et al., drawbacks of this study that should be mentioned. First, 2011; Littleton & Ullman, 2013; McLaughlin et al., 2013), a clinical sample was used with patients reporting high may increase help-seeking behaviour in an early stage. mean levels of psychological distress. This ceiling effect Furthermore, efforts to encourage early disclosure must may explain why no differences were found between consider peer-to-peer victimization as a primary factor, early and delayed disclosers on psychological function- as most participants in this study experienced this type ing, contrary to prior studies (Broman-Fulks et al., 2007; of victimization, and may initially not have defined or Ruggiero et al., 2004). Second, posttraumatic stress was acknowledged the incident as rape because they rationalize only assessed for children up to 18 years, and for young such experiences as normal (Hlavka, 2014), leading to the adults additional suitable measures were not used. Third, finding of delayed disclosure. information could have been lost due to dichotomizing In conclusion, the results of the present study suggest the variable disclosure latency. Fourth, results may not be that adolescent victims of rape with penetration by Citation: Eurccean Journal d Paychouaumatology 2015. 8: 25883 napiktx.doi.crott0.3402teipt.v8.25883 7 (pope number not loe Otarken pu.po.$ EFTA00024217 tva A. E. Scant et al. someone close are at increased risk for delayed disclosure, References and that delayed disclosers are less likely to use medical services and to report to the police. These findings may Achenbach, T. M.. & Rescorla. L. A. (2001). Afanualfor the ASEBA school age forms & profiles. Burlington, VT: University of assist clinicians and policymakers in understanding rape Vermont. Research Centre for Children. Youth, and Families. and help to develop interventions (Unterhitzenberger & Ahrens, C. E.. Stansell. 1, & Jennings. A. (2010). To tell or not Rosner, 2014), specifically targeted to support adoles- to tell: The impact of disclosure on sexual assault survivors' cents and young adults to disclose in an early-phase post- recovery. Violence and Victims. 25(5), 631 648. Alisic. E.. Eland. A. Huijbregts. R. A. D., & Kleber. R. 1 (2012). rape. Although the vast majority of the participants was Schokvenwrkingslijst voor kinderen (Children's responses to living at their parental home, many of the sample did trauma inventory revised version). Amsterdam: Boom test not first disclose to their parents. Therefore, it could be uitgever& argued that in prevention programs specific attention Alisic. E.. Eland, 1., & Klcber. R. J. (2006). Schoberwenkingslijst should be given to the strengthening of the child—parent mor Kinderen herziene versie [Children's responses to trauma inventory revised version). Utrecht: Institute for Psychotrauma relationship, to facilitate disclosure to parents (Schonbucher in collaboration with Clinical Psychology (University of et al., 2012). Next, as victims tend to disclose mostly to Utrecht) and Psychotrauma Centre for Children and Youth peers, prevention programmes may need to aim at teach- (University Medical Centre Utrecht). ing adolescents how they can help a peer victim if they Alisic. E.. & Kleber. R. 1 (2010). Measuring posttraumatic stress reactions in children: A preliminary validation of the children's become a recipient of disclosure (Schonbucher et al., responses to trauma inventory. Journal of Child & Adolescent 2012). In addition, education may increase victims' Tratana. 3(3). 192 204. willingness to disclose early, thereby increasing opportu- Arata. C. M. (1998). To tell or not to tell: Current functioning of nities for access to health and police services. It is more child sexual abuse survivors who disclosed their victimization. Child Maltreatment. Al). 63 71. likely to reach adolescents with direct, active, and online Arrindell. W. A.. & Ettema. J. H. M. (1986). SCL 90: Handfeeding outreach programs via communication channels that are hif een multidimensionele psychopathologic indicator [SCL 90: frequently used by adolescents and young adults parti- manual for a multidimensional measure of psychopathology). cularly social media (i.e., Facebook, Twitter, YouTube, Lisse: Swets Test. etc.), forums, and mobile apps. Such programmes, where- Basile. K. C.. Chen. 1. Black. M. C.. & Saltzman. L. E. (2007). Prevalence and characteristics of sexual violence victimization in adolescents and young adults are being treated as among U.S. adults. Violence & Victims, 22, 437 448. agents and decision makers (Hlavka, 2014), should focus Berube R. L.. & Achenbach. T M. (2006). Bibliography of published on information concerning what rape actually is—not studies using ASEBA: 2006 edition. Burlington. VT: University only the stereotypical idea of rape and what (not) to do in of Vermont. Research Centre for Children. Youth and Families the aftermath of rape especially in the first week post- Bicanic. 1.. Snetselaar. H.. De Jongh. A., & Van de Putte. E. (2014). rape. Another way to help improve the support of victims Victims' use of professional services in a Dutch sexual assault of rape is the implementation of multidisciplinary sexual centre. European Journal of Psychotraumatology, 5. 23645. doi: assault centres (Bicanic, Snetselaar, De Jongh, & Van de http://dx.doi.org/10.3402fejpt.v5.23645 Bramsen. R. H.. Elklit. A.. & Nielsen. L. H. (2009). A Danish Putte, 2014; Bramsen, Elklit, & Nielsen, 2009), as these model for treating victims of rape and sexual assault: The may be the most suitable places to organize education multidisciplinary public approach. Journal of Aggression. campaigns and offer integrated post-rape services in one Maltreatment & Trauma. 18(8), 886 905. location. Future research should investigate whether the Broman Fulks. J. 1, Ruggiero. K. I. Hanson. R. R. Smith. D. W. availability of such centres increases the prevalence of police Resnick. H. S.. Kilpatrick, D. G., et al. (2007). Sexual assault disclosure in relation to adolescent mental health: Results from reporting and use of medical care. Moreover, as discussed, the National Survey of Adolescents. Journal of Clinical Child previous research concerning the topic of disclosure has and Adolescent Psychology. 36(2), 260 266. focused on the disclosure process, mainly the effect of Crisma, M.. Bascelli. E., Pad. D.. & Romito, P. (2004). Adolescents negative social reactions, and not the latency. In future who experienced sexual abuse: Fears, needs and impediments research, social reactions in relation to disclosure (latency) to disclosure. Child Abuse & Neglect. 28(10). 1035 1048. De Ham. S.. Van Berle. W. Bakker. F.. & Vanwesenbeeck. I. (2012). should be assessed by using the Social Reactions Ques- Prevalence and characteristics of sexual violence in the tionnaire, as well as the victim's perception of their own Netherlands. the risk of re•ictimization and pregnancy: Results experience being defined as rape, as many girls and young from a national population survey. Violence and Victims, 27(4). women do not report or seek help because they regard 592 608. Elwood. L. S.. Smith. D. W., Resnick. H. S.. Gudmundsdottir, R. sexual violence against them as normal (Hlavka, 2014). Amstadter. A. R. Hanson. R. F.. a al. (2011). Predictors of rape: Findings from the National Survey of Adolescents Journal of Traumatic Stress. 24(2). 166 173. Conflict of interest and funding Fisher. B. S.. Cullen. F. T.. & Turner. M. G. (2000). The sexual victimization of college women. Washington. DC: U.S. Depart There is no conflict of interest in the present study for any meet of Justice. National Institute of Justice. and Bureau of of the authors. Justice Statistics 8 Citation: European Journal of Psychotraumatdogy 2016.6: 25883 htip://dxsti.orW10.3402tept.v8.25BE3 pee WSW nutlet Olnuon fennel EFTA00024218 Predictors of delayed disclosue of rape Hanson. R. F.. Kievit, L. W.. Saunders. B. E., Smith, D. W.. Justice Reference Service). Washington. DC: U.S. Department Kilpatrick. D. G.. Resnick. H. S. et al. (2003). Correlates of Justice. of adolescent reports of sexual assault: Findings from the Ruggiero. K. J.. Smith. D. W. Hanson. R. F.. Resnick. H. S.. national survey of adolescents. Child Maltreatment, 8(4), Saunders. B. E.. Kilpatrick. a G.. et al. (2004). Is disclosure of 261 272. childhood rape associated with mental health outcome? Hlavka, H. R. (2014). Normalizing sexual violence: young women Results from the National Women's Study. Child Maltreatment. account for harassment and abuse. Gender & Society. doi: 9(1).62 77. 10.1177/0891243214526468. Schonbucher, V.. Maier. T.. Mohler Kuo, M.. Schnyder. U.. & Humphrey. J. A., & White. J. W. (2000). Women's vulnerability to Landolt. M. (2012). Disclosure of child sexual abuse by sexual assault from adolescence to young adulthood. Journal of adolescents: A qualitative in depth study. Journal of Interper Adolescent Health, 27(6). 419 424. .sonal Violence, 27, 3486 3513. doi: 10.117710886260512445380. Kogan. S. M. (2004). Disclosing unwanted sexual experiences: Smith. D. W.. Letoumeau, E. 1.. Saunders. B. E.. Kilpatrick• D. G.. Results from a national sample of adolescent women. Child Resnick• H. S., & Best. C. L. (2000). Delay in disclosure of Abuse and Neglect. 28. 147 165. childhood rape: Results from a national survey. Child Abuse & Koss• M. P. (1988). Criminal victimization among nnmetr Impact on Neglect. 24(2). 273 287. health status and medical service usage (Grant No. 85 U CX Starzynski, L. L., Ullman. S. E.. Filipas. H. H.. & Townsend. S. M. 0038). Washington. DC: National Institute of Justice. (2005). Correlates of women's sexual assault disclosure to Kovacs. M. (1992). Children depression inventory CDI: Manual. informal and formal support sources Violence and Victims, 20. New York: Multi Health Systems. 417 432. Lacy. J. W.. & Stark. C E. (2013). The neuroscience of memory: Timbremont, B.. & Bract. C. (2002). Children's depression inventory: Implications for the courtroom. Nature Reviews Neuroscience. Nederlandstalige versie (Children's Depression Inventory: /4(9), 649 658. Dutch version). Lisse: Swots & Zeitlinger. Linden. J. A. (2011). Care of the adult patient after sexual assault. Timbremont. B.. Bract, C.. & Roelofs. J. (2008). Handfeeding New England Journal of bfedieine• 365(9). 834 841. Children's Depression Inventory (Children's Depression Inven Littleton, H.. & Ullman. S. E. (2013). PTSD symptomatology and tory: Dutch version). Amsterdam: Pearson Assessment and hazardous drinking as risk factors for sexual assault revicti Information B.V. mization: Examination in European American and African Tjaden. P. G.. & Thoennes. N. (2006). Extent. nature. and American women. Journal of Traumatic Stress. 26(3). 345 353. consequences of rape victimization: Findingsfrom the National McLaughlin. K. A.. Koenen. K. C. Hill. E. D., Petukhova, M.. Violence against Women Survey. Washington. DC: U.S. Sampson. N. A.. Zaslaysky, A. M., et al. (2013). Trauma Department of Justice. exposure and posttraumatic stress disorder in a national Ullman• S. E. (1996). Correlates and consequences of adult sexual sample of adolescents. Journal of the American Academy of assault disclosure. Journal of Interpersonal Violence. 11(4). Child and Adolescent Psychiatry. 52(8), 815 830. 554 571. Patterson. D.. Grceson. M.. & Campbell. R. (2009). Understanding Ullman• S. E.. & Filipas. H. H. (2001). Correlates of formal and rape survivors decisions not to seek help from formal social informal support seeking in sexual assault victims. Journal of systems. Health & Social Work, 34(2). 127 136. Interpersonal Violence. /6(10). 1028 1047. Priebe. G., & Svedin, C. G. (2008). Child sexual abuse is largely Unterhitzenberger. J., & Rosner. R. (2014). Lessons from writing hidden from the adult society. An epidemiological study of sessions: A school based randomized trial with adolescent adolescent? disclosures. Child Abuse & Neglect. 32. 1095 1108. orphans in Rwanda. European Journal of Psythotratonatology. Resnick. H. S.. Holmes. M. M.. Kilpatrick. D. G.. Clum. G.. 5. 24917. doi: http://dx.doi.org/10.3402Jejpt.v5.24917 Acierno. R.. Best. C. L.. et al. (2000). Predictors of post rape Wolitzky Taylor. K. B.. Resnick. H. &. Amstadter. A. B., McCauley. medical care in a national sample of women. American Journal J. L.. Ruggiero. K. J.. & Kilpatrick. D. G. (2011). Reporting of Preventive Medicine. 19(4). 214 219. rape in a national sample of college women. Journal of Rickert. V. I.. Wiemann. C M.. & Vaughan. R. D. (2005). American College Health. 59(7). 582 587. Disclosure of date/acquaintance rape: Who reports and when. Zinzow. H. M.. Resnick. H. S• Barr, S. C. Danielson. C. K.. & Journal of Pediatric and Adolescent Gynecology. 18(1). 17 24. Kilpatrick. D. G. (2012). Receipt of post rape medical care Ruch, L. R.. Coyne, & Perrone. P. A. (2000). Reporting sexual in a national sample of female victims. American Journal of assault to the policy in Hawaii (NCI 188264. National Criminal Preventive Medicine. 43(2). 183 187. Citation: Eurcpean Jaanal of Psychotraumatology 2015.8: 25883 htip://cbc.dol.mgri0.3402teipt.v8.25883 9 (pope ...Amber nor be can minne4ti EFTA00024219