Exhibit B EFTA00024175

Ctc•ckl.e 4.pdzAco Review Manuscript Facilitators and Barriers to Child Sexual Abuse (CSA) Disclosures: A Research Update (2000-20 I 6) Ramona Alaggial , Delphine Collin-Vezina2, and Rusan Lateefl TRAUMA. VIOLENCE & ABUSE 2019, Vol. 20(2) 260-283 C The Author(s) 2017 Artock roust guidelines: sacepub comlioumalvptimoskin DOI, 10117711124838017697312 nals sagepuboornlhomakva OSAGE 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 Timely access to supportive and therapeutic resources for child sexual abuse (CSA) survivors can mitigate risk to the health and mental health well-being of children, youth, and adults. Identifying and understanding factors that promote or inhibit CSA disclosures have the potential to facilitate earlier disclo- sures, assist survivors to receive services without delay, and potentially prevent further sexual victimization. Increased 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, Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). Incidence studies in the United States and Canada report decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Turner, & Hamby, 2014; Trocme et al., 2005, 2008), while at the same time global trends from systematic reviews and meta- analyses have found concerning rates of CSA, with averages of 18-20% for females and of 8-10% for males (Pereda, Guilera, Fours, & Gomez-Benito, 2009). The highest rates found for girls is in Australia (21.5%) and for boys in Africa (19.3%), with the lowest rates for both girls (11.3%) and boys (4.1%) reported in Asia (Stoltenborgh, van Uzendoorn, Euser, & Bakermans-Kranenburg, 20 I 1). These findings point to the incongruence between the low number of official reports of I Factor-Inwentash Faculty of Social Work. University of Toronto. Toronto. Ontario. Canada 2 Centre for Research on Children and Families. School of Social Work, McGill University. Montreal. Qubec. Canada Corresponding Author: Ramona Alaggia. Factor-Inwentash Chair in Children's Mental Health. Factor- Inwentash Faculty of Social Work. University of Toronto. 246 Moor St West. Toronto, Ontatio, Canada M4K I W I. ramonaalaggiaeutorortoca EFTA00024176

Alaggia et at 261 CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stolten- borgh, van LIzendoom, Euser, and Bakermans-Kranenburg (2011) combining estimations of CSA in 217 studies published between 1980 and 2008 revealed rates of CSA to be more than 30 times greater in studies relying on self-reports (127 in 1,000) than in official report inquiries, such as those based on data from child protection services and the police (4 in 1,000) (Ju- lian, Cotter, & Perreault, 2014; Statistics Canada 2013). In other words, while 1 out of 8 people retrospectively report having experienced CSA, official incidence estimates indicate only 1 per 250 children. In a survey of Swiss child services, Maier, Mohler-Kuo, Landholt, Schnyder, and Jud (2013) fur- ther found 2.68 cases per 1,000 of CSA disclosures, while in a recent comprehensive review McElvaney (2015) details the high prevalence of delayed, partial, and nondisclosures in childhood indicating a persistent trend toward withholding CSA disclosure. It is our view that incidence statistics are likely an under- estimation of CSA disclosures, and this drives the rationale for the current review. Given the persistence of delayed disclosures with research showing a large number of survivors only dis- closing in adulthood (Collin-Vezina et al., 2015; Easton, 2013; Hunter, 2011; McElvaney, 2015; Smith et al., 2000), these issues should be a concern for practitioners, policy makers, and the general public (McElvaney, 2015). The longer disclosures are delayed, the longer individuals potentially live with serious negative effects and mental health problems such as depres- sion, anxiety, trauma disorders, and addictions, without receiv- ing necessary treatment. This also increases the likelihood of more victims falling prey to undetected offenders. Learning more about CSA disclosure factors and processes to help advance our knowledge base may help professionals to facil- itate earlier disclosures. Previous literature reviews examining factors influencing CSA disclosure have served the field well but are no longer current. Important contributions on CSA disclosures include Paine and Hansen's (2002) original review covering the liter- ature largely from the premillennium era, followed by London, Bruck, Ceci, and Shuman's (2005) subsequent review, which may not have captured publications affected by "lag to print" delays so common in peer-reviewed journals. These reviews are now dated and therefore do not take into account the plethora of research that has been accumulated over the past 15 years. Other recent reviews exist but with distinct contribu- tions on the dialogical relational processes of disclosure (Reit- 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 disclosures in children, youth, and adults from childhood and into adulthood—over the life course. Method Kiteley and Stogdon's (2014) systematic review framework was utilized to establish what has been investigated in CSA disclosure research, through various mixed methods, to high- light the most convincing findings that should be considered for future research, practice, and program planning. This review centered on the question: What is the state of CSA disclosure research and what can be learned to apply to future research and practice? By way of clarification, the term systematic refers to a methodologically sound strategy for searching liter- ature on studies for knowledge construction, in this case the CSA disclosure literature, rather than intervention studies. The years spanned for searching the literature were 2000-2016, building on previous reviews without a great deal of overlap. Retrieval of relevant research was done by searching interna- tional electronic databases: PsycINFO, PsycARTICLES, Edu- cational Resources Information Center, Canadian Research Index, International Bibliography of the Social Sciences, Pub- lished International Literature on Traumatic Stress, Sociologi- cal Abstracts, Social Service Abstracts, and Applied Social Science Index and Abstracts. This review searched peer- reviewed studies. A search of the gray literature (unpublished literature such as internal agency documents, government reports, etc.) was beyond the scope of this review because unpublished studies are not subjected to a peer-review process. Keyword search terms used were child sexual abuse, childhood sexual abuse, disclosure, and telling. A search of the 9 databases produced 322 peer-reviewed articles. Selected search terms yielded 200 English publica- tions, I French study, and 1 Portuguese review. The search was further refined by excluding studies focusing on forensic inves- tigations, as these studies constitute a specialized legal focus on interview approaches and techniques. As well, papers that focused exclusively on rates and responses to CSA disclosure were excluded, as these are substantial areas unto themselves, exceeding the aims of the review question. Review articles were also excluded. Once the exclusion criteria were applied, the search results yielded 33 articles. These studies were sub- jected to a thematic analysis as described by Braun and Clarke (2006). This entailed (I) multiple readings by the three authors; (2) identifying patterns across studies by coding and charting specific features; (3) examining disclosure definitions used, sample characteristics, and measures utilized; and (4) major findings were extrapolated. Reading of the articles was initially conducted by the authors to identify general trends in a first level of analyses and then subsequently to identify themes through a deeper second-level analyses. A table of studies was generated and was continuously revised as the selection of studies was refined (see Table 1). Key Findings First-level analysis of the studies identified key study charac- 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 term disclosure. In the absence of standardized questionnaires or disclosure instruments, telling emerges as a practical term 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- Vez na (2016) Braze ton (2015) Co n-Vez na, Sab onn . Pa mer, and M ne (20 I 5) Lec erc and Wort ey (20 I 5) To exp ore d sc osure processes for ma e v ct ms of CA To exp ore the mean rig Afr can Amer can women make of the r traumat c exper ences w th CSA and how they d sc osed across the fe course To prov de a mapp ng of factors that prevent CSA d sc osures through an eco og ca ens from a samp e of CSA adu t sury von. Study object yes nvest gated the factors that fac tate CSA d sc osures Phenomeno og ca methodo ogy used to ntery ew ma e CSA sury vors. The Long Intery ew Method (LIM) gu ded data co ea on and ana yses. Co ect ve case study des gn w th us ng narrat ve wad t on (storyboard) for data co ea on and am ys s. Qua tat ve ntery ew ng Qua at ve des gn us ng LIM. Adu t ma e ch d sexua offenders were ntery ewed to exam ne pred ctors of 17 men ranged n age from 19 to 67— average age 47. Purpos ve samp rig strategy was used 17 Afr can Amer can women n m d- fe between 40 and 63 who exper enced ntrafam a CSA_ Purpos ye. snowba ng strategy 67 ma e and fema e CSA adu t sury vors (76% dent f ed as fema e and 24% as ma e). Age ranges from 19 to 69 years (M = 44.9). Purpos ve samp ng strategy 369 adu t ma es who had been cony cted of a sexua offense aga nst a ch d aged between I The major ty of the men n the study wa ted unt adu thood to d sc ose the r abuse. w th negat ve stereotypes contr but ng to the r de ayed d sc osures. Negat ve stereotypes contr buted to de ayed d sc osure w th try ng to forget. Break ng so at on was c ted as a mot vator to d sc osure a ong w th the a d of var ous forms of med a on d sc osure. Important contextua ssues such as negat ve stereotyp ng of ma es. sexua ty. and v ct ms were noted. Soc a med a was seen as a fac tator of d sc osures CSA onset was arge y between the ages 5 and 9. No one ever ta ked to them about sex, so they d dn't have anguage to d sc ose. Barr en: fear of fam y breakdown and remova , not want ng to tarn sh the fam y's name, and fear of retr but on by tam y members f they d sc osed. Pattern of st fed and d sm ssed d sc osures dent f ed over the fe course. A 17 part c pants dent f ed sp r tua ty as a pr mary source of strength throughout the fe course Three broad categor es were dent fed as barr en to CSA d sc osure: Barr ers from w th n- nterna zed v a m b am ng, mechan sms to protect onese f. and mmature deve opment at t me of abuse: barr en n re at on to others—v o ence and dysfuna on n the fam y, power dynam a. awareness of the mpact of to ng, and frag e soc a network; barr en n re at on to the soc a wor d abe ng, taboo of sexua ty, ack of sery ces ava ab e. and cu ture or t me per od. D sc osure ncreased w th the age of the v ct m: f penetrat on had occurred, f the v ct m was re aced to the offender, f the v ct m was not v ng w th die offender at A part c pants had d sc osed and rece ved sery ces before part c pat ng n the study. Member check ng cou d not be done w th the part c pants to check themes. Sma but surf c ent s ze for a qua tat ve nqu ry. Otherw se, h gh eve of r gor n estab sh ng trustworth ness of the data and ana ys s. Retrospect ve study cou d mp y reca ssues One of few stud es to focus exc us ye y on Afr can Amer can women. Sma but stiff cent s ze for a qua tat ve nqu ry. Important cu tura and contextua ssues were brought forward. Retrospect ye study that may have been affected by reca ssues. Use of a fe-course perspect ye as a theoret ca ens for understand ng CSA n the m dd e to ater years of fe that shou d be cons dered n further nvest gat ons Ha f of the part c pants had not d sc osed the r CSA exper ences before the age of 19. Retrospect ye aspect of the study cou d mp y reca ssues. A pan c pants had d sc osed and rece ved counse ng at some before part c pat ng n the study. H gh eve of rgor n estab sh ng trustworth ness of the data and ana ys s Offender generated data through se (-reports cou d be subject to cogn t ve d stort ons— m n m sat on or exaggerat ons. (continued) EFTA00024178

Table I. (cont nued) Study Purpose Des gn Samp e F nd rags Summary McE vaney and Cu hane (2015) Dumont, Messerschm tt V a, Bohu. and Rey-Sa mon (2014) Easton. Sa tzman. and W 5 (2014) To nvest gate the teas b ty of us ng ch d assessments as data sources of nforma CSA d sc osure. To assess f these reports prov de substant ye data on d sc osures Th s study a med to exp ore how the re at onsh p between the perpetrator and the v ct m, espec a y whether these re at ons are ntrafam a or extrafam a, mpact CSA d sc osure Study focus was on dent f cat on of barr en to CSA d sc osure w th ma e sury von v ct m d sc osure. Sem structured ntery ews based on the QID quest onna re. F e reports of ch dren seen for assessment n a ch d sexua abuse un t n a ch dren's hosp ta were rev ewed F e reports of ch dren seen for assessment n a ch d sexua abuse un t n a ch dren's hasp ta were rev ewed Us ng qua tat ve content ana ys s, researchers conducted a secondary ana ys s of on ne survey data. the 2010 Heath and We -Be ng Survey. that nc uded men w th se (-reported CSA h stor es w th an open-ended tem on d sc osure barr ers and I7 years o d. Major ty were Wh te. uneducated, a most ha f unemp oyed before the r arrest Content ana ys s was comp eted on 39 f es (32 fema es and 7 ma es) based on a cod ng framework. Parents were asked to consent to have the r ch d's f e rev ewed for the study. V a ms assessed were 12-18 years of age 220 m nor v a rns- 78.2% fema e v a ms. 41.8% aged between 14 and 18 (most preva ent age range). and 48.2% were abused by a fam y member 460 men w th CSA h stor es comp eted an anonymous, Internet- based survey. Recta ted from sury yore organ zat ons. Age range of 18-84 years. Two th rds of respondents reported c ergy-re ated abuse. Major ty of respondents were Wh te the t me of the abuse, or f the v a m res sted dur ng the offense. Ma e v a ms and v a ms from dysfuna ona backgrounds were ess ke y to d sc ose Major ty of ch dren to d the r mothers (43%) and peers (33%) f rst_ Three major themes were dent fed as nf uenc ng the d sc osure process: (I) fee ng d stressed. (2) opportun ty to te . and (3) fears for se f. Add t ona themes of be ng be eyed. shame/se f-b ame. and peer nf uence were a so dent fed D sc osure processes were more cone ex when t concerned sexua abuse comm tted by ntrafam a perpetrator 60% of the v a ms revea the facts seven years after, and most often to nd v dua s outs de the fam y (78.6% of the d sc osures done at schoo): on the contrary. extrafam a d sc osures take p ace more spontaneous y and qu ck y: 80% of the v a ms revea the facts a few days after, most often to the r mother or peers Vast major ty of part c pants (94.6%) were sexua y abused by another ma e. Durst on of sexua abuse broke down nto: 30.2% ess than 6 months. 32.3% 6 months to 3 years. and 34.3% more than 3 years. Ten years o d was average age of CSA onset Ten categor es of barr en were c ass fed nto three doma ns: (I) soc opo t ca: mascu n ty. m ted resources; (2) nterpersona : m strust of others, fear of be ng abe ed "gay," safety and protect on ssues, past responses: and (3) persona: ntema emot ons. see ng the exper ence as sexua abuse. and sexua or enat on. Penpect ves of offenders on vu nerab ty of v ct ms n re at on to d sc osure cou d be mportant nformat on to nform ntervent ons The samp e s ze s sma but w toner bute to a arge mu t s te study n Ire and. Serves as an mportant exp oratory p of br ng ng forward d sc osure themes for cons dent on The re at onsh p w th the perpetrator has a s gn f cant mpact on both t m ng and rec p ent of d sc osure. w th ntrafam a abuses ess ke y to be d sc osed prompt y and w th n the tam y system At t me of the study. th s was the argest qua tat ve data set to have been ana yzed w th an exp c t focus on adu t ma e sury vors' percept ons of barr en to CSA d sc osure. Because the samp e was m ted n terms of the ow percentage of rac a m nor t es (9.3%). d sc osure d fferences based on race or ethn c ty were not d scerned. The major ty of abuse reported was by c ergy wh ch m ght present a un que set of barr ers to d sc osure (continued) EFTA00024179

Pt' Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Easton (2013) McE vaney. Greene. and Hogan (2012) Schonbucher, Ma er, Moh er-Kuo, Schnyder, and Lando t (20 I 2) Study purpose was to descr be ma e CSA d sc osure processes us ng a fe span approach exam n ng d fferences based on age. A so. to exp ore re at onsh ps between d sc osure attr butes and men's menta hea th Qua tat ve study asked the centre research quest on: "How do ch dren te ?" Object ve was to deve op theory of how ch dren te of the r CSA d sc osure exper ences. Parents were ntery ewed. To nvest gate the process of CSA d sc osure w th ado escents from the genera popu at on who had exper enced CSA. How many d sc osed, who d d Cross-sect ona survey des grt.E gbe part c pants were screened and comp eted an anonymous, Internet- based survey dur ng 2010. Measures used: Genera Menta Heath D stress Sca e and Genera Assessment of Ind v dua Needs. Quest ons re ated to CSA d sc osure and supports were nc uded Grounded theory method study. Intery ews were conducted. L ne-by- ne open and ax a cod ng was conducted on verbat m transcr pts Data co ect on was through face-to-face qua tat ve ntery ews. Standard zed quest ons and measures were adm n stered on fam y s tuat on. soc odemograph c Purpos ve samp ng of 487 men from three nat ona organ zat ons devoted to ra s ng awareness of CSA among men. Age range: 19-84 years. Mean age for onset of CSA was 10.3 years Samp e of 22 young peop 16 g r s and 6 boys: age range: 8-18 years: 22 ntery ewed n ton between the ages of 8 and 18. M xed samp e of some endur ng ntrafam a CSA, some extrafam a CSA, and two endured both forms Conven ence samp e of 26 sexua y v ct m zed ado escents. 23 g r s and 3 boys. Age range: I5—I8 years. On ne advert cements and f yen were used to recru t youth from O der age and be ng abused by a fam y member were both re ated to de ays n d sc osure. Most part c pants who to d someone dur ng ch dhood d d not rece ve emot ona y support ve or protect ve responses and the he pfu ness of responses across the fe span was m xed. De ays n te ng were s gn f cant per ods oft me (over 20 years). Approx mate y one ha f of the part c pants f rst to d about the sexua abuse to a spouse/partner (27%) or a menta hea th profess ona (20%): 42% of part c pants reported that the r most he pfu d scuss on was w th a menta hea th profess ona. However. unhe pfu 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 A theoret ca mode was deve oped that conceptua zes the process of CSA d sc osure as one of conta n ng the secret (I) the act ve w thho d ng of the secret on the part of the ch d; (2) the exper ence of a "pressure cooker effect" ref ect ng a conf ct between the w sh to te and the w sh to keep the secret; and (3) the conf d ng tse f wh ch often occurs n the context of a trusted re at onsh p. These were der ved from e even categor es that were deve oped through open and ax a cod ng Less than one th rd of part c pants mmed ate y d sc osed CSA to another person. In most cases, rec p ents of both mmed ate and de ayed d sc osure were to peers. More than one th rd of part c pants had never d sc osed the abuse to a parent. Part c pants reported re uctance to d sc ose to parents so as Purpos ye samp ng of men from awareness ra s ng organ zat ons may have attracted part cu ar part c pants who had a ready d sc osed and rece ved he p. Part c pants needed to have access to Internet wh ch wou d have e m nated men n ower SES groups and requ red prof c ency n Eng sh wh ch wou d e m nate certa n cu tura groups. However. the samp ng strategy ga ned access to a predom nant y h dden popu at on. Important c n ca recommendat ons are made w th an emphas son a fe-course focus Modest but suff c ent samp e for an exp oratory qua tat ve nqu ry. H gh eve of trustworth ness r gor. A subsamp e of random y se ected transcr pts was ndependent y coded. Very young ch dren and young adu is were not captured n th s samp e. Transferab ty of f nd ngs can on y be made to the age range samp ed n the context of Ire and Two th rds of the samp e d d not d sc ose r ght away. Strengthen ng parent—ch d re at onsh ps may be one of the most mportant ways to ncrease d sc osure to parents. D sc osure to peers has been found a common trend n other (continued) EFTA00024180

Table I. (cant nued) Study Purpose Des gn Samp e F nd ngs Summary Hunter (20 I I ) Schaeffer, Leventha , and Asnes (2011) they d sc ose to, and what were the r mot yes for d Sc os ng A m of th s study was to deve op a fu er understand ng of CSA d sc osures Th s study a med to: (I) add d rect nqu ry about the process of a ch d's CSA d sc osure; (2) determ ne f ch dren w d scuff process that ed them to te : and (3) descr be factors that ch dren dent fy that ed them to te about or caused them to de ay CSA d sc osure data, sexua v ct m sat on. genera . and menta hea th. Sexua Assau t Modu e of the Juven e V ct m sat on Quest onna re was used Narrat ve nqu ry methodo ogy. Face-to- face n-depth ntery ews were conducted w th part c pants. Data were ana yzed us ng Rosentha and F scher— Rosentha 's (2004) method. Study sought to f nd out f process flues of d sc osure cou d be dent f ed n the context of forens c ntery ews. Forens c ntery ewers were asked to ncorporate quest ons about "te ng" nto an ex st ng forens c ntery ew protoco Intery ew content re ated to the ch dren's reasons for te ng or wa t ng was extracted, transcr bed, and ana yzed us ng grounded theory method of ana ys s commun ty and counse ng sery ces Purpos ye samp ng was emp oyed. Samp e cons sted of 22 part c pants aged 25- 70 years: 13 women and 9 men. Part c pants were sexua y abused at IS years or under w th someone over the age of It 191 ntery ews of CSA v ct ms aged 3-18 over a -year per od were used for the study. Inc us on cr ter a nc uded ch dren who made a statement about CSA pr or to refers. reasons for te ng or wa t ng to te , and those who spoke Eng sit. Part c pants were ch dren who were ntery ewed at a ch d sexua abuse c n c. 74% were ferna e and 51% were Caucas an not to burden them. Ear er d sc osures were re ated to extrafam a CSA, s ng e occurrence CSA, age of v ct m at abuse onset, and parents who were v ng together. H gher eves of reported gu t and shame were re ated to de ayed d sc osures. Peers were v ewed by th s samp e as more re ab e con( darts On y 5 out of 22 part c pants to d anyone about the r ear y sexua exper ences as ch dren. Fear, shame, and se f-b ame were the man nh b ton to d sc osure. These factors are further dem ed through subthemes. Te ng as a ch d and as an adu t was further expanded upon us ng A agg a's (2004) framework ver fy ng behav on nd rect attempts to te and purposefu d sc osure as categor es. Themat c ana ys s supported that CSA d sc osure shou d be conceptua zed and v ewed as a comp ex and fe ong process Reasons the ch dren dent fed for te ng were c ass fed nto three doma ns: (1) d sc osure as a resu t of nterna st mu (e.g. the ch d had n ghtmares): (2) d sc osure fac tated by outs de of uences (e.g. the ch d was quest oned): and (3) d sc osure due to d rect ev dente of abuse (e.g., the ch d's abuse was w tnessed). The barr ers to d sc osure dent f ed fe nto f ve groups: (I) threats made by the perpetrator (e.g.. the ch d was to d she or he wou d get n troub e f she or he to 4 (2) fears (e.g.. the ch d was afra d someth ng bad wou d happen f she or he to d), (3) ack of opportun ty (e.g., the ch d fe t the opportun ty to d sc ose never presented), (4) ack of understand ng (e.g.. the ch d fa ed to recogn ze abus ye 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) research and bears more exam nat on De ayed d sc osure was common n th s qua tat ve samp e. Most part c pants d d not make a se ect ve d sc osure unt adu thood. These f nd ngs support A agg a's (2004) mode of d sc osure but a so h gh ghts the mportance of fe stage. Modest but suff c ent samp e s ze for a qua tat ve nqu ry. We -des gned study w th dem ed ana ys s for transferab ty off nd ngs An nnovat ve study to try to assess f forma nvest gat ye ntery ews can fac tate d sc osures of CA. Data were based on a arge number of ntery ews. Dem ed ana ys s produced dem ed f nd ngs support ng other study f nd ngs on CSA d sc osure (continued) EFTA00024181

I-, Table I. (coin nued) cr. P Study Purpose Des gn Samp e F nd ngs Summary A agg a (2010) Fontes and P ummer (2010) Ungar, Barter. McConne . Tutty, and Fa rho m. (2009a) The study a med to dent fy factors mped ng or promot ng CSA d sc osures. Overarch ng research quest on: What nd v dua, nterpersona . env ronmenta . and contextua nf uences mpede or promote CSA d sc osures. Th s exam nat on of CSA d sc osure exp ored the ways cu ture affects processes of CSA d sc osure and report ng. both n the Un ted States and nternat ona y Th s study exp ored d sc osure strateg es w th a nat ona sampe of youth focus ng on A qua tat ve phenomeno og ca des gn, LIM, was used to ntery ew adu t CSA sury von about the r d sc osure exper ences to prov de retrospect ve accounts of CSA d sc osure and mean ng-mak ng of these exper ences. Themat c ana ys s was done through a soc a — eco og ca ens. Us ng pub shed terature wthc nca data, th s art c e conducted an ana ys s to prov de a cu tura y competent framework for CSA d sc osure quest on ng Forms were comp eted by youth fo ow ng pan c pat on n abuse prevent on Purpos ye samp ng was emp oyed. Snowba samp ng was a so used to recru t more ma e sury von. 40 adu t sury von of CA were ntery ewed: 36% men and 64% women. Age range of 18-65 w th a mean age of 40.1 years. Average age of abuse onset was 5.3 years o d. 36% of the samp e was non-Wh te. D verse soc oeconom c backgrounds Data cons sted of pub shed terature on d sc osure and cu ture that was tr angu ated wthc n ca case mater a Exam nat on of resu is from a nat ona sampe of 1,621 eva uat on forms where youth Themes fe nto four doma ns: (I) nd v dua and deve opmenta factors, deve opmenta factors as to whether they comprehended what was happen ng, persona ty tra is a so had some bear ng on the r ab ty to te . and ant c pat ng not be ng be eyed; (2) d sc osure nh b ted by fam y character st cs such as rgdy fxed gender ro es w th dom nat ng fathers, chaos and aggress on. other forms of ch d abuse, domest c v o ence. dysfunct ona commun cat on. and soc a so at on; (3) ne ghborhood and commun ty context. that s. ack of nterest from ne ghbors and teachers not 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 Cu tura and structura factors affect ng CSA d sc osure are dent f ed n n-depth deta Recommendat ons made nc ude ( I) d sc osure ntery ew ng shou d be ta ored to the ch d's cu tura context. (2) quest on ng shou d a so take nto cons dent on age and gender factors. and (3) cu ture stands as an mportant factor n a cases n wh ch ch dren are cons der ng d sc os ng or be ng asked to 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 Youth who have been abused or w tnesses to abuse emp oy f ve d sc osure strateg es: us ng se f-harm ng behav on to s gna the abuse to others; not ta k ng The study presents a comprehens ve soc a —eco og ca ana ys s to CSA d sc osure h gh ght ng the mu t faceted of uences. Of note, 42% had d sc osed the abuse dur ng ch dhood: 26% had not d sc osed because they had repressed the memory, or the abuse had occurred n preschoo years and they had d dal ty w th reca . The rema nder had attempted some form of d sc osure n nd rett ways dur ng ch dhood. A retrospect ye approach that cou d be affected by reca ssues One of the few works that adds know edge to cu tun y contextua d sc osure ntery ew ng. Un que comb nat on of teraturefnd ngswthcn ca mater a . Anecdota accounts may prec ude transferab ty of f nd ngs. Oven adds to an mpover shed area of CSA d sc osure nformat on Th s study h gh ghts that d sc osure s an nteract ye ongo ng process. F nd ngs end support to stud es 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 h dden exper ences of abuse among Canad an youth? (2) What mpact does part c pat on n abuse prevent on programs have on youth to express the r abuse exper ences? (3) What d sc osure barr en do youth face? (4) What are young peop es d sc osure patterns? and (5) Who do they to ? Ungar, Tutty. McConne . Th s study exp ored Barter, and Fa rho m abuse d sc osure (20096) strateg es w th a nat ona samp e of Canad an youth who part c paced nvoence prevent on programm ng. One of the goa s of the study was to document not prey ous y dent f ed exper ences of abuse and youth att tudes toward d sc osure of abuse exper ences program ng by the Canad an Red Cross (RespectED). A ser es of focus groups and observat ons of the workshops were used to he p contextua ze the f nd ngs. Eva uat on forms were ana yzed from two v o ence prevent on programs: ( I) It's not your fau t and (2) What's ove got to do w th It? Exp oratory des gn w th a nonrepresentat ve samp es. Qua tat ye ana ys s of 1,099 eva uat on forms comp Ned fo ow ng Red Cross RespectED v o ence prevent on programm ng de vered between 2000 and 2003. Forms of anonymous abuse d sc osures by youth pan c pants of neg emot ona phys ca . and sexua abuse. Twenty-seven ntery ews and focus groups were a so done to understand contextua ssues and engage youth and program fac tators n the nterpretat on of f nd ngs. A cod ng structure was deve oped for ana ys s to synthes ze themes across data sources anonymous y d sc osed abuse exper ences. Respondent's ages: 13 and under (27%). 14- IS (37%), 16-17 (25%). 18 and o der (4%), and unknown (7%) Purposefu samp e of 1,099 eva uat on forms comp eted fo ow ng Red Cross RespectED v o ence prevent on programm rig de vered between 2000 and 2003 at a about the abuse to prevent ntrus ve ntervent ons by others; seek ng he p from peers; seek ng he p from nforma adu t supports: and seek ng he p from mandated sery ce prov den (soc a workers and po ce). Resu is suggest d sc osure s an nteract ye process, w th expectat ons regard ng consequences to d sc osure. Patterns of ncrementa y char ng abuse exper ences are shaped by young peop e's nteract ons w di peers, educators, and careg vers. About three- quarters of fema es prey ous y d sc osed: s gn f cant y ess ma es d sc osed F nd ngs suggest h gh rates of h dden abuse, w th ess than one quarter of youth report ng a d sc osure. 244 of the 1,099 youth who d sc osed abuse on the r eva uat on forms dent fed spec f c nd v dua s they to d about the r abuse. D sc osure patterns vary w th boys, youth aged I4-15, v ct ms of phys ca abuse, and those abused by a fan y member be ng most ke y to d sc ose to profess ona s or the po ce. One th rd of d sc osures were d rected toward profess ona s and the east. 5% percent each, were d rected toward fr ends, parents. and others. Part c pants were most ke y to d sc ose sexua abuse to parentsffam y. profess ona s. and the po ce/courts. w th fewer choos ng fr ends. Out of a 1.099 part c pants, 225 ma es and 779 fema es nd cated that they had been abused. Out of those. 43 ma es and 180 fema es nd cated that they had d sc osed the abuse. Of those who had d sc osed, on y a port on of ma es and fema es spec fed who they had d sc osed the abuse to c'VVh e 1.099 eva uat ons w th d sc osure statements were ana yzed. on y 22% made ment on of peop e to nteract ye modes of d sc osure such as those deta ed by A agg a (2004) and Sta er and Ne son- Garde (2005). Th s m xed samp e of youth who exper enced d fferent forms of abuse and v o ence exposure were part c pants—not in ted to CSA SW, / vors Innovat ve des gn of th s study prov des ns ght nto young peop es percept ons of d sc osure exper ences. H gh eve of r gor w th trustworth ness of the data ana ys s ensured through use of youth focus groups. ntery ews. and observat ona data. The study resu is are somewhat m ted n the th ckness of the descr pt ons t can offer because most of the data are survey based. Reg ona d fferences may not have been p cked up. Scope of the study s broad and approach s treat ve (continued) EFTA00024183

Table I. (cont nued) ao Study Purpose Des gn Samp e Fnd ngs Summary Pr cbc and Svcd n (2008) Th s study a med to nvest gate d sc osure rates and d sc osure patterns and exam ne pred ctors of nond sc osure n a samp e of ma e and fema e ado escents w th se (-reported exper ences of sexua abuse Sorso , K a-Keat ng, and Grossman (2008) Study focused on d sc osure cha ences for ma e sury von of CSA to understand three ssues: (I) To Part c pants competed 65- tern quest onna re that nc uded quest ons about background, consensua sex. sexua abuse exper ences (noncontact, contact or penetrat rig abuse, nc ud ng peer abuse), d sc osure of CSA, own sexua abus ve behav or. sexua att tudes. and exper ences w th pornography and sexua exp o at on. The quest onna re nc uded 6 mod( ed terns from the SCL-90 and 9 of 25 tems from the Parenta Bond ng Instrument_ The data for g r s and boys were ana yzed separate y Ma e sun von of CA were ntery ewed about the r d sc osure exper ences. Ana yt c techn ques nc uded The samp e cons sted of 4,339 h gh schoo students n Sweden (2,324 g r s and 2,0 I 5 boys). The mean age of the part c pants was 18.15 years. Th s study used a subsamp e of 1,962 part c pants who reported CSA and who answered d sc osure quest ons The samp e cons sted of 16 ma e sury vors of ch dhood sexua abuse; I I Caucas an, 2 Afr can Amer can. I 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 Of the samp e, 1.505 g r s (65%) and 457 boys (23%) reported CS& The d sc osure rate was 81% (g r s) and 69% (boys). G r s and boys d sc osed most often to a fr end of the r own age. Few had d sc osed to profess ona s. and even fewer had reported to the author t es. There were h gher rates of d sc osure to a profess ona w th more severe abuse (contact abuse w th or w thout penetrat on) for g r s. but ower rates for boys The more severe the sexua abuse was, the ess key both g r s and boys had ta ked to the r mother, father. or a s b ng. G r s were ess ke y to d sc ose f they had exper enced contact sexua abuse w th or w thout penetrat on. ess frequent abuse, abuse by a fam y member, or f they had perce ved the r parents as ess car rig and ess overprotect ve and h gh y overprotect ve. Boys were ess key to d sc ose f a fam y member abused them, they were study ng a vocat ona program (vs. an academ c program), ved w th both parents or had perce ved the r parents as ess car rig and not overprotect ve. 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 Barr en to d sc osure were found to be operant n three nterre aced doma ns: (I) persona (e.g.. ack of cogn t ve awareness. ntent ona avo dance, emot ona read ness. and shame); (2) Th s study h gh ghted that sexua abuse s arse y h dden from adu t soc ety. espec a y from profess ona s and the ega system. However. t me apsed to d sc osure was not reported. S nce fr ends appeared to be the man rec p ents of sexua abuse d sc osures, pract ce mp cat ons of th s cou d be to f nd ways to g ye young peop e better nformat on and gu dance about how to support a sexua y abused peer. A qua tat ve component to the study wou d have prov ded a broader understand ng of d sc osure processes. Study m tat ons nc ude a s gn f cant amount of boys who d d not comp ete the quest ons regard rig d sc osure on: the t m rig of d sc osures (whether they were de ayed or not) was not measured: poss b ty of reca b as w th retrospect ve stud es based on se (-reports; and youth part c pants may not have understood a the quest ons S nce the vast major ty of men n the samp e had not d sc osed n ch dhood, they may have been pred spored to dent fy ng barr ers to d sc osure more (continued) EFTA00024184

Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Hershkow tz. Lanes, and Lamb (2007) whom and n what contexts have they d sc osed these exper ences? (2) What do they have to say about the r d sc osure exper ences? and (3) What are the r percept ons of pos t ve and negat ye aspects of the r d sc osure. nc ud ng ncent ves and barren? The goa of the present study was to exam ne how ch d v ms of extrafam a sexua abuse d sc osed the abuse exper ence grounded theory method of ana ys s for cod ng and deve opment of conceptua y c ustered matr ces. Part c pants comp eted two n- depth, sem -structured ntery ews, ast ng between 2 and 3 hr each tak ng p ace approx mate y a week apart A eged v a ms of sexua abuse and the r parents were ntery ewed. Ch dren were ntery ewed us ng the NICHD Invest gat ve Intery ew Protoco by exper enced youth nvest gators. Informat on on d sc osure processes was obta ned n the f rst forma ntery ew, before any po ce nvest gat on or ch d we fare ntervent on Puerto R can. I part Nat ve Amer can, Afr can Cuban: age range of 24-61 years; 9 dent fed themse yes as heterosexua, 5 as homosexua, and 2 as b sexua Th ny a eged v ct ms of CSA: 18 boys and 12 g r s. Ch d samp e was 7- to I2-year-o ds w th an avenge age of 9.2 years. Twenty mothers and 10 fathers were a so ntery ewed for a tota of 30 parent ntery ews. A content ana ys s was conducted on ch d and parent ntery ews re at ona (e.g.. fears about negat ve repercuss ons. so at on); and (3) zoc ocu tura (e.g., ack of acceptance for men to exper ence or acknow edge v ct m zat on). On y I of the 16 men n th s samp e d sc osed the fu extent of h s sexua abuse exper ences wh e he was st a ch d. The other men reported that they had not d sc osed. a though some reported attempts to to that were nd rect or ncomp ete. Seven other 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 D sc osure categor es were dent fed as fo ows: (I) de ayed 53% of the ch dren de ayed d sc osure for between I week and 2 years: (2) rec p ent of d sc osure: 47% of ch dren f rst d sc osed to s b ngs or fr ends, 43% f rst d sc osed to the r parents. and I0% f rst d sc osed to another adu t. 57% of the ch dren spontaneous y d sc osed abuse, but 43% d sc osed on y after they were prompted. 50% of the ch dren reported fee ng afn d or ashamed of the r parents' responses. Parents' react ons: support ve (37%) and unsupport ve (63%). There was a strong corre at on between pred cted and acwa parenta 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 read y. Retrospect ve accounts are subject to reca ssues. Invest gators made s gn f cant efforts to gather a d verse samp e. H gh eve of r gor was executed n the dependab ty of the data and tent ve process of the nterpretat on of f nd ngs was conducted Innovat ve des gn to gather d sc osure data from young ch dren. Focus s on extrafam a CA wh ch may d Her than d sc osure patterns of ntnfam a CSA. Two th rds of the parents reg stered unsupport ve responses wit ch s h gh rconunuedt EFTA00024185

Table I. (cont nued) •-•1 Study Purpose Des gn Samp e F nd ngs Summary A agg a and K rshenbaum The object ves of the (2005) current study were to dent fy a broad range of factors, nc ud ng fam y dynam cs that corn bute to or h nder a ch d's ab ty to d sc ose CSA. A au a (2005) Co ngs, Gr ff ths. and Kuma o (2005). The study purpose was to qua at ve y exp ore dynam cs that mpede or promote d sc osure by exam n ng a range of factors nc ud ng gender as a dynam c— how d sc osures of fema es and ma es are s m ar and d fferent. and n what ways gender affects CSA d sc osure Study exam ned patterns of d sc osure n a arge represent ve samp e of South Afr can CSA v ct ms. Two study object ves to: ( I ) exam ne how and A qua tat ve phenomeno og ca des gn—LIM—was used toe c t d sc osure exper ences: fac tators and barr en: and re evant c rcumstances. Intery ews were transcr bed verbat m. L ne-by- ne open cod ng was conducted to capture fam y- eve factors. Ax a and se ect ve cod ng fac tated dent f at on of themes Sury von of CSA were ntery ewed about the r d sc osure exper ences us ng LIM. Ana ys s of 30 part c pant narrat ves was used for theme deve opment regard ng mpact of gender on d sc osure. Intery ews were transcr bed verbat m for open. ax a . and se ect ve cod ng. Categor es and subcategor es were co apsed and ref n ng nto theme areas F e rev ews of a soc a work and med a case f es for CSA v ct ms seen at the cr s s center where a cases of CSA reported to the North Durban Purpos ye samp ng was emp oyed to recru t 20 adu t sun von between the ages of and 65 who were sexua y abused by a fam y member. Average age of part c pants was 40.1 years: 60% of part c pants were fema e and 40% ma e. Avenge age of onset of abuse was 6.7 years. M xed c n ca and nonc n ca samp e. The major ty had rece ved treatment for CSA at some po nt n the r ves Purpos ve samp ng of women and men. a ong w th those who d sc osed dur ng the abuse and those who d d not. I9 fema es and II ma es; 18-65 (mean 40.1) years who were sexua y abused by a fam y member or a trusted adu t. Avenge age of abuse onset was 5.3 years, 36% were nonwh te, and 58% had not d sc osed dur ng ch dhood 1.737 cases of CSA reported n the North Durban area of KwaZu u-Nata . South Afr ca, dur ng January 2001 to December 2003. 1,614 grs and Four major themes emerged suggest ng that CSA d sc osure can be s gn f cant y comprom sed when certa n fam y condtons ex st (I) rg dy f xed, gender ro es based on a patr archy-based fain y structure; (2) presence of fam y v o ence; (3) c osed, nd rect fam y commun cat on patterns; and (4) soc a so at on of the fam y as a who e, or spec f c members, payed a part n CSA v ct ms fee ng they had no one safe to te . Fam y systems formu at ons through a fem n st ens are mportant n understand ng ch dren and fam es at r sk of d sc osure barr en Three themes emerged for men that nh b ted or prec p tated d sc osure for reasons re ated to gender: (I) fear of be ng v ewed as homosexua : (2) profound fee ngs of st gmat zat on or so at on because of the be of that boys are rare y v ct m zed; and (3) fear of becom ng an abuser, wh ch acted as a prec p cant for d sc osure. Two predom nant themes w th fema e part c pants re ated to d ff cu t es d sc os ng: (I) they fe t more conf cted about who was respons b e for the abuse and (2) they more strong y ant c paced be ng b amed and/or not be eyed Content ma ys s dent fed two broad d mens ons of d sc osure: (I) agency: ch d- n t aced d sc osure versus detect on by a th rd party and (2) tempon durst on: an event versus a process. These d sc osure d mens ons def ned four d screte categor es of Over ha f the part c pants had not d sc osed the abuse dur ng ch dhood. Of the nond sc os ng part c pants, s x d d not d sc ose because they had repressed or forgotten the memory. A most one th rd w thhe d d sc osure ntent ona y. More data are needed on ear y d sc osures to garner more nformat on on fac atop of d sc osure. Retrospect ye approach mp es reca ssues. H gh eve of trustworth ness of the data and nterpretat ons were ach eyed through cred b ty. dependab ty. and conf rmab ty through d rect quotes One n a dearth of stud es that conduct gender ana ys s. Comparat ye ana ys s draws out mportant pract ce mp cat ons. Retrospect ve des gn of the study wh ch mp es poss b e reca ssues. Hgh eve of trustworth ness of the data and nterpretat ons were ach eyed through cred b ty. dependab ty. and conf rmab ty through d rect quotes These resu tsft nto A agg a's (2004) d sc osure framework. Through data ana ys s two raters coded d sc osure categor es us ng author's d sc osure framework, wh ch proved to be both 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 d sc ose the r abuse and (2) Ident fy factors assoc ated w th d fferent patterns of d sc osure po c ng area were referred dur ng the per od of January 2001 to December 2003 123 boys: average age of v ct m zed ch dren was 9.9 years. 47% reports were made w th n 72 hr of the abuse, 31% from 72 hr to I month, and 22% more than a month after the abuse d sc osure: (I) purposefu d sc osure (30% of cases), (2) nd rect d sc osure (9% of cases), (3) eyew tness detect on (18% of cases), and (4) acc dents detect on (43% of cases). D sc osure ndependent y pred cted by v a m's age. nature of the v ct m—perpetrator re at onsh p. offender's age. frequency of 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 w th the percentage of nternter agreement at 98%. Genera zab ty of th s study s m ted to ch d o ents rece v ng a cr s s assessment referred through a po ce report 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 Is ne 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 the r d sc osure processes boys. Sexua y abused by someone n the tam y or a c ose person to the fam y The ch dren fe t t was d ff cu t to f nd s tuat ons conta n ng enough pr vacy and prompts that they cou d share the r exper ences. When the ch dren d d pact ce mp cat on ICOtitinUed) EFTA00024187

Table I. (coot nued) Study Purpose Des gn Samp e F nd ngs Summary Sta er and Ne son- Garde (2005) A agg a (2004) The purpose of th s study was to understand the fu process of CSA d sc osure and how th s unfo ded for preado escent and ado escent g r s. Exam ned what fac tated and h ndered d sc osure and subsequent consequences The study sought to exam ne nf uences that nh b t or promote ch dren's d sc osure of CSA to address gaps n know edge about how, when, and under what c rcumstances v a ms of CSA d sc ose Secondary ana ys s of qua tat ve focus group data. Or g na project cons seed of four focus groups conducted w th n the context of ongo ng therapy for g r s who had exper enced CSA. Secondary am ys s cons seed of wr tten narrat ye summar es of each secs on group ng these conceptua y, and exam n ng the r nterconnectedness The study emp oyed LIM—a phenomeno og ca des gn. Intens ve ntery ew ng that were 2 hr ong on average generated data for a themat c am ys s. The ntery ew gu de was Samp e cons seed of 34 part c pants from four groups. Sess ons ana yzed were between 60 and 90 m n ong: and otaped and ater transcr bed for content am ys s Us ng purpos ye samp ng 24 adu t sun von of ntnfam a abuse between ages of 18 and 65 (average age 41.2) were recru ted from agent es and one un vers ty: 57% ma e and 43% fema 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 F nd ngs are reported n three major doma ns: ( I ) se (-phase: where ch dren come to understand v ct m at on nterna y (2) conf dant se ect on- react on phase: where they se ect a t me, p ace, and person to te and then whether that person's react on was support ve or host e: and (3) consequences phase: good and bad that cone nued to nform the r ongo ng strateg es of te ng. The act ons and react ons of adu is were s gn f cant and nformed the g r s' dec s ons. The consequences phase was further subd v ded nto four aspects: (I) 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 Through ana ys s of the ntery ew new categor es of d sc osure were dent fed to add to ex st ng types. Three prey ous y dent f ed were conf rmed n these data: acc denta purposefu . and prompted!e c ted accounted for 42% of d sc osure patterns n the study samp e. Over ha f the d sc osure patterns descr bed by the study samp e d d not f t these Th s study prov ded a contextua exam nat on of the ent re d sc osure process. c oser to the po nt n t me when the abuse and d sc osure occurred. Sma groups of preado escent and ado escent g r s who had sury ved sexua abuse a so served as consu tants and were encouraged to share the r know edge for the benef t of profess ona prate t oners Th s study expanded types of CSA d sc osures to more fu y understand how ch dren and adu is d sc ose. And under what c rcumstances. Ask ng peop e to recount events that occurred n ch dhood s suscept b e to memory ft ure. espec a y when memor es were forgotten. (continued) EFTA00024188

Table I. (tont nued) Study Purpose Des gn Samp e F nd ngs Summary Cr sma, Basce , Pac. and The ma n goa s of th s Rom to (2004) study were to understand mped menu that prevent ado escents from d sc os ng CSA and seek ng he p from the r soc a network and/or the sery ces Jonzon and L ndb ad Study purpose was to (2004) exp ore how abuse tra ts. openness, react ons to CSA d sc osure. and soc a support were re ated. D fferences based on sever ty of abuse. t m ng and outcomes of d sc osure. soc a support. and pred a ng factors of pos t ve and negat ve react ons were probed deve oped to probe for nd v dua , nterpersona . env ronmenta . and cu tura factors of uenc ng CSA d sc osure In-depth to ephone (anonymous) ntery ews were conducted after nformed consent was exp a ned and obta ned. Three nvest gators exper enced n counse ng CSA counse ng conducted the ntery ews wh ch were recorded w th perm ss on. Three researchers ndependent y scored the ntery ews accord ng to a cod ng framework Adu t women report ng CSA by someone c ose were ntery ewed us ng sem -structured gu des together w th quest onna res. Data on v a m zat on and current soc a support were retr eyed through the quest onna res, and data on d sc osure and react ons were gathered through the ntery ews w th part c pants average age of abuse onset was 6.5 years: 42% of the part c pants had d sc osed the abuse dur ng ch dhood: 58% d sc osed as adu is The samp e was compr sed of 36 young peop e who exper enced sexua abuse n ado escence: 35 fema es and I ma c aged 12-17. Some of the samp e exper enced sexua v o ence n a dat ng re at onsh p 122 adu t women between 20 and 60 years o d (average age of 41 years) report ng exposure to ch d sexua abuse by someone c ose before the age of I8 and had to d someone about at east one abuse event 90% were Swed sh subjects. Purpos ve samp ng strategy was used prey ous y estab shed categor es. Three add t ona d sc osure categor es emerged: behav ora and nd rect verba attempts. d sc osures ntent ona y w thhe d. and d sc osures tr ggered by recovered memor es The ma n mped menu to d sc ose to a fam y member were: fear of not be ng be eyed, shame, and fear of at ng troub e to the fam y. The ma n mped menu for not seek ng sery ces were: unaware of appropr ate sery ces. w sh to keep the secret. ack of awareness of be ng abused, m strust of adu ts and profess ona s. and fear of the consequences of d sc os ng sexua abuse. When they d d d sc ose to profess ona s. teens rece ved very m ted support as many profess ona s were not tra ned on sexua abuse and cou d not offer appropr ate ntervent ons co v ct ms Abuse character st a: abuse by mu t p e perpetrators was more common than by a s ng e perpetrator. Age of onset was often before age of 7. w th an average durat on of 7 years. Severe y abused women had to ked to more of the r soc a network. espec a y to profess ona s. D sc osures: 32% d sc osed dur ng ch dhood (before the age of 18) w th an average of 21 years de ay. Women who had d sc osed n ch dhood reported more nstances of phys ca abuse, mu t p e perpetrators. use of v o ence, and were more ke y to have confronted a perpetrator, and had rece ved a negat ve f rst react on. Factors de ayed. or repressed and ater recovered. D stop on and rev s on of events are a so potent a prob ems nreca . H gh degree of trustworth ness of the data was ach eyed and quotes prov ded supported the categor es Th s study represented the f nd ngs of a m xed samp e of sun von of ch d sexua abuse and nt mate partner v o ence. The study was conducted n Ita y and t s not c ear what sexua abuse response tra n ng s an ab e. There may have been a se ect on b as as the most d scat sf ed sury vors responded to the research ca 68% de ayed d sc osure unt adu thood. At the t me of the study, t was one of the f rst stud es to focus on the nterp ay between soc a support networks and d sc osure of ch d sexua abuse. The study resu u are somewhat m ted by an overrepresentat on of severe y abused women. Retrospect ve study and se f-report of nformat on cou d mp y reca ssues and thus m ts the accuracy of the nformat on obta ned on abuse and d sc osure character st a. Cross-sect ona (continued) EFTA00024189

;el a. Table I. (cont nued) Study Purpose Des gn Samp e F ndngs Summary Kogan (2004) Goodman-Brown, Ede ste n. Goodman. Jones, and Gordon (2003) The purpose of th s study was to dent fy factors that of uence the d sc osures made by fema e sury vors of USE n ch dhood and ado escence. The pred tears of both the t m ng of d sc osure and the rec pent of the d sc osure were nvest gated The purpose of th s study was to nvest gate var ab es assoc ated w th de ay of d sc osure of CSA and test a mode for factors that of uence how qu ck y ch dren d sc ose sexua abuse Data were gathered from a subsamp e of fema e ado escents that part c pared n the NSA, wh ch cons sted of structured phone ntery ews. USES reported n the NSA were assessed us ng a mod f ed vers on of the Inc dent C ass f cat on Intent ew. They were then asked a ser es of quest ons about each ep sode of unwanted sexua contact nc ud ng event character st a and perpetrator character st a Case f e rev ews of data obta ned from prosecut on f es, as we as from structured ntery ews w th the ch dren 's caretaker and observat ons of ch d ntery ews. Tn ned graduate students and one v ct m advocate comp eted the Sexua Assau t Prof e A subsamp e of 263 ado escent fema es between 12 and 17 years o d, mean age of 15.2 years o d, who reported at east one exper ence of unwanted sexua contact n the NSA. Part c pant character st a. USE character st a. and fam y contextua attr butes were exp ored Samp e cons sted of 218 dr dren referred to prosecutors' off ces for a eged CSA. A ch dren n the samp e had d sc osed the r abuse n some manner. Ch dren ranged n age from 2 to I6 years at the beg nn ng of abuse; 3-16 years at the end of the abuse, and 4-16 years at the t me of the s gn f cant y pred ct ng de ay were younger age at f rst event and no use of v o ence. D sc osure outcomes: of the 26 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 Ch dren under the age of 7 were at a h gher r sk for de ayed d sc osures. Part c pants whose USE occurred between the ages of 7 and 13 were most key to te an adu t. Ado escents (14- 17) were more ke y to te on y peers than ch dren aged 7-10 years. Ch dren under II were more ke y to te an adu t. but were at r sk for de ay ng d sc osure beyond a month. Ch dren aged II-13 tended to d sc ose w th n a month. C oser re at onsh p to the perpetrator or a fam y member was assoc ated w th de ayed d sc osure. Immed ate d sc osure was more ke y w th stranger perpetrat on. Fear for ones fe dur ng and penetrat on were assoc ated w th d sc osure to adu ts. Fam y factors nked to d sc osure were (I) drug abus ng househo d member, wh ch made sury von more key to d sc ose more prompt y and (2) never v ng w th both parents was assoc ated w th nond sc osure 64% d sc osed w th n a month and 29% w th n 6 months. F ve var ab es for the mode were tested. (I) age: ch dren who were o der took onger to d sc ose and o der ch dren feared more negat ve consequences to others than younger ch dren: (2) type of abuse: v ct ms of ntrafam a fam es took onger to d sc ose—v ct ms of ntrafam a abuse feared greater negat ye consequences to others compared to v ct ms of extrafam a abuse: (3) fear of negat ve consequences: ch dren who feared des gn does not a ow for def n te conc us ons of cause and effect on the re at onsh ps found Th s study exam ned factors nc ud ng d sc osures of USES n ch dhood and ado escence n a nat ona y representat ye samp e of fema e ado escents who part c pared n the NSA. Surveys for nvest gat ons of v ct m zat on exper ences may be b ased due to underreport ng. Ado escents who refused to report or d scuss an USE may represent a source of systemat c b as and wou d make the resu ts genera zab e on y to ado escents who are w ng to d sc ose USE v a survey. A though data may be retrospect ye, reca b as may have been m n m zed n th s study s nce part c pants were ado escents. and so the t me ag between the USE and the ntery ew were presumab y shorter than a study of adu t part c pants reca ng CSA exper ences Th s study represents a h gher rate of d sc osers w th n a month. These cases had been reported to author t es and were n process of prosecut on wh ch may exp a n h gher rate of ear y d sc osures. Lega samp e w th h gher rate of extrafam a abuse (52%) may a so account for ear er d sc osures. Mode suggests that o der ch dren, v ct ms of ntrafam a abuse: fe t greater respons b ty for the abuse, and perce v ng (continued) EFTA00024190

Table 1. (coot nued) Study Purpose Des gn Samp e F nd ngs Summary Sm th. Letourneau. Saunders, K paw ck. Resn ck and Best (2000) The study focus was to gather data from a arge samp e of women about the ength of t me women who were raped before age 18 de ayed d sc osure who they d sc osed to. and var ab es that pred cted d sc osure w th n I month quest onna re for ch d character st cs. the abuse and the r d sc osure. Ch dren's percept on of respons b ty and fear of negat ve consequences were probed. Corre at ona ana yses were conducted w th path ana yses to test the hypothes zed causa re at ons among var ab es Structured te ephone ntery ews that asted approx mate y 35 m n were used to co ect data us ng a computer- ass sted te ephone ntery ew system. A te ephone ntery ews were conducted w th each quest on on a computer screen. The survey cons sted of seven measures des gned toe ct demograph c nformat on. psych atr c symptoms. substance use, and v ct m zat on h story. The present study reports on data from the demograph c and ch d rape v a m zat on quest ons n t a po ce report: 77% fema e. 70% Caucas an. 17% H span c. and I I% Mr can Amer can. Predom nant y m dd e to ow SES. Approx mate y 47% ntrafam a abuse Two probab ty samp es. Wave I was a random samp e of 2.009 respondents se ected from stmt fed samp es of def ned jur sd ct ons. Random d g ta d a rig was used to so c t househo ds for seed and un seed te ephone numbers. Second random samp e of 2.000 women between the ages of 18 and 34 Was se ected. Both Wave I and Wave 2 data were we ghted to conform to the 1989 Census stat st a negat ve consequences of d se osure took onger to d sc ose, ch dren who be eyed that the r d sc osure wou d br ng harm to others took onger to d sc ose, fear of negat ye consequences to the se f or the perpetrator was unre ated to t me of d sc osure. and g r s more than boys feared negat ye consequences to others: (4) Perce ved respons b ty: ch dren who fe t greater respons b ty for the abuse took onger to d sc ose and o der ch dren fe t more respons b ty for the abuse: and (5) gender was not s gn f cant y corre ated w th t me to d sc osure 288 (9%) reported exper enc ng at east one event that met the study's def n t on of ch dhood rape. The average age at the t me of the f rst rape was 10.9 years. Of the 288 women who reported a ch d rape. 28% stated that they had never to d anyone about th s sexua assau t unt spec f a y quer ed by the ntery ewer for th s study. 58% d d not d sc ose for over 1 year and up to 5 years post-rape. 27% d sc osed w th n a month. Among women who d sc osed pr or to the r NWS ntery ew c ose fr ends were the most common person to whom v a ms made d sc °sures, fo owed by mothers and other mmed ate fam y members. Fewer than 10% of ir a ms reported mak ng the r nta dsc osure to soc a workers or aw enforcement personne . On y 12% of ch d rape v ct ms stated that the r assau is were reported to author t es at some po nt negat ve consequences to d sc os ng took onger to d sc on. We -des gned study w th h gh eve of r gor. Produced a v ab e mode of d sc osure for further nvest gat ons. However. researchers were not ab e to ntery ew ch dren d rect y The t me frame of th s survey may have had contextua mp cat ons. The major ty of ch d rapes reported by th s samp e occurred pr or to the arge-sca e ch d assau t prevent on educat on programs that were begun n the I 980s that teach ch dren that assau is ( nc ud ng CSA) are wrong and Thou d be d sc osed to respons b e adu u. Th s nformat on may have nf uenced (and may current y be nf uenc ng) young women's d sc osure patterns. For Wave I, compar son of these data w th the popu at on parameters obta ned from the U.S. Census Bureau nd cated that the samp e c ose y matched the demograph c attr butes of the popu at on of U.S. women 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, interview guides, and surveys examined: "How and when do people decide to tell others about their early sexual experiences with adults?" (Hunter, 2011, p. 161); "Some men take many years to tell someone that they were sexually abused. Please describe why it may be difficult for men to tell about/discuss the sexual abuse" (Easton, Saltzman, & Willis, 2014, p. 462). "Participants were asked a series of open-ended questions to elicit a narrative regarding their experiences of telling..." (McElvaney, Greene, & Hogan, 2012, p. 1160). "Who was the first person you told?" (Schaeffer, Leventhal, & Anes, 2011, p. 346). There was sound consistency between studies, defining dis- closure in multifaceted ways with uniform use of categories of prompted, purposeful, withheld, accidental, direct, and indi- rect. However, defining the period of time that would delineate a disclosure as delayed varied widely across studies, wherein some studies viewed I week or I month as a delayed disclosure (i.e., Hershkowitz et al., 2007; Kogan, 2004; Schembucher, Maier, Moher-Kuo, Schnyder, & Lamdolt, 2012). Other studies simply reported average years of delay sometimes as long as from 20 to 46 years (Easton, 2013; Jonzon & Linblad, 2004; 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 previous dearth of qualitative studies. Based on Jones's (2000) observation that disclosure factors and outcomes had been well documented through quantitative methods; in a widely read editorial, he recommended "Qualitative studies which are able to track the individual experiences of children and their percep- tion of the influences upon them which led to their disclosure of information are needed to complement ... " (p. 270). Third, although a few studies strived to obtain representative samples in quantitative investigations (Hershkowitz, Horowitz, & Lamb, 2005; Kogan, 2004; Smith et al., 2000), sampling was for the most part convenience based, relying on voluntary par- ticipation in surveys and consent-based participation in file reviews (Collings, Griffiths, & Kumalo, 2005; Priebe & Sve- din, 2008; Schembucher et al., 2012; Ungar, Barter, McConnell, Tutty, & Fairholm, 2009a). Therefore, generalizability of find- ings is understandably limited. The qualitative studies used purposive sampling as is deemed appropriate for transferability of findings to similar populations. Some of those samples con- tained unique characteristics, since they were sought through counseling centers or sexual advocacy groups. These would be considered clinical samples producing results based on disclo- sures that may have been delayed or problematic. This might presumably produce data skewed toward bathers and bring fonvard less information on disclosure facilitators. Through an in-depth, second-level analysis, this review identified five distinct themes and subthemes beyond the gen- eral trends as noted earlier. Theme 1: Disclosure is viewed as an ongoing process as opposed to a discrete event—iterative and interactive in nature. A subtheme was identified regarding disclosure as being facilitated within a dialogical and relational context is being more clearly delineated. Theme 2: Contemporary disclosure models reflect a social—ecological, person-in-environment perspective to understand the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure. Subthemes include new categories of disclosure and a grow- ing focus on previously missing cultural and contextual factors. Theme 3: Age and gender are strong predictors for delaying disclosure or withholding disclosure with trends showing fewer disclosures by younger children and boys. One sub- theme emerged that intrafamilial abuse/family-like relation- ship of perpetrator has a bearing on disclosure delays or withholding. Theme 4: There is a lack of a cohesive life-course perspec- tive. One subtheme includes the lack of data within the 18- to 24-year-old emerging adult population. Theme 5: Significantly more information is available on barriers than on facilitators of CSA disclosure. Subthemes of shame, self-blame, and fear are uniformly identified as disclosure deterrents. Disclosure as an ongoing process: Iterative and interactive in nature. Disclosure is now generally accepted as a complex and lifelong process, with current trends showing that CSA disclosures are too often delayed until adulthood (Collin-Vezina et al., 2015; Easton, 2013; Hunter, 2011). Knowledge building about CSA disclosure has moved in the direction of understanding this as an iterative and interactive process rather than a discrete, one- time event. Since the new millennium, disclosure is being viewed as a dynamic, rather than static, process and described "not as a single event but rather a carefully measured process" (Alaggia, 2005, p. 455). The catalyst for this view originates from Summit (I 983) who initially conceptualized CSA disclo- sures as process based, although this notion was not fully explored until several years later. Examinations of Summit's (1983) groundbreaking proposition of the CSA accommodation (CSAA) model produced varying results as to whether his five stages of secrecy, helplessness, entrapment and accommoda- tion, delayed, conflicted, and unconvincing disclosures, and retraction or recantation, hold validity (for a review, see Lon- don, Bruck, Ceci, & Shuman, 2005). However, the idea of disclosure as a process has been carried over into contemporary thinking. Recently, McElvaney, Greene, and Hogan (2012) detailed a process model of disclosure wherein they describe an interac- tion of internal factors with external motivators which they liken to a "pressure cooker" effect, preceded by a period of containment of the secret. Moreover, this and other studies strongly suggest disclosures are more likely to occur within a dialogical context—activated by discussions of abuse or pre- vention forums providing information about sexual abuse (Hershkowitz et al., 2005; Jensen, Gulbrandsen, Mossige, Reichelt, & Tjersland, 2005; Ungar et al., 2009a). The term EFTA00024192

Maggie et al. 277 dialogical simply means to participate in dialogue. Key dialo- gical vehicles identified in these studies were providing sexual abuse information through prevention programs, being asked about sexual abuse, and being prompted to tell (McElvaney et al., 2012; Ungar et al., 2009a). Contemporary models of CSA disclosure reflect a social cological perspective. Knowledge on CSA disclosure has been steadily advancing toward a holistic understanding of the complex interplay of individual, familial, contextual, and cultural fac- tors (Alaggia & Kirshenbaum, 2005; Brazelton, 2015; Fontes & Plummer, 2010). Where at one time factors examined and identified were predominantly of intrapersonal factors of child victims, knowledge construction has shifted to fuller social— ecological, person-in-environment explanations (Alaggia, 2010; Collin-Vezina et al., 2015; Easton et al., 2014; Hunter, 2011; Ungar, Tutty, McConnell, Barter, & Fairholm, 2009b). Social-ecological explanations open up more opportunities to intervene in facilitating earlier disclosures. Alaggia (2010) pro- poses an ecological mapping of what individual, interpersonal, environmental, and contextual influences impede or promote CSA disclosures based on analysis of in-depth interview data of 40 adult survivors. Subsequently, based on a sample of 67 adult survivors, Collin-Vezina, Sablonni, Palmer, and Milne (2015) identified three broad categories, closely aligned with an eco- logical framework that impede CSA disclosure: (1) barriers from within, (2) barriers in relation to others, and (3) bathers in relation to the social world which can be aligned to intra- personal, interpersonal, and contextual factors. A summary of knowledge building using a social—ecologi- cal framework follows. Knowledge gained in the intrapersonal domain includes expanded conceptualization of disclosure by building on previous categories of accidental, purposeful, and prompted disclosure to also include behavioral and indirect attempts to tell, intentionally withheld disclosure, and triggered and recovered memories (Alaggia, 2004). Categories of indi- rect behavioral disclosure patterns have been further verified in follow-up research by Hunter (2011), and through an extensive file review that used Alaggia's (2004) disclosure framework to analyze their data (Collings et al., 2005) for verification. Interpersonal factors have also emerged in regard to certain family characteristics as disclosure barriers. Families with rigidly fixed gender roles, patriarchal attitudes, power imbal- ances, other forms of child abuse and domestic violence, chao- tic family structure, dysfunctional communication, and social isolation have been found to suppress disclosure (Alaggia Kirshenbaum, 2005; Collin-Vezina et al., 2015; Fontes & Plummer, 2010). In addition, relationship with perpetrator is a factor whereby research indicates that disclosure is made more difficult when the perpetrator is a family member or close to the family (Dumont, Messerschmitt, Vila, Bohu, & Rey- Salmon, 20 I 4;Easton, 2013; Goodman-Brown et al., 2003; Hershkowitz et al., 2005; Priebe & Svedin, 2008; Schanbucher et al., 2012). This is especially a barrier when the perpetrator lives with the victim (LeClerc & Wortley, 2015). In terms of environmental factors, one study revealed that neighborhood/community conditions can hinder disclosure when there is lack of school involvement in providing a sup- portive environment, such as in following up on troubling stu- 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 neighbors or other community members, has shown to deter disclosure (Collin-Vezina et al., 2015). Cultural factors influencing CSA disclosure have been stud- ied to a much lesser degree. Despite this, a few important studies examining critical sociocultural factors now exist for better understanding CSA disclosure within a cultural context (Brazelton, 2015; Fontes & Plummer, 2010). Among these important contributions, Brazelton's (2015) research has deli- neated CSA disclosure processes as "shaped by relational, racial, socio-cultural, historical, and developmental factors" (p. 182). In a unique study using culturally focused research literature as data triangulated with clinical case material, cul- turally based belief systems in many cultures have been found to foster family climates that can silence children from disclos- ing abuse (Fontes & Plummer, 2010). Taboos about sexuality, patriarchal attitudes, and devaluation of women are among some of the cultural barriers that inhibit disclosure (Fontes & Plummer, 2010). Clearly, disclosure conceptualizations are being integrated into a social—ecological model of individual and developmental factors, family dynamics, neighborhood, and community con- text as well as cultural and societal attitudes toward better understanding disclosure barriers and facilitators (Alaggia, 2010), although more data are needed on cultural and contex- tual factors. Age and gender as predictors of disclosure Age. Age is consistently found to be an influential factor in CSA disclosure, making the life stage of the victim/survivor a critical consideration. Studies draw distinctions in age-groups falling into either under or over 18 years of age. Eighteen years of age was the common age cutoff point that investigators chose in order to distinguish child/youth populations from adult sam- ples. Sixteen of the studies drew on samples of children and youth, while the other 15 studies sampled adults over the age of 18, and a further two studies used mixed age-groups (refer to Table I). Among the child and youth samples, the age ranges spanned from preschool to late adolescence (3-17 years of age), with varying methodological approaches implemented across age cohorts. For younger cohorts, file reviews and secondary data analyses of CSA reports were typically undertaken. Ado- lescents were most often given surveys. Sometimes children and youth were interviewed as part of administering a survey or as a follow-up (Crisma et al., 2004; Hershkowitz et al., 2005; Ungar et al., 200%). In the majority of child and adolescent samples, sexual abuse concerns were already flagged to investigative authorities. However, the work of Ungar, Barter, McConnell, Tutty, and Fairholm (2009a, 200%) is one exception, whereby their survey elicited new disclosures. EFTA00024193

278 TRAUMA, VIOLENCE, & ABUSE 20(2) Adult studies typically had a mean age between 40 and 50 years. Interviews were the main data collection method with a few exceptions using survey designs (i.e., Easton, 2013; Kogan, 2004; Smith et al., 2000) and case file reviews (i.e., Collings et al., 2005; Goodman-Brown et al., 2003). Results show a clear trend toward increased likelihood of disclosure in older youth, and findings from adult samples showing a preponderance of disclosures in adulthood, with the large majority of participants of adults reporting never having had a sexual abuse complaint filed with investigative authorities as a child or an adolescent (i.e., Hunter, 2011; Gagnier & Collin-Vezina, 2016; Sorsoli, Kia-Keating, & Grossman, 2008; Ungar et al., 200%). With children and youth under the ages of 18 distinct patterns emerged. First, accidental detection, rather than purposeful disclosure, is more likely to occur with younger children. For example, in one large-scale study of over 1,737 file reviews, over half of the CSA-related cases were identified through accidental and eyewitness detection (61%), while less than one third were purposeful disclosures initiated by the child victim (Collings et al., 2005). A second pattern which emerged is that rates of disclosure increase with age, especially into adulthood, which is supported by persistent findings of high rates of delayed disclosure reported later in the life course by adult survivors (Collings et al., 2005; Collin-Vezina et al., 2015 ; Easton, 2013; Jonzon & Linblad, 2004; Kogan, 2004; Leclerc & Wortley, 2015; Sorsoli et al., 2008). While gender and relationship with the perpetrator are considerable factors in CSA disclosure, age is consistently a stronger predictor of disclosure (or nondisclosure) (Hershko- witz et al., 2005; Leclerc & Wortley, 2015). Third, younger children who disclose are more likely to do so in an interview situation or other environment that provides prompts or questions about sexual abuse (Hershkowitz et al., 2005; McElvaney, Greene, & Hogan, 2014; Schaeffer et al., 2011), but this trend can also be seen in older youth (Ungar et al., 2009a, 2009b). Gender. A number of studies have recently focused on CSA disclosures with male victims, since males have been an under- studied population (Alaggia, 2005; Easton, 2013; Easton et al., 2014; Gagnier & Collin-Vezina, 2016). Most investigations that sampled both sexes show females outweighing male parti- cipants. Although women are at double the risk of being sub- jected to CSA, the ratio of women to men in most disclosure studies has not been representative. This finding may be indi- cative of male victims more likely delaying disclosing their CSA experiences, leaving male disclosure in child and youth samples underrepresented (Hebert, Tourigny, Cyr, McDuff, & Joly, 2009; Ungar et al., 2009b). Easton, Saltzman, and Willis (2014) have been developing gender-specific modeling of disclosure examining male disclo- sures. Their proposed model groups male disclosures into barrier categories as determined by individual factors, interpersonal issues, and factors that are sociopolitical in nature. These authors suggest that predominant gender norms around masculinity rein- force the tendency for male victims of CSA to blame themselves for the abuse, resulting in no disclosure. Male participants in a subsequent study also relayed that gender norms and stereotypes contributed to them concealing the abuse because they were abused by a woman (Gagnier & Collin-Vezina, 2016). In the one study that compared male and female disclosures, investigator found that men's fears of being viewed as homosexual; profound feelings of stigmatization or isolation because of the belief that boys are rarely victimized; and fear of becoming an abuser acted as disclosure barriers. Whereas females felt more conflicted about who was responsible for the abuse and more strongly anticipated being blamed and not believed (Alaggia, 2005). Lack of a life-course perspective. Given that the study of CSA disclosure draws on age-groups ranging from samples of very young children to retrospective studies of adult survivors, with significant developmental considerations, this area of study lacks an intentional cohesive life-course perspective. Most data are derived from either cross-sectional or retrospective designs, with few longitudinal studies. There are a series of sound, yet disconnected, studies focusing on specific age-groups of chil- dren and adolescents, along with adult retrospective studies. Thus, the available knowledge base does not allow for a cohe- sive picture of CSA disclosure processes and pathways over the life course to emerge. The life-course perspective has long been recommended as a critical lens for the study of child abuse (Browning & Lau- mann, 1997; Williams, 2003). For example, a life-course per- spective has been utilized to understand the immediate- and long-term effects of CSA on the developing child victim (Browning & Laumann, 1997). Further, a life-course perspec- tive is important in terms of examining age of onset of CSA to explain the differential effects of sexual victimization and developmental impacts in terms of understanding their ability to disclose—effects that need to be understood within a devel- opmental context, especially for designing appropriate inter- ventions for disclosure at critical transitions from early childhood through to adolescence and into adulthood. In addi- tion, important "turning points" in life may facilitate disclo- sures. For example, entry into adulthood given that delayed disclosure occurs more often in adulthood. Alaggia (2004, 2005) found that being in a committed relationship or the birth of children acted as facilitators for some survivors to disclose, especially to their spouses. These significant life events, as contributing to disclosures, bear further examination. Summary of barriers and facilitators. Research over the past 15 years continues to uncover barriers to CSA disclosure at a higher frequency than that of facilitators. As stated previously, this might be the result of sampling methods whereby partici- pants who volunteer for disclosure research may have had more negative disclosure experiences, especially since many report delays in disclosure. The following section outlines the major trends in both barriers and facilitators (see Table 2). Barriers. Age and gender were found to contribute to barriers 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 disclose. Gender: Males may be less likely to disclose in childhood/adolescence, fear of being seen as homosexual and as a victim, females experience more self blame and anticipation of being blamed and/or not believed Relationship to perpetrator: If the perpetrator is a family member or in a family like role. disclosure is less likely to happen Internal: Shame, self blame, and fear are psychological barriers. In addition, fear of negative consequences on the family and for self safety inhibits disclosure Family relations: families with a patriarchal structure, rigidly fixed gender roles, dysfunctional communication. other forms of abuse (i.e.. domestic violence), and isolation inhibit disclosure Environmental and cultural context Lack of discussion about sexuality; passive acceptance that unwanted sexual experiences are inevitable; 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 Age: Disclosures Increase with age. especially in adulthood. Gender. Slight trend toward females who are older (adolescent) to disclose before adulthood Relationship to perpetrator: If the perpetrator is not living with the victim, disclosure rates increase Dialogical context Opportunities to disclose through discussion. therapeutic relationship, information sessions on sexuality, and sexual abuse prevention programs Family relations: Supportive parent-child relationship. Involvement of others: Eyewitnesses coming forward and reporting: detection through community members, professionals Environmental and cultural context: Promotion of open discussion of sexuality; community member involvement as children gain more developmental capacity, understanding of sexual abuse as victimization, and increased independence. Males are somewhat less likely to disclose, but this is often in interaction with other factors in the environment such as soci- etal attitudes that promote hypermasculinity as desirable, atti- tudes that perpetuate negative views of boys and men who are victims, and homophobic attitudes (Alaggia, 2010; Easton et al., 2014; Gagnier & Collin-Vezina, 2016). Victims of intrafamilial abuse when the offender is a parent, caregiver, significant family member, or someone in a family- like role are less likely to disclose immediately or at all in childhood/adolescence because of obvious power differentials and dependency needs (Collings et al., 2005; Dumont et al., 2014; Hershkowitz et al., 2005; Kogan, 2004; Leclerc & Wort- ley, 2015; Paine & Hansen, 2002; Schaeffer et al., 2011). Further, the perpetrator residing with their victim(s) increases the likelihood of no disclosure (Leclerc & Wortley, 2015). Internalized victim-blaming, mechanisms to protect oneself (such as minimizing the impact of the abuse), and developmen- tal immaturity at the onset of abuse constituted internal bar- riers. Further, shame, self-blame, and fear have been identified as significant factors deterring disclosure (Collin-Vezina et al., 2015; Crisma et al., 2004; Goodman-Brown et al., 2003; Hun- ter, 2011; Kogan, 2004; McElvaney & Culhane, 2015; McEl- vaney et al., 2014). However, aspects of shame, self-blame and fear, and have not been fully explored in research. Since these are strong predictors of disclosure suppression, they bear fur- ther examination in future research to understand more fully how they operate in disclosure processes. In terms of interpersonal and environmental factors, family dynamics can play a part in deterring disclosure. As previously mentioned, families characterized by rigidly defined gender roles, patriarchal attitudes that perpetuate power imbalances between men and women, parents and children, presence of other forms of child abuse and/or domestic violence, chaotic family structure, dysfunctional communication, and social iso- lation have been found to suppress disclosure (Alaggia & Kir- shenbaum, 2005; Collin-Vezina et al., 2015; Fontes & Plummer, 2010). In regard to broader environmental factors, disclosure can be hindered when involved and supportive com- munity members are not available, or not trained in sensitive responses, or when child victims anticipate not being believed by neighbors and other people outside the family (Alaggia, 2010; Collin-Vezina et al., 2015). Further, barriers in relation to the social world were identified as stigmatization, the neg- ative labeling of sexual abuse victims, and taboos surrounding sexuality and talking about sex as driven by cultural norms (Collin-Vezina et al., 2015; Fontes & Plummer, 2010). Identification of cultural barriers is important recent contri- bution to understanding disclosure processes—and in particular to the obstacles. Findings related to cultural barriers included themes of children's voices not being heard leading to silen- cing, the normalization of the sexualization and objectification of girls and women, and the perpetuation of hypermasculinity in men—all acting as barriers in terms of stigma to disclosure (Alaggia, 2005, 2010; Easton et al., 2014). Brazelton (2015) similarly found that lack of discussions about sex, young age at the onset of sexual abuse, therefore not having the language to express what was happening to them, and preserving the family good name by not talking about abuse in the family were also barriers to disclosure. Finally, it may be the case that more barriers continue to be identified over facilitators of CSA disclosure perhaps because of the methods employed in studies—particularly those draw- ing on adult populations who delayed disclosure. These sam- ples may not be representative of the overall population of CSA victims, since they may have had more negative disclosure EFTA00024195

280 TRAUMA, VIOLENCE, & ABUSE 20(2) experiences, consequently more readily identifying barriers. On the other hand, these findings may speak to the actual imbalance between facilitating factors and barriers for disclo- sure, the latter carrying more weight in the victims/survivors' experiences, thus, explaining the high rates of disclosures delayed until adulthood. Facilitators. Although fewer disclosure facilitators are identi- fied in this review, very important facilitators were nonetheless uncovered—ones that should be noted for professionals in this field of practice. Internal factors that facilitate disclosures include symptoms that become unbearable, getting older with increased developmental efficacy, and realizing that an offence was committed (Collin-Vezina et al., 2015; Crisma et al., 2004; Easton, 2013; Hershkowitz et al. 2007; McElavaney, Greene, & Hogan, 2014; Schaeffer et al., 2011). Circumstantial facil- itators are those where the child discloses because there has been evidence provided, eye-witnessing has occurred, and a report has been made. Environmental factors include settings that provide opportunities such as counseling, interviews, information sessions and educational forumsAvorIcshops, and prevention programs for children and youth to disclose. To elaborate, dialogical contexts about CSA for children and youth can provide opportunities for discussion that may facilitate disclosures (Jensen et al., 2005). The research shows creating open dialogue in relationship contexts, to offset the power and influence of the perpetrator, can facilitate earlier disclosure. Among disclosure facilitators is being asked about abuse and given the opportunity to "tell" (McElavaney et al., 2014); workshops on abuse and sexual abuse, in particular, can facilitate disclosures (Ungar et al., 2009b); and using culturally sensitive probes and questions (Fontes & Plummer, 2010). In Gagnier and Collin-Vezina's (2016) study, positive disclosure experiences were described by participants as those where they felt that they had been listened to, were safe, were believed, and were not judged by the person they disclosed to. Further, family members and friends (peers) of the child victim can act as key supports to creating an open relational context and fostering positive responses (Jensen et al., 2005; Priebe & Svedin, 2008; Schonbucher et al., 2012; Ungar et al., 20096). In particular, as children grow older, they are more likely to disclose to a peer, as shown in a number of studies, and this is an important reality for counselors and educators to be aware of (Dumont et al., 2014; Kogan, 2004; Sclainbucher et al., 2012; Ungar et al., 2009b). Discussion Through examination of 33 studies published since the year 2000, this review identified five distinct themes regarding CSA disclosure: (1) Disclosure is best viewed as an iterative, interactive process rather than a discrete event done within a relational context; (2) contemporary models reflect a social—ecological, person-in-environment framework for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure; (3) age and gender are significant disclosure factors; (4) there is a lack of a life-course perspective; and (5) barriers to disclo- sure continue to outweigh facilitators. Based on these themes, a number of conclusions are drawn from this review. First, dis- closure as a process is emphasized throughout contemporary research. Advances have been made in understanding these complex processes. However, the disclosure process over time—for example, how the first detection of CSA or attempts to disclose in childhood impact later disclosures—are not well understood. This is the result of the absence of a cohesive life- course perspective in investigations, although age consistently surfaces as significantly influencing CSA disclosure. Using a life-course perspective through the use of longitudinal studies is recommended. The use of varied methodological designs, depending on the developmental stage of the victims/survivors, influences the data generated and subsequent findings. For example, most studies on children and youth are based on file reviews of cases that have been brought to the attention of authorities, or sur- veys, with only a few studies using interviewing of younger children. Therefore, there is less information available on pro- cess issues with children and youth. In contrast, research on adult populations largely favors the use of qualitative interview methods for retrospective inquiry producing important process findings. In addition, investigations have not yet captured the disclosure experiences of adults in the "emerging adult" stage given that adult studies have failed to recognized that the age range of 18-24, which is now considered a developmental phase defined by neurobiological developmental uniqueness. As well, late adulthood has not been given attention as shown by the absence of participants representing this age-group in current research (70+). With a swelling geriatric population in North America, issues of historic CSA can be expected to surface and, with that, new disclosures. This trend is also antici- pated due to attitudinal shifts that have presumably occurred over the last two generations about revealing such traumas and changing views about discussing sexual victimization. Interview guides used in a number of studies intentionally probed for facilitators, producing notable findings. For exam- ple, one such finding focuses on the importance of creating a contextually supportive environment to promote disclosure across the life course. These include developing therapeutic relational contexts for disclosure by providing information about sexuality, sexual abuse, prevention programming, and 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 problematic in legal settings, seriously compromising testimo- nies for trial proceedings. This is one example that speaks to the structural barriers victims and survivors run up against time and time again. Facilitators that show evidence to promote disclo- sure in one domain (therapeutic) are seen to work against CSA survivors in another domain—such as legal settings when per- petrators face prosecution. Defense attorneys will use this as evidence that the disclosure was prompted, and therefore the 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 perpetrator through media outlets, often sensationalized, become a further compounding barrier. Given the review find- ings, we conclude that barriers and facilitators to CSA disclo- sures are nuanced and clearly embedded within intrapersonal, interpersonal, environmental, contextual, and cultural domains—often interlocked in complex ways. Limitations Although comprehensive in nature with its life-course cover- age, this review may be limited by its qualitative, thematic focus rather than providing an evaluative, quantitative account- ing of CSA disclosures. However, because of the recent focus on disclosure processes, the authors chose a suitably compati- ble approach—qualitative in nature. As well, a traditional checklist approach in rating the studies was not employed for interrater reliability, since two of the authors hold expertise in CSA disclosure research and are well versed with the literature. This expertise, and through closely following a systematic review framework (Kiteley & Stogdon, 2014), assures that a thorough adjudication of the research literature was completed. Implications for Research and Practice These review findings have implications that can be useful in guiding future research and practice: • Solid strides are being made in the use of a social—eco- logical framework to underpin investigations in the CSA disclosure investigations. Research efforts and practice considerations should continue in this vein. Investigat- ing environmental factors and contextual and cultural forces is understudied, necessitating more research in these areas to more fully fill out understanding of CSA disclosure from a social—ecological perspective. • There is good evidence that CSA disclosures are more likely to occur in a dialogical context—formal helping relationships but as well as other relationships such as peers and trusted adults. Providing information and edu- cation on topics of sexuality in general, and sexual abuse specifically, can help children and youth to disclose. Raising awareness and prevention programs can pro- mote disclosures of sexual violence committed against children and youth. • Goals of therapeutically supported disclosures (i.e., through therapy) may need to take precedence over for- ensic approaches, if well-being of child victims and adult survivors is to be made paramount. Legal pro- cesses may act to facilitate disclosures but can also act as barriers because of the negative outcomes experi- enced in the court process. • Practitioners need to keep in mind that the legal system is lagging far behind in knowledge uptake of recent evidence on CSA disclosures so that victims and survivors continue to be systemically and structurally disadvantaged in legal proceedings. • Health-care practitioners (i.e., child abuse pediatricians, family practice doctors, clinical nurse specialists, and public health nurses) should be made aware of the evi- dence in the CSA disclosure literature to create environ- ments for facilitating therapeutic disclosures. • Given that age is a stable predictor of disclosure of CSA, more studies are needed that make use of a life-course perspective. More longitudinal studies are needed to better identify trends over different life stages. • The emerging young adult as a developmental age group needs specific investigation. Neuroscience research has established that ages 18-24 is a distinct developmental phase. Late adulthood is another life stage that deserves to be researched. • Gender needs to be more fully investigated in relation to impact on disclosure. Awareness that boys and girls have unique challenges and barriers in disclosing CSA should be paramount for practitioners. • Intervention planning should take note that disclosures increase when perpetrators no longer reside with vic- tims, and this finding should be heeded by policy and law makers. • Shame, self-blame, and fear are intrapersonal factors that persistently emerge as barriers to CSA disclosures and warrant more research to understand how to redress these barriers for earlier disclosures. Conclusion There are still a substantial number of children and youth who are subjected to sexual abuse, despite preventative efforts. Just as concerning is the fact that many victims continue to suffer in silence as evidenced by the high num- bers of delayed disclosure. These hidden cases should not be overlooked, and these victims should not be forgotten. Despite significant progress in bringing the issue of CSA to the forefront, improving facilitation of disclosure and increasing positive influences on disclosure processes are still critical in order to protect current and future genera- tions of children and youth from the grave effects of sexual violence. Further, the focus should not be simply on strengthening and shoring up intrapersonal resources of vic- tims to disclose but rather to change environmental condi- tions to create a more supportive and safer context for CSA victims and survivors to disclose. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research. author ship, and/or publication of this article. EFTA00024197

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Retrieved from the Statistics Canada website httplAvww.statcan.gc.ca/pub/85 002 x/2013001/ article/11854 eng.htm#n2 Stoltenborgh, M., van Uzendoom, M. II., Fuser, E. M., & Balcemtans Kranenburg, M. (2011). A global perspective on child sexual abuse: Meta analysis of prevalence around the world. Child Mal treatment, 16, 79 101. doi:10.1177/1077559511403920 Summit, R. C. (1983). The sexual abuse accommodation syndrome. Child Abuse & Neglect, 7, 177 193. Tener, D., & Murphy, S. (2015). Adult disclosure of child sexual abuse. Trauma, Violence & Abuse, 16, 391 400. Trocme, N., Fallon, B., MacLaurin, B., Daciuk, J., Felstiner, C., Black, T., ... Cloutier, R. (2005). Canadian incidence study of reported child abuse and neglect 2003: Major findings. Ottawa: Minister of Public Works and Government Services Canada. Trocme, N., Fallon, B., MacLaurin, B., Sinha, V., Black, T., Fast, E., ... Holroyd, J. (2008). Characteristics of substantiated maltreatment. Canadian incidence study of reported child abuse and neglect: Major findings (Chapter 4). Retrieved from http:// www.phac aspc.gc.ca/cm vee/public eng.php Ungar, M., Baxter, K., McConnell, S. M., Tutty, L. M., & Fairholm, J. (2009a). Patterns of abuse disclosure among youth. Qualitative Social Work, 8, 341 356. Ungar, M., Tutty, L. M., McConnell, S., Barer, K., & Fairholm, J. (2009b). What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33, 699 708. Williams, L. M. (2003). Understanding child abuse and violence against women: A life course perspective. Journal of Interpersonal Violence, 18,441 451. Author Biographies Ramona Alaggia, MSW, PhD, is an associate professor in social work and the Factor Inwentash Chair in Children's Mental Health at the University of Toronto. Iler teaching and research focuses on gender and violence, sexual abuse disclosures, domestic violence exposure, and resilience processes. Delphine Collin-Vezina, PhD, is an associate professor for School of Social Work, McGill University and director for Centre for Research on Children and Families. She holds the Nicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in Community and the Canada Research Chair (Tier II) in Child Welfare. Her work focuses on research and clinical topics related to child maltreatment, child sexual abuse, and trauma. Rusan Lateef, MSW, is a social worker employed in the criminal justice system with adult male offenders in Ontario, Canada. She specializes in the intersection of health and mental health, child sexual abuse disclosures, and she is a researcher on the "Make Resilience Matter" project examining childhood exposure to domestic violence with Dr. Alaggia at the Factor Inwentash Faculty of Social Work, 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 Sexual Abuse: Delays, 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 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 of adults in both informal and formal networks, and the opportunities to tell, is key to helping young people speak more promptly about their experiences of sexual abuse. Copyright O 2013 John Wiley & Sons, Ltd. 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. KEY WORDS: child sex abuse; disclosure; research to practice 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 Rosaleen McElvaney School of Nursing and Human Sciences. Dublin City University, Dublin. Ireland `The importance of understanding the dynamics of disclosure' 'Adolescents need to know about how to ask and what to do if someone tells' Copyright © 2013 John Wiley & Sons, Ltd. Accepted: 17 February 2013 EFTA00024200

160 McElvaney `This paper reviews the research on disclosure patterns of childhood sexual abuse' 'Most people who experience sexual abuse in childhood do not disclose this abuse until adulthood' mental health outcomes. This paper reviews the research on disclosure patterns of childhood sexual abuse, specifically delays in disclosure, non-disclosure (as evident through adult retrospective studies) and partial disclosures, and discusses implications for practice. Literature searches of the online databases PSYCINFO and Social Sciences Citation Index, in addition to manual searches of texts published since 2000, were conducted using the search terms 'child 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 sexual abuse in childhood do not disclose this abuse until adulthood, and when disclosure does occur in childhood, significant delays are common. Table 1 summarises two large-scale studies to highlight the extent of delays in disclosure and the percentage of those who did not disclose to anyone prior to the study. Kogan (2004) examined the timing of disclosure of unwanted sexual 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 reassuring finding given the increased awareness of sexual abuse in society during the past 20 years. Goodman-Brown and colleagues (2003) examined USA district attorney files of 218 children. Their categories were slightly different from the previous two studies but in summary, immediate disclosers (within 1 month) constituted 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. In Sweden, Priebe and Svedin (2008) conducted a national survey of 4339 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 from this study. However, of those who had disclosed and answered the 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. Studies of children in the context of forensic/investigative interviews 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 The rates for immediate disclosure are lower in the adolescent study than in the adult study' 'Children who disclose more promptly may be overrepresented in legal samples' `Delays ranging from 20 years to 50 years' Copyright ID 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOE 10.1002/car EFTA00024202

162 McElvaney `High numbers of respondents disclosing to researchers for the first time' `They found that interviewers behaved differently with the two groups' 'A parent described how her teenage son told her over a period of days' proportions of adults have never disclosed such abuse, as evidenced by the high numbers of respondents disclosing to researchers for the first time. Patterns of Disclosure — Partial Disclosure Information on how children disclose over time can be obtained from studies of children who participated in forensic/investigative interviews where 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 differently with the two groups, using different types of prompts with children who presented as somewhat uncooperative, offered fewer details and gave more uninformative responses at the beginning of the interview. It would appear that interviewers responded to less communicative children by 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 her think it made her think that it happened but I didn't tell her' (p. 127). A parent described how her teenage son told her over a period of days, keeping the most difficult parts of the story until last: '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' (p. 204). Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure 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 who are abused by a family member are less likely to disclose and more likely to delay disclosure than those abused by someone outside the family (Smith 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 to disclose due to concerns of upsetting their parents while others were concerned 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 cousins would be left without a father: '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) 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 of abuse 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 of disclosure has been identified as a predictor of delayed disclosure and this in turn is associated with the age of the child (Goodman-Brown a at, 2003). Older children are more cognitively competent in terms of being able to reflect on and anticipate possible reactions to their disclosure. This can act then as an inhibitor to disclosure, although as noted above, most studies have found that older children are more likely to disclose than younger children. Fears of not being believed have been described by young people as inhibiting their disclosure and these fears are often "When children do disclose, it often takes them a long time to do so" `Younger children are less likely to disclose than older children' `Many young people in her study were reluctant to disclose due to concerns of upsetting their parents' `Fear of the consequences of disclosure has been identified as a predictor of delayed disclosure' Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024204

164 McElvaney `Investigating the precise circumstances that led to disclosures for children' `Significant proportions of disclosure have been prompted by questions by caregivers, friends or others' `The implications of these findings can be considered in interrelated contexts' 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 precise circumstances that led to disclosures for children. McElvaney (2008) found that parents' questioning of children was prompted by their concern about the young person's emotional distress. On occasion, young people were communicating that something was not right in their world but were not able to articulate this verbally. Signs of psychological distress 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, research studies are finding that significant proportions of disclosure have been prompted by questions by caregivers, friends or others in the child's educational and social milieu that in themselves provide an opportunity for the young person to tell (Jensen et at, 2005; Hershkowitz a at, 2007; McElvaney et al., 2012). Finally, some children need time to tell. Mudaly and Goddard (2006) quote 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 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 these findings can be considered in interrelated 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 therapeutic contexts where a comprehensive account is required to enable child 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 and giving additional detail to original formal statements can be interpreted within child protection, therapeutic and legal contexts as a contradiction of an earlier account. Listening to children's accounts of their experiences of disclosure helps us understand why it is that disclosure can be delayed and that when they do 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 and increased awareness are needed on how to question children in an appropriate manner. McElvaney (2008) noted that questions did not need to be about sexual abuse per se, but rather questions prompted by the young person's psychological distress, asking after the young people's wellbeing. This questioning in effect acted as an external pressure for the young person to tell his/her secret (McElvaney et al., 2012). In Ungar el at's (2009a) study 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 to engage with the legal system? Are delays in disclosing contributing to decisions not to prosecute child sexual abuse crimes? In Ireland, the 1990s saw a significant increase in the numbers of complainants coming before the courts reporting experiences of childhood sexual abuse. Many of these cases were referred to the higher courts for judicial review proceedings to establish whether the cases could proceed without prejudicing the accused given the 'Contradiction in witness statements is a well-known feature of false statements' 'Education and increased awareness are needed on how to question children in an appropriate manner' 'Are children who delay in disclosing less likely to engage with the legal system?' Copyright 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car EFTA00024206

166 McElvaney 'Concerns that engagement with the legal system will lead to further psychological trauma need to be considered' 'Many young people who delayed disclosure to an adult had told a friend' 'An adaptive strategy on the part of the young person to contain the experience' 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 of childhood 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. In addition, concerns that engagement with the legal system will lead to further psychological trauma need to be considered. A prospective longitudinal study conducted by Quas et al. (2005) indicated that the consequences of legal involvement change over the course of development and as a function of the child's reactions to and experiences during the legal case. The associations between legal involvement and outcomes varied with age. The authors suggested that although younger children may be at increased risk for some 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. One interesting finding in recent studies is that many young people who delayed disclosure to an adult had told a friend. McElvaney (2008) and Ungar et al. (2009b) identified peer influence as significant in encouraging disclosure among adolescents. There is some suggestion from the research that regardless 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 disclosure as representing an adaptive strategy on the part of the young person 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 mediated by what they term the 'pressure cooker effect'. Young people in their 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 making disclosures rather than solely on identifying bathers to disclosure is perhaps more helpful in informing awareness-raising campaigns and professional interventions. The author is involved in a large-scale review of children's files in an assessment service to ascertain those factors that helped children tell about their experiences of sexual abuse. A pilot study has 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 anonymity (not being identified until they are ready for this) and confidentiality (the right to control who knows); and effective responses by adults both in informal and formal contexts. Ungar etal. (2009b) support recent developments in prevention programmes that target supportive formal and informal caregivers in being better able to detect the possibility of abuse and support disclosures rather than focusing on empowering children themselves in making disclosures. Their findings in 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 of Psychology 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. Child Abuse & Neglect 30: 753 769. 'More recent focus on investigating those strategies that children use in making disclosures' 'Having a sense of control over the process of disclosure both in terms of their anonymity and confidentiality' 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 of accidental abuse discovery by diagnosis of STD. Journal of Interpersonal Violence 7(4): 532 542. London K, Bruck M, Ceci SJ, Shuman D. 2005. Disclosure of child 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 Society for Research in Child Development 70(2): 104 117. Quayle E, Jonsson L, Loaf L. 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 of civilian 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 of Psychiatry 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 of child sexual abuse (Review). Cochrane Database of Systematic 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 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 of rape has been associated with impaired 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: [email protected] 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 p revious studies have shown that disclosure of rape to formal agencies, such as police or mental health services, is uncommon (Fisher, Cullen, & Turner, 2000; Wolitzky-Taylor et al., 2011), especially when the rape has been committed on a date or by an acquaintance and involves the victim's use of drugs and/or alcohol (Resnick et al., 2000; Wolitzky-Taylor et al., 2011). There is evidence to suggest that victims believe that professionals will not be helpful to them because their rape experience does not match stereotypical conceptions of rape, such as involving a stranger, a weapon, and severe injury (Patterson, Greeson, & Campbell, 2009; Resnick et al., 2000). Accordingly, adolescents and young adults, who are more at risk to be victimized by rape than other age 88flon groups (De Haas, Van Berlo, Bakker, & Vanwesenbeeck, 2012; Tjaden & Thoennes, 2006), may not receive targeted mental health care and may not report the crime to the police (Ruch, Coyne, & Perrone, 2000). For reasons of mental health and public safety, it is important to understand the potential factors that are related to disclosure. Timing of disclosure may be a crucial factor, as early disclosers are more likely to utilize appro- priate medical care and report to the police than delayed disclosers (Ahrens, Stansell, & Jennings, 2010; Ullman & Filipas, 2001). In contrast, adults who wait longer than month to disclose the rape are more likely to suffer from posttraumatic stress disorder (PTSD) and depres- 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 lothelicense Isprosided. and mat you /Ideate (Changeswere mace. You may 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 at least I month after the incident took place are found to be at higher risk for major depressive disorder and delinquency (Broman-Fulks et al., 2007) compared to those who disclosed within I month. Victim—assailant relationship is crucial in disclosure latency, with victims being at higher risk for delayed dis- closure if there is a close relation with the assailant (Kogan, 2004; Koss, 1988; Rickert, Wiemann, & Vaughan, 2005). In contrast, delayed disclosure is less common in victims of a stereotypical rape, i.e., rape by a stranger including a weapon and injury (Smith et al., 2000). Victims of prior sexual trauma are more likely to postpone disclosure of a subsequent assault than those without prior victimization (Smith et al., 2000; Ullman, 1996). This is in contrast with the findings of Ahrens et al. (2010), who report no dif- ference in rates of prior sexual trauma between early and delayed disclosers. In addition, the victim's age appears to be an important variable in predicting disclosure. Evidence suggests that young children are at higher risk for delayed disclosure than adolescents (Kogan, 2004; Schonbucher, Maier, Mohler-Kuo, Schnyder, & Landolt, 2012). Thus, various rape and victim-related character- istics have been found to be associated with timing of disclosure. The majority of the aforementioned studies included college and adult female rape victims. It is important to examine rape disclosure latency in an age and sex group that is most at risk for rape victimization. There is only one prior quantitative study in adolescents (those aged 12-17 years) that identified factors that might influence disclosure latency (Kogan, 2004). He found that identity of the assailant, a familial relationship with the assailant, and a history of drug abuse in the household were related to the timing of disclosure. The results suggested that a familial relationship with the assailant will postpone disclosure, whereas a history of drug abuse in the house- hold, albeit this seems counterintuitive, makes prompt disclosure more likely. This study had some limitations, including the fact that the interviews were conducted by telephone and that the description of the relationship with the assailant was limited. Therefore, in the present study, we investigated a sample of female adolescent and young adult victims of rape who were admitted to a specialized mental health centre for victims of sexual assault. The first aim of this study was to compare demographics, post-rape characteristics, and psychological functioning between early and delayed disclosers in this group. The second aim, based on the exploratory findings of Kogan (2004), was to determine the predictors for delayed disclosure in adoles- cents and young adults, including age, prior trauma, and victim—assailant relationship using logistic regression analyses. Insight into the predictors for delayed disclosure for adolescents and young adults may reveal not only potential causal mechanisms but also possible targets for interventions that increase victims' opportunities to receive timely post-rape services. Methods Subjects and data collection Rape was defined as "an event that occurred without the victim's consent that involved the use or threat of force in vaginal, anal, or oral intercourse" (Tjaden & Thoennes, 2006). The definition includes both attempted and com- pleted rape; the term "completed" referring to vaginal, oral, anal, or multiple penetrations. Victims who disclosed within 1 week were defined as "early disclosers," whereas those who disclosed at least after 1 week were defined as "delayed disclosers." This dichotomization of the variable "disclosure latency" was based on the study of Ahrens et al. (2010) and the national standard criteria for admis- sion to a Rape Centre in the Netherlands, i.e., a maximum of 7 days post-rape. The study was conducted in the Dutch National Psychotrauma Centre, which provides psychological ser- vices for rape victims aged 12-25 years and their parents. Between May 2005 and December 2011, the centre re- ceived 621 phone calls concerning alleged rape victims from police authorities, mental health services, and self- referrals. In 178 cases, the phone call did not result in admission at the centre because of age limitations, or motivational reasons. In 108 cases, referrals were made to other institutions because the index trauma was chronic childhood sexual abuse rather than rape in adolescence/ young adulthood. Of the 335 cases admitted to the centre, 12 were not included in this study because of male gender, resulting in a final sample of 323 females with the index trauma being single rape. Referral sources for this final sample included the police (33.7%), mental health services (40.7%). and self-referrals, i.e., victims or parents (25.6%). Procedure During admission, all patients underwent a psychological assessment, consisting of 1) a structured interview for obtaining demographic and post-rape characteristics and 2) self-report questionnaires to obtain information about mental health functioning. Information from the inter- view was transcribed onto a form designed for this purpose. The following variables were obtained and dichotomized or categorized for the purpose of the study: Demographic and victim characteristics We asked patients about their current age, educational level (lower, middle, or higher), and whether they were of Dutch origin (i.e., in case of having parents born in the Netherlands). Those between 12 and 17 years of age were defined as adolescents and those between 18 and 25 years of age as young adults. We also asked whether the patient 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 parents were living together (yes/no). Patients were then asked to confirm the presence of prior negative sexual experiences (yes/no), and whether they had a current sexual relationship (yes/no). Rape characteristics Information about date and time of the rape was ob- tained to calculate the time since rape at admission. Next, patients were requested to describe the rape. Their re- sponse was categorized into use of penetration (yes/no), group rape (yes/no), use of physical violence (yes/no), and use of threats verbally and/or with a weapon (yes/no). Also, information regarding the victim's relationship to the assailant was obtained. The assailant was defined as a stranger when the victim had never been in contact with the assailant before the rape. Responses were used to form a closeness category (yes in case of family, (boy) friend, or mentor). Patients were also asked about the (estimated) age of the assailant (categorized into 12-17 years or > 18 years), and whether the victim had used alcohol prior to the rape (yes/no). Post-rape characteristics Patients were asked when they first talked about the rape. The response was used to calculate the disclosure time and the help-seeking time. At the end of the interview, patients were asked whether they had reported to the police after the incident (yes/no), and whether they had received any medical care after the incident (yes/no). The study was performed in accordance with the precepts and regulations for research as stated in the Declaration of Helsinki, and the Dutch Medical Research involving Humans Subjects Act concerning scientific research. According to the Ethical Medical Committee of the University Medical Centre Utrecht, this act was not applicable to the present study. Written informed consent was obtained from both patients and parents. Measures Posttraumatic stress The Children's Responses to Trauma Inventory (CRTI; Alisic, Eland, & Kleber, 2006) was used for participants aged 12-18 years. This is a 34-item questionnaire asses- sing severity of PTSD symptoms according to DSM-IV. Patients are asked to indicate to what extent a reaction to a traumatic event was present during the past week. Scores range from I to 5, with higher scores indicating more symptomatology. The four subscales: Intrusion, Avoidance, Arousal, and Other Child-Specific Reactions consist of 7, 11, 6, and 10 items, respectively. The reli- ability of this instrument is good to excellent (Cronbach's a 0.92 for total score, 0.79 for Intrusion, 0.77 for Avoidance, 0.71 for Arousal; Alisic & Kleber. 2010). For the purpose of the study, only the total score was analysed. Depression Children Depression Inventory (CDI; Kovacs, 1992; Timbremont & Braet, 2002) was used for participants aged 12-17 years of age. The CDI is a 27-item ques- tionnaire, assessing cognitive, affective, and behavioural symptoms of depression. The Dutch CDI has a satisfac- tory internal consistency, with Cronbach's a ranging between 0.71 and 0.89 (Timbremont & Braet, 2002). Behavioural problems The Youth Self-Report (YSR; Achenbach & Rescorla, 2001) was used for participants aged 12—I8 years. This questionnaire evaluates the teenager's perception of be- havioural and emotional problems. YSR has shown to be internally reliable (Cronbach's a's ranging from 0.71 to 0.95), and convergent and discriminant validity is reported to be satisfactory (Berube & Achenbach, 2006). The YSR includes four broadband scales and nine narrow-band scales to assess behaviour problems. For the purpose of the study, only the total score on behaviour problems was included in the analyses. General psychopathology The Symptom Checklist-90-R (SCL-90-R; Arrindell & Ettema, 1986) was used for participants aged 12-25 years. This is a 90-item self-report inventory to assess psycho- social distress. Patients were instructed to indicate the amount they were bothered by each of the distress symptoms during the preceding week. Patients rated 90 distress symptoms on a five-point Liken scale with being "not at all" and 5 being "extremely." The state- ments are assigned to eight dimensions, reflecting various types of psychopathology: anxiety, agoraphobia, depres- sion, somatization, insufficiency, sensitivity, hostility, and insomnia. The Global Severity Index (GSI) can be used as a summary of the test and reflects the severity of all answered statements as a global measure of distress. 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. Data analyses To compare demographic and post-rape characteristics between the early and delayed disclosers, chi-square tests were used. To compare multiple continuous psychological scores, MANCOVA was used with "time since trauma" as a covariate to correct for the potential influence of time since trauma. Delayed disclosure was used as a dependent variable. The strength of the univariate associations between each potential risk factor and delayed disclosure was estimated by calculating the odds ratio (OR) along with 95% confidence intervals (95% CI). To determine the strongest 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- nificant OR (p <0.05) was entered as a predictor variable into the multivariable model, using a stepwise forward logistic regression (LR) analysis with delayed disclosure as the outcome variable. The Hosmer—Lemeshow goodness- of-fit chi-square was used to calculate how well the data fit the model. For all statistical analyses, a p-value of <0.05 was considered statistically significant. All statistical analyses were conducted using SPSS (IBM SPSS Statistics for Windows, Version 20.0, IBM Corp., Armonk, NY). Results Socio-demographic characteristics Socio-demographic characteristics of the sample are pre- sented in Table I. Victims' age ranged from 12 to 25 years, with a mean age of 16.7 years (SD =2.7) and a median age of 16.1 years. Victims' mean age at time of rape was 14.3 years (SD =2.7) and a median age of 13.9 years. Penetration occurred in 79.6% of the cases. None of the victims reported prior chronic child sexual abuse. Data about victim—assailant relationship are presented in Table 2. Victims first disclosed after a mean 20.8 weeks (SD =56.8, range 1-624 weeks), although 58.5% of the cases told within 1 week. First disclosure was to a friend (45.8%), parent(s) (17.1%), (ex) boy-friend (9.4%), family member (6.8%), professional (5.8%), or other adult (15.2%). With regard to post-rape services, 53.8% of all victims consulted a doctor for medical care and 51.4% reported to the police. On average, victims were admitted to the centre 59.8 weeks post-rape (SD =93.7, range 1-676). The mean GSI of the rape victims on the SCL-90- R (Al = 209.7, SD = 61.8) was comparable with previously reported data of psychiatric populations [M=203.55, SD = 61.60; 4269) =1.629, p = 0.104] and was substantially Table I. Demographic characteristics of rape victims (N-323) in valid percentages N 44 Dutch origin° 274 84.8 Education lever Low 182 58.0 Medium 76 24.2 High 56 17.8 Parents divorced 102 31.9 Lives at parental home 273 85.3 Current relationship 81 26.5 Prior negative sex 46 14.8 'Dutch origin was defined as being a child from parents born in the Netherlands: °after 6 years of general primary school, at the age of 12 years. students enter low (4 years). medium (5 years). or high (6 years) secondary education level. Table 2. Victim assailant relationship (N-323) in valid percentages Stranger 94 29.5 (Ex-)Boyfriend 32 10.0 Friend 33 10.3 Acquaintance 61 19.1 Person met during nightlife 30 9.4 Second-degree relative 15 4.7 Person seen only once 15 4.7 Person from school 14 4.4 Person met on the intemet 12 3.8 Colleague 10 3.1 Mentor 3 1.0 higher [4269) =24.297, p <0.001] compared to the gen- eral population (M=118.28, SD =32.38; Arrindell & Ettema, 1986). For the CDI, mean scores were in the clinical range (M=17.2, SD =4.6) and rape victims had significantly higher mean scores (1(230)=15,923, p <0.001), in comparison to previously reported data of the general population of adolescent girls (Timbremont, Braet, & Roelofs, 2008; M=9.01, SD =6.45). Differences between early and delayed disclosers Fifty-nine percent of the sample consisted of early dis- closers (disclosure within I week). No significant differ- ences in demographic characteristics were found between early and delayed disclosers, except that there were more delayed disclosers in the age category 12-17 years compared to the early disclosers group (x2 (1) =6.96; p = 0.008). For rape characteristics, significant differences between groups were found for the use of penetration, with more victims of penetration in the delayed disclosers group compared to the early disclosers group (x2 (I) = 5.37; p =0.02). Also, the delayed disclosers group pre- sented more victims of verbal and/or weapon threats than the early disclosers group (x2 (I)=5.35; p =0.02). Furthermore, among the delayed disclosers more victims identified the assailant as a close person compared to the early disclosers (x2 (I) =10.84; p =0.001). Alcohol was used more often in the early disclosers group compared to the delayed disclosers group (x2 (I) =20.24;p <0.001). With respect to post-rape characteristics, a significantly smaller proportion of the delayed disclosers (15.9%) utilized medical services following the rape compared to the early disclosers (30.3%; z2 (1)=5.32; p =0.02). Similarly, a significantly smaller proportion of the delayed disclosers (14.6%) compared to the early disclosers (34.3%) reported the rape to the police (x2 (I) =16.15; p <0.001). The time since trauma at admission was sig- nificantly lower for early disclosers (M=41.1 weeks, SD =79.4) than for delayed disclosers (M =82.9 weeks, 4 woe norribt• nor to Minion ouposel Cuban: European Journal of Psychotraumatclogy 2016.6: 25883 htlp://dxartorW10.3407Jept.v6.25P83 EFTA00024214

Predictors of delayed disclosise of rape SD =103.3: 4314) =4.06, p <0.001). Mean and median time to seek help were 37.7 and 12.0 weeks, respectively. Mean time to seek help did not differ between groups (1(309)=2.54, p <0.48). Excluding outliers (M±3 SD, N = II) did not change the outcome of this analysis. Both early and delayed disclosers scored in the highest level of psychological distress when compared to previously reported norm scores (CRTI, Alisic, Eland, Huijbregts, & Kleber, 2012; CDI, Timbremont et al., 2008; YSR, Achenbach & Rescorla, 2001; SCL-90, Arrindell & Ettema, 1986), but the MANCOVA results showed that when comparing multiple continuous psychological scores, the overall psychological functioning (posttrau- matic stress, depression, behavioural problems, and gen- eral psychopathology) did not differ significantly between early and delayed disclosers (F(6,I98) = 0.88, p =0.51). Table 3 shows the ORs with 95% Cls for the associa- tions between potential risk factors and delayed disclosure. Delayed disclosers, when compared to early disclosers, were significantly more likely to be in the age category of 12-17 years (OR =2.10), to have experienced rape by a close person (OR = 2.35), to have been threatened verbally and/or with a weapon (OR =1.75), and to have experienced penetration (OR = 1.99). Delayed disclosers were also found less likely to have used alcohol prior to the rape (OR = 0.22). None of the other factors were found to be significant risk factors for delayed disclosure. Predicting delayed disclosure A stepwise forward LR analysis was conducted to predict delayed disclosure, using "age category," "close assailant," "use of threats," and "penetration" as predictors. Victims' alcohol use was not entered in the analysis because of missing values for 33.4% of the cases. The use of threats was not a significant predictor in the model. A test of the full model against a constant-only model was statistically significant, indicating that the predictors (i.e., age cate- gory 12-17 years, close assailant, penetration) reliably distinguished between early and delayed disclosers (2 2 (3) = 23.09, p <0.000). There were no significant interac- tions between the predictors. Nagelkerke's R2 of 10.5% suggests only a modest association between the predic- tors and delayed disclosure, although the model did show an adequate fit to the data (Hosmer-Lemeshow x 2 (4) = 2.77, p <0.60). In total, 62% of the respondents were categorized correctly, when using the three predictors that contributed significantly to the prediction of delayed disclosure: age category 12-17 years (OR 2.05, CI 1.13- 3.73), penetration (OR 2.36, CI 1.25-4.46), and closeness to the assailant (OR 2.64, CI 1.52-4.60). Discussion The results of this study show that, although no dif- ferences were found between delayed and early disclosers in psychological functioning and time to seek help, delayed disclosers were less likely to use medical services and to report to the police than early disclosers. Furthermore, this study identified a number of factors related to the timing of rape disclosure, showing that delayed disclosers represented significantly more adoles- cents than young adults, significantly more victims of penetration than assault, significantly more victims who were threatened than not threatened, and significantly more victims who were close with the assailant. The finding that delayed disclosers are less likely to utilize medical services and report to the police than early disclosers is in line with previous studies in adult women (Ahrens et al., 2010; Ullman, 1996; Ullman & Filipas, 2001). It suggests that disclosure latency is important for public health and safety, as delayed disclosure may not only impede reception of proper medical care, such as treating anogenital injuries and preventing the onset of STDs and unwanted pregnancy (Linden, 2011), but also impede the forensic investigation and apprehension of the assailant (Lacy & Stark, 2013). Three variables were identified that successfully pre- dicted delayed disclosure: age category 12-17 years, penetration, and the assailant being a close person. The finding that the victim's age significantly predicts disclo- sure latency is in line with previous research showing that adolescents are at a greater risk for delayed disclosure when compared to their older counterparts (Kogan, 2004; Smith et al., 2000). Adolescents may be less able to over- come the barriers to disclose, including factors such as assailant tactics for maintaining secrecy, stigma that often accompanies rape, and fear that their parents would consequently limit their freedom (Crisma, Bascelli, Paci, & Romito, 2004). Also, as victims approach adulthood, they may possess more information about their rights and options after victimization, and have more possibilities for whom to disclose. In our study, most adolescents disclosed the rape event to peers, in line with prior research (Crisma et al., 2004; Priebe & Svedin, 2008). The use of penetration was found to make victims more likely to postpone disclosure, opposite to the results from Priebe and Svedin (2008), but in line with an older study by Arata (1998), who found that more severe forms of sexual abuse were associated with less disclosure. Penetration may influence disclosure latency through a variety of mechanisms. It could be argued that more severe rape, indicated by the use of penetration, is more likely to be accompanied by extensive coercive use of tactics to maintain the victim's silence, with fear of re- prisal possibly contributing to the finding of delayed dis- closure (Kogan, 2004). Also, adolescents may think that social reactions in response to disclosure are more nega- tive in case of completed rape compared to assault. Another factor that seems to make immediate dis- closure of rape less likely is closeness to the assailant, 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 (N=185) Delayed disclosure (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- vious studies showing that the closer the relationship between the victim and assailant, the less likely the young woman was to report this victimization to anyone (Koss, 1988; Rickert et al., 2005; Wolitzky-Taylor et al., 2011). The dynamics of intrafamilial abuse is often proposed as 6 imp meow 101 Mr OS*, wpm) Crlaten: European Journal of Psycholraumatdogy 2016. 6: 25883 htlp://dxsttorW10.3607Jept.v6.25666 EFTA00024216

Predictors of delayed disclosue of rape the explanation for delayed or non-disclosure (Kogan, 2004; Smith et al., 2000). In the present study, however, only 5% of the assailants were identified as a family member. Most close relationships referred to (boy)friends, suggesting that a significant percentage of the sample experienced peer-to-peer victimization. This type of vic- timization is most likely to occur during adolescence, as compared to childhood or young adulthood, and greatly increases the risk of revictimization (Humphrey & White, 2000). Hence, victims of rape by peers may be a target group for interventions promoting early disclosure. Clearly, there are many variables working in tandem to affect the timing of victim's disclosure. A closer look at the final model, which identified three unique variables that contributed significantly to the prediction of delayed dis- closure, can help us to better understand the phenomenon of initial disclosure in adolescents and young adults. Younger adolescent victims who are raped by a close per- son are more likely to delay disclosure than older victims of attempted rape by a stranger or acquaintance. Perhaps, they struggle with the notion that someone close to them performed such a violent act against them, which con- fuses them about what might happen in terms of safety if they would disclose (or not). This finding is especially important in the light of the fact that approximately 80% of victims had some sort of relationship with their per- petrator prior to the assault (Basile, Chen, Black, & Saltzman, 2007). With regard to rape types, it would intuitively seem that less severe forms of sexual assault are associated with delayed disclosure and that completed rape would be easier to identify as clearly inappropriate and wrong. Victims of completed rape, however, may be more likely to experience negative psychological reac- tions, e.g., self-blame and avoidance coping. It is con- ceivable that they delay their disclosure as a result of rape-induced psychological distress (Starzynski, Ullman, Filipas, & Townsend, 2005), not necessarily the severity of the assault. Although the final model showed acceptable goodness of fit, the percentage of explained variance of delayed disclosure was modest. Thus. there must be other variables predictive of delayed disclosure, such as the assailant's use of alcohol or weaker support systems, that we did not assess in this study. Besides this limitation, there are other drawbacks of this study that should be mentioned. First, a clinical sample was used with patients reporting high mean levels of psychological distress. This ceiling effect may explain why no differences were found between early and delayed disclosers on psychological function- ing, contrary to prior studies (Broman-Fulks et al., 2007; Ruggiero et al., 2004). Second, posttraumatic stress was only assessed for children up to 18 years, and for young adults additional suitable measures were not used. Third, information could have been lost due to dichotomizing the variable disclosure latency. Fourth, results may not be generalizable to all rape victims, because the percentage of victims that consulted a medical professional and reported to the police was higher in our sample than in most studies (Hanson et al., 2003; Resnick et al., 2000; Zinzow, Resnick, Bare, Danielson, & Kilpatrick, 2012). Perhaps, these differences could, at least partially, be explained by the fact that stranger rape, representing 30% of our sample, leads to higher likelihood of help-seeking and police reporting because of its association with higher acknowledgment of victim status (Resnick et al., 2000; Smith et al., 2000). The fact that this is a help-seeking sample is critical for the reasons cited in the discussion, but also because the generalizability of these data to rape victims who never tell anyone—perhaps the group most at risk—simply cannot be known. Besides these limita- tions, several strengths of the current study need to be noted. One strength is the unique set of adolescents and young adults who presented at a mental health care centre after a single rape event, but who reported no prior chronic sexual abuse in childhood. For 85% of the sample, the index trauma was a first time rape. Moreover, data were collected at a designated referral centre for victims of rape and, therefore, the sample is likely to represent the clinical population of Dutch victims in the age group of 12-25 years. The findings of the current study, suggesting that delayed disclosers are less able to benefit from emergency medical care and evidence collection, have a number of practical implications. One of the strategies to enhance victims' willingness to disclose within the first week post- rape may be sexual education campaigns in school and media, as being uninformed is one of the reasons for them not to disclose (Crisma et al., 2004). Education may include medical information on rape-related pregnancy and STDs, as well as the need for timely emergency contraception and prophylaxis, given that these concerns appear to be facilitators of seeking medical help (Zinzow et al., 2012). Also, practical information about DNA evi- dence and how to best protect it, e.g., related to shower- ing, clothing, eating, and drinking, may increase the awareness of opportunities in the early-phase post-rape. Moreover, facts about the potential psychological impact of rape, such as PTSD and revictimization, but also in- formation about evidence-based treatments (Elwood et al., 2011; Littleton & Ullman, 2013; McLaughlin et al., 2013), may increase help-seeking behaviour in an early stage. Furthermore, efforts to encourage early disclosure must consider peer-to-peer victimization as a primary factor, as most participants in this study experienced this type of victimization, and may initially not have defined or acknowledged the incident as rape because they rationalize such experiences as normal (Hlavka, 2014), leading to the finding of delayed disclosure. In conclusion, the results of the present study suggest 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, and that delayed disclosers are less likely to use medical services and to report to the police. These findings may assist clinicians and policymakers in understanding rape and help to develop interventions (Unterhitzenberger & Rosner, 2014), specifically targeted to support adoles- cents and young adults to disclose in an early-phase post- rape. Although the vast majority of the participants was living at their parental home, many of the sample did not first disclose to their parents. Therefore, it could be argued that in prevention programs specific attention should be given to the strengthening of the child—parent relationship, to facilitate disclosure to parents (Schonbucher et al., 2012). Next, as victims tend to disclose mostly to peers, prevention programmes may need to aim at teach- ing adolescents how they can help a peer victim if they become a recipient of disclosure (Schonbucher et al., 2012). In addition, education may increase victims' willingness to disclose early, thereby increasing opportu- nities for access to health and police services. It is more likely to reach adolescents with direct, active, and online outreach programs via communication channels that are frequently used by adolescents and young adults parti- cularly social media (i.e., Facebook, Twitter, YouTube, etc.), forums, and mobile apps. Such programmes, where- in adolescents and young adults are being treated as agents and decision makers (Hlavka, 2014), should focus on information concerning what rape actually is—not only the stereotypical idea of rape and what (not) to do in the aftermath of rape especially in the first week post- rape. Another way to help improve the support of victims of rape is the implementation of multidisciplinary sexual assault centres (Bicanic, Snetselaar, De Jongh, & Van de Putte, 2014; Bramsen, Elklit, & Nielsen, 2009), as these may be the most suitable places to organize education campaigns and offer integrated post-rape services in one location. Future research should investigate whether the availability of such centres increases the prevalence of police reporting and use of medical care. Moreover, as discussed, previous research concerning the topic of disclosure has focused on the disclosure process, mainly the effect of negative social reactions, and not the latency. 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