Exhibit B

Exhibit B EFTA00088888 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 EFTA00088889 Alaggia et al. 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 I 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 EFTA00088890 Table I. Ch d Sexua Abuse (CSA) D se 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 a ms of CSA To exp ore the mean ng 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 sun vors. Study object ves nvest gated the factors that fac tate CSA d sc osures Phenomeno og ca methodo ogy used to ntery ew ma e CSA sun 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 ect on and ana ys s. Qua tat ve ntery ew ng Qua tat 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 ng strategy was used 17 Afr can Amer can women n m d- fe between 40 and 63 who exper enced ntrafam a CSA. Purpos ve. snowba ng strategy 67 ma e and fema e CSA adu t sun von (76% dent f ed as fema e and 24% as ma e). Age ranges from 19 to 69 years (M = 44.9). Purpos ye samp ng strategy 369 adu t ma es who had been cony cted of a sexua offense aga nst a ch d aged between 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 eyed 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 ater 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 cantor 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 cs. 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 the 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 suff 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 ve y on Afr can Amer can women. Sma but suff cent s ze for a qua tat ve nqu ry. Important cu tura and contextua ssues were brought forward. Retrospect ve 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 ve 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 zat on or exaggerat ons. (continued) EFTA00088891 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary McE vaney and Cu hanc (2015) Dumont, Messerschm tt V a, Bohu. and Rey-Sa mon (2014) Easton. Sa tzman. and W 5 (20 I 4) 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 ve 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 hosp ta were rev ewed Us ng qua tat ye 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 ct ms assessed were 12-18 years of age 220 m nor v a ms- 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. Recru ted from sury vors' 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. Mae v ct 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 of 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 of uence were a so dent fed D sc osure processes were more comp 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. Perspect 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 contr 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 fam 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) EFTA00088892 Pi Table I. (corm nued) Study Purpose Des r Samp e F nd ngs Summary Easton (2013) McE vaney. Greene. and Hogan (2012) Sthonbucher, 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 cents 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 cued, who d d Cross-sect ona survey des grt.E g be 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 endurng 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 heath profess ona (20%): 42% of part c pants reported that the r most he pfu d scuss on was w th a menta heath profess ona. However. unhe phi responses caused most menta d stress. C n a 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 a between the w sh to te and the w sh to keep the secret; and (3) the conf d ng Ise 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 ve samp ng of men from awareness n 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 SE groups and requ red prof c ency n Eng sh wh ch wou d e m nate certa n cu tun 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) EFTA00088893 Table I. (cant nued) Study Purpose Des gn Samp e F rid ngs Summary Hunter (20 I I ) Schaeffer. Leventha , and Asnes (2011) they d sc ose to, and what were the r mot ves for d sc os ng A m of the study was to deve op a fu er understand rig 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 scuss 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 ssues of d sc osure cou d be dent( ed n the context of forens c ntery ews. Forens c ntery ewers were asked to ncorporate quest ons about "te rig" nto an ex st rag forens c may ew protoco . Intery ew content re ated to the ch dren's reasons for te ng or wa t ng was extracted, cranscr bed, and ana yzed us rig grounded theory method of ana ys s commun ty and counse ng sem ces Purpos ve 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 sh. 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 rig 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 conf dants 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 rah b ton to d sc osure. These factors are further den 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 rid rect attempts to te and purposefu d sc osure as categor es. Thematcana 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 rig were c ass f ed nto three doma ns: (1) d sc osure as a resu t of nterna sc mu (e.g. the ch d had n ghtmares): (2) d sc osure hc ated 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 ve 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 surf c ent samp e s ze for a qua tat ve nqu ry. We -des gned study w th den ed aria ys s for transferab ty off nd ngs An nnovat ve study to try to assess f forma nvest gat ve ntery ews can fac tate d sc osures of CSA. Data were based on a arge number of ntery ews. Den ed ana ys s produced den ed f rid ngs support ng other study f rid ngs on CSA d sc osure (continued) EFTA00088894 I-, Table I. (tom nued) 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 cure 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 samp e of youth focus ng on A qua tat ve phenomeno og ca des gn. LIM, was used to ntery ew adu t CSA sury vors 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 w thcnca data, th s art c e conducted an ana ys s to prov de a cu tura y competent framework for CA 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 sun von. 40 adu t sun von of CSA 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 wth c n ca case mater a Exam nat on of resu ts from a nat ona samp e 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 ts 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 nf 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 osen Cu tura and structure factors affect ng CSA d sc osure are dent f ed n n-depth den 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 shoo 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 nwhch ch dren are from not ceab e m nor ty groups. Presents a comprehens ve ntery ew framework ntegnt ng cu tura cons dent ons Youth who have been abused or w tnesses to abuse emp oy f ye 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 nf 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 ff cu 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 ve approach that cou d be affected by reca ssues One of the few works that adds know edge to cu tura y contextua d sc osure ntery ew ng. Un que comb nat on of teraturefnd ngs w th c n a mater a . Anecdota accounts may prec ude transferab ty of f nd ngs. Overa adds to an mpover shed area of CSA d sc osure nfonnat on Th s study h gh ghts that d sc osure s an nteract ve ongo ng process. F nd ngs end support to stud es that have dent f ed s m ar y (continued) EFTA00088895 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary (1) 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 as 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 ye samp es. Qua tat ve ana ys s of 1,099 eva uat on forms comp eted 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 ect 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 ng 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 ve 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 14-15, v ct ms of phys ca abuse, and those abused by a fam 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 ceicourts. 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 IS0 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 ve modes of d sc osure such as those Beta 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 m ted to CSA SUM vors Innovat ye 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 ye (continued) EFTA00088896 Table I. (tont 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 ferns 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 enges for ma e sury von of CSA to understand three ssues: (I) To Part c pants comp eted 65- tern quest onna re that nc uded quest ons about background, consensus sex. sexua abuse exper ences (noncontact, contact or penetrat ng abuse, nc ud ng peer abuse), d sc osure of CSA, own sexua abus ye behav or. sexua att tudes. and exper ences w th pornography and sexua exp o tat on. The quest onna re nc uded 6 mod( ed terns from the SCL-90 and 9 of 25 terns from the Parents Bond ng Instrument_ The data for g r s and boys were ana yzed separate y Ma e sury 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 2,015 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; 1 1 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 ng 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 sb 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 ng 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 ng 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 arge 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 ng d sc osure on: the t m ng 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) EFTA00088897 Table I. (cons nued) Study Purpose Des gn Samp e F nd ngs Summary Hershkow a. 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 ye and negat ye aspects of the r d sc osure. nc ud ng ncent ves and barr ers? The goa of the present study was to exam ne how ch d v a 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 ye Amer can, Afr can Cuban: age range of 24-61 years; 9 dent fed themse ves as heterosexua , 5 as homosexua , and 2 as b sexua Th rty a eged v a 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) sot 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 certa 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 ps, nc ud ng those w th fam y members, partners. therap sts, and nfrequent y fr ends. Seven had on y m ted d scuss 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 10% 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' key 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, suspect? dent t es, and strateg es used to foster secrecy read y. Retrospect ye 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 ye 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 CSA 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 wh ch s h gh continued/ EFTA00088898 I-, Table 1. (cont nued) Study Purpose Des gn Samp e F nd rags Summary A agg a and K rshenbaum The object yes of the (2005) current study were to dent fy a broad range of factors, nc ud ng fain y dynam cs that contr bute to or h nder a ch d's ab ty to d sc ose CSA. A agg a (2005) Co ngs, Gr ff ths. and Kuma o (2005). The study purpose was to qua tat 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 representat ve samp e of South Afr can CSA v a ms. Two study object ves to: ( ) 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 fain 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 ye 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 ca 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 ve samp ng was emp oyed to recru t 20 adu t sun von between the ages of 18 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 yes 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) rgdyfxed, gender ro es based on a patr archy-based tarn 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 a ms fee ng they had no one safe to te . Fain 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 sat on or so at on because of the be of that boys are rare y vam 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 durat 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 pan 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 tators 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) EFTA00088899 Table I. (cont 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 thn 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) eyewthess detect on (18% of cases), and (4) acc denta 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- to 4-year-o 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 lsrae 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 den Ana yses on y nvo 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 tra ned youth to I0-year-o ds. and 74% of the I I- to off c a agent 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 nvestgated Qua tat ve approach to 20 fam es w th a tota of None of the ch dren to d of abuse Ev dente for de ayed d sc osures. Moss ge, Re the t. and the context n wh dr 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 fundamenta 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. I 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 GSA. 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 1 year ater years (average age 7.5 ch d nadaogue 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 fam 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 ;continued) EFTA00088900 Table I. (cont nued) 4.4 Study Purpose Des gn Samp e F nd ngs Summary Sn er and Ne son- Garde (2005) A agg a (2004) The purpose of th s study was to understand the hi process of CSA d sc osure and how th s unto 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 ct 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 ana 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 ye ntery ew ng that were 2 hr ong on average generated data for a themat c ana ys s. The ntery ew gu de was Samp e cons sted 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 ana ys s Us ng purpos ye samp ng 24 adu t sun von of ntrafam 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 dd t nstuat 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 zat 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 cont 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) chant ng re at onsh ps, (3) nst tut ona responses and the after fe of te n& 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 f ed to add to ex st ng types. Three prey ous y dent f ed were conf rmed n these data: acc denta , purposefu . and promptedfe 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) EFTA00088901 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Cr sma, Basce Pac . and The man 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 ct 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 ts 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 e: 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 caus 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 to 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 stort on and rev s on of events are a so potent a prob ems nreca . I-Igh 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 np of a m xed samp e of sun vors 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 ssat sf ed sun 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) EFTA00088902 t Table I. (cont nued) u. 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 von of USE n ch dhood and ado escence. The pred ctors 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 Intery 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 a 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 cs, and fam y contextua attr butes were exp ored Samp e cons sted of 218 ch 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 key 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 one's fe dur ng and penetrat on were assoc ated w th d sc osure to adu ts. Fain 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 ve 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 ve samp e of fema e ado escents who part c pared n the NSA. Surveys for nvest gat ons of v ct m sat on exper ences may be b aced 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 ve, 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) EFTA00088903 Table 1. (tont nued) Study Purpose Des gn Samp e F nd ngs Summary Sm th. Letourneau. Saunders, K patrck. 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 coed 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 ned of seven measures des gned toe ct demograph c nformat on. psych atr c symptoms. substance use, and v ct m at 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% Tema 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 strat f ed 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 sted 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 sc 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 avenge 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 ca 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 ct ms made d sc osures, fo owed by mothers and other mmed ate fam y members. Fewer than 10% of v 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 ose. We -des geed 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 shou d be d sc osed to respons b e adu ts. 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-9R SES = socioeconomic status: L N = ong interview method: CSA = chi d sexua abuse: N CHD = Nation nstitute of Chid Hea th and Human Deveopment 115E = unwanted sexua experiences: NSA = Nation Survey of Ado escents: NWS = Nationa Women's Study: Q DS = Questionnaire intormattse sur es de inquants sexeu s. EFTA00088904 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; Schonbucher 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 bathers 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 EFTA00088905 Maggio 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-ecological 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) barriers 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 (200%, 2009b) is one exception, whereby their survey elicited new disclosures. EFTA00088906 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., 20096). 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 EFTA00088907 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 bathers to disclosure. Finally, it may be the case that more bathers 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 EFTA00088908 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., 2009b). 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