Crock ice towns

Crock ice towns Review Manuscript Facilitators and Barriers to Child Sexual Abuse (CSA) Disclosures: A Research Update (2000-2016) Ramona Alaggial , Delphine Collin-Vezina2, and Rusan Lateef' TRAUMA. ,aOLENCE. & ABUSE 2019. Vet 2012) 260.2M The Author(s) 2017 CiI0I &ode rizeu of shuts *Urn <cmlounalscermissrons 001 le 1177! 152038017697312 Icurnshiagepubccm, codou 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 disclosures 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: (1 ) Disdosure 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 CSA disclosure: (3) age and gender significantly influence disclosure; (4) there is a lack of a life-course perspective: and (S) 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- closure 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; McElvancy, 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, Foms, & 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 LIzendoom, Euser, & Bakermans-Krancnburg, 2011). These findings point to the incongruence between the low number of official reports of Factor•Inveentash Facuky of Social Work. University of Toronto. Toronto. °nano. Canada a Centre for Research on Children and Families. School c4 Social Work. McGill University. Montreal. Qubec. Canada Corresponding Author: Ramona Magee. Factor-Inwenash Chair in Children's Mental Health. Factor. lnwentash Faculty of Social Work. University of Toronto. 246 Bloor St West. Toronto. Ontario. Canada M4K I W I. Erna* ramecia.abgpalgutorcoto.ca 3502-021 Page 1 of 24 EFTA_00001523 EFTA00156864 Maggio et at. 261 CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stollen- borgh, van Ilzendoorn, 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) (Ea- ken, Cotter, & Perreault, 2014; Statistics Canada 2013). In other words, while I 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, Schnyde•, 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; Ilunter, 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 IS 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, 2015). 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 intema- 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, 1 French study, and 1 Portuguese review. The search was further refined by excluding studies focusing on forensic inves- tigations, as these studies constitute a specialized legal focus on interview approaches and techniques. As well, papers that focused exclusively on rates and responses to CSA disclosure were excluded, as these are substantial areas unto themselves, exceeding the aims of the review question. Review articles were also excluded. Once the exclusion criteria were applied, the search results yielded 33 articles. These studies were sub- jected to a thematic analysis as described by Braun and Clarke (2006). This entailed ( l) 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 I). 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 3502-021 Page 2 of 24 EFTA_00001524 EFTA00156865 m Table I. Child Sexual Abuse (CSA) Disclosure Studies: 2000-2016. 1.4 Study Purpose Design Sample Findings Summary Gagnier and Collin- Vezina (2016) Braze1ton (2015) Sablonni. Palmer. and Milne (2015) Leclerc and Wortley (2015) To explore disclosure processes for male victims of CSA To explore the meaning African American women make of their traumatic experiences with CSA and how they disclosed across the life course To provide a mapping of factors that prevent CSA disclosures through an ecological lens from a sample of CA adult survivors. Study objectives investigated the factors that facilitate CSA disclosures Phenomenological methodology used co interview male CSA survivors. The Long Interview Method (UM) guided data collection and analyses. Collective case study design with using narrative tradition (storyboard) for data collection and analysis. Qualitative interviewing Qualitative design using LIM. Adult male child sexual offenders were interviewed to examine predictors of 17 men ranged in age from 19 to 67— average age 47. Purposive sampling strategy was used 17 African American women in midlife between 40 and 63 who experienced intrafamilial CSA. Purposive. snowballing strategy 67 male and female CSA adult survivors (76% identified as female and 24% as male). Age ranges from 19 to 69 years (M = 44.9). Purposive sampling strategy 369 adult males who had been convicted of a sexual offense against a child aged between The majority of the men in the study waited until adulthood co disclose their abuse. with negative stereotypes contributing to their delayed disclosures. Negative stereotypes contributed to delayed disclosure with trying to forget. Breaking isolation was cited as a motivator to disclosure along with the aid of various forms of media on disclosure. Important contextual issues such as negative stereotyping of males. sexuality. and victims were noted. Social media was seen as a facilitator of disclosures CSA onset was largely between the ages 5 and 9. No one ever talked to them about sex. so they didn't have language to disclose. Barriers: fear of family breakdown and removal. not wanting co tarnish the family's name. and fear of retribution by family members if they disclosed. Pattern of stifled and dismissed disclosures identified over the life course. All 17 participants identified spirituality as a primary source of strength throughout the life course Three broad categories were identified as barriers to CSA disclosure: Barriers from within-internalized victim blaming. mechanisms to protect oneself, and immature development at time of abuse: barriers in relation to others—violence and dysfunction in the family. power dynamics. awareness of the impact of telling, and fragile social network: barriers in relation to the social world labeling. taboo of sexuality. lack of services available. and culture or time period. Disclosure increased with the age of the victim: if penetration had occurred, if the victim was related co the offender. if the victim was not living with the offender at All participants had disclosed and received services before participating in the study. Member checking could not be done with die participants co check themes. Small but sufficient sae for a qualitative inquiry. Otherwise. high level of rigor in establishing trustworthiness of the data and analysis. Retrospective study could imply recall issues One of few studies co focus exclusively on African American women. Small but sufficient size for a qualitative inquiry. Important cultural and contextual issues were brought forward. Retrospective study that may have been affected by recall issues. Use of a life-course perspective as a theoretical lens for understanding CSA in the middle to later years of life that should be considered in further investigations Half of the participants had not disclosed their CA experiences before the age of 19. Retrospective aspect of the study could imply recall issues. All participants had disclosed and received counseling at some before participating in the study. High level of rigor in establishing trustworthiness of the data and analysis Offender generated data through self-reports could be subject to cognitive distortions— minimization or exaggerations. (continued) EFTA00156866 Table I. (continued) Study Purpose Design Sample Findings Summary McElvaney and Culhane (2015) Dumont. Messerschmitt. Vila, Bohu. and Rey-Salmon (2014) Easton. Salzman. and Willis (2014) To investigate the feasibility of using child assessments as data sources of informal CSA disclosure. To assess If these reports provide substantive data on disclosures This study aimed to explore how the relationship between the perpetrator and the victim. especially whether these relations are intrafamilial or extrafamilial. impact CSA disclosure Study focus was on identification of barriers to CSA disclosure with male survivors victim disclosure. Seinistructured interviews based on the QID questionnaire. File reports of children seen for assessment in a child sexual abuse unit in a children's hospital were reviewed File reports of children seen for assessment in a child sexual abuse unit in a children's hospital were reviewed Using qualitative content analysis. researchers conducted a secondary analysis of online survey data. the 2010 Health and Well-Being Survey. that included men with self-reported CSA histories with an open-ended item on disclosure barriers and 17 years old. Majority were White. uneducated, AMOR half unemployed before their arrest Content analysis was completed on 39 files (32 females and 7 males) based on a coding framework. Parents were asked to consent to have their child's file reviewed for the study. Victims assessed were 12-18 years of age 220 minor victims- 78.2% female victims. 41.8% aged between 14 and 18 (most prevalent age range). and 48.2% were abused by a family member 460 men with CSA histories completed an anonymous. Internet- based survey. Recruited from survivors organizations. Age range of 18-84 years. Two thirds of respondents reported dery-related abuse. Majority of respondents were White the time of the abuse. or if the victim resisted during the offense. Male victims and victims from dysfunctional backgrounds were less likely co disclose Majority of children cold their mothers (43%) and peers (33%) first. Three major themes were identified as influencing the disclosure process: (I) feeling distressed. (2) opportunity to tell, and (3) fears for self. Additional themes of being believed. shamefself-blame, and peer influence were also identified Disclosure processes were more complex when it concerned sexual abuse committed by intrafaminal perpetrator 60% of the victims reveal the facts several years after. and most often to individuals outside the family (78.6% of the disclosures done at school): on the contrary. extrafamilial disclosures take place more spontaneously and quickly: 80% of the victims reveal the facts a few days after. most often to their mother or peers Vast majority of participants (94.6%) were sexually abused by another male. Duration of sexual abuse broke down into: 30.2% less than 6 months. 32.3% 6 months to 3 years. and 34.3% more than 3 years. Ten years old was average age of CSA onset Ten categories of barriers were classified into three domains: (I) sociopolitical: masculinity. limited resources: (2) interpersonal: mistrust of others. fear of being labeled 'gay.- safety and protection issues. past responses: and (3) personal: internal emotions. seeing the experience as sexual abuse. and sexual orientation. Perspectives of offenders on vulnerability of victims in relation to disclosure could be important information to inform interventions The sample size is small but will contribute to a large multisite study in Ireland. Serves as an important exploratory pilot bringing forward disclosure themes for consideration The relationship with the perpetrator has a significant impact on both timing and recipient of disclosure, with inumfamilial abuses less likely to be disclosed promptly and within the family system At time of the study. this was the largest qualitative data set to have been analyzed with an explicit focus on adult male survivors' perceptions of barriers to CSA disclosure. Because the sample was limited in terms of the low percentage of racial minorities (9.3%). disclosure differences based on race or ethnicity were not discerned. The majority of abuse reported was by clergy which might present a unique set of barriers co disclosure (continued) EFTA00156867 Table I. (continued) Study Purpose Design Sample Findings Summary Easton (2013) McElvaney, Greene. and Hogan (2012) Schonbucher. Maier. Mohler-Kuo. Schnyder. and Landolt (2012) Study purpose was to describe male CA disclosure processes using a life span approach examining differences based on age. Also. to explore relationships between disclosure attributes and men's mental health Qualitative study asked the central research question: "How do children tell?" Objective was to develop theory of how children tell of their CSA disclosure experiences. Parents were interviewed. To investigate the process of CSA disclosure with adolescents from the general population who had experienced CSA. How many disclosed. who did Cross-sectional survey design. Eligible participants were screened and completed an anonymous. Internet- based survey during 2010. Measures used: General Mental Health Distress Scale and General Assessment of Individual Needs. Questions related to CSA disclosure and supports were included Grounded theory method study. Interviews were conducted. Line-by- line open and axial coding was conducted on verbatim transcripts Data collection was through face-to-face qualitative interviews. Standardized questions and measures were administered on family situation. sociodemographic Purposive sampling of 487 men from three national organizations devoted to raising awareness of CSA among men. Age range: 19-84 years. Mean age for onset of CSA was 10.3 years Sample of 22 young people: 16 girls and 6 boys: age range: 8-18 years: 22 interviewed in total between the ages of 8 and 18. Mixed sample of some enduring innfamilial CSA. some extrafamilial CSA. and two endured both forms Convenience sample of 26 sexually victimized adolescents. 23 girls and 3 boys. Age range: 15-18 years. Online advertisements and flyers were used to recruit youth from Older age and being abused by a family member were both related to delays in disclosure. Most participants who told someone during childhood did not receive emotionally supportive or protective responses and the helpfulness of responses across the life span was mixed. Delays in telling were significant periods of time (over 20 years). Approximately one half of the participants first told about the sexual abuse to a spouse/partner (27%) or a mental health professional (20%): 42% of participants reported that their most helpful discussion was with a mental health professional. However. unhelpful responses caused most mental distress. Clinical recommendations included more of a life-course perspective be adopted. understanding impact of unhelpful responses and the importance of expanding networks for male survivors A theoretical model was developed that conceptualizes the process of CSA disclosure as one of containing the secret (I) the active withholding of the secret on the part of the child; (2) the experience of a "pressure cooker effect" reflecting a conflict between the wish to tell and the wish to keep che secret and (3) the confiding itself which often occurs in the context of a trusted relationship. These were derived from eleven categories that were developed through open and axial coding Less than one third of participants immediately disclosed CSA to another person. In most cases. recipients of both immediate and delayed disclosure were to peers. More than one third of participants had never disclosed the abuse to a parent. Participants reported reluctance to disclose to parents so as Purposive sampling of men from awareness raising organizations may have attracted particular participants who had already disclosed and received help. Participants needed co have access to Internet which would have eliminated men in lower SES groups and required proficiency in English which would eliminate certain cultural groups. However. the sampling strategy gained access to a predominantly hidden population. Important clinical recommendations are made with an emphasis on a life-course focus Modest but sufficient sample for an exploratory qualitative inquiry. High level of trustworthiness rigor. A subsample of randomly selected transcripts was independently coded. Very young children and young adults were not captured in this sample. Transferability of findings can only be made to the age range sampled in the context of Ireland Two thirds of the sample did not disclose right away. Strengthening parent—child relationships may be one of the most important ways co increase disclosure co parents. Disclosure to peers has been found a common trend in other (continued) EFTA00156868 Table I. (continued) Study Purpose Design Sample Findings Summary Hunter (2011) they disclose to. and what were their motives for disclosing Aim of this study was to develop a fuller understanding of CSA disclosures Schaeffer. Leventhal. and This study aimed to: (I) Asnes (2011) add direct inquiry about the process of a child's CSA disclosure: (2) determine if children will discuss process that led them to tell: and (3) describe factors that children identify that led them to tell about or caused them co delay CSA disclosure data. sexual victimization. general. and mental health. Sexual Assault Module of the Juvenile Victimization Questionnaire was used Narrative inquiry methodology. Face-to- face in-depth interviews were conducted with participants. Data were analyzed using Rosenthal and Fischer— Rosenthal's (2004) method. Study sought to find out if process issues of disclosure could be identified in the context of forensic interviews. Forensic interviewers were asked to incorporate questions about "telling" into an existing forensic interview protocol. Interview content related to the children's reasons for telling or waiting was extracted. transcribed. and analyzed using grounded theory method of analysis community and counseling services Purposive sampling was employed. Sample consisted of 22 participants aged 25- 70 years: 13 women and 9 men. Participants were sexually abused at IS years or under with someone over the age of IS. I91 interviews of CSA victims aged 3-18 over a -year period were used for the study. Inclusion criteria included children who made a statement about CSA prior to referral. reasons for telling or waiting co tell. and those who spoke English. Participants were children who were interviewed at a child sexual abuse clinic. 74% were female and 51X were Caucasian not to burden thent Earlier disclosures were related to extrafamilial CSA. single occurrence CSA. age of victim at abuse onset. and parents who were living together. Higher levels of reported guilt and shame were related to delayed disclosures. Peers were viewed by this sample as more reliable confidants Only 5 out of 22 participants told anyone about their early sexual experiences as children. Fear. shame. and self-blame were the main inhibitors to disclosure. These factors are further detailed through subthemes. Telling as a child and as an adult was further expanded upon using Alaggia's (2004) framework verifying behavioral indirect attempts to tell and purposeful disclosure as categories. Thematic analysis supported that CSA disclosure should be conceptualized and viewed as a complex and lifelong process Reasons the children identified for telling were classified into three domains: (I) disclosure as a result of internal stimuli (e.g.. the child had nightmares): (2) disclosure facilitated by outside influences (e.g.. the child was questioned): and (3) disclosure due to direct evidence of abuse (e.g.. the child's abuse was witnessed). The barriers to disclosure identified fell into five groups: (I) threats made by the perpetrator (e.g.. the child was told she or he would get in trouble if she or he told). (2) fears (e.g.. the child was afraid something bad would happen if she or he told). (3) lack of opportunity (e.g.. the child felt the opportunity to disclose never presented). (4) lack of understanding (e.g.. the child failed to recognize abusive behavior as unacceptable). and (5) relationship with the perpetrator (e.g.. the child thought the perpetrator was a friend) research and bears more examination Delayed disclosure was common in this qualitative sample. Most participants did not make a selective disclosure until adulthood. These findings support Alaggia's (2004) model of disclosure but also highlights the importance of life stage. Modest but sufficient sample size for a qualitative inquiry. Well-designed study with detailed analysis for transferability of findings An innovative study to cry to assess if formal investigative interviews can facilitate disclosures of CSA. Data were based on a large number of interviews. Detailed analysis produced detailed findings supporting other study findings on CSA disclosure (continued) EFTA00156869 Table I. (continued) Study Purpose Design Sample Findings Summary Alauia (2010) Fontes and Plummer (2010) Ungar. Barter. McConnell. Tuay. and Faith*1m. (20092) The study aimed to identify factors impeding or promoting CA disclosures. Overarching research question: What individual, interpersonal. environmental. and contextual influences impede or promote CA disclosures. This examination of CSA disclosure explored the ways culture affects processes of CA disclosure and reporting. both in the United States and internationally This study explored disclosure strategies with a national sample of youth focusing on A qualitative phenomenological design. LIM. was used to interview adult CA survivors about their disclosure experiences to provide retrospective accounts of CA disclosure and meaning-making of these experiences. Thematic analysis was done through a social— ecological lens. Using published literature with clinical data. this article conducted an analysis co provide a cull:unity competent framework for CA disclosure questioning Forms were completed by youth following participation in abuse prevention Purposive sampling was employed. Snowball sampling was also used co recruit more male survivors. 40 adult survivors of CA were interviewed: 36% men and 64% women. Age range of 18-65 with a mean age of 40.1 years. Average age of abuse onset was 5.3 years old. 36% of the sample was non-White. Diverse socioeconomic backgrounds Data consisted of published literature on disclosure and culture that was triangulated with clinical case material Examination of results from a national sample of 1.621 evaluation forms where youth Themes fell into four domains: (I) indMdual and developmental factors. developmental factors as to whether they comprehended what was happening. personality traits also had some bearing on their ability to tell. and anticipating not being believed: (2) disclosure inhibited by family characteristics such as rigidly fixed gender roles with dominating fathers. chaos and aggression. ocher forms of child abuse. domestic violence. dysfunctional communication. and social isolation: (3) neighborhood and community context. that is. lack of interest from neighbors and teachers not pursuing troubling behavior: and (4) cultural and societal attitudes. media messages and societal attitudes. feeling unheard as kids. gender socialization for males. and cultural attitudes influencing parent's reactions. Purposeful disclosure is higher than reported in other studies because of the sampling attempts co purposefully locate disclosers Cultural and structural factors affecting CSA disclosure are identified in in-depth detail. Recommendations made include (I) disclosure interviewing should be tailored to the child's cultural context. (2) questioning should also take into consideration age and gender factors. and (3) culture stands as an important factor in all cases in which children are considering disclosing or being asked to disclose. and not solely in cases in which children are from noticeable minority groups. Presents a comprehensive interview framework integrating cultural considerations Youth who have been abused or witnesses to abuse employ five disclosure strategies: using self-harming behaviors to signal the abuse to others: not talking The study presents a comprehensive social—ecological analysis to CA disclosure highlighting the multifaceted influences. Of note. 42% had disclosed the abuse during childhood: 26% had not disclosed because they had repressed the memory. or the abuse had occurred in preschool years and they had difficulty with recall. The remainder had attempted some form of disclosure in indirect ways during childhood. A retrospective approach that could be affected by recall issues One of the few works that adds knowledge to culturally contextual disclosure interviewing. Unique combination of literature findings with clinical material. Anecdotal accounts may preclude transferability of findings. Overall adds to an impoverished area of CSA disclosure information This study highlights that disclosure Is an interactive ongoing process. Findings lend support to studies chat have identified similarly (continued) EFTA00156870 Table I. (continued) Study Purpose Design Sample Findings Summary (I) What are the hidden experiences of abuse among Canadian youth! (2) What impact does participation in abuse prevention programs have on youth to express their abuse experiences! (3) What disclosure barriers do youth face? (4) What are young people's disclosure patterns? and (5) Who do they tell? Ungar. Tufty. McConnell. This study explored Barter. and Fairholm abuse disclosure (200%) strategies with a national sample of Canadian youth who participated in violence prevention programming. One of the goals of the study was to document not previously identified experiences of abuse and youth attitudes toward disclosure of abuse experiences programming by the Canadian Red Cross (RespectED). A series of focus groups and observations of the workshops were used co help contextualize the findings. Evaluation forms were analyzed from two violence prevention programs: (I) ies not your fault and (2) What's love got to do with It? Exploratory design with a nonrepresentative samples. Qualitative analysis of 1.099 evaluation forms completed following Red Cross RespectED violence prevention programming delivered between 2000 and 2003. Forms of anonymous abuse disclosures by youth participants of neglect. emotional. physical. and sexual abuse. Twenty-seven interviews and focus groups were also done co understand contextual issues and engage youth and program facilitators in the interpretation of findings. A coding structure was developed for analysis co synthesize themes across data sources anonymously disclosed abuse experiences. Respondents ages: 13 and under (27%). 14- 15 (37%). 16-17 (25%). 18 and older (4%). and unknown (7%) Purposeful sample of 1.099 evaluation forms completed following Red Cross RespectED violence prevention programming delivered between 2000 and 2003 at all about the abuse to prevent intrusive interventions by others: seeking help from peers: seeking help from informal adult supports: and seeking help from mandated service providers (social workers and police). Results suggest disclosure is an interactive process. with expectations regarding consequences to disclosure. Patterns of incrementally sharing abuse experiences are shaped by young people's interactions with peers. educators. and caregivers. About three- quarters of females previously disclosed: significandy less males disclosed Findings suggest high rates of hidden abuse. with less than one quarter of youth reporting a disclosure. 244 of the 1.099 youth who disclosed abuse on their evaluation forms identified specific individuals they told about their abuse. Disclosure patterns vary with boys. youth aged 14-15. victims of physical abuse. and those abused by a family member being most likely to disclose to professionals or the police. One third of disclosures were directed toward professionals and the least. 5% percent each. were directed toward friends. parents. and others. Participants were most likely to disclose sexual abuse to parenuffamily. professionals. and the police/courts. with fewer choosing friends. Out of all 1.099 participants. 225 males and 779 females indicated that they had been abused. Out of those. 43 males and 180 females indicated that they had disclosed the abuse. Of those who had disclosed. only a portion of males and females specified who they had disclosed the abuse to (-While 1.099 evaluations with disclosure statements were analyzed. only 22% made mention of people to interactive models of disclosure such as chose detailed by Alaggia (2004) and Scalier and Nelson- Gardell (2005). This mixed sample of youth who experienced different forms of abuse and violence exposure were pardcipants—not limited to CSA survivors Innovative design of this study provides insight into young people's perceptions of disclosure experiences. High level of rigor with trustworthiness of the data analysis ensured through use of youth focus groups. interviews. and observational data. The study results are somewhat limited in the thickness of the descriptions it can offer because most of the data are survey based. Regional differences may not have been picked up. Scope of the study is broad and approach is creative (continued) EFTA00156871 cr. Table I. (continued) co Study Purpose Design Sample Findings Summary Priebe and Svedln (2008) Sorsoil. Kia-Keating, and Grossman (2008) This study aimed to investigate disclosure rates and disclosure patterns and examine predictors of nondisclosure in a sample of male and female adolescents with self-reported experiences of sexual abuse Study focused on disclosure challenges for male survivors of CSA co understand three issues: (I) To Participants completed 65-Item questionnaire chat included questions about background. consensual sex. sexual abuse experiences (noncontact. contact or penetrating abuse. Including peer abuse). disclosure of CSA. own sexual abusive behavior. sexual attitudes. and experiences with pornography and sexual exploitation. The questionnaire included 6 modified items from the SCL-90 and 9 of 25 items from the Parental Bonding Instrument. The data for girls and boys were analyzed separately Male survivors of CSA were interviewed about their disclosure experiences. Analytic techniques included The sample consisted of 4.339 high school students in Sweden (2.324 girls and 2.015 boys). The mean age of the participants was 18.15 years. This study used a subsample of 1.962 participants who reported CSA and who answered disclosure questions The sample consisted of 16 male survivors of childhood sexual abuse: 11 Caucasian. 2 African American. I whom disclosures occurred:') More females specified who they disclosed to compare to males. The data show perceptions among youth of negative consequences following disclosure Of the sample. 1.505 girls (65%) and 457 boys (23%) reported CSA The disclosure rate was 81% (girls) and 69% (boys). Girls and boys disclosed most often co a friend of their own age. Few had disclosed to professionals. and even fewer had reported to the authorities. There were higher rates of disclosure co a professional with more severe abuse (contact abuse with or without penetration) for girls. but lower races for boys The more severe the sexual abuse was. the less likely both girls and boys had talked to their mother. father. or a sibling. Girls were less likely to disclose if they had experienced contact sexual abuse with or without penetration. less frequent abuse, abuse by a family member. or if they had perceived their parents as less caring and less overprotective and highly overprotective. Boys were less likely to disclose if a family member abused them. they were studying a vocational program (vs. an academic program). lived with both parents or had perceived their parents as less caring and not overprotective. Adolescents who reported CSA perceived their mental health as poorer compared to adolescents without CSA. Nondisdosers reported more symptoms on the Mental Health Scale than those who had disclosed Barriers to disclosure were found to be operant in three interrelated domains: (1) personal (e.g.. lack of cognitive awareness. intentional avoidance. emotional readiness, and shame): (2) This study highlighted that sexual abuse is largely hidden from adult society. especially from professionals and the legal system. However. time lapsed to disclosure was not reported. Since friends appeared to be the main recipients of sexual abuse disclosures. practice implications of this could be to find ways to give young people better information and guidance about how to support a sexually abused peer. A qualitative component to the study would have provided a broader understanding of disclosure processes. Study limitations include a significant amount of boys who did not complete the questions regarding disclosure on: the timing of disclosures (whether they were delayed or not) was not measured: possibility of recall bias with retrospective studies based on self-reports: and youth participants may not have understood all the questions Since the vast majority of men in the sample had not disclosed in childhood. they may have been predisposed to identifying barriers to disclosure more (continued) EFTA00156872 Table I. (continued) Study Purpose Design Sample Findings Summary Hershkowiu. Lanes, and Lamb (2007) whom and in what contexts have they disclosed these experiences? (2) What do they have to say about their disclosure experiences? and (3) What are their perceptions of positive and negative aspects of their disclosure. including incentives and barriers? The goal of the present study was to examine how child victims of extrafamilial sexual abuse disclosed the abuse experience grounded theory method of analysis for coding and development of conceptually clustered matrices. Participants completed two in- depth. semi-structured interviews. lasting between 2 and 3 hr each taking place approximately a week apart Alleged victims of sexual abuse and their parents were interviewed. Children were interviewed using the NICHD Investigative Interview Protocol by experienced youth investigators. Information on disclosure processes was obtained in the first formal interview. before any police investigation or child welfare intervention Puerto Rican. I part Native American. African Cuban: age range of 24-61 years:9 identified themselves as heterosexual. 5 as homosexual. and 2 as bisexual Thirty alleged victims of CSA.; 18 boys and 12 girls. Child sample was 7- to 12-year-olds with an average age of 9.2 years. Twenty mothers and 10 fathers were also interviewed for a total of 30 parent interviews. A content analysis was conducted on child and parent interviews relational (e.g.. fears about negative repercussions. isolation): and (3) sociocultural (e.g.. lack of acceptance for men to experience or acknowledge victimization). Only I of the 16 men in this sample disclosed the MI extent of his sexual abuse experiences while he was still a child. The other men reported that they had not disclosed. although some reported attempts to tell that were indirect or incomplete. Several other men disclosed certain experiences or elements of their abuse. but concealed others. By the time of the study. many of these men had disclosed their past experiences in a variety of relationships. including those with family members. partners. therapisu. and infrequently friends. Several had only limited discussions of their sexual abuse Disclosure categories were identified as follows: (I) delayed 53% of the children delayed disclosure for between 1 week and 2 years: (2) recipient of disclosure: 47% of children first disclosed to siblings or friends. 43% first disclosed to their parents. and 10% first disclosed to another adult 57% of the children spontaneously disclosed abuse. but 43% disclosed only after they were prompted. 50% of the children reported feeling afraid or ashamed of their parenu' responses. Parents' reactions: supportive (37%) and unsupportive (63%). There was a strong correlation between predicted and actual parental reactions suggesting children anticipated their parents' likely reactions accurately. Disclosure processes varied depending on the children's ages (e,gt. younger children disclosed to parents). severity and frequency of abuse. parents' expected reactions, suspects' identities. and strategies used co foster secrecy readily. Retrospective accounts are subject to recall issues. Investigators made significant efforts to gather a diverse sample. High level of rigor was executed in the dependability of the data and iterative process of the interpretation of findings was conducted Innovative design to gather disclosure data from young children. Focus is on extrafamilial CSA which may differ than disclosure patterns of intrafamilial CSA Two thirds of the parents registered unsupportive responses which is high (continued) EFTA00156873 t4 Table I. (continued) Study Purpose Design Sample Findings Summary Alaggia and Kirshenbaum The objectives of the (2005) current study were to identify a broad range of factors. including family dynamics that contribute to or hinder a child's ability co disclose CSA Alaggia (2005) Collings. Griffiths. and Karnak. (2005). The study purpose was CO qualitatively explore dynamics that impede or promote disclosure by examining a range of factors including gender as a dynamic— how disclosures of females and males are similar and different. and in what ways gender affects CSA disclosure Study examined patterns of disclosure in a large representative sample of South African CSA victims. Two study objectives to: (I) examine how and A qualitative phenomenological design—LIM—was used CO elicit disclosure experiences: facilitators and barriers: and relevant circumstances. Interviews were transcribed verbatim. Line-by-line open coding was conducted to capture family4evel factors. Axial and selective coding facilitated identification of themes Survivors of CA were interviewed about their disclosure experiences using LIM. Analysis of 30 participant narratives was used for theme development regarding impact of gender on disclosure. Interviews were transcribed verbatim for open. axial. and selective coding. Categories and subcategories were collapsed and refining into theme areas File reviews of a0 social work and medical case files for CA victims seen at the crisis center where all cases of CSA reported to the North Durban Purposive sampling was employed to recruit 20 adult survivors between the ages of 18 and 65 who were sexually abused by a family member. Average age of participants was 40.1 years: 60% of participants were female and 40% male. Average age of onset of abuse was 6.7 years. Mixed clinical and nonclinical sample. The majority had received treatment for CA at some point in their lives Purposive sampling of women and men. along with those who disclosed during the abuse and chose who did not. 19 females and 11 males: 18-65 (mean 40.1) years who were sexually abused by a family member or a trusted adult. Average age of abuse onset was 5.3 years. 36% were nonwhite. and 58% had not disclosed during childhood 1.737 cases of CSA reported in the North Durban area of KwaZulu-Nacal. South Africa. during January 2001 to December 2003. 1.614 Orb and Four major themes emerged suggesting that CA disclosure can be significantly compromised when certain family conditions exist (I) rigidly fixed. gender roles based on a patriarchy-based family structure: (2) presence of family violence: (3) closed. indirect family communication patterns: and (4) social isolation of the family as a whole. or specific members. played a part in CSA victims feeling they had no one safe CO tell. Family systems formulations through a feminist lens are important in understanding children and families at risk of disclosure barriers Three themes emerged for men that inhibited or precipitated disclosure for reasons related to gender: (I) fear of being viewed as homosexual: (2) profound feelings of stigmatization or isolation because of the belief that boys are rarely victimized: and (3) fear of becoming an abuser. which acted as a precipitant for disclosure. Two predominant themes with female participants related to difficulties disclosing: ( I ) they felt more conflicted about who was responsible for che abuse and (2) they more strongly anticipated being blamed and/or not believed Content analysis identified two broad dimensions of disclosure: (I) agency: child-initiated disclosure versus detection by a third party and (2) temporal duration: an event versus a process. These disclosure dimensions defined four discrete categories of Over half the participants had not disclosed the abuse during childhood. Of the nondisclosing participants. six did not disclose because they had repressed or forgotten the memory. Almost one third withheld disclosure intentionally. More data are needed on early disclosures to garner more information on facilitators of disclosure. Retrospective approach implies recall issues. High level of trustworthiness of the data and interpretations were achieved through credibility. dependability. and confirmability through direct quotes One in a dearth of studies that conduct gender analysis. Comparative analysis draws out important practice implications. Retrospective design of che study which implies possible recall issues. High level of trustworthiness of the data and interpretations were achieved through credibility. dependability. and confiivnability through direct quotes These results fit into Alaggia's (2004) disclosure framework_ Through data analysis two raters coded disclosure categories using author's disclosure frameworic which proved co be both exhaustive and mutually exclusive frontMued) EFTA00156874 Table I. (continued) Study Purpose Design Sample Findings Summary Hershkowia. Horowia. and Lamb (2005). Jensen. Gulbrandsen. Mossige. Reichelt. and Tjersbnd (2005) when CSA tins disclose their abuse and (2) Identify factors associated with different patterns of disclosure This study aimed to identify characteristic of suspected child abuse victims that are associated with disclosure and nondisclosure during formal investigations This study investigated the context in which children were able co report their child sexual abuse experiences; their views as co what made it difficult to talk about abuse: what helped them in the disclosing process: and their parents perceptions of their disclosure processes policing area were referred during the period of January 2001 to December 2003 Large database of suspected cases of physical and sexual abuse investigated in Israel between 1998 and 2002 was analyzed. Interviews were also conducted using standardized NICHD Investigative Interview Protocol. Archival data were analyzed Qualitative approach to data collection and analysis was used. Therapeutic interviews o the children and mostly their mothers were analyzed through a qualitative approach. Follow-up interviews were held I year later 123 boys: average age of victimized children was 9.9 years. 47% reports were made within 72 hr of the abuse. 31% from 72 hr to 1 month. and 22% more than a month after the abuse The sample was comprised of 26.446 of 3- co 14-year-old alleged victims of sexual and physical abuse interviewed in Israel in the 5-year period from 1998 to 2002. 140 experienced trained youth investigators conducted interviews 20 families with a total of 22 children participated. Al children had told about experiences that created concerns for care-givers about CSA. Children's ages ranged between 3 and 16 years (average age 7.5 years): 15 girls and 7 boys. Sexually abused by someone in the family or a close person to the family disclosure: (I) purposeful disclosure (30% of cases). (2) indirect disclosure (9% of cases). (3) eyewitness detection (18% of cases), and (4) accidental detection (43% of cases). Disclosure independently predicted by victim's age. nature of the victim—perpetrator relationship. offender's age. frequency of abuse, and reporting latency. Mean age of purposeful disclosures (10.67) was higher than the mean age of indirect disclosures (5.84). Explicit forms of disclosure were less likely when the offender was a family member. Shorter reporting latency was more likely with repeated abuse Overall. 65% of che 26.446 children made allegations when interviewed. Rates of disclosure were greater for sexual abuse (71%) over physical abuse (61%). Children of all ages were less likely to disclose/allege abuse when a parent was the suspected perpetrator. Disclosure rates increased as children grew older: 50% with 3- to 6-year-olds. 67% of the 7- to I0-year-olds. and 74% of the II- to 14-year-olds disclosed abuse when questioned None of the children cold of abuse immediately after it occurred. Children exposed to repetitive abuse kept this as a secret for up to several years: 17 told their mothers first. 3 first cold a friend. I told their father. and I their uncle. Majority of remarks that led co the suspicion of CSA were made in situations where someone engaged the child in a dialogue about what was bothering them. resulting in a referral. The children felt it was difficult co find situations containing enough privacy and prompts that they could share their experiences. When the children did with the percentage of interrater agreement at 98%. Generafizabilicy of this study is limited to child clients receiving a crisis assessment referred through a police report Overall findings indicated that rates of disclosure varied systematically depending on the nature of the alleged offences. the relationship between alleged victims and suspected perpetrators. and the age of the suspected victims. Analyses only involved cases that had come co the attention of official agencies. making it difficult co determine how many of abuse take place without ever triggering any kind of official investigation Evidence for delayed disclosures. The results indicate that disclosure is a fundamentally dialogical process that becomes less difficult if children perceive chat there is an opportunity co talk, a purpose for speaking and a connection has been established to what they are talking about. Strengthening parent—child relationships is an important practice implication (continued) EFTA00156875 Table I. (continued) Study Purpose Design Sample Findings Summary Seller and Nelson- Gardell (2005) Alaggia (2004) The purpose of this study was to understand the full process of CSA disclosure and how this unfolded for preadolescent and adolescent girls. Examined what facilitated and hindered disclosure and subsequent consequences The study sought to examine influences that inhibit or promote children's disclosure of CSA co address gaps in knowledge about how. when, and under what circumstances victims of CSA disclose Secondary analysis of qualitative focus group data. Original project consisted of four focus groups conducted within the context of ongoing therapy for girls who had experienced CSA. Secondary analysis consisted of written narrative summaries of each session grouping these conceptually. and examining their interconnectedness The study employed L1M—a phenomenological design. Intensive interviewing that were 2 hr long on avenge generated data for a thematic analysis. The interview guide was Sample consisted of 34 participants from four groups. Sessions analyzed were between 60 and 90 min long: audiotaped and later transcribed for content analysis Using purposive sampling 24 adult survivors of intrafamilial abuse between ages of 18 and 65 (average age 41.2) were recruited from agencies and one university: 57% male and 43% female; disclose they did it in situations where the topic of child sexual abuse was in some form addressed or activated. where someone recognized the child's cues and probed further. They also were sensitive to others reactions. and whether their disclosures would be misinterpreted. Several of the children perceived negative consequences as major factors contributing to delaying disclosure. They were primarily concerned about negative effects for the mother. The mothers said they were also sensitive to the children's feelings. If their children showed signs of distress and did not want to talk the mothers would change the subject or not pursue the topic further Findings are reported in three major domains: (I) self-phase: where children come to understand victimization internally: (2) confidant selection- reaction phase where they select a time. place. and person to tell and then whether that person's reaction was supportive or hostile: and (3) consequences phase: good and bad chat continued to inform their ongoing strategies of telling. The actions and reactions of adults were significant and informed the girls' decisions. The consequences phase was further subdivided into four aspects: (I) gossiping and news networks. (2) changing relationships. (3) institutional responses and the afterlife of telling, and (4) insider and outsider communities Through analysis of the interview new categories of disclosure were identified to add to easdng types. Three previously identified were confirmed in these data: accidental. purposeful. and prompted/elicited accounted for 42% of disclosure patterns in the study sample. Over half the disclosure patterns described by the study sample did not fit these This study provided a contextual examination of the entire disclosure process. closer to the point in time when the abuse and disclosure occurred. Small groups of preadolescent and adolescent girls who had survived sexual abuse also served as consultants and were encouraged to share their knowledge for the benefit of professional practitioners This study expanded types of CSA disclosures to more fully understand how children and adults disclose. And under what circumstances. Asking people to recount events that occurred in childhood is susceptible to memory failure. especially when memories were forgotten. (continued) EFTA00156876 Table I. (continued) Study Purpose Design Sample Findings Summary Crisma. BasteIli. Paci. and The main goals of this Romito (2004) study were to understand impediments that prevent adolescents from disclosing CSA and seeking help from their social network and/or the services Jonzon and Lindblad Study purpose was to (2004) explore how abuse traits. openness. reactions to CSA disclosure. and social support were related. Differences based on severity of abuse. timing and outcomes of disclosure. social support. and predicting factors of positive and negative reactions were probed developed to probe for individual. interpersonal. environmental. and cultural factors influencing CSA disclosure In-depth telephone (anonymous) interviews were conducted after informed consent was explained and obtained. Three investigators experienced in counseling CA counseling conducted the interviews which were recorded with permission. Three researchers independently scored the interviews according to a coding framework Adult women reporting CSA by someone close were interviewed using semi-structured guides together with questionnaires. Data on victimization and current social support were retrieved through the questionnaires. and data on disclosure and reactions were gathered through the interviews with participants avenge age of abuse onset was 6.5 years: 42% of the participants had disclosed the abuse during childhood: 58% disclosed as adults The sample was comprised of 36 young people who experienced sexual abuse in adolescence: 35 females and I male: aged 12-17. Some of the sample experienced sexual violence in a dating relationship 122 adult women between 20 and 60 years old (average age of 41 years) reporting exposure to child sexual abuse by someone close before the age of 18 and had told someone about at least one abuse event. 90% were Swedish subjects. Purposive sampling strategy was used previously established categories. Three additional disclosure categories emerged: behavioral and indirect verbal attempts. disclosures intentionally withheld. and disclosures triggered by recovered memories The main impediments co disclose to a family member were: fear of not being believed. shame. and fear of causing trouble to the family. The main impediments for not seeking services were: unaware of appropriate services. wish to keep the secret. lack of awareness of being abused. mistrust of adults and professionals. and fear of the consequences of disclosing sexual abuse. When they did disclose co professionals. teens received very limited support as many professionals were not trained on sexual abuse and could not offer appropriate interventions to victims Abuse characteristics: abuse by multiple perpetrators was more common than by a single perpetrator. Age of onset was often before age of 7. with an average duration of 7 years. Severely abused women had talked co more of their social network especially to professionals. Disclosures: 32% disclosed during childhood (before the age of 18) with an average of 21 years delay. Women who had disclosed in childhood reported more instances of physical abuse. multiple perpetrators. use of violence. and were more likely to have confronted a perpetrator. and had received a negative first reaction. Factors delayed. or repressed and later recovered. Distortion and revision of events are also potential problems in recall. High degree of trustworthiness of the data was achieved and quotes provided supported the categories This study represented the findings of a mixed sample of survivors of child sexual abuse and intimate partner violence. The study was conducted in Italy and it is not clear what sexual abuse response training is available. There may have been a selection bias as the most dissatisfied survivors responded co the research call 68% delayed disclosure until adulthood. At the time of the study. it was one of the first studies to focus on the interplay between social support networks and disclosure of child sexual abuse. The study results are somewhat limited by an overrepresentation of severely abused women. Retrospective study and self-report of information could imply recall issues and thus limits the accuracy of the information obtained on abuse and disclosure characteristics. Cross-sectional (continued) EFTA00156877 Table I. (continued) Study Purpose Design Sample Findings Summary Kogan (2004) Goodman-Brown. Edelstein. Goodman. Jones. and Gordon (2003) The purpose of this study was co identify factors chat influence the disclosures made by female survivors of USE in childhood and adolescence. The predictors of both the timing of disclosure and the recipient of the disclosure were investigated The purpose of this study was co investigate variables associated with delay of disclosure of CSA and test a model for factors that influence how quickly children disclose sexual abuse Data were gathered from a subsample of female adolescents that participated in the NSA which consisted of structured phone interviews. USEs reported in the NSA were assessed using a modified version of the Incident Classification Interview. They were then asked a seats of questions about each episode of unwanted sexual contact including event characteristics and perpetrator characteristics Case file reviews of data obtained from prosecution files. as well as from structured interviews with the children's caretaker and observations of child interviews. Trained graduate students and one victim advocate completed the Sexual Assault Profile significantly predicting delay were younger age at first event and no use of violence. Disclosure outcomes: of the 26 women who told in childhood during a period with ongoing abuse. 15 women were continuously abused after disclosure A subsample of 263 Children under the age of 7 were at a adolescent females higher risk for delayed disclosures. between 12 and 17 Participants whose USE occurred years old. mean age of 15.2 years old. who reported at least one experience of unwanted sexual contact in the NSA. Participant characteristics. USE characteristics. and family contextual attributes were explored Sample consisted of 218 children referred to prosecutors offices for alleged CSA. All children in the sample had disclosed their abuse in some manner. Children ranged in age from 2 to 16 years at the beginning of abuse: 3-16 years at the end of the abuse. and 4-16 years at the time of the between the ages of 7 and 13 were most likely co tell an adult Adolescents (14- 17) were more likely co tell only peers than children aged 7-10 years. Children under 11 were more likely to cell an adult but were at risk for delaying disclosure beyond a month. Children aged 11-13 tended to disclose within a month. Closer relationship co the perpetrator or a family member was associated with delayed disclosure. Immediate disclosure was more likely with stranger perpetration. Fear for one's life during and penetration were associated with disclosure to adults. Family factors linked to disclosure were (I) drug abusing household member. which made survivors more likely to disclose more promptly and (2) never living with both parents was associated with nondisclosure 64% disclosed within a month and 29% within 6 months. Five variables for the model were tested. (I) age: children who were older cook longer to disclose and older children feared more negative consequences to others than younger children: (2) type of abuse: victims of intrafamilial families cook longer to disclose—victims of intrafamilial abuse feared greater negative consequences to others compared to victims of extrafamilial abuse: (3) fear of negative consequences: children who feared design does not allow for definite conclusions of cause and effect on the relationships found This study examined factors including disclosures of USEs in childhood and adolescence in a nationally representative sample of female adolescents who participated in the NSA Surveys for investigations of victimization experiences may be biased due to underreporting. Adolescents who refused to report or discuss an USE may represent a source of systematic bias and would make the results generalizable only to adolescents who are willing to disclose USE via survey. Although data may be retrospective. recall bias may have been minimized in this study since participants were adolescents. and so the time lag between the USE and the interview were presumably shorter than a study of adult participants recalling CSA experiences This study represents a higher rate of disclosers within a month. These cases had been reported to authorities and were in process of prosecution which may explain higher rate of early disclosures. Legal sample with higher rate of extrafamilial abuse (52%) may also account for earlier disclosures. Model suggests that older children. victims of intrafamilial abuse: felt greater responsibility for the abuse. and perceiving (continued) EFTA00156878 Table I. (continued) Study Purpose Design Sample Findings Summary Smith. Letourneau. The study focus was co Saunders. Kilpatrick, gather data from a Resnick. and Best large sample of women (2000) about the length of dme women who were raped before age IS delayed disclosure who they disclosed to. and variables that predicted disclosure within I month questionnaire for child characteristics. the abuse and their disclosure. Children's perception of responsibility and fear of negative consequences were probed. Correlational analyses were conducted with path analyses to test the hypothesized causal relations among variables Structured telephone interviews that lasted approximately 35 min were used to collect data using a computer- assisted telephone interview system. All telephone interviews were conducted with each question on a computer screen. The survey consisted of several measures designed to elicit demographic information. psychiatric symptoms. substance use. and victimization history. The present study reports on data from the demographic and child rape victimization questions initial police report: 77% female. 70% Caucasian. 17% Hispanic. and 11% African American. Predominantly middle to low SES. Approximately 47% incrafam0ial abuse Two probability samples. Wave I was a random sample of 2.009 respondents selected from stratified samples of defined jurisdictions. Random digital dialing was used to solicit households for listed and unlisted telephone numbers. Second random sample of 2.000 women between the ages of 18 and 34 was selected. Both Wave I and Wave 2 data were weighted to conform to che 1989 Census statistics negative consequences of disclosure took longer to disclose. children who believed that their disclosure would bring harm co others took longer to disclose. fear of negative consequences to the self or the perpetrator was unrelated to time of disclosure. and girls more than boys feared negative consequences to others; (4) Perceived responsibility: children who felt greater responsibility for the abuse cook longer to disclose and older children felt more responsibility for the abuse: and (5) gender was not significantly correlated with time to disclosure 288 (9%) reported experiencing at least one event that met the study's definition of childhood rape. The average age at the time of the first rape was 10.9 years. Of the 288 women who reported a child rape. 28% stated that they had never told anyone about this sexual assault until specifically queried by the interviewer for this study. 58% did not disclose for over I year and up co 5 years post-rape. 27% disclosed within a month. Among women who disclosed prior to their NWS interview close friends were the most common person to whom victims made disclosures. followed by mothers and other immediate family members. Fewer than 10% of victims reported making their initial disclosure to social workers or law enforcement personnel. Only 12% of child rape victims stated that their assaults were reported to authorities at some point negative consequences to disclosing cook longer to disclose. Well-designed study with high level of rigor. Produced a viable model of disclosure for further investigations. However. researchers were not able to interview children directly The time frame of chis survey may have had contextual implications. The majority of child rapes reported by this sample occurred prior to the large-scale child assault prevention education programs that were begun in the 1980s chat teach children chat assaults (including CSA) are wrong and should be disclosed to responsible adults. This information may have influenced (and may currently be influencing) young women's disclosure patterns. For Wave I. comparison of these data with the population parameters obtained Worn the U.S. Census Bureau indicated that che sample closely matched the demographic attributes of che population of U.S. women Note. SCL.90 = Symptom Check List-90: SE = socioeconomic status: UM = long interview method: CSA = child sexual abuse: NICHD National Institute of Child Health and Human Dreelopmen sexual experiences: NSA = National Survey of Adolescents: NWS = National Wanen's Study: ()IDS = Questionnaire infamous< :ur les delinquants sexeuls. USE unwznted EFTA00156879 276 TRAUMA VIOLENCE, & ABUSE 20(2) examples of this usage were found in the research questions, interview guides, and surveys examined: "Ilow 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; Schonbucher, 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 forward 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 I: Disclosure is viewed as an ongoing process as opposed to a discrete event—iterative and interactive in nature. A subtheme was identified regarding disclosure as being facilitated within a dialogical and relational context is being more clearly delineated. Theme 2: Contemporary disclosure models reflect a social—ecological, person-in-environment perspective to understand the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure. Subthemes include new categories of disclosure and a grow- ing focus on previously missing cultural and contextual factors. Theme 3: Age and gender are strong predictors for delaying disclosure or withholding disclosure with trends showing fewer disclosures by younger children and boys. One sub- theme emerged that intrafamilial abuse/family-like relation- ship of perpetrator has a bearing on disclosure delays or withholding. Theme 4: There is a lack of a cohesive life-course perspec- tive. One subtheme includes the lack of data within the 18- to 24-year-old emerging adult population. Theme 5: Significantly more information is available on barriers than on facilitators of CSA disclosure. Subthemes of shame, self-blame, and fear are uniformly identified as disclosure deterrents. Disclosure as an ongoing process: Iterative and interactive in nature. Disclosure is now generally accepted as a complex and lifelong process, with current trends showing that CSA disclosures are too often delayed until adulthood (Collin-Vezina et al., 2015; Easton, 2013; Hunter, 2011). Knowledge building about CSA disclosure has moved in the direction of understanding this as an iterative and interactive process rather than a discrete, one- time event. Since the new millennium, disclosure is being viewed as a dynamic, rather than static, process and described "not as a single event but rather a carefully measured process" (Alaggia, 2005, p. 455). The catalyst for this view originates from Summit (1983) 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 lIogan (20 I2) 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 3502-021 Page 17 of 24 EFIA_00001539 EFTA00156880 Maggio et at. 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 CM disclosure reflect a social-ecological perspecthe 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; Braze1ton, 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, 20096). 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: (I) bathers from within, (2) bathers in relation to others, and (3) barriers in relation to the social world which can be aligned to infra- 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, 2014;Easton, 2013; Goodman-Brown et al., 2003; Ilershkowitz et al., 2005; Priebe & Svedin, 2008; Schonbucher 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, sociocultural, 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 IS studies sampled adults over the age of I8, and a further two studies used mixed age-groups (refer to Table l). 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; Ilershkowitz 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 Fairbolm (2009a, 200%) is one exception, whereby their survey elicited new disclosures. 3502-021 Page 18 of 24 EFIA_00001540 EFTA00156881 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, 20 II; 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 (tIershkowitz 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, 20096). 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., 20096). 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 (Caviler & 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). Lock of a Ide-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 bathers 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 3502-021 Page 19 of 24 EFIA_00001541 EFTA00156882 Maggio et at. 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 co perpetrator. If the perpetrator is a family member or in a family-like role. disclosure is less likely co 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 co 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 & Won- 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). Elrazelton (2015) similarly found that lack of discussions about sex, young age at the onset of sexual abuse, therefore not having the language to express what was happening to them, and preserving the family good name by not talking about abuse in the family were also barriers to disclosure. Finally, it may be the case that more barriers continue to be identified over facilitators of CSA disclosure perhaps because of the methods employed in studies—particularly those draw- ing on adult populations who delayed disclosure. These sam- ples may not be representative of the overall population of CSA victims, since they may have had more negative disclosure 3502-021 Page 20 of 24 EFIA_00001542 EFTA00156883 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