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# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016)

TRAUMA, VIOLENCE, & ABUSE
2019, Vol. 20(2) 260-283
The Author(s) 2017



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DOI: 10.1177/1524838017697312
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Ramona Alaggia', Delphine Collin-Vézina², and Rusan Lateef'

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## 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) Disclosure is an iterative, interactive process rather than a discrete event best done within a relational context; (2) contemporary disclosure models reflect a social-ecological, person-in-environment orientation for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure; (3) age and gender significantly influence disclosure; (4) there is a lack of a life-course perspective; and (5) barriers to disclosure continue to outweigh facilitators. Although solid strides have been made in understanding CSA disclosures, the current state of knowledge does not fully capture a cohesive picture of dis- 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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Abstract (cont.)

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-Vézina, Sablonni, Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000).

Incidence studies in the United States and Canada report decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Tumer, & Hamby, 2014; Trocmé et al., 2005, 2008), while at

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Introduction (cont.)

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, & Gómez-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 IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). These findings point to the incongruence between the low number of official reports of

'Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada

2 Centre for Research on Children and Families, School of Social Work, McGill University, Montreal, Qubec, Canada

## Corresponding Author:

Ramona Alaggia, Factor-Inwentash Chair in Children's Mental Health, Factor-

Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. West,

Toronto, Ontario, Canada M4KIWI.

Email: ramona.alaggia@utoronto.ca

EFTA00025248

Alaggia et al.

261

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stolten- borgh, van IJzendoorn, 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) (Jil- lian, Cotter, & Perreault, 2014; Statistics Canada 2013). In other words, while 1 out of 8 people retrospectively report having experienced CSA, official incidence estimates indicate only 1 per 250 children. In a survey of Swiss child services, Maier, Mohler-Kuo, Landholt, Schnyder, and Jud (2013) fur- ther found 2.68 cases per 1,000 of CSA disclosures, while in a recent comprehensive review McElvaney (2015) details the high prevalence of delayed, partial, and nondisclosures in childhood indicating a persistent trend toward withholding CSA disclosure.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

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-Vézina et al., 2015; Easton, 2013; Hunter, 2011; McElvaney, 2015; Smith et al., 2000), these issues should be a concern for practitioners, policy makers, and the general public (McElvaney, 2015). The longer disclosures are delayed, the longer individuals potentially live with serious negative effects and mental health problems such as depres- sion, anxiety, trauma disorders, and addictions, without receiv- ing necessary treatment. This also increases the likelihood of more victims falling prey to undetected offenders. Learning more about CSA disclosure factors and processes to help advance our knowledge base may help professionals to facil- itate earlier disclosures.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

Previous literature reviews examining factors influencing CSA disclosure have served the field well but are no longer current. Important contributions on CSA disclosures include Paine and Hansen's (2002) original review covering the liter- ature largely from the premillennium era, followed by London, Bruck, Ceci, and Shuman's (2005) subsequent review, which may not have captured publications affected by "lag to print" delays so common in peer-reviewed journals. These reviews are now dated and therefore do not take into account the plethora of research that has been accumulated over the past 15 years. Other recent reviews exist but with distinct contribu- tions on the dialogical relational processes of disclosure (Reit- sema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McEl- vaney, 2015). This literature review differs by focusing on CSA Key Findings into adulthood-over the life course.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

disclosure research, through various mixed methods, to high- light the most convincing findings that should be considered for future research, practice, and program planning. This review centered on the question: What is the state of CSA disclosure research and what can be learned to apply to future research and practice? By way of clarification, the term systematic refers to a methodologically sound strategy for searching liter- ature on studies for knowledge construction, in this case the CSA disclosure literature, rather than intervention studies. The years spanned for searching the literature were 2000-2016, building on previous reviews without a great deal of overlap. Retrieval of relevant research was done by searching interna- tional electronic databases: PsycINFO, PsycARTICLES, Edu- cational Resources Information Center, Canadian Research Index, International Bibliography of the Social Sciences, Pub- lished International Literature on Traumatic Stress, Sociologi- cal Abstracts, Social Service Abstracts, and Applied Social Science Index and Abstracts. This review searched peer- reviewed studies. A search of the gray literature (unpublished literature such as internal agency documents, government reports, etc.) was beyond the scope of this review because unpublished studies are not subjected to a peer-review process. Keyword search terms used were child sexual abuse, childhood sexual abuse, disclosure, and telling.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

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 (1) multiple readings by the three authors; (2) identifying patterns across studies by coding and charting specific features; (3) examining disclosure definitions used, sample characteristics, and measures utilized; and (4) major findings were extrapolated. Reading of the articles was initially conducted by the authors to identify general trends in a first level of analyses and then subsequently to identify themes through a deeper second-level analyses. A table of studies was generated and was continuously revised as the selection of studies was refined (see Table 1).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Corresponding Author: (cont.)

disclosures in children, youth, and adults from childhood and First-level analysis of the studies identified key study charac-

## Method

Kiteley and Stogdon's (2014) systematic review framework was utilized to establish what has been investigated in CSA

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

EFTA00025249

Table I. Ch d Sexua Abuse (CSA) D sc osure Studes: 2000-2016.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Method (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>F nd ngs</th><th>Summary</th></tr><tr><td>Gagn er and Co n-
Véz na (2016)</td><td>To exp ore d sc osure
processes for ma e
v ct ms of CSA</td><td>Phenomeno og ca
methodo ogy used to
nterv ew ma e CSA
surv vors. The Long
Interv ew Method
(LIM) gu ded data
co ect on and
ana yses.</td><td>17 men ranged n age
from 19 to 67-
average age 47.
Purpos ve samp ng
strategy was used</td><td>The major ty of the men n the study wa ted
unt adu thood to d sc ose the r abuse,
w th negat ve stereotypes contr but ng
to the r de ayed d sc osures. Negat ve
stereotypes contr buted to de ayed
d sc osure with try ng to forget. Break ng
so at on was cted as a mot vator to
d sc osure a ong with the ad of var ous
forms of med a on d sc osure. Important
contextua ssues such as negat ve
stereotyp ng of ma es, sexua ty, and
v ct ms were noted. Soc a med a was
seen as a fac tator of d sc osures</td><td>A part c pants had d sc osed and
rece ved serv ces before
part c pat ng n the study. Member
check ng cou d not be done with
the part c pants to check themes.
Sma but suff c ent s ze for a
qua tat ve nqu ry. Otherw se,
hgh eve of r gor n estab sh ng
trustworth ness of the data and
ana ys s. Retrospect ve study
coud mp y reca ssues</td></tr><tr><td>Braze ton (2015)</td><td>To exp ore the mean ng
Afr can Amer can
women make of the r
traumat c exper ences
wth CSA and how
they d sc osed across
the fe course</td><td>Co ect ve case study
des gn with us ng
narrat ve trad ton
(storyboard) for data
co ect on and ana ys s.
Qua tat về
nterv ew ng</td><td>17 Afr can Amer can
women n m d- fe
between 40 and 63
who exper enced
ntrafam a CSA.
Purpos ve, snowba ng
strategy</td><td>CSA onset was arge y between the ages 5
and 9. No one ever ta ked to them about
sex, so they didn't have anguage to
d scose. Barr ers: fear of fam y
breakdown and remova, not want ng to
tarn sh the fam y's name, and fear of
retr but on by fam y members f they
dsc osed. Pattern of st fed and
d sm ssed d sc osures dent fed over the
fe course. A 17 part c pants dent fed
sp r tua ty as a pr mary source of
strength throughout the fe course</td><td>One of few stud es to focus
exc us ve y on Afr can Amer can
women. Sma but suff c ent s ze
for a qua tat ve nqu ry. Important
cu tura and contextua ssues
were brought forward.
Retrospect ve study that may
have been affected by reca ssues.
Use of a fe-course perspect ve as
a theoret ca ens for
understand ng CSA n the m dd e
to ater years of fe that should be
cons dered n further
nvest gat ons</td></tr><tr><td>Co n-Véz na, Sab onn,
Pa mer, and M ne
(2015)</td><td>To prov de a mapp ng of
factors that prevent
CSA d sc osures
through an eco og ca
ens from a sampe of
CSA adut surv vors.</td><td>Qua tat ve des gn us ng
LIM.</td><td>67 ma e and fema e CSA
adut surv vors (76%
dent fed as fema e and
24% as ma e). Age
ranges from 19 to 69
years (M = 44.9).
Purpos ve samp ng
strategy</td><td>Three broad categor es were dent fed as
barr ers to CSA d sc osure: Barr ers
from w th n-nterna zed v ct m bam ng.
mechan sms to protect onese f, and
mmature deve opment at t me of abuse;
barr ers n re at on to others-v o ence
and dysfunct on n the fam y. power
dynam cs, awareness of the mpact of
te ng, and frag e soc a network;
barr ers n re at on to the soc a word
abe ng, taboo of sexua ty, ack of
serv ces ava ab e, and cu ture or t me
per od.</td><td>Haf of the part c pants had not
d sc osed the r CSA exper ences
before the age of 19.
Retrospect ve aspect of the study
coud mp y reca ssues. A
part c pants had d sc osed and
rece ved counse ng at some
before part c pat ng n the study.
Hgh eve of r gor nestab sh ng
trustworth ness of the data and
ana ys s</td></tr><tr><td>Lec erc and Wort ey
(2015)</td><td>Study object ves
nvest gated the
factors that fac tate
CSA d sc osures</td><td>Adut ma e ch d sexua
offenders were
nterv ewed to
exam ne pred ctors of</td><td>369 adut ma es who had
been conv cted of a
sexua offense aga nst a
ch d aged between I</td><td>D sc osure ncreased with the age of the
v ct m: f penetrat on had occurred, f the
v ct m was re ated to the offender, f the
v ct m was not vng w th the offender at</td><td>Offender generated data through
se f-reports could be subject to
cogn t ve d stort ons-
mnm zat on or exaggerat ons.</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Method (cont.)

EFTA00025250

(continued)

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Method (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td>McE vaney and Cu hane
(2015)</td><td>To nvest gate the
feas b ty of us ng ch d
assessments as data
sources of nforma
CSA d sc osure. To
assess f these reports
prov de substant ve
data on d sc osures</td><td>v ct m d sc osure.
Sem structured
nterv ews based on
the QID
quest onna re.
Fe reports of ch dren
seen for assessment n
a ch d sexua abuse
unt na ch dren's
hosp ta were
rev ewed</td><td>and 17 years o d.
Major ty were Wh te,
uneducated, a most
ha f unemp oyed
before the r arrest
Content ana yss was
competed on 39 f es
(32 fema es and 7
ma es) based on a
cod ng framework.
Parents were asked to
consent to have the r
ch d's fe rev ewed for
the study. V ct ms
assessed were 12-18
years of age</td><td>the t me of the abuse, or f the v ct m
res sted during the offense. Ma e v ct ms
and v ct ms from dysfunct ona
backgrounds were ess key to d sc ose

Major ty of ch dren to d the r mothers
(43%) and peers (33%) frst. Three major
themes were dent fed as nf uencing the
dsc osure process: (1) fee ng d stressed,
(2) opportun ty to te, and (3) fears for
se f. Add tona themes of be ng be eved,
shame/se f-b ame, and peer nfuence
were a so dent fed</td><td>Perspect ves of offenders on
vu nerab ty of v ct ms n re at on
to d sc osure coud be mportant
Informat on to nform
ntervent ons
The sampe s ze s sma but w
contr bute to a arge muts te
study n Ire and. Serves as an
mportant exp oratory p ot
br ng ng forward d sc osure
themes for cons derat on</td></tr><tr><td>Dumont, Messerschm tt,
Va, Bohu, and
Rey-Sa mon (2014)</td><td>This study a med to
exp ore how the
re at onsh p between
the perpetrator and
the v ct m, espec a y
whether these
re at ons are
ntrafam a or
extrafam a, mpact
CSA d sc osure</td><td>Fe reports of ch dren
seen for assessment n
a ch d sexua abuse
unt na ch dren's
hosp ta were
rev ewed</td><td>220 m nor v ct ms-
78.2% fema e v ct ms,
41.8% aged between
14 and 18 (most
preva ent age range),
and 48.2% were
abused by a fam y
member</td><td>Dsc osure processes were more comp ex
when t concerned sexua abuse
comm tted by ntrafam a perpetrator:
60% of the v ct ms revea the facts
severa years after, and most often to
nd v dua s outs de the fam y (78.6% of
the d sc osures done at schoo); on the
contrary, extrafam a d sc osures take
pace more spontaneous y and qu cky:
80% of the v ct ms revea the facts a few
days after, most often to the r mother or
peers</td><td>The re at onshp with the
perpetrator has a sgn f cant
mpact on both tm ng and
rec p ent of d sc osure, w th
ntrafam a abuses ess key to
be d sc osed prompt y and with n
the fam y system</td></tr><tr><td>Easton, Sa tzman, and
W s (2014)</td><td>Study focus was on
dent f cat on of
barr ers to CSA
dsc osure with ma e
surv vors</td><td>Us ng qua tat ve content
ana ys s, researchers
conducted a secondary
ana yss of on ne
survey data, the 2010
Hea th and We-Beng
Survey, that nc uded
men w th se f-reported
CSA h stores with an
open-ended tem on
d sc osure barr ers</td><td>460 men wth CSA
h stor es competed an
anonymous, Internet-
based survey.
Recru ted from
surv vors'
organ zat ons. Age
range of 18-84 years.
Two th rds of
respondents reported
cergy-re ated abuse.
Major ty of
respondents were
Wh te</td><td>Vast major ty of part c pants (94.6%) were
sexua y abused by another ma e.
Durat on of sexua abuse broke down
nto: 30.2% ess than 6 months, 32.3% 6
months to 3 years, and 34.3% more than
3 years. Ten years o d was average age of
CSA onset. Ten categor es of barr ers
were cass fed nto three doma ns: (1)
soc opo t ca: mascu nty, m ted
resources; (2) nterpersona: m strust of
others, fear of be ng abe ed "gay," safety
and protect on ssues, past responses;
and (3) persona: nterna emot ons,
see ng the exper ence as sexua abuse,
and sexua or entat on.</td><td>At t me of the study, this was the
argest qua tat ve data set to have
been ana yzed with an exp ct
focus on adut ma e surv vors'
percept ons of barr ers to CSA
d sc osure. Because the samp e
was mted n terms of the ow
percentage of raca m nor tes
(9.3%), d sc osure differences
based on race or ethn cty were
not d scerned. The major ty of
abuse reported was by cergy
wh ch m ght present a un que set
of barr ers to d sc osure</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Method (cont.)

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263

(continued)

264

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>F nd ngs</th><th>Summary</th></tr><tr><td>Easton (2013)</td><td>Study purpose was to
descr be ma e CSA
d sc osure processes
us ng a fe span
approach exam n ng
d fferences based on
age. A so, to exp ore
re at onsh ps between
dsc osure attr butes
and men's menta
hea th</td><td>Cross-sect ona survey
des gn. E g be
part c pants were
screened and
competed an
anonymous, Internet-
based survey dur ng
2010. Measures used:
Genera Menta Hea th
D stress Sca e and
Genera Assessment of
Ind v dua Needs.
Quest ons re ated to
CSA d sc osure and
supports were
nc uded</td><td>Purpos ve samp ng of
487 men from three
nat ona organ zat ons
devoted to ra s ng
awareness of CSA
among men. Age
range: 19-84 years.
Mean age for onset of
CSA was 10.3 years</td><td>O der age and be ng abused by a fam y
member were both re ated to de ays n
d sc osure. Most part c pants who to d
someone dur ng ch dhood d d not
rece ve emot ona y support ve or
protect ve responses and the he pfu ness
of responses across the fe span was
mxed. De ays n te ng were s gn f cant
per ods of t me (over 20 years).
Approx mate y one ha f of the
part c pants first to d about the sexua
abuse to a spouse/partner (27%) or a
menta hea th profess ona (20%); 42% of
part c pants reported that the r most
he pfu d scuss on was with a menta
heath profess ona. However, unhe pfu
responses caused most menta d stress.
Cn ca recommendat ons nc uded
more of a fe-course perspect ve be
adopted, understand ng mpact of
unhe pfu responses and the mportance
of expand ng networks for ma e
surv vors</td><td>Purpos ve samp ng of men from
awareness ras ng organ zat ons
may have attracted part cu ar
part c pants who had a ready
d sc osed and rece ved he p.
Part c pants needed to have
access to Internet which wou d
have e m nated men n ower SES
groups and requ red profcency n
Eng sh which wou d e m nate
certa n cu tura groups. However,
the samp ng strategy ga ned
access to a predom nant y h dden
popu at on. Important c n ca
recommendat ons are made with
an emphas s on a fe-course focus</td></tr><tr><td>McE vaney, Greene, and
Hogan (2012)</td><td>Qua tat ve study asked
the centra research
quest on: "How do
ch dren te ?"
Object ve was to
deve op theory of how
ch dren te of the r
CSA d sc osure
exper ences. Parents
were nterv ewed.</td><td>Grounded theory
method study.
Interv ews were
conducted. L ne-by-
ne open and ax a
cod ng was conducted
on verbat m
transcr pts</td><td>Sampe of 22 young
peop e; 16 grs and 6
boys; age range: 8-18
years; 22 nterv ewed
In tota between the
ages of 8 and 18. M xed
samp e of some
endur ng ntrafam a
CSA, some
extrafam a CSA, and
two endured both
forms</td><td>A theoret ca mode was deve oped that
conceptua zes the process of CSA
d sc osure as one of conta n ng the
secret: (1) the act ve w thho d ng of the
secret on the part of the ch d; (2) the
exper ence of a "pressure cooker effect"
refect ng a conf ct between the wish to
te and the wish to keep the secret; and
(3) the conf d ng tse f which often
occurs n the context of a trusted
re at onsh p. These were der ved from
e even categor es that were deve oped
through open and ax a cod ng</td><td>Modest but suff c ent sampe for an
exp oratory qua tat ve nqu ry.
Hgh eve of trustworth ness
r gor. A subsampe of random y
se ected transcr pts was
Independent y coded. Very young
ch dren and young adu ts were
not captured n this sampe.
Transferab ty of findings can on y
be made to the age range samp ed
In the context of Ire and</td></tr><tr><td>Schonbucher, Ma er,
Moh er-Kuo, Schnyder,
and Landot (2012)</td><td>To nvest gate the
process of CSA
d sc osure with
ado escents from the
genera popu at on
who had exper enced
CSA. How many
dsc osed, who dd</td><td>Data co ect on was
through face-to-face
qua tat ve nterv ews.
Standard zed quest ons
and measures were
adm n stered on fam y
s tuat on,
soc odemograph c</td><td>Conven ence sampe of
26 sexua y v ct m zed
ado escents. 23 grs
and 3 boys. Age range:
15-18 years. On ne
advert sements and
fyers were used to
recrut youth from</td><td>Less than one th rd of part c pants
mmed ate y d sc osed CSA to another
person. In most cases, rec p ents of both
mmed ate and de ayed d sc osure were
to peers. More than one third of
part c pants had never d sc osed the
abuse to a parent. Part c pants reported
re uctance to d sc ose to parents so as</td><td>Two thirds of the sampe did not
dsc ose r ght away. Strengthen ng
parent-ch d re at onsh ps may be
one of the most mportant ways
to ncrease d sc osure to parents.
D sc osure to peers has been
found a common trend n other</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025252

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Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td>they d sc ose to, and
what were the r
mot ves for d sc os ng</td><td>data, sexua
v ct m zat on, genera,
and menta heath.
Sexua Assaut Modu e
of the Juven e
V ct m zat on
Quest onna re was
used</td><td>commun ty and
counse ng serv ces</td><td>not to burden them. Ear er d sc osures
were re ated to extrafam a CSA, s ng e
occurrence CSA, age of v ct m at abuse
onset, and parents who were vng
together. Higher eves of reported gu t
and shame were re ated to de ayed
d sc osures. Peers were v ewed by th s
samp e as more re ab e conf dants</td><td>research and bears more
exam nat on</td></tr><tr><td>Hunter (2011)</td><td>Am of this study was to
deve op a fu er
understand ng of CSA
d sc osures</td><td>Narrat ve nqu ry
methodo ogy. Face-to-
face n-depth
Interv ews were
conducted w th
part c pants. Data
were ana yzed using
Rosentha and F scher-
Rosentha's (2004)
method.</td><td>Purpos ve samp ng was
emp oyed. Samp e
cons sted of 22
part c pants aged 25-
70 years; 13 women
and 9 men. Part c pants
were sexua y abused
at 15 years or under
with someone over
the age of 18.</td><td>On y 5 out of 22 part c pants to d anyone
about the reary sexua exper ences as
ch dren. Fear, shame, and se f-b ame
were the man nh b tors to d sc osure.
These factors are further deta ed
through subthemes. Te ng as a ch d and
as an adut was further expanded upon
us ng A agg a's (2004) framework
ver fy ng behav ora nd rect attempts to
te and purposefu d scosure as
categor es. Themat c ana ys s supported
that CSA d sc osure should be
conceptua zed and v ewed as a comp ex
and fe ong process</td><td>De ayed d sc osure was common n
this qua tat ve samp e. Most
part c pants d d not make a
se ect ve d sc osure unt
adu thood. These fnd ngs support
A agg a's (2004) mode of
d sc osure but a so high ghts the
Importance of fe stage. Modest
but suff cent sampe s ze for a
qua tat ve nqu ry. We -des gned
study with deta ed ana ys s for
transferab ty of findings</td></tr><tr><td>Schaeffer, Leventha, and
Asnes (2011)</td><td>This study a med to: (1)
add d rect nqu ry
about the process of a
ch d's CSA d sc osure;
(2) determ ne f
ch dren w d scuss
process that ed them
to te ; and (3) descr be
factors that ch dren
dent fy that ed them
to te about or caused
them to de ay CSA
d sc osure</td><td>Study sought to find out f
process ssues of
dsc osure coud be
dent fed n the
context of forens c
nterv ews. Forens c
nterv ewers were
asked to ncorporate
quest ons about
"te ng" nto an
ex st ng forens c
nterv ew protoco
Interv ew content
re ated to the
ch dren's reasons for
te ng or wat ng was
extracted, transcr bed,
and ana yzed using
grounded theory
method of ana ys s</td><td>191 nterv ews of CSA
v ct ms aged 3-18 over
a 1-year per od were
used for the study.
Inc us on cr ter a
nc uded ch dren who
made a statement
about CSA pr or to
referra, reasons for
te ng or wat ng to
te, and those who
spoke Eng sh.
Part c pants were
Ich dren who were
nterv ewed at a ch d
sexua abuse cnc.
74% were fema e and
51% were Caucas an</td><td>Reasons the ch dren dent fed for te ng
were cass fed nto three doma ns: (1)
dsc osure as a resut of nterna st mu
(e.g., the ch d had n ghtmares); (2)
dsc osure fac tated by outs de
nfuences (e.g., the ch d was
quest oned); and (3) d sc osure due to
d rect ev dence of abuse (e.g., the ch d's
abuse was w tnessed). The barr ers to
dsc osure dent fed fe nto f ve groups:
(1) threats made by the perpetrator
(e.g., the ch d was to d she or he wou d
get n troub e f she or he to d), (2) fears
(e.g., the ch d was afra d someth ng bad
would happen f she or he to d). (3) ack
of opportun ty (e.g., the ch d fet the
opportun ty to d sc ose never
presented), (4) ack of understand ng
(e.g., the ch d fa ed to recogn ze abus ve
behav or as unacceptab e), and (5)
re at onsh p wth the perpetrator (e.g..
the ch d thought the perpetrator was a
fr end)</td><td>An nnovat ve study to try to assess
f forma nvest gat ve nterv ews
can fac tate d sc osures of CSA.
Data were based on a arge
number of nterv ews. Deta ed
ana ys s produced deta ed
fndings support ng other study
fnd ngs on CSA d sc osure</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025253

265

(continued)

266 Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td>A agga (2010)</td><td>The study a med to
dent fy factors
mped ng or promot ng
CSA d sc osures.
Overarch ng research
quest on: What
nd v dua,
nterpersona,
env ronmenta, and
contextua nfuences
mpede or promote
CSA d sc osures.</td><td>A qua tat ve
phenomeno og ca
des gn, LIM, was used
to nterv ew adut CSA
surv vors about the r
d sc osure exper ences
to prov de
retrospect ve accounts
of CSA d sc osure and
mean ng-mak ng of
these exper ences.
Themat c ana yss was
done through a soca-
eco og ca ens.</td><td>Purpos ve samp ng was
emp oyed. Snowba
samp ng was a so used
to recrut more ma e
surv vors. 40 adut
surv vors of CSA were
nterv ewed: 36% men
and 64% women. Age
range of 18-65 wth a
mean age of 40.1 years.
Average age of abuse
onset was 5.3 years
od. 36% of the samp e
was non-Wh te.
D verse
soc oeconom c
backgrounds</td><td>Themes fe nto four doma ns: (1)
nd v dua and deve opmenta factors,
deve opmenta factors as to whether
they comprehended what was
happen ng, persona ty tra ts a so had
some bear ng on the r ab ty to te, and
ant c pat ng not be ng be eved; (2)
dsc osure nh b ted by fam y
character st cs such as rgdy fxed
gender ro es with dom nat ng fathers,
chaos and aggress on, other forms of
ch d abuse, domest c v o ence,
dysfunct ona commun cat on, and soca
so at on; (3) ne ghborhood and
commun ty context, that s, ack of
nterest from ne ghbors and teachers not
pursu ng troub ng behav or; and (4)
cu tura and soc eta att tudes, med a
messages and soc eta att tudes, fee ng
unheard as k ds, gender soca zat on for
ma es, and cu tura att tudes nfuenc ng
parent's react ons. Purposefu d sc osure
s higher than reported n other stud es
because of the samp ng attempts to
purposefu y ocated sc osers</td><td>The study presents a comprehens ve
soca-eco og ca ana yss to CSA
dsc osure high ght ng the
mut faceted nf uences. Of note,
42% had d sc osed the abuse
dur ng ch dhood; 26% had not
d sc osed because they had
repressed the memory, or the
abuse had occurred n preschoo
years and they had d ff cu ty w th
reca The rema nder had
attempted some form of
d sc osure n nd rect ways dur ng
ch dhood. A retrospect ve
approach that cou d be affected by
reca ssues</td></tr><tr><td>Fontes and P ummer
(2010)</td><td>This exam nat on of CSA
d sc osure exp ored
the ways cu ture
affects processes of
CSA d sc osure and
report ng, both n the
Un ted States and
Internat ona y</td><td>Us ng pub shed terature
w th c nca data, th s
art ce conducted an
ana yss to prov de a
cu tura y competent
framework for CSA
d sc osure quest on ng</td><td>Data cons sted of
pub shed terature on
dsc osure and cu ture
that was trangu ated
wth cnca case
mater a</td><td>Cu tura and structura factors affect ng
CSA d sc osure are dent fed n n-depth
deta. Recommendat ons made nc ude
(I) d scosure nterv ew ng should be
ta ored to the ch d's cu tura context,
(2) quest on ng shoud a so take nto
cons derat on age and gender factors,
and (3) cu ture stands as an mportant
factor na cases n wh ch ch dren are
cons der ng d sc os ng or be ng asked to
d scose, and not so ey n cases n wh ch
ch dren are from not ceab e m nor ty
groups. Presents a comprehens ve
nterv ew framework ntegrat ng cu tura
cons derat ons</td><td>One of the few works that adds
know edge to cu tura y
contextua d sc osure
nterv ew ng. Un que comb nat on
of terature fnd ngs with c n ca
mater a. Anecdota accounts may
prec ude transferab ty of
fnd ngs. Overa adds to an
mpover shed area of CSA
dsc osure nformat on</td></tr><tr><td>Ungar, Barter,
McConne, Tutty, and
Fa rho m. (2009a)</td><td>This study exp ored
d sc osure strateg es
with a nat ona sampe
of youth focus ng on</td><td>Forms were competed
by youth fo ow ng
part c pat on n abuse
prevent on</td><td>Exam nat on of resu ts
from a nat ona sampe
of 1,621 eva uat on
forms where youth</td><td>Youth who have been abused or wtnesses
to abuse emp oy fve d sc osure
strateg es: us ng se f-harm ng behav ors
to s gna the abuse to others; not ta k ng</td><td>This study high ghts that d sc osure
s an nteract ve ongo ng process.
Findings end support to stud es
that have dent fed sm ary</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025254

(continued)

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td>(1) What are the
h dden exper ences of
abuse among Canad an
youth? (2) What
mpact does
part c pat on n abuse
prevent on programs
have on youth to
express the r abuse
exper ences? (3) What
dsc osure barrers do
youth face? (4) What
are young peop e's
d sc osure patterns?
and (5) Who do they
te?</td><td>programm ng by the
Canad an Red Cross
(RespectED).
A ser es of focus groups
and observat ons of
the workshops were
used to he p
contextua ze the
fnd ngs. Eva uat on
forms were ana yzed
from two vo ence
prevent on programs:
(1) It's not your faut
and (2) What's ove
got to do with It?</td><td>anonymous y d sc osed
abuse exper ences.
Respondent's ages: 13
and under (27%), 14-
15 (37%), 16-17 (25%),
18 and o der (4%), and
unknown (7%)</td><td>at a about the abuse to prevent
ntrus ve ntervent ons by others;
seek ng he p from peers; seek ng he p
from nforma adut supports; and
seek ng he p from mandated serv ce
prov ders (soc a workers and po ce).
Resu ts suggest d sc osure s an
nteract ve process, with expectat ons
regard ng consequences to d sc osure.
Patterns of ncrementa y shar ng abuse
exper ences are shaped by young
peop e's nteract ons with peers,
educators, and careg vers. About three-
quarters of fema es prev ous y d sc osed;
sgn f cant y ess ma es d sc osed</td><td>nteract ve modes of d sc osure
such as those deta ed by A agg a
(2004) and Sta er and Ne son-
Garde (2005). Th s m xed samp e
of youth who exper enced
d fferent forms of abuse and
vo ence exposure were
part c pants-not m ted to CSA
surv vors</td></tr><tr><td>Ungar, Tutty, McConne.
Barter, and Fa rhom
(2009b)</td><td>This study exp ored
abuse d sc osure
strateg es with a
nat ona sampe of
Canad an youth who
part cpated n v o ence
prevent on
programm ng. One of
the goas of the study
was to document not
prev ous y dent fed
exper ences of abuse
and youth att tudes
toward d sc osure of
abuse exper ences</td><td>Exp oratory des gn with a
nonrepresentat ve
samp es. Qua tat ve
ana yss of 1,099
eva uat on forms
competed fo ow ng
Red Cross RespectED
vo ence prevent on
programm ng
de vered between
2000 and 2003. Forms
of anonymous abuse
dsc osures by youth
part c pants of neg ect,
emot ona, phys ca,
and sexua abuse.
Twenty-seven
nterv ews and focus
groups were a so done
to understand
contextua ssues and
engage youth and
program fac tators n
the nterpretat on of
fnd ngs. A cod ng
structure was
deve oped for ana ys s
to synthes ze themes
across data sources</td><td>Purposefu sampe of
1,099 eva uat on forms
competed fo owing
Red Cross RespectED
vo ence prevent on
programm ng
de vered between
2000 and 2003</td><td>F nd ngs suggest high rates of h dden abuse,
wth ess than one quarter of youth
report ng a d sc osure. 244 of the 1,099
youth who d sc osed abuse on the r
eva uat on forms dent fed spec fc
nd v duas they to d about the r abuse.
D sc osure patterns vary with boys,
youth aged 14-15, v ct ms of phys ca
abuse, and those abused by a fam y
member be ng most key to d scose to
profess ona s or the po ce. One third of
d sc osures were d rected toward
profess ona s and the east, 5% percent
each, were d rected toward fr ends,
parents, and others. Part c pants were
most key to d sc ose sexua abuse to
parents/fam y, profess ona s, and the
po ce/courts, with fewer choos ng
fr ends.
Out of a 1,099 part c pants, 225 ma es and
779 fema es nd cated that they had been
abused. Out of those, 43 ma es and 180
fema es nd cated that they had d sc osed
the abuse. Of those who had d sc osed,
on y a port on of ma es and fema es
spec fed who they had d sc osed the
abuse to ("Wh e 1,099 eva uat ons with
d sc osure statements were ana yzed,
on y 22% made ment on of peop e to</td><td>Innovat ve des gn of this study
prov des ns ght nto young
peop e's percept ons of d sc osure
exper ences. H gh eve of r gor
wth trustworth ness of the data
ana ys s ensured through use of
youth focus groups, nterv ews,
and observat ona data. The study
resu ts are somewhat m ted n
the th ckness of the descr pt ons t
can offer because most of the data
are survey based. Reg ona
d fferences may not have been
pcked up. Scope of the study s
broad and approach s creat ve</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025255

267

(continued)

268

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td>Prebe and Sved n (2008)

Sorso, Ka-Keat ng, and
Grossman (2008)</td><td>This study a med to
nvest gate d sc osure
rates and d sc osure
patterns and exam ne
pred ctors of
nond sc osure na
sampe of ma e and
fema e ado escents
wth se f-reported
exper ences of sexua
abuse

Study focused on
dsc osure cha enges
for ma e surv vors of
CSA to understand
three ssues: (1) To</td><td>Part c pants competed
65-tem quest onna re
that nc uded quest ons
about background,
consensua sex, sexua
abuse exper ences
(noncontact, contact
or penetrat ng abuse,
nc ud ng peer abuse).
d sc osure of CSA,
own sexua abus ve
behav or, sexua
att tudes, and
exper ences w th
pornography and
sexua exp o tat on.
The quest onna re
nc uded 6 mod fed
tems from the SCL-90
and 9 of 25 tems from
the Parenta Bond ng
Instrument. The data
for grs and boys were
ana yzed separate y

Ma e surv vors of CSA
were nterv ewed
about the r d sc osure
exper ences. Ana yt c
techn ques nc uded</td><td>The samp e cons sted of
4,339 h gh schoo
students n Sweden
(2,324 grs and 2,015
boys). The mean age of
the part c pants was
18.15 years. This study
used a subsample of
1,962 part c pants who
reported CSA and
who answered
d sc osure quest ons

The samp e cons sted of
16 ma e surv vors of
ch dhood sexua
abuse; Caucas an, 2
Afr can Amer can, I</td><td>whom dsc osures occurred.") More
fema es spec fed who they d sc osed to
compare to ma es. The data show
percept ons among youth of negat ve
consequences fo ow ng d scosure
Of the samp e, 1,505 grs (65%) and 457
boys (23%) reported CSA. The
d scosure rate was 81% (grs) and 69%
(boys). Grs and boys d sc osed most
often to a fr end of the r own age. Few
had d sc osed to profess ona s, and even
fewer had reported to the author t es.
There were h gher rates of d sc osure to
a profess ona w th more severe abuse
(contact abuse wth or without
penetrat on) for grs, but ower rates for
boys The more severe the sexua abuse
was, the ess key both grs and boys
had ta ked to the r mother, father, or a
sb ng. Grs were ess key to d sc ose f
they had exper enced contact sexua
abuse with or w thout penetrat on, ess
frequent abuse, abuse by a fam y
member, or f they had perce ved the r
parents as ess car ng and ess
overprotect ve and high y
overprotect ve. Boys were ess key to
dsc ose fa fam y member abused them,
they were study ng a vocat ona program
(vs. an academ c program), ved w th
both parents or had perce ved the r
parents as ess car ng and not
overprotect ve.
Ado escents who reported CSA perce ved
ther menta hea th as poorer compared
to ado escents without CSA.
Nond scosers reported more
symptoms on the Menta Heath Sca e
than those who had d sc osed
Barr ers to d sc osure were found to be
operant n three nterre ated doma ns:
(1) persona (e.g., ack of cogn t ve
awareness, ntent ona avo dance,
emot ona read ness, and shame); (2)</td><td>This study high ghted that sexua
abuses arge y h dden from adu t
soc ety, espec a y from
profess ona s and the ega system.
However, t me apsed to
d sc osure was not reported.
Snce fr ends appeared to be the
man recp ents of sexua abuse
dsc osures, pract ce mp cat ons
of this could be to find ways to
gve young peop e better
nformat on and gu dance about
how to support a sexua y abused
peer. A qua tat ve component to
the study would have prov ded a
broader understanding of
d sc osure processes. Study
m tat ons nc ude a sgn f cant
amount of boys who did not
comp ete the quest ons regard ng
d sc osure on; the tm ng of
d sc osures (whether they were
de ayed or not) was not
measured; poss b ty of reca bas
wth retrospect ve stud es based
on se f-reports; and youth
part c pants may not have
understood a the quest ons

Snce the vast major ty of men n the
sampe had not d sc osed n
ch dhood, they may have been
pred sposed to dent fy ng
barr ers to d sc osure more</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025256

(continued)

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td>whom and n what
contexts have they
d sc osed these
exper ences? (2) What
do they have to say
about the r d sc osure
exper ences? and (3)
What are the r
percept ons of post ve
and negat ve aspects of
the r d sc osure,
nc ud ng ncent ves
and barr ers?</td><td>grounded theory
method of ana yss for
cod ng and
deve opment of
conceptua y custered
matr ces. Part c pants
comp eted two n-
depth, sem-structured
nterv ews, ast ng
between 2 and 3 hr
each tak ng pace
approx mate y a week
apart</td><td>Puerto R can, I part
Nat ve Amer can, I
Afr can Cuban; age
range of 24-61 years; 9
dent fed themse ves
as heterosexua, 5 as
homosexua, and 2 as
b sexua</td><td>re at ona (e.g., fears about negat ve
repercuss ons, so at on); and (3)
soc ocu tura (e.g., ack of acceptance for
men to exper ence or acknow edge
v ct m zat on).
On y I of the 16 men n ths samp e
d sc osed the fu extent of his sexua
abuse exper ences wh e he was st a
ch d. The other men reported that they
had not d sc osed, a though some
reported attempts to te that were
nd rect or ncomp ete. Severa other
men d sc osed certa n exper ences or
e ements of the r abuse, but concea ed
others. By the t me of the study, many of
these men had d sc osed the r past
exper ences na var ety of re at onsh ps,
nc ud ng those with fam y members,
partners, therap sts, and nfrequent y
fr ends. Severa had on y m ted
d scuss ons of the r sexua abuse</td><td>read y. Retrospect ve accounts
are subject to reca ssues.
Invest gators made sgn f cant
efforts to gather a d verse samp e.
Hgh eve of r gor was executed
n the dependab ty of the data
and terat ve process of the
nterpretat on of findings was
conducted</td></tr><tr><td>Hershkow tz, Lanes, and
Lamb (2007)</td><td>The goa of the present
study was to exam ne
how ch d v ct ms of
extrafam a sexua
abuse d sc osed the
abuse exper ence</td><td>A eged v ct ms of sexua
abuse and the r
parents were
Interv ewed. Ch dren
were nterv ewed
us ng the NICHD
Invest gat ve Interv ew
Protoco by
exper enced youth
nvest gators.
Informat on on
d sc osure processes
was obta ned n the
frst forma nterv ew,
before any po ce
nvest gat on or ch d
we fare ntervent on</td><td>Th rty a eged v ct ms of
CSA; 18 boys and 12
grs. Ch d sampe was
7- to 12-year-o ds w th
an average age of 9.2
years. Twenty mothers
and 10 fathers were
a so nterv ewed for a
tota of 30 parent
Interv ews. A content
ana ys s was conducted
on ch d and parent
nterv ews</td><td>D sc osure categor es were dent fed as
fo ows: (1) de ayed 53% of the ch dren
de ayed d sc osure for between I week
and 2 years; (2) rec p ent of d sc osure:
47% of ch dren first d sc osed to s b ngs
or fr ends, 43% frst d sc osed to the r
parents, and 10% frst d sc osed to
another adu t. 57% of the ch dren
spontaneous y d sc osed abuse, but 43%
d sc osed on y after they were
prompted. 50% of the ch dren reported
fee ng afra d or ashamed of the r
parents' responses. Parents' react ons:
support ve (37%) and unsupport ve
(63%). There was a strong corre at on
between pred cted and actua parenta
react ons suggest ng ch dren ant c pated
ther parents' key react ons accurate y.
D scosure processes var ed depend ng
on the ch dren's ages (e.g., younger
ch dren d sc osed to parents), sever ty
and frequency of abuse, parents'
expected react ons, suspects' dent t es,
and strateg es used to foster secrecy</td><td>Innovat ve des gn to gather
d sc osure data from young
ch dren. Focus s on extrafam a
CSA wh ch may differ than
d sc osure patterns of ntrafam a
CSA. Two th rds of the parents
reg stered unsupport ve
responses wh ch shgh</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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270

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td>A agg a and K rshenbaum
(2005)</td><td>The object ves of the
current study were to
dent fy a broad range
of factors, nc ud ng
fam y dynam cs that
contr bute to or
hnder a ch d's ab ty
to d sc ose CSA.</td><td>A qua tat ve
phenomeno og ca
des gn―LIM-was
used to e ct
dsc osure
exper ences;
fac tators and
barr ers; and re evant
crcumstances.
Interv ews were
transcr bed verbat m.
L ne-by- ne open
cod ng was conducted
to capture fam y-eve
factors. Axa and
se ect ve cod ng
fac tated
dent f cat on of
themes</td><td>Purpos ve samp ng was
emp oyed to recrut 20
adut surv vors
between the ages of 18
and 65 who were
sexua y abused by a
fam y member.
Average age of
part c pants was 40.1
years; 60% of
part c pants were
fema e and 40% ma e.
Average age of onset
of abuse was 6.7 years.
Mxed cnca and
nonc nca samp e. The
major ty had rece ved
treatment for CSA at
some po nt n the r
ves</td><td>Four major themes emerged suggest ng
that CSA d sc osure can be s gn f cant y
comprom sed when certa n fam y
cond tons ex st: (I) rgdy fxed, gender
ro es based on a patr archy-based fam y
structure; (2) presence of fam y
vo ence; (3) cosed, nd rect fam y
commun cat on patterns; and (4) soca
so at on of the fam y as a who e, or
spec fc members, payed a part n CSA
v ct ms fee ng they had no one safe to
te Fam y systems formu at ons through
a fem n st ens are mportant n
understand ng ch dren and fam es at
rsk of d sc osure barr ers</td><td>Over ha f the part c pants had not
dsc osed the abuse dur ng
ch dhood. Of the nond sc os ng
part c pants, sx d d not d sc ose
because they had repressed or
forgotten the memory. A most
one third w thhe d d sc osure
Intent ona y. More data are
needed on ear y d sc osures to
garner more nformat on on
fac tators of d sc osure.
Retrospect ve approach mp es
reca ssues. H gh eve of
trustworth ness of the data and
nterpretat ons were ach eved
through cred b ty, dependab ty,
and confrmab ty through d rect
quotes</td></tr><tr><td>A agga (2005)</td><td>The study purpose was
to qua tat ve y exp ore
dynam cs that mpede
or promote d sc osure
by exam n ng a range of
factors nc ud ng
gender as a dynam c—
how d sc osures of
fema es and ma es are
sm ar and d fferent,
and n what ways
gender affects CSA
d sc osure</td><td>Surv vors of CSA were
nterv ewed about
the r d sc osure
exper ences us ng LIM.
Ana yss of 30
part c pant narrat ves
was used for theme
deve opment regard ng
mpact of gender on
dsc osure. Interv ews
were transcr bed
verbat m for open,
axa, and se ect ve
cod ng. Categor es and
subcategor es were
co apsed and ref n ng
nto theme areas</td><td>Purpos ve samp ng of
women and men, a ong
wth those who
d sc osed dur ng the
abuse and those who
dd not. 19 fema es and
II ma es; 18-65 (mean
40.1) years who were
sexua y abused by a
fam y member or a
trusted adu t. Average
age of abuse onset was
5.3 years, 36% were
nonwh te, and 58% had
not d sc osed during
ch dhood</td><td>Three themes emerged for men that
nh b ted or prec p tated d sc osure for
reasons re ated to gender: (1) fear of
be ng v ewed as homosexua; (2)
profound fee ngs of st gmat zat on or
so at on because of the be ef that boys
are rare y v ct m zed; and (3) fear of
becom ng an abuser, wh ch acted as a
prec p tant for d sc osure. Two
predom nant themes with fema e
part c pants re ated to d ff cut es
dsc os ng: (1) they fet more conf cted
about who was respons be for the abuse
and (2) they more strong y ant c pated
be ng bamed and/or not be eved</td><td>One na dearth of stud es that
conduct gender ana ys s.
Comparat ve ana ys s draws out
mportant pract ce mp cat ons.
Retrospect ve des gn of the study
which mp es poss be reca
ssues. Hgh eve of
trustworth ness of the data and
nterpretat ons were ach eved
through cred b ty, dependab ty.
and confrmab ty through d rect
quotes</td></tr><tr><td>Co ngs, Gr ff ths, and
Kuma o (2005).</td><td>Study exam ned patterns
of d sc osure na arge
representat ve samp e
of South Afr can CSA
v ct ms. Two study
object ves to: (1)
exam ne how and</td><td>F e rev ews of a soca
work and med ca case
fes for CSA v ct ms
seen at the crss
center where a cases
of CSA reported to
the North Durban</td><td>1,737 cases of CSA
reported n the North
Durban area of
KwaZu u-Nata, South
Afr ca, dur ng January
2001 to December
2003. 1,614 grs and</td><td>Content ana ys s dent fed two broad
d mens ons of d sc osure: (1) agency:
ch d-ntated d sc osure versus
detect on by a third party and (2)
tempora durat on: an event versus a
process. These d sc osure d mens ons
def ned four d screte categor es of</td><td>These resu ts ft nto A agg a's (2004)
d sc osure framework. Through
data ana ys s two raters coded
d sc osure categor es us ng
author's d sc osure framework,
wh ch proved to be both
exhaust ve and mutua y excus ve</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td>when CSA v ct ms
d sc ose the r abuse
and (2) Ident fy factors
assoc ated with
d fferent patterns of
d sc osure</td><td>po cng area were
referred during the
per od of January 2001
to December 2003</td><td>123 boys; average age
of v ct m zed ch dren
was 9.9 years. 47%
reports were made
wth n 72 hr of the
abuse, 31% from 72 hr
to I month, and 22%
more than a month
after the abuse</td><td>d scosure: (1) purposefu d sc osure
(30% of cases). (2) nd rect d sc osure
(9% of cases). (3) eyew tness detect on
(18% of cases), and (4) acc denta
detect on (43% of cases). D sc osure
ndependent y pred cted by v ct m's age,
nature of the v ct m-perpetrator
re at onsh p, offender's age, frequency of
abuse, and report ng atency. Mean age of
purposefu d sc osures (10.67) was
hgher than the mean age of nd rect
dsc osures (5.84). Exp ct forms of
d sc osure were ess key when the
offender was a fam y member. Shorter
report ng atency was more key w th
repeated abuse</td><td>with the percentage of nterrater
agreement at 98%.
Genera zab ty of this study s
m ted to ch dc ents rece v ng a
cr ss assessment referred
through a po ce report</td></tr><tr><td>Hershkow tz, Horow tz,
and Lamb (2005).</td><td>This study a med to
dent fy character st cs
of suspected ch d
abuse v ct ms that are
assoc ated with
d sc osure and
nond sc osure dur ng
forma nvest gat ons</td><td>Large database of
suspected cases of
phys ca and sexua
abuse nvest gated n
Israe between 1998
and 2002 was ana yzed.
Interv ews were a so
conducted us ng
standard zed NICHD
Invest gat ve Interv ew
Protoco. Arch va data
were ana yzed</td><td>The sampe was
compr sed of 26,446 of
3- to 14-year-o d
a eged v ct ms of
sexua and phys ca
abuse nterv ewed n
Israe n the 5-year
per od from 1998 to
2002. 140 exper enced
tra ned youth
nvest gators
conducted nterv ews</td><td>Overa, 65% of the 26,446 ch dren made
a egat ons when nterv ewed. Rates of
d sc osure were greater for sexua abuse
(71%) over phys ca abuse (61%).
Ch dren of a ages were ess key to
d sc osela ege abuse when a parent was
the suspected perpetrator. D sc osure
rates ncreased as ch dren grew o der:
50% with 3- to 6-year-o ds, 67% of the 7-
to 10-year-o ds, and 74% of the 11-to
14-year-o ds d sc osed abuse when
quest oned</td><td>Overa fndings nd cated that rates
of d sc osure var ed systemat ca y
depend ng on the nature of the
a eged offences, the re at onsh p
between a eged v ct ms and
suspected perpetrators, and the
age of the suspected v ct ms.
Ana yses on y nvo ved cases that
had come to the attent on of
off ca agences, mak ng t d ff cut
to determ ne how many of abuse
take pace without ever tr gger ng
any kind of off ca nvest gat on</td></tr><tr><td>Jensen, Gu brandsen,
Moss ge, Re che t, and
Tjers and (2005)</td><td>This study nvest gated
the context n wh ch
ch dren were ab e to
report the r ch d
sexua abuse
exper ences; ther
vews as to what made
td ff cut to ta k about
abuse; what he ped
them n the d sc os ng
process; and the r
parent's percept ons of
the r d sc osure
processes</td><td>Qua tat ve approach to
data co ect on and
ana yss was used.
Therapeut c nterv ews
o the ch dren and
most y the r mothers
were ana yzed through
a qua tat ve approach.
Fo ow-up nterv ews
were he d I year ater</td><td>20 fam es with a tota of
22 ch dren
part cpated. A
ch dren had to d about
exper ences that
created concerns for
care-g vers about CSA.
Ch dren's ages ranged
between 3 and 16
years (average age 7.5
years): 15 grs and 7
boys. Sexua y abused
by someone n the
fam y or a cose
person to the fam y</td><td>None of the ch dren to d of abuse
mmed ate y after t occurred. Ch dren
exposed to repet t ve abuse kept ths as a
secret for up to severa years; 17 to d
the r mothers frst, 3 frst to da fr end, I
to d the r father, and I the r unc e.
Major ty of remarks that ed to the
susp con of CSA were made n
s tuat ons where someone engaged the
chd na da ogue about what was
bother ng them, resut ng na referra.
The ch dren fet t was diff cut to find
s tuat ons conta n ng enough pr vacy and
prompts that they could share the r
exper ences. When the ch dren dd</td><td>Ev dence for de ayed d sc osures.
The resu ts nd cate that
d scosures a fundamenta y
da og ca process that becomes
ess dff cut fch dren perce ve
that there s an opportun ty to
ta k, a purpose for speaking and a
connect on has been estab shed
to what they are ta k ng about.
Strengthen ng parent-ch d
re at onsh ps s an mportant
pract ce mp cat on</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td></td><td></td><td></td><td>dsc ose they d d t ns tuat ons where
the top c of ch d sexua abuse was n
some form addressed or act vated,
where someone recogn zed the ch d's
cues and probed further. They a so were
sens t ve to others react ons, and
whether the r d sc osures woud be
ms nterpreted. Severa of the ch dren
perce ved negat ve consequences as
major factors contr but ng to de ay ng
d sc osure. They were pr mar y
concerned about negat ve effects for the
mother. The mothers sad they were
a so sens t ve to the ch dren's fee ngs. If
ther ch dren showed signs of d stress
and d d not want to ta k, the mothers
wou d change the subject or not pursue
the top c further</td><td></td></tr><tr><td>Sta er and Ne son-
Garde (2005)</td><td>The purpose of this study
was to understand the
fu process of CSA
dsc osure and how
ths unfo ded for
preado escent and
ado escent grs.
Exam ned what
fac tated and
hndered d sc osure
and subsequent
consequences</td><td>Secondary ana yss of
qua tat ve focus group
data. Org na project
cons sted of four focus
groups conducted
wth n the context of
ongo ng therapy for
grs who had
exper enced CSA.
Secondary ana ys s
cons sted of wr tten
narrat ve summar es of
each sess on group ng
these conceptua y.
and exam n ng the r
nterconnectedness</td><td>Samp e cons sted of 34
part c pants from four
groups. Sess ons
ana yzed were
between 60 and 90 m n
ong: aud otaped and
ater transcr bed for
content ana ys s</td><td>Fnd ngs are reported n three major
doma ns: (1) se f-phase: where ch dren
come to understand v ct m zat on
Interna y; (2) conf dant se ect on-
react on phase: where they se ect a t me,
pace, and person to te and then
whether that person's react on was
support ve or host e; and (3)
consequences phase: good and bad that
cont nued to nform the r ongo ng
strateg es of te ng. The act ons and
react ons of adu ts were s gn f cant and
nformed the grs' dec s ons. The
consequences phase was further
subd v ded nto four aspects: (1)
goss p ng and news networks, (2)
chang ng re at onsh ps, (3) nst tut ona
responses and the after fe of te ng, and
(4) ns der and outs der commun tes</td><td>This study prov ded a contextua
exam nat on of the ent re
d sc osure process, coser to the
po nt nt me when the abuse and
d sc osure occurred. Sma groups
of preado escent and ado escent
grs who had surv ved sexua
abuse a so served as consu tants
and were encouraged to share
the r know edge for the beneft of
profess ona pract toners</td></tr><tr><td>A agga (2004)</td><td>The study sought to
exam ne nf uences
that nh bt or promote
ch dren's d sc osure of
CSA to address gaps n
know edge about how,
when, and under what
c rcumstances v ct ms
of CSA d sc ose</td><td>The study emp oyed
LIM-a
phenomeno og ca
des gn. Intens ve
nterv ew ng that were
2 hr ong on average
generated data for a
themat c ana ys s. The
nterv ew gu de was</td><td>Us ng purpos ve samp ng
24 adut surv vors of
Intrafam a abuse
between ages of 18
and 65 (average age
41.2) were recru ted
from agences and one
un vers ty: 57% ma e
and 43% fema e;</td><td>Through ana yss of the nterv ew new
categor es of d sc osure were dent fed
to add to ex st ng types. Three
prev ous y dent fed were conf rmed n
these data: acc denta, purposefu, and
prompted/e cted accounted for 42% of
dsc osure patterns n the study samp e.
Over ha f the d sc osure patterns descr bed
by the study sampe d d not ft these</td><td>This study expanded types of CSA
dsc osures to more fu y
understand how ch dren and
adu ts d scose. And under what
crcumstances. Ask ng peop e to
recount events that occurred n
ch dhood s suscept be to
memory fa ure, especa y when
memor es were forgotten,</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025260

(continued)

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td></td><td>deve oped to probe
for nd v dua,
nterpersona,
env ronmenta, and
cu tura factors
nfuenc ng CSA
dsc osure</td><td>average age of abuse
onset was 6.5 years;
42% of the part c pants
had d sc osed the
abuse dur ng
ch dhood; 58%
d sc osed as adu ts</td><td>prev ous y estab shed categor es. Three
add tona d sc osure categor es
emerged: behav ora and nd rect verba
attempts, d sc osures ntent ona y
w thhe d, and d sc osures tr ggered by
recovered memor es</td><td>de ayed, or repressed and ater
recovered. D stort on and
rev s on of events are a so
potent a prob ems n reca. Hgh
degree of trustworth ness of the
data was ach eved and quotes
prov ded supported the
categor es</td></tr><tr><td>Cr sma, Basce, Pac, and
Rom to (2004)</td><td>The man goas of this
study were to
understand
mped ments that
prevent ado escents
from d sc os ng CSA
and seek ng he p from
ther soc a network
and/or the serv ces</td><td>In-depth te ephone
(anonymous)
nterv ews were
conducted after
Informed consent was
exp a ned and
obta ned. Three
nvest gators
exper enced n
counse ng CSA
counse ng conducted
the nterv ews wh ch
were recorded with
perm ss on. Three
researchers
ndependent y scored
the nterv ews
according to a cod ng
framework</td><td>The samp e was
comprised of 36 young
peop e who
exper enced sexua
abuse n ado escence;
35 fema es and I ma e;
aged 12-17. Some of
the samp e
exper enced sexua
vo ence na dat ng
re at onsh p</td><td>The man mped ments to d sc ose to a
fam y member were: fear of not be ng
be eved, shame, and fear of caus ng
troub e to the fam y. The man
mped ments for not seek ng serv ces
were: unaware of appropr ate serv ces,
w sh to keep the secret, ack of
awareness of be ng abused, m strust of
adu ts and profess ona s, and fear of the
consequences of d sc os ng sexua abuse.
When they d d d sc ose to profess ona s,
teens rece ved very m ted support as
many profess ona s were not tra ned on
sexua abuse and cou d not offer
approprate ntervent ons to v ct ms</td><td>This study represented the findings
of a mixed sampe of surv vors of
Ich d sexua abuse and nt mate
partner v o ence. The study was
conducted n Ita y and t s not
cear what sexua abuse response
tran ng s ava ab e. There may
have been a se ect on b as as the
most d ssat sf ed surv vors
responded to the research ca</td></tr><tr><td>Jonzon and L ndb ad
(2004)</td><td>Study purpose was to
exp ore how abuse
tra ts, openness,
react ons to CSA
d sc osure, and soca
support were re ated.
D fferences based on
sever ty of abuse,
tm ng and outcomes
of d sc osure, soc a
support, and
pred ct ng factors of
post ve and negat ve
react ons were probed</td><td>Adut women report ng
CSA by someone cose
were nterv ewed
us ng sem -structured
gu des together with
quest onna res. Data
on v ct m zat on and
current soc a support
were retr eved
through the
quest onna res, and
data on d sc osure and
react ons were
gathered through the
nterv ews w th
part c pants</td><td>122 adut women
between 20 and 60
years o d (average age
of 41 years) report ng
exposure to ch d
sexua abuse by
someone cose before
the age of 18 and had
to d someone about at
east one abuse event.
90% were Swed sh
subjects. Purpos ve
samp ng strategy was
used</td><td>Abuse character st cs: abuse by mutpe
perpetrators was more common than by
a s ng e perpetrator. Age of onset was
often before age of 7, with an average
durat on of 7 years. Severe y abused
women had ta ked to more of the r
soca network, especa y to
profess ona s. D sc osures: 32%
dsc osed during ch dhood (before the
age of 18) with an average of 21 years
de ay. Women who had d sc osed n
ch dhood reported more nstances of
phys ca abuse, mut pe perpetrators,
use of v o ence, and were more key to
have confronted a perpetrator, and had
rece ved a negat ve first react on. Factors</td><td>68% de ayed d sc osure unt
adu thood. At the time of the
study, t was one of the first
stud es to focus on the nterp ay
between soc a support networks
and d sc osure of ch d sexua
abuse. The study resu ts are
somewhat m ted by an
overrepresentat on of severe y
abused women. Retrospect ve
study and se f-report of
nformat on coud mp y reca
ssues and thus m ts the accuracy
of the nformat on obta ned on
abuse and d sc osure
character st cs. Cross-sect ona</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>F nd ngs</th><th>Summary</th></tr><tr><td>Kogan (2004)</td><td>The purpose of this study
I was to dent fy factors
that nfuence the
d sc osures made by
fema e surv vors of
USE n ch dhood and
ado escence. The
pred ctors of both the
tm ng of d sc osure
and the rec p ent of the
d sc osure were
nvest gated</td><td>Data were gathered from
a subsampe of fema e
ado escents that
part cpated n the
NSA, wh ch cons sted
of structured phone
nterv ews. USES
reported n the NSA
were assessed us ng a
mod fed vers on of the
Inc dent C ass f cat on
Interv ew. They were
then asked a ser es of
quest ons about each
ep sode of unwanted
sexua contact
nc ud ng event
character st cs and
perpetrator
character st cs</td><td>A subsample of 263
ado escent fema es
between 12 and 17
years o d, mean age of
15.2 years o d, who
reported at east one
exper ence of
unwanted sexua
contact n the NSA.
Part c pant
character st cs, USE
character st cs, and
fam y contextua
attr butes were
exp ored</td><td>sgn f cant y pred ct ng de ay were
younger age at frst event and no use of
vo ence. D sc osure outcomes: of the 26
women who to d n ch dhood during a
per od wth ongo ng abuse, 15 women
were cont nuous y abused after
d sc osure
Ch dren under the age of 7 were at a
h gher risk for de ayed d sc osures.
Part c pants whose USE occurred
between the ages of 7 and 13 were most
key to te an adu t. Ado escents (14-
17) were more key to te on y peers
than ch dren aged 7-10 years. Ch dren
under II were more key to te an
adu t, but were at r sk for de ay ng
dsc osure beyond a month. Ch dren
aged 11-13 tended to d sc ose with na
month. Coser re at onsh p to the
perpetrator or a fam y member was
assocated with de ayed d sc osure.
Immed ate d sc osure was more key
w th stranger perpetrat on. Fear for
one's fe during and penetrat on were
assoc ated with d sc osure to adu ts.
Fam y factors nked to d sc osure were
(I) drug abus ng househo d member,
wh ch made surv vors more key to
d sc ose more prompt y and (2) never
vng with both parents was assoc ated
wth nond sc osure</td><td>des gn does not a ow for def n te
conc us ons of cause and effect on
the re at onsh ps found

This study exam ned factors
nc ud ng d sc osures of USES n
ch dhood and ado escence na
nat ona y representat ve samp e
of fema e ado escents who
part cpated n the NSA. Surveys
for nvest gat ons of v ct m zat on
exper ences may be based due to
underreport ng. Ado escents who
refused to report or d scuss an
USE may represent a source of
systemat c b as and would make
the resu ts genera zab e on y to
ado escents who are w ng to
d sc ose USE va survey. A though
data may be retrospect ve, reca
bas may have been m n m zed n
this study s nce part c pants were
ado escents, and so the t me ag
between the USE and the
nterv ew were presumab y
shorter than a study of adu t
part c pants reca ng CSA
exper ences</td></tr><tr><td>Goodman-Brown,
Ede ste n, Goodman,
Jones, and Gordon
(2003)</td><td>The purpose of this study
was to nvest gate
var ab es assocated
wth de ay of
d sc osure of CSA and
test a mode for
factors that nfuence
how qu ck y ch dren
dsc ose sexua abuse</td><td>Case f e rev ews of data
obta ned from
prosecut on f es, as
we as from
structured nterv ews
with the ch dren's
caretaker and
observat ons of ch d
nterv ews. Tra ned
graduate students and
one v ct m advocate
competed the Sexua
Assaut Prof e</td><td>Samp e cons sted of 218
ch dren referred to
prosecutors' off ces
for a eged CSA. A
ch dren n the samp e
had d sc osed the r
abuse n some manner.
Ch dren ranged n age
from 2 to 16 years at
the beg nn ng of abuse;
3-16 years at the end
of the abuse, and 4-16
years at the t me of the</td><td>64% d sc osed wth n a month and 29%
wth n 6 months. F ve var ab es for the
mode were tested. (1) age: ch dren who
were o der took onger to d sc ose and
o der ch dren feared more negat ve
consequences to others than younger
ch dren; (2) type of abuse: v ct ms of
Intrafam a fam es took onger to
d sc ose-v ct ms of ntrafam a abuse
feared greater negat ve consequences to
others compared to v ct ms of
extrafam a abuse; (3) fear of negat ve
consequences: ch dren who feared</td><td>This study represents a higher rate
of d scosers with n a month.
These cases had been reported to
author tes and were n process of
prosecut on wh ch may expan
h gher rate of ear ry y d sc osures.
Lega sampe with h gher rate of
extrafam a abuse (52%) may a so
account for ear er dsc osures.
Mode suggests that o der
ch dren, v ct ms of ntrafam a
abuse; fet greater respons b ty
for the abuse, and perce v ng</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025262

(continued)

Table I. (cont nued)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

<table><tr><th>Study</th><th>Purpose</th><th>Des gn</th><th>Samp e</th><th>Fnd ngs</th><th>Summary</th></tr><tr><td></td><td></td><td>quest onna re for ch d
character st cs, the
abuse and ther
dsc osure. Ch dren's
percept on of
respons b ty and fear
of negat ve
consequences were
probed.
Corre at ona ana yses
were conducted with
path ana yses to test
the hypothes zed
causa re at ons among
var ab es</td><td>Inta po ce report;
77% fema e, 70%
Caucas an, 17%
H span c, and 11%
Afr can Amer can.
Predom nant y m dd e
to ow SES.
Approx mate y 47%
Intrafam a abuse</td><td>negat ve consequences of d sc osure
took onger to d sc ose, ch dren who
be eved that the r d sc osure wou d
br ng harm to others took onger to
d sc ose, fear of negat ve consequences
to the sef or the perpetrator was
unre ated to t me of d sc osure, and grs
more than boys feared negat ve
consequences to others; (4) Perce ved
respons b ty: ch dren who fet greater
respons b ty for the abuse took onger
to d sc ose and o der ch dren fet more
respons b ty for the abuse; and (5)
gender was not s gn f cant y corre ated
wth t me to d sc osure</td><td>negat ve consequences to
dsc os ng took onger to d sc ose.
We -des gned study with high
eve of r gor. Produced a vab e
mode of d sc osure for further
nvest gat ons. However,
researchers were not ab e to
Interv ew ch dren d rect y</td></tr><tr><td>Sm th, Letourneau,
Saunders, K patr ck,
Resn ck, and Best
(2000)</td><td>The study focus was to
gather data from a
arge sampe of women
about the ength of
t me women who
were raped before age
18 de ayed d sc osure
who they d sc osed to,
and var ab es that
pred cted d sc osure
wth n I month</td><td>Structured te ephone
nterv ews that asted
approx mate y 35 m n
were used to co ect
data us ng a computer-
ass sted te ephone
nterv ew system. A
te ephone nterv ews
were conducted with
each quest on on a
computer screen. The
survey cons sted of
severa measures
des gned to e ct
demograph c
nformat on,
psych atr c symptoms,
substance use, and
v ct m zat on h story.
The present study
reports on data from
the demograph c and
ch d rape v ct m zat on
quest ons</td><td>Two probab ty samp es.
Wave I was a random
sampe of 2,009
respondents se ected
from strat fed samp es
of def ned
jur sd ct ons.
Random dg ta da ng
was used to so ct
househo ds for sted
and un sted te ephone
numbers. Second
random sampe of
2,000 women between
the ages of 18 and 34
was se ected. Both
Wave I and Wave 2
data were we ghted to
conform to the 1989
Census stat st cs</td><td>288 (9%) reported exper encing at east
one event that met the study's def n ton
of ch dhood rape. The average age at the
t me of the frst rape was 10.9 years. Of
the 288 women who reported a ch d
rape, 28% stated that they had never to d
anyone about this sexua assaut unt
spec f ca y quer ed by the nterv ewer
for this study. 58% d d not d sc ose for
over I year and up to 5 years post-rape.
27% d sc osed wth n a month. Among
women who d sc osed pr or to the r
NWS nterv ew cose fr ends were the
most common person to whom v ct ms
made d sc osures, fo owed by mothers
and other mmed ate fam y members.
Fewer than 10% of v ct ms reported
mak ng the r nta dsc osure to soc a
workers or aw enforcement personne.
On y 12% of ch d rape v ct ms stated
that the r assau ts were reported to
author t es at some po nt</td><td>The time frame of this survey may
have had contextua mp cat ons.
The major ty of ch d rapes
reported by th s samp e occurred
pr or to the arge-sca e ch d
assaut prevent on educat on
programs that were begun n the
1980s that teach ch dren that
assau ts (nc ud ng CSA) are
wrong and shoud be d sc osed to
respons be adu ts. This
nformat on may have nfuenced
(and may current y be nf uencing)
young women's d sc osure
patterns. For Wave I, compar son
of these data with the popu at on
parameters obta ned from the
U.S. Census Bureau nd cated that
the samp e cose y matched the
demograph c attr butes of the
popu at on of U.S. women</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

EFTA00025263

Note. SCL-90 Symptom Check List-90; SES = socioeconomic status; L M = ong interview method; CSA chi d sexua abuse; N CHD Nationa nstitute of Chid Heath and Human Deve opment; USE = unwanted sexua experiences; NSA Nationa Survey of Ado escents; NWS Nationa Women's Study: Q DS = Questionnaire informattsé sur es dé inquants sexeus.

275

276

TRAUMA, VIOLENCE, & ABUSE 20(2)

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

examples of this usage were found in the research questions, interview guides, and surveys examined: "How and when do people decide to tell others about their early sexual experiences with adults?" (Hunter, 2011, p. 161); "Some men take many years to tell someone that they were sexually abused. Please describe why it may be difficult for men to tell about/discuss the sexual abuse" (Easton, Saltzman, & Willis, 2014, p. 462). "Participants were asked a series of open-ended questions to elicit a narrative regarding their experiences of telling..." (McElvaney, Greene, & Hogan, 2012, p. 1160). "Who was the first person you told?" (Schaeffer, Leventhal, & Anes, 2011, p. 346). There was sound consistency between studies, defining dis- closure in multifaceted ways with uniform use of categories of prompted, purposeful, withheld, accidental, direct, and indi- rect. However, defining the period of time that would delineate a disclosure as delayed varied widely across studies, wherein some studies viewed 1 week or 1 month as a delayed disclosure (i.e., Hershkowitz et al., 2007; Kogan, 2004; Schönbucher, 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; Schönbucher 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 barriers and bring forward less information on disclosure facilitators.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

Through an in-depth, second-level analysis, this review identified five distinct themes and subthemes beyond the gen- eral trends as noted earlier.

Theme 1: Disclosure is viewed as an ongoing process as opposed to a discrete event-iterative and interactive in nature. A subtheme was identified regarding disclosure as

being facilitated within a dialogical and relational context is being more clearly delineated.

Theme 2: Contemporary disclosure models reflect a social-ecological, person-in-environment perspective to understand the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure. Subthemes include new categories of disclosure and a grow- ing focus on previously missing cultural and contextual factors.

Theme 3: Age and gender are strong predictors for delaying disclosure or withholding disclosure with trends showing fewer disclosures by younger children and boys. One sub- theme emerged that intrafamilial abuse/family-like relation- ship of perpetrator has a bearing on disclosure delays or withholding.

Theme 4: There is a lack of a cohesive life-course perspec- tive. One subtheme includes the lack of data within the 18- to 24-year-old emerging adult population.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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-Vézina 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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

Recently, McElvaney, Greene, and Hogan (2012) detailed a process model of disclosure wherein they describe an interac- tion of internal factors with external motivators which they liken to a "pressure cooker" effect, preceded by a period of containment of the secret. Moreover, this and other studies strongly suggest disclosures are more likely to occur within a dialogical context-activated by discussions of abuse or pre- vention forums providing information about sexual abuse (Hershkowitz et al., 2005; Jensen, Gulbrandsen, Mossige, Reichelt, & Tjersland, 2005; Ungar et al., 2009a). The term

EFTA00025264

Alaggia et al.

277

dialogical simply means to participate in dialogue. Key dialo- gical vehicles identified in these studies were providing sexual abuse information through prevention programs, being asked about sexual abuse, and being prompted to tell (McElvaney et al., 2012; Ungar et al., 2009a).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

Contemporary models of CSA disclosure reflect a social-ecological perspective. Knowledge on CSA disclosure has been steadily advancing toward a holistic understanding of the complex interplay of individual, familial, contextual, and cultural fac- tors (Alaggia & Kirshenbaum, 2005; Brazelton, 2015; Fontes & Plummer, 2010). Where at one time factors examined and identified were predominantly of intrapersonal factors of child victims, knowledge construction has shifted to fuller social ecological, person-in-environment explanations (Alaggia, 2010; Collin-Vézina et al., 2015; Easton et al., 2014; Hunter, 2011; Ungar, Tutty, McConnell, Barter, & Fairholm, 2009b). Social-ecological explanations open up more opportunities to intervene in facilitating earlier disclosures. Alaggia (2010) pro- poses an ecological mapping of what individual, interpersonal, environmental, and contextual influences impede or promote CSA disclosures based on analysis of in-depth interview data of 40 adult survivors. Subsequently, based on a sample of 67 adult survivors, Collin-Vézina, Sablonni, Palmer, and Milne (2015) identified three broad categories, closely aligned with an eco- logical framework that impede CSA disclosure: (1) barriers from within, (2) barriers in relation to others, and (3) barriers in relation to the social world which can be aligned to intra- personal, interpersonal, and contextual factors.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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-Vézina 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; Hershkowitz et al., 2005; Priebe & Svedin, 2008; Schönbucher et al., 2012). This is especially a barrier when the perpetrator lives with the victim (LeClerc & Wortley, 2015).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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-Vézina et al., 2015).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

Cultural factors influencing CSA disclosure have been stud- ied to a much lesser degree. Despite this, a few important studies examining critical sociocultural factors now exist for better understanding CSA disclosure within a cultural context (Brazelton, 2015; Fontes & Plummer, 2010). Among these important contributions, Brazelton's (2015) research has deli- neated CSA disclosure processes as "shaped by relational, racial, socio-cultural, historical, and developmental factors" (p. 182). In a unique study using culturally focused research literature as data triangulated with clinical case material, cul- turally based belief systems in many cultures have been found to foster family climates that can silence children from disclos- ing abuse (Fontes & Plummer, 2010). Taboos about sexuality, patriarchal attitudes, and devaluation of women are among some of the cultural barriers that inhibit disclosure (Fontes & Plummer, 2010).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Table I. (cont nued) (cont.)

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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure

Age. Age is consistently found to be an influential factor in CSA disclosure, making the life stage of the victim/survivor a critical consideration. Studies draw distinctions in age-groups falling into either under or over 18 years of age. Eighteen years of age was the common age cutoff point that investigators chose in order to distinguish child/youth populations from adult sam- ples. Sixteen of the studies drew on samples of children and youth, while the other 15 studies sampled adults over the age of 18, and a further two studies used mixed age-groups (refer to Table 1). Among the child and youth samples, the age ranges spanned from preschool to late adolescence (3-17 years of age), with varying methodological approaches implemented across age cohorts. For younger cohorts, file reviews and secondary data analyses of CSA reports were typically undertaken. Ado- lescents were most often given surveys. Sometimes children and youth were interviewed as part of administering a survey or as a follow-up (Crisma et al., 2004; Hershkowitz et al., 2005; Ungar et al., 2009b). In the majority of child and adolescent samples, sexual abuse concerns were already flagged to investigative authorities. However, the work of Ungar, Barter, McConnell, Tutty, and Fairholm (2009a, 2009b) is one exception, whereby their survey elicited new disclosures.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

EFTA00025265

278

TRAUMA, VIOLENCE, & ABUSE 20(2)

Adult studies typically had a mean age between 40 and 50 years. Interviews were the main data collection method with a few exceptions using survey designs (i.e., Easton, 2013; Kogan, 2004; Smith et al., 2000) and case file reviews (i.e., Collings et al., 2005; Goodman-Brown et al., 2003). Results show a clear trend toward increased likelihood of disclosure in older youth, and findings from adult samples showing a preponderance of disclosures in adulthood, with the large majority of participants of adults reporting never having had a sexual abuse complaint filed with investigative authorities as a child or an adolescent (i.e., Hunter, 2011; Gagnier & Collin-Vézina, 2016; Sorsoli, Kia-Keating, & Grossman, 2008; Ungar et al., 2009b).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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-Vézina et al., 2015; Easton, 2013; Jonzon & Linblad, 2004; Kogan, 2004; Leclerc & Wortley, 2015; Sorsoli et al., 2008). While gender and relationship with the perpetrator are considerable factors in CSA disclosure, age is consistently a stronger predictor of disclosure (or nondisclosure) (Hershko- witz et al., 2005; Leclerc & Wortley, 2015). Third, younger children who disclose are more likely to do so in an interview situation or other environment that provides prompts or questions about sexual abuse (Hershkowitz et al., 2005; McElvaney, Greene, & Hogan, 2014; Schaeffer et al., 2011), but this trend can also be seen in older youth (Ungar et al., 2009a, 2009b).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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-Vézina, 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 (Hébert, Tourigny, Cyr, McDuff, & Joly, 2009; Ungar et al., 2009b). Easton, Saltzman, and Willis (2014) have been developing gender-specific modeling of disclosure examining male disclo- sures. Their proposed model groups male disclosures into barrier categories as determined by individual factors, interpersonal issues, and factors that are sociopolitical in nature. These authors suggest that predominant gender norms around masculinity rein- force the tendency for male victims of CSA to blame themselves

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

for the abuse, resulting in no disclosure. Male participants in a subsequent study also relayed that gender norms and stereotypes contributed to them concealing the abuse because they were abused by a woman (Gagnier & Collin-Vézina, 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).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

Lack of a life-course perspective. Given that the study of CSA disclosure draws on age-groups ranging from samples of very young children to retrospective studies of adult survivors, with significant developmental considerations, this area of study lacks an intentional cohesive life-course perspective. Most data are derived from either cross-sectional or retrospective designs, with few longitudinal studies. There are a series of sound, yet disconnected, studies focusing on specific age-groups of chil- dren and adolescents, along with adult retrospective studies. Thus, the available knowledge base does not allow for a cohe- sive picture of CSA disclosure processes and pathways over the life course to emerge.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

Summary of barriers and facilitators. Research over the past 15 years continues to uncover barriers to CSA disclosure at a higher frequency than that of facilitators. As stated previously, this might be the result of sampling methods whereby partici- pants who volunteer for disclosure research may have had more negative disclosure experiences, especially since many report delays in disclosure. The following section outlines the major trends in both barriers and facilitators (see Table 2).

Barriers. Age and gender were found to contribute to barriers as covered in Theme 3. Disclosures generally increase with age

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Table 2. Factors Influencing Child Sexual Abuse Disclosures.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

<table><tr><th>Barriers</th><th>Facilitators</th></tr><tr><td>Age: The younger the child victim, the less likely they will purposefully
disclose.</td><td>Age: Disclosures increase with age, especially in adulthood.</td></tr><tr><td>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</td><td>Gender: Slight trend toward females who are older (adolescent) to
disclose before adulthood</td></tr><tr><td>Relationship to perpetrator: If the perpetrator is a family member or in
a family like role, disclosure is less likely to happen
Internal: Shame, self blame, and fear are psychological barriers. In
addition, fear of negative consequences on the family and for self
safety inhibits disclosure
Family relations: Families with a patriarchal structure, rigidly fixed
gender roles, dysfunctional communication, other forms of abuse
(i.e., domestic violence), and isolation inhibit disclosure
Environmental and cultural context: Lack of discussion about sexuality;
passive acceptance that unwanted sexual experiences are inevitable;
not wanting to bring shame to the family by admitting sexual abuse;
lack of involvement from neighbors, school personnel; and stigma
perpetuated by societal perceptions</td><td>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</td></tr></table>

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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-Vézina, 2016).

Victims of intrafamilial abuse when the offender is a parent, caregiver, significant family member, or someone in a family- like role are less likely to disclose immediately or at all in childhood/adolescence because of obvious power differentials and dependency needs (Collings et al., 2005; Dumont et al., 2014; Hershkowitz et al., 2005; Kogan, 2004; Leclerc & Wort- ley, 2015; Paine & Hansen, 2002; Schaeffer et al., 2011).

Further, the perpetrator residing with their victim(s) increases the likelihood of no disclosure (Leclerc & Wortley, 2015).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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-Vézina 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

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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-Vézina 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-Vézina 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-Vézina et al., 2015; Fontes & Plummer, 2010).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

Identification of cultural barriers is important recent contri- bution to understanding disclosure processes and in particular to the obstacles. Findings related to cultural barriers included themes of children's voices not being heard leading to silen- cing, the normalization of the sexualization and objectification of girls and women, and the perpetuation of hypermasculinity in men all acting as barriers in terms of stigma to disclosure (Alaggia, 2005, 2010; Easton et al., 2014). Brazelton (2015) similarly found that lack of discussions about sex, young age at the onset of sexual abuse, therefore not having the language to express what was happening to them, and preserving the family good name by not talking about abuse in the family were also barriers to disclosure.

Finally, it may be the case that more barriers continue to be identified over facilitators of CSA disclosure perhaps because of the methods employed in studies-particularly those draw- ing on adult populations who delayed disclosure. These sam- ples may not be representative of the overall population of CSA victims, since they may have had more negative disclosure

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# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

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 and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

Facilitators. Although fewer disclosure facilitators are identi- fied in this review, very important facilitators were nonetheless uncovered ones that should be noted for professionals in this field of practice. Internal factors that facilitate disclosures include symptoms that become unbearable, getting older with increased developmental efficacy, and realizing that an offence was committed (Collin-Vézina et al., 2015; Crisma et al., 2004; Easton, 2013; Hershkowitz et al. 2007; McElavaney, Greene, & Hogan, 2014; Schaeffer et al., 2011). Circumstantial facil- itators are those where the child discloses because there has been evidence provided, eye-witnessing has occurred, and a report has been made. Environmental factors include settings that provide opportunities such as counseling, interviews, information sessions and educational forums/workshops, and prevention programs for children and youth to disclose.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Age and gender as predictors of disclosure (cont.)

To elaborate, dialogical contexts about CSA for children and youth can provide opportunities for discussion that may facilitate disclosures (Jensen et al., 2005). The research shows creating open dialogue in relationship contexts, to offset the power and influence of the perpetrator, can facilitate earlier disclosure. Among disclosure facilitators is being asked about abuse and given the opportunity to "tell" (McElavaney et al., 2014); workshops on abuse and sexual abuse, in particular, can facilitate disclosures (Ungar et al., 2009b); and using culturally sensitive probes and questions (Fontes & Plummer, 2010). In Gagnier and Collin-Vézina's (2016) study, positive disclosure experiences were described by participants as those where they felt that they had been listened to, were safe, were believed, and were not judged by the person they disclosed to. Further, family members and friends (peers) of the child victim can act as key supports to creating an open relational context and fostering positive responses (Jensen et al., 2005; Priebe & Svedin, 2008; Schönbucher et al., 2012; Ungar et al., 2009b). In particular, as children grow older, they are more likely to disclose to a peer, as shown in a number of studies, and this is an important reality for counselors and educators to be aware of (Dumont et al., 2014; Kogan, 2004; Schönbucher et al., 2012; Ungar et al., 2009b).

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Discussion

Through examination of 33 studies published since the year 2000, this review identified five distinct themes regarding CSA disclosure: (1) Disclosure is best viewed as an iterative, interactive process rather than a discrete event done within a relational context; (2) contemporary models reflect a social-ecological, person-in-environment framework for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure;

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Discussion (cont.)

(3) age and gender are significant disclosure factors; (4) there is a lack of a life-course perspective; and (5) barriers to disclo- sure continue to outweigh facilitators. Based on these themes, a number of conclusions are drawn from this review. First, dis- closure as a process is emphasized throughout contemporary research. Advances have been made in understanding these complex processes. However, the disclosure process over time-for example, how the first detection of CSA or attempts to disclose in childhood impact later disclosures are not well understood. This is the result of the absence of a cohesive life- course perspective in investigations, although age consistently surfaces as significantly influencing CSA disclosure. Using a life-course perspective through the use of longitudinal studies is recommended.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Discussion (cont.)

The use of varied methodological designs, depending on the developmental stage of the victims/survivors, influences the data generated and subsequent findings. For example, most studies on children and youth are based on file reviews of cases that have been brought to the attention of authorities, or sur- veys, with only a few studies using interviewing of younger children. Therefore, there is less information available on pro- cess issues with children and youth. In contrast, research on adult populations largely favors the use of qualitative interview methods for retrospective inquiry producing important process findings. In addition, investigations have not yet captured the disclosure experiences of adults in the "emerging adult" stage given that adult studies have failed to recognized that the age range of 18-24, which is now considered a developmental phase defined by neurobiological developmental uniqueness. As well, late adulthood has not been given attention as shown by the absence of participants representing this age-group in current research (70+). With a swelling geriatric population in North America, issues of historic CSA can be expected to surface and, with that, new disclosures. This trend is also antici- pated due to attitudinal shifts that have presumably occurred over the last two generations about revealing such traumas and changing views about discussing sexual victimization.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Discussion (cont.)

Interview guides used in a number of studies intentionally probed for facilitators, producing notable findings. For exam- ple, one such finding focuses on the importance of creating a contextually supportive environment to promote disclosure across the life course. These include developing therapeutic relational contexts for disclosure by providing information about sexuality, sexual abuse, prevention programming, and by asking directly. Disclosures to professionals are positive outcomes of how therapeutic contexts work; however, for for- ensic purposes prompting such disclosures would be viewed as problematic in legal settings, seriously compromising testimo- nies for trial proceedings. This is one example that speaks to the structural barriers victims and survivors run up against time and time again. Facilitators that show evidence to promote disclo- sure in one domain (therapeutic) are seen to work against CSA survivors in another domain-such as legal settings when per- petrators face prosecution. Defense attorneys will use this as evidence that the disclosure was prompted, and therefore the disclosure is potentially seen as not credible. Broadcasting of

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Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Discussion (cont.)

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281

the frequency of acquitted cases or rulings in favor of the perpetrator through media outlets, often sensationalized, become a further compounding barrier. Given the review find- ings, we conclude that barriers and facilitators to CSA disclo- sures are nuanced and clearly embedded within intrapersonal, interpersonal, environmental, contextual, and cultural domains often interlocked in complex ways.

## Limitations

Although comprehensive in nature with its life-course cover- age, this review may be limited by its qualitative, thematic focus rather than providing an evaluative, quantitative account- ing of CSA disclosures. However, because of the recent focus on disclosure processes, the authors chose a suitably compati- ble approach-qualitative in nature. As well, a traditional checklist approach in rating the studies was not employed for interrater reliability, since two of the authors hold expertise in CSA disclosure research and are well versed with the literature. This expertise, and through closely following a systematic review framework (Kiteley & Stogdon, 2014), assures that a thorough adjudication of the research literature was completed.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Implications for Research and Practice

These review findings have implications that can be useful in guiding future research and practice:

• Solid strides are being made in the use of a social-eco- logical framework to underpin investigations in the CSA disclosure investigations. Research efforts and practice considerations should continue in this vein. Investigat- ing environmental factors and contextual and cultural forces is understudied, necessitating more research in these areas to more fully fill out understanding of CSA disclosure from a social-ecological perspective.

• There is good evidence that CSA disclosures are more likely to occur in a dialogical context-formal helping relationships but as well as other relationships such as peers and trusted adults. Providing information and edu- cation on topics of sexuality in general, and sexual abuse specifically, can help children and youth to disclose. Raising awareness and prevention programs can pro- mote disclosures of sexual violence committed against children and youth.

(i.e.,

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Implications for Research and Practice (cont.)

• Goals of therapeutically supported disclosures
through therapy) may need to take precedence over for-
ensic approaches, if well-being of child victims and
adult survivors is to be made paramount. Legal pro-
cesses may act to facilitate disclosures but can also act
as barriers because of the negative outcomes experi-
enced in the court process.

- Practitioners need to keep in mind that the legal system is lagging far behind in knowledge uptake of recent evidence on CSA disclosures so that victims and

	- survivors continue to be systemically and structurally disadvantaged in legal proceedings.

•

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Implications for Research and Practice (cont.)

	- Health-care practitioners (i.e., child abuse pediatricians,
family practice doctors, clinical nurse specialists, and
public health nurses) should be made aware of the evi-
dence in the CSA disclosure literature to create environ-
ments for facilitating therapeutic disclosures.

- Given that age is a stable predictor of disclosure of CSA, more studies are needed that make use of a life-course perspective. More longitudinal studies are needed to better identify trends over different life stages.

- The emerging young adult as a developmental age group needs specific investigation. Neuroscience research has established that ages 18-24 is a distinct developmental phase. Late adulthood is another life stage that deserves to be researched.

• Gender needs to be more fully investigated in relation to impact on disclosure. Awareness that boys and girls have unique challenges and barriers in disclosing CSA should be paramount for practitioners.

• Intervention planning should take note that disclosures increase when perpetrators no longer reside with vic- tims, and this finding should be heeded by policy and law makers.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Implications for Research and Practice (cont.)

- Shame, self-blame, and fear are intrapersonal factors that persistently emerge as barriers to CSA disclosures and warrant more research to understand how to redress these barriers for earlier disclosures.

## Conclusion

There are still a substantial number of children and youth who are subjected to sexual abuse, despite preventative efforts. Just as concerning is the fact that many victims continue to suffer in silence as evidenced by the high num- bers of delayed disclosure. These hidden cases should not be overlooked, and these victims should not be forgotten. Despite significant progress in bringing the issue of CSA to the forefront, improving facilitation of disclosure and increasing positive influences on disclosure processes are still critical in order to protect current and future genera- tions of children and youth from the grave effects of sexual violence. Further, the focus should not be simply on strengthening and shoring up intrapersonal resources of vic- tims to disclose but rather to change environmental condi- tions to create a more supportive and safer context for CSA victims and survivors to disclose.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this

article.

## Funding

The author(s) received no financial support for the research, author ship, and/or publication of this article.

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Update (2000-2016) (cont.)

## References (cont.)

	- Trocmé, N., Fallon, B., MacLaurin, B., Sinha, V., Black, T., Fast, E., Holroyd, J. (2008). Characteristics of substantiated maltreatment. Canadian incidence study of reported child abuse and neglect: Major findings (Chapter 4). Retrieved from http:// www.phac aspc.gc.ca/cm vee/public eng.php

Ungar, M., Barter, K., McConnell, S. M., Tutty, L. M., & Fairholm, J. (2009a). Patterns of abuse disclosure among youth. Qualitative Social Work, 8, 341 356.

Ungar, M., Tutty, L. M., McConnell, S., Barter, K., & Fairholm, J. (2009b). What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33, 699 708.

Williams, L. M. (2003). Understanding child abuse and violence against women: A life course perspective. Journal of Interpersonal Violence, 18, 441 451.

# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Author Biographies

Ramona Alaggia, MSW, PhD, is an associate professor in social work and the Factor Inwentash Chair in Children's Mental Health at the University of Toronto. Her teaching and research focuses on gender and violence, sexual abuse disclosures, domestic violence exposure, and resilience processes.

Delphine Collin-Vézina, PhD, is an associate professor for School of Social Work, McGill University and director for Centre for Research on Children and Families. She holds the Nicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in Community and the Canada. Research Chair (Tier II) in Child Welfare. Her work focuses on research and clinical topics related to child maltreatment, child sexual abuse, and trauma.

Rusan Lateef, MSW, is a social worker employed in the criminal justice system with adult male offenders in Ontario, Canada. She specializes in the intersection of health and mental health, child sexual abuse disclosures, and she is a researcher on the "Make Resilience Matter" project examining childhood exposure to domestic violence with Dr. Alaggia at the Factor Inwentash Faculty of Social Work, University of Toronto.

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# Facilitators and Barriers to Child Sexual
Abuse (CSA) Disclosures: A Research
Update (2000-2016) (cont.)

## Author Biographies (cont.)

Child Abuse Review Vol. 24: 159–169 (2015) Published online 9 May 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2280

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice

## Rosaleen McElvaney

School of Nursing and Human
Sciences, Dublin City University,
Dublin, Ireland

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## Rosaleen McElvaney (cont.)

This paper reviews the research on disclosure of child sexual abuse with specific reference to delays in disclosing, non-disclosure and partial disclosure of experiences of child sexual abuse. Findings from large-scale national probability studies highlight the prevalence of both non-disclosure and delays in disclosure, while findings from small-scale qualitative studies portray the complexity, diversity and individuality of experiences. The possible explanations regarding why children are reluctant to disclose such experiences have significant implications for addressing the issue of child sexual abuse from the perspectives of child protection, legal and therapeutic professionals. The importance of understanding the dynamics of disclosure, in particular the needs of young people to maintain control over the disclosure process, the important role that peers play in this process, the responses of adults in both informal and formal networks, and the opportunities to tell, is key to helping young people speak more promptly about their experiences of sexual abuse. Copyright © 2013 John Wiley & Sons, Ltd.

'The importance of
understanding the
dynamics of
disclosure'

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## Rosaleen McElvaney (cont.)

KEY PRACTITIONER MESSAGES:

- Children typically delay disclosing experiences of abuse.

	- Asking children questions about their wellbeing gives them the opportunity to tell when they are ready.

• The challenge is to find the right questions at the right time.

• Peers can be the right people to ask these questions.

• Adolescents need to know about how to ask and what to do if someone tells.

KEY WORDS: child sex abuse; disclosure; research to practice

'Adolescents need to
know about how to
ask and what to do if
someone tells'

A n issue of increasing concern in recent years is the phenomenon of delayed disclosure of childhood sexual abuse and the need to understand the process of how children and adults disclose their experiences of child sexual abuse, given the implications for child protection, social justice and

*Correspondence to: Rosaleen McElvaney, School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin 9, Ireland. E-mail: rosaleen.mcelvaney@dcu.ie

Copyright © 2013 John Wiley & Sons, Ltd.

Accepted: 17 February 2013

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McElvaney

## 'This paper reviews
the research on
disclosure patterns of
childhood sexual
abuse'

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## 'This paper reviews
the research on
disclosure patterns of
childhood sexual
abuse' (cont.)

mental health outcomes. This paper reviews the research on disclosure patterns of childhood sexual abuse, specifically delays in disclosure, non-disclosure (as evident through adult retrospective studies) and partial disclosures, and discusses implications for practice. Literature searches of the online databases PSYCINFO and Social Sciences Citation Index, in addition to manual searches of texts published since 2000, were conducted using the search terms "child sexual abuse', 'sex abuse' and 'disclosure'.

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## 'This paper reviews
the research on
disclosure patterns of
childhood sexual
abuse' (cont.)

The research to date on disclosure patterns is based on two sampling methodologies studies of adults reporting retrospective experiences and studies of children. The former group of studies has the benefit of drawing on large-scale national probability samples which can be considered to be representative of the general population. The latter group with some small exceptions (predominantly adolescent studies) uses samples of young people who have disclosed sexual abuse but would not be considered as representative of all children who have been abused:

'children who decide to tell someone about being sexually abused and whose cases therefore come to court are not representative of sexually abused children in general' (Olafson and Lederman, 2006, p. 29).

## Patterns of Disclosure: Delays and Non-disclosure

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## 'Most people who
experience sexual
abuse in childhood do
not disclose this
abuse until adulthood'

There is consensus in the research literature that most people who experience sexual abuse in childhood do not disclose this abuse until adulthood, and when disclosure does occur in childhood, significant delays are common. Table 1 summarises two large-scale studies to highlight the extent of delays in disclosure and the percentage of those who did not disclose to anyone prior to the study.

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## 'Most people who
experience sexual
abuse in childhood do
not disclose this
abuse until adulthood' (cont.)

Kogan (2004) examined the timing of disclosure of unwanted sexual experiences in childhood or adolescence in a sub-sample (n = 263 adolescent women, aged 12 to 17) of the National Survey of Adolescents (Kilpatrick and Saunders, 1995) in the USA a nationally representative study. Kogan's results can be summarised as follows: immediate disclosure (within 1 month) 43 per cent, delayed disclosure (less than 1 year) 31 per cent and non-disclosure (disclosed only during the survey) 26 per cent. Smith and colleagues (2000) examined a sub-sample (n = 288) of the National Women's Study in the USA (Resnick et al., 1993, cited in Smith et al., 2000) who had reported a childhood rape prior to the age of 18. Smith et al.'s findings can be summarised as follows: immediate disclosure (within 1 month) 27 per cent, delayed disclosure (more than a year) 58 per cent and non-disclosure (survey only) 28 per cent. Those who had never disclosed prior to the survey constitute comparable proportions in these two studies while the rates for immediate

# Disclosure of Child
Sexual Abuse: Delays,
Non-disclosure and
Partial Disclosure. What
the Research Tells Us and
Implications for Practice (cont.)

## 'Most people who
experience sexual
abuse in childhood do
not disclose this
abuse until adulthood' (cont.)

Table 1. Patterns of disclosure delay and non-disclosure

<table><tr><th></th><th>Kogan (2004)
(n 263 adolescents)</th><th>Smith et al. (2000)
(n 288 adults)</th></tr><tr><td>Told within 24 hours</td><td>24%</td><td>18%</td></tr><tr><td>Told within 1 month</td><td>19%</td><td>9%</td></tr><tr><td>Told within 1 year</td><td>12%</td><td>11%</td></tr><tr><td>Delayed telling more than 1 year</td><td>19%</td><td>47%</td></tr><tr><td>Never told before survey</td><td>26%</td><td>28%</td></tr></table>

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disclosure are higher in the adolescent study than in the adult study, a reassuring finding given the increased awareness of sexual abuse in society during the past 20 years.

# Disclosure Patterns in Child Sexual Abuse (cont.)

Goodman-Brown and colleagues (2003) examined USA district attorney files of 218 children. Their categories were slightly different from the previous two studies but in summary, immediate disclosers (within 1 month) constituted 64 per cent of the sample while 29 per cent disclosed within six months. This study is unusual insofar as the sample studied had reported their experience of abuse to the authorities and a prosecution was in progress. Goodman-Brown et al. also pointed out that families who participated in this study were more likely to represent those children who experienced abuse by someone outside the family. Research has found that delays in disclosure are longer for those abused within the family (Sjoberg and Lindblad, 2002; Goodman-Brown et al., 2003; Kogan, 2004; Hershkowitz et al., 2005). Therefore, children who disclose more promptly may be overrepresented in legal samples. In Sweden, Priebe and Svedin (2008) conducted a national survey of 4339 adolescents, of whom 1962 reported some form of sexual abuse (65% of girls and 23% of boys). Details of the time lapse in disclosing were not available from this study. However, of those who had disclosed and answered the questions on disclosure (n = 1493), 59.5 per cent had told no-one of their experiences prior to the survey. Of those who did disclose, 80.5 per cent mentioned a 'friend of my own age' as the only person who they had told. In this study, 6.8 per cent had reported their experiences to the social authorities or police. A further Swedish study of 122 women who had experienced childhood sexual abuse (Jonson and Lindblad, 2004) found that 32 per cent disclosed during childhood (before the age of 18) while the majority told in adulthood (68%). The delay was up to 49 years, with an average of 21 years (SD 12.9). Of those who told in childhood, 59 per cent told only one person. In Ireland, the SAVI study (n = 3118, McGee et al., 2002) found that 47 per cent of those respondents who had experienced some form of sexual assault prior to age 17 had told no-one of this experience until the survey. McElvaney (2002) investigated delay in a legal sample of ten adults who had made formal complaints of childhood sexual abuse in Ireland and found delays ranging from 20 years to 50 years. Studies of children in the context of forensic/investigative interviews where children are interviewed by professionals due to concerns that the child has been sexually abused also point to high non-disclosure rates, particularly striking in cases where there is corroborative evidence that abuse has occurred medical evidence (Lyon, 2007), or confessions from the abuser or videotaped evidence/witness reports (Sjoberg and Lindblad, 2002). Lyon (2007) reported his findings from a review of studies published between 1965 and 1993 of children diagnosed with gonorrhoea where the average disclosure rate among 579 children was 43 per cent (n=250). In a study where the evidence for the abuse was available on videotape, children have denied abuse when interviewed by the police (Sjoberg and Lindblad, 2002). In summary, significant numbers of children do not disclose experiences of sexual abuse until adulthood and adult survey results suggest that significant

# Disclosure Patterns in Child Sexual Abuse (cont.)

'The rates for
immediate disclosure
are lower in the
adolescent study than
in the adult study'

'Children who disclose
more promptly may be
overrepresented in
legal samples'

'Delays ranging from
20 years to 50 years'

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McElvaney

# Disclosure Patterns in Child Sexual Abuse (cont.)

<table><tr><th>'High numbers of
respondents
disclosing to
researchers for the
first time'

'They found that
interviewers behaved
differently with the
two groups'

'A parent described
how her teenage son
told her over a period of
days'</th><th>proportions of adults have never disclosed such abuse, as evidenced by the
high numbers of respondents disclosing to researchers for the first time.
Patterns of Disclosure - Partial Disclosure

Information on how children disclose over time can be obtained from studies
of children who participated in forensic/investigative interviews where
children are interviewed by professionals due to concerns that the child has
been sexually abused. The issue of partial disclosures was highlighted by
earlier studies such as those by DeVoe and Faller (1999) of five- to ten-year
olds (i.e. making detailed informal disclosures that were not replicated in
formal interviews) and Elliott and Briere (1994) of children aged eight to
15 years (i.e. disclosing only partial information until confronted with external
evidence that led to more complete disclosures).
More recently, investigators have examined the role of the interviewer and
questioning styles in the forensic interview and how this impacts on children's
disclosures and the level of detail provided in interview. Hershkowitz et al.
(2006) compared tapes of interviews with children who disclosed sexual abuse
and those who did not (but about whom there was 'substantial' reason to
believe that they had been abused). They found that interviewers behaved
differently with the two groups, using different types of prompts with children
who presented as somewhat uncooperative, offered fewer details and gave
more uninformative responses at the beginning of the interview. It would
appear that interviewers responded to less communicative children by
increasing the proportion of closed questions which in turn led to children
being less forthcoming. Lamb et al. (2002) have found that the use of a
protocol that emphasises the use of prompts that elicit free narrative (e.g. 'tell
me about that') as compared with closed questions (those requiring a yes/no
response) has resulted in more detail and more accuracy in children's
accounts.
Although few studies exist that examine the phenomenon of disclosure in
informal settings (when disclosure is made to a friend or family member),
some qualitative studies have described this process. McElvaney (2008) quoted
one teenage girl who described hinting to her mother prior to disclosing the
experience: 'I didn't tell her what happened but I was saying things that made
her think it made her think that it happened but I didn't tell her' (p. 127). A
parent described how her teenage son told her over a period of days, keeping
the most difficult parts of the story until last:

'He came out with like it came out over two or three days so you know....he'd say well
I've something else to tell you... the bad stuff last... what hurt him most and what he's
saying what hurt him most' (p. 92)

And finally, one young person described how she told her social worker:

'I couldn't tell her most things but I just gave things to her to read... I told her at first I told</th></tr><tr><td></td><td>her bits of it and em then just the others. I finished writing and then I gave them to her... later
I told her that it was the father as well." (p. 93)

This young person had been abused by both a father and son in a family with
whom she was staying.</td></tr></table>

# Disclosure Patterns in Child Sexual Abuse (cont.)

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In reviewing the literature on this subject, London and colleagues (2005) noted, 'when children do disclose, it often takes them a long time to do so' (p. 204).

# Disclosure Patterns in Child Sexual Abuse (cont.)

## Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure

There are many influences on disclosure that have been identified in the research literature to help explain why it is that children delay disclosure, are reluctant to disclose, provide details of their experiences over time or do not disclose at all. Age has been identified as a significant predictor of disclosure in that younger children are less likely to disclose than older children. Children who are abused by a family member are less likely to disclose and more likely to delay disclosure than those abused by someone outside the family (Smith et al., 2000; Goodman-Brown et al., 2003; Kogan, 2004). Children who do disclose during forensic interviews compared to children who do not disclose in such contexts (yet concerns remain that they have been abused) are more likely to have parents (particularly mothers) who are more supportive (Lawson and Chaffin, 1992). In Priebe and Svedin's (2008) study of young people, parental bonding (positive relationship with parent who was not overprotective) was identified as the most significant predictor of disclosure for both boys and girls. However, close relationships can also act as an inhibitor to disclosure. McElvaney (2008) found that many young people in her study were reluctant to disclose due to concerns of upsetting their parents while others were concerned about the consequences for others of their disclosure. One 13-year-old girl described her concern that if she told, her uncle would go to jail and her small cousins would be left without a father:

# Disclosure Patterns in Child Sexual Abuse (cont.)

## Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure (cont.)

'I didn't want them to grow up with no Dad and just looking at... their other little friends having their Dad holding their hand I felt like I was taking their Dad away from them' (p. 130)

Gender has been found to influence disclosure in that boys appear to be more reluctant to disclose than girls (Goodman-Brown et al., 2003; Hershkowitz et al., 2005; Ungar et al., 2009a). Mental health difficulties on the part of the child have also been found to be relevant, particularly when children experience dissociative symptoms or other post-traumatic stress symptomatology (Priebe and Svedin, 2008).

# Disclosure Patterns in Child Sexual Abuse (cont.)

## Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure (cont.)

Some studies have found that the severity of abuse (e.g. penetrative abuse) predicts earlier disclosure while other studies have found no relationship between different types of abuse and disclosure timing. Similarly, the relationship between the duration of abuse-one-off incidents of abuse compared with abuse that takes place over a significant period of time - and timely disclosure has been investigated with mixed findings. Fear of the consequences of disclosure has been identified as a predictor of delayed disclosure and this in turn is associated with the age of the child (Goodman-Brown et al., 2003). Older children are more cognitively competent in terms of being able to reflect on and anticipate possible reactions to their disclosure. This can act then as an inhibitor to disclosure, although as noted above, most studies have found that older children are more likely to disclose than younger children. Fears of not being believed have been described by young people as inhibiting their disclosure and these fears are often

# Disclosure Patterns in Child Sexual Abuse (cont.)

## Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure (cont.)

"When children do
disclose, it often takes
them a long time to do
SO"

'Younger children are
less likely to disclose
than older children'

'Many young people
in her study were
reluctant to disclose
due to concerns of
upsetting their
parents'

'Fear of the
consequences of
disclosure has been
identified as a
predictor of delayed
disclosure'

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# McElvaney

'Investigating the
precise
circumstances that
led to disclosures for
children'

## 'Significant
proportions of
disclosure have been
prompted by
questions by
caregivers, friends or
others'

justified. Hershkowitz et al. (2007) interviewed children about their initial disclosures prior to formal interview and 50 per cent of the sample (n = 30) reported feeling afraid or ashamed of their parents' reaction. The authors reported that parents did show a tendency to blame their children and react angrily to the disclosure.

# McElvaney (cont.)

## 'Significant
proportions of
disclosure have been
prompted by
questions by
caregivers, friends or
others' (cont.)

Recent research has highlighted the need for children to be asked direct questions to facilitate their disclosure. Of those children who did disclose, significant proportions disclosed following prompts rather than it being initiated by the child (Kogan, 2004). Qualitative studies drawing on interviews with children that focus on the disclosure process are important in investigating the precise circumstances that led to disclosures for children. McElvaney (2008) found that parents' questioning of children was prompted by their concern about the young person's emotional distress. On occasion, young people were communicating that something was not right in their world but were not able to articulate this verbally. Signs of psychological distress were, however, evident and questions targeted at the reasons for this distress were identified by McElvaney as a factor that helped young people to tell. Thus, many children may not have told about their experiences of abuse because they were not asked. McGee et al. (2002) followed up a sample of their respondents who had disclosed childhood abuse for the first time in their survey. When asked why they had not disclosed prior to the survey, many respondents noted that it was because they had not been asked. Increasingly, research studies are finding that significant proportions of disclosure have been prompted by questions by caregivers, friends or others in the child's educational and social milieu that in themselves provide an opportunity for the young person to tell (Jensen et al., 2005; Hershkowitz et al., 2007; McElvaney et al., 2012).

# McElvaney (cont.)

## 'Significant
proportions of
disclosure have been
prompted by
questions by
caregivers, friends or
others' (cont.)

Finally, some children need time to tell. Mudaly and Goddard (2006) quote a 13-year-old girl: 'she (mother) helped by not making me, not rushing me to get it out, which, um, I think it's a really stupid idea to make kids get it out A.S.A.P.' (p. 91).

## Implications for Practice

'The implications of
these findings can be
considered in
interrelated contexts'

The consensus in the research literature at the present time is that disclosure is multi-determined, influenced by a complex range of factors that may influence each child in a different way. Large-scale national probability studies confirm that non-disclosure and delays in disclosure are significant problems facing society and in particular for those professionals tasked with safeguarding the wellbeing of children. Children's fears and anxieties in relation to telling need to be understood and contained by those in their environment so that early disclosure can be encouraged and facilitated.

# McElvaney (cont.)

## Implications for Practice (cont.)

The implications of these findings can be considered in interrelated contexts: the legal context where action can only be taken if the child is able to give a clear, credible account of his/her experiences; child protection and therapeutic contexts where a comprehensive account is required to enable child protection professionals to intervene and where the psychological sequelae can be addressed to minimise the long-term impact of the experiences; and family and community contexts where early disclosure needs to be encouraged, and

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other family issues addressed in the aftermath of disclosure and where peers play an important role.

# Disclosure Patterns in Child Sexual Abuse (cont.)

Studies have confirmed the importance of professionals asking children and young people in a sensitive, open manner about possible experiences of abuse using non-leading questioning styles to minimise inaccurate accounts or contaminate children's narratives. It is clearly important for professionals to remain open to the possibility of abuse and further disclosure. It is equally important for professionals to be able to avoid persisting with questioning those children who are 'reluctant disclosers'. Similarly, professionals engaged with children in therapeutic work need to be open to the possibility of both initial and further disclosures. Contradiction in witness statements is a well-known feature of false statements and giving additional detail to original formal statements can be interpreted within child protection, therapeutic and legal contexts as a contradiction of an earlier account. Listening to children's accounts of their experiences of disclosure helps us understand why it is that disclosure can be delayed and that when they do feel ready to tell this is not an 'all or nothing' decision. As one young person in Staller and Nelson-Gardell's (2005) study noted, 'it's never finished, never' p. 1426. This understanding in turn helps us identify those circumstances and reactions that may encourage the child to disclose. The importance of asking children questions, thus giving them an opportunity to tell, has been identified. While parents, teachers and those in daily contact with children are often reluctant to question children, it is clear that many children do not disclose unless given this opportunity. Education and increased awareness are needed on how to question children in an appropriate manner. McElvaney (2008) noted that questions did not need to be about sexual abuse per se, but rather questions prompted by the young person's psychological distress, asking after the young people's wellbeing. This questioning in effect acted as an external pressure for the young person to tell his/her secret (McElvaney et al., 2012). In Ungar et al.'s (2009a) study of Canadian youth, they found that young people used a range of disclosure strategies ranging from less direct strategies (such as risk-taking behaviours, not talking about the abuse) to direct strategies (such as seeking support from peers, turning to non-professional adult supports, disclosing to formal service providers), representing a process that relied heavily on others to 'build the bridges between the youth and formal care providers' (p. 352). The tendency to delay disclosing and the partial nature of many disclosures are not conducive to successful legal investigations and prosecutions. In addition, the knowledge base that exists within the legal sphere is limited if only a percentage of the children who experience sexual abuse engage with this system. The disproportionately high 'immediate disclosure' rate found in Goodman-Brown et al.'s (2003) legal sample compared to Kogan's (2004) community sample raises the question of the representation of delayed disclosers in the legal system. Are children who delay in disclosing less likely to engage with the legal system? Are delays in disclosing contributing to decisions not to prosecute child sexual abuse crimes? In Ireland, the 1990s saw a significant increase in the numbers of complainants coming before the courts reporting experiences of childhood sexual abuse. Many of these cases were referred to the higher courts for judicial review proceedings to establish

# Disclosure Patterns in Child Sexual Abuse (cont.)

'Contradiction in
witness statements is
a well-known feature
of false statements'

'Education and
increased awareness
are needed on how to
question children in
an appropriate
manner'

'Are children who
delay in disclosing
less likely to engage
with the legal system?'

whether the cases could proceed without prejudicing the accused given the

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# McElvaney

<table><tr><th>'Concerns that
engagement with the
legal system will lead
to further
psychological trauma
need to be considered'

'Many young people
who delayed
disclosure to an adult
had told a friend'

'An adaptive strategy
on the part of the
young person to
contain the experience'</th><th>delay in the complaint being made and giving due regard to the accused's right
to a speedy trial. Psychological expert testimony was sought as part of these
proceedings to explain the delay in disclosure in each individual case to enable
the courts to adjudicate on whether the delay in reporting was reasonable (see
McElvaney, 2002). This legal mechanism provided an opportunity to enhance
the knowledge base within the legal profession as to the complexities involved
in disclosing and formally reporting experiences of childhood sexual abuse for
adults. While one might expect that the legal system would be more
sympathetic to children's difficulties in making disclosures, it may also be
the case that the belief that "if the child was really sexually abused, why would
they not tell?', as articulated by Summit (1983), still prevails.
In addition, concerns that engagement with the legal system will lead to further
psychological trauma need to be considered. A prospective longitudinal study
conducted by Quas et al. (2005) indicated that the consequences of legal
involvement change over the course of development and as a function of the
child's reactions to and experiences during the legal case. The associations
between legal involvement and outcomes varied with age. The authors
suggested that although younger children may be at increased risk for some
adverse outcomes such as mental health problems, older children may be at
increased risk for other undesirable sequelae such as the negative attitudes
of others toward them. Quas and Goodman's (2011) recent review notes that
older children are more at risk in developing poor mental health outcomes.
Thus, as noted earlier, young people's fears of the consequences of disclosure
may well be justified. Raised awareness of both the prevalence of non-disclosure
of sexual abuse and the importance of supporting children to disclose may
go some way to addressing children's fears.
One interesting finding in recent studies is that many young people who
delayed disclosure to an adult had told a friend. McElvaney (2008) and Ungar
et al. (2009b) identified peer influence as significant in encouraging disclosure
among adolescents. There is some suggestion from the research that regardless
of the age at the time of abuse, adolescence may be a 'critical period' for
disclosure. It may be that targeting adolescents in general (rather than those
at risk of abuse) may be a powerful prevention tool in encouraging early
disclosure. Evaluations of child abuse prevention programmes have shown
significant improvements in the levels of awareness of child abuse in children
and young people (Rispers et al., 1997; Zwi et al., 2007). It may be that the
increasing trend towards peer disclosure is a by-product of such educational
and awareness-raising programmes. There is evidence that public awareness
campaigns when implemented as part of a multi-dimensional strategy that
involves targeting children, parents and communities (see Lalor and McElvaney,
2010, for a review of child abuse prevention programmes) are an effective tool in
the prevention of child abuse.
McElvaney et al. (2012) describe the importance for young people of
containing the secret of abuse and their need for confidentiality following
disclosure as representing an adaptive strategy on the part of the young person
to contain the experience and his/her emotional reaction to it. The conflict
between wanting/needing to keep the secret and wanting/needing to tell is
mediated by what they term the 'pressure cooker effect'. Young people in their
study described influences from within and without that led to a build up of</th></tr><tr><td></td><td>pressure, ultimately leading to disclosure. They suggest that building up the</td></tr></table>

# McElvaney (cont.)

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167

pressure for young people by providing opportunities to tell may be needed to help young people tell more promptly. However, the lack of control that young people experience following disclosure remains an issue (Ungar et al., 2009b; Quayle et al., 2012). This highlights the need for dissemination of information directly to young people about the legal process, the possible consequences of disclosure, as well as ongoing developments in legal proceedings when young people and their families interface with the legal system.

# Disclosure Patterns in Child Sexual Abuse (cont.)

The more recent focus on investigating those strategies that children use in making disclosures rather than solely on identifying barriers to disclosure is perhaps more helpful in informing awareness-raising campaigns and professional interventions. The author is involved in a large-scale review of children's files in an assessment service to ascertain those factors that helped children tell about their experiences of sexual abuse. A pilot study has suggested that this is an appropriate methodology for gathering data on children's experiences of informal disclosure, acknowledging the limitations of such an approach. Ungar et al. (2009a) describe the optimal conditions for disclosure as follows: being directly asked about experiences of abuse; having access to someone who will listen, believe and respond appropriately; having knowledge and language about what constitutes abuse and how to access help; having a sense of control over the process of disclosure both in terms of their anonymity (not being identified until they are ready for this) and confidentiality (the right to control who knows); and effective responses by adults both in informal and formal contexts.

# Disclosure Patterns in Child Sexual Abuse (cont.)

Ungar et al. (2009b) support recent developments in prevention programmes that target supportive formal and informal caregivers in being better able to detect the possibility of abuse and support disclosures rather than focusing on empowering children themselves in making disclosures. Their findings in relation to the importance of bridge building for young people to access formal supports are supported by Jensen et al.'s (2005) emphasis on the dialogical nature of disclosure, and the important role that trusted adults and peers play in the disclosure process through noticing signs of psychological distress and asking young people about their psychological wellbeing (Collings et al., 2005; Jensen et al., 2005; McElvaney et al., 2012). More emphasis is therefore needed on providing opportunities for children and young people to disclose. The challenge for professionals and those who care for children is how to do this in a way that protects children and promotes their wellbeing.

'More recent focus on
investigating those
strategies that
children use in
making disclosures'

'Having a sense of
control over the
process of disclosure
both in terms of their
anonymity and
confidentiality'

# Disclosure Patterns in Child Sexual Abuse (cont.)

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# McElvaney

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# McElvaney (cont.)

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EUROPEAN JOURNAL OF
PSYCHOTRAUMATOLOGY

actior
PUBLISHING

CLINICAL RESEARCH ARTICLE

# Predictors of delayed disclosure of rape in female adolescents and young adults

Iva A. E. Bicanic¹*, Lieve M. Hehenkamp¹, Elise M. van de Putte², Arjen J. van Wijk³ and Ad de Jongh³,4

National Psychotraumacenter for Children and Youth, University Medical Center Utrecht, Utrecht The Netherlands; 2Department of Paediatrics, University Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Behavioral Sciences, ACTA, University of Amsterdam and VU University, Amsterdam, The Netherlands; School of Health Sciences, Salford University, Manchester, United Kingdom

Background: Delayed disclosure of rape has been associated with impaired mental health; it is, therefore, important to understand which factors are associated with disclosure latency. The purpose of this study was to compare various demographics, post rape characteristics, and psychological functioning of early and delayed disclosers (i.e., more than 1 week post rape) among rape victims, and to determine predictors for delayed disclosure.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

Methods: Data were collected using a structured interview and validated questionnaires in a sample of 323 help seeking female adolescents and young adults (12 25 years), who were victimized by rape, but had no reported prior chronic child sexual abuse.

Results: In 59% of the cases, disclosure occurred within 1 week. Delayed disclosers were less likely to use medical services and to report to the police than early disclosers. No significant differences were found between delayed and early disclosers in psychological functioning and time to seek professional help. The combination of age category 12 17 years [odds ratio (OR) 2.05, confidence intervals (CI) 1.13 3.73], penetration (OR 2.36, CI 1.25 4.46), and closeness to assailant (OR 2.64, CI 1.52 4.60) contributed significantly to the prediction of delayed disclosure.

Conclusion: The results point to the need of targeted interventions that specifically encourage rape victims to disclose early, thereby increasing options for access to health and police services.

Keywords: Adolescents, young adults; rape; sexual assault; disclosure; latency to disclosure, posttraumatic stress disorder

Responsible Editor: Rita Rosner, KU Eichstaett Ingolstadt, Germany.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

*Correspondence to: Iva A. E. Bicanic, National Psychotrauma Center for Children and Youth, University Medical Center Utrecht, P.O. Box 85090, NL 3508 AB Utrecht, The Netherlands, Email: i.a.e.bicanic@umcutrecht.nl

For the abstract or full text in other languages, please see Supplementary files under 'Article Tools'

Received: 31 August 2014; Revised: 30 March 2015; Accepted: 13 April 2015; Published: 11 May 2015

revious studies have shown that disclosure of rape Pto to formal agencies, such as police or mental health 2000; Wolitzky-Taylor et al., 2011), especially when the rape has been committed on a date or by an acquaintance and involves the victim's use of drugs and/or alcohol (Resnick et al., 2000; Wolitzky-Taylor et al., 2011). There is evidence to suggest that victims believe that professionals will not be helpful to them because their rape experience does not match stereotypical conceptions of rape, such as involving a stranger, a weapon, and severe injury (Patterson, Greeson, & Campbell, 2009; Resnick et al., 2000). Accordingly, adolescents and young adults, who are more at risk to be victimized by rape than other age

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

groups (De Haas, Van Berlo, Bakker, & Vanwesenbeeck, 2012: Tjaden & Thoennes, 2006), may not receive targeted mental health care and may not report the crime to the police (Ruch, Coyne, & Perrone, 2000).

For reasons of mental health and public safety, it is important to understand the potential factors that are related to disclosure. Timing of disclosure may be a crucial factor, as early disclosers are more likely to utilize appro- priate medical care and report to the police than delayed disclosers (Ahrens, Stansell, & Jennings, 2010; Ullman & Filipas, 2001). In contrast, adults who wait longer than 1 month to disclose the rape are more likely to suffer from posttraumatic stress disorder (PTSD) and depres- sion compared to early disclosers (Ruggiero et al., 2004).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

European Journal of Psychotraumatology 2015. ©2015 Iva A. E. Bicanic et al. This is an Open Access article distributed under the terms of the Creative Commons 1 Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883

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In addition, adolescents who disclose their rape experience at least 1 month after the incident took place are found to be at higher risk for major depressive disorder and delinquency (Broman-Fulks et al., 2007) compared to those who disclosed within 1 month.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

Victim-assailant relationship is crucial in disclosure latency, with victims being at higher risk for delayed dis- closure if there is a close relation with the assailant (Kogan, 2004; Koss, 1988; Rickert, Wiemann, & Vaughan, 2005). In contrast, delayed disclosure is less common in victims of a stereotypical rape, i.e., rape by a stranger including a weapon and injury (Smith et al., 2000). Victims of prior sexual trauma are more likely to postpone disclosure of a subsequent assault than those without prior victimization (Smith et al., 2000; Ullman, 1996). This is in contrast with the findings of Ahrens et al. (2010), who report no dif- ference in rates of prior sexual trauma between early and delayed disclosers. In addition, the victim's age appears to be an important variable in predicting disclosure. Evidence suggests that young children are at higher risk for delayed disclosure than adolescents (Kogan, 2004; Schönbucher, Maier, Mohler-Kuo, Schnyder, & Landolt, 2012). Thus, various rape and victim-related character- istics have been found to be associated with timing of disclosure.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

The majority of the aforementioned studies included college and adult female rape victims. It is important to examine rape disclosure latency in an age and sex group that is most at risk for rape victimization. There is only one prior quantitative study in adolescents (those aged 12-17 years) that identified factors that might influence disclosure latency (Kogan, 2004). He found that identity of the assailant, a familial relationship with the assailant, and a history of drug abuse in the household were related to the timing of disclosure. The results suggested that a familial relationship with the assailant will postpone disclosure, whereas a history of drug abuse in the house- hold, albeit this seems counterintuitive, makes prompt disclosure more likely. This study had some limitations, including the fact that the interviews were conducted by telephone and that the description of the relationship with the assailant was limited. Therefore, in the present study, we investigated a sample of female adolescent and young adult victims of rape who were admitted to a specialized mental health centre for victims of sexual assault. The first aim of this study was to compare demographics, post-rape characteristics, and psychological functioning between early and delayed disclosers in this group. The second aim, based on the exploratory findings of Kogan (2004), was to determine the predictors for delayed disclosure in adoles- cents and young adults, including age, prior trauma, and victim-assailant relationship using logistic regression analyses. Insight into the predictors for delayed disclosure for adolescents and young adults may reveal not only potential causal mechanisms but also possible targets for

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

interventions that increase victims' opportunities to receive timely post-rape services.

## Methods

## Subjects and data collection

Rape was defined as "an event that occurred without the victim's consent that involved the use or threat of force in vaginal, anal, or oral intercourse" (Tjaden & Thoennes, 2006). The definition includes both attempted and com- pleted rape; the term "completed" referring to vaginal, oral, anal, or multiple penetrations. Victims who disclosed within 1 week were defined as "early disclosers," whereas those who disclosed at least after 1 week were defined as "delayed disclosers." This dichotomization of the variable "disclosure latency" was based on the study of Ahrens et al. (2010) and the national standard criteria for admis- sion to a Rape Centre in the Netherlands, i.e., a maximum of 7 days post-rape.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Subjects and data collection (cont.)

The study was conducted in the Dutch National Psychotrauma Centre, which provides psychological ser- vices for rape victims aged 12-25 years and their parents. Between May 2005 and December 2011, the centre re- ceived 621 phone calls concerning alleged rape victims from police authorities, mental health services, and self- referrals. In 178 cases, the phone call did not result in admission at the centre because of age limitations, or motivational reasons. In 108 cases, referrals were made to other institutions because the index trauma was chronic childhood sexual abuse rather than rape in adolescence/ young adulthood. Of the 335 cases admitted to the centre, 12 were not included in this study because of male gender, resulting in a final sample of 323 females with the index trauma being single rape. Referral sources for this final sample included the police (33.7%), mental health services (40.7%), and self-referrals, i.e., victims or parents (25.6%).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Procedure

During admission, all patients underwent a psychological assessment, consisting of 1) a structured interview for obtaining demographic and post-rape characteristics and 2) self-report questionnaires to obtain information about mental health functioning. Information from the inter- view was transcribed onto a form designed for this purpose. The following variables were obtained and dichotomized or categorized for the purpose of the study:

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Demographic and victim characteristics

We asked patients about their current age, educational level (lower, middle, or higher), and whether they were of Dutch origin (i.e., in case of having parents born in the Netherlands). Those between 12 and 17 years of age were defined as adolescents and those between 18 and 25 years of age as young adults. We also asked whether the patient was living with their parent(s) (yes/no), and whether the

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family structure was complete, i.e., whether the biological parents were living together (yes/no). Patients were then asked to confirm the presence of prior negative sexual experiences (yes/no), and whether they had a current sexual relationship (yes/no).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Rape characteristics

Information about date and time of the rape was ob- tained to calculate the time since rape at admission. Next, patients were requested to describe the rape. Their re- sponse was categorized into use of penetration (yes/no), group rape (yes/no), use of physical violence (yes/no), and use of threats verbally and/or with a weapon (yes/no). Also, information regarding the victim's relationship to the assailant was obtained. The assailant was defined as a stranger when the victim had never been in contact with the assailant before the rape. Responses were used to form a closeness category (yes in case of family, (boy) friend, or mentor). Patients were also asked about the (estimated) age of the assailant (categorized into 12-17 years or 18 years), and whether the victim had used alcohol prior to the rape (yes/no).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Post-rape characteristics

Patients were asked when they first talked about the rape. The response was used to calculate the disclosure time and the help-seeking time. At the end of the interview, patients were asked whether they had reported to the police after the incident (yes/no), and whether they had received any medical care after the incident (yes/no).

The study was performed in accordance with the precepts and regulations for research as stated in the Declaration of Helsinki, and the Dutch Medical Research involving Humans Subjects Act concerning scientific research. According to the Ethical Medical Committee of the University Medical Centre Utrecht, this act was not applicable to the present study. Written informed consent was obtained from both patients and parents.

## Measures

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Posttraumatic stress

The Children's Responses to Trauma Inventory (CRTI; Alisic, Eland, & Kleber, 2006) was used for participants aged 12-18 years. This is a 34-item questionnaire asses- sing severity of PTSD symptoms according to DSM-IV. Patients are asked to indicate to what extent a reaction to a traumatic event was present during the past week. Scores range from 1 to 5, with higher scores indicating more symptomatology. The four subscales: Intrusion, Avoidance, Arousal, and Other Child-Specific Reactions consist of 7, 11, 6, and 10 items, respectively. The reli- ability of this instrument is good to excellent (Cronbach's a 0.92 for total score, 0.79 for Intrusion, 0.77 for Avoidance, 0.71 for Arousal; Alisic & Kleber, 2010).

For the purpose of the study, only the total score was analysed.

## Depression

Children Depression Inventory (CDI; Kovacs, 1992; Timbremont & Braet, 2002) was used for participants aged 12-17 years of age. The CDI is a 27-item ques- tionnaire, assessing cognitive, affective, and behavioural symptoms of depression. The Dutch CDI has a satisfac- tory internal consistency, with Cronbach's ranging between 0.71 and 0.89 (Timbremont & Braet, 2002).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Behavioural problems

The Youth Self-Report (YSR; Achenbach & Rescorla, 2001) was used for participants aged 12-18 years. This questionnaire evaluates the teenager's perception of be- havioural and emotional problems. YSR has shown to be internally reliable (Cronbach's a's ranging from 0.71 to 0.95), and convergent and discriminant validity is reported to be satisfactory (Bérubé & Achenbach, 2006). The YSR includes four broadband scales and nine narrow-band scales to assess behaviour problems. For the purpose of the study, only the total score on behaviour problems was included in the analyses.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## General psychopathology

The Symptom Checklist-90-R (SCL-90-R; Arrindell & Ettema, 1986) was used for participants aged 12-25 years. This is a 90-item self-report inventory to assess psycho- social distress. Patients were instructed to indicate the amount they were bothered by each of the distress symptoms during the preceding week. Patients rated 90 distress symptoms on a five-point Likert scale with 1 being "not at all" and 5 being "extremely." The state- ments are assigned to eight dimensions, reflecting various types of psychopathology: anxiety, agoraphobia, depres- sion, somatization, insufficiency, sensitivity, hostility, and insomnia. The Global Severity Index (GSI) can be used as a summary of the test and reflects the severity of all answered statements as a global measure of distress. Cronbach's has been found to range from 0.73 to 0.97. For the purpose of the study, only the GSI was analysed.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Data analyses

To compare demographic and post-rape characteristics between the early and delayed disclosers, chi-square tests were used. To compare multiple continuous psychological scores, MANCOVA was used with "time since trauma" as a covariate to correct for the potential influence of time since trauma.

Delayed disclosure was used as a dependent variable. The strength of the univariate associations between each potential risk factor and delayed disclosure was estimated by calculating the odds ratio (OR) along with 95% confidence intervals (95% CI). To determine the strongest risk factors for delayed disclosure, each potential risk

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# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Data analyses (cont.)

Iva A. E. Bicanic et al.

factor identified in the univariate analyses with a sig- nificant OR (p<0.05) was entered as a predictor variable into the multivariable model, using a stepwise forward logistic regression (LR) analysis with delayed disclosure as the outcome variable. The Hosmer-Lemeshow goodness- of-fit chi-square was used to calculate how well the data fit the model. For all statistical analyses, a p-value of <0.05 was considered statistically significant.

All statistical analyses were conducted using SPSS (IBM SPSS Statistics for Windows, Version 20.0, IBM Corp., Armonk, NY).

## Results

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Socio-demographic characteristics

Socio-demographic characteristics of the sample are pre- sented in Table 1. Victims' age ranged from 12 to 25 years, with a mean age of 16.7 years (SD = 2.7) and a median age of 16.1 years. Victims' mean age at time of rape was 14.3 years (SD = 2.7) and a median age of 13.9 years. Penetration occurred in 79.6% of the cases. None of the victims reported prior chronic child sexual abuse. Data about victim-assailant relationship are presented in Table 2. Victims first disclosed after a mean 20.8 weeks (SD = 56.8, range 1-624 weeks), although 58.5% of the cases told within 1 week. First disclosure was to a friend (45.8%), parent(s) (17.1%), (ex) boy-friend (9.4%), family member (6.8%), professional (5.8%), or other adult (15.2%). With regard to post-rape services, 53.8% of all victims consulted a doctor for medical care and 51.4% reported to the police. On average, victims were admitted to the centre 59.8 weeks post-rape (SD-93.7, range 1-676). The mean GSI of the rape victims on the SCL-90- R (M=209.7, SD = 61.8) was comparable with previously reported data of psychiatric populations [M=203.55, SD=61.60; 1(269)=1.629, p=0.104] and was substantially

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Socio-demographic characteristics (cont.)

Table 1. Demographic characteristics of rape victims (N=323) in valid percentages

<table><tr><th></th><th>N</th><th>%</th></tr><tr><td>Dutch origin</td><td>274</td><td>84.8</td></tr><tr><td>Education levelb</td><td></td><td></td></tr><tr><td>Low</td><td>182</td><td>58.0</td></tr><tr><td>Medium</td><td>76</td><td>24.2</td></tr><tr><td>High</td><td>56</td><td>17.8</td></tr><tr><td>Parents divorced</td><td>102</td><td>31.9</td></tr><tr><td>Lives at parental home</td><td>273</td><td>85.3</td></tr><tr><td>Current relationship</td><td>81</td><td>26.5</td></tr><tr><td>Prior negative sex</td><td>46</td><td>14.8</td></tr></table>

"Dutch origin was defined as being a child from parents born in the Netherlands; after 6 years of general primary school, at the age of 12 years, students enter low (4 years), medium (5 years), or high (6 years) secondary education level.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Socio-demographic characteristics (cont.)

Table 2. Victim assailant relationship (N=323) in valid
percentages

<table><tr><th></th><th>N</th><th>%</th></tr><tr><td>Stranger</td><td>94</td><td>29.5</td></tr><tr><td>(Ex-)Boyfriend</td><td>32</td><td>10.0</td></tr><tr><td>Friend</td><td>33</td><td>10.3</td></tr><tr><td>Acquaintance</td><td>61</td><td>19.1</td></tr><tr><td>Person met during nightlife</td><td>30</td><td>9.4</td></tr><tr><td>Second-degree relative</td><td>15</td><td>4.7</td></tr><tr><td>Person seen only once</td><td>15</td><td>4.7</td></tr><tr><td>Person from school</td><td>14</td><td>4.4</td></tr><tr><td>Person met on the internet</td><td>12</td><td>3.8</td></tr><tr><td>Colleague</td><td>10</td><td>3.1</td></tr><tr><td>Mentor</td><td>3</td><td>1.0</td></tr></table>

higher [(269) 24.297, p <0.001] compared to the gen- eral population (M=118.28, SD = 32.38; Arrindell & Ettema, 1986). For the CDI, mean scores were in the clinical range (M=17.2, SD-4.6) and rape victims had significantly higher mean scores (t(230) = 15,923, p<0.001), in comparison to previously reported data of the general population of adolescent girls (Timbremont, Braet, & Roelofs, 2008; M-9.01, SD = 6.45).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Differences between early and delayed disclosers

Fifty-nine percent of the sample consisted of early dis- closers (disclosure within 1 week). No significant differ- ences in demographic characteristics were found between early and delayed disclosers, except that there were more delayed disclosers in the age category 12-17 years compared to the early disclosers group (x² (1)=6.96; p=0.008). For rape characteristics, significant differences between groups were found for the use of penetration, with more victims of penetration in the delayed disclosers group compared to the early disclosers group (x² (1)= 5.37; p=0.02). Also, the delayed disclosers group pre- sented more victims of verbal and/or weapon threats than the early disclosers group (x² (1)=5.35; p=0.02). Furthermore, among the delayed disclosers more victims identified the assailant as a close person compared to the early disclosers (x²(1) 10.84; p=0.001). Alcohol was used more often in the early disclosers group compared to the delayed disclosers group (x² (1) = 20.24; p<0.001).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Differences between early and delayed disclosers (cont.)

With respect to post-rape characteristics, a significantly smaller proportion of the delayed disclosers (15.9%) utilized medical services following the rape compared to the early disclosers (30.3%; x² (1)=5.32; p=0.02). Similarly, a significantly smaller proportion of the delayed disclosers (14.6%) compared to the early disclosers (34.3%) reported the rape to the police (x(1)=16.15; p<0.001). The time since trauma at admission was sig- nificantly lower for early disclosers (M=41.1 weeks, SD 79.4) than for delayed disclosers (M-82.9 weeks,

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# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Differences between early and delayed disclosers (cont.)

SD 103.3; 1(314)=4.06, p<0.001). Mean and median time to seek help were 37.7 and 12.0 weeks, respectively. Mean time to seek help did not differ between groups (t(309)=2.54, p <0.48). Excluding outliers (M+3 SD, N=11) did not change the outcome of this analysis. Both early and delayed disclosers scored in the highest level of psychological distress when compared to previously reported norm scores (CRTI, Alisic, Eland, Huijbregts, & Kleber, 2012; CDI, Timbremont et al., 2008; YSR, Achenbach & Rescorla, 2001; SCL-90, Arrindell & Ettema, 1986), but the MANCOVA results showed that when comparing multiple continuous psychological scores, the overall psychological functioning (posttrau- matic stress, depression, behavioural problems, and gen- eral psychopathology) did not differ significantly between early and delayed disclosers (F(6,198)=0.88, p=0.51).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Differences between early and delayed disclosers (cont.)

Table 3 shows the ORs with 95% CIs for the associa- tions between potential risk factors and delayed disclosure. Delayed disclosers, when compared to early disclosers, were significantly more likely to be in the age category of 12-17 years (OR = 2.10), to have experienced rape by a close person (OR 2.35), to have been threatened verbally and/or with a weapon (OR=1.75), and to have experienced penetration (OR=1.99). Delayed disclosers were also found less likely to have used alcohol prior to the rape (OR 0.22). None of the other factors were found to be significant risk factors for delayed disclosure.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Predicting delayed disclosure

A stepwise forward LR analysis was conducted to predict delayed disclosure, using "age category," "close assailant," "use of threats," and "penetration" as predictors. Victims' alcohol use was not entered in the analysis because of missing values for 33.4% of the cases. The use of threats was not a significant predictor in the model. A test of the full model against a constant-only model was statistically significant, indicating that the predictors (i.e., age cate- gory 12-17 years, close assailant, penetration) reliably distinguished between early and delayed disclosers (x² (3) 23.09, p<0.000). There were no significant interac- tions between the predictors. Nagelkerke's R² of 10.5% suggests only a modest association between the predic- tors and delayed disclosure, although the model did show an adequate fit to the data (Hosmer-Lemeshow x² (4) = 2.77, p <0.60). In total, 62% of the respondents were categorized correctly, when using the three predictors that contributed significantly to the prediction of delayed disclosure: age category 12-17 years (OR 2.05, CI 1.13– 3.73), penetration (OR 2.36, CI 1.25-4.46), and closeness to the assailant (OR 2.64, CI 1.52-4.60).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion

The results of this study show that, although no dif- ferences were found between delayed and early disclosers in psychological functioning and time to seek help,

delayed disclosers were less likely to use medical services

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

and to report to the police than early disclosers. Furthermore, this study identified a number of factors related to the timing of rape disclosure, showing that delayed disclosers represented significantly more adoles- cents than young adults, significantly more victims of penetration than assault, significantly more victims who were threatened than not threatened, and significantly more victims who were close with the assailant. The finding that delayed disclosers are less likely to utilize medical services and report to the police than early disclosers is in line with previous studies in adult women (Ahrens et al., 2010; Ullman, 1996; Ullman & Filipas, 2001). It suggests that disclosure latency is important for public health and safety, as delayed disclosure may not only impede reception of proper medical care, such as treating anogenital injuries and preventing the onset of STDs and unwanted pregnancy (Linden, 2011), but also impede the forensic investigation and apprehension of the assailant (Lacy & Stark, 2013). Three variables were identified that successfully pre- dicted delayed disclosure: age category 12-17 years, penetration, and the assailant being a close person. The finding that the victim's age significantly predicts disclo- sure latency is in line with previous research showing that adolescents are at a greater risk for delayed disclosure when compared to their older counterparts (Kogan, 2004; Smith et al., 2000). Adolescents may be less able to over- come the barriers to disclose, including factors such as assailant tactics for maintaining secrecy, stigma that often accompanies rape, and fear that their parents would consequently limit their freedom (Crisma, Bascelli, Paci, & Romito, 2004). Also, as victims approach adulthood, they may possess more information about their rights and options after victimization, and have more possibilities for whom to disclose. In our study, most adolescents disclosed the rape event to peers, in line with prior research (Crisma et al., 2004; Priebe & Svedin, 2008). The use of penetration was found to make victims more likely to postpone disclosure, opposite to the results from Priebe and Svedin (2008), but in line with an older study by Arata (1998), who found that more severe forms of sexual abuse were associated with less disclosure. Penetration may influence disclosure latency through a variety of mechanisms. It could be argued that more severe rape, indicated by the use of penetration, is more likely to be accompanied by extensive coercive use of tactics to maintain the victim's silence, with fear of re- prisal possibly contributing to the finding of delayed dis- closure (Kogan, 2004). Also, adolescents may think that social reactions in response to disclosure are more nega- tive in case of completed rape compared to assault.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

Another factor that seems to make immediate dis- closure of rape less likely is closeness to the assailant, as indicated by the assailant being a (boy)friend, family

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Table 3. Demographic and (post )rape characteristics by disclosure time (early vs. delayed disclosers) and odds ratios for delayed disclosure

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

<table><tr><th rowspan="2">Demographic and (post-)rape characteristics</th><th colspan="2">Early disclosure
(N=185)</th><th colspan="2">Delayed disclosure
(i.e., &gt;1-week post-rape), N=131</th><th></th><th rowspan="2">95% CI</th></tr><tr><td>N</td><td>%</td><td>N</td><td>%</td><td>OR</td></tr><tr><td colspan="7">Age category (years)</td></tr><tr><td>18 25</td><td>55</td><td>17.4</td><td>མཤྩ 22</td><td>7.0</td><td></td><td></td></tr><tr><td>12 17</td><td>3ཤྩ་སེཡྻ་མཤྩ 130</td><td>41.1</td><td>109</td><td>34.5</td><td>2.10</td><td>1.20 3.65*</td></tr><tr><td>Dutch origin</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>27</td><td>8.5</td><td>སྐུཤྩ 22</td><td>7.0</td><td></td><td></td></tr><tr><td>Yes</td><td>158</td><td>50.0</td><td>109</td><td>34.5</td><td>0.85</td><td>0.46 1.56</td></tr><tr><td>Living with parent(s)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>29</td><td>9.2</td><td>16</td><td>5.1</td><td></td><td></td></tr><tr><td>Yes</td><td>155</td><td>49.2</td><td>115</td><td>36.5</td><td>1.35</td><td>0.70 2.59</td></tr><tr><td>Complete family structure</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>58</td><td>18.4</td><td>42</td><td>13.3</td><td></td><td></td></tr><tr><td>Yes</td><td>127</td><td>40.3</td><td>289 88</td><td>27.9</td><td>0.96</td><td>0.59 1.55</td></tr><tr><td>Current sexual relationship</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>127</td><td>41.8</td><td>97</td><td>31.9</td><td></td><td></td></tr><tr><td>Yes</td><td>53</td><td>17.4</td><td>27</td><td>8.9</td><td>0.67</td><td>0.39 1.14</td></tr><tr><td>Prior negative sexual experience(s)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>152 6</td><td>49.4</td><td>110</td><td>35.7</td><td></td><td></td></tr><tr><td>Yes</td><td>82 32</td><td>10.4</td><td>110 14</td><td>4.5</td><td>0.61</td><td>0.31 1.19</td></tr><tr><td>Known assailant</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>56</td><td>17.7</td><td>36</td><td>11.4</td><td></td><td></td></tr><tr><td>Yes</td><td>129</td><td>40.8</td><td>95</td><td>30.1</td><td>1.15</td><td>0.70 1.88</td></tr><tr><td>Close to assailant</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>150</td><td>47.6</td><td>84</td><td>26.7</td><td></td><td></td></tr><tr><td>Yes</td><td>35</td><td>11.1</td><td>46</td><td>14.6</td><td>2.35</td><td>1.40 3.93"</td></tr><tr><td>Group rape</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>160</td><td>50.8</td><td>116</td><td>36.8</td><td></td><td></td></tr><tr><td>Yes</td><td>24</td><td>7.6</td><td>155</td><td>4.8</td><td>0.86</td><td>0.43 1.71</td></tr><tr><td>Age of assailant (years)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>12 17</td><td>63</td><td>20.6</td><td>54</td><td>17.6</td><td></td><td></td></tr><tr><td>&gt;18</td><td>117</td><td>38.2</td><td>72</td><td>23.5</td><td>0.72</td><td>0.45 1.14</td></tr><tr><td>Use of penetration</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>46</td><td>14.7</td><td>19</td><td>6.1</td><td></td><td></td></tr><tr><td>Yes</td><td>136</td><td>43.5</td><td>112</td><td>35.8</td><td>1.99</td><td>1.10 3.60°</td></tr><tr><td>Use of threats</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>90 22</td><td>31.6</td><td>48</td><td>16.8</td><td></td><td></td></tr><tr><td>Yes</td><td>76</td><td>26.7</td><td>71</td><td>24.9</td><td>1.75</td><td>1.09 2.82*</td></tr><tr><td>Use of physical violence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>130</td><td>42.6</td><td>82</td><td>26.9</td><td></td><td></td></tr><tr><td>Yes</td><td>51</td><td>16.7</td><td>42</td><td>13.8</td><td>1.31</td><td>0.80 2.14</td></tr><tr><td>Victim's alcohol use</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>72</td><td>33.5</td><td>69</td><td>32.1</td><td></td><td></td></tr><tr><td>Yes</td><td>61</td><td>28.4</td><td>13</td><td>6.0</td><td>0.22</td><td>0.11 0.44*</td></tr></table>

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

*p<0.05. Seven participants were dropped from analyses due to missing disclosure time data.

member, or mentor. This finding is consistent with pre- vious studies showing that the closer the relationship between the victim and assailant, the less likely the young

woman was to report this victimization to anyone (Koss, 1988; Rickert et al., 2005; Wolitzky-Taylor et al., 2011). The dynamics of intrafamilial abuse is often proposed as

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the explanation for delayed or non-disclosure (Kogan, 2004; Smith et al., 2000). In the present study, however, only 5% of the assailants were identified as a family member. Most close relationships referred to (boy)friends, suggesting that a significant percentage of the sample experienced peer-to-peer victimization. This type of vic- timization is most likely to occur during adolescence, as compared to childhood or young adulthood, and greatly increases the risk of revictimization (Humphrey & White, 2000). Hence, victims of rape by peers may be a target group for interventions promoting early disclosure.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

Clearly, there are many variables working in tandem to affect the timing of victim's disclosure. A closer look at the final model, which identified three unique variables that contributed significantly to the prediction of delayed dis- closure, can help us to better understand the phenomenon of initial disclosure in adolescents and young adults. Younger adolescent victims who are raped by a close per- son are more likely to delay disclosure than older victims of attempted rape by a stranger or acquaintance. Perhaps, they struggle with the notion that someone close to them performed such a violent act against them, which con- fuses them about what might happen in terms of safety if they would disclose (or not). This finding is especially important in the light of the fact that approximately 80% of victims had some sort of relationship with their per- petrator prior to the assault (Basile, Chen, Black, & Saltzman, 2007). With regard to rape types, it would intuitively seem that less severe forms of sexual assault are associated with delayed disclosure and that completed rape would be easier to identify as clearly inappropriate and wrong. Victims of completed rape, however, may be more likely to experience negative psychological reac- tions, e.g., self-blame and avoidance coping. It is con- ceivable that they delay their disclosure as a result of rape-induced psychological distress (Starzynski, Ullman, Filipas, & Townsend, 2005), not necessarily the severity of the assault.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

Although the final model showed acceptable goodness of fit, the percentage of explained variance of delayed disclosure was modest. Thus, there must be other variables predictive of delayed disclosure, such as the assailant's use of alcohol or weaker support systems, that we did not assess in this study. Besides this limitation, there are other drawbacks of this study that should be mentioned. First, a clinical sample was used with patients reporting high mean levels of psychological distress. This ceiling effect may explain why no differences were found between early and delayed disclosers on psychological function- ing, contrary to prior studies (Broman-Fulks et al., 2007; Ruggiero et al., 2004). Second, posttraumatic stress was only assessed for children up to 18 years, and for young adults additional suitable measures were not used. Third, information could have been lost due to dichotomizing the variable disclosure latency. Fourth, results may not be

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

generalizable to all rape victims, because the percentage of victims that consulted a medical professional and reported to the police was higher in our sample than in most studies (Hanson et al., 2003; Resnick et al., 2000; Zinzow, Resnick, Barr, Danielson, & Kilpatrick, 2012). Perhaps, these differences could, at least partially, be explained by the fact that stranger rape, representing 30% of our sample, leads to higher likelihood of help-seeking and police reporting because of its association with higher acknowledgment of victim status (Resnick et al., 2000; Smith et al., 2000). The fact that this is a help-seeking sample is critical for the reasons cited in the discussion, but also because the generalizability of these data to rape victims who never tell anyone-perhaps the group most at risk-simply cannot be known. Besides these limita- tions, several strengths of the current study need to be noted. One strength is the unique set of adolescents and young adults who presented at a mental health care centre after a single rape event, but who reported no prior chronic sexual abuse in childhood. For 85% of the sample, the index trauma was a first time rape. Moreover, data were collected at a designated referral centre for victims of rape and, therefore, the sample is likely to represent the clinical population of Dutch victims in the age group of 12-25 years. The findings of the current study, suggesting that delayed disclosers are less able to benefit from emergency medical care and evidence collection, have a number of practical implications. One of the strategies to enhance victims' willingness to disclose within the first week post- rape may be sexual education campaigns in school and media, as being uninformed is one of the reasons for them not to disclose (Crisma et al., 2004). Education may include medical information on rape-related pregnancy and STDs, as well as the need for timely emergency contraception and prophylaxis, given that these concerns appear to be facilitators of seeking medical help (Zinzow et al., 2012). Also, practical information about DNA evi- dence and how to best protect it, e.g., related to shower- ing, clothing, eating, and drinking, may increase the awareness of opportunities in the early-phase post-rape. Moreover, facts about the potential psychological impact of rape, such as PTSD and revictimization, but also in- formation about evidence-based treatments (Elwood et al., 2011; Littleton & Ullman, 2013; McLaughlin et al., 2013), may increase help-seeking behaviour in an early stage. Furthermore, efforts to encourage early disclosure must consider peer-to-peer victimization as a primary factor, as most participants in this study experienced this type of victimization, and may initially not have defined or acknowledged the incident as rape because they rationalize such experiences as normal (Hlavka, 2014), leading to the finding of delayed disclosure.

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

In conclusion, the results of the present study suggest that adolescent victims of rape with penetration by

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# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Discussion (cont.)

someone close are at increased risk for delayed disclosure, and that delayed disclosers are less likely to use medical services and to report to the police. These findings may assist clinicians and policymakers in understanding rape and help to develop interventions (Unterhitzenberger & Rosner, 2014), specifically targeted to support adoles- cents and young adults to disclose in an early-phase post- rape. Although the vast majority of the participants was living at their parental home, many of the sample did not first disclose to their parents. Therefore, it could be argued that in prevention programs specific attention should be given to the strengthening of the child-parent relationship, to facilitate disclosure to parents (Schönbucher et al., 2012). Next, as victims tend to disclose mostly to peers, prevention programmes may need to aim at teach- ing adolescents how they can help a peer victim if they become a recipient of disclosure (Schönbucher et al., 2012). In addition, education may increase victims' willingness to disclose early, thereby increasing opportu- nities for access to health and police services. It is more likely to reach adolescents with direct, active, and online outreach programs via communication channels that are frequently used by adolescents and young adults parti- cularly social media (i.e., Facebook, Twitter, YouTube, etc.), forums, and mobile apps. Such programmes, where- in adolescents and young adults are being treated as agents and decision makers (Hlavka, 2014), should focus on information concerning what rape actually is not only the stereotypical idea of rape and what (not) to do in the aftermath of rape especially in the first week post- rape. Another way to help improve the support of victims of rape is the implementation of multidisciplinary sexual assault centres (Bicanic, Snetselaar, De Jongh, & Van de Putte, 2014; Bramsen, Elklit, & Nielsen, 2009), as these may be the most suitable places to organize education campaigns and offer integrated post-rape services in one location. Future research should investigate whether the availability of such centres increases the prevalence of police reporting and use of medical care. Moreover, as discussed, previous research concerning the topic of disclosure has focused on the disclosure process, mainly the effect of negative social reactions, and not the latency. In future research, social reactions in relation to disclosure (latency) should be assessed by using the Social Reactions Ques- tionnaire, as well as the victim's perception of their own experience being defined as rape, as many girls and young women do not report or seek help because they regard sexual violence against them as normal (Hlavka, 2014).

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## Conflict of interest and funding

There is no conflict of interest in the present study for any of the authors.

## References

# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## References (cont.)

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# Predictors of delayed disclosure of rape in female adolescents and young adults (cont.)

## References (cont.)

Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883

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