EFTA00024175

Exhibit B EFTA00024175 Ctc•ckl.e 4.pdzAco Review Manuscript Facilitators and Barriers to Child Sexual Abuse (CSA) Disclosures: A Research Update (2000-20 I 6) Ramona Alaggia l, Delphine Collin-Vezina 2, and Rusan LateeflTRAUMA. VIOLENCE & ABUSE 2019, Vol. 20(2) 260-283 C The Author(s) 2017 Artock roust guidelines: sacepub comlioumalvptimoskin DOI, 10117711124838017697312 nals sagepuboornlhomakva OSAGE Abstract Identifying and understanding factors that promote or inhibit child sexual abuse (CSA) disclosures has the potential to facilitate earlier disclosures, assist survivors to receive services without delay, and prevent further sexual victimization. Timely access to therapeutic services can mitigate risk to the mental health of survivors of all ages. This review of the research focuses on CSA disdosures with children, youth, and adults across the life course. Using Kiteley and Stogdon's literature review framework. 33 studies since 2000 were identified and analyzed to extrapolate the most convincing findings to be considered for practice and future research. The centering question asked: What is the state of CSA disclosure research and what can be learned to apply to practice and future research? Using Braun and Clarke's guidelines for thematic analysis. five themes emerged: (I) Disclosure is an iterative, interactive process rather than a discrete event best done within a relational context; (2) contemporary disclosure models reflect a social—ecological, person-in-environment orientation for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CA disclosure; (3) age and gender significantly influence disclosure; (4) there is a lack of a life-course perspective; and (5) barriers to disclosure continue to outweigh facilitators. Although solid strides have been made in understanding CSA disclosures, the current state of knowledge does not fully capture a cohesive picture of dis. dosure processes and pathways over the life course. More research is needed on environmental. contextual, and cultural factors. Barriers continue to be identified more frequently than facilitators, although dialogical forums are emerging as important facil- itators of CSA disclosure. Implications for practice in facilitating CSA disclosures are discussed with recommendations for future research. Keywords sexual abuse, child abuse, cultural contexts Introduction Timely access to supportive and therapeutic resources for child sexual abuse (CSA) survivors can mitigate risk to the health and mental health well-being of children, youth, and adults. Identifying and understanding factors that promote or inhibit CSA disclosures have the potential to facilitate earlier disclo- sures, assist survivors to receive services without delay, and potentially prevent further sexual victimization. Increased knowledge on both the factors and the processes involved in CSA disclosures is timely when research continues to show high rates of delayed disclosures (Collin-VEzina, Sablonni, Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). Incidence studies in the United States and Canada report decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Turner, & Hamby, 2014; Trocme et al., 2005, 2008), while at the same time global trends from systematic reviews and meta- analyses have found concerning rates of CSA, with averages of 18-20% for females and of 8-10% for males (Pereda, Guilera, Fours, & Gomez-Benito, 2009). The highest rates found for girls is in Australia (21.5%) and for boys in Africa (19.3%), with the lowest rates for both girls (11.3%) and boys (4.1%) reported in Asia (Stoltenborgh, van Uzendoorn, Euser, & Bakermans-Kranenburg, 20 I 1). These findings point to the incongruence between the low number of official reports of I Factor-Inwentash Faculty of Social Work. University of Toronto. Toronto. Ontario. Canada 2 Centre for Research on Children and Families. School of Social Work, McGill University. Montreal. Qubec. Canada Corresponding Author: Ramona Alaggia. Factor-Inwentash Chair in Children's Mental Health. Factor- Inwentash Faculty of Social Work. University of Toronto. 246 Moor St West. Toronto, Ontatio, Canada M4K I W I. ramonaalaggiaeutorortoca EFTA00024176 Alaggia et at 261 CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stolten- borgh, van LIzendoom, Euser, and Bakermans-Kranenburg (2011) combining estimations of CSA in 217 studies published between 1980 and 2008 revealed rates of CSA to be more than 30 times greater in studies relying on self-reports (127 in 1,000) than in official report inquiries, such as those based on data from child protection services and the police (4 in 1,000) (Ju- lian, Cotter, & Perreault, 2014; Statistics Canada 2013). In other words, while 1 out of 8 people retrospectively report having experienced CSA, official incidence estimates indicate only 1 per 250 children. In a survey of Swiss child services, Maier, Mohler-Kuo, Landholt, Schnyder, and Jud (2013) fur- ther found 2.68 cases per 1,000 of CSA disclosures, while in a recent comprehensive review McElvaney (2015) details the high prevalence of delayed, partial, and nondisclosures in childhood indicating a persistent trend toward withholding CSA disclosure. It is our view that incidence statistics are likely an under- estimation of CSA disclosures, and this drives the rationale for the current review. Given the persistence of delayed disclosures with research showing a large number of survivors only dis- closing in adulthood (Collin-Vezina et al., 2015; Easton, 2013; Hunter, 2011; McElvaney, 2015; Smith et al., 2000), these issues should be a concern for practitioners, policy makers, and the general public (McElvaney, 2015). The longer disclosures are delayed, the longer individuals potentially live with serious negative effects and mental health problems such as depres- sion, anxiety, trauma disorders, and addictions, without receiv- ing necessary treatment. This also increases the likelihood of more victims falling prey to undetected offenders. Learning more about CSA disclosure factors and processes to help advance our knowledge base may help professionals to facil- itate earlier disclosures. Previous literature reviews examining factors influencing CSA disclosure have served the field well but are no longer current. Important contributions on CSA disclosures include Paine and Hansen's (2002) original review covering the liter- ature largely from the premillennium era, followed by London, Bruck, Ceci, and Shuman's (2005) subsequent review, which may not have captured publications affected by "lag to print" delays so common in peer-reviewed journals. These reviews are now dated and therefore do not take into account the plethora of research that has been accumulated over the past 15 years. Other recent reviews exist but with distinct contribu- tions on the dialogical relational processes of disclosure (Reit- sema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McEl- vaney, 20I5). This literature review differs by focusing on CSA disclosures in children, youth, and adults from childhood and into adulthood —over the life course. Method Kiteley and Stogdon's (2014) systematic review framework was utilized to establish what has been investigated in CSA disclosure research, through various mixed methods, to high- light the most convincing findings that should be considered for future research, practice, and program planning. This review centered on the question: What is the state of CSA disclosure research and what can be learned to apply to future research and practice? By way of clarification, the term systematic refers to a methodologically sound strategy for searching liter- ature on studies for knowledge construction, in this case the CSA disclosure literature, rather than intervention studies. The years spanned for searching the literature were 2000-2016, building on previous reviews without a great deal of overlap. Retrieval of relevant research was done by searching interna- tional electronic databases: PsycINFO, PsycARTICLES, Edu- cational Resources Information Center, Canadian Research Index, International Bibliography of the Social Sciences, Pub- lished International Literature on Traumatic Stress, Sociologi- cal Abstracts, Social Service Abstracts, and Applied Social Science Index and Abstracts. This review searched peer- reviewed studies. A search of the gray literature (unpublished literature such as internal agency documents, government reports, etc.) was beyond the scope of this review because unpublished studies are not subjected to a peer-review process. Keyword search terms used were child sexual abuse, childhood sexual abuse, disclosure, and telling. A search of the 9 databases produced 322 peer-reviewed articles. Selected search terms yielded 200 English publica- tions, I French study, and 1 Portuguese review. The search was further refined by excluding studies focusing on forensic inves- tigations, as these studies constitute a specialized legal focus on interview approaches and techniques. As well, papers that focused exclusively on rates and responses to CSA disclosure were excluded, as these are substantial areas unto themselves, exceeding the aims of the review question. Review articles were also excluded. Once the exclusion criteria were applied, the search results yielded 33 articles. These studies were sub- jected to a thematic analysis as described by Braun and Clarke (2006). This entailed (I) multiple readings by the three authors; (2) identifying patterns across studies by coding and charting specific features; (3) examining disclosure definitions used, sample characteristics, and measures utilized; and (4) major findings were extrapolated. Reading of the articles was initially conducted by the authors to identify general trends in a first level of analyses and then subsequently to identify themes through a deeper second-level analyses. A table of studies was generated and was continuously revised as the selection of studies was refined (see Table 1). Key Findings First-level analysis of the studies identified key study charac- teristics. Trends emerged around definitions of CSA disclosure, study designs, and sampling issues. First, in regard to defini- tions, the term "telling" is most frequently used in place of the term disclosure. In the absence of standardized questionnaires or disclosure instruments, telling emerges as a practical term more readily understood by study participants. Several EFTA00024177 rig Table I. Ch d Sexua Abuse (CSA) D sc osure Stud es: 2000-2016. Study Purpose Des gn Samp e F nd ngs Summary Gagner and Co n- Vez na (2016) Braze ton (2015) Co n-Vez na, Sab onn . Pa mer, and M ne (20 I 5) Lec erc and Wort ey (20 I 5) To exp ore d sc osure processes for ma e v ct ms of CA To exp ore the mean rig Afr can Amer can women make of the r traumat c exper ences w th CSA and how they d sc osed across the fe course To prov de a mapp ng of factors that prevent CSA d sc osures through an eco og ca ens from a samp e of CSA adu t sury von. Study object yes nvest gated the factors that fac tate CSA d sc osures Phenomeno og ca methodo ogy used to ntery ew ma e CSA sury vors. The Long Intery ew Method (LIM) gu ded data co ea on and ana yses. Co ect ve case study des gn w th us ng narrat ve wad t on (storyboard) for data co ea on and am ys s. Qua tat ve ntery ew ng Qua at ve des gn us ng LIM. Adu t ma e ch d sexua offenders were ntery ewed to exam ne pred ctors of 17 men ranged n age from 19 to 67— average age 47. Purpos ve samp rig strategy was used 17 Afr can Amer can women n m d- fe between 40 and 63 who exper enced ntrafam a CSA_ Purpos ye. snowba ng strategy 67 ma e and fema e CSA adu t sury vors (76% dent f ed as fema e and 24% as ma e). Age ranges from 19 to 69 years (M = 44.9). Purpos ve samp ng strategy 369 adu t ma es who had been cony cted of a sexua offense aga nst a ch d aged between I The major ty of the men n the study wa ted unt adu thood to d sc ose the r abuse. w th negat ve stereotypes contr but ng to the r de ayed d sc osures. Negat ve stereotypes contr buted to de ayed d sc osure w th try ng to forget. Break ng so at on was c ted as a mot vator to d sc osure a ong w th the a d of var ous forms of med a on d sc osure. Important contextua ssues such as negat ve stereotyp ng of ma es. sexua ty. and v ct ms were noted. Soc a med a was seen as a fac tator of d sc osures CSA onset was arge y between the ages 5 and 9. No one ever ta ked to them about sex, so they d dn't have anguage to d sc ose. Barr en: fear of fam y breakdown and remova , not want ng to tarn sh the fam y's name, and fear of retr but on by tam y members f they d sc osed. Pattern of st fed and d sm ssed d sc osures dent f ed over the fe course. A 17 part c pants dent f ed sp r tua ty as a pr mary source of strength throughout the fe course Three broad categor es were dent fed as barr en to CSA d sc osure: Barr ers from w th n- nterna zed v a m b am ng, mechan sms to protect onese f. and mmature deve opment at t me of abuse: barr en n re at on to others—v o ence and dysfuna on n the fam y, power dynam a. awareness of the mpact of to ng, and frag e soc a network; barr en n re at on to the soc a wor d abe ng, taboo of sexua ty, ack of sery ces ava ab e. and cu ture or t me per od. D sc osure ncreased w th the age of the v ct m: f penetrat on had occurred, f the v ct m was re aced to the offender, f the v ct m was not v ng w th die offender at A part c pants had d sc osed and rece ved sery ces before part c pat ng n the study. Member check ng cou d not be done w th the part c pants to check themes. Sma but surf c ent s ze for a qua tat ve nqu ry. Otherw se, h gh eve of r gor n estab sh ng trustworth ness of the data and ana ys s. Retrospect ve study cou d mp y reca ssues One of few stud es to focus exc us ye y on Afr can Amer can women. Sma but stiff cent s ze for a qua tat ve nqu ry. Important cu tura and contextua ssues were brought forward. Retrospect ye study that may have been affected by reca ssues. Use of a fe-course perspect ye as a theoret ca ens for understand ng CSA n the m dd e to ater years of fe that shou d be cons dered n further nvest gat ons Ha f of the part c pants had not d sc osed the r CSA exper ences before the age of 19. Retrospect ye aspect of the study cou d mp y reca ssues. A pan c pants had d sc osed and rece ved counse ng at some before part c pat ng n the study. H gh eve of rgor n estab sh ng trustworth ness of the data and ana ys s Offender generated data through se (-reports cou d be subject to cogn t ve d stort ons— m n m sat on or exaggerat ons. (continued) EFTA00024178 Table I. (cont nued) Study Purpose Des gn Samp e F nd rags Summary McE vaney and Cu hane (2015) Dumont, Messerschm tt V a, Bohu. and Rey-Sa mon (2014) Easton. Sa tzman. and W 5 (2014) To nvest gate the teas b ty of us ng ch d assessments as data sources of nforma CSA d sc osure. To assess f these reports prov de substant ye data on d sc osures Th s study a med to exp ore how the re at onsh p between the perpetrator and the v ct m, espec a y whether these re at ons are ntrafam a or extrafam a, mpact CSA d sc osure Study focus was on dent f cat on of barr en to CSA d sc osure w th ma e sury von v ct m d sc osure. Sem structured ntery ews based on the QID quest onna re. F e reports of ch dren seen for assessment n a ch d sexua abuse un t n a ch dren's hosp ta were rev ewed F e reports of ch dren seen for assessment n a ch d sexua abuse un t n a ch dren's hasp ta were rev ewed Us ng qua tat ve content ana ys s, researchers conducted a secondary ana ys s of on ne survey data. the 2010 Heath and We -Be ng Survey. that nc uded men w th se (-reported CSA h stor es w th an open-ended tem on d sc osure barr ers and I7 years o d. Major ty were Wh te. uneducated, a most ha f unemp oyed before the r arrest Content ana ys s was comp eted on 39 f es (32 fema es and 7 ma es) based on a cod ng framework. Parents were asked to consent to have the r ch d's f e rev ewed for the study. V a ms assessed were 12-18 years of age 220 m nor v a rns- 78.2% fema e v a ms. 41.8% aged between 14 and 18 (most preva ent age range). and 48.2% were abused by a fam y member 460 men w th CSA h stor es comp eted an anonymous, Internet- based survey. Recta ted from sury yore organ zat ons. Age range of 18-84 years. Two th rds of respondents reported c ergy-re ated abuse. Major ty of respondents were Wh te the t me of the abuse, or f the v a m res sted dur ng the offense. Ma e v a ms and v a ms from dysfuna ona backgrounds were ess ke y to d sc ose Major ty of ch dren to d the r mothers (43%) and peers (33%) f rst_ Three major themes were dent fed as nf uenc ng the d sc osure process: (I) fee ng d stressed. (2) opportun ty to te . and (3) fears for se f. Add t ona themes of be ng be eyed. shame/se f-b ame. and peer nf uence were a so dent fed D sc osure processes were more cone ex when t concerned sexua abuse comm tted by ntrafam a perpetrator 60% of the v a ms revea the facts seven years after, and most often to nd v dua s outs de the fam y (78.6% of the d sc osures done at schoo): on the contrary. extrafam a d sc osures take p ace more spontaneous y and qu ck y: 80% of the v a ms revea the facts a few days after, most often to the r mother or peers Vast major ty of part c pants (94.6%) were sexua y abused by another ma e. Durst on of sexua abuse broke down nto: 30.2% ess than 6 months. 32.3% 6 months to 3 years. and 34.3% more than 3 years. Ten years o d was average age of CSA onset Ten categor es of barr en were c ass fed nto three doma ns: (I) soc opo t ca: mascu n ty. m ted resources; (2) nterpersona : m strust of others, fear of be ng abe ed "gay," safety and protect on ssues, past responses: and (3) persona: ntema emot ons. see ng the exper ence as sexua abuse. and sexua or enat on. Penpect ves of offenders on vu nerab ty of v ct ms n re at on to d sc osure cou d be mportant nformat on to nform ntervent ons The samp e s ze s sma but w toner bute to a arge mu t s te study n Ire and. Serves as an mportant exp oratory p of br ng ng forward d sc osure themes for cons dent on The re at onsh p w th the perpetrator has a s gn f cant mpact on both t m ng and rec p ent of d sc osure. w th ntrafam a abuses ess ke y to be d sc osed prompt y and w th n the tam y system At t me of the study. th s was the argest qua tat ve data set to have been ana yzed w th an exp c t focus on adu t ma e sury vors' percept ons of barr en to CSA d sc osure. Because the samp e was m ted n terms of the ow percentage of rac a m nor t es (9.3%). d sc osure d fferences based on race or ethn c ty were not d scerned. The major ty of abuse reported was by c ergy wh ch m ght present a un que set of barr ers to d sc osure (continued) EFTA00024179 Pt' Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Easton (2013) McE vaney. Greene. and Hogan (2012) Schonbucher, Ma er, Moh er-Kuo, Schnyder, and Lando t (20 I 2) Study purpose was to descr be ma e CSA d sc osure processes us ng a fe span approach exam n ng d fferences based on age. A so. to exp ore re at onsh ps between d sc osure attr butes and men's menta hea th Qua tat ve study asked the centre research quest on: "How do ch dren te ?" Object ve was to deve op theory of how ch dren te of the r CSA d sc osure exper ences. Parents were ntery ewed. To nvest gate the process of CSA d sc osure w th ado escents from the genera popu at on who had exper enced CSA. How many d sc osed, who d d Cross-sect ona survey des grt.E gbe part c pants were screened and comp eted an anonymous, Internet- based survey dur ng 2010. Measures used: Genera Menta Heath D stress Sca e and Genera Assessment of Ind v dua Needs. Quest ons re ated to CSA d sc osure and supports were nc uded Grounded theory method study. Intery ews were conducted. L ne-by- ne open and ax a cod ng was conducted on verbat m transcr pts Data co ect on was through face-to-face qua tat ve ntery ews. Standard zed quest ons and measures were adm n stered on fam y s tuat on. soc odemograph c Purpos ve samp ng of 487 men from three nat ona organ zat ons devoted to ra s ng awareness of CSA among men. Age range: 19-84 years. Mean age for onset of CSA was 10.3 years Samp e of 22 young peop 16 g r s and 6 boys: age range: 8-18 years: 22 ntery ewed n ton between the ages of 8 and 18. M xed samp e of some endur ng ntrafam a CSA, some extrafam a CSA, and two endured both forms Conven ence samp e of 26 sexua y v ct m zed ado escents. 23 g r s and 3 boys. Age range: I5—I8 years. On ne advert cements and f yen were used to recru t youth from O der age and be ng abused by a fam y member were both re ated to de ays n d sc osure. Most part c pants who to d someone dur ng ch dhood d d not rece ve emot ona y support ve or protect ve responses and the he pfu ness of responses across the fe span was m xed. De ays n te ng were s gn f cant per ods oft me (over 20 years). Approx mate y one ha f of the part c pants f rst to d about the sexua abuse to a spouse/partner (27%) or a menta hea th profess ona (20%): 42% of part c pants reported that the r most he pfu d scuss on was w th a menta hea th profess ona. However. unhe pfu responses caused most menta d stress. C n ca recommendat ons nc uded more of a fe-course perspect ve be adopted. understand ng mpact of unhe pfu responses and the mportance of expand ng networks for ma e sury von A theoret ca mode was deve oped that conceptua zes the process of CSA d sc osure as one of conta n ng the secret (I) the act ve w thho d ng of the secret on the part of the ch d; (2) the exper ence of a "pressure cooker effect" ref ect ng a conf ct between the w sh to te and the w sh to keep the secret; and (3) the conf d ng tse f wh ch often occurs n the context of a trusted re at onsh p. These were der ved from e even categor es that were deve oped through open and ax a cod ng Less than one th rd of part c pants mmed ate y d sc osed CSA to another person. In most cases, rec p ents of both mmed ate and de ayed d sc osure were to peers. More than one th rd of part c pants had never d sc osed the abuse to a parent. Part c pants reported re uctance to d sc ose to parents so as Purpos ye samp ng of men from awareness ra s ng organ zat ons may have attracted part cu ar part c pants who had a ready d sc osed and rece ved he p. Part c pants needed to have access to Internet wh ch wou d have e m nated men n ower SES groups and requ red prof c ency n Eng sh wh ch wou d e m nate certa n cu tura groups. However. the samp ng strategy ga ned access to a predom nant y h dden popu at on. Important c n ca recommendat ons are made w th an emphas son a fe-course focus Modest but suff c ent samp e for an exp oratory qua tat ve nqu ry. H gh eve of trustworth ness r gor. A subsamp e of random y se ected transcr pts was ndependent y coded. Very young ch dren and young adu is were not captured n th s samp e. Transferab ty of f nd ngs can on y be made to the age range samp ed n the context of Ire and Two th rds of the samp e d d not d sc ose r ght away. Strengthen ng parent—ch d re at onsh ps may be one of the most mportant ways to ncrease d sc osure to parents. D sc osure to peers has been found a common trend n other (continued) EFTA00024180 Table I. (cant nued) Study Purpose Des gn Samp e F nd ngs Summary Hunter (20 I I ) Schaeffer, Leventha , and Asnes (2011) they d sc ose to, and what were the r mot yes for d Sc os ng A m of th s study was to deve op a fu er understand ng of CSA d sc osures Th s study a med to: (I) add d rect nqu ry about the process of a ch d's CSA d sc osure; (2) determ ne f ch dren w d scuff process that ed them to te : and (3) descr be factors that ch dren dent fy that ed them to te about or caused them to de ay CSA d sc osure data, sexua v ct m sat on. genera . and menta hea th. Sexua Assau t Modu e of the Juven e V ct m sat on Quest onna re was used Narrat ve nqu ry methodo ogy. Face-to- face n-depth ntery ews were conducted w th part c pants. Data were ana yzed us ng Rosentha and F scher— Rosentha 's (2004) method. Study sought to f nd out f process flues of d sc osure cou d be dent f ed n the context of forens c ntery ews. Forens c ntery ewers were asked to ncorporate quest ons about "te ng" nto an ex st ng forens c ntery ew protoco Intery ew content re ated to the ch dren's reasons for te ng or wa t ng was extracted, transcr bed, and ana yzed us ng grounded theory method of ana ys s commun ty and counse ng sery ces Purpos ye samp ng was emp oyed. Samp e cons sted of 22 part c pants aged 25- 70 years: 13 women and 9 men. Part c pants were sexua y abused at IS years or under w th someone over the age of It 191 ntery ews of CSA v ct ms aged 3-18 over a -year per od were used for the study. Inc us on cr ter a nc uded ch dren who made a statement about CSA pr or to refers. reasons for te ng or wa t ng to te , and those who spoke Eng sit. Part c pants were ch dren who were ntery ewed at a ch d sexua abuse c n c. 74% were ferna e and 51% were Caucas an not to burden them. Ear er d sc osures were re ated to extrafam a CSA, s ng e occurrence CSA, age of v ct m at abuse onset, and parents who were v ng together. H gher eves of reported gu t and shame were re ated to de ayed d sc osures. Peers were v ewed by th s samp e as more re ab e con( darts On y 5 out of 22 part c pants to d anyone about the r ear y sexua exper ences as ch dren. Fear, shame, and se f-b ame were the man nh b ton to d sc osure. These factors are further dem ed through subthemes. Te ng as a ch d and as an adu t was further expanded upon us ng A agg a's (2004) framework ver fy ng behav on nd rect attempts to te and purposefu d sc osure as categor es. Themat c ana ys s supported that CSA d sc osure shou d be conceptua zed and v ewed as a comp ex and fe ong process Reasons the ch dren dent fed for te ng were c ass fed nto three doma ns: (1) d sc osure as a resu t of nterna st mu (e.g. the ch d had n ghtmares): (2) d sc osure fac tated by outs de of uences (e.g. the ch d was quest oned): and (3) d sc osure due to d rect ev dente of abuse (e.g., the ch d's abuse was w tnessed). The barr ers to d sc osure dent f ed fe nto f ve groups: (I) threats made by the perpetrator (e.g.. the ch d was to d she or he wou d get n troub e f she or he to 4 (2) fears (e.g.. the ch d was afra d someth ng bad wou d happen f she or he to d), (3) ack of opportun ty (e.g., the ch d fe t the opportun ty to d sc ose never presented), (4) ack of understand ng (e.g.. the ch d fa ed to recogn ze abus ye behav or as unacceptab e), and (5) re at onsh p w th the perpetrator (e.g. the ch d thought the perpetrator was a fr end) research and bears more exam nat on De ayed d sc osure was common n th s qua tat ve samp e. Most part c pants d d not make a se ect ve d sc osure unt adu thood. These f nd ngs support A agg a's (2004) mode of d sc osure but a so h gh ghts the mportance of fe stage. Modest but suff c ent samp e s ze for a qua tat ve nqu ry. We -des gned study w th dem ed ana ys s for transferab ty off nd ngs An nnovat ve study to try to assess f forma nvest gat ye ntery ews can fac tate d sc osures of CA. Data were based on a arge number of ntery ews. Dem ed ana ys s produced dem ed f nd ngs support ng other study f nd ngs on CSA d sc osure (continued) EFTA00024181 I-, Table I. (coin nued) cr. P Study Purpose Des gn Samp e F nd ngs Summary A agg a (2010) Fontes and P ummer (2010) Ungar, Barter. McConne . Tutty, and Fa rho m. (2009a) The study a med to dent fy factors mped ng or promot ng CSA d sc osures. Overarch ng research quest on: What nd v dua, nterpersona . env ronmenta . and contextua nf uences mpede or promote CSA d sc osures. Th s exam nat on of CSA d sc osure exp ored the ways cu ture affects processes of CSA d sc osure and report ng. both n the Un ted States and nternat ona y Th s study exp ored d sc osure strateg es w th a nat ona sampe of youth focus ng on A qua tat ve phenomeno og ca des gn, LIM, was used to ntery ew adu t CSA sury von about the r d sc osure exper ences to prov de retrospect ve accounts of CSA d sc osure and mean ng-mak ng of these exper ences. Themat c ana ys s was done through a soc a — eco og ca ens. Us ng pub shed terature wthc nca data, th s art c e conducted an ana ys s to prov de a cu tura y competent framework for CSA d sc osure quest on ng Forms were comp eted by youth fo ow ng pan c pat on n abuse prevent on Purpos ye samp ng was emp oyed. Snowba samp ng was a so used to recru t more ma e sury von. 40 adu t sury von of CA were ntery ewed: 36% men and 64% women. Age range of 18-65 w th a mean age of 40.1 years. Average age of abuse onset was 5.3 years o d. 36% of the samp e was non-Wh te. D verse soc oeconom c backgrounds Data cons sted of pub shed terature on d sc osure and cu ture that was tr angu ated wthc n ca case mater a Exam nat on of resu is from a nat ona sampe of 1,621 eva uat on forms where youth Themes fe nto four doma ns: (I) nd v dua and deve opmenta factors, deve opmenta factors as to whether they comprehended what was happen ng, persona ty tra is a so had some bear ng on the r ab ty to te . and ant c pat ng not be ng be eyed; (2) d sc osure nh b ted by fam y character st cs such as rgdy fxed gender ro es w th dom nat ng fathers, chaos and aggress on. other forms of ch d abuse, domest c v o ence. dysfunct ona commun cat on. and soc a so at on; (3) ne ghborhood and commun ty context. that s. ack of nterest from ne ghbors and teachers not pursu ng troub ng behav or; and (4) cu tura and soc eta an tudes, med a messages and soc eta an tudes. fee ng unheard as k ds, gender soc a zat on for ma es. and cu tura an tudes of uenc ng parent's react ons. Purposefu d sc osure s h gher than reported n other stud es because of the samp ng attempts to purposefu y ocate d sc osers Cu tura and structura factors affect ng CSA d sc osure are dent f ed n n-depth deta Recommendat ons made nc ude ( I) d sc osure ntery ew ng shou d be ta ored to the ch d's cu tura context. (2) quest on ng shou d a so take nto cons dent on age and gender factors. and (3) cu ture stands as an mportant factor n a cases n wh ch ch dren are cons der ng d sc os ng or be ng asked to d sc ose. and not so e y n cases nwh ch ch dren are from not ceab e m nor ty groups. Presents a comprehens ye ntery ew framework ntegrat ng cu tura cons dent ons Youth who have been abused or w tnesses to abuse emp oy f ve d sc osure strateg es: us ng se f-harm ng behav on to s gna the abuse to others; not ta k ng The study presents a comprehens ve soc a —eco og ca ana ys s to CSA d sc osure h gh ght ng the mu t faceted of uences. Of note, 42% had d sc osed the abuse dur ng ch dhood: 26% had not d sc osed because they had repressed the memory, or the abuse had occurred n preschoo years and they had d dal ty w th reca . The rema nder had attempted some form of d sc osure n nd rett ways dur ng ch dhood. A retrospect ye approach that cou d be affected by reca ssues One of the few works that adds know edge to cu tun y contextua d sc osure ntery ew ng. Un que comb nat on of teraturefnd ngswthcn ca mater a . Anecdota accounts may prec ude transferab ty of f nd ngs. Oven adds to an mpover shed area of CSA d sc osure nformat on Th s study h gh ghts that d sc osure s an nteract ye ongo ng process. F nd ngs end support to stud es that have dent f ed s mar y (continued) EFTA00024182 Table I. (cont nucd) Study Purpose Des gn Samp e F nd ngs Summary (I) What are the h dden exper ences of abuse among Canad an youth? (2) What mpact does part c pat on n abuse prevent on programs have on youth to express the r abuse exper ences? (3) What d sc osure barr en do youth face? (4) What are young peop es d sc osure patterns? and (5) Who do they to ? Ungar, Tutty. McConne . Th s study exp ored Barter, and Fa rho m abuse d sc osure (20096) strateg es w th a nat ona samp e of Canad an youth who part c paced nvoence prevent on programm ng. One of the goa s of the study was to document not prey ous y dent f ed exper ences of abuse and youth att tudes toward d sc osure of abuse exper ences program ng by the Canad an Red Cross (RespectED). A ser es of focus groups and observat ons of the workshops were used to he p contextua ze the f nd ngs. Eva uat on forms were ana yzed from two v o ence prevent on programs: ( I) It's not your fau t and (2) What's ove got to do w th It? Exp oratory des gn w th a nonrepresentat ve samp es. Qua tat ye ana ys s of 1,099 eva uat on forms comp Ned fo ow ng Red Cross RespectED v o ence prevent on programm ng de vered between 2000 and 2003. Forms of anonymous abuse d sc osures by youth pan c pants of neg emot ona phys ca . and sexua abuse. Twenty-seven ntery ews and focus groups were a so done to understand contextua ssues and engage youth and program fac tators n the nterpretat on of f nd ngs. A cod ng structure was deve oped for ana ys s to synthes ze themes across data sources anonymous y d sc osed abuse exper ences. Respondent's ages: 13 and under (27%). 14- IS (37%), 16-17 (25%). 18 and o der (4%), and unknown (7%) Purposefu samp e of 1,099 eva uat on forms comp eted fo ow ng Red Cross RespectED v o ence prevent on programm rig de vered between 2000 and 2003 at a about the abuse to prevent ntrus ve ntervent ons by others; seek ng he p from peers; seek ng he p from nforma adu t supports: and seek ng he p from mandated sery ce prov den (soc a workers and po ce). Resu is suggest d sc osure s an nteract ye process, w th expectat ons regard ng consequences to d sc osure. Patterns of ncrementa y char ng abuse exper ences are shaped by young peop e's nteract ons w di peers, educators, and careg vers. About three- quarters of fema es prey ous y d sc osed: s gn f cant y ess ma es d sc osed F nd ngs suggest h gh rates of h dden abuse, w th ess than one quarter of youth report ng a d sc osure. 244 of the 1,099 youth who d sc osed abuse on the r eva uat on forms dent fed spec f c nd v dua s they to d about the r abuse. D sc osure patterns vary w th boys, youth aged I4-15, v ct ms of phys ca abuse, and those abused by a fan y member be ng most ke y to d sc ose to profess ona s or the po ce. One th rd of d sc osures were d rected toward profess ona s and the east. 5% percent each, were d rected toward fr ends, parents. and others. Part c pants were most ke y to d sc ose sexua abuse to parentsffam y. profess ona s. and the po ce/courts. w th fewer choos ng fr ends. Out of a 1.099 part c pants, 225 ma es and 779 fema es nd cated that they had been abused. Out of those. 43 ma es and 180 fema es nd cated that they had d sc osed the abuse. Of those who had d sc osed, on y a port on of ma es and fema es spec fed who they had d sc osed the abuse to c'VVh e 1.099 eva uat ons w th d sc osure statements were ana yzed. on y 22% made ment on of peop e to nteract ye modes of d sc osure such as those deta ed by A agg a (2004) and Sta er and Ne son- Garde (2005). Th s m xed samp e of youth who exper enced d fferent forms of abuse and v o ence exposure were part c pants—not in ted to CSA SW,/ vors Innovat ve des gn of th s study prov des ns ght nto young peop es percept ons of d sc osure exper ences. H gh eve of r gor w th trustworth ness of the data ana ys s ensured through use of youth focus groups. ntery ews. and observat ona data. The study resu is are somewhat m ted n the th ckness of the descr pt ons t can offer because most of the data are survey based. Reg ona d fferences may not have been p cked up. Scope of the study s broad and approach s treat ve (continued) EFTA00024183 Table I. (cont nued) ao Study Purpose Des gn Samp e Fnd ngs Summary Pr cbc and Svcd n (2008) Th s study a med to nvest gate d sc osure rates and d sc osure patterns and exam ne pred ctors of nond sc osure n a samp e of ma e and fema e ado escents w th se (-reported exper ences of sexua abuse Sorso , K a-Keat ng, and Grossman (2008) Study focused on d sc osure cha ences for ma e sury von of CSA to understand three ssues: (I) To Part c pants competed 65- tern quest onna re that nc uded quest ons about background, consensua sex. sexua abuse exper ences (noncontact, contact or penetrat rig abuse, nc ud ng peer abuse), d sc osure of CSA, own sexua abus ve behav or. sexua att tudes. and exper ences w th pornography and sexua exp o at on. The quest onna re nc uded 6 mod( ed terns from the SCL-90 and 9 of 25 tems from the Parenta Bond ng Instrument_ The data for g r s and boys were ana yzed separate y Ma e sun von of CA were ntery ewed about the r d sc osure exper ences. Ana yt c techn ques nc uded The samp e cons sted of 4,339 h gh schoo students n Sweden (2,324 g r s and 2,0 I 5 boys). The mean age of the part c pants was 18.15 years. Th s study used a subsamp e of 1,962 part c pants who reported CSA and who answered d sc osure quest ons The samp e cons sted of 16 ma e sury vors of ch dhood sexua abuse; I I Caucas an, 2 Afr can Amer can. I whom d sc osures occurred.") More fema es spec fed who they d sc osed to compare to ma es. The data show percept ons among youth of negat ve consequences fo ow rig d sc osure Of the samp e, 1.505 g r s (65%) and 457 boys (23%) reported CS& The d sc osure rate was 81% (g r s) and 69% (boys). G r s and boys d sc osed most often to a fr end of the r own age. Few had d sc osed to profess ona s. and even fewer had reported to the author t es. There were h gher rates of d sc osure to a profess ona w th more severe abuse (contact abuse w th or w thout penetrat on) for g r s. but ower rates for boys The more severe the sexua abuse was, the ess key both g r s and boys had ta ked to the r mother, father. or a s b ng. G r s were ess ke y to d sc ose f they had exper enced contact sexua abuse w th or w thout penetrat on. ess frequent abuse, abuse by a fam y member, or f they had perce ved the r parents as ess car rig and ess overprotect ve and h gh y overprotect ve. Boys were ess key to d sc ose f a fam y member abused them, they were study ng a vocat ona program (vs. an academ c program), ved w th both parents or had perce ved the r parents as ess car rig and not overprotect ve. Ado escents who reported CA perce ved the r menta heath as poorer compared to ado escents w thout CS& Nond sc osers reported more symptoms on the Mena Heath Sca e than those who had d sc osed Barr en to d sc osure were found to be operant n three nterre aced doma ns: (I) persona (e.g.. ack of cogn t ve awareness. ntent ona avo dance, emot ona read ness. and shame); (2) Th s study h gh ghted that sexua abuse s arse y h dden from adu t soc ety. espec a y from profess ona s and the ega system. However. t me apsed to d sc osure was not reported. S nce fr ends appeared to be the man rec p ents of sexua abuse d sc osures, pract ce mp cat ons of th s cou d be to f nd ways to g ye young peop e better nformat on and gu dance about how to support a sexua y abused peer. A qua tat ve component to the study wou d have prov ded a broader understand ng of d sc osure processes. Study m tat ons nc ude a s gn f cant amount of boys who d d not comp ete the quest ons regard rig d sc osure on: the t m rig of d sc osures (whether they were de ayed or not) was not measured: poss b ty of reca b as w th retrospect ve stud es based on se (-reports; and youth part c pants may not have understood a the quest ons S nce the vast major ty of men n the samp e had not d sc osed n ch dhood, they may have been pred spored to dent fy ng barr ers to d sc osure more (continued) EFTA00024184 Table I. (cont nued) Study Purpose Des gn Samp e F nd ngs Summary Hershkow tz. Lanes, and Lamb (2007) whom and n what contexts have they d sc osed these exper ences? (2) What do they have to say about the r d sc osure exper ences? and (3) What are the r percept ons of pos t ve and negat ye aspects of the r d sc osure. nc ud ng ncent ves and barren? The goa of the present study was to exam ne how ch d v ms of extrafam a sexua abuse d sc osed the abuse exper ence grounded theory method of ana ys s for cod ng and deve opment of conceptua y c ustered matr ces. Part c pants comp eted two n- depth, sem -structured ntery ews, ast ng between 2 and 3 hr each tak ng p ace approx mate y a week apart A eged v a ms of sexua abuse and the r parents were ntery ewed. Ch dren were ntery ewed us ng the NICHD Invest gat ve Intery ew Protoco by exper enced youth nvest gators. Informat on on d sc osure processes was obta ned n the f rst forma ntery ew, before any po ce nvest gat on or ch d we fare ntervent on Puerto R can. I part Nat ve Amer can, Afr can Cuban: age range of 24-61 years; 9 dent fed themse yes as heterosexua, 5 as homosexua, and 2 as b sexua Th ny a eged v ct ms of CSA: 18 boys and 12 g r s. Ch d samp e was 7- to I2-year-o ds w th an avenge age of 9.2 years. Twenty mothers and 10 fathers were a so ntery ewed for a tota of 30 parent ntery ews. A content ana ys s was conducted on ch d and parent ntery ews re at ona (e.g.. fears about negat ve repercuss ons. so at on); and (3) zoc ocu tura (e.g., ack of acceptance for men to exper ence or acknow edge v ct m zat on). On y I of the 16 men n th s samp e d sc osed the fu extent of h s sexua abuse exper ences wh e he was st a ch d. The other men reported that they had not d sc osed. a though some reported attempts to to that were nd rect or ncomp ete. Seven other men d sc osed terra n exper ences or e ements of the r abuse, but concea ed others. By the t me of the study. many of these men had d sc osed the r past exper ences n a var ety of re at onsh nc ud ng those w th fam y members, partners. therap sts, and nfrequent y fr ends. Seven had on y m ted d scuts ons of the r sexua abuse D sc osure categor es were dent fed as fo ows: (I) de ayed 53% of the ch dren de ayed d sc osure for between I week and 2 years: (2) rec p ent of d sc osure: 47% of ch dren f rst d sc osed to s b ngs or fr ends, 43% f rst d sc osed to the r parents. and I0% f rst d sc osed to another adu t. 57% of the ch dren spontaneous y d sc osed abuse, but 43% d sc osed on y after they were prompted. 50% of the ch dren reported fee ng afn d or ashamed of the r parents' responses. Parents' react ons: support ve (37%) and unsupport ve (63%). There was a strong corre at on between pred cted and acwa parenta react ons suggest ng ch dren ant c pated the r parents' ke y react ons accurate y. D sc osure processes var ed depend ng on the ch dren's ages (e.g.. younger ch dren d sc osed to parents). sever ty and frequency of abuse, parents' expected react ons, suspects' dent t es, and strateg es used to foster secrecy read y. Retrospect ve accounts are subject to reca ssues. Invest gators made s gn f cant efforts to gather a d verse samp e. H gh eve of r gor was executed n the dependab ty of the data and tent ve process of the nterpretat on of f nd ngs was conducted Innovat ve des gn to gather d sc osure data from young ch dren. Focus s on extrafam a CA wh ch may d Her than d sc osure patterns of ntnfam a CSA. Two th rds of the parents reg stered unsupport ve responses wit ch s h gh rconunuedt EFTA00024185 Table I. (cont nued) •-•1 Study Purpose Des gn Samp e F nd ngs Summary A agg a and K rshenbaum The object ves of the (2005) current study were to dent fy a broad range of factors, nc ud ng fam y dynam cs that corn bute to or h nder a ch d's ab ty to d sc ose CSA. A au a (2005) Co ngs, Gr ff ths. and Kuma o (2005). The study purpose was to qua at ve y exp ore dynam cs that mpede or promote d sc osure by exam n ng a range of factors nc ud ng gender as a dynam c— how d sc osures of fema es and ma es are s m ar and d fferent. and n what ways gender affects CSA d sc osure Study exam ned patterns of d sc osure n a arge represent ve samp e of South Afr can CSA v ct ms. Two study object ves to: ( I ) exam ne how and A qua tat ve phenomeno og ca des gn—LIM—was used toe c t d sc osure exper ences: fac tators and barr en: and re evant c rcumstances. Intery ews were transcr bed verbat m. L ne-by- ne open cod ng was conducted to capture fam y- eve factors. Ax a and se ect ve cod ng fac tated dent f at on of themes Sury von of CSA were ntery ewed about the r d sc osure exper ences us ng LIM. Ana ys s of 30 part c pant narrat ves was used for theme deve opment regard ng mpact of gender on d sc osure. Intery ews were transcr bed verbat m for open. ax a . and se ect ve cod ng. Categor es and subcategor es were co apsed and ref n ng nto theme areas F e rev ews of a soc a work and med a case f es for CSA v ct ms seen at the cr s s center where a cases of CSA reported to the North Durban Purpos ye samp ng was emp oyed to recru t 20 adu t sun von between the ages of and 65 who were sexua y abused by a fam y member. Average age of part c pants was 40.1 years: 60% of part c pants were fema e and 40% ma e. Avenge age of onset of abuse was 6.7 years. M xed c n ca and nonc n ca samp e. The major ty had rece ved treatment for CSA at some po nt n the r ves Purpos ve samp ng of women and men. a ong w th those who d sc osed dur ng the abuse and those who d d not. I9 fema es and II ma es; 18-65 (mean 40.1) years who were sexua y abused by a fam y member or a trusted adu t. Avenge age of abuse onset was 5.3 years, 36% were nonwh te, and 58% had not d sc osed dur ng ch dhood 1.737 cases of CSA reported n the North Durban area of KwaZu u-Nata . South Afr ca, dur ng January 2001 to December 2003. 1,614 grs and Four major themes emerged suggest ng that CSA d sc osure can be s gn f cant y comprom sed when certa n fam y condtons ex st (I) rg dy f xed, gender ro es based on a patr archy-based fain y structure; (2) presence of fam y v o ence; (3) c osed, nd rect fam y commun cat on patterns; and (4) soc a so at on of the fam y as a who e, or spec f c members, payed a part n CSA v ct ms fee ng they had no one safe to te . Fam y systems formu at ons through a fem n st ens are mportant n understand ng ch dren and fam es at r sk of d sc osure barr en Three themes emerged for men that nh b ted or prec p tated d sc osure for reasons re ated to gender: (I) fear of be ng v ewed as homosexua : (2) profound fee ngs of st gmat zat on or so at on because of the be of that boys are rare y v ct m zed; and (3) fear of becom ng an abuser, wh ch acted as a prec p cant for d sc osure. Two predom nant themes w th fema e part c pants re ated to d ff cu t es d sc os ng: (I) they fe t more conf cted about who was respons b e for the abuse and (2) they more strong y ant c paced be ng b amed and/or not be eyed Content ma ys s dent fed two broad d mens ons of d sc osure: (I) agency: ch d- n t aced d sc osure versus detect on by a th rd party and (2) tempon durst on: an event versus a process. These d sc osure d mens ons def ned four d screte categor es of Over ha f the part c pants had not d sc osed the abuse dur ng ch dhood. Of the nond sc os ng part c pants, s x d d not d sc ose because they had repressed or forgotten the memory. A most one th rd w thhe d d sc osure ntent ona y. More data are needed on ear y d sc osures to garner more nformat on on fac atop of d sc osure. Retrospect ye approach mp es reca ssues. H gh eve of trustworth ness of the data and nterpretat ons were ach eyed through cred b ty. dependab ty. and conf rmab ty through d rect quotes One n a dearth of stud es that conduct gender ana ys s. Comparat ye ana ys s draws out mportant pract ce mp cat ons. Retrospect ve des gn of the study wh ch mp es poss b e reca ssues. Hgh eve of trustworth ness of the data and nterpretat ons were ach eyed through cred b ty. dependab ty. and conf rmab ty through d rect quotes These resu tsft nto A agg a's (2004) d sc osure framework. Through data ana ys s two raters coded d sc osure categor es us ng author's d sc osure framework, wh ch proved to be both exhaust ve and mutua y exc us ve (continued) EFTA00024186 Table I. (cone nued) Study Purpose Des gn Samp e F nd ngs Summary when CSA v ct ms d sc ose the r abuse and (2) Ident fy factors assoc ated w th d fferent patterns of d sc osure po c ng area were referred dur ng the per od of January 2001 to December 2003 123 boys: average age