2Centre for Research on Children and Families. School of Social Work, McGill University. Montreal. Qubec. Canada
+
+CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stoltenborgh, 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) (Julian, 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) further 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 underestimation 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 disclosing 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 depression, anxiety, trauma disorders, and addictions, without receiving 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 facilitate 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+Previous literature reviews examining factors influencing CSA disclosure have served the field well but are no longer current.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 literature 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 contributions on the dialogical relational processes of disclosure (Reitsema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McElvaney, 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 highlight 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 literature 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 international electronic databases: PsycINFO, PsycARTICLES, Educational Resources Information Center, Canadian Research Index, International Bibliography of the Social Sciences, Published International Literature on Traumatic Stress, Sociological Abstracts, Social Service Abstracts, and Applied Social Science Index and Abstracts. This review searched peerreviewed 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 publications, I French study, and 1 Portuguese review. The search was further refined by excluding studies focusing on forensic investigations, 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 subjected 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 characteristics. Trends emerged around definitions of CSA disclosure, study designs, and sampling issues. First, in regard to definitions, 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
+
+**Table 1.** Ch d Sexua Abuse (CSA) D sc osure Stud es: 2000–2016.
+
+| Study | Purpose | Des gn | Samp e | Fnd ngs | Summary |
+|-----------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Gagn er and Co n-Véz na (2016) | To exp ore d sc osure processes for ma e v ct ms of CSA | Phenomeno og ca methodo ogy used to interv ew ma e CSA surv vors. The Long Interv ew Method (LIM) gu ded data co ect on and ana yses. | 17 men ranged n age from 19 to 67—average age 47. Purpos ve samp ng strategy was used | 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 | 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 w th the part c pants to check themes. Sma but suff c ent s ze for a qua tat ve nqu ry. Otherw se, h gh eve of r gor n estab sh ng trustworth ness of the data and ana ys s. Retrospect ve study cou d mp y reca ssues |
+| Braze ton (2015) | To exp ore the mean ng Afr can Amer can women make of the r traumat c exper ences w th CSA and how they d sc osed across the fe course | Co ect ve case study des gn w th us ng narrat ve trad t on (storyboard) for data co ect on and ana ys s. Qua tat ve interv ew ng | 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 | CSA onset was arge y between the ages 5 and 9. No one ever ta ked to them about sex, so they d di'n have anguage to d sc ose. 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 d sc osed. Pattern of st f ed 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 | 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 shou d be cons dered n further nvest gat ons |
+| Co n-Véz na, Sab onn, Pa mer, and M ne (2015) | 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 surv vors. | Qua tat ve des gn us ng LIM. | 67 ma e and fema e CSA adu t surv 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 | Three broad categor es were dent f ed as barr ers to CSA d sc osure. Barr ers from w th n- nterna zed v ct m b am 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 wor d abe ng, taboo of sexua ty, ack of serv ces ava ab e, and cu ture or t me per od. | Ha f of the part c pants had not d sc osed the r CSA exper ences before the age of 19. Retrospect ve aspect of the study cou d mp y reca ssues. A part 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 r gor n estab sh ng trustworth ness of the data and ana ys s |
+| Lec erc and Wort ey (2015) | Study object ves nvest gated the factors that fac tate CSA d sc osures | Adu t ma e ch d sexua offenders were interv ewed to exam ne pred ctors of | 369 adu t ma es who had been conv cted of a sexua offense aga nst a ch d aged between 1 | D sc osure increased w th 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 v ng w th the offender at | Offender generated data through se f-reports cou d be subject to cogn t ve d stort ons—m n m zat on or exaggerat ons. |
+
+Table I. (cont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary | |
+|----------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|
+| McEvaney and Cuhane (2015) | To investigate the feasibility of using child assessments as data sources of information for CSA discipline. To assess fitness reports provide substantive data on disciplines | Field reports of children seen for assessment a child sexual abuse until na children's hospital were reviewed | Content analysis was completed on 39 fes (32 females and 7 males) based on a coding framework. Parents were asked to consent to have their child's field reviewed for the study. Victims assessed were 12–18 years of age | Majority of children to dither mothers (43%) and peers (33%) first. Three major themes were dentified as influencing the discipline process: (1) feeling distressed, (2) opportunity to tell, and (3) fears for self. Additional themes of being believed, shame/self-blame, and peer influence were also dentified | The sample size is small but we contribute to a large multitude of study in lire and. Serves as an important exploratory pilot bringing forward discipline themes for consideration interventions | Perspectives of offenders on vulnerability of victims in relation to discipline source could be important information to inform interventions |
+| Dumont, Messerschmitt, Vila, Bohu, and Rey-Salmon (2014) | This study alluded to explore how the relationship between the perpetrator and the victim, especially whether these relations are intrafamilial or extrafamilial, impact CSA discipline | Field reports of children seen for assessment a child sexual abuse until na children's hospital were reviewed | 220 million victims—78.2% female victims, 41.8% aged between 14 and 18 (most prevalent age range), and 48.2% were abused by a family member | Discipline processes were more complex when the concerned sexual abuse committed by intrafamilial perpetrator: 60% of the victims reveal the facts several years after, and most often to individuals outside the family (78.6% of the disciplines done at school); on the contrary, extrafamilial disciplines take place more spontaneously and quickly: 80% of the victims reveal the facts a few days after, most often to their mother or peers | The relationship with the perpetrator has a significant impact on both timing and recipient of discipline, with intrafamilial abuses leading to beliefs disclosed promptly and within the family system | The perspectives of offenders on vulnerability of victims in relation to discipline source could be important information to inform interventions |
+| Easton, Saltzman, and Wilson (2014) | Study focus was on dentification of barriers to CSA discipline with male survivors | Using qualitative content analysis, researchers conducted a secondary analysis of one interview data, the 2010 Health and Well-Being Survey, that included men with self-reported CSA histories with an open-ended term on discipline barriers | 460 men with CSA histories completed an anonymous, linternet-based survey. Recruited from survivors' organizations. Age range of 18–84 years. Two thirds of respondents reported clergy-related abuse. Majority of respondents were White | Vast majority of participants (94.6%) were sexually abused by another male. Duration of sexual abuse broke down into: 30.2% estimated at 32.3% months to 3 years, and 34.3% more than 3 years. Ten years old was average age of CSA onset. Ten categories of barriers were cassified into three domains: (1) sociopolitical: masculinity, military resources; (2) interpersonal: mistrust of others, fear of being able to "gay," safety and protection issues, past responses; and (3) personal: internal emotions, seeing the experience as sexual abuse, and sexual or emotion. | At time of the study, this was the largest qualitative data set to have been analyzed with an explicit focus on adult male survivors' perceptions of barriers to CSA discipline. Because the sample was militarian terms of the own percentage of racial mortalities (9.3%), discipline differences based on race or ethnicity were not discerned. The majority of abuse reported was by clergy which might present a unquestion of barriers to discipline | |
+
+Pt' Table I. (cont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|--------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Easton (2013) | Study purpose was to describe male CSA discourse processes using a felspan approach examining differences based on age. A so, to explore relationships between discourse attributes and men's mental health | Cross-sectional survey design. Eligible participants were screened and completed an anonymous, Internet-based survey during 2010. Measures used: General Mental Health Distress Scale and General Assessment of Individual Needs. Questions related to CSA discourse and supports were included | Purpose velocity of men from 487 men from three national organizations devoted to ralising awareness of CSA among men. Age range: 19–84 years. Mean age for onset of CSA was 10.3 years | Older age and being abused by a family member were both related to delays in discourse. Most participants who told someone during childhood did not receive emotional support velocity or protective responses and the helpfulness of responses across the felspan was mixed. Delays in teling were significant periods of time (over 20 years). Approximately one half of the participants first told about the sexual abuse to a spouse/partner (27%) or a mental health professional (20%); 42% of participants reported that the remote helpful discussion was with a mental health professional. However, unhelpful responses caused most mental distress. Child recommendations included more of a fel-course perspective be adopted, understanding impact of unhelpful responses and the importance of expanding networks for male survivors | Purpose velocity of men from awareness ralising organizations may have attracted particular participants who had a ready discoused and received help. Participants needed to have access to Internet which would have eliminated men's ower SES groups and required proficiency in English which would eliminate mental health problems. However, the sampling strategy gained access to a predominantly hidden population. Important child recommendations are made with an emphasis on a fel-course focus |
+| McEvaney, Greene, and Hogan (2012) | Qualitative study asked the central research question: "How do children tell?" Objective was to develop theory of how children tell of the research question as discourse experiences. Parents were interviewed. | Grounded theory method study. Interviews were conducted. Line-by-line open and axial coding was conducted on verbatim transcripts | Sample of 22 young people; 16 girls and 6 boys; age range: 8–18 years; 22 interviewed in total between the ages of 8 and 18. Mixed sample of some enduring nutritional CSA, some extrafamilial CSA, and two endured both forms | A theoretical model was developed that conceptualizes the process of CSA discourse as one of containing the secret (1) the active withholding of the secret on the part of the child; (2) the experience of a "pressure cooker effect" reflecting a conflict between the wish to tell and the wish to keep the secret; and (3) the confliding tise fill which often occurs in the context of a trusted relationship. These were derived from even categories that were developed through open and axial coding | Modest but sufficient sample for an exploratory qualitative inquiry. High level of trustworthiness rigor. A subsample of randomly selected transcripts was independently coded. Very young children and young adults were not captured in this sample. Transferability of findings can only be made to the age range sampled in the context of lire and |
+| Schonbucher, Maler, Mohler-Kuo, Schnyder, and Lando t (2012) | To investigate the process of CSA discourse with adolescents from the general population who had experienced CSA. How many discoused, who did | Data collection was through face-to-face qualitative interviews. Standardized questions and measures were administered on family stuation, sociodemographic | Convenience sample of 26 sexually victimized adolescents. 23 girls and 3 boys. Age range: 15–18 years. On line advertisements and filers were used to recruit youth from | Less than one third of participants immediately discoused CSA to another person. In most cases, recipients of both immediate and delayed discourse were to peers. More than one third of participants had never discoused the abuse to a parent. Participants reported reluctance to discouse to parents so as | Two thirds of the sample did not discouse right away. Strengthening parent-child relationships may be one of the most important ways to increase discourse to parents. Discourse to peers has been found a common trend in other |
+
+Table I. (cant nued)
+
+| Study | Purpose | Des gn | Samp e | Fnd ngs | Summary |
+|---------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Hunter (2011) | they d sc ose to, and what were the r mot ves for d sc os ng | data, sexua v ct m zat on, genera and menta hea th. | commun ty and counse ng serv ces | 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 eve s 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 | research and bears more exam nat on |
+| | A m of th s study was to deve op a fu er understand ng of CSA d sc osures | Narrat ve nqu ry methodo ogy. Face-to-face n-depth interv ews were conducted w th part c pants. Data were ana yzed us ng Rosentha and F scher-Rosentha 's (2004) method. | 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 w th someone over the age of 18. | 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 ma n nh b tors to d sc osure. These factors are further deta 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 ora 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 | 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 fnd ngs support A agg a's (2004) mode of d sc osure but a so h gh ghts the importance 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 deta ed ana ys s for transferab ty of f nd ngs |
+| Schaeffer, Leventha, and Asnes (2011) | Th s 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 | Study sought to f nd out f process ssues of d sc osure cou d be dent f ed n the context of forens c interv ews. Forens c interv ewers were asked to ncorporate quest ons about "te ng" nto an ex st ng forens c interv ew protoco . Interv 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 | 191 interv 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 wa t ng to te , and those who spoke Eng sh. Part c pants were ch dren who were interv ewed at a ch d sexua abuse c n c. 74% were fema e and 51% were Caucas an grounded theory method of ana ys s | Reasons the ch dren dent f ed for te ng were c ass f ed nto three doma ns: (1) d sc osure as a resu t of interna st mu (e.g., the ch d had n ghtmares); (2) d sc osure fac tated by outs de nf uences (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 d sc osure dent f ed 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 wou d happen f she or he to d), (3) ack of opportun ty (e.g., the ch d fe t the opportun ty to d sc ose never presented), (4) ack of understand ng (e.g., the ch d fa ed to recogn ze abus ve behav or as unacceptab e), and (5) re at onsh p w th the perpetrator (e.g., the ch d thought the perpetrator was a fr end) | An movat ve study to try to assess f forma nvest gat ve interv ews can fac tate d sc osures of CSA. Data were based on a arge number of interv ews. Deta ed ana ys s produced deta ed fnd ngs support ng other study fnd ngs on CSA d sc osure |
+
+Table I. (coin nued) cr. P
+
+| Study | Purpose | Design | Sample | Findings | Summary | | | |
+|-----------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Aagg a (2010) | The study aimed to dentify factors impeding or promoting CSA disciplines. Overarching research question: What individual, interpersonal, environmental, and contextual influences impede or promote CSA disciplines. | A qualitative phenomenology called gri, LIM, was used to interview adult CSA survivors about the risk of discipline experiences to provide retrospective accounts of CSA discipline and meaning-making of these experiences. Thematic analysis was done through a socio-ecology called ens. | Purposive sampling was employed. Snowba sampling was also used to recruit more male survivors. 40 adult survivors of CSA were interviewed: 36% men and 64% women. Age range of 18–65 with a mean age of 40.1 years. Average age of abuse onset was 5.3 years old. 36% of the sample was non-White. Diverse socioeconomic backgrounds | Themes fell into four domains: (1) individual and developmental factors, developmental factors as to whether they comprehended what was happening, personality traits also had some bearing on the risk to tell, and categorized the risk by age and science pattern believed; (2) discipline nihilitied by family characteristics such as rigidity fixed gender roles with dominating fathers, chaos and aggression, other forms of child abuse, domestic violence, dysfunctional communication, and social socialization; (3) neighborhood and community context, that is, ackliff interest from neighbors and teachers not pursuing troubling behavior; and (4) cultural and societal attitudes, media messages and societal attitudes, feeling unheard as kilds, gender socialization for males, and cultural attitudes influencing parent's reactions. Purposeful discipline situations that reported in other studies because of the sampling attempts to purposefully illicitate disciplines | The study presents a comprehensive socio-ecology called analysis to CSA discipline survival in gibiting the multifaceted influences. Of note, 42% had disciplined abuse during childhood; 26% had not disciplined because they had repressed the memory, or the abuse had occurred in preschool years and they had difficulty with recall. The remainder had attempted some form of discipline in indirect ways during childhood. A retrospective approach that could be affected by recall issues | The study presents a comprehensive socio-ecology called analysis to CSA discipline survival in gibiting the multifaceted influences. Of note, 42% had disciplined abuse during childhood; 26% had not disciplined because they had repressed the memory, or the abuse had occurred in preschool years and they had difficulty with recall. The remainder had attempted some form of discipline in indirect ways during childhood. A retrospective approach that could be affected by recall issues | The study highlights that discipline survival in gibiting the multifaceted influences. Of note, 42% had disciplined abuse during childhood; 26% had not disciplined because they had repressed the memory, or the abuse had occurred in preschool years and they had difficulty with recall. The remainder had attempted some form of discipline in indirect ways during childhood. A retrospective approach that could be affected by recall issues | The study highlights that discipline survival in gibiting the multifaceted influences. Of note, 42% had disciplined abuse during childhood; 26% had not disciplined because they had repressed the memory, or the abuse had occurred in preschool years and they had difficulty with recall. The remainder had attempted some form of discipline in indirect ways during childhood. A retrospective approach that could be affected by recall issues |
+| Fontes and Pillmeier (2010) | The study aimed to dentify factors impeding or promoting CSA disciplines. Overarching research question: What individual, interpersonal, environmental, and contextual influences impede or promote CSA disciplines. | Using published terature with cincaldata, the study conducted an analysis to provide a culturally competent framework for CSA discipline questioning internationally | Data consisted of published terature on discipline and culture that was triangulated with cincaldata material | Cultural and structural factors affecting CSA discipline are dentified in in-depth detail. Recommendations made include (1) discipline interviewing should be tallored to the child's cultural context, (2) questioning should also take into consideration age and gender factors, and (3) culture stands as an important factor in a cases in which children are considering discipline or being asked to discipline, and not solely in cases in which children are from not cealed minority groups. Presents a comprehensive interview framework integrating cultural considerations | One of the few works that adds knowledge to culturally contextual discipline interviewing. Unquestionable terature findings with cincaldata. Anecdota accounts may preclude transferability of findings. Overall adds to an impoverished area of CSA discipline information | The study highlights that discipline survival in gibiting the multifaceted influences. Of note, 42% had disciplined abuse during childhood; 26% had not disciplined because they had repressed the memo | | |
+
+**Table 1.** (continued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|-----------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| | (1) What are the hidden experiences of abuse among Canadian youth? (2) What impact does participation in abuse prevention programs have on youth to express their abuse experiences? (3) What disciplinary barriers do youth face? (4) What are young people's disciplinary patterns? and (5) Who do they tell? | programming by the Canadian Red Cross (RespectED). A series of focus groups and observations of the workshops were used to help contextualize the findings. Evaluation forms were analyzed from two video encipe prevention programs: (1) It's not your fault and (2) What's overgot to do with it? | anonymously disclosed abuse experiences. Respondent's ages: 13 and under (27%), 14–15 (37%), 16–17 (25%), 18 and older (4%), and unknown (7%) | at a nurse or provider interviewing the peer for information and providers to complete the programming statement. Results suggest disclosure interactive process, with expectations regarding consequences to disclosure. Patterns of incremental sharing abuse experiences are shaped by young people's interactions with peers, educators, and caregivers. About three-quarters of females previously disclosed; significantly less males disclosed | niteractive models of disclosure such as those detailed by Aagga (2004) and Stailer and Nelson-Garde (2005). This makes sample of youth who experienced different forms of abuse and video encipe exposure were participants—not mated to CSA survivors |
+| Ungar, Tutty, McConne, Barter, and Farlhoim (2009b) | This study explored abuse disclosure strategies with a national sample of Canadian youth who participated in video encipe prevention programming. One of the goals of the study was to document not previously dentified experiences of abuse and youth attitudes toward disclosure of abuse experiences | Exploratory design with a nonrepresentative sample. Qualitative analysis of 1,099 evaluation forms completed by video encipe prevention programming. Red Cross RespectED video encipe between 2000 and 2003 | Purposeful sample of 1,099 evaluation forms completed by video encipe prevention programming. Red Cross RespectED video encipe between 2000 and 2003 | Findings suggest high rates of hidden abuse, with less than one quarter of youth reporting a disclosure. 244 of the 1,099 youth who disclosed abuse on the review until forms dentified specific dividuals they told about their abuse. Disclosure patterns vary with boys, youth aged 14–15, victims of physical abuse, and those abused by a family member being most likely to disclose to professionals or the police. One third of disclosures were directed toward professionals and the east, 5% percent each, were directed toward friends, parents, and others. Participants were most likely to disclose sexual abuse to parents/family, professionals, and the police/courts, with fewer choosing friends. | Innovative design of this study provides nating to young people's perceptions of disclosure experiences. High level of rigor with trustworthiness of the data analysis ensured through use of youth focus groups, interviews, and observational data. The study results are somewhat mated to the thickness of the descriptions that offer because most of the data are survey based. Regional differences may not have been predicted. Scope of the study is broad and approach is creative |
+| | | | | | |
+| | | | | | |
+| | | | | | |
+| | | | | | |
+| | | | | | |
+
+Table I. (cont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary | | |
+|----------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Priebe and Svedin (2008) | This study aimed to investigate disclosure rates and disclosure patterns and examine predictors of nondisclosure in a sample of male and female adolescents with self-reported experiences of sexual abuse | | The sample consisted of 65-templet onnaire that included questions about background, consensual sex, sexual abuse experiences (noncontact, contact or penetrating abuse, including peer abuse), disclosure of CSA, own sexual abuse behavior, sexual attitudes, and experiences with pornography and sexual exploitation. The questionnaire included 6 modified tems from the SCL-90 and 9 of 25 tems from the Parental Bonding Instrument. The data for girls and boys were analyzed separately | The sample consisted of 4,339 high school students in Sweden (2,324 girls and 2,015 boys). The mean age of the participants was 18.15 years. This study used a subsample of 1,962 participants who reported CSA and who answered disclosure questions | The sample consisted of 4,357 girls (65%) and 457 boys (23%) reported CSA. The disclosure rate was 81% (girls) and 69% (boys). Girls and boys disclosed most often to a first end of their own age. Few had disclosed to professionals, and even fewer had reported to the authorities. There were higher rates of disclosure to a professional with more severe abuse (contact abuse with or without penetration) for girls, but owner rates for boys. The more severe the sexual abuse was, the less likely both girls and boys had talked to their mother, father, or a sibling. Girls were less likely to disclose fithey had experienced contact sexual abuse with or without penetration, less frequent abuse, abuse by a family member, or fithey had perceived their parents as less caring and less overprotective and highly overprotective. Boys were less likely to disclose fithail family member abused them, they were studying a vocational program (vs. an academic program), lived with both parents or had perceived their parents as less caring and not overprotective. | This study highlighted that sexual abuse is a risk factor for disclosure from adult society, especially from professionals and the egg system. However, the appeal to disclosure was not reported. Since first ends appeared to be the main risk points of sexual abuse disclosures, practice implications of this could be to find ways to give young people better information and guidance about how to support a sexually abused peer. A qualitative component to the study would have provided a broader understanding of disclosure processes. Study materials include a significant amount of boys who did not complete the questions regarding disclosure on; the timing of disclosures (whether they were delayed or not) was not measured; possibility of recall bearing the retrospective studies based on self-reports; and youth participants may not have understood a lithe questions | Since the vast majority of men in the sample had not disclosed in the childhood, they may have been predisposed to dentify ng barriers to disclosure more |
+| Sorso, Ka-Keating, and Grossman (2008) | Study focused on disclosure challenges for male survivors of CSA to understand three issues: (1) To | | Male survivors of CSA were interviewed about their disclosure experiences. Analytic techniques included | The sample consisted of 16 male survivors of the childhood sexual abuse; 11 Caucasian, 2 African American, 1 | Barriers to disclosure were found to be operant in three interrelated domains: (1) personal (e.g., acklogicity view awareness, intentional avoidance, emotional readiness, and shame); (2) | Since the vast majority of men in the sample had not disclosed in the childhood, they may have been predisposed to dentify ng barriers to disclosure more | |
+
+Table I. (cont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|-------------------------------------|-----------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Hershkow tz, Lanes, and Lamb (2007) | The goal of the present study was to examine how child victims of extrafamiliar sexual abuse disclosed the abuse experience | Aged victims of sexual abuse and their parents were interviewed. Children were interviewed using the NICHD Investigative Interview Protocol by experienced youth investigators. Information on disclosure processes was obtained in the first formal interview, before any police investigation or child we fare intervention | Thirty aged victims of CSA; 18 boys and 12 girls. Child sample was 7- to 12-year-olds with an average age of 9.2 years. Twenty mothers and 10 fathers were also interviewed for a total of 30 parent interviews. A content analysis was conducted on child and parent interviews | Disclosure categories were dentified as follows: (1) delayed 53% of the children delayed disclosure for between 1 week and 2 years; (2) recipient of disclosure: 47% of children first disclosed to bings or friends, 43% first disclosed to their parents, and 10% first disclosed to another adult. 57% of the children spontaneously disclosed abuse, but 43% disclosed only after they were prompted. 50% of the children reported feeling afraid or ashamed of their parents' responses. Parents' reactions: support vie (37%) and unsupport vie (63%). There was a strong correlation between predicted and actual parent reactions suggesting children anticipated the irreparable reactions accurately. Disclosure processes varied depending on the children's ages (e.g., younger children disclosed to parents), severity and frequency of abuse, parents' expected reactions, suspects' dentities, and strategies used to foster secrecy | reading vi. Retrospect vie accounts are subject to recall susses. Investigators made significant efforts to gather a diverse sample. High level of irrigor was executed in the dependability of the data and terraine process of the interpretation of findings was conducted |
+| Hershkow tz, Lanes, and Lamb (2007) | The goal of the present study was to examine how child victims of extrafamiliar sexual abuse disclosed the abuse experience | Aged victims of sexual abuse and their parents were interviewed. Children were interviewed using the NICHD Investigative Interview Protocol by experienced youth investigators. Information on disclosure processes was obtained in the first formal interview, before any police investigation or child we fare intervention | Thirty aged victims of CSA; 18 boys and 12 girls. Child sample was 7- to 12-year-olds with an average age of 9.2 years. Twenty mothers and 10 fathers were also interviewed for a total of 30 parent interviews. A content analysis was conducted on child and parent interviews | Disclosure categories were dentified as follows: (1) delayed 53% of the children delayed disclosure for between 1 week and 2 years; (2) recipient of disclosure: 47% of children first disclosed to bings or friends, 43% first disclosed to their parents, and 10% first disclosed to another adult. 57% of the children spontaneously disclosed abuse, but 43% disclosed only after they were prompted. 50% of the children reported feeling afraid or ashamed of their parents' responses. Parents' reactions: support vie (37%) and unsupport vie (63%). There was a strong correlation between predicted and actual parent reactions suggesting children anticipated the irreparable reactions accurately. Disclosure processes varied depending on the children's ages (e.g., younger children disclosed to parents), severity and frequency of abuse, parents' expected reactions, suspects' dentities, and strategies used to foster secrecy | Innovative design to gather disclosure data from young children. Focus is on extrafamiliar CSA which may differ than disclosure patterns of intrafamiliar CSA. Two thirds of the parents registered unsupport vie responses which is high |
+
+**Table 1.** (continued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|-----------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| A agg and Kirshenbaum (2005) | The objectives of the current study were to dentify a broad range of factors, including family dynamics that contribute to or hinder a child's ability to discipline CSA. | A qualitative phenomenological design—LIM—was used to elicit discipline experiences; facilitators and barriers; and relevant circumstances. Interviews were transcribed verbatim. Line-by-line open coding was conducted to capture family-eve factors. Axial and selective coding facilitated dentification of themes | Purposive sampling was employed to recruit 20 adult survivors between the ages of 18 and 65 who were sexually abused by a family member. Average age of participants was 40.1 years; 60% of participants were female and 40% male. Average age of onset of abuse was 6.7 years. Mixed cinical and noncinical sample. The majority had received treatment for CSA at some point in their ves | Four major themes emerged suggesting that CSA discipline can be significantly compromised when certain family conditions exist: (1) lightly fixed, gender role based on a patriarchy-based family structure; (2) presence of family violence; (3) closed, indirect family communication patterns; and (4) social attion of the family as whole, or specific members, played a part in CSA victimism feeling they had no one safe to tell. Family systems formulations through a feministic enslave important in understanding children and families at risk of discipline barriers | Over half the participants had not disciplined the abuse during childhood. Of the nondiscipline participants, six did not discipline because they had repressed or forgotten the memory. A most one third within discipline intentionally. More data are needed on early disciplines to garner more information on facilitators of discipline. Retrospective approach implies recall sisters. High level of trustworthiness of the data and interpretations were achieved through credibility, dependability, and confirmability through direct quotes |
+| A agg a (2005) | The study purpose was to qualify explore dynamics that impede or promote discipline by examining a range of factors including gender as a dynamic—how disciplines of females and males are similar and different, and in what ways gender affects CSA discipline | Survivors of CSA were interviewed about their discipline experiences using LIM. Analysis of 30 participant narratives was used for theme development regarding impact of gender on discipline. Interviews were transcribed verbatim for open, axial, and selective coding. Categories and subcategories were collapsed and refining into theme areas | Purposive sampling of women and men, along with those who disciplined during the abuse and those who did not. 19 females and 11 males; 18–65 (mean 40.1) years who were sexually abused by a family member or a trusted adult. Average age of abuse onset was 5.3 years; 36% were nonwhite, and 58% had not disciplined during childhood | Three themes emerged for men that inhibited or precipitated discipline for reasons related to gender: (1) fear of being viewed as homosexual; (2) profound feelings of stigmatization or solicition because of the belief that boys are rarely victimized; and (3) fear of becoming an abuser, which acted as a precipitant for discipline. Two predominant themes with female participants related to difficulties disciplining: (1) they felt more conflicted about who was responsible for the abuse and (2) they more strongly anticipated being blamed and/or not believed | One in a dearth of studies that conduct gender analysis. Comparative analysis draws out important practice implications. Retrospective design of the study which implies possibility of sisters. High level of trustworthiness of the data and interpretations were achieved through credibility, dependability, and confirmability through direct quotes |
+| Collings, Griffiths, and Kumalo (2005). | Study examined patterns of discipline in a large representative sample of South African CSA victims. Two study objectives to: (1) examine how and | Field reviews of a social work and medical case field for CSA victims seen at the crisis center where a case of CSA reported to the North Durban | 1,737 cases of CSA reported in the North Durban area of KwaZulu-Nata, South Africa, during January 2001 to December 2003. 1,614 girls and no theme areas | Content analysis dentified two broad dimensions of discipline: (1) agency: child-initiated discipline versus detection by a third party and (2) temporal duration: an event versus a process. These discipline dimensions defined four discrete categories of | These results find two broad discipline framework. Through data analysis two raters coded discipline categories using author's discipline framework, which proved to be both exhaustive and mutually exclusive |
+
+Table I. (cone nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|----------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Hershkowitz, Horowitz, and Lamb (2005). | This study aimed to dental characteristics of suspected child abuse victims that are associated with discissorian and formal nevestigations | Large database of suspected cases of physician and sexual abuse investigated in Israel between 1998 and 2002 was analyzed. Interviews were also conducted using standardized NICHD linestigative Interview Protocol. Archival data were analyzed | The sample was comprised of 26,446 of 3- to 14-year-old abuse victims of sexual and physical abuse interviewed in Israel in the 5-year period from 1998 to 2002. 140 experienced trained youth investigators conducted interviews | Overall, 65% of the 26,446 children made a legal ons when interviewed. Rates of discissorian were greater for sexual abuse (71%) over physical abuse (61%). Children of a legal were less likely to discisse/abuse when a parent was the suspected perpetrator. Discissorian rates increased as children grew older; 50% with 3- to 6-year-olds, 67% of the 7- to 10-year-olds, and 74% of the 11- to 14-year-olds discissed abuse when questioned | Overall findings indicated that rates of discissorian varied systematically depending on the nature of the legal offences, the relationship between a legal victims and suspected perpetrators, and the legal of the suspected victims. Analysis only involved cases that had come to the attention of official agencies, making it difficult to determine how many of abuse take place without ever triggering any kind of official investigation. Evidence for delayed discissories. |
+| Jensen, Guibrandisen, Mossige, Reicheit, and Tjers and (2005). | This study investigated the context in which children were able to report their child sexual abuse experiences; their views as to what made it difficult to talk about abuse; what he ped them in the discissing process; and their parent's perceptions of their discissorian processes | Qualitative approach to data collection and analysis was used. Therapeutic interviews of the children and mostly their mothers were analyzed through a qualitative approach. Follow-up interviews were held 1 year after the study investigated | 20 families with a total of 22 children participated. A children had to diabout children had to diabout experiences that created concerns for care-givers about CSA. Children's ages ranged between 3 and 16 years (average age 7.5 years); 15 girls and 7 boys. Sexual abused by someone in the family or a citizen | None of the children to diabouse immediately after it occurred. Children exposed to repetitive abuse kept this as a secret for up to several years; 17 to die their mothers first, 3 first to diafriend, 1 to die their father, and 1 their uncle. Majority of remarks that led to the suspiction of CSA were made in situations where someone engaged the child in a diagnose about what was bothering them, resulting in a referral. The children felition was difficult to find situations containing enough privacy and prompts that they could share their experiences. When the children died | The results indicate that discissorian situational fundamentally dialogical process that becomes less difficult if children perceive that there is an opportunity to talk, a purpose for speaking and a connection has been established to what they are talking about. Strengthening parent-child relationships is an important practice implication |
+| | | | | | |
+
+ICOtitinUed)
+
+**Table 1.** (continued)
+
+| Study | Purpose | Des gn | Samp e | F nd ngs | Summary |
+|--------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Sta er and Ne son-Garde (2005) | The purpose of th s study was to understand the fu process of CSA d sc osure and how th s unfo ded for preado escent and ado escent g r s. Exam ned what fac tated and h ndered d sc osure and subsequent consequences | Secondary ana ys s of qua tat ve focus group data. Or g na project cons sted of four focus groups conducted w th n the context of ongo ng therapy for g r s who had exper enced CSA. Secondary ana ys s cons sted of wr tten narrat ve summar es of each sess on group ng these conceptua y, and exam n ng the r nterconnectedness | 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 | F nd ngs are reported n three major doma ns: (1) se f-phase: where ch dren come to understand v ct m zat on nterna y; (2) conf dant se ect on-react on phase: where they se ect a t me, p ace, and person to te and then whether that person's react on was support ve or host e; and (3) consequences phase: good and bad that cont nued to nform the r ongo ng strateg es of te ng. The act ons and react ons of adu ts were s gn f cant and nformed the g r s' dec s ons. The consequences phase was further subd v ded nto four aspects: (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 t es | Th s study prov ded a contextua exam nat on of the ent re d sc osure process, c oser to the po nt n t me when the abuse and d sc osure occurred. Sma groups of preado escent and ado escent g r s who had surv ved sexua abuse a so served as consu tants and were encouraged to share the r know edge for the benef t of profess ona pract t oners |
+| A agg a (2004) | The study sought to exam ne nf uences that nh b t or promote ch dren's d sc osure of CSA to address gaps n know edge about how, when, and under what c rcumstances v ct ms of CSA d sc ose | 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 | Us ng purpos ve samp ng 24 adu t surv vors of ntrafam a abuse between ages of 18 and 65 (average age 41.2) were recru ted from agenc es and one un vers ty; 57% ma e and 43% fema e; | Through ana ys s of the nterv ew new categor es of d sc osure were dent f ed to add to ex st ng types. Three prev ous y dent f ed were conf rmed n these data: acc denta , purposefu , and prompted/e c ted accounted for 42% of d sc osure patterns n the study samp e. Over ha f the d sc osure patterns descr bed by the study samp e d not f these | Th s study expanded types of CSA d sc osures to more fu y understand how ch dren and adu ts d sc ose. And under what c rcumstances. Ask ng peop e to recount events that occurred n ch dhood s suscept b e to memory fa ure, espec a y when memor es were forgotten, |
+
+Table I. (tont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary | |
+|---------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Crisma, Basce, Pac, and Rom to (2004) | The main goals of this study were to understand impediments that prevent adolescents from disciosing CSA and seeking help from the risk of a network and/or the services | In-depth telephone (anonymous) interviews were conducted after informed consent was explained and CSA and seeking help from the risk of a network and/or the services | The sample was comprised of 36 young people who experienced sexual abuse in adolescence; 35 females and 1 male; aged 12–17. Some of the sample experienced sexual violence in a dating relationship | The main impediments to disciose to a family member were: fear of not being believed, shame, and fear of causing trouble to the family. The main impediments for not seeking services were: unaware of appropriate services, wish to keep the secret, acklof awareness of being abused, mistrust of adults and professionals, and fear of the consequences of disciosing sexual abuse. When they did disciose to professionals, teens received very limited support as many professionals were not trained on sexual abuse and could not offer appropriate interventions to victims | This study represented the findings of a mixed sample of survivors of child sexual abuse and nitmate partner violence. The study was conducted in litaly and this is not clear what sexual abuse response training is available. There may have been a selection basis as the most dissatisfied survivors responded to the research categories | delayed, or repressed and ater recovered. Distortion and revision of events are a so potential problems in recall. High degree of trustworthiness of the data was achieved and quotes provided supported the categories |
+| Jonzon and Lindbad (2004) | Study purpose was to explore how abuse traits, openness, reactions to CSA disciosure, and social support were related. Differences based on severity of abuse, timing and outcomes of disciosure, social support, and predicting factors of positive and negative reactions were probed | Adult women reporting CSA by someone close were interviewed using semi-structured guides together with questionnaires. Data on victim zation and current social support were retrieved through the questionnaires, and data on disciosure and reactions were gathered through the interviews with participants | 122 adult women between 20 and 60 years old (average age of 41 years) reporting exposure to child sexual abuse by someone close before the age of 18 and had to disomeone about at east one abuse event. 90% were Swedish subjects. Purposive sampling strategy was used | Abuse characteristics: abuse by multiple perpetrators was more common than by a single perpetrator. Age of onset was often before age of 7, with an average duration of 7 years. Severely abused women had taked to more of their social network, especially to professionals. Disciosures: 32% disciosed during childhood (before the age of 18) with an average of 21 years delay. Women who had disciosed in childhood reported more instances of physical abuse, multiple perpetrators, use of violence, and were more likely to have confronted a perpetrator, and had received a negative first reaction. Factors received a negative first reaction. | 68% delayed disciosure until adulthood. At the time of the study, this was one of the first studies to focus on the interplay between social support networks and disciosure of child sexual abuse. The study results are somewhat limited by an overrepresentation of severely abused women. Retrospective study and self-report of information could imply recall sistes and thus limits the accuracy of the information obtained on abuse and disciosure | |
+
+;el a. Table I. (cont nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary | |
+|--------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Kogan (2004) | The purpose of this study was to dentify factors that influence the discosures made by female survivors of USE in childhood and adolescence. The predictors of both the timing of discosure and the recipient of the discosure were investigated | Data were gathered from a subsample of female adolescents that participated in the NSA, which consisted of structured phone interviews. USEs reported in the NSA were assessed using a modified version of the Incident Cassification Interview. They were then asked a series of questions about each episode of unwanted sexual contact including event characteristics and perpetrator characteristics | A subsample of 263 adolescent females between 12 and 17 years old, mean age of 15.2 years old, who reported at east one experience of unwanted sexual contact in the NSA. Participant characteristics, USE characteristics, and family contextual attributes were explored | Children under the age of 7 were at a higher risk for delayed discosures. Participants whose USE occurred between the ages of 7 and 13 were most between the ages of 7 and 13 were most less likely to tell an adult. Adolescents (14–17) were more likely to tell only peers than children aged 7–10 years. Children under 11 were more likely to tell an adult, but were at risk for delaying discosure beyond a month. Children aged 11–13 tended to discose within a month. Coloser relationship to the perpetrator or a family member was associated with delayed discosure. Immediate discosure was more likely with stranger perpetration. Fear for one's fellduring and penetration were associated with discosure to adults. Family factors inked to discosure were (1) drug abusing household member, which made survivors more likely to discose more promptly and (2) never ving with both parents was associated with nondiscosure | This study examined factors including discosures of USEs in childhood and adolescence in a nationally representative sample of female adolescents who participated in the NSA. Surveys for investigations of victimization experiences may be based due to underreporting. Adolescents who refused to report or discuss an USE may represent a source of systematic bias and would make the results generalizable only to adolescents who are wing to discose USE via survey. A thought data may be retrospective, recall bias may have been minimized in this study since participants were adolescents, and so the time age between the USE and the interview were presumably shorter than a study of adult participants recalling CSA experiences | design does not allow for definition conclusions of cause and effect on the relationships found |
+| | Ede stein, Goodman, Jones, and Gordon (2003) | The purpose of this study was to investigate variables associated with delay of discosure of CSA and test a mode for factors that influence how quickly children discose sexual abuse | Case flier reviews of data obtained from prosecution flies, as well as from structured interviews with the children's caretaker and observations of child interviews. Trained graduate students and one victim advocate completed the Sexual Assault Profile | Sample consisted of 218 children referred to prosecutors' offices for a leged CSA. A children in the sample had discosed their abuse in some manner. Children ranged in age from 2 to 16 years at the beginning of abuse; 3–16 years at the end of the abuse, and 4–16 years at the time of the years | 64% discosed within a month and 29% within 6 months. Five variables for the mode were tested. (1) age: children who were older took onger to discose and older children feared more negative consequences to others than younger children; (2) type of abuse: victims of nitrafamilial families took onger to discose—victims of nitrafamilial abuse feared greater negative consequences to others compared to victims of extrafamilial abuse; (3) fear of negative consequences: children who feared | This study represents a higher rate of discosers within a month. These cases had been reported to authorities and were in process of prosecution with chill may explain higher rate of early discosures. Legal sample with higher rate of extrafamilial abuse (52%) may also account for earlier discosures. Mode suggests that older children, victims of nitrafamilial abuse; felt greater responsibility for the abuse, and perceiving |
+
+Table 1. (coot nued)
+
+| Study | Purpose | Design | Sample | Findings | Summary |
+|-----------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Smith, Letourneau, Saunders, Kpatrick, Resnick, and Best (2000) | The study focus was to gather data from a large sample of women about the ength of time women who were raped before age 18 deayed discosure who they discosed to, and variables that predicted discosure within 1 month | Structured telephone interviews that asted approximately 35 min were used to collect data using a computer-assisted telephone interview system. A telephone interviews were conducted with who were conducted with each question on a computer screen. The survey consisted of several measures designed to elicit demographic information, psychiatric symptoms, substance use, and victim zation history. The present study reports on data from the demographic and child rape victim zation | Two probability samples. Wave 1 was a random sample of 2,009 respondents selected from stratified samples of defined jurisdictions. Random digital dialog was used to solicit households for sted and united telephone numbers. Second random sample of 2,000 women between the ages of 18 and 34 was selected. Both Wave 1 and Wave 2 data were weighted to conform to the 1989 Census statistics | The study reported that the study's definition of the first rape was 10.9 years. Of the 288 women who reported a child rape, 28% stated that they had never to dialyone about this sexual assault until specifically queried by the interviewer for this study. 58% did not discose for over 1 year and up to 5 years post-rape. 27% discosed within a month. Among women who discosed prior to their NWS interview cose friends were the most common person to whom victims made discosures, followed by mothers and other nimed ate family members. Fewer than 10% of victims reported making their nital discosure to social workers or awlenforcement personnel. Only 12% of child rape victims stated that their assaults were reported to authorities at some point | The time frame of this survey may have had contextual implications. The majority of child rapes reported by this sample occurred prior to the arge-scale child assault prevention education programs that were begun in the 1980s that teach children that assaults (including CSA) are wrong and should be discosed to responsible adults. This information may have influenced (and may currently be influencing) young women's discosure patterns. For Wave 1, comparison of these data with the population parameters obtained from the U.S. Census Bureau indicated that the sample cosely matched the demographic attributes of the population of U.S. women |
+| | | | nital police report; 77% female, 70% Caucasian, 17% Hispanic, and 11% African American. Predominantly middle to ow SES. Approximately 47% nitraliamila abuse | negative consequences of discosure took onger to discose, children who believed that their discosure would bring harm to others took onger to discose, fear of negative consequences to the self or the perpetrator was unrelated to time of discosure, and girls more than boys feared negative consequences to others; (4) Perceived responsibility for the abuse took onger to discose and older children felt more responsibility for the abuse; and (5) gender was not significantly correlated with time to discosure | negative consequences to discosing took onger to discose. We -designed study with high eveloped rigor. Produced a valuable mode of discosure for further investigations. However, researchers were not able to interview children directly |
+
+quest ons
+
+Note. SCL-90 = Symptom Check List-90: SES = socioeconomic status: L N = ong interview method: CA = chi d sexua abuse: N CHD = Nationa nstitute of Chi d Heath and Human Deve opmenc USE = unwanted sexua experiences: NSA = Nationa Survey of Ado escents: NWS = Nationa Women's Study: Q DS = Questionnaire informattse sur es dE inquants sexeu s. 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 disclosure in multifaceted ways with uniform use of categories of prompted, purposeful, withheld, accidental, direct, and indirect. However, defining the period of time that would delineate a disclosure as delayed varied widely across studies, wherein some studies viewed I week or I month as a delayed disclosure (i.e., Hershkowitz et al., 2007; Kogan, 2004; Schembucher, Maier, Moher-Kuo, Schnyder, & Lamdolt, 2012). Other studies simply reported average years of delay sometimes as long as from 20 to 46 years (Easton, 2013; Jonzon & Linblad, 2004; Smith et al., 2000).
+
+Second, the number of qualitative studies has increased significantly 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 perception 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 participation in surveys and consent-based participation in file reviews (Collings, Griffiths, & Kumalo, 2005; Priebe & Svedin, 2008; Schembucher et al., 2012; Ungar, Barter, McConnell, Tutty, & Fairholm, 2009a). Therefore, generalizability of findings is understandably limited. The qualitative studies used purposive sampling as is deemed appropriate for transferability of findings to similar populations. Some of those samples contained unique characteristics, since they were sought through counseling centers or sexual advocacy groups. These would be considered clinical samples producing results based on disclosures that may have been delayed or problematic. This might presumably produce data skewed toward bathers and bring fonvard less information on disclosure facilitators.
+
+Through an in-depth, second-level analysis, this review identified five distinct themes and subthemes beyond the general 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 growing 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 subtheme emerged that intrafamilial abuse/family-like relationship of perpetrator has a bearing on disclosure delays or withholding.
+
+Theme 4: There is a lack of a cohesive life-course perspective. One subtheme includes the lack of data within the 18 to 24-year-old emerging adult population.
+
+Theme 5: Significantly more information is available on barriers than on facilitators of CSA disclosure. Subthemes of shame, self-blame, and fear are uniformly identified as disclosure deterrents.
+
+# Disclosure as an ongoing process: Iterative and interactive in nature.
+
+Disclosure is now generally accepted as a complex and lifelong process, with current trends showing that CSA disclosures are too often delayed until adulthood (Collin-Vezina et al., 2015; Easton, 2013; Hunter, 2011). Knowledge building about CSA disclosure has moved in the direction of understanding this as an iterative and interactive process rather than a discrete, onetime event. Since the new millennium, disclosure is being viewed as a dynamic, rather than static, process and described "not as a single event but rather a carefully measured process" (Alaggia, 2005, p. 455). The catalyst for this view originates from Summit (I 983) who initially conceptualized CSA disclosures 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 accommodation, delayed, conflicted, and unconvincing disclosures, and retraction or recantation, hold validity (for a review, see London, Bruck, Ceci, & Shuman, 2005). However, the idea of disclosure as a process has been carried over into contemporary thinking.
+
+Recently, McElvaney, Greene, and Hogan (2012) detailed a process model of disclosure wherein they describe an interaction 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 prevention forums providing information about sexual abuse (Hershkowitz et al., 2005; Jensen, Gulbrandsen, Mossige, Reichelt, & Tjersland, 2005; Ungar et al., 2009a). The term
+
+dialogical simply means to participate in dialogue. Key dialogical vehicles identified in these studies were providing sexual abuse information through prevention programs, being asked about sexual abuse, and being prompted to tell (McElvaney et al., 2012; Ungar et al., 2009a).
+
+Contemporary models of CSA disclosure reflect a social cological perspective. Knowledge on CSA disclosure has been steadily advancing toward a holistic understanding of the complex interplay of individual, familial, contextual, and cultural factors (Alaggia & Kirshenbaum, 2005; Brazelton, 2015; Fontes & Plummer, 2010). Where at one time factors examined and identified were predominantly of intrapersonal factors of child victims, knowledge construction has shifted to fuller social ecological, person-in-environment explanations (Alaggia, 2010; Collin-Vezina et al., 2015; Easton et al., 2014; Hunter, 2011; Ungar, Tutty, McConnell, Barter, & Fairholm, 2009b). Social-ecological explanations open up more opportunities to intervene in facilitating earlier disclosures. Alaggia (2010) proposes an ecological mapping of what individual, interpersonal, environmental, and contextual influences impede or promote CSA disclosures based on analysis of in-depth interview data of 40 adult survivors. Subsequently, based on a sample of 67 adult survivors, Collin-Vezina, Sablonni, Palmer, and Milne (2015) identified three broad categories, closely aligned with an ecological framework that impede CSA disclosure: (1) barriers from within, (2) barriers in relation to others, and (3) bathers in relation to the social world which can be aligned to intrapersonal, interpersonal, and contextual factors.
+
+A summary of knowledge building using a social—ecological 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 indirect behavioral disclosure patterns have been further verified in follow-up research by Hunter (2011), and through an extensive file review that used Alaggia's (2004) disclosure framework to analyze their data (Collings et al., 2005) for verification.
+
+Interpersonal factors have also emerged in regard to certain family characteristics as disclosure barriers. Families with rigidly fixed gender roles, patriarchal attitudes, power imbalances, other forms of child abuse and domestic violence, chaotic family structure, dysfunctional communication, and social isolation have been found to suppress disclosure (Alaggia Kirshenbaum, 2005; Collin-Vezina et al., 2015; Fontes & Plummer, 2010). In addition, relationship with perpetrator is a factor whereby research indicates that disclosure is made more difficult when the perpetrator is a family member or close to the family (Dumont, Messerschmitt, Vila, Bohu, & Rey-Salmon, 20 I 4;Easton, 2013; Goodman-Brown et al., 2003; Hershkowitz et al., 2005; Priebe & Svedin, 2008; Schanbucher et al., 2012). This is especially a barrier when the perpetrator lives with the victim (LeClerc & Wortley, 2015).
+
+In terms of environmental factors, one study revealed that neighborhood/community conditions can hinder disclosure when there is lack of school involvement in providing a supportive environment, such as in following up on troubling student behavior (Alaggia, 2010). Additionally, a child victim's anticipation of a negative response to disclosure, especially that they may not be believed by others outside their family such as neighbors or other community members, has shown to deter disclosure (Collin-Vezina et al., 2015).
+
+Cultural factors influencing CSA disclosure have been studied 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 delineated 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, culturally based belief systems in many cultures have been found to foster family climates that can silence children from disclosing abuse (Fontes & Plummer, 2010). Taboos about sexuality, patriarchal attitudes, and devaluation of women are among some of the cultural barriers that inhibit disclosure (Fontes & Plummer, 2010).
+
+Clearly, disclosure conceptualizations are being integrated into a social—ecological model of individual and developmental factors, family dynamics, neighborhood, and community context as well as cultural and societal attitudes toward better understanding disclosure barriers and facilitators (Alaggia, 2010), although more data are needed on cultural and contextual factors.
+
+# Age and gender as predictors of disclosure
+
+Age. Age is consistently found to be an influential factor in CSA disclosure, making the life stage of the victim/survivor a critical consideration. Studies draw distinctions in age-groups falling into either under or over 18 years of age. Eighteen years of age was the common age cutoff point that investigators chose in order to distinguish child/youth populations from adult samples. Sixteen of the studies drew on samples of children and youth, while the other 15 studies sampled adults over the age of 18, and a further two studies used mixed age-groups (refer to Table I). Among the child and youth samples, the age ranges spanned from preschool to late adolescence (3-17 years of age), with varying methodological approaches implemented across age cohorts. For younger cohorts, file reviews and secondary data analyses of CSA reports were typically undertaken. Adolescents were most often given surveys. Sometimes children and youth were interviewed as part of administering a survey or as a follow-up (Crisma et al., 2004; Hershkowitz et al., 2005; Ungar et al., 200%). In the majority of child and adolescent samples, sexual abuse concerns were already flagged to investigative authorities. However, the work of Ungar, Barter, McConnell, Tutty, and Fairholm (2009a, 200%) is one exception, whereby their survey elicited new disclosures.
+
+Adult studies typically had a mean age between 40 and 50 years. Interviews were the main data collection method with a few exceptions using survey designs (i.e., Easton, 2013; Kogan, 2004; Smith et al., 2000) and case file reviews (i.e., Collings et al., 2005; Goodman-Brown et al., 2003). Results show a clear trend toward increased likelihood of disclosure in older youth, and findings from adult samples showing a preponderance of disclosures in adulthood, with the large majority of participants of adults reporting never having had a sexual abuse complaint filed with investigative authorities as a child or an adolescent (i.e., Hunter, 2011; Gagnier & Collin-Vezina, 2016; Sorsoli, Kia-Keating, & Grossman, 2008; Ungar et al., 200%).
+
+With children and youth under the ages of 18 distinct patterns emerged. First, accidental detection, rather than purposeful disclosure, is more likely to occur with younger children. For example, in one large-scale study of over 1,737 file reviews, over half of the CSA-related cases were identified through accidental and eyewitness detection (61%), while less than one third were purposeful disclosures initiated by the child victim (Collings et al., 2005). A second pattern which emerged is that rates of disclosure increase with age, especially into adulthood, which is supported by persistent findings of high rates of delayed disclosure reported later in the life course by adult survivors (Collings et al., 2005; Collin-Vezina et al., 2015 ; Easton, 2013; Jonzon & Linblad, 2004; Kogan, 2004; Leclerc & Wortley, 2015; Sorsoli et al., 2008). While gender and relationship with the perpetrator are considerable factors in CSA disclosure, age is consistently a stronger predictor of disclosure (or nondisclosure) (Hershkowitz et al., 2005; Leclerc & Wortley, 2015). Third, younger children who disclose are more likely to do so in an interview situation or other environment that provides prompts or questions about sexual abuse (Hershkowitz et al., 2005; McElvaney, Greene, & Hogan, 2014; Schaeffer et al., 2011), but this trend can also be seen in older youth (Ungar et al., 2009a, 2009b).
+
+Gender. A number of studies have recently focused on CSA disclosures with male victims, since males have been an understudied population (Alaggia, 2005; Easton, 2013; Easton et al., 2014; Gagnier & Collin-Vezina, 2016). Most investigations that sampled both sexes show females outweighing male participants. Although women are at double the risk of being subjected to CSA, the ratio of women to men in most disclosure studies has not been representative. This finding may be indicative of male victims more likely delaying disclosing their CSA experiences, leaving male disclosure in child and youth samples underrepresented (Hebert, Tourigny, Cyr, McDuff, & Joly, 2009; Ungar et al., 2009b).
+
+Easton, Saltzman, and Willis (2014) have been developing gender-specific modeling of disclosure examining male disclosures. 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 reinforce the tendency for male victims of CSA to blame themselves
+
+for the abuse, resulting in no disclosure. Male participants in a subsequent study also relayed that gender norms and stereotypes contributed to them concealing the abuse because they were abused by a woman (Gagnier & Collin-Vezina, 2016). In the one study that compared male and female disclosures, investigator found that men's fears of being viewed as homosexual; profound feelings of stigmatization or isolation because of the belief that boys are rarely victimized; and fear of becoming an abuser acted as disclosure barriers. Whereas females felt more conflicted about who was responsible for the abuse and more strongly anticipated being blamed and not believed (Alaggia, 2005).
+
+Lack of a life-course perspective. Given that the study of CSA disclosure draws on age-groups ranging from samples of very young children to retrospective studies of adult survivors, with significant developmental considerations, this area of study lacks an intentional cohesive life-course perspective. Most data are derived from either cross-sectional or retrospective designs, with few longitudinal studies. There are a series of sound, yet disconnected, studies focusing on specific age-groups of children and adolescents, along with adult retrospective studies. Thus, the available knowledge base does not allow for a cohesive picture of CSA disclosure processes and pathways over the life course to emerge.
+
+The life-course perspective has long been recommended as a critical lens for the study of child abuse (Browning & Laumann, 1997; Williams, 2003). For example, a life-course perspective 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 perspective 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 developmental context, especially for designing appropriate interventions for disclosure at critical transitions from early childhood through to adolescence and into adulthood. In addition, important "turning points" in life may facilitate disclosures. For example, entry into adulthood given that delayed disclosure occurs more often in adulthood. Alaggia (2004, 2005) found that being in a committed relationship or the birth of children acted as facilitators for some survivors to disclose, especially to their spouses. These significant life events, as contributing to disclosures, bear further examination.
+
+Summary of barriers and facilitators. Research over the past 15 years continues to uncover barriers to CSA disclosure at a higher frequency than that of facilitators. As stated previously, this might be the result of sampling methods whereby participants 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
+
+Table 2. Factors Influencing Child Sexual Abuse Disclosures.
+
+| Barriers | Facilitators |
+|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------|
+| Age: The younger the child victim, the less likely they will purposefully disclose. | Age: Disclosures increase with age, especially in adulthood. |
+| 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 | Gender: Slight trend toward females who are older (adolescent) to disclose before adulthood |
+| Relationship to perpetrator: If the perpetrator is a family member or in a family like role, disclosure is less likely to happen | Relationship to perpetrator: If the perpetrator is not living with the victim, disclosure rates increase |
+| Internal: Shame, self blame, and fear are psychological barriers. In addition, fear of negative consequences on the family and for self safety inhibits disclosure | Dialogical context: Opportunities to disclose through discussion, therapeutic relationship, information sessions on sexuality, and sexual abuse prevention programs |
+| 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 | Family relations: Supportive parent-child relationship. |
+| 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 | Involvement of others: Eyewitnesses coming forward and reporting; detection through community members, professionals |
+| | Environmental and cultural context: Promotion of open discussion of sexuality; community member involvement |
+
+as children gain more developmental capacity, understanding of sexual abuse as victimization, and increased independence. Males are somewhat less likely to disclose, but this is often in interaction with other factors in the environment such as societal attitudes that promote hypermasculinity as desirable, attitudes that perpetuate negative views of boys and men who are victims, and homophobic attitudes (Alaggia, 2010; Easton et al., 2014; Gagnier & Collin-Vezina, 2016).
+
+Victims of intrafamilial abuse when the offender is a parent, caregiver, significant family member, or someone in a familylike 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 & Wortley, 2015; Paine & Hansen, 2002; Schaeffer et al., 2011).
+
+Further, the perpetrator residing with their victim(s) increases the likelihood of no disclosure (Leclerc & Wortley, 2015).
+
+Internalized victim-blaming, mechanisms to protect oneself (such as minimizing the impact of the abuse), and developmental immaturity at the onset of abuse constituted internal barriers. Further, shame, self-blame, and fear have been identified as significant factors deterring disclosure (Collin-Vezina et al., 2015; Crisma et al., 2004; Goodman-Brown et al., 2003; Hunter, 2011; Kogan, 2004; McElvaney & Culhane, 2015; McElvaney 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 further examination in future research to understand more fully how they operate in disclosure processes.
+
+In terms of interpersonal and environmental factors, family dynamics can play a part in deterring disclosure. As previously mentioned, families characterized by rigidly defined gender roles, patriarchal attitudes that perpetuate power imbalances between men and women, parents and children, presence of other forms of child abuse and/or domestic violence, chaotic family structure, dysfunctional communication, and social isolation have been found to suppress disclosure (Alaggia & Kirshenbaum, 2005; Collin-Vezina et al., 2015; Fontes & Plummer, 2010). In regard to broader environmental factors, disclosure can be hindered when involved and supportive community members are not available, or not trained in sensitive responses, or when child victims anticipate not being believed by neighbors and other people outside the family (Alaggia, 2010; Collin-Vezina et al., 2015). Further, barriers in relation to the social world were identified as stigmatization, the negative labeling of sexual abuse victims, and taboos surrounding sexuality and talking about sex as driven by cultural norms (Collin-Vezina et al., 2015; Fontes & Plummer, 2010).
+
+Identification of cultural barriers is important recent contribution 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 silencing, 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 drawing on adult populations who delayed disclosure. These samples may not be representative of the overall population of CSA victims, since they may have had more negative disclosure experiences, consequently more readily identifying barriers. On the other hand, these findings may speak to the actual imbalance between facilitating factors and barriers for disclosure, the latter carrying more weight in the victims/survivors' experiences, thus, explaining the high rates of disclosures delayed until adulthood.
+
+Facilitators. Although fewer disclosure facilitators are identified in this review, very important facilitators were nonetheless uncovered—ones that should be noted for professionals in this field of practice. Internal factors that facilitate disclosures include symptoms that become unbearable, getting older with increased developmental efficacy, and realizing that an offence was committed (Collin-Vezina et al., 2015; Crisma et al., 2004; Easton, 2013; Hershkowitz et al. 2007; McElavaney, Greene, & Hogan, 2014; Schaeffer et al., 2011). Circumstantial facilitators are those where the child discloses because there has been evidence provided, eye-witnessing has occurred, and a report has been made. Environmental factors include settings that provide opportunities such as counseling, interviews, information sessions and educational forumsAvorIcshops, and prevention programs for children and youth to disclose.
+
+To elaborate, dialogical contexts about CSA for children and youth can provide opportunities for discussion that may facilitate disclosures (Jensen et al., 2005). The research shows creating open dialogue in relationship contexts, to offset the power and influence of the perpetrator, can facilitate earlier disclosure. Among disclosure facilitators is being asked about abuse and given the opportunity to "tell" (McElavaney et al., 2014); workshops on abuse and sexual abuse, in particular, can facilitate disclosures (Ungar et al., 2009b); and using culturally sensitive probes and questions (Fontes & Plummer, 2010). In Gagnier and Collin-Vezina's (2016) study, positive disclosure experiences were described by participants as those where they felt that they had been listened to, were safe, were believed, and were not judged by the person they disclosed to. Further, family members and friends (peers) of the child victim can act as key supports to creating an open relational context and fostering positive responses (Jensen et al., 2005; Priebe & Svedin, 2008; Schonbucher et al., 2012; Ungar et al., 20096). In particular, as children grow older, they are more likely to disclose to a peer, as shown in a number of studies, and this is an important reality for counselors and educators to be aware of (Dumont et al., 2014; Kogan, 2004; Sclainbucher et al., 2012; Ungar et al., 2009b).
+
+# Discussion
+
+Through examination of 33 studies published since the year 2000, this review identified five distinct themes regarding CSA disclosure: (1) Disclosure is best viewed as an iterative, interactive process rather than a discrete event done within a relational context; (2) contemporary models reflect a social—ecological, person-in-environment framework for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure;
+
+(3) age and gender are significant disclosure factors; (4) there is a lack of a life-course perspective; and (5) barriers to disclosure continue to outweigh facilitators. Based on these themes, a number of conclusions are drawn from this review. First, disclosure 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 lifecourse perspective in investigations, although age consistently surfaces as significantly influencing CSA disclosure. Using a life-course perspective through the use of longitudinal studies is recommended.
+
+The use of varied methodological designs, depending on the developmental stage of the victims/survivors, influences the data generated and subsequent findings. For example, most studies on children and youth are based on file reviews of cases that have been brought to the attention of authorities, or surveys, with only a few studies using interviewing of younger children. Therefore, there is less information available on process 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 anticipated due to attitudinal shifts that have presumably occurred over the last two generations about revealing such traumas and changing views about discussing sexual victimization.
+
+Interview guides used in a number of studies intentionally probed for facilitators, producing notable findings. For example, 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 forensic purposes prompting such disclosures would be viewed as problematic in legal settings, seriously compromising testimonies 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 disclosure in one domain (therapeutic) are seen to work against CSA survivors in another domain—such as legal settings when perpetrators 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 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 findings, we conclude that barriers and facilitators to CSA disclosures 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 coverage, this review may be limited by its qualitative, thematic focus rather than providing an evaluative, quantitative accounting of CSA disclosures. However, because of the recent focus on disclosure processes, the authors chose a suitably compatible approach—qualitative in nature. As well, a traditional checklist approach in rating the studies was not employed for interrater reliability, since two of the authors hold expertise in CSA disclosure research and are well versed with the literature. This expertise, and through closely following a systematic review framework (Kiteley & Stogdon, 2014), assures that a thorough adjudication of the research literature was completed.
+
+# Implications for Research and Practice
+
+These review findings have implications that can be useful in guiding future research and practice:
+
+- Solid strides are being made in the use of a social—ecological framework to underpin investigations in the CSA disclosure investigations. Research efforts and practice considerations should continue in this vein. Investigating 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 education on topics of sexuality in general, and sexual abuse specifically, can help children and youth to disclose. Raising awareness and prevention programs can promote disclosures of sexual violence committed against children and youth.
+- Goals of therapeutically supported disclosures (i.e., through therapy) may need to take precedence over forensic approaches, if well-being of child victims and adult survivors is to be made paramount. Legal processes may act to facilitate disclosures but can also act as barriers because of the negative outcomes experienced in the court process.
+- Practitioners need to keep in mind that the legal system is lagging far behind in knowledge uptake of recent evidence on CSA disclosures so that victims and
+
+survivors continue to be systemically and structurally disadvantaged in legal proceedings.
+
+- Health-care practitioners (i.e., child abuse pediatricians, family practice doctors, clinical nurse specialists, and public health nurses) should be made aware of the evidence in the CSA disclosure literature to create environments 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 victims, and this finding should be heeded by policy and law makers.
+- Shame, self-blame, and fear are intrapersonal factors that persistently emerge as barriers to CSA disclosures and warrant more research to understand how to redress these barriers for earlier disclosures.
+
+# Conclusion
+
+There are still a substantial number of children and youth who are subjected to sexual abuse, despite preventative efforts. Just as concerning is the fact that many victims continue to suffer in silence as evidenced by the high numbers 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 generations 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 victims to disclose but rather to change environmental conditions to create a more supportive and safer context for CSA victims and survivors to disclose.
+
+# Declaration of Conflicting Interests
+
+The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
+
+# Funding
+
+The author(s) received no financial support for the research. author ship, and/or publication of this article.
+
+- References Alaggia, R. (2004). Many ways of telling: Expanding conceptualiza tions of child sexual abuse disclosure. Child Abuse & Neglect, 28, 1213 1227. Alaggia, R. (2005). Disclosing the trauma of child sexual abuse: A gender analysis. Journal of Loss and Trauma, 10, 453 470. Alaggia, R. (2010). An ecological analysis of child sexual abuse dis closure: Considerations for child and adolescent mental health. Journal of the Canadian Academy of Child and Adolescent Psy chiatty Journal De ?Academie Canadienne De Psychiatric De ?Enfant Et De ?Adolescent, 19, 32 39. Alaggia, It., & Kirshenbaum, S. (2005). Speaking the unspeakable: Exploring the impact of family dynamics on child sexual abuse disclosures. Families in Society, 86, 227 234. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 93. doi:10.1191/ 1478088706qp063oa Brannon, J. F. (2015). The secret storm: Exploring the disclosure process of African American women survivors of child sexual abuse across the life course. Traumatology: An International Jour nal, 21, 181 187. Browning, C. R., & Laumann, E. O. (1997). Sexual contact between children and adults: A life course perspective. American Socio logical Review, 62, 540 560. Collings, S. J., Griffiths, S., & Kuntalo, M. (2005). Patterns of disclo sure in child sexual abuse. South African Journal of Psychology, 35,270 285. Collin Vezina, D., Sablonni, D. L., Palmer, A. M., & Milne, L. (2015). A preliminary mapping of individual, relational, and social factors that impede disclosure of childhood sexual abuse. Child Abuse & Neglect, 43, 123 134. doi:10.10160.chiabu.2015.03.010 Crisma, M., Bascelli, E., Paci, D., & Romito, P. (2004). Adolescents who experienced sexual abuse: Fears, needs and impediments to disclosure. Child Abuse & Neglect, 28, 1035 1048. Dumont, M., Messerscluniu, P., Vila, G., Bohu, D., & Rey Salmon, C. (2014). Is processus de revelation dans les agressions sexuelles intrafamiliales et extrafamiliales sur mineurs. Annales Medico Psychologiques, 172, 426 431. doi:10.1016/j.amp.2012.06.024 Easton, S. D. (2013). Disclosure of child sexual abuse among adult male survivors. Clinical Social Work Journal,41,344 355. doi:10. 1007/s10615 012 0420 3 Easton, S. D., Saltzman, L. Y., & Willis, D. G. (2014). "Would you tell under circumstances like that?": Barriers to disclosure of child sexual abuse for men. Psychology of Men & Masculinity, 15, 460 469. Fallon, B., Van Wert, M., Troeme, N., MacLaurin, B., Sinha, V., Lefebvre, R., ... Goel, S. (2015). Ontario Incidence Study of Reported Child Abuse and Neglect 2013 (OIS 2013). Toronto, ON: Child Welfare Research Portal. Finkelhor, D., Shattuck, A., Turner, FL A., & Ilamby, S. L. (2014). Trends in children's exposure to violence, 2003 to 2011. JAMA Pediatrics, 168, 540 546. doi:10.1001/jamapediatrics.2013.5296 Fontes, L. A., & Plummer, C. (2010). Cultural issues in disclosures of child sexual abuse. Journal of Child Sexual Abuse, 19, 491 518. Gagnier, C., & Collin Vezina, D. (2016). The disclosure experiences of male child sexual abuse survivors. Journal of Child Sexual Abuse, 25, 221 241. Goodman Brown, T. B., Edelstein, R. S., Goodman, G. S., Jones, D., & Gordon, D. S. (2003). Why children tell: A model of children's disclosure of sexual abuse. Child Abuse & Neglect, 27, 525 540. When, M., Tourigny, M., Cyr, M., McDuff, P., & Joly, J. (2009). Prevalence of childhood sexual abuse and timing of disclosure in a representative sample of adults from Quebec. Canadian Journal of Psychiatry, 54, 631 636. Retrieved from http://search.proquest. com/docview/222860811?accountid= 14771 Hershkowitz, I., Horowitz, D., & Lamb, M. E. (2005). Trends in children's disclosure of abuse in Israel: A national study. Child Abuse & Neglect, 29, 1203 1214. Hershkowitz, 1., Lanes, O., & Lamb, M. E. (2007). Exploring the disclosure of child sexual abuse with alleged victims and their parents. Child Abuse & Neglect, 31, III 123. Hunter, S. V. (2011). Disclosure of child sexual abuse as a life long process: Implications for health professionals. The Australian and New Zealand Journal of Family Therapy, 32, 159 172. Jensen, T. K\_, Gulbrandsen, W., Mossige, S., Reichelt, S., & Tjersland,
+ - O. A. (2005). Reporting possible sexual abuse: A qualitative study on children's perspectives and the context for disclosure. Child Abuse & Neglect, 29, 1395 1413. Jillian, B., Cotter, A., & Perreault, S. (2014). Police reported crime statistics in Canada, 2013 (Catalogue number 85 002 X). Ottawa, ON: Statistics Canada. Jones, D. P. H. (2000). Editorial: Disclosure of child sexual abuse. Child Abuse & Neglect, 24, 269 271. Jonzon, E., & Lindbald, F. (2004). Disclosure, reactions, and social support: Findings from a sample of adult victims of child sexual abuse. Child Maltreatment, 9, 190 200. Kiteley, It., & Stogdon, C. (2014). Literature reviews in social murk. London, England: Sage. Kogan, S. (2004). Disclosing unwanted sexual experiences: Results from a national sample of adolescent women. Child Abuse & Neglect, 28, 147 165. Leclerc, B., & Wortley, It. (2015). Predictors of victim disclosure in child sexual abuse: Additional evidence from a sample of incar cerated adult sex offenders. Child Abuse & Neglect, 43, 104 Ill. London, K., Bruck, M., Ceci, S. J., & Shuman, D. W. (2005). Disclo sure of child sexual abuse: What does the research tell us about the ways that children tell? Psychology, Public Policy, and Law, 11, 194 226. McElvaney, R. (2015). Disclosure of child sexual abuse: Delays, non disclosure and partial Disclosure. What the research tells us and implications for practice. Child Abuse Review, 24, 159 169. McElvaney, R., & Culhane, M. (2015). A retrospective analysis of children's assessment reports: What helps children tell? Child Abuse Review. doi:10.1002/car.2390. McElvaney, It., Greene, S., & Hogan, D. (2012). Containing the secret of child sexual abuse. Journal of Interpersonal Violence, 27, 1155 1175.
+
+McElvaney, R., Greene, S., & Hogan, D. (2014). To tell or not to tell? Factors influencing young people's informal disclosures of child sexual abuse. Journal of Interpersonal Violence, 29, 928 947. Maier, T., Mohler Kuo, M., Landholt, M. A., Schnyder, U., & Jud, A. (2013). The tip of the iceberg. Incidence of disclosed cases of child sexual abuse in Switzerland: Results from a Nationwide Agency Survey. International Journal of Public Health, 58, 875 883. Paine, M. L., & Hansen, D. J. (2002). Factors influencing children to self disclose sexual abuse. Clinical Psychology Review, 22, 271 295. doi:10.1016/S0272 7358(01)00091 5 Pereda, N., Guilera, G., Fonts, M., & Gomez Benito, J. (2009). The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994). Child Abuse & Neglect, 33, 331. Retrieved from http://search.proquest.com/docview/230158315? accountid= 14771 Priebe, G., & Svedin, C. G. (2008). Child sexual abuse is largely hidden front the adult society: An epidemiological study of ado lescents' disclosures. Child Abuse & Neglect, 32, 1095 1108. Reitsema, A. M., & Grietens, II. (2015). Is anybody listening? The literature on the dialogical process of child sexual abuse disclosure reviewed. Trauma Violence Abuse. doi:10.1177/152483801 5584368 Rosenthal, G., & Fisher Rosenthal, W. (2004). The analysis of narra tive biographical interviews in U Flick. In E. von Kardorff & I. Steinke (Eds.), A Companion to Qualitative Research (pp. 259 265). London, UK: Sage. Schaeffer, P., Leventhal, J. M., & Asnes, A. G. (2011). Children's disclosures of sexual abuse: Learning from direct inquiry. Child Abuse & Neglect, 35, 343 352. doi:10.1016/j.chiabu.2011.01.014 Schtinbucher, V., Maier, T., Molder Kuo, M., Schnyder, U., & Land olt, M. A. (2012). Disclosure of child sexual abuse by adolescents: A qualitative in depth study. Journal of Interpersonal Violence, 27, 3486 3513. doi:10.1177/0886260512445380 Smith, D. W., Letoumeau, E. J., Saunders, B. E., Kilpatrick, D. G., Resnick, H. S., & Best, C. L. (2000). Delay in disclosure of child hood rape: Results from a national survey. Child Abuse & Neglect, 24,273 287. Retrieved from http://search.proquest.com/docview/ 70933344?accountid= 14771 Sorsoli, L., Kia Keating, M., & Grossman, F. K. (2008). "I keep that hush hush": Male survivors of sexual abuse and the challenges of disclosure. Journal of Counseling Psychology, 55, 333 345. doi: 10.1037/0022 0167.55.3.333 Seller, K. M., & Nelson Gardell, D. (2005). "A burden in your heap": Lessons of disclosure from female preadolescent and adolescent survivors of sexual abuse. Child Abuse & Neglect, 29, 1415 1432. Statistics Canada. (2013). Police reported crime statistics in Canada. 2012 (Catalogue number 85 002 X). Retrieved from the Statistics Canada website httplAvww.statcan.gc.ca/pub/85 002 x/2013001/ article/11854 eng.htm#n2 Stoltenborgh, M., van Uzendoom, M. II., Fuser, E. M., & Balcemtans Kranenburg, M. (2011). A global perspective on child sexual abuse: Meta analysis of prevalence around the world. Child Mal treatment, 16, 79 101. doi:10.1177/1077559511403920 Summit, R. C. (1983). The sexual abuse accommodation syndrome. Child Abuse & Neglect, 7, 177 193. Tener, D., & Murphy, S. (2015). Adult disclosure of child sexual abuse. Trauma, Violence & Abuse, 16, 391 400. Trocme, N., Fallon, B., MacLaurin, B., Daciuk, J., Felstiner, C., Black, T., ... Cloutier, R. (2005). Canadian incidence study of reported child abuse and neglect 2003: Major findings. Ottawa: Minister of Public Works and Government Services Canada. Trocme, N., Fallon, B., MacLaurin, B., Sinha, V., Black, T., Fast, E., ... Holroyd, J. (2008). Characteristics of substantiated maltreatment. Canadian incidence study of reported child abuse and neglect: Major findings (Chapter 4). Retrieved from http:// www.phac aspc.gc.ca/cm vee/public eng.php Ungar, M., Baxter, K., McConnell, S. M., Tutty, L. M., & Fairholm, J. (2009a). Patterns of abuse disclosure among youth. Qualitative Social Work, 8, 341 356. Ungar, M., Tutty, L. M., McConnell, S., Barer, K., & Fairholm, J. (2009b). What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33, 699 708. Williams, L. M. (2003). Understanding child abuse and violence against women: A life course perspective. Journal of Interpersonal Violence, 18,441 451. Author Biographies Ramona Alaggia, MSW, PhD, is an associate professor in social work and the Factor Inwentash Chair in Children's Mental Health at the University of Toronto. Iler teaching and research focuses on gender and violence, sexual abuse disclosures, domestic violence exposure, and resilience processes. Delphine Collin-Vezina, PhD, is an associate professor for School of Social Work, McGill University and director for Centre for Research on Children and Families. She holds the Nicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in Community and the Canada Research Chair (Tier II) in Child Welfare. Her work focuses on research and clinical topics related to child maltreatment, child sexual abuse, and trauma. Rusan Lateef, MSW, is a social worker employed in the criminal justice system with adult male offenders in Ontario, Canada. She specializes in the intersection of health and mental health, child sexual abuse disclosures, and she is a researcher on the "Make Resilience Matter" project examining childhood exposure to domestic violence with Dr. Alaggia at the Factor Inwentash Faculty of Social Work, University of Toronto.
+
+# Disclosure of Child Sexual Abuse: Delays, Non-disclosure and Partial Disclosure. What the Research Tells Us and Implications for Practice
+
+This paper reviews the research on disclosure of child sexual abuse with specific reference to delays in disclosing, non-disclosure and partial disclosure of experiences of child sexual abuse. Findings from large-scale national probability studies highlight the prevalence of both non-disclosure and delays in disclosure, while findings from small-scale qualitative studies portray the complexity, diversity and individuality of experiences. The possible explanations regarding why children are reluctant to disclose such experiences have significant implications for addressing the issue of child sexual abuse from the perspectives of child protection, legal and therapeutic professionals. The importance of understanding the dynamics of disclosure, in particular the needs of young people to maintain control over the disclosure process, the important role that peers play in this process, the responses of adults in both informal and formal networks, and the opportunities to tell, is key to helping young people speak more promptly about their experiences of sexual abuse. Copyright O 2013 John Wiley & Sons, Ltd.
+
+#### KEY PRACTITIONER MESSAGES:
+
+- Children typically delay disclosing experiences of abuse.
+- Asking children questions about their wellbeing gives them the opportunity to tell when they are ready.
+- The challenge is to find the right questions at the right time.
+- Peers can be the right people to ask these questions.
+- Adolescents need to know about how to ask and what to do if someone tells.
+
+KEY WORDS: child sex abuse; disclosure; research to practice
+
+A n issue of increasing concern in recent years is the phenomenon of delayed disclosure of childhood sexual abuse and the need to understand the process of how children and adults disclose their experiences of child sexual abuse, given the implications for child protection, social justice and
+
+Rosaleen McElvaney
+
+School of Nursing and Human Sciences. Dublin City University, Dublin. Ireland
+
+`The importance of understanding the dynamics of disclosure'
+
+'Adolescents need to know about how to ask and what to do if someone tells'
+
+•Correspondence to: Rosaleen McElvaney. School of Nursing and Human Sciences. Dublin City University. Glasnevin, Dublin 9. Ireland. E-mail: rosaleen.mcelvaneygdcu.ie
+
+`This paper reviews
+
+the research on
+
+disclosure patterns of
+
+childhood sexual
+
+abuse'
+
+'Most people who experience sexual
+
+abuse in childhood do
+
+not disclose this
+
+abuse until adulthood'
+
+mental health outcomes. This paper reviews the research on disclosure patterns of childhood sexual abuse, specifically delays in disclosure, non-disclosure (as evident through adult retrospective studies) and partial disclosures, and discusses implications for practice. Literature searches of the online databases PSYCINFO and Social Sciences Citation Index, in addition to manual searches of texts published since 2000, were conducted using the search terms 'child
+
+sexual abuse', 'sex abuse' and 'disclosure'.
+
+The research to date on disclosure patterns is based on two sampling methodologies — studies of adults reporting retrospective experiences and studies of children. The former group of studies has the benefit of drawing on large-scale national probability samples which can be considered to be representative of the general population. The latter group with some small exceptions (predominantly adolescent studies) uses samples of young people who have disclosed sexual abuse but would not be considered as representative
+
+of all children who have been abused:
+
+'children who decide to tell someone about being sexually abused and whose cases therefore come to court are not representative of sexually abused children in general'
+
+(Olafson and Lederman, 2006, p. 29).
+
+Patterns of Disclosure: Delays and Non-disclosure
+
+There is consensus in the research literature that most people who experience sexual abuse in childhood do not disclose this abuse until adulthood, and when disclosure does occur in childhood, significant delays are common. Table 1 summarises two large-scale studies to highlight the extent of delays in disclosure and the percentage of those who did not disclose to anyone prior to the study. Kogan (2004) examined the timing of disclosure of unwanted sexual experiences in childhood or adolescence in a sub-sample (n = 263 adolescent women, aged 12 to 17) of the National Survey of Adolescents (Kilpatrick and Saunders, 1995) in the USA — a nationally representative study. Kogan's results can be summarised as follows: immediate disclosure (within 1 month) 43 per cent, delayed disclosure (less than 1 year) 31 per cent and non-disclosure (disclosed only during the survey) 26 per cent. Smith and colleagues (2000) examined a sub-sample (n = 288) of the National Women's Study in the USA (Resnick a al., 1993, cited in Smith et at, 2000) who had reported a childhood rape prior to the age of 18. Smith el al.'s findings can be summarised as follows: immediate disclosure (within 1 month) 27 per cent, delayed disclosure (more than a year) 58 per cent and non-disclosure (survey only) 28 per cent. Those who had never disclosed prior to the survey constitute comparable proportions in these two studies while the rates for immediate
+
+Table I. Panerns of disclosure delay and non-disclosure
+
+Kogan (2004) Smith a a). (2000) (n 263 adolescents) (n 288 adults)
+
+Told within 24 hours 24% 18% Told within 1 month 19% 9% Told within 1 year 12% 11% Delayed telling more than I year 19% 47% Never told before survey 26% 28%
+
+disclosure are higher in the adolescent study than in the adult study, a reassuring finding given the increased awareness of sexual abuse in society during the past 20 years.
+
+Goodman-Brown and colleagues (2003) examined USA district attorney files of 218 children. Their categories were slightly different from the previous two studies but in summary, immediate disclosers (within 1 month) constituted 64 per cent of the sample while 29 per cent disclosed within six months. This study is unusual insofar as the sample studied had reported their experience of abuse to the authorities and a prosecution was in progress. Goodman-Brown et at also pointed out that families who participated in this study were more likely to represent those children who experienced abuse by someone outside the family. Research has found that delays in disclosure are longer for those abused within the family and Lindblad, 2002; Goodman-Brown et at, 2003; Kogan, 2004; Hershkowitz a at, 2005). Therefore, children who disclose more promptly may be overrepresented in legal samples.
+
+In Sweden, Priebe and Svedin (2008) conducted a national survey of 4339 adolescents, of whom 1962 reported some form of sexual abuse (65% of girls and 23% of boys). Details of the time lapse in disclosing were not available from this study. However, of those who had disclosed and answered the questions on disclosure (n = 1493), 59.5 per cent had told no-one of their experiences prior to the survey. Of those who did disclose, 80.5 per cent mentioned a 'friend of my own age' as the only person who they had told. In this study, 6.8 per cent had reported their experiences to the social authorities or police. A further Swedish study of 122 women who had experienced childhood sexual abuse (Jonson and Lindblad, 2004) found that 32 per cent disclosed during childhood (before the age of 18) while the majority told in adulthood (68%). The delay was up to 49 years, with an average of 21 years (SD = 12.9). Of those who told in childhood, 59 per cent told only one person. In Ireland, the SAVI study (n = 3118, McGee et al., 2002) found that 47 per cent of those respondents who had experienced some form of sexual assault prior to age 17 had told no-one of this experience until the survey. McElvaney (2002) investigated delay in a legal sample of ten adults who had made formal complaints of childhood sexual abuse in Ireland and found delays ranging from 20 years to 50 years.
+
+Studies of children in the context of forensic/investigative interviews where children are interviewed by professionals due to concerns that the child has been sexually abused also point to high non-disclosure rates, particularly striking in cases where there is corroborative evidence that abuse has occurred — medical evidence (Lyon, 2007), or confessions from the abuser or videotaped evidence/witness reports ( 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 and Lindblad, 2002).
+
+In summary, significant numbers of children do not disclose experiences of sexual abuse until adulthood and adult survey results suggest that significant
+
+The rates for immediate disclosure are lower in the adolescent study than in the adult study'
+
+'Children who disclose more promptly may be overrepresented in legal samples'
+
+`Delays ranging from 20 years to 50 years'
+
+# `High numbers of respondents disclosing to researchers for the first time'
+
+# `They found that interviewers behaved differently with the two groups'
+
+# 'A parent described how her teenage son told her over a period of days'
+
+proportions of adults have never disclosed such abuse, as evidenced by the high numbers of respondents disclosing to researchers for the first time. Patterns of Disclosure — Partial Disclosure Information on how children disclose over time can be obtained from studies of children who participated in forensic/investigative interviews where children are interviewed by professionals due to concerns that the child has been sexually abused. The issue of partial disclosures was highlighted by earlier studies such as those by DeVoe and Faller (1999) of five- to ten-year olds (i.e. making detailed informal disclosures that were not replicated in formal interviews) and Elliott and Briere (1994) of children aged eight to 15 years (i.e. disclosing only partial information until confronted with external evidence that led to more complete disclosures). More recently, investigators have examined the role of the interviewer and questioning styles in the forensic interview and how this impacts on children's disclosures and the level of detail provided in interview. Hershkowitz et at (2006) compared tapes of interviews with children who disclosed sexual abuse and those who did not (but about whom there was `substantial' reason to believe that they had been abused). They found that interviewers behaved differently with the two groups, using different types of prompts with children who presented as somewhat uncooperative, offered fewer details and gave more uninformative responses at the beginning of the interview. It would appear that interviewers responded to less communicative children by increasing the proportion of closed questions which in turn led to children being less forthcoming. Lamb el al. (2002) have found that the use of a protocol that emphasises the use of prompts that elicit free narrative (e.g. 'tell me about that') as compared with closed questions (those requiring a yes/no response) has resulted in more detail and more accuracy in children's accounts. Although few studies exist that examine the phenomenon of disclosure in informal settings (when disclosure is made to a friend or family member), some qualitative studies have described this process. McElvaney (2008) quoted one teenage girl who described hinting to her mother prior to disclosing the experience: 'I didn't tell her what happened but I was saying things that made her think it made her think that it happened but I didn't tell her' (p. 127). A parent described how her teenage son told her over a period of days, keeping the most difficult parts of the story until last: 'Ile came out with like it came out over two or three days so you know.. \_he'd say well I've something else to tell you... the bad stuff last... what hun him most and what he's saying what hurt him most' (p. 92) And finally, one young person described how she told her social worker: 'I couldn't tell her most things but I just gave things to her to read... I told her at first I told her bits of it and em then just the others. I finished writing and then I gave them to her... later I told her that it was the father as well.' (p. 93) This young person had been abused by both a father and son in a family with whom she was staying.
+
+In reviewing the literature on this subject, London and colleagues (2005) noted, `when children do disclose, it often takes them a long time to do so' (p. 204).
+
+# Reasons for Patterns of Delay, Partial Disclosure and Non-disclosure
+
+There are many influences on disclosure that have been identified in the research literature to help explain why it is that children delay disclosure, are reluctant to disclose, provide details of their experiences over time or do not disclose at all. Age has been identified as a significant predictor of disclosure in that younger children are less likely to disclose than older children. Children who are abused by a family member are less likely to disclose and more likely to delay disclosure than those abused by someone outside the family (Smith a at, 2000; Goodman-Brown a at, 2003; Kogan, 2004). Children who do disclose during forensic interviews compared to children who do not disclose in such contexts (yet concerns remain that they have been abused) are more likely to have parents (particularly mothers) who are more supportive (Lawson and Chaffin, 1992). In Priebe and Svedin's (2008) study of young people, parental bonding (positive relationship with parent who was not overprotective) was identified as the most significant predictor of disclosure for both boys and girls. However, close relationships can also act as an inhibitor to disclosure. McElvaney (2008) found that many young people in her study were reluctant to disclose due to concerns of upsetting their parents while others were concerned about the consequences for others of their disclosure. One 13-year-old girl described her concern that if she told, her uncle would go to jail and her small cousins would be left without a father:
+
+'I didn't want them to grow up with no Dad and just looking at ... their other little friends having their Dad holding their hand I felt like I was taking their Dad away from them' (p. 130)
+
+Gender has been found to influence disclosure in that boys appear to be more reluctant to disclose than girls (Goodman-Brown a at, 2003; Hershkowitz a at, 2005; Ungar a al., 2009a). Mental health difficulties on the part of the child have also been found to be relevant, particularly when children experience dissociative symptoms or other post-traumatic stress symptomatology (Priebe and Svedin, 2008).
+
+Some studies have found that the severity of abuse (e.g. penetrative abuse) predicts earlier disclosure while other studies have found no relationship between different types of abuse and disclosure timing. Similarly, the relationship between the duration of abuse — one-off incidents of abuse compared with abuse that takes place over a significant period of time — and timely disclosure has been investigated with mixed findings. Fear of the consequences of disclosure has been identified as a predictor of delayed disclosure and this in turn is associated with the age of the child (Goodman-Brown a at, 2003). Older children are more cognitively competent in terms of being able to reflect on and anticipate possible reactions to their disclosure. This can act then as an inhibitor to disclosure, although as noted above, most studies have found that older children are more likely to disclose than younger children. Fears of not being believed have been described by young people as inhibiting their disclosure and these fears are often "When children do disclose, it often takes them a long time to do so"
+
+`Younger children are less likely to disclose than older children'
+
+`Many young people in her study were reluctant to disclose due to concerns of upsetting their parents'
+
+`Fear of the consequences of disclosure has been identified as a predictor of delayed disclosure'
+
+`Investigating the precise circumstances that led to disclosures for children'
+
+`Significant proportions of disclosure have been prompted by questions by caregivers, friends or others'
+
+`The implications of these findings can be considered in interrelated contexts'
+
+justified. Hershkowitz a at (2007) interviewed children about their initial disclosures prior to formal interview and 50 per cent of the sample (n = 30) reported feeling afraid or ashamed of their parents' reaction. The authors reported that parents did show a tendency to blame their children and react angrily to the disclosure.
+
+Recent research has highlighted the need for children to be asked direct questions to facilitate their disclosure. Of those children who did disclose, significant proportions disclosed following prompts rather than it being initiated by the child (Kogan, 2004). Qualitative studies drawing on interviews with children that focus on the disclosure process are important in investigating the precise circumstances that led to disclosures for children. McElvaney (2008) found that parents' questioning of children was prompted by their concern about the young person's emotional distress. On occasion, young people were communicating that something was not right in their world but were not able to articulate this verbally. Signs of psychological distress were, however, evident and questions targeted at the reasons for this distress were identified by McElvaney as a factor that helped young people to tell. Thus, many children may not have told about their experiences of abuse because they were not asked. McGee a al. (2002) followed up a sample of their respondents who had disclosed childhood abuse for the first time in their survey. When asked why they had not disclosed prior to the survey, many respondents noted that it was because they had not been asked. Increasingly, research studies are finding that significant proportions of disclosure have been prompted by questions by caregivers, friends or others in the child's educational and social milieu that in themselves provide an opportunity for the young person to tell (Jensen et at, 2005; Hershkowitz a at, 2007; McElvaney et al., 2012).
+
+Finally, some children need time to tell. Mudaly and Goddard (2006) quote a 13-year-old girl: `she (mother) helped by not making me, not rushing me to get it out, which, um, I think it's a really stupid idea to make kids get it out A.S.A.P.' (p. 91).
+
+# Implications for Practice
+
+The consensus in the research literature at the present time is that disclosure is multi-determined, influenced by a complex range of factors that may influence each child in a different way. Large-scale national probability studies confirm that non-disclosure and delays in disclosure are significant problems facing society and in particular for those professionals tasked with safeguarding the wellbeing of children. Children's fears and anxieties in relation to telling need to be understood and contained by those in their environment so that early disclosure can be encouraged and facilitated.
+
+The implications of these findings can be considered in interrelated contexts: the legal context where action can only be taken if the child is able to give a clear, credible account of his/her experiences; child protection and therapeutic contexts where a comprehensive account is required to enable child protection professionals to intervene and where the psychological sequelae can be addressed to minimise the long-term impact of the experiences; and family and community contexts where early disclosure needs to be encouraged, and other family issues addressed in the aftermath of disclosure and where peers play an important role.
+
+Studies have confirmed the importance of professionals asking children and young people in a sensitive, open manner about possible experiences of abuse using non-leading questioning styles to minimise inaccurate accounts or contaminate children's narratives. It is clearly important for professionals to remain open to the possibility of abuse and further disclosure. It is equally important for professionals to be able to avoid persisting with questioning those children who are 'reluctant disclosers'. Similarly, professionals engaged with children in therapeutic work need to be open to the possibility of both initial and further disclosures.
+
+Contradiction in witness statements is a well-known feature of false statements and giving additional detail to original formal statements can be interpreted within child protection, therapeutic and legal contexts as a contradiction of an earlier account. Listening to children's accounts of their experiences of disclosure helps us understand why it is that disclosure can be delayed and that when they do feel ready to tell this is not an 'all or nothing' decision. As one young person in Staller and Nelson-Gardell's (2005) study noted, 'it's never finished, never' p. 1426. This understanding in turn helps us identify those circumstances and reactions that may encourage the child to disclose.
+
+The importance of asking children questions, thus giving them an opportunity to tell, has been identified. While parents, teachers and those in daily contact with children are often reluctant to question children, it is clear that many children do not disclose unless given this opportunity. Education and increased awareness are needed on how to question children in an appropriate manner. McElvaney (2008) noted that questions did not need to be about sexual abuse per se, but rather questions prompted by the young person's psychological distress, asking after the young people's wellbeing. This questioning in effect acted as an external pressure for the young person to tell his/her secret (McElvaney et al., 2012). In Ungar el at's (2009a) study of Canadian youth, they found that young people used a range of disclosure strategies ranging from less direct strategies (such as risk-taking behaviours, not talking about the abuse) to direct strategies (such as seeking support from peers, turning to non-professional adult supports, disclosing to formal service providers), representing a process that relied heavily on others to 'build the bridges between the youth and formal care providers' (p. 352).
+
+The tendency to delay disclosing and the partial nature of many disclosures are not conducive to successful legal investigations and prosecutions. In addition, the knowledge base that exists within the legal sphere is limited if only a percentage of the children who experience sexual abuse engage with this system. The disproportionately high 'immediate disclosure' rate found in Goodman-Brown a al.'s (2003) legal sample compared to Kogan's (2004) community sample raises the question of the representation of delayed disclosers in the legal system. Are children who delay in disclosing less likely to engage with the legal system? Are delays in disclosing contributing to decisions not to prosecute child sexual abuse crimes? In Ireland, the 1990s saw a significant increase in the numbers of complainants coming before the courts reporting experiences of childhood sexual abuse. Many of these cases were referred to the higher courts for judicial review proceedings to establish whether the cases could proceed without prejudicing the accused given the
+
+# 'Contradiction in witness statements is a well-known feature of false statements'
+
+# 'Education and increased awareness are needed on how to question children in an appropriate manner'
+
+# 'Are children who delay in disclosing less likely to engage with the legal system?'
+
+'Concerns that engagement with the legal system will lead to further psychological trauma need to be considered'
+
+'Many young people who delayed disclosure to an adult had told a friend'
+
+'An adaptive strategy on the part of the young person to contain the experience'
+
+delay in the complaint being made and giving due regard to the accused's right to a speedy trial. Psychological expert testimony was sought as part of these proceedings to explain the delay in disclosure in each individual case to enable the courts to adjudicate on whether the delay in reporting was reasonable (see McElvaney, 2002). This legal mechanism provided an opportunity to enhance the knowledge base within the legal profession as to the complexities involved in disclosing and formally reporting experiences of childhood sexual abuse for adults. While one might expect that the legal system would be more sympathetic to children's difficulties in making disclosures, it may also be the case that the belief that 'if the child was really sexually abused, why would they not tell?', as articulated by Summit (1983), still prevails.
+
+In addition, concerns that engagement with the legal system will lead to further psychological trauma need to be considered. A prospective longitudinal study conducted by Quas et al. (2005) indicated that the consequences of legal involvement change over the course of development and as a function of the child's reactions to and experiences during the legal case. The associations between legal involvement and outcomes varied with age. The authors suggested that although younger children may be at increased risk for some adverse outcomes such as mental health problems, older children may be at increased risk for other undesirable sequelae such as the negative attitudes of others toward them. Quas and Goodman's (2011) recent review notes that older children are more at risk in developing poor mental health outcomes. Thus, as noted earlier, young people's fears of the consequences of disclosure may well be justified. Raised awareness of both the prevalence of non-disclosure of sexual abuse and the importance of supporting children to disclose may go some way to addressing children's fears.
+
+One interesting finding in recent studies is that many young people who delayed disclosure to an adult had told a friend. McElvaney (2008) and Ungar et al. (2009b) identified peer influence as significant in encouraging disclosure among adolescents. There is some suggestion from the research that regardless of the age at the time of abuse, adolescence may be a 'critical period' for disclosure. It may be that targeting adolescents in general (rather than those at risk of abuse) may be a powerful prevention tool in encouraging early disclosure. Evaluations of child abuse prevention programmes have shown significant improvements in the levels of awareness of child abuse in children and young people (Rispers et al., 1997; Zwi el al., 2007). It may be that the increasing trend towards peer disclosure is a by-product of such educational and awareness-raising programmes. There is evidence that public awareness campaigns when implemented as part of a multi-dimensional strategy that involves targeting children, parents and communities (see Lalor and McElvaney, 2010, for a review of child abuse prevention programmes) are an effective tool in the prevention of child abuse.
+
+McElvaney et al. (2012) describe the importance for young people of containing the secret of abuse and their need for confidentiality following disclosure as representing an adaptive strategy on the part of the young person to contain the experience and his/her emotional reaction to it. The conflict between wanting/needing to keep the secret and wanting/needing to tell is mediated by what they term the 'pressure cooker effect'. Young people in their study described influences from within and without that led to a build up of pressure, ultimately leading to disclosure. They suggest that building up the
+
+pressure for young people by providing opportunities to tell may be needed to help young people tell more promptly. However, the lack of control that young people experience following disclosure remains an issue (Ungar et al., 2009b; Quayle a al., 2012). This highlights the need for dissemination of information directly to young people about the legal process, the possible consequences of disclosure, as well as ongoing developments in legal proceedings when young people and their families interface with the legal system.
+
+The more recent focus on investigating those strategies that children use in making disclosures rather than solely on identifying bathers to disclosure is perhaps more helpful in informing awareness-raising campaigns and professional interventions. The author is involved in a large-scale review of children's files in an assessment service to ascertain those factors that helped children tell about their experiences of sexual abuse. A pilot study has suggested that this is an appropriate methodology for gathering data on children's experiences of informal disclosure, acknowledging the limitations of such an approach. Ungar a al. (2009a) describe the optimal conditions for disclosure as follows: being directly asked about experiences of abuse; having access to someone who will listen, believe and respond appropriately; having knowledge and language about what constitutes abuse and how to access help; having a sense of control over the process of disclosure both in terms of their anonymity (not being identified until they are ready for this) and confidentiality (the right to control who knows); and effective responses by adults both in informal and formal contexts.
+
+Ungar etal. (2009b) support recent developments in prevention programmes that target supportive formal and informal caregivers in being better able to detect the possibility of abuse and support disclosures rather than focusing on empowering children themselves in making disclosures. Their findings in relation to the importance of bridge building for young people to access formal supports are supported by Jensen et at's (2005) emphasis on the dialogical nature of disclosure, and the important role that trusted adults and peers play in the disclosure process through noticing signs of psychological distress and asking young people about their psychological wellbeing (Collings a al., 2005; Jensen et at, 2005; McElvaney et at, 2012). More emphasis is therefore needed on providing opportunities for children and young people to disclose. The challenge for professionals and those who care for children is how to do this in a way that protects children and promotes their wellbeing.
+
+# References
+
+Collings SJ, Griffiths S, Kumalo M. 2005. Patterns of disclosure in child sexual abuse. South African Journal of Psychology 35(2): 270 285. DeVoe ER, Faller KC. I 999.The characteristics of disclosure among children who may have been sexually abused. Child Maltreatment 4: 217 227. Elliott DM, Briere 1 1994. Forensic sexual abuse evaluations of older children: Disclosures and symptomatology. Behavioral Sciences & the Law 12: 261 277. Goodman Brown TB, Edelstein RS, Goodman GS, Jones DP14, Gordon DS. 2003. Why children tell: A model of children's disclosure of sexual abuse. Child Abuse & Neglect 27: 525 540. Hershkowitz I, Horowitz D, Lamb ME. 2005. Trends in children's disclosure of abuse in Israel: A national study. Child Abuse & Neglect 29(11): 1203 1214. Ilashkowitz I, O,bach Y, Lamb ME, Sternberg KJ, Ilorowitz D. 2006. Dynamics of forensic interviews with suspected abuse victims who do not disclose. Child Abuse & Neglect 30: 753 769.
+
+'More recent focus on investigating those strategies that children use in making disclosures'
+
+'Having a sense of control over the process of disclosure both in terms of their anonymity and confidentiality'
+
+llershkowitz I, Lanes O, Lamb ME. 2007. Exploring the disclosure of child sexual abuse with alleged victims and their parents. Child Abuse & Neglect 31: Ill 123. Jensen TK, Gulbrandsen W, Mossige S, Reichelt S, Tjersland OA. 2005. Reporting possible sexual abuse: A qualitative study on children's perspectives and the context for disclosure. Child Abuse & Neglect 29(12): 1395 1413. Jonson E, Lindblad F. 2004. Disclosure, reactions and social support: Findings from a sample of adult victims of child sexual abuse. Child Maltreatment 9(2): 190 200. Kilpatrick DG, Saunders BE. 1995. The National Survey of Adolescents in the United States [Computer File]. Medical University of South Carolina [producer], 1999. Inter university Consortium for Political and Social Research [distributor], 2000: Ann Arbor, MI. Kogan SM. 2004. Disclosing unwanted sexual experiences: Results from a national sample of adolescent women. Child Abuse & Neglect 28: 147 165. Lalor K, McElvaney R. 2010. Child sexual abuse, links to later sexual exploitation/high risk sexual behavior, and prevention/treatment programs. Trauma, Violence & Abuse 11(4): 159 177. DOI: 10.1177/1524838010378299 Lamb ME, Orbach Y, Sternberg KJ, Esplin PW, Hershkowitz I. 2002.The effects of forensic interview practices on the quality of information provided by alleged victims of child abuse. In Children's Testimony: A handbook of Psychological Research and Forensic Practice, Westcon ILL, Davies GM, Bull R (eds). John Wiley & Sons Ltd: Chichester, England; 131 145. Lawson L, Chaffin, M. 1992. False negatives in sexual abuse disclosure interviews: Incidence and influence of caretaker's belief in abuse in cases of accidental abuse discovery by diagnosis of STD. Journal of Interpersonal Violence 7(4): 532 542. London K, Bruck M, Ceci SJ, Shuman D. 2005. Disclosure of child sexual abuse: What does the research tell us about the ways that children tell? Psychologn Public Policy, and Law 11(1): 194 226. Lyon TD. 2007. False denials: Overcoming methodological biases in abuse disclosure research. In Child sexual abuse: Disclosure, delay and denial, M Pipe, M Lamb, Y Orbach, AC Cederborg (eds). Lawrence Erlbaum Associates: London; 41 62. McElvaney R. 2002. Delays in reporting childhood sexual abuse and implications for legal proceedings. In Sex and Violence: The Psychology of Crime and Risk Assessment, Farrington DP, Rollin CR, McMurran M (eds). Routledge: London; 138 153. McElvaney R. 2008. How children tell: containing the secret of child sexual abuse. Unpublished doctoral dissertation, Trinity College, Dublin. McElvaney R, Greene S, Hogan D. 2012. Containing the secret of child sexual abuse. Journal of Interpersonal Violence 27(6):I 155 1175. DOI: 10.1177/0886260511424503 McGee H, Caravan R, deBarra M, Byrne J, Conroy R. 2002. The SAVI Report: Sexual Abuse and Violence in Ireland. The Liffey Press: Dublin. Mudaly N, Goddard C. 2006. The truth is longer than a lie: Children's experiences of abuse and professional interventions. Jessica Kingsley Publishers: London. Olafson E, Lederman CS. 2006. The state of the debate about children's disclosure patterns in child sexual abuse cases. Juvenile and Family Court Journal 57(1): 27 40. Priebe G, Svedin CG. 2008. Child sexual abuse is largely hidden from the adult society: An epidemiological study of adolescents' disclosures. Child Abuse & Neglect 32: 1095 1108. Quas JA, Goodman GS. 2011. Consequences of criminal court involvement for child victims. Psychology, Public Policy and Law 18, 392 414 10.1037/a0026146 Quas JA, Goodman GS, Ghetti SA, Kristen W, Edelstein RR, Allison D, Cordon IM, Jones, DPII. 2005. Childhood sexual assault victims: Long term outcomes after testifying in criminal court: VII. General discussion. Monographs oldie Society for Research in Child Development 70(2): 104 117. Quayle E, Jonsson L, Loaf L. 2012. Online Behaviour related to Child Sexual Abuse: Preliminary Version. ROBERT Project. Available: http://www.innocenceindangendeffileadmin/user upload/ Downloads/ROBERT/Interview analysis PRELIMINARIpdf [18 June 2012]. Resnick HS., Kilpatrick DG., Dansky BS, Saunders BE, & Best CL. 1993. Prevalence of civilian trauma and posttraumatic stress disorder in representative national sample of women. Journal of Consulting and Clinical Psychology 61: 984 991. Rispers 1, Aleman A, Goudena PP. 1997. Prevention of child sexual abuse victimization: A meta analysis of school programs. Child Abuse & Neglect 21: 975 987. RL, Lindblad F. 2002.Limited disclosure of sexual abuse in children whose experiences were documented by videotape. The American Journal of Psychiatry• 159: 312 314.
+
+Smith DW, Letoumeau EJ, Saunders BE, Kilpatrick DG, Resnick, HS, Best CL. 2000. Delay in disclosure of childhood rape: Results from a national survey. Child Abuse & Neglect 24: 273 287. Staller KM, Nelson Gardell D. 2005. "A burden in your heart": Lessons of disclosure from female preadolescent and adolescent survivors of sexual abuse. Child Abuse & Neglect 29: 1415 1432. Summit R. 1983. The child sexual abuse accommodation syndrome. Child Abuse & Neglect 7(2): 177 193 Ungar M, Barter K, McConnell S, Tutty L, Fairholm I 2009a. Patterns of disclosure among youth. Qualitative Social Ifbrk 8(3): 341 356. DOI: 10.1177/1473325009337842. Ungar M, linty LM, McConnell S, Barter K, Fairholm J. 2009b. What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33: 699 708. Zwi KJ, Woolfenden SR, Wheeler DM, O'Brien TA, Tait P, Williams KW 2007. School based education programmes for the prevention of child sexual abuse (Review). Cochrane Database of Systematic Review 3: CD004380.
+
+# CLINICAL RESEARCH ARTICLE
+
+# Predictors of delayed disclosure of rape in female adolescents and young adults
+
+Iva A. E. Bicanicl ", Lieve M. Hehenkampl , Elise M. van de Puttee, Arjen J. van Wijk3 and Ad de Jongh3•4
+
+Background: Delayed disclosure of rape has been associated with impaired mental health; it is, therefore, important to understand which factors are associated with disclosure latency. The purpose of this study was to compare various demographics, post rape characteristics, and psychological functioning of early and delayed disclosers (i.e., more than I week post rape) among rape victims, and to determine predictors for delayed disclosure.
+
+Methods: Data were collected using a structured interview and validated questionnaires in a sample of 323 help seeking female adolescents and young adults (12 25 years). who were victimized by rape, but had no reported prior chronic child sexual abuse.
+
+Results: In 59% of the cases, disclosure occurred within I week. Delayed disclosers were less likely to use medical services and to report to the police than early disclosers. No significant differences were found between delayed and early disclosers in psychological functioning and time to seek professional help. The combination of age category 12 17 years [odds ratio (OR) 2.05, confidence intervals (CI) 1.13 3.73], penetration (OR 2.36, CI 1.25 4.46), and closeness to assailant (OR 2.64, CI 1.52 4.60) contributed significantly to the prediction of delayed disclosure.
+
+Conclusion: The results point to the need of targeted interventions that specifically encourage rape victims to disclose early, thereby increasing options for access to health and police services.
+
+Keywords: Adolescents; young adults: rape: sexual assault: disclosure; latency to disclosure; posurauniatic stress disorder
+
+Responsible Editor: Rita Rosner, KU Eichstaett Ingolstadt. Germany.
+
+For the abstract or full text in other languages, please see Supplementary files under Article Tools'
+
+Received: 31 August 2014; Revised: 30 Mardi 2015: Accepted: 13 April 2015; Published: 11 May 2015
+
+p revious studies have shown that disclosure of rape to formal agencies, such as police or mental health services, is uncommon (Fisher, Cullen, & Turner, 2000; Wolitzky-Taylor et al., 2011), especially when the rape has been committed on a date or by an acquaintance and involves the victim's use of drugs and/or alcohol (Resnick et al., 2000; Wolitzky-Taylor et al., 2011). There is evidence to suggest that victims believe that professionals will not be helpful to them because their rape experience does not match stereotypical conceptions of rape, such as involving a stranger, a weapon, and severe injury (Patterson, Greeson, & Campbell, 2009; Resnick et al., 2000). Accordingly, adolescents and young adults, who are more at risk to be victimized by rape than other age
+
+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 appropriate medical care and report to the police than delayed disclosers (Ahrens, Stansell, & Jennings, 2010; Ullman & Filipas, 2001). In contrast, adults who wait longer than month to disclose the rape are more likely to suffer from posttraumatic stress disorder (PTSD) and depression compared to early disclosers (Ruggiero et al., 2004).
+
+'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
+
+'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.bicanio@rencutrecht.n1In addition, adolescents who disclose their rape experience at least I month after the incident took place are found to be at higher risk for major depressive disorder and delinquency (Broman-Fulks et al., 2007) compared to those who disclosed within I month.
Victim—assailant relationship is crucial in disclosure latency, with victims being at higher risk for delayed disclosure 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 difference in rates of prior sexual trauma between early and delayed disclosers. In addition, the victim's age appears to be an important variable in predicting disclosure. Evidence suggests that young children are at higher risk for delayed disclosure than adolescents (Kogan, 2004; Schonbucher, Maier, Mohler-Kuo, Schnyder, & Landolt, 2012). Thus, various rape and victim-related characteristics have been found to be associated with timing of disclosure.
The majority of the aforementioned studies included college and adult female rape victims. It is important to examine rape disclosure latency in an age and sex group that is most at risk for rape victimization. There is only one prior quantitative study in adolescents (those aged 12-17 years) that identified factors that might influence disclosure latency (Kogan, 2004). He found that identity of the assailant, a familial relationship with the assailant, and a history of drug abuse in the household were related to the timing of disclosure. The results suggested that a familial relationship with the assailant will postpone disclosure, whereas a history of drug abuse in the household, 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 adolescents and young adults, including age, prior trauma, and victim—assailant relationship using logistic regression analyses. Insight into the predictors for delayed disclosure for adolescents and young adults may reveal not only potential causal mechanisms but also possible targets for
interventions that increase victims' opportunities to receive timely post-rape services.
Methods
Subjects and data collection
Rape was defined as "an event that occurred without the victim's consent that involved the use or threat of force in vaginal, anal, or oral intercourse" (Tjaden & Thoennes, 2006). The definition includes both attempted and completed 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 admission to a Rape Centre in the Netherlands, i.e., a maximum of 7 days post-rape.
The study was conducted in the Dutch National Psychotrauma Centre, which provides psychological services for rape victims aged 12-25 years and their parents. Between May 2005 and December 2011, the centre received 621 phone calls concerning alleged rape victims from police authorities, mental health services, and selfreferrals. In 178 cases, the phone call did not result in admission at the centre because of age limitations, or motivational reasons. In 108 cases, referrals were made to other institutions because the index trauma was chronic childhood sexual abuse rather than rape in adolescence/ young adulthood. Of the 335 cases admitted to the centre, 12 were not included in this study because of male gender, resulting in a final sample of 323 females with the index trauma being single rape. Referral sources for this final sample included the police (33.7%), mental health services (40.7%). and self-referrals, i.e., victims or parents (25.6%).
Procedure
During admission, all patients underwent a psychological assessment, consisting of 1) a structured interview for obtaining demographic and post-rape characteristics and 2) self-report questionnaires to obtain information about mental health functioning. Information from the interview was transcribed onto a form designed for this purpose. The following variables were obtained and dichotomized or categorized for the purpose of the study:
Demographic and victim characteristics
We asked patients about their current age, educational level (lower, middle, or higher), and whether they were of Dutch origin (i.e., in case of having parents born in the Netherlands). Those between 12 and 17 years of age were defined as adolescents and those between 18 and 25 years of age as young adults. We also asked whether the patient was living with their parent(s) (yes/no), and whether the
family structure was complete, i.e., whether the biological parents were living together (yes/no). Patients were then asked to confirm the presence of prior negative sexual experiences (yes/no), and whether they had a current sexual relationship (yes/no).
Rape characteristics
Information about date and time of the rape was obtained to calculate the time since rape at admission. Next, patients were requested to describe the rape. Their response was categorized into use of penetration (yes/no), group rape (yes/no), use of physical violence (yes/no), and use of threats verbally and/or with a weapon (yes/no). Also, information regarding the victim's relationship to the assailant was obtained. The assailant was defined as a stranger when the victim had never been in contact with the assailant before the rape. Responses were used to form a closeness category (yes in case of family, (boy) friend, or mentor). Patients were also asked about the (estimated) age of the assailant (categorized into 12-17 years or > 18 years), and whether the victim had used alcohol prior to the rape (yes/no).
Post-rape characteristics
Patients were asked when they first talked about the rape. The response was used to calculate the disclosure time and the help-seeking time. At the end of the interview, patients were asked whether they had reported to the police after the incident (yes/no), and whether they had received any medical care after the incident (yes/no).
The study was performed in accordance with the precepts and regulations for research as stated in the Declaration of Helsinki, and the Dutch Medical Research involving Humans Subjects Act concerning scientific research. According to the Ethical Medical Committee of the University Medical Centre Utrecht, this act was not applicable to the present study. Written informed consent was obtained from both patients and parents.
Measures
Posttraumatic stress
The Children's Responses to Trauma Inventory (CRTI; Alisic, Eland, & Kleber, 2006) was used for participants aged 12-18 years. This is a 34-item questionnaire assessing severity of PTSD symptoms according to DSM-IV. Patients are asked to indicate to what extent a reaction to a traumatic event was present during the past week. Scores range from I to 5, with higher scores indicating more symptomatology. The four subscales: Intrusion, Avoidance, Arousal, and Other Child-Specific Reactions consist of 7, 11, 6, and 10 items, respectively. The reliability 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 questionnaire, assessing cognitive, affective, and behavioural symptoms of depression. The Dutch CDI has a satisfactory internal consistency, with Cronbach's a ranging between 0.71 and 0.89 (Timbremont & Braet, 2002).
Behavioural problems
The Youth Self-Report (YSR; Achenbach & Rescorla, 2001) was used for participants aged 12—I8 years. This questionnaire evaluates the teenager's perception of behavioural and emotional problems. YSR has shown to be internally reliable (Cronbach's a's ranging from 0.71 to 0.95), and convergent and discriminant validity is reported to be satisfactory (Berube & Achenbach, 2006). The YSR includes four broadband scales and nine narrow-band scales to assess behaviour problems. For the purpose of the study, only the total score on behaviour problems was included in the analyses.
General psychopathology
The Symptom Checklist-90-R (SCL-90-R; Arrindell & Ettema, 1986) was used for participants aged 12-25 years. This is a 90-item self-report inventory to assess psychosocial distress. Patients were instructed to indicate the amount they were bothered by each of the distress symptoms during the preceding week. Patients rated 90 distress symptoms on a five-point Liken scale with being "not at all" and 5 being "extremely." The statements are assigned to eight dimensions, reflecting various types of psychopathology: anxiety, agoraphobia, depression, somatization, insufficiency, sensitivity, hostility, and insomnia. The Global Severity Index (GSI) can be used as a summary of the test and reflects the severity of all answered statements as a global measure of distress. Cronbach's a has been found to range from 0.73 to 0.97. For the purpose of the study, only the GSI was analysed.
Data analyses
To compare demographic and post-rape characteristics between the early and delayed disclosers, chi-square tests were used. To compare multiple continuous psychological scores, MANCOVA was used with "time since trauma" as a covariate to correct for the potential influence of time since trauma.
Delayed disclosure was used as a dependent variable. The strength of the univariate associations between each potential risk factor and delayed disclosure was estimated by calculating the odds ratio (OR) along with 95% confidence intervals (95% CI). To determine the strongest risk factors for delayed disclosure, each potential risk
factor identified in the univariate analyses with a significant 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 goodnessof-fit chi-square was used to calculate how well the data fit the model. For all statistical analyses, a p-value of <0.05 was considered statistically significant.
All statistical analyses were conducted using SPSS (IBM SPSS Statistics for Windows, Version 20.0, IBM Corp., Armonk, NY).
Results
Socio-demographic characteristics
Socio-demographic characteristics of the sample are presented in Table I. Victims' age ranged from 12 to 25 years, with a mean age of 16.7 years (SD =2.7) and a median age of 16.1 years. Victims' mean age at time of rape was 14.3 years (SD =2.7) and a median age of 13.9 years. Penetration occurred in 79.6% of the cases. None of the victims reported prior chronic child sexual abuse. Data about victim—assailant relationship are presented in Table 2. Victims first disclosed after a mean 20.8 weeks (SD =56.8, range 1-624 weeks), although 58.5% of the cases told within 1 week. First disclosure was to a friend (45.8%), parent(s) (17.1%), (ex) boy-friend (9.4%), family member (6.8%), professional (5.8%), or other adult (15.2%). With regard to post-rape services, 53.8% of all victims consulted a doctor for medical care and 51.4% reported to the police. On average, victims were admitted to the centre 59.8 weeks post-rape (SD =93.7, range 1-676). The mean GSI of the rape victims on the SCL-90- R (Al = 209.7, SD = 61.8) was comparable with previously reported data of psychiatric populations [M=203.55, SD = 61.60; 4269) =1.629, p = 0.104] and was substantially
Table I. Demographic characteristics of rape victims (N-323) in valid percentages
| N | 44 |
|---|
| Dutch origin° Education lever | 274 | 84.8 |
| Low | 182 | 58.0 |
| Medium | 76 | 24.2 |
| High | 56 | 17.8 |
| Parents divorced | 102 | 31.9 |
| Lives at parental home | 273 | 85.3 |
| Current relationship | 81 | 26.5 |
| Prior negative sex | 46 | 14.8 |
'Dutch origin was defined as being a child from parents born in the Netherlands: °after 6 years of general primary school, at the age of 12 years. students enter low (4 years). medium (5 years). or high (6 years) secondary education level.
Table 2. Victim assailant relationship (N-323) in valid percentages
| Stranger | 94 | 29.5 |
|---|
| (Ex-)Boyfriend | 32 | 10.0 |
| Friend | 33 | 10.3 |
| Acquaintance | 61 | 19.1 |
| Person met during nightlife | 30 | 9.4 |
| Second-degree relative | 15 | 4.7 |
| Person seen only once | 15 | 4.7 |
| Person from school | 14 | 4.4 |
| Person met on the intemet | 12 | 3.8 |
| Colleague | 10 | 3.1 |
| Mentor | 3 | 1.0 |
higher [4269) =24.297, p <0.001] compared to the general population (M=118.28, SD =32.38; Arrindell & Ettema, 1986). For the CDI, mean scores were in the clinical range (M=17.2, SD =4.6) and rape victims had significantly higher mean scores (1(230)=15,923, p <0.001), in comparison to previously reported data of the general population of adolescent girls (Timbremont, Braet, & Roelofs, 2008; M=9.01, SD =6.45).
Differences between early and delayed disclosers
Fifty-nine percent of the sample consisted of early disclosers (disclosure within I week). No significant differences in demographic characteristics were found between early and delayed disclosers, except that there were more delayed disclosers in the age category 12-17 years compared to the early disclosers group (x2 (1) =6.96; p = 0.008). For rape characteristics, significant differences between groups were found for the use of penetration, with more victims of penetration in the delayed disclosers group compared to the early disclosers group (x2 (I) = 5.37; p =0.02). Also, the delayed disclosers group presented more victims of verbal and/or weapon threats than the early disclosers group (x2 (I)=5.35; p =0.02). Furthermore, among the delayed disclosers more victims identified the assailant as a close person compared to the early disclosers (x2 (I) =10.84; p =0.001). Alcohol was used more often in the early disclosers group compared to the delayed disclosers group (x2 (I) =20.24;p <0.001).
With respect to post-rape characteristics, a significantly smaller proportion of the delayed disclosers (15.9%) utilized medical services following the rape compared to the early disclosers (30.3%; z2 (1)=5.32; p =0.02). Similarly, a significantly smaller proportion of the delayed disclosers (14.6%) compared to the early disclosers (34.3%) reported the rape to the police (x2 (I) =16.15; p <0.001). The time since trauma at admission was significantly lower for early disclosers (M=41.1 weeks, SD =79.4) than for delayed disclosers (M =82.9 weeks,
SD =103.3: 4314) =4.06, p <0.001). Mean and median time to seek help were 37.7 and 12.0 weeks, respectively. Mean time to seek help did not differ between groups (1(309)=2.54, p <0.48). Excluding outliers (M±3 SD, N = II) did not change the outcome of this analysis. Both early and delayed disclosers scored in the highest level of psychological distress when compared to previously reported norm scores (CRTI, Alisic, Eland, Huijbregts, & Kleber, 2012; CDI, Timbremont et al., 2008; YSR, Achenbach & Rescorla, 2001; SCL-90, Arrindell & Ettema, 1986), but the MANCOVA results showed that when comparing multiple continuous psychological scores, the overall psychological functioning (posttraumatic stress, depression, behavioural problems, and general psychopathology) did not differ significantly between early and delayed disclosers (F(6,I98) = 0.88, p =0.51).
Table 3 shows the ORs with 95% Cls for the associations between potential risk factors and delayed disclosure. Delayed disclosers, when compared to early disclosers, were significantly more likely to be in the age category of 12-17 years (OR =2.10), to have experienced rape by a close person (OR = 2.35), to have been threatened verbally and/or with a weapon (OR =1.75), and to have experienced penetration (OR = 1.99). Delayed disclosers were also found less likely to have used alcohol prior to the rape (OR = 0.22). None of the other factors were found to be significant risk factors for delayed disclosure.
Predicting delayed disclosure
A stepwise forward LR analysis was conducted to predict delayed disclosure, using "age category," "close assailant," "use of threats," and "penetration" as predictors. Victims' alcohol use was not entered in the analysis because of missing values for 33.4% of the cases. The use of threats was not a significant predictor in the model. A test of the full model against a constant-only model was statistically significant, indicating that the predictors (i.e., age category 12-17 years, close assailant, penetration) reliably distinguished between early and delayed disclosers (2 2 (3) = 23.09, p <0.000). There were no significant interactions between the predictors. Nagelkerke's R2 of 10.5% suggests only a modest association between the predictors and delayed disclosure, although the model did show an adequate fit to the data (Hosmer-Lemeshow x 2 (4) = 2.77, p <0.60). In total, 62% of the respondents were categorized correctly, when using the three predictors that contributed significantly to the prediction of delayed disclosure: age category 12-17 years (OR 2.05, CI 1.13- 3.73), penetration (OR 2.36, CI 1.25-4.46), and closeness to the assailant (OR 2.64, CI 1.52-4.60).
Discussion
The results of this study show that, although no differences were found between delayed and early disclosers in psychological functioning and time to seek help,
delayed disclosers were less likely to use medical services and to report to the police than early disclosers. Furthermore, this study identified a number of factors related to the timing of rape disclosure, showing that delayed disclosers represented significantly more adolescents 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 predicted delayed disclosure: age category 12-17 years, penetration, and the assailant being a close person. The finding that the victim's age significantly predicts disclosure 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 overcome 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 reprisal possibly contributing to the finding of delayed disclosure (Kogan, 2004). Also, adolescents may think that social reactions in response to disclosure are more negative in case of completed rape compared to assault.
Another factor that seems to make immediate disclosure of rape less likely is closeness to the assailant, as indicated by the assailant being a (boy)friend, family
lithie 3. Demographic and (post )rape characteristics by disclosure time (early vs. delayed disclosers) and odds ratios for delayed disclosure
| Demographic and (post-)rape characteristics Age category (years) | Early disclosure (N=185) | | | Delayed disclosure (i.e., >1-week post-rape), N=131 | OR | 95% CI |
|---|
| 18 25 | 55 | 17.4 | 22 | 7.0 | | |
| 12 17 Dutch origin | 130 | 41.1 | 109 | 34.5 | 2.10 | 1.20 3.65' |
| No | 27 | 8.5 | 22 | 7.0 | | |
| Yes Living with parent(s) | 158 | 50.0 | 109 | 34.5 | 0.85 | 0.46 1.56 |
| No | 29 | 9.2 | 16 | 5.1 | | |
| Yes Complete family structure | 155 | 49.2 | 115 | 36.5 | 1.35 | 0.70 2.59 |
| No | 58 | 18.4 | 42 | 13.3 | | |
| Yes Current sexual relationship | 127 | 40.3 | 88 | 27.9 | 0.96 | 0.59 1.55 |
| No | 127 | 411 | 97 | 31.9 | | |
| Yes Prior negative sexual experience(s) | 53 | 17.4 | 27 | 8.9 | 0.67 | 0.39 1A4 |
| No | 152 | 49.4 | 110 | 35.7 | | |
| Yes Known assailant | 32 | 10.4 | 14 | 4.5 | 0.61 | 0.31 1.19 |
| No | 56 | 17.7 | 36 | 11.4 | | |
| Yes Close to assailant | 129 | 40.8 | 95 | 30.1 | 1.15 | 0.70 1.88 |
| No | 150 | 47.6 | 84 | 26.7 | | |
| Yes Group rape | 35 | 11.1 | 46 | 14.6 | 2.35 | 1.40 3.9r |
| No | 160 | 50.8 | 116 | 36.8 | | |
| Yes Age of assailant (years) | 24 | 7.6 | 15 | 4.8 | 0.86 | 0.43 1.71 |
| 12 17 | 63 | 20.6 | 54 | 17.6 | | |
| >18 Use of penetration | 117 | 38.2 | 72 | 23.5 | 0.72 | 0.45 1.14 |
| No | 46 | 14.7 | 19 | 6.1 | | |
| Yes Use of threats | 136 | 43.5 | 112 | 35.8 | 1.99 | 1.10 3.60' |
| No | 90 | 31.6 | 48 | 16.8 | | |
| Yes Use of physical violence | 76 | 26.7 | 71 | 24.9 | 1.75 | 1.09 2.82' |
| No | 130 | 42.6 | 82 | 26.9 | | |
| Yes | 51 | 16.7 | 42 | 13.8 | 1.31 | 0.80 2.14 |
| No | 72 | 33.5 | 69 | 32.1 | | |
| Yes | 61 | 28.4 | 13 | 6.0 | 0.22 | 0.11 0.44' |
'p <0.05.
Seven participants were dropped from analyses due to missing disclosure time data.
member, or mentor. This finding is consistent with previous 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
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 victimization is most likely to occur during adolescence, as compared to childhood or young adulthood, and greatly increases the risk of revictimization (Humphrey & White, 2000). Hence, victims of rape by peers may be a target group for interventions promoting early disclosure.
Clearly, there are many variables working in tandem to affect the timing of victim's disclosure. A closer look at the final model, which identified three unique variables that contributed significantly to the prediction of delayed disclosure, 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 person 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 confuses 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 perpetrator 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 reactions, e.g., self-blame and avoidance coping. It is conceivable that they delay their disclosure as a result of rape-induced psychological distress (Starzynski, Ullman, Filipas, & Townsend, 2005), not necessarily the severity of the assault.
Although the final model showed acceptable goodness of fit, the percentage of explained variance of delayed disclosure was modest. Thus. there must be other variables predictive of delayed disclosure, such as the assailant's use of alcohol or weaker support systems, that we did not assess in this study. Besides this limitation, there are other drawbacks of this study that should be mentioned. First, a clinical sample was used with patients reporting high mean levels of psychological distress. This ceiling effect may explain why no differences were found between early and delayed disclosers on psychological functioning, contrary to prior studies (Broman-Fulks et al., 2007; Ruggiero et al., 2004). Second, posttraumatic stress was only assessed for children up to 18 years, and for young adults additional suitable measures were not used. Third, information could have been lost due to dichotomizing the variable disclosure latency. Fourth, results may not be
generalizable to all rape victims, because the percentage of victims that consulted a medical professional and reported to the police was higher in our sample than in most studies (Hanson et al., 2003; Resnick et al., 2000; Zinzow, Resnick, Bare, Danielson, & Kilpatrick, 2012). Perhaps, these differences could, at least partially, be explained by the fact that stranger rape, representing 30% of our sample, leads to higher likelihood of help-seeking and police reporting because of its association with higher acknowledgment of victim status (Resnick et al., 2000; Smith et al., 2000). The fact that this is a help-seeking sample is critical for the reasons cited in the discussion, but also because the generalizability of these data to rape victims who never tell anyone—perhaps the group most at risk—simply cannot be known. Besides these limitations, 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 postrape 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 evidence and how to best protect it, e.g., related to showering, 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 information about evidence-based treatments (Elwood et al., 2011; Littleton & Ullman, 2013; McLaughlin et al., 2013), may increase help-seeking behaviour in an early stage. Furthermore, efforts to encourage early disclosure must consider peer-to-peer victimization as a primary factor, as most participants in this study experienced this type of victimization, and may initially not have defined or acknowledged the incident as rape because they rationalize such experiences as normal (Hlavka, 2014), leading to the finding of delayed disclosure.
In conclusion, the results of the present study suggest that adolescent victims of rape with penetration by
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 adolescents and young adults to disclose in an early-phase postrape. Although the vast majority of the participants was living at their parental home, many of the sample did not first disclose to their parents. Therefore, it could be argued that in prevention programs specific attention should be given to the strengthening of the child—parent relationship, to facilitate disclosure to parents (Schonbucher et al., 2012). Next, as victims tend to disclose mostly to peers, prevention programmes may need to aim at teaching adolescents how they can help a peer victim if they become a recipient of disclosure (Schonbucher et al., 2012). In addition, education may increase victims' willingness to disclose early, thereby increasing opportunities 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 particularly social media (i.e., Facebook, Twitter, YouTube, etc.), forums, and mobile apps. Such programmes, wherein 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 postrape. 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 Questionnaire, 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).
Conflict of interest and funding
There is no conflict of interest in the present study for any of the authors.
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