Document 397-2

Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 1 of 45 Exhibit B DOJ-OGR-00005911 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 2 of 45 Review Manuscript TRAUMA, VIOLENCE, & ABUSE 2019, Vol. 20(2) 260–283 © The Author(s) 2017 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1524838017697312 journals.sagepub.com/home/tva SAGE Facilitators and Barriers to Child Sexual Abuse (CSA) Disclosures: A Research Update (2000–2016) Ramona Alaggia1, Delphine Collin-Vézina2, and Rusan Lateef1 Abstract Identifying and understanding factors that promote or inhibit child sexual abuse (CSA) disclosures has the potential to facilitate earlier disclosures, assist survivors to receive services without delay, and prevent further sexual victimization. Timely access to therapeutic services can mitigate risk to the mental health of survivors of all ages. This review of the research focuses on CSA disclosures with children, youth, and adults across the life course. Using Kiteley and Stogdon's literature review framework, 33 studies since 2000 were identified and analyzed to extrapolate the most convincing findings to be considered for practice and future research. The centering question asked: What is the state of CSA disclosure research and what can be learned to apply to practice and future research? Using Braun and Clarke's guidelines for thematic analysis, five themes emerged: (1) Disclosure is an iterative, interactive process rather than a discrete event best done within a relational context; (2) contemporary disclosure models reflect a social-ecological, person-in-environment orientation for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure; (3) age and gender significantly influence disclosure; (4) there is a lack of a life-course perspective; and (5) barriers to disclosure continue to outweigh facilitators. Although solid strides have been made in understanding CSA disclosures, the current state of knowledge does not fully capture a cohesive picture of disclosure processes and pathways over the life course. More research is needed on environmental, contextual, and cultural factors. Barriers continue to be identified more frequently than facilitators, although dialogical forums are emerging as important facilitators of CSA disclosure. Implications for practice in facilitating CSA disclosures are discussed with recommendations for future research. Keywords sexual abuse, child abuse, cultural contexts Introduction Timely access to supportive and therapeutic resources for child sexual abuse (CSA) survivors can mitigate risk to the health and mental health well-being of children, youth, and adults. Identifying and understanding factors that promote or inhibit CSA disclosures have the potential to facilitate earlier disclosures, assist survivors to receive services without delay, and potentially prevent further sexual victimization. Increased knowledge on both the factors and the processes involved in CSA disclosures is timely when research continues to show high rates of delayed disclosures (Collin-Vézina, Sablonniere, Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb, 2007; Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). Incidence studies in the United States and Canada report decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Turner, & Hamby, 2014; Trocmé et al., 2005, 2008), while at the same time global trends from systematic reviews and meta-analyses have found concerning rates of CSA, with averages of 18–20% for females and of 8–10% for males (Pereda, Guilera, Forns, & Gómez-Benito, 2009). The highest rates found for girls is in Australia (21.5%) and for boys in Africa (19.3%), with the lowest rates for both girls (11.3%) and boys (4.1%) reported in Asia (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). These findings point to the incongruence between the low number of official reports of 1Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada 2Centre for Research on Children and Families, School of Social Work, McGill University, Montreal, Quebec, Canada Corresponding Author: Ramona Alaggia, Factor-Inwentash Chair in Children's Mental Health, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. West, Toronto, Ontario, Canada M4KIW1. Email: ramona.alaggia@utoronto.ca DOI-OGR-00005912 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 3 of 45 Alaggia et al. 261 CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stoltenborgh, van IJzendoorn, Euser, and Bakermans-Kranenburg (2011) combining estimations of CSA in 217 studies published between 1980 and 2008 revealed rates of CSA to be more than 30 times greater in studies relying on self-reports (127 in 1,000) than in official report inquiries, such as those based on data from child protection services and the police (4 in 1,000) (Jillian, 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-Vézina et al., 2015; Easton, 2013; Hunter, 2011; McElvaney, 2015; Smith et al., 2000), these issues should be a concern for practitioners, policy makers, and the general public (McElvaney, 2015). The longer disclosures are delayed, the longer individuals potentially live with serious negative effects and mental health problems such as 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 (Reiterma & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McElvaney, 2015). This literature review differs by focusing on CSA disclosures in children, youth, and adults from childhood and into adulthood—over the life course. Method Kiteley and Stogdon's (2014) systematic review framework was utilized to establish what has been investigated in CSA disclosure research, through various mixed methods, to 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 review 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 peer-reviewed studies. A search of the gray literature (unpublished literature such as internal agency documents, government reports, etc.) was beyond the scope of this review because unpublished studies are not subjected to a peer-review process. Keyword search terms used were child sexual abuse, childhood sexual abuse, disclosure, and telling. A search of the 9 databases produced 322 peer-reviewed articles. Selected search terms yielded 200 English publications, 1 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 (1) multiple readings by the three authors; (2) identifying patterns across studies by coding and charting specific features; (3) examining disclosure definitions used, sample characteristics, and measures utilized; and (4) major findings were extrapolated. Reading of the articles was initially conducted by the authors to identify general trends in a first level of analyses and then subsequently to identify themes through a deeper second-level analyses. A table of studies was generated and was continuously revised as the selection of studies was refined (see Table 1). 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 DOJ-OGR-00005913 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 4 of 45 (continued) Table I. Child Sexual Abuse (CSA) Disclosure Studies: 2000-2016 Study Purpose Disclosure (CSA) Design Sample Findings Summary Gagner and Co n-Véz na (2016) To explore disclosure processes for male victims of CSA Phenomenogra ca methodo gy used to interview male CSA survivors. The Long Interview (LIM) gu ded data co ect on and ana ysis. 17 men n the study were abused, ranged n age from 19 to 67, average age was 47. Purposive samp ng strategy was used. The majority of the men n the study wa s closed and unt d to d scose the r abuse, with negative stereotypes controlling the r dec s on to d scose. Negat ve delayed d sclosures butted to be ng try ng to forget. Both soat on and a ack of vout us forms of media on d sclosure, linging to vout us stereotyping of ma e sexua ty, and ays contextua s negat ve. Had a mpact on d scoure issues such as negat ve stereotyping of ma e sexua ty, and ays contextua s negat ve. One of few stud es to focus excus y on Afr can Amer can women, but stuff s ze for a qua tat ve nqur y Important issues were brought forward. Retrospect ve study that may have been affected by reca of a fe-course perspect ve as a theoretca ng CSA n the m d d of fe cons dered n further years throughout the fe. 17 Afr can Amer can women n m d-d e between 40 and 63 exper enced ntraff ck ng or a CSA. Purpos ve snowba ng strategy Qua tat ve ntervew ng Co ect ve case study des gn w th use of narrat ve trad (storyboard) for data co ect on and ana ysis. 67 ma e and fema e CSA surv vors (76%) d scosed as chi dren to CSA d sclosure: Barr ers to d scoure were ident fed as fema e and from w th n-tema barr ers and dysfunction n the fam y dynam cs, awareness of the soc a network, and frag e soca network. Barr ers n reat on to d scosure of sexua ty- v ct m, ack abe ty, ava abe a ternat ves ava abe a e, and culture of sexua ty, ack abe ty, ava abe a ternat ves ava abe a e, and culture. D scosure ncreased w th the age of the offender generated data through se f-reports cou d be subject to cogn t ve d stort ons— n m n zat on or exaggerat ons. 369 adu t ma e ch offenders were been conv cted of a sexua offense nst a ch d d ranged between 1 Braze ton (2015) To explore the meaning Afr can Amer can women make of the trauma t c experiences w th CSA and how they d scosed across the fe course Qua tat ve ntervew ng To prov de a mapping of factors that prevent CSA d sclosures LlIM. Qua tat ve des gn us ng ens from a samp e of CSA adu t surv vors. Study object ves nvest gated the factors that fac cate CSA d sclosures Lec erc and Wort ey (2015) Adu t ma e ch offenders were nterv ewed to exam ne pred ctors of 262 DOJ-OGR-00005914 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 5 of 45 (continued) Table I. (continued) Study Purpose Design Sample Findings Summary McEvaney and Cu hane (2015) To investigate the feasibility of using child abuse assessment tools based on CSA disclosure. Victim disclosure interviews based on the QID. Female reports of children seen for assessment and CSA abuse unit in the hospital were reviewed. Sample and 17 years old. Majority were female, educated, and employed. White. Content analysis was conducted on 39 female and 7 male cases based on a coded framework. Parents were asked to have the child reveal for the study, were assessed. Majority of children (43%) were dent fed (1) lack of opportu nity to (2) opportu ty to self dent fed (3) Add ona themes of the b ing fed for cons dent fed shame/embarassment and peer influence were also dent fed. Perspectives of offenders on victim disclosure by victims rested during the offense. Majority of children and peers key to disclosure process. The sample size was small but with characteristics important to the study. Serves as an important exploratory process bringing forward potential themes for consideration. Disclosure processes sexua abuse perpetrator: with ntrarf perpetrator commit ted abuse and most (78.6%) of the victims did outs de the fam y take place more spontaneously and quickly; contrary, extrafam d sclosures done at school (80%) most often to the fam y member or a few other peers (94.6%) were abused by another adult. At time of the study, this was the largest qua tave data set to have been analyzed with an exp ct focus on adult male survivors' perceptions of barriers to CSA disclosure. Because the sample was med n terms of racial or ethnic differences (7.3%) disclosure differences based on race or ethnicity were not discerned. The majority of abuse reported was by c regy wh ch might present a un que set of barr ers to d sclosure. 220 of age (most age range 12-18 years) 78.2% were female victims, and 41.8% were male. In 14 cases, the perpetrator was a family member and in four cases, the perpetrator was a family member or acquaintance. Using qualitative content analysis, researchers conducted a secondary analysis on one study focus was on barriers to CSA disclosure with male survivors. Recruitment organization based survey. We Being organized from survey data, the 2010 CSA history survey, that used CSA history open-ended term on disclosure barriers. 460 men with CSA history completed an anonymous, Internet-based survey. Survey respondents were categorized into three domains of sociocultural: (1) interpersonal mistrust of others; (2) fear of not being believed; and (3) personal internal responses; past responses; and sexual abuse. Two thirds of respondents were of ages 18–84 years. Wh th respondents were Dumont, Messerschm tt: V a, Bohu, and Rey-Sal mon (2014) This study examined how the relationship between the perpetrator and victim, especially the victim at a or within the family, impact CSA disclosure. Female reports of children seen for assessment and CSA abuse unit in the hospital were reviewed. Easton, Salzman, and W s (2014) --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 6 of 45 Table I. (continued) Study | Des gn | Sample | Findings | Summary Easton (2013) | Cross-sect onal survey des gn. E g be des gn were anonymous, Internet-based survey dur ng dfferences based on age. A fe span approx mately so, to exp ore react ons based on dsc losure attr butes and men's mental health p3 between dsc losure and men's mental health was s gnf cant. Mean age for onset of CSA was 10.3 years. | Purpose was to descr be CSA d sure processes us ng a fe span approach. A fe span dfferences based on dsc losure attr butes and men's mental health were nvest gated. | O der age and be ng abused by a fam ly member were both re ated to n creased ra s ng zat ons awareness n CSA v ct ms wh ch d not d sc ose part cu ar d sc osure. Most part cpants wh d d sc ose rece ved y support n emot onal responses and the he span protect ve responses and the he span was m xed. Deays n t me (over 20 years) were s gnf cant. Approx mate y ha f of part cpants rst to d sc ose to a spouse/partner (27%); the samp ng strategy ga ned access to a predom nantly h dden popu at on. Important c n ca recommendat ons are made wth an emphas s on a fe-course focus | Purpos ve samp ng f ng men from awareness ra s ng zat ons part cpants who had a ready d scosed part cu ar d sc osure needed to have access to Internet wh ch would requ re men n over SES groups wh ch f cant Eng sh wh ch e n mate certa n cu tura groups. However, McEvaney, Greene, and Hogan (2012) | Grounded theory method study. | Sample of 22 young peop e, 16 gr s and 6 boys; age range: 8-18 years. | A theoret ca mode was deve oped that conceptua zes the process of CSA d sc osure qua tat ve y. H gh eve of secrecy was d scosed as one of contain ng CSA surv vors | Modest but suff cient emp r ca support for an exploratory qua tat ve study of trustworthiness | (continued) Schonbucher, Maer, Mohler-Kuo, Schnyder, and Landolt (2012) | Conven ence samp e of 26 sexu a y ado escent boys and 31 gr s. Age range: 15-18 years. On ne surveys and n-depth nterv ews were adm n stered on fam y soc oeconom c status, to nvest gate the process of CSA d scosure wth d scourse from the ado escents from the genera popu at on who had exper enced CSA. How many d scosed, who d scosed, were used to recru t youth from 264 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 7 of 45 (continued) Table 1. (continued) Study Hunter (2011) Schaeffer, Leventhal, and Asnes (2011) Summary Findings Design Purpose A majority of the 22 part c pants d d not make a d sclosure unt l and a er they ngs support agg s (2004) mode c disclosure but suff ent samp e sze s for very ng behav or nd rect attempts to category. cs d sclosure shou d be a comp ex process. An innovat ve study to try to assess can fac tate d sclosures of CSA. Data were based on a large number of nterv ews. Data ed anays s produced deta ed findings supporting other ngs on d sclosure. The barr ers to ch d sclosure dent f ed were: (1) ch d s w tnessed (e.g., the perpetrator abuse was a request ev dence of abuse) (e.g., the ch d was tntesed); (2) fears get n trouble she he to d); (3) ack of understand ng ty (e.g., the ch d fa ed to recogn zeabus ve behavior as unaccepta e); and (5) the perpetrator was a fr end not to burden them. Ear er d sclosures are reated to extra fam occurrence of v ct m abuse together, and parents who were vewed as conf dan ts samp e sze. More y out of 22 part c pants d d report h gher eve s of shame and se f-b ame about the r y sexua exper ences. Fear, shame and se f-b ame were further det ected n the man n tors d sclosure. The ngs are further det a ed and through subthemes. The ngs support agg s (2004) mode c disclosure but suff ent samp e sze s for very ng behav or nd rect attempts to category. cs d sclosure shou d be a comp ex process. Study sought to f nd out f 191 nterv ews of CSA v ct ms aged 3-18 over a 1-yr per od were add dress nqry ry about the process of a ch d s d sclosure; (2) determ ne f ch d s d sclosure fac l tated f orens c nterv ews Forens c nterv ewers were asked to incorporate quest ons about "rea sons for d sclosure" and to test f they "ran" or "fy" ed them to de ay d sclosure. Interview protoco related to the ex sting forens c nterv ew content. Interview protoco related to the ex sting forens c nterv ew content. ch d ren's reasons for d sclosure were extracted, transcribed and analyzed us ng grounded theory method of anays s. Sample community and couns ng serv ces v ct ms genera y, v ct m heath, and mental heath. Sexua Assault Module of the Juven le V ct m zat on used Narrat ve nqry ry methodo gy. Face-to-face nterv ews were conducted w th 713 women part c pants. Data were ana yzed us ng Rosentha s (2004) F-scher- Rosentha s (2004) method. Purpose of th s study was to deve op a fu er understand ng of CSA d sclosures. Th s study med to: (1) add dress nqry ry about the process of a ch d s d sclosure; (2) determ ne f ch d s d sclosure fac l tated f orens c nterv ews; (3) descr be factors that ed them to test f they "ran" or "fy" ed them to de ay d sclosure. 74% of ch dren were female and 51% were Caucas an 265 DOJ-OGR-00005917 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 8 of 45 (continued) Table I. (continued) Study Alaggia (2010) Fontes and Pummer (2010) Ungar, Barter, McConnech, Tutty, and Fathom. (2009a) Summary Findings Themes Sample Design Purpose The study presents a comprehensive socio-ecological analysis of CSA disclosure. Of note, 42% had disclosed the abuse during childhood; 26% had not disclosed because they had repressed the memory of the abuse; and the remainder had attempted some form of disclosure, but it was not successful. A retrospective approach that could be affected by recall issues. One of the few works that adds knowledge to cultural contextual factors affecting CSA disclosure. Uniquely combines findings with an in-depth study of CSA disclosure. Recommendations made to (1) disclose CSA details; (2) question cultural competency; and (3) culture stands as an important factor in disclosure, not so much in CSA cases which are not so different. Youths' experiences of CSA disclosure were examined in a national sample of 1621 youths. Evaluation forms were completed by youth owing to participation in abuse prevention programs. --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 9 of 45 (continued) Table 1. (continued) Study Design Purpose/findings Sample Summary Ungar, Tutty, McComne , Barter, and Fa rhom (2009b) This study explored abuse disclosure strategies with a nonrepresentative sample of 1,099 Canadian youth who completed own victimization forms Red Cross RespectED programming between 2000 and 2003 was the focus of the study. One of the goals of the study was to document not only youth's experiences of abuse but also their attitudes towards abuse prevention programs: (1) What forms of abuse disclosure barriers do youth face? (2) What's their abuse disclosure patterns? (3) What are youth's experiences with abuse disclosure? (4) What are youth's interactions with peers, educators, and caregivers? About three-quarters of youth disclosed; significantly more youth disclosed to peers than to adults. About half disclosed to CSA survivors. Findings suggest disclosure is a process, with expectations shaped by young people's previous experiences of abuse. Patterns of incremental disclosure were reported. Innovative designs of this study provide insights into young people's perceptions of good disclosure experiences. High trustworthiness of the data was ensured through use of youth focus groups, interviews, and observation data. The study results are somewhat limited because most of the descriptions of abuse can offer because of the clinical nature of the data. Regional survey-based differences may not have been picked up. Scope and approach were broad and creative. 1,099 youth evaluated forms of abuse disclosure. Out of 1,099 participants, 225 males and 779 females indicated that they had been abused. Of those, 43 males and 180 females disclosed the abuse. Of those who disclosed, a portion of males and females reported that they had disclosed to "When I was abused" or "When I was younger". 5% were directed towards professionals and others, with fewer choosing parents/family, and others. Twenty-seven interviewers and focus groups were so done to understand contextual issues and engage youth program facilitators in the interpretation of findings. A coding structure was developed for analyses to synthesize themes across data sources. --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 10 of 45 Table 1. (continued) Study Purpose Design Sample Findings Summary Priebe and Svedin (2008) This study aimed to investigate disclosure patterns and examine predictors of disclosure and nondisclosure. Participants completed 65-item questionnaires that included questions about background, consensual sex, sexual abuse experiences, noncontact abuse (e.g., exhibitionism), and female- and male-perpetrated CSA and whether they disclosed CSA or not. The sample consisted of 4,339 high school students in Sweden (2,324 boys). The mean age of the participants was 18.15 years. This study used a subsample of 1,962 participants who reported CSA and answered disclosure questions. Fewer had reported the abuse to a professional (contact abuse) with more severe CSA, but over 69% of boys (23%) and girls (6%) reported disclosure to someone. More of the sexual abuse boys experienced was key to disclosure; father or other male relative, rather than a female abuser. A qualitative component of the study provided a broader understanding of disclosure processes. Study focused on male survivors of CSA disclosure challenges for male survivors of CSA: (1) To understand three issues: (1) To understand --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 11 of 45 (continued) Summary Findings Sample Design Purpose and content of the present study Table 1. (cont nued) Study --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 12 of 45 Table I. (continued) Study A gg a and K rts henbaum (2005) A gg a (2005) Co gngs Gr f f ths and Kuma o (2005) 270 Purpose ves of the current study were to f y a broad range of factors, nclud ng fam dynam cs that contribute to or Purpose samp ng of men and women a ong h ndrose CSA was to quetate y exp ore or promote d scosure by exa n ng a range of factors nclud ng gender c dynam c- The study's purpose was to quetate y exp ore Summary Over ha f the part c pants had not d closed the abuse dur ng ch hood. Of the nond sclosers, part c pants x d scose because they had repressed or forgotten the memory. A most one th rd of the d scosure Three themes emerged for men that nh b ted or prec p tated d scosure: (1) reasons re ated to gender Content ana ys s dent f ed two broad d mens ons of d scosure: (1) agency: ch-d nated d scosure versus These resu ts ft nto A gg a's (2004) d scosure framework. Through data ana ys s, two raters coded F nd ngs Four major themes emerged suggest ng that CSA d scosure can be seen as a cond t ng when certa n fam- needed on γ. More data are garner more nformat on on d sc osure. prec bant for d sc osure, and (3) fea that prec bant for nond sc osure. Two predom nant themes w th ffect author's d scosure es us a def ned four d screte categor es ons wh ch proved to be both exhaustive and mutua y excusive (continued) 1,737 cases of CSA Durban area of KwZulu-Nata, South Afr ca v ct ms Two study object ves to: (1) exam ne how and Des gn A qua tat ve og ca des gn—LIM—was used to e ct d scosure Surv vors of CSA were nterv ewed about ther d scosure Narrat ve nterv ews were conducted to capture fam y eve factors. Axa and L ne-by- ne open cod ng was conducted to capture fam y eve factors and Study exam ned patterns of d scosure n a arge representat ve samp e of South Afr can CSA v ct ms 1,614 g rls and 2001 to December 2003 g ts and 1,737 cases of CSA reported to the North Durban object ves to: (1) exam ne how and DOJ-OGR-00005922 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 13 of 45 (continued) Table 1. (continued) Study | Purpose | Design | Sample | Findings | Summary Hershkovitz and Lamb (2005) | To identify characteristics of suspected child abuse victims that are associated with disclosure during interviews | Large database of suspected cases of child abuse between 1998 and 2002 was analyzed. Interviews using standardized NICHD Protocol were conducted. Interview data were analyzed. | The sample comprised 26,446 children aged 3- to 14-years-old. 65% of the 26,446 children reported sexual abuse and physical abuse was reported in 6% of cases. Analyses only involved cases that had come to the attention of the agency making the referral. Disclosure rates increased 1- to 5-year-olds: 50% to 67%; 6- to 10-year-olds: 67% to 74%; and 11- to 14-year-olds: 74% disclosed abuse when questioned. None of the children were asked about physical abuse. Evidence for delayed disclosure was found. The results indicate that disclosure is a fundamental process that becomes more difficult the longer it is delayed. Children first told a family member. Shorter delay was more likely when the perpetrator was a family member. Over 90% of the 26,446 children made key findings of disclosure. Rates of disclosure varied systematically depending on the nature of the alleged offenses and the relationship between the victim and the suspected perpetrator. Children aged 3- to 6-years-old were less likely to disclose abuse during a forensic interview. Disclosure rates grew with age. | Generalizability of this study is limited by the fact that the sample was comprised of children who were referred for assessment referred through a police report. Overall findings indicate that rates of disclosure vary systematically depending on the nature of the alleged offenses and the relationship between the victim and the suspected perpetrator. Analyses only involved cases that had come to the attention of the agency making the referral. Disclosure rates increased 1- to 5-year-olds: 50% to 67%; 6- to 10-year-olds: 67% to 74%; and 11- to 14-year-olds: 74% disclosed abuse when questioned. None of the children were asked about physical abuse. Evidence for delayed disclosure was found. The results indicate that disclosure is a fundamental process that becomes more difficult the longer it is delayed. Children first told a family member. Shorter delay was more likely when the perpetrator was a family member. Strengthening parent-child relationships is an important practice when the child's experiences are taken into account. Jensen, Jørundsen, Mossige, and Tjersland (2005) | To study how children and parents were able to report their experiences in the context of an interview which dated back to what made them talk about sexual abuse experiences; the reactions of the parents; and what the parents and children perceived as helpful in the disclosure process. | Qualitative approach to data collection was used. Therapeutic conversations were analyzed through a tentative approach. | 20 families were interviewed 22 times in total. 3-4 participants in each family were interviewed. Children and parents were interviewed separately. Follow-up interviews were held 1 year after the initial interviews. | The study involved 20 families with a total of 22 children. Children aged 3-15 years (average age 7.5 years) and 16 adults participated. Sexually abused children felt it was difficult to share their experiences with someone in the family or close relative. When the child's experiences were taken into account, a purpose to talk, a connection on what they are talking about, and strengthening parent-child relationships is an important practice when the child's experiences are taken into account. | DOJ-OGR-00005923 271 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 14 of 45 Table 1. (continued) Study Purpose Design Sample Findings Summary Sta er and Nelson-Garde (2005) The purpose of this study was to understand the process of CSA disclosure and how this unfolded for ado escent gr's who had experienced CSA. Examined and subsequent consequences of CSA. Samp econs sted of 34 part pants from four groups: Sessions were seen between 60 and 90 m n and were audio taped and transcribed for content ana ysis. Us ng purpos ve samp ng of survivors of CSA, 24 ad teen (ages of 18 between 1.5 and 6 years) were recruited by 57% male and 43% female agen ts. The study emp oyed a LIM—a design/ ca des geno ca phenomenon or construct that drives or promote CSA d'sc osure—and to address gaps n knowledge about what, when, and under what c rcumstances v ct ms of CSA d'sc ose. (continued) Findings The mothers said they were concerned about negative effects for the ch dren as a consequence of d'sc osure. They reported n three major doma ns: (1) self-phase, where they coser to the d'sc osure process, coser to the abuse and d'sc osure occurred. Sma groups of pea ado escent gr's who survived sexua gr's who had survived sexua abuse a so served as constuants and were encouraged to share the know edge for the benefit of prof essiona pract oners. This study prov ded a contextua exam nat on of the entr d'sc osure process and what adult d ren and c rcumstances that occurred n ch dhood suscept b e n memory fa espec a y when these memories were forgotten. Th s study expanded types of CSA d'sc osures to more fu y understand how d ren and adult d'sc ose. And under what c rcumstances that occurred n ch dhood suscept b e n memory fa espec a y when these memories were forgotten. Over ha f the study samp e d d not frget these 272 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 15 of 45 Table 1. (continued) Study Purpose Cr ma Base Pac and Romto (2004) The main goals of this study were to understand Jonzon and Lindbad (2004) Study purpose was to explore how abuse exposure traits are related to CSA Design Sample In-depth telephone (anonymous) interviews were obtained after exp n informed asent was obta ned. Three invest gators Adult women reporting CSA by someone close before the age of 18 and someone close at the age of 18 and had Summary Findings reve on of events are a so potent a prob em n reca 68% delayed disclosure unt at the time of the first adult hood. At the time of the study, one of the lots of support networks prev us y estab shed categor es: Three verba abuse character st cs abuse by mu t p e average age of abuse onset was 6.5 years; 42% of the part c pants 122 adult women between 20 and 60 (average age of 41 years) reporting CSA by someone cose before the age of 18 and had --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 17 of 45 Table 1. (continued) Study Purpose Design Sample questionnaire for childhood abuse characteristics and the disclosure. Child disclosure, perception of response and fear of negative consequences probed. Correlate analyses were conducted with path analyses to test the hypothesized causal relations among variables. The study focus was to gather data from a large sample of women about the length of time to disclosure. Structured telephone interviews were conducted with approximately 2,009 women who reported being sexually assaulted before age 18 and who were randomly selected from a sample of 2,009 respondents. A computer-assisted telephone interviewing (CATI) system was used to conduct the interviews. Random digit dialing (RDD) was used to select the sample. The survey consisted of several measures designed to assess the disclosure of child sexual abuse and its consequences. The present study reports on data from the demographic and disclosure variables. Two probability samples, Wave 1 and Wave 2, were selected from the 1989 and 1995 National Crime Victimization Surveys (NCVS). The average age at the time of the first rape was 10.9 years. Of the 288 women who reported being sexually assaulted, 28% stated that they had told no one about the assault at the time it occurred. The time frame of this survey may have had contextual influences on the major types of events reported in the sample. The average number of sexual assaults (including CSA) reported was 2.09. Anyone queried by the interviewer was considered to be a disclosure. Approximately 47% of women between 18 and 34 years old reported being sexually assaulted. Fewer than 10% of victims reported making a report to law enforcement personnel. On average, 12% of child rape victims stated that they had reported the assault to someone. The time frame of this survey may have influenced the major types of events reported in the sample. The average number of sexual assaults (including CSA) reported was 2.09. Anyone queried by the interviewer was considered to be a disclosure. Summary negative consequences to disclosure took longer to disclose. We designed a study with a high level of rigor. Produced a valuable mode of disclosure for further investigation. Researchers were not able to interview children. However, perceptions were not able to be determined. Findings negative consequences to disclosure took longer to disclose. Children who brought harm to others took longer to disclose. Fear of negative consequences to disclosure took longer to disclose. Approximately 47% of women between 18 and 34 years old reported being sexually assaulted. Smith, LeTourneau, Saunders, K. Patrick, Resnick and Best (2000) Note. SCL-90 = Symptom Check-List-90; SES = socioeconomic status; LIM = long interview method; CSA = child sexual abuse; NCHD = National Institute of Child Health and Human Development; QIS = Questionnaire Informatique sur les Aggressions Sexuelles; NWS = National Women's Study; DSA = Disclosure of Sexual Abuse; NSA = National Survey of Adolescents. --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 18 of 45 276 TRAUMA, VIOLENCE, & ABUSE 20(2) examples of this usage were found in the research questions, interview guides, and surveys examined: "How and when do people decide to tell others about their early sexual experiences with adults?" (Hunter, 2011, p. 161); "Some men take many years to tell someone that they were sexually abused. Please describe why it may be difficult for men to tell about/discuss the sexual abuse" (Easton, Saltzman, & Willis, 2014, p. 462). "Participants were asked a series of open-ended questions to elicit a narrative regarding their experiences of telling . . ." (McElvaney, Greene, & Hogan, 2012, p. 1160). "Who was the first person you told?" (Schaeffer, Leventhal, & Anes, 2011, p. 346).There was sound consistency between studies, defining 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 1 week or 1 month as a delayed disclosure (i.e., Hershkowitz et al., 2007; Kogan, 2004; Schönbucher, Maier, Moher-Kuo, Schneider, & Lamolt, 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; Schönbucher 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 barriers and bring forward less information on disclosure facilitators.Through an in-depth, second-level analysis, this review identified five distinct themes and subthemes beyond the 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-Vézina et al., 2015; Easton, 2013; Hunter, 2011). Knowledge building about CSA disclosure has moved in the direction of understanding this as an iterative and interactive process rather than a discrete, one-time event. Since the new millennium, disclosure is being viewed as a dynamic, rather than static, process and described "not as a single event but rather a carefully measured process" (Alaggia, 2005, p. 455). The catalyst for this view originates from Summit (1983) who initially conceptualized CSA 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 its 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 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 19 of 45 Alaggia et al. 277 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-ecological 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-Vézina et al., 2015; Easton et al., 2014; Hunter, 2011; Ungar, Tutty, McConnell, Barter, & Fairholm, 2009b). Social-ecological explanations open up more opportunities to intervene in facilitating earlier disclosures. Alaggia (2010) 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-Vézina, 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) barriers 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-Vézina et al., 2015; Fontes & Plummer, 2010). In addition, relationship with perpetrator is a factor whereby research indicates that disclosure is made more difficult when the perpetrator is a family member or close to the family (Dumont, Messerschmitt, Vila, Bohu, & Rey-Salmon, 2014; Easton, 2013; Goodman-Brown et al., 2003; Hershkowitz et al., 2005; Priebe & Svedin, 2008; Schönbucher et al., 2012). This is especially a barrier when the perpetrator lives with the victim (LeClerc & Wortley, 2015). 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-Vézina 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 1). Among the child and youth samples, the age ranges spanned from preschool to late adolescence (3–17 years of age), with varying methodological approaches implemented across age cohorts. For younger cohorts, file reviews and secondary data analyses of CSA reports were typically undertaken. 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., 2009b). In the majority of child and adolescent samples, sexual abuse concerns were already flagged to investigative authorities. However, the work of Ungar, Barter, McConnell, Tutty, and Fairholm (2009a, 2009b) is one exception, whereby their survey elicited new disclosures. DOJ-OGR-00005929 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 20 of 45 278 TRAUMA, VIOLENCE, & ABUSE 20(2) Adult studies typically had a mean age between 40 and 50 years. Interviews were the main data collection method with a few exceptions using survey designs (i.e., Easton, 2013; Kogan, 2004; Smith et al., 2000) and case file reviews (i.e., Collings et al., 2005; Goodman-Brown et al., 2003). Results show a clear trend toward increased likelihood of disclosure in older youth, and findings from adult samples showing a preponderance of disclosures in adulthood, with the large majority of participants of adults reporting never having had a sexual abuse complaint filed with investigative authorities as a child or an adolescent (i.e., Hunter, 2011; Gagnier & Collin-Vézina, 2016; Sorsoli, Kia-Keating, & Grossman, 2008; Ungar et al., 2009b). 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 emerges is that rates of disclosure increase with age, especially into adulthood, which is supported by persistent findings of high rates of delayed disclosure reported later in the life course by adult survivors (Collings et al., 2005; Collin-Vézina et al., 2015 ; Easton, 2013; Jonzon & Linblad, 2004; Kogan, 2004; Leclerc & Wortley, 2015; Sorsoli et al., 2008). While gender and relationship with the perpetrator are considerable factors in CSA disclosure, age is consistently a stronger predictor of disclosure (or nondisclosure) (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-Vézina, 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 this 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 (Hébert, Tourigny, Cyr, McDuff, & Joly, 2009; Ungar et al., 2009b). Easton, Saltzman, and Willis (2014) have been developing gender-specific modeling of disclosure examining male 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-Vézina, 2016). In the one study that compared male and female disclosures, investigator found that men's fears of being viewed as homosexual; profound feelings of stigmatization or isolation because of the belief that boys are rarely victimized; and fear of becoming an abuser acted as disclosure barriers. Whereas females felt more conflicted about who was responsible for the abuse and more strongly anticipated being blamed and not believed (Alaggia, 2005). 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 DOJ-OGR-00005930 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 21 of 45 Alaggia et al. 279 Table 2. Factors Influencing Child Sexual Abuse Disclosures. Barriers Facilitators Age: The younger the child victim, the less likely they will purposefully disclose. 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. Involvement of others: Eyewitnesses coming forward and reporting; detection through community members, professionals 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 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-Vézina, 2016). Victims of intrafamilial abuse when the offender is a parent, caregiver, significant family member, or someone in a family-like role are less likely to disclose immediately or at all in childhood/adolescence because of obvious power differentials and dependency needs (Collings et al., 2005; Dumont et al., 2014; Hershkowitz et al., 2005; Kogan, 2004; Leclerc & 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-Vézina 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-Vézina 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-Vézina 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-Vézina 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 DOJ-OGR-00005931 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 22 of 45 280 TRAUMA, VIOLENCE, & ABUSE 20(2) experiences, consequently more readily identifying barriers. On the other hand, these findings may speak to the actual imbalance between facilitating factors and barriers for 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-Vézina et al., 2015; Crisma et al., 2004; Easton, 2013; Hershkowitz et al. 2007; McElvaney, 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 forums/workshops, 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" (McElvaney et al., 2014); workshops on abuse and sexual abuse, in particular, can facilitate disclosures (Ungar et al., 2009b); and using culturally sensitive probes and questions (Fontes & Plummer, 2010). In Gagnier and Collin-Vézina's (2016) study, positive disclosure experiences were described by participants as those where they felt that they had been listened to, were safe, were believed, and were not judged by the person they disclosed to. Further, family members and friends (peers) of the child victim can act as key supports to creating an open relational context and fostering positive responses (Jensen et al., 2005; Priebe & Svedin, 2008; Schönbucher et al., 2012; Ungar et al., 2009b). In particular, as children grow older, they are more likely to disclose to a peer, as shown in a number of studies, and this is an important reality for counselors and educators to be aware of (Dumont et al., 2014; Kogan, 2004; Schönbucher et al., 2012; Ungar et al., 2009b). (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 life-course perspective in investigations, although age consistently surfaces as significantly influencing CSA disclosure. Using a life-course perspective through the use of longitudinal studies is recommended. 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 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; --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 23 of 45 Alaggia et al. 281 the frequency of acquitted cases or rulings in favor of the perpetrator through media outlets, often sensationalized, become a further compounding barrier. Given the review 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, authorship, and/or publication of this article. DOJ-OGR-00005933 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 24 of 45 282 TRAUMA, VIOLENCE, & ABUSE 20(2) References Alaggia, R. (2004). Many ways of telling: Expanding conceptualizations 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). 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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., & Lindblad, F. (2004). Disclosure, reactions, and social support: Findings from a sample of adult victims of child sexual abuse. Child Maltreatment, 9, 190 200. Kiteley, R., & Stogdon, C. (2014). Literature reviews in social work. 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, R. (2015). Predictors of victim disclosure in child sexual abuse: Additional evidence from a sample of incarcerated adult sex offenders. Child Abuse & Neglect, 43, 104 111. London, K., Bruck, M., Ceci, S. J., & Shuman, D. W. (2005). Disclosure 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, R., Greene, S., & Hogan, D. (2012). Containing the secret of child sexual abuse. Journal of Interpersonal Violence, 27, 1155 1175. DOJ-OGR-00005934 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 26 of 45 Child Abuse Review Vol. 24: 159–169 (2015) Published online 9 May 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/car.2280 Disclosure of Child Sexual Abuse: Delays, Non-disclosure and Partial Disclosure. What the research Tells Us and Implications for Practice Rosaleen McElvaney School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland This paper reviews the research on disclosure of child sexual abuse with specific reference to delays in disclosing, non-disclosure and partial disclosure of experiences of child sexual abuse. Findings from large-scale national probability studies highlight the prevalence of both non-disclosure and delays in disclosure, while findings from small-scale qualitative studies portray the complexity, diversity and individuality of experiences. The possible explanations regarding why children are reluctant to disclose such experiences have significant implications for addressing the issue of child sexual abuse from the perspectives of child protection, legal and therapeutic professionals. The importance of understanding the dynamics of disclosure, in particular the needs of young people to maintain control over the disclosure process, the important role that peers play in this process, the responses of adults in both informal and formal networks, and the opportunities to tell, is key to helping young people speak more promptly about their experiences of sexual abuse. Copyright © 2013 John Wiley & Sons, Ltd. 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 An issue of increasing concern in recent years is the phenomenon of delayed disclosure of childhood sexual abuse and the need to understand the process of how children and adults disclose their experiences of child sexual abuse, given the implications for child protection, social justice and *Correspondence to: Rosaleen McElvaney, School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin 9, Ireland. E-mail: rosaleen.mcelvaney@dcu.ie Copyright © 2013 John Wiley & Sons, Ltd. Accepted: 17 February 2013 DOI-OGR-00005936 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 27 of 45 160 McElvaney 'This paper reviews the research on disclosure patterns of childhood sexual abuse' 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 'Most people who experience sexual abuse in childhood do not disclose this abuse until adulthood' There is consensus in the research literature that most people who experience sexual abuse in childhood do not disclose this abuse until adulthood, and when disclosure does occur in childhood, significant delays are common. Table 1 summarises two large-scale studies to highlight the extent of delays in disclosure and the percentage of those who did not disclose to anyone prior to the study. Kogan (2004) examined the timing of disclosure of unwanted sexual experiences in childhood or adolescence in a sub-sample (n = 263 adolescent women, aged 12 to 17) of the National Survey of Adolescents (Kilpatrick and Saunders, 1995) in the USA - a nationally representative study. Kogan's results can be summarised as follows: immediate disclosure (within 1 month) 43 per cent, delayed disclosure (less than 1 year) 31 per cent and non-disclosure (disclosed only during the survey) 26 per cent. Smith and colleagues (2000) examined a sub-sample (n = 288) of the National Women's Study in the USA (Resnick et al., 1993, cited in Smith et al., 2000) who had reported a childhood rape prior to the age of 18. Smith et al.'s findings can be summarised as follows: immediate disclosure (within 1 month) 27 per cent, delayed disclosure (more than a year) 58 per cent and non-disclosure (survey only) 28 per cent. Those who had never disclosed prior to the survey constitute comparable proportions in these two studies while the rates for immediate disclosure and delayed disclosure vary. Table 1. Patterns of disclosure - delay and non-disclosure | | Kogan (2004) (n = 263 adolescents) | Smith et al. (2000) (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 1 year | 19% | 47% | | Never told before survey | 26% | 28% | Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159–169 (2015) DOI: 10.1002/car DOJ-OGR-00005937 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 28 of 45 Disclosure Patterns in Child Sexual Abuse 161 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 al. also pointed out that families who participated in this study were more likely to represent those children who experienced abuse by someone outside the family. Research has found that delays in disclosure are longer for those abused within the family (Sjoberg and Lindblad, 2002; Goodman-Brown et al., 2003; Kogan, 2004; Hershkowitz et al., 2005). Therefore, children who disclose more promptly may be overrepresented in legal samples. In Sweden, Priebe and Svedin (2008) conducted a national survey of 4339 adolescents, of whom 1962 reported some form of sexual abuse (65% of girls and 23% of boys). Details of the time lapse in disclosing were not available from this study. However, of those who had disclosed and answered the questions on disclosure (n = 1493), 59.5 per cent had told no-one of their experiences prior to the survey. Of those who did disclose, 80.5 per cent mentioned a 'friend of my own age' as the only person who they had told. In this study, 6.8 per cent had reported their experiences to the social authorities or police. A further Swedish study of 122 women who had experienced childhood sexual abuse (Jonson and Lindblad, 2004) found that 32 per cent disclosed during childhood (before the age of 18) while the majority told in adulthood (68%). The delay was up to 49 years, with an average of 21 years (SD = 12.9). Of those who told in childhood, 59 per cent told only one person. In Ireland, the SAVI study (n = 3118, McGee et al., 2002) found that 47 per cent of those respondents who had experienced some form of sexual assault prior to age 17 had told no-one of this experience until the survey. McElvaney (2002) investigated delay in a legal sample of ten adults who had made formal complaints of childhood sexual abuse in Ireland and found delays ranging from 20 years to 50 years. Studies of children in the context of forensic/investigative interviews where children are interviewed by professionals due to concerns that the child has been sexually abused also point to high non-disclosure rates, particularly striking in cases where there is corroborative evidence that abuse has occurred - medical evidence (Lyon, 2007), or confessions from the abuser or videotaped evidence/witness reports (Sjoberg and Lindblad, 2002). Lyon (2007) reported his findings from a review of studies published between 1965 and 1993 of children diagnosed with gonorrhoea where the average disclosure rate among 579 children was 43 per cent (n = 250). In a study where the evidence for the abuse was available on videotape, children have denied abuse when interviewed by the police (Sjoberg and Lindblad, 2002). In summary, significant numbers of children do not disclose experiences of sexual abuse until adulthood and adult survey results suggest that significant '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' Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00005938 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 29 of 45 162 McElvaney 'High numbers of respondents disclosing to researchers for the first time' proportions of adults have never disclosed such abuse, as evidenced by the high numbers of respondents disclosing to researchers for the first time. Patterns of Disclosure - Partial Disclosure Information on how children disclose over time can be obtained from studies of children who participated in forensic/investigative interviews where children are interviewed by professionals due to concerns that the child has been sexually abused. The issue of partial disclosures was highlighted by earlier studies such as those by DeVoe and Faller (1999) of five- to ten-year olds (i.e. making detailed informal disclosures that were not replicated in formal interviews) and Elliott and Briere (1994) of children aged eight to 15 years (i.e. disclosing only partial information until confronted with external evidence that led to more complete disclosures). More recently, investigators have examined the role of the interviewer and questioning styles in the forensic interview and how this impacts on children's disclosures and the level of detail provided in interview. Hershkowitz et al. (2006) compared tapes of interviews with children who disclosed sexual abuse and those who did not (but about whom there was 'substantial' reason to believe that they had been abused). They found that interviewers behaved differently with the two groups, using different types of prompts with children who presented as somewhat uncooperative, offered fewer details and gave more uninformative responses at the beginning of the interview. It would appear that interviewers responded to less communicative children by increasing the proportion of closed questions which in turn led to children being less forthcoming. Lamb et al. (2002) have found that the use of a protocol that emphasises the use of prompts that elicit free narrative (e.g. 'tell me about that') as compared with closed questions (those requiring a yes/no response) has resulted in more detail and more accuracy in children's accounts. 'They found that interviewers behaved differently with the two groups' Although few studies exist that examine the phenomenon of disclosure in informal settings (when disclosure is made to a friend or family member), some qualitative studies have described this process. McElvaney (2008) quoted one teenage girl who described hinting to her mother prior to disclosing the experience: 'I didn't tell her what happened but I was saying things that made her think it made her think that it happened but I didn't tell her' (p. 127). A parent described how her teenage son told her over a period of days, keeping the most difficult parts of the story until last: 'He came out with like it came out over two or three days so you know...he'd say well I've something else to tell you... the bad stuff last... what hurt him most and what he's saying what hurt him most' (p. 92) And finally, one young person described how she told her social worker: 'I couldn't tell her most things but I just gave things to her to read... I told her at first I told 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. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car Copyright 2013 John Wiley & Sons, Ltd. DOJ-OGR-00005939 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 30 of 45 Disclosure Patterns in Child Sexual Abuse 163 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 et al., 2000; Goodman-Brown et al., 2003; Kogan, 2004). Children who do disclose during forensic interviews compared to children who do not disclose in such contexts (yet concerns remain that they have been abused) are more likely to have parents (particularly mothers) who are more supportive (Lawson and Chaffin, 1992). In Priebe and Svedin's (2008) study of young people, parental bonding (positive relationship with parent who was not overprotective) was identified as the most significant predictor of disclosure for both boys and girls. However, close relationships can also act as an inhibitor to disclosure. McElvaney (2008) found that many young people in her study were reluctant to disclose due to concerns of upsetting their parents while others were concerned about the consequences of 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 et al., 2003; Hershkowitz et al., 2005; Ungar et al., 2009a). Mental health difficulties on the part of the child have also been found to be relevant, particularly when children experience dissociative symptoms or other post-traumatic stress symptomatology (Priebe and Svedin, 2008). Some studies have found that the severity of abuse (e.g. penetrative abuse) predicts earlier disclosure while other studies have found no relationship between different types of abuse and disclosure timing. Similarly, the relationship between the duration of abuse - one-off incidents of abuse compared with abuse that takes place over a significant period of time - and timely disclosure has been investigated with mixed findings. Fear of the consequences of disclosure has been identified as a predictor of delayed disclosure and this in turn is associated with the age of the child (Goodman-Brown et al., 2003). Older children are more cognitively competent in terms of being able to reflect on and anticipate possible reactions to their disclosure. This can act then as an inhibitor to disclosure, although as noted above, most studies have found that older children are more likely to disclose than younger children. Fears of not being believed have been described by young people as inhibiting their disclosure and these fears are often "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' Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00005940 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 31 of 45 164 McElvaney justified. Hershkowitz et al. (2007) interviewed children about their initial disclosures prior to formal interview and 50 per cent of the sample (n = 30) reported feeling afraid or ashamed of their parents' reaction. The authors reported that parents did show a tendency to blame their children and react angrily to the disclosure. Recent research has highlighted the need for children to be asked direct questions to facilitate their disclosure. Of those children who did disclose, significant proportions disclosed following prompts rather than it being initiated by the child (Kogan, 2004). Qualitative studies drawing on interviews with children that focus on the disclosure process are important in investigating the precise circumstances that led to disclosures for children. McElvaney (2008) found that parents' questioning of children was prompted by their concern about the young person's emotional distress. On occasion, young people were communicating that something was not right in their world but were not able to articulate this verbally. Signs of psychological distress were, however, evident and questions targeted at the reasons for this distress were identified by McElvaney as a factor that helped young people to tell. Thus, many children may not have told about their experiences of abuse because they were not asked. McGee et al. (2002) followed up a sample of their respondents who had disclosed childhood abuse for the first time in their survey. When asked why they had not disclosed prior to the survey, many respondents noted that it was because they had not been asked. Increasingly, research studies are finding that significant proportions of disclosure have been prompted by questions by caregivers, friends or others in the child's educational and social milieu that in themselves provide an opportunity for the young person to tell (Jensen et al., 2005; Hershkowitz et al., 2007; McElvaney et al., 2012). 'Investigating the precise circumstances that led to disclosures for children' 'Significant proportions of disclosure have been prompted by questions by caregivers, friends or others' 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 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 Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159–169 (2015) DOI: 10.1002/car DOJ-OGR-00005941 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 32 of 45 Disclosure Patterns in Child Sexual Abuse 165 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 et al.'s (2009a) study of Canadian youth, they found that young people used a range of disclosure strategies ranging from less direct strategies (such as risk-taking behaviours, not talking about the abuse) to direct strategies (such as seeking support from peers, turning to non-professional adult supports, disclosing to formal service providers), representing a process that relied heavily on others to 'build the bridges between the youth and formal care providers' (p. 352). The tendency to delay disclosing and the partial nature of many disclosures are not conducive to successful legal investigations and prosecutions. In addition, the knowledge base that exists within the legal sphere is limited if only a percentage of the children who experience sexual abuse engage with this system. The disproportionately high 'immediate disclosure' rate found in Goodman-Brown et al.'s (2003) legal sample compared to Kogan's (2004) community sample raises the question of the representation of delayed disclosers in the legal system. Are children who delay in disclosing less likely to engage with the legal system? Are delays in disclosing contributing to decisions not to prosecute child sexual abuse crimes? In Ireland, the 1990s saw a significant increase in the numbers of complainants coming before the courts reporting experiences of childhood sexual abuse. Many of these cases were referred to the higher courts for judicial review proceedings to establish whether the cases could proceed without prejudicing the accused given the Copyright © 2013 John Wiley & Sons, Ltd. '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?' Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00005942 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 33 of 45 166 McElvaney 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. 'Concerns that engagement with the legal system will lead to further psychological trauma need to be considered' In addition, concerns that engagement with the legal system will lead to further psychological trauma need to be considered. A prospective longitudinal study conducted by Quas et al. (2005) indicated that the consequences of legal involvement change over the course of development and as a function of the child's reactions to and experiences during the legal case. The associations between legal involvement and outcomes varied with age. The authors suggested that although younger children may be at increased risk for some adverse outcomes such as mental health problems, older children may be at increased risk for other undesirable sequelae such as the negative attitudes of others toward them. Quas and Goodman's (2011) recent review notes that older children are more at risk in developing poor mental health outcomes. Thus, as noted earlier, young people's fears of the consequences of disclosure may well be justified. Raised awareness of both the prevalence of non-disclosure of sexual abuse and the importance of supporting children to disclose may go some way to addressing children's fears. One interesting finding in recent studies is that many young people who delayed disclosure to an adult had told a friend. McElvaney (2008) and Ungar et al. (2009b) identified peer influence as significant in encouraging disclosure among adolescents. There is some suggestion from the research that regardless of the age at the time of abuse, adolescence may be a 'critical period' for disclosure. It may be that targeting adolescents in general (rather than those at risk of abuse) may be a powerful prevention tool in encouraging early disclosure. Evaluations of child abuse prevention programmes have shown significant improvements in the levels of awareness of child abuse in children and young people (Rispers et al., 1997; Zwi et al., 2007). It may be that the increasing trend towards peer disclosure is a by-product of such educational and awareness-raising programmes. There is evidence that public awareness campaigns when implemented as part of a multi-dimensional strategy that involves targeting children, parents and communities (see Lalor and McElvaney, 2010, for a review of child abuse prevention programmes) are an effective tool in the prevention of child abuse. 'An adaptive strategy on the part of the young person to contain the experience' 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/need to keep the secret and wanting/need 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 Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159–169 (2015) DOI: 10.1002/car --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 34 of 45 Disclosure Patterns in Child Sexual Abuse 167 pressure for young people by providing opportunities to tell may be needed to help young people tell more promptly. However, the lack of control that young people experience following disclosure remains an issue (Ungar et al., 2009b; Quayle et al., 2012). This highlights the need for dissemination of information directly to young people about the legal process, the possible consequences of disclosure, as well as ongoing developments in legal proceedings when young people and their families interface with the legal system. The more recent focus on investigating those strategies that children use in making disclosures rather than solely on identifying barriers to disclosure is perhaps more helpful in informing awareness-raising campaigns and professional interventions. The author is involved in a large-scale review of children's files in an assessment service to ascertain those factors that helped children tell about their experiences of sexual abuse. A pilot study has suggested that this is an appropriate methodology for gathering data on children's experiences of informal disclosure, acknowledging the limitations of such an approach. Ungar et al. (2009a) describe the optimal conditions for disclosure as follows: being directly asked about experiences of abuse; having access to someone who will listen, believe and respond appropriately; having knowledge and language about what constitutes abuse and how to access help; having a sense of control over the process of disclosure both in terms of their anonymity (not being identified until they are ready for this) and confidentiality (the right to control who knows); and effective responses by adults both in informal and formal contexts. Ungar et al. (2009b) support recent developments in prevention programmes that target supportive formal and informal caregivers in being better able to detect the possibility of abuse and support disclosures rather than focusing on empowering children themselves in making disclosures. Their findings in relation to the importance of bridge building for young people to access formal supports are supported by Jensen et al.'s (2005) emphasis on the dialogical nature of disclosure, and the important role that trusted adults and peers play in the disclosure process through noticing signs of psychological distress and asking young people about their psychological wellbeing (Collings et al., 2005; Jensen et al., 2005; McElvaney et al., 2012). More emphasis is therefore needed on providing opportunities for children and young people to disclose. The challenge for professionals and those who care for children is how to do this in a way that protects children and promotes their wellbeing. 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Sjoberg 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. Copyright 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00005945 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 36 of 45 Disclosure Patterns in Child Sexual Abuse 169 Smith DW, Letourneau 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 J. 2009a. Patterns of disclosure among youth. Qualitative Social Work 8(3): 341 356. DOI: 10.1177/1473325009337842. Ungar M, Tutty 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. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car Copyright © 2013 John Wiley & Sons, Ltd. DOJ-OGR-00005946 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 37 of 45 EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY CLINICAL RESEARCH ARTICLE Predictors of delayed disclosure of rape in female adolescents and young adults Iva A. E. Bicanic1*, Lieve M. Hehenkamp1, Elise M. van de Putte2, Arjen J. van Wijk3 and Ad de Jongh3,4 1National Psychotrauma Center for Children and Youth, University Medical Center Utrecht, Utrecht The Netherlands; 2Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Behavioral Sciences, ACTA, University of Amsterdam and VU University, Amsterdam, The Netherlands; 4School of Health Sciences, Salford University, Manchester, United Kingdom Background: Delayed disclosure of rape has been associated with impaired mental health; it is, therefore, important to understand which factors are associated with disclosure latency. The purpose of this study was to compare various demographics, post-rape characteristics, and psychological functioning of early and delayed disclosers (i.e., more than 1 week post-rape) among rape victims, and to determine predictors for delayed disclosure. Methods: Data were collected using a structured interview and validated questionnaires in a sample of 323 help-seeking female adolescents and young adults (12-25 years), who were victimized by rape, but had no reported prior chronic child sexual abuse. Results: In 59% of the cases, disclosure occurred within 1 week. Delayed disclosers were less likely to use medical services and to report to the police than early disclosers. No significant differences were found between delayed and early disclosers in psychological functioning and time to seek professional help. The combination of age category 12-17 years [odds ratio (OR) 2.05, confidence intervals (CI) 1.13-3.73], penetration (OR 2.36, CI 1.25-4.46), and closeness to assailant (OR 2.64, CI 1.52-4.60) contributed significantly to the prediction of delayed disclosure. Conclusion: The results point to the need of targeted interventions that specifically encourage rape victims to disclose early, thereby increasing options for access to health and police services. Keywords: Adolescents; young adults; rape; sexual assault; disclosure; latency to disclosure; posttraumatic stress disorder Responsible Editor: Rita Rosner, KU Eichstaett Ingolstadt, Germany. *Correspondence to: Iva A. E. Bicanic, National Psychotrauma Center for Children and Youth, University Medical Center Utrecht, P.O. Box 85090, NL 3508 AB Utrecht, The Netherlands, Email: i.a.e.bicanic@umcutrecht.nl For the abstract or full text in other languages, please see Supplementary files under 'Article Tools' Received: 31 August 2014; Revised: 30 March 2015; Accepted: 13 April 2015; Published: 11 May 2015 Previous 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 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 1 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). European Journal of Psychotraumatology 2015. © 2015 Iva A. E. Bicanic et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883 (page number not for citation purpose) 1 DOJ-OGR-00005947 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 38 of 45 Iva A. E. Bicanic et al. In addition, adolescents who disclose their rape experience at least 1 month after the incident took place are found to be at higher risk for major depressive disorder and delinquency (Broman-Fulks et al., 2007) compared to those who disclosed within 1 month. 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; Schönbucher, 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 self-referrals. In 178 cases, the phone call did not result in admission at the centre because of age limitations, or motivational reasons. In 108 cases, referrals were made to other institutions because the index trauma was chronic childhood sexual abuse rather than rape in adolescence/young adulthood. Of the 335 cases admitted to the centre, 12 were not included in this study because of male gender, resulting in a final sample of 323 females with the index trauma being single rape. Referral sources for this final sample included the police (33.7%), mental health services (40.7%), and self-referrals, i.e., victims or parents (25.6%). 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 2 (page number not for citation purpose) Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ept.v6.25883 DOJ-OGR-00005948 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 39 of 45 Predictors of delayed disclosure of rape 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 1 to 5, with higher scores indicating more symptomatology. The four subscales: Intrusion, Avoidance, Arousal, and Other Child-Specific Reactions consist of 7, 11, 6, and 10 items, respectively. The reliability of this instrument is good to excellent (Cronbach's α 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 α 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 12–18 years. This questionnaire evaluates the teenager's perception of behavioural and emotional problems. YSR has shown to be internally reliable (Cronbach's α's ranging from 0.71 to 0.95), and convergent and discriminant validity is reported to be satisfactory (Bérubé & Achenbach, 2006). The YSR includes four broadband scales and nine narrow-band scales to assess behaviour problems. For the purpose of the study, only the total score on behaviour problems was included in the analyses. General psychopathology The Symptom Checklist-90-R (SCL-90-R; Arrindell & Ettema, 1986) was used for participants aged 12–25 years. This is a 90-item self-report inventory to assess psycho-social distress. Patients were instructed to indicate the amount they were bothered by each of the distress symptoms during the preceding week. Patients rated 90 distress symptoms on a five-point Likert scale with 1 being “not at all” and 5 being “extremely.” The 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 α 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 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 40 of 45 Iva A. E. Bicanic et al. 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 goodness-of-fit chi-square was used to calculate how well the data fit the model. For all statistical analyses, a p-value of <0.05 was considered statistically significant. All statistical analyses were conducted using SPSS (IBM SPSS Statistics for Windows, Version 20.0, IBM Corp., Armonk, NY). Results Socio-demographic characteristics Socio-demographic characteristics of the sample are presented in Table 1. Victims' age ranged from 12 to 25 years, with a mean age of 16.7 years (SD = 2.7) and a median age of 16.1 years. Victims' mean age at time of rape was 14.3 years (SD = 2.7) and a median age of 13.9 years. Penetration occurred in 79.6% of the cases. None of the victims reported prior chronic child sexual abuse. Data about victim–assailant relationship are presented in Table 2. Victims first disclosed after a mean 20.8 weeks (SD = 56.8, range 1–624 weeks), although 58.5% of the cases told within 1 week. First disclosure was to a friend (45.8%), parent(s) (17.1%), (ex) boy-friend (9.4%), family member (6.8%), professional (5.8%), or other adult (15.2%). With regard to post-rape services, 53.8% of all victims consulted a doctor for medical care and 51.4% reported to the police. On average, victims were admitted to the centre 59.8 weeks post-rape (SD = 93.7, range 1–676). The mean GSI of the rape victims on the SCL-90-R (M = 209.7, SD = 61.8) was comparable with previously reported data of psychiatric populations [M = 203.55, SD = 61.0; t(269) = 1.629, p = 0.104] and was substantially Table 1. Demographic characteristics of rape victims (N = 323) in valid percentages | | N | % | | --- | --- | --- | | Dutch origin^a | 274 | 84.8 | | Education level^b | | | | 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 | ^aDutch origin was defined as being a child from parents born in the Netherlands; bafter 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. 4 (page number not for citation purpose) Table 2. Victim assailant relationship (N = 323) in valid percentages | | N | % | | --- | --- | --- | | 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 internet | 12 | 3.8 | | Colleague | 10 | 3.1 | | Mentor | 3 | 1.0 | higher [t(269) = 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 (t(230) = 15,923, p < 0.001), in comparison to previously reported data of the general population of adolescent girls (Timbremont, Braet, & Roelofs, 2008; M = 9.01, SD = 6.45). Differences between early and delayed disclosers Fifty-nine percent of the sample consisted of early disclosers (disclosure within 1 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 (χ2 (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 (χ2 (1) = 5.37; p = 0.02). Also, the delayed disclosers group presented more victims of verbal and/or weapon threats than the early disclosers group (χ2 (1) = 5.35; p = 0.02). Furthermore, among the delayed disclosers more victims identified the assailant as a close person compared to the early disclosers (χ2 (1) = 10.84; p = 0.001). Alcohol was used more often in the early disclosers group compared to the delayed disclosers group (χ2 (1) = 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%; χ2 (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 (χ2 (1) = 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 = 79.4) DOJ-OGR-00005950 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 41 of 45 Predictors of delayed disclosure of rape SD = 103.3; t(314) = 4.06, p < 0.001). Mean and median time to seek help were 37.7 and 12.0 weeks, respectively. Mean time to seek help did not differ between groups (t(309) = 2.54, p < 0.48). Excluding outliers (M ± 3 SD, N = 11) did not change the outcome of this analysis. Both early and delayed disclosers scored in the highest level of psychological distress when compared to previously reported norm scores (CRTI, Alisic, Eland, Huijbregts, & Kleber, 2012; CDI, Timbrell 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(6,198) = 0.88, p = 0.51). Table 3 shows the ORs with 95% CIs 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 (χ2 (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 χ2 (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 Svedlin (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 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 42 of 45 Iva A. E. Bicanic et al. Table 3. Demographic and (post-)rape characteristics by disclosure time (early vs. delayed disclosers) and odds ratios for delayed disclosure Demographic and (post-)rape characteristics Early disclosure (N = 185) Delayed disclosure (i.e., > 1-week post-rape), N = 131 N % N % OR 95% CI Age category (years) 18 25 55 17.4 22 7.0 12 17 130 41.1 109 34.5 2.10 1.20 3.65* Dutch origin No 27 8.5 22 7.0 Yes 158 50.0 109 34.5 0.85 0.46 1.56 Living with parent(s) No 29 9.2 16 5.1 Yes 155 49.2 115 36.5 1.35 0.70 2.59 Complete family structure No 58 18.4 42 13.3 Yes 127 40.3 88 27.9 0.96 0.59 1.55 Current sexual relationship No 127 41.8 97 31.9 Yes 53 17.4 27 8.9 0.67 0.39 1.14 Prior negative sexual experience(s) No 152 49.4 110 35.7 Yes 32 10.4 14 4.5 0.61 0.31 1.19 Known assailant No 56 17.7 36 11.4 Yes 129 40.8 95 30.1 1.15 0.70 1.88 Close to assailant No 150 47.6 84 26.7 Yes 35 11.1 46 14.6 2.35 1.40 3.93* Group rape No 160 50.8 116 36.8 Yes 24 7.6 15 4.8 0.86 0.43 1.71 Age of assailant (years) 12 17 63 20.6 54 17.6 > 18 117 38.2 72 23.5 0.72 0.45 1.14 Use of penetration No 46 14.7 19 6.1 Yes 136 43.5 112 35.8 1.99 1.10 3.60* Use of threats No 90 31.6 48 16.8 Yes 76 26.7 71 24.9 1.75 1.09 2.82* Use of physical violence No 130 42.6 82 26.9 Yes 51 16.7 42 13.8 1.31 0.80 2.14 Victim's alcohol use 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 6 (page number not for citation purpose) Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883 DOJ-OGR-00005952 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 397-2 Filed 10/29/21 Page 43 of 45 Predictors of delayed disclosure of rape 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, Barr, Danielson, & Kilpatrick, 2012). Perhaps, these differences could, at least partially, be explained by the fact that stranger rape, representing 30% of our sample, leads to higher likelihood of help-seeking and police reporting because of its association with higher acknowledgment of victim status (Resnick et al., 2000; Smith et al., 2000). The fact that this is a help-seeking sample is critical for the reasons cited in the discussion, but also because the generalizability of these data to rape victims who never tell anyone—perhaps the group most at risk—simply cannot be known. Besides these 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 post-rape may be sexual education campaigns in school and media, as being uninformed is one of the reasons for them not to disclose (Crisma et al., 2004). Education may include medical information on rape-related pregnancy and STDs, as well as the need for timely emergency contraception and prophylaxis, given that these concerns appear to be facilitators of seeking medical help (Zinzow et al., 2012). Also, practical information about DNA 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. 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K., & Kilpatrick, D. G. (2012). Receipt of post rape medical care in a national sample of female victims. American Journal of Preventive Medicine, 43(2), 183 187. Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883 (page number not for citation purpose) 9 DOJ-OGR-00005955