Document 452-2

Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 1 of 45 Exhibit B DOJ-OGR-00006836 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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, Sablonni, Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007 Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). Incidence studies in the United States and Canada report decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Turner, & Hamby, 2014; 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, Forms, & 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 M4K1W1. Email: ramona.alaggia@utoronto.ca DOI-OGR-00006837 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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" 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-00006838 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 4 of 45 Table I. Child Sexual Abuse (CSA) Disclosure Studies: 2000-2016 Study Purpose of Disclosure (CSA) Design Sample Findings Summary Gagner and Co Ventura (2016) To explore disclosure processes for male victims of CSA Phenomenological method used to interview male CSA survivors. Interview (LIM) guided data collection and analysis. 17 men ranged in age from 19 to 67, average age 47. Purposive sampling strategy was used The majority of the men in the study had disclosed and received services before. Member checking was used to control for negative delayed disclosure. Negative disclosure was associated with stereotyping. Negative disclosure butted to be forgotten. Both disclosure and non-disclosure was cited as a motivator for further inquiry. Other issues such as negative trustworthiness of the data and contextual issues were noted. Socio-cultural stereotyping of male sexuality, linking disclosure to forms of media on disclosure, and a retrospective study and analysis of CSA disclosure were important One of the few studies to focus exclusively on African American women. Small sample size but sufficient to bring forward cultural and contextual issues. Retrospective study that may have been affected by recall bias. Use of a fe-course perspective as a theoretical framework throughout the study. 17 African Canadian women in mid-life between 40 and 63 experienced CSA, ntrafficking, and snowboarding strategy 17 Afr can women n m d-life between 40 and 63 exper enced ntraff ck ng and sn wba ng Purpos ve strategy CSA onset was noted at ages 5 and 9. One never talked to them about sex; one didn't understand the language or breakdown or removal of family name. Barr's fear of tarnishing the family name was not wanting to by family members felt but not by family members felt. Pattern of self-disclosure identified. 17 participants identified disclosure as a primary source of strength throughout the court process. Half of the participants had disclosed CSA experiences before the age of 19. Three broad categories were identified as barriers to CSA disclosure: barriers from female and male survivors (76%); barriers from family and friends (24%); and barriers from professionals. 67 male and female CSA adult survivors were identified as having CSA experiences from 9 to 69 years (M = 44.9) ranges from 9 to 69 years. Purposive sampling strategy Qualitative design using LIM. To provide a mapping of factors that prevent CSA disclosures through a sample of CSA adult survivors. 369 adult male sexual offenders were convicted of a sexual offense; the offense age increased with the age of the offender at the time of the offense. Disclosure was related to the offender's cognitive distortions - if the offender was not living with the offender at the time of the offense, the disclosure was not associated with the offender's cognitive distortions. Adult male child sexual offenders were interviewed to examine predictors of CSA disclosures (continued) 262 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 5 of 45 (continued) Table I. (continued) Study McEvaney and Cu hane (2015) Dumont, Messerschm tt: V a, Bohu, and Rey-Salmon (2014) Easton, Satzman, and W s (2014) Purpose To investigate the feasibility of using child disclosure assessments as data sources of CSA assessment and disclosure. To provide substantive evidence for how children disclose sexual abuse. This study examined how the perpetrator and intrafamilial CSA impact disclosure processes. Study focus was on barriers to CSA disclosure. Design Victim disclosure interviews structured on the QID questions. File reports of children seen for assessment and disclosure. To understand CSA disclosure, these reports were reviewed. File reports of children seen for assessment and disclosure. To understand CSA disclosure, these reports were reviewed. Using qualitative content analysis, researchers conducted a secondary analysis on one anonymous, Internet-based survey. Health data, the 2010 survey data, the We Being survey, were used. Survey that used CSA history as one of the organizations reported two-thirds of respondents reported CSA history. Age range 7 years old and 17 years old. Majority were female (78.2%) and had been arrested on 39 occasions and 7 based on a coded framework. Parents were asked to have the child reveal for the study, were assessed. 220 victims (78.2% female) were between 12-18 years of age (most range 14-18). 41.8% were abused by a family member and 41.8% by a non-family member. 460 men with CSA history completed an anonymous, Internet-based survey. Recruited from organizations. Age range 18-84 years. 30.2% less than 6 months, 32.3% 6 months to 3 years, and 34.3% more than 3 years. Ten categories of barriers were identified: (1) socio-cultural: masculinity resources; (2) interpersonal: mistrust of safety others, fear of not being believed; and (3) personal: internal emotional responses; past experiences of sexual abuse, and sexual abuse. Findings Majority of children (43%) first disclosed to their major themes: (1) fear/embarrassment; (2) opportunity to tell; and (3) themes of the bringing for disclosure. At time of the study, this was the largest qualitative data set to have been analyzed with an expert focus on adult male survivors' perceptions of barriers to CSA disclosure. Because the sample was not unique set of barriers to disclosure, 60% of victims revealed the facts done at school; contrary, extrafamilial CSA disclosure more spontaneously and quickly; 80% of victims revealed the facts often to mother or another family member. Vast majority of participants (94.6%) were abused by another male or female peers. Duration of sexual abuse broken down: 30.2% less than 6 months, 32.3% 6 months to 3 years, and 34.3% more than 3 years. Ten categories of barriers were identified: (1) socio-cultural: masculinity resources; (2) interpersonal: mistrust of safety others, fear of not being believed; and (3) personal: internal emotional responses; past experiences of sexual abuse, and sexual abuse. Summary Perspectives of offenders on victim disclosure by victims rested during the offense. Major findings on victim disclosure rested on dysfunctional backgrounds were key to their major themes: (1) fear/embarrassment; (2) opportunity to tell; and (3) themes of the bringing for disclosure. The sample size was relatively small but within the study in line and serves as an important exploratory process for bringing forward potential themes for consideration. The relationship with the perpetrator has a significant impact on both timing and recipient of disclosure, was disclosed promptly and within the family system. At time of the study, this was the largest qualitative data set to have been analyzed with an expert focus on adult male survivors' perceptions of barriers to CSA disclosure. Because the sample was not unique set of barriers to disclosure, 263 DOJ-OGR-00006840 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 6 of 45 (continued) Table I. (continued) Study | Des gn | Sample | Findings | Summary Easton (2013) | Cross-sect ona survey des gn. E g be des gn were part c pants screened and anonymous, Internet-based survey dur ng 2010. Measures used: General Mental Health D stress Scale and Ind v dual Needs. Quest ons related to CSA disclosure and supports were | Purpose was to be male CSA descr be processes using a fe span approach. Age differences based on react ons between disclosure and mental health problems were assessed. | 487 men from three nat ona zat ons devot ed to r a se awareness of CSA. Age range: 19-84 years. Mean age of CSA onset was 10.3 years | O der age and be ng abused by a fam y member were both re ated to d scosure. Most part cpants wh ch d d not d scose were emot on y support ve and the he pfu ness of responses across the fe span was mixed. Deas n't e span was s ght y s gnf cant. Approx mate y ha f of part cpants rst to d about the set t ng (27%); the samp ng strategy ga ned a predom nant y h dden popula on. Important c n ca recommendat ons are made wth an emphas s on a fe-course focus | Purpos ve samp ng f ng awareness ra s ng zat ons part cpants who had a ready d scosed and rece ved he p. Part cpants needed to have access to Internet wh ch would have e m nated men n over SES groups wh ch requ red prof energy n certa n cu tura groups. However, | McEvaney, Greene, and Hogan (2012) | Grounded theory method study. | Sample of 22 young people, 16 gr s boys; 6 gr s , age range: 8-18 years. n tot 22 men were ewed ages of 8 and 18. M xed samp e of some who d CSA and some who d not. CSA, extra-fam CSA and two even categor es. Parents were nterv ewed. | A theoret ca mode was deve oped that conceptua zes the process of CSA d scosure qua te ta tv ness. H gh eve of trustworthiness | Modest but suff cent emp e exp oratory qua te ta tv ry. A subsampe of random y se ected transcripts was independently coded. Very young ch dren and young adu ts were not captured by the f nd ngs can on y be made n the context of re and n the range samp ed | Two th rds of the samp d d not d scose ght away. Strengthen ng parent-ch d CSA to and d scosure to parents one of the most mportant ways to ncrease d scosure has been. Part cpants reported found a common trend n other | Schonbucher, Moe r-Kuo, Schnyder, and Landolt (2012) | To nvest gate the processes of CSA d scosure wth d srespondents from the popula on who had exper enced CSA. How many d scosed, who d d scose and to whom | Conven ence samp e of 26 sexu y ado escent boys, 23 gr s , age range: 15-18 years. On average, d srespondents were 13 years on fam y members and 3 years on socodemograph c recru ted to youth from | Data was co ected through face-to-face qua tat ve nterv ews. Standard quest ons and measures were on fam y members and socodemograph c data. n sterd on fam y members and socodemograph c data. | Less than one th rd of part cpants d scosed CSA to another mmed ate y and de ayed d scosure to peers. More than d scosed to a parent: Part cpants reported so as to re ect ance to d scose to parents 264 DOJ-OGR-00006841 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 7 of 45 (continued) Table 1. (continued) Study Hunter (2011) Schaeffer, Leventhal, and Asnes (2011) ... --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 8 of 45 (continued) Table I. (continued) Study Aagga (2010) Fontes and Pummer (2010) Ungar, Barter, McConne 'Turty, and Fatho m. (2009a) Purpose The study a med to dent fy factors mp ng on or promot ng CSA d scosures. Overew research quest on: What persona , env ronmenta , and contextua nfluences mp ng on or promot ng CSA d scosures. Th s exam nat on of CSA d scosure exp ored the ways cultura affects processes of CSA d scosure and reporting, both n the Un ted States and nterna on y. Th s study exp ored d sclosure strateg es w th a nat ona samp e of youth focus ng on forms were comp eted by youth owng part c pat on n abuse prevent on Summary The study presents a comprehens ve soc a -eco og ca naly ys to CSA d scosure h gh ght ng the mu t faceted nfluences Of note. 42% had d scosed the abuse dur ng ch dhood; 26% had not d scosed because they had repressed the memory of the abuse had occurred n ch dhood; and 26% had not d scosed because they had d ff culty wth reca . The rema nder had attempted some form of d scosure ona soc a -eco og ca context, that s, ack of soc a support, d srupt ve nghborhood. A retrospec ve ng approach that coud be affected by reca ssues Themes fe nto four doma ns: (1) v dua and deve opmenta factors, (2) persona ty and character st cs such as gender ro es wth doma n v ct ms of CSA, (3) nghborhood and soc a -eco og ca factors not pursu ng troub e and soc a eta tudes, and (4) parent's react ons for unhea th ng soc a messages and k ds zatt ng on for hea th ng soc a messages. Purposefu ness es s h gher than the reported n c dence of CSA d scosers Cultura and y soc ate factors effects d scosure are dent fed. Recommendat ons made for (1) d sc osure detal ed nterv ew ng shoud be tr nguated wth c d's cultura context, (2) quest on shoud a so take nto account age and gender factors, and (3) cu ture stands as an mpdrcant factor n d cos ng or be ng asked to d sc ose. Presents a comprehens ve framework nterv ew derat ons to abuse emp oy fve strateg es: us ng se -harm ng behav ors Youths end ngs behaving or worsen ng process. that have dent ed m ary to others; not tak ng Findings The study h gh ghts that d scosure s an interact ve ongo ng process. Exam nat on of resu ts from a nat ona samp e of 1621) eva uat on where youth forms where comp eted Sample samp e samp ng was emp oyed Snowba samp ng was used to recrut more adu ts to revew surv vors about the r d sc osure exper ences. 40 men nterv ewed about CSA 44% were women and 66% wth a range of 18-65 wth an average age of abuse onset of 5.3 years d = 3.6). Dysoeconom c backgrounds Data cons sted of pub shed tertature on CSA d scosure and unpub shed tertature on CSA d scosure wth a competent y cultura ys to prov de a framework for CSA d scosure quest on ng. Forms were comp eted by youth owng part c pat on n abuse prevent on --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 9 of 45 (continued) Summary Findings Sample Design Purpose/What's the Study Ungar, Tutty, McCombe, Barter, and Fairholm (2009b) Table 1. (continued) --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 10 of 45 Table 1. (continued) Study | Purpose | Design | Sample | Findings | Summary Priebe and Svedin (2008) | This study aimed to investigate disclosure rates and predictors of disclosure and nondisclosure | Participants completed a 65-item questionnaire that included questions about background, consensual sex, sexual abuse experiences, and disclosure | The sample consisted of 4,339 high school students in Sweden (2,322 boys) | The mean age of participants was 18.15 years. This study used CSA and noncontact abuse (contact abuse or penetration). 1,962 participants reported CSA and answered questions about disclosure | Fewer had reported to a professional (contact abuse or penetration) for girls, but overall rates for girls were higher than for boys. The more severe the sexual abuse, the more likely girls were to disclose to a professional. Boys were less likely to disclose to a professional, but more likely to disclose to a peer. Key to disclosure was having a supportive mother or father. Boys were more likely to disclose to a peer. Study focused on male survivors of CSA disclosure challenges: (1) To understand three issues: (1) To understand disclosure rates and predictors of disclosure and nondisclosure | Male survivors of CSA were interviewed about their disclosure experiences. Analyses included 16 male survivors of CSA | 268 DOJ-OGR-00006845 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 11 of 45 (continued) Summary Findings Sample Design Purpose and content of the present study Study Hershkowitz, Lamb (2007) Table 1. (cont'nued) --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 12 of 45 Table I. (continued) Study A gg a and K rts henbaum (2005) A gg a (2005) Co ngs Griffiths, and Kuma o (2005) 270 Summary Over half the participants had not disclosed the abuse during childhood. Of the nondisclosers, participants had repressed or forgotten the memory. A most one third of the disclosers needed more data on γ. More data are garnered more informat on disclosure. Four major themes emerged suggesting that CSA disclosure can be seen as a signifying process when certain gender roles based on a patriarchal-based structure exist; (2) presence of family violence; (3) closed communication within family; and (4) economic status as a who either paid no visits or visits fee to One n a dearth of studies that conduct gender anaysis. Comparative anaysis draws out important practice cat ons or fee ngs of stigmat on or v ctimization, and (3) fear of boys being rare y v ctimized, which mp ess be reca prec bant for d sc osure Three themes emerged for men who had or prec rated d sc osure reasons related to gender (1) fear of being v ewed as homosexual or prec rat d sc osure reasons related to gender (1) fear of being v ewed as homosexual or prec rat d sc osure reasons related to gender (1) fear of being v ewed as homosexual or These results fit nto A gg a's (2004) d sc osure framework. Through data anaysis, two raters coded author's d sc osure category es us ng ch-d nated d sc osure versus tempo d sc osure on an event dura on process. These d sc osure d mens ons proved to be both exhaustive and mutuall y ex clusive Sample Purpos ve samp ng was employed to recruit 20 adult turvors who were between the ages of 18 and 65 y abused by a sexual member. Average age of fam was 40.1 years. 60% of part pants were female and 40% male. Average age of abuse onset was 6.7 years. M xed c nc a samp e. The nonc a samp e had rece ved treatment for CSA at some point n ther Purpose samp ng of men and women a ong d sc osure pathway was used. An a ysis of 30 part c pant narrat ves was used for theme deve opment regard ng gender c d sc osure and impact of gender on d sc osure Study exam ned patterns of d sc osure n a large representat ve samp e of South Afr can cases of CSA v ct ms seen at the cr s s center where the cr s s work and med ca tes for CSA v ct ms were 1,737 cases of CSA reported to the North Durban Kwaz u-Natal, South Afr ca during January 2001 to December 2003 1,614 g rls and Design A qua tat ve og ca des gn--LIM-was used to e ct d sc osure exper ences; fac tators and re evant barr ers; and re evant c rcumstances. Interv ews were transcribed verbat m. LI ne-by- ne open cod ng was conducted to capture fam y eve factors. Axa and se ect ve cod ng fac tated d ent cat on of themes The study's purpose was to qualt at e y exp ore or promote d sc osure by exper ences of factors nc ud ng dynam c- or h d den CSA to d sc ose CSA Surv vors of CSA were interv ewed about ther d sc osure experiences us ng LIM. An a ysis of 30 part c pant narrat ves was used for theme deve opment regard ng gender c d sc osure and impact of gender on d sc osure Interv ews were tr nscribed verbat m and bed cod ng axa and se ect ve cod ng subc ateg es and co themes were a bsed and re fined nto theme areas F re vews of a soc a work and med ca cases for CSA v ct ms seen at the cr s s center where the cr s s work and med ca tes for CSA v ct ms were The object ves of the current study were to qualt at e y exp ore dynam cs of factors nc ud ng dynam c- or h d den CSA to d sc ose CSA or promote d sc osure by exper ences of factors nc ud ng dynam c- or h d den CSA to d sc ose CSA Two study objectives were to: (1) examine how and (continued) --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 13 of 45 (continued) Table 1. (continued) Study Purpose CSA victims when they disclose the abuse and (2) identify factors associated with different patterns of disclosure Findings Sample: 123 boys; average age of victims was 9.7 years. 47% were made with 72 hrs of disclosure, 31% from 72 hrs to 1 month and 22% more than a month after the abuse Design: Cases referred during the period of January 2001 to December 2003 Summary Findings: (1) purposeful disclosure (30% of cases) and (2) incorrect disclosure (18% of cases) and (3) eyewitness detection (43% of cases) independently predicted by victims age, frequency of abuse and reporting latency. Mean age of purposeful disclosure (10.67) was higher than the mean age of non-purposeful disclosure (9.84). Expert forms of disclosure were more likely when the reporter was a family member. Shorter reporting latency was more common among the 26,446 children aged 3- to 14-years-old. Overall, 65% of the 26,446 children reported sexual abuse and 71% reported physical abuse. Rates of disclosure were greater for sexual abuse (6%) than for physical abuse (5%). Children aged 3- to 5-years-old grew at a slower rate than children aged 6- to 12-years-old. Disclosure rates increased from 1998 to 2002, and experienced interviewers conducted standardized NICHD protocol. Archive data were analyzed Hershkowitz, Horowitz, and Lamb (2005) This study aimed to identify characteristics of suspected child abuse victims that are associated with disclosure during nondisclosure interviews The study investigated 20 families with a total of 22 children who were able to participate in the context in which they reported sexual abuse experiences; the children were able to talk about what happened to them. What the parents and the children's perceptions of the disclosure process were The study used a qualitative approach to collect data on 20 families with a total of 22 children who were able to participate in the context in which they reported sexual abuse experiences; the children were able to talk about what happened to them. What the parents and the children's perceptions of the disclosure process were Jensen, Gulbrandsen, Mossige, Reichelt, and Tjersland (2005) 271 DOJ-OGR-00006848 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 escents and rs who had experienced CSA. Examined and subsequent consequences of CSA. Samp e cons sted of 34 part cipants from four groups: Sessions were seen between 60 and 90 m n and were audiotaped and transcribed for content ana ysis. Using purposive samp ng of survivors of CSA, 24 adults (ages of 18 between 5 and 61.2) were recruited by 57% male and 43% female agen ts. The study emp oyed a LIM—a descr pt ve ca phenomeno ca design—and the interv ew new ed 2 hr on average, generated data for a themat c ana ysis. The interv ew gu de was d c c ose of CSA ct ms The study sought to examine the inf uences that dr b or promote CSA d scourse and to address gaps n knowledge about what circumstances v s ect ms of CSA d sclose and under what c rcumstances v ct ms of CSA d sclosure occurred. Sma groups of preado escent and ado escent g rs who had surv ved sexual abuse a so served as consta nts and were encouraged to share the k now edge on the benefit of profes ona pract toners. This study prov ded a contextua exam nat on of the d scourse process, coser to the d scourse that occurs n tme when abuse and d scourse occurred. Sma groups of preado escent and ado escent g rs who had surv ved sexual abuse a so served as consta nts and were encouraged to share the k now edge on the benefit of profes ona pract toners. The mothers sad they were concerned about negat ve effects for the ch dren as a consequence of d scosur ng the r stress. If the ch dren showed s gns of d stress they woud not ta k, pursue the subject or not ta k further. F nd ngs n three major doma ns: (1) sepha se: conf dent se ect on of tme, (2) conf dent se ect on of person and persona reacton phase, and (3) support ve or hostile reactons. The act ongo ng consequences phase, and the k now edge on the benefit of profes ona pract toners. The study expanded types of CSA d sc osures to more fu y understand how ch dren and adu ts d sc ose. And under what c rcumstances that occurred n ch dhood suscept b e n memory fa es, espec a y when these memor es were forgotten. Over ha f the study samp e d d not fr get these (continued) 272 A agga (2004) --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 disclosure and reactions to CSA Design Sample Developed to probe individual, environmental, and cultural factors influencing CSA disclosure In-depth telephone (anonymous) interviews were conducted after informed consent was obtained. Three investigators sought help from a social network and/or the services and/or Adult women reporting CSA by someone close before the age of 18 and had someone to tell were retrieved through the quest onma res and data on disclosure and reactions were gathered through the interviews with participants using semi-structured guides together with victim questionnaires based on current social support Summary Findings: Three previously established categories emerged: behavioral or verbal disclosure attempts triggered by recovered memories The main impediments to disclosure were: fear of not being believed, fear of family members, and fear of causing trouble to the family. The main reasons for disclosure were: sexual abuse and intimate partner violence. The majority of survivors had been abused by multiple perpetrators. At the time of the first study, one of the studies was on average 7 years after the abuse. Age of onset was often before age 7, with an average age of 36 young people who experienced sexual abuse by multiple perpetrators. 68% delayed disclosure until adulthood. Abuse characteristics: abuse by multiple perpetrators was more common than by one perpetrator. Age of onset was often before age 7, with an average age of 36 young people who experienced sexual abuse. Women had taken to professional networks especially to the police. 32% disclosed during childhood (below age of 18). Women who had disclosed reported more negative reactions and were less likely to report to the police. Purpose and negative reactions were probed 273 DOJ-OGR-00006850 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 16 of 45 (continued) Table I. (continued) Study Kogan (2004) Goodman-Brown, Edelstein, Jones and Gordon (2003) Purpose The purpose of this study was to identify factors that influence the disclosure made by female survivors of childhood sexual abuse and to assess the nature of both the disclosure and the receipt of the disclosure. The purpose of this study was to investigate variables associated with child sexual abuse disclosure. Case file reviews of data obtained from prosecutors' offices were conducted for CSA and prosecution on files, as well as structured interviews with the children's caretaker. Incident Categorization modified CSA categorization questions about each sexual event including unwanted sexual contact, character stats and perpetrator character stats were investigated. A subsample of 263 adolescent females between 12 and 17 years old, mean age of 15.7 years old, who reported at least one experience of sexual contact in the NSA, were assessed using a modified CSA categorization. Interviewers asked a series of questions about each unwanted sexual event including unwanted sexual contact, character stats and perpetrator character stats. Data were gathered from a subsample of female adolescents who participated in the NSA. Sample Participants were 218 children referred to CSA, a program for children who had allegedly been sexually abused CSA, a program for children who had allegedly been sexually abused. A total of 64% disclosed within a month and 29% disclosed within 6 months. Five variables were tested: (1) age of child disclosure mode, (2) type of victim consequences of abuse, (3) fear of negative consequences of disclosure. Findings Significant predictors of delay were younger age at first event and evidence of the 26 women who did not disclose during the period with ongoing abuse, 15 worried about not being believed after disclosure. Children under the age of 7 were at risk for delayed disclosure. CSA participants whose USE occurred between the ages of 7 and 13 were more likely to tell an adult. Adolescent peers were more likely to be told than children aged 7-10 years. Children beyond 11-13 tended to disclose to a family member or a friend. Immediate disclosure was associated with a stranger perpetrator. Fear of negative consequences was minimized when the perpetrator was a family member. Legal sample (32%) may account for earlier disclosures. Account suggests that older children with higher rates of extrafamilial abuse compared to intrafamilial abuse, felt greater negative consequences of disclosure, and so the time lag between the USE and disclosure was presumably shorter than study of adult CSA participants. Summary This study examined factors related to disclosure of USEs that occurred in childhood and adolescence. Although data may be retrospective, recall bias may have minimized the results since participants were asked to disclose USE via survey. A though ado escents were associated with a household member, (2) they made surveys more prompt, and (3) they were more likely to tell an adult. This study represents a higher rate of disclosure than in a reported author on which they may expand mode. These cases had been reported to prosecutors and were in process of prosecution. Legal sample with higher rate of extrafamilial abuse (52%) may account for earlier disclosures. Account suggests that older children with higher rates of extrafamilial abuse compared to intrafamilial abuse, felt greater negative consequences of disclosure, and so the time lag between the USE and disclosure was presumably shorter than study of adult CSA participants. Design Data were gathered from a subsample of female adolescents who participated in the NSA. Data were gathered from a subsample of female adolescents who participated in the NSA. 274 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 17 of 45 Table 1. (continued) Study Purpose Design Sample questionnaire for childhood abuse characteristics and the disclosure. Children reported the character of abuse and their disclosure, perception of response and fear consequences were probed. Correlation 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 extent of childhood sexual abuse, the age at first rape, and the time elapsed since the last rape. Two probability samples. Wave 1 = 2,009 respondents selected from a computer-assisted telephone interview (CATI) sample of approximately 35 minutes. Random digit dialing was used to contact potential respondents. A juror questionnaire was used to screen for women who were sexually assaulted before age 18 and who reported disclosure to at least one person. The telephone interview was conducted on a computer screen. The survey consisted of several measures designed to assess disclosure and the number of persons to whom disclosure was made. Both Wave 1 and Wave 2 data were collected. Wave 2 respondents were selected from the ages of 18 and 34 and were given a confidential status in 1989. Census statistics were used to compare the demographic characteristics of the sample to the U.S. population. The present study reports on data from the demographic and child rape victimization questions. Smith, LeTourneau, Saunders, K. Patrick, Resnick, and Best (2000) Summary Findings negative consequences to disclosure who took longer to disclose. We designed a study with high eve of disclosure for further mode of disclosure for further negative consequences to disclosure. However, researchers were not able to interview children who feared negative consequences to others took longer to disclose. Children who brought harm, fear of negative consequences to the self or perpetrators were unrelated to time of disclosure. (4) Perceived negative consequences to others took longer to disclose. The time frame of this survey may have had contextual influences on the major types of comparisons reported by the sample. Of the 288 women who reported n assault during the average length of time since the first rape was 10.9 years. The 288 women stated that they had told no one about the sexual assault at the time of the interview, 58% did not tell anyone within 5 years post-assault, and 27% disclosed to no one for over a year. At the time of the interview, women who disclosed to e phone were more likely to have been influenced by CSA (and should be disclosed to) response bias and may currently be influencing young women's disclosure patterns. For Wave 1, compared to the U.S. Census Bureau, the sample matched the demographic characteristics of the U.S. women population. Fewer than 10% of victims reported making or awareness of someone else's disclosure. Only 12% of child rape victims stated that the rape victimization author at some point 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 = National Survey of Adolescents; SES = socioeconomic status --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 DOJ-OGR-00006853 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006854 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006855 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006856 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 452-2 Filed 11/12/21 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-00006858 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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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DOJ-OGR-00006859 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 'The importance of understanding the dynamics of disclosure' 'Adolescents need to know about how to ask and what to do if someone tells' 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-00006861 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006863 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 Page 29 of 45 McElvaney proportions of adults have never disclosed such abuse, as evidenced by the high numbers of respondents disclosing to researchers for the first time. '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) 'A parent described how her teenage son told her over a period of days' 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-00006864 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006865 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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). Finally, some children need time to tell. Mudaly and Goddard (2006) quote a 13-year-old girl: 'she (mother) helped by not making me, not rushing me to get it out, which, um, I think it's a really stupid idea to make kids get it out A.S.A.P.' (p. 91). Implications for Practice The consensus in the research literature at the present time is that disclosure is multi-determined, influenced by a complex range of factors that may influence each child in a different way. Large-scale national probability studies confirm that non-disclosure and delays in disclosure are significant problems facing society and in particular for those professionals tasked with safeguarding the wellbeing of children. Children's fears and anxieties in relation to telling need to be understood and contained by those in their environment so that early disclosure can be encouraged and facilitated. The implications of these findings can be considered in interrelated contexts: the legal context where action can only be taken if the child is able to give a clear, credible account of his/her experiences; child protection and therapeutic contexts where a comprehensive account is required to enable child protection professionals to intervene and where the psychological sequelae can be addressed to minimise the long-term impact of the experiences; and family and community contexts where early disclosure needs to be encouraged, and 'Investigating the precise circumstances that led to disclosures for children' 'Significant proportions of disclosure have been prompted by questions by caregivers, friends or others' 'The implications of these findings can be considered in interrelated contexts' Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00006866 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 '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?' Copyright © 2013 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 24: 159 169 (2015) DOI: 10.1002/car DOJ-OGR-00006867 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 DOJ-OGR-00006868 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006870 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006871 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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-00006872 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 http://dx.doi.org/10.3402/ept.v6.25883 DOJ-OGR-00006873 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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 452-2 Filed 11/12/21 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) than for delayed disclosers (M = 82.9 weeks, SD = 79.4). Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ept.v6.25883 DOJ-OGR-00006875 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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, Timbrement 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 452-2 Filed 11/12/21 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-00006877 --- PAGE BREAK --- Case 1:20-cr-00330-PAE Document 452-2 Filed 11/12/21 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. Furthermore, efforts to encourage early disclosure must consider peer-to-peer victimization as a primary factor, as most participants in this study experienced this type of victimization, and may initially not have defined or acknowledged the incident as rape because they rationalize such experiences as normal (Hlavka, 2014), leading to the finding of delayed disclosure. In conclusion, the results of the present study suggest that adolescent victims of rape with penetration by Citation: European Journal of Psychotraumatology 2015, 6: 25883 http://dx.doi.org/10.3402/ejpt.v6.25883 (page number not for citation purpose) 7 DOJ-OGR-00006878