EFTA00156864.pdf

Crock ice towns Review Manuscript TRAUMA. ,aOLENCE. & ABUSE 2019. Vet 2012) 260.2M Facilitators and Barriers to Child Sexual The Author(s) 2017 CiI0I Abuse (CSA) Disclosures: A Research &ode rizeu of shuts *Urn <cmlounalscermissrons 001 le 1177!152038017697312 Update (2000-2016) Icurnshiagepubccm, codou OSAGE Ramona Alaggia l , Delphine Collin-Vezina2, and Rusan Lateef' 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) Disdosure 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 (S) barriers to disclosure continue to outweigh facilitators. Although solid strides have been made in understanding CSA disclosures, the current state of knowledge does not fully capture a cohesive picture of dis- closure processes and pathways over the life course. More research is needed on environmental, contextual. and cultural factors. Barriers continue to be identified more frequently than facilitators, although dialogical forums are emerging as important facil- itators of CSA disclosure. Implications for practice in facilitating CSA disclosures are discussed with recommendations for future research. Keywords sexual abuse. child abuse. cultural contexts Introduction the same time global trends from systematic reviews and meta- analyses have found concerning rates of CSA, with averages of Timely access to supportive and therapeutic resources for child 18-20% for females and of 8-10% for males (Pereda, Guilera, sexual abuse (CSA) survivors can mitigate risk to the health Foms, & Gomez-Benito, 2009). The highest rates found for and mental health well-being of children, youth, and adults. girls is in Australia (21.5%) and for boys in Africa (19.3%), Identifying and understanding factors that promote or inhibit with the lowest rates for both girls (11.3%) and boys (4.1%) CSA disclosures have the potential to facilitate earlier disclo- reported in Asia (Stoltenborgh, van LIzendoom, Euser, & sures, assist survivors to receive services without delay, and Bakermans-Krancnburg, 2011). These findings point to the potentially prevent further sexual victimization. Increased incongruence between the low number of official reports of knowledge on both the factors and the processes involved in CSA disclosures is timely when research continues to show high rates of delayed disclosures (Collin-Vezina, Sablonni, Factor•Inveentash Facuky of Social Work. University of Toronto. Toronto. Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, °nano. Canada 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, a Centre for Research on Children and Families. School c4 Social Work. McGill Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; University. Montreal. Qubec. Canada Jonzon & Lindblad, 2004; McElvancy, 2015; Smith et al.. 2000). Corresponding Author: Ramona Magee. Factor-Inwenash Chair in Children's Mental Health. Factor. Incidence studies in the United States and Canada report lnwentash Faculty of Social Work. University of Toronto. 246 Bloor St West. decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, Toronto. Ontario. Canada M4K I WI. Turner, & Hamby, 2014; Trocme et al., 2005, 2008), while at Erna* ramecia.abgpalgutorcoto.ca 3502-021 Page 1 of 24 EFTA_00001523 EFTA00156864 Maggio et at. 261 CSA to authorities and the high rates reported in prevalence disclosure research, through various mixed methods, to high- studies. For example, a meta-analysis conducted by Stollen- light the most convincing findings that should be considered for borgh, van Ilzendoorn, Euser, and Bakermans-Kranenburg future research, practice, and program planning. This review (2011) combining estimations of CSA in 217 studies published centered on the question: What is the state of CSA disclosure between 1980 and 2008 revealed rates of CSA to be more than research and what can be learned to apply to future research 30 times greater in studies relying on self-reports (127 in 1,000) and practice? By way of clarification, the term systematic than in official report inquiries, such as those based on data refers to a methodologically sound strategy for searching liter- from child protection services and the police (4 in 1,000) (Ea- ature on studies for knowledge construction, in this case the ken, Cotter, & Perreault, 2014; Statistics Canada 2013). In CSA disclosure literature, rather than intervention studies. The other words, while I out of 8 people retrospectively report years spanned for searching the literature were 2000-2016, having experienced CSA, official incidence estimates indicate building on previous reviews without a great deal of overlap. only 1 per 250 children. In a survey of Swiss child services, Retrieval of relevant research was done by searching intema- Maier, Mohler-Kuo, Landholt, Schnyde•, and Jud (2013) fur- tional electronic databases: PsycINFO, PsycARTICLES, Edu- ther found 2.68 cases per 1,000 of CSA disclosures, while in a cational Resources Information Center, Canadian Research recent comprehensive review McElvaney (2015) details the Index, International Bibliography of the Social Sciences, Pub- high prevalence of delayed, partial, and nondisclosures in lished International Literature on Traumatic Stress, Sociologi- childhood indicating a persistent trend toward withholding cal Abstracts, Social Service Abstracts, and Applied Social CSA disclosure. Science Index and Abstracts. This review searched peer- It is our view that incidence statistics are likely an under- reviewed studies. A search of the gray literature (unpublished estimation of CSA disclosures, and this drives the rationale for literature such as internal agency documents, government the current review. Given the persistence ofdelayed disclosures reports, etc.) was beyond the scope of this review because with research showing a large number of survivors only dis- unpublished studies are not subjected to a peer-review process. closing in adulthood (Collin-Vezina et al., 2015; Easton, 2013; Keyword search terms used were child sexual abuse, childhood Ilunter, 2011; McElvaney, 2015; Smith et al., 2000), these sexual abuse, disclosure, and telling. issues should be a concern for practitioners, policy makers, and A search of the 9 databases produced 322 peer-reviewed the general public (McElvaney, 2015). The longer disclosures articles. Selected search terms yielded 200 English publica- are delayed, the longer individuals potentially live with serious tions, 1 French study, and 1 Portuguese review. The search was negative effects and mental health problems such as depres- further refined by excluding studies focusing on forensic inves- sion, anxiety, trauma disorders, and addictions, without receiv- tigations, as these studies constitute a specialized legal focus on ing necessary treatment. This also increases the likelihood of interview approaches and techniques. As well, papers that more victims falling prey to undetected offenders. Learning focused exclusively on rates and responses to CSA disclosure more about CSA disclosure factors and processes to help were excluded, as these are substantial areas unto themselves, advance our knowledge base may help professionals to facil- exceeding the aims of the review question. Review articles itate earlier disclosures. were also excluded. Once the exclusion criteria were applied, Previous literature reviews examining factors influencing the search results yielded 33 articles. These studies were sub- CSA disclosure have served the field well but are no longer jected to a thematic analysis as described by Braun and Clarke current. Important contributions on CSA disclosures include (2006). This entailed ( l) multiple readings by the three authors; Paine and Hansen's (2002) original review covering the liter- (2) identifying patterns across studies by coding and charting ature largely from the premillennium era, followed by London, specific features; (3) examining disclosure definitions used, Bruck, Ceci, and Shuman's (2005) subsequent review, which sample characteristics, and measures utilized; and (4) major may not have captured publications affected by "lag to print" findings were extrapolated. Reading of the articles was initially delays so common in peer-reviewed journals. These reviews conducted by the authors to identify general trends in a first are now dated and therefore do not take into account the level of analyses and then subsequently to identify themes plethora of research that has been accumulated over the past through a deeper second-level analyses. A table of studies was IS years. Other recent reviews exist but with distinct contribu- generated and was continuously revised as the selection of tions on the dialogical relationalprocesses of disclosure (Reit- studies was refined (see Table I). sema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McEl- vaney, 2015). This literature review differs by focusing on CSA Key Findings disclosures in children, youth, and adults from childhood and First-level analysis of the studies identified key study charac- into adulthood—over the life course. teristics. Trends emerged around definitions ofCSA disclosure, study designs, and sampling issues. First, in regard to defini- tions, the term "telling" is most frequently used in place of the Method term disclosure. In the absence of standardized questionnaires Kiteley and Stogdon's (2014) systematic review framework or disclosure instruments, telling emerges as a practical term was utilized to establish what has been investigated in CSA more readily understood by study participants. Several 3502-021 Page 2 of 24 EFTA_00001524 EFTA00156865  m Table I. Child Sexual Abuse (CSA) Disclosure Studies: 2000-2016. 1.4 Study Purpose Design Sample Findings Summary Gagnier and Collin- To explore disclosure Phenomenological 17 men ranged in age The majority of the men in the study waited All participants had disclosed and Vezina (2016) processes for male methodology used co from 19 to 67— until adulthood co disclose their abuse. received services before victims of CSA interview male CSA average age 47. with negative stereotypes contributing participating in the study. Member survivors. The Long Purposive sampling to their delayed disclosures. Negative checking could not be done with Interview Method strategy was used stereotypes contributed to delayed die participants co check themes. (UM) guided data disclosure with trying to forget. Breaking Small but sufficient sae for a collection and isolation was cited as a motivator to qualitative inquiry. Otherwise. analyses. disclosure along with the aid of various high level of rigor in establishing forms of media on disclosure. Important trustworthiness of the data and contextual issues such as negative analysis. Retrospective study stereotyping of males. sexuality. and could imply recall issues victims were noted. Social media was seen as a facilitator of disclosures Braze1ton (2015) To explore the meaning Collective case study 17 African American CSA onset was largely between the ages 5 One of few studies co focus African American design with using women in midlife and 9. No one ever talked to them about exclusively on African American women make of their narrative tradition between 40 and 63 sex. so they didn't have language to women. Small but sufficient size traumatic experiences (storyboard) for data who experienced disclose. Barriers: fear of family for a qualitative inquiry. Important with CSA and how collection and analysis. intrafamilial CSA. breakdown and removal. not wanting co cultural and contextual issues they disclosed across Qualitative Purposive. snowballing tarnish the family's name. and fear of were brought forward. the life course interviewing strategy retribution by family members if they Retrospective study that may disclosed. Pattern of stifled and have been affected by recall issues. dismissed disclosures identified over the Use of a life-course perspective as life course. All 17 participants identified a theoretical lens for spirituality as a primary source of understanding CSA in the middle strength throughout the life course to later years of life that should be considered in further investigations Sablonni. To provide a mapping of Qualitative design using 67 male and female CSA Three broad categories were identified as Half of the participants had not Palmer. and Milne factors that prevent LIM. adult survivors (76% barriers to CSA disclosure: Barriers disclosed their CA experiences (2015) CSA disclosures identified as female and from within-internalized victim blaming. before the age of 19. through an ecological 24% as male). Age mechanisms to protect oneself, and Retrospective aspect of the study lens from a sample of ranges from 19 to 69 immature development at time of abuse: could imply recall issues. All CA adult survivors. years (M = 44.9). barriers in relation to others—violence participants had disclosed and Purposive sampling and dysfunction in the family. power received counseling at some strategy dynamics. awareness of the impact of before participating in the study. telling, and fragile social network: High level of rigor in establishing barriers in relation to the social world trustworthiness of the data and labeling. taboo of sexuality. lack of analysis services available. and culture or time period. Leclerc and Wortley Study objectives Adult male child sexual 369 adult males who had Disclosure increased with the age of the Offender generated data through (2015) investigated the offenders were been convicted of a victim: if penetration had occurred, if the self-reports could be subject to factors that facilitate interviewed to sexual offense against a victim was related co the offender. if the cognitive distortions— CSA disclosures examine predictors of child aged between victim was not living with the offender at minimization or exaggerations. (continued) EFTA00156866  Table I. (continued) Study Purpose Design Sample Findings Summary victim disclosure. and 17 years old. the time of the abuse. or if the victim Perspectives of offenders on Seinistructured Majority were White. resisted during the offense. Male victims vulnerability of victims in relation interviews based on uneducated, AMOR and victims from dysfunctional to disclosure could be important the QID half unemployed backgrounds were less likely co disclose information to inform questionnaire. before their arrest interventions McElvaney and Culhane To investigate the File reports of children Content analysis was Majority of children cold their mothers The sample size is small but will (2015) feasibility of using child seen for assessment in completed on 39 files (43%) and peers (33%) first. Three major contribute to a large multisite assessments as data a child sexual abuse (32 females and 7 themes were identified as influencing the study in Ireland. Serves as an sources of informal unit in a children's males) based on a disclosure process: (I) feeling distressed. important exploratory pilot CSA disclosure. To hospital were coding framework. (2) opportunity to tell, and (3) fears for bringing forward disclosure assess If these reports reviewed Parents were asked to self. Additional themes of being believed. themes for consideration provide substantive consent to have their shamefself-blame, and peer influence data on disclosures child's file reviewed for were also identified the study. Victims assessed were 12-18 years of age Dumont. Messerschmitt. This study aimed to File reports of children 220 minor victims- Disclosure processes were more complex The relationship with the Vila, Bohu. and explore how the seen for assessment in 78.2% female victims. when it concerned sexual abuse perpetrator has a significant Rey-Salmon (2014) relationship between a child sexual abuse 41.8% aged between committed by intrafaminal perpetrator impact on both timing and the perpetrator and unit in a children's 14 and 18 (most 60% of the victims reveal the facts recipient of disclosure, with the victim. especially hospital were prevalent age range). several years after. and most often to inumfamilial abuses less likely to whether these reviewed and 48.2% were individuals outside the family (78.6% of be disclosed promptly and within relations are abused by a family the disclosures done at school): on the the family system intrafamilial or member contrary. extrafamilial disclosures take extrafamilial. impact place more spontaneously and quickly: CSA disclosure 80% of the victims reveal the facts a few days after. most often to their mother or peers Easton. Salzman. and Study focus was on Using qualitative content 460 men with CSA Vast majority of participants (94.6%) were At time of the study. this was the Willis (2014) identification of analysis. researchers histories completed an sexually abused by another male. largest qualitative data set to have barriers to CSA conducted a secondary anonymous. Internet- Duration of sexual abuse broke down been analyzed with an explicit disclosure with male analysis of online based survey. into: 30.2% less than 6 months. 32.3% 6 focus on adult male survivors' survivors survey data. the 2010 Recruited from months to 3 years. and 34.3% more than perceptions of barriers to CSA Health and Well-Being survivors 3 years. Ten years old was average age of disclosure. Because the sample Survey. that included organizations. Age CSA onset Ten categories of barriers was limited in terms of the low men with self-reported range of 18-84 years. were classified into three domains: (I) percentage of racial minorities CSA histories with an Two thirds of sociopolitical: masculinity. limited (9.3%). disclosure differences open-ended item on respondents reported resources: (2) interpersonal: mistrust of based on race or ethnicity were disclosure barriers dery-related abuse. others. fear of being labeled 'gay.- safety not discerned. The majority of Majority of and protection issues. past responses: abuse reported was by clergy respondents were and (3) personal: internal emotions. which might present a unique set White seeing the experience as sexual abuse. of barriers co disclosure and sexual orientation. (continued) EFTA00156867  Table I. (continued) Study Purpose Design Sample Findings Summary Easton (2013) Study purpose was to Cross-sectional survey Purposive sampling of Older age and being abused by a family Purposive sampling of men from describe male CA design. Eligible 487 men from three member were both related to delays in awareness raising organizations disclosure processes participants were national organizations disclosure. Most participants who told may have attracted particular using a life span screened and devoted to raising someone during childhood did not participants who had already approach examining completed an awareness of CSA receive emotionally supportive or disclosed and received help. differences based on anonymous. Internet- among men. Age protective responses and the helpfulness Participants needed co have age. Also. to explore based survey during range: 19-84 years. of responses across the life span was access to Internet which would relationships between 2010. Measures used: Mean age for onset of mixed. Delays in telling were significant have eliminated men in lower SES disclosure attributes General Mental Health CSA was 10.3 years periods of time (over 20 years). groups and required proficiency in and men's mental Distress Scale and Approximately one half of the English which would eliminate health General Assessment of participants first told about the sexual certain cultural groups. However. Individual Needs. abuse to a spouse/partner (27%) or a the sampling strategy gained Questions related to mental health professional (20%): 42% of access to a predominantly hidden CSA disclosure and participants reported that their most population. Important clinical supports were helpful discussion was with a mental recommendations are made with included health professional. However. unhelpful an emphasis on a life-course focus responses caused most mental distress. Clinical recommendations included more of a life-course perspective be adopted. understanding impact of unhelpful responses and the importance of expanding networks for male survivors McElvaney, Greene. and Qualitative study asked Grounded theory Sample of 22 young A theoretical model was developed that Modest but sufficient sample for an Hogan (2012) the central research method study. people: 16 girls and 6 conceptualizes the process of CSA exploratory qualitative inquiry. question: "How do Interviews were boys: age range: 8-18 disclosure as one of containing the High level of trustworthiness children tell?" conducted. Line-by- years: 22 interviewed secret (I) the active withholding of the rigor. A subsample of randomly Objective was to line open and axial in total between the secret on the part of the child; (2) the selected transcripts was develop theory of how coding was conducted ages of 8 and 18. Mixed experience of a "pressure cooker effect" independently coded. Very young children tell of their on verbatim sample of some reflecting a conflict between the wish to children and young adults were CSA disclosure transcripts enduring innfamilial tell and the wish to keep che secret and not captured in this sample. experiences. Parents CSA. some (3) the confiding itself which often Transferability of findings can only were interviewed. extrafamilial CSA. and occurs in the context of a trusted be made to the age range sampled two endured both relationship. These were derived from in the context of Ireland forms eleven categories that were developed through open and axial coding Schonbucher. Maier. To investigate the Data collection was Convenience sample of Less than one third of participants Two thirds of the sample did not Mohler-Kuo. Schnyder. process of CSA through face-to-face 26 sexually victimized immediately disclosed CSA to another disclose right away. Strengthening and Landolt (2012) disclosure with qualitative interviews. adolescents. 23 girls person. In most cases. recipients of both parent—child relationships may be adolescents from the Standardized questions and 3 boys. Age range: immediate and delayed disclosure were one of the most important ways general population and measures were 15-18 years. Online to peers. More than one third of co increase disclosure co parents. who had experienced administered on family advertisements and participants had never disclosed the Disclosure to peers has been CSA. How many situation. flyers were used to abuse to a parent. Participants reported found a common trend in other disclosed. who did sociodemographic recruit youth from reluctance to disclose to parents so as (continued) EFTA00156868  Table I. (continued) Study Purpose Design Sample Findings Summary they disclose to. and data. sexual community and not to burden thent Earlier disclosures research and bears more what were their victimization. general. counseling services were related to extrafamilial CSA. single examination motives for disclosing and mental health. occurrence CSA. age of victim at abuse Sexual Assault Module onset. and parents who were living of the Juvenile together. Higher levels of reported guilt Victimization and shame were related to delayed Questionnaire was disclosures. Peers were viewed by this used sample as more reliable confidants Hunter (2011) Aim of this study was to Narrative inquiry Purposive sampling was Only 5 out of 22 participants told anyone Delayed disclosure was common in develop a fuller methodology. Face-to- employed. Sample about their early sexual experiences as this qualitative sample. Most understanding of CSA face in-depth consisted of 22 children. Fear. shame. and self-blame participants did not make a disclosures interviews were participants aged 25- were the main inhibitors to disclosure. selective disclosure until conducted with 70 years: 13 women These factors are further detailed adulthood. These findings support participants. Data and 9 men. Participants through subthemes. Telling as a child and Alaggia's (2004) model of were analyzed using were sexually abused as an adult was further expanded upon disclosure but also highlights the Rosenthal and Fischer— at IS years or under using Alaggia's (2004) framework importance of life stage. Modest Rosenthal's (2004) with someone over verifying behavioral indirect attempts to but sufficient sample size for a method. the age of IS. tell and purposeful disclosure as qualitative inquiry. Well-designed categories. Thematic analysis supported study with detailed analysis for that CSA disclosure should be transferability of findings conceptualized and viewed as a complex and lifelong process Schaeffer. Leventhal. and This study aimed to: (I) Study sought to find out if I91 interviews of CSA Reasons the children identified for telling An innovative study to cry to assess Asnes (2011) add direct inquiry process issues of victims aged 3-18 over were classified into three domains: (I) if formal investigative interviews about the process of a disclosure could be a -year period were disclosure as a result of internal stimuli can facilitate disclosures of CSA. child's CSA disclosure: identified in the used for the study. (e.g.. the child had nightmares): (2) Data were based on a large (2) determine if context of forensic Inclusion criteria disclosure facilitated by outside number of interviews. Detailed children will discuss interviews. Forensic included children who influences (e.g.. the child was analysis produced detailed process that led them interviewers were made a statement questioned): and (3) disclosure due to findings supporting other study to tell: and (3) describe asked to incorporate about CSA prior to direct evidence of abuse (e.g.. the child's findings on CSA disclosure factors that children questions about referral. reasons for abuse was witnessed). The barriers to identify that led them "telling" into an telling or waiting co disclosure identified fell into five groups: to tell about or caused existing forensic tell. and those who (I) threats made by the perpetrator them co delay CSA interview protocol. spoke English. (e.g.. the child was told she or he would disclosure Interview content Participants were get in trouble if she or he told). (2) fears related to the children who were (e.g.. the child was afraid something bad children's reasons for interviewed at a child would happen if she or he told). (3) lack telling or waiting was sexual abuse clinic. of opportunity (e.g.. the child felt the extracted. transcribed. 74% were female and opportunity to disclose never and analyzed using 51X were Caucasian presented). (4) lack of understanding grounded theory (e.g.. the child failed to recognize abusive method of analysis behavior as unacceptable). and (5) relationship with the perpetrator (e.g.. the child thought the perpetrator was a friend)