® Checa tor updates Review Manuscript TRAUMA, VIOLENCE, & ABUSE . . . 2019, Vet. 20/2) 260-283 Facilitators and Barriers to Child Sexual The Author(s} 2017 rowel Abuse (CSA) Disclosures: A Research Arte rene padelnes com/journals-permissions sagepub Update (2000-2016) Ot a7 seo 7312 (SAGE Ramona Alaggia', Delphine Collin-Vézina’, 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: (|) 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 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- Timely ace ive and thera - for child analyses have found concerning rates of CSA, with averages of imely access to supportive and therapeutic resources for chi 18-20% for females and of 83-10% for males (Pereda, Guilera, sexual abuse (CSA) survivors can mitigate risk to the health Forms, & Gomez-Benito, 2009). The highe: . , sng 7 os - » - ghest rates found for and mental health well-being of children, youth, and adults. 9:44, ig in Australia (21.5%) and for boys in Africa (19.3%), Identifying and understanding factors that promote or inhibit ith 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 Uzendoorm, Euser, & sures, assist survivors to receive services without delay, and Bakermans-Kranenburg, 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 e Po CSA disclosures is timely when research continues to show high rates of delayed disclosures (Collin-Vézina, Sablonni, \ Pacecastrevnnaas Fa # Social Worle, Un oft * Palmer, & Milne, 2015; Crisma, Bascelli, Paci, & Romito, Cnsarlo, Canada culty 0 nereny ot horante, Teresi, 2004; Easton, 2013; Goodman-Brown, Edelstein, Goodman, — 2 Centre for Research on Children and Families, School of Social Work, McGill Jones, & Gordon, 2003; Hershkowitz, Lanes, & Lamb; 2007; University, Montreal, Qubec, Canada Jonzon & Lindblad, 2004; McElvaney, 2015; Smith et al., 2000). ‘Corresponding Author: idence studies i : , . Ramona Alaggia, Factor-inwentash Chair in Children’s Mental Health, Factor- Incidence studies in the United States and Canada report (on ch Faculey of Sacial Work, University of Toronto, 246 Bloor Se. West, decreasing CSA rates (Fallon et al., 2015; Finkelhor, Shattuck, — Toronto, Ontario, Canada M4KIW1I. Turner, & Hamby, 2014; Trocmé et al., 2005, 2008), while at — Emait ramona.alaggia@utorento.ca 3502-021 Page | of 24 EFTA_00001523 EFTA00156864

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Alaggia et al. CSA to authorities and the high rates reported in prevalence studies. For example, a meta-analysis conducted by Stolten- borgh, van Uzendoorn, 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) (Jil- lian, Cotter, & Perreault, 2014; Statistics Canada 2013). In other words, while 1 out of 8 people retrospectively report having experienced CSA, official incidence estimates indicate only | per 250 children. In a survey of Swiss child services, Maier, Mohler-Kuo, Landholt, Schnyder, and Jud (2013) fur- ther found 2.68 cases per 1,000 of CSA disclosures, while in a recent comprehensive review McElvaney (2015) details the high prevalence of delayed, partial, and nondisclosures in childhood indicating a persistent trend toward withholding CSA disclosure. It is our view that incidence statistics are likely an under- estimation of CSA disclosures, and this drives the rationale for the current review. Given the persistence of delayed disclosures with research showing a large number of survivors only dis- closing in adulthood (Collin-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 depres- sion, anxiety, trauma disorders, and addictions, without receiv- ing necessary treatment. This also increases the likelihood of more victims falling prey to undetected offenders. Learning more about CSA disclosure factors and processes to help advance our knowledge base may help professionals to facil- itate earlier disclosures. Previous literature reviews examining factors influencing CSA disclosure have served the field well but are no longer current. Important contributions on CSA disclosures include Paine and Hansen's (2002) original review covering the liter- ature largely from the premillennium era, followed by London, Bruck, Ceci, and Shuman’s (2005) subsequent review, which may not have captured publications affected by “lag to print” delays so common in peer-reviewed journals. These reviews are now dated and therefore do not take into account the plethora of research that has been accumulated over the past 15 years. Other recent reviews exist but with distinct contribu- tions on the dialogical relational processes of disclosure (Reit- sema & Grietens, 2015), CSA disclosures in adulthood (Tener & Murphy, 2015), and delayed disclosures in childhood (McEI- vaney, 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 261 disclosure research, through various mixed methods, to high- light the most convincing findings that should be considered for future research, practice, and program planning. This review centered on the question: What is the state of CSA disclosure research and what can be learned to apply to future research and practice? By way of clarification, the term systematic refers to a methodologically sound strategy for searching liter- ature on studies for knowledge construction, in this case the CSA disclosure literature, rather than infervention 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 intemna- tional electronic databases: PsycINFO, PsycARTICLES, Edu- cational Resources Information Center, Canadian Research Index, International Bibliography of the Social Sciences, Pub- lished International Literature on Traumatic Stress, Sociologi- cal Abstracts, Social Service Abstracts, and Applied Social Science Index and Abstracts. This review searched peer- reviewed studies. A search of the gray literature (unpublished literature such as internal agency documents, government reports, etc.) was beyond the scope of this review because unpublished studies are not subjected to a peer-review process. Keyword search terms used were child sexual abuse, childhood sexual abuse, disclosure, and telling. A search of the 9 databases produced 322 peer-reviewed articles. Selected search terms yielded 200 English publica- tions, | French study, and | Portuguese review. The search was further refined by excluding studies focusing on forensic inves- tigations, as these studies constitute a specialized legal focus on interview approaches and techniques. As well, papers that focused exclusively on rates and responses to CSA disclosure were excluded, as these are substantial areas unto themselves, exceeding the aims of the review question. Review articles were also excluded. Once the exclusion criteria were applied, the search results yielded 33 articles. These studies were sub- jected to a thematic analysis as described by Braun and Clarke (2006). This entailed (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 charac- teristics. Trends emerged around definitions of CSA disclosure, study designs, and sampling issues. First, in regard to defini- tions, the term “telling” is most frequently used in place of the term disclosure. In the absence of standardized questionnaires or disclosure instruments, telling emerges as a practical term more readily understood by study participants. Several 3502-021 Page 2 of 24 EFTA_00001524 EFTA00156865

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(panuauo) (puavy sem sorenadsad aya ayZnoys pay aip “Ba) sowe.nedsad sup yam drysuonryas (s) pur ‘(ajqeadazzeun se sojaryaq sisdjeue yo poyjaw @nsnge azjuzo>a4 O1 payey PIy>? ayp “3'a) Asoayp papunous Bujputassapun jo »>x] (p) “(paruasaid URISTINED BuIM KIS Bujsn pazAjeue pue 49AaU aS0/25|P 02 AyuMIoddo PUR S/EWAy vam %ps = “‘Paq|IsuLA ‘paneaxe ‘BUp 3/9) pyry> atp “B'a) AUMau0ddo yo “DJUYD BsNge jenxas sem Bupyem Jo Buyer ye] (E) “(ppoa ay 40 ays y Uaddey pjnom Pry? © Ie pamajasaquy JO} SUOSTAY S,UaUp|/Yy> peg Supawos preye sem pyy> aip “B'a) ‘ua OYM UBIPIIY> ay 02 partes saeay (Z) ‘(pjoa ay 40 ays y ayqno.n uy ad 343M sluedppueg 1UBIUO? Ma|AIaIU] aunsopsip PINOM ay JO BYS Pjor sem PIIyD ap “Za) “ysifiug ayods "Jo20200d MaiAsaaUy WSD Avjap o2 wayp Jorenadsad aya Aq apew siwaayp (|) OYM @soUp pur ‘{ja2 2suas0y Buns}xe Pasne> 4o anoge |j92 02 ssdnoul aay o2u) [j} PayNUAP! aanso|>sIP 02 Zunrem 40 Buypaa ue out ,3uyjpa3,, walp pa] ze Ajnuapy 01 ssajueg ayy “(passauIMm sem asnge JO) SUOSBaL ‘[R1saya4 anoge suopsanb ua.upyyy> 2eyp S4023—y BuNSOPSIP YSD vO sBuypuy —s,pyy> au “a) asnge jo s2uapyaa 1DauIp 02 4oyad S> Inoge aivsodso>ul o1 payse —-Bquu2sap (F) pur ‘ya2 02 Apras sano Sujsoddns sSujpuy ©] anp aunsopsip (¢) pur ‘(pavopsanb quaWwaIms & apr BUM S4BMBIAJIIUY walp pa] 2eyp ssa2oud payeiap paonpoud sisdjeue SUM PINE ap “) saruanyu! ym UaspEY? Papnyrut DASUBIOS “SMAIAJOIUY SSNDSIP IM UB4pIY> Payeiag ‘sMaAsequy jo Jaquinu apisino Aq pareayyoey aunsoj>sip P4a1149 UOIsNPUL 2|SUBJOJ JO 1XB32U09 3] aujwuarap (z) aBue] & uo paseg avam mtg (Z) Msazewnysiu pry pyy> arp “8'a) “Apmas aip 2oy pasn Bla Ul PaynUap! —“BANSO}PSIP YSD S,PIIY> “WSD JO Saunsojrsip saerj>7 ueD |jnwins jeusaquy Jo 2jNsav E Se auNsoj>sip auam pojsad sead-| & 8g Pino? aunsojasip = —& Jo. Ssa20Ud ap inoge SMAIAJTIU| BALZNSaAU! [EUIOY yt (1) ssurewop aauya cau) pay!sstj> auam JAO BI—-E pase swinr|a JO sanssy ssav0ud Aaynbuy a2a41p ppt (1107) seusy ssasse 01 Aun on Apnas aaneaouul uy — Bulan 4Oy paynUap] UBIp)Y> ap sUOSeaY —YSD) JO SMAIAZANUT 16] INC Puy oraysnos Apmag — (|) :01 pale Apmas SY] pu "yeyUAAST ‘JayeEYyS ssazoud Buojayl) pue xajdwod t st pamaja put paziyenadazu0> s8ujpuy yo Anqesaysuesa 2q Pinoys aunsojsip SD IEP 404 sjsdjeue paymap wpim Apnas pavioddns sjsAjeur spewayy ‘sajosare> pauilsap-yeAq “Aanbuy aanenyenb S® aunsojasip jnyasodund pur 1/32 | jo ade ap powmaw © 404 az)s aydwes auapyNs Inq 02 sidwane 22.3s;puy jesoueyaq BulApuaa 4aA0 BUOBWOS WIM (007) s.jeyauasoy IsapopY ‘aFers ayy yo svuTUOdW} yromaweyy (pQ0Z) 5.eBFepy Bujsn dapun Jo suvak §] 1 —J8Ups|4 pur jeyaUAsOY aun sayZyysiy osye ang aunsopsip uodn papuedxa saying sem aNpe UE SE pasnge Ajjenxas asa Buysn pazAyeue asa JO [apOWw (/007) seRBepy put pyr ese Zuyjay “sewarpgns ySnosp =— sau y>pUTY ‘UaW 6 puT eg “suedpued woddns siupuy asay) ‘poowjnpe Palerap saying ave ssondey asayy uaWom g| ‘suvak Of \pIM paxnpuo> JauN aunsojasip arndajas “BUNSO/ISIP 02 SACIIgIYU! UTE aya a4aM -S7 pave suedppued Bam SVBAISIUL saunsopsip © ayew 20u pip swuedppsed ‘SUR |G-Hes PUE ‘wWeEYs “see “UaspHy> TZ JO paas|suo> wadep-uy aoe} VSD 40 Bupurassapun Iso) “Bjdwes aaneyyend siya se saouajedxa jenxas Ajsea sey inoge adwies -pakojduia -02-3984 AZojopomaw saying © dojaaap U] UOWWOD SEM aunsOpsip padejaq suodur pjor sauednued Zz yoIno ¢ AU —_ sem Buyjdwies aaysodung Aginbuy aaneaeyy 01 sem Apnas syip jo wi (1107) aanunyy SUEpYyVO? ajquijas asow se aydures pasn spin Aq pamala asam suaag “Saunsoj>sip SUM aureuUoNsand padtjap 02 parejas auam aweys pue voneznwn>|,, ayn’ parrodas yo sjanaj sayaiy “saypasor ayruaanf axp yo Buyal auava Oy Sluased pur “esu0 BINPOLY Ness jenxes BSNGE IE WIIDIA JO BBE “ST 32Ua4INI20 “yyjeay eauaw pue Bupsopsip 40y saanow vontuWwexs = —a[BuyS “WWSD [eINWEyEIAxe 01 parejas Bua Sa2|Asas Suyjasuno> ‘Peaauad ‘vopeZ}WA HA JWR ae wey BJOW Suva Pur YDIEases S@JNSO|>SIP Ja!]JeZ “WAY UBPiNg 03 10U pure AjUunWWOD Jenxas “wep Pure “02 asojsip Aays Asewwng sBupurg aduies us\sag asodung Apms (panunuos) "| age 3502-021 Page 6 of 24 EFTA_00001528 EFTA00156869

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(panuaua2) AR|RUIS PayUapy aALy ey saipms 03 oddns pua] suipury “ssa20ud FujoZuo aanzesaquy ue Ss} aunsopsip rey saysyysiy Apmos sry UONEUOyU! auNsOpSsIP WSD JO kau paystanoduy UE O2 SPpe |E4BAD “sSuppuy Jo Ayjqesaysuesa apnpaad Aew squno22e jmopaauy jeuarew Je2/Uy> YM sBulpuy aanaesaay jo YvOReUIqWO? anbwup Suyrajasaiuy BuNsoOpssip feMxsIUOD Ajpeanajn2 02 aBpaynoux SPPE JEU 5>1J0M Maj KA JO BUD ‘SaNss| ere Aq parzaye aq pjno2 aeya yoeoudde aanzadso.nas y ‘PooYpyiy> Buunp she 2Waspur ul auNsopsip yO WO} awos paidwane pry sepurewas ayy “eres pi Agin2yIp pey Aaup puke suvad Jooypsaad uy pasuno30 pey asnge ap so *Asowaw aya passaudas pry Aaip asne2aq pasopsip 20U pry %97 ‘PooypylyD Sujsnp asnge aN PasopsIp pry XT7p “S20U JO “Se2uaNyu! paIa>e~NyNW ap Sunysyysiy aunsopsip SD 02 syskjeur jer/Fojo29—jepos aaisuayasdwod & squasaid Apmis ayy Asewwing Bupyea 10U ‘suatpo O21 asnge ay jeus}s o2 suowaeyaq Sujwsey-as Buysn :sayBarens aunsojasip any Aojdwa asnqe 02 S@SSBLNIM JO pasnge Ua|q aArY OYM LINO) suo;esap|suod Jeamyn> SupeuSaqwy ysomauesy MaAsaIUt aasuayasdwiod & sluasaug “sdnous Asoujw ajqea220U Wo. eae UaUp—Yy> UDIYM U} SaseD Ul AjajOS 10U PUT ‘asO)>5|p o1 payse Bujaq 20 Fusopsip Zusapjsuod B4E UBUPHYD YDIYA Ul} SASED [IE U} JOI>Ep queodwy ut se spurs aunqyno (¢) put ‘su012e} Japua’ put ade uopesapisuo> ‘O2U] EI OSye Pynoys ZujuoRsanb (z) ‘IxBIUO> jeINgIND s_pypy> a~ O21 paso}ED gq pynoys Zumaiasaauy aunsojasip (1) @pNPuy apew suopepuauAUOray “map \padap-ul ul payauapy aue aunsopsip ys> Bunraye sso27 peaMINAS pue jesnajND Suas0]2sIp a3e20) Alnjasodind 02 sidwane Suydwes aun yo asne2aq salpms saypo uy pazsodas urip saysiy sp aunsojasip jryasodung “suop2eas sauaued @upuanyu! sapmanae peanajno pur “sayew 40) UONEZIIEIIOS JapUas “sppy se purayun Zula ‘sapranie peiapos pur sadessow PIpaw “sapnanze jexa}>0s pur jeamyn> (p) pur souwryaq Suyqno.n Sumnsand JOU SuaYy>IeaI puke svOgYsaU Woy IsavaIU! JO 28] “S| 2eyp “IXxaIUED AyUNWIWOD pur pooysoquysjau (¢) :uoprjosy [P05 put ‘voREDUNWWOD jeUoR>UTysAD ‘aDUB[OIA WAsBWOP “asnge pyy> yO SWIOy JO ‘vOrSsauTFe pue sory> ‘suaunty SupeUIWOP WIM Salo. sapuas paxy Ajpisiu se yans sonsjaazesey> Ayuuey Aq paarquyu! aansoj>sip (z) (panayeq Sujaq 20u Zunedopue pur ‘yan 02 Arige vai Uo Zuuwag awos prey osye sayesa Ayeuosuad ‘Sujuaddey Sem 2eYM Papuayasdwos Aaya 4aYPEYM 02 SE S2029t) [UaWdO;BAap ‘sacn2gy jruaWdojaAap put ;ENPIAIPU ypnod auayM sWOy YORENEAs 1Z9'] JO ajdwes pevopeu & wow sujnsa4 yo uoptuRueXg [ease SED [EDIUID WIA paaginguea sem ey @.ungjn2 pur asnsops|p uo auniesan] paysiiqnd JO paastsuco eae spunos2ypeq >IWOUOIBOPOS aSu9NIGg “BRIYAA-“UOU Sem aydues ap JO %9E PIO sua £°¢ SEM IaSUO asnge jo aft adtuany ~suvad [Op jo ade uraw FIM S9-B] JO aBurs ally ‘vawom xp9 pur UBL ZOE :pamalAsaquy BBM SD JO SJOAIAUNS AINPE Op “SuOAlAuNS ByewW avOW INZ2aJ 02 pasn osje sem Suydwes Iequous -padoydua (,) :surewop sno ous jay sawayy = st Buydwes aarsodung sBupuig ayduies uonuaaaid asnge ul vonedpued Bumoyioy wanod Aq Parajdwos au9Mm suOy Bujvonsanb aunsojsip WSD 40} promauuesy aquaaadwo> Ayesnayn> B apiaoud 02 sisAjeue ue pa2npuo? appue ‘SYA “eaep [eD-UIID YM aanaesany) paysyqnd Burspy “sua{ |E21B0}029 —(t1205 & YFnow auop sem sisdjeue DneWwaY “sanuajiadxe asaip jo Suppew-Suyueaw pur aunsojasip WS> Jo squnoozr aanzadso.nas apiaoud oa saruatadxe aunsoj>sip amu INoge ssoAUNS WSD 2INPE MaiAsaaUy O12 pasn sem “rq ‘usisap [e21Z0jouawouayd aaneayend y uljsag Uo Bursn>0y YANK Jo ajdwes jevomeu & yim saiZareas aunsopsip pasojdxe Apnas sry Aqevonewaquy pur sazeis paaun ap ul (peg ‘Bunsodau pur aunsopsip yS> JO sassazoud sizaye aungyna shea aya pavojdxa aunsopsip WSD JO UOPEUpWEXe sIy “SBUNSO|ISIP YSD a2owo.d 40 apadwy sa2uanyul jemMaxs1U0> pur ‘uawuosjAua *jeuosvadsaquy “PRMpIAIpU ARYAA “UONsanb \purases BuppuesanQ “Saunso|25|P WSD Bupowoud 40 Supaduy saoaaey Ayauapy on pawye Apmis ayy asodung (e6007) “wrowsrey pur “Anny ‘auuoD2}y ‘vaaieg ‘uesup, (o10z) JPWWN|g PUE saIU0y (0107) eisieny Apnas (panunuos)*y aqey 3502-021 Page 7 of 24 EFTA_00001529 EFTA00156870

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{panuguos) Jeuonras-ssosD “sSIpsaIEeYD BuNsopsip pur asnqe UO PaUNEIGO UONTUOJU al JO Azeana2e ay] Spa] SNYA PUT sanss} qeraa Ayu) pino> uonewoyuy Jo wodau-jjas pue Apnas aansedso.nay ‘uaWwoM pasnge Ajaaanas Jo vonmauasasdaszan0 ue Aq paul eymawos ‘aur synsau Apnas ayy “asnge Agydsaquy ay uo sn20} 02 saipnas ‘Isay Bip JO BuO sem a “ApNas tp yo awn ai ay ‘pooyrinpe Inun aunsopsip pacejap %89 J yaueasas aip 02 papuodsas SJOAIAINS PaYySNESS|p Is0W ‘BU SE Stig UORDA\asS E UIq BATY Aew asayy “aqeyeae sy Suyuyesa asuodsay asnge jenxas IY seap 20U 5} 3} pur Ajay UE pax2npUoD sem Apmis ayy “@2uajo1A sauaied ‘@2eWAY! pur asnge jenxas pjlyP JO SJOAJAUNS JO ajdwres paxiu & jo SSupuy ap paauasadas Apms siyy sajso%aae> aya pawoddns papjacud saionb pur paaayor sem wep @qp JO ssaulysomasnn jo aauZap us} e294 Ul swajgoud jenuaacd OS[E BIT SIUBAT JO UOIS|ABA PU UONs0IS1g "pasanoras Jaae] put passaiday so ‘padejap Agewung S40198{ “UONIEaJ 1S4y BAnesau e parjaras prey pur ‘sorenadsad & paauo.uos ancy 01 Aja] 240W asa" PUT ‘B2U]O/A Jo Bsn ‘ssorenediad ajdajnw ‘asnge jeasAyd JO sazurisu) avow paodas pooypyy> Ul PaSOPsip pey OYM UaWOA, “Arjap suvad |Z JO aBeuane ue yam (gy Jo ate aya asoyaq) pooypyyp Fujin pasojrsip STE ‘seunsojasiq “sjeuorssayoud 02 Ayepadsa “ysomaau [e205 ajaup yO asow 03 payed pey UaWOM Pasnge Ajauanag “suead / yo uontunp aiesant ue yum “7 Jo ae azojaq Uso SEM 1BSUO JO aBy ~sorenadad ajfuys © Aq veip uowwo2 asow sem ssoreaadiad aydpjnus Aq asnge :saas|saaoesey> asnqy SWNIIA O12 sUOBUAAJAIU aIR|Jdoudde 4ayo 20U PyNo put asnge jenxes UO paure.n 10U auam seuo|ssajoud Auew se auoddns pag) Asan paalazay suaad ‘speuoyssajoud 03 asoyasip pip day UayAA "asnge jenxas Sujsopsip jo saauanbasuo> 21 JO Akay pur “sjeuo!ssajoud pue syNpE JO Isn.as|wW ‘pasnge Sujaq yo ssauaseme JO 9Pz| “Jaudas aip daar o2 YsIM “sanjasas aaeudoudde yo avemeun 7348 sanjauas Supjaas 20u soy sauawuypadwy uyew ayy “Ayjuey ay O2 ayqno.n Buysne> jo sea pur “aweys “paraijaq Buyaq 20u Jo stay cavam saquiaw Ajpwey 8 01 BsOpsip 02 suaUjpadw) UE ayy S@UOWSW P343A0I94 Aq paval3.n saansoj2sip pur ‘preyyum Ajeuonuaiyy saunsopsip ‘sidwane fequaa 1Da4IpUI pUE (eso\AEYaq ;paTaWwe sauoSaie? aunsojasip jeuonippe Bauy] ‘sasofare> paysyquisa Ajsnojaud sBupurg pasn sem Adarens Suydwes aasodung ‘sizaiqns ae aNoge auOaWOS pjor pry pur g| jo ave aya au0Jaq 9350/2 aUOBaWOS Aq asnge jenxas pyly> 01 aunsodxa Bunsodas (suead jp jo ade aBesanr) pyo surah 09 pur OZ vaaMaaq UBWOM INPE ZZ] diysuonrjas Bupep & ul a2uajo}A jenxes paouajadke ajdwes ap yO awios “{|-Z| pale Saye | pur sajewsay SE Bunod 9¢ jo pasjidwo> sem ajdwes ayy SANPE SE Pasopsip ‘%BS !POOYPIY> Bujnp asnge 3ip pasopsip pry suedjpued ap Jo x7 tsuvad §°9 SEM 2aSUO asnge yo ale altuaar ayduies squedjpued {IM SmapAsaauy ain ysno.np pasauned auam suon eas PUE aunsojasip uo wep pur ‘sauyeuuopsanb aip ygnonn panaunas avam asoddns |e/205 auausn2 Pur UOREZILUIIIIA UO meq ‘saueuuonsanb (pm saupagon sapint paumonas-jwas Zujsn pamaisaauy sam 350]2 auoawos Aq WS> Zunsodas uaWwoMm anp ypomauey Buppoo & 02 Suppuorse SMaIAaIUT 9 pavoos Anuapuadapuy \pIM papsozas auam YDIYA SM@TAJBIUT aU paionpuo? Zulesuno> WSD Suyjasuno> SEM IUBSUOD PAWJOJUL 4aye par2npuor Byam SMAIAIBIU} (snowAuour) auoydajan yadap-uy @unsoj>sip WSD Supuanyu ss0228} [esngyn> Pur ‘JeuaWUO. AUS “yeuossadsaauy ‘TENPINpU 404 aqoud o2 padojanap uBisaq Paqoud auam suonzeas aanesau pur aanisod Jo s2022%5 Bun>1pasd pur ‘woddns [EROS ‘aunsoj>sip jo saworine pur Sui ‘asnge yo Ajuanas uo paseq saquasayig “paaejay auam asoddns [eDOs pur ‘aunsopsip WSD 91 suonreas ‘ssauuado “sie. asnge Moy asojdxe 03 sem asodind Apmas SOD|AJBS BYI JO/PUT OMIBU [BIOS Jay wou djay Suppaas put VSD Susopsyp woy Squa2sajope quanaud qe Suaupaduy pursvapun on ava Apmis Sip Jo sjeo8 yew ay, PUR “I>tg ‘]e2sTg “EWS {p00z) Peiqpury pur vozuof (y007) ouwoy Apmag (panunuo>) "| age 273 3502-021 Page 14 of 24 EFTA_00001536 EFTA00156877

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(panunuo2) Bujajaoued pur “asnge ap Joy Auyqsuodsas saaeasd yay tasnge PRyUURZRIAUF JO SWRA “U@APYYD Japjo Jen sasa¥¥ns papopy “SBUNSO|ISIP JaI]1¥B 40} IUNOIIE osye Avw (%7§) asnqe peypuryenxe jo anes say3iy up aydures jeBaq “saunsopasip Ajiva yo ares sayiiry urydxe Aew yy voansesosd yO ssa20ud uy 3.9m pur sanuoyine 02 pawodas useq pry sase> asayy “YQUOW F UIYBIM S4aSO/25/p JO Paueay OY UBIPIIyD -se2uaNbasuOD aaneSau yo sway (¢) sasnqe jeqjweyenxe JO SWNA 02 pasedwod sua\po 02 sazuanbasuo> aaneSau saataus pastay Bsnge jeyWEyLAU JO SWNrA—9sO)>SIp 02 saZuoj YOO sayyjuUrey peyUUEyEsIU yO swn2ia vasnge yo adda (7) suaupyy> sadunod uewn suayio 01 sa2uanbasuo> aaneiau a40W pavtay UapyYy> Japjo PUR asO/>51P 02 JaBU0] YOO JapjO alam OM Uaupyyp save (|) (parsaa 21am japow BYR 4O} SBITHURA BALZ “SYUOU g UIYDIAL Mp jo awh ay ae saeah 91-+ pur “asnge aip jo Pua aip ie suead 9|-¢ sasnge yo Zujuuidag aya ae suvad 9] 017 WO ade ul padues uaupyuD ~uauURW aWOS UF asnge 4RAp pasopsip pry apdwes up uy uaspyD IY "WSD Paiaye 204 59240 ssoinzasoud 02 pausayau UaIpIIP MYOug YyNessy Jenxag ayp parajduo> BILIOAPE WHA BuO put siuapms arenpead pauyeL ‘sMaIAsaaUy PIIy? JO SuCEAJaSgO pur sayeiase> S,UBJPIIP BY Ya} Sma|Auaquy pasnaonas Woy SE IBM ‘st ‘sayy UOANIas0Nd wouy paureigo asnge [enxas asoj2sip uaupiiy> Appin’ moy aouanygul 2eWp sucIIEy 404 |APOW Fv IS92 Pur yS> Jo aunsopsip Jo Avjap wim PaIenosse sajqeier aaeZpsaauy 02 sem (£007) UOps0y pure ‘sauof “UBWPOOD *Ul935|9PZ ares Jay3yy © sauasauday Apmas siyy %6T PUT YRUOW © UIYDIM Pasoj>sIp %p9 BIZ JO Parsjsuo> ajdwes IEP yo smajaay aly aseD Apnas siup yo asodund ayy “UMO.1g-URWPOOS saoualedxe B.UNSOPS|PUOU YIM WSD Buyesas syuedpaued Parzjrosse sem sauased ylog yum Bully qynpe yo Apms & ueya sa0ys aanau (Zz) put Andwoad asow asoj2sip Aiqewinsaad azam majasaquy 03 Ajay] B40 SAOAIAINS BpEW YY alp PUT 3SF ap uaaMaag “saquiaw pjoyasnoy Zuysnqe Snap (1) sonsyaaseuey> Be] awn ap os pur ‘mua2sajope auaM BUNSOPSIp 02 paxuly SsoIdEy Aywey sorrnadiad auam swedpased aouys Apms sip “SINE 2 auNsoj>sIp uM paIeposse pur sonspan2esey> Ul pazjWiURY Uaag aAey Ae SIG @uam vonenaued put Zujinp apy s,2u0 quand Supnpuy [18234 “aanzedso.nas aq Aew eaep 40} stag ‘uonenaded saduras yim 3>8qUOD jENxes y8noyapy “Aavuns eA 45F asopsip Ajay] BIO SEM auNsOpIsIP aze~PawWU] pasojdxa Paiuemun jo aposida 02 Buyin aue OYM SWUa2Sa|OpT “eunsopsip padtjap way pareposse auam SaINquUNe pra inoge suopsanb 01 Ajuo ayqeziesauad synsas ayp Sem saquiaw Ajwrey & JO sorenadiad Jenaxaquo> Apurey JO sauas © payse ual SEW PINOM pur seq InewWaIsds ap 03 diysuonepas vasojD “uoWw pur ‘sonsyaiesey> auam Ady] “MayAsaIU] pareiasanuy yO a0unos & quasaudas Aew 35 B UIYRIM BSOPs!p 02 papuar ¢|—|| pave 3S/ ‘sepswaiesey> UONTIYISST|> IAP/>U} 348M BUNSOpISIP ur ssn2sip Jo w0dau 01 pasnyas uaupyYyD “yauow & puodag aunsojasip aquedppseg aya Jo UOs4aA payypow up jo qward)2—a4 ay put YM squa2sajoply “Supzoda.uapun BuyAepap 404 45]4 7e avaM ING “YyNpE “WSN 24 ul 39"2U09 & Buysn passasse asam aunsopsip jo Zujwp 01 anp pastyg aq Aew saoualiadxa Ut [)22 02 Ajax] B40 auam || JepUN yenxes paweaun WSN 242 ul paqodas @Ip tog jo suorajpaud UOPEZIWNAIIA JO suONeTAsaAu] 105 UBupyYyD ‘saved O[—Z pave uaspyyp ueyp Jo a2uayedxa 595M “sMaseqUy BYL “B2UaIsaOpE SABANS “WSN 2p UI paredppued suvad Ayuo |Ja2 02 Ajanyj B40 auaM (7 ] uO iseay Ie parsodas auoyd paumonuas jo Pur pooypyly? ul 35n OYM SIUBISB[OPE B/EUIaY JO bl) suaasajopyy ape ue 4]92 02 Aja>I] Oym ‘plo saad 7S] Paas}suo> U2IYM “WSN JO SJOAIAINS O]CURy ajdwes aanruasaides Ayeuoneu ISOW azaM F] PUT / jo sade aip uaaMIaq Jo aie uvaw ‘plo sueah ap uy paedpjued Aq apew saunsojosip © Uy) BIUa2Sa|Ope pue pooypyy> Pa.un230 45/F asoym sauedionueg LI pur Z| uaamaeq Jey uarsajope ap a2uaNyul Jey U} S3SN JO Saunsopsip Suipnpuy “saunsopsip padejap 40) 4s14 49y3}y SOPLUIaJ IUBISBIOPT apeusay Jo ayduvesqns © suordyy Aynuapy 02 Sem ssoi2yy pauywexe Apmas sIyL Bae quam / JO ae aya sapun uaupyIYyD £97 JO ajdwesqns y wo. pavauped avam meg = Apnas siya yo asodund ayy (p007) vetoy aunsoj2sip aaye pasnge Ajsnonunuo> asam uaWOM ¢] ‘asnge FujoZuO WIM pojiad @ Buuunp PooupHY? UI! Pjor OYM UaWOM PUNO} sdiysuonejas aya =——«9Z_ BUA JO “SaWOTINO auNsops|q “B2UB/0}A UO 23aya PUE aSNTD yO SUO|sNPVOD JO asn OU put vara Is4y Iv ave saZuNod SUYaP 2Oy MIE 10U SBOP Uilsap auam Avjap Sunapaid Apuroyruies Aaewuing s8upulg ajdwies uljsaq asodung Apras (panunuos) "| aqeL = a 3502-021 Page 15 of 24 EFTA_00001537 EFTA00156878

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“s7naxes Quenbuljsp sj ans asyeuscyu! azreuUONsaNd = sqid ‘Apnas s,uawo,, jeuoneny = SAAN ‘Sus2se}Opy jo Aanung jruCMtyy = YSN ‘sa2uatadse jenxas Pasuemun = 357- aUAWdojaAag UEWUN}Y pur YIe>}4 PRYD yO seNIISUY ;EUONERY = QHDIN @5Nge jenxas p> = WED ‘PoyIsu MatAsazUI Buoy = Py] “sMAEYs WUWOUOISOIIOS = $95 ‘06°35'] YIOUD WoIduits = OE-TDS “AION suonsanb voneziwnsia ade pyy> aod aWos 28 sapOyNe pure 2yydeuZowap aya UaWOM °S'f JO UOAE;Ndod 2 paioday auam sinesse sjaup aeup wou Hep uO swuodas aq Jo saanquaae 21ydesZowep paamis swan ades pyyr jo %Z) AUD SspTs snsuaD Apnas quasaud au aun payne Ajasop ajdwes aya = auuosvad 2uaWa2v0JUa ME] JO S4a>40M 6861 242 01 WIOJUOD “Asoasyy UO;eZIWUIZIIA 2ey pare"puy neaung snsuaD “sf, [PPOs 02 aunsopsip peyUy sat Fupew =n paayZjam asa eaep pur ‘asn a2urisqns ay wo.y paujrago suaxewesed pavodas suj2)A Jo 30] UEYD Jamey TZ BARAA PUE | BAEAA ‘susoadwAs >y2e9yadsd voneindod aa wai exep asatp jo “suaquuaw Aywuey aaeipawwy seUp0 puE \pog “parejas sem “UORULIOpU uosuedwod "| aARAA Joy “susaned suaqpow Aq pamoyjoy “saunsojasip apew PE PUE gl JO sade ap aydeuZowap BUNSOPs|p 5,uaWOM Funod SWNIIA WOYM 02 UOSJad UOWWO? Is0W usaMIag UBLUOM 900'T Iya 02 pauisap (Bupuanyuy aq Apuassn> Aew pur) ‘BU auaM SpUalsy BSO/> MAAISIUT SAAN yo ajdues wopues SSUNSEIW [LIBAS Paouenyuy ary Aew uopeUoyul JU 02 Jo\4d pasopsip Oy UBLIOM puoras “suaquinu JO parsysuo> Aaaans SIYL “sunpe ajqrsuodsay Tuowy vow & unAMA pasopsip %4Z —«- @uoYydajan paysyuN pue = BY. “UBaUDs JaINdwoD (puoW | UII 01 pasojsip aq pynoys pur Suosm sadeu-2s0d suvad ¢ 01 dn pur uead | sano Ppars}| 40} spjoyasnoy uO uONsanb yrta aunsopsip paipaid aut (ySD Suppnpuy) synesse 40} B50)25|p 20u prp %gg “APM sIy> 40} IPOS 02 pasn sem {pIM parnpuo? avam TeUP SBIqEIIEA pu Je VEsp}YP YPeAI Ie SORE! samalasaqul aya Aq pasanb Ajjeaypads Suyeip padyp wopury —ssmajAsaquy suoYydayaa— “02 pasoyasip Aaya Oy ‘up uy unZaq avam ey) sweZ0ud JRUN aNeSse jeNxas siya InogE auoAUE “suonapsint Inv “warsks mayasaiuy aunsopsip padrpp g] vontonpa uopuaraad ynesse pjo2 sanau pry Aaip iew pains xgz ‘ades pauyap jo auoydayar parsysse aie asoyaq pades auam PIMP ajers-aFse] ayp 02 vojd Pilly? & paqiodas oy UaWwOoM Bgz aun sajdwes payneas wo4y ~aaindwiod & 3ujsn wep OyM UaWOM awh pauinss0 ajdwes sap Aq pawodas ¥O “Sutadk 69] Sem ades Isuy ay jo awn paidajas s1uapuodsas 3DaYOI O2 pasn auamn yo wp3ua] ap anoge (oo0z) sades pyy> jo Awolew ayy aup Je aie aieuane ayy ‘ades pooypyy> yo 600°7 Jo ajdwes up §¢ Ajarew)xoudde UBWOM jo ajdwes ats] 359g PUT "YDUSey “suoneay|dwy jenaxeqvo> pey arey = UONJuyap s,Apmas ay] Jaw IeYIIWaAB|UO —« WOPUEY & SEM | BATA, Parse] IL Sma|AsaqUy T wo4y wep says puaed|ry ‘ssapunes Aew Aasuns siyp yo awe aw ayy asta] 10 Supuasadxe pavoday (x6) gaz “saydwies Aryiqeqoud om suoydayaa paynazn.ag =—-02. sem Sm205 Anas ay “NRBUINOIW] "WW @uNsojrsip 02 LUT YUM sayqeura parejass0> Apuraya}s 20u sem sapual Buowr suonejas jesne> (5) pur tasnqe ays soy Arypqisuodsau pazisayoddy aya BJOW 2/3) UBJPIIY> 4aPJO Pue asOPsIp o2 3sa2 02 sasdjeue wed 4auoj YOO asnge aya 405 Arppq\suodsas {RIM palanpucs ava dareasd yay OYA UBUD “Aapqisuodsau Sasdfeur jeuONe|ass07> Panja2Jag (p) suayo 01 saouanbasuo2 asnge peypueyesauy “paqoud Apoasip uaupyry> malasaauy annviau pasea sdog uri asow %Lb Ajarewpcouddy auam saouanbasuo> 02 a/ge 10U azaM SuayDueasa4 — 5418 pur ‘aunsoj2s|p Jo awn O1 parejauun “SaS Mo] 02 aaneiau jo “UaAIMOH “Suontspsanuy sem sorenadsad aya JO yjas au 02 aypprw Apueujwopaig 4eay pur Aniqrsuodsas JBYLIN} 404 BUNSOPSIp jo japow sa2uanbasuo anjeiau jo say ‘asoj2s|p “URDIaWYy URDLpY jo vondazsed AIGRIA & PAINPOAY “JOBL JO [Ad] 02 salud] Yoo? szay20 03 WEY BuLAq S61] pur ‘quedsiry S,UBIPIIYD “BUNSO]2SIp ysiy yam Apmas pauiisap-9, PINOM auNsolrsip saya JEL Parsyaq Jad | “URseone> ayayp pur asnge “BSOPsIP 02 JaBUO] 402 Fursopsip OWA UBUPIP “BSOPSIP 02 JaBUO] 4001 MOL “EWR See tp “opsjaesey 01 saduanbasuo? aaneseu @uNso]2s|p jo sa2uanbasuo> aane#au tuuoday aayod yenyur PyIy>? 404 aayeuuonsanb Arewswung sBurpuig ayduies uiisaq asodung Apras (panunuos) *| a1qeL 275 3502-021 Page 16 of 24 EFTA_00001538 EFTA00156879

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276 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 dis- closure in multifaceted ways with uniform use of categories of prompted, purposeful, withheld, accidental, direct, and indi- rect. However, defining the period of time that would delineate a disclosure as delayed varied widely across studies, wherein some studies viewed | week or | month as a delayed disclosure (ie., Hershkowitz et al., 2007; Kogan, 2004; Schénbucher, Maier, Moher-Kuo, Schnyder, & Lamdolt, 2012). Other studies simply reported average years of delay sometimes as long as from 20 to 46 years (Easton, 2013; Jonzon & Linblad, 2004; Smith et al., 2000). Second, the number of qualitative studies has increased sig- nificantly 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 percep- tion 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 par- ticipation in surveys and consent-based participation in file reviews (Collings, Griffiths, & Kumalo, 2005; Priebe & Sve- din, 2008; Schénbucher et al., 2012; Ungar, Barter, McConnell, Tutty, & Fairholm, 2009a). Therefore, generalizability of find- ings is understandably limited. The qualitative studies used purposive sampling as is deemed appropriate for transferability of findings to similar populations. Some of those samples con- tained unique characteristics, since they were sought through counseling centers or sexual advocacy groups. These would be considered clinical samples producing results based on disclo- sures 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 gen- eral 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 TRAUMA, VIOLENCE, & ABUSE 20/2) 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 grow- ing 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 sub- theme emerged that intrafamilial abuse/family-like relation- ship of perpetrator has a bearing on disclosure delays or withholding. Theme 4: There is a lack of a cohesive life-course perspec- tive. 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- lime 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 disclo- sures as process based, although this notion was not fully explored until several years later. Examinations of Summit's (1983) groundbreaking proposition of the CSA accommodation (CSAA) model produced varying results as to whether his five stages of secrecy, helplessness, entrapment and accommoda- tion, delayed, conflicted, and unconvincing disclosures, and retraction or recantation, hold validity (for a review, see Lon- don, 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 interac- tion 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 pre- vention forums providing information about sexual abuse (Hershkowitz et al., 2005; Jensen, Gulbrandsen, Mossige, Reichelt, & Tjersland, 2005; Ungar et al., 2009a). The term 3502-021 Page 17 of 24 EFTA_00001539 EFTA00156880

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Aloggia et al dialogical simply means to participate in dialogue. Key dialo- gical 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 fac- tors (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) pro- poses 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 eco- logical 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 intra- personal, interpersonal, and contextual factors. A summary of knowledge building using a social—-ecologi- cal 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 indi- rect 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 imbal- ances, other forms of child abuse and domestic violence, chao- tic 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; Schénbucher et al., 2012). This is especially a barrier when the perpetrator lives with the victim (LeClere & Wortley, 2015). 277 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 sup- portive environment, such as in following up on troubling stu- dent 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 stud- ied 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 deli- neated 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, cul- turally based belief systems in many cultures have been found to foster family climates that can silence children from disclos- ing 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 con- text as well as cultural and societal attitudes toward better understanding disclosure barriers and facilitators (Alaggia, 2010), although more data are needed on cultural and contex- tual 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 sam- ples. 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. Ado- lescents 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. 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278 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 (ie., 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 (ie., 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 emerged is that rates of disclosure increase with age, especially into adulthood, which is supported by persistent findings of high rates of delayed disclosure reported later in the life course by adult survivors (Collings et al., 2005; Collin-Vézina et al., 2015 ; Easton, 2013; Jonzon & Linblad, 2004; Kogan, 2004; Leclere & 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) (Hershko- witz 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 under- studied population (Alaggia, 2005; Easton, 2013; Easton et al., 2014; Gagnier & Collin-Vézina, 2016). Most investigations that sampled both sexes show females outweighing male parti- cipants. Although women are at double the risk of being sub- jected to CSA, the ratio of women to men in most disclosure studies has not been representative. This finding may be indi- cative 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 disclo- sures. 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 rein- force the tendency for male victims of CSA to blame themselves TRAUMA, VIOLENCE, & ABUSE 20/2) 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). Lock 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 chil- dren and adolescents, along with adult retrospective studies. Thus, the available knowledge base does not allow for a cohe- sive 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 & Lau- mann, 1997; Williams, 2003). For example, a life-course per- spective 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 perspec- tive 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 devel- opmental context, especially for designing appropriate inter- ventions for disclosure at critical transitions from early childhood through to adolescence and into adulthood. In addi- tion, important “turning points” in life may facilitate disclo- sures. 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 partici- pants 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 3502-021 Page 19 of 24 EFTA_00001541 EFTA00156882

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Alaggia et al. Table 2. Factors Influencing Child Sexual Abuse Disclosures. 279 Barriers Facilitators Age: The younger the child victim, the less likely they will purposefully disclose. 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 Relationship to perpetrator: If the perpetrator is a family member or in a family-like role, disclosure is less likely to happen Internal: Shame, self-blame, and fear are psychological barriers. In addition, fear of negative consequences on the family and for self- safety inhibits disclosure Family relations: Families with a patriarchal structure, rigidly fixed gender roles, dysfunctional communication, other forms of abuse (Le., domestic violence), and isolation inhibit disclosure 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 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 soci- etal attitudes that promote hypermasculinity as desirable, atti- tudes 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; Leclere & Wort- ley, 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 developmen- tal immaturity at the onset of abuse constituted internal bar- riers. 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; Hun- ter, 2011; Kogan, 2004; McElvaney & Culhane, 2015; McEl- vaney 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 fur- ther 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 Age: Disclosures increase with age, especially in adulthood. Gender: Slight trend toward females who are older (adolescent) to disclose before adulthood Relationship to perpetrator: If the perpetrator is not living with the victim, disclosure rates increase Dialogical context: Opportunities to disclose through discussion, therapeutic relationship, information sessions on sexuality, and sexual abuse prevention programs Family relations: Supportive parent-child relationship. Involvement of others: Eyewitnesses coming forward and reporting: detection through community members, professionals Environmental and cultural context: Promotion of open discussion of sexuality; community member involvement 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 iso- lation have been found to suppress disclosure (Alaggia & Kir- shenbaum, 2005; Collin-Vézina et al., 2015; Fontes & Plummer, 2010). In regard to broader environmental factors, disclosure can be hindered when involved and supportive com- munity 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 neg- ative 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 contri- bution 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 silen- cing, 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 al 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 draw- ing on adult populations who delayed disclosure. These sam- ples may not be representative of the overall population of CSA victims, since they may have had more negative disclosure 3502-021 Page 20 of 24 EFTA_00001542 EFTA00156883

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280 experiences, consequently more readily identifying barriers. On the other hand, these findings may speak to the actual imbalance between facilitating factors and barriers for disclo- sure, 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 identi- fied 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; McElavaney, Greene, & Hogan, 2014; Schaeffer et al., 2011). Circumstantial facil- itators 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” (McElavaney et al, 2014); workshops on abuse and sexual abuse, in particular, can facilitate disclosures (Ungar et al., 2009b); and using culturally sensitive probes and questions (Fontes & Plummer, 2010). In Gagnier and Collin-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; Schénbucher 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; Schénbucher et al., 2012; Ungar et al, 2009b). Discussion Through examination of 33 studies published since the year 2000, this review identified five distinct themes regarding CSA disclosure: (1) Disclosure is best viewed as an iterative, interactive process rather than a discrete event done within a relational context; (2) contemporary models reflect a social-ecological, person-in-environment framework for understanding the complex interplay of individual, familial, contextual, and cultural factors involved in CSA disclosure; TRAUMA, VIOLENCE, & ABUSE 20/2) (3) age and gender are significant disclosure factors; (4) there is a lack of a life-course perspective; and (5) barriers to disclo- sure continue to outweigh facilitators. Based on these themes, a number of conclusions are drawn from this review. First, dis- closure 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 sur- veys, with only a few studies using interviewing of younger children. Therefore, there is less information available on pro- cess 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 antici- pated 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 exam- ple, 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 for- ensic purposes prompting such disclosures would be viewed as problematic in legal settings, seriously compromising testimo- nies 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 disclo- sure in one domain (therapeutic) are seen to work against CSA survivors in another domain—such as legal settings when per- petrators 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 3502-021 Page 21 of 24 EFTA_00001543 EFTA00156884

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Alaggia et al. 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 find- ings, we conclude that barriers and facilitators to CSA disclo- sures are nuanced and clearly embedded within intrapersonal, interpersonal, environmental, contextual, and cultural domains—ofien interlocked in complex ways. Limitations Although comprehensive in nature with its life-course cover- age, this review may be limited by its qualitative, thematic focus rather than providing an evaluative, quantitative account- ing of CSA disclosures. However, because of the recent focus on disclosure processes, the authors chose a suitably compati- ble 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: e Solid strides are being made in the use of a social—eco- logical framework to underpin investigations in the CSA disclosure investigations. Research efforts and practice considerations should continue in this vein. Investigat- ing 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. e 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 edu- cation on topics of sexuality in general, and sexual abuse specifically, can help children and youth to disclose. Raising awareness and prevention programs can pro- mote disclosures of sexual violence committed against children and youth. e Goals of therapeutically supported disclosures (i.e., through therapy) may need to take precedence over for- ensic approaches, if well-being of child victims and adult survivors is to be made paramount. Legal pro- cesses may act to facilitate disclosures but can also act as barriers because of the negative outcomes experi- enced in the court process. e 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 281 survivors continue to be systemically and structurally disadvantaged in legal proceedings. e Health-care practitioners (i.¢., child abuse pediatricians, family practice doctors, clinical nurse specialists, and public health nurses) should be made aware of the evi- dence in the CSA disclosure literature to create environ- ments for facilitating therapeutic disclosures. e 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. e 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. e 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. e Intervention planning should take note that disclosures increase when perpetrators no longer reside with vic- tims, and this finding should be heeded by policy and law makers. e 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 num- bers 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 genera- tions 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 vic- tims to disclose but rather to change environmental condi- tions 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. 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Canadian incidence study of reported child abuse and neglect: Major findings (Chapter 4). Retrieved from http:// www.phac-aspe.ge.ca/em-vee/public-eng.php Ungar, M., Barter, K., McConnell, S. M., Tutty, L. M_, & Fairholm, J. (20094). Patterns of abuse disclosure among youth. Qualitative Social Work, 8, 341-356. Ungar, M., Tutty, L. M., McConnell, S., Barter, K.. & Fairholm, J. (2009b). What Canadian youth tell us about disclosing abuse. Child Abuse & Neglect, 33, 699-708. Williams, L. M. (2003). Understanding child abuse and violence against women: A life course perspective. Journal of Interpersonal Violence, 18, 441-451. Author Biographies Ramona Alaggia, MSW, PhD, is an associate professor in social work and the Factor-Inwentash Chair in Children’s Mental Health at the University of Toronto. Her teaching and research focuses on gender and violence, sexual abuse disclosures, domestic violence exposure, and resilience processes. Delphine Collin-Vézina, PhD, is an associate professor for School of Social Work, McGill University and director for Centre for Research on Children and Families. She holds the Nicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in Community and the Canada Research Chair (Tier Il) in Child Welfare. Her work focuses on research and clinical topics related to child maltreatment, child sexual abuse, and trauma. Rusan Lateef, MSW, is a social worker employed in the criminal justice system with adult male offenders in Ontario, Canada. She specializes in the intersection of health and mental health, child sexual abuse disclosures, and she is a researcher on the “Make Resilience Matter” project examining childhood exposure to domestic violence with Dr. Alaggia at the Factor-Inwentash Faculty of Social Work, University of Toronto. 3502-021 Page 24 of 24 EFTA_00001546 EFTA00156887