AN ECOLOGICAL ANALYSIS OF ADOLESCENT SEXUAL ASSAULT DISCLOSURE AND HELP-SEEKING By Giannina Fehler-Cabral A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Psychology 2011 ABSTRACT AN ECOLOGICAL ANALYSIS OF ADOLESCENT SEXUAL ASSAULT DISCLOSURE AND HELP-SEEKING By Giannina Fehler-Cabral Adolescent sexual assault is a pervasive social problem that can have long-term negative consequences for victims‘ emotional well-being and physical health. In an effort to prevent these problems, survivors are encouraged to seek formal help from the legal and medical systems. Previous research has provided a preliminary understanding of who adolescents disclose to and when; but how and why survivors disclose to informal support providers and eventually seek formal help remains to be investigated. To fill this gap, the current study used an ecological theoretical framework to study the dynamic process of adolescent sexual assault helpseeking. Utilizing qualitative data from 20 interviews with adolescent female sexual assault survivors who entered formal help systems, the findings revealed the significance of individuallevel beliefs, assault characteristics, peer and family microsystems, mesosystem interactions, and chronosystem factors. Specifically, negative anticipatory beliefs about how others would react to risky behavior and being assaulted by an acquaintance hindered how soon after the assault survivors were likely to disclose and who survivors chose to disclose to. Given these beliefs, survivors were more likely to first disclose to peers followed by their mothers/guardians. As a result, the interactions within the peer and family microsystems were decisive in how survivors continued to disclose and how willing they were to enter formal systems. Furthermore, the process of disclosure and help-seeking became more complex when family, school, and peer microsystems interacted. When these interconnections occurred with survivors‘ consent and produced a helpful response, they were perceived as positive. Alternatively, mesosystems in which survivors had minimal control resulted in unwanted disclosures and greater reluctance to enter formal systems. Finally, the chronosystem played a salient role among adolescents with a prior history of sexual or physical abuse. Those who had been previously victimized disclosed more readily and were more determined to seek justice, even if their prior help-seeking experiences had gone poorly. Overall, the current study suggests that disclosure and help-seeking is a dynamic and complex process involving multiple intersecting systems. The findings highlight the utility of an ecological theoretical approach to study sexual assault disclosure and suggest that future studies become attune to higher-level interactions among ecological systems. Finally, the conclusions bring forth the need for community-based interventions that will improve the response from support providers in order to make the disclosure process easier and beneficial for survivors‘ recovery and well-being. Copyright by GIANNINA FEHLER-CABRAL 2011 ACKNOWLEDGEMENTS This dissertation would not have been made possible without the support of the amazing people in my life. First, I would like to thank the strong, courageous, and insightful young women who were willing to share their experiences with me. Your stories made me appreciate how emotionally difficult sexual assault can be for teenagers. More importantly, you taught me that the human spirit can heal and thrive even in the most challenging circumstances. Without your participation, this research would not have been achievable. I would also like to express my undying gratitude to my chair and committee members. Dr. Rebecca Campbell, you have been more than my advisor. You are my mentor and I have learned so much more than I ever expected during the last five years working with you. The opportunities you have given me to grow as a researcher will forever be appreciated and the life lessons you have shared with me have been invaluable. You have taught me that what is more important than hard work and determination is being a humble, honest, and generous person. Thank you, thank you, thank you! Dr. Jenna Neal, I want to thank you for your genuine support. Your feedback on this project has been truly helpful. I would also like to thank you for all of our informal chats on surviving graduate school and transitioning into the ―real world‖. I have learned so much from you and will continue taking your thoughtful advice. Dr. William Davidson, I want to thank you for being a great listener and for always taking the time out to be there for your students. Besides the practical feedback on this dissertation, your advice on future career plans and life in general has been tremendously helpful. Thank you for everything. Dr. Angie Kennedy, thank you for willing to be part of my committee and for sharing your knowledge and expertise with v me. This study would not have been possible without your guidance and support. Thank you for your time and interest in my work. Finally, the last five years of graduate school would not have been successful without the love and support of my family and friends. Paul, you are my best friend and my biggest supporter. You always told me I would make it and here I am! Thank you for supporting my dreams and for always believing in me. You have taught me that without love, respect, and patience, there is nothing. To my parents Hector and Eli Cabral, there are no words that can express what this accomplishment means to me. I share this honor with you. Because of all your hard work and struggles, I have been able to fulfill my academic goals. Thank you for always having faith in me and encouraging me to reach for the top. You are the most amazing, loving, and understanding parents. Los quiero muchisimo! To my brother, Hector Giancarlo Cabral, thank you being my first role model. You taught me that higher education is a possibility and could lead to great opportunities. Thank you for your continuous care and support. And finally, to my colleagues who have supported me along the way, Megan Greeson, Charles Collins, Jason Forney, Dr. Marisa Beeble, Dr. Mercedes Morales, Dr. Nidal Karim, and Dr. Lauren Lichty. Thank you for everything and I look forward to collaborating with you in the future. vi TABLE OF CONTENTS List of Tables ................................................................................................................................. ix List of Figures ................................................................................................................................. x Introduction ..................................................................................................................................... 1 Chapter 1: Literature Review .......................................................................................................... 4 Adolescent Sexual Assault: Prevalence and Impact ................................................................... 4 General Help-Seeking Among Adolescents ............................................................................... 6 Prevalence of Help-Seeking .................................................................................................... 7 Correlates of Informal and Formal Help-Seeking .................................................................. 7 The Unique Role of Peers and Parents in Help-Seeking ...................................................... 10 Disclosure and Help-Seeking Among Adolescent Sexual Assault Survivors .......................... 13 Prevalence of Disclosure and Help-Seeking ......................................................................... 14 Correlates of Informal and Formal Help-Seeking ................................................................ 15 The Unique Role of Peers and Parents in Disclosure and Help-Seeking ............................. 21 Limitations of the Adolescent Sexual Assault Literature ..................................................... 24 Sexual Assault Disclosure & Help-Seeking Through an Ecological Framework .................... 29 The Current Study ..................................................................................................................... 34 Research Questions ............................................................................................................... 34 Methodological Framework ...................................................................................................... 36 Analytic Induction ................................................................................................................ 38 Chapter 2: Method ........................................................................................................................ 41 Participants ................................................................................................................................ 41 Recruitment ............................................................................................................................... 42 Procedures ................................................................................................................................. 44 Interview Guide ........................................................................................................................ 46 Data Analysis ............................................................................................................................ 46 Credibility of Data Collection and Analyses ............................................................................ 52 Chapter 3: Results ......................................................................................................................... 54 Individual Anticipatory Beliefs about Disclosure and Help-seeking ....................................... 57 Microsystem: The Role of Peers and Parents in Disclosure and Help-Seeking ....................... 62 Mesosystem: The Role of Peer, Family and School Interactions ............................................. 72 Chronosystem: The Impact of Prior Victimization on Disclosure and Help-Seeking .............. 80 Chapter 4: Discussion ................................................................................................................... 88 Key Finding #1: Negative Anticipatory Beliefs and Assault Characteristics Impact Disclosure and Help-Seeking ...................................................................................................................... 89 Key Finding #2: Peers Provide Emotional Support, Validation and Guidance to Adult Help . 91 Key Finding #3: Mothers/Guardians Provide Emotional Support, Validation and Guidance to Formal Systems ......................................................................................................................... 93 vii Key Finding #4: Family-Peer-School Interactions Influence Subsequent Disclosure and Entry into Formal Help ....................................................................................................................... 95 Key Finding #5: The Chronosystem has a Significant Impact on Survivors‘ Willingness to Disclose and Seek Formal Help. ............................................................................................... 99 Summary of Findings .............................................................................................................. 101 Limitations .............................................................................................................................. 101 Implications for Research ....................................................................................................... 104 Implications for Practice ......................................................................................................... 107 Conclusion .............................................................................................................................. 109 Appendix A: Interview Protocol ................................................................................................. 111 REFERENCES ........................................................................................................................... 126 viii List of Tables Table 1. Structural Coding………………………………………………………………... 47 Table 2. Detailed Structural Coding……………………………………………................ 48 Table 3. Victim and Assault Characteristics …………………………………………….. 55 Table 4. Disclosure Patterns Prior to Entering Formal Help……………………………... 56 ix List of Figures Figure 1. Example of Assertion Testing and Generation………………………………... 50 Figure 2. An Ecological Model of Adolescent Sexual Assault Disclosure and HelpSeeking …………………………………………………………………………………… 54 Figure 3. Disclosure and Help-seeking: Individual-level and Microsystem Factors…….. 72 Figure 4. Figure 4. Disclosure and Help-seeking: Mesosystem and Chronosystem Factors…………………………………………………………………………………..... 87 x Introduction Sexual assault is a severe trauma that causes long-term negative outcomes, such as posttraumatic stress disorder (PTSD), depression, substance abuse, suicidality, repeated sexual victimization, and chronic physical health problems (Kilpatrick & Acierno, 2003; Koss, Bailey, Yuan, Herrera, & Lichter, 2003). As a result, many sexual assault survivors disclose what happened to them and seek help from friends, family, or formal support systems. There is a growing body of research on sexual assault survivors‘ help-seeking, which examines how and why disclosure occurs, victims‘ experiences seeking informal support, and their encounters seeking professional help from formal systems. Whereas most sexual assault survivors turn to family and friends for emotional support (Ahrens, Campbell, Ternier-Thames, Wasco, & Sefl, 2007), a substantial minority of survivors seek assistance from the medical, legal, and mental health systems (Campbell, 2008). Sexual assault survivors who require medical care may go to a local emergency department or seek specialized care from Sexual Assault Nurse Examiners (SANEs), for treatment of sexually transmitted infections [STIs], emergency contraception, and forensic evidence collection (Campbell, 2008). Some sexual assault survivors also require legal assistance (e.g., making formal police reports, prosecuting), and/or mental health support (e.g., individual or group counseling) (Campbell, 2008). Furthermore, social reactions from informal and formal support providers has been shown to play a significant role (both positive and negative) on survivors‘ subsequent help-seeking and well-being (Ahrens, 2006; Ahrens, Cabral, & Abeling, 2009; Ahrens et al., 2007). The extant literature has provided a basic understanding of the help-seeking experiences of adult sexual assault survivors. However, less is known about how and why adolescent survivors disclose and seek help. Because adolescents are at a particularly high risk of being 1 sexually assaulted (McCart et al., 2010; Snyder, 2000; Snyder & Sickmond, 2006), researchers are now beginning to examine the post-assault and help-seeking experiences that are unique to adolescent survivors from a developmental perspective. In doing such research, it is important to not only consider the distinct developmental changes adolescents experience, but also their social contexts. Bronfenbrenner‘s ecological model of human development (Bronfenbrenner, 1979, 1986) is suited for such exploration as it examines the role of the individual nested within various interacting systems (e.g., home, school). Examining the role of multi-systemic factors from a developmental, ecological lens is imperative given that the current literature has not fully captured the unique and complex experiences of adolescents during sexual assault disclosure and help-seeking. Furthermore, recognizing which factors are most salient and influential for adolescent survivors during help-seeking may provide a foundation for future theoretical models to guide developmentally appropriate interventions for sexually abused adolescents. To set the stage for understanding disclosure and help-seeking among adolescent sexual assault survivors, an overview of adolescent sexual assault will be presented first. Second, the current research on disclosure and help-seeking among adolescents will be discussed to explore how and why adolescents seek help within the context of adolescent development more generally. Third, the literature review will cover what is currently known about disclosure and help-seeking with respect to adolescent sexual assault specifically. Fourth, the limitations in the adolescent sexual assault literature will be highlighted by integrating relevant theory and research from the adult sexual assault help-seeking literature. Given the limited empirical and theoretical work on adolescent sexual assault disclosure and help-seeking, the current study sought to qualitatively examine the mechanisms by which adolescent survivors disclose and eventually enter formal systems. Using an ecological 2 framework to guide the analyses, special attention was given to the influential nature of individual-level, microsystem, mesosystem, and chronosystem factors to explore two major issues: 1) Who, why, and when do adolescent sexual assault survivors disclose, and what occurs within microsystems that impact further help-seeking?; and 2) how do systemic interactions (i.e., mesosystem, chronosystem) influence subsequent disclosure and entry into formal systems? 3 Chapter 1: Literature Review Adolescent Sexual Assault: Prevalence and Impact Sexual assault is defined as attempted or completed vaginal, anal, and/or oral penetration or sexual contact committed by the use or threat of force (Tjaden & Theonnes, 2006). Sexual assault is particularly prevalent during adolescence, which developmental psychologists characterize as either early adolescence (10-13 years of age), middle adolescence (14-17), and late adolescence (18-22 years of age) (Arnett, 2000; Lipsitz, 1977; Steinberg, 2005). Because most of the adolescent sexual assault literature to date has focused on the 14-17 age group, this review will primarily discuss sexual assault during middle adolescence. Research has consistently shown that adolescents are at a considerable risk for sexual assault. National reports have found that 7% to 10% of adolescents between the ages of 12-17 have reported being forced to have sex (CDC, 2006; Howard, Wang, & Yan, 2007; McCart et al., 2010; Nofziger & Stein, 2006), making them the largest group of sexual assault victims and twice as likely to be victimized as adults (Snyder, 2000; Snyder & Sickmond, 2006). In a study examining data from the 2005 Youth Risk Behavior Survey, 8% of high school students reported being physically forced to have sexual intercourse in their lifetime (Howard, Wang, & Yan, 2007). Adolescent sexual assault and re-victimization (i.e., being assaulted multiple times during one‘s lifetime) is more common among females than males (Boney-McCoy & Finkelhor, 1995; Finkelhor, Ormrod, & Turner, 2009; Nofziger & Stein, 2006; Wolitzky-Taylor, Ruggiero, Danielson, Saunders, & Kilpatrick, 2008; Young & Furman, 2008). Adolescent girls were also four times more likely to be assaulted than older females (Canterbury, Grossman, & Lloyd, 1993; Hashima & Finkelhor, 1999; Snyder & Sickmund, 2006). Furthermore, adolescents were more likely to be assaulted by acquaintances in comparison to younger children and adults 4 (Hanson et al., 2003; Muram, Hostetler, Jones, & Speck, 1995; Stein & Nofziger, 2008; Snyder & Sickmund, 2006; Tjaden & Theonnes, 2006). Sexual assault victimization has been associated with numerous physical and psychological outcomes, including increased risk of post-traumatic stress, major depressive disorder, low self-esteem, emotional distress, social isolation, substance abuse, eating disorders, and suicide (Ackard & Neumark-Sztainer, 2002; Arellano, Kuhn, & Chavez, 1997; BoneyMcCoy & Finkelhor, 1995; Cecil & Matson, 2005; Wolitzky-Taylor et al., 2008). In terms of gender differences, adolescent female survivors were more likely to suffer from psychological symptoms (e.g., mood disorders, somatic complaints, nightmares), whereas adolescent male survivors were more likely to suffer from behavioral symptoms (e.g., running away, suicide attempts, aggression) (Darves-Bornoz, Choquet, Ledoux, Gasquet, & Manfredi, 1998). Various risk factors have also been identified as increasing the likelihood that an adolescent would be sexually assaulted, including older age, alcohol use, substance abuse, association with deviant peers, low parental monitoring, low familial support, increased sexual activity and dating, and a prior history of sexual abuse (Arellano, Kuhn, & Chavez, 1997; Cecil & Matson, 2005; Laccasse & Mendelson, 2007; Livingston, Hequembourg, Testa, & VanZile-Tamsen, 2007; Maxwell, Robinson & Post, 2003; Small & Kerns, 1993; Wolitzky-Taylor et al., 2008; Young & Furman, 2008). As these findings suggest, adolescent females are particularly at risk of being sexually assaulted by someone they know and to suffer from a wide range of psychological and physical problems. Therefore, the remainder of this review will be based on studies that are specific to adolescent female sexual assault survivors. While most of the current literature has focused on documenting the risk factors associated with sexual assault and its impact on health and well- 5 being, fewer studies have examined what happens after an assault during disclosure and helpseeking. It is during this crucial period that sexual assault survivors decide whether to seek informal or formal help and how to begin the course of their recovery. To explore these issues, the literature on adolescent help-seeking processes in general (not including clinical samples) will be reviewed to establish how and why adolescents seek help within this developmental period. General Help-Seeking Among Adolescents Adolescence is a time when family relations change and the development and maintenance of strong ties with peers are of significant importance. Due to an increased sense of independence, emotional autonomy, and need for privacy, adolescents spend additional time outside of the home and less time under the supervision of their families (Csikszentmihalyi & Larson, 1984; Steinberg & Morris, 2001). During this period, the family system can become unstable due to an adolescent‘s biological, social, and cognitive changes, which may result in greater conflict between parent and child (Baer, 2002; Larson, Richards, Moneta, Holmbeck, & Duckett, 1996). As youth enter middle adolescence, peer group dynamics also change, where larger groups of friends are formed, including more opposite sex peers (Connolly, Furman & Konarski, 2000; Cooksey, Mott & Neubauer, 2002). The combination of less adult supervision and the formation of more diverse peer groups may increase the likelihood of interpersonal problems. While most adolescents transition and adapt into adulthood with minor psychological or behavioral problems (Steinberg, 2005), adolescence is a life stage where new experiences (e.g., dating, employment, school transitions) can contribute to an increase in overall stress. In fact, before adolescents turn eighteen, 40% to 70% experience some form of stressful event, such as divorce or academic difficulties (Gans, 1990; Giaconia, Reinherz, Silverman, & Pakiz, 1995). 6 Because of increasing stressful experiences during adolescence, and decreasing time spent with family as a main support system, it is imperative to understand how adolescents seek help and navigate their social support systems during stressful and emotional times. Prevalence of Help-Seeking As many as 81% of adolescents turn to someone for help when encountering a stressful event (Schonert-Reichl & Muller, 1996), which is encouraging because help-seeking in general has been found to be an adaptive coping strategy (Bal, Crombez, Oost, & Debourdeaudhuij, 2003). Adolescents are generally more likely to seek help from informal support providers such as friends and family, rather than formal support providers, like teachers, counselors or doctors (Benson, 1990; Boldero & Fallon, 1995; Finkelhor & Ormrod, 2001; Raviv, Sills, Raviv & Wilansky, 2000; Rickwood, Deane, Wilson, & Ciarrochi, 2005; Zwaanswijk, Verhaak, Bensing, Van der Ende, & Verhulst, 2003). For example, in a study by Boldero and Fallon (1995), 55% of adolescents indicated that they turned to someone for help for their problems. Among these adolescents, 40% sought help from friends, 36% sought help from parents, 13% sought help from a counselor or doctor, and 11% sought help from a teacher. Whereas most studies document that the vast majority of adolescents seek the support of friends and family, many have also found that a significant minority never seek help from others and choose to deal with their problems on their own (e.g., Boldero & Fallon, 1995; Dubow, Lovko & Kausch, 1990; SchonertReichl & Muller, 1996). Correlates of Informal and Formal Help-Seeking Several studies have investigated what factors influence and/or prevent adolescents from seeking help. Because adolescents perceive their problems differently depending on their age and gender, subsequent help-seeking behavior also varies greatly (Boldero & Fallon, 1995). As 7 children transition into their adolescent years and enter high school, boys and girls tend to decrease seeking help from their families (Larson & Richards, 1991; Rickwood et al., 2005), making peer support more likely. As adolescents get older, they are also more likely to seek professional help for problems compared to younger adolescents (Schonert-Reichl & Muller, 1996; Sears, 2004; Zwaanswijk et al., 2003). In regards to gender differences, females are more likely than males to seek help overall, and they are specifically more likely to seek help from friends and professionals (Boldero & Fallon, 1995; Kuhl, Jarkon-Horlick & Morrisey, 1997; Rickwood et al., 2005; Schonert-Reichl & Muller, 1996; Stanton-Salazar & Spina, 2005). In addition, female adolescents‘ likelihood of seeking help from friends increases with age (Rickwood et al., 2005; Stanton-Salazar & Spina, 2005), which is consistent with research suggesting that adolescent females place a higher value and expect more emotional support from their friendships than males (Clark & Ayers, 1993; Stanton-Salazar & Spina, 2005). While racial differences in help-seeking has not been extensively examined, some studies suggest that youth from ethnic minority groups tend to seek informal help over formal help (Zwaanswijk et al., 2003), which may be a result of the lack of awareness or accessibility to formal services for minority families. As mentioned earlier, adolescence is a period where cognitive and socio-emotional changes occur. Such cognitive and emotional development is paramount in connection to problem-solving and seeking help. Research on emotional competence has found that adolescents who were low in emotional awareness (i.e., inability to understand and verbalize emotions) were less likely to seek help from informal and formal support sources (Ciarrochi, Wilson, Deane & Rickwood, 2003; Rickwood et. al, 2005). Furthermore, even when adolescents have high levels of social support available, they are less likely to use social support networks 8 when they have low emotional competence (Rickwood et al., 2005). On the other hand, adolescents with higher self-worth (who presumably already have a greater sense of self-efficacy to solve their own problems) are more likely to seek help from professionals compared to those with lower self-worth (Schonert-Reichl & Muller, 1996). Adolescents also consider how others may react before disclosing their problems. These anticipatory beliefs and perceptions can influence if and how help-seeking occurs. For instance, adolescents who are self-conscious, are too embarrassed to talk about their problems, fear the loss of confidentiality, fear that their peers will find out, feel that no person or helping service can help, feel that their problem is too personal or minor, and feel that they could handle their problem on their own, are less likely to seek help from informal and formal providers (Dubow, Lovko & Kausch, 1990; Raviv, Raviv, Vago-Gefen & Fink, 2009; Rickwood et al., 2005; Schonert-Reichl & Muller, 1996; Wilson, Bignell, & Clancy, 2003; Wilson & Deane, 2001). These findings suggest that adolescents go through a process of evaluating whether their problem is important or serious enough, and that they also anticipate how others will react before even deciding to seek help. Such anticipatory beliefs or expectations of support can either help or hinder adolescents‘ willingness to disclose and seek help for personal problems. In addition to individual differences such as age, gender, emotional competence, and anticipatory beliefs, research on adolescent help-seeking has begun to examine the interpersonal and contextual factors that are associated with help-seeking behavior. In general, adolescents find it easier to seek help when previous help-seeking experiences were successful and prefer to seek help from someone with whom they have a strong trusting relationship- who is able to listen, maintain confidentiality, and provide validation (Lindsey & Kalafat, 1998; Wilson & Deane, 2001). Wilson and Deane (2001) highlighted that what is most crucial for youth in 9 seeking help is perceiving that a support provider has gone through the same kind of problem and is therefore able to relate and make them feel that they are not alone. With formal help, adolescents who had previous negative experiences, such as not being helped or not being taken seriously, served as barriers to future help-seeking (Rickwood et al., 2005). Altogether, these studies suggest that adolescents weigh the pros and cons of help-seeking by taking into account the current relationship and prior positive and/or negative interactions they have had with support providers. The Unique Role of Peers and Parents in Help-Seeking As was just reviewed, interpersonal factors play a significant role in how and why adolescents seek help from informal and formal support providers. Peers and parents have particularly salient roles in adolescent help-seeking, which merits a more in-depth analysis of these sources of support. Therefore, this next section will highlight the unique role of peers and parents to better understand why peers and parents are sought out most. More importantly, why do adolescents prefer the help of their peers rather than parents? And in what contexts do adolescents prefer the support of parents over peers? Adolescents take into consideration the problem at hand and the expected responses of peers and parents. In particular, when adolescents feel they need the help of an ―expert,‖ someone who is able to solve a problem, they are likely to turn to their mothers. Adolescents are also more likely to seek help from parents (specifically mothers) for health, school, and career problems (Sears, 2004; Sullivan et al., 2002). On the other hand, when adolescents expect a nurturing and supportive response, they are more likely to seek the help of a friend, and prefer peer support for interpersonal problems like dating and sex (Boldero & Fallon, 1995; Raffaelli & Duckett, 1989; Sullivan et al., 2002; Youniss & Smollar, 1985). Adolescents are also less likely 10 to seek help from family when they have serious problems compared to adolescents who report having few or no problems (Sears, 2004). While adolescents prefer initial support from friends for interpersonal problems, parents are often central in initiating and connecting adolescents to more formal sources of help (Logan & King, 2001; Wintre & Crowley, 1993; Wilson & Deane, 2001; Zwaanswijk et al., 2003). Taken together, these findings propose that adolescent helpseeking involves a selection process that considers the expected response of peers and/or family members, the amount/type of support someone can provide, what the problem is, and the severity of the problem before deciding whom to seek help from. The current findings also suggest that peer networks play a central nurturing role during help-seeking. In fact, developmental researchers assert that peers serve important emotional functions. Youniss and Smollar (1985) coined the phrase ―principled relationships‖, which describes peer social networks as the context for learning about mature symmetrical relationships. Mutual caring and trust in relationships is critical because of the expectation that private matters will be kept confidential. Because adolescents are in the stage of forming their social identity, betrayal of confidence among friends can be very harmful to adolescents‘ socioemotional development. And, once an adolescent‘s confidence is shattered by a close friend (e.g., during help-seeking), the selection of future friends becomes even more discerning (Stanton-Salazar & Spina, 2005). Sullivan et al. (2002) further proposed that peer disclosure and help-seeking serve two important purposes: to cope with the problem at hand and for the development and maintenance of friendships. Therefore, seeking help from peers does not simply entail revealing interpersonal issues to help deal with problems, but also serves to solidify developing friendships. Moreover, peer support may compensate for the negative effects of inadequate familial support (Gauze, 11 Bukowski, Aquan-Assee & Sippola, 1996) and even predict fewer symptoms of depression in female adolescents (Slavin & Rainer, 1990). Thus, peer friendships are far more complex, and indeed adaptive, than the negative ―peer pressure‖ and ―deviant‖ stereotype often overrepresented in mainstream society and in the current literature (e.g., Capaldi, Dishion, Stoolmiller, & Yoerger, 2001; Maxwell, 2002; Reitz et al., 2006). Peer networks can serve a beneficial developmental and social support function that is uniquely different from parental support. In sum, adolescent help-seeking is a conscious and selective process shaped by multiple factors, including age, gender, anticipatory beliefs, type of problem, and the quality of support from various support providers, especially peers and parents. These findings regarding how adolescents seek help in general can facilitate our understanding of how adolescents respond to the stresses of a sexual assault in particular. First, given that sexual assault is a stigmatized interpersonal problem, it is likely that female adolescent survivors would also first seek help from their friends. They may be less inclined to initially seek the help of their mothers and even less so from formal support providers. However, because sexual assault can cause substantial psychological and physical harm, it is also probable that adolescent survivors may require adult guidance from their parents to obtain appropriate formal help (e.g., medical and legal services). It is also important to note that most of the current literature on adolescent help-seeking in general is primarily descriptive in nature. That is, while it is clear that certain individual and interpersonal factors are associated with the likelihood of help-seeking from particular support providers, there is no research that explores, for example, how and why peers influence adolescents in continued help-seeking, or how peer and parental support interconnect during help-seeking. When research has investigated the effects of peer and parental support, they are 12 analyzed as combined or spill-over effects (e.g., peer deviance plus family dysfunction) rather than interacting effects (e.g., peers communicating with family system) (Bronfenbrenner, 1986; Baril, Julien,Chartrand, &Dubé, 2009; Véronneau & Dishion; 2010). Therefore, research needs to tap into how and why such factors work together during the process of disclosure and helpseeking. Such investigation can advance sexual assault research by revealing the pathways that adolescent survivors go through when deciding to disclose and seek help by identifying influential individual, interpersonal, and contextual factors. Investigating these processes is especially important for adolescents who experience traumatic events because it can explain what factors motivate an adolescent to seek the help of one informal provider over another, and can help explain the perceived barriers adolescents face when seeking informal and/or formal help. Disclosure and Help-Seeking Among Adolescent Sexual Assault Survivors As discussed above, the general adolescent help-seeking literature can facilitate our understanding of how adolescent sexual assault survivors disclose and seek help. Nonetheless, because sexual assault is a traumatic experience unlike the more common stressors youth face during adolescence, this next section will present what is currently known about disclosure and help-seeking among adolescent sexual assault survivors in particular, and will connect what has been learned from the research on general adolescent help-seeking. Before reviewing this literature, it is important to note some conceptual and definitional limitations. The sexual assault literature uses the terms ―disclosure,‖ ―telling,‖ and ―helpseeking‖ interchangeably. While the literature has yet to successfully differentiate and operationalize these terms, ―disclosure‖ has unique significance in the sexual assault literature. From a feminist perspective, remaining silent after traumatic experiences such as sexual assault, 13 is another form of keeping females powerless in a sexist and patriarchal society (Brownmiller, 1975; MacKinnon, 1987). Therefore, many sexual assault researchers describe disclosure as the position where survivors find the strength to ―speak out‖ about their abuse (Ahrens, 2006, Ullman, 2010). In this study, the term ―disclosure‖ refers to telling an informal support provider, given that it is not always apparent that ―disclosing‖ is for the purpose of receiving tangible help. The term ―help-seeking‖ refers to seeking help from formal systems, such as legal or medical providers. Prevalence of Disclosure and Help-Seeking Overall, national studies find that as many as 85% of adolescents tell someone about their sexual assault (Black, Tolman, Callahan, Saunders, & Weisz, 2008; Broman-Fulks, et. al, 2007; Kogan, 2004; Stein & Nofziger 2008; Nofziger & Stein 2006). In a nationwide sample of adolescents, Broman-Fulks and colleagues (2007) found that approximately two-thirds had disclosed to informal and/or formal support providers while nearly one-third had never disclosed to anyone. Smaller scale studies have found similar rates, with 58% of adolescents who experienced rape or attempted rape disclosing to someone about their assault (Rickert et al., 2005). In addition to whether adolescent survivors choose to disclose, researchers have recently examined how long it takes survivors to disclose. Using a sub-sample from the National Survey of Adolescents, Kogan (2004) found that among adolescents who disclosed their assault, 24% disclosed within a day, 19% disclosed by the first month, 12% disclosed a year after, and 19% disclosed more than a year after the assault. Broman-Fulks and colleagues similarly (2007) reported that 39% of survivors in their national sample told someone within a month and 28.6% waited longer than a month to disclose, with 23% not sure about disclosure timing. Long delays 14 in disclosure is an important factor to consider as part of the disclosure process because it has been shown to negatively impact psychological well-being (Broman-Fulks et al., 2007) and it can also influence how soon survivors gets the support they need. Furthermore, the disclosure process is even more complex than what most of the current literature proposes. Researchers have recently suggested that sexually abused girls may lose control of their disclosures if peers or family members take it upon themselves to inform other friends/family or contact formal services (Staller & Nelson-Gardell, 2005). Therefore, disclosure is more than a simple event, rather it is a process that can occur over time and may involve the interjection of others. Similar to findings in the general adolescent help-seeking literature, rates of sexual assault disclosure differ depending on the source of support. Adolescent sexual assault survivors are more likely to disclose to informal support providers than formal support providers (Rickert et al., 2005; Stein & Nofziger, 2008). Adolescent survivors are also more likely to first disclose and seek help from a friend, with mothers being the second most likely confidant (Kogan, 2004; Rickert et al, 2005; Stein & Nofziger, 2008; Weisz et al., 2007). Kogan (2004) found that 74% of 263 adolescent females in the National Survey of Adolescents who reported unwanted sexual contact told someone about their experience, with the most common initial contact being a friend (36%), followed by mothers (35%), and other relatives (8%). In terms of formal disclosures, approximately 6% to 7% of adolescent sexual assault survivors disclose to mandatory reporters like police, teachers, social workers, counselors, and clergy (Kogan, 2004; Stein & Nofziger, 2008). Correlates of Informal and Formal Help-Seeking Adolescent sexual assault disclosure and help-seeking depends on multiple factors. For instance, adolescent females have been found to more likely than males to seek help for a sexual 15 assault (Black et al., 2008; Nofziger & Stein, 2006). This may be due to the gender socialization that occurs during childhood and adolescence, where boys are taught to be ―masculine‖ and deal with problems on their own, while girls are encouraged to be ―feminine‖ by embracing one‘s emotions and turning to others for emotional support (Steinberg, 2005). Age differences have also been found, whereby older adolescent survivors (14-17) tend to disclose to only peers versus adults, while younger adolescent survivors (11-13) are more likely to seek help from an adult (Kogan, 2004; Nofziger & Stein, 2006). Younger adolescents (11-13) are also more likely to disclose immediately compared to older adolescents (14-17) who are less likely to disclose at all (Kogan, 2004). These findings are consistent with the adolescent help-seeking literature that shows an increase in seeking help from peers and a decrease in seeking help from parents once youth transition into middle adolescence (Larson & Richards, 1991; Rickwood et al., 2005). Another similar finding to the general help-seeking literature is that youth are more likely to report their assault to authorities as they get older (Finkelhor & Ormrod, 2001). While racial differences in disclosure have been inconsistently reported (Rickert et al., 2005; Neville & Pugh, 1997), Rickert and colleagues (2005) found that African American adolescents take longer to disclose a sexual assault than Caucasian adolescents. Given the history of negative treatment of minority groups by law enforcement and concerns that formal services are not sensitive to culture, class, race, and/or gender, ethnic minority adolescents may be particularly hesitant to seek help from formal services (Hamby, 2008; Neville & Pugh, 1997; Washington, 2001). Likewise, cultural norms may inhibit minority adolescents from seeking help outside of their group in order to protect themselves from further negative stereotypes (Hamby, 2008; Washington, 2001). 16 In regards to individual beliefs and perceptions, adolescent sexual assault survivors first try to understand what happened to them and become more self-aware of their feelings before they decide to disclose (Staller & Nelson-Gardell, 2005). Adolescent survivors may have different reasons for why they decide to disclose in the first place. Some do so for altruistic needs because they want to stop the perpetrator from harming anyone else (Clements et al., 2004), while some survivors‘ attachment of anger, jealousy, and fear of injury or death may also increase the likelihood of disclosure (Black et al., 2008; Kogan, 2004; Nofziger & Stein, 2006). Similar to the general adolescent help-seeking literature, adolescent sexual assault survivors use anticipatory beliefs and consider how certain people will react to their disclosures, such as whether people will be trusting, non-judgmental, and supportive (Staller & Nelson-Gardell, 2005; Petronio et al., 1996). Adolescent survivors also seem to take into account their own sexual histories in considering how others will react prior to disclosure. Research has found that disclosure is less likely for adolescents who had three or more sexual partners in the last 12 months prior to the assault (Rickert et al., 2005). Although this finding was marginally significant, it suggests that female adolescents may fear that their prior consensual sexual behavior will be perceived negatively by family members or formal support providers within the context of seeking help for a sexual assault. In terms of other historical factors, it is less clear how prior childhood sexual abuse or adolescent sexual assault may impact disclosures and help-seeking for the most recent assault. Prior sexual assault had been found to be significant risk factor for future sexual assault victimizations (Classen, Palesh, & Aggarwal, 2005; Desai, Arias, Thompson, & Basile, 2002; Gidycz, Hanson & Layman, 1995; Messman-Moore & Long, 2003) and is related to poor coping strategies, such as alcohol use and risky sexual behavior (Niehaus, Jackson, & Davies, 2010; 17 Rich, Combs-Lane, Resnick, & Kilpatrick, 2004; Ullman & Najdowski, 2009). However, no research to date has explored how a history of sexual abuse influences disclosure and helpseeking for a current assault. Assault characteristics (i.e., who is the assailant, where the assault took place, degree of forced used to commit the assault, etc.) have also been found to be associated with adolescent sexual assault disclosure and help-seeking. With respect to the relationship a victim has with the assailant, greater familiarity makes disclosure less likely compared to disclosing a stranger rape (Kogan, 2004; Finkelhor & Ormrod, 2000; Stein & Nofziger, 2008). Furthermore, Rickert and colleagues (2005) found that survivors who had more than five dates with the perpetrator were six times less likely to tell someone about the assault. Studies have also reported that victims who are assaulted by another juvenile versus an adult are less likely to contact the police (Finkelhor & Ormrod, 2001; Finkelhor & Wolak, 2003). Being assaulted by a peer also affects informal disclosure and help-seeking. In one recent study, 65% of the cases involving a peer perpetrator were disclosed to a friend while only 19% of cases involving a peer were disclosed to mothers (Stein & Nofziger, 2008). These findings imply that the closer one is with the perpetrator, specifically a peer or dating partner, the more difficult it is to tell someone about the victimization. In fact, it has been suggested that acquaintance rape is fundamentally different than stranger rape in that is involves a personal investment in the relationship where feelings of obligation are concerned (Koss, Dinero, Seibel, & Cox, 1988). Assault characteristics also impact when an adolescent survivor chooses to disclose. For example, being assaulted by a peer and being assaulted multiple times (versus a single time) delays disclosure and increases the likelihood of non-disclosure (Kogan, 2004). The delay in disclosing peer perpetration may be due to the fear of being blamed or ridiculed by other peers 18 who may share a relationship with the perpetrator. Adolescents‘ fear that peers will become aware of their personal problems is consistent with the general adolescent help-seeking literature (Rickwood et al., 2005; Wilson, Bignell, & Clancy, 2003). However, the fact that adolescents are still willing to talk to peers about peer perpetration rather than adults could be due to the perception that parents may not understand the complexity of peer relationships during adolescence (Stanton-Salazar & Spina, 2005). Survivors might also consider where the assault took place and how severe it was prior to seeking help. While location of the assault has not been studied at length, Finkelhor and Wolak (2003) found that sexual and physical assaults that occur within schools are less likely to be reported to the police due to schools having their own police authorities. Disclosure is also less likely if the assault occurred in the victim‘s home compared to other locations such as a relative‘s home, a friend‘s home, or outside the neighborhood (Nofziger & Stein, 2006). On the other hand, Black et al. (2008) found that location was unrelated to disclosure, and instead, having witnesses versus being assaulted in isolation increased the willingness for survivors to disclose. Assault severity also plays a role in disclosure. For example, some have found that being vaginally penetrated was related to disclosing to an adult versus not disclosing at all (Kogan, 2004; Nofziger & Stein, 2006), while other studies have found that the severity of violence and injury was unrelated to disclosure (Black et al., 2008). It may be that some survivors are more likely to ascribe to and be influenced by stereotypical rape myths in deciding if and when to disclose. For instance, survivors who are severely assaulted in a public place may feel that their story will be taken more serious compared to adolescents that are assaulted in their own home with minimal fondling and/or injuries. 19 Although alcohol use prior to or during the assault is quite common in adolescent rapes (Basile et al., 2006; McCauley et al., 2009; Young & Furman, 2008), few studies have examined how this contextual factor influences disclosure and help-seeking. Rickert et al. (2005) found that adolescents are more likely to disclose rape or attempted rape sooner than later if the perpetrator had consumed two or more alcoholic beverages. They also found that adolescents are more likely to disclose the assault if they had been pressured to use alcohol. Consensual drinking, on the other hand, was related to disclosing verbal sexual coercion but not rape/attempted rape. It is likely that adolescents who had been pressured to drink prior to being sexually assaulted are less likely to fear being blamed for the assault compared to those who had been raped after drinking consensually. Interpersonal and lifestyle factors have also been identified as influencing post-assault disclosure and help-seeking. While anticipatory beliefs consists of what survivors believe may happen as a result of disclosing, interpersonal factors such as initial reactions from peers, are quite influential on subsequent help-seeking. For instance, Staller and Nelson-Gardell (2005) reported that sexually abused girls consider the initial reactions of people once they begin to disclose to see whether further disclosure is beneficial. Therefore, if a survivor receives negative reactions from friends or family members during the initial disclosure process, they are less likely to want to continue seeking help. An adolescent‘s associations with certain peers and community surroundings may also play a role in help-seeking. Nofziger and Stein (2006) reported that victims who have deviant peers and witness community violence are less likely to disclose, while a victim‘s own deviance increases the likelihood of disclosure. They clarify these findings by suggesting that adolescents who have deviant peers and witness violence may perceive themselves as less deserving of help. In terms of adolescents‘ own deviant behavior, 20 they propose that those who engage in deviant lifestyles may not perceive their behavior as extremely deviant. Because these adolescents are more aware of violence in general, they may also believe more strongly in personal safety, making them more likely to disclose. While research examining lifestyle factors is sparse, it appears that adolescents‘ broader social settings, such as one‘s neighborhood characteristics, are influential to their disclosure decisions. The Unique Role of Peers and Parents in Disclosure and Help-Seeking While there are multiple factors involved in disclosure and help-seeking after a sexual assault, the unique roles that peers and parents serve in this process merits an in-depth review. As mentioned earlier, adolescent sexual assault survivors are more likely to first seek help from a friend before seeking help from a parent. In the general adolescent help-seeking literature it is suggested that adolescents connect to peers (versus parents) during stressful times for socioemotional development (Sullivan et al., 2002). Given these findings, is it likely that adolescent sexual assault survivors also engage in a similar selection process? Petronio and colleagues (1996) pointed out that sexually abused adolescents engage in a selection process where they consider how trusting and attractive a potential helper may be, and how symmetrical the relationship is in order to determine whether and how much to disclose. They found that because peers are considered more symmetrical and less risky, they are disclosed to more often than parents and other adults. The adolescent help-seeking literature has also shown that friends are important in providing emotional support during stressful times. While there is limited research on the social reactions of friends toward adolescent sexual assault survivors, Weisz et al. (2007) examined the reactions of peers provided to adolescent dating violence survivors. Overall, peers tended to react in a nurturing manner (e.g., listened, empathized), regardless of the severity of violence. 21 However, peers were more likely to avoid the victim when the violence was most severe (i.e., involving forced sex, beating, choking, etc), signifying that some peers may find it increasingly difficult to talk about severe forms of dating violence, leaving those in most need without enough support. Future research is needed to understand how peers respond to sexual assault survivors and how their initial reactions to the assault influence survivors‘ willingness to continue disclosing and seeking help. In terms of parental disclosure, some have suggested that this process may be very difficult for adolescents. Not only are parents unprepared to hear that their child has been sexually abused, but they may have experienced child sexual abuse themselves, which may make them underestimate or deny the severity of the abuse of their child (Clements & Burgess, 2002). Adolescents may also fear disclosing to parents because they do not want to upset them or get in trouble for engaging in what could be perceived as ―risky behavior‖ prior to the assault (Clements, Speck, Crane, & Faulkner, 2004). Furthermore, the fact that sexual assault involves talking about sex may also discourage young females from talking about the assault with parents. In a recent retrospective study of college-aged females, Smith and Cook (2008) reported that adolescent sexual assault survivors were more likely to disclose to their parents if they had spoken to them about sex in a frank and positive manner growing up. On the other hand, survivors found it difficult to disclose to their parents if they received negative messages about sex, if their parents held strong religious beliefs, and if they were intimately involved with their assailant. Therefore, disclosing sexual assault to parents may depend greatly on how socially stigmatized issues (e.g., sex) were discussed during childhood and adolescence. Overall, disclosing sexual assault to parents may have positive and/or negative effects on adolescent survivors. Adolescents who disclosed to their mothers have been shown to have 22 significantly lower PTSD symptoms compared to those who did not disclose to their mothers and to those who never disclosed to anyone (Broman-Fulks et al., 2007). In fact, adolescents who never disclosed to their mothers were four times more likely to have PTSD compared to those who did disclose to their mothers. Finkelhor and Wolak (2003) also studied the role of parents and proposed that they serve as a gateway in getting their children into the legal system. Specifically, parents go through a recognition and consideration stage; whereby parents first identify the incident as a crime, and then weigh the pros and cons of entering the criminal justice system. In their study, parents were more likely to recognize the incident as a crime if the assault occurred against a female adolescent versus preadolescent, had an adult or multiple perpetrators, resulted in physical injuries, and if the family had prior experiences with the police (i.e., any family member was previously a victim or suspect of a crime). Finkelhor and Wolak (2003) also found that reporting was more likely to occur when the assault was perpetrated by an adult, if the family was advised to make a report, if the family had prior experiences with the police, if they felt that the police would take their case serious, and if they believed that their child will still be in danger if a report was not made. These findings are concerning because it suggests that adolescents who are not assaulted by multiple assailants and victimized by similar-aged peers (which occurs most often in adolescent sexual assault) are less likely to be believed by their parents and are less likely to receive legal help. The relative effect of peer disclosure over parental disclosure has not been studied in detail, yet is important to consider given the importance of peer relationships during adolescence. For instance, adolescent survivors who come from unsupportive households may choose their peers over parents for support. Kogan (2004) proposed that survivors who live in drug-abusing households are more likely to disclose an assault because adolescents who have unsupportive 23 families may focus more on building a stronger peer support network whom they are then more likely to disclose to. This is consistent with the general adolescent help-seeking literature that finds that adolescents who turn to peers for help may compensate for the negative effects of inadequate familial support (Gauze et al., 1996). Whether the disclosure experiences survivors have with parents are better or worse than with peers may not be the most important issue, however. Parental disclosure seems to involve a different trajectory and purpose than peer disclosure. In a recent study by Stein and Nofziger (2008), adolescents who disclosed their assault to their mothers were more likely to make an official report to the police and to have their cases end in an arrest compared to only confiding in their friends. Therefore, peers may not have the ability to connect their friends to the appropriate formal help and to support a survivor during the legal process. Parents have the experience and knowledge to initiate and connect their children to formal help (e.g., Logan & King, 2001; Wilson & Deane, 2001) whereas peers may not be fully aware of all the resources to make appropriate referrals. Regardless of the different functions that exist between peer and parental support, what the current research does not explain is how adolescent survivors feel about their parents initiating entering formal systems and how helpful they perceive this process to actually be. Furthermore, it is not clear if and how the peer and family system interact during the disclosure and help-seeking process. While studies examining the effect of peer and parental support can explain the independent influence of each of these systems, research has yet to explain if and how peer-family interactions occur and impact subsequent disclosure and help-seeking. Limitations of the Adolescent Sexual Assault Literature Overall, the literature on adolescent sexual assault disclosure and help-seeking presents a wide range of factors that influence if and when survivors will turn to others for help after an 24 assault. To summarize, individual differences such as age and gender are associated with disclosure and help-seeking behaviors, where older female adolescents are more likely to go to peers for support (Black et al., 2008; Kogan, 2004, Stein & Nofziger, 2008). Adolescent survivors also take account anticipatory beliefs and assumptions, characteristics of assault, characteristics of the assailant, and reactions from providers before and during help-seeking (Clements et al., 2004; Kogan, 2004; Rickert et al. 2005; Nofziger & Stein, 2006). In terms of the type of help that adolescent sexual assault survivors seek out, they are more likely to turn to informal rather than formal help (Kogan, 2004; Rickert et al., 2005; Stein & Nofziger, 2006). An important finding is that parental support is essential for adolescent survivors who enter formal systems, such as the medical or legal systems (Finkelhor & Wolak, 2003). Likewise, peers are particularly significant and are most often disclosed to before parents (Rickert et al., 2005; Stein & Nofziger, 2008). As with the general adolescent help-seeking literature, peers can offer emotional support that is essential for socio-emotional development, but may not be able to offer survivors with the knowledge of getting formal help (Stein & Nofziger, 2008). That is, adolescent peers may not know about the available community resources, such how to obtain a medical forensic exam or make a police report. Overall, the literature to date has studied disclosure and help-seeking as a linear process by identifying a number of individual, interpersonal, and contextual factors that predict if and when disclosure occurs. However this approach oversimplifies this process as merely a series of factors (as if a series of independent variables in quantitative analyses) that are expected to predict disclosure and help-seeking (the dependent variable) without considering that there may be interrelationships between the various factors. For example, most of the research examines whether survivors told someone (e.g., ―Have you ever told anyone about the assault, yes or no?‖) 25 and examine whether this is related to individual level factors and assault characteristics (e.g., Kogan, 2004). However, researchers have not asked how the interrelationship between individual level factors (e.g., anticipatory beliefs) and systemic factors (e.g., peer support) influence disclosure and help-seeking. Furthermore, the literature has not been able to fully explain that the predicted outcome of disclosure/help-seeking (the dependent variable) can also become a significant factor (independent variable) in subsequent disclosures. Instead, disclosure is often seen as a single event, without understanding that it can be delayed and influenced by how support providers react to initial disclosures, thus creating a complex and dynamic disclosure process (e.g., Stein & Nofziger, 2008). Likewise, with the exception of a few studies (Black et al., 2008) many conceptualize disclosure as something an adolescent survivor has complete control over, instead of as a process that may be initiated and continued by others (e.g., Hanson et al., 2003; Nofziger & Stein, 2006). Such conceptual limitations are confounded with some notable methodological gaps as well. That is, given the manner in which disclosure and help-seeking are conceptualized and operationalized, the extant research has emphasized descriptive and correlational analyses that describe simple relationships among variables without understanding how and why these variables work together during the help-seeking process. While not specific to adolescent survivors, the adult sexual assault literature has attempted to examine disclosure and help-seeking as a dynamic and complex process involving multiple interrelated factors, rather than a simple linear process. For example, some qualitative research has been able to describe how anticipatory beliefs such as fearing negative reactions and not being able to define the incident as a crime can lead to a delay in disclosure (Washington, 2001, Symes, 2000). In Symes‘ (2000) study on how adult sexual assault survivors prepare to 26 disclose, survivors go through a process by which they are first silenced from not being able to define the assault as a crime, to weighing the pros and cons of possible reactions from support providers, to ―testing the waters‖ with initial disclosures. Furthermore, disclosure is conceptualized as a process that can occur relatively quickly or a process that takes longer periods of time depending on various individual and interpersonal factors. It can be expected that some adolescent survivors also delay disclosing their assault, which could be a result of how survivors define the assault, the assault characteristics, and how survivors anticipate the help of others. Ahrens et al. (2007) also examined the expectations that survivors have of support providers to understand the ―how‘s‖ and ―why‘s‖ of help-seeking. They found that survivors seek help for multiple reasons, including emotional support (i.e., receiving comfort and validation), to ―get it off her chest‖ as a form of emotional release, and for tangible aid (e.g., formal assistance). Depending on these reasons, survivors sought help from friends, family, and/or professionals. Young survivors may also have different reasons for why they choose to disclose to certain support providers versus others. It may be that peers are sought out more so for emotional support, where parents are sought out for adult guidance and tangible aid. As mentioned earlier, the adolescent sexual assault literature has not fully investigated how the disclosure outcome (dependent variable) can also become an influential factor (independent variable) in continued help-seeking. In the adult sexual assault help-seeking literature, studies have shown that survivors‘ initial disclosures impact future disclosures, whereby negative and/or positive social reactions from friends and family can facilitate or serve as barriers to continued help-seeking (Ahrens, 2006; Sudderth, 1998; Symes, 2000). In a qualitative study on the impact of social reactions on adult disclosure of rape, Ahrens (2006) reported that silencing often occurs during those initial disclosures. Specifically, negative reactions from professionals led to 27 survivors questioning if future disclosures would be effective or helpful. In addition, survivors who received negative reactions from friends and family led to greater feelings of self-blame and negative reactions from any kind of provider made survivors feel unsure if their assault actually qualified as rape. Such interpersonal interactions may also impact adolescent survivors in negative ways. Particularly, the role of peers and parents may be of greater impact on adolescent survivors than adult survivors. However, it is not clear if and how parents and adolescent survivors work together to decide whether to seek formal help, or how peers specifically help or hinder subsequent help-seeking. Furthermore, it is not clear if peer and parental disclosure are somehow interrelated, or if one leads to another. Finally, there is no research to date that explains the impact of prior sexual abuse on current sexual assault disclosure and help-seeking. Taken what is known from the general help-seeking, revictimization, and sexual assault social reactions literature, it is possible that those who have had history of abuse and received negative social support in the past, engage in poorer coping strategies (e.g., avoidance), and are less willing to talk to people about their most current assault (Ahrens, 2006; Lindsey & Kalafat, 1998; Niehaus, Jackson, & Davies, 2010; Wilson & Deane, 2001; Ullman & Najdowski, 2009). Besides the conceptual limitations that have implications on how methods are conducted, the current adolescent sexual assault literature can also benefit from more varied and reliable methodological approaches. For instance, most of the current research is conducted using quantitative methods, which is able to provide data on significant relationships among variables of interest. However, because the existing quantitative studies have not used highly sophisticated models that test hypothesized processes or mediational models (e.g., SEM), they have not be able to capture the dynamic, cyclical process that is involved in disclosure and help- 28 seeking. The use of qualitative methods can also be used to reveal how individual, interpersonal, and contextual-level factors interact during the disclosure process. Furthermore, qualitative research can initiate our theoretical understanding of how and why such significant factors (e.g., individual perceptions, assault characteristics, positive/negative informal reactions, etc.) work together and influence disclosure and help-seeking. Another methodological limitation is the sampling approach used in many of the adolescent sexual assault studies. Several studies used retrospective accounts of adult survivors‘ experiences as adolescent victims, while others combine child sexual abuse with adolescent sexual assault (Hanson et al., 2003; Staller & Nelson-Gardell, 2005; Petronio et al., 1996; Smith & Cook, 2008). In order to capture what is unique about adolescent sexual assault, using a sample of recently-assaulted adolescents is optimal to ensure reliable data that is not confounded with unrelated factors. Likewise, because adolescents are undergoing significant developmental changes in cognitive ability, it is important to refrain, whenever possible, from retrospective accounts that may be biased with memory decay (Hardt & Rutter, 2004; Henry et al., 1994). Overall, as a result of the conceptual and methodological limitations in the current adolescent sexual assault help-seeking literature, disclosure and help-seeking has yet to be examined as a process that is dependent on multiple interacting factors. Using an ecological framework that naturally taps into interacting multi-level factors may help further understand disclosure and help-seeking among adolescent sexual assault survivors. Sexual Assault Disclosure & Help-Seeking Through an Ecological Framework The emerging literature suggests that disclosure and help-seeking is a dynamic cyclical process whereby multi-level factors are interrelated. As a whole, these findings imply that using an ecological model as a guiding framework would be a fruitful approach for studying the 29 processes of disclosure and help-seeking among adolescent sexual assault survivors. Because similar research on adult interpersonal violence and adolescents‘ exposure to violence has used this framework (e.g., Campbell, Dworkin & Cabral, 2009; Kennedy, 2008; Liang, Goodman, Tummala-Narra & Weintraub, 2005), the adolescent sexual assault disclosure literature could also benefit from such an approach. Furthermore, although other theoretical models used in the adolescent literature may also be valuable (e.g., life course theory, risk and resilience theory), the ecological model, with its emphasis on child and adolescent development, is particularly applicable because it focuses on the most influential settings in which a youth develops (family, peers, schools) as well as how these systems are interrelated. Life course theory and risk and resilience theory are better suited when one is able to examine the cumulative risk and protective factors that develop over time within historical and social contexts (Arrington & Wilson, 2000; Fraser, Kirby, & Smokowski, 2004; Elder et al., 2004; Gore & Eckenrode, 1996; Kennedy, Agbényiga, Kasiborski, & Gladden, 2010). Moreover, the current study is based on a the most recent sexual assault and how disclosure and help-seeking occurred within the context of survivors‘ most influential settings, not on the accumulation of traumatic experiences, changing relationships within systems, and the impact of socio-historical factors such as gender and race. The ecological model was first presented by Urie Bronfenbrenner (1979) as an innovative way to study human development. As a developmental psychologist, he described the ecology of human development as involving the study of ―progressive, mutual accommodation between an active, growing human being and the changing properties of the immediate settings in which the developing person lives, as this process is affected by relations between these settings, and the larger contexts in which the settings are embedded‖ (pg. 21). Therefore, a person is viewed as one that both influences and is influenced by his/her immediate settings, making it a two 30 directional or reciprocal process. Furthermore, these immediate settings are part of larger set of interconnected systems that likewise influence development. Bronfenbrenner describes the ecological model as five major systems in which the developing person is embedded. Microsystems are settings that are made up of specific relationships, activities, and roles that a person actively participates in (e.g., home, peer group, clubs, and schools). A mesosystem consists of the interrelation of two or more microsystems in which a person actively participates in (e.g., school and home, work and school). There are five general types of mesosystems that can influence a developing person. The most basic and simplest mesosystem is referred to as multisetting participation, which is when a person participates in more than one setting (e.g., adolescent goes to school and interacts with peers). The more complex mesosystems include supplementary links, which occur when other people in an individual‘s life participate in the same two settings (e.g., Lisa‘s mother attends a PTA meeting) and intersetting communications, where messages are intentionally transmitted from 1 one setting to another (e.g., teacher calls Lisa‘s mother concerning her grades) . In this study, multisetting participation will be explained in terms of how an individual interacts within multiple microsystems (e.g., family, peers, and schools) and the mesosystem will be examined as microsystems interacting via intersetting communications and supplementary links. Another major system is the exosystem, which refers to settings in which the person is not an active participant, but that indirectly affects their development (e.g., school policies, health insurance, and parents‘ workplace). Additionally, the macrosystem includes cultural factors or belief 1 The other types of mesosystems include intersetting knowledge which refers to knowledge or experience that exists in one system about the other (e.g., library books, the internet), and indirect linkage, which occurs when the same person is not an active member of two systems, but may be connected to both through a third party (i.e.,‖ intermediate link‖). For the purposes of this study, these mesosystem interactions were not examined. 31 systems (e.g., sexism, racism, and classism) that engulf and influence all the other systems. Finally, the chronosystem explains the evolving interconnectedness of the person, environment, and processes over time. The chronosystem examines the cumulative effects of multiple events, including normative events (i.e., transition into high school) and non-normative events (e.g., child abuse, sexual assault) that shape how an individual responds to her environment and vice versa (Bronfenbrenner, 1989; Elder, 1995). Bronfenbrenner (1979) further explained that child and adolescent development can be best understood by examining how one perceives these systems. Therefore, what is important is not how these systems operate objectively, but how the maturing person gives meaning to them over time. For example, in the case of sexual assault survivors, what is more important is how adolescents perceive the help provided by their peers or how they feel when their parents take them to obtain a forensic medical exam. Bronfenbrenner also suggests that as children develop; the immediate microsystem of the home is no longer the most important and influential setting. The peer group becomes an important setting in which youth place great meaning to and recognize as an influential system. The significance of the peer group is seen repeatedly in the general adolescent help-seeking literature and is also likely to influence how adolescent sexual assault survivors seek help. Although Bronfenbrenner (1979) did not specifically focus on the impact of traumatic events on adolescent development, his conceptual model provides a useful heuristic for exploring these events within a developmental context. For example, Kennedy (2008) recently used an ecological framework to examine risk factors (e.g., physical violence and family violence) across community, familial, and interpersonal contexts to understand the cumulative exposure of violence among African American adolescents. What is innovative about Kennedy‘s study is 32 that prior research has not been able to examine the cumulative exposure to violence experienced across different ecological settings (e.g., community, family). Kennedy‘s use of the ecological model helped examine how violence experienced in one domain impacts the violence experienced in other domains. In her study, youth who witnessed violence in the home were more likely to be physically assaulted in their communities, suggesting that what youth experience in the home (i.e., ascribing to the role of the victim) may influence what occurs in other ecological settings (e.g., being assaulted in the streets). Therefore, the experience of interpersonal violence can be explained as a more complex risk factor that transcends multiple settings. Adolescent sexual assault disclosure and help-seeking is also likely to be dependent on the functioning of different domains (i.e., ecological settings). That is, adolescent sexual assault survivors‘ anticipatory beliefs, such as fear of judgment or self-blame are not due to psychological traits alone. It can be a result of how peer and family microsystems react interpersonally to issues regarding sex and other stigmatized adolescent behavior, or how these systems interact when supporting adolescent survivors (i.e., mesosystem). In addition, community-based sexual assault protocols (e.g., police refer victims to SANEs) can significantly affect adolescent survivors‘ post-assault experiences (i.e., exosystem). Cultural and social norms (i.e., macrosystem) regarding sexual assault can also influence individual beliefs and reactions from informal and formal support providers, which can be helpful or hurtful to survivors. Finally, the cumulative effect of other traumas such as prior child sexual abuse or adolescent sexual assault (i.e. chronosystem) can also influence how and when survivors seek help for a recent victimization. 33 Accordingly, using an ecological model to examine adolescent sexual assault disclosure and help-seeking can help advance the literature beyond an individualistic paradigm by examining how sexual assault disclosure may result in heterogeneous processes that result from survivors‘ various perceptions and interactions within their ecological systems. It is important to note that the use of Bronfenbrenner‘s ecological framework for understanding adolescent sexual assault is not intended to validate how the entire theoretical model applies to this particular phenomenon. Instead, the use of the most salient ecological concepts (e.g., interpersonal relationships within the microsystem) as ―sensitizing concepts‖ or interpretive devices will guide the analytical exploration of disclosure and help-seeking among adolescent sexual assault survivors (Bowen, 2006). That is, it is expected that adolescent survivors will be more aware of how their individual level beliefs and relationships within their immediate microsystems impact their disclosure processes. On the other hand, it is less likely that adolescent survivors will be able to reflect on the impact of broader socio-cultural factors such as race or class. As Bronfenbrenner (1979) points out, youth are more likely to reflect on their most immediate systems. As they develop, they eventually become more aware of how their immediate settings are interrelated, and how exosystem and macrosystem factors impact their lives. Therefore, this study focused on the most salient ecological systems that are most likely to developmentally impact adolescent sexual assault survivors‘ disclosure processes. The Current Study Research Questions Given the lack of knowledge on the disclosure processes of adolescent sexual assault survivors, this study is guided by an ecological framework and two overarching research questions that seek to articulate the pathways of disclosure and informal/formal help-seeking by 34 taking into account the relative and interacting influence of individual (e.g., anticipatory beliefs about informal and formal help)and perceptions of contextual (i.e., assault characteristics), interpersonal (e.g., reactions from support sources within survivor‘s microsystems), mesosystem (i.e., interrelations between peer, family and school systems) and chronosystem (i.e., prior sexual and physical abuse) factors. First, when adolescent sexual assault survivors initially disclose the assault, who, why, and when do they disclose? Specifically, how do survivors‘ anticipatory beliefs about how people (i.e., within their peer and family microsystems and in formal systems) will react to the disclosure shape who and when to disclose? And, to what extent do assault characteristics influence the choice of who and when to disclose? Furthermore, what occurs within microsystems that impact subsequent disclosures and entry into formal systems? The adolescent literature has found that initial disclosure occurs from within a month to years after the assault (Kogan, 2004). However, the research has vaguely touched on why survivors delay their initial disclosures. The current literature has also been inconsistent in regards to how assault characteristics (e.g., location, injuries) impact disclosure (Black et al., 2008; Kogan, 2004). Furthermore, while we now understand that peer perpetration decreases the likelihood of disclosing to a parent, it is not entirely clear why (Stein & Nofziger, 2008). The literature has also not examined the unique role of peers and adults in connecting to formal help. While some studies have suggested that parents are better able to provide the guidance needed to connect to formal help and peers provider better emotional support (Stein & Nofziger, 2008; Weisz et al., 2007), it is not clear how the these distinct social support systems impact the way adolescents continue to seek informal help and eventually end up in formal help systems. Likewise, the research has not examined how support providers‘ initial reactions of the nature of the sexual 35 assault itself (i.e., assault characteristics) impacts subsequent disclosure and help-seeking. Therefore, the first set of questions will contribute to the current literature by tapping more into why and how the interaction between anticipatory beliefs and assault characteristics influence the type of informal support that is sought out and when it is sought out, and will help explain the relative impact of peer and family microsystems throughout the disclosure and help-seeking process. Second, what systemic interactions occur throughout the disclosure and help-seeking process? Specifically, do interrelations between survivors‘ most immediate microsystems (e.g., peer, family, school) occur? If so, how do these interactions influence subsequent disclosures and entry into the formal system? Do prior experiences of sexual and physical abuse (i.e., chronosystem) impact the disclosure and help-seeking process? Specifically, does prior victimization play a role in when and how adolescent survivors disclose and seek formal help? The existing literature has not yet examined if and how these systemic interactions occur or how they may impact disclosure and formal help-seeking. Thus the second set of questions led to innovative findings regarding the dynamic nature of disclosure and help-seeking among adolescent sexual assault survivors. Methodological Framework A qualitative methodology was used to explore the processes involved in adolescent sexual assault disclosure and help-seeking. Qualitative inquiry has been described as ―the studied commitment to actively enter the worlds of interacting individuals‖ (Denzin, 1978, pp.89). That is to say, qualitative inquiry allows for the understanding of both observed behavior (e.g., disclosing a sexual assault or not) and internal states (e.g., why did you disclose?), which are dependent on the context (i.e., alcohol use prior to being sexually assault) at hand (Patton, 36 2002). In particular, qualitative interviewing allows a researcher to capture rich and descriptive process-focused data directly from the perspective, and in the own words of the people who lived it. According to Tesch (1990), there are four major types of qualitative inquiry driven by one‘s epistemological stance, ranging from the humanistic or non-positivist to the most formal, almost quantitative in nature approach. The qualitative inquiry in this study was guided by what Patton (2002) calls Reality-Oriented Correspondence Theory and falls into the group of qualitative analysis Tesch (1990) describes as ―research in which connections among the identified and categorical elements are sought‖. That is, a reality-oriented researcher seeks out more than just what is, but also how and why it is. In the search for the how‘s and why‘s, this approach to qualitative inquiry is not intended to create theory, but to facilitate theory by developing a set of theoretical propositions that explains relationships. Specifically, reality-oriented correspondence theory is distinct from logical positivism that suggests real knowledge can only be logically deduced from theory, operationally measured, and empirically replicated. It is also unlike the constructivist position that suggests there is no single truth because individuals shape and construct their own realities based on cultural and linguistic constructs (Guba & Lincoln, 1990; Patton, 2002). Influenced by realism, the basic assumption in reality-oriented correspondence theory is that while there is a world that can be made sense of, the actual constructions that people make about their world also need to be taken into account. Therefore, this theory calls for causal explanations of behavior and evidence to show that each event is an instance of that explanation while also understanding that truth is based on everyday experiences which can therefore vary and be imperfect. 37 Analytic Induction Given this theoretical orientation, analytic induction was selected as the primary analytic method because its objective is to formulate a set of hypothesis or assertions (that capture processes or connections) from the data and then examine how well the rest of the data fit the hypotheses, until the phenomenon is explained satisfactorily (Patton, 2002). In other words, the goal is to find some kind of ―truth‖ in the sense that the data will show connections among variables of interest and an explanation for these connections. Additionally, the ecological perspective used in this study compliments this method by framing the analyses of connections within and between ecological settings. Analytic induction was first introduced by Florian Znaniecki (1934) as the method that should be adopted by all sociology research and as an alternative to statistical sampling or enumerative induction methods. Robinson (1951) and Turner (1953) later critiqued Znaniecki‘s analytic induction technique because of the deterministic stance in searching for universals. Specifically, Znaniecki (1934) believed that through using analytic induction, one can study a phenomenon of interest well enough to understand it as a closed system by which you can then make predictions or causal laws whereby further study is no longer necessary. In contrast, Robinson (1951) and Turner (1953) believed that it is impossible to make predictions through causal law, whether if it‘s from using statistical techniques or analytic qualitative techniques, because there will always be some form of intrusive or external variables that will bring forth uncertainty. Robinson (1951) therefore provided a modified version of analytic induction that is useful in providing explanations of necessary but not sufficient conditions for a phenomenon in order to develop theory. The steps of modified analytic induction include: 1) develop a rough definition and explanation of phenomenon of interest early 38 on in the research, 2) hold the definition and explanation up to the data throughout data collection, 3) modify the definition and explanation as negative cases arise, 4) actively seek negative cases that you think may not fit the definition, and 5) re-define the phenomenon and reformulate the explanation until a universal relationship is established (Bogdan & Biklen, 2007). While the application of analytic induction has changed throughout history, the basic elements have remained. The current study utilized analytic induction as outlined by Erickson (1986), who studied teacher and student behavior within the classroom setting. On an epistemological level, Erickson‘s view of qualitative inquiry fits the reality-oriented theoretical and ecological approach: ―In substance, my work is an attempt to combine close analysis of fine details of behavior and meaning in everyday social interaction with analysis of the wider social context…in method my work is an attempt the be empirical without being positivist; to be rigorous and systematic in investigating the slippery phenomenon of everyday interaction and its connections, through the medium of subjective meaning, with the wider social world‖ (pg. 120). Erickson‘s (1986) use of analytic induction further modifies Robinson‘s (1951) modified analytic induction. He claimed that his inquiry is not to search for ―abstract‖ universals that will then arrive at statistical generalizations, but for ―concrete‖ universals that result from studying a specific case in detail and then comparing it to future cases. Erickson listed four main reasons for using analytic induction, which will be explained using examples of the current study. First, analytic induction is used to understand the specific structure of occurrences rather than their general character or distribution. The current study sought to understand how adolescent sexual 39 assault survivors go from initially disclosing to informal providers to seeking help from formal providers, versus simply asking, ―How many people do adolescent sexual assault survivors seek help from?‖ Second, analytic induction should also be used to understand the ―meaningperspectives‖ of the particular actors in particular events. In other words, the current study examined the perspective of adolescent sexual assault survivors who have decided to disclose their assaults. Third, analytic induction should be used when you cannot examine the phenomenon in an ethical manner using experimental methods. Clearly, it is impractical and unethical to use random assignment techniques with the examination of sexual assault disclosure and help-seeking. Finally, one should use analytic induction when you want to know more about the causal linkages and to begin to develop theory that experimental methods or survey methods were not able to find. Given that the majority of the literature on adolescent sexual assault has been descriptive, it has failed to explain the processes or causal linkages involved in disclosure and help-seeking. Therefore, coupled with an ecological framework and reality-oriented correspondence theory, the use of analytic induction to understand the process of adolescent sexual assault disclosure and help-seeking was the best fit. Now that the methodological and theoretical framework has been explained in terms of how adolescent sexual assault disclosure and help-seeking was studied, the following section will present the methods, including a description of the target sample, recruitment techniques, and procedures. Then, a description of the specific analytical plan and the steps used for ensuring the credibility of data collection will be presented. 40 Chapter 2: Method Participants To examine adolescent sexual assault disclosure and help-seeking, this study utilized data from a larger research project on adolescent sexual assault survivors‘ experiences with Sexual Assault Nurse Examiner programs (SANE‘s), and the criminal justice system from two different counties in Mid-Michigan (IRB # 06-1106) (See Appendix A). The qualitative component of this larger program (which was the data source for this study) had four main foci: 1) the context of the sexual assault (e.g., who was involved, what was involved, where did the assault take place, etc.,) 2) who the survivor disclosed to and why, 3) the social reactions of informal support, such as family and friends, and 4) how the survivor ended up seeking help from either the medical or legal system (i.e., whichever formal system was entered first). The target sample for this study was twenty adolescent sexual assault victims 14-17 years old who: (1) received a full medical forensic exam (i.e., a patient history was taken and medical forensic evidence was collected) from one of the two focal SANE programs; and (2) were victimized in one of the two focal counties. Participant age was restricted to 14-17 year olds because in the state in which the study was conducted, minors are able to consent to certain services, including mental health and sexually transmitted infection treatment, at the age of 14. Therefore, in collaboration with the community partners and the university IRB, the research team limited the sample to adolescents at least 14 years old so that this study would be congruent with state laws regarding minors‘ ability to consent. While the participants in this study may not be considered a normative sample of adolescent sexual assault survivors (i.e., all disclosed, all received medical treatment, and many reported to the law enforcement), their experiences provided specific information on how 41 adolescent victims connect to informal and formal systems. Trickett (1997) argued for the utility of ―seeking out samples of inconvenience‖—those that are ‗unusual‘ vis-à-vis a field‘s ‗typical‘ samples for ―purposefully sampling ecologically different settings as well as groups within those settings‖ (p. 203). Therefore, interviewing adolescent survivors who connected to informal and formal systems provided a rare opportunity to understand adolescents‘ help-seeking processes, including the perceived barriers that young women face during disclosure. Recruitment A prospective sampling strategy was used to recruit adolescent sexual assault victims who sought medical care at the two focal SANE programs. This approach was preferable to retrospective recruitment for two main reasons. First, the research team and both SANE programs agreed it would have been an unethical violation of patients‘ confidentiality to use program records to contact former sexual assault victims ―out of the blue.‖ Second, it is unlikely that other methods of recruitment (e.g., community-based advertising) would have been successful in reaching an unbiased sample of former patients. Furthermore, this approach has the advantage of asking adolescent survivors about their help-seeking experiences soon after they have occurred, rather than using a retrospective approach that is limited by memory decay. As mentioned earlier, a key limitation in the literature on adolescent sexual assault has been an overreliance on retrospective methods, whereby adult female survivors are asked to recollect their child and/or adolescent sexual abuse experiences. For prospective recruitment, nurses in both programs provided eligible patients with information about the study. Patients were then asked whether they were willing to be contacted at a later date by a member of the research team; if so, patients completed an ―Agree to be Contacted Form,‖ which asked them to provide guidance on how and when they could be 42 reached so that their privacy and safety would be protected (i.e., safest phone number to reach them at, best days and times, etc). This form emphasized that by providing their information, adolescent sexual assault survivors were only agreeing to be contacted about the study, not committing to participate. Research team members attended both SANE programs‘ monthly meetings in order to collect completed forms as well as to troubleshoot any challenges in recruitment. During these meetings, the research assistant and the SANE directors also compared the number of patients who received information about the study to the number of patients who were eligible to participate in the study. This allowed the researchers to monitor that the nurses were in fact providing information about the study to all eligible patients. Survivors who agreed to be contacted were called by a research assistant approximately three weeks after the date they completed the form. Participant recruitment and interviewing continued until the sample size allowed for saturation, whereby the same themes were repeated, with no new themes emerging among participants (Starks & Trinidad, 2007). A sample of N=20 participants is a reasonable size for a qualitative study examining phenomenon in-depth (Creswell, 2007; Sandelowski, 1995). A total of 119 survivors agreed to be contacted for information about the study: 10% percent were unreachable due to incorrect phone numbers; 39% were never able to be reached (despite numerous attempts); 14% we reached, but we were unable to complete an interview with them (e.g., interviews were scheduled, but the teens did not show up, and they were unreachable afterward); 5% were unavailable to do an interview (e.g., one had been committed to a residential home); 11% decided not to participate, and 21% (n=25) participated. Five of the adolescent survivors who participated were later discovered to be ineligible for the project; for instance, in the interview itself, it came out that they had been assaulted in a different county (not 43 the focal county, per the sampling criteria). The data from these five interviews were not included in the analyses, resulting in a final sample size of 20 interviews. Because there are no other qualitative studies of prospectively recruited sexually assaulted adolescents in the literature (i.e., not as adults in retrospective accounts), we cannot know whether these participation rates are normative for such a population. The literature on research with vulnerable populations certainly suggests that the recruitment challenges experienced in this study are highly typical (see Liamputtong, 2007 for a review), and that traumatized, stigmatized, or otherwise hard-toreach adolescent populations may be particularly hesitant to participate in research (Zayas, Hausmann-Stabile, & Pilat, 2009). Procedures Qualitative interviews were conducted to obtain descriptive information on how and why adolescent sexual assault survivors disclosed and sought help from various informal and formal support providers. Interviews were conducted in-person by two female interviewers, including the author, at the offices of the rape crisis centers affiliated with the focal SANE programs. Both interviewers had extensive prior experience interviewing adult survivors of violence. The PI trained the interviewers on strategies for building rapport and increasing the victims‘ comfort during the interviews (see Campbell, Adams, Wasco, Ahrens, & Sefl, 2009) for details regarding the interviewer training program). As will be described further in the data analysis section, analytic induction begins during data collection and continues throughout the actual analysis phase. As such, interviewer meetings were held regularly to monitor data quality and discuss emerging assertions to explore in subsequent interviews (i.e., development of new probes, follow-up questions). 44 In research with minors it is typical to seek parental consent for participation, but in this study IRB approval was obtained for a substitute in loco parentis consent process. An alternative consent mechanism was necessary for two key reasons: (1) adolescents are frequently assaulted by their parents or persons who have close relationships to their parents (e.g., a parent‘s dating partner), and therefore seeking parental permission could have put them at risk; and (2) many adolescents do not disclose the assault to their parents, and asking parental permission could have seriously deterred their participation in the study, which would have resulted in a substantially biased sample. Therefore, the research team worked together with the IRB, the SANE program directors, and the affiliated rape crisis center directors to construct an appropriate alternative. During the assent/consent process, a rape crisis center counselor sat in with the interviewer and the participant while the interviewer explained the traditional components of informed consent (e.g., what participation entails, risks, benefits, etc.). Then, the interviewer left the room, allowing the counselor and the adolescent to discuss participation in the project privately. During this time, the counselor assessed whether the adolescent understood her rights as a research participant. If in the counselor‘s evaluation the adolescent understood all elements of consent and was willing to participate, the counselor signed (in loco parentis) as a witness to the adolescent‘s assent signature. The counselor then left and the interview was conducted privately between the participant and the interviewer. Interviews were 90 minutes to two hours in duration. With the participant‘s permission, all interviews were digitally recorded. At the end of the interview, the participant received $30 in compensation for their time and a booklet of resources for sexual assault victims. Interviews were then transcribed and transcripts were checked for errors by a research assistant. 45 Interview Guide The interview guide was based on the PI‘s prior study of adult sexual assault survivors‘ experiences with SANE programs and the criminal justice system (See Appendix B). However, the interview was modified to be developmentally appropriate for adolescent participants (e.g., additional introductory get-to-know-you questions to establish rapport, additional questions regarding peers and parents, language changes to ensure a more conversational tone, longer transitions between interview sections to provide more context). The revised interview was reviewed by the SANE program directors and rape crisis center directors for their input and approval. The final semi-structured interview consisted of four main topics: (1) the assault itself; (2) the survivors‘ initial disclosures; (3) their experiences with the SANE program; and (4) their interactions with the criminal justice system. In addition, each interview concluded by asking the survivors what it was like for them to participate in the study and if they had any suggestions for improving the interview. For the current study, sections 1 and 2, as well as how adolescent survivors entered the medical or legal system were used for analyses. Data Analysis Data analysis unfolded in two cycles, with the primary coding method being analytic induction. Using more than one coding method and analytic approach has been said to enhance accountability and breadth of findings (Mello, 2002; Saldana, 2009) and as a result, most qualitative studies now utilize multiple coding methods. Saldana (2009) describes coding as a ―cyclical‖ process rather than a linear process, where codes can be re-coded and re-fined. He divides coding into first and second cycle methods. The first cycle involves methods that help with the initial, more simplistic coding while the second cycle involves coding methods that require analytical skills, conceptualizing, and synthesizing. Saldana (2009) also suggests that 46 analytical memos should be written before, during, and after the coding cycles. Thus, memo writing was used continuously to document and reflect on the entire coding process. Memos also helped with personal reflection on what was being examined, research questions, coding choices and operational definitions, emergent patterns, possible linkages, and any problems throughout the study. During the first cycle of coding, structural coding (MacQueen, McLellan-Lemal, Bartholow, & Milstein, 2008) was used as a way to quickly access and prepare data for the next phase of coding. Structural coding included labeling or chunking data pertaining to the topic of inquiry from the larger data set. This included labeling large chunks of data that describes how survivors disclosed the assault to informal and formal support providers. The following table demonstrates how a larger portion of data was structurally coded. Table 1. Structural Coding Data from survivor interview Interviewer: And after that you said you went up and you told H (girlfriend)? Respondent: She was sleeping on the other couch on the other side of the living room… I tried waking her up and then he kept saying, you know, let her sleep and then she finally got up and I told her we need to go upstairs. And then he went in the kitchen. I: Okay, so what did you tell H? R: I told her that everything that happened…and I was like I laid down and my bra felt wet and I looked at my bra and there was a lot of blood in there. And she is like what‟s that from and I was like your brother. And so she is like, oh my gosh I knew he was like that, but I didn‟t know he was going to do it to you… I: Okay. So you told her what happened…why do you think [you] told her? R: I don‟t know. Just because she was, I don‟t know..She was like my best friend and it was her brother and just I don‟t know. 47 Structural coding (cycle 1) Initial informal disclosure Structural coding continued to be used to search for more descriptive emerging themes within the larger data chunks. An example of more detailed structural coding is provided in Table 2. Table 2. Detailed Structural Coding Structural coding (cycle 1) Data from survivor interview I: And then after that you said you went up and you told H (friend). Initial informal disclosure R: She was sleeping on the other couch on the other side of the living room… I tried waking her up and then he kept saying, you know, let her sleep and then she finally got up and I told her we need to go upstairs. And then he went in the kitchen. I: Okay, so what did you tell H? R: I told her that everything that happened…and I was like I laid down and my bra felt wet and I looked at my bra and there was a lot of blood in there. And she is like what‟s that from and I was like your brother. And so she is like, oh my gosh I knew he was like that, but I didn‟t know he was going to do it to you. First disclosure to peer Initial reaction from first confidant- neither positive or negative I: Okay. So you told her what happened and then why do you think [you] told her? R: I don‟t know. Just because she was, I don‟t know..She was like my best friend and it was her brother and just I don‟t know. I: That‟s okay…And then what happened after that? R: I was like we wait or she fell asleep and I was just laying in bed thinking about it. I didn‟t know if I was supposed to tell anybody because it was a major thing or what to do. And I was going to call my best friend, he‟s like my brother, he is really close to my mom and everybody. I was going to call him and ask him what should I do, but her phone was off, so I was just like I‟ll wait until tomorrow morning. Survivor unclear about the assault or what to do. Contemplating second peer disclosure. 48 During the second cycle of coding, analytic induction was used to generate assertions from the data corpus indentified during structural coding. Erickson (1986) used analytic induction as a way to generate and test assertions or hypotheses through induction. An important distinction in analytic induction is that analyses occurs simultaneously with data collection, rather than after all data have been collected. Thus, initial identification of assertions occurred during the data collection period, where data were monitored and emergent themes were discussed at regularly held interviewer meetings and continued after data collection was finished (i.e., during memo-writing, data reduction/pattern coding & analytic induction). Problems that can arise as a result of not conducting data collection accurately and therefore not developing satisfactory assertions include: inadequate amounts of evidence, inadequate variety in kinds of evidence, faulty interpretive status of evidence, inadequate disconfirming evidence, and inadequate discrepant case analysis. Erickson‘s (1986) guidelines for properly conducting analytic induction were followed in the current study: 1. Search the entire data corpus. In this case, the data prepped during structural coding. 2. Establish evidentiary warrant for the assertions one wishes to make. That is, review the data repeatedly to test the validity of assertions and seek disconfirming and confirming evidence. 3. Reframe the assertions as the analyses proceeds. 4. If discrepant cases outnumber those that fit an assertion, then the assertion would not be warranted by the data. 5. Even if most cases fit an assertion, discrepant cases will be analyzed further and may become its‘ own assertion. 49 6. Assertions can vary in levels of scope (broad to narrow) and inference (low to high). 7. Assertions begin to be generated during data collection and continue after data collection is finished. 8. Search for key linkages while testing assertions. A key linkage is of central significance for the major assertions. Erickson‘s process is designed to ensure that there is adequate and systematic evidence for the key assertions made and that the patterns of generalizations within the data are in fact what the researcher claims they are. Figure 1 below provides an example of generating and testing an assertion following Erickson‘s guidelines. Figure 1. Example of Assertion Testing and Generation Assertion 1: Adolescent sexual assault survivors first disclose to peers Develop general assertion after reviewing the data Go back into data and search for confirming and disconfirming evidence Continue seeking for disconfirming evidence. Second coder checks final assertions Assertion 1a: Some survivors disclose to peers first 99 when they engage in risky behavior Assertion 1b: Survivors disclose to peers first if risky behavior was involved, and if they were assaulted by an acquaintance. Assertion 2: Some survivors disclose to parents first Assertion 2a: Some survivors disclose to parents first when they need immediate medical help. As illustrated above, assertion 1 would have been generated after reviewing all of the data that had been prepped during structural coding. However, the notion that survivors tend to 50 disclose to their peers first emerged early on during data collection and was discussed and noted during interviewer meetings and memos. After creating an initial assertion, it is important to go back into the data and search for confirming evidence that validates this assertion, and search for disconfirming evidence that may require modification of the assertion. As a result, distinct pathways could be discovered in the data, creating two separate assertions. Assertion 1a describes that survivors disclose to peers first if they engaged in risky behavior (e.g., drinking alcohol), making the initial assertion more specific and with a greater level of inference. Assertion 2 shows that there was disconfirming evidence to suggest that survivors do not always disclose to peers first, and in fact, choose parents as their first confidants. These new assertions are then checked against the data to search for more disconfirming evidence that may require further revisions. Finally, key assertions 1b and 2a are generated and are tested until they are fully warranted and no other evidentiary data suggests otherwise. Final assertions can therefore be broad in scope (e.g., cover all the ways in which informal disclosure occurs) and high in inference (e.g., explains how certain factors influence the disclosure pathways). After the primary analyst tested the assertions multiple times against the data, a second coder tested the final assertions against the data to provide greater credibility. Erickson further advises researchers to search for ―key linkages‖ between the data and assertions in order to find patterns of generalization. For example, to validate that adolescent survivors disclose to their peers first, one would have to collect all instances of peer and nonpeer disclosure within the data (across interviews). While the key linkages show that peers are the most likely confidant for most survivors, the reasons for why this occurs can vary depending on other factors, which is why creating more refined assertions to describe the different processes is necessary. Therefore, a strong assertion is one that has been tested and re-tested 51 against the data, and one that occurs numerous times across interviews. While Erickson‘s technique of searching for key linkages was mainly intended for use across data collection techniques (e.g., how often do you see instances of peer disclosure across interview data, field notes, observations, etc.), he also states that patterns of generalization can be found within one form of data collection technique (i.e., interviews). Credibility of Data Collection and Analyses In order to enhance the confirmability, credibility and dependability of the data collection and analyses, several strategies recommended by Lincoln and Guba (1985) were used. First, to ensure that the findings were grounded in the data (confirmability), open coding techniques were used to become familiarize with the data prior to development of the analytic induction assertions (e.g., reviewing transcripts, interview meetings, etc). Furthermore, the use of analytic induction as a primary analytic method was in itself a systematic way of searching for disconfirming evidence or rival hypotheses (i.e., negative case analyses) that subsequently, enhanced confirmability. The use of multiple analysts also prevented single-perspective interpretations of the data, which further enhanced the confirmability of the findings. Specifically, regular meetings with the study‘s advisor (who is also the PI of the larger study) were held to discuss the developing assertions and confirm whether cases and quotes presented as evidence for findings actually fit with the data. To establish credibility (confidence in the ‗truth‘ of the findings), the research team had prolonged engagement in the research settings. While direct observation of program services (i.e., sexual assault medical forensic exams) by research personnel is not appropriate, the members of the research team had extensive experience as community-based volunteer sexual assault advocates. Additionally, the research team had worked on several collaborative research 52 projects with the focal SANE programs prior to the beginning of this study. For example, sexual assault survivors and community personnel provided input into the interview questions and both interviewers regularly attended SANE program staff meetings throughout the duration of the study. Furthermore, the research team had extensive experience working with sexual assault survivors and the community response to rape. Finally, dependability, or the stability of the research process, is typically demonstrated through an audit trail. An audit trail was kept, in the form of memos and tables, documenting the various rounds of assertions, the problems that were identified with the assertions, and the corresponding revisions. 53 Chapter 3: Results Adolescent sexual assault survivors‘ disclosure and help-seeking process was examined from an ecological theoretical perspective. Specially, this study examined how individual-level beliefs and assault characteristics influenced disclosure and help-seeking. This research also investigated who adolescent sexual assault survivors disclosed to and why, and the unique roles of peer and family support (i.e., microsystems) in helping adolescents connect to formal help. Additionally, in order to comprehend the multifaceted nature of disclosure and help-seeking, mesosystemic factors (e.g., peer and family microsystem interactions) that influenced these processes were analyzed. Furthermore, several survivors took into account their prior sexual and physical abuse experiences, which impacted their disclosure and help-seeking processes. These cumulative, lifespan effects (i.e., chronosystem) were as influential as the current context of the survivors‘ lives. Five assertions emerged that describe the patterns of interactions within and between systems. Figure 2 below illustrates the most influential ecological systems during disclosure and help-seeking. Figure 2. An Ecological Model of Adolescent Sexual Assault Disclosure and Help-seeking Mesosystem Peer,family, and school system interactions Microsystem Peer and family disclosure and support Individual Anticipatory beliefs about informal and formal help Chronosystem Prior sexual and physical abuse 54 Before presenting the ecological analyses, basic descriptive information regarding the survivors and their post-assault disclosures is necessary. Overall, the survivors were on average 15.75 years, and mostly Caucasian, which is consistent with the racial composition of the sampled counties. All survivors were assaulted by males, which consisted of mainly a single acquaintance in a location other than the survivor‘s home, such as a friend‘s home or party. Over half endured some form of physical injury, and half of the victims stated they were under the influence of alcohol at the time of the assault. Among these alcohol related cases, three survivors were unconscious; two of which were unable to identify who their assailant was (See Table 3 below). Table 3. Victim and Assault Characteristics. Victim Age M= 15.75, Range 14-17 Victim Race Caucasian African American Asian American Multi-racial 75% (N=15) 15% (N=3) 5% (N=1) 5% (N=1) Relationship with Assailant Friend/Acquaintance Intimate Partner/Ex-partner Family Member Stranger Unknown Survivor‘s home Assailant‘s home/car Party/hotel Acquaintance‘s home Outside One assailant Two assailants Three or more assailants Unknown 50% (N=10) 30% (N=6) 10% (N=2) 5% (N=1) 10% (N=2) 25% (N=5) 20% (N=4) 30% (N=6) 25% (N=5) 5% (N=1) 75% (N=15) 5% (N=1) 10% (N= 2) 10% (N=2) Assault Location Number of Assailants Use of Force/Injury 65% (N= 13) Alcohol Use by Survivor 45% (N=9) Alcohol Use by Assailant 55% (N=11) 55 Survivors also varied in terms of how many people they disclosed to after the assault. Overall, survivors told between 1 and 20 informal support providers prior to entering formal help, with peers being the most common first confidant and mothers being the second most common. Most second disclosures were to peers and parents, while 3rd, 4th, 5th, etc. disclosures were more variable (e.g., teachers, friend‘s mom, aunt). However, there were a few outliers that did not follow these patterns. For example, one survivor initially contacted her parents but was unable to fully disclose because her cellular phone ran out of batteries. After her parents realized she may be in trouble, they suggested she call the police immediately, who consequently became her first disclosure. Likewise, two survivors were unable to initiate their first disclosures because they were unconscious from being intoxicated. More survivors disclosed their assault within 0-1 days and most were also connected to formal help quickly (within 0-4 days) (See Table 2 below). Table 4. Disclosure Patterns Prior to Entering Formal Help First Disclosure Time of First Disclosure Second Informal Disclosure Number of Informal Disclosures Days to Legal or Medical system Peer Parent Police Unconscious Within 24 hours of assault One day after assault Missing Peer Parent Peer‘s mother 0-2 people 3-5 people ≥9 people Within 24 hours of assault 2-4 days after assault Missing 56 65% (N=13) 20% (N=4) 5% (N=1) 10% (N=2) 75% (N=15) 20% (N=4) 5% (N=1) 50% (N=10) 20% (N=4) 15% (N=3) 50% (N=10) 40% (N=8) 10% (N=2) 75% (N=15) 20% (N=4) 5% (N=1) Individual Anticipatory Beliefs about Disclosure and Help-seeking The first area of inquiry was to examine who and why adolescent sexual assault survivors disclose. In order to address this question, particular attention was paid to the beliefs adolescent survivors held prior to disclosing to informal and formal help providers. Overall, adolescent survivors held negative anticipatory beliefs of how people would react to the assault and these beliefs were shaped by their prior experiences and specific assault characteristics. These negative perceptions of support appeared to hinder their initial and continued help-seeking. Assertion 1: Adolescent survivors who are assaulted by acquaintances or dating partners, involved in risky behavior, and/or had prior negative experiences with law enforcement are more likely to hold negative anticipatory beliefs about informal and formal support, which makes them more hesitant to seek help from these sources. Several adolescent survivors were concerned with the fact that the person who assaulted them was an acquaintance or dating partner and therefore they would not be believed. For example, some survivors feared that peers at school would find out and spread gossip, or were worried that their existing relationships would change as a result of reporting the assault. The following quote is from a seventeen year-old adolescent who was assaulted in her home by the friend of her best friend. She was initially hesitant about going to the police because of how her friend may react, I came home from work and I talked to M[male best friend]. This is another big thing too is like I didn‟t know what M would think if like I went to the cops and like told them like my best friend‟s friend just did this to me. But I talked to M that night and you know, after he told me that his friend was basically a douche bag, that I should go to the cops and do what I needed to do to make myself feel better and that he was no longer friends with him because he‟s not friends with somebody that does that. As shown in this excerpt, gaining the approval and validation from her peer negated her anticipatory beliefs about reporting, making this survivor more willing to seek help from the 57 police. Because the majority of the survivors were assaulted by an acquaintance or dating partner, the concern over how this would impact their reputation at school and relationship with their peers was fairly typical. In one particular case, a 16 year-old was assaulted by a 24 year-old male co-worker in his home. Because she willingly went to his home and ―consented‖ to kissing him, she felt that her peers and boyfriend would be upset and not believe her. As a result, her disclosures extended over four days, where she told her story in small increments to peers before telling any adults and entering formal help, I: Okay. When then did you tell your boyfriend? He is the first one you told, right? R: Right. I had told, I told him that night that he had kissed me, but I didn‟t tell him anything about going to his house or you know anything that really happened. I just said that he had kissed me one day on the way out from work. Because I was too, I guess I felt guilty so I felt like I had to get something out. But at the same time I couldn‟t get all of it out, I guess. And my boyfriend was like really, really mad and the next day it was really starting to eat at me, „cause I like I started to say, I‟m upset I lied about it so that like made it even worse I think, so I ended up telling him, I don‟t even remember the second thing that I told him. But then it all kind of progressed because of I told my friend, P, and he was like well I‟m not going to like leave you alone until you tell me the truth, because I feel that, you know, if you are going to be with somebody he deserves to know the truth and decide if he still wants to be with you based on that. And my boyfriend goes to Western. So he like doesn‟t live here or anything, so I went to my friend, P‟s house and he like talked to me and like talked me in to telling my boyfriend that I had sex with him. But I guess P didn‟t know the entire story. He really just knew that I had sex with him. He didn‟t really ask questions… This survivor blamed herself for meeting with her coworker and was hesitant in telling her boyfriend and male friend the entire story. While she eventually sought formal help, the fact that she was resistant about fully disclosing resulted in people blaming and forcing her to report to the police and ―prove‖ herself. Unfortunately her anticipatory beliefs of being blamed were actualized, making entry into the system more difficult. Even though they were concerned about how disclosing the assault could impact their relationships with their peers and intimate partners, survivors still preferred to seek help from friends versus adults and formal help providers because of the need for validation. This diffidence to seek adult and formal help is demonstrated 58 in the fact that only four survivors told an adult first (i.e., parent). Survivors were also concerned about disclosing the assault if they had engaged in what could be construed as risky behavior at the time of the assault. This was the case for nine survivors who had consumed alcohol prior to the assault and anticipated negative reactions from their parents and/or law enforcement officers. Additionally, while over half of the assailants also consumed alcohol, this did not make survivors more or less willing to disclose the assault. Adolescents who consumed alcohol prior to the assault were more worried about being judged, getting in trouble and upsetting their parents, or getting charged with a ―minor in possession‖ (MIP) for drinking under the legal age limit. The following interview passage is from a fifteen year-old adolescent, who was assaulted by an acquaintance while intoxicated at a hotel party, I: Did the fact that you‟d been drinking at the time, did that kind of influence what you‟re thinking about whether or not you wanted to tell your Mom? R: Yeah. I: How so? R: I just thought if I told my mom, she would, “How did that happen? How did that happen?” So I would have had to tell her I was drinking, then she‟d be mad. I: OK, worried you‟d get in trouble? R: yeah, drinking under age. Another example of the influence of alcohol use on disclosure is from a seventeen yearold survivor who was assaulted by an acquaintance after having a small get-together with friends in her home. Earlier in the interview she expressed her fear of being blamed for the assault because it occurred in her home. Because there was alcohol involved, the interviewer also inquired about her feelings on drinking alcohol prior to the assault, 59 I: I‟m wondering if some of what was playing into your fears about like people will not believing you and blaming you for it was the fact that there had been alcohol involved? Was that a concern for you? R: Yeah, that too. But like I mean, like I really didn‟t want her to tell people and like I told, I believe I told the deputy and the detective this too, that like you could ask anybody that was there that night that like I only had like literally two beers and I stopped drinking like at 10:00. So, but because there was alcohol involved, you know, one I‟m a minor and like two, they would think that like any alcohol in the system would like impair my judgment which after two beers, you know, they‟d think that I gave consent. But, you know, when you…. I: Okay, so like it could have been worse „cause you were able to say, look I wasn‟t drunk. But it was still kind of a concern with like the cops and with your mom too or R: It was like, the alcohol thing with my mom didn‟t, you know, that‟s she knows I drink and like I‟m responsible about it. I don‟t really do it anymore at all because of this actually. And I know I‟m 18 and it‟s a terrible thing to say, but that‟s, yeah, I don‟t know it is just like, there are just so many thoughts and emotions running through, I really didn‟t know what to do. I never thought I‟d be in that situation. As this excerpt illustrates, this survivor was concerned that the police would question her ability to make rational decisions because she had been drinking. While she entered formal help within a day after the assault, she disclosed to several friends before going to the hospital and making a police report. This particular case also highlights that not all of the nine adolescents who drank alcohol were concerned about how their parents would react because they already knew about their daughters‘ drinking behaviors and somewhat normalized underage drinking. Even so, most survivors were fearful of their parents‘ reactions to underage drinking. Additionally, survivors anticipated negative reactions from their parents when they engaged in other ―risky‖ behaviors, such as hanging out with older peers or being in a location unknown to their parents. Finally, a third factor that impacted survivors‘ anticipatory beliefs was prior experience with law enforcement. A few survivors had negative experiences with law enforcement in the past, including family involvement with the police and truancy, making them less willing to seek 60 help from them for the current assault. This was particularly salient in the few cases involving African American adolescents, as is seen in the following passage from a sixteen year-old who was assaulted by her ex- dating partner, R: I knew CPS was going to get involved. I: Okay, okay and that was your main reason as to why you didn‟t even want to get this whole thing started? R: Yeah and the outcome and everybody else‟s would be brought in it at the end. I: Okay. How did you know that CPS would get involved in something like this? R: Well because they were recently involved with us and so I knew the cops, cops don‟t like us so I don‟t really understand why. But, so they, of course, called CPS. Later in the interview this survivor continues to explain that her initial hesitation about contacting the police had to do with her family‘s involvement with the police, Well, I don‟t know, because by the time I told the second person, it was too late because I was, I told her I was like don‟t call the police, I don‟t want no police contact, nothing or whatever, because my sisters were on probation on top of that. So, I didn‟t want no police contact at all and everything else. This survivor was scared of calling more attention to her family given their current involvement with the system and was involuntarily connected to law enforcement when her friend‘s mother called the police without her consent. She is also a mother of an infant who was present during the assault. As a result of the police being contacted, Child Protective Services (CPS) took her child into custody and she too was taken away from her mother‘s custody. Therefore, her anticipated beliefs regarding law enforcement and CPS were confirmed and her post-assault disclosure experience was negative overall. In general, the findings show that many adolescents held anticipatory beliefs such as the fear of getting in trouble or being judged by adults for engaging in risky behavior, and the possible disruption of peer relationships when disclosing an assault from an acquaintance or 61 dating partner. While all of the survivors were eventually connected to formal help within days of the assault, these feelings served as barriers to disclosing to adults and formal support providers immediately and voluntarily. Microsystem: The Role of Peers and Parents in Disclosure and Help-Seeking Given the negative anticipatory beliefs at the intrapersonal level, it is important to further examine why survivors disclosed to certain confidants over others and what occurred during these initial interactions that influenced continued help-seeking. In other words, despite survivors‘ concerns about support providers‘ reactions, they overcame these worries and still chose to disclose the assault. Therefore we need to understand how and why adolescent survivors are able to reach out to others. Overall, adolescent survivors disclosed within the peer microsystem first followed by disclosures within the family microsystem. Assertion 2: Most adolescent survivors seek help within the peer microsystem first for emotional support, validation, to preserve their current peer relationships, and/or when they engage in risky behavior. Thirteen survivors made their first disclosure to a peer, such as a female friend, dating partner, or other male friend. In this study, similar-aged family members, such as cousins, were also labeled as ―peers‖ because survivors perceived them more as friends rather than older family members such as mothers or aunts. For these adolescents, peer disclosures were crucial for emotional support and validation. Adolescent survivors trusted their friends and often described them as ―sisters‖ or ―brothers‖ who provided them the confidence to vent freely. As was presented in the first assertion, some survivors were concerned with how their peers would react, but even so, they still preferred to disclose to them rather than adults. The findings suggest that peer relationships are complex, such that survivors are worried about being blamed and 62 disrupting current peer relationships, but also feel the need to ―tell them everything‖ and ―not wanting to lie.‖ However, as the following passage shows, survivors tend to disclose to their ―closest‖ peers, who are less likely to judge or blame, I: So, why did you decide to tell your friend first? The first person you told? What is it about her that you wanted toR: Well she is the closest to me, she is like a sister to me. I: Okay. R: She has been there for everything, I‟ve known her since like third grade. Yeah. I: Did you, um, how did she respond to you? R: She was upset, not because I told her, but because of the fact that it happened and she told me that I needed to go and get checked and make sure I was okay, because it is serious, more serious than I was making it [16 year-old assaulted by ex-dating partner]. Because of this survivor‘s long-standing relationship with her friend, she felt comfortable and safe disclosing to her and was consequently provided with emotional support and validation that the assault was a serious problem. Validation from peers was also necessary when survivors engaged in risky behavior and feared judgment from parents or authorities. The following example of peer disclosure is from a fourteen year-old who was assaulted at an acquaintance‘s home while drinking alcohol with older males. She decided to first disclose to her friend who was present at the assault location. Interestingly, her friend reacted shocked and blamed herself for putting the survivor in a risky situation, leading the survivor to comfort her friend instead of the other way around. Even though she did not receive the most supportive emotional response from her first confidant, she continued to disclose and seek support from other friends in order to vent, …I have some close friends at my school and I told a couple of them. It was L2 and S. And L2 is really into Christian stuff and I told her you got to promise me you are not going to tell nobody. I remember we were walking down the stairs and I told her that I 63 needed to talk to her and she goes about what? And I was like about me and last weekend. She goes, okay, is it with B? And I was like, no, it is not and I wish, I would be happier if it was. And she goes, what do you mean? And I was like, well let me spell it out for you. And I spelled it out for [her] and she stopped on the stairs and she looks at me with these puzzled eyes. And she was like, are you serious? And I was like, yeah, she goes you are not lying to me are you? And I was like, L do you really think I‟d lie to you about this? You are one of my closest friends and I‟m going to lie about this. She goes, I‟m sorry, I just, I can‟t believe this and I said, yeah, promise me you are not going to tell nobody. While all survivors expected emotional support and/or validation from their peers, the social reactions they actually received were not always as expected. Even though most peers reacted in a positive and supportive ways, others were upset, avoided or blamed survivors, making them feel unsupported and in some cases, like they had to prove themselves by reporting to the police. The lack of emotional support is presented in the following quote taken from a seventeen year-old who was assaulted by two male acquaintances at a party. Her first disclosure was to her boyfriend via a text message and resulted in a mixed reaction. That is, while he wanted to pick her up from the party (but was unable to); he also lacked an emotionally supportive response. The survivor was left having to seek help from two recently acquainted people at the party, who then took her to her boyfriend‘s home. In the following excerpt, this survivor explains her feelings about her boyfriend‘s reaction once she arrived at his home, R: At first he was really upset. Like, when I got there and everything. But you know like it kind of made me mad because I walked in the house and I was standing there and I was crying and he sent me up to his mom. Like he didn‟t hug me or anything, he was like, go talk to my mom. And I was like, okay. So I walked up the stairs and I hugged his mom, like I didn‟t even know his mom. I had met his mom once before that and I hugged her. I: Okay, how did that reaction from your boyfriend at the time make you feel? R: I don‟t know, I wanted him to like be there for me more. Like, I don‟t know. I: Like in what way? R: Like a hug or like are you okay or like anything you know. Like 64 I: So more emotional support? R: yeah The lack of emotional reaction from her boyfriend left this survivor feeling hurt and unsupported which further highlights the importance of emotional support from peers during sexual assault disclosure. Initially, this survivor was only seeking peer support and validation and did not want adults or authorities involved. Nonetheless, his mother quickly became involved and contacted the survivor‘s mother without her consent, making her disclosure 2 experience emotionally difficult . In other cases, even when survivors received negative social reactions from peers, they continued to seek support. While this study is limited in understanding why this occurs, the available data suggest that survivors continue to disclose to vent emotionally and seek validation from peers. Assertion 2a: When adolescent survivors seek help from peers, the peers often give advice and/or influence survivors to seek out help from parents and/or formal systems. Another important role of the peer microsystem was influencing and guiding survivors to seek parental and formal help. While survivors did not initiate peer disclosures for the purpose of getting connected to adult and formal help, it was still a common response. This is seen in the following interview passage from a sixteen year-old that was assaulted in her home by her exdating partner, I: Did you, um, how did she respond to you? R: She was upset, not because I told her, but because of the fact that it happened and she told me that I needed to go and get checked and make sure I was okay, because it is serious, more serious than I was making it. I: Ah-huh and how did you feel about how she reacted to you? 2 Unwanted disclosures that occur across systems are conceptualized as mesosystem interactions and will be discussed in the mesosystem section. 65 R: I understood what she was saying, but I didn‟t want to go get checked out because I didn‟t want to deal with everything. I‟m more of a-to myself person. Even though this survivor appreciated her friend‘s validation and concern, she was still hesitant to seek medical attention. It is important to remember that most survivors held anticipatory beliefs about adult and formal help. Therefore, even when peers encouraged this kind of help-seeking, survivors remained somewhat resistant, R: It was probably about 5:00 in the morning and after he left I finally like let myself cry and I called my best friend who was at work at the time, because she works nights too and even though she lives like an hour and a half away from me, I still called her and she listened to me cry for like a half hour and then once I settled down I told her what happened and she told me to go to the cops and stuff like that. I: Okay, she told you to do that? R: Yeah…Yeah and she, after she assured me that everything was okay and you know, just doing the friend thing, she told me I should, she said well first she told me I should tell my mom. And then I should go to the cops, but I didn‟t want to tell my mom and I didn‟t really want to go to the cops, I was so scared, so.. [17 year-old assaulted by an acquaintance]. Even with this continued fear, peer support served to break down the negative anticipatory beliefs about adult and formal help and many peers successfully guided their friends to adult help. The following quote is from a sixteen year-old survivor, who describes her boyfriend‘s reaction after she disclosed being repeatedly assaulted by her father, … And so I told him [boyfriend] over the phone after I got back up at my house. And because I didn‟t want to lie to him, because I have not the type of lying person, so I told him and um, he was just like, I can‟t do this. He was like, I was like we‟ll wait until after my birthday for me to tell. Because he was like, you either tell by your birthday or I am. So, that whole weekend it happened again and I didn‟t tell my boyfriend it happened „cause I knew what he would do. He‟d make me go tell it that second. And so I told him, you know, Monday morning I called him and I was like, listen, like it happened again Saturday, I was like I‟m going to tell, I‟m like don‟t worry about it. And then he was like, okay, and I got to school, you know, I got my best friend, [name], and I just started crying and I walked into my teacher, which was a good friend of mine, like he was my [subject] teacher and I just started crying. Like, hysterically and he was just like, okay, 66 he says, you know, I have to report this, it‟s my job. And I was like, yeah, I know, like that why I came to you. So I can trust you. This particular example shows how a peer advised a survivor to seek informal adult help (i.e. teacher), which resulted in obtaining formal help. Although survivors did not expect that their friends would advise them to seek adult help, more often than not, their peers did in fact urge them to reach out to adults. Taken together, these findings suggest that disclosure within the peer microsystem results in emotional support, validation, and ―bridging‖ survivors to adult disclosure and help-seeking. Assertion 3: Adolescent survivors disclose to parents for emotional support, help, and/or guidance to enter formal systems. When survivors are not close or comfortable with their parents, disclosure is less likely to occur immediately or voluntarily. Survivors who engaged in risky behaviors, such as drinking and hanging out with older peers, were understandably concerned about disclosing the assault to their parents and more likely to seek help from a peer first. While most survivors eventually disclosed to their parents through the guidance of their peers, only four told their parents first. Regardless of when survivors told their parents, their underlying reasons for reaching out to them were consistent; in addition to wanting comfort and validation, they also knew that their parents would help them enter a formal system. Thus, where peers were not always knowledgeable about the appropriate resources for sexual assault victims, parents were the key link to medical and legal services. Furthermore, it was the encouragement from parents to obtain a forensic exam and to make a police report that helped survivors become more willing to enter the system. The following excerpt is from an interview with a seventeen year-old that was assaulted by her ex-dating partner. She explains the importance of parental support after the trauma of being assaulted and then entering a formal system-where many important decisions had to be made, 67 R: I just didn‟t know what to do with myself. Like I really didn‟t know what to do. … I had all these options, but I couldn‟t choose, you know. I: Okay. What were some of the options that you felt like you had? R: Like go to the emergency room, get checked, don‟t go to the emergency room and don‟t get checked. You know, forget about it and go on with it. You know, I just didn‟t know what to do. So I‟m kind of glad that my mom did take matters into her hands and tell me what I‟m doing, because I wouldn‟t know what to do and then say I did think about it and wanted to go get the exam, it would have been way too late. The fact that this survivor did not make the decision to seek medical help may be misinterpreted as the mother not giving her ―control‖. However, it is clear that she wanted and needed her mother to ―take matters into her own hands‖ during such a difficult time. The next passage also describes how parental support and guidance led to the survivor to being more willing to go to the police department. R: So, I called my mom, told her that she should come to their house, and it was important. And she said that she‟d come over there, and she was so scared, because she didn‟t know what I was going to tell her. So when she got there, she was a little upset, and she said, “Let‟s go, let‟s go to the police department.” And then we took H[friend] for the uh, for just being there. I: Oh, OK. When you told your mom what happened, how did she react? R: She was upset. Not really mad that I was drinking, but more upset. I: Upset that that happened to you? R: Yeah. I: And did you feel like your mom—did your mom say, “OK, we‟re going to the police department!” Or did you guys talk it over--? R: She just said, “We‟re going to the police department.” I: OK. Did you feel like you had a choice over whether or not it got reported? R: If I had a choice to go report him? I: Yeah. R: Well, that‟s what we talked about, so we just decided that was probably best. 68 I: What were some of the things that you talked about when you were trying to decide whether or not to go to the police? R: Just AIDs, and how it was wrong, and like I could get him in trouble if something was wrong with me, or I got some kind of STD. I: Was getting him in trouble something that you wanted to happen? R: Yeah because of what he did [16 year-old assaulted while intoxicated at a party] Even though the survivor had been drinking, her mother did not judge her for engaging in risky behavior and instead focused on getting her daughter help. Unlike the previous excerpt, this case involved a mutual decision making process prior to seeking formal help. Cases like these involved conversations between parent and child about the pros and cons of making a report or getting a forensic exam, and acknowledgement of their daughter‘s feelings before entering a system. While these young women appreciated being given the choice to seek formal help, others were satisfied with their mothers taking more control of the situation. Again, while most survivors feared their parents‘ reaction to the assault, once they disclosed, most did not receive the negative reaction they anticipated. When parents focused on the assault and not on the risky behavior their daughters engaged in, the survivors were much more receptive of the idea of seeking formal help. The following selection comes from an adolescent who was scared to tell her mother she was assaulted at home, while her mother was asleep. As a result of her best friend‘s encouragement, she disclosed to her mother and was relieved by her positive reaction and guidance, R: And so, but she [mom] was just upset, you know, she was crying because, you know, I was crying. But she wasn‟t angry at me which was a relief and I told her, you know, I was like, I thought you‟d be angry at me and she like didn‟t yell at me, but you know, scolded me because I said that. And yeah and she wanted to do anything, she wasn‟t going to make me go to the hospital, if I didn‟t want to, she wasn‟t going to make me report it if I didn‟t want to, you know. And she asked me what I wanted to do and if I would have said, 69 no, I‟m sure she would have supported me. But she definitely complimented me a few times for going in and like reporting it and like doing what I did. I: So it sounds like it was a relief that, you know, she wasn‟t blaming you or you know, kind of yelling at you for it, she was being supportive I guess. R: yeah I: And then she asked you what you wanted to do? How did you feel about her like asking versus, like you said she could have said you are doing this? R: Her asking me was basically, I was still stuck in the same spot, you know, I didn‟t like know what I wanted to do and like I kind of wanted her to just tell me, you know, okay well we are going to go to the hospital or we are going to do this, we are going to do that, you know. But, at the same time I did feel respected because she like treated me like an adult and it really was my decision, you know. The significant impact of parental support can also be examined by examining cases where adolescents did not receive positive reactions. Overall, four cases involved a combination of positive and negative reactions from parents, and six involved solely negative reactions. Negative parental reactions included blaming, judging, or forcing survivors to make a police report and/or get a forensic exam. Unlike the previous examples where survivors were provided with the choice of entering formal help or feeling comfortable with their mother taking care of the difficult decisions, these parental reactions were perceived negatively, making entry into the system more difficult. The following passage is from an interview with a fourteen year-old that was assaulted by eleven acquaintances and strangers over a three week period. Once her mother began to suspect what was going on, she decided to disclose to her first, who then told her father, I: Wow, this must have been really hard to talk about with someone. Like, who was the first person you talked to? R: Well, it was just my mom and I ended up telling her everything, so we were both like crying when I told her all of it. And like obviously it wasn‟t that in detail like when I told her at first „cause it was just happening and everything. And then she called my dad from there and my dad was like really angry, so like him and my step-mom drove to my mom‟s house and then my dad like started screaming at me. He is like, you are a whore, you are a slut, why would you do this? I‟m like, he had me on the ground in like choking me and 70 I: Oh God. R: My sister was like trying to get him off of me and everything. And like my mom and my sister were just like crying trying to get him off of me. And like he is like, you have no reason to cry right now and then he would like slap me in my face like that, like push me away and stuff. And then he like made me write down like all the names of the guys and then we went to the [police department] and then from there like they made me write my whole report as like best as I could right then. This survivor was particularly hurt by her father‘s abusive reaction and not surprisingly felt forced to make a report and enter the legal system. While most survivors expected emotional support and help from their parents, parental disclosure was not an easy process, especially when the survivors engaged in risky behavior or if their relationship with their parents were not particularly strong. Furthermore, when parents responded to survivors negatively, it was extremely hurtful and made seeking formal help more difficult. Overall, the findings regarding peer and parental support provide a better understanding of how these microsystems uniquely influence the process of disclosure and help-seeking for adolescent sexual assault survivors. While the majority of the social reactions from peers and parents were positive and supported entry into the formal system, some disclosures resulted in negative reactions which made entry into the system more difficult. What is interesting is that even though some survivors received negative peer support, they continued to disclose in the search for validation. And while some parents were initially blaming and judgmental, if they became supportive over time, it helped survivors become more willing to enter the system. On the other hand, solely negative reactions from parents made it emotionally difficult for survivors 71 to enter the system. Taken together, the findings show that peers are typically the key link to 3 adult disclosure and parents serve as the key link to formal help (See Figure 3) . Figure 3. Disclosure and Help-seeking: Individual-level and Microsystem Factors. Emotional support and validation Peer Microsystem Family Microsystem Guidance to parental help Adolescent Survivor: Anticipatory beliefs Assault characteristics Emotional support and validation Guidance to formal help Legal and medical system Guidance to Guidance parental to formal Mesosystem: The Role of Peer, Family and School Interactions help help The previous findings discussed the interactions between the survivors and their most influential microsystems. However, the process of disclosure and help-seeking can be more complex and dynamic as a result of the interactions between these microsystems (i.e. mesosystem). To address the second research question (What systemic interactions occur throughout the disclosure and help-seeking process?), it was necessary to examine if and how microsystems interact (i.e., mesosystem) and how this impacts subsequent disclosures and entry into formal systems. Mesosystem interconnections include supplementary links whereby other people in the survivor‘s lives participate in the same two settings (e.g., peer takes survivor to her home) and intersetting communications, where messages are intentionally transmitted from one 3 In this study the microsystem consisted of survivors‘ interactions with peers and families. Whereas schools are microsystems in their own right, the role of teachers and counselors was more salient in mesosystem interactions and will therefore be presented in the following section. 72 setting to another (e.g., teacher calls survivor‘s mother regarding the sexual assault). Out of the twenty cases, ten involved one or more interconnections between peer-family, peer-school, or school-family (see Figure 4). The following findings pertain to the cases in which the mesosystem was present and exclude those where no interactions occurred between microsystems. Assertion 4: Mesosystem interactions occasionally shape the disclosure process, where peerfamily, peer-school, or school-family systems influence subsequent disclosures and entry into a formal system. Survivors perceive these interactions positively when the reason and/or outcome of those interactions are helpful and wanted; and negatively when the reason/outcome of those interactions are unhelpful and unwanted. Of the ten mesosystem cases, six were perceived as positive and four as negative. That is, the survivor perceived the mesosystem as unhelpful when the interaction between peers, family and/or school was out of her control; and helpful when these interactions were done with her consent. Therefore, the findings show that regardless of the type of interaction (peer-family, school-family), it was the way in which these interactions occurred that made the most impact on how survivors continued disclosing and entered formal help. One of the most common types of helpful mesosystems was the linkage between the peer system and the survivor‘s family, which served to help the survivor seek adult and formal guidance. The following excerpt describes how a peer interacts with the family microsystem in order to help the survivor, So, I was upset with a lot of like people at that point in time. „Cause I just, I just like, you know, so my boyfriend dropped me off at home, he like if you don‟t tell them, I‟m going to tell them and you know like, okay, there better be other things, I don‟t kick the door down and all that. So I‟m like, yeah. So, I go in the house, because I started beating on the door and crying. And my auntie came to the door, like who is it? I‟m like, just please open the 73 door. Just please open the door. She like, what? I‟m like I just got raped, open the door, please. Whereas peer microsystem interactions often include a peer advising the survivor to seek adult help (see Assertion #2a), this case became a mesosystem because the survivor‘s boyfriend took her home and transitioned into her family microsystem (i.e., supplementary link). Without her boyfriend‘s assistance, she would not have been able to leave the house party and go to her aunt/legal guardian for immediate help. Even though she was not sure how to interpret her boyfriend‘s initial reaction, she appreciated his support and was able to get medical attention that night, So, I had to deal with that. But you know, then that‟s when I came to reality, like it is not his fault and I thank my boyfriend a lot, because if it wasn‟t for him I probably would have been in a worser situation. I probably would have like, it would have been worser than what it is now. Because he took me out of the house. He was like, if you don‟t come out, I‟m coming in there to get you and it is not going to be pretty. So, I‟m like okay, I‟m going to leave. Therefore, peer-family mesosystem cases were considered positive and helpful when the interaction was done consensually and when the outcome was positive, which in this case was leaving the dangerous situation and getting help. The mesoystem was also considered positive if it helped make disclosure an easier process. In the following example of a peer-family mesosystem, a survivor‘s friend recommended she call her mother over to their friends‘ house to disclose the assault and seek formal help, Well, I told her[mom] that she should come, because me and H were at T and C‟s house, and we were talking. And she told me that I should have my mom come there, so we could all talk about it, and what happened. So, I called my mom, told her that she should come to their house, and it was important. And she said that she‟d come over there, and she was so scared, because she didn‟t know what I was going to tell her. So when she got there, she was a little upset, and she said, “Let‟s go, let‟s go to the police department.” And then we took H for the uh, for just being there. [15 year-old assaulted by acquaintance at a party] 74 Despite the fact that this survivor had consumed alcohol prior to the assault and was fearful of her mother‘s reaction, the advice and support from her peers to have her mother come to their home (i.e., supplementary link) and ―all talk about it‖ (i.e., intersetting communication) made the disclosure process emotionally easier. After discussing her options and reasons for reporting to the police with her mother, she felt that entering the legal system was her choice and was more determined to seek justice. Furthermore, her friend continued to offer support by accompanying her to the police department. It is important to note that what made this mesosystem interaction particularly helpful was that the survivor was offered advice and support in a respectful and sensitive manner. That is, the survivor‘s initial disclosures to her peers and the subsequent parental disclosure that was supported by her peers were all voluntary and in her control. Another helpful mesosystem that assisted in disclosure and help-seeking was between the survivor‘s school and family microsystems. The following passage is from a fourteen year-old who was assaulted by a twenty-five year-old acquaintance. After disclosing to several friends, she was advised to notify her teacher. Here she describes her teacher‘s role in disclosing to her father, I: Why did you decide to tell her and not another teacher? R: Because Miss O is the one that I am most close to, „cause she knows that I have a lot of problems in my life about my mom and stuff and how bad that affects me and stuff, because my mom is a really, really heavy alcoholic. I: Okay, so since she knew you had some other problems you wanted to tell her. R: Yup. And she has always been there for me. This is the first year of high school for me and she has always been there since this year and I felt a special kind of connection type feel. I: You were kind of close to her. 75 R: Uh-huh. I: Okay, how did you feel about how she reacted? R: I was like, I could tell she cared and that made me feel good inside that she cared. I: Uh-huh, so then how did you feel when you found out that they were going to call your dad? R: Really embarrassed and like my dad is the one that I‟m closest to because my mom is really heavy alcoholic and I am a slut and everything to her. And we are not close at all, that‟s why I said L‟s mom is like my mom. I: Yeah. R: But he‟s a male, so I didn‟t feel comfortable at all. And we get in the truck and I was really uncomfortable. I have no clue why, but I was not comfortable at all around him. It was so weird, it was the weirdest feeling ever. I was just like, oh my gosh, get me out of this car. I have no clue, but I really wasn‟t comfortable and S[friend] was in there because I made her leave school with me. So we are really close and so I really didn‟t like the fact that they told my dad, but they had to, so I: Okay. R: I was really uncomfortable with that. This survivor sought adult support from her female teacher because she was not able to turn to her mother and was understandably uncomfortable telling her father. While she was not entirely pleased that the teacher called her father (i.e., intersetting communication), she knew it was something that had to be done and ultimately was comfortable with this arrangement. Additionally, the presence of her friend (peer-family mesosystem) while driving to receive medical care made the parental disclosure process and entry into the system easier. Thus, mesosystem interactions were not only helpful in subsequent informal disclosures, but also in seeking medical and legal help, as is further illustrated in the following interview except, R: Like my counselor has been so good to me at school. Like, she was there through like everything, she told me my options and then we have a police liais, I don‟t even know, liaison, whatever. And he works in our school and he was telling me my rights and what I could do and everything before my mom got to the school. „Cause actually I told my counselor and she was the one that called my mom. 76 I: Oh okay. R: To tell her to take me to the emergency room, „cause my mom knew, but she didn‟t know what to do. Like, she was just going to take me to [clinic]. So, and then mom is like, okay, you know, I‟m going to leave work and I‟m going to come and take her [17 year-old assaulted by an acquaintance]. Therefore, this counselor was not only instrumental in helping refer the survivor and her mother to more appropriate medical treatment (i.e., SANE), she also connected the survivor to the police. This intersetting communication resulted in the survivor and mother being more knowledgeable about sexual assault services and the survivor feeling more comfortable about entering the formal system. It is important to note that the survivors who sought help from teachers or counselors perceived them not only as trustworthy, but also as dependable resources for seeking formal help. Likewise, teachers were sought out when seeking help from parents was perceived as particularly emotionally difficult for survivors. While most mesosystem interactions were positive and helpful for subsequent disclosures and formal help-seeking, there were several instances where these interactions were unwanted and perceived as unhelpful. These negative interactions often made it more emotionally difficult for survivors to enter formal help, as is demonstrated in the following passage from a survivor who initially disclosed to the friend, but did not realize her friend‘s mother told to her mother without her consent, I: And then she[friend‟s mother] also talked to your mom. Were you there when she talked to your mom over the phone? So you have no idea what she told your mom? R: Well my mom told me what she, she just kept yelling at my mom that she didn‟t need my problem and she‟s got heart pacemaker, whatever, and it is three in the morning and her grandkids are sleeping and my mom needs to come and get me. She kept screaming at my mom that my mom needs to come and get me. And my mom kept telling her to let my mom talk to the police officer and she would scream at her that she needs to come get me. My mom was like, well let me talk to the police officer and I don‟t know, I guess my mom was just getting frustrated. 77 In this example, the unwanted disclosure to her friend‘s mother resulted in the involuntary disclosure to her mother, which in turn resulted in a frustrating situation where the survivor felt she had no choice in seeking formal help, I: Okay. So do you think, this is a hypothetical question, do you think if your friend‟s mom didn‟t get involved, like you never told her anything, she didn‟t know anything, that you would ever have contacted the police? R: No I wouldn‟t have. I: Do you think your mom would have ever found out? R: No. I: Okay, so all of this kind of happened against your choice. Like, this was not your choice to continue and to start the whole prosecution process R: Yeah. I: and reporting and all that, okay. So, knowing that this kind of happened without your choice, like how does that make you feel about everything? R: I don‟t know, it doesn‟t really make me feel any different. It is just what happens, you can‟t change. I: Ah-huh, do you wish it didn‟t happen this way? I mean do you wish his mom never found out? R: I don‟t know, „cause I don‟t know what it would have been like the other way, you know, so I can‟t really say that I wish I would have. [17 year-old assaulted by two acquaintances] Peer-family mesosystems where a peer told their own mother, without the survivor‘s consent, who then forced the survivor to tell her own mother/guardian was not unique. As is demonstrated in the following passage, even though the survivor‘s friend was intending to be helpful by telling his mother, it is clear that this was unwanted, R: C[friend] told me that his mom wanted to talk to me. I didn‟t know at that point that C‟s mom knew. So …me walking to his house, G[assailant] only lives like six blocks away from me. His mom pulled up in a car and talked to me and told me that C told her. I didn‟t know until she pulled up and told me that he said anything. 78 I: Okay and how did she act? R: She was persistent and made me go home and tell my aunt that she said that me going to G‟s house and causing a scene would not be the right thing to do. So she drove me home and then that‟s when I told my aunt. I: Okay. Do you live with your aunt? R: Yeah, she is my guardian. I: Okay, so C‟s mom made you go home and tell your aunt? R: Yeah. I: Did you feel like that was a choice or did you feel like, like you had to? R: I pretty much had to. It was me doing or her doing it, I think it was better if I said it. I: Okay, so she basically told you if you don‟t tell, I will. R: Yeah. I: Okay, got it. So, how were you feeling that you had to tell your aunt? R: At that moment I was worried that she wasn‟t going to believe me in which she didn‟t. Pretty much I was upset, so I was feeling upset and confused and all that and then I was worried about her not believing me and thinking I was making it up [17 year-old assaulted by an ex-dating partner]. In this particular case, the survivor was hesitant to tell her guardian because she did not have a close relationship with her and was scared of not being believed. The fact that her friend‘s mother got involved (i.e., supplementary link) made the disclosure process complicated and resulted in her guardian being upset. However, later in the interview the survivor explained that even though she did not like being pressured to tell her guardian, she would have never told if it was not for her friend‘s mother, and now regrets that her delayed disclosure affected how soon the police were able to respond. As the findings suggest, mesosystem interactions occur often during adolescent sexual assault disclosure and help-seeking. In general, mesosystem interactions between peers, family, 79 and school systems were perceived as positive and helpful when they facilitated subsequent disclosures or entry into a formal system with survivors‘ consent. Negative mesosystem interactions consisted of more unwanted disclosures, where survivors did not have full control over how parents/guardians found out. Therefore, the disclosure and help-seeking process is more than the simple connection from peer to family and from family to formal systems. This process can become especially complicated when microsystems interact via supplementary links and intersetting communication. When family, peer, and school systems interact, there is a greater likelihood that more people will get involved (voluntarily or involuntarily), resulting in more social reactions (negative or positive) that can have a significant impact on how survivors experience disclosures and how willing they are to enter a formal system. Chronosystem: The Impact of Prior Victimization on Disclosure and Help-Seeking Adolescent sexual assault disclosure and help-seeking is a complex process that involves a survivor‘s anticipatory beliefs, the interaction of the survivor with her peer and family microsystems, and the interrelation between multiple microsystems- all of which influence subsequent disclosures and entry into formal systems. However, an ecological factor that adds an additional layer of complexity is the chronosystem (See Figure 4). The chronosystem is made up of prior experiences of sexual or physical abuse, including childhood sexual abuse, adolescent sexual assault, dating violence, and repeated sexual assault from the current perpetrator. In this study, eight survivors were victims of sexual or physical abuse in the past, which influenced their disclosure process and made them more determined and hopeful about getting help for their current assault. Assertion 5: Survivors with a history of sexual abuse or physical abuse take into account their prior abuse and experiences with the system. Overall, they are more likely to disclose to parents 80 sooner, have fewer informal disclosures, enter the system more willingly, and more hopeful about seeking justice for their current assault than those without a history of sexual abuse. Survivors with a history of victimization were also more likely to engage in fewer informal disclosures across microsystems and fewer mesosystem interactions prior to entering formal help. While most survivors entered a formal system within a day of the assault, survivors with a history of abuse typically engaged in fewer disclosures which resulted in telling parents and entering a formal system sooner than those without a history of abuse. One of the main reasons survivors with a history of abuse disclosed and sought formal help sooner was because they did not want to wait to tell someone, as is seen in the following excerpt from a seventeen year-old assaulted by her father, R: I didn‟t want to prosecute my dad, because he is my dad, and I don‟t want anything bad happening to him, even though he did something wrong to me. So. But, I know it was right for them to call the police on him. I: Can you tell me more about that? R: It was because I have had, I had got raped when I was 16, which was a year before this, and I was having a hard time with it already, and then it happened again. So, that was really rough because it was only like a year apart. I: Yeah, that‟s hard. So, even though you didn‟t really want to prosecute him, you kind of thought, well, maybe that‟s the right thing to do anyway? R: Yeah, because I didn‟t get justice the first time when I went through it. I: OK, do you think you will this time? R: Yeah. I: Why do you think that? R: Because the cops are waiting for me to go to court until after they get the DNA test, because they said there‟s no reason to go to court if the DNA isn‟t his, or anything like that. 81 This survivor had been sexually assaulted a year prior and was not able to obtain justice. Even though she had a negative experience with the criminal justice system in the past, she felt that because she disclosed immediately (her mother being her first and only informal disclosure), the police would be better able to help her with her current case. Similarly, the following excerpt from a fourteen year-old that was assaulted by three acquaintances at a party explains how her prior experience impacted her current disclosure, I: Why did you decide to tell her? R: Because I wanted, I know if I wouldn‟t have say nothing to her, I didn‟t try to not tell nobody, like, like when I got molested when I was nine, I didn‟t say nothing. That was going on for a long time and all that. I felt like if I say something, I can get it off my chest. This won‟t be in my conscience, I can, I won‟t have to be thinking about this all the time. I won‟t be picturing this as much as I do now. I know if I would have like kept it inside, it would have just been in my head all the time and I just would have been messed up. I know I probably would have like seriously, probably tried to kill myself or something like that. That is just like, you know… This survivor attributed her inability to cope with her childhood molestation to her lack of disclosing and therefore felt that disclosing this time was an important process to help her heal emotionally. Consequently the two informal disclosures (boyfriend and foster mom) she engaged in prior to seeking formal help occurred immediately after the assault. Later in the interview, this survivor explains her urgency in telling the police, I: So the person who decided to contact the police was obviously your foster mother and you said it was okay for her to call, that you wanted her to call. Why did you want the police to be called? R: Because I wanted something, I wanted action to happen right away, like I wanted it to be brought to their attention really as before, you know, just like hurry up and disappear, so I wanted it to happen real fast. I wanted everybody like them to know as quick as possible. I: When you said action, what do you mean by that? R: I wanted them to probably try to go to the house and find them or find, you know, evidence or something of something happening. So, I called so fast like, you know… 82 While this survivor did not discuss whether she had gone to the police for being molested as a child, she seemed very determined and aware of the importance of reporting to the police and collecting evidence. Along with the fact that she never told before, she felt that her immediate disclosures for the current assault would help her case. Therefore, the current findings suggest that survivors with history of abuse seemed to have more knowledge about going to the police and collecting evidence than those without a history, which in turn significantly impacts how an adolescent responds to her most recent assault, I: Why did you not want to tell your mom? R: Because three years ago, or it was four years ago or something, it was me and my friend were drinking with older guys, whatever, and me and my friend had sex with the older guys, and my mom found out about it, and her mom found out about it. And we wanted to press statutory rape, but the detective in [city] that‟s for sex crimes blamed it all on me and my friend, that why it happened, and stuff like that. So it was kind of, “If you didn‟t believe me then when there was proof and stuff, and they took their time, like the evidence was already gone by the time that they went around to go do it, then I didn‟t find a point. I: So it seems, then, you‟ve already gone through this before. R: Mm hmm. I: And you‟ve gone through the whole system. You went through prosecution and everything—or they dropped your case, it seems. R: Yeah, he didn‟t even take- a couple years ago, he didn‟t take it to prosecution at all, and stuff like that. This survivor felt that in her previous assault, the police blamed her and dropped the case because she was drinking and hanging out with older males. In the current assault, she was not drinking and was assaulted by a schoolmate after a high school football game. While not specifically asked during the interview, it is possible that she may have compared the two assaults and felt that she would not be blamed as much, giving her more hope that she would be taken serious. Even though her prior negative experiences made her hesitant to seek formal help, 83 she immediately disclosed to her peers and mother and went to the police department the following day. Unfortunately the same detective that dropped her case before was the same person investigating her current case, I: OK. So what were you expecting from the police this time? R: I was kind of hoping that they would do something about it, until my mom found out who the detective was, and it being the same person that it was the three years ago. So then that‟s when it really was, nothing‟s going to be done, and stuff like that. So I felt doubtful, and just not feeling that anything would happen. Even in cases where prior experiences with the legal system were negative; there was still a glimpse of hope for justice, making the chronosystem effect particularly complex. Clearly this survivor was not initially willing to go to the police given her past experience and was even asked by her mother if she was prepared to go through the entire process again. However, after taking into account her last assault and receiving advice from her peers and mother, she felt ―more positive‖ that ―something would happen‖ this time. What made this case discouraging however, is that the detective once again dropped her case. While not all chronosystem cases involved prior legal contact and knowledge of how the system works, survivors with a history of abuse still had hope and were more willing to enter the system than those without a history. For example, a few survivors had been repeatedly abused by their current assailant (sexually or physically), making them feel as though ―enough was enough.‖ This is exemplified in the next passage from a fifteen year-old who was assaulted by her abusive boyfriend and willingly decided to seek help from the police, I: So, you told the police officer what happened. Why did you decide to tell him what happened? R: I did because I was mad at D, and that was my way of getting even, I guess. I: You wanted to get back at him because you were mad at him? R: And I wanted to get free from him. 84 I: Did you think that telling the police would help you do that? R: Yeah, because he‟d get in trouble. And he wouldn‟t be able to talk to me anymore, so it set me free right away. I: It did? R: Mm hmm. I: Do you feel safe now— R: Yeah. Therefore, the chronosystem effect is more than whether or not survivors sought help during the last assault. For those with repeated victimizations from the same perpetrator, the history of abuse became too much to bear and prompted them to seek help. This point is illustrated in the following excerpt from a sixteen year-old who had been repeatedly assaulted by her father during the past summer. While she was very concerned that reporting her father to the police would disrupt her family system, she also wanted the push and guidance from her boyfriend to do something about it. R: I wanted to tell somebody. I was and I know that he [boyfriend] would have made me do it, so that‟s why I told him. I just told him because I know that he would have been like you need to do it or I‟d do it. And that‟s what I needed. I needed somebody to say, that enough is enough and it is time to do it, you know. I: Okay. R: You don‟t want your sisters when they are older to go through what you went through by their father, because that‟s not right. So, I needed that push and he gave it to me, so I did it. Given her experience with her father, this survivor knew that if she did not report, her sisters could also be sexually abused. After the encouragement of her boyfriend to seek formal help, she disclosed to her teacher who then contacted social services and the police. While this survivor had endured sexual abuse from her father for about a month, once she decided to tell, 85 the disclosure process went fairly quickly and she sought formal help within two days of the last incident. While it was a difficult process, this survivor felt determined that reporting was the right thing to do, I: Okay, that makes sense. Okay. And then he told, he called the police or he had somebody call the police? R: He told my counselor and my counselor had to tell my principal and my principal called the social services and social services then called the police station. And then I had detectives and social workers come and talk to me and asked me what happened and I explained to them. And then I had to go to the police station and you know, be interviewed. I: Okay. How did you feel about those people finding out? R: I was okay with that because I just knew it was for a good thing and that I couldn‟t live this way anymore and you know, I was hoping that every day would get easier. Overall, survivors with a history of sexual and physical abuse were significantly guided by their past experiences of being victimized. Among the survivors who endured repeated victimizations from their current perpetrator, there was a shared feeling of ―enough is enough‖ and a greater willingness to put a stop to the violence. Among those survivors who had negative experiences with legal systems during prior victimizations, many felt that justice would now be served if they immediately reported to the police and sought a medical forensic exam. Therefore, even though most survivors were apprehensive about reporting to law enforcement (See Assertion #1), these adolescents were much more willing and determined to enter the formal help system despite their negative experiences. This determination may be a result of their increased understanding of how the system works (or does not work), and their belief that disclosing sooner could lead to prompt police response and collection of evidence that could be used to support their case. Finally, among those who never disclosed during their prior sexual 86 assault, the inability to vent to others and emotionally cope, as well as the absence of police or medical attention, prompted their disclosure and help-seeking during the current assault. Figure 4. Disclosure and Help-seeking: Mesosystem and Chronosystem Factors Peers School Medical and Legal System Survivor Family Chronosystem: Prior Victimization 87 Chapter 4: Discussion This study used an ecological theoretical framework to explore the multifaceted process of adolescent sexual assault disclosure and help-seeking. Whereas ecological models have been used to explain sexual and intimate partner violence among adults (Campbell, Dworkin & Cabral, 2009; Kennedy, 2008; Liang, Goodman, Tummala-Narra & Weintraub, 2005) and adolescent violence and victimization more generally (Johnson-Reid, 1998; Kennedy, 2008; Williamson, Borduin, & Howe, 1991), no study to date has used this framework to examine sexual assault disclosure and help-seeking among adolescents. That is, there has been no research on how and why adolescents seek help after a sexual assault and how they transition from informal to formal help within the context of multiple ecological systems. Using Bronfenbrenner‘s theoretical perspective of human development, this study revealed how influential environmental factors are to adolescents‘ help-seeking. In this study, five key findings emerged that explain how individual beliefs, assault characteristics, microsystems, mesosystems, and chronosystems work together to shape how adolescent victims disclose and seek help. For instance, adolescents consider negative anticipatory beliefs about adult support, which typically prompts their initial disclosures to be directed to a peer. Peer support then facilitates parental disclosure via advice (peer microsystem) or direct communication with the family microsystem (mesosystem). Next, parental encouragement and guidance (family microsystem) help survivors enter formal systems. However, for adolescents who have had prior abuse experiences (chronosystem), these disclosure and help-seeking experiences tend to follow similar patterns, but unfold more quickly. The following discussion will first review the key findings relative to prior research on 88 adolescent help-seeking. Then, a summary of the strengths and limitations of this study will be presented, followed by implications for future research and practice. Key Finding #1: Negative Anticipatory Beliefs and Assault Characteristics Impact Disclosure and Help-Seeking Adolescents consider how other people will react to their problems before seeking help (Dubow, Lovko & Kausch, 1990; Raviv, Raviv, Vago-Gefen & Fink, 2009; Rickwood et al., 2005; Schonert-Reichl & Muller, 1996; Wilson, Bignell, & Clancy, 2003; Wilson & Deane, 2001) and sexual assault survivors are likely to hold negative anticipatory beliefs about how others will react to their victimization disclosures (Staller & Nelson-Gardell, 2005; Petronio et al., 1996). Consistent with this prior research, the survivors in this study also held perceptions and negative anticipatory beliefs about how their peers, parents, and legal authorities would react to their disclosures of sexual assault. Similar to Staller and Nelson-Gardell (2005) and Petronio et al. (1996), adolescent survivors feared judgment and disbelief prior to making their first disclosure. The current analysis expanded on prior research by explaining why these negative beliefs exist and how they might make disclosing emotionally difficult. For example, risky behavior (e.g., alcohol use) played a pivotal role in how survivors felt about disclosing in the first place. While the research on alcohol use as a risk factor in adolescent sexual assault has been extensively studied (e.g., Basile et al., 2006; Young & Furman, 2008), the impact of alcohol use on disclosure has only recently been questioned (Rickert et al., 2005). Consistent with Rickert et al. (2005), survivors who engaged in alcohol use prior to the assault were more fearful of seeking parental and formal help. However, in contrast to the results obtained by Rickert and colleagues (2005), alcohol consumption by the perpetrator did not influence disclosure and seeking formal help. Overall, the survivors in the current study were far more concerned about 89 their actions and how others would perceive their role in the assault rather than what the perpetrators did. Survivors also feared judgment and disbelief by peers and parents if they were assaulted by an acquaintance or intimate partner (Kogan, 2004; Finkelhor & Ormrod, 2000; Stein & Nofziger, 2008; Rickert et. al, 2005). This finding is not surprising because acquaintance rape is different than stranger rape in that is involves a personal investment in the relationship where feelings of obligation are concerned (Koss, Dinero, Seibel, & Cox, 1988). Therefore, when an adolescent is assaulted by an acquaintance or dating partner, people are likely to expect that the survivor had some amount of culpability given the closeness of their relationship (Bridges & McGrail, 1989). Given the salience of maintaining peer relationships during adolescence, survivors‘ concerns over how peers would react were particularly strong. Adolescent survivors were worried about gossip spreading in school and how their peer relationships would change as a result of reporting to the police. When something as taboo as sexual assault occurs and involves a perpetrator who schoolmates may know, it is likely to bring forth rumors among the peer group which can disrupt current peer relationships. Finally, prior experiences with law enforcement also emerged as an issue that influenced survivors‘ perceptions and beliefs about seeking help for the current assault. Previous work by Rickwood and colleagues (2005) found that adolescents in general have a difficult time seeking formal help when their prior experiences were unhelpful and negative. The findings in this study support Rickwood et al.‘s (2005) conclusions in that survivors also took into account previous interactions with formal systems. Specifically, survivors who had prior issues with the law (e.g., truancy, prior MIP) or had family members who are/were involved with the legal system, were 90 concerned about shedding more negative light to their family. As a result, these survivors anticipated negative outcomes and were more uncertain about seeking help from formal systems. Overall, survivors‘ negative anticipatory beliefs of how others would react were based on ―risky‖ behavior prior to the assault, relationship with the assailant, and their prior experiences with the legal system. Although these findings are generally consistent with what prior research defines as barriers that prevent disclosure and help-seeking, the same conclusions cannot be made in this study. That is, given that all survivors disclosed within a few days of the assault, these factors did not serve as barriers that prevented disclosure. Rather, these factors made adolescent survivors feel more apprehensive about seeking help from informal and formal support providers. Key Finding #2: Peers Provide Emotional Support, Validation and Guidance to Adult Help The peer microsystem is a context where adolescents develop socially and emotionally (Sullivan et al., 2002), and learn about mature symmetrical relationships (Youniss & Smollar, 1985). Additionally, help-seeking within the peer group solidifies relationships through the act of divulging personal information that is expected to remain confidential (Sullivan et al., 2002). In terms of disclosing traumatic experiences such as sexual abuse, adolescents also are likely to tell peers because they are perceived as similar to them and less risky compared to adults (Petronio et al., 1996). Consistent with prior research, the survivors in this study first disclosed within their peer microsystem for emotional support and validation (Boldero & Fallon, 1995; Raffaelli & Duckett, 1989; Sullivan et al., 2002; Youniss & Smollar, 1985). Even though some adolescent survivors held negative anticipatory beliefs about how their peers would react, it did not prevent them from seeking their support. Because several adolescent survivors engaged in behavior that may be interpreted as ―risky‖ or ―inappropriate‖ by adults, they chose to disclose to 91 friends who may also engage in similar behavior and therefore less likely to be judgmental. The findings also imply that survivors attempted to maintain their current peer relationships through disclosure. That is, disclosing a personal traumatic experience like sexual assault was likely to send the message to peers that they are considered important and trustworthy friends. Social reactions following sexual abuse disclosures have only recently been examined (Staller & Nelson-Gardell, 2005;Wiesz et al., 2007), and no research to date has specifically studied peer reactions following adolescent sexual assault disclosure. The only research that provides an understanding of peer social reactions is a study from Weisz et al. (2007) who examined peer support following adolescent dating violence (which included ―forced sex‖). They found that peers reacted in a nurturing manner, including being sympathetic and listening to survivors‘ feelings. Similarly, the survivors in the current study received mostly positive reactions from their peers, including emotional support and validation. Specifically, survivors in this study found it particularly helpful when they received validating messages like, ―it was wrong,‖ ―it‘s not your fault,‖ and ―this is serious‖. On the other hand, some survivors received negative peer reactions following disclosure, including blame, judgment and avoidance. While not thoroughly examined, adolescent peers may have reacted in unsupportive ways as a result of not knowing the appropriate helpful responses for sexual assault survivors. Indeed, one participant mentioned that sexual assault is something that ―just doesn‘t happen,‖ and is not really discussed in school. Thus, it may be that when peers avoided survivors, it was because they were unsure of how to respond. Even so, while a few survivors received peer reactions that were perceived negatively, it did not seem to hinder their entire help-seeking process. Survivors still tended to disclose to several peers, especially close friends, because they were easier to talk to. 92 A novel finding in this study was the role peers played in guiding adolescent survivors to adult help. As the first responders, peers were instrumental in encouraging survivors to continue with the disclosure process and get additional support from other providers. Despite the fact that adolescent survivors did not explicitly seek peer support for the purpose of being directed to adult or formal help; it was nevertheless the most common outcome of peer disclosure. In addition to validating that the assault was serious, peers encouraged survivors to tell their mothers, obtain medical help, and report to the police. Therefore while peers may not know the purpose of SANEs, or whether contacting law enforcement is the appropriate first step, their reactions confirmed the importance of telling adults, who then helped their daughters seek formal services. It is important to mention that many survivors feared adult disclosure and formal helpseeking, but the validation and encouragement from their peers (in spite of the risky behaviors that many engaged in) helped them take the next step in their disclosure process. Key Finding #3: Mothers/Guardians Provide Emotional Support, Validation and Guidance to Formal Systems While parents were considered important support providers throughout the help-seeking process, few survivors disclosed to them first. To appreciate this from a developmental standpoint, adolescents go through biological, cognitive, and socio-emotional changes which can lead to changes within the family system, including a greater need for privacy, and less time spent with parents (Baer, 2002; Larson et al., 1996; Csikszentmihalyi & Larson, 1984; Steinberg & Morris, 2001). During these changes, greater conflict between parent and child are also likely, which may lead to more time spent with peers (Baer, 2002; Larson et al., 1996). Therefore, it is not surprising that adolescent survivors in this study opted for peer disclosure before parental disclosure. 93 Moreover, it can be particularly difficult for adolescents to discuss issues related to sexuality and/or sexual abuse with their parents (Clements & Burgess, 2002; Clements, Speck, Crane, & Faulkner, 2004), which further explains why so many survivors in this study held negative anticipatory beliefs about parental disclosure. The survivors in study were also uncomfortable talking to their parents about sexual assault if they engaged in behavior that their parents would disapprove of, which has also been documented in prior research (Clements, Speck, Crane, & Faulkner, 2004). Furthermore, several adolescent survivors mentioned that the reason they hesitated seeking parental support was because they lacked close relationships with their parents. For adolescents who engaged in risky behavior and did not have a strong relationship with their mother or father, parental disclosure was even more emotionally difficult and likely to be delayed. Prior research has also found that parental disclosure and help-seeking is less likely when the family unit is unsupportive and dysfunctional, making peer support more likely (Gauze et al., 1996; Kogan, 2004). The current findings also suggest that the dysfunction in some of the survivors‘ families (e.g., divorce, alcoholism, and mental health problems) made adolescents less likely to seek parental support. The results of this project indicate that adolescent survivors seek parental support for slightly different reasons than peer support. Similar to other studies, parental support was sought out when adolescents needed further guidance to enter formal help systems, in addition to emotional support and validation (Finkelhor & Wolak 2003; Stein & Nofziger, 2008; Logan & King, 2001; Wintre & Crowley, 1993; Wilson & Deane, 2001; Zwaanswijk et al., 2003). However, the current findings address the gaps in this literature because there is now a greater understanding of how this process occurs and how it impacts survivors. The current findings imply that adolescent survivors knew that their parents were able to offer them the guidance into 94 formal systems, something that their peers were unable to do. Once parents found out about the assault, there were two general reactions about how to enter formal help systems. Some mothers would involve their daughters in a mutual decision-making process about the pros and cons of seeking medical help and/or reporting to the police. Given that adolescence is a time when youth want increased independence and are developing the cognitive skills to make rational decisions (Baer, 2002; Larson et al., 1996; Csikszentmihalyi & Larson, 1984; Steinberg, 2005; Steinberg & Morris, 2001), being part of the decision-making process made survivors feel valued and respected. And while most survivors did not know when or how to enter formal systems, it was still important for parents to offer them the choice to move forward. On the other hand, some parents did not provide much choice in seeking formal help, making survivors feel forced to enter the medical or legal system. Therefore, parental support played a significant role in how willing and comfortable adolescent survivors were with obtaining a SANE exam or reporting to the police. It was also helpful when parents validated (e.g., not your fault) survivors‘ experiences and offered emotional support (e.g., listen, hug, cry with daughter). Conversely, survivors found it hurtful when parents blamed them for the assault and judged them for the risky behaviors they engaged in prior to the assault. Therefore it was easier for survivors to enter formal systems when their parents would provide them with choices, emotional validation, and encouragement to seek medical and legal help. Key Finding #4: Family-Peer-School Interactions Influence Subsequent Disclosure and Entry into Formal Help The results of this study (among others) have demonstrated that the peer and family microsystems are vital support systems for adolescent victims, but fewer studies have looked at 95 the interrelationships of these systems. Given that the peer, family, and school systems intersect throughout other aspects of adolescents‘ lives, it is reasonable that these interactions would also occur during traumatic events, such as sexual assault. Traditionally, developmental research on mesosystem interactions focus on what has been termed ―multisetting participation,‖ where an individual participates in more than one microsystem, and where the events in one setting can affect other settings (Bronfenbrenner, 1986; Kogan, 2004; Stein & Nofziger, 2008;Véronneau & Dishion, 2010). For example, Veronneau and Dishion (2010) recently examined the main and interactive effects of peer rejection, peer acceptance, and parental monitoring on adolescent antisocial behavior. They found support for a ―mesosystem‖ effect in that higher parental monitoring buffered the negative effects of peer rejection. While the peer system and family system may never physically interact, they can have cumulative or interactive effects on an individual. This study also found support for multisetting participation, but also examined more complex mesosystems such as ―supplementary links‖ and ―intersetting communication.‖ Supplementary links take place when people from different microsystems enter each other‘s settings (e.g., parent visits school) and intersetting communication occurs when people from different microsystems communicate about an individual (e.g., principle talks to parent about child‘s behavior). To date, the developmental literature has focused on complex mesosystems such as parent-teacher linkages (e.g., parent participation in school) and their impact on academic achievement (Comer & Haynes, 1991; Spera, 2006). And, while the current sexual assault literature has found evidence for multisetting participation (e.g., survivors seek support from family and friends for different reasons), no research has examined the more complex mesosystem interactions that occur during disclosure and help-seeking. 96 The current study filled this gap in the literature and found that it was common for complex interactions between peer, family and school systems to occur. For example, some peers took survivors home to help initiate parental disclosure (supplementary links), while other peers went a step beyond and met with survivors and survivors‘ mothers to talk about the assault (intersetting communication). The current findings further suggest that peer-family-school mesosystems can lead to positive or negative outcomes during the disclosure process. That is, once systems interact, it is likely that more people will become involved (with or without survivors‘ consent), making this process increasingly complex. While it is unlikely that support providers had ill intentions, the most hurtful mesosystem interaction occurred when a friend or friend‘s mother disclosed the assault to other people without the survivor‘s consent. This form of intersetting communication was unwanted and made survivors‘ subsequent disclosures and entry into the formal system emotionally difficult. The impact of negative reactions from informal support providers on subsequent disclosures has also been found in the adult helpseeking literature (Ahrens, 2006; Sudderth, 1998; Symes, 2000), and these findings suggest that adolescent survivors respond in similar ways. Research on adolescent and adult sexual assault has also proposed that survivors are not always in full control of their disclosure process. Sometimes, support providers initiate disclosures (e.g., insist that survivors tell them what happened) or disclose to others without survivors‘ consent (Ahrens, 2006; Staller & Nelson-Gardell, 2005). Lack of control during this process was also found in the current study, which consequently impacted how survivors entered formal help systems. In one case, a survivor entrusted her close friend to keep the assault to herself. Instead, her friend told her own mother, who then called the police (without the survivor‘s consent). Once the police was contacted, the survivor‘s mother found out and became 97 upset. Given that this survivor‘s family was involved in the system (e.g., prior arrests, probation), the survivor had no intention of disclosing to law enforcement. Thus the communication between systems, although well-intentioned, may not always result in positive outcomes. Furthermore, this example illustrates the break in confidentiality and trust in a friendship, which can be particularly harmful for an adolescent‘s socio-emotional development (Stanton-Salazar & Spina, 2005). Whereas some mesosystem interactions were hurtful to survivors, more were positive and helped facilitate subsequent disclosures and formal help-seeking. What was helpful about the interactions between peer and family systems was that the survivor wanted them to occur. This was especially the case for survivors who feared telling their parents and depended on their friends to aid in parental disclosure. Therefore, peers not only served as the link to parental disclosure (within the peer microsystem), but may also act as buffers to the possible negative reactions from survivors‘ parents. The mesosystem analyses also revealed findings on the influential role of the school microsystem. Whereas the first research question guided the examination of initial disclosures (peers, parents), it was not until systemic interactions were analyzed that the role of teachers and counselors became apparent. The findings from the four cases of school-family mesosystems suggest that teachers and counselors are able to offer adult support and formal guidance to both the survivor and the parent. Specifically, teachers were able to help with parental disclosures and refer survivors to appropriate medical and legal services. Furthermore, every survivor who disclosed to a teacher or counselor had an already established relationship where they felt comfortable sharing other personal issues. Therefore, teachers and counselors were viewed as 98 trustworthy, non-judgmental individuals, who could facilitate parental disclosure, and provide guidance to formal systems. Key Finding #5: The Chronosystem has a Significant Impact on Survivors’ Willingness to Disclose and Seek Formal Help. Many female adolescents are victims of multiple sexual assaults in their lifetime (BoneyMcCoy & Finkelhor, 1995; Nofziger & Stein, 2006; Wolitzky-Taylor, Ruggiero, Danielson, Saunders, & Kilpatrick, 2008; Young & Furman, 2008). Repeated victimization can lead to numerous negative outcomes, including problem drinking and poorer mental and physical health (Koss, Bailey, Yuan, Herrera, & Lichter, 2003; Niehaus, Jackson, & Davies, 2010; Rich, et al., 2004; Ullman & Najdowski, 2009). Given the pervasiveness and deleterious effects of revictimization, it is surprising that prior research has not examined how these prior abuse experiences can affect disclosure and help-seeking. To address this gap in the literature, this study examined whether there was evidence that such a chronosystem effect impacted adolescents‘ disclosure patterns. The current study found evidence that a history of prior sexual or physical abuse, and the corresponding informal and formal social support experiences that occurred during those prior assaults, had a significant impact on survivors‘ current help-seeking processes. Of the twenty survivors who were interviewed, almost half had been previously abused. And, even though several of these survivors had negative experiences with formal systems in the past, they still disclosed to informal support providers and entered the legal and/or medical system. According to the help-seeking literature, adolescents find it easier to seek help when previous help-seeking experiences were successful (Lindsey & Kalafat, 1998; Wilson & Deane, 2001), and less likely to seek future assistance from formal help providers who did not take them serious (Rickwood et 99 al., 2005). However, in this study, adolescents with prior histories of abuse still sought help regardless of how their prior help-seeking experiences unfolded. In fact, the survivors in this study were more determined to disclose to their peers and parents, more willing to enter formal help systems, and more hopeful about obtaining justice. Consequently, survivors with histories of abuse were more likely to engage in fewer disclosures across systems, which resulted in fewer mesosystem interactions and entering formal systems relatively quicker. While this seems counterintuitive, the findings imply that through their prior (positive and negative) experiences with informal and formal providers, adolescent survivors learned what to expect during disclosure and help-seeking. Specifically, survivors with a history of abuse seemed to understand the implications of remaining silent and not contacting formal services (i.e., SANEs and the police) immediately after an assault. On the other hand, survivors who were assaulted a single time may have a greater fear of the unknown. Unlike previously-abused adolescents, they never had to consider disclosing such a traumatic experience to their friends and parents, obtaining a forensic exam, or reporting to the police. Going through the emotionally difficult process of disclosing sexual or physical abuse and entering formal help previously may take away some of the ―unknowns,‖ which explains why those with a history of prior abuse sought help more quickly. Finally, while all of the adolescent survivors in this study had the courage to speak out about their experiences, those with a history of abuse expressed a different level of strength and determination that ―telling‖ was important for healing, that ―enough was enough‖, and that the system should help this time. 100 Summary of Findings Overall, this study revealed how individual-level beliefs about social support impacted disclosure and help-seeking. The current research also illuminated how disclosures within survivors‘ most influential microsystems and the interconnections between these systems facilitated continued disclosure and entry into formal help systems. Specifically, this study found that survivors‘ beliefs about informal and formal support guided initial disclosures. Negative anticipatory beliefs about how others will react to risky behavior and being assaulted by an acquaintance may hinder how soon after the assault survivors are likely to disclose and who survivors choose to disclose to. Given these beliefs, survivors were most likely to first disclose to peers followed by their mothers/guardians. As a result, the interactions within the peer and family microsystems were decisive in how survivors continued to disclose and how willing they were to enter formal systems. Furthermore, the process of disclosure and helpseeking became more complex when family, school, and peer microsystems interacted. When these interconnections occurred with survivors‘ consent and a produced a helpful response, they were perceived as positive. On the other hand, mesosystems in which survivors had minimal control result in unwanted disclosures and greater reluctance to enter formal systems. Finally, the chronosystem played a salient role among adolescents with a prior history of sexual or physical abuse. The chronosystem findings suggest that survivors‘ determination to disclose and obtain justice is a result of their prior experiences and knowledge of what disclosing (or lack thereof) and entering the system (or not) could lead to during their current sexual assault. Limitations There are several limitations in the current study that merit discussion. First, it is important to mention that the overall goal of this research was to examine how adolescent sexual 101 assault survivors sought informal support and entered formal systems. Because the prior literature has found that very few adolescent survivors actually seek formal support, and the current sample consisted of survivors who all entered formal systems, this sample should be considered ―atypical.‖ Consequently, it is critical to note that these findings should not and cannot be generalized to the normative population of adolescent sexual assault survivors. Even so, this sample was appropriate in addressing the research questions raised and provided valuable insight about an exceptional disclosure and help-seeking process, which led to a greater understanding of how difficult this process can actually be for young survivors. It is also necessary to acknowledge that this study is unable to address whether disclosing and entering formal systems is a helpful or hurtful process. It is often assumed that seeking formal help will in fact help survivors, but in fact, that assumption has not yet been empirically tested-in this study or in other prior work. As such, the findings in this study should not be interpreted as advocacy for seeking formal support after a sexual assault. The adult sexual assault literature has consistently found that survivors are often revictimized within formal help systems (Campbell, 2008), which begs to question whether this also occurs for adolescent survivors. Therefore, future research is necessary to ascertain if and how disclosing and seeking formal help impacts psychological outcomes. Another limitation of this study is that data cannot provide any insight into the disclosure and help-seeking process from the perspectives of various support providers. While the findings suggest that peers and family members are important during this process, the results of this study are solely based on the perspective of the survivors. Whereas it was beyond the scope of this study to collect companion data, future research should consider such methods because doing so could further explain the multifaceted process of disclosure and help-seeking. Collecting 102 companion data could not only investigate why support providers react in certain ways, but may also reveal other helpful behavior that survivors were unaware of. For instance, it is possible that parents sought out advice from other informal or formal systems (without survivors‘ knowledge) prior to guiding their daughters to SANE. It is also important to note that this study was conducted in two communities that had specialized medical care programs for sexual assault survivors (i.e., SANEs). Given that the goal of this research was to examine how and why adolescent survivors disclose to informal providers and link to formal systems, it is not necessarily problematic that participants were recruited from SANE programs. However, this may explain why the survivors in this study got connected to formal help within four days, which is sooner than what other research would suggest (BromanFulks et al., 2007; Kogan, 2004). That is, once parents and other adults learned about the assault and explored formal help services in the community, the well-known existence of SANE programs could have increased the speed at which victims and their families obtained medical help. Thus, the delay in entering formal systems may be different in communities that depend solely on non-specialized medical care (e.g., hospitals). Even so, this limitation is not particularly problematic given that most survivors entered the formal system through initial contact with the police (who then referred them to SANE) or went to the police after getting medical treatment, suggesting that law enforcement is a typical entry point among adolescent survivors. Finally, another key limitation was the sample size of N=20. Although this sample size was sufficient to reach saturation on all key themes, interviewing a larger group of adolescent survivors could have unveiled other factors that could impact the disclosure and help-seeking process. For example, this study had a very small number of adolescents who were assaulted by 103 family members or who were from an ethnic minority group. It was difficult to make conclusions about the unique issues that could result from familial rape, such as survivors‘ feelings about reporting their father to the police, and the impact that could have on their family. Likewise, there were only two African American survivors in this study and therefore it was not possible to examine how race and racial stereotypes may have affected their disclosure and helpseeking processes. More importantly, some of the main assertions (e.g., chronosystem and mesosystem) were based on a small subsample of participants. For example, the chronosystem effect was based on the prior victimization experiences of eight survivors compared to twelve who did not discuss prior victimization. Additionally, because this sample is an already ―atypical‖ group of survivors (i.e., they all entered formal help systems), it is critical for future research to replicate these findings. Given these sampling limitations, future research should examine the disclosure and help-seeking processes of a larger, more diverse group of adolescent survivors. Implications for Research The current study highlights the utility of an ecological model for examining adolescent sexual assault disclosure and help-seeking, which can guide future research to examine helpseeking at all levels of the ecological system. First, the literature could benefit from further investigating individual-level and contextual factors (i.e., assault characteristics) that serve as barriers to disclosure. The current findings suggest that risky behavior, knowing the assailant, and prior negative experiences with law enforcement played a role in survivors‘ negative expectations of support, which in turn impacted who survivors disclosed to first. Because of the small sample size and limited range of assault experiences, other factors (e.g., presence of injuries, assault location) that are likely to impact survivors‘ anticipatory beliefs did not emerge. 104 Furthermore, given the inconsistent findings in other research regarding the impact of assault location and assault severity on survivors‘ perceptions of social support (Black et al.,2008; Kogan, 2004; Nofziger & Stein, 2006), it is important to examine if and how these factors are salient during this process. Identifying how these (and other) assault characteristics influence survivors‘ beliefs about disclosure and help-seeking can further explain why so many adolescent sexual assault survivors have significant delays in disclosure or never disclose at all. Given that research has shown that adolescents who disclose have significantly lower PTSD symptoms compared to those who do not disclose (Broman-Fulks et al., 2007), identifying such barriers can inform future prevention efforts that can help make disclosure easier for young survivors. Second, given that we now know the relative influence of peers and parents during disclosure and help-seeking, it would be helpful to further examine the impact of these relationships as they change over time following sexual assault disclosure. The literature has yet to examine how relationships change within the peer group or family after an adolescent discloses a sexual assault. Recovery is a very long process and survivors may need to talk about their assault experiences and require additional social support from family and friends following their initial disclosures. Furthermore, sexual assault disclosure is likely to have an emotional impact on family and friends which can influence how they respond to survivors (Ahrens & Campbell, 2000; Banyard, Moynihan, Walsh, Cohn, & Ward, 2010; Williamson, Borduin, & Howe, 1991). Given the significant influence of these systems during adolescence, it is important to understand the post-assault experiences of survivors as they navigate through these social support networks in order to discover which social reactions are helpful or hurtful for survivors‘ long-term recovery. In addition, future research needs to examine what resources peers and family need to sustain their continued support of survivors. 105 This study also offered preliminary findings on the positive and negative impact of the mesosystem on disclosure and help-seeking. Prior research has not typically examined the more complex mesosystems (i.e., intersetting communication and supplementary links) and the current findings provide incentive to explore these more nuanced ecological effects on help-seeking. Moreover, because these findings were based on a smaller subset of survivors in this study, it would be beneficial for future research to examine how peer, family, and school systems interact during the disclosure process, and how these interactions impact post-assault recovery and wellbeing. Specifically, while this study identified the occurrence of mesosystem interactions, the contexts or circumstance under which they are more or less likely to occur have not been fully examined. For example, is it more likely for mesosystems to occur when survivors endure greater physical or psychological trauma? Do peer groups intersect with the school system when the family system is dysfunctional? Furthermore, it is likely that other influential systems (e.g., community-based youth groups) beyond school, peer, and family, could also intersect with these systems during the help-seeking process. Therefore, further examination of mesosystem interactions could reveal when they occur (i.e., under which circumstances), what systems are more likely to interconnect and why, and what interactions between systems lead to outcomes that are hurtful and/or helpful for survivors. Likewise, the chronosystem effect suggests that prior sexual and physical abuse impact how survivors cope with a recent sexual assault and how they decide to disclose and seek help. Specifically, survivors with a prior history were more determined to disclose and had more hope that formal systems would help. Because these preliminary findings are somewhat unexpected to what the extant literature would suggest, replications of these findings are particularly important. Future research should consider examining how prior victimization impacts help-seeking for a 106 recent assault. Specifically, a better understanding of the chronosystem effect would require examining how survivors‘ prior coping strategies, support providers‘ responses to prior victimizations, and the outcome of the last victimization guide current help-seeking behavior. Additionally, this research considered the chronosystem effect as prior adolescent sexual assault, child sexual abuse, physical abuse from a dating partner, and repeated victimization from the current perpetrator. Because these victimizations are different (i.e., they occurred during different developmental periods, from different perpetrators, or from the same person repeatedly), untangling these issues further would also be necessary to truly understand the chronosystem effect on help-seeking. Finally, the exosystem and the macrosystem were not investigated in this study. It could be argued that these broader systems are not as salient to adolescent development given their relative importance to the more proximal microsystems. However, research should consider how these distal factors play a role in adolescent disclosure and help-seeking. While not extensive, exosystem and macrosystem factors have been examined in the adult sexual assault literature as factors that impact survivors‘ well-being (Campbell, Dworkin, & Cabral, 2009). Thus, it is likely that adolescents are also impacted by these systems. For example, it would be important to examine how exosystems such as SANEs or Sexual Assault Response Teams (SARTs) impact the formal help-seeking experiences of adolescent survivors and their families. Additionally, it would be interesting to study how broader macrosystem beliefs, such as rape myths, impact social support providers‘ willingness and ability to offer appropriate guidance for survivors. Implications for Practice The current findings also have several implications for social support providers. First, peers were identified as the primary responders and the key link to subsequent adult disclosures 107 and help-seeking. While most offered helpful guidance to survivors, it is clear that many peers are still unsure of the appropriate ways to respond to sexual assault disclosure. While schools provide minimal, in any sexual assault education, national efforts have recently pushed for an increase in rape awareness education and rape prevention programming for youth (Centers for Disease Control [CDC], 2004). The current findings on the impact of peer support confirm this educational need. Specifically, it is important for school-based programs to educate youth about the ―helpful‖ and ―not so helpful‖ responses following sexual assault disclosure. Likewise, it is important for youth to learn about the various social services available for sexual assault survivors (e.g., SANEs, rape crises centers), and what occurs within formal systems (e.g., what happens when you report to the police, what are rape kits and how are they used, etc.). This study also validated the importance of parental support during adolescent helpseeking. While parents were the key link to formal system entry, not all were aware of the specialized services provided by SANEs. Therefore, it would be helpful for rape crisis centers (who often collaborate with SANEs) to educate parents about the appropriate formal services for sexual survivors as well as the steps that are taken once a report is made to the police. Furthermore, rape crisis centers should consider educating parents on the appropriate ways to emotionally respond to their children following sexual assault disclosure. Given that adolescent sexual assault is likely to impact the family as a whole, rape crisis counselors should also provide guidance for parents on how to support their children throughout the post-assault recovery period. Finally, teachers and counselors can be instrumental support providers after an adolescent sexual assault. As was illustrated in this study, survivors who disclosed to their teachers had built a strong relationship with them prior to the assault, and were consequently provided with 108 the emotional support and guidance to seek formal help. Given that school personnel have daily contact with youth and have the capacity to build these personal relationships, training them to become effective responders to sexual assault would also be beneficial. As mandated reporters, teachers should be trained to identify the signs of sexual abuse and how to respond to sexual assault disclosures. Finally, because there is now evidence that the school and family systems sometimes interact during this help-seeking process, training teachers on how to facilitate parental disclosure and how to connect families to proper formal care is also critical. Adolescent survivors require emotional support and guidance from friends, family, and school personnel throughout the disclosure and help-seeking process. Systematic community education targeting the most influential social support providers is likely to improve the response to victims, making disclosure and help-seeking easier, and taking the steps toward recovery more promising. Conclusion In conclusion, while many adolescent survivors never disclose and even fewer report to the police and get medical treatment, the personal accounts of these young women allowed for a greater understanding and appreciation of what it took to get there and what it meant to get there. As was illustrated, disclosure is not an easy process for adolescent victims. As individuals who are already in the midst of multiple developmental transitions, being sexually assaulted and making the decision to disclose and seek formal help can be a complicated process involving numerous systemic factors. 109 APPENDIX 110 Appendix A: Interview Protocol Qualitative Survivor/Victim Interview Protocol Participant ID Number ____________________Interviewer ID Number____________________ Date Interview Conducted ________________Length of Interview ______________________ INTRODUCTION AND OVERVIEW Thank you so much for coming in today, I know that what you have/are gone/going through is not easy and I understand that it may be difficult to talk about it. But please know that we will go at your pace during this interview and there are no right or wrong answers- we are simply interested in your personal experience. Before we start, I want to tell you exactly why we are doing these interviews. We want to get a better understanding of teenage girls‘ experiences with the sexual assault nurse examiner program and the criminal justice system (such as police, prosecutors, etc.). Your personal experiences are very important to help us understand what was helpful and not so helpful with these systems/programs. We will then combine all the feedback and experiences from other teenage girls we interviewed in an effort to improve these programs for future teenage sexual assault survivors. However, there is one very important thing to remember- everything we talk about today will be kept confidential. This means that everything you say will be kept private. Your parents, teachers, friends, people from [name of agency], police, etc. will not be told about anything we talk about today. Your name will not be connected to anything you say. I will not write your name on the interview itself. This interview will take approximately 2 hours to complete. As we‘re going through the interview, if you need to take a break or stop, just let me know. If there are any questions that you don‘t want to answer, just say so, and I will move on to the next section. Feel free to change the topic if you feel uncomfortable and you can let me know if you want to get back to it later. Also feel free to ask me questions throughout the interview if you are not sure about something. It is completely up to you how much or how little you tell me. Keep in mind that I‘m not looking for any particular response,- there‘s no right or wrong answers. I am interested in hearing what you have to say. If it‘s ok with you, I would like to tape record this interview. The only reason I would like to do this is because it is hard for me to get everything down on paper, so the tape can help me fill in anything I might have missed later. The only other person who will listen to this tape will be the supervisor of this project. I will not use your name throughout the interview and your name will not be written on the tape. When the project is done, the tape will be destroyed. May I tape record our discussion? 111 Before we get started I need to get your consent/permission to be interviewed (go through procedures step by step to obtain informed consent). Do you have any questions before we start? SECTION ONE: INVOLVEMENT IN THE INTERVIEW I’d like to start off by talking a little about how you decided to participate in the interview. Q1. Why did you decide to participate in the interview? What made you want to talk with me today? Q2. When you learned about the study, what did you think about being part of it? Q3. Were there specific things that made you feel unsure about participating in the study and being interviewed? a. If so, what were those things? b. What can I do to make you feel more comfortable during the interview? Note to Interviewer: use her language- how does she refer to “sexual assault”, what does she call the assailant, SANE, prosecutor, etc.? SECTION TWO BACKGROUND ON THE ASSAULT Before we start, I want to tell you the main sections of the interview so that you know what to expect. First, we will talk about what happened the day/night of the assault. Second we will talk about what happened afterwards- like who you told, and what that was like for you. Third we will talk about your experiences with the nurse and advocate at SANE/SASS. Finally we will talk about any experiences you might have had with the police or anyone else from the criminal justice system (detectives, attorney, etc.). So if it‘s ok with you I would like to go ahead and begin by asking you about the assault itself. Q4.Could you tell me happened? Could you tell me about the assault? Please feel free to tell me as little or as much as you want about that day- whatever you feel comfortable with. 112 Thank you for sharing your experience with me. If it’s ok, I’d like to ask you a few specific questions about the assault so that I can understand a little better about what happened. PROBES: a. How long ago did the assault happen? Do you remember the date? b. How old were you at the time of the assault? c. Type of assault (Do not ask this out loud. If you cannot get this from her story, then you may get it from probe D below) 1 = STRANGER RAPE 2 = ACQUAINTANCE RAPE 3 = DATE RAPE 4 = LONG-TERM DATING PARTNER 5 = MARITAL RAPE 6 = GANG RAPE/ STRANGER 7 = GANG RAPE/ ACQUAINTANCE 8 = Gang Rape/ stranger AND acquaintance 9 = Relative 10 =OTHER (Specify___________________________) d. What was your relationship with assailant(s) before the assault? (Specify___________________________________) 1 = NONE, WERE STRANGER 2 = KNEW EACH OTHER BY SIGHT 3 = FRIENDS, CASUAL 4 = FRIENDS, CLOSE 5 = DATE 6 = BOYFRIEND/GIRLFRIEND 113 7 = EXBOYFRIEND/GIRLFRIEND 8 = FAMILY 9 = OTHER (________________________________) 10 = DON‘T REMEMBER Ask only if she was the victim of non-stranger rape e. Were you living together at the time? 1 = YES 2 = NO ee. Was this the first and only time he/she assaulted you? Or was he/she hurtful to you in the past? 1 = SINGLE SEXUAL ASSAULT (Probe: so, just to clarify, was he emotionally, physically, or sexually abusive/hurtful outside of the incident you described?) (CIRCLE ALL THAT APPLY) 2 = MULTIPLE SEXUAL ASSAULTS (e.g.,sexually assaulted you before) 3= EMOTIONALLY ABUSIVE (e.g., acted jealous, controlled who you can hang out with and/or and told you hurtful things repeatedly ) 4 = NON-SEXUAL PHYSICAL VIOLENCE (e.g., hit, slapped, punched, pushed) f. Race/ethnicity of the assailant 1 = WHITE 2 = AFRICAN-AMERICAN/BLACK 3 = LATINO/HISPANIC 4 = NATIVE AMERICAN INDIAN 5 = ASIAN AMERICAN 6 = ARABIC-AMERICAN 7 = BIRACIAL-MULTIRACIAL 114 8 = OTHER (Specify____________________________) 9 = DON‘T KNOW g. In addition to the injury of rape itself, were there any other physical injuries you got from the assault? 1 = YES (Specify__________________________________________________) 0 = NO 2 = DON‘T KNOW h. Was a weapon used in the assault? 1 = YES (Specify__________________________________________________) 0 = NO 2 = DON‘T KNOW i. Was the assailant using alcohol at the time of the assault? 1 = YES 0 = NO 2 = DON‘T KNOW j. Was the assailant using drugs at the time of the assault? 1 = YES (GO TO QUESTION jj) 0 = NO (GO TO QUESTION k) 2 = DON‘T KNOW jj. Assailant was using MARIJUANA 1 = YES 2 = NO TRANQUILIZERS 1 = YES 2 = NO AMPHETAMINES 1 = YES 2 = NO 115 COCAINE/CRACK 1 = YES 2 = NO HEROIN 1 = YES 2 = NO HALLUCINOGENIC 1 = YES 2 = NO OTHER (SPECIFY_________________________) 8 = DON‘T REMEMBER SECTION THREE: EXPERIENCE AFTER THE ASSAULT/ INITIAL DISCLOSURES Thank you for sharing that with me. Now I would like to discuss how your feelings after the assault and who you talked to right after the assault. Q5. Can you describe your initial reactions after the assault? Can you describe your feelings for me? Q6. Who did you tell? Who found out first? (Probes: How/What did you tell them? How did they find out if it wasn‘t from you?) Q7. Why did you tell them? Q8. How did they respond to you? (Probes: What did they say or do? What was good or bad about how they acted or treated you?) Q9. What happened right after you told _____? Where did you go first? Jump to section on experiences with SANE (PAGE 8) or police (PAGE 12) depending on her answer. SECTION FOUR: 116 EXPERIENCE WITH SANE Now I would like to talk to you about your experiences with the SANE program Q10. How did you end up going to the SANE program? Probes: a. Why did you go to the SANE program? b. Was it your choice to go to the SANE program? Why / Why not? c. Who did you talk to about whether or not you should go to SANE? What did you discuss? How did this influence your decision/what you wanted to do? Q11. Before you got there, what did you expect from the SANE program? (Probes: what did you know about the program / what was going to happen? Q12. What were your thoughts about having a sexual assault exam/rape kit done? (Probe: Did you have any concerns? First Pelvic exam? Q13. Could you tell me about your experience with the SANE program? What happened once you got there? NURSE TOPIC PROBES a. Was the nurse supportive? Was the nurse helpful? What did the nurse do that was good? b. What was not so good during your experience with the nurse? What did she do/say that you wish she wouldn‘t have? What do you wish had been different? c. What did you need from the nurse that you didn‘t get? ADVOCATE TOPIC PROBES 117 a. Was the advocate supportive/helpful/good? b. What was not so good/hurtful during your experience with the advocate? What did she do/say that you wish she wouldn‘t have? What do you wish had been different? c. What did you need from the advocate that you didn‘t get? d. If survivor did NOT have an advocate available: Would you have liked someone else besides the nurse to be there for you? Why? Q14. Did anyone go with you to the SANE program? Probes: a. b. c. d. Who? What was it like having them there? What was good about having them there? What was not so good about having them there? Ask only IF SHE HAD PARENT/GUARDIAN/OTHER ADULT THERE WITH HER: Q15. Do you feel the nurse paid attention to what you wanted/what you said/what you thought? (or was she paying more attention to your mother/guardian?) How did that make you feel? Q16. Do you feel the advocate paid attention to what you wanted/what you said/what you thought? (or was she paying more attention to your mother/guardian?) How did that make you feel? Q17. What should nurses know about working with teens? What should advocates know about working with teens? (What can they do better when working with teens?) Q18. Did anyone tell you if you had injuries from the assault? Did anyone tell you if they found DNA from the rape kit? Who told you? Was this helpful information? [Ask only if relevant] PROBES: What were the findings of your forensic exam? 118 DNA 0 = Negative 1 = Positive 2 = Inconclusive 8 = Don‘t Know INJURIES 0 = Negative 1= Positive 2 = Inconclusive 8 = Don‘t know Q19. Was having a medical forensic exam important to you? Why? Q20. Looking back at your experiences with SANE, what would have been good to know before going there? Q21. Looking back, are you glad that you went to the SANE program? Why or why not? SECTION FIVE: CONTACTING THE POLICE [Ask only if relevant] Great, thank you for sharing your experiences and views about SANE, they were very helpful. If it’s alright, now I’d like to ask you some questions about your thoughts on contacting the police about the assault. 119 Q22. Who decided to contact or not contact the police? (Probe: Did you want the police to be called? Was it your choice?) Q23. Who did you talk to about whether you should call the police? (Probe: What did you discuss? How did this influence your decision? Q24. How did you feel when the police were/weren‘t contacted? Q25. What were your thoughts about contacting the police? (Probe: any concerns?) Q26. What did you expect from the police? What did you think the police would do if they were called? If they were called, what did you want them to do? SECTION SIX: EXPERIENCES WITH POLICE/DETECTIVES Q27. What was your experience with the police like? (Probe: What happened when you had your first contact with the police?) [Ask only if relevant] TOPIC PROBES: a. What happened during the time you talked with the police? (Find out if she made a police report and if she participated in the continued investigation). b. Why/How did you decide to make a police report? Why/How did you decide to continue the investigation? c. What did the police do that was good? d. What did the police do that was not so good? e. What do you wish had been different with the police? What did you need from the police that you didn‘t get? Q28. Was anyone with you when you talked to the police? Who? How was it having ___with you? 120 ASK ONLY IF SOMEONE WAS THERE WITH HER Q29. Do you feel the police officers paid attention to what you wanted/what you said/what you thought? (or were they paying more attention to your parents, guardian?) How did that make you feel? Q30. What was your experience with the detective like? (Probe: What happened when you had your first contact with the detective?) [Ask only if relevant] TOPIC PROBES: a. b. c. d. What happened during the time you talked with the detective? Why/How did you decide to continue the investigation and prosecute? What did the detective do that was good? not so good? What do you wish had been different with the detective? What did you need from the detective that you didn‘t get? Q31. Was anyone with you when you talked to the detective? Who? How was it having _______with you? ASK ONLY IF SOMEONE WAS THERE WITH HER Q32. Do you feel the detective paid attention to what you wanted/what you said/what you thought? (or were they paying more attention to your parents, guardian?) How did that make you feel? Q33. What should police officers/detectives know about working with teens? (What can police officers/detectives do better when working with teens? Q34. Looking back at your experience with the police/detectives, what would have been good for you to know before contacting them? Q35. Looking back, are you glad the police were called? Why/why not? 121 SECTION SEVEN: DECISION TO PARTICIPATE IN PROSECUTION [Ask only if relevant] In this next section of the interview, I would like to talk about your experiences with the prosecution (by prosecution, I mean the court charges him with a crime and tries to show he is guilty) of your case. Q36. Who did you talk to about whether or not you wanted to participate in prosecution? What did you talk about? How did that influence your decision? Q37. What did you want to happen with your case? (Probe: Did you want your case to be prosecuted? Why/ why not? Q38. What were your thoughts about continuing with prosecution? (any concerns?) SECTION EIGHT: EXPERIENCES WITH PROSECUTION Q39. What was your experience with prosecution like? What was it like to talk with the prosecutors/attorney? [Ask only if relevant]` TOPIC PROBES: 1. Experience with prosecutor/prosecution a. What did the prosecutor do that was good? b. What did the prosecutor do that was not so good? What do you wish had been different with the prosecutor? c. What did you need from the prosecutor that you didn‘t get? Q40. Was anyone with you when you talked with the prosecutors? 122 (Probe: Who? What was it like to having them there?) ASK ONLY IF SOMEONE WAS WITH THEM Q41. Do you feel your prosecutor paid attention to what you wanted/what you said/what you thought? (or was he/she paying more attention to your parents, guardian?) How did that make you feel? Q42. Looking back at your experience with prosecution, what would you have liked to have known before going through with it? Q43. What should prosecutors know about working with teens? SECTION NINE: OUTCOME OF THE CASE [Ask section only if relevant] Q44. What was the last thing that happened with your case? Q45. How did you know about what was happening with your case? (Probe: What was good about that? What was not so good about that?) Q46. How did you feel about____________(the outcome)? Q47. IF COURT HEARINGS (and if they were ever in court room) COURT HEARINGS PROBES: 1. How did you feel when the nurse testified? 2. How did you feel when pictures of your injuries were being shown in court? 3. Was a Turning Point staff person/SASS or court advocate there to support you? a. What did they do that was good? b. What was not so good about them? What did you wish they didn‘t say? What do you wish they had done differently? c. What did you need from them that you didn‘t get? SECTION TWELVE: 123 OTHER HELP-SEEKING Thank you for telling me about your experiences with SANE and the police and/or prosecutors. Now I would like to talk to you about other services/programs you might have contacted after the assault. Q48. Have you contacted any other programs or services after the assault? (e.g., counseling, support groups, clinic, doctors, STD services, etc.) Q49. How did you end up getting these services? (Why did you contact them?) Q50. What was it like getting these services? SECTION THIRTEEN: DEMOGRAPHIC INFORMATION Thank you so much for sharing your experience with me. Everything you shared with me today will be very helpful. I would like to ask you questions about yourself to get better picture of the people we are interviewing. Remember this will also be kept confidential. Q51. What is your gender? Q52. What is your race/ethnicity? Q53. How old are you? Q54. What is the highest grade in school that you completed? SECTION FOURTEEN: CLOSING We are almost done! We’ve talked for a long time and about many different issues related to the assault, and now I would just like to ask some final questions about your experiences and what it was like to do this interview. Q55. What has helped you the most after the assault? (probe: What has been the most healing to you?) Q56. Based on your experiences, what would you say or do for another teenage girl who has just been sexually assaulted? 124 We’re always in the process of making this interview better, so I’d also like to get your honest feedback on the interview. Don’t worry—you won’t hurt my feelings. Q57. What has it been like for you to talk about the assault with me? What is like for you to be a part of this study? (What did it mean to you to do this interview?) Q58. Are there questions I should have asked you but didn‘t? Is there a topic that I should have asked you more about? Less about? Q59. Can you tell me some ways that this interview can be better (more appropriate) for teenage girls? 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