Adolescent victims of sexual abuse and music therapy: A systematic review

Background: Sexual violence represents a major public health issue that impacts the future of adolescents. Several studies have examined music therapy as treatment option by suggesting multiples ways on dealing with music experiences. However, not much information in literature is known in professional practice. The current research contributes in understanding use of music as a therapy with adolescent’s victims of sexual abuse. Objective: Identify primary research about music therapy towards adolesce nts’ victims of sexual abuse to understand context of care, participants’ age, length of therapy, therapist training, clinical goals, methods applied, potentials and issues related to adolescent period of life. Participants and setting: Adolescent, who suffered from sexual abuse in childhood and / or adolescence attending public or private health service. Methods: Qualitative systematic review, seven databases and three specific journals were qualitative systematically searched, as well as been identified primary studies screened against inclusion criteria. Results: Among 492 findings, seven studies between the years 1992 and 2018 were included. Music therapy methodology has been offered in hospitals, private offices, institutions, [of short, medium and long term], by a qualified music therapist; several symptoms were addressed like depression, post-traumatic stress disorder, anxiety with goals to improve social skills; positive affective experiences; emotional self-regulation; autobiographical narrative; expression and communication of ideas and feelings with a variety of methods. Conclusions: Music therapy seems to be an important therapeutic method/tool for young patients who feel comfortable upon music, it facilitates therapeutic bond, helps expression of feelings and is less confrontational therapy.


Introduction
Sexual abuse is one of the classifications of violence that has been increasingly investigated in recent years (WHO, 2012). Children and adolescents pass through [full] development and sexual abuse can impact the rest of their lives, such as early pregnancy (Kenney, 1997;Cox, 1991), sexually transmitted infection (STI) (Vermund, 1990), depression (Diaz, 1993), anxiety (Tonmyr, 2011), low self-esteem (Edinburgh, 2009), Post-Traumatic Stress Disorder (Gerson, 2013). Music therapy is a recent [modality] of therapy and uses music experiences as the main tool for helping people in a variety of contexts and ways. It is well-known that in the adolescent's period of life, music is an important tool to express feelings and thoughts. Music therapy is a systematic science that has been consolidated as a service to different populations including adolescents dealing with mental health problems such as anxiety (Witusik, 2019) and substance abuse (Aletraris, 2014) for example. Listening to a song and reflecting on its content helps young people to express their thoughts (McFerran, 2010); interacting musically with the therapist favors the therapeutic bond (Yinger, 2014), establishes a strong bond and relationship of trust by then promoting positive experiences in such relationships (Clendenon-Wallen, 1991). Music in music therapy is a tool, and through it, the therapist proposes ways to express, communicate, interact and organize their feelings (McFerran, 2010;Clendenon-Wallen, 1991).
In addition to risks above presented, sexual abuse can lead to a greater chance of young people developing harmful change of behaviors such as drug addiction, prostitution, dropping out of school, and aggressive relationships (Rotheram-Borus, 1996). In guidelines that bring up music essays on the treatment of traumatized children and adolescents (MacIntosh, 2003), music therapy emerges as a less confrontational [modality], while traditional therapies have produced way more lack of adherence to treatment, anxiety, and dropouts (Smyth, 2018).
Secondly, an important aspect regarding potential of music therapy lays on the disclosure of sexual abuse. In the UK, for example, (Schaeffer, 2011) one third of children who suffered violence did not report the sexual abuse they suffered, a study that investigated the disclosure of 23 cases of sexual abuse in Switzerland, found that less than 1/3 of adolescents immediately revealed the abuse and more than 1/3 never revealed the abuse to any relatives (Schönbucher, 2012). There are several reasons for non-disclosure, such as fear of parents' disbelief, disregard from authorities, shame, fear of family consequences, fear of public disclosure, fear of femicide, or even difficulty in perceiving symptoms (Morrison, 2018). Case report points out that the disclosure of sexual abuse was facilitated by music therapy in the first sessions (Rogers, 1992).
However, as it is a relatively new therapeutic modality, evidence-based practice is an important means of knowing how music therapy is growing on this field and to understand means and ways to act. It is known that music therapy is practiced in neurological and psychotherapeutic rehabilitation scenarios, composing a multidisciplinary care team involving physicians, psychiatrists, psychologists, social workers, and other health and education professionals. In Brazil, the National

Plan for Integrative and Complementary Practices of the Unified Health System coded as SUS [Brazil's Unified Public Health
System], has included music therapy, which reveal the importance of this practice in the community settings and public health settings, while requiring greater structuring of practice. Given the relevance of sexual abuse in public health, this article summarizes the practice of music therapy as an option treatment modality.

Methodology
In this section, we start by confirming the approval of the current study has been approved by the Research Ethics Committee of the Federal University of São Paulo under number nº 2732070218.
In this research, a systematic qualitative review was conducted, using the guideline Systematic Review of Qualitative Evidence (Lockwood, 2017). This type of review is related to the humanities and seeks to understand the phenomenon in its natural environment, extracting meaning, possibilities of use, and, characteristics of use. It is characterized by the inductive method, which can be interpretive or critical (Barroso, 2006). As a result, systematic reviews synthesize the content of existing research on a given subject, through its filters and criteria, thus providing recommendations for practices and policies (Lockwood, 2017).
A protocol for systematic review has been enabled and registered under PROSPERO (International prospective registration of systematic reviews) (PROSPERO, 2018). The research question was developed from the acronym PICo (Population / Intervention / Context). According to PICo, P (population) was defined as: adolescent, who suffered sexual abuse in childhood and/or adolescence, of both sexes; I (intervention): music therapy in the treatment (practiced by music therapists) and; Co (context): public or private health service. From this, the following guiding question was created: For adolescent victims of sexual abuse, how is the treatment of music therapy offered by health services? The keywords were determined from the MESH-Medical Subject Headings (Alves, 2023): sex offenses; music therapy; adolescent; and sexual abuse.
The databases containing highest quantity of indexations in health area were chosen according to the following: COCHRANE; CAPES TESES; PUBMED; EBSCO; LILACS; SCOPUS; WEBOFSCIENCE as well as the following the journals: Music Therapy Perspectives; Journal of Music Therapy; British Journal of Music Therapy. The COCHRANE database was consulted to check for the existence of systematic reviews based on the question in this review. The inclusion criteria were defined: 1) Age (10 to 19 years) (WHO, 2021) 2) Description of care (method, duration) 3) Victims of sexual abuse (that occurred during childhood and/or adolescence, chronically or acutely and, intrafamilial or extrafamilial) 4) Health service (hospital, clinic, institution) 5) Qualitative research or case study. Exclusion criteria were defined: cases with suspected sexual abuse. After researching the databases, articles were screened and the first exclusion was made by title and/or abstract, also eliminating those that were not in English, Spanish and Portuguese. Right after selection, the articles were analyzed Research, Society andDevelopment, v. 12, n. 6, e28812642356, 2023 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v12i6.42356 4 strictly according to the inclusion and exclusion criteria. From the included articles, three more forms of the search were carried out to ensure that all relevant publications were included by the following methods: 1) screening the references of these articles 2) from the citation of the articles included and 3) from the authors of the included articles. A reading guide has also been applied in order to familiarize with content, methodology, style, and format of each article (Barroso, 2006), which served as a support on the understanding of elements such as: objective of the author, questions of the paper, theoretical perspective, bibliographic recommendations, duration of treatment, resources, validation and recommendations, and also to reformulate inclusion and exclusion criteria if necessary. An extraction form also was created to identify specific information related to the review question: 1) Context (Where it is applied); 2) Training of the Therapist (by whom?); 2) Age of the population; 3) Duration of Treatment (how long the session lasts and how long the process took); 4) Type of trauma or abuse (what happened to the patient); 5) Specific clinical objectives (What to treat?); 6) Intervention Method (How to Treat?); 7) Potentials of the Method (Results and Experience of the Therapist) e; 8) Issues related to adolescence (behavior, comments, involvement in music therapy).Categories were created based on the topic of interest in the research and presented with verbatim from the speeches of the music therapists who treated patients who were victims of abuse. The quality assessment of the articles was based on the Checklist for case reports (Gagnier, 2013).
The databases were consulted in the period between March 2018 and October 2019. The reference management system Zotero (Zotero, 2021) was used, which exported the following information directly from the databases: authorship, title, year of publication, journal and volume/issue of the included articles.

Study Selection
The review covered the period from 1992 to 2018, based time of period which corresponds to the year from the first finding all the way to the very last one. The database searches (see Figure 1) identified 492 findings and seven studies were included after inclusion and exclusion criteria.

Data Organization
To classify and summarize results, we have clustered information in context, duration and method as it follows: In context where the care takes place was presented in 1) Hospital: music therapy care for patients admitted to a hospital, psychiatric inpatient unit, psychiatric department of hospital (short-term hospitalization). 2) Consultancy: all consultations that took place in a private practice or music therapy center 3) Institution: consultations that took place in institutions specialized in welcoming victims, offering residency, protection, counseling, legal referral, monitoring and psychological treatment. The duration of care has been short (1 to 2 sessions), medium (more than two sessions up to 2 years) and long term (minimum 2 years). The methods were framed in four types of experiences in music therapy: improvisation, re-creative; musical composition and receptive (Bruscia, 2014).  Records identified from*:  Research, Society and Development, v. 12, n. 6, e28812642356, 2023 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v12i6.42356 9

Music Therapy Method´s Used
We found the use of the four main methods of music therapy as described in the literature (Bruscia, 2014). Some articles used extramusical resources (Bruscia, 2014) like drawing and painting. One study used the four types of methods [A7].
The improvisation method was the most used [A1, A2,A5,A7]. One study [A3] used the composition method and one study [A6] used receptive music therapy.
The included articles presented different theoretical bases related to the application of the improvisation method (Bruscia, 1999). In general, their means offered the opportunity to work on interaction and issues of interpersonal relationships, dealing with symbolic content (expressed through musical instruments) and favoring the expression of emotions.

Quality Assessment of Case Studies
The articles were evaluated according to quality assessment criteria for case studies. The "Check List for Case Report" has been used (Gagnier, 2013) which assesses what types of information are contained in articles from guiding questions. One article [A7], although it was clearly qualitative research, was evaluated as a case study because it contains most of the information sought.
As a quality criterion were defined studies that brought the greatest amount of information regarding the question and the criteria of the systematic review. According to Barroso (2006), the quality of qualitative research may be related to the method applied, although it is not always possible to validate the quality of the research through the method. Therefore, the quality for this review has been declared based on the presence or absence of questions raised under the research question  Qualitative research in music therapy has specific characteristics of the area, as well as related areas. As a relatively new science, the determination of the quality of studies has been defined over almost three decades, the first discussions of which arose in the 1990s. In music therapy research, audio and video records of music and musical elements are given in Research, Society andDevelopment, v. 12, n. 6, e28812642356, 2023 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v12i6.42356 10 research and have been considered as ways to preserve the quality and validity of studies. Thinking about the role of the music therapist as a therapist and researcher at the same time, preserving ethical and methodological needs, without research [negatively affecting] clinic and vice versa, are also aspects discussed aiming at preserving quality (Langenberg, 1996).

Categories
The results of the research led to a meta-synthesis (Matheos, 2009), where categories of the main themes addressed were created and illustrated using verbatim from the speeches of the music therapists.
Category 1) potentials of music therapy in the face of sexual abuse, was divided into four main issues: Trauma, Anger, Interpersonal Relationship and Identity. Category 2) music therapy and adolescent, was divided into communication and learning.

Potentials of Music Therapy:
This category associated technique with symptom / diagnosis.

1) Trauma: recognize, communicate, express:
Recognizing one's own emotions and communicating feelings and ideas resulting from trauma out of sexual abuse is an enlightening condition that allows the individual to change and grow. "Lena's songs enabled her to acknowledge her sadness and loneliness, her anger and her joy as her music began to forge a new sense of herself, developing her confidence to face the future" [A3] "Music as a way out of silence. (…) as a space for good and secure experiences. (…) as a projection plane (for themes that are not allowed to sound). (…) as a way of mirroring emotional experiences (initiation into the ability to mentalize). (…) as a space for pleasurable experiences (with no sexual connection). Re-enactment of traumatic relationship patterns through musical interactions (e.g., terror, isolation, powerlessness). Music lets traumatic emotions be perceptible. Music as a way of clarifying, preserving and modulating unbearable experiences. Music as a space for experimenting with new experiences of relationships." [A5]

2) Anger
Anger represents one of the feelings that results from impossibility of self-defense and is closely related to assertiveness [A2]. Music therapy has the potential to deal with the main constituent elements of anger / assertiveness, such as: self-perception, emotional self-regulation, recognition of trauma, practice of tolerance, impulsivity and empowerment.
"This technique has been used mostly frequently in adolescents, the majority of whom have been females working on developing assertiveness" [A2] "The goals of this technique is to help out patients to develop assertiveness and/or anger management: by increasing awareness of body sensations, emotions, thoughts, and experiences; by increasing awareness of personal coping styles and having an opportunity to try other coping methods; by learning about the effects of early trauma on present behavior, feelings, and thoughts; by practicing tolerating uncomfortable feelings rather than acting impulsively; and by practicing acting assertively and/or practicing anger management." [A2]

3) Encourage Interpersonal Relationships
Interpersonal relationships are a difficult issue for many victims of sexual abuse. Trusting an adult is a difficult task, especially for those who were abused in childhood by family members or close to the family. Music therapy has the potential to foster a relationship of trust by promoting a space of wide existential possibilities for the patient, in a safe environment.
"Working through trauma towards normal sensory and play experiences that brought with them basic sense of body boundaries and physical safety" [A4] "Developing capacity for relationshipdeveloping trust through experiences of predictability and variation". [A4] "Proved to be a creative and safe way for her to explore an inner world of suffering, imbued with painful memories, which surfaced when listening to Nono's dissonant music" [A6]

4) Building or reconstructing identity
Identity is especially impaired in victims of sexual abuse and may result in borderline personality disorder (Wilkinson-Ryan, 2000). Music therapy allows aspects of identity to be created and recreated through self-discovery; the exchange of affection that affirms or reaffirms values, favors the awakening of wills that were previously asleep or never awake.
"The metaphorical use of instruments, including the voice, was also used to experiment with alternative, preferred constructions of identity in a safe environment [A7]

Music therapy and adolescent:
The use of musical elements in music therapy offers ways of expressing feelings, thoughts, ideas, emotions in a less confrontational way (Clendenon-Wallen, 1991) A study that compared adolescents with or without music therapy, concluded that adolescents may be more successful in music therapy treatment by reducing hostility, and thus offering them the opportunity to participate in therapy in a constructive way (Clendenon-Wallen, 1991)

1) Communication
The evidence raised pointed out that in adolescence, verbal communication can be an obstacle for therapy (Clendenon-Wallen, 1991) and also to disclosure the sexual abuse (Bae, 2017). Sexual abuse is also a limiting, restrictive factor, the violence of which includes a silence, referring to "those who are silent", "from which the voice is drawn", revealing a double challenge. Both aspects can be supported by the potential that music therapy has to give the patient a voice and provide less confrontational therapeutic paths without the need of verbalization.
"This may reveal the possibility that arts-based therapies could provide a more enjoyable introduction to the therapeutic space for adolescents, who may not initially be as drawn to verbal therapy" [A7] "It provides an enjoyable therapeutic space that does not rely only on verbal work, and may therefore be seen as less threatening and more playful than verbal psychotherapy, while still addressing important issues in creative ways [A7] "The following quotation from an adolescent [client] who had been receiving music therapy for eight months indicates clearly how an articulate client was able to avoid expressing any of the pain of her inner emotional world on a verbal level, but found these feelings very quickly being explored when expressing herself through the medium of clinical improvisation. The emotions explored were initially externalized through the improvisations, which were discussed with the client. Thus, interaction with the client was through both music and words, the primary agents of therapeutic change being the client-therapist relationship and the music (…)" [A7]

2) Learning and searching for the brand new:
Learning is inherent to the therapeutic process and from it a new way of relating to the world develops. In music therapy, learning can also appear as a musical skill revealed in the therapeutic process, improving self-esteem and selfconfidence. The young person's involvement can also include different musical experiences, exploring unusual repertoires.
"Additionally, Nancy's response to the music reveals that Nono's focused and fragile composition fits her own adolescent experience of emotional intensity and uncertainty, questioning self-identity and independence, and experimentation and novelty-seeking behaviors." [A6]

Discussion
Although there are few studies identified and included, the qualitative systematic review seeks to understand the meaning (Lockwood, 2017;Barroso, 2006) of the practice. Thus, the studies brought substantial information so that we could understand how the practice has been established so far.
The results revealed that music therapy for victims of sexual abuse is a potential means of treatment, capable of facing specific themes and difficulties resulting from violence that occurred in childhood and / or adolescence with regard to guilt and shame, self-esteem, self-confidence and social skills. We also know that the topic of sexual abuse encompasses a wide network of activities and music therapy has been present in a wide variety of contexts of care acting with a variety of methods.
Music therapy is a potential means of treatment for adolescent victims of sexual abuse in childhood and / or adolescence because it facilitates the process of communicating feelings and can facilitate the disclosure of sexual abuse; promotes anger management; favors the therapeutic bond; it is a less confrontational way to deal with abuse, it does not depend only on speech as a means of communication and expression; it is a type of art that is much appreciated at this stage of life. It can also offer paths of growth and identity formation, through the development of skills and insertion in musical practices, favoring self-esteem and self-confidence.
We were able to find in the results, objectives and potentials of music therapy in accordance with the main symptoms and consequences of sexual abuse as described in the literature: depression; anxiety; Post-traumatic Stress Disorder and several psychosocial outcomes (substance abuse, non-suicidal self-injury, suicide attempts) (Maniglio, 2009;Hailes, 2019).
The articles did not directly address the family, although in the patient's history family conditions were presented, which generally involved mistreatment and neglect (Hershkowitz, 2007). Some children lived in shelters and others were adopted.
Issues of justice, referral to shelter, educational aspects were also present in the articles included.
Disclosure of sexual abuse does not always happen after the abuse due to feelings of shame, guilt or even fear of the consequences, especially when the abuse is practiced by family members (Landi, 2019;Silva, 2020;Monge, 2020). Within the scope of revealing sexual abuse in the therapeutic process, we identified patients who revealed violence after the beginning of music therapy treatment, whose disclosure was facilitated by the non-verbal process of music therapy. The symbolization and projection of abuse through musical instruments in the process of musical improvisation within the therapeutic context were also considered forms of trauma´s communication. In some studies, patients who were abused in childhood were initially referred to music therapy for reasons for depression, or difficulty in communicating and at the end, the issue that caused it, was sexual abuse [A4, A5, A7].

Conclusion
In seeking to understand how music therapy works in adolescent victims of sexual abuse, we concluded that it uses a variety of methods and techniques to facilitate communication, expression, positive interaction, which result in improved self-esteem, self-confidence and anger management. Music therapy also presents itself as a less confrontational therapeutic modality, reduces the youth's hostility in the therapeutic process and favors the bond between patient and therapist. The music therapy process takes place in different care settings and is part of the multidisciplinary care on adolescent victim of sexual abuse.
This work is a precursor of research on the subject and, with that, presents articles with theoretical and methodological weight on music therapy for adolescents' victims of sexual abuse in childhood and/or adolescence so far. Its results may sensitize managers and health professionals, including music therapists, which may result in the offer of this therapy to this population, given the differentials of the practice and the benefits it promotes.
Our recommendations suggest that new research may add more studies related to the topic if they qualitatively investigate music therapy for symptoms of sexual abuse related to Post-Traumatic Stress Disorders, Dissociative States, Neglect, Domestic Violence, since these themes are directly correlated with sexual abuse. As well as research that develops care protocols in hospitals and outpatient clinics may contribute to the protocols of music therapists and facilitate the insertion of music therapy in health systems. Our limitations may have been the exclusion of suspected sexual abuse. It is known that many cases of sexual abuse are unknown. Children who have suffered physical abuse and neglect may have been exposed to sexual abuse and its disclosure has become increasingly complex over the years, configuring a specific music therapy service.
Studies focusing on adolescence are few, most of the publications included children and adolescents or the sexual abuse that occurred in childhood, so we cannot state the potentials of the techniques related to this phase of life specifically, although we have filtered the subject based on the knowledge about music therapy and about adolescent health.