Visual attention is the process that enables us to select relevant visual stimuli in our environment to achieve a goal or perform adaptive behaviors. In this process, bottom-up mechanisms interact with top-down mechanisms underlying the automatic and voluntary orienting of attention. Cognitive functions, such as emotional processing, can influence visual attention by increasing or decreasing the resources destined for processing stimuli. The relationship between attention and emotion has been explored mainly in the field of automatic attentional capturing; especially, emotional stimuli are suddenly presented and detection rates or reaction times are recorded. Unlike these paradigms, natural visual scenes may be comprised in multiple stimuli with different emotional valences. In this setting, the mechanisms supporting voluntary visual orientation, under the influence of the emotional components of stimuli, are unknown. We employed a mosaic of pictures with different emotional valences  and explored the dynamics of attentional visual orientation, assessed by eye tracking and measurements of pupil diameter. We found that pictures with affective content display increased dwelling times when compared to neutral pictures with a larger effect for negative pictures. The valence, regardless of the arousal levels, was the main factor driving the behavioral modulation of visual orientation. On the other hand, the visual exploration was accompanied by a systematic pupillary response, with the pupil contraction and dilation influenced by the arousal levels, with minor effects driven by the valence. Our results emphasize that arousal and valence should be considered different dimensions of emotional processing both interacting with cognitive processes such as visual attention. In vision as well as in other sensory modalities, our capacity to process stimuli is limited. Therefore, attention or the ability to select relevant information for the current task is central to adaptive behavior and survival . One mecOn visual attention, many efforts were dedicated to establish how the physical properties of the stimuli, such as color, contrast, or orientation, could explain exploratory behavior and how these characteristics fit in saliency models capable of predicting ocular exploration . HoweverThis may explain why saliency models do not perform well in free viewing paradigms, where the effect of voluntary behavior is larger than in restricted detection tasks. The actual trend in saliency modeling is to include cognitive factors in order to increase the accuracy of the models .One of the many cognitive factors related to visual attention is emotional processing. From an evolutionary perspective, emotions are essential to quickly identify potential threats or benefits and perform appropriate responses to secure survival .The emotional experience is accompanied by a series of physiological responses, which are triggered in an involuntary and unconscious fashion. The physiological responses are under autonomic control and involve changes in blood pressure, heart frequency, skin conductance, and pupillary diameter. Pupillary diameter reflexively regulates the amount of light that enters the eye but also changes its size when the subject performs a cognitive effort . A partiPrevious studies have explored the relationship of emotional content with visual attentional orienting using ocular behavior , microsaWe conjecture that the emotional content of the visual object would contribute to enhance the saliency of elements of visual scenes and thus contribute to modulate visual exploration toward the emotional images, increasing the time spent on emotional pictures. In agreement with previous evidence, we also expect the magnitude of the pupillary response to be similar when attention is located on emotional stimuli regardless of the hedonic value and to significantly differ when attention is located on non-emotional stimuli. By showing an arrangement of pictures with different emotional content, we examined the attentional bias toward emotional stimuli during voluntary orienting of attention, differentiating the contribution of the emotional valence and arousal.M = 28 years, DS 4.9) participated in this study. All participants had normal or corrected to normal vision, did not report any psychiatric or neurological condition, did not consume drugs that acted on the nervous system, and gave written informed consent. The experiment was approved by and was carried out in accordance with the recommendations of the Human Research Ethics Committee from the Facultad de Medicina, Universidad de Chile. All subjects gave written informed consent in accordance with the Declaration of Helsinki.Twenty-eight  healthy volunteers, ranging from 20 to 37 years  . Each mot(754) = 41.79; p < 0.001] and an ANOVA on the valence scores . Multicomparison analysis with Bonferroni correction indicated significant differences between all the pairs of valences .To ensure that images differ from each other, we performed a t-test on the arousal scores , and not the arousal  nor the interaction of them  , explained the differences in dwelling time between conditions. Thus, although the visual exploration differs according to the valence and arousal of the images, the valence of the picture is the main factor driving the observed ocular behavior.However, an ANOVA test indicated that it was the valence of the picture . This reduction in exploration is consistent with previous observation that demonstrated that subjects initially globally explore the image to then move into more local regions , we found that immediately after the transition of one picture to another, within the same mosaic, the pupil exhibits a fast contraction that reaches its smallest value around 500 ms. This response was followed by a dilation phase, with a maximum value of 1000–2000 ms. Figure p < 0.001, SC p < 0.001, LC p < 0.001). Between categories, neutral and positive picture do not present significant differences in any of the parameters studied – maximum contraction (MC p = 1), the latency of maximum contraction (LC p = 1) and speed of contraction (SC p = 1). Negative pictures trigger the same curve pattern but with smaller contraction, shorter latency, and slower speed of contraction; all of them are statistically significant in comparison to neutral  and positive pictures . This result suggests that the autonomic response triggered by the pictures is affected by the hedonic value, resulting in a smaller and slower contraction phase for negative pictures.During the contraction phase, all the variables studied showed significant differences . The latency of dilation didn’t show differences between categories (LD p = 0.1). Negative pictures compared to positive pictures show significant differences only in maximum dilation  and speed of dilation . The lack of difference in the delta dilation (DD p = 1) reflects a similar pupil size change, thus we could infer a similar autonomic activation, although the response is faster for negative pictures. Between the negative and neutral pictures, we found significant differences in MD , DD , and SD , giving an account of faster and larger dilation responses for negative pictures. Lastly, when neutral pictures were compared with positive pictures, we found a significant difference only in DD ; hence, the pupil reactivity is larger but not faster for positive pictures in comparison with neutral pictures.After the contraction phase, maximum dilation (MD), delta of dilation (DD), and speed of dilation (SD), significantly differ between emotional categories .We found that every variable studied was influenced by the level of arousal, where significant differences exist from the contraction to the dilation phase. High arousal pictures triggered contractions of smaller amplitude, which occurred earlier in time and with slower speed when compared to low arousal pictures .During the dilation phase, the pupillary dilation observed was larger in amplitude for high arousal pictures, the DD was also larger, and the peak of amplitude was reached later and slower than the one triggered by low arousal pictures . After the initial contraction, the pupillary diameter dilated in both cases but with significantly larger maximum dilation, the delta of dilation, and faster speed, in the case of high arousal negative pictures . Thus, within the negative category, the arousal significantly impacts the pupillary reactivity from contraction to dilation phase.The pupillary response to negative pictures showed a clear modulation that began in the contraction phase Figure . High arp = 0.025, U3 = 0.33). The dilation phase had a similar speed for high and low arousal pictures; however, for positive-high arousal pictures, the amplitude peak was significantly larger and was reached later in comparison to positive-low arousal pictures . Then, in the case of positive pictures, the arousal level can also influence the pupillary reactivity, though in the dilation phase mainly and in a milder way than the one found within the negative category.For positive pictures, the differences were evident only within the dilation phase. During contraction, only the latency of contraction was significantly smaller for the high arousal pictures in comparison to the low arousal pictures Figure   = 7.52, p = 0.007; LC F = 10.4, p = 0.002; SC F = 3.9, p = 0.0499]. For the dilation phase we found that the maximum and delta of dilation depended on the arousal exclusively , while the speed of dilation depended on the arousal  and also on the interaction between valence and arousal , and latency of dilation on the interaction .The ANOVA test indicated that the differences observed during the contraction phase weren’t due to the valence or the arousal independently but due to the interaction of valence and arousal [CM Overall, our data demonstrated that while ocular behavior was explained by the valence of the pictures observed, the pupillary response, which gives us an approximation of the autonomic state linked to the emotional process, was mainly influenced by the arousal level of the pictures with a much smaller effect of the valence.In our study, we investigated the influence of the emotional component over the visual attentional process. When subjects explored an arrangement of emotional pictures in a free viewing paradigm, we evidenced a facilitation exerted by the emotional component of the pictures over the voluntary visual attentional driving. We described a bias toward hedonic pictures due to the valence and not the arousal dimension of the images. This bias is characterized by an increased time spent observing emotional pictures, especially the ones of a negative nature. At the same time, the pupillary recording gave us an indirect measurement of the autonomic state experience during the gaze shifting, and we determined that although the valence is relevant to the visual behavior and the emotional state triggered, the effect is mainly due to the arousal level of the pictures with some level of interaction with the valence dimension.The attentional bias to emotional stimuli had previously been studied with different strategies. The first approach investigated how the exposure to an emotion can favor or diminish the performance of subjects during an attentional task like emotion recognition  or flickThe top-down modulation is also present from the attentional capture to the maintenance since it influences the saccades programming  and the Single presentation of stimuli or simultaneous and sudden presentation of two or more pictures do not necessarily explain the process of visual orienting of attention in an ecological situation, where the emotional context is neither homogeneous nor changes randomly and constantly. With our paradigm, we approached the behavior in a better way in an open uncontrolled situation. By allowing the subjects to explore self-limited pictures of opposite emotional value for a long period of time and in a free fashion, they had the chance to look for or avoid the perception of any emotion.To distinguish the stages of attention within a task, some authors have used the terms vigilance and maintenance referring to the initial detection of and the posterior dwelling on a stimulus accordingly . Using tIt is possible that along with an emotional bias, other spatial biases are present. The central fixation bias indicates that the central area of a picture always concentrates a larger amount of fixations in comparison to the periphery of the image . In our Our results are in the same line of other authors who have established an independent mechanism for processing arousal and valence dimension of emotional stimuli. Although many studies explore the cerebral activity when the valence or the arousal vary , the impWhen we separated our data according to valence and arousal levels, we observed that the main variable that influences the ocular behavior is valence, but arousal does have an impact on the emotional state of the subject experiments. We considered it essential to include a metric as the pupillary diameter to give an account of the emotional state triggered by the pictures. All the studies previously mentioned that relate emotion to visual attention rely on the preconceived hedonic value of the pictures, lacking any metric indicating the adequate perception of the picture and if the behavioral variables explored are accompanied by some physiological specific response.Previous work using single emotional pictures had described how the pupil was modulated by the emotional value of the stimuli in dissimilar situations. One study established that when subjects listened to emotional sounds, they experiment an increase in their pupillary diameter for negative and positive emotions . The modOne interesting aspect of the pupil response in our parading, is that although the temporal profile of the pupil response characteristically extend over 1 or 2 s , our pupOur study supports the idea of differential processing of valence and arousal and provides a novel paradigm which allows the study of the voluntary orienting of visual attention and delivers an accurate metric of pupillary response that could be used in ecological situations.CA and PM designed the study and wrote the manuscript. CA and KM carried out the data acquisition and analyzed the data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Physical manifestations of Turner syndrome include short stature, a webbed neck, and a shield chest with widely spaced nipples. An aspect of the disease which has not been sufficiently explored so far is the tactile sensitivity of Turner syndrome patients. Thus, the aim of the study was to assess the threshold of tactile sensitivity on hands and feet of women suffering from Turner syndrome. Information on the participants of the study was collected on the basis of questionnaires, as well as anthropometric measurements using a skinfold caliper. Semmes-Weinstein Aesthesiometer was used to find the tactile sensitivity threshold of hands and feet of study participants. Based on the results of the study, significant differences in tactile sensitivity between women with Turner syndrome and healthy women were found. Affected women seem be more sensitive to the touch on the feet than healthy volunteers. The results of the study showed that the tactile sensitivity of women with Turner syndrome is different from that of healthy women. Turner syndrome affects one in 2500 live female births and is caused by a complete or partial loss of one X chromosome. Half of the individuals suffering from the condition have a monosomy X karyotype, while the other half is characterized by mosaicism.Newborns affected by Turner syndrome have lower body weight and are shorter compared to healthy infants. Other physical manifestations which are seen in girls with Turner syndrome include skeletal disproportions, such as micrognathia, high-arched palate, short fourth metacarpals, genu valgum, Madelung wrist deformities, and short limbs.Since growth is usually compromised in untreated patients with Turner syndrome, affected girls have an average final height of 143 cm, which is about 20 cm lower compared to the healthy population . NonetheTurner syndrome patients are at risk of congenital malformations of the heart and renal abnormalities. Ovarian dysgenesis and premature ovarian failure in Turner syndrome are associated with the lack of properly developed secondary sex characteristics, infertility, and osteoporosis. However, sex hormones deficiency may also lead to increased cardiovascular risk, diabetes, autoimmune disorders, and influences the state of physical fitness. Since research evidence supports the effectiveness of pubertal estrogen replacement with E2 in Turner syndrome most patients undergo this regimen .Studies show that Turner syndrome girls perform worse on spatial, attentional, and memory cognitive tasks and have more psychosocial problems than short-stature girls with a normal karyotype. It is postulated that estrogen may act as a neuro-protector, which may selectively benefit certain cognitive tasks. Thus, deficiencies in estrogen, like the ones experienced by Turner syndrome patients can result in impairment of cognitive abilities .Among the many impaired factors, senses are included: Touch, sight, hearing, smell, and taste determine human cognitive abilities, starting in infancy. Thus, the impairment of any of the senses, including the sense of touch, reduces cognitive abilities. What is more tactile sensitivity is a feature that can significantly support the performance of daily motor coordination tasks and human’s motor development which improves body composition and physique. Tactile sensitivity of hands and feet can also profoundly influence physical fitness and affect the overall quality of life.We believe that tactile sensitivity of Turner syndrome patients is an aspect of the disease, which has not been sufficiently explored. Especially in the light of studies showing how important sensory integration is in treatment of children with developmental and behavioral disorders. This article is the first that documented the phenomenon of changes in tactile sensitivity in women suffering from Turner syndrome.Thus, the aim of the study was to assess the threshold of tactile sensitivity on hands and feet of patients suffering from Turner syndrome compared to heathy female volunteers.The study also verified whether growth hormone therapy, the use of hormone replacement therapy, body fat, height, and body weight of patients have an impact on the threshold of tactile sensitivity.The study group consisted of 30 women with Turner syndrome (group T), while the control group (group Z) included 37 healthy female volunteers not affected by the condition. Women from the control group were of similar age and lived in similar social conditions to those with Turner syndrome.Information about the research was disseminated among Turner syndrome support societies and participants were recruited during support meetings. The inclusion criteria for the study were the following: Females diagnosed with Turner syndrome, 10–70 years old, with no history of diabetes. After completing the screening process which determined patients who met the inclusion criteria, the potential participants had a consultation and were provided with all information about the study. Written informed consent for the study was obtained from all participants or their legal guardians. The control group was recruited among healthy female individuals, 10–70 years old, who were not diagnosed with Turner Syndrome and did not suffer from any diseases associated with growth.The exclusion criteria were blindness and visual impairment of participants as well as severe intellectual disability and mental disorders preventing proper verbal contact.The study was approved by the Bioethical Committee of the Poznan University of Medical Sciences (Resolution No. 517/14).Measurement of the tactile sensitivity threshold of hand and feet was carried out with the use of Touch-Test™ Sensory Evaluators  according to the Semmes-Weinstein Monofilaments Test.Tactile sensitivity was measured using Semmes-Weinstein Aesthesiometer on both hands and both feet. The measurement points were the little finger, the index finger, and the metacarpus of the hands; on the toe, the external edge of the foot at the small toe, and the outer edge of the foot in the middle of its length in case of feet.During the test the subject was lying on their back with their eyes closed. Aesthesiometer’s filaments were applied perpendicularly to the above-mentioned measurement points. The thinnest filament which exerted a tactile impression determined the threshold of the subject’s tactile sensitivity . The numTactile sensitivity as a human sense depends on the distribution of touch receptors on the skin and the depth of their location on the skin. If the skin is thick, the receptors are deeper and thus the researcher will find a higher tactile sensitivity threshold what means a weaker response to touch. Nevertheless, the researcher noted the specific reaction of the examined person either “I feel the touch of the measuring device” or “I do not feel the touch”. Therefore, testing the threshold of tactile sensitivity using the Semmes-Weinstein aesthesiometer gives precise results appropriate for statistical analysis. However, the impact of various factors on tactile sensitivity was not studied, but differences in tactile sensitivity between women with Turner syndrome and healthy women were researched. Researcher examined correlations of tactile sensitivity with the thickness of skinfolds, the use of growth hormone, the use of replacement therapy, and the level of education.A skinfold caliper was used to measure the fatness of the body. Participants were examined in a standing position, with upper limbs hanging freely along the torso and eyes directed forward. The researcher, using his fingers, grabbed a given skinfold and measured its thickness with a caliper. The thickness of the following skinfolds was assessed: Folds on the cheek, folds on the chin, axillary folds, folds on the back and the front of the arm, shoulder folds, folds on the tenth rib, folds on the abdomen, folds on the side of the trunk, kneecap folds, and popliteal folds. Anthropometric measurements included also the assessment of height and weight of the participants.All women were subjected to a questionnaire in which personal data and information regarding growth hormone treatment and hormone replacement therapy and accompanying diseases were collected.p < 0.05 was considered to indicate statistical significance.All obtained data was analyzed using Statistica 13.3 software . Due to the lack of normal distribution of the data, non-parametric statistics were applied. Differences between the two studied groups were analyzed using Mann-Whitney U test, while associations between variables in the studied groups of Turner syndrome patients and healthy volunteers were assessed using Spearman’s rank correlations. The age of patients with Turner syndrome (group T) was between 10 and 61 years, while women in the control group were aged between 17 and 68. No difference in the age of the analyzed groups of women was detected .Of all women with Turner syndrome taking part in the study, 12 had never been treated with growth hormone; the remaining 17 had been or were being treated with the hormone. One patient did not answer the question about the use of growth hormone.The examined groups of women showed differences in height and body weight .The study showed that there are no significant differences in terms of tactile sensitivity of hands between women with Turner syndrome and heathy women. All studied women showed similar sensitivity to the touch on both right  and leftThe analysis of the results obtained in the Semmes-Weinstein Monofilaments Test conducted on the study participants showed differences in tactile sensitivity of selected points on the feet between the group of Turner syndrome women and healthy volunteers.p < 0.05). The tactile sensitivity threshold of the point identified at the outer edge of the right foot in the middle of its length was the same for both studied groups.Individuals with Turner syndrome showed higher tactile sensitivity of the right foot in the measurement point of the first toe and the external edge of the foot at the small toe than healthy women . In bothp < 0.001) and in the middle on the outer edge of the left foot (p < 0.05)  . In all The data obtained in tactile sensitivity tests showed associations with results obtained in body structure measurement of the participants. In both groups, tactile sensitivity showed statistically significant negative correlation with the thickness of selected skinfolds .The results obtained from the comparison of tactile sensitivity threshold between women with Turner syndrome who underwent growth hormone stimulation with those who did not undergo such treatment showed statistically significant differences in selected points of the hands and feet.p < 0.05), the small finger (p < 0.05), and on the metacarpus of the right hand (p < 0.05), as well as on the outer edge of the right foot at the small toe (p < 0.05) (Women within the T group who were treated with the growth hormone were more sensitive to the touch on the index finger ( < 0.05) .p < 0.05)  .In the group of Turner syndrome women, those who had higher education turned out to be less sensitive on left feet on the first toe, in comparison with women with low education .Touch is the first of senses to develop in a human being and it provides the body with a sensory scaffolding. However, tactile perception is in truth a part of a complex human sensory system, consisting of proprioception, mechanoreception, thermoreception, and nociception. Studies show also that tactile sensitivity supports the performance during movement tasks.Among many physical manifestations, tactile sensitivity of women with Tuner syndrome has not received much attention and our study is the first to document changes in tactile perception of hands and feet of Turner syndrome patients in comparison to healthy female volunteers.The Semmes-Weinstein Monofilaments Test did not show any statistically significant differences in tactile sensitivity of the hands between groups. However, such differences were found on feet. What is more, a correlation between thickness of skinfolds and the threshold of tactile sensitivity in patients was found, which proves that higher fatness in the upper body was associated with reduced tactility on the feet.Ontogenetic development of tactile sensitivity depends on many genetic and environmental factors ,12. It hIn other studies of Kaluga et al., it was proven that the type of sports discipline practiced also influences the threshold of tactile sensitivity. These studies have shown that individuals who practice swimming have a decreased threshold of tactile, while basketball players exhibit an opposite phenomenon .Hennig and Sterzing examined the threshold of tactile sensitivity in 30 places on the plantar and dorsal sides of feet using Semmes-Weinstein Monofilaments. The research was conducted in a group of women and men aged 20–35. The plantar side of the feet turned out to be more sensitive . In thesThe level of tactile sensitivity may be influenced by various factors, including biological ones , psychic (intelligence level), or social. According to Kozłowska, the body dimensions may be related to the tactile sensitivity. For example, individuals with low height, have a higher receptor distribution on a given surface unit. Similarly, assuming that higher tactile sensitivity is associated with a higher density of receptors, leaner people will be more sensitive to the touch than obese people . In our The conducted studies showed that treatment with growth hormone had a positive effect on the feeling of touch of upper limbs. Patients who used this hormone showed greater tactile sensitivity on right hands. As far as we know there were no other studies documenting the relationship between growth hormone therapy and tactile sensitivity. Other researchers who analyzed tactile sensitivity in people aged 19–88 also did not show statistically significant relationships between the use of medication and the threshold of tactile sensitivity .The results of this research confirmed that the use of hormone replacement therapy affected patients’ tactile sensitivity of their left feet. The effect was negative. A direct relationship between these traits has not been established so far, but the results of studies in 32 women prove that there is a connection between lower tactile sensitivity and estrogen deficiency, which is treated with hormone replacement therapy . What isIn further research it should be considered what the differences in feet and hand sensitivity are caused by.First of all, the obtained results have a status of basic research. A completely new knowledge about the tactile sensitivity of women with Turner syndrome have been acquired.Surprisingly we learnt that women with Turner syndrome are more tactile on the feet than healthy women. This is a feature for practical use, they can be more effective in developing body balance. Tactile sensitivity allows to feel the pressure of the feet on the ground and unevenness of the ground, significantly helps the body balance in standing and in motion. This can be a clue for the direction of professional or sports development, and for those who are less physically fit to choose exercises during physical rehabilitation.We learnt that tactile sensitivity of women with Turner syndrome is similarly conditioned as in the population studies of other authors: Slim and more educated individuals are more tactile sensitive.Women with Turner syndrome treated with growth hormone are more tactile and this should be an additional argument for using this treatment. What is more Turner syndrome patients treated with estrogen replacement therapy were less touch sensitive. This is certainly not an argument for suspending such treatment but it is a very interesting information. The obtained result can act as a basis for further research where such correlation would be thoroughly explored.The results of the study confirmed that Turner syndrome patients are characterized by lower stature and greater weight compared to healthy women. It is the first study to document that female individuals with Turner syndrome are more sensitive to the touch on their feet than healthy women. Based on the conducted research, it may be also postulated that among Turner syndrome patients’ differences in tactile sensitivity may be associated with estrogen and growth hormone therapy.


Thematic content analysis was used. descriptive research with a qualitative approach, based on 214 reportsselected from the Brazilian campaign #girls were the main victims of sexual abuse. The perpetrators were mostlymale and people they knew. Five categories emerged from the narratives:Sexual abuse in the aggressors’ discourse; The child as the object of sexualpleasure; Violated childhood; Victims’ guilty feelings; and Repercussions ofsexual abuse experienced in childhood. sexual abuse often occurs in the family context and, even if sometimesveiled, the submission of girls’ power in gender relations and of childrenin generation relationships is evident. Analyzing sexual abuse under thecategories of gender and generation contributes to an in-depth understandingof the phenomenon, directing practices more effectively to their coping. Child sexual abuse is a complex social phenomenon of great repercussion. An Americanstudy of fatal and nonfatal sexual abuse cases found that in 2015 they representedan economic cost of $9.3 billion to the US. This cost was associated with health,productivity, child welfare, violence, crime, education and quality of lifeAccording to a report by the United Nations Children’s Fund, in 2012, an average of17 million reports of sexually abused women in childhood were recorded in 38 low-and middle-income countries. In 28 European countries, there were approximately 2.5million reports of adolescents sexually abused before 15 years of ageMost sexually abused children often do not report the situation due to fear, guilt,shame, lack of trust and lack of knowledge about support servicesprimeiroassedio (first harassment), based on the case of a12-year-old girl who, after participating in a television program, suffered variousforms of aggression, mainly via the internet. In this campaign, women were able toreport and share situations of sexual abuse experienced during childhood.In the year 2015, in Brazil, a social network created the campaign#The present study used this database. Although, the campaign has the word“harassment” in the title, in this research we adopted the term “sexual abuse”. Thisis the way in which Brazilian legislation criminalizes the actions practiced againstchildren and adolescents, from the carnal conjunction or libidinous act, in personor by electronic means-It is noteworthy that reports on child sexual abuse do not reveal its magnitude,since there is a significant number of sexually abused children who externalize ordenounce this traumatic experience only in adult lifeAiming to contribute to the development of analyzes on child violence, as well as toprovide a broader understanding of child sexual abuse, in addition to the merelydescriptive approach, i.e., looking at interventions in social reality, theobjective of this study was to analyze the narratives of women who had been sexuallyabused in childhood identifying issues related to gender and generation.This is a descriptive research of a qualitative approach, based on reports from theusers of a social network, Twitter, which establishes momentary connections. Itsusers use the “#” (hashtag) to highlight a subject in a tweet, which consists of amessage with a maximum of 140 characters. Tweets that have the same label can begrouped and searchable on a specific topicprimeiroassedio (first harassment), in which young women andadults published tweets about sexual abuse experienced in childhood. Data collectionwas performed from October 22 to November 22, 2015, one month after the creation ofthe hashtag.In this research, reports were selected from the Brazilian campaign#For the collection and systematization of the data, a structured instrument was used,containing the number of the tweet, the victim sex and age, the location of theaggression, the relationship between the aggressor and the victim, the date and timeof publication, and full report.A total of 530 tweets, identified by codes from T1 (tweet 1) to T530 (tweet 530),were collected. For the research, 214 tweets were selected, considering theinclusion criteria: reports of women; age between four and nine years at the time ofsexual abuse; presenting the location of the aggression; the aggressor’s sex; andrelationship of the aggressor with the victim. We excluded publications that did notrefer to personal reports of sexual violence and repeated messages.-The minimum age at the time of sexual abuse was established as four years due to thepossibility of users remembering and describing the situation more accurately.Studies carried out with children allegedly sexually abused to verify thepotentiality of the forensic interview to investigate the crimes also presented fouryears as the minimum age of participantsThe reports of the selected tweets were submitted to thematic content analysisIn this context, the gender category is based on the difference between men andwomen, which composes the social relations and the construction of meanings on therelations of power in societyThis research did not require approval from the Research Ethics Committee because itused data from a social network, of free access on the Internet. The ConsolidatedCriteria for Reporting Qualitative Research (COREQ) guide was applied in order toverify the scientific quality of the research. This guide was adapted according tothe specificity of the research database. In this way, the criteria of the seconddomain were partially met and those of the third domain were completely met.In the data collected, a total of 214 Brazilian women reported having been sexuallyabused in childhood. It should be noted that, due to the use of tweets, it was notpossible to characterize these participants. Violations had occurred when they werebetween four and nine years of age. Approximately one quarter (27.57%) of theparticipants stated that the situation of violence had occurred at the age of eight;21.02%, at nine years of age; 16.82%, at seven years of age; 15.88%, at six years ofage; 10.74%, at five years of age; and 7.94% at four years of age. The number ofcases increased as age increased.Concerning the location of the aggressions, 48.13% of the participants reported itwas at home and 13.55% in the street. The other participants mentioned the school,the church, the park, the beach, the farm, the pool, the shop, the bakery, the malland the bus. We found that child sexual abuse is more frequent in the homeenvironment.Regarding the authors of the aggressions, 97.66% were male. The age of the aggressorswas not reported in 84.11% of the tweets. When reported, the victims informed thatthe perpetrators of sexual abuse were older than the victims. As for the type ofrelationship with the aggressors, 22.42% were unknown persons. The otherparticipants were victims of known persons, such as family members and friends ofthe family.The analysis of the reports allowed the emergence of five empirical categories:“Sexual abuse in the aggressors’ discourse”; “The child as an object of sexualpleasure”; “Violated childhood”; “Victims’ guilty feelings”; and “Repercussions ofsexual abuse experienced in childhood”.Sexual abuse in the aggressors’ discourse, theparticipants revealed that the abuse was not restricted to physical contact. Theaggressors used terms that expressed desire for the developing female body:When I was seven, a friend of my father’s, every time he saw me, he usedto say I was beautiful, and that when I turned 15 I would marry him(T204). I remembered that when I was eight, a 16-year-old boy said that Iwas ‘just ready’ (T51). At the age of eight I used to be calledhottie by the masons (T134).In the category The reports revealed that the aggressors expressed desire for the female body duringthe childhood of the victims and their adolescence was the moment for theconsummation of that desire. Such a fact leads us to believe that the aggressors seethe child being prepared to become an adult and to “be ready” to be “attacked.” Itis as if in the phase of adolescence or of adult life the woman was allowed bysociety to be violated, which, in childhood, would be socially condemned.The speeches also revealed the child’s reification (“being ready”) and a wilddisposition (“attack”), in which the adult man is the predator and the strongelement, while the child is the prey, the weak and helpless element of therelationship.The child as an object of sexual pleasure, thesurvey participants reported that, in the context of sexual abuse, their bodiesappeared to be territories of free access to the perpetrators insofar as they weretouched without consent: When I was seven, a priest of my family was here athome. He and I were alone in the bedroom and he ran his hand over my ass.Disgusting! (T167). My stepfather. He ran his hand over my bodywhile my mother slept [...] (T294). A grandfather of a littlefriend took advantage of the fact that he was taking care of us to put his handin the middle of my legs (T409). A great-uncle always keptputting me on his lap and was running his hand over me over my shorts(T83). In the living room of my grandmother’s house, I was alone with myuncle and he put his hand inside my panties (T122). A friend’sfather would put me in his lap and put my hand inside my panties, touchingme (T228).In the category The comments emphasized the domestic environment as a frequent place for theoccurrence of sexual abuse. Violations generally occurred in situations understoodas caring and affection, at times when the aggressor and the child were alone.Violated childhood, the speeches revealed thataggressors took advantage of the naivety and innocence of children to engage insexual abuse: My dad made an album of me taking a shower. I was sexuallysuggestive in the photos, ‘in his sick mind’. I was six years old (T68). It waswith a painter at my parents’ house. I was nine years old. He made me suck hismember. I had no idea what I was doing (T245). My aunt’shusband used to caress my legs and moan as he did so. I was only four; it tookme about 10 [years] to understand what it meant (F306).In the category At the beach house, a family friend put his hand under mydress and asked if I wanted to play (T501). The neighbor used to do a “game”throwing me and his daughter, at same age, up and letting us falling downthrough his body (T386). I was playing, and then an uncle putme on his lap and smoothed the breasts that I did not even have (T496).An uncle called me to play doctor. He put himself on top of me and beganrubbing himself (T168).The moments of play, a characteristic activity of childhood, consisted of appropriatesituations for adults to practice sexual violence in a veiled and somewhatpermissive way: The aggressors took advantage of situations characteristic of childhood, such asplay, to practice sexual abuse. In this way, the participants could not immediatelyrecognize the violence, which prevented the attackers from being blamed andreported.Victims’ guilty feelings included testimonies ofparticipants who, when in childhood, had difficulties to report sexual abuse torelatives or persons they knew because they felt guilty. Even in situations wherethey tried to report what happened to some adult, they did not receive attention. Insome cases, the violation was considered a reason for mockery: My firstharassment came from my stepfather when I was eight, unfortunately! I wasashamed to tell my mother, but today he is paying for everything(T231). Me, nine years, swimming training. He, the driver who used totake me to the club. For years I thought it was my fault (T471).I was nine years old and a neighbor squeezed my breasts. I told an adultand everyone laughed. I was still blamed for what happened (T415).The category The fact that the perpetrators of sexual abuse are known adults or who have anaffective bond with the participants may have further confused the perception inchildhood about the abusive act.Repercussions of sexual abuse experienced in childhood,the reports described long-term consequences for the participants’ lives. Theyreferred mainly to psychological and social traumas, which influenced theinteraction with other people and the perception about themselves: Nineyears old, a man tried to grab me in front of my cousin’s old house. To this dayI do not walk the street where it occurred (T263). I was eightyears old, a relative kissed me against my will and ran my hand all over mybody. No one knows the psychological consequences of this (T182).Seven years old. A man grabbed hold of me inside the church. Afterkissing me, he apologized. I felt disgusted with myself, developed OCD(Obsessive Compulsive Disorder) (T388). At six, on vacation, Iwoke up with a friend of my brother’s hand on my ass. I was never a childanymore (T280).In category The reports show that sexual abuse in childhood consisted of a traumatic experiencethat had many repercussions in the life of the participants.The analysis of the reports of Brazilian women who experienced sexual abuse inchildhood confirms that the phenomenon is determined by unequal relations ofgeneration associated with the constructions of gender roles, which influencepatterns for the female and male since childhood-,The differences between the generations and the genders, which underlie themanifestations of violence in childhood, are results of the established asymmetry ofpower between the female and the male (intergender relationship) and between thechild and the adult The fact that the participants had suffered sexual abuse between the ages of four andnine, especially in the domestic context and by men they knew, is similar to thatfound in other research with sexually abused children and adolescents. It wasidentified that the first violations were recorded in the pre-school and schoolphases and that the perpetrators were predominantly male and known by thevictimsThis aspect demonstrates the submission and dependence of the victims in relation tothe perpetrators, most of whom are responsible for the victim’s subsistence. Thus,some adults responsible for the care of the child or who maintains an affective bondwith her have totally distorted the love or care relationship, committing acts thatimplied child sexual abuse, with attitudes vastly opposed to that expected.The domestic environment presents itself as a favorable place for perpetrating childsexual abuse, since, in general, it guarantees protection to the aggressors and thesilence of the victims. Data from the Violence and Accidents Surveillance System(VIVA) Report from 2009 to 2011 reiterate the results of this study revealing thatthe highest proportions (62.4%) of the cases of violence against children andadolescents occurred at homeGirls suffered sexual abuse mainly from male offenders. This highlights theimportance of considering the gender issues for understanding and interpreting thisphenomenon. This result also corroborates the data from the VIVA Report, from 2009to 2011, in which girls stood out among the victims of sexual violence (79.8%), andmost perpetrators were male (95.5%)-The fact that girls represent the majority of victims of child sexual abuse isassociated with the relationship of domination between the aggressors and thevictims, forming two forms of submission: related to gender  andto generation (an adult over a child)These forms of domination become more expressive when perpetrators are known to thevictims, since children are often dependent on adults - usually family members - tosurvive. Since the family is socially recognized as responsible for providing carefor the child, guaranteeing adequate conditions for child development, it iscontradictory that the person who should protect and care for the children harmsthem. For children, acknowledging the abuse even when adults represents a doubleviolence - the aggression itself and the refusal of protection.On the other hand, the State, which should share with the families the responsibilityfor child protection, appears to be negligent both in public policies and ineffective actions. Studies highlight the failures of services and the childprotection network, with lack of knowledge of professionals about what to do andwhere to refer victims, shortage of workers and lack of support from other services.There are also gaps in professional training, lack of clarification in thedefinition of roles, work overload, lack of time to implement more effective care,fear of involvement with the problem and fear of invading family privacyprimeiroassedio (first harassment)campaign also revealed that the manifestation of sexual desire by men is not limitedto adult women, but extends to girls, arousing greed, situation that incurs inabuse. Therefore, the female body has become the object of sexual desire sincechildhood, with the foreshadowing that, at some point of its development, it can besexually dominated.The reports published in the #When the victim of sexual violence is a child, there is also the difficulty tounderstand the abusive relationship. A survey of 118 children between five and eightyears of age, using a risk scenario simulation, found that 20% of the participantsaccepted verbally leaving a place with an unknown person, while half of the samplereported the presence of this unknown only after having been questioned, andone-third of the children did not disclose this information after beingquestionedThe location and author of the aggression make it prone to perpetrate child sexualabuse, since the victim is involved in power relations associated with gender andgeneration issues, occupying the weakest and most powerless pole, including on theautonomy of their own body.Concealed and hidden abuse in the private spaces of homes or in relations offriendship and kinship confuse children, who have no defense mechanisms andarguments against adult domination. This is aggravated when sexual abuse is reportedto adults and disqualified.A survey of 11,364 Finnish children about the communication of sexual abuse inchildhood found that 80% of the participants had shared the situation, in whichfriends (48%) and mothers (20%) were the most frequent listeners. However, only 7%had reported it to the police, 5% to a teacher, 4% to a social worker, 3% to theschool counselor and 2% to the school nurse. The main justification for notrevealing it was to consider the experience as irrelevant (41%)In addition, the fear, guilt and concern associated with the reaction of adultsconstitute barriers to reporting cases of sexual abuse experienced in childhood andadolescence. This situation can be overcome by the dialogue established for thesharing of experiences and the search for support to cope with violenceThe frailty manifested by children in recognizing sexual abuse and the difficulty indistinguishing reality from fantasy were artifices used by perpetrators to commitrape during false play. Thus, the experience of being abused in childhood reflectedin the play of the victims, which is one of the ways children interpret the world inwhich they live.With regard to the recognition of violence, a study of 161 participants aged four to17 years found that only from 14 years of age children were able to provide adequateterms for the sexual parts of the human body. This may be related to the lack ofknowledge about the terms, the use of colloquial terms or the refusal to talk aboutthe subjectThe difficulty of children in understanding sexual abuse and the feelings of guiltlater unleashed are generally recognized in adult life. And, of course, recognizingthe situation can leave short-term and long-term marks on women’s livesA study of 67 adult participants who had been victims of sexual abuse in childhoodfound three barriers to the denunciation. The first was the internal barrier,associated with guilt, shame and self-protection, as well as with immaturedevelopment and the attempt to minimize effects on their own. The second barrier wasrelated to the relationships with other people, marked by family problems, powerrelations with the aggressor, repercussions of the complaint and the fragility ofthe support network. The third referred to the social world, especially tostereotypes regarding sexualityAnother repercussion of violence against children that does not reveal the magnitudeof the problem is the silence of the victims about sexual abuse, evidenced by thehigh number of revelations only in adult life. Thus, the longer the time elapsed fordisclosure, the lower the criminalization rates of the aggressors and the greaterthe effects and aggravations against the health of the victims,,It is well known that children who have been sexually abused experience the negativeeffects of this throughout life. The most common manifestations are inadequateschool performance, psychological problems  and personal relationships. They can also be victimsin other relationships that occur in different spaces of society and presentdifficulties in following socially imposed normsA study of 222 men and 660 women that had been victims of child sexual abuse foundthat girls were more likely (1.2-2.2 times) than boys to seek medical care becauseof physical health problems, such as digestive, locomotor and genitourinarysymptoms. The authors describe that child sexual abuse is responsible for generatingcosts for the health system and highlights the need for qualified services to treatphysical and mental health problems of sexually abused girls and boysShort-term and long-term health problems triggered by the sexual abuse of girlshighlight the importance of recognizing and coping with this problem through actionsplanned and implemented by professionals responsible for the care of children,adolescents and women in health services.A study conducted with adults who experienced sexual abuse in childhood emphasizedthat care services need to recognize the barriers that prevent denunciation, sinceabuse usually remains hidden for a long time because the understanding aboutsexuality is not disclosed to childrenMeeting the care needs of girls and women who had suffered sexual abuse in childhoodrequires the presence of a physical space in the health service that guaranteesprivacy and hospitality, as well as qualified professionals to establish arelationship of trust and recognition of health needs. This highlights theimportance of training and improving the approach to this subject.A Canadian study on the skills, education, and experience of professionalsresponsible for caring for children has found that higher education does notguarantee preparation for care practice. However, it found that participating intraining courses proposed by the health service is significant when associated tothe time of professional practiceIn this perspective, we highlight the importance of inserting reflections anddiscussions on this theme in the curricula of the health, education, socialassistance and justice undergraduate courses, which are somehow responsible for theassistance of sexually abused girls, adolescents and women in the childhood. Inaddition, it is necessary to create permanent education programs on child sexualabuse in the care and coping services in order to promote the updating andqualification of professionals regarding the laws, public policies and serviceprotocols, which are subject to continuous changes.Assistance to victims of child sexual abuse has been a challenge for both theprofessionals and the services that make up the support network, since thedetermination thereof lies in the historical and social construction of children andwomen in society. This research provides support for the understanding of how thissocial phenomenon is expressed among Brazilian women in order to support thedevelopment and implementation of public policies aimed at prevention and reductionof cases.In addition, it allows health professionals, and especially nurses, responsible forserving women in different generational moments to reflect on this problem in orderto incorporate, in individual or group care, questions that may give visibility tosituations of sexual abuse in the childhood that remain silenced by users.The limitations of this study are in the tweeted reports, which restrict thedescription of the sexual abuse experienced in childhood to 140 words and describeexperiences that happened in previous years. Confirmation of the veracity of thecases consists of a limitation of the field of research that addresses testimonialsof adults who had been sexually abused in childhood, since they are usually based onlate memories. However, these limitations do not invalidate the study because thecampaign has stimulated and facilitated the free expression of participants and thesharing of situations of child sexual abuse.Therefore, this research presents advances in the field of knowledge about childsexual abuse by pointing issues that allow understanding the unveiling of cases inadult life, considering the perspective of gender and generation. In addition, theresearch provides subsidies for nurses to develop care practices that help victimsto express and deal with the traumatic experience, as opposed to there-victimization of women.This study revealed that child sexual abuse has multiple faces that could be revealedin the empirical categories that emerged from the narratives of the women whoparticipated in the social network campaign. The results disclosed the submissivesituations of gender and generation, determined by the social construction offemininity, masculinity and childhood.The consequences of sexual violence were also highlighted, represented by physical,psychological, emotional and social damages, of acute or late character. Thishighlights the importance of developing and implementing measures to protect,prevent, intervene and confront this problem, which has still been veiled insociety.The creation and use of campaigns in social networks is valid for disseminating thetheme and contributes to the increase of denunciations. In addition, it makespossible to understand the experiences lived by sexually abused women in childhoodand can trigger responses from public policies, institutions and professionalsresponsible for care.In this perspective, the Internet can be an important tool for the rapid unveiling ofthe facets of sexual abuse against children. However, the results of studies likethis must sustain and mobilize intervention actions, qualifying institutions andprofessionals for the prevention and confrontation of child violence.


In the past, numerous non-operative treatments for adolescent idiopathic scoliosis (AIS), including exercise, physical therapy, electrical stimulation, and brace treatment, have been tried to delay or prevent the curve progression. Of these, brace treatment is the only option that is widely accepted and has demonstrated the efficacy to alter the natural history of AIS. Recently, the importance of brace treatment for AIS has been increasing since the efficacy was objectively established by the BrAIST  study in 2013. This editorial article summarizes the current status of brace treatment in patients with AIS and discusses future prospects on the basis of our clinical experiences. Scoliosis is a lateral curvature of the spine measuring at least 10° on an X-ray as determined by the Cobb method. Structural scoliosis is characterized by vertebral and trunk rotation . In numeThe goal of brace treatment for AIS is to halt the progression of a curve and to improve cosmetic appearance in accordance with maintaining whole body alignment and balance during a period of growth. Efficacy of brace treatment in AIS has continued to be controversial, with some authors reporting control of curve progression with bracing and others reporting that bracing fails to alter the natural history . HoweverThe history of brace treatment began in the 16th century when Paré advocated metal braces made by an armorer for scoliosis; however, these braces were not used generally . Before Braces employed for the treatment of spinal deformity are divided into CTLSO and TLSO. They are implemented depending on the location of curves, that is, the CTLSO is appropriate for the upper thoracic curve, where its apex is over T7 and would be difficult to correct using the TLSO. However, patient acceptance is poorer with CTLSO because of the visible neck ring . Th. Th16]. The efficacy of brace treatment for AIS continues to be controversial by reasons of the lack of consistency of both the inclusion criteria of subjects and the definition of brace effectiveness. To make the comparison among studies more valid and reliable, the Scoliosis Research Society (SRS) has standardized criteria for brace studies in patients with AIS. The SRS criteria consist of; age is 10 years or older when the brace is prescribed, Risser 0–2, primary curve angles 25–40°, no prior treatment, and if female, either premenarche or less than one year postmenarchal .We previously attempted the clinical study to evaluate the efficacy of OMC brace for AIS in accordance with the modified SRS criteria (immature AIS patients who have a progressive curve from 20 to 24° were included as subjects) and compared our results with other previous reports.In our previous study , 67.7% oOur clinical experiences identified that maintenance of compliance, avoidance of dropout, and support for emotional burden were essential factors during brace treatments. In particular, maintenance of compliance was directly associated with clinical results. However, in brace treatment, there exists an inevitable issue of over-treatment for AIS patients, who may be free from the possibility of progress. Recently, prediction of curve progression has been made possible by the advancement of genetic testing ,39. BohlBrace treatment is indispensable for AIS management as conservative care because it can alter the natural history of AIS and significantly decrease the progression of curve in skeletally-immature patients. However, it is not easy to smoothly accomplish brace treatment, since brace wearing must be, not only physically, but also emotionally, burdensome for adolescent patients. In the future, not only the development or improvement of more effective braces, and reinforcement of patient support, but also the introduction of a tailor-made treatment in which each patient can utilize genetic diagnosis and are expected to maintain motivation for brace wearing and to avoid dropouts relative to treatment success.


Thedissatisfactions brought up in that study can be easily observed in the daily medicalpractice in almost all Brazilian cities, notably emergency care in general, andemergency cardiovascular care in particular. In the later, the issue is compounded bythe frequent need for combining good and prompt care to yield effectiveness.One of the major problems detected in the care provided to emergency patients is thephysicians’ lack of specific training in cardiovascular diseases, which might be thereason of the other finding in the study referred to, the physicians’ dissatisfactionwith their work.2 More recently, the Mixed Committee ofMedical Specialties (CME), comprising the Federal Council of Medicine (CFM), theBrazilian Medical Association (AMB) and the National Committee of Medical Residency(CNRM), has put their seal of approval on the education program for emergency medicine,which resulted from the commendable initiative of the Brazilian Association of EmergencyMedicine (ABRAMEDE).It is certainly not reasonable to assume that physicians trained in cardiovasculardiseases will be available at all less populated regions of Brazil. Grouping the careprovided according to complexity, with an agile referral system between units from lowerto higher capacity for care, would be desirable, as long as more qualified careconditions would be assured, extending beyond cardiologists, involving trainedclinicians and mainly the finally recognized specialists in emergency medicine. Althoughthe emergency medicine specialty already exists in several parts of the world, such asthe United States, where the first residency program in the specialty was inaugurated atthe Cincinnati University in 1970, it was recognized in Brazil only in 2016.It is worth noting that, in the study referred to, although specialized physicianspredominated in the care provided to cardiovascular emergencies, both at level II, IIIand IV hospitals and at SAMU (68.6%), most of them had specialized in areas not relatedto specific care to cardiovascular diseases, such as pediatrics, general surgery,gynecology and obstetrics, and internal medicine, only 2.9% being cardiologists, whilethe others had not even attended a medical residency program (31.4%).3 Otherforms of training less directed to that objective, or even the lack of any training,leave a lot to be desired regarding the quality of the care provided to patients withcardiovascular diseases.Our guidelines for the formation of cardiologists recommend a minimum 288-hour trainingin cardiovascular emergency.In addition, the study referred to evidenced the dissatisfaction with the structure ofcare provided at cardiovascular emergency units as an important reason for thephysicians’ dissatisfaction. However, it is worth highlighting the importance of‘technical support’ as one of the items related to physicians’ satisfaction, reinforcingthe significance of recognizing the area as a relevant element for professionalaction.4 it issomething to be considered in future studies, even for the desired retention ofprofessionals.Another element that decisively influences the professional’s satisfaction relates toprofessional and financial appreciation. Although the topic was not directly assessed byuse of the CARDIOSATIS scale,5This set of measures should be implemented. The practice of medicine amidst suchdiscontentment is inconceivable, mainly at a time with increasing evidence of thesignificant loss of quality and amount of life among physicians.


Family therapy has advanced as an important therapeutic approach in Europe and, in Germany, future family therapists enter a three-year-training programme every year. Family therapist trainees (FTTs) have hardly been studied in terms of their value-orientations (VOs) and how they see the world. This study aims at researching the value-orientation developments in FTTs during the three-year training period and based on the Schwartz value model. A longitudinal study was carried out over a three-year period. The sample consisted of 65 FTTs. VOs were investigated using open questions in self-developed questionnaires. The findings show that FTTs focus mainly on VOs in the Schwartz value domain of "benevolence", followed by "self-direction" and "universalism". This shows that the well-being of others is in the centre of interest in FTTs. However, VOs which indicate a freedom to make decisions and be self-directed are also extremely important. The least-mentioned value domains include "power" and "stimulation", showing that FTTs are neither focused on status, wealth or richness, nor on excitement or a varied life. With regard to the Schwartz value dimensions, the dimension of "self-transcendence" was the most frequently mentioned, followed by "conservation", "openness to change" and "self-enhancement". Self-transcendence includes the value domains of benevolence and universalism and shows that the preservation and enhancement of welfare of other individuals are highly important, as well as VOs such as understanding, appreciation, tolerance and protection of human beings and the environment. So-called collectivist VOs seem to be more important to German FTTs than individualistic VOs: they focus on the needs of the social group and their VOs show that the systemic view is inherent in their social VOs. Findings further show that FTTs develop their professional identity while consciously strengthening their VOs. This study contradicts previous research which claims that FTs are, to a large extent, unconscious in respect of their VOs. The study shows that FTTs are aware of their VOs and this supports them in facilitating client-centred approaches and develop themselves as FT professionals. Recommendations for future research and practice are provided. Research on value orientations (VOs) follows a long tradition within the psychological disciplines . DiscourVOs are essentially dialectic and contradictory  and the Since the 1970s, research on VOs has gained momentum and, based on Values are desirable trans-situational goals, varying in importance, that serve as guiding principles in the life of a person or other social entities . Impliciopenness to change: independent thoughts and actions, as well as change, self-direction, stimulation, hedonism; (2) conservation: self-restriction, maintenance of traditional practices, protection of stability, security, conformity, tradition; (3) self-enhancement: sense and purpose of success and dominance over others: power and achievement, hedonism; and (4) self-transcendence: acceptance of others as equals and caring for the well-being of others: universalism and benevolence.These value domains have been supported by various research projects  and it hi found that, along the dimension "conservation" versus "openness to change", health care professionals working in maternity wards (MW-HCPs) ascribe higher importance to the values of "conformity" and "security", whereas health care professionals working in palliative care (PC-HCPs), ascribed higher importance to the values of "self-direction" and "stimulation". This difference was also observed on a dimensional level, with PC-HCPs preferring values in the value-dimension "openness to change" and MW-HCPs preferring values in the value dimension of "conservation". No differences amongst the samples were found in the “self” dimension. Furthermore, self-direction: e.g., freedom, creativity, being independent, being curious; stimulation: e.g., living an exciting and/or diversified life, being adventurous), whereas MW-HCPs scored significantly higher in “conservation” values .Fegg et al. (2014)In Family therapy (FT) is based on the belief that the family is a unique social system with its own structure and patterns of communication and VOs have been well-researched in family members . Each faPast research has shown that values in families and FT play a central role in terms of how the therapy develops and how the family might change through family therapy . FurtherThe purpose of this study is to respond to the need to gain an in-depth understanding of the VOs and their development in FTTs. The study was undertaken during a three-year training course in systemic family therapy (SFT) and using the well-researched value model of Schwartz as a theoretical and conceptual framework . The maiThis study adopts a qualitative research design by using a longitudinal case study approach within the contemporary hermeneutical tradition . Since tThe study uses a longitudinal design to capture the development of VOs in FTTs throughout the three-year SFT course.The sample was composed of FTTs registered for a three-year SFT course, at a private family therapy institution in Germany. The FTTs hold university degrees in Psychology, Social Work, Education or Social Sciences and are employed in related professions as, for example, psychologists, social workers, educators and consultants. Participants attend five to six course modules per year (the duration of each module is three to five days). Participants also meet in small peer-groups, between the facilitated modules, for supervision purposes and these meetings include exercises, reflection, discussions and interpersonal group coaching. Qualification criteria for participation are an A-level/Matric, a university degree and five years of professional/work experience in a relevant field of psychology, social work or education. Participation was not obligatory. All participants were enrolled for the three-year training course and, therefore, the entire population was targeted. All the FTTs completed the questionnaires at the beginning of each training year (three points of measurements). A few of the trainees discontinued the course of the training after year 1 or year 2.The biographical data of FTTs show that, in the first year (2013), 66 individuals participated, while in 2014 and 2015, 55 and 43 individuals participated respectively. Participants stopped the training due to personal or professional reasons, such as change of place of residence, financial problems or illness. During the first year, out of the 65 individuals, 58 were German, one Polish, three Russian/German, one German/Persian, one German Swiss and one Croatian. Altogether, 12 participants were male, whilst 53 were female. The age range of the participants lay between 27 and 59 years. In year one, 33 were married, 23 single, 2 were living in partnerships, 5 were divorced, 2 were separated and 1 was widowed. One person spoke Croatian as a mother tongue, 5 were bilingual  and 59 participants spoke German as a mother tongue. Altogether, 35 participants were Protestant, 20 participants were Catholic, 1 was Lutheran, 1 was Greek-Orthodox, and 8 did not comment on religious affiliation. All the participants work in occupations within the social contexts .At the commencement of each training year, participants were invited to complete two questionnaires.The first questionnaire included closed-ended and open-ended questions of (1) a biographical and (2) a demographical nature in order to establish biographical and demographical insight. The second questionnaire explored VOs. This questionnaire was developed on the basis of sound literature research and SFT, FTTs and VO. The questionnaire included questions, such as: "Please describe what VOs are important to you."; "What VO contribute to your health as a professional FTT?"; and "What are your personal interests and aims within the professional context?"The participants completed the questionnaires on three separate occasions. The researchers used the same questionnaires throughout study in order to gain insight into the development of VO and, for example, changes in profession, family status and so on.familiarisation and immersion – the researchers familiarised themselves with the gathered data, whilst integrating course observations; inducing themes – general themes in the data were defined; coding – categories and codes were inductively developed by identifying similarities and differences in the data; elaboration – categories and codes were further elaborated to enable understanding and reconstruction of the data; and interpretation and checking to ensure data quality – data were reconstructed and interpreted and set in a more complex context.Questionnaires were administered verbally, either by one of the researchers (during the first two years) or by the course facilitators (third year). A paper and pencil approach was applied. Data was analysed using the five-step process of content analysis , "reliability" (35 statements), "friendship" (28 statements), "trust" (24 statements) and "sincerity" (11 statements). FTTs highlight honesty through, for example, this statement: "It is important for me to be honest when I work with my clients" (honesty). In terms of reliability, FTTs emphasise, for example: "I am a very reliable person and I like to work with people and help them." Another participant said: "In order to support people's well-being, you have to build trust in the relationship" (trust) and, "Sincerity is one of my most important values and it is also connected to honesty" (sincerity/honesty). The FTTs refer to the domain of "Benevolence", particularly with regard to the clients and in the development of the relationship between themselves as therapists and their clients.Secondly, the value domain, "Self-direction", is referred to frequently in the data see . The FTTFreedom is so important to me. I want to live a free, self-directed life and be free in my decisions. That is very important to me.""The increase in statements regarding the value of freedom might be due to the fact that FTTs have, by this point, come to understand the interrelationships within their families, their dependencies and their individual ways of individualisation and freedom from restrictions and dependencies. This development relates to the values, such as "self-respect", "prosperity", "compassion" and "optimism", which are frequently mentioned in year 3 (not before). One FTT explains, for example:It is important to respect myself and to understand where I come from and why I am how I am. And I see now that sometimes, I thought I was free, but now I can see that I behaved like this, because of where I come from. I know I have to develop and to free myself and stay positive. The work with myself helps me in my profession.""The high frequency of values in the domain "self-direction" shows the importance to FTTs of independent thought and action-choosing, creating and exploring, matters that are also important for the therapy practice. In some instances, the importance of being aware of the direction of the self is connected to a professional therapeutic practice and for FTTs to be clear about who they are and what they believe in order to become professional therapists. One participant mentions:For growth I need to know what is important to me and I need to free myself from preoccupied thoughts and stereotypes.""The third most-mentioned domain is "Universalism", with 74 statements see . "UniverLove is the basis to work with people. And only if I love, I can be tolerant."""When I have this deep love, then I can relate more easily to people.""Tolerance! However, this is not always easy!""Love", as an overall approach to life and work, and within the work of FTTs, is the most important value, followed by "tolerance" and "justice", which are often integrated requirements in the profession of FT, where therapists work with individuals and families. FTs need to balance their own ideas and values when working with family systems with whom they might not share similar values and/or lifestyles.The value domain, "Tradition", was important for FTTs, particularly with regard to the values of "respect" (23 statements), "acknowledgement" (15 statements) and "faith" (14 statements) see . "RespecIt is interesting that faith is the only value which increases in frequency within the three-year training period. This might show that FTTs experience an increase in faith in terms of spirituality and, particularly, meaningfulness. All the other values mentioned decrease in frequency of being stated. Values such as "gratefulness", "hope", "commitment", "humbleness" and "ethics" are mentioned, but not very often.One participant stated:I need to believe in myself to be a good therapist. It is about believing and having faith ... in myself and in what I do ... and in the process.""It can, however, be recognised that "humbleness" and "ethics", in particular, are mentioned only from year 2 onwards, for instance,I want to behave in an ethical manner" or "To become humble is important to me ... humbleness ... and to be grateful"."This might relate to the increase of faith (including meaningfulness): FTTs experienced an increase in ethical values and humbleness towards their own processes and their life.The value domain of "Conformity" (41 statements) closely follows the number of statements in respect of the value domain of "Tradition" see . Here, tFamily. I think you must value people in the family and I just like to be with my family and do something with my family.""The value domain of "Hedonism" is one that is not mentioned frequently in the data set see . ExampleI want to be happy and content in my life and in my work. That is important. If I am not happy, I should change.""The domain "Security" is one of the domains not frequently mentioned by FTTs see . "SecuriI think the environment needs to be safe and secure. Then you can feel healthy and connected and peaceful and this is a good basis.""Seven statements refer to security in terms of "peace", "peacefulness" and "calmness". Six statements refer to "safety" and only three statements highlight the importance of "continuity", mainly referring to the experiences of continuous learning and continuing positive experiences for example in a family or during the socialisation and enculturation processes.I feel secure when I have got long-term relationships, stable and enduring relationships which are good for me.""With 25 statements altogether, "security" is one of the least mentioned value domains in this sample, probably due to the fact that it can be assumed that the participants belonged to the middle or higher class in society. All participants held a university degree and most of the participants were German-speaking German citizens and, like a majority of Germans, had been born and raised in middle or upper-class contexts within Germany. It might be assumed that security is important to them, but it is not mentioned more frequently, due to the fact that it is seen as "a given" and, therefore, hardly mentioned in this research as an important value domain. It is also interesting that only female FTTs refer to the value domain of "security".The value domain, "Achievement", was mentioned only in the context of seven statements and it is highlighted that this was particularly in years 1 and 2 see . This meThe two value domains mentioned least frequently by FTTs are "stimulation" and "power" see . One perI like it when I become excited and when I can start something new with excitement and learn.""Only one person in year 2 mentioned "wealth" as an important value in the value domain of "power". Interestingly, the value domains, "stimulation" and "power" were highlighted by male participants. No female participant referred to the categories "stimulation" and "power".The findings show that, with regard to the four value dimensions mentioned in This shows that caring for the well-being of others and acceptance of others as equals are highly important for FTTs, which is probably an advantage when working in therapeutic or social professions, as FTTs do. Further on, the second highest value domain of "self-direction" might also help FTTs to find their own, independent way of working with their clients in the value dimension of "openness to change". The second most frequently mentioned value dimension of "conservation" shows that values such as family, along with the applying of self-restrictions in order to fit in with the social norms and security/stability are highly important for FTTs, something that is probably reflected in the fact that they work primarily with families, the traditional core unit of the nation state. For FTTs, self-enhancement and their careers, their power and achievement are at least frequently mentioned and therefore interpreted as being of less importance. This fact, however, also includes the potential danger that FTTs might forget about themselves and their own, personal well-being whilst working with clients, by focusing on the well-being of the clients only.This study stands in the tradition of value research within the psychological discipline , focusinFindings in this study show the frequency of VOs  – from mThe focus on the social realm, the system, as the family, seems to be more important than the focus on the individual. The systemic perspective is therefore inherent in the value domains and dimensions mentioned.The study does not provide information on the dialectics and contradictions of VO, as highlighted in previous research such as that of The VO described by FTTs in the study seem to fit positively with the development of the professional identity  of the FThis study does not support the findings by Since, to date, hardly any studies could be found which examine the values of FTTs within a longitudinal and developmental research setting, either internationally or in Germany, only a few similar previous studies were available with which to compare the data. In comparison to occupational therapists , p. 273,The brevity of the discussion of findings within the context of existing literature shows that the findings should be viewed and interpreted against certain limitations of the study. The first limitation relates to the limited and explorative nature of the research as the researchers had access to only three sets of data over a period of three years. Secondly, the study is limited to a relatively small sample size. Thirdly, the study is limited with regard to the demographic and biographic composition of the sample, a clear cultural and religious bias . The study should therefore be replicated in different contexts and cultures and compared with the VO of FTTs in different countries. Fourthly, only a limited number of questions were asked in the questionnaire and no interviews could be conducted to explore the responses in more depth. Therefore, the depth of the statements is limited and could not be explored more deeply. Finally, the study's findings could be discussed only in the context of a limited literature review in terms of the specific context and setting of the study. This study is, therefore, clearly of an explorative nature.This study aimed at exploring and understanding the development of VOs in FTTs over a three-year training course period. They show that FTTs focus mainly on VOs in the value domain of "benevolence", followed by "self-direction" and "universalism" and are therefore anchored in collectivist values rather than in individual ones. The least mentioned value domains include "power" and "stimulation". With regard to the Schwartz value dimensions, the dimension of "self-transcendence" is most frequently mentioned, followed by "conservation", "openness to change" and "self-enhancement". This shows that FTTs’ VOs relate strongly to caring for the well-being of others, independent thought, action and acceptance of others as equals, and are therefore particularly socially directed.Over the three-year period, minor value shifts were observed, specifically an increase in value statements such as "freedom" (self-direction) – which might relate to an increased understanding of personal family dependencies across the training period, and an increase in the value frequencies of "justice" , as well as "faith" , in the value domain of "tradition". All other VOs showed a decrease in the frequency of statements over the three-year period. With regard to future research, further investigations are needed and these should explore VOs and their change in FTTs in different institutions across a three-year training period. Studies should use mixed methods to explore the VOs, based on quantitative and qualitative methodological approaches, with this being achieved by using questionnaires as well as in-depth interviews. Follow-up studies with the FTTs should be conducted after they have worked as FTs, while VOs should be compared between FTTs and FTs, who have been in practice for a certain amount of time.On a practical note, the development of VOs in FTTs should become a conscious process during the three-year training period. Trainers and FTTs need to increase their awareness regarding their VOs and the changes they experience with regard to their personal and professional development in terms of VOs. VOs could be consciously developed through self-reflections in the context of personality development and professionalism and the connection between the VO, the shift in the VO and the behavioural patterns of FTTs should be explored to understand how VOs (shifts) influence and are influenced by behavioural patterns. VOs could be explored during the training through self-reflection, discussions in small groups, exercises, and the learning unit regarding the development of ethical behaviour in FT. Trainers in FT institutes also need to develop their awareness regarding the development of VOs and make it a conscious part within FT training, which influences and informs behaviour patterns which are established in FTTs during the three-year training course.