{'fraction_non_alphanumeric': 0.024522383803820928, 'fraction_numerical': 0.012603364699173083, 'mean_word_length': 4.843385538153949, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 8, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

Objectives To explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual abuse. Design Descriptive analysis of reports about sexual violence against persons with an intellectual disability submitted to the Dutch Health and Youth Care Inspectorate by healthcare organisations. Setting Residential settings for people with an intellectual disability in The Netherlands. Selection 186 incident reports submitted to the Inspectorate between January 2017 and December 2019 were included. Results 125 incident reports concerned sexual abuse by fellow clients and 61 reports concerned sexual abuse by professionals. Client perpetrators were predominantly male whereas almost 30% of the abusing professionals were female. The majority of the perpetrating professionals were unlicensed professionals. Clients who committed sexual abuse were mostly relocated to another residential setting. Most healthcare organisations invested in education and training for employees instead of improving the sexual education programme for clients after an incident of sexual abuse. If there was a strong suspicion of sexual abuse by a professional, resignation followed in most cases. In just two cases, the perpetrating professional was reported to a warning registry. Conclusions A small amount of the perpetrating professionals held a licensed profession, which makes it challenging to address this form of sexual abuse through healthcare regulation. It raises the question why warning registries are not engaged more often after alleged sexual abuse. Constantly relocating abusing clients might endanger the (sexual) safety of clients in these new environments. Previous literature suggests that adequate sexual education regarding social skills and sexual behaviour is very effective for the majority of clients who commit sexual abuse. Healthcare organisations could take up a more prominent role in this to ensure safety for their own clients and for clients residing elsewhere.

Page 4, line 50. There should be a colon after questionsuch as "This raises the question: What can be done…" and ending with a question mark "people with disabilities?" Page 5, Line 27, it should read: existence of a dependent relationship, rather than dependency relationship. Page 6, line 10, should be the data were extracted rather than was. The word data is plural. Page 7 Line 10 and Page 12 Line 17the word scarcely is used. I believe the word rarely would be more appropriate. Page 11, Line 58, it should read were male rather than was male. Victims is plural. Page 12, Line 38, it might read better if it stated: "…majority of clients who commit sexual abuse." Page 12, Line 51, it might read better if it stated: "the improvement plans of healthcare organizations revealed that most invested in education and training for employees instead of improving the sexual education program for clients…" Page 13, Line 41, instead of a comma after clients, perhaps a period and start a new sentence: Our study does show… Lin 57, insert However before implementing a culture change. Page 15, Line 4 -could this be changed to "vulnerable and often dependent" rather than "vulnerable and dependent."

REVIEWER
Gil-Llario, María University of Valencia, Department of Developmental and Educational Psychology REVIEW RETURNED 28-Jul-2021

GENERAL COMMENTS
This is a very interesting and necessary work since there is a significant lack of studies that analyze the phenomenon of abuse in people with intellectual disabilities. However, the study suffers from some problems that I detail below: The study has not been sufficiently grounded in recent studies. There are only 6 studies from the last 5 years. Given that this is a problem whose research has grown exponentially in recent years, important shortcomings such as the important meta-analysis of the prevalence of abuse (DOI: 10.3390/ijerph18041980) or the study on the sequelae of abuse (doi: 10.1111/jir.12555), to name just a few recent ones, are striking. It would be convenient for the authors to improve the bibliographic search by including recent valid studies, which would not only improve the introduction, which has been excessively brief and where the subject matter of the study is barely framed without sufficient analysis, but also the discussion by deepening the analysis of the results obtained. With regard to the data collection section, it is indicated that 186 incidents have been analyzed, but no reference is made to the reference population, i.e., the number of centers and/or persons with ID living in residence. Further on, it is included as a limitation that it is not known whether the results obtained can be representative. To solve this limitation, it would be sufficient to relate them to the total number of people who could potentially be victims, i.e., the total number of people living in such residences. This would give prevalence data that could be compared with those offered in the literature, some of which were proposed above.
In the results section, it would be advisable to make cross tables instead of a single list of descriptive data in order to better analyze the results. It would be interesting, for example, to cross-tabulate the sex of the perpetrators with the severity of the incident. This would be particularly relevant in order to be able to interpret the result obtained by the authors in relation to the sex of the professionals who perpetrated the abuse. Indeed, this is a data that contradicts the statistics. Given that this also includes consensual sex, touching only, etc., knowing what type of coercion was exercised by men and women could shed light on these unexpected results. On the other hand, as highlighted in the summary, it seems that there were more women than men. A look at the table shows that 70% were indeed men. The reader is left wondering why the authors, instead of analyzing the possible causes of these anomalous results, present them as a remarkable headline.
Another aspect that would be interesting to analyze by means of a crosstabulation would be the degree to which they need support from the partners of victims and perpetrators, as was done in "victim and perpetrator gender patterns". This would also make it possible to contrast whether the usual pattern of mild perpetrator and moderate victim is reproduced, given that in these results the mild have the highest percentages as victims and perpetrators. This would also help to compare between cases of abuse that have a professional as perpetrator and those that have another client. By the way, Table 2 includes as excluding categories both those referring to the support they need, following the DSM-5 classification, although it is not cited (mild, moderate and severe) but then lists causes of the disability: down syndrome, ADHD, etc. This information is unnecessary and adds noise. It is sufficient to indicate the degree of support they require and that the sum of these three categories would be 100% of the sample. In general, the paper provides relevant information, but the degree of analysis that has been made of the data as well as of the existing literature makes it advisable to carry out a major revision.

VERSION 1 -AUTHOR RESPONSE
Reviewer: 1 Dr. Rhonda Black, University of Hawai'i at Manoa I found the manuscript very informative and very well-written. The background and results were presented clearly, and the text flowed well from one paragraph to the next. In my opinion, the manuscript should be accepted for publication with only a few minor edits. It is a great contribution to the literature on abuse of adults with intellectual disability. I have not seen a report as detailed regarding the types of abuse, not have I seen information on how organizations respond to such abuse. This is a very good contribution to our understanding. I learned a lot from reading the manuscript.
AUTHORS' REPLY: Thank you very much for the time and effort you put into reviewing our manuscript, and also for your compliments regarding the manuscript.
I would like to suggest two clarifications that may help readers. First, the term Attachment Disorders. Could you clarify? That is not a disability diagnosis in the United States, so I was not sure how that manifested in adults with intellectual disability in the Netherlands.
AUTHORS' REPLY: By attachment disorders we mean the attachment disorders as included in the DSM-V: the reactive attachment disorder as well as the disinhibited social engagement disorder. In our data, some of the clients with an intellectual disability were diagnosed with, for example, one of these attachment disorders in addition to the disability diagnosis. However, after reading the comments of our second reviewer we have decided to remove additional diagnoses from our dataset. The additional diagnoses do not provide important insights for this paper.
Second, could the authors clarify the meaning of structural abuse? I was not sure what was meant by that phrase.
AUTHORS' REPLY: By structural abuse we mean that the abuse happened more than once. We have clarified this in the text of the manuscript on page 7 of the document: "Examination of the location(s) of the incident highlights whether the abuse was a one-off incident or whether the abuse was structural, meaning that the victim's sexual boundaries were violated by the same perpetrator more than once." "vulnerable and dependent." AUTHORS' REPLY: We have adjusted this sentence as you suggested.
Reviewer: 2 Dr. María Gil-Llario, University of Valencia This is a very interesting and necessary work since there is a significant lack of studies that analyze the phenomenon of abuse in people with intellectual disabilities. However, the study suffers from some problems that I detail below: AUTHORS' REPLY: Thank you very much for the time and effort you put into reviewing our manuscript and for your valuable comments.
The study has not been sufficiently grounded in recent studies. There are only 6 studies from the last 5 years. Given that this is a problem whose research has grown exponentially in recent years, important shortcomings such as the important meta-analysis of the prevalence of abuse (DOI: 10.3390/ijerph18041980) or the study on the sequelae of abuse (doi: 10.1111/jir.12555), to name just a few recent ones, are striking. It would be convenient for the authors to improve the bibliographic search by including recent valid studies, which would not only improve the introduction, which has been excessively brief and where the subject matter of the study is barely framed without sufficient analysis, but also the discussion by deepening the analysis of the results obtained.
AUTHORS' REPLY: As you suggested, we have added additional and more recent studies as references to strengthen the embedding of our manuscript. Also, we have revised our introduction and included more recent studies and context. Finally, we have used the additional literature to deepen our analysis in the discussion. The 18 new references that we added can be found in the reference list under the numbers 5, 6, 7, 8, 14, 15, 16, 17, 18, 20, 21, 22, 29, 34, 35, 37, 47, 48. With regard to the data collection section, it is indicated that 186 incidents have been analyzed, but no reference is made to the reference population, i.e., the number of centers and/or persons with ID living in residence. Further on, it is included as a limitation that it is not known whether the results obtained can be representative. To solve this limitation, it would be sufficient to relate them to the total number of people who could potentially be victims, i.e., the total number of people living in such residences. This would give prevalence data that could be compared with those offered in the literature, some of which were proposed above.
AUTHORS' REPLY: Data of Statistics Netherlands (CBS) shows that in 2018 almost 70.000 persons with an intellectual disability were living in a residential setting in The Netherlands (StatLine -Personen met gebruik Wlz-zorg in natura; leveringsvorm, zzp/zorgvorm, regio (cbs.nl)). Looking at the prevalence data, just 186 cases of sexual abuse in residential settings in the years of 2017, 2018 and 2019 seem unlikely to be accurate. It is very likely that a large proportion of sexual abuse within residential settings is not reported to the Inspectorate and that our dataset is not representative of all sexual abuse in residential settings. This is a limitation of our study. We have included this point in our manuscript under the heading 'strengths and limitations' as follows: "Data of Statics Netherlands (CBS) shows that in 2018 almost 70.000 persons with an intellectual disability were living in a residential setting in The Netherlands (37). Looking at literature about the prevalence of sexual abuse of persons with an intellectual disability, the occurrence of 186 cases of sexual abuse in residential settings in three years seems unlikely to be an accurate representation (2, 13-15)." In the results section, it would be advisable to make cross tables instead of a single list of descriptive data in order to better analyze the results. It would be interesting, for example, to cross-tabulate the sex of the perpetrators with the severity of the incident. This would be particularly relevant in order to be able to interpret the result obtained by the authors in relation to the sex of the professionals who perpetrated the abuse. Indeed, this is a data that contradicts the statistics. Given that this also includes consensual sex, touching only, etc., knowing what type of coercion was exercised by men and women could shed light on these unexpected results. On the other hand, as highlighted in the summary, it seems that there were more women than men. A look at the table shows that 70% were indeed men. The reader is left wondering why the authors, instead of analyzing the possible causes of these anomalous results, present them as a remarkable headline.
AUTHORS' REPLY: We have already explored our data in cross tables in SPSS and more specifically what type of coercion was exercised by men and women. The description of this analysis could already be found in the second paragraph of our results section. In response to your suggestion we have added our crosstables as appendices. We have adjusted the text on page 6 of the manuscript as follows: "As can be seen in Appendix (X), these female perpetrators were mostly in a (sexual) relationship with a client. They were rarely involved in sexual abuse where coercion or violence was used." We have chosen not to include cross tables in the article itself in order to keep the manuscript comprehensible. Since we have extracted an extensive amount of data, we believe that adding cross tables in the written text of the article will compromise readability and structure of the manuscript.
Another aspect that would be interesting to analyze by means of a crosstabulation would be the degree to which they need support from the partners of victims and perpetrators, as was done in "victim and perpetrator gender patterns". This would also make it possible to contrast whether the usual pattern of mild perpetrator and moderate victim is reproduced, given that in these results the mild have the highest percentages as victims and perpetrators. This would also help to compare between cases of abuse that have a professional as perpetrator and those that have another client.
AUTHORS' REPLY: Thank you for this suggestion, we have added these specific results of cross tabulation in table 2. The usual pattern of mild perpetrator and moderate victim does not seem to be reproduced. The largest group in our study is the mild perpetrator and mild victim. A reason for this could be that the setting of this study is abuse that has occurred in residential settings. It is possible that clients with an equal severity of their disability are often placed together (as moderate victim and moderate perpetrator is the second largest group). A different reason could be that not all abuse is reported to the inspectorate, despite the obligation to report. We have included the foregoing considerations in our manuscript on page 12.
By the way, Table 2 includes as excluding categories both those referring to the support they need, following the DSM-5 classification, although it is not cited (mild, moderate and severe) but then lists causes of the disability: down syndrome, ADHD, etc. This information is unnecessary and adds noise. It is sufficient to indicate the degree of support they require and that the sum of these three categories would be 100% of the sample.
AUTHORS' REPLY: We have removed additional diagnosis from our dataset. Indeed, the degree of support the clients require is most important for this study.
In general, the paper provides relevant information, but the degree of analysis that has been made of the data as well as of the existing literature makes it advisable to carry out a major revision.
AUTHORS' REPLY: Again, thank you very much for taking the time to provide us with your comments. As you suggested we have carried out a significant revision and we believe it has improved the quality of our paper.