Sexual Assault of People in Aged Care Settings: Towards a Better Understanding and Response

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1 Northern Sydney Sexual Assault Service J Blyth, L Kelly Sexual Assault of People in Aged Care Settings: Towards a Better Understanding and Response In the past 25 years there has been widespread focus and study of sexual assault of children and adults. With increasing awareness and knowledge has come greater insight into offender s behaviour, and profiles of sexual perpetration. This paper looks at one such profile of perpetration: the sexual assault of adults in aged care settings. It also explores key responses for professionals working in the aged care industry. Profile of Sexual Assault of Adults with a Disability Emerging research, both in Australia and internationally, indicates that sexual assault of people with a disability, particularly intellectual disability, is a serious problem. It is estimated that 50-90% of people with a disability are sexually assaulted in their lifetime (Crossmaker 1991). We also know from Australian research that people with a disability are 3 times more likely to be a victim of violent crime (that is physical assault, robbery and sexual assault) than people without a disability (Wilson & Brewer 1992). Many people with disabilities are unable to disclose due to cognitive or communication difficulties, and too often when they do disclose they are discounted. Thus the abuse is likely to have gone on for a long while without being detected, be more severe- that is more likely to involve penetration, and less likely to be believed and acted on if it is found out (Sobsey & Doe 1991, Nosek 1997, Brown & Craft 1992, Connelly & Keilty 2000). Moving people out of institutional care has not made them safer. The rates of sexual assaults in residential facilities is high, with perpetrators having greater access and opportunity to assault highly vulnerable people. Service providers, for example residential care workers, teachers and therapists, make up the largest group of perpetrators in many large studies (Sobsey & Doe 1991). Other service users also make up a significant proportion of perpetrators(brown & Turk 1992). Offenders, both staff and other residents,will often move from facility to facility, so that when suspicions arise in one place, they move or are moved on to other facilities.

2 Profile of Sexual Assault of Older Adults While there is good research on elder abuse of people in their homes, most of the work focuses on physical, emotional and financial abuse, and neglect. Research on sexual abuse of older adults, particularly in care settings is small, and the real extent of elder sexual assault remains unknown. However, from clinical experience, as well as from studies by researchers such as Burgess (2000) and Ramsey-Klawsnik (1991) & Teaster & Roberto (2003) in the US, and Jeary (2005) in the UK, the emerging profile of sexual assault of older adults is chillingly similar to that of people with disabilities. In particular, those who are more vulnerable, ie, in the older age group (80-90 years old), and those with communication and cognitive impairments are more likely to be targeted by offenders( Teaster 2003, Burgess et al 2005). For similar reasons, they will not be believed, nor action taken in many cases (Teaster & Roberto 2003). They are also more likely to suffer multiple types of sexual assault (Teaster & Roberto 2005). In Burgess s (2000) study, over half the victims died within a year of trauma related complications such as physical injury and shock. In a recent study reviewing 125 cases of female elder sexual assault in the US (Burgess et al 2005), 43% lived alone, and 38% in nursing homes. The majority were aged years, and the majority had physical and/or cognitive impairments. Almost half the offenders were acquaintances (48%), 26% caretakers, 19% were other nursing home residents, and only 3% strangers. For the victims living in nursing homes, they was significantly less likely to have the sexual assault reported, acted upon, charges laid and a conviction reached. There is scant evidence on male elder sexual assault, with only a few documented cases in the research. In a study of 50 cases of sexual assault that occurred in a nursing home( Teaster & Roberto 2003), 90% of offenders were other residents. In only three (6%) of cases was the offender prosecuted, and only one case resulted in a conviction. Of the perpetrators, the profile is similar to what is seen in abuse of people with disabilities, 93% were male, and 7% female ( Burgess et al 2005) Once again, service users, along with service providers, make up the majority of perpetrators. ( Teaster & Roberto 2003). Of particular importance is that a significant proportion of offenders have previous offending histories and convictions. Of the convicted offenders in Jeary s( 2005) research of 52 cases, nearly one third had at least one previous conviction for sexual offences, and in nearly half of these the victim was elderly. Several men also had convictions for offences against children, and the majority convictions for other offences such as violence, robbery or theft.

3 The Northern Sydney Sexual Assault Service, has seen an increasing number of elderly female victims of sexual assault in recent years. A profile of 18 recent sexual assault victims seen at the service in the past 4 years reveals a similar profile emerging to the research presented above. the largest group were aged years ( 43%) Age of Victims 60's - 32% 70's - 16% 80's - 47% 90's - 5% 1/08/ setting of the assault was primarily their home or care facility Setting of Assault Own Home Perp. Home Res. Care Other 1/08/ the majority of sexual assaults involved penetration. It is also interesting to note that drug facilitated sexual assault (DFSA) occurred in two cases. Type of Assault Vaginal Oral DFSA Unclear Digital Multiple Attempt In Ex. 1/08/

4 Whilst just over half of the victims had no injuries, there was a strong correlation between age and injury ie the older the person the more likely they were to sustain significant injury. Three of those hospitalized as a result of the injuries sustained in the assault, died shortly afterwards. Injuries No Injuries Minor Vaginal Hospital 1/08/ Offenders were both strangers and people known to the victim. As expected, those assaulted by strangers occurred mostly in the victim s home. Perpetrator Profile Nursing/Staff Stranger Unknown Acquaintance Husband 1/08/ Despite the fact that a serious crime had been committed, only one resulted in a criminal conviction. The majority did not even result in a police statement being taken, largely due to the victim s cognitive and physical impairments. Legal Action No Police Police - No Stmt Police - Stmt Conviction 1/08/

5 Challenges for Service Providers Such a profile provides us with some serious challenges: Firstly, it is difficult to comprehend that these most vulnerable people would be targets for sex offenders. There are many myths about what sort of person gets raped- and it s assumed not to be an elderly or disabled person. Groth s ( 1979) study of offenders lends some understanding as to why vulnerable adults may be targeted, Sexual offenders are attracted by vulnerability and availability, rather than by physical attributes of potential victims Many people with cognitive impairments such as dementia, are disbelieved about many things they report, sexual assault among them. Those with more severe levels of impairment may never be able to tell us. They will have to rely on someone witnessing and reporting, or medical evidence- things perpetrators are careful to avoid. Secondly, people in care settings can become invisible members of our community. Abuse thrives in a context of secrecy, and sometimes a culture of white or hidden violence. Many don t believe these people would be raped, and organizations fear litigation. Thirdly, studies and clinical experience shows that staff are often slow to report this crime, resulting in loss of vital crime scene evidence. Lack of police expertise in dealing with this group, and investigation delays generally, mean again that offenders may not be apprehended, and victims not safe from further assaults. The criminal justice system also makes little provision for those who are not verbal or have disabilities, particularly memory impairments. Towards a More Effective Response Clearly this most vulnerable group is dependent upon attention to four key areas. The first is Creating Safe Environments. This is the key to prevention of sexual assault in aged care settings. - A Staff Code of Conduct is critical, along with clear expectations of staff regarding such things as personal care, and roles. - A clear and visible organizational mission statement, with complaint mechanisms and client participation is also important. - Ideally, the current mandatory criminal record check for working with children should be extended to include vulnerable adults as well. More rigorous attention to recruitment, including checking previous employment

6 records, and staff training on awareness and reporting of sexual abuse are also critical. This is particularly important given when it is emerging from research that perpetrators frequently have a prior sexual assault offending history. It is important to be aware that sexual assault can happen. Sexual assault in care settings is mostly not a reflection of the facility or level of care. Most sexual assaults reported by residential care settings reflect a culture of care and commitment to patient care, and safe environments. Some agencies may fear litigation and media exposure and may never report because of this. However, litigation and media exposure are more likely to happen where there is cover up and silencing. The second key area is detection. The ways in which sexual abuse may be detected are: Witness- commonly the only way sexual abuse of people with severe cognitive impairments is detected. This may include witnessing an act or suspicion aroused. Disclosure- many victims don t disclose to staff due to fear of reprisals and not being believed. They may disclose partially due to memory problems eg disclose sexual assault but be unable to remember when or where. Physical Evidence- may include pelvic bruising, presence of semen, sexually transmitted infection, vaginal discharge, genital bleeding. Behavioural Indicators- may include: + expressions of fear eg of certain staff/ residents, being left alone, of places eg bathroom + unexplained agitation & anxiety + sleep disturbance and nightmares + re-enactments eg repeated holding of genital area, inappropriate language + avoidance + protest behaviors eg not wanting to be bathed, toileted, go to dining room or with a staff person + withdrawal + somatic complaints such as coldness & muscle rigidity Many of these indicators are common in elderly patients and people with dementia. However, it is important to consider they may, in clusters, and where there are changes, be also indicators of abuse. Half of those abused in Burgess s study (2000) reported feeling very cold, and experienced muscular rigidity, especially during personal care.

7 Consultation and collaboration is also key to an effective response. Management should be informed. Consultation with a Sexual Assault Service is advisable. These services offer 24 hr medical & counselling responses to victims of recent sexual assault. They can assist workers and agencies in an appropriate response even when there is only behavioural indicators or a suspicion. Likewise, police can advise if it is suspected that a crime has been committed. They also provide a 24hr crisis response & consultation. If a recent sexual assault is suspected, investigation of these matters requires an immediate, coordinated interagency response that ensures crime scene preservation, prompt statement taking from victim, especially if they have difficulties with memory retention, and appropriate and flexible care of the victim, with special consideration of ongoing safety issues. Conclusion Whilst the extent of sexual assault of older adults remains unclear, emerging research reveals a profile of sexual offending that targets the most vulnerable members of our communities. In the words of Crossmaker (1994), These are the ones chosen because they cannot speak the horror. These are the ones chosen because they cannot run away, there is nowhere to run. These are the ones chosen because their very lives depend on not fighting back An effective response is imperative, which both seeks to create safer aged care residential environments, and provides prompt and effective action to report incidents of sexual assault. References Brown,H & Turk,V (1992) Defining Sexual Abuse as it Affects Adults with Learning Disabilities Mental Handicap 20, Burgess, A (2000) Sexual Abuse of Nursing Home Residents Journal of Psychological Nursing vol 38 no.6 Burgess,A, Hanrahan,N & Baker,T (2005) Forensic Markers in Elder Female Sexual Abuse Cases Clinical Geriatric Medicine Connelly,G & Keilty,J (2000) Making a Statement: An Exploratory Study of Barriers Facing Women with Intellectual Disabilities when making a Statement about Sexual Assault to the Police Intellectual Disability Rights Service Sydney NSW

8 Crossmaker,M (1991) Behind Closed Doors: Institutional Sexual Abuse Sexuality & Disability (3) Jeary,K (2005) Sexual Abuse and Sexual Offending against Elderly People: A Focus on perpetrator and Victims Journal of Forensic Psychiatry & Psychology 16(2) Nosek,MA et al Abuse of Women with Disabilities: Policy Implications Journal of Disability Policy Studies vol Ramsey-Klawsnik,H (1991) Elder sexualabuse: Preliminary Findings Journal of Elder Abuse and Neglect 3(3), Sobsey,D & Doe,T (1991) Patterns of Sexual Abuse and Assault Sexuality & Disability (3) Teaster,P & Roberto,K (2003) Sexual Abuse of Older Women Living in Nursing Homes Journal of Gerontological Social Work vol 40(4) Wilson,N & Brewer,N (1992) Incidence of Criminal Victimization of Individuals with Intellectual Disability Australian Feminist vol

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