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Correspondence: Address correspondence to Pamela B. Teaster, PhD, Gerontology and Public Health, 306 Health Sciences Building, 900 S. Limestone, University of Kentucky, Lexington, KY 40536-0200. E-mail: pteaster{at}uky.edu
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Key Words: Sexual abuse • Older men • Older women • Adult Protective Services • Nursing homes
Sexual abuse, the most hidden form of elder abuse, constitutes less than 1% of all cases reported and substantiated upon conclusion of APS investigation (Teaster & Colleagues, 2003). Researchers and practitioners alike assert that these estimates represent only the most overt cases and that APS reports significantly underestimate the incidence of the sexual abuse of older adults who are vulnerable as a result of physical or cognitive disabilities (Bonnie & Wallace, 2003). One reason for this small percentage is that some states group substantiated sexual abuse cases under physical abuse when they report data, which has hindered systematic studies of sexual abuse. To be able to better understand instances of the sexual abuse cases concerning older adults as well as to effectively prevent and intervene in the lives of elders who suffer sexual mistreatment, a better understanding of circumstances and outcomes of their situations is required. Thus, our purpose in this study was to develop a unique profile of sexual abuse cases, distinct from other forms of abuse, of older adults receiving attention from APS in the Commonwealth of Virginia.
Sexual Abuse in Late Life
Because of the hidden nature of late-life sexual abuse and the difficulties in obtaining data on the topic, a paucity of research exists on the sexual abuse of older adults in both domestic and institutional settings. Only a few published, empirical articles specifically address the sexual abuse of older adults. In one of the first investigations of adult sexual abuse, Ramsey-Klawsnik (1991) found 28 cases of suspected domestic elder sexual abuse as described by APS workers in Massachusetts. All the victims were female, and most were sexually assaulted by their caregivers, with the largest category of perpetrators being husbands and adult sons (n = 18). In only two cases were the women abused by unrelated caregivers. Drawing on Ramsey-Klawsnik's work, Holt (1993) used a mail questionnaire sent to professionals in Great Britain and described 90 cases of sexual abuse, 51 (57%) of which were confirmed. The majority of cases (both domestic and institutionalized settings were included) concerned women (86%), most of whom experienced dementia (77%) and frailty (67%). Typically, abusers were men upon whom the victim was dependent for care (90%).
A 3.5-year study by Muram, Miller, and Cutler (1992) of women in one county in Tennessee compared rape injuries sustained by older and younger sexual assault victims. The authors found that a greater majority of older women (i.e., ages 55 and older) sustained genital injury from their assault compared with their younger counterparts (i.e., ages 18–45). Most assailants were complete strangers to the victims, and the majority of assaults occurred in the women's homes. This finding was in contrast to the younger victims in the study, for whom the majority of assailants were known to them and the majority of assaults occurred outside the women's homes. The authors also indicated that younger women were more likely than older women to report a previous assault.
Residents in long-term-care settings are especially vulnerable to abuse, neglect, and exploitation, as they often present with dementia and are increasingly dependent on others for their care. Of 488 incidents of abuse of residents in nursing homes derived from Medicaid Fraud Reports from 42 states over a 5-year period, Payne and Civokic (1996) found 8.8% cases of sexual abuse. Across all types of abuse, physical abuse was the most prevalent (94.2%), with 62.9% of abuse concerning a male employee. Approximately one half (56%) of the sexual abuse cases resulted in a criminal conviction; however, only 25% of the offenders received a prison sentence.
According to 1998 data from the National Ombudsman Reporting System, in a 2-year period, there were more than 1,700 complaints of alleged sexual abuse (Hawes, 2003). A recent General Accounting Office report (2002) concerned investigations of 158 allegations of physical and sexual abuse, which in turn revealed intolerable rates of sexual abuse in nursing homes. A study by Burgess, Dowdel, and Prentky (2000) focused exclusively on the sexual abuse of 20 nursing home residents referred to Burgess as part of her forensic work. She discovered that the victims were predominately older, exhibited rape-related trauma symptoms, and had cognitive deficits. In 14 cases the perpetrator was part of the nursing home staff, and in three cases the perpetrator was a resident. Eleven of the 20 victims died within 12 months of the assault, with half between the ages of 80 and 99. A need for intervention was readily apparent: The researchers stated that the most striking observation of the study was the "lack of sensitivity of nursing home staff to the gravity of the assaults on the residents" (Burgess et al., 2000, p. 14).
Teaster and colleagues (2000) examined the sexual abuse of 42 older adults in both domestic and institutional settings in Virginia over a 3-year period. Data were collected only on substantiated cases with information taken from APS records. Most victims were older women who were disoriented in two of three domains (i.e., person, time, or place). The majority of victims were in nursing homes, and the most frequent perpetrator was a facility resident. Findings from a later study building on these data revealed that, for older women between the ages of 70 and 89 living in nursing homes, the most common types of sexual abuse involved instances of sexualized kissing and fondling and unwelcome sexual interest in the women's body (Teaster & Roberto, 2003). Women between the ages of 80 and 89 were more likely to experience multiple types of abuse than those between the ages of 70 and 79. In particular, there was a greater tendency for women who needed assistance with ambulation to experience more than one type of sexual abuse than women who did not need assistance.
Collectively, these investigations reveal that older victims of sexual abuse are primarily women with cognitive limitations or physical care needs and who endure multiple forms of sexual abuse. Most reports are based on small study samples (20–53) and provide descriptive accounts of one or more aspects of the cases, including the background of the individuals involved, the perpetrators and their relationship to the victims, the investigation, and case outcomes. Because sexual abuse is very personal and highly intrusive, it requires extraordinary intervention efforts. In order to develop a profile of the sexual abuse of older adults, we conducted a systematized study of substantiated APS cases in the Commonwealth of Virginia.
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Methods |
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Procedure
Upon approval of the research plan by Virginia Tech's Institutional Review Board, we developed an extensive data collection instrument that drew upon information gathered by Ramsey-Klawsnik (1991) and input from APS professionals. Workers recorded information on substantiated cases only and completed it by using case file information. In compliance with protections for confidentiality, either local APS workers completed the six-page questionnaire by using case files for reference or they sent the files to their regional consultants, who read each file and completed the forms. At the beginning of the study, only APS regional consultants completed the forms, but by Year 3 of the study, the researchers and APS supervisors determined that those workers closest to the case could provide information as reliable as the regional consultants and that having staff complete the data collection forms would not add a significant time burden to their work schedule. The state APS consultant then collected information and submitted it to the Center for Gerontology at Virginia Tech for analysis. Data gathered included personal characteristics of the older adults, their ability to care for themselves (i.e., orientation, money management, and mobility), a description of the sexual abuse, the number of witnesses (if any) to the abuse, the alleged offender, the resolution of the case, the outcome for the older adults, and any additional relevant facts of the case.
The questionnaire was divided into eight sections and consisted mostly of questions with forced-choice response sets. Information about the victims' age, gender, and living arrangements was solicited in the first section. The second section focused on self-care abilities, including the older adults' orientation to person, place, and time, ability to ambulate, and their ability to manage their financial affairs. We combined the three orientation items to establish a measure of the older adults' general level of awareness or orientation. We coded each item as oriented (1), oriented some of the time (2), and not oriented (3), and we summed for a total orientation score (
=.92). We used this to categorize the older adults with high orientation (total score = 3), medium orientation (total score ranging 4–6), and low orientation (total scores ranging 7–9). A description of the sexual abuse was ascertained in the third and fourth sections. APS professionals were asked to identify, from a list of 15 potential types of sexual abuse, the type or types of abuse investigated, if the abuse was an isolated case or ongoing occurrence, where the abuse occurred, the number of witnesses to the abuse, and the relationship of the witness(es) to the older adults. In the fifth section, information was gathered about the alleged perpetrator, including his or her age, gender, relationship to the older adult, and the existence of other personal characteristics often associated with abuses (e.g., dependent on victim, abuse of alcohol or drugs, past history of criminal activity). Resolution of the case was addressed in the sixth section. The APS professionals provided information that was available about who handled the investigation, prosecution of the case, and reasons why the case was not prosecuted. The seventh section focused on outcomes for the victim (e.g., treatment, relocation, and risk for further sexual abuse) and the alleged perpetrator (e.g., treatment or relocation). The final section provided the professionals an opportunity to describe any relevant factors about the cases that were not addressed in the other sections of the questionnaire. Not all the information requested was present in every case file; however, missing data for most study variables constituted less than 10%.
Data Analysis
A preliminary review of the data and descriptive (chi-square) analyses conducted across the 5 years of the study period revealed no substantial individual year differences in case characteristics. Specific areas examined included the older adults' background (e.g., gender, age, and living arrangements), abuse experience (e.g., type of abuse, place, perpetrators, and witnesses), and outcomes (e.g., prosecutions, treatment for victims, and relocation of victims). Thus, all the data are presented in the tables but discussed in the aggregate.
The data for this study are primarily categorical, and the analyses presented here are as follows. First, we present a description of the cases and the significant bivariate relationships between the characteristics of the older adults (e.g., age, orientation, and living arrangements), and we report the types of sexual abuse and case outcomes (results of all chi-square analyses are available upon request from P. Teaster).
Second, we used multiple correspondence analysis (MCA), a multivariate method for categorical data (Clausen, 1998), to explore and describe the relationships between the characteristics of the older adults and the type of sexual abused experienced. Using a weighted principal components analysis of a contingency table, we examined correspondence between the rows (observations within a data set) and the columns (variables). We summarized the associations between a set of categorical variables in a small number of dimensions (Greenacre, 1984) to provide a pictorial representation of the proximity between variables. We used chi-square (
2) to statistically determine the distance between data points. The results are most similar to those found in exploratory factor analysis; categories with similar distributions are represented as an array of close points, and categories with dissimilar distributions are represented by points spread farther apart. In the present investigation, we included the following variables in the analysis: the older adults' age, orientation level, living arrangement, and the occurrence of unwelcome touching and unwelcome sexual interest. We selected these two types of sexual abuse for inclusion in the analysis on the basis of their frequency of occurrence.
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Alleged Perpetrator
The alleged perpetrator was identified in 95% of the cases (Table 3). All but one of the perpetrators was identified as male; most perpetrators were 60 years of age and older (88%). For older adults living in the community, alleged perpetrators were just as likely to be a nonrelative living either in the household or outside of it (11%) as a family member (9%). When the incidence occurred in a facility, the alleged perpetrator was most often a resident in the nursing home (69%); only in 5% of the cases were staff members identified as the perpetrators. Limited information was available about the alleged offenders. Approximately 28% of the alleged perpetrators reportedly had untreated psychiatric illness, 16% abused alcohol or other drugs, and 14% were financially dependent on the older adults.
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2(1, N = 76) = 11.02, p 
.01, 
=.37] and were 80 years of age and older [2(2, N = 75) = 4.58, p .05, =.25]. Similarly, victims unable to participate in the prosecution tended to have low orientation [2(1, N = 76) = 9.68, p .01, =.36] and were 80 years of age and older [2(2, N = 75) = 4.51, p .05, =.24].
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Configurations of Abuse
Figure 1 offers a pictorial representation of the relationship between the personal characteristics of the older adults and the most common types of sexual abuse experienced, according to the first two factors emerging from the MCA. The proportion of total inertia (i.e., variance) explained by the two factors was 46%. Factor 1 (horizontal axis) distinguishes sexualized touching (negative values) from sexualized interest (center) and sexual abuse of persons between the ages of 60 and 79 years (positive values) from abuse suffered by persons 80 years of age and older (negative values). Factor 2 (vertical axis) differentiates abuse occurring in the community (negative values) from abuse occurring in facilities (positive values) as well as abuse of persons with medium orientation (positive values) from abuse of persons with low orientation (negative values). An examination of the configuration of the variables in Figure 1 reveals two distinct situations: (a) sexualized interests in persons 80 years of age and older, with medium orientation abilities, and (b) sexualized touching of persons living in nursing homes, between the ages of 60 and 79, with low orientation abilities.
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Discussion and Implications |
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Younger sample members (i.e., ages 60–79) with low orientation abilities most often experienced incidents of sexualized touching. Conversely, the sexual abuse experienced by older sample members (i.e., ages 80 and older) with medium orientation most often involved sexualized interest by another in either domestic or institutional settings. Two thirds of the victims living in a nursing home had low to moderate orientation abilities. This finding suggests that a lower level of orientation affects the degree of invasiveness of the sexual abuse experienced by the older adults (Shinoda-Tagawa et al., 2004). Further research with a larger sample size is needed to determine if this relationship remains consistent.
The findings in our study, derived from information on substantiated APS files, depart from findings in the study by Holt (1993) that used a mail survey sent to professionals in England, in that the majority of the sexually abused older adults resided in institutional settings rather than in domestic settings. Our findings also differ from the study by Payne and Civokic (1996), which used Medicaid Fraud Reports data, and from that of Burgess and colleagues (2000), which included nursing home residents referred to the first author as part of her forensic work. In both studies, the majority of perpetrators of the sexual abuse were staff members in a nursing home rather than residents. We suggest that our findings may be different from that of previous researchers as a result of the sample from which we gathered our data, that is, from substantiated APS case files over a 5-year period rather than the samples used in earlier collection methods.
In our study, the majority (approximately 70%) of perpetrators were residents residing in a facility. Such a finding has at least three policy implications. First, all staff should be thoroughly trained to detect possible sexual abuse and to know how to assist both victims and perpetrators. Staff should be thoroughly familiar with proper prevention and intervention strategies. They should be knowledgeable concerning reporting guidelines both inside and outside the facility, as well as techniques for the preservation of evidence of sexual abuse. Second, our findings imply that adequate staffing measures are necessary to help protect vulnerable residents from residents who might have orientation problems that predispose them to sexual abuse. One, certainly not the only, strategy for prevention is to place residents prone to abuse near a nurse's desk or in an area away from residents who are less oriented and less mobile than other residents. A final policy measure concerns facility residents. Residents in facilities were often witnesses to the abuse. Providing them with clear information about suspicious behavior and behaviors that constitute sexual abuse, as well as how to report this information, could prevent an abusive situation from occurring.
That most perpetrators were overwhelmingly nursing home residents explains in large part the very low prosecution rates of sex abuse, one outcome of state intervention. Such low prosecution rates imply that case resolution by means of avenues other than prosecution may produce better outcomes for both victim and perpetrator. In such instances, perpetrators may need protections from themselves, such as therapeutic intervention, rather than enhanced efforts toward incarceration.
As with earlier studies of the sexual abuse of older adults, we recognize the limitations of our data collection methods. First, we collected data only on cases substantiated by APS. Cases that are substantiated may differ from elder sexual abuse cases that are not reported, screened out when reported, and investigated but not substantiated. Cases were sent to researchers at the discretion of local APS units and may not represent all substantiated cases of older adult sexual abuse for any collection year. Although cases were substantiated according to Virginia APS protocols (e.g., private interview with the victim, record searches, interviews with collaterals, and interviews with the alleged offender when appropriate), we did not have access to the specific evidence upon which the individual cases were substantiated. Second, our information on these substantiated cases in no way captures the true occurrences of all elder sexual abuse that occurred in Virginia during the 5 years of our study. We recognize that, during the study period, there were cases of sexual abuse that were valid but not substantiated. According to the NCEA (1998), only one in five cases of elder mistreatment is actually reported. We conjecture that the reports of elder sexual abuse are even less frequently reported. Finally, our results and conclusions drawn from them are descriptive and exploratory in character; they do not adequately portray either the nature of the older adults' situations or the effects of sexual abuse on the health and well-being of the older adults. Future research must use more sophisticated research methodologies with larger samples in order to better capture the incidence and types of sexual abuse in later life. For example, to more fully understand the magnitude of this type of abuse requires an examination of sexual abuse across multiple states and multiple years. In addition, the long-term impact as well as the effectiveness of intervention on the lives of individuals most affected by sexual abuse warrant attention.
Although we, as researchers, emphasize the necessity of future work on this topic, it is important to fully recognize the difficulties inherent in conducting a study of this sort. Our attempts to change state law to allow us to gather data and to gain approval for the study by the state's Attorney General both failed. Permission to conduct research was only given as a result of the vigilant efforts of APS staff members at the state level, who convinced their state commissioner to authorize the study. We worked closely with APS staff at all levels—state, regional, and local—to develop data collection procedures. We recognize that the ability to gather these highly confidential data on a controversial subject was accomplished only through the zealous efforts of those who recognized the importance and timeliness of this study. We suggest that changes to state laws should be investigated and amended to allow for the conduct of research in areas such as the sexual abuse of older adults.
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Footnotes |
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1 School of Public Health, University of Kentucky, Lexington.
2 Center for Gerontology, Virginia Polytechnic Institute and State University, Blacksburg.
Decision Editor: Linda S. Noelker, PhD
Received for publication June 6, 2003. Accepted for publication March 31, 2004.
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This article has been cited by other articles:
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  H. Ramsey-Klawsnik, P. B. Teaster, M. S. Mendiondo, E. L. Abner, K. A. Cecil, and M. R. Tooms Sexual Abuse of Vulnerable Adults in Care Facilities: Clinical Findings and a Research Initiative Journal of the American Psychiatric Nurses Association, January 1, 2007; 12(6): 332 - 339. [Abstract] [PDF]
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 B. S. Fisher and S. L. Regan The Extent and Frequency of Abuse in the Lives of Older Women and Their Relationship With Health Outcomes Gerontologist, April 1, 2006; 46(2): 200 - 209. [Abstract] [Full Text] [PDF]
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