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Annotated Bibliography:


Elder Sexual Abuse

Although relatively rare compared to other types of reported elder abuse, a growing body of literature suggests that sexual abuse is a problem that significantly impacts a substantial number of seniors. Research indicates that it occurs within the community as well as in institutional settings. Individuals are victimized by spouses and other relatives, acquaintances and strangers, caregivers and other residents. When older women are sexually assaulted, they face additional challenges to reporting the incident and accessing treatment services than younger assault victims face. They are also at increased risk for injury as well as loss of independence.

The following references highlight many of the complexities of identifying and addressing elder sexual abuse.* Most of these reference materials may be obtained through your local university and community libraries or interlibrary loan services. Some must be ordered directly through the publisher or production company. When available, contact and pricing information is included with the abstract. Increasingly, many resources are available online, and the web addresses are also included.** If you have difficulty obtaining any of these materials, please contact the CANE office for assistance.

CANE is a service of the National Center on Elder Abuse (NCEA) which is supported by a grant from the Administration on Aging.

*We wish to thank Karla Vierthaler, Statewide Outreach Coordinator of the Pennsylvania Coalition against Rape, for her contributions in preparing this resource compilation. Ms. Vierthaler provides an excellent overview on this topic in an article which appeared in the April 2004 NCEA Newsletter, entitled "Speaking Out on a Silent Crime."

(**Like the mysterious staircases at Hogwart's Academy, web addresses may change without notice. If an address provided is no longer accurate, we recommend using a generic search engine, such as Google, to find a current link. If you cannot locate the online publication, contact the CANE offices for assistance.)



2004

1. P5698-4
Ramsey-Klawsnik, H.
Elder Sexual Abuse Perpetrated by Residents in Care Settings
Victimization of the Elderly and Disabled; Vol. 6 (6), p81and p93-p95; March/April 2004.
Journal article (scholarship)
In this article, the author draws upon experiences in consulting with adult protective services, Ombudsmen and nursing home personnel to present an overview of resident-to-resident elder sexual abuse. Two types of such abuse occur within residential care facilities. The first involves coercion of a victim who is able to, but has not, provided consent to the sexual activity. The second occurs when the elder lacks capacity to provide consent for sexual activity due to cognitive impairment. Perpetrators are typically male and victims typically female. Abuse may be directed toward multiple victims, or may occur within the context of a special relationship (such as a friendship). Areas in which such cases may be mishandled are identified and discussed: mistaking assault for consenting activity; assuming no harm has occurred; failing to recognize assault within a special relationship; minimizing the offender's behavior; failing to recognize and support victims' efforts to self-protect; and blaming the victim. Appropriate guidelines for nursing home staff intervention (including filing required reports, assessing and addressing the victim's medical and mental health needs, completing factual documentation, and supervising the alleged offender) are provided.

2. P5713-3
Talbot, N. et al.
Preliminary Report on Childhood Sexual Abuse, Suicidal Ideation, and Suicide Attempts Among Middle-Aged and Older Depressed Women
American Journal of Geriatric Psychiatry; Vol. 12 (5), 536-538; September-October 2004.
Journal article (research)
In this study, researchers examined the association between childhood sexual abuse history and suicidal ideation and attempts among older, female, psychiatric inpatients. The sample was comprised of 127 women, aged 50 and over, who met the diagnostic criteria for major depression. Each woman was assessed by use of the Clinical Interview for DSM-III-R, and asked about sexual abuse occurring before age 18. By using the Scale of Suicidal Ideation (SSI) and discussing the patient's history of suicidal behaviors, researchers evaluated the outcomes of death ideation, suicidal ideation, and suicide attempt status. Eighteen of the participants reported a history of childhood sexual abuse. Among the findings, women who reported histories of childhood sexual abuse were more likely to have an additional Axis I psychiatric diagnosis (including dysthymia, phobias, panic disorders, and substance abuse), and were more likely to experience suicidal ideation, suicidal behaviors, and multiple suicide attempts.

3. P5549-2
Vierthaler, K.
Speaking Out on a Silent Crime - Elder Sexual Abuse: The Dynamics of Problem and Community-Based Solutions
National Center on Elder Abuse Newsletter; Vol. 6 (7), 2-3; April 2004.
Newsletter article (online)
This article, the centerpiece of an NCEA newsletter, provides an overview of the dynamics of elder sexual abuse and the barriers of identification, reporting, and prosecution of this crime. The author, the outreach coordinator of the Pennsylvania Coalition Against Rape elder victims services (PCAR), summarizes what is known about elder sexual assault, including risk factors and effective response techniques. It also highlights a recent collaborative initiative by the Pennsylvania Department on Aging and PCAR that resulted in a six-module training curriculum which is intended to improve coordination of services for older victims. (interdisciplinary/multidisciplinary) (Note: The entire NCEA newsletter can be accessed from the home page of the NCEA web site at www.elderabusecenter.org or directly at http://www.elderabusecenter.org/pdf/newsletter/newsletter_040426.pdf)

4. M104
Wisconsin Coalition Against Domestic Violence (WCADV), National Clearinghouse on Abuse in Later Life (NCALL)
Anticipate: Identifying Victim Strengths and Planning For Safety Concerns Training Guide
Wisconsin Coalition Against Domestic Violence (WCADV), National Clearinghouse on Abuse in Later Life (NCALL), Madison, WI; 2004.
Manual/training kit
This manual is part of an interactive training exercise designed to "enhance the safety planning skills of professionals who work with older victims and/or people with disabilities" who live in abusive environments. It is designed for use in groups of four to eight people, with a target audience of professionals from the fields of domestic violence, sexual assault, the disability and aging networks, and adult protective services (APS). A breakdown of safety planning is provided, and includes prevention strategies, protection strategies, notification strategies, referral services, and emotional support contingencies. For victims who are leaving, the safety planning encompasses practical decisions regarding living arrangements, financial support, health decisions, legal decisions, and assistance for others affected by the victim's decision (children and grandchildren, other residents of the home, pets). The kit contains handouts, safety planning tools and other materials needed to facilitate the training exercises. (Note: Training kits are available only through NCALL/WCADV. To order, visit the web site at www.ncall.us, email at [email protected] or telephone 608/255-0539. Price: $40.00.)


2003

5. P5716-5
Sweeney, P.
Exploitation of Adults on the Internet
Victimization of the Elderly and Disabled; July/August; 2003.
Newsletter article
In this article, the author describes various ways in which elders may be exploited through the use of internet technology. Not only are elders susceptible to identify theft and financial exploitation through frauds and scams, pornographic web sites have been identified that sexually exploit older females. Advice is provided for investigators attempting to intervene and prosecute. The article also includes information on web sites such as "www.scambusters.org" designed to provide information on such criminal activity.

6. P5310-00
American Bar Association (ABA) Commission on Law and Aging
Resource Packet on Domestic Violence and Sexual Abuse in Later Life
American Bar Association (ABA) Commission on Law and Aging, with funding from Office on Violence Against Women at the U.S. Department of Justice, ABA Fund for Justice and Education; Washington, D.C., July 2003.
Resource packet
This resource packet was designed for use in developing training and educational programs to address the needs of older victims of domestic violence and sexual abuse. It includes an adaptable PowerPoint presentation (with CD), resource materials from the National Clearinghouse on Abuse in Later Life (NCALL) and the Wisconsin Coalition Against Sexual Assault (WCASA), a list of state Adult Protective Services (APS) administrators, and reprints of the following articles: "Developing Services for Older Women Who are Victims of Domestic Violence or Sexual Assault," "Developing Services for Older Victims of Domestic Violence or Sexual Assault: The Approach of Wisconsin Coalitions," and "Domestic Violence Among the Elderly: A Blueprint for the Criminal Justice System." (Note: The resource packet is available for $15.00, which includes shipping and handling, through the ABA Commission on Law and Aging, 740 15th St. NW, 9th Floor, Washington, D.C., 20005. Telephone 202/662 8690; web site: www.abanet.org ; email [email protected] .)

7. P5543-18
Brandl, B., in collaboration with the Colorado Task Force and the Wisconsin Coalition Against Domestic Violence/National Clearinghouse on Abuse in Later Life
Safety Planning: How You Can Help - A Guide for Individuals with Cognitive Disabilities
Wisconsin Coalition Against Domestic Violence/National Clearinghouse on Abuse in Later Life; Madison, WI; 2003.
Booklet
As quoted from the WCADV web site: "This booklet offers suggestions to caring individuals willing to help persons with cognitive disabilities who are being abused. Persons with cognitive disabilities may not recognize that they are being abused, or are afraid to tell anyone. This booklet guides individuals to create a safety plan with the cognitively disabled person that fits his or her specific needs depending on their level of functioning." The guidebook provides a list of practical suggestions and a form for a safety plan (including simplified steps, contact information, etc.). It also includes such concrete information as the top ten items to pack. (Note: This booklet is accessible online from the NCALL web site publication page at http://www.ncall.us/docs%5CSafetyPlanCogDisText.pdf . Print copies are available by contacting Wisconsin Coalition Against Domestic Violence/National Clearinghouse on Abuse in Later Life, 307 S. Paterson St. Suite 1, Madison, WI 53703. Phone: 608/255-0539/Fax 608/255-3560. Cost: $2.25 members/$2.50 non-members.)

8. P5672-18
Lingler, J.
Ethical Issues in Distinguishing Sexual Activity from Sexual Maltreatment among Women with Dementia
Journal of Elder Abuse and Neglect; Vol. 15 (2), 85-102; 2003.
Journal article (scholarship)
This article considers the ethical complexities of distinguishing between sexual activity and sexual abuse of women with dementia. In particular, the author challenges the National Center on Elder Abuse (NCEA) definition of sexual abuse as "nonconsensual sexual contact of any kind with an elderly person." To illustrate the difficulty in assessing sexual abuse, she presents a case study of a loving couple who remains sexually active after the wife becomes moderately cognitively impaired. The husband is viewed as a "model caregiver" by all health and social service professionals involved. At issue is the impaired individual's ability to provide consent. Overly simplified definitions appear limiting and detrimental to the vulnerable spouse. The author presents a paradigm for the contextual ethical analyses of such situations that is based upon feminist bioethical approaches, and contends that "some, if not most, sexual activity between loving spouses may be morally permissible even when one partner has dementia and cannot consent." The approach involves assessment of various forms of oppression, such as ageism plus sexism, and hypercognitivism, which places a higher value on rationality and productivity as opposed to other elements of an individual's humanity. The trust level between the partners before the onset of dementia is an important consideration.

9. P5574-16
Ramsey-Klawsnik, H.
Elder Sexual Abuse Within the Family
Journal of Elder Abuse & Neglect; Vol.15 (1), 43-58; 2003.
Journal article (scholarship)
The author, a sociologist and mental health clinician long affiliated with the Protective Services Program of the Massachusetts Executive Office of Elder Affairs, presents a qualitative analysis of one hundred domestic sexual abuse cases presented between 1993 and 2002. Marital sexual elder abuse and incestuous elder abuse are described. Three patterns of marital sexual abuse emerged. Long-term domestic violence or domestic violence "grown old" involves cases of physical, psychological and sexual abuse, and if victims experience a decline due to illness or disability, they become more vulnerable. Recent onset of sexual abuse within long-term relationships is less frequent and may be due to changes in the physical and mental status of the abuser, such as aggressive behaviors related to a progressive dementia. Victimization within a new marriage also occurs but is relatively infrequent compared to long-term domestic violence. Though rare, cases of wives sexually abusing elderly husbands have been substantiated and fit into the same three patterns of marital abuse. Three types of incestuous elder abuse are also described: cases involving adult child perpetrators, other relatives as perpetrators, and borderline cases involving "quasi-relatives." Risk factors include mental illness, substance abuse, financial dependence, and social underdevelopment. Questions arise regarding culpability when cases involve juveniles. The range of behaviors involving sexual elder abuse is extremely wide and the causes are equally diverse and complex. Forensic markers include verbal disclosure by victims, reports by witnesses, and medical evidence such as genital injuries, bite marks, bruising on thighs, buttocks, breasts and other areas. Abusers often feel justified in their actions. Analysis also revealed that in some cases, disclosure to a professional was not believed or reported.

10. P5465-4
Sievers, V., Murphy, S. & Miller, J.
Sexual Assault Evidence Collection More Accurate When Completed by Sexual Assault Nurse Examiners: Colorado's Experience
Journal of Emergency Nursing; Vol. 29 (6), 511-514; December 2003.
Journal article (research)
This research examines whether sexual assault nurse examiners (SANEs) are more effective at evidence collection than non-SANE nurses and physicians. Five-hundred fifteen evidence kits (279 completed by SANEs and 236 by non-SANES), collected from October 1999 through April 2002 in Colorado, were audited by crime laboratory analysts from the Colorado Bureau of Investigation. Overall, kits collected by SANE practitioners were more complete and accurate. For example, kits collected by SANEs documented a completed chain of evidence at a 92 per cent rate, while those collected by non-SANEs were at 81 per cent; and SANEs were also more likely to collect sufficient amounts of pubic hair, head hair, swabs and blood tubes. (Note: This article addresses sexual assault evidence collection, not elder sexual abuse evidence collection.)

11. P5539-8
Teaster, P. & Roberto, K.
Sexual Abuse of Older Women Living in Nursing Homes
Journal of Gerontological Social Work; Vol. 40 (4), 105-119; 2003.
Journal article (research)
Elder sexual abuse is the least recognized and reported form of elder mistreatment, representing less than one per cent of mistreatment reported in the U.S. This article presents data on the sexual abuse of older female nursing home residents reported to the Virginia department of Adult Protective Services from July 1, 1996 through June 30, 2001. Fifty cases of sexual abuse of female residents were substantiated during this time period. Half of those abused were aged 70 to 79 and the other half were aged 80 to 89. Among the victim characteristics, more than two-thirds had problems in orientation, ambulatory limitations, and required assistance in handling financial affairs. Seventy-six per cent of the abuse involved sexualized kissing and fondling, and 38 per cent involved unwelcome sexual interest in the victim's body. Other forms of sexual abuse are also described. In 90 per cent of the cases, the alleged perpetrator was a male resident of the same facility, typically 70 years of age or older. No staff members were identified as perpetrators. Other offender characteristics are discussed, along with interventions made.

12. P5328-123
Wisconsin Coalition Against Domestic Violence (WCADV) / National Clearinghouse on Abuse in Later Life (NCALL)
National Domestic Abuse in Later Life Resource Directory
Wisconsin Coalition Against Domestic Violence/National Clearinghouse on Abuse in Later Life, Madison, WI; 2003
Resource Directory
This first edition directory includes a listing of resources throughout the United States that provide services for older victims of domestic abuse. The listing includes national hotlines and resources, along with a state by state listing of services, ranging from shelters to protective services to self-defense training programs. It also includes a listing of domestic violence and sexual assault coalitions. (Note: This resource directory can be accessed online at http://www.ncall.us/docs%5CNCALL_Directory.pdf. Print copies can be ordered through the web site at www.ncall.us, by email at [email protected], or by telephone at 608 255-0539. Price: $5.00.)

13. P5325-68
Wisconsin Coalition Against Sexual Assault (WCASA)
Creating a Balance: Promoting Healthy Relationships and Preventing Sexual Assault of People with Cognitive Disabilities
Wisconsin Coalition Against Sexual Assault, Madison, WI; 2003.
Booklet
As quoted from the introduction: "This booklet is designed to promote healthy sexuality and prevent the sexual assault of people with cognitive disabilities...The underlying premise of the booklet is that sexuality begins at birth and without sexuality education an individual is at high risk for abuse...As a caregiver, administrator, advocate, family member, or person with a disability, this information may help change the way society looks at and/or treats people with cognitive disabilities and, thereby, prevent sexual assault..." The material addresses individuals with cognitive developmental disabilities, such as mental retardation. Environmental factors that may contribute to vulnerability, such as little privacy and poor boundaries, and consent and other legal considerations are among the topics discussed. In addition, Wisconsin state statutes governing sexual assault, abuse of vulnerable adults, and reporting caregiver misconduct are provided. (Note: This booklet may only be obtained through WCASA, 123 E. Main St., 2nd floor, Madison, WI, 53703, voice/TTY 608 257-1516, or visit the web site at www.wcasa.org. Price: $5.00 for WCASA members/$7.00 for non-members.)


2002

14. P5117-14
Basile, K.
Prevalence of Wife Rape and Other Intimate Partner Sexual Coercion in a Nationally Representative Sample of Women
Violence and Victims; Vol. 17 (5), 511-524; October 2002.
The purpose of this study was to develop a national estimate of wife rape and six other types of sexual coercion by spouses and intimate partners. The issue of sexual violence was included in a 1997 national random telephone survey conducted by the Applied Research Center at Georgia State University. The data for this study draws upon the responses of the 602 women who answered questions about unwanted sexual experiences, with 17 per cent of the sample being women aged 65 and older. Responses are reported for all women, those women surveyed in current relationships, and those women currently married. Thirty-four per cent of the participants indicated that they had unwanted sexual experiences with a spouse or intimate partner during their lifetime. The most common experiences of women with their current partners were when they felt it was their duty to have sex (43 per cent), following a romantic experience (29 per cent), when the partner begged or pleaded (26 per cent), or after their partner spent money on them (24 per cent). Nine per cent of the respondents experienced being bullied into having sex, 7 per cent were physically forced, and 3 per cent were threatened with physical harm.

15. P5606-11
Burgess, A. & Frederick, A.
Sexual Violence and Trauma: Policy Implications for Nursing
Nursing and Health Policy Review; Vol. 1 (1), 17-36; 2002.
This article provides a historical overview of the anti-rape movement. It also provides a review of major contributions of nurse researchers in understanding the emotional impact of this trauma upon victims. Adult domestic violence, child sexual abuse, elder sexual abuse, barriers to care, forensic nursing, recidivism and policy implications are among the topics raised. The authors note that there is a dearth of research on elder sexual abuse, despite the vulnerability of this growing segment of population.

16. P5280-15
Osgood, N. & Manetta, A.
Physical and Sexual Abuse, Battering, and Substance Abuse: Three Clinical Cases of Older Women
Journal of Gerontological Social Work; Vol. 38 (3), 99-113; 2002.
Journal article (case study)
By focusing on three clinical case studies, this article explores substance abuse among older women who have been physically or sexually abused. The first client was a homeless, alcohol abusing 80-year-old woman with a history childhood abuse and subsequent victimization as an adult; the second woman had a history of alcohol abuse and ongoing valium abuse, who eventually revealed a history of childhood sexual abuse; the third was a victim of domestic violence throughout her 60-year marriage, first asked about the abuse at age 68 by her physician. Each client demonstrated characteristics of post-traumatic stress disorder (PTSD) and the literature indicates that women often abuse substances in order to numb themselves to the trauma, past or present. Social workers and mental health professionals working with women with abuse histories must first help them to attend to basic survival needs and assist them in developing safety plans if the abusive situation is ongoing. Awareness of community resources for shelter, substance abuse treatment, support groups, etc., are essential. In these cases, treatment consisted of ongoing evaluation of the clients' status, education regarding the nature of abusive relationships and their effect on mental health and self-esteem, and reminiscence therapy, which allowed the women to process their experiences at their own pace.

17. N4885-13
Safarik, M., Jarvis, J. & Nussbaum, K.
Sexual Homicide of Elderly Females
Journal of Interpersonal Violence; Vol. 17 (5), 500-525; May 2002.
Using data from the FBI's Supplementary Homicide Reports (SHR) of the Uniform Crime Reports (UCR) and the National Center for the Analysis of Violent Crime (NCAVC), this article presents an empirical analysis of victim characteristics, crime scene attributes and offender demographics related to sexual homicides of 128 elderly women from 1976 through 1999. The research is intended to produce predictive information for use in investigating these relatively rare but brutal crimes. One observation links knowledge of the racial homogeneity of the neighborhood of the crime to an increased ability to accurately predict the offender's race. The following are among other implications of this research: offenders often engage in "mental mapping" of victim information; while they may not have an established relationship with the victim, they may have a marginal acquaintanceship; and most offenders demonstrate a disorganized typology of criminal behavior. Race and age are two other variables addressed in this study.

18. P5605-6
Teitelman, J. & Copolillo, A.
Sexual Abuse among Persons with Alzheimer's Disease Guidelines for Recognition and Intervention
Alzheimer's Care Quarterly; Vol. 3 (3), 252-257; Spring 2002.
Journal article (scholarship)
Although no studies have been conducted specifically on the incidence and prevalence of elder sexual abuse of individuals with dementia, research suggests that a high percentage of those victimized are cognitively impaired. This article is intended to present an overview of sexual abuse among individuals with dementia related to Alzheimer's disease or other conditions. It offers guidelines for health care practitioners for the identification of sexual abuse among this vulnerable population. Physical indicators include injury to the genitals, the presence of sexually transmitted diseases, and infections. Less obvious indicators would include pain or difficulty performing routine functions, such as walking, sitting, or urinating. Although emotional and psychological indicators are more difficult to detect in the presence of other symptoms that may be related to the dementing process, dramatic changes from the individual's baseline behavior and demeanor should be noted. Sexual abuse is defined not only as nonconsensual sexual activity, but also as sexual activity occurring when an adult is incapacitated and therefore unable to provide consent. Therefore questions are included that address the individual's awareness of the relationship, his or her ability to avoid exploitation, and the awareness of potential risks. Interview and assessment techniques (such as the use of anatomically correct dolls) are provided. The article concludes with discussion of appropriate interventions, depending upon whether the sexual activity is determined to be consensual or exploitative.

19. N4774-90
U.S. Senate Special Committee on Aging
Safeguarding Our Seniors: Protecting the Elderly from Physical and Sexual Abuse in Nursing Homes, March 4, 2002.
Hearing
This hearing was presented to the Senate Special Committee on Aging, on March 4, 2002. Testimony was offered by eight witnesses, including family and advocates of victims of institutional abuse and neglect. The General Accounting Office (GAO) report, Nursing Homes: More Can Be Done to Protect Residents from Abuse (accessible online at http://www.gao.gov/new.items/d02312.pdf ), was also presented at this time. Hearing chairman: Senator John Breaux (D-LA) (Note: Testimony of this hearing can be accessed online at http://aging.senate.gov/ .)

2001

20. N4799-11
Acierno, R. et al.
Rape and Physical Violence: Comparison of Assault Characteristics in Older and Younger Adults in the National Women's Study
Journal of Traumatic Stress; Vol.14 (4), 685-695; 2001.
Journal article (research)
This article reports on a study conducted to compare the characteristics of older women (aged 55-89) who experienced assault in the earlier part of the 20th century with the characteristics of younger women (18-34) who experienced assault recently. The subsamples (2,669 younger women and 549 older women) were drawn from the National Women's Study, a longitudinal research project involving 4,009 randomly selected women. In the current study, those who agreed to participate were interviewed by telephone regarding physical trauma and sexual assault. Participants were interviewed initially, then at one and two year intervals. This study supports earlier research in that it reports a lower prevalence of interpersonal victimization in older women. However, most characteristics of the assault were not statistically different. While younger women perceived a greater life threat during victimization, the number of women who knew the assailant, experienced multiple assaults, experienced injury, reported the assault to the police, reported either that they, the perpetrator or both were abusing substances at the time, were consistent for both groups.

21. P5324-106
Wisconsin Coalition Against Sexual Assault (WCASA),
Transcending Silence: A Series About Speaking Out & Taking Action In Our Communities - 4: Focus on Sexual Assault and the Elderly
Booklet
Wisconsin Coalition Against Sexual Assault, Madison, WI; 2001.
This booklet is an extension of the manual from WCASA entitled "Widening the Circle." It is designed to help both volunteers and professionals who assist older victims/survivors of sexual abuse. It addresses the myths (such as older individuals are asexual, and therefore unlikely victims) and factors that contribute to vulnerability, and also impact upon treatment interventions. Indicators of sexual assault are highlighted and guidelines for service providers are discussed. Relevant Wisconsin state statutes (including Caregiver Misconduct Reporting laws) are outlined and presented, along with a listing of state and national resources. (Note: This handbook is one of four from the Transcending Silence series, including Focus on Sexual Assault and People with Developmental Disabilities, Focus on Sexual Assault and People with Physical and/or Sensory Disabilities, and Focus on Sexual Assault and People with Psychiatric Disabilities. These booklets may only be purchased through WCASA at: 123 E. Main St., 2nd floor, Madison, WI, 53703, voice/TTY 608 257-1516, or visit the web site at www.wcasa.org. Price: $5.00 for WCASA members/$7.00 for non-members for each booklet.)

2000

22. P5609-3
Burgess, A., Dowdell, E. & Brown, K.
The Elderly Rape Victim: Stereotypes, Perpetrators, and Implications for Practice
Journal of Emergency Nursing; Vol. 26 (5), 516-518; October 2000.
Using a case study as a focal point, this article provides guidelines for the emergency nursing treatment of elderly rape victims. Perpetrators of elder sexual abuse are classified as either gerophiles (who often seek employment in nursing homes), sexually aggressive men (who may also reside in nursing facilities), and strangers. The authors stress the importance of following appropriate sexual assault examination and forensic evidence collection protocols, as well as the need for accurate documentation and referral for rape trauma counseling and mental health services. Specific clinical recommendations regarding special needs (such as cognitive impairment and physical limitations) are included.

23. K4285-8
Burgess, A., Dowdell, E. and Prentky, R.
Sexual Abuse of Nursing Home Residents
Journal of Psychosocial Nursing; Vol. 38 (6), 10-18; June 2000.
This article reports on a study of the sexual abuse of twenty nursing home residents. Sixteen victims were frail elderly, eighteen were female, fifteen were non-ambulatory, and sixteen victims displayed varying levels of cognitive impairment, due to dementia or other illness or injury. The article examines characteristics of the abusive incidents such as the mental status of victims, if and how assaults were reported, perpetrator identification, physical and forensic evidence, resident response and nursing home response. Researchers emphasize the need for increased sensitivity to changes in residents' baseline behavioral, emotional and mental status. (Note: A paper based upon this study, presented at Elder Justice: Medical Forensic Issues Concerning Abuse and Neglect roundtable discussion, held in Washington, D.C. on October 18, 2000.)

24. P5701-10
Burgess, A., Prentky, R. & Dowdell, E.
Sexual Predators in Nursing Homes
Journal of Psychosocial Nursing; Vol. 38 (8), 26-35; August 2000.
Journal article (research)
This descriptive study analyzes characteristics of 18 perpetrators of sexual abuse who victimized residents of nursing homes and other 24-hour care facilities. Data was drawn from facility records, police reports, reports to human service agencies, depositions and testimonies, and forensic evaluations. Among the findings, 15 of the perpetrators were employees (13 were nurses' aides) and three were residents; 11 were White, six were Black, and one was Hispanic. Of the employees, 11 were arrested (with five convictions) and four were not investigated by the police. Complete data sets were available for only eight perpetrators. In terms of dynamics of the offense, all victims were at high risk for abuse due to incapacity, dementia and frailty. Mere presence of the abuser was sufficient to control the victim in most cases. In ten cases, victims were assaulted multiple times, and in one confirmed case the perpetrator had victimized two residents. The only common offender characteristics identified within this sample were that all predators were classified as low in social competence and that all chose victims who were incapacitated and defenseless. A range of sexual acts were identified, including sadistic assaults. Case vignettes suggest that the motives for elder sexual assault are diverse. In certain cases, criminal background checks were either ignored, incomplete, or contained errors of input. Liability issues are discussed as facilities failed to protect residents from foreseeable risks.

25. P5699-11
Capezuti, E. & Swedlow, D.
Sexual Abuse in Nursing Homes
Elder's Advisor: The Journal of Elder Law and Post-Retirement Planning; Vol. 2, 51-61; 2000.
Journal article (scholarship)
This article presents guidelines for addressing sexual abuse of residents in nursing homes. It includes discussion of victim characteristics, signs and symptoms of sexual assault (including psychological and behavioral reactions), and recommendations regarding interviewing the victim and collection of evidence. In particular, nursing home administrators and staff are instructed to report incidents to appropriate authorities for complete investigations that preserve the integrity of the physical evidence. Relevant laws and theories of liability (including negligence, negligent hiring practices and supervision, respondeat superior and the non-delegable duty exception) are also considered.

26. N4608-3
Hauda, W.
Development of a Forensic Center for the Collection of Forensic Evidence in Abuse and Neglect Cases
Prepared for the Elder Justice: Medical Forensic Issues Concerning Abuse and Neglect roundtable discussion; Washington, D.C.; October 18, 2000.
Paper (online)
In this paper, the Adult Services Medical Director of the Inova FACT Center of Virginia discusses the evolution of this program from a center specializing in child abuse to an all inclusive forensic medical response service. He describes the Sexual Assault Nurse Examiner (SANE) program, and concludes with the hope that FACT will expand into the area of elder abuse by developing specific protocols and staff training.

27. L4550-6
Ramsey-Klawsnik, H.
Elder-Abuse Offenders: A Typology
Generations; p17-p22; Summer 2000.
Journal article (scholarship)
In this article, the author provides descriptions of five types of elder abuse offenders. The overwhelmed offender is well-intentioned but succumbs to caregiver stress, while the impaired offender cannot provide consistent, competent caregiving due to his or her own problems. The remaining three types of offenders (the narcissistic offender, the domineering or bullying offender, the sadistic offender) seek out victims and/or opportunities to exploit. Scenarios are provided to illustrate these situations. (This article is part of a special edition of Generations dedicated to the recognition of the problem of elder abuse.)

28. P5696-7
Safarik, M., Jarvis, J. & Nussbaum, K.
Elderly Female Serial Sexual Homicide
Homicide Studies; Vol. 4 (3), 294-307; August 2000.
Journal article (research)
This article describes the process of criminal investigation analysis (popularly referred to as criminal profiling) as a valid methodology for investigation of elderly female serial sexual homicides. The authors are using the Federal Bureau of Investigation (FBI) description of profiling, in which the major personality and behavioral characteristics of the perpetrator are identified through the process of analyzing the crimes committed. Four variables of 33 identified solved cases were analyzed: race of offender, age of offender, relationship of offender to victim, and distance (in city blocks) from the offender's residence to the victim's residence. Results of this analysis indicate that this method is a viable tool in investigating such crimes. Analysis also revealed that White victims were more likely to have been murdered by Black offenders, while an intra-racial offending pattern was demonstrated among the Black victims, and offenders were considerably younger than their victims.

29. P5692-6
Stein, M. & Barrett-Connor, E.
Sexual Assault and Physical Health: Findings From a Population-Based Study of Older Adults
Psychosomatic Medicine; Vol. 62, 838-843; 2000.
Journal article (research)
Sexual trauma has been linked to psychiatric symptoms, and is increasingly recognized in association with adverse physical health outcomes. This article reports upon a study designed to analyze adverse, long-term health outcomes of older victims of sexual assault. Beginning July 1992, 1,359 men and women (average age 74) who had been evaluated in a previous study (Rancho Bernard Heart and Chronic Disease Study, 1972-1974) participated in a follow-up interview and completed a sexual assault questionnaire. Of the results, 12.7 per cent of the women and 5.4 per cent of the men reported a history of sexual assault, and first sexual assault was reported as occurring before age 18 in 69 per cent of the male victims and 59 per cent of the female victims. Ten chronic medical conditions were analyzed for association with assault history. Male victims experienced a higher risk of thyroid disease, while women reporting a history of abuse experienced significantly increased risks of arthritis and breast cancer. Additionally, women who were repeatedly victimized were four times more likely to develop these chronic conditions than women who were never abused.

30. N4900-10
Stiegel, L., Heisler, C., Brandl, B. & Judy, A.
Developing Services for Older Women Who Are Victims of Domestic Violence or Sexual Assault
Victimization of the Elderly and Disabled; Vol. 3 (2), 17-28 and Vol. 3 (4), 49-60; 2000.
Journal article (scholarship)
This two part article reports upon the information generated during a teleconference held on December 16, 1999, under the STOP Grants Technical Assistance Project (STOP TAP). The conference (presented by the authors) was designed to assist State STOP Grant Program Administrators and domestic violence advocates in the development of services for older battered women and victims of sexual assault. Among the topics discussed were recommendations to enhance the criminal justice system's response to these older victims, including suggestions for training and education. The need for collaboration between APS, criminal justice systems and domestic violence programs was emphasized. Contributions of several programs, including the Wisconsin Coalition Against Domestic Violence (WCADV) and the Wisconsin Coalition Against Sexual Assault (WCASA) were highlighted. (Note: Reprints of these articles are included in the Resource Packet on Domestic Violence and Sexual Abuse in Later Life; American Bar Association Commission on Law and Aging; 2003. See CANE file number P5310-00 for more details.)

31. L4420-16
Teaster, P., Roberto, K., Duke, J. & Kim M.
Sexual Abuse of Older Adults: Preliminary Findings of Cases in Virginia
Journal of Elder Abuse & Neglect; Vol. 12 (3/4), 1-16; 2000.
From July 1, 1996 to June 30, 1999, data was collected from APS case files of sexually abused adults in Virginia, including 42 substantiated cases of abuse. The study identifies trends regarding the victims' ability to care for self, the type, pattern and location of the abuse, information regarding witnesses and offenders, and case resolution. In this sample, most victims were women, aged 70 and over, living in facilities, and most perpetrators were male. The article provides discussion on the complexities of identifying and prosecuting such cases.


1999

32. K4230-6
Teitelman, J. & O'Neill, P.
Elder and Adult Sexual Abuse: A Model Curriculum for Adult Services/Adult Protective Services Workers
Journal of Elder Abuse & Neglect; Vol.11 (3), 91-100; 1999.
Journal article (scholarship)
This paper describes a comprehensive, three-day competency-based training curriculum designed to prepare service providers working with elderly patients to recognize and effectively respond to the signs of sexual abuse in their clients. This curriculum was developed for Adult Services and Adult Protective Services workers in Virginia. This paper includes discussions of the course themes, course content, and objectives. Recommendations for the development of similar courses are included.


1998

33. P5690-7
Kuhn, D., Greiner, D. & Arseneau, L.
Addressing Hypersexuality in Alzheimer's Disease
Journal of Gerontological Nursing; Vol. 24 (4), 44-50; April 1998.
Journal article (scholarship)
Though relatively uncommon, hypersexuality in Alzheimer's patients presents challenges to providing adequate care not only for these individuals but for other nursing home residents. This article presents an overview of hypersexuality, which authors define as "persistent, uninhibited sexual behavior directed at oneself or other people" and which differs from sexual behavior that is inappropriate simply because it occurs in the wrong place. Possible causes for the syndrome be may brain atrophy associated with particular types of dementia, medication reactions, hormonal changes, and psychological issues. A case illustration is presented that highlights the complexity of interpreting the behavioral symptoms and in appropriately intervening. Interventions include staff education and an assessment of the patient's environment as well as physical, psychological and emotional status. Distraction, redirection, and environmental modifications should be attempted before pharmacological interventions (including the use of Provera).

34. M98
Wisconsin Coalition Against Sexual Assault (WCASA)
Widening the Circle: Sexual Assault/Abuse and People with Disabilities
Wisconsin Coalition Against Sexual Assault, Madison, WI; 1998.
Manual/video
As quoted from the introduction, "This manual...is structured to assist sexual assault service provider agencies, human services personnel and others to widen the circle of our communities to include all of us who are vulnerable to being victims/survivors of sexual violence..." The manual (which is accompanied by a video) covers such topics as increasing service accessibility for people with developmental, physical, psychiatric and cognitive disabilities and the elderly, and promoting awareness of these services to these populations. The manual provides many practical guidelines, including the "Disability Etiquette," which instructs service providers in terminology and communication skills that are person-centered and facilitative. Various case scenarios of "hands off," "hands on," and "harmful genital practices" are used to illustrate different types of sexual abuse that include stranger or acquaintance sexual assault, caregiver sexual assault, incest and intimate partner violence. Guidelines for responding to disclosure, investigating allegations made by individuals with cognitive and communicative limitations, and interviewing guidelines are outlined. In addition, the manual provides an overview on developmental disabilities (such as mental retardation, autism, cerebral palsy, brain injury), mental illnesses (including schizophrenia and bi-polar mood disorder), physical and/or sensory disabilities (including mobility impairment, visual impairment, speech and hearing impairment, and a range of other conditions). Assisting older survivors of childhood sexual assault, counseling interventions (including a section on dealing with suicidality as a result of victimization and/or post traumatic stress disorder), programming considerations and working with guardians are among the other topics addressed. (Note: This manual is available only through WCASA, 123 E. Main St., 2nd floor, Madison, WI, 53703, voice/TTY 608 257-1516; web site: www.wcasa.org. Price: $30.00 WCASA members/$40.00 non-members.)


1997

35. P5691-3
McCartney, J. & Severson, K.
Sexual Violence, Post-traumatic Stress Disorder and Dementia
Journal of the American Geriatrics Society (JAGS); Vol. 45, 76-78; 1997.
Journal article (scholarship)
This brief article presents a case study of an 82-year-old female diagnosed with Alzheimer's dementia who was suffering from symptoms of post-traumatic stress disorder (PTSD) in response to being sexually assaulted. The authors describe the symptom clusters that she experienced (intrusive symptoms, avoidance symptoms and hyperarousal symptoms) following the assault. The patient was treated effectively with sertraline.

36. P5694-13
Moses, J., for the Sexual Assault Crisis Centre Kingston Inc.
Senior Women and Sexual Violence It's Never Too Late To Heal
1997
Agency publication (scholarship)
This publication provides an overview of the needs of sexually assaulted older women. Due to normal aging processes, older victims are more likely to incur physical injuries as a result of sexual assault and the injuries are likely to be serious in nature and may require longer recovery times. Isolation, and the fear of losing independence, may contribute to not reaching out for assistance or revealing the sexual abuse. Service providers are encouraged to identify the ageist beliefs that act as barriers to effective interventions, such as the notion that older women are emotionally fragile, and that they are not sexual beings. (Note: To obtain this publication, please contact the Sexual Assault Crisis Centre Kingston Inc. at 613/545-0762 for more information.)


1996

37. P5704-00
Baumhover, L. & Beall, S. (Eds.)
Abuse, Neglect and Exploitation of Older Persons
Health Professions Press; Baltimore, MD; 1996.
Book
This book contains chapters addressing investigation and intervention of various types of elder abuse, including sexual abuse. It is intended as a practical guide to assist health and social service professionals in detection, assessment, intervention and referral. Chapters also address multidisciplinary approaches as well as training and education for long-term care staff. (Note: This book is not available through CANE.)

38. P5693-6
Philo, S., Richie, M. & Kaas, M.
Inappropriate Sexual Behavior
Journal of Gerontological Nursing; p17-p22; November 1996.
Journal article (scholarship)
This overview is intended to assist nurses and caregivers in identifying and managing inappropriate sexual behavior. Causes may include physical conditions (including dementia), psychological issues (such as aggression and frustration, and panic associated with death), the need for intimacy, and decreased impulse control. The effect of such behaviors creates problems in continuity of care, and often disrupts the surrounding environment, such as the nursing home unit. The first step in intervention is a comprehensive assessment to determine the underlying cause(s) and triggers of the individual's behavior, and should include a consideration of previous inappropriate or criminal sexual behavior. Patients should be provided opportunities for expression of appropriate sexual behavior. Redirection (such as leading a resident back to his or her bedroom if he or she begins to disrobe) and modifications (to clothing, environment, etc.) are additional strategies to consider. Caregivers are urged to reframe their perception of the behavior as a call for attention, and are encouraged to moderate their own response in order to diffuse the problem.

39. A123-3
Simmelink, K.
Sexual Assault: Clinical Issues - Lessons Learned From Three Elderly Sexual Assault Survivors
Journal of Emergency Nursing; Vol. 22 (6), 619-621; December 1996.
Journal article (scholarship)
This article uses the case studies of three elderly women seen at the Sexual Assault Resource Services (SARS), a nurse clinician program in Minneapolis, Minnesota, to discuss insights learned in helping them to recover.

40. P5700-6
Tyra, P.
Helping Elderly Women Survive Rape Using a Crisis Framework
Journal of Psychosocial Nursing; Vol. 34 (12), 20-25; 1996.
Journal article (scholarship)
In this article, the author discusses nursing and mental health interventions with elderly rape victims using a crisis framework. A case study is used to describe the process of how crisis counseling assists the victim, who frequently experiences rape trauma syndrome or post-traumatic stress disorder, to increase adaptive coping skills, to regain equilibrium, and to transition from being a victim to being a survivor. Among the other issues specific to older victims of sexual abuse not usually experienced among younger victims are loss of independence and the fear of further limitations of autonomy. The importance of adequate time, empathic listening, support, and public education are also noted.


1993

41. P5697-5
Benbow, S & Haddad, P.
Sexual Abuse of the Elderly Mentally Ill
Postgraduate Medical Journal; Vol. 69 (816), 803-807; 1993.
In this overview of elder sexual abuse, four case histories are provided that illustrate a vast range of complexities in identifying and addressing it. In particular, the case scenarios demonstrate difficulties in dealing with suspected abuse when either the alleged victim or perpetrator has a diagnosis of dementia or other cognitive disability. Health care professionals are encouraged to offer help whether or not the suspected abuse can be proven. Multidisciplinary assessment and treatment planning are considered essential. (U.K.)

42. P5695-5
Holt, M.
Elder Sexual Abuse in Britain: Preliminary Findings
Journal of Elder Abuse and Neglect; Vol. 5 (2), 63-7; 1993.
Journal article (research)
In this study, the author enlisted the participation of health and social service professionals through various British journals to provide case histories (or to complete surveys based upon cases) of suspected elder sexual abuse that they had encountered. Ninety cases of suspected sexual abuse were reported, with 57 confirmed. Seventy-seven victims were female and 13 were male, and 85 per cent were aged 75 and over. Seventy-seven per cent of the women had dementia, 67 per cent were frail, and 48 per cent had impaired mobility, while 46 per cent of the males had dementia, 31 per cent were stroke victims, and 31 per cent were frail. Eighty-four per cent of the women functioned at a poor level or were completely dependent, and 93 per cent of the men also functioned at a poor or very poor level. The abuser was male in all but two cases, and the victim was dependent upon the abuser for some type of care in 88 per cent of the cases. Rape was reported in over two-thirds of the cases (both male and female). Despite the limitations of this methodology, results support earlier research conducted in the U.S. by Dr. Ramsey-Klawsnik regarding victim characteristics.

43. P5689-12
Ramsey-Klawsnik, H.
Interviewing Elders for Suspected Sexual Abuse: Guidelines and Techniques
Journal of Elder Abuse & Neglect; Vol. 5 (1), 5-19; 1993.
This article presents guidelines for interviewing elders for suspected sexual abuse, which should be considered either when an elder reports having been victimized or when he or she presents with possible symptoms. In addition to the more obvious symptoms of genital injury or the presence of a sexually transmitted disease, the individual may also make a "coded" disclosure of abuse (a hint rather than a direct statement about the violation). Behavioral and emotional changes (such as phobic responses or intense fears) are among the indicators highlighted. The author provides practical recommendations for interviewing, including who should conduct the interview, the environment in which the interview should take place, and the process of the interview itself (rapport-building and screening). Interventions involve providing support for the victim, making reports in accordance with local laws, and assisting the victim in obtaining the necessary legal and medical follow-up. In particular, the victim should be protected from unsupervised contact with the perpetrator in order to avoid repeat offenses.


1992

44. N4671-4
Allers, C., Benjack, K. & Allers, N.
Unresolved Childhood Sexual Abuse: Are Older Adults Affected
Journal of Counseling & Development; 71, 14-17; September/October 1992.
Journal article (scholarship)
Survivors of unresolved childhood sexual abuse may experience lifelong patterns of depression and revictimization. The authors of this article provide clinical case studies to explore the connections between elderly clients presenting with chronic depression, as victims of elder abuse and, at times, having been misdiagnosed with dementia and other mental illness.

45. N4802-4
Muram, D., Miller, K. & Cutler, A.
Sexual Assault of the Elderly Victim
Journal of Interpersonal Violence; Vol. 7 (1), 70-76; March 1992.
Journal article (research)
This study of rape victims, designed to determine which variables are solely affected by the victims age, utilized data from the Memphis Sexual Assault Resource Center (MSARC), formerly known as the Rape Crisis Center. From January 1987 through September 1990, 1722 adult patients were seen at this facility. The medical records of 53 women, aged 55-87 were evaluated and compared to the medical records of 53 women, aged 18-45. Significant findings include that the elderly were most often victimized in their own homes (71.7 per cent) and by strangers (79 per cent). The younger women were most often victimized in public places (64.2 per cent) and by known assailants (43 per cent). It is suggested that many sexual assaults on elderly victims occur during the course of attempted robberies, accounting for the predominance of assaults occurring in the victims' homes. In addition, elderly victims were more likely to sustain genital injury during the assault, with 28 per cent of these victims requiring surgical repair. This vulnerability may be due to decreased estrogen levels in post-menopausal women. Also of concern was that younger women reported a much higher rate of previous victimization (24.5 per cent as compared to 9.4 per cent), which may suggest a societal trend towards increased sexual violence, or a difference in how younger and older women interpret the term "sexual assault."

46. N4804-5
Ramin, S., Satin, A., Stone, I. & Wendel, G.
Sexual Assault in Postmenopausal Women
Obstetrics & Gynecology; Vol. 80 (5), 860-864; November 1992.
Journal article (research)
The purpose of this study was to examine patient characteristics, patterns of injury, forensic evidence, and frequency of sexual assault in postmenopausal women. The medical records of 129 women, aged 50-100, were compared with the records of 129 women, aged 14-49. All women were examined at the Dallas County Parkland Memorial Hospital after reporting sexual assault (1986-1991). During this time period, a total of 5,975 victims were examined, with postmenopausal women representing 2.2 per cent of all assaults. Of the findings, postmenopausal victims sought medical attention within six hours of the rape more often than younger victims, and trauma was noted in 69 per cent of all women with no significant differences between the age groups. However, the patterns of injury were significantly different. Genital trauma occurred in 43 per cent of postmenopausal victims as compared to 18 per cent in younger victims; 25per cent of the postmenopausal victims sustaining such trauma required surgical repair while none of the younger victims did. Younger victims experienced extragenital trauma 66 per cent of the time compared to 49 per cent of the older group, with more injuries to the head and neck. While five per cent of the postmenopausal victims were hospitalized, only two per cent of the younger victims were hospitalized.


1991

47. G3215-10
Ramsey-Klawsnik, H.
Elder Sexual Abuse: Preliminary Findings
Journal of Elder Abuse & Neglect; Vol. 3 (3), 73-90; 1991.
Journal article (research)
Twenty-eight cases of suspected elder sexual abuse were identified and described by elder protective service workers. All victims were female. All but one of the suspected offenders were male. Eighty-one per cent were caregivers and 78 per cent were family members. Findings of the study are presented, and issues relative to the sexual victimization of elders are discussed.


1989

48. N4803-2
Cartwright, P. & Moore, R.
The Elderly Victim of Rape
Southern Medical Journal; Vol. 82 (8), 988-989; August 1989.
Journal article (research)
This brief article describes a retrospective analysis of data regarding the 21 elderly rape victims (aged 60-90) who presented to the Metropolitan Nashville General Hospital from 1984-1986. In 17 cases, the victims were White, in 4 cases Black; in 20 cases the assailant was reported to be Black. In 17 cases, the assault occurred in the victim's home; in 18 cases between the 6PM and 6AM. Weapons were involved in 21 cases. While 11 victims sustained genital injuries, only one required surgical repair. The researchers indicate that this study supports the concept that many rapes are motivated by a need to exert power and not due to sexual desire, and that they may be racially related. The fact that one rapist was convicted in five of these cases suggests the possibility that rape of the elderly may be serial in nature.

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