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Sexual abuse is the least perceived, acknowledged, detected, and reported type of elder mistreatment. Thus, it is helpful for lawyers to understand this problem, to be alert for it both professionally with their elderly clients, particularly those in nursing homes, and personally with their family members. The issue of elder sexual abuse involves some potentially surprising aspects. Frequently, the perpetrators are not young people or nursing home staff, but rather fellow nursing home residents. And the perpetrators are infrequently prosecuted in criminal courts, requiring nursing homes to address how to prevent some residents from abusing others. The National Center on Elder Abuse defines sexual abuse as “non-consenting sexual contact of any kind.” It includes unwanted touching; sexual assault or battery, such as rape, sodomy, and coerced nudity; sexually explicit photographing; and sexual contact with any person incapable of giving consent. Sexual abuse constitutes less than 1 percent of all reports substantiated after an investigation by Adult Protective Services. (APS is the name commonly given to the state agency responsible for protecting the safety, health, and civil liberties of individual older adults and for investigating allegations of sexual abuse.) Researchers and practitioners assert that such an estimate represents the most overt cases. Other cases likely exist that are not included in this statistic. IN VIRGINIA To gain a better understanding of the scope of the problem and to develop a profile of sexual abuse cases (as distinct from other forms of abuse), we studied the sexual abuse of older adults in Virginia. Before our study, only a few published empirical articles specifically addressed the sexual abuse of older adults, largely because of the hidden nature of the problem and the inherent difficulties in obtaining data. These previous studies indicated that older sexual abuse victims are primarily women with cognitive limitations or physical-care needs who endure multiple forms of sexual abuse. Most previous studies were based on small samples (20 to 53 people). They provide descriptive accounts of one or more aspects, including the background of the individuals involved, the perpetrators and their relationship to the victims, the investigation, and outcomes of cases investigated by a government agency. In our Virginia study, we collected data from local units of APS across Virginia, where APS staff investigate in both domestic and institutional settings. Data are derived from case files of persons 60 years of age and older found to be sexually abused over a five-year period: July 1, 1996, through June 30, 2001. Collection yielded a total of 82 cases, with 8 to 19 cases reported each year. Using a survey instrument that drew upon the work of sociologist Holly Ramsey-Klawsnik and input from APS professionals, APS staff recorded information on substantiated cases only. Data gathered from APS staff 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 to the abuse (if any), the alleged offender, the resolution of the case, the outcome for the older adults, and any additional relevant facts of the case. Not all information requested was present in every case file; missing data for most study variables constituted less than 10 percent. A preliminary review of data and descriptive analyses revealed no substantial individual yearly differences. Specific areas examined included older adults’ background (i.e., gender, age, and living arrangements), abuse experience (i.e., type of abuse, place, perpetrators, and witnesses), and outcomes (i.e., prosecutions, treatment for victims, and relocation of victims). Presented here is a description of the cases, the significant relationships among the characteristics of the older adults, the types of sexual abuse, and case outcomes. WHAT WE FOUND Most victims were women (95 percent), and approximately half (52 percent) of the older adults were between the ages of 60 and 79. Seventy-two percent resided in a nursing home or other residential facility; 17 percent lived with a family member (e.g., spouse, child, or sibling). Living arrangements were not reported for 11 percent of the sample. The majority of these older adults needed help with orientation to time (86 percent) and place (81 percent). Eleven percent were categorized as having low orientation, 29 percent had medium orientation, and 57 percent had high orientation (with a high score meaning a higher degree of orientation). Fifty percent of these older adults could not walk without assistance, and 15 percent were not ambulatory at all. Only 11 percent could manage their own financial affairs, even with assistance. The most common type of sexual abuse involved sexualized kissing and fondling (73 percent), with the second most frequently reported abuse being unwelcome sexual interest in the older adult’s body (43 percent). Other types of verbal or physical sexual abuse included unwelcome description or discussion of sexual activity (12 percent), general sexual jokes and comments (7 percent), oral-genital contact (7 percent) or penetration (5 percent), and vaginal rape (5 percent). In 49 percent of cases, multiple types of sexual abuse occurred within a single case. Abuse was an isolated incident in 79 percent of cases and it was ongoing in 16 percent. For older adults living in the community, the abuse typically occurred in their own home (16 percent of all abuse cases) or the home of the alleged perpetrator (7 percent of all abuse cases). For older adults living in nursing homes or other residential facilities, the abuse typically occurred in the facility (77 percent of all abuse cases). In a few instances, the abuse occurred when the older adults were taken outside the facility, such as to the perpetrator’s home or to the hospital. It was common for there to be at least one witness (51 percent of cases), if not two (24 percent), to the sexual abuse. In nursing home facilities, the witnesses were most likely to be residents of the facility (52 percent) or staff members (41 percent). ELDERLY MALE PERPETRATORS Alleged perpetrators were identified in 95 percent of cases. All but one of the perpetrators were male, and most of the perpetrators were 60 years of age and older (88 percent). 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 percent of the total abuse cases studied) as a family member (9 percent of the total). When abuse occurred in a facility, the alleged perpetrator was most often a resident in the nursing home (69 percent). Staff members were identified as perpetrators in only 5 percent of cases. Approximately 28 percent of alleged perpetrators reportedly had untreated psychiatric illness, 16 percent abused alcohol or other drugs, and 14 percent were financially dependent on the victim. The alleged offender was prosecuted in court in only four cases (5 percent), with three victims in these cases living in a nursing home. In three of the four cases, the offender was convicted. The most common reasons noted for not prosecuting cases were insufficient evidence (63 percent) and the older victim being unable to participate in the prosecution (26 percent). Insufficient evidence was more likely to be given as a reason for not prosecuting when the older adult had low orientation. Similarly, victims unable to participate in the prosecution tended to have low orientation and were at least 80 years old. Of the abused older adults, 16 percent were relocated either within the facility or to another facility after the abuse, and 11 percent received physical or psychological treatment for the abuse. APS staff reported that only 12 percent continued to be at risk of further sexual abuse by the alleged perpetrator. In 29 percent of cases, alleged perpetrators were relocated, and 10 percent received psychiatric treatment. VICTIMS’ VULNERABILITY Analysis revealed a relatively homogenous group of older adult victims, most of whom were women with cognitive and functional limitations residing in nursing homes. Self-care limitations enhanced dependency and vulnerability, which may have increased susceptibility to being abused. Two-thirds of victims living in a nursing home had low to moderate orientation abilities. Younger sample members (i.e., those ages 60-79) with low orientation abilities most often experienced incidents of sexualized touching. Conversely, sexual abuse experienced by older sample members (i.e., those age 80 and older) with medium orientation most often involved sexualized interest by another. This finding suggests that a lower level of orientation permits a higher degree of invasiveness in the sexual abuse older adults experience. Some findings in our study depart from previous studies. Earlier studies had hypothesized that most abuse occurred at home and that the majority of institutional abuse was perpetrated by the staff. As noted, our research found that the majority of the sexually abused older adults resided in institutional settings and the majority of abusers in these facilities were other residents. That most perpetrators were nursing home residents explains in large part the very low prosecution rates of sex abuse. Low prosecution rates may suggest that case resolution by means other than prosecution may in fact produce better outcomes for both victim and perpetrator. In such instances, perpetrators may need protection from themselves, such as therapeutic intervention, rather than greater efforts toward incarceration. We recognize that these results and conclusions are descriptive and exploratory. They do not adequately portray either the nature of the older adults’ situations or the effects of sexual abuse on their well-being. Future research must use more sophisticated methodologies with larger samples to better capture the problem of sexual abuse later in life. LONG-TERM QUESTIONS To that end, co-author Pamela Teaster and her colleagues are conducting a three-year study of the sexual abuse of vulnerable adults in facilities in New Hampshire, Oregon, Tennessee, Texas, and Wisconsin. Funded by the National Institute on Aging, this ongoing research expands on our study by looking at the entire investigatory process of these cases. It also examines the health-related changes in substantiated cases of sexually abused residents in nursing homes. Although the three-year research project is groundbreaking, it still will not capture the long-term impact of the sexual abuse and the effectiveness of state intervention. We are still at the very beginning of fully understanding this problem and how regulators and the legal system can best address it. Pamela B. Teaster is an assistant professor at the Center for Gerontology and Department of Health Behavior at the University of Kentucky. Karen A. Roberto is a professor and director of the Center for Gerontology at Virginia Polytechnic Institute and State University. They may be reached at [email protected] and [email protected], respectively. This research was first presented in an academic article in The Gerontologist.

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