Sexual Abuse of the Elderly

By Barbara Katayama, RN, BSN, LNC

The public at large is generally unaware of the incidences of sexual assaults against the elderly. It is an unsavory thing to think of, yet it occurs and possibly with more frequency than we previously imagined. Unfortunately, the statistics will take a while to catch up with reality, as with child sexual abuse. What we don't know, we turn our backs on. After all who would want to believe that anyone would be so low as to attack an elderly, incapacitated individual? If we look at the reasoning of a perpetrator then we would assume that we would want the perfect victim. A perfect victim is one that cannot fight back, report, or be believed, and one that can be intimidated into continued contacts for fear of retaliation.

The incidence of sexual abuse against the elderly in long-term care has not been sampled. The Administration on Aging (AOA) conducted a study in on elder abuse; however, the focus was on domestic, or in-home abuse, not facility-based. The AOA did confirm the validity of the iceberg theory of elder abuse. This theory states that agencies receiving reports of elder abuse receive reports of only the most visible cases. Those that are more egregious go unidentified and unreported.

In an interview, Holly Ramsey-Klawsnik, of Klawnik & Klawnik, a specialist in elder abuse, stated that elder sexual abuse consists of an elderly person of age 60 or so being tricked or coerced or manipulated into unwanted sexual contact. She also stated this includes elders who are unable to grant informed consent to sexual contact. Ramsey-Klawnik says she recognizes that a patient's mental capacity can figure prominently in sexual abuse cases. From my own experience as a surveyor in long-term care facilities, I've found that elderly women are often hesitant or unwilling to tell others that they have been abused. For them, matters concerning their genitals are considered an improper subject to discuss. Most of them will refrain from any direct mention of these areas. If we look at the era in which most of those over 60 emerged, we can see that frank discussions regarding sex just didn't occur in polite company. A healthcare provider might have to rely on nonverbal indicators to uncover sexual abuse such as genital irritation that isn't related to incontinence, vaginal discharge, bleeding from the rectum or vagina, and any skin bruises or skin tears. Fractures can also be a possible indicator. Bite marks on thighs, buttocks or breasts may also be a sign of abuse. More often than not the offender in elder abuse is a family member, or someone the elderly person knows and trusts such as a regular caregiver.

If the incidence of elder abuse is under reported, then we must expect that elderly victims get no post-assault care, something we afford to persons outside a long-term nursing facility. Elder sexual assault victims can also be exposed to sexually transmitted diseases including HIV. If these victims get no medical care, then certainly they are also denied emotional support following the abuse. Post-traumatic rape syndrome is a recognized phenomenon among sexual assault experts. Rape crisis centers across the country provide counseling and support for victims free of charge.

Long-term care facilities can help in uncovering and properly attending to victims of elder sexual abuse. First, they must educate staff that this does occur and train them in what signs to look for. They should also be trained in how to listen to an elderly person when they complain of things that are slightly out of the ordinary.

Long-term care facilities must learn to not dismiss every report of abuse that sounds abnormal as a delusional moment or hallucination. Federal guidelines such as OBRA require that incidents be investigated fully. Certified nursing assistants (CNAs) are on the front line in terms of prevention and reporting. CNAs provide the most intimate care to elderly patients and are often the first on the scene, or the first to hear something. Administrators must recognize that rape is a crime, and when it happens inside the walls of a nursing facility it doesn't take it out of the realm of a criminal offense punishable by the law. Long-term facility staff members are not trained law enforcement officers and should not undertake the investigation of a crime that involves maintaining a crime scene and interviewing victims and witnesses. This is best done by local law enforcement. Important physical evidence is often destroyed or disturbed by well-meaning nursing home staff. Physical evidence can speak for the victim when the victim is not capable of doing so. Finally, facilities should cooperate fully with any investigation by law enforcement and not "circle the wagons" in an attempt to cover up or keep the problem behind the walls of the facility. There is a growing need to cultivate relationships with outside agencies that can provide support to facilities that are taking the steps to make a change in how elder sexual assault is addressed.

Barbara Katayama, RN, BSN, LNC, is a SART nurse and a legal nurse consultant.

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