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Elder Sexual Abuse - An Update of the Literature

Though less common than other types of abuse perpetrated against older individuals, increasingly, research indicates that elder sexual abuse occurs within the community and within institutional settings, with far reaching and negative consequences for those victimized. Ageism, in particular, simultaneously marginalizes elders and depicts them as asexual, contributing to the societal invisibility of the problem. The physical and cognitive limitations of many victims increase their vulnerability to this and other types of abuse, and create barriers to detecting, reporting, substantiating, and prosecuting abusive incidents. The subject continues to gain attention among scholars and researchers in disciplines such as aging services, domestic violence, health care, women's studies, sexual assault, and law enforcement.

The following collection of references is intended to update and supplement an earlier compilation, "Elder Sexual Abuse," produced in 2004*. Entries examine multiple aspects of elder sexual abuse, including analysis of victim and perpetrator characteristics, development of screening tools and protocols, and identification of issues that may enhance the risk of such mistreatment. Several articles have been included that address sexuality among older individuals, as an understanding of the topic may have a positive impact upon abuse prevention and policy initiatives. Resources from other countries demonstrate that this problem is not limited to the United States.

Most of the reference materials can be obtained through 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 by emailing [email protected] or telephoning (302) 831-3525.

Note: This is a selected annotated bibliography, which does not include all published references related to this topic. To review earlier publications on the topic, see "Elder Sexual Abuse," posted on the NCEA Web site at: http://www.elderabusecenter.org/default.cfm?p=cane_sexualabuse.cfm . To search for additional references on this and related topics, please visit the CANE Web site at:
http://db.rdms.udel.edu:8080/CANE . To search the CANE Bibliography Series, go to www.elderabusecenter.org/default.cfm?p=cane.cfm .

*When updating a topic that was the focus of a previously posted bibliography, we occasionally identify references from earlier years that were not highlighted. We may opt to include these earlier references, in order to provide a broad range of information on a given theme.

**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 by e-mailing [email protected] or telephoning (302)-831-3525.

The National Center on Elder Abuse (NCEA) serves as a national resource for adult protective services, elder rights advocates, law enforcement and legal professionals, public policy leaders, researchers, and citizens. It is the mission of NCEA to promote understanding, knowledge sharing, and action on elder abuse, neglect, and exploitation.
The NCEA is administered under the auspices of the National Association of State Units on Aging.
NCEA Partners
  • National Association of State Units on Aging (NASUA), Lead Partner
  • American Bar Association (ABA) Commission on Law and Aging
  • Clearinghouse on Abuse and Neglect of the Elderly (CANE) at the University of Delaware
  • National Adult Protective Services Association (NAPSA)
  • National Committee for the Prevention of Elder Abuse (NCPEA)

This publication was supported, in part by a grant, No. 90AM2792 from the Administration on Aging, U.S. Department of Health and Human Services. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not necessarily represent official Administration on Aging policy.


1. T6596-5
Ramsey-Klawsnik, H., Teaster, P., Mendiondo, M., Abner, E., Cecil, K. & Tooms, M.
Sexual Abuse of Vulnerable Adults in Care Facilities: Clinical Findings and a Research Initiative
Journal of the American Psychiatric Nurses Association; Vol. 12 (6), 332-339; 2007.
Journal article (scholarship)
This article provides an overview on sexual abuse among elderly and disabled residents of long-term care. Five types of abuse categorized by perpetrators are depicted: abuse by a stranger or acquaintance; abuse by a care provider; incestuous abuse; marital or partner sexual abuse; and resident-to-resident sexual abuse. Nurses and other health care professionals are often unprepared to recognize signs of abuse and/or efforts to self-protect, and are often unprepared to intervene appropriately. Practice implications for nurses in institutional settings include hiring strategies and the need for criminal background checks, ongoing training and supervision regarding abuse and neglect issues (such as reporting obligations and protocols) and residents' rights, and the development of prevention initiatives. Psychiatric nurses may become involved in abuse cases, particularly when mental health or cognitive impairments are evident or suspected. Relevant literature is reviewed, and a research initiative currently underway is described. This research initiative is a national study of sexual abuse occurring in long-term care, and is designed to "...(a) investigate patterns of sexual abuse in institutional facilities, (b) refine an emergent theory regarding the mistreatment of vulnerable adults, and (c) collect and analyze empirical data to inform facility sexual abuse prevention, recognition, and intervention efforts...."


2. T6549-5
Bledsoe, W.
Criminal Offenders Residing in Long-Term Care Facilities
Journal of Forensic Nursing; Vol. 3 (2), 142-146; Fall 2006.
Journal article (scholarship)
This article, written by the founder of "A Perfect Cause," a grassroots advocacy group for elders and the disabled, summarizes the group's efforts to raise awareness about violent and sexual offenders residing in long-term care facilities. An initial investigation revealed that 18 registered sex offenders were living in nursing homes throughout Oklahoma in 2004. Subsequent analysis identified 380 registered sex offenders residing in nursing homes in 37 states throughout the U.S. in 2004. A 2005 report indicated that there were 800 registered sex offenders residing in 36 states throughout the country. (Note: This article is part of an issue of the Journal of Forensic Nursing dedicated to the topic of elder abuse. The above noted reports are available online: "Predators in America's Nursing Homes - 2004 Report" at http://aperfectcause.org/PDF_APC/
; and "Predators in America's Nursing Homes - 2005 Report"
at http://aperfectcause.org/PDF_APC/

3. T6569-157
Burgess, A.
Elderly Victims of Sexual Abuse and Their Offenders
Conducted with funds from the U.S. Department of Justice; December 2006.
Paper (online)
In this exploratory "hypothesis generating" study, data from a convenience sample of 284 cases of actual or suspected elder sexual abuse referred for investigation to adult protective services (APS) or law enforcement were analyzed and compared. The study also tested the psychometric properties of the Comprehensive Sexual Assault Assessment Tool - Elder (CSAAT-E), which was used to examine victim characteristics, offender characteristics, crime characteristics, and case dispositions. In addition, data was drawn from a sample of 77 convicted sex offenders of elderly women (including information obtained through interviews with 25 inmates). In cases where there was a known relationship between the perpetrator and the victim, APS investigations were less likely to result in criminal investigations, physical examinations of the elder, and referrals for prosecution than were cases referred to law enforcement. Dementia was present in 70 percent of the cases referred to APS compared to 43 percent referred to law enforcement. Victims with dementia were more likely to have been abused by someone they knew. Multidisciplinary and collaborative efforts, particularly among health care practitioners, criminal justice and law enforcement professionals, and APS professionals were recommended to increase prevention, detection, and intervention. (Note: This report is accessible online at:
http://www.ncjrs.gov/pdffiles1/nij/grants/216550.pdf .) (Note: This article draws upon the same data set as that of CANE file #s T6558-8 and T6560-12, items 3 and 4 of this compilation.)

4. T6558-8
Burgess, A. & Clements, P.
Information Processing of Sexual Abuse in Elders
Journal of Forensic Nursing; Vol. 3 (2), 113-120; Fall 2006.
Journal article (research)
This descriptive study considers the question: "What post-trauma symptoms can be noted in records of elder victims of sexual assault?" Data was analyzed from 284 case records submitted by a multidisciplinary working group of experts in the field of elder sexual abuse. The SPAN scale was used to assess the following symptoms of Post-Traumatic Stress Disorder (PTSD): Startle; Physiological upset; Anger; and Numbness. Although relatively few case records provided sufficient information to complete the SPAN scale, when adequate evidence was available, numbness, sometimes described as being in a state of shock, was identified among 27 victims; physiological upset (including sleeping and eating disturbance, mood changes, etc.) was observed among 25 victims; the startle reflex was noted among 14 victims; and anger (which was typically not verbalized but manifested in agitated behaviors uncharacteristic of the victim) was observed among 12 victims. Two case studies are presented that illustrate the importance of assessing for symptoms of PTSD in identifying sexual abuse and implementing treatment. PTSD and Rape Trauma symptoms experienced by elderly and disabled victims can further negatively impact physical, cognitive, and psychological functioning. The interaction of these symptoms and aspects of the normal aging process, as well as symptoms of dementia, are considered. (Note: This article is currently available online at: http://iafn.org/publication/JFNFall2006.pdf . It can also be accessed through Medscape at: http://www.medscape.com/viewarticle/546942_print.) (Note: This article, part of an issue dedicated to the topic of elder abuse, draws upon the same data set as that of CANE file #s T6569-157, T6560-12, items 2 and 4 of this compilation.)

5. T6560-12
Burgess, A. & Phillips, S. L.
Sexual Abuse, Trauma and Dementia in the Elderly: A Retrospective Study of 284 Cases
Victims & Offenders; Vol. 1 (2), 193-204; April 2006.
Journal article (research)
Two-hundred eighty-four investigated cases of actual or suspected elder sexual abuse were retrospectively analyzed in order to compare the method of disclosure of abuse, forensic markers of sexual abuse, and the legal outcomes of the cases among victims who were identified as having dementia and those who were not. Victims were predominantly female (261 of the 284), and ranged in age from 56 to 100. Although only 194 cases included information on methods of disclosure of abuse, available results indicate that elders without dementia were more likely to self-disclose the abuse than victims with dementia; 5 out of 8 elders without dementia reported the abuse themselves, compared to 1 out of 8 with dementia. However, elders with dementia were more likely to demonstrate indirect or behavioral indications of abuse. Among the cases that included data on the relationship between the victim and abuser and on the presence of dementia (n=205), resident-to-resident abuse occurring in nursing homes was predominantly perpetrated against elders with dementia. In general, elders with dementia were more likely to be victimized by someone they knew when compared to elders without dementia. Of the cases involving victims with dementia that were followed through the criminal justice system, suspects were less likely to be arrested, indicted, or to accept plea bargains. The article concludes with a discussion of the impact of trauma on the aging brain, including "trauma learning," which results when the victim is immobilized and cannot escape the abuse. The authors refute that individuals with dementia cannot experience physical or psychological pain as a result of the traumatic event. (Note: This article draws upon the same data set as that of CANE file #s T6569-157, T6558-8, items 2 and 3 of this compilation.)

6. T6611-7
Burgess, A., Watt, M., Brown, K. & Petrozzi, D.
Management of Elder Sexual Abuse Cases in Critical Care Settings
Critical Care Nursing Clinics of North America; Vol. 18 (3), 313-319; September 2006.
Journal article (scholarship)
This article provides an overview of elder sexual abuse for critical care nurses. These health care professionals may not only provide acute care intervention, but are also likely to be responsible for forensic evidence collection. Guidelines are presented for collecting evidence and documenting and photographing injuries, in order to enhance the possibility of potential criminal accountability of perpetrators.

7. T6548-5
Cooper, G. & King, M.
Interviewing the Incarcerated Offender Convicted of Sexually Assaulting the Elderly
Journal of Forensic Nursing; Vol. 3 (2), 130-133, 146; Fall 2006.
Journal article (scholarship)
This article provides guidelines for conducting research-based forensic interviews with offenders convicted of elder sexual assault. Recommendations include: conducting a detailed pre-interview assessment (including mental health and criminal history assessments, and a thorough review of the case material); co-interviewing to enhance the personal safety of the involved researchers; emphasizing to the perpetrator that the purpose of the interview is to gain an understanding of his or her behavior, rather than to criminally investigate (while understanding the responsibility to report any unsolicited admissions of guilt for additional crimes); and developing an interview protocol to be used consistently with each participant to enhance the reliability of findings as well as the study's replicability. (Note: This article is part of an issue dedicated to the topic of elder abuse.)

8. S6450-6
Jones, H. & Powell, J.
Old Age, Vulnerability and Sexual Violence: Implications for Knowledge and Practice
International Nursing Review; Vol. 53 (3), 211-216; September 2006.
Journal article (scholarship)
A review of existing literature reveals the convergence of ageism, sexism, and vulnerability that has contributed to poor recognition of elder sexual abuse. The authors note that research on sexual violence typically focuses on younger victims, and when it is observed among older victims, the consequences appear to be perceived as less significant. The general marginalization of the older population has lead to an inadequate societal response to the problem, and health care professionals are urged to be alert to the possibility of sexual abuse among older patients, and to listen to and learn from their experiences. (U.K.)

9. T6565-15
Martin, S., Ray, N., Sotres-Alvarez, D., Kupper, L., Moracco, K., Dickens, P., Scandlin, D., & Gizlice, Z.
Physical and Sexual Assault of Women with Disabilities
Violence Against Women; Vol. 12 (9), 823-837; September 2006.
Journal article (research)
Five-thousand three-hundred twenty-six women living in North Carolina participated in a community based, statewide random sample survey (the North Carolina Behavioral Risk Factor Surveillance System or NC-BRFSS) in order to compare the risk of physical and sexual assault among those with and without disabilities. Participants ranged in age from 18 to 99 years, with a mean age of 46.3 years. The prevalence rate of reporting some type of disability (physical, mental, emotional, and/or cognitive) was 26 percent, with the mean age of those with disabilities being 54 years old. The prevalence rate of the entire study sample for having experienced physical or sexual assault during the previous year was 3.1 percent; for physical assault only the prevalence rate was 2.6 percent; and the prevalence rate for sexual assault was 0.8 percent. There was no significant difference between the rate of physical abuse alone among women with disabilities and women without; however, women with disabilities were significantly more likely to have experienced sexual assault during the preceding year than women without disabilities (1.5 percent compared to .6 percent). Further analysis revealed that women who reported cognitive impairments experienced a prevalence rate of 1.7 percent for sexual assault.

10. T6544-6
Morgenbesser, L., Burgess, A., Boersma, R. & Myruski, E.
Media Surveillance of Elder Sexual Abuse Cases
Journal of Forensic Nursing; Vol. 2 (3), 121-126; Fall 2006.
Journal article (research)
This article describes the methodology and results of media surveillance of elder sexual abuse cases used to develop a descriptive data base. Information from a convenience sample of 112 cases reported in the public media over a two year period was analyzed. Cases were reported from sixteen states. Perpetrators were predominantly male; ranged in age from 14 to 70; 11 were identified as having a diagnosed mental illness, two abused substances, and one was identified as mentally incompetent. Information on race, occupation, criminal charges or convictions, and access to victims was also gathered. Victim characteristics were analyzed; they were predominantly female, and ranged in age from 54 to 100 years old. Data was gathered on race, living circumstances, and impairments (although this was rarely reported). Sensational headlines, articles that reported judicial critiques of various systems, and dangerous residents in nursing homes were among the themes identified. Researchers noted that rural coverage appeared more subjective than urban coverage. Analysis of media coverage was also instrumental in identifying career criminals. Researchers encourage collaboration among journalists and professionals addressing cases of elder sexual abuse in order to maximize media coverage as an informational resource. (Note: This article is part of an issue dedicated to the topic of elder abuse.)

11. T6599-10
Teitelman, J.
Sexual Abuse of Older Adults: Appropriate Responses for Health and Human Services Providers
Journal of Health and Human Services Administration; Vol. 29 (2), 209-227; Fall 2006.
Journal article (scholarship)
This overview of sexual abuse of older individuals discusses the scope, dynamics, risk factors, signs and symptoms, issues surrounding capacity determination, and appropriate responses for health care and social services professionals who encounter suspected mistreatment. A lack of awareness and ageism may create barriers to identification of elder sexual abuse. Sexually abusive behaviors are placed on a continuum, beginning with covert, non-touching abuse (which involves innuendo, inappropriate interest in the victim's body, sexual harassment, etc.), ranging to more obvious physical offenses (such as sexualized kissing and fondling), and ultimately increasing to extremes of violent and sadistic behaviors (including penetration and even torture). Behaviors that are non-consensual among all parties are considered abusive, and include acts involving individuals incapable of providing consent due to impairment. Issues of power and control are examined. Physical, cognitive, and functional incapacity on the part of the victim, dependence upon the victim, inadequate screening practices for employment with vulnerable populations, and mental health and substance abuse issues on the part of the perpetrator have been associated with elder sexual abuse. Service providers are encouraged to watch for physical signs (such as injury to the genitals, infection) and psychological signs (such as depression, anxiety, and emotional changes on the part of the victim, sexual acting out) that may indicate abuse. Guidelines for assessing consensuality are provided. If health and social services professionals can reasonably determine that sexual activity was consensual, no further investigation is needed. However, if there is a suspicion of abuse, providers are urged to immediately contact adult protective services (APS), or other local law enforcement or health regulatory agencies as mandated by state law. Guidelines for preserving physical evidence and documenting information are outlined.

12. S6363-49
U.S. Government Accountability Office (GAO)
Long-Term Care Facilities - Information on Residents who are Registered Sex Offenders or Are Paroled for Other Crimes (GAO-06-326)
U.S. Government Accountability Office (GAO); Washington, D.C.; March 2006.
Government report (online)
This report was intended to determine the prevalence of sex offenders and paroled non-sex offenders residing in nursing homes and long-term care facilities, identify the legal requirements for notifying facilities and others when offenders are residents, and assess the extent to which long-term care facilities provide different supervision for these residents. Analysis of data from the FBI's National Sex Offender Registry (NSOR) revealed that approximately 700 registered sex offenders were living in nursing homes or intermediate care facilities for people with mental retardation (ICF-MR), comprising about 0.5 percent of the nation's 1.5 million long-term care population. Most offenders were male and under age 65. About 3 percent of all homes and 0.7 percent of ICF-MR receiving Medicare and Medicaid funds housed at least one sex offender during 2005, although this figure is considered an underestimate due to state data reporting limitations. Information was gathered from 8 reviewed states in which 204 residents were identified as paroled non-sex offenders. Because offender status is not tracked with abuse reporting, the overall risk posed by registered sex offenders and parolees could not be determined. Facility administrators voiced most concern for risk to cognitively impaired and mentally ill residents. The extent to which long-term care facilities are notified regarding the status of sex offenders varies significantly from state to state, as does the extent to which this information is shared by the administrators with staff and others. Specialized supervision of these residents is not typically based upon prior convictions but upon their demonstrated behaviors. As a result of this report, the GAO recommended that the Attorney General direct the FBI to conduct an assessment of the completeness of the NSOR, including state submission rates, and to consider ways in which this database could be more effective on a national level. (Note: This report is accessible online at: http://www.gao.gov/new.items/d06326.pdf#search=%22GAO-06-326%20Offenders%22 .)


13. S6465-6
Burgess, A., Brown, K., Bell, K., Ledray, L. & Poarch, J.
Sexual Abuse of Older Adults: Assessing for Signs of a Serious Crime
American Journal of Nursing/AJN; Vol. 105 (10), 66-71; October 2005.
Journal article (research)
This study was designed to identify barriers to reporting sexual abuse of older adults and to identify the signs and symptoms of elder sexual abuse. Data was gathered and analyzed from a convenience sample of 125 sexual abuse cases involving women aged 61 to 98 throughout 22 states. Cognitive impairment on the part of the victim, reluctance to disclose, and erroneous assumptions by caregivers and relatives were among the barriers to reporting and prosecution. Fifty-two percent of the victims had sustained one or more signs of physical injury; 46 percent had signs of vaginal trauma; 17 percent had signs of anal trauma. Victims also reported a wide range of emotional trauma related to the assaults. The structure of the forensic interview is described with an emphasis on recording all pertinent information in the written case record. (Note: This article draws upon the same data set as CANE file #R6095-14 and #R6047-8, items 11 and 15 of this compilation.)

14. R6095-14
Burgess, A., Hanrahan, N. & Baker, T.
Forensic Markers in Elder Female Sexual Abuse Cases
Clinics in Geriatric Medicine; Vol. 21 (2), 399-412; May 2005.
Journal article (research)
This article summarizes the findings of the National Institute for Justice's sponsored working group, convened to develop a framework to establish a national database to track the following types of information: mechanisms and patterns of injury in elder sexual abuse cases; forensic evidence; characteristics and behavioral patterns of perpetrators; characteristics and behavioral patterns of the victims; the criminal justice process; and outcomes of elder sexual abuse cases. The multidisciplinary working group was comprised of representatives from health, social service, law enforcement, criminal justice, and other fields, who were experienced in elder sexual abuse case work. Participants submitted 125 cases for retrospective analysis to determine forensic markers unique to elder sexual abuse. Samples included both substantiated and unfounded or nonprosecuted cases. Although African American, Hispanic, and Asian victims were identified, victims were predominantly Caucasian, and nearly half suffered from a mental or physical disability. Those victimized sustained a broad range of injuries stemming from many types of abuses. Of note, elderly victims were not typically assessed for post-traumatic stress disorder (PTSD) or other psychological consequences to the assault. Offender characteristics were also analyzed. Among the findings, 44 percent of the perpetrators were reportedly under the influence of drugs or alcohol at the time of the incident, and 44 percent of the offenders had multiple offenses. Information is also presented concerning the relationship between offenders and victims. (Note: This article draws upon the same data set as CANE file #S6465-6 and R6047-8, items 10 and 15 of this compilation.)

15. S6466-5
Burgess, A. & Morgenbesser, L.
Sexual Violence and Seniors
Brief Treatment and Crisis Intervention; Vol. 5 (2) 193-202; May 2005.
Journal article (scholarship)
This overview is intended to raise awareness among mental health clinicians regarding elder
sexual abuse and therapeutic responses. Signs and symptoms of emotional and physical trauma
are presented, along with guidelines for interview and assessment. Rape trauma symptoms (such
as being fearful in places where the assault occurred, being fearful of males if assaulted by a male; flashbacks; etc.) and rape trauma syndrome (which includes both acute and long-term symptoms after the assault) are described. Group therapy, music therapy, counseling for the victim and for family members are also discussed. A number of case scenarios illustrate various circumstances and interventions.

16. S6366-5
Edwards, D.
Thinking About the Unthinkable: Staff Sexual Abuse of Residents; Although Few Staff Members Ever Cross the Line, Those Who Do Grab Headlines, Cost Facilities Millions, and Destroy Seniors' Golden Years
Nursing Homes; Vol. 54 (6), 44-47; June 2005.
Journal article (scholarship)
This article presents an overview of the problem of sexual abuse of nursing home residents by staff, and presents general measures for prevention and intervention. It is noted that all institutional residents may be at risk for mistreatment for a variety of reasons, including increased physical and cognitive vulnerability, the homogenization of the population receiving care, and the necessary close contact with care providers. Prevention efforts begin with criminal background checks and guidelines are offered for enhancing the reliability of these investigations. Possible indicators of sexual abuse are outlined. A model program, the result of collaboration between the Nursing Home Ombudsman Agency of the Bluegrass and Bluegrass Rape Crisis Center in Kentucky, which involves educating not only staff but residents and their families as well, is featured. (Note: This article is currently available online at: http://findarticles.com/p/articles/mi_m3830/is_6_54/ai_n14735161 .)

17. R6080-16
Elman, R.
Confronting the Sexual Abuse of Women with Disabilities
Applied Research Forum - National Electronic Network on Violence Against Women; January 2005.
Paper (online resource)
This paper provides an overview of the sexual abuse of women with disabilities. One of the earliest studies involved an analysis of records from the Seattle Rape Relief Center (May 1977 through December 1979) that indicated there were over 300 sexual abuse cases involving women with physical and/or cognitive impairments. Less than a third of these women reported the abuse to authorities. Difficulties in conducting research with this population are highlighted, and include not only the diversity of the women in terms of age, ethnicity, gender identity, etc., but also the diversity of the physical and developmental conditions that they experience. While some research suggests that women with physical disabilities experience sexual abuse at rates similar to women without disabilities, it also indicates that these women experience such abuse for longer durations. Research also indicates that 70 percent of women with developmental disabilities experience sexual abuse. The majority of the perpetrators appear to be male caregivers and male family members; relatively few appear to be strangers. They often seek out victims they perceive as powerless. Centralized tracking of perpetrators, improved service response (for example, more accommodating medical examination equipment and techniques), research on the impact of abuse, and public awareness campaigns that include women with disabilities are among the recommendations presented. (Note: This paper is accessible online at: http://www.vawnet.org/SexualViolence/Research/VAWnetDocuments/AR_SVDisability.pdf .)

18. R6047-8
Hanrahan, N., Burgess, A. & Gerolamo, A.
Core Data Elements Tracking Elder Sexual Abuse
Clinics in Geriatric Medicine; Vol. 21 (2), 413-427; 2005.
Journal article (research)
This article reports upon the development of a screening tool as part of a project designed to identify core data elements of elder sexual abuse. In 2002, experts in the field (including health care professionals, investigators, and prosecutors) provided 125 case descriptions of female elder sexual abuse for analysis. Researchers used the Comprehensive Sexual Assault Assessment Tool (CSAAT) to document four aspects of each case: victim characteristics, offender characteristics, investigative data, and case disposition. Based upon case analysis by the panel, the tool was revised for use with elders (Comprehensive Sexual Assault Assessment Tool - Elder or CSAAT-E). Key changes in the instrument include the need to document the time frame of the crime (time of examination relative to disclosure), the victim's physical and mental status (pre- and post-assault), the severity of injury, the setting of the crime, the outcomes related to assault, as well as the offender's history of interpersonal violence and/or substance abuse, and mental or physical limitations of the perpetrator. The CSAAT-E requires the documentation of greater detail regarding forensic evidence, data correlating mortality and adverse outcomes (injuries, changes in mental status, etc.) related to the sexual abuse, and information regarding victim's status at case closure as well as prosecution details. (Note: This article draws upon the same data set as CANE file #R6095-14 and #S6465-6-8, items 11 and 10 of this compilation.)

19. S6518-9
Jeary, K.
Sexual Abuse and Sexual Offending Against Elderly People: A Focus on Perpetrators and Victims
The Journal of Forensic Psychiatry & Psychology; Vol. 16 (2), 328-343; June 2005.
Journal article (research)
This exploratory study was designed to examine the spectrum of sexual abuse and offenses
committed against the elderly; the context in which abuse occurs; the relationships between
victim and perpetrator; and consequences for the victim. Fifty-two cases involving 54 victims were identified for analysis through prison and probation facilities throughout the U.K. and from two Adult Protection Units. Four categories of offenses were established: sexual assault and killing (n=12); rape and attempted rape (n=20); indecent assault and alleged indecent assault (n=20); and sexual harassment (n=2). Abusers in this study ranged in age from 16 to over 70. Two-thirds of the sexual assaults, killings and rape/attempted rapes were committed by males aged 16 to 30, and most offenses were perpetrated by strangers in the victims' homes. Nearly one-third of all perpetrators had previous convictions for sexual offenses and, among those previously convicted, nearly half had committed previous offenses against elderly victims. Almost ten percent of the offenders denied committing the abuse and were therefore unlikely to undergo therapy; the remaining perpetrators were either involved in a sex offender treatment group in prison or in the community or were currently under supervision. Only one-third of the 22 cases involving alleged indecent assault and sexual harassment were prosecuted since these cases were less clear cut, with little forensic evidence available. Of the prosecuted cases, most offenses occurred in the victims' homes, with other non abusing family members and/or other acquaintances and professionals unaware of the mistreatment. Overall, the sexual abuse was characterized by extreme violence, and those who survived sustained extensive physical injuries as well as psychological repercussions. Financial motivation, countering sexual inadequacy, sexual gratification, power, control and revenge, and a history of childhood sexual abuse were elicited as motives through clinical interviews and case documentation. Of note, half of the convicted perpetrators indicated that they had been physically, and more often, sexually abused as children. Further, 20 percent of the perpetrators had also been convicted of sexually abusing children. (U.K.) (Note: This article draws upon the same data set as that of CANE file #R6068-10, item 25 of this compilation.)

20. S6154-7
Pearsall, C.
Forensic Biomarkers of Elder Abuse: What Clinicians Need to Know
Journal of Forensic Nursing; Vol. 1 (4), 182-186; December 2005.
Journal article (scholarship)
This overview describes biomarkers that could signal elder abuse and neglect (including sexual abuse) to physicians, nurses, and other health care practitioners. Bruises, lacerations, abrasions, and fractures are among the potential indicators of physical abuse, and although they may be the result of accident or complications of the aging process, such biomarkers should trigger further discussion and assessment on the part of the clinician. Dehydration, decubiti, malnutrition, and burns may be indicators of intentional or unintentional abuse, neglect, and self-neglect. In addition to physical indicators that are common among sexual assault victims of all ages (such as bruising on the inner thighs), older victims may exhibit behavioral indicators of sexual abuse, such as withdrawal, fear, an increased interest in sex, or an increase in sexual behavior or aggressiveness. Dementia and mental health issues contribute to the risk for mistreatment. Guidelines for nursing assessments for all types of abuse are outlined. (Note: This article is currently available online through Medscape at: http://www.medscape.com/viewarticle/521362. A no fee registration is required for access.)

21. S6554-31
A Perfect Cause
Predators in America's Nursing Homes - Registered Sex Offenders in Nursing Homes - 2005 Report
A Perfect Cause; 2005.
Paper (online)
"A Perfect Cause" is a grassroots advocacy group for elders and the disabled. In an effort to raise awareness of violent and sexual offenders residing in long-term care facilities, the group has attempted to assess the magnitude of this problem, initially in Oklahoma, and more recently throughout the country. This paper reports that 800 registered sex offenders have been identified living in 36 states throughout the country as of July 2005. (Note: This paper is accessible online at: http://aperfectcause.org/PDF_APC/
. The group's previous paper, "Predators in America's Nursing Homes - Registered Sex Offenders in Nursing Homes - 2004 Report," is accessible online at: http://aperfectcause.org/PDF_APC/

22. P5915-32
Roberto, K. A. & Teaster, P. B.
Sexual Abuse of Vulnerable Young and Old Women
Violence Against Women; Vol. 11 (4), 473-504; April 2005.
Journal article (research)
After a discussion of the existing (though scant) literature on elder sexual abuse and the sexual abuse of women with disabilities, the authors present an analysis of the nature of sexual abuse cases substantiated by the adult protective services (APS) throughout Virginia from July 1996 through June 2001. The immediate context of the abusive situation (including the victim's functional abilities), the relationship between victim and abuser, the impact of external systems (such as APS), and the broader, cultural context (including institutional norms and values) are considered. Of those addressed by APS professionals throughout the state, 125 substantiated cases, involving women aged 18 and older, were submitted to researchers for analysis. Among the findings, 63 percent of the women victimized were over 59, and the most common type of abuse (regardless of age) involved sexualized kissing or fondling, or unwelcome sexual interest. Younger women victimized were more likely to live in the community, were more likely to be oriented and ambulatory, their abusers were more likely to be family members, and they were more likely to be raped than older victims. Older women victimized were more likely to be disoriented and to have mobility limitations. In contrast to previous research regarding sexual abuse occurring in nursing homes, abusers of older women were more likely to be male residents aged 60 and over (as opposed to facility staff). Findings regarding case outcomes are also presented. (Note: This article draws upon the same data set as that of CANE file # P5768-9, item 29 of this compilation.)

23. P5918-3
Templeton, D.
Sexual Assault of a Postmenopausal Woman
Journal of Clinical Forensic Medicine; Vol. 12 (2), 98-100; 2005.
Journal article (research)
In this brief article, a case report of a sexually assaulted 63 year old female is presented. The author reviews earlier research that describes characteristics that are more prevalent in the sexual assault of older women versus younger women, including the greater likelihood and severity of genital trauma.

24. S6454-5
Zink,T., Fisher, B., Regan, S. & Pabst, S.
The Prevalence and Incidence of Intimate Partner Violence in Older Women in Primary Care Practices
Journal of General Internal Medicine; Vol. 20 (10), 884-888; 2005.
This study was designed to analyze the incidence and prevalence of intimate partner violence (IPV) among women, aged 55 and older, who were seen at least one time in a primary care practice during the previous year. Nine-hundred and ninety-five women who had been seen in health care settings affiliated with an academic institution completed telephone interviews that assessed health status and the experience of psychological, physical, and sexual abuse occurring since age 55. The prevalence rate of physical abuse (since age 55) among those surveyed was 1.52 percent, and the incidence rate for the preceding year was 0.41 percent. Prevalence and incidence rates for sexual abuse were 2.14 percent and 1.12 percent respectively. Victims of IPV reported a greater number of health conditions (3.84) than those not victimized (3.21), and victims were more likely to experience chronic pain, anxiety, and depression.        


25. P5850-9
Brown, K., Streubert, G. & Burgess, A.
Effectively Detect and Manage Elder Abuse
The Nurse Practitioner: The American Journal of Primary Health Care; Vol. 29 (8), 22-31; August 2004.
Journal article (scholarship)
This continuing education article is designed to assist nurse practitioners in identifying elder abuse and initiating appropriate interventions. Guidelines are offered for examination of bruises, abrasions, lacerations, the condition of skin and genitalia, as well as injuries to the head, neck, chest wall, abdomen, extremities, and genitals. The authors note that decreased pain perception and memory impairment can contribute to difficulty in assessment. (Note: This article is currently available online at:
http://www.findarticles.com/p/articles/mi_qa3958/is_200408/ai_n9454134 .)

26. P5940-13
Burgess, A. & Hanrahan, N.
Issues in Elder Sexual Abuse in Nursing Homes
Nursing and Health Policy Review; Vol. 3 (1), 5-17; 2004.
Journal article (scholarship)
This article presents case studies of elder sexual abuse occurring in nursing homes in order to
illustrate key elements of identification, assessment, and treatment. Trauma masked as accidental bruising, communication deficits, recanting, physical and emotional indicators, inadequate evidentiary examination, sexually transmitted diseases, and resident to resident sexual abuse are among the issues analyzed.

27. S6346-37
Department of Health and Human Services, Office of Inspector General
Survey of Physical and Sexual Abuse in Alabama Nursing Homes (A-04-03-07027)
Washington, D.C.; June 7, 2004.
Government report (online)
This review was conducted to assess the effectiveness of the Alabama Department of Public Health - Complaint Unit methods of investigation, tracking, and monitoring of physical and sexual abuse in nursing facilities. Among the findings, the study revealed that investigations were not conducted within established timeframes; policies and procedures for monitoring and tracking required improvement and greater detail; and the abuse registry was not in compliance with federal requirements. (Note: This report is accessible online at: http://oig.hhs.gov/oas/reports/region4/40307027.pdf .)

28. R6068-10
Jeary, K.
Sexual Abuse of Elderly People: Would We Rather Not Know the Details?
Journal of Adult Protection; Vol. 6 (2), 21-30; September 2004.
Journal article (research)
This exploratory study was designed to analyze sexual harassment, inappropriate touching, and extreme sexual violence perpetrated against elders. Fifty-two case records of elder sexual abuse, randomly selected from predominantly criminal justice agencies, were examined in order to determine the range of sexually abusive behaviors and the contexts in which they occurred. In addition, semi-structured interviews were conducted with professionals working with sex offenders and involved in the development of treatment programs, and focus groups were conducted with professionals working with elders in residential and long-term care settings. One-third of the cases involved reported sexual abuse occurring in residential care settings. These victims were predominantly female, and abusers were fellow residents, staff members, or family members or other visitors. One case illuminated the complexity of addressing sexuality and the need for intimacy among elders with questionable decision-making capacity. The study also describes cases of elder sexual abuse occurring in the community. Rarely, the perpetrators were professional home care providers. Case examples depict sexual harassment towards patients, and also situations wherein caregivers were encouraged or drawn into abusive behavior patterns. Cases were also reported involving elders living independently in the community, without formal care. In many of these assaults, offenders admitted that it was not the vulnerable appearance of the elder, but of the home, that caused them to target the particular victim. Poor documentation in case records, an inability to substantiate allegations in some cases, and ageism were problems identified through the study. (U.K.) (Note: This article draws upon the same data set as that of CANE file #6518-9, item 16 of this compilation.)

29. R6028-18
Lundy, M. & Grossman, S.
Elder Abuse: Spouse/Intimate Partner Abuse and Family Violence Among Elders
Journal of Elder Abuse & Neglect; Vol. 16 (1), 85-102; 2004.
Journal article (research)
This descriptive research analyzes the characteristics of 1,057 victims of domestic violence (DV), aged 65 and over, who sought or utilized support through DV services throughout the state of Illinois from 1990 through 1995. Data was collected by the Illinois Coalition Against Domestic Violence (ICADV). Older service users were predominantly female (90 percent), White (75 percent), and nearly half were currently married (47 percent). Although nearly 40 percent were abused by either a current or former spouse or male friend, 46.6 percent of the abusers identified were nonspousal relatives. Almost all reported psychological abuse, 71 percent reported physical abuse, and nearly five percent reported sexual abuse. Most referrals were made by police (34 percent), followed by legal sources, social services professionals, and self. Service users most frequently needed support followed by legal assistance. Eleven percent required emergency shelter while six percent required assistance finding housing. Compared with younger victims, older women are more likely to need legal assistance regarding interdependent financial issues (such as retirement benefits), but were less likely to need assistance regarding education, employment and child care.

30. S6368-12
Reingold, D. & Burros, N.
Sexuality in the Nursing Home
Journal of Gerontological Social Work; Vol. 43 (2), 175-186; 2004.
Journal article (scholarship)
This article discusses the issues surrounding the sexuality of residents of nursing homes.
Expressions of sexuality in this setting have been viewed basically as behavioral problems and not as part of the human condition or within the context of resident rights. Issues surrounding the sexuality of cognitively impaired residents are most ambiguous. The social worker's role in advocating for residents rights and privacy is discussed, along with a training program on this topic developed at the Hebrew Home for the Aged at Riverdale, New York.

31. S6370-9
Roach, S.
Sexual Behaviour of Nursing Home Residents: Staff Perceptions and Responses
Journal of Advanced Nursing; Vol. 48 (4), 371-379; 2004.
Journal article (research)
A grounded theory approach was used to study the perceptions and responses of nursing home staff regarding affectionate and sexual behaviors of residents. Fifty-three participants from Australia and Sweden participated in interviews and group discussion. Participants' individual comfort levels with sexuality issues along with the organizational climate influenced perceptions and responses. The author recommends that staff and administrators collaborate to develop an environment supportive of residents' rights that permits expression of sexuality. (Australia, Sweden)

32. P5768-9
Teaster, P. B. & Roberto, K. A.
Sexual Abuse of Older Adults: APS Cases and Outcomes
The Gerontologist; Vol. 44 (6), 788-796; 2004.
Journal article (research)
This article provides a profile of elder sexual abuse cases addressed by the adult protective services (APS) units in Virginia. Of the incidents addressed by APS professionals throughout the state from July 1996 through June 2001, in both domestic and institutional settings, 82 substantiated cases were submitted to researchers for analysis. Data analyzed included victim characteristics (such as age, orientation, self-care ability), perpetrator characteristics, type of sexual abuse, resolution of the case, and outcomes for the victim (such as treatment, relocation, and risk for future victimization). Researchers used a multivariate analysis to examine relationships between victim characteristics and types of victimization. Of the results, 95 percent of the victims were women, approximately half were aged 60 to 79, 72 percent resided in nursing homes or other institutional care facilities, and 17 percent lived with a family member. Most victims required help with orientation to time and place (86 and 81 percent, respectively), and half could not ambulate without assistance. The most common types of abuse were sexualized kissing and fondling (73 percent) and unwelcome sexual interest (43 percent). Victims also experienced exposure to unwelcome discussion regarding sexual activity, sexual jokes and comments, oral genital contact, penetration, and vaginal rape. Nearly half of the cases involved multiple types of sexual abuse. Perpetrators, identified in 95 percent of the cases, were male in all but one instance, and typically aged 60 and over (88 percent). In 69 percent of the cases in residential facilities, the perpetrator was another resident; in 5 percent the perpetrator was a staff member. Approximately 28 percent were identified as having untreated psychiatric illness, 16 percent were substance abusers, and 14 percent were financially dependent upon the victim. Only four of the perpetrators were prosecuted (three were convicted). Insufficient evidence was the most common reason for not prosecuting. Relocation was the most common outcome for both victims (16 percent) and perpetrators (29 percent), with relatively few victims receiving physical or psychological treatment (11 percent) and even fewer of the perpetrators receiving psychiatric treatment (10 percent). (Note: This article draws upon the same data set as that of CANE file # P5915-32, item 19 of this compilation.)

33. P5727-141
U.S. Department of Justice Office on Violence Against Women
A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents
September 2004
Online resource
This publication presents detailed guidelines for the health care and criminal justice professionals who respond to victims of sexual assault. The protocol is intended to instruct responders in the effective collection of forensic evidence necessary to prosecute sexual abuse crimes, while being sensitive to the personal and emotional needs of the victims. Topics considered include the need for a victim-centered approach to examination, issues surrounding informed consent and confidentiality, reporting, documentation, evidence integrity and collection procedures, and court appearances. One segment is dedicated to the specific needs of older victims. (Note: This publication is available online at http://www.ncjrs.org/pdffiles1/ovw/206554.pdf .)

34. P5747-238
Vierthaler, K., for the Pennsylvania Department
of Aging and the Pennsylvania Coalition Against Rape (PCAR)
Addressing Elder Sexual Abuse: Developing a Community Response
Pennsylvania Department of Aging and the Pennsylvania Coalition Against Rape (PCAR);
Training curriculum (online)
This multimedia curriculum is designed to promote collaboration and community partnerships in addressing elder sexual abuse. It is divided into six modules covering the topics of sexual violence, gerontology, elder sexual abuse, detection of elder sexual abuse, Pennsylvania laws applied to elder sexual abuse, and collaboration. Each module contains an outline and talking points, suggested activities to illustrate the themes identified, handouts, and other tools. The material presented includes a history of the recognition of rape as a crime of violence. There is also a brief summary of the role and function of the Pennsylvania Coalition Against Rape (PCAR) and of Pennsylvania's Area Agencies on Aging (AAA). The module on elder sexual abuse focuses on differences experienced by the older victim, which include increased risk for physical injury and longer recovery time. It includes information on domestic and institutionalized victimization. (Note: This training curriculum is accessible online at: http://www.aging.state.pa.us/aging/cwp/view.asp?a=541&q=252220 and also may be requested by emailing [email protected] or telephoning (717) 783-1549.)


35. S6561-25
Christie, D. and members of the Working Group - Long Term Care in the Hamilton Region of Ontario, Canada
Intimacy, Sexuality and Sexual Behaviour in Dementia - How to Develop Practice Guidelines and Policy for Long Term Care Facilities
Working Group - Long Term Care in the Hamilton Region; Ontario, Canada; 2002.
Online resource
This guide was developed by a multidisciplinary working group representing long term care facilities in the Hamilton region of Ontario, Canada. The group reviewed the existing policies and literature on the topic of sexuality and intimacy among nursing home residents with dementia, and synthesized the findings into a guideline for those developing policy. Authors indicate that policy should be developed with input from all strata of employees of the facility. A decision tree is provided for assessing the competency of the resident to participate in an intimate relationship. Further steps include identifying interventions, drafting the policy, implementing the policy, and evaluating effectiveness. A reading list, resource list, contact list, and templates for educational focus groups and for evaluating behaviors are included. (Note: This guide is accessible online at: http://www.fhs.mcmaster.ca/mcah/cgec/toolkit.pdf .)

To review earlier publications on the topic, see "Elder Sexual Abuse," posted on the NCEA Web site at: http://www.elderabusecenter.org/default.cfm?p=cane_sexualabuse.cfm .

To search for additional references on this and related topics, please visit the CANE Web site at:
http://db.rdms.udel.edu:8080/CANE .

To search the CANE Bibliography Series, go to www.elderabusecenter.org/default.cfm?p=cane.cfm .

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