SEXUAL ABUSE of the ELDERLY MENTALLY ILL 805 Him, and Felt That It Would Get Her 'A Bad Name'
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Postgrad Med J (1993) 69, 803 - 807 i) The Fellowship of Postgraduate Medicine, 1993 Postgrad Med J: first published as 10.1136/pgmj.69.816.803 on 1 October 1993. Downloaded from Medicine in the Elderly Sexual abuse ofthe elderly mentally ill Susan M. Benbow and Peter M. Haddad' York House, Manchester Royal Infirmary, Oxford Road, Manchester M13 9BX and 'CRC Psychological Medicine Group, Stanley House, 553 Wilmslow Road, Withington, Manchester, UK Summary: Sexual abuse of the elderly may occur more commonly than is recognized. Reasons for the neglect of this area and possible risk factors are discussed. A definition of elder sexual abuse is proposed, and four case histories, each ofwhich raises various issues about the nature, detection and management of sexual abuse, are described. In the absence ofprocedures for dealing with elder sexual abuse, professional staffneed to be open to its occurrence and to be prepared to carry out thorough, sympathetic, collaborative assessments of both parties involved where it is suspected. Problems of definition Before attempting to define elder sexual abuse it is relatives, such as professional care staff,2'9-"1 and useful to review the problems in defining the more Pritchard12 has noted that the main types of abuse general term 'elder abuse'. Widely different views can all occur in institutional settings. Finally, exist on what constitutes -3 as abuse' and yet there is should there be thresholds for the frequency and by copyright. no universally accepted definition. The central severity of acts which are considered abusive? dilemma is that elder abuse is an elastic term, For clinical purposes the concept of inadequate covering a wide variety of presentations, from a care'3 overcomes many of these problems, but for relative who repeatedly batters an elderly person to research purposes an operational definition is society failing to provide sufficient community care needed. If elder abuse definitions are not always for their elders.4 appropriate, are there useful parallels in work with There are four key issues in definition. Firstly, childhood sexual abuse which could be taken and what areas should be included within definitions of applied in work with older people? There are abuse? Eastman5 considered elder abuse as 'the various definitions of sexual abuse in children, for systematic maltreatment, physical, emotional or example, 'any form of coerced sexual interaction http://pmj.bmj.com/ financial, of an elderly person by a care-giving between an individual and a person in a position of relative', and included within this definition 'sexual power over that individual','4 and 'when (an) ... assault', as a form of physical abuse. Most adult on whom the child depends uses his or her definitions include physical, emotional and finan- authority ... so as to meet their own sexual needs'.'5 cial abuse but do not mention sexual abuse.6 It may be more difficult to include the notion of Secondly, should abuse encompass neglect, and, if power or authority in work with older people, and so, what types of neglect, for example, active and in this article we define elder sexual abuse as passive neglect by carers, self-neglect? The in- occurring when an individual has a physical sexual on September 29, 2021 by guest. Protected clusion of self-neglect has been criticized on the relationship with an elderly person without that grounds that it does not represent maltreatment by person's informed consent, excluding sexual a carer but instead society's failure to meet the assaults by complete strangers. 'Physical sexual needs of its elderly members.2'3'7'8 Thirdly, should relationship' refers not only to intercourse but to abuse only refer to acts between elderly people and other forms of intimate sexual contact, such as those people in relationships with them or should it touching the genital areas. This is an arbitrary extend to include formal carers, acquaintances definition, and includes acts perpetrated by non- outside the family and even strangers? Some carers, unlike some definitions referred to earlier. definitions' include only care-giving relatives, others include the possibility of abuse by non- A neglected topic Correspondence: S.M. Benbow, M.R.C.Psych. Little has been written about the sexual abuse of Accepted: 14 April 1993 older people and detection is the first hurdle:'6 804 S.M. BENBOW & P.M. HADDAD Postgrad Med J: first published as 10.1136/pgmj.69.816.803 on 1 October 1993. Downloaded from Eastman'7 stated that he had only personally come with mental illnesses, especially dementia, may be across two cases of sexual abuse and McCreadie unable to inform others of abuse or may be and Tinker'8 state that it appears to be rare. Ogg'9 unaware of being abused, although elderly people stated that it should be regarded as a possibility. without mental or physical infirmity may also be Kimsey et al.20 stated that homosexual and subject to abuse.26 heterosexual abuse of the aged may be much more We present below four case histories, where frequent than is generally recognized, because of sexual abuse was suspected, and which illustrate under-reporting, but provided no evidence. Ben- key issues in assessment and management. The case nett2' listed the possible physical indicators of histories are classified by the relationship between sexual abuse in older people on examination. the individuals involved, a system which we have Possible reasons for this neglect include the follow- previously proposed as a useful framework for ing: sexual problems in the elderly mentally ill in 1. Elder abuse in general has only recently general.27 come to public attention. Bennett22 pointed out that child and spouse abuse received attention in the 1960s and 1970s, respectively, but only in the 1980s did elder abuse become an acknowledged 1. Problems independent of a sexual partner problem. 2. The elderly have been portrayed as having Case history 1: Mr G no interest in sex.23 Researchers may not have considered the possibility that elderly people could Mr G was a 62-year-old man who was admitted to a have peers who might sexually abuse them, because continuing care psychogeriatric ward from an of the stereotype of sexless older people. In reality, elderly persons' home because of disturbed research has shown that there is no upper limit to behaviour which continued despite trials of depot sexual activity and a significant proportion ofolder and oral neuroleptics and which included exposing people remain sexually interested and active.24 himself, masturbating in public areas, and 3. Sexuality in late life is a taboo area.23 urinating and defaecating indiscriminately overby copyright. 4. In other forms of elder abuse both abuser people's belongings and food. He was known to and victim tend to deny that it has occurred. abuse alcohol and had been diagnosed as having a Recognized cases are likely to be only a small pre-senile dementia 4 years earlier. On the ward proportion of those occurring.6'25 Victims fre- these behaviours continued: he would sexually quently fear reprisals or removal from their home. touch staff and patients, often forcefully. On one It is likely that reluctance to admit abuse might be occasion he was found in bed with a severely even more marked when it is of a sexual nature. demented woman attempting to have sexual inter- This might partly reflect elderly people internaliz- course with her against her will. Staff felt he was ing society's stereotype of them as sexless and sexually abusing other patients and he was sedated partly embarrassment ofhaving grown up at a time heavily whilst the possibility of treatment with an http://pmj.bmj.com/ when people where far less open about discussing anti-androgen was discussed. He died a few months sexuality. later of bronchopneumonia. 5. Sexual involvement outside marriage was regarded in a negative light when many of today's Case history 2: Mrs B older people grew up and some unmarried women were placed in institutions after becoming preg- Mrs B was an 84-year-old widow who lived in a rest nant. Cognitively impaired older people may have home. She was disabled by rheumatoid arthritis, on September 29, 2021 by guest. Protected active memories of such times and therefore be cognitively impaired and deaf. She had been admit- unlikely to report sexual abuse. ted to a geriatric medical ward with anaemia 6. The move towards community care and secondary to the use of non-steroidal anti- more open mixing of the sexes in remaining inflammatory agents. She expressed to the nursing institutions may bring problems to light which staff ideas which led them to suspect that she had formerly would have remained hidden. been sexually abused by a male carer at the home. Medical staff were concerned that she could be misinterpreting events at the home and did not Risk factors want to take action without good grounds. Mrs B had told nursing staff that a particular There are several reasons why the elderly might be carer 'puts his hand right in ... I don't like it.' She more susceptible to sexual abuse. They may be could not understand why it happened as she was a weak and frail and physically unable to resist widow and knew she was too old to have children. unwanted sexual advances. They may live in insti- She said he washed her 'privates', making her sore tutions with inadequate supervision. Finally those and distressing her. She did not want to 'mess' with Postgrad Med J: first published as 10.1136/pgmj.69.816.803 on 1 October 1993. Downloaded from SEXUAL ABUSE OF THE ELDERLY MENTALLY ILL 805 him, and felt that it would get her 'a bad name'.