Sexual Abuse of Elders •Kathleen Brown •Associate Professor •University of Pennsylvania •School of Nursing Kearsley Home Retirement home for elderly women Located in West Philadelphia Gothic stone home over 200 years old 60 residents, ages 60-94 Security force on grounds Small in-patient unit; Highly trained staff 1. Margaret Eckard Popular, bubbly 92 year old resident One of longest residents at Kearsley January 23, 1983: missed at breakfast Nurse went to investigate; door ajar Body lying on floor next to rumpled bed Clad in nightgown; curled in fetal position Signs of rigor mortis starting to appear 1 Examination MD concerned over bruises on face; smears of blood around nose and mouth Streaks of blood in vagina and anus Decided not sufficiently disturbing to make an issue; decided natural death due to her age Funeral held 2. Katherine A. Maxwell 85 year old resident February 12, 1983: 21 inch snow storm Katherine failed to show for breakfast Door ajar; body lying on bed Pajamas spotted with blood Storm kept Dr. Webster from the Home Katherine Maxwell Body taken to hospital; no autopsy Blood believed to have occurred by natural causes at her death 2 3. Elizabeth Monroe Celebrated her 86th birthday with a party Next morning, failed to appear at breakfast Nurse found door ajar and her body in bed Face discolored; vaginal bleeding Dr. Webster away; substitute MD Sent body to undertaker Dr. Webster’s Concern Webster called the undertaker; suspicious over the 3 deaths ME’s office were not concerned over the 3 elderly victims’ deaths Webster insistent and ME accepted it for investigation but embalming made it difficult Ruled natural cause death 4. Lillie T. Amlie 89 year old resident described as flamboyant, colorful, offbeat Continued to attract men despite age; had boyfriend whom she saw regularly Never locked apartment door Failed to appear for dinner Last seen in afternoon going for nap 3 Lillie Amlie Body discovered immersed facedown in a few inches of lukewarm water Traces of blood around nose, mouth, vagina and rectum Wearing hose and jewelry 5. Eugenia Borda In June 1983 Miss Borda moved to Kearsley House Never married; found dead in bed Blood around mouth, nose, vagina, rectum Dr. Webster refused to sign death certificate to force ME to investigate as suspicious death 6. Mildred Alston 72 year old resident found dead same day as Miss Borda Lived across the hall 4 Autopsy Borda died of strangulation Alston was suffocated Alston was robbed: wedding rings; purse missing Investigation Detectives believed suspect was worker at home or known to the residents Killer possibly a night worker Kearsley employed over 40 staff Anthony Joyner became a focus Anthony Joyner Polite, young black man; age 22 Hired to kitchen staff as assistant diet tech Administrator impressed with his manners and apparent affection for older women Described by friends as “cool dude” Slight build; neighborhood made jokes: weird 5 Acquaintance of Joyner’s Said Joyner bragged about raping an elderly woman and stealing her jewelry Police found unsolved case of 68 year old woman in West Phila and arrested Joyner Confessed, “Okay, okay. I killed them all.” Confessed Motive Wanted to prove he was a man Murder after fighting with girlfriend Said sex was not a motive MO: slip into the victim’s room, press pillow over face to keep her from screaming and from recognizing him Then rape Planning Teased by friend at bar; drinking beer; go to Kearsley; enter building through cellar Selected victims at random Targeted Ms. Amlie because she accused him of stealing (which he had) Tried to smother her; she got up; he drowned her 6 Post Mortem Behavior When victim stopped struggling, “thought she went back to sleep.” Joyner attended Alston’s wake and funeral With legal representation, recanted his confession; said he was tricked Claimed he didn’t hear the judge charge him with murder Investigation of Kearsley Were there more victims? 17 women died at Kearsley during Joyner’s employment More than 25% of resident population Prosecution Witnesses 23 year old girl friend Bragged 2 days before arrest: “I’m going to be famous. Watch the news.” Told police he was angry that friends teased him; called him a faggot Convicted and sentenced to life: happy he had “beaten the death penalty” 7 8 Concept of Vulnerability Elderly patients in a health care system Sexual Abuse (available: http://www.elderabusecenter.org) Non-consensual sexual contact of any kind Sexual contact with any person incapable of giving consent Includes: unwanted touching, all types of sexual assault or battery (e.g. rape, sodomy, coerced nudity, sexually explicit photographing) Barriers To Preventing & Identifying Sexual Abuse Social and health care system Myths about aging Myths about factors contributing to abuse Staffing Physiologic barriers due to aging Multiple medical problems complicate assessment Markers of abuse mimic changes of aging Increased prevalence of depression, isolation Cognitive and sensory impairment Research barriers Epidemiology, instruments 9 Some age-related changes: Atrophy of skin tissues Increased vascular fragility Loss of muscle mass Decreased estrogen Pubic area loses fatty deposits (labia majora and minora thinner; clitoris not as protected) The brain is our interpreter of conscious experience - Hippocrates Model of Multifaceted Assessment Person with Dementia Cognitive losses Remaining abilities Inability to Respond Reduction in to Verbal Need: Self-Report Assessment Tool Multifaceted -Under-Recognition Assessment -Under-Treatment Adverse Consequences Adapted from: Feldt, Warne, & Ryden, 1998, J. Geron. Nsg, 24 (11), p.17 10 An alternative view of behavior BACKGROUND PROXIMAL Behavior FACTORS FACTORS • Resistiveness •Neurological •Personal to Care •Cognitive •Physical • Agitation •Health Environment -Verbal •Psychosocial •Social -Physical Environment • Aggression • Others Based on: Algase, D.L., et al., (1996) Amer. J. of Alzheimer’s Disease MILD MODERATE SEVERE TERMINAL I MEMORY RESISTIVENESS N PERSONALITY INCONTINENCE SPATIAL EATING D DISORIENTATION DIFFICULTIES MOTOR E APHASIA IMPAIRMENT P APRAXIA BEDFAST E CONFUSION AGITATION MUTE N INSOMNIA DYSPHAGIA D INTERCURRENT INFECTIONS E N C E TIME “People do not consist of memory alone. They have feeling, will, sensibilities, moral being . It is here that you may find ways to touch them” Luria 11 Elder Sexual Abuse Elder Sexual Abuse 1976 NIMH report: no information on topic Nat’l Coalition for Nursing Home Reform: 600+ cases and increasing. NIMH realized, in the 90’s, that this was the only place reporting sexual abuse of elders Concerns Elderly, especially Alzheimer patients can’t remember. Do they experience trauma from sexual abuse? Who would want to rape an elderly person? Elderly with decreased cognition? Is rape a fantasy? Elders: consensual sex versus non-consensual sex 12 Ground Breaking Work: Nursing Home Study Burgess, Dowdell & Prentky in Journal Psychosocial Nursing, 38 (6):June 2000 20 cases derived from civil litigation. All founded cases Sample: One 16 and one 33 year old year old gun shot head trauma; 53 year old ALS Remainder 70-94 year old Multiple medical problems and many with cognitive deficits Victims Reporting the Assault Inform a family member (7) or staff (3) Abuse witnessed or suspected (7) Clues (4), e.g., bruising, pain Perpetrator Identification Some gave full descriptions Many confused some details Some staff disbelieve and think it a “delusion” Out of 20, 18 perpetrators were identified by the victim Not identified by the victim: 2 cases of HPV 13 Style of Attack Confidence style: “let’s go for a walk” Blitz style: one case of extensive injury Deception style: most cases where no physical force used Threats in 2 cases Physical and Forensic Evidence Difficulty in collecting evidence Resistance to pelvic exam Difficulty visualizing area (eg. leg contractures) Communication problems Difficulty obtaining accurate report from victim and staff Signs and Symptoms Sign: visible or witnessed Trauma to genitals, rectum, breasts including bleeding, bruises, skin tears; bite marks; burns; scarring, redness; finger imprints; forcible restraint Infection; sexually transmitted diseases Eyewitness observes sexually abusive behavior 14 Symptoms of Sexual Abuse Symptoms: suggestive of sexual abuse Sexually-oriented statements Expression of fear of male staff Avoidant behaviors with male staff Withdrawn behavior; fetal position Staying near nurses station Reenactment behaviors Behavioral Symptoms Protest behaviors Appears to be in shock Crying spells Sleep and appetite changes Immune system compromised Deterioration of health Gerophiles Study of 18 sexual predators Burgess, Prentky & Dowdell in Journal Psychosocial Nursing 38(8) 2000 15 were employees of nursing home 3 were male residents 15 Dynamics of Offense Victims were all highly vulnerable due to decreased cognition, physical fragility, helplessness 16 assaults in victim’s bed; 3 victims were taken off unit; one was assaulted in wheelchair (multiple assaults) Usually evening or night shift Style of Attack Confidence style: “let’s go for a walk” Blitz style: one case of extensive injury Deception style: most cases where no physical force used Threats in 2 cases Control of Victim Mere presence One threatened with knife One had wrists secured Victim resistance in 2 cases Victim screamed in 3 cases but