Live in Sudbury, Ontario. Member of Forensic Nurses’ Society of Canada

2. Live in Sudbury, Ontario. Member of Forensic Nurses’ Society of Canada Have less than 1yr till I am finished my Masters of Science in Nursing Who I am Elder Sexual Assault... The Hidden Truth 2

3. I am a Registered Nurse who works in the Domestic Violence/Sexual Assault Treatment Program at HRSRH. Provide care to survivors (adult and pediatric) of Domestic Violence and Sexual Assault. Part of the Ontario Network of Sexual Assault/ Domestic Violence Treatment Centers. Where I work Elder Sexual Assault... The Hidden Truth 3

4. Overview • Realities of Elder Sexual Assault • Assessment of Elder Sexual Assault Victim • Implications for SANE • Moving Forward Elder Sexual Assault... The Hidden Truth

5. Overview of Elder Population • Seniors account for more than 13% of the nation’s population… projection is that it will reach 15% by 2011.(Statistics Canada, 2001) • It is estimated that the population of those over the age of 65 will be 4.81 million by the year 2011, a growth rate of 82.9%.(Statistics Canada, 2001) Elder Sexual Assault... The Hidden Truth

6. Realities of Elder Abuse • Abuse of the elderly is manifested in several ways: • Physical abuse • Sexual abuse • Emotional or psychological abuse • Neglect • Abandonment • Financial or material exploitation(Lynch, 2006) Elder Sexual Assault... The Hidden Truth

7. Realities ofElder Sexual Abuse/ Assault • Sexual abuse of an elder involves anynon-consensual sexual conduct or contact between an elder and an abuser. • Without consent it is considered sexual assault… no matter what age the person. Elder Sexual Assault... The Hidden Truth

8. Realities of Elder Sexual Abuse/ Assault(continued) • The problem of elder sexual abuse is particularly troubling in view of the expected doubling of the number of older adults worldwide from 1995-2025. (Ploeg, Hutchison, MacMillan and Bolan, 2009) • The prevalence of elder abuse is difficult to quantify for a number of reasons.(House of Commons Health Committee, 2004) Elder Sexual Assault... The Hidden Truth

9. Realities of Elder Sexual Abuse/ Assault(continued) • Sexual abuse victims tend to be of advanced age, frail and dependent on others for care.(Vierthaler, 2008) • Elder sexual abuse is being recognized as a public health issues with important nursing implications, especially for forensic nurses.(Paulos and Sheridan, 2008) Elder Sexual Assault... The Hidden Truth

10. Perpetrators ofElder Sexual Assault • The reasons for elder maltreatment are as varied as the individual elders themselves.(Olshaker, Jackson and Smock, 2007) • The perpetrators of elder sexual abuse; • 81% were healthcare providers • 78% were family members (predominantly sons and husbands) • Ages ranged from 16 to over 70 years(Ramsey-Klawsnik et al., 2008) Elder Sexual Assault... The Hidden Truth

11. Perpetrators ofElder Sexual Assault(continued) • Anyone who comes into contact with an older person can be a potential abuser. • Abusers are not always care givers or persons under stress. • Abuse can be deliberate, premeditated or caused by accident or ignorance. Elder Sexual Assault... The Hidden Truth

12. Perpetrators ofElder Sexual Assault(continued) • Contributing factors include: • Power and Control • Mental illness • Substance abuse • Domineering or sadistic personality traits • Sexual deviance • Paternalistic view of wives as sexual property Elder Sexual Assault... The Hidden Truth

13. Reporting Elder Sexual Assault • Sexual victimization is under-reported in all age groups. • Older victims less likely to report due to: • Restrictive cultural view of sexuality • Self blame and feelings of humiliation • Verbal limitations Elder Sexual Assault... The Hidden Truth

14. Barriers to Reporting • Cognitive impairment • Reluctance to disclose • Cultural factors • Fear of losing independence • Fear of not being believed Elder Sexual Assault... The Hidden Truth

15. Vulnerability • There are many indicators of vulnerability, some which include: • Illness • Communication problems • Physical disability • Family history of violence • Support services • Staffing issues Elder Sexual Assault... The Hidden Truth

16. Assessment • Taking a medical history from a senior in general is a complex and elaborate process.(Olshaker, Jackson and Smock, 2007) • It is important to develop trust with the elder in order to do an accurate assessment of the sexual abuse.(Burgess and Morgenbesser, 2005) Elder Sexual Assault... The Hidden Truth

17. Listening • Always listen to what the person is telling you. • Never dismiss what a person says. • Always take it seriously even when the person appears to be confused. Not all disclosures occur verbally but through behavioral changes. Elder Sexual Assault... The Hidden Truth

18. Recognizing Abuse • When it comes to recognizing sexual abuse there are some “Red Flags” to remember: • Observed, suspected or reported incidents or forced participation • Patient history • Bruises and/or bleeding around breasts/genital area • Difficulty sitting or walking • Genital infections or disease Elder Sexual Assault... The Hidden Truth

19. Recognizing Abuse(continued) • Torn, dirty, stained or bloody underclothing • Lack of privacy • Inappropriate touching, sexual innuendo by patient or another • Withdrawn un-communicative person • Observed or reported feelings of blame and guilt • Isolation or changes in behaviors • Disturbed sleep pattern Elder Sexual Assault... The Hidden Truth

20. Disclosure • When a person is disclosing an incident to you: • Do no ask leading questions • Do not challenge abuse • Find out what the person wants (ie. medical treatment, police involvement, etc.) • Record what is said in the person’s words Elder Sexual Assault... The Hidden Truth

21. Challenges In Elders • Normal/common changes • Multiple co-morbidities • Medication effects • Cognitive impairment Elder Sexual Assault... The Hidden Truth

22. Implications for Sexual Assault Nurse Examiner (SANE) • SANEs are responsible for obtaining medically relevant history of the assault, collecting evidence and documenting medical findings.(Cook-Daniels, 2007) • Elderly victims have the same wide spread response as younger victims of sexual assault. Elder Sexual Assault... The Hidden Truth

23. Implications for SANE (continued) • Older people are more likely to die from physical injuries than younger people. • High morbidity and mortality rates attributed to: • Concurrent medical conditions • Decreased physiologic reserve • Current medications • Physical limitations Elder Sexual Assault... The Hidden Truth

24. Sexual Assault Assessment • Should take place in area that ensures privacy. • A few important things to remember: • Evaluation of sensory abilities (vision and hearing) • Record the history of assault • Perform a thorough assessment (including diagnoses, medications prescribed and current lab values) Elder Sexual Assault... The Hidden Truth

25. Physical Examination • The goal of the SANE examination is the systematic and comprehensive collection of evidence from the victim that has been transferred from the perpetrator.(Burgess and Morgenbesser, 2005). • It is conducted in a psychologically supportive manner by explaining and requesting consent for each step in the process. Elder Sexual Assault... The Hidden Truth

26. Physical Examination (continued) • While conducting the physical exam SANE nurses look for: • Wounds • Infection • Bleeding • Pain/Tenderness • Signs of physical restraint • Inappropriate sexual comments by care giver Elder Sexual Assault... The Hidden Truth

27. Physical Examination (continued) • Assistance may be required • Positioning the patient • A small speculum is recommended • Examination may require more time Elder Sexual Assault... The Hidden Truth

28. Physical Examination (continued) • Often more difficult to perform due to: • Cognitive or physical impairment • Knowledge deficit • Normal changes in older females(Paulos and Sheridan, 2008) Elder Sexual Assault... The Hidden Truth

29. Health Issues for the Elderly General Issues Emotional Trauma Physical Trauma

30. General Health Issues • Elderly victims, like all victims of sexual assault, often experience severe emotional and physical trauma. • Often the elderly access fewer services and intervention than younger victims.(Vierthaler, 2008) • The world in which today’s elderly grew up affects how they experience and view sexual victimization. Elder Sexual Assault... The Hidden Truth

31. Emotional Trauma • Elderly individuals have higher rates of depression, anxiety and other mental health issues which increases their vulnerability to abuse and exploitation.(Cook-Daniels, 2007) • The elderly often become the victims of unwanted sexual contact because they’re perceived to be easily overpowered and manipulated. Elder Sexual Assault... The Hidden Truth

32. Behavioural Changes • Unexplained changes in appetite, eating, sleep patterns and mood levels • Anxiety about their residence • Decreased enjoyment of social activities • Behaviours described as “out of character” • Fear of going to sleep • Suicidal thoughts Elder Sexual Assault... The Hidden Truth

33. Physical Trauma • Older people are more likely to sustain injuries as a result of a violent attack and are more likely to require medical care for these injuries than younger adults.(Burgess, Hanrahan and Baker, 2005) • Elderly victims are at increased risk for the following: • Genital or urinary irritation • Physical injuries • Sexually Transmitted Infections (STI) & HIV Elder Sexual Assault... The Hidden Truth

34. Injuries Based on current literature, it is evident that genital injuries occur with more frequency and more severity in sexually assaulted women who are postmenopausal that in younger victims. (Burgess and Morgenbesser, 2005) In more than ½ of victims there are documented signs of bruising, abrasions, redness, swelling and tears in the perineal area.(Burgess, Ramsey-Klawsnik and Gregorina, 2008)

35. Genital Injuries (Burgess, Hanrahan and Baker, 2005) Elder Sexual Assault... The Hidden Truth

36. Prevalence of Injury (continued) Non-Genital Injuries (Burgess, Hanrahan and Baker, 2005) Elder Sexual Assault... The Hidden Truth

37. Lack of Research 1. Research data is scarce as the efficacy of treatment programs in the area of elder sexual abuse. 2. There is a history of discrimination against the elderly as well as misperceptions and stereotypes against older adults that has put elders at an increased risk for sexual assault. Elder Sexual Assault... The Hidden Truth

38. Lack of Research (continued) 3. Barriers to effective health care interventions include delayed reporting of the sexual abuse. 4. There are few resources available for educating seniors and others about the prevention of sexual abuse. 5. There is little information on the motivation of offenders who sexually assault the elderly. (Burgess and Morgenbesser, 2005) Elder Sexual Assault... The Hidden Truth

39. Moving Forward • Changing stereotypes • Research • Education • Assessment Elder Sexual Assault... The Hidden Truth

40. Summary of Main Points • Severe under reporting. • Elderly victims of sexual assault represent a vulnerable and poorly understood population.(Burgess, Dowdel and Brown, 2000) • Reporting and identifying elder sexual assault is the cornerstone to intervention, treatment and prevention.(Burgess, Brown, Bell, Ledray and Poarch, 2005) Elder Sexual Assault... The Hidden Truth

41. Further Information • Please feel free to contact me for further information, with additional questions or comments. Christine Bouffard RN, BScN, SANE CBouffard@hrsrh.on.ca 1-705-675-4743 or 1-866-469-0822 ext. 4743 Elder Sexual Assault... The Hidden Truth

42. Reference List • Burgess, A.W., Brown, K., Ledray, L.E. and Poarch, J.C. (2005). Sexual abuse of older adults: Assessing for signs of a serious crime and reporting it. American Journal of Nursing, 105 (10), 66-71. • Burgess, A.W., Dowdell, E.B. and Brown, K. (2000). The elderly rape victim: Stereotypes, perpetrators, and implications for practices. Journal of Emergency Nursing, 26 (5), 516-518. • Burgess, A.W., Hanrahan, N.P. and Baker,T. (2005). Forensic markers in elder female sexual abuse cases. Clinics in Geriatric Medicine, 21, 339-412. • Burgess, A.W., and Morgenbesser, L.I. (2005). Sexual violence and seniors. Brief Treatment and Crisis Intervention, 5(2), 193-202. • Burgess, A.W. and Phillips, S.L. (2006). Sexual abuse, trauma and dementia in the elderly: A retrospective study of 284 cases. Victims and Offenders, 1, 193-204. • Burgess, A.W., Ramsey-Klawsnik, H. and Gregorina, S.B. (2008). Comparing routes of reporting in elder sexual abuse cases. Journal of Elder Abuse and Neglect, 20 (4), 336-352. • CDNA. (2003). Community and district nursing association: Response to elder abuse. Accessed on Oct 2nd, 2009 from http://www.cdnaonline.org/documents/ElderAbuse.pdf Elder Sexual Assault... The Hidden Truth

43. Reference List(continued) • Cook-Daniels, L. (2007). Transgender survivors of elder or disabled adult abuse, part 1. Victimization of the Elderly and Disabled, 10 (1), 81-96. • Cronin, G. (2007). Elder abuse: The same old story? Emergency Nurse, 15 (3), 11-13. • House of Commons. (2004). Elder abuse: Second report. Volume 1. Accessed on Oct 2nd, 2009 from http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/111/111.pdf • Jones, H., and Powell, J.L. (2006). Old age, vulnerability and sexual violence: Implications for knowledge and practice. International Nursing Review, 53, 211-216. • Lynch, V.A. (2006). Forensic nursing. Mosby; USA. Chapter 25. • Neundorfer, M.M., Harris, P.B., Britton, P.J. and Lynch, D.A. (2005). HIV-risk factors for midline and older women. The Gerontologist, 45 (5), 617-625. • Olshaker, J.S., Jackson, M.C. and Smock, W.S. (2007). Forensic emergency medicine. Lippincott Williams and Wilkins; Philadelphia, USA. • Ploeg, J., Hutchison, B., MacMillan, H. and Bolan, G. (2009). A systematic review of interventions for elder abuse. Journal of Elder Abuse and Neglect, 21, 187-210. Elder Sexual Assault... The Hidden Truth

44. Reference List(continued) • Poulos, C.A. and Sheridan, D.J. (2008). Genital injuries in postmenopausal women after sexual assault. Journal of Elder Abuse and Neglect, 20 (4), 323-335. • Ramsey-Klawsnik, H., Teaster, P.B., Mendiondo, M.S., Marcum, J.L. and Abner, E.L. (2008). Sexual predators who target elders: Finding from the first national study of sexual abuse in care facilities. Journal of Elder Abuse and Neglect, 20 (4), 353-376. • Stieber Roger, K. and Ursel, J. (2009). Public opinion on mandatory reporting of abuse and/or neglect of older adults in Manitoba, Canada. Journal of Elder Abuse and Neglect, 21, 115-140. • Toronto. (1996). Remember elderly women can also be sexual assault victims. Medical Post, 32 (7), 75. • Tyra, P.A. (1996). Helping elderly women survive rape using a crisis framework. Journal of Psychosocial Nursing, 34 (12), 20-25. • Vierthaler, K. (2008). Best practices for working with rape crisis centers to address elder sexual abuse. Journal of Elder Abuse and Neglect, 20 (4), 306-332. Elder Sexual Assault... The Hidden Truth