1. Sexual Assault of Older Women and Men: The Tip of the Iceberg Madeleine Hollitt Monash University MBBS Year 2 Community Based Practice Program SECASA East Bentleigh

2. Scope of the issue (Part 1) Assault of elderly individuals Assault within the community i.Assault by someone known to them (acquaintances and friends almost 50%) ii.Assault by stranger Assault within residential aged care i.Assault by another resident ii.Assault by a care worker/staff member (67%) Elderly victims of previous sexual assault New disclosure Previous disclosure

3. What we know about elder sexual assault (1) 256 cases of alleged sexual assault in residential care facilities reported to DHS in the 2009-2010 year (mandatory reporting) Older victims less likely to report and the older the victim, the less likely that the offender will be prosecuted Older victims most often females over age 70 that are partially or totally dependent on a caregiver Majority of victims have some degree of psychological (most common) or physical impairment

4. What we know about elder sexual assault (2) Older victims suffer more genital (and physical) trauma from sexual assault than younger victims Sexual assault of older people usually occurs within the context of other forms of abuse (implications for detection) Offenders are less likely to be prosecuted if the offence took place in an assisted living situations A US study found that over half of older victims of sexual assault died within one year of an assault due to trauma

5. What we know: Perpetrator statistics Majority are male caregivers/relatives and are younger than victims 44% of perpetrators under the influence (drugs and/or alcohol) Common characteristics: Previous psychiatric condition (28%) History of substance abuse (16%) History of criminal behaviour (6%) Financial dependence on victims (14%) There are many sex offenders who now live in residential aged care, and many services are not made aware of their history

6. Key issues to consider (Part 2) Mental capacity Guardianship Family dynamics Societal factors Attitudes toward sexual assault in older generations Placement in residential care Involvement of carers and health care professionals Capacity to recover Different reactions and recovery course Similarities and variations between victims Similarities and differences with children

7. Information sheets 3 sheets: Victims, family and friends and carers/residential care workers Define sexual assault and focus on detection and response Suggested techniques for encouraging and responding to a disclosure Outline available services and resources both internal and external to SECASA

8. Counselling older victims (1) Reduce background noise Begin conversations with casual topics or interests Try not to change topic too often Keep sentences and questions short where possible Allow extra time for responding Use open ended questions, but if they are struggling to make a decision, try presenting them with options They may use euphemisms or may have different definitions of terms – important to clarify

9. Counselling older victims (2) Witnesses or carers may need to be involved if there is memory or sensory loss Always reassure them that you believe what they are saying – Fear of being labelled ‘senile’ or ‘demented’ Consider the role of music therapy in clients with severe cognitive impairment (has been shown to be beneficial in studies) Group counselling: Older people tend to have both positive and negative reactions depending on personal qualities

10. Potential challenges in responding to older clients Age of a younger advocate: This may create generational barriers or cause the older person to feel labelled as ‘old’ Recanting by the victim: Highly likely in older victims Fear of retaliation Fear of being labelled ‘senile’ Fear of placement in a nursing home Self-doubt (questioning own memory) Refusal to disclose even if abuse has been discovered: Building rapport can take much longer Medical examinations: These must be performed with much more care, as they can do further damage

11. Generational differences and myths Different language: May not be comfortable with anatomical terms, etc. May believe it is a woman’s responsibility to deny a man’s advances Spousal rape: It would have been legal for an 80 year old woman’s husband to assault her until she was in her 50s. Only strangers can be offenders May believe that only women are assaulted: Older male victims may experience more psychological trauma due to traditional gender role

12. Areas for further research and development (Part 3) How is the incidence changing over time? What is the distribution? What are contributing factors? Post Traumatic Stress Disorder in the elderly and differentiating between PTSD and dementia Counselling for clients with dementia Education programs and evaluating effectiveness Services specific to elderly people: Home and residential care facility home counselling visits Relationship counselling – how should it be different? Development of support groups with increasing incidence Computer literacy for use of online support groups

13. The Pennsylvania Elder Sexual Abuse Project Qualitative study: Indicated professionals wanted education on detection Free cross-training curriculum: 6 modules Rape crisis staff, protective service workers, residential care staff, police and district attorneys Awareness campaign (posters and flyers): “Sexual Assault Knows No Age Limit” – multilingual Flyers to educate older adults (multilingual) Elder Sexual Abuse Technical Assistance Guides – quick reference for professionals

14. Why the Pennsylvania Project worked Pennsylvania has an Older Adult Protective Services Act: Adults over age 60 Interdisciplinary education: Encouraged collaboration and awareness of all stages of responding to an assault Advisory council comprising different professionals consulted in developing curriculum Brought increased awareness and led to more research

15. PTSD and dementia (1) DSM IV CRITERIA PTSDDementia Re-experiencing (flashbacks,etc.)Hallucinations, memory loss Avoidance symptomsRigidity/inflexibility Emotional numbingDecreased interpersonal interaction, emotional blunting Hyper-vigilanceVariations in attention and alertness Altered or absent speech Same changes on neuro-imaging Same results in clinical testing More sudden onset and involves TRAUMATIC EVENT More gradual onset not prompted by trauma

16. PTSD and dementia (2) Theory: Is PTSD an accelerated cognitive ageing process? How can it be detected when superimposed on normal ageing? ‘ De novo’ PTSD in the elderly: Needs much more research PTSD patients who report psychotic symptoms are older and tend to have experienced trauma later in life Older PTSD sufferers tend to score higher on arousal symptoms than intrusion symptoms DSM V (2013: Discussion of including age-based criteria (mostly adolescents and children)

17. Further reading and resources Sexual Assault in Disability and Aged Care (SADA) Project – NSW http://www.sadaproject.org.au http://www.sadaproject.org.au With Respect to Age (2009) – Victorian Government guidelines for health services and community agencies for the prevention of elder abuse Elder Sexual Assault Technical Assistance Manual for Pennsylvania’s Sexual Violence Centres – Useful information for counsellors on working with older victims. Available from: http://www.nsvrc.org/sites/default/files/Elder_Sexual_Assault_Technical-Assistance- Manual.pdfhttp://www.nsvrc.org/sites/default/files/Elder_Sexual_Assault_Technical-Assistance- Manual.pdf Elder Abuse Background Paper – ACSA background paper March 2006 Best Practices for Working with Rape Crisis Centres to Address Elder Sexual Abuse - Journal of Elder Abuse & Neglect, 2008. 20:4; 306-322 Elderly Victims of Sexual Abuse and Their Offenders – Burgess, A. December 2006. Available from: https://www.ncjrs.gov/pdffiles1/nij/grants/216550.pdf