Information Processing of Sexual Abuse in Elders

Ann W. Burgess; Paul T. Clements


J Foren Nurs. 2006;2(3):113-120. 

In This Article

Abstract and Introduction

Sexual abuse is considered to be a pandemic contemporary public health issue, with significant physical and psychosocial consequences for its victims. However, the incidence of elder sexual assault is difficult to estimate with any degree of confidence. A convenience sample of 284 case records were reviewed for Post-Traumatic Stress Disorder (PTSD) symptoms. The purpose of this paper is to present the limited data noted on record review on four PTSD symptoms of startle, physiological upset, anger, and numbness. A treatment model for information processing of intrapsychic trauma is presented to describe domain disruption within a nursing diagnosis of rape trauma syndrome and provide guidance for sensitive assessment and intervention.

The 1990s witnessed increasing attention to the scope, magnitude, and effect of crimes involving sexual victimization of women (Crowell & Burgess, 1996; Goodman, Koss, & Russo, 1993; Goodman, Koss, Fitzgerald, Russo, & Keita, 1993; Koss, 1993, 1990; Prentky & Burgess, 2000). During that decade, it was estimated that 1.5 million women experience rape or physical assault annually in the United States, with the alarming fact that the majority of these crimes are perpetrated by offenders known to the victim (Tjaden & Thoennes, 1998). Sexual abuse of women, as a contemporary public health issue, is not only considered pandemic, but heralded as a socio-politically and epidemiologically major medical and psychosocial health problem with significant physical and psychological consequences for its victims (U.S. Department of Health and Human Services [USD HHS], 2000; Centers for Disease Control [CDC], 2006; U.S. Department of Justice [DOJ], 2006).

However, the incidence of elder sexual assault is difficult to estimate with any degree of confidence (CDC, 2003). In one study of 760 inner city hospital victims, 2.7% of the sexually assaulted victims were 60 years and older (Cartwright & Moore, 1989) and in a Texas study, 2.2% (n = 109) of the reported sexual assault victims involved women over 50 (Ramin, Satin, Stone, & Wendel, 1992).

Unfortunately, although there are no reliable estimates of the incidence or prevalence of elder sexual abuse in the general community (Lachs, Williams, O'Brien, Pillemar, & Charlson, 1998), the National Citizens' Coalition for Nursing Home Reform (NCCNHR) has identified a startling number of 1,749 cases of such abuse in the institutionalized elderly in its first 3 years of record keeping initiated in 1996. Furthermore, according to the National Crime Victimization Survey, 261,000 rapes and sexual assaults occurred in the United States in 2000, with collateral data from the National Crime Victimization Survey of 2000 identifying 3,270 of these victims as age 65 or older (Klaus & Maston, 2002). Of note is that serious underreporting continues to occur with an estimate of only 30% reported to police (Rennison, 2002).

Such underreporting of sexual abuse continues to occur in all age groups in a significant number of cases and for historically persistent reasons (shame, stigma, fear of reprisal, lack of awareness of resources) (CDC, 2006; Crowell & Burgess, 1996; Kilpatrick, Edmunds, & Seymour, 1992) with the extent of nondisclosure or nonreporting for the 2002 calendar year estimated as high as 68% (DOJ, n.d.). For elders, the typically inherent nature of dependence on others (family members, caretakers, agency staff, etc.) (Anetzberger, 2000; Marshall, Benton, & Brazier, 2000; Wyandt, 2004) often combined with physical frailty and/or alterations in mental status (Swagerty, Takahashi & Evans, 1999) can provide for increased risk of abuse with subsequently low rates of reporting (Nerenberg, 2002). For example, a study of victims who delayed reporting a rape identified several reasons, including fear of retribution, humiliation, lack of knowledge and trust in the legal and medical systems, and impaired cognitive processing that occurs following intense trauma (Burgess, Fehder, & Hartman, 1995).

The estimated proportion of nonreported cases differs considerably as a function of several known factors (degree of violence in the assault and the relationship of the victim to the perpetrator) with reason to believe that nonreporting in cases of elder sexual assault may be extraordinarily high. In addition to the factors initially cited by Butler and Lewis (1973) (the fact that sexual assault of elderly victims is incomprehensible to most people and relative to stereotypes and myths stemming from ageism), there are a number of other critical considerations. Elderly victims of sexual abuse may be unable to communicate clearly, particularly those with varying degrees of dementia (Gambassi et al., 1998; Hawes et al., 1995; Phillips, Chu, Morris, & Hawes, 1993) or those who are unwilling to communicate based on sociocultural beliefs (National Center on Elder Abuse [NCEA], 1998; Tatara, 1999), fear of shame and stigma (Buchwald,, 2000), or as a result of a carefully crafted necessary dependence of the victim on the offender (NCEA, 2003; Reay & Browne, 2001).

From a medical standpoint, bruises may be attributed to the aging process rather than to an assault. Medical personnel typically are not trained to evaluate elderly victims of sexual assault. One of the critical problems in the observation of genital injury in the elderly, for instance, is an understanding of the mechanism of injury. The most common explanation of genital bruising (and bleeding) in institutionalized elderly is either a "botched catheterization" or "rough perineal care." Bruising to the abdominal area is often attributed to tight restraints for "patient safety." Clearly, there are many reasons to believe that the known cases of elder sexual assaults are underestimates of the true number of such cases.

An additional issue of significance related to the difficulty in studying elder sexual abuse involves assessment of post-trauma symptoms in older adults. Research has shown those individuals experiencing traumatic events share similar patterns of responses (Burgess & Holmstrom, 1974; Campbell, 2002; Foa, Riggs, & Gershuny, 1995). However, little is known about the response of older adults to the trauma of sexual abuse. Understanding the unique psychological patterns of the elder who has been a victim of sexual assault is important.

The presence or absence of post-traumatic stress disorder (PTSD) in older adults has been studied in three trauma areas: combat, natural and man-made disasters, and the Holocaust (Falk, Hersen, & Van Hasselt, 1994). The review of over 50 studies in these three trauma-related areas revealed several general findings that remained constant across trauma type. First, the impact of the trauma tended to be long lasting, defined as 12 months to 40 years post-trauma; second, the long-lasting effects wax and wane over the years; third, there was a failure to identify a single assessment strategy as psychometrically adequate; and fourth, PTSD can either be delayed or a cyclic disorder in long-term follow-up (Green, 1994).


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