Elder Sexual Abuse: Preliminary Findings
Holly Ramsey-Klawsnik, PhD
ABSTRACT. Twenty-eight cases of suspected elder sexual abuse were identified and described by elder protective service workers. All the victims were female, and 71% experienced significant limitations in capacity for independent functioning and self-protection. Indicators of sexual abuse included victim self-report and third party observation of assault, physical injury, and psychosocial symptoms. All but one of the suspected offenders were male. Eighty-one percent were caregivers for the women they allegedly assaulted, and 78% were family members, predominantly sons and husbands. Repeated vaginal rape was the most prevalent type of reported assault. Findings of the study are presented, and issues relative to the sexual victimization of elders are discussed.
Intrafamilial abuse and neglect have rightfully attracted society’s attention. Recognition that older people are frequently victims has resulted in research, practice, and legislative attention to elder maltreatment. Although no generally accepted definition of elder abuse and neglect exists (Pillemer & Finkelhor, 1988; Kosberg, 1988), usual definitions include some or all of the following: physical abuse, emotional or psychological abuse, financial or material exploitation, and active and passive neglect (for example, Block & Sinnott, 1979; Douglass et al., 1980; Pedrick-Cornell & Gelles, 1982; Pillemer & Finkelhor, 1988). Intrafamilial violence towards wives and children is considered to encompass all of these forms of maltreatment and, in addition, sexual abuse. During recent years the sexual abuse of wives and children has received considerable attention while, in contrast, that of elders has received little public or professional recognition.
A literature search revealed only three articles specifically addressing elder sexual abuse. Groth (1978) reports twenty-two cases of elder rape. The majority of these victims did not know their assailants. Reay and Eisele (1983) describe one case of the sexual abuse and murder of an elderly woman by an unrelated acquaintance. Cartwright and Moore (1989) report twenty-one cases of stranger-rape of women between the ages of sixty and ninety. These accounts focus on the sexual assault of elders by strangers rather than by family members in care-giving roles.
The literature contains few references to elder sexual abuse by family members and other caregivers. Some authors include sexual abuse as a form of elder physical abuse (Douglass et al., 1980; Sengstock & Hwalek, 1985; Wolf et al., 1984). Wolf and colleagues indicate that three of the 328 cases of elder abuse and neglect they studied involved sexual molestation. O’Malley (1979) lists sexual abuse as a type of elder abuse distinct from physical abuse but does not address the problem. Chen et al. (1981) and St. Vincent Medical Center (1985) identify sexual abuse as a form of elder maltreatment but limit their definition to rape and attempted rape, excluding other forms of sexual abuse such as exhibitionism and molestation. Other references to elder sexual abuse are sparse. Kosberg (1988) mentions that elder women are more vulnerable than men to sexual molestation. Campbell (1988) includes sexual abuse/assault as a type of elder abuse and provides a list of seven physical indicators of possible sexual abuse. Halamandaris (1986) discusses a yearlong investigation of elder abuse, including sexual abuse, by the House Select Committee on Aging. One illustrative case is offered involving a twenty-two year old male who physically and sexually assaulted his elderly grandmother. Notably absent from the literature is research about investigating elder sexual abuse investigation. Despite the lack of formal study, protective service workers are encountering elder sexual abuse and expressing a need for training on the topic. A request for information on elder sexual abuse was made by the Massachusetts Executive Office of Elder Affairs. In response, an exploratory study was undertaken.
Elder protective service workers and supervisors who attended the 1989 annual Massachusetts Elder Affairs Conference and Recognition Day were queried concerning their experience with cases of suspected elder sexual abuse. A total of twenty-eight cases of suspected elder sexual abuse were reported and described. (A second wave of data-collection during the 1990 conference yielded thirty-two additional cases. This data is presently undergoing analysis.) The staff who were surveyed work with elders residing in the community. Since they are not responsible for serving elders abused in nursing homes and other institutional settings, this study did not screen for institutional sexual abuse of elders.
During the first data-collection period, questionnaires were administered to twenty workers and supervisors who attended an elder sexual abuse training workshop. Questionnaires were completed during the workshop, following a presentation of the range and types of behaviors which constitute sexual abuse and common signs and symptoms indicative of possible sexual abuse. The Sexual Abuse Continuum presented in Figure 1 was utilized to delineate the range and types of sexually abusive behaviors addressed in the study.
|COVERT SEXUAL ABUSE||Sexualized Relationship Sexual Interest in Victim’s Body Sexualized Jokes, Comments, Harassment “Romantic” Relationship Discussion of Sexual Activity|
|OVERT SEXUAL ABUSE||Pre-touching Phase Voyeurism Exhibitionism Inflicting Pornography on Victim Sexualized Kissing and Fondling Victim is Passive Recipient Victim Activity is Forced Oral – Genital Contact Digital Penetration of Vagina or Anus Vaginal Rape with Penis Anal Rape with Penis Vaginal/Anal Rape with Objects Exploitation Sadistic Activity Ritualistic Abuse|
The continuum was developed based upon research and clinical findings (Groth, 1979; MacFarlane & Waterman, 1986; Mayer, 1983; Russel, 1990; Sgroi, 1982) and the author’s extensive experience interviewing child and adult victims of sexual violence. The continuum presents the activities typically described by victims during their reports of sexual abuse. The activities are listed in rank order from (generally) least to most severe in terms of degree of violence and trauma to the victim. Sexual abuse often begins with activities in the less severe range and escalates over time to more severe types of abuse. To constitute sexual abuse, the recipient would have been forced, tricked, threatened, or otherwise coerced into the sexual contact against his or her will.
Covert sexual abuse does not mean sexual contact between offender and victim, but rather, involves an offender who treats the victim as a sex object and/or as a potential sex partner. (See Herman, 1981, for a further description of covert sexual abuse.) Sexual harassment, inappropriate comments, and threats are examples of this behavior.
The pre-touching phase of overt sexual abuse involves use of the victim for voyeuristic purposes, the offender exposing himself or others to the victim and forcing the victim to view pornographic materials. Activities ranging from sexualized kissing and touching the victim to rape with objects are self-explanatory. Exploitation encompasses situations in which the offender gains something illicit in addition to sexual contact from the victim.
Examples would be “swapping” the victim with another offender, prostituting the victim, or using the victim to produce pornography. Sadistic activity includes situations in which the offender gains erotic pleasure through the deliberate infliction of physical pain upon the victim during the sexual assault. Sadistic offenders may burn, beat, tie or otherwise physically torture victims during the sexual assault. Ritualistic abuse is a severe form of maltreatment which involves repetitive and often sadistic sexual, physical, and psychological assault usually perpetrated by multiple offenders acting in concert (Hudson, 1989; Kelley, 1988; Ritual Abuse Task Force, 1989). This continuum was discussed with the questionnaire respondents as was the list of signs and symptoms of possible sexual abuse that are presented in List 1.
List 1. Signs and Symptoms of Possible Sexual Abuse
- Genital or Urinary Irritation, Injury, Infection or Scarring
- Presence of a Sexually Transmitted Disease
- Frequent, Unexplained Physical Illness
- Intense Fear Reaction to an Individual or to People in General
- Mistrust of others
- Nightmares, Night Terrors, Sleep Disturbances
- Phobic Behavior
- Extreme Upset When Changed or Bathed
- Regressive Behaviors
- Aggressive Behaviors
- Direct or Coded Disclosure of Sexual abuse
- Disturbed Peer Interactions
- Depression or Blunted affect
- Poor Self-Esteem
- Self-Destructive Activity or Suicidal Ideation
Many of these signs and symptoms are also indicative of problems other than sexual victimization. The presence of one or more of these does not prove the existence of sexual abuse. A pattern of indicators would suggest the possibility of sexual victimization, however, and should lead protective workers to screen for possible sexual abuse.
Following presentation of the continuum and signs and symptoms, participants were asked to complete the questionnaires. Their instructions were to report all cases in which they suspected an elderly client had experienced (at age sixty or over) any abusive acts listed on the continuum. To ensure the reported cases were mutually exclusive, supervisors were instructed to only report cases if the worker who had serviced the case was not present to provide data. Workers were instructed to avoid duplicate reporting in the event that two or more workers who had serviced the same suspected sexual abuse victim were among the group of respondents. Workers and supervisors were provided time to confer regarding the reporting of shared cases.
Questionnaires were completed by twenty workshop participants. Seventy-five percent indicated they had serviced one or more victims of suspected elder sexual abuse, and over half had serviced more than one. These respondents were asked to provide, to the best of their knowledge and recollection, a variety of case specifies regarding the client, nature and extent of the suspected sexual abuse, factors leading to suspicions, and the alleged offender. Respondents were also invited to write comments on the questionnaires and to add comments during a discussion following completion of the questionnaire.
Suspected Victims and Sexual Victimization
All twenty-eight suspected elder sexual abuse victims were females. Their ages ranged from sixty-five to one hundred and one. Forty-six percent were in their 70s and 21% in their 80s. These women were quite limited in their capacity to protect and care for themselves. The majority (71%) were described as “totally dependent” or functioning “very poorly” or “poorly.” Twelve of these women were described by their protective workers as suffering severe psychiatric impairments, three had Alzheimer’s disease, two were mentally retarded, four were bedridden, and one was an aphasic stroke patient.
Questionnaire respondents were asked to describe the nature and extent of sexual abuse to the best of their knowledge. As can be seen from Table 1, allegations ranged the gamut of the sexual abuse continuum from covert activities to ritualistic abuse. In 61% of the cases, rape was suspected. Repeated vaginal rape was the most commonly reported type of assault. In three cases, more than one activity was reported. The suspected ritualistic victim was assaulted by a male and a female caregiver to whom she was unrelated. She suffered multifaceted sadistic assault which included being tied and burned on numerous areas of her body.
|ACITVITY||# OF SUSPECTED VICTIMS|
|Repeated vaginal rape||10|
|Vaginal rape (single episode)||3|
|Vaginal rape with objects||3|
|Subjecting to pornographic films||2|
|Anal rape with objects||1|
Note: in 3 cases multiple activities were reported.
Factors Lending to Suspicion of Sexual Abuse
Table 2 presents the factors which led to the suspicion of sexual abuse. In almost one-third of the cases, sexually abusive acts towards elders were actually witnessed by others. The observers included family members, home health aides and nursing staff, protective service workers, and a neighbor. In one case, multiple service providers repeatedly observed an adult son engage in open mouth kissing of his elderly mother which lasted for many minutes.
|FACTORS||# OF SUSPECTED VICTIMS|
|Third party observation of sexual abuse||9|
|Victim’s disclosure of sexual abuse||8|
|suspected offender’s observed behavior||7|
|Victim’s coded disclosure of sexual abuse||2|
Note: In 57% of the cases, multiple indicators wore reported.
Witnessed abuse also included acts at the more severe end of the continuum. For example, a violent vaginal rape was observed by a concerned neighbor who came running upon hearing the screams of the victim.
Nine elderly victims disclosed sexual abuse to a service-provider or confidant. Two additional women made coded disclosure or hinted that they had been sexually abused. Because the humiliation typically experienced by sexual abuse victims tends to inhibit disclosure, it is not unusual for victims to deny ongoing abuse, or to make only coded, rather than direct disclosure.
Physical injuries reported included: repeated vaginal infections, bleeding, tearing; genital scarring; burns; and prolapsed uterus. (While there may be many causes of a prolapsed uterus in an elderly woman which are unrelated to sexual abuse, this condition in one woman, coupled with other medical evidence, caused the worker to suspect sexual abuse. Prolapsed rectums have occasionally been diagnosed in children who have been violently and repeatedly anally raped.) Psychosocial symptoms such as fear, anxiety, and mistrust of specific others were observed and reported by the protective service workers. Suspected offenders’ observed behavior included alcoholism, reluctance to allow others access to the woman for whom they provided care, and comments conveying perceptions of the elder as sexual property. For example, in one case a husband caring for his bedridden wife did not clothe the woman but instead had her lie undressed beneath the bedclothes. He expressed to the worker that this made it easier to “get at her.”
In 57% of the cases (N = 16), multiple indicators were reported. For example, one woman experienced significant vaginal tears and bleeding. The caregiver was her alcoholic son with whom she resided. In another case, a mute Alzheimer patient who exhibited genital scars resided with and was cared for by her brother. She was observed backing away and screaming in evident fear when he entered her room. It is noteworthy that he had refused outside care-taking for this woman. In 71% of the cases (N = 20), other service providers (in addition to the workers) also had suspicions of sexual abuse which had been conveyed to the worker.
Except in one case, specific individuals were identified as the suspected perpetrators, twenty-six cases indicating a male offender, and in another case a male and female caregiver were the most likely perpetrators. In 81% of the cases, the suspected offenders were caregivers, and 78% were family members (primarily sons and husbands). Over half of the cases constitute incest. Table 3 presents the relationships of suspected offenders to victims.
Ages of suspected offenders ranged from twenty-two (the grandson) to eighty-eight. Twenty-one percent were under age forty.
|RELATIONSHIP||# OF SUSPECTED VICTIMS|
Forty-three percent were age forty to sixty, primarily the sons of victims. Over one-third (36%) of the suspected offenders were themselves elders. Seven were in their sixties and seventies, and three were in their eighties. These men were the husbands, boyfriend, and brothers of victims. The elder offenders were healthier and physically stronger than their victims and served as their care-givers.
Reactions of Respondents
Many respondents made comments in the space provided on the questionnaire. Several reported that, only in retrospect, they recognized some of their previous clients as victims of elder sexual abuse. For example, one worker discussed a client who had been repeatedly subjected to pornographic film-viewing. The offender was her son who propped the immobile woman in front of the television for hours at a time and showed X-rated videos. The only available escape for this woman was sleeping, and she frequently expressed disgust and displeasure about viewing the films. The worker commented, “I knew that was wrong and I felt very upset about it. I didn’t know it was sexual abuse but I didn’t feel empowered to stop it.”
Workers discussed other situations in which they believed abusive sexual activity was forced upon their elderly clients, while they as workers felt powerless to intervene. They expressed frustration about not knowing how to interview clients for possible sexual abuse, as well as the lack of training and literature on the subject. Workers reported feeling hampered in their attempts to help sexually abused elders by ignorance on the part of other professionals who down-played or ignored their concerns. They also cited elder abuse legislation which does not specifically address sexual abuse as handicapping them in their protection efforts.
The most typical picture of the elder sexual abuse victim which emerged from this preliminary study is of a woman in her seventies, suffering major impediments to self-care. She is dependent upon another for care and is sexually assaulted by that person. The abuser is male, likely a grown son or husband. The sexual abuse consists of repeated vaginal rape, probably accompanied by other forms of molestation. She is receiving elder protective services for another form of maltreatment. In the course of service-delivery her worker comes to suspect possible sexual abuse due to a constellation of symptoms. The worker has had no formal training in interviewing or treating sexual abuse victims. She receives little support or guidance from other professionals in exploring these concerns and feels helpless to help the client.
The degree to which this picture is representative of sexually abused elders is impossible to determine from this exploratory effort. The study utilized a small, non-random clinical sample consisting of sexual abuse cases identified primarily as a result of protective service involvement for other maltreatment concerns. The findings are therefore not generalizable. A further problem with the methodology is the reliance upon worker memory, rather than written records. The protective service staff who provided the data may not be representative of their peers. Although seventy-five percent of them had experience with suspected elder sex abuse cases, it is likely that workers who had encountered the problem were attracted to the Elder Sexual Abuse Workshop. A further limitation is the lack of information provided directly from suspected victims.
Despite the limitations, this study demonstrates that elder sexual abuse by family members and caregivers does occur and requires recognition, intervention, and scientific investigation. Kosberg (1988) and Finkelhor and Yllo (1983) have pointed out the value of exploratory research which describes a previously unstudied problem and outlines issues for further inquiry. Exploratory studies raise more questions than they answer. Future research should address a number of questions. Why does elder sexual abuse occur? How prevalent is it? In what ways is it similar to and different from other forms of elder abuse and family violence? Who are the victims and perpetrators? What intervention is required?
Why Elder Sexual Abuse?
Early research on elder physical and emotional abuse and neglect found that victims tend to be female, very old, and physically and mentally impaired (Block & Sinnott, 1979; Lau & Kosberg, 1978; O’Malley, 1979). The victims in the Wolf et al. (1984) study were typically female, about 75 years old, and physically and mentally impaired. They were most often abused by younger live-in males who depended financially upon the elder. Kosberg (1988) provides a list of twelve characteristics which make elders particularly vulnerable to abuse. These include being female, of advanced age, dependent, impaired, and having a history of intergenerational conflict and past abuse. Pillemer and Finkelhor (1988) found elders in poor health and living with others to be at highest risk of abuse. Contrary to earlier studies, they report males twice as likely as females to be abused. Elder abuse against men was disclosed to be less serious than that against women, and the women reported suffering more physical and psychological consequences of abuse than did the men.
Females are predisposed to victimization due to the greater physical, social, political, and financial power generally held by males. Old age and impairment decrease personal power and thereby increase the risk of abuse. It is not physical attributes, but rather vulnerability, which attracts a sexual offender (Groth, 1979). Elderly, impaired individuals make excellent sex abuse victims, precisely because of their inherent vulnerability. Speech and language deficits are common in the geriatric population, especially in the stroke patient. These people are at even greater risk of sexual abuse due to their inability to disclose victimization. Elders capable of verbal disclosure are not immune from abuse. Those experiencing short-term memory loss, dementia, and other mental impairments often lack credibility. Their disclosures of sexual abuse may be discounted. Any factor which decreases an individual’s credibility also increases vulnerability to abuse. Consequently, elderly, disabled females make excellent sexual abuse victims.
Victims and Perpetrators
Spouses As Sexual Offenders. Twenty-nine percent of the studied cases appear to be situations of marital rape and/or other forms of sexual abuse by mates (seven husbands and one boyfriend were the reported offenders). It is unknown if their victims experienced sexual abuse throughout the relationships, or if the abuse began when the women became ill, infirm, and dependent. Russell (1990) reports that 14% of all married women have experienced completed or attempted marital rape and that this is the most prevalent form of rape. Marital rape typically begins early in the life of the woman, as well as early in the development of the relationship (Russell, 1990; Douglass, 1987). This suggests the possibility that some or all of these women experienced sexual abuse throughout the marriage. Future research on elder sexual abuse should include interviewing victims. One of the areas of inquiry for marital victims should be the duration of abuse and conditions under which onset occurred.
For generations, women have been socialized to believe that it is their duty as wives to perform sexually for their husbands upon demand. Until the mid-1970s, this norm was sanctioned by laws which exempted men from any legal consequences for forcing themselves sexually upon their wives. Criminalization of marital rape in most states represents significant progress away from the view of women as the property of their husbands. As of March, 1991 forty-four states had criminalized marital rape (Schulman et al., 1990; X, 1991). Older women who have been married for many years lived for long periods of time (conceivably as long as thirty to forty years) without legal protection from sexual exploitation by their husbands. These women, believing that they have no alternative, may be more likely than younger women to endure spousal sexual abuse.
Among the forty-four states which have criminalized marital rape, thirteen exclude husbands from prosecution if their wives suffer from a temporary or permanent mental or physical disability (Schulman, 1990; X, 1991). These exclusions potentially have serious ramifications for elderly married women who develop impairments, leaving them legally vulnerable to sexual exploitation by their husbands.
The finding that almost a third of the sex offenders were spouses is consistent with other research results. Studies investigating other forms of elder abuse have revealed that a significant percentage of abusers are spouses. Wolf et al. (1984) report that 23% of the elder offenders they studied were spouses (husbands and wives). O’Malley et al, (1979) found 20% of elder abusers were husbands. Pillemer and Finkelhor (1988) found that 58% of the elder abusers in their survey were spouses, and 22% were husbands. They report that elder abuse perpetrated by spouses is incorrectly considered less serious and dangerous than that perpetrated by adult children, but the level of violence inflicted by spouse perpetrators and adult child perpetrators was about equal. Similarly, there has been a popular belief that marital rape is less traumatic than assault by non-intimates. Russell (1990) and Finkelhor and Yllo (1983) found marital rape to be more traumatic than rape by others. These findings suggest that sexual abuse of elderly women by their husbands is likely violent and traumatic and requires the serious attention of professionals serving abused elders.
Pillemer and Finkelhor (1988) conclude that elder abuse has much more in common with spouse abuse than child abuse and that spouse abuse has basically been ignored by those concerned with elder abuse. Wolf et al. (1984) also found that elder physical abuse is similar to spouse abuse, typically Involving two relatively independent people sharing a residence with the stronger abusing the weaker. These findings indicate that elder protective service workers require training about physical and sexual spouse abuse, including dynamics, indicators, interviewing methods, and intervention strategies. Pillemer and Finkelhor (1988) have also suggested similar education of elder service providers.
Sons As Sexual Offenders. The largest category (over 39%) of suspected offenders were sons believed to be sexually abusing their elderly mothers. This is a much larger percentage than has been reported in studies investigating other forms of elder abuse and neglect. Pillemer and Finkelhor (1988) found 16% of elder abusers are sons. Sons engaging in elder sexual abuse may be qualitatively different from those engaging in other forms of elder mistreatment. Further research in this area is required.
Significant questions arise in regard to this form of incest. Why would a grown son sexually assault his elderly mother? Do men who rape their mothers also rape other women? Was incest a formative experience in the childhoods of these men? Did they suffer early abuse by their mothers or other caretakers? Cartwright and Moore (1989) conclude that elder rape by younger men is motivated by anger and desire for power over the victim. Groth (1978) suggests an elder rape victim may symbolize an authority figure over whom the offender desires power. She may or may not be the actual woman against whom he wants to retaliate. Further research is needed, including qualitative study of the victims and their assailants, to understand the dynamic of son-mother sexual assault.
Interestingly, all of the victims in this study were female and almost all of the perpetrators male. This finding is consistent with the trend noted by Wolf and colleagues (1984) that “As the evidence mounts, elder abuse comes more and more to look like other social problems: violence against women carried out predominantly by men.’’ It is also consistent with statistics regarding child sexual abuse victims and perpetrators (Finkelhor, 1984). In all probability, women are predominately the victims and men the perpetrators of elder sexual abuse. However, the possibility of male victimization and female perpetration should not be disregarded.
Incidence and Prevalence
The extent of elder sexual abuse is unknown. The methodology of this study does not permit drawing inferences regarding prevalence. Pillemer and Finkelhor (1988) estimate the prevalence of elder abuse and neglect, exclusive of sexual abuse, to be 32 maltreated elders per 1000. Including sexual abuse in the definition of elder abuse and neglect may yield a higher prevalence rate. The lack of formal attention thus far attracted by elder sexual abuse might suggest that it is a rarely occurring phenomenon. Child sexual abuse, marital rape, and other forms of family violence were also considered rare prior to identification and research by the scientific community. Prevalence studies insist researching sexual abuse as a separate and distinct category of elder abuse and neglect. In addition, future studies addressing the broad range of behaviors constituting elder abuse and neglect should include investigation of sexual abuse.
Policy and Practice Implications
Sexual assault of dependent elders by family members and care-givers is alarming and distasteful, and, therefore, difficult to acknowledge. However acknowledgement is the first step towards ameliorating a problem. Because elder sexual abuse has been over looked by policy-makers and practitioners, legislative and intervention initiatives are required.
Pedrick-Cornell and Gelles (1982) discuss the dangers of legislation and intervention strategies hastily enacted upon discovery of previously overlooked social problems. Bolton and Bolton (1987), Clark-Daniels et al. (1989), Daniels et al. (1989), Fredriksen (1989), Faulkner (1982), and Kosberg (1988) have discussed the potential negative consequences of addressing elder abuse by adopting child abuse legislation and intervention strategies, particularly mandatory reporting. Arguments against mandatory reporting include the belief that the policy treats elders like children and is an intrusion into privacy. The possibility of overwhelming the capacity of the system for investigation and service-delivery is also cited as a reason against requiring professionals to report suspected elder abuse. Daniels et al. (1989) urge that adequate resources be allocated for investigation and intervention following mandatory reporting of elder abuse cases. They argue that abolishing mandatory reporting of suspected cases of elder abuse and neglect will result in burying the problem.
Forty-two states and three jurisdictions have adapted legislation requiring professionals to report cases of suspected elder abuse and neglect (Tatara, 1990). Just as the words “sexual abuse” have been excluded from most definitions of elder maltreatment, they have similarly been largely omitted from mandated reporting and other legislation addressing elder abuse. Mandated reporting is an appropriate method for identifying abused elders who are unable to protect themselves and/or unable to independently seek help due to disabilities. Sexual abuse should be specifically included in definitions of elder abuse and neglect cited in mandatory reporting and other elder abuse legislation.
Elder protective service staff should be trained to identify the signs and symptoms of sexual abuse and to recognize the types of activities which constitute sexual abuse. They further require training and supervised practice in methods of interviewing and treating victims. Successful intervention into elder sexual abuse requires acknowledgment of the problem, professional training in case identification and service-delivery, and legislation to promote the reporting, investigation, and treatment of cases.