Interviewing Elders for Suspected Sexual Abuse: Guidelines and Techniques
Holly Ramsey-Klawsnik, PhD
Abstract. There is little professional literature, research, or training regarding elder sexual abuse, despite the fact that cases are being identified in many locales. This article presents guidelines and techniques for Identifying and Interviewing possible elder victims of sexual abuse. Signs and symptoms of sexual abuse are provided and the variety of sexually abusive behaviors is delineated. Guidelines are presented regarding who should conduct interviews, the location and setting, and rapport-building. The range and nature of focused questioning are examined. Examples are provided of non-leading, open-ended questions designed to screen for sexual abuse. Specific techniques are illustrated for working with non-verbal elders. Intervention strategies are suggested for cases in which sexual abuse has been substantiated.
Physical abuse, emotional abuse, neglect, and financial exploitation of the elderly have been identified as problems since the late 1970s. Recently, professionals serving elders have also identified cases of sexual abuse, although the prevalence of this abuse has not been established. While cases of elder sexual victimization are being documented, little research, literature, or training on elder sexual abuse exists. Recently, however, the author has published a study of 28 cases identified by Massachusetts elder protective service workers (Ramsey-Klawsnik, 1991). The second-wave of data collection in Massachusetts yielded reports of an additional 24 cases of elder sexual abuse by caregivers.
Thus far, no formal studies of elder sexual abuse in institutional settings have been reported, although anecdotal case data is emerging. In a preliminary study underway in England, 30 cases of elder sexual abuse had been identified by June 1992. Five of these occurred in institutions, the remainders were in domestic settings (Holt, 1992).
Elder sexual abuse victims deserve our attention and protection. It is important that professionals serving elders learn about this problem, screen for sexual abuse when indicated, and assist victims in gaining protection from further abuse. One consequence of the recent identification of this problem is that most of those responsible for investigating cases of elder abuse have not received training specific to sexual abuse. Lack of training frequently results in failure to recognize, substantiate, and intervene in cases. Workers who have dealt with cases of elder sexual abuse report frustration with the lack of available literature and training. This article is offered to assist professionals in knowing when to suspect elder sexual abuse and to serve as a guide to interviewing and assisting sexually abused elders.
The guidelines are applicable to elder abuse investigations in both domestic and institutional settings. Many of the suggestions can also be applied to investigations of suspected sexual abuse among developmentally, cognitively, and physically impaired adults of varied ages.
SUSPICIONS OF POSSIBLE SEXUAL ABUSE
Sexual abuse of an elder should be considered as a possibility in two situations. The first is when an elder reports sexual victimization. The second is when symptoms commonly associated with sexual victimization are present. These symptoms are listed below. Many of these signs are also indicative of problems other than abuse. The presence of one or more of these does not prove the existence of sexual abuse, but rather suggests the possibility. Professionals, paraprofessionals, and other individuals should report cases of suspected elder sexual abuse to the agency legally mandated to investigate cases of elder abuse.
Symptoms of Possible Elder Sexual Abuse
- Genital or urinary irritation, injury, infection, or scarring
- Presence of sexually transmitted disease
- Intense fear reaction to an individual or to people in general
- Nightmares, night terrors, sleep disturbance
- Phobic behavior
- Mistrust of others
- Extreme upset when changed, bathed, or examined
- Regressive behaviors
- Aggressive behaviors
- Disturbed peer interactions
- Depression or blunted affect
- Poor self-esteem
- Self-destructive activity or suicidal ideation
- Coded disclosure of sexual abuse
A “coded” disclosure is a hint, rather than a direct statement, of sexual victimization. Victims of sexual violence often wish to disclose their experience to seek help, but fear may prevent them from directly disclosing. They may instead “test the waters” by hinting at their victimization to see how others react. These hints, particularly if accompanied by any of the other indicators listed above, should cause suspicion of elder sexual abuse.
A case presented to the author for clinical consultation illustrates the “coded disclosure.” For example. Mrs. B., a 69-year-old partially paralyzed nursing home resident, consistently expressed dislike toward one of the aides, Martha. When this aide was assigned to her unit, she often asked if the other aide could be the one to bathe her. When the staff social worker asked the reasons for this, Mrs. B. stated that she did not like the way Martha washed her, but did not elaborate. Several months later another resident, Mrs. S., tearfully confided to her daughter that Martha regularly inserted her fingers and other objects into Mrs. S.’s vagina and rectum during bathing. The daughter, in turn, complained to the administration, which prompted an investigation. In retrospect, Mrs. B.’s statements were recognized as coded disclosures of sexual abuse. Mrs. B. was interviewed and revealed that Martha had sexually assaulted her during bathing in the same manner as described by Mrs. S.
Mrs. B.’s coded disclosure (repeated statements that she did not like Martha and did not wish to be bathed by this woman) were accompanied by the additional indicators of mistrust and fear (toward Martha), and upset when bathed. Unfortunately, coded disclosures are easy to overlook or misinterpret as suggestive of problems other than sexual abuse. Individuals serving elders need to be aware of coded disclosure. When recognized, these statements should be carefully explored by a trained interviewer in an attempt to determine if sexual or other types of maltreatment have occurred.
WHAT TO LOOK FOR WHEN INTERVIEWING
Sexual abuse occurs when an individual is forced, tricked, threatened, or otherwise coerced into sexual contact of any type against his or her will. A broad range of activities constitutes sexually abusive behavior. On one end of the spectrum, the abuse is covert. No sexual contact occurs, but the perpetrator engages in offensive verbal and/or nonverbal behavior of a sexual nature.
A second case referred to the author for clinical consultation illustrates the nature of covert sexual abuse. Seventy-two-year-old Mrs. J. resided with her daughter and son-in-law. While her daughter war absent from the home, her son-in-law frequently discussed his sexual relationships in explicit detail in the presence of Mrs. J. This included discussion of the sexual activities in which he engaged with his wife, as well as specific details of his sexual exploits with other women. Mrs. J. found this behavior offensive and threatening. When she asked him to stop, he laughed and continued his discussions. Mrs. J. was afraid to complain to her daughter, and thus endured the behavior for many months. She feared she would be asked to leave the home if she was perceived as “causing trouble.” Mrs. J. did discuss her son-in-law’s behavior with her daughter when he began masturbating in her presence while discussing his sexual activities. In this case, disclosure was made when the abuse shifted from covert to overt.
Overt sexual abuse includes a pre-touching phase of exhibitionism and voyeurism and/or displaying pornography to an unwilling viewer. It further consists of physically intrusive acts such as sexualized kissing, molestation, oral/genital contact, digital penetration (insertion of fingers) of vagina or rectum, and vaginal and anal rape with penis or objects. Overt abuse also includes using the victim to produce pornography or allowing others sexual access to the victim.
While the vast majority of identified sexual offenders have been male, females have also been identified as perpetrators (Groth, 1979: Faller, 1987; Finkelhor & Russell, 1984; Finkelhor & Williams, 1988; Mathews et al., 1989; Ramsey-Klawsnik, 1990). It is important that professionals serving elders recognize this and consider allegations of suspected female offences as seriously as those allegations involving male offenders. Similarly, professionals need to be concerned about male as well as female victims. Male sexual abuse victims have been underserved in the past (Finkelhor, 1984; Lew, 1990; Pescosolido, 1989; Porter, 1986).
Investigators should be aware that in many documented cases of sexual abuse multiple, as opposed to single, perpetrators have been identified (Groth, 1979; Faller, l9S7 Finkelhor & Williams, 1988). Reports of sexual victimization should not be seen as lacking credibility because they contain allegations of multiple perpetrators.
It is not unusual for individuals sexually assaulted by family members to have ambivalent feelings toward their offenders. The presence of mixed feelings is quite common. The fact that an elder who alleges sexual victimization displays love, loyalty, and attachment to the offender should not be considered evidence that the allegation is fictitious. It is not uncommon for victims to recant their allegations following disclosure. This can occur for a variety of reasons, including love and loyalty toward the offender.
GUIDELINES FOR INTERVIEWING SUSPECTED VICTIMS
The following guidelines are offered to elder protective service workers, medical personnel, law enforcement officers, and others who may be responsible for interviewing elders for possible sexual abuse.
Who Should Interview?
An interview to screen for sexual abuse should ideally be conducted by a trained and experienced individual. Interviewing victims is easier and more effective when the interviewer is knowledgeable regarding elder maltreatment and sexual victimization. It is also far more comfortable for the victim to have a trained and experienced interviewer. In some cases, the sex of the interviewer is significant. Some victims feel more at ease talking to a member of their own sex about this problem. Others are able to discuss the abuse with interviewers of the opposite sex, provided they are skilled and compassionate. An interviewer of the opposite sex may perceive victim discomfort and embarrassment, which might be alleviated by providing a same-sex interviewer. In this event, the elder should be offered the opportunity to discuss the abuse with a same-sex interviewer.
Location of Interviews
Interview the suspected victim privately, unless that person states a desire to have a “trusted other” present. Outnumbering a sexual abuse victim with multiple interviewers is intimidating to the victim and likely to make disclosure difficult or even impossible.
The ideal site for a sexual abuse interview is an office in which privacy and lack of distractions are assured. It is particularly important to assure privacy from the suspected offender. Many abused elders suffer from physical impairments that make travel to an office impractical. In these situations, it may be necessary to conduct the interview in the elder’s home or institutional setting. If the sexual assault occurred at that location, the victim may not feel safe there. When interviewing at the site of the suspected abuse, take steps to insure the victim’s sense of safety, or disclosure will not occur.
For example, Mrs. N. is bedridden and resides with her alcoholic husband. She suffered recurrent, unexplained vaginal bleeding and frequent bruising about the wrists and ankles. Home health aides noticed that Mrs. N. displayed fear of her husband, particularly when he was drinking. When questioned by the aides about her vaginal bleeding, Mrs. N. became highly anxious and mumbled inaudibly. The home health aide agency reported these observations and concerns of possible abuse to adult protective services. It was not appropriate for the protective service investigator to interview Mrs. N. in her husband’s presence. Her bedridden status made interviewing in the protective service office impractical. Protective service staff decided to visit the home on Thursday afternoon when Mr. N. did the weekly grocery shopping. A female worker conducted a sexual abuse screening interview, while her male coworker waited in another room to intervene with Mr. N. in the event he returned home early. During the interview, Mrs. N. confided that several times weekly her husband tied her wrists and ankles to her hospital bed and vaginally raped her.
Conducting the Interview
Rapport-Building. It is necessary to introduce oneself and develop a rapport with the client prior to asking questions about possible victimization. It may be helpful to arrange for a concerned relative or a trusted service provider to introduce the interviewer to the elder. During rapport-building the investigator and elder become acquainted, and the interviewer communicates interest in and respect for the elder. Respect can be conveyed in a variety of ways. Calling the person by her last name (Mrs. Jones) until she invites you to call her by her first name (Mary) is one example.
Allow the elder to have as much control over the interview as possible. For example, when making a home visit to an ambulatory elder, ask where she would like you to sit. Control helps a victim to feel empowered and more able to discuss the abuse. Refrain from taking notes during early portions of the interview. It is intimidating to victims and interferes with building and maintaining rapport. If sexual abuse is disclosed, the interviewer can then explain the need for precise notes. The client can be asked to clarify important points and notes can be taken. If the victim is upset by note-writing, do not take notes during the interview, but rather immediately following the interview while memory is fresh.
Screening for Sexual Abuse. In screening for possible sexual abuse, questioning must be accomplished in a way that maintains rapport and preserves the dignity of the elder. Proceed slowly and carefully, at the elder’s pace. Use speech and language that are easily comprehended and comfortable for the elder. Ask only one question at a time. Tell the elder that he is free to refuse to answer any or all questions. Phrase questions in a non-leading, non-suggestive manner that will not compromise the credibility of the interview should sexual abuse be disclosed. It is appropriate and necessary to ask direct questions, but these are different from suggestive questions. A suggestive question is one which implies its own answer, for example, “Someone has sexually assaulted you, isn’t that true?” Inappropriate questioning may cause disclosures to be dismissed and result in lack of protection for the victim.
Initially, ask open-ended questions designed to screen for sexual abuse. Should open-ended questions fail to lead to disclosure, ask more focused questions. The precise nature of the questions will be related to the information that led to the suspicions. If a previous disclosure has been made, begin with that information.
In a previously cited case example, Mrs. S. disclosed to her daughter that Martha, a nurse’s aide, had raped her. Following a 20-minute period of rapport-building, the protective service interviewer explained her job as talking to older people to see if they are safe. She then explored suspected sexual abuse by stating, “I understand you shared some very important information with your daughter. She told the nursing home administrator, and that’s why I came to visit with you. Can you tell me about it?” When this general inquiry failed to lead to a disclosure, the interviewer probed further, “I have spoken with your daughter, and she told me you have some important concerns about Martha. I’d like to know about those concerns so that something can be done about them.”
When screening for sexual abuse in the absence of a previous disclosure, the interviewer might ask about presenting symptoms suggestive of sexual abuse. For example, “Mrs. N., the home health aides who come to help you have been concerned about the marks on your wrists and ankles and about the unexplained bleeding. Can you tell me what’s been causing these problems?”
Another approach to focused sexual abuse interviewing is to discuss one’s role, particularly that of protective service investigator. For example, “I work for the Department of Elder Affairs. My job is to talk to older people to find out if they are okay. I talk to lots of older people who have been hurt, sometimes even by people they love. Some seniors are hurt by neglect, when someone they depend upon fails to give them the things they need, like food or medicine. Sometimes seniors are hurt by physical abuse when they are hit, kicked, or hurt in some other physical way. Some are hurt when others take their money or property without permission. Some seniors are hurt by sexual abuse, when another person forces them into a sexual act against their wishes. When I find out that any of these things are happening, I work very hard to make the hurting stop. Has anything like this ever happened to you?”
If the elder denies sexual assault, but clinical evidence suggests the contrary, embarrassment or fear may be prohibiting disclosure. Provide information about elder abuse, particularly elder sexual abuse. Explain that sometimes people cannot talk about things like this when they are first asked because it is very upsetting. Let her know that you can help if she is being hurt. Tell her that she does not have to tolerate arty kind of assault. Explain that you have concerns about her safety and plan to return again in several days to provide another opportunity to talk.
If an elder discloses that he or she has been sexually victimized, remain calm and ask the victim to tell you more about ft. Assure your client that she is an important and valuable person who deserves to be safe and that you will work to ensure safety from further sexual assault.
Disclosures such as those presented the case examples are likely to elicit strong emotional reactions within interviewers. Refrain from sharing these emotional reactions with victims. Interviewers may need to process these reactions with a supervisor, colleague, or other appropriate person. Do not express judgment, anger, or other emotion toward the offender. Although the interviewer may feel disgust and rage toward the offender, the client may love the offender and not wish that person any harm or retribution. Explore the victim’s feelings about the abuse and the offender. When appropriate, validate the victim’s feelings.
Ask clarifying questions following an elder’s disclosure of sexual abuse. It is important to ask when and where the abuse happened and the frequency of occurrence. It is also important to determine the specific abuse activities. Often, multiple forms of maltreatment occur. Ask sexually abused elders if the perpetrator engaged in any other offensive behavior. This often leads to additional disclosures of accompanying physical abuse, neglect, or emotional abuse. Ask if anyone else, in addition to the identified perpetrator, has committed similar acts. If the victim indicates an unwillingness to continue the discussion, respect those limits. One can return to finish an incomplete interview at another time, should the victim be unable to provide all the necessary data at one sitting.
Interviewing Elders with Speech and Language Limitations. Abused elders unable to verbally communicate due to speech and language impairments can often convey their experience nonverbally. A variety of nonverbal means can be employed in the interview. Prior to the meeting with the suspected victim, the interviewer should inquire about the elder’s usual method of communication and conduct the interview using that method. For example, the interviewer may learn that the elder is an aphasic stroke victim who communicates effectively through nodding.
Communication with people who are able to use their hands or fingers for pointing can be greatly enhanced through the use of large cards reading “YES,”“NO,” and “PASS” Questions can be posed to allow yes/no answers. “Pass” provides a way for subjects to avoid answering questions they are unprepared to handle. Elders unable to read can use cards indicating a “+“ for a positive response, and a “—“ for a negative response. Pass can be indicated by a blank card.
Anatomical drawings (Forensic Mental Health Associates, 1984) can be used to elicit details of the victimization when a positive response indicates the elder has been sexually abused. This tool consists of a set of 32 tine drawings of front and back views of males and females at four stages of development (pre-school, grammar school, teenage, and adult). Although the set does not contain elders, seniors can point to or mark the adult drawings to demonstrate what parts of their bodies have been violated. The drawings also enable nonverbal victims to indicate the parts of the body the offender used in the assault.
Anatomically detailed dolls have been used extensively to assist child victims in demonstrating their sexual abuse (Boat & Everson, 1986; Faller, 1990; MacFarlane & Waterman. 1986). Many of the doll manufacturers’ produce male and female elder dolls to accompany the adult, child, and infant doll sets. The author has found anatomical dolls to be an effective means of communicating with adult sexual abuse victims who are unable to speak or who have limited verbal ability. Victims can point to parts of the dolt to indicate how their bodies were assaulted. Victims can also point to areas of a doll representing the offender to indicate what body parts were used to abuse. In addition, dolls representing victim and offender can be manipulated to demonstrate the abuse activities.
Nonverbal means of communication such as drawings and dolls can also be utilized with elders who can speak but are too uncomfortable to use words to describe their assault(s).
Following case identification, a number of steps must be taken to ensure the safety and well-being of the elder sexual abuse victim. Tell the sexually abused elder that she is not alone in her victimization. Explain that she not at fault. Provide the client an opportunity to ask questions. Many victims, even those who are mentally competent and capable of wise decision-making, enter a state of crisis following sexual assault. It is important that intervening professionals explain options and give information about victims’ rights and steps necessary for protection. All sexual abuse victims, including elders, should be encouraged and supported in making as many decisions as possible themselves.
The following tasks should be accomplished:
- Provide emotional support to the victim. Sexual assault is humiliating, emotionally traumatic, and often physically painful and injurious. Discussing the abuse can cause painful emotions and memories to surface. Victims may require crisis intervention, rape counseling, or other forms of mental health intervention. If the interviewer is not equipped to deliver counseling services, a referral should be made to an appropriate agency or individual. It is very important that sex abuse victims not be left alone to deal with their emotional pain and trauma.
- File all appropriate reports with elder or adult protective services as legally required in your state. In some states, protective service workers and other professionals must also notify law enforcement officials.
- If necessary, seek legal intervention such as a restraining order to assure the protection of the victim.
- Arrange for medical services for the victim, including appropriate procedures after a sexual assault. Ask the elder if she would like a trusted person to accompany her through the examination.
- The victim should be protected from all unsupervised contact with the offender. If the victim is left alone with the offender, repeated abuse is likely. Even if the offender admits the problem and promises to refrain from further assault, it is critical to prohibit unsupervised access to the victim. Sexually abusive individuals should not have any power over the victim, should not be allowed to make decisions for the elder, and should not be responsible for any caregiving. The elder may love the perpetrator and wish to have visitation, particularly if he is a family member. If so, visits should be arranged. However, visits must be carefully supervised to prevent repeated assault. Plans for protecting the elder from the abusive caregiver should be made in a manner that least disturbs the victim. For example, it is more appropriate to have the offender leave the home, rather than the victim.
A very difficult and frustrating situation occurs when an elder discloses sexual victimization but refuses protective services to prevent further abuse. If the elder is competent to make independent decisions, these decisions must be respected. In situations in which the elder is not competent, normal protective services procedure should be implemented to ensure the individual’s safety.
I. Identifying information regarding this and cited subsequent case examples has been deleted and/or altered to protect the confidentiality of the victims.
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