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Speaking the unspeakable

An interview about elder sexual assault with Holly Ramsey-Klawsnik

From nexus Volume 4, Issue 1, April 1998.

Holly Ramsey-Klawsnik PhD, of Klawsnik & Klawsnik Associates of Canton Massachusetts, is a sociologist, social worker, and marriage and family therapist. She has written extensively on elder sexual assault and developed a typology on offenders.

nexus: Could you start by describing what constitutes elder sexual abuse?

Holly Ramsey- Klawsnik: I define it as situations in which a person over the age of 60 is forced, tricked, coerced, or manipulated into unwanted sexual contact. It also includes sexual contact with elders who are unable to grant informed consent or sexual contact between service providers and their elderly clients.

nexus: The issues of mental capacity and consent figure prominently in sexual abuse cases, don't they? Is there agreement as to what type or level of mental capacity is needed for someone to exercise consent to sexual contact?

HRK: Determining when someone is able to grant consent to sexual activity is difficult and depends on several factors. The first is the degree of disability. I've had cases in which a wife was comatose and the husband was having sex with her in a hospital bed. Some people want to believe that this is not abuse because she's his wife. But she's clearly not able to grant informed consent and so, in my opinion, that would be abusive. If there's mild dementia, I'd be less likely to consider it abusive as long as there is no force or coercion. In borderline cases, you have to also look at the overall quality of the relationship. If there appears to be a loving and trusting relationship, I certainly wouldn't consider that abusive.

nexus: But it's improper for service providers, helpers, and attendants to have sexual contact with clients even if the client is competent and consenting?

HRK: Service providers have a responsibility to meet their clients' mental and physical needs and so it is never acceptable for them to use clients to meet their own needs, regardless of whether those needs are social, financial, or sexual. I find that people have an easy time with that as long as the elder didn't want the sexual contact. Where confusion arises is when the elder didn't refuse or may have initiated the contact. But we need to have these prohibitions because it is so easy for persons in positions of authority to take advantage of elderly clients. Most licensed professionals would lose their licenses for it.

nexus: Many older women are unwilling or perhaps unable to tell others that they've been abused. What are the non-verbal indicators to watch for?

HRK: Sometimes the signs are very blatant. In a number of cases I've had, the abuse was discovered when a service provider or family member walked into a room and actually witnessed someone sexually assaulting an older person. Others have walked into rooms and seen things that were very suspicious like a caregiver jumping back from the bed and looking upset and worried. Sometimes it is the older person who acts stressed, fearful, or combative when a particular caregiver approaches to bathe or dress them, take them to the bathroom, or care for an injury or wound. That would certainly lead you to suspect that something is wrong and warrants further investigation. It might be sexual abuse, physical abuse, or something else. Other nonverbal indicators include genital irritation, injury, redness, or infection, particularly if it is recurrent and there are no other possible explanations. Sometimes you find evidence of what appears to be physical abuse, like human bite-marks, cigarette burns, or rope burns on wrists and ankles which indicate that the person has been tied up. Thumb or finger imprints on genitals, thighs, buttocks, or breasts could also indicate either physical or sexual abuse.

We've had a number of cases in which a worker has gone into a home and discovered an elderly woman and her middle aged son sharing a double bed. You need to find out if they're sharing the bed because there's no place else to sleep, because of psychological enmeshment, or because there's an incestuous relationship. You have to explore all the possibilities.

I've also had cases that were originally identified as neglect, financial exploitation, or physical abuse but where good investigation yielded proof or disclosure of sexual abuse.

nexus: It would seem that seniors in nursing homes would be at extremely high risk. Do we know how the incidence of sexual assault in nursing homes compares with assault in the community?

HRK: There's not a lot of research on elder sexual abuse and we still don't know which is more common. What we do know is that we have bona fide, substantiated cases in both settings.

nexus: You've served as an expert witness in a number of legal proceedings. Are many cases prosecuted?

HRK: Some are, but it's still rather unusual. Often, if the offender is a family member, the victim is unwilling to cooperate in a prosecution so the case needs to be proven through the testimony of third parties and other evidence. I've helped a few district attorneys with cases but I'm more likely to testify in civil cases because most of what I'd have to say would be considered "hearsay" in a criminal case. For example, if I'd interviewed a victim and he or she had told me that they'd been sexually assaulted, I'm not going to be called as a witness. In a civil case in which an abusive son is the victim's guardian and someone is trying to revoke the guardianship, I might be called as a witness because the testimony I can provide is much more likely to be allowed.

nexus: Are the motives or causal factors associated with sexual assault different from those in other types of elder abuse?

HRK: Let me address that in relation to the five types of offenders I see with all types of family violence. They are 1) caregivers who are normal and capable of providing good care but who are chronically stressed and lash out through abuse and neglect; 2) people who are well intentioned but who have significant impairments themselves, like physical or mental illness or low IQs, which prevent them from providing adequate care; 3) narcissistic persons with "user mentalities" who get themselves into caregiving arrangements because of what they expect to get out of them; 4) persons with abusive personalities who are unhappy, frustrated, easily angered, and who feel entitled to lash out at others with less power, and 5) sadistic persons who enjoy inflicting harm and terrifying others.

It's unusual to find sexual abuse by persons who fall into the first and second categories. These persons may be neglectful or physically abusive but they don't typically abuse others sexually. Those in the third category, the "users," may use elders for their own sexual gratification although they are more likely to neglect or financially exploit seniors. It is the "fours" and "fives" who are most likely to be sexually abusive. By the way, these offenders are also the most likely to abuse pets, a form of abuse which you discussed in the last issue of nexus.

nexus: The traumatic effects of sexual abuse must be incredibly intense for elderly victims. Do you find that recovery is more difficult for them than it is for younger survivors?

HRK: I've worked with victims of all ages including children who have been sexually abused, young women who have been raped by strangers, and women who have been physically and sexually assaulted by partners. I don't find that age itself makes as much of a difference as victims' pre-assault levels of functioning. People who were functioning well have more resiliency than those who had serious impairments, problems, and limitations. Of course, elderly women are more likely to have these problems; that is what made them vulnerable to sexual assault in the first place.

Other factors that affect recovery are the extent of the abuse, victims' relationships to their abusers, and their support networks. Obviously, the more serious the abuse, the more difficult the recovery. People who are close to their offenders and depend on them will feel more betrayal and have a harder time psychologically. Generally, people with good social support recover quicker. If your victim is 76 years old and has lost her husband and close friends, she is going to have less support than a forty year old woman with a good marriage and close friends.

nexus: These cases can be extremely disturbing to service providers, too. What can you tell them?

HRK: Try not to panic. Remember what you already know about investigation, case identification, victim interviewing, and victim protection. You need to respect victims' right to self determination, offer them a continuum of services and interventions, and encourage them to decide for themselves what they want. It's a mistake, especially when the offender is a family member, to assume that a victim will automatically want a restraining order or to have the abuser prosecuted. Other strategies we use with battered women of any age can help elderly women who are being sexually assaulted: empowerment, education, and support in assessing their options. It's also important not to get judgmental and punitive when she doesn't do what we think she should. Sadly, that's a common response.

Service providers also need to know the limits of their knowledge. While much of what we already know about elder abuse is relevant to sex abuse cases, specialized knowledge and interventions are also needed. The problem is that when you need a specialized rape crisis counselor to deal with your 82 year old victim, they're just not there. They don't exist. That's why we need to do some cross training. Let's get the rape crisis center people, the battered women's center people, and the elder abuse people all together. If we give the rape crisis treatment people some training in elder abuse, they'll be there when we need them. And the people who know elder abuse need to be talking to the people who know domestic violence. We need all three pieces. The shared training is so important. It's something that all communities need to do.

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