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CHAPTER SEVEN: SEXUAL ABUSE
Introduction
7.1 This chapter defines sexual abuse, considers the range of potential signs or indicators that professionals should be aware of, and explores the available options for intervention, protection, and support.
Definition of sexual abuse
7.2 The ' No Secrets' guidance (DoH, 2000a) defines the sexual abuse of adults as:
"...rape and sexual assault and sexual acts to which the vulnerable adult has not consented or could not consent or was pressured into consenting…" (DoH, 2000a, p. 2.7).
7.3 The World Health Organisation defines sexual violence as:
"Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women's sexuality, using coercion, threats of harm, or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work." ( WHO, 2003: 6).
7.4 Various other definitions exist including:
Any act of a sexual nature performed in a criminal manner, as with a child or a non-consenting adult, including rape, incest, sodomy, oral copulation, and penetration of genital or anal opening with a foreign object; also included are lewd and lascivious acts with a child or any sexual act which could be expected to irritate, trouble, or offend a child performed by one motivated by an abnormal sexual interest in children, as well as acts related to sexual exploitation of children, including activities related to pornography or prostitution involving minors and coercion of minors to perform obscene acts 19.
Sexual abuse is the involvement of a child, with or without the child's consent, with an adult (or age-appropriate adolescent) within or without the family in sexual behaviour designed for the gratification of the adult or older adolescent who has charge of the child, whether heterosexual or homosexual ( www.polity.org.za/html/govdocs/white_papers/social97gloss.html).
Any sexual activity involving an employee, agent, contractor, or a patient; for example: kissing, hugging, stroking, or fondling with sexual intent; oral sex or sexual intercourse, request or suggestion or encouragement by staff for performance of sex with the employee him or herself, or with another patient ( www.uth.tmc.edu/uth_orgs/hcpc/procedures/volume2/chapter1/patient_focused_support-12.htm).
"engage[ment] in sexual contact or sexualized behaviour with a congregant, client, employee, student, staff member, co-worker, or volunteer" by a person with a ministerial role of leadership (lay or clergy, pastor, educator, counsellor, youth leader, or other position of leadership) (Book of Resolutions, 2004, p. 150-51; www.gcsrw.org/ethics/definitions.html).
Please note: a number of definitions within this section have been quoted because of the variation in their focus; for example, the range of abusers can include a stranger within the family, other patients, contractors, employees, faith leaders, counsellors, youth leaders, or other positions of leadership. Finally, various definitions also point to the potential for victims of sexual abuse to themselves become sexual predators.
7.5 Legal definitions are extensive (it is not possible within this review to explore all the territory). However, the Sexual Offences Act 2003 (c.42) Schedule 3 outlines sexual offences for the purpose of part 2, and covers the law as applied to Scotland (see www.statutelaw.gov.uk) 20.
Characteristics of sexual abuse
7.6 Sexual abuse of a vulnerable adult, particularly when there are issues relating to consent and capacity, is considered as a crime (for example, rape or sexual assault) with specific legislation in place to protect individuals. Sexual abuse may involve the deliberate targeting of "at risk" individuals in order to sexually exploit them. It is possible to differentiate between abuse by family friends, intimates, and strangers (Bennett, Kingston, and Penhale, 1997).
7.7 Sexual abuse may occur where a vulnerable adult resides in a particular setting ( e.g. residential or nursing home care) or attends day care provision. Sexual abuse or assault may be perpetrated by a member of care staff or another service user from that setting (Brown and Stein, 2000). Evidence suggests that the risk of service user to service user abuse is very high (McKeough and Knell-Taylor, 2002). However, McKeough and Knell-Taylor argue that insufficient emphasis has been placed on the potential of one service user to abuse another. McKeough (1999) expressed concerns about:
"…the ability of private and voluntary sector providers to cope with the needs and support available for vulnerable adults who are themselves perpetrators of abuse. Many of these service users are placed in residential services that have little or no ability to provide appropriate levels of support to them or protection to other service users or staff. Many of these services are the subject of frequent adult protection alerts." (McKeough, 1999: 12).
7.8 Further concern is noted in the National Patient Safety Report (2006). In this report, 558 reports of patient abuse by a third party are recorded. This included 122 sexual incidents including: allegations of rape (19), consensual sex (20), exposure (13), sexual advances (18), touching (26), and other incidents (26). Perhaps the most disturbing finding is that the report suggests that:
"In the majority of incidents (114) the degree of harm was categorised [by the official investigations into the incidents] as no harm." (National Patient Safety Agency, 2006: 38).
This categorisation suggests health and welfare agencies may not be classifying incidents of actual or potential abuse as significant and harmful.
7.9 Exploitation in therapy is an enduring challenge for health and social care agencies (Hetherington, 2000; McLeod, 1999). Abuse in therapy is predominantly a gendered phenomenon with studies suggesting that " the vast majority of professionals who are reported to be sexually active with their clients are male therapists working with female clients" (Pope et al., 1986; Pope and Vetter, 1991; Rutter, 2000).
7.10 Sexual and physical victimisation of homeless women and men has recently emerged within the literature. Wenzel, Koegel, and Gelberg (2000) found that 23% of homeless women reported being physically or sexually victimised within 30 days: 18% had been physically victimised, 9% had been sexually victimised, and 2% sexually but not physically victimised. Furthermore, 20% of men reported being physically abused and 1% sexually abused.
7.11 Women with a major psychiatric diagnosis are more likely to be sexually assaulted. Eckert, Sugar, and Fine (2002) reported that 26% of a sample of 819 women with a sexual abuse history had a major psychiatric diagnosis. They conclude:
"Sexual assaults in women with a major psychiatric diagnosis are common. These assaults are more violent and result in body trauma more frequently than do sexual assaults in women without a psychiatric diagnosis. Prevention and treatment strategies should target this vulnerable population." (Eckert, Sugar, and Fine, 2002: 2).
7.12 Specific studies have also found that women suffering from schizophrenia and bipolar disorder are also at more risk of sexual abuse. In a sample of 64 women, 36% of those suffering schizophrenia and 28% of those with bipolar disorder had been victims of sexual abuse involving bodily contact. Over their lifetime, the prevalence of rape was 23% in the two clinical groups (bi-polar and schizophrenia) (Darves-Bornoz et al., 1995). Sexual coercion was reported by 30% of women admitted to psychiatric care in Southern India (Chandra et al., 2003).
7.13 Relevant agencies and authorities may be involved in any of the issues mentioned above, perhaps particularly those occurring in care settings. There will normally be an assessment and decision about alleged abuse (or assault) and how best to protect the individual involved. Much of the existing literature, as well as the current legal framework, are predisposed to view sexual abuse as a single discreet occurrence rather than an on-going process (Brown and Stein, 2000). However, care should be taken to interpret the situation and the complex dynamics involved with sexual abuse and consider the wider context in which ongoing sexual abuse may occur.
Support and protection for adults "at risk" of sexual abuse
Primary intervention
7.14 Primary intervention involves the development of a range of public health sexual abuse prevention strategies, education programmes for vulnerable adults, health and welfare professionals, legal professionals, police, clergy, and public awareness programmes. In the United States, Muccigrosso (1991) outlines a range of sexual abuse prevention strategies and programmes for persons with developmental disabilities. Programmes are differentiated by length i.e. short term, or long-term. Both strategies are aimed at a range of individuals: families, parents, people with disabilities, professional carers and the public. Muccigrosso argues that the main success of these programmes is allowing vulnerable adults the means to communicate that they have been abused. Once this disclosure has happened:
" …it becomes possible to work toward altering some basic practices, which may thusly reverse the vulnerability." (Muccigrosso, 1991: 263.).
7.15 Identifying vulnerable populations and individuals through screening and risk assessment instruments is essential in health and welfare services. Screening should be followed by establishing a suitable degree of ongoing monitoring and continued review of individuals, putting in place clear guidelines and processes to distinguish and recognise sexual abuse. Screening for potential abuse has also been considered by genetic counsellors who are offering advice and counselling to parents and people with learning disabilities (Levy and Packman, 2004):
"By taking developmental factors into account, genetic counsellors can perform an appropriate needs assessment for patients with mental retardation and, when a need is identified, provide resources and referrals to community agencies or other health care professionals capable of providing comprehensive sexuality education and sexual abuse prevention training." (Levy & Packman, 2004: 204).
7.16 The provision of sexual assault centres and rape crisis advice and guidance for individuals within communities is of assistance, but may not be accessed by vulnerable adults. Few sexual assault centres are currently equipped to deal with individuals with specific and complex needs, although the St. Mary's Sexual Assault Centre in Manchester 21 has begun to develop a programme for older people (specifically older women), and is developing a model of good practice, which will eventually extend to cover the entire range of vulnerable adults.
7.17 Within care settings, sexual abuse has raised issues surrounding the sexual needs of vulnerable individuals with intellectual disabilities and other cognitive impairments, and the management of these needs in relation to others who may be vulnerable to potential assault and unable to consent to sexual acts or relationships. Each community care setting should have specific policies and procedures to refer to in relation to abuse in general, and sexual abuse specifically. Adult protection procedures should dovetail with the policies of the local authority; such processes should be available in all forms of community care ( SENSE, 1999 22).
7.18 Contact between vulnerable adults and social care or primary health care professionals may occur on a regular basis (see 5.12), and therefore risk assessments should incorporate elements concerning personal relationships, sexual safety, and degrees of risk involved for the individual.
Secondary intervention
7.19 Secondary intervention involves responding rapidly to allegations of potential abuse. This requires a thorough assessment of the situation, with particular emphasis on the sensitivities involved. If there has been disclosure of possible sexual abuse, the police need to be involved in the interview process and also in forensic examination.
7.20 In responding to allegations of abuse, there is a need to safeguard the individual(s) involved in order to prevent further abuse occurring, particularly whilst the investigation is taking place. This may include the suspension of an alleged perpetrator who is working within a care setting. Successful investigations should involve other agencies and authorities in a multi-agency approach. In relation to sexual abuse this will generally necessitate involvement of the police and forensic medical practitioners. This is important in order to achieve an overall view of how best to proceed and guarantee the future security of "at risk" adults. One expert programme in North America, the 'Athens-Clarke County Sexual Assault Nurse Examiners' ( ACC- SANE) (Hatmaker et al., 2002:127), claims to have developed a specialist team that:
"…decreases the trauma of the investigation to sexual assault victims while maintaining expert evidence collection and increasing successful prosecutions." (Hatmaker et al., 2002: 127).
7.21 Education is essential if staff are expected to be aware of abuse and to have the confidence to intervene when actual or alleged situations are discovered. Hogg et al., (2001) evaluated an open learning course on 'Approaches to Sexual Abuse of Adults with Learning Disabilities'. The evaluation reported a significant increase in knowledge, an acceptance of practices to deal with abuse, and finally increased confidence in having the skills to deal with abuse (Hogg et al., 2001). Educating practitioners to understand and empathise with victims can be enhanced by the use of the 'Victim's voice'. Analysing the transcripts of 21 victims of violence, Nicolaidis (1999) produced a 30 minute educational documentary that identified the main themes that victims wanted physicians to understand about life in an abusive relationship.
7.22 Boundary setting is important for all staff working with vulnerable adults. Educational packages are available to inform staff how to set and maintain social and sexual boundaries (White, 2004a and 2004b). This area overlaps with Cambridge's work on intimate care; see 6.14.
Tertiary intervention
7.23 Tertiary intervention focuses on moderating the harmful effects of the abuse or exploitation. Suitable arrangements to ensure the safety of the adult and prevent a similar incident occurring in the future need to be initiated. This includes prevention of abuse by the same perpetrator, of other potential victims, as well as of the same victim. Numerous agencies provide counselling services; however, the ability to secure a counselling service varies enormously by geography and care sector. Counselling services should be a standard component of interventions in all health and social care agencies, and should not be restricted or rationed to certain age or user groups; see 4.25.
7.24 The potential actions in response to abuse are influenced by the nature of the abuse, and also the characteristics of the perpetrator (Brown, Burns, & Wilson, 2003). In order to prevent the perpetrator making future contact with vulnerable adults the perpetrator may be prosecuted, removed from their respective professional register, placed on the protection of vulnerable adults ( POVA) list, or banned from owning or managing a care home by the Commission for Social Care Inspection or Care Commission in Scotland; see 5.18.
7.25 There is a widely recognised need for enhanced and 'joined up' services to improve support for survivors of childhood sexual abuse. Survivors need better access to services and an appropriate response when using services. There is also widespread misunderstanding of the specific needs of survivors of childhood sexual abuse. For this reason the Adult Survivors of Childhood Sexual Abuse Strategy 23 was launched by the Scottish Executive in September 2005. Progress is being made on an awareness raising campaign in relation to existing services to utilise these and the resources that are already in place more effectively. The strategy is geared towards identifying tasks for local authorities and health boards to take forward, utilising these existing resources. Work is well underway on the design and creation of a website intended to underpin the strategy 24. This will be a source of information, guidance, and contacts for further information on services available, or personal or professional help.
Conclusions
7.26 Sexual abuse is not automatically considered when discussing abuse; in many ways it is the 'last taboo', as was the recognition of child sexual abuse in the late 1980s. It also appears to be the least frequent form of abuse in terms of prevalence data, although there may be some under-reporting of this type of abuse. From existing evidence, adults with intellectual disabilities appear to be most at risk of sexual abuse, often from other service users (Brown & Stein, 1998; 2000). However, care should be taken to not neglect other vulnerable groups, including older people with cognitive deficits or mental health difficulties, as individuals in these groups are "at risk" of sexual abuse due to variable levels of capacity.
7.27 Developing appropriate relational contact with individuals who are vulnerable may help to ensure that these individuals are able to access appropriate services when necessary. Existing literature recommends risk assessments for vulnerable individuals (Fear et al., 2004; McCreadie, 2001) and appropriate systems of inter-agency communication (Fear et al., 2004).
7.28 Staff must be made aware that a single abusive act of a sexual nature demands as much attention as allegations of repeated and multiple abuse. Staff must also be supported when they report incidents they are concerned about, but are unsure about the nature of the acts. This is especially important in the area of boundary violations and intimate care. Education can assist in accurate identification of instances of abuse in the future.
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