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Who I am
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Live in Sudbury, Ontario.
Member of Forensic Nurses’ Society of Canada
Have less than 1yr till I am finished my Masters
of Science in Nursing
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Where I work
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I am a Registered Nurse who works in the
Domestic Violence/Sexual Assault Treatment
Program at HRSRH.
Provide care to survivors (adult and pediatric) of
Domestic Violence and Sexual Assault.
Part of the Ontario Network of Sexual Assault/
Domestic Violence Treatment Centers.
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1.
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Realities of Elder Sexual Assault
Assessment of Elder Sexual Assault Victim
Implications for SANE
Moving Forward
Elder Sexual Assault... The Hidden Truth
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Seniors account for more than 13% of the
nation’s population… projection is that it will
reach 15% by 2011.
(Statistics Canada, 2001)
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It is estimated that the population of those over
the age of 65 will be 4.81 million by the year 2011,
a growth rate of 82.9%.
(Statistics Canada, 2001)
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Abuse of the elderly is manifested in several
ways:
Physical abuse
 Sexual abuse
 Emotional or psychological abuse
 Neglect
 Abandonment
 Financial or material exploitation
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(Lynch, 2006)
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Sexual abuse of an elder involves any
non-consensual sexual conduct or contact
between an elder and an abuser.
Without consent it is considered sexual assault…
no matter what age the person.
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The problem of elder sexual abuse is particularly
troubling in view of the expected doubling of the
number of older adults worldwide from 19952025. (Ploeg, Hutchison, MacMillan and Bolan, 2009)
The prevalence of elder abuse is difficult to
quantify for a number of reasons.
(House of Commons Health Committee, 2004)
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Sexual abuse victims tend to be of advanced age,
frail and dependent on others for care.
(Vierthaler, 2008)
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Elder sexual abuse is being recognized as a
public health issues with important nursing
implications, especially for forensic nurses.
(Paulos and Sheridan, 2008)
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The reasons for elder maltreatment are as varied
as the individual elders themselves.
(Olshaker, Jackson and Smock, 2007)
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The perpetrators of elder sexual abuse;
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81% were healthcare providers
78% were family members (predominantly sons and
husbands)
Ages ranged from 16 to over 70 years
(Ramsey-Klawsnik et al., 2008)
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Anyone who comes into contact with an older
person can be a potential abuser.
Abusers are not always care givers or persons
under stress.
Abuse can be deliberate, premeditated or caused
by accident or ignorance.
Elder Sexual Assault... The Hidden Truth
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Contributing factors include:
Power and Control
 Mental illness
 Substance abuse
 Domineering or sadistic personality traits
 Sexual deviance
 Paternalistic view of wives as sexual property
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Elder Sexual Assault... The Hidden Truth
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Sexual victimization is under-reported in all age
groups.
Older victims less likely to report due to:
Restrictive cultural view of sexuality
 Self blame and feelings of humiliation
 Verbal limitations
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Cognitive impairment
Reluctance to disclose
Cultural factors
Fear of losing independence
Fear of not being believed
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There are many indicators of vulnerability, some
which include:
Illness
 Communication problems
 Physical disability
 Family history of violence
 Support services
 Staffing issues
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Taking a medical history from a senior in general
is a complex and elaborate process.
(Olshaker, Jackson and Smock, 2007)
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It is important to develop trust with the elder in
order to do an accurate assessment of the sexual
abuse.
(Burgess and Morgenbesser, 2005)
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Always listen to what the person is telling you.
Never dismiss what a person says.
Always take it seriously even when the person
appears to be confused.
Not all disclosures occur verbally but
through behavioral changes.
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When it comes to recognizing sexual abuse there
are some “Red Flags” to remember:
Observed, suspected or reported incidents or forced
participation
 Patient history
 Bruises and/or bleeding around breasts/genital area
 Difficulty sitting or walking
 Genital infections or disease
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Torn, dirty, stained or bloody underclothing
Lack of privacy
Inappropriate touching, sexual innuendo by patient or
another
Withdrawn un-communicative person
Observed or reported feelings of blame and guilt
Isolation or changes in behaviors
Disturbed sleep pattern
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When a person is disclosing an incident to you:
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Do no ask leading questions
Do not challenge abuse
Find out what the person wants (ie. medical treatment,
police involvement, etc.)
Record what is said in the person’s words
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Normal/common changes
Multiple co-morbidities
Medication effects
Cognitive impairment
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SANEs are responsible for obtaining medically
relevant history of the assault, collecting
evidence and documenting medical findings.
(Cook-Daniels, 2007)
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Elderly victims have the same wide spread
response as younger victims of sexual assault.
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Older people are more likely to die from physical
injuries than younger people.
High morbidity and mortality rates attributed to:
Concurrent medical conditions
 Decreased physiologic reserve
 Current medications
 Physical limitations
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Sexual Assault Assessment
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Should take place in area that ensures privacy.
A few important things to remember:
Evaluation of sensory abilities (vision and hearing)
 Record the history of assault
 Perform a thorough assessment (including diagnoses,
medications prescribed and current lab values)
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Physical Examination
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The goal of the SANE examination is the
systematic and comprehensive collection of
evidence from the victim that has been
transferred from the perpetrator.
(Burgess and Morgenbesser, 2005).
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It is conducted in a psychologically supportive
manner by explaining and requesting consent for
each step in the process.
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Physical Examination (continued)
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While conducting the physical exam SANE
nurses look for:
Wounds
 Infection
 Bleeding
 Pain/Tenderness
 Signs of physical restraint
 Inappropriate sexual comments by care giver
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Physical Examination (continued)
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Assistance may be required
Positioning the patient
A small speculum is recommended
Examination may require more time
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Physical Examination (continued)
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Often more difficult to perform due to:
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Cognitive or physical impairment
Knowledge deficit
Normal changes in older females
(Paulos and Sheridan, 2008)
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General Issues
Emotional Trauma
Physical Trauma
General Health Issues
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Elderly victims, like all victims of sexual assault,
often experience severe emotional and physical
trauma.
Often the elderly access fewer services and
intervention than younger victims.
(Vierthaler, 2008)
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The world in which today’s elderly grew up
affects how they experience and view sexual
victimization.
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Elderly individuals have higher rates of
depression, anxiety and other mental health
issues which increases their vulnerability to abuse
and exploitation.
(Cook-Daniels, 2007)
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The elderly often become the victims of
unwanted sexual contact because they’re
perceived to be easily overpowered and
manipulated.
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Unexplained changes in appetite, eating, sleep
patterns and mood levels
Anxiety about their residence
Decreased enjoyment of social activities
Behaviours described as “out of character”
Fear of going to sleep
Suicidal thoughts
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Older people are more likely to sustain injuries as
a result of a violent attack and are more likely to
require medical care for these injuries than
younger adults.
(Burgess, Hanrahan and Baker, 2005)
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Elderly victims are at increased risk for the
following:
Genital or urinary irritation
 Physical injuries
 Sexually Transmitted Infections (STI) & HIV
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Based on current literature, it is evident that
genital injuries occur with more frequency and
more severity in sexually assaulted women who
are postmenopausal that in younger victims.
(Burgess and Morgenbesser, 2005)
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In more than ½ of victims there are documented
signs of bruising, abrasions, redness, swelling
and tears in the perineal area.
(Burgess, Ramsey-Klawsnik and Gregorina, 2008)
Genital Injuries
(Burgess, Hanrahan and Baker, 2005)
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Non-Genital Injuries
(Burgess, Hanrahan and Baker, 2005)
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1. Research data is scarce as the efficacy of
treatment programs in the area of elder sexual
abuse.
2. There is a history of discrimination against the
elderly as well as misperceptions and stereotypes
against older adults that has put elders at an
increased risk for sexual assault.
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3. Barriers to effective health care interventions
include delayed reporting of the sexual abuse.
4. There are few resources available for educating
seniors and others about the prevention of sexual
abuse.
5. There is little information on the motivation of
offenders who sexually assault the elderly.
(Burgess and Morgenbesser, 2005)
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Moving Forward
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Changing stereotypes
Research
Education
Assessment
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Severe under reporting.
Elderly victims of sexual assault represent a
vulnerable and poorly understood population.
(Burgess, Dowdel and Brown, 2000)
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Reporting and identifying elder sexual assault is
the cornerstone to intervention, treatment and
prevention.
(Burgess, Brown, Bell, Ledray and Poarch, 2005)
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Please feel free to contact me for further
information, with additional questions or
comments.
Christine Bouffard RN, BScN, SANE
[email protected]
1-705-675-4743 or
1-866-469-0822 ext. 4743
Elder Sexual Assault... The Hidden Truth
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
Burgess, A.W., Brown, K., Ledray, L.E. and Poarch, J.C. (2005). Sexual abuse of older adults: Assessing for
signs of a serious crime and reporting it. American Journal of Nursing, 105 (10), 66-71.
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Burgess, A.W., Dowdell, E.B. and Brown, K. (2000). The elderly rape victim: Stereotypes, perpetrators, and
implications for practices. Journal of Emergency Nursing, 26 (5), 516-518.
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Burgess, A.W., Hanrahan, N.P. and Baker,T. (2005). Forensic markers in elder female sexual abuse cases. Clinics
in Geriatric Medicine, 21, 339-412.
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Burgess, A.W., and Morgenbesser, L.I. (2005). Sexual violence and seniors. Brief Treatment and Crisis
Intervention, 5(2), 193-202.
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Burgess, A.W. and Phillips, S.L. (2006). Sexual abuse, trauma and dementia in the elderly: A retrospective study
of 284 cases. Victims and Offenders, 1, 193-204.
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Burgess, A.W., Ramsey-Klawsnik, H. and Gregorina, S.B. (2008). Comparing routes of reporting in elder sexual
abuse cases. Journal of Elder Abuse and Neglect, 20 (4), 336-352.
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CDNA. (2003). Community and district nursing association: Response to elder abuse. Accessed on Oct 2nd,
2009 from http://www.cdnaonline.org/documents/ElderAbuse.pdf
Elder Sexual Assault... The Hidden Truth
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Cook-Daniels, L. (2007). Transgender survivors of elder or disabled adult abuse, part 1. Victimization of the
Elderly and Disabled, 10 (1), 81-96.
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Cronin, G. (2007). Elder abuse: The same old story? Emergency Nurse, 15 (3), 11-13.
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House of Commons. (2004). Elder abuse: Second report. Volume 1. Accessed on Oct 2nd, 2009 from
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Jones, H., and Powell, J.L. (2006). Old age, vulnerability and sexual violence: Implications for knowledge and
practice. International Nursing Review, 53, 211-216.
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Lynch, V.A. (2006). Forensic nursing. Mosby; USA. Chapter 25.
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Neundorfer, M.M., Harris, P.B., Britton, P.J. and Lynch, D.A. (2005). HIV-risk factors for midline and older
women. The Gerontologist, 45 (5), 617-625.
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Olshaker, J.S., Jackson, M.C. and Smock, W.S. (2007). Forensic emergency medicine. Lippincott Williams and
Wilkins; Philadelphia, USA.
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Ploeg, J., Hutchison, B., MacMillan, H. and Bolan, G. (2009). A systematic review of interventions for elder
abuse. Journal of Elder Abuse and Neglect, 21, 187-210.
Elder Sexual Assault... The Hidden Truth
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Poulos, C.A. and Sheridan, D.J. (2008). Genital injuries in postmenopausal women after sexual assault. Journal
of Elder Abuse and Neglect, 20 (4), 323-335.
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Ramsey-Klawsnik, H., Teaster, P.B., Mendiondo, M.S., Marcum, J.L. and Abner, E.L. (2008). Sexual predators
who target elders: Finding from the first national study of sexual abuse in care facilities. Journal of Elder
Abuse and Neglect, 20 (4), 353-376.
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Stieber Roger, K. and Ursel, J. (2009). Public opinion on mandatory reporting of abuse and/or neglect of older
adults in Manitoba, Canada. Journal of Elder Abuse and Neglect, 21, 115-140.
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Toronto. (1996). Remember elderly women can also be sexual assault victims. Medical Post, 32 (7), 75.
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Tyra, P.A. (1996). Helping elderly women survive rape using a crisis framework. Journal of Psychosocial
Nursing, 34 (12), 20-25.
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Vierthaler, K. (2008). Best practices for working with rape crisis centers to address elder sexual abuse. Journal
of Elder Abuse and Neglect, 20 (4), 306-332.
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