Rapists prey on various categories of helpless victims. The rape of young and attractive women has been a constant of history. The widespread sexual abuse of children has come to be an accepted fact, when once it was hardly ever discussed or accepted. The rape of elderly women and men in nursing homes and hospitals is similarly not discussed, but should now be made a focus of urgent investigation.
The following accounts of sexual abuse have not been chosen to deliberately shock, indeed, some details have been excluded, and more horrific accounts have been omitted.
Throughout this account, a case is given for the rape of elderly nursing home residents being facilitated by greedy corporations which put profit before patient safety; a view expressed by lawyers collectives, judges, newspaper reporters, and researchers. This is not to suggest that the sexual abuse of elderly patients is confined to the private sector; it is to suggest that the low staffing levels associated with cost-cutting business models of care increase the incidence of sexual abuse of elderly patients.
Nor is it suggested that the sexual exploitation of patients is a modern phenomena, associated with any particular political system. I quote from Mr Mitford’s work of 1885, which exposed the cruelties to be found in ‘Mr Warburton’s Mad-House’: ‘I am induced to give one more case of a female, and shall particularise no other. This lady had been a dweller in darkness for some years, and was apparently about twenty-five or twenty-six years old; she was a harmless lunatic, dressing herself up with flowers, carrying a basket of them, and chanting simple songs, at intervals, as she repeatedly paced the galleries or the garden; they called her “Crazy Jane,” and that was the only name I ever knew her by; she was very pretty, but with all that wildness of appearance about her, which Shakspeare has given to Cassandra, the inspired denouncer of the fate of Troy … This poor maniac – this Crazy Jane, had sufficient beauty to attract the eyes of the keepers, and was made the victim of their lust; and 1 have often seen her hurried by them down into the cellar, before I knew the horrid purposes for which it was done. That she had some feeling I know – but whether bodily or mental sufferings brought it forth I am ignorant, though in either case it is dreadful to think of; for I have seen her hurry tottering up the cellar steps, from that cavern of pollution, her eyes streaming with tears, which she tried to hide as she ran into the garden. And at such times 1 have seen her beaten, the keeperess declaring ‘she could not keep her from the men’ – a burning lie to my certain knowledge; depraved in themselves, they knew not what virtue meant, and the sacred stream of pity never flowed in their corrupt veins’.
I do suggest that any place of care of the vulnerable has always been a magnet for a certain type of pervert, who take pleasure in the degradation, hurt and humiliation of their victims, whether children, or young or old men and women. Though they may be a minority, they tend to intimidate fellow workers, who are often too afraid to voice their suspicions.
Generally, the rape of elderly women by young men has been under-reported for decades. (Grant 1994), gave a landmark account of this phenomenon in England: ‘On Christmas Day 1991 a severely disabled 70-year-old woman was raped in Sussex. In January 1992, a man was jailed for nine years for raping the 66-year-old housekeeper of a Catholic priest. The following month a Worcester man was jailed for life after sexually assaulting an 88-year-old, punching her in the eye and mouth and slitting her clothes from the chest down. He had already served an eight-year sentence for raping a 50-year-old woman. In April 1992, Manchester Police investigated what the police authority’s chairman Stephen Murphy called ‘the worst case of its kind I have ever heard of’. An 88-year-old widow was left with a fractured skull, two broken ribs and other injuries after a four-hour attack in which she was kicked, battered and bitten by two men who raped her three times, forcing her to carry out what newspapers called ‘a series of perverted sex acts’. In June of that year, a 16-year-old was convicted at Norwich Crown Court of the rape of a woman aged 100′.
Grant quoted Ginny Jenkins, director of Action on Elder Abuse, who suggested: ‘that the lack of interest in this crime reflects society’s attitudes to old people and sex. We can’t cope with old people having sex, so we can’t cope with abusive sex’. Grant also mentions research undertaken by Dr Mezey: ‘her interviews indicate that (rapists of the elderly) are very hostile to women and feel belittled by them’. The central point of Susan Brown Miller’s study of the mid-Seventies, Against Our Will, is also given – that rape is not about sex but power. Grant continues: ‘One theory put forward in an American study holds that older women symbolise an authority figure over whom the offender wants control or an actual woman against whom he wants to avenge himself. The desire, in such rapes, is not for sex but for the degradation, hurt and humiliation of the victim. How did he get an erection?’, we guiltily wonder. The arousal may come from rage, nervous excitement or fear, as is suggested by the evidence of rapes in wartime. Others argue that these rapists are simply woman haters, and older women may just be easier to attack because of their vulnerability’.
Grant summarized: ‘The real shame is not the kind that elderly women feel who have been raped, but our ignorance of the subject. A study of sexual assaults on elderly women would throw light on the nature of rape itself, perhaps finally removing any lingering doubt that rape is about power rather than sex. Child sexual abuse, sexual abuse of frail, elderly women, is there so much difference? At the beginning and at the end of life, the weakest, the least likely to be believed, are the rapist’s most vulnerable victims’.
More recently, Christie (2014), reported a Cincinatti nursing home resident being raped ‘on her deathbed’ … She lay helpless in a room unable to appreciate her 92-year-old life’s photographs and mementos. No family, no friends, no one to help her … (the rapist) returning again and again to rape her. She bled. When the man’s supervisor walked into her room, he discovered her naked with her gown pushed up, bleeding from her vagina. Then he found the nurse’s aide’s pants, underwear and shoes but no nurse’s aide. The rapist was hiding in her locked bathroom – stark naked. His semen was discovered in her vagina and other parts of her body’.
Sexual abuse in nursing homes occurs more frequently than many would like to imagine. In America, the National Center on Elder Abuse, Bureau of Justice Statistics, 2014, give the following statistics: Average number of elderly abuse cases each year 2,150,000. Percent of female elder abuse victims 67.3 %. Median age of elder abuse victims 77.9. Breakdown of Reported Elder Abuse Cases: Neglect 58.5 %. Physical Abuse 15.7 %. Financial Exploitation 12.3 %. Emotional Abuse 7.3 %. Sexual Abuse 0.04 %. All other types 5.1 %. Unknown 0.06 %. These figures suggest 4 cases per thousand of elderly abuse are sexual. They are not confined to nursing homes. The same study showed that the percent of nursing homes that lack adequate staff to properly care for patients was 91 %. Percent of nursing homes that have been in violation of elderly abuse laws 36 %.
Pamela Teaster, a University of Kentucky professor conducts national research on sex abuse in nursing homes, said she suspects that such abuse is under-reported and “woefully” under-prosecuted” (Spears 2010), which follows on her earlier study, which found that the majority of sexually abused elderly people were abused in care facilities: ‘During a three year study of elder sexual abuse, 16.7% of elder sexual abuse victims lived with family members while the majority (83.3%) lived in a nursing home or other adult care facility (Teaster et al. 2001). The same study found that ‘it was more common for there to be at least one witness to the sexual abuse (76.2%) than for it to occur without being witnessed (23.8%), which raises the disturbing possibility of rapist networks being established in nursing homes.
Julie May ( 2014) gives an account of research conducted in Australia, which highlights disturbing statistics about sexual abuse of the elderly: ‘The under-reporting of sexual abuse against nursing home residents is suggested in ‘Norma’s Project’, a report by Catherine Barrett of La Trobe University that addresses sexual assault of older women in Australia … In 2012 there were 344 reports of alleged unlawful sexual contact in Australian aged-care facilities. Using the estimated proportion of sexual assaults that are reported across the board as a guide – 19 per cent – the number of assaults against older women annually in aged-care facilities could be close to 2000. It’s likely to be even higher, however, as older, dependent women are less likely to report abuse. Add in assaults in other contexts where data isn’t collected- such as homes, hospitals, retirement villages and other settings such as crisis accommodation and the numbers would be dramatically higher’.
Susan Ryan, the Age Discrimination Commissioner, who wrote the foreword to ‘Norma’s Project’, says: ‘With child abuse we’ve found how widespread it is – it occurs in almost every situation in which adults have power over a child. Unfortunately we’re starting to see a similar picture with older people, particularly those who are frail or dependent (on carers at home) or in aged-care residences. There are perverted, vile people who get some sort of satisfaction out of abusing them.’
There is not a climate of openness regards the issue of sexual abuse of the elderly in Australia, which is consistent with the general attitude toward abuse. A recent report (Strachan 2014), quoted Combined Pensioners and Superannuates Association spokeswoman Charmaine Crowe: “The problem is the public has no idea how well or how poorly these nursing homes are doing,” she said. “It’s not possible to know how many complaints have been substantiated against a facility. You may walk into a facility that’s had 30 complaints upheld in the past 12 months and you’d never know. It’s being run like a secret society”.
As indicated, incidences of sexual abuse can be associated with low staffing levels. Margot O’Neill (2013), reported that: ‘Aged care workers say their industry is facing a staffing crisis, with claims of abuse and neglect as patients struggle to get even basic care. In phone calls and emails with scores of carers, nurses, facility managers and even former health bureaucrats, ABC’s Lateline program has uncovered a pattern of failure in many facilities. Staff say they often do not get time to properly feed, hydrate or toilet residents, that broken bones and infections can go undiagnosed and that there are frequent medication mistakes, at least 10 a month’.
The association of abuse with low staffing levels was also discussed in a Canadian context (The Hamilton Spectator 2011): ‘Seniors in Ontario nursing homes are being beaten, neglected and even raped by the people hired to care for them. In one case, a helpless 71-year-old Toronto woman with advanced dementia was raped in her bed, allegedly by a male nurse identified months earlier by other staff at the home as someone who regularly disappeared on shift “without explanation”. The report mentions nursing homes admitting more patients with advanced dementia without increasing staffing levels to care for them. ‘The Star obtained 1,500 inspection reports. Serious problems were found in 900 cases. Of those, roughly 125 were abuse related, 350 revealed neglectful treatment of a senior and the remainder found other types of poor care. There are 627 homes in Ontario with 77,000 residents’.
Massachusetts Lawyers for Victims of Nursing Home Sexual Abuse (bostoninjurylaw.org, 2014), place blame for sexual abuse of the elderly on corporations: ‘Nursing homes that do not require background checks on their employees allow sexual predators to be employed in nursing homes too easily. Moreover, the corporations that own nursing homes look to cut costs by reducing the number and quality of staff at their facilities. By understaffing nursing homes, sexual predators often have unsupervised contact with residents and go unnoticed. Nursing home sexual abuse that is facilitated by greedy corporations putting profit ahead of patient safety is morally appalling, extremely dangerous and otherwise completely unacceptable’.
In Deerings West Nursing Center v. Scott, a Texas court found a nursing home liable for an assault on an elderly visitor committed by an unlicensed aide with past criminal convictions for theft. The court reasoned that the “basis of responsibility under the doctrine of negligent hiring is the employer’s own negligence in hiring or retaining in its employ an … employee who the employer knows or … should have known was incompetent or unfit, and thereby, causing an unreasonable risk of harm to others.
Perversely, the hiring of people to work in nursing homes who have past convictions is now allowed in England, because, it is argued, blanket checks did not comply with human rights laws, under article 8 of the European Convention on Human Rights.
Old and minor cautions and convictions will no longer appear on criminal records checks undertaken by employers for positions where the recruit will be working unsupervised with children and vulnerable adults, the Home Office announced. Under the proposed changes adult cautions will be omitted from records after a period of six years, while those received by a young offender will be omitted after two years. All serious violent and sexual offences will continue to be disclosed.
A spokesperson at The Home Office told HR magazine: “It’s important employers do not just rely on checks by the DBS to make recruitment decisions. They have a professional duty to ensure that staff are properly managed and supervised and that, if they have concerns, information is referred to both the police and DBS.”
A report by John Bingham (2012), showed that this ‘professional duty’ was largely being ignored: ‘Frail and vulnerable elderly people are being forced to rely on care in their homes from workers with convictions for theft and violence, an investigation has found. Private care agencies, fulfilling contracts for councils across the country, have been employing convicted criminals to work in elderly people’s homes. In some cases, the criminals have been sent in without police checks or risk assessments being carried out, publicly available records show. One agency in Birmingham hired 23 people with criminal records, including assault and theft … More than 220 care agencies working in elderly people’s homes in England have failed to show they were employing properly qualified and vetted staff in recent CQC inspections. There are fears this could be the tip of an iceberg. Not all agency records on vetting staff are checked at each inspection. Fewer than two thirds of the 6,000 agencies have been inspected by the watchdog, set up four years ago … More than 6,000 private care agencies are working in the homes of elderly people across England. Many of them are working on contracts for local councils, which are under pressure to slash their budgets and find the best “value” for taxpayers … Even after failings (to check staff) were uncovered, (an) agency retained its £800,000-a-year contract with Birmingham City Council and is licensed by the CQC … Neil Duncan-Jordan, of the National Pensioners’ Convention, said: “The CQC seems incapable of doing the job that the public thinks that it is doing because it is reactive, it goes in after the problems have been identified. That is not good enough. If they are not able to do more, then we need another agency that will.”
The situation is even more dire regarding foreign workers, because the Criminal Records Bureau cannot access criminal records held outside the United Kingdom. In order to get a ‘fuller picture’ of a foreign national’s background, additional checks may be required. The advice given to employers by the government is to obtain ‘a certificate of good conduct’ and any other references from potential overseas employees. How reassuring! How many English employers are going to write to the applicant’s local police station, court, or previous employer, or phone the same, in the language of the applicant’s country? Employers are advised that foreign embassies may assist them in translation. This farcical situation is made more plain by the fact that within EU countries there is a wide disparity in the way records are kept, and they have wildly varying sentences for different offences. The market in (impossible to detect) fake certificates is also rife in many EU countries ( Nightingale 2014).
The onus in England is on the employer to check the employee. The Neocon government of whatever Party label only advise. Their role is not to interfere in the ‘free market’; the free movement of cheap sources of labour. Whereas a Texas court found a nursing home liable for an assault on an elderly visitor committed by an unlicensed aide with past criminal convictions (and fined them accordingly), an English agencies which failed to check employees’ records kept their £800,000-a-year contract.
This points toward a fundamental difference between the American stance on the abuse of the elderly and that of other countries. A recent report (Caya 2014) quoted Attorney General Eric T. Schneiderman: “Nursing home residents are among our state’s most vulnerable citizens, and the perpetual neglect in this case is shameful”, whose comment pertained to 8 nurses and 9 certified nursing assistants who were sacked following a New York state investigation that showed neglect of duty and making false records.
The investigation used hidden cameras to show that a highly dependent 56-year-old male resident, who suffered from Huntington’s chorea, was not routinely given pain medication, liquids, and incontinence care at Highpointe on Michigan Health Care Facility, with charts and nursing notes routinely claiming he had.
The 17 accused appeared at Buffalo City Court, facing various charges of wilful violation of health law, endangering the welfare of an incompetent or physically disabled person, and falsifying business records. Endangering this patient is a charge which is a felony and carries a maximum prison term of four years.
Schneiderman in Caya commented: “The charges filed send the message that my office will not tolerate anyone being neglected by those responsible for his or her care. We will use every tool in our arsenal, including hidden cameras, to ensure that nursing home residents receive the care they need and the respect they deserve.” (ibid.). This follows the New York authorities arresting 22 people in 2010 after hidden cameras revealed maltreatment of patients in two facilities .
In America, those found guilty of the abuse and neglect of elderly residents, including nursing staff and care home owners, may be charged with a federal offence by the FBI, and may face imprisonment or very large fines. This contrasts with the ‘softly-softly’ approach of other countries, such as Australia and England, which seem to protect care facility businesses at the expense of vulnerable patients, by having ‘inspectorate’ organisations that are largely, and deliberately, ineffectual. Although countries such as America, Australia, Canada, and England are part of the same ‘free market’ World Order, America appears to be the most regulatory in the health care market, whereas the other countries appear to follow a strategy of ‘lighter’ interference in the ‘market’ of health care.
The reporting of sexual abuse of the elderly is more rigorous in many American States than in England. In Massachusetts, reporting of any and all sexual abuse including assaults is mandatory in nursing homes. Nursing homes are required to have “zero tolerance” policies toward rape and sexual assaults of their dependant residents. Rapes and sexual assaults are designated to be “never events” which Medicare states should never happen in a nursing home environment. There is no excuse for a rape to ever occur in a nursing home if employees are monitored, residents are protected and room and floor security is in force to prevent unknown assailants. An assailant is unknown only because the Nursing home allowed the rape and then did not report it or preserve evidence or acknowledge the crime in a timely manner as required by law and regulations. Nursing homes can not ignore the security and safety of their residents and then claim no responsibility for crimes of violence that harm their residents.
Nursing homes are required to immediately report and investigate all sexual abuse claims whether they are substantiated or not. Sex abuse victims should not be changed or cleaned until medical professionals can examine and preserve any evidence of rape including DNA, semen or clothing. Objects of sexual assaults must be secured and turned over to police. Failure to treat the scene as a crime scene allows perpetrators to often escape as the victims often have dementia and cannot assist in the identification or prosecution of felons or abusers.
‘A facility’s culpability can be the result of a number of systemic failures. Does the facility properly screen potential employees? Does the facility call references and conduct background checks, as required by state and federal law? Does the facility assure that each staff member is fully and appropriately trained before providing service to residents? Does the facility provide adequate supervision of workers? Does the facility have an appropriate abuse prevention protocol in place? And finally, does the facility employ enough staff to provide care to residents so that staff are not called from one crisis to another, leaving residents vulnerable and subject to avoidable harm’? (Senate Special Committee on Aging 2000).
Tim Ross ( 2011), reported on the scale of general abuse of the elderly and vulnerable adults in care homes in England: ‘More than 34,000 vulnerable adults were alleged to have been hit, slapped, kicked or suffered another type of physical abuse while almost 27,000 allegations of neglect were recorded. Ministers and elderly rights campaigners condemned the picture of care home staff and relatives who exploit society’s most vulnerable citizens’. Thus, sexual abuse of the elderly occurs within a wider context of generalised abuse.
Sexual abuse of the elderly can take the form of degrading games: An Australian report (news.com.au 2011), described nurses being sacked for ‘allegedly photographing residents’ genitals in a game called the “Genital Friday Club”. A whistleblower said the “Genital Friday Club” had been going on “for some months and was known of by quite a few members of staff”. A second staff member said at least one nurse took photographs of elderly residents’ private parts on an iPhone and asked colleagues to guess who they belonged to’.
Elderly victims of sexual abuse are not likely to be believed. Serres (2014), told of how an ’89-year-old woman was raped by a nursing assistant in her bed at a senior living home in Hermantown, Minn., and then placed in a mental health unit of a hospital in nearby Duluth for nearly three days without treatment for her injuries’. The victim was suffering from the early stages of dementia. The rapist had plied her with narcotics to incapacitate her. He received a 53 month sentence. Was that remotely enough?
Another report of the rape of an elderly American nursing home patient stated: “A 20-year-old … is accused of raping a wheelchair bound patient at Manchester Community Living Center Nursing Home. (He) physically assaulted and forcibly raped a wheelchair bound female patient at the home” (Thunder Radio, Tennessee, 2012).
Cavaliere (2012) reported on two agency nurses: ‘While dressed in blue nurses uniforms, (they) fondled one another and touched the hand and face of a helpless female patient, home video shows. In one incident, a nurse places the woman’s hand inside his pants, an attorney said. The patient’s family had installed security cameras in her home to monitor the care provided by private 12-hour shift nurses. These offences would have not surfaced without cameras’.
This is a point that bears constant repetition: These offences would have not surfaced without cameras. The offences described in this account would not have occurred if cameras were installed. In Britain, ‘a nurse secretly filmed a pervert handyman sexually abusing elderly resident at a Borough Green care home’ (Sevenoaks Chronicle 2014). Her suspicions were ignored by her manager, so she placed a camera in the room of an 88 female patient, which recorded her sexual abuse by a 66 year old carer. ‘The nurse responsible for his downfall won the praise of the judge for “her sense of duty and presence of mind in doing what she did”. He said: “She had been effectively dismissed by the clinical nurse manager, but she was not prepared to let that happen. She took matters into her own hands”. Yet, such praise was not echoed by the Care Quality Commission (CQC), the so-called independent regulator of all health and social care services in England. Their spokesman said: “The CQC was not aware that the nurse had raised concerns about (the abuser) at the time of the inspection”. Why not? Why is it not mandatory for all managers in England to be compelled to report concerns expressed to them by their staff as it is in Massachusetts? It is as if care home businesses are being allowed to run as secret societies. The CQC spokesman also gave a ‘business-friendly’ opinion on cameras: “On the issue of hidden cameras, we know that there are wide ranging opinions for their potential use, both by inspectors, providers and members of the public, to monitor care. We recently held a public consultation into this sensitive and complex issue and we are considering the comments that we received”.
These words apparently give weight to the concern of some regarding the invasion of an individual’s privacy by the use of cameras. They, in fact, mirror the concerns of the private equity firms that operate the bulk of nursing home care in America, Australia, Canada, and the UK.
The use of hidden cameras to record instances of poor nursing care has been a constant theme in the American press. Hoffman (2013) reported a hidden camera catching a nursing assistant stuffing latex gloves into the mouth of a ninety six year old patient, as another taunted her and tapped her on the head. Once thrown on a bed, one of the nursing assistants assaulted her with heavy-handed chest compressions. Their treatment was accompanied by laughter.
The power of business interest to block the use of cameras in nursing homes is evidenced by the vote in the Senate Medical Affairs Committee concerning the right of families to install cameras in South Carolina’s nursing homes. The committee was evenly divided , with a 7-7 vote, meaning that it will not progress. Adcox (2014) quoted the sponsor of the bill, Sen. Paul Thurmond, “This is really about empowering an individual who’s in a nursing home. The older generation is fraught with neglect and abuse.” They also quoted committee member Sen. Brad Hutto, who commented on the opposition of the nursing home industry to the bill: “They are concerned this is a ploy to catch them doing bad things to patients. That’s not what this is about. This is empowering families to take care of loved ones”. He added, “Generally, people with cameras on them behave better”.
On the ethical issue of the invasion of privacy by cameras, would any opponent of their use change their mind if it were they (or their mother, sister, or daughter), who was being repeatedly raped? I suspect so. It is easy to pontificate from a ‘politically correct’ distance, rather like the English social workers who claimed young girls being groomed and raped by gangs of men were making ‘lifestyle choices’.
Brad Hutto’s point about businesses which control the ‘elderly market’ being reticent to use cameras can be made more plain: They do not want anyone to be aware of the totally inadequate number of staff they employ, especially at night, so as to enhance their profits at the expense of elderly human beings. They are the proverbial pigs with their snouts in the trough of exploitation. They oppose the use of cameras in terms of ethics, of which they have none. The CQC parrot their ‘concerns’.
Another report (CBSNewYork, 2014), stated that ‘a nursing aide was accused … of the rape of a 64-year-old woman at the Bronx nursing home where he worked. Police said another employee found (the attacker) on top of the woman around 1:20 a.m. Other staff members held (him) until police arrived. The woman was treated for non-life-threatening injuries. She is unable to speak because of a stroke’. Yet, we are told that the use of cameras, which would have stopped this despicable act, is a ‘sensitive and complex issue’ – not to those being raped, I suggest.
The Boston News (2010) reported on a man ‘who pleaded guilty to raping a 74-year-old woman at the nursing home where he worked having been sentenced to 10 years by a judge who said he considered the punishment too lenient. Do you agree with the judge?
It is not only women who are victims of sexual abuse in nursing homes. A Fox news report (2008) told of an 18 year old nursing assistant sexually assaulting a 55-year-old man as he lay partially paralyzed in his bed at a Rehabilitation Home. Another such case was that of a ‘developmentally disabled New Mexico man ‘who was raped in 2004 by a nursing home employee. ‘The home had continual problems with under staffing, insufficient staffing, inadequately trained staff, and inadequate documentation – and this case was no exception’ (law.freeadvice.com/2014).
Woman are, however, far more likely to be abused than men. In one study of suspected elder sexual abuse, females were assaulted six times as much as males (Holt 1993).
The BBC (bbc.co.uk-scotland, 2012), reported that a ‘care home worker has admitted raping a 65-year-old dementia patient and sexually abusing two women, aged 84 and 74, who had Alzheimer’s. These attacks had been committed between December 2010 and April 2012. The Telegraph and Argus (Loweth 2010) told of a 17 year old kitchen assistant delivering a Christmas Day cup of tea to an elderly female resident, before raping her. The Star (www.thestar 2009), reported that a ‘carer has been jailed for eight years for the horrific rape of a disabled woman in a nursing home. Relatives of the victim have told of the devastation they suffered after learning of the “horrendous attack”. The rapist was ‘discovered by a colleague in the room of his victim, who was in the final stages of Huntington’s disease, with his trousers round his ankles’. The victim died a few weeks after the attack. Was an 8 years sentence nearly enough? Why no camera?
It is not just the elderly who are raped in nursing facilities. The Mirror (Collins 2014) told of a ‘mental health patient raped up to 60 times by a care worker (who) has branded psychiatric hospitals a “playground for predators”. ‘The woman described how she was preyed on for a year by a senior staff member who would sneak into her room for sex and groom her with gifts such as Valium, cigarettes and chocolate. She said: “The mentally ill are the most vulnerable in society in terms of being abused and having themselves believed. It’s an open playing field for predators in that environment”. The rapist received a suspended sentence. Would you agree that this sentence was a farce?
I suggest that the RCN’s guidelines (2014) on sexual abuse are somewhat lacking, being too generalistic. ‘Sexual offence’ is a term applied to many activities which are defined throughout the UK by the Sexual Offences Act (UK Parliament, 2003). The term includes rape and assault which are the focus of this section. Understandably, such experiences are traumatic for the person presenting to health care services, and difficult for non-specialist staff to manage. This learning will enable you to recognise the key points and find guidance for immediate management.
A far more rigorous guideline as to the assessment and dealing with sexual abuse of the elderly is given in an American study: Capezuti, Swedlow (2000) “Sexual Abuse in Nursing Homes. ‘For the purposes of this paper … sexual abuse is limited to rape or sexual assault, which has been defined in Massachusetts as sexual intercourse or unnatural sexual intercourse with a person, during which one is compelled to submit by force and against his or her will, or compelled to submit by threat of bodily injury.The legal definition, however, varies from state to state’. The study identifies three main categories of victim:
(1) The physically Disabled Older Resident. ‘One of the authors, Elizabeth A. Capezuti, served as a nurse consultant in the case of Mrs. Jane Doe who was admitted to a nursing home for physical rehabilitation of her right arm following a fracture. During her six-week stay, the head of a facility department raped her approximately ten times. Although Mrs. Doe was not mentally impaired, she did not report the repeated rapes because she was afraid of the rapist’s reprisal and felt shame over
(2) The cognitively Impaired Resident. ‘Consider, for example, the sexual abuse of a cognitively impaired nursing home resident with Alzheimer’s disease or other dementia. Behavioral reactions are similar to those of the cognitively intact resident, including avoidance and hyperarousal symptoms when confronted with a person similar to the assailant. The major difference is that the cognitively impaired resident is unable to describe the assault event, the fears, or the feelings of helplessness. Instead, the demented abuse victim displays new and troublesome behaviors that reflect his or her emotional distress post-rape, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff
(3) The physically Impaired Younger Resident. ‘In this category, the younger resident may have a physical impairment due to a chronic neuromuscular disorder such as multiple sclerosis or amyotrophic lateral sclerosis (also known as ALS or Lou Gehrig’s disease). Another possibility is physical impairment as a result of trauma such as paralysis secondary to a gunshot wound to the spine. In Andrea N. v. Laurelwood Convalescent Center, an eighteen-year-old disabled resident, institutionalized after being seriously injured in a car accident, was raped by another nursing home resident. The young victim, Andrea, was bedridden and physically incapable of caring for herself. She communicated with family only through gestures and smiles. Andrea’s family noticed that she seemed restless, cried often, and had missed her menstrual periods. Pregnancy was confirmed, rape assumed, and an abortion followed. Liability was based on the facts that the offending resident had been known to molest other residents and that the facility failed to take action’.
The study reports: ‘Sexual abuse has profound physical and psychological consequences … Studies conducted in hospital emergency departments report that between one-quarter and two-thirds of rape victims sustain physical injuries. Several studies demonstrate that older women are more likely, when compared to younger victims, to have injuries of the genitalia and increased frequency of vaginal lacerations or tears; one-quarter of such injuries requiring surgical repair. Decreased strength of the vaginal tissue due to reduced estrogen in postmenopausal women is the major contributor to genital tract trauma. Genital trauma may result in vaginal bleeding as well as swelling, bruising, abrasions, and lacerations of the genital area. Appropriate treatment for pain should be administered as well as antibiotic therapy for possible sexually transmitted disease’.
The psychological/Emotional consequences of sexual abuse are summarised: ‘Denial and disbelief, especially immediately following the assault. Embarrassment and humiliation. Intrusive recurrent recollections about the assault. Difficulty making decisions to seek medical assistance or counseling. Intense fear reaction such as physical (e.g., combative) or verbal aggression (e.g., cursing) to persons that look like the assailant. Guilt, self-blame, low self-esteem. Anxiety, e.g., mild expression of apprehension, exaggerated startle response, panic attack. Depression – crying, sobbing or ‘flat affect’, i.e., demonstrating little or no emotion. Expressions of hopelessness or helplessness. Phobias or avoidance behaviors – fear of being alone, in a crowd, indoors, outdoors, or global fear of everyone. Anger – feelings of resentment to homicidal rage against the assailant’.
The following recommendations are suggested to reform the present systems of safeguarding the elderly from sexual abuse in Australia, England, and Canada.
1. The implementation of the Sexual Assault Reform Act (SARA).
The Sexual Assault Reform Act (SARA) became effective in America in February, 2001. The law requires the establishment of sexual assault forensic examiner (SAFE) programs in hospitals designated as 24-hour centers of excellence. (www.sthcs.org).
As a result of this legislation, the New York State Department of Health (NYSDOH) developed standards for approving SAFE hospital programs, approving programs that train individual SAFE examiners, and certifying individual SAFE examiners.
DOH-approved SAFE programs and specifically trained health professionals will ensure that victims of sexual assault are provided with competent, compassionate and prompt care, while providing the most advanced technology associated with DNA and other sexual assault forensic evidence collection and preservation.
The SAFE program philosophy is based upon the belief that providing a specialized standard of medical care and evidence collection to victims of sexual assault will support recovery and prevent further injury or illness arising from victimization, and may increase the successful prosecution of sex offenders for victims who choose to report crimes to law enforcement.
The SAFE program aims to:
1. Provide timely, compassionate, patient-centered care in private settings that provide emotional support and reduces further trauma to the patient.
2. Provide quality care to patients who report sexual assault, including evaluation, treatment, referral and follow-up.
3. Ensure the quality of collection, documentation, preservation and custody of physical evidence by utilizing a trained and New York State Department of Health (DOH) – certified sexual assault forensic examiner to perform exams.
4. Utilize an interdisciplinary approach by working with rape crisis centers and other service providers, law enforcement and prosecutors’ offices to effectively meet the needs of sexual assault victims and the community.
5. Provide expert testimony when needed if patients choose to report crimes to law enforcement; and
6. Improve and standardize date regarding the incidence of sexual assault victims seeking treatment in hospital emergency departments.
2. The mandatory reporting of all suspicions of sexual abuse by staff to their manager, who is compelled to immediately pass this information to a nursing regulatory organisation and law enforcement agencies, which will initiate an immediate investigation under a SARA-style operation.
3. The manager of a nursing facility to be a registered nurse. Failure to comply with this requirement to result in the closure of the facility.
4. The setting up of a toll free telephone line for healthcare workers who may feel too intimidated to report suspicions or accusations of sexual abuse in their place of work. Their name not to be disclosed.
5. The possibility of imprisonment or severe fines for those employers which do not carry out thorough checks on those they employ. These checks to particularly include those of foreign workers. The checks to be undertaken by professional, independent companies, which will also undertake checks on the validity of certificates. The abolition of local council/government contracts for those nursing care organisations which do not comply with this requirement.
6. The mandatory disclosure of all minor cautions or convictions for those working with vulnerable clients, who have a right to be cared for by those whose past conduct might indicate a defect of character which may manifest itself in more serious ways within care facilities.
7. The banning of male nurses or care assistants working alone with vulnerable patients. They are to be accompanied by a female co-worker at all times.
8. The setting of mandatory staffing levels in elderly nursing care facilities. A thirty-bedded facility, as an example, to have a minimum of one registered nurse and five carers during both day and night shifts. When staffing levels are in danger of falling below this requirement, the care home manager to have a mandatory duty to engage agency staff. Failure to do so to result in substantial fines.
9. The banning of 12 hour nursing shifts. Shifts to be morning (7 hours), afternoon (7 hours), and night (10 hours, with a two hour sleep break). Nursing has been subject to the exploitation of its staff by employing less staff to do more work, to the obvious economic advantage of the employer. Tired nursing staff are less able to care for their patients, and fewer staff equates to less surveillance of those who may commit offences. Nursing staff not to work more than 40 hours per week.
10. The mandatory training of at least one nurse from elderly nursing care facilities in the recognition of the signs and symptoms of sexual abuse. The certificated course of training to be based on Capezuti’s and Swedlow’s (2000) ‘Sexual Abuse in Nursing Homes” guidelines.
11. The installation of cameras and microphones in thr rooms of all nursing care facilities. The cost to be met by the facility. The exception to this being those patients who are deemed compos mentis, and who request that recording devices are not used in their case. The recordings to be viewed by an external agency linked to a SARA-style
12. The scrapping of ineffectual regulatory organisations, such as the CQC, and their replacement with a regulator which responds to individual cases of complaint (in conjunction with law enforcement agencies in the case of serious complaints).
13. The nature of all complaints against nursing facilities, whether substantiated or not, to be made public.
14. The establishment of an international collaboration of interested ….. to collate information on the sexual abuse of the elderly in nursing facilities, and to act as a pressure group for reform.
The following recommendations are suggested to replace the present system of the nursing care of the elderly in Australia, England, and Canada:
1. Nationalise all care of the elderly. Safe care can not be delivered under the profit-motive system, which seeks to cut costs by reducing the number and quality of staff.
2. Nationalised care facilities to be based on the ‘Nightingale Ward’ system, where all care given is easily observable.
3. Elderly care to be a separate and specialist branch of nursing, with its own (non-degree) training requirements. Re-introduce the entry level of this branch of nursing to that of the old cadet level, with those that progress attaining the State Enrolled Nurse status, and those chosen to progress from that to attain Staff Nurse status. The most talented, hard-working, and caring of those to obtain Nursing Sister or Charge Nurse status. Each facility to be in charge of a Matron, a senior Sister who has demonstrated an ability to impose a impartial level of strict discipline, so ensuring that all basic nursing care is promptly carried out to a high standard. Degrees in the basic nursing care of the elderly do not make for better nurses, they serve the interests of the nurse education industry. The basic nursing care of the elderly should attract those with a caring attitude and aptitude for hard work, not a careerist-minded academic.
4. All training to be carried out at a School of Nursing attached to the Nationalised care facility. Those trained to be guaranteed a job. Tutors to be Sisters or Charge Nurses who complete a Registered Nurse Tutor Diploma.
5. All students to attend one week in ‘school’ before each 8 week ward placement, where they will be a fully hands-on member of the nursing team, and where they will have to pass practical assessments, such as wound dressings, the ‘turning’ of patients to prevent pressure sores, bed making, safe feeding techniques, the giving of injections and drugs, the hydration and toileting of patients, etc., under the mentorship of a Senior SEN or Staff Nurse, with all competencies obtained to be verified by the Ward Sister or Charge Nurse.
6. Places of work to offer crèche facilities to encourage the retention of staff.
7. Nationalised nursing facilities to be exempt from utility bills.
8. Nationalised nursing facilities to be given food by local supermarkets at cost-price to them; the facility to bear the cost of the transport of food.
9. Recommendations (1-14), as above noted, to apply.
lenin nightingale 2014
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