Domestic violence against elderly with handicap

1 DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP Marília Santos Silva1 1Faculty of Medicine of the University of Porto, Portugal Author Note: Correspondence concerning this article should be addressed to Marília Santos Silva, Faculty of Medicine of Porto University, Al. Prof. Hernani Monteiro, 4200-319 Porto, Portugal. Phone number: +351 912035658. E-mail: [email protected]. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 2 Abstract Abuse against elders with disability is a problem with tendency to grow as the world population is aging. Though of obligatory reporting, cases of abuse are most frequently ignored by health professionals, for a variety of reasons, one of which is the difficulty of making the correct diagnosis, even though they are on a privileged position by the proximity to both victims and abusers. By making a revision of alleged domestic violence cases against elders with moderate to severe disability we aimed to promote a better knowledge about this theme to encourage the detection and prevention of future cases, namely by health professionals. In our sample, the most frequently reported type of abuse was physical (86%), perpetrated by male abusers (63%) living with their victims (90%), most commonly their children (47%) or their partners (when victims are married; 49%). Victims were most frequently female (63%), with motor disabilities (49%), and presented a history of previous episodes of abuse in 74% of cases, though only 28% were reported. Consequences of abuse were most frequently minor injuries (95%) with or without associated pain, with permanent consequences (scars) resulting in only 6.8% of cases. Lesions were multiple in the majority of cases (64%), the preferential locations being the head and neck (75%). Keywords Domestic Violence; Elder; Disability DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 3 Introduction The most consensual definition, adopted by the World Health Organization, describes elder abuse as a single or repeated act or lack of appropriate action, occurring within any relationship in which there is an expectation of trust or dependence, that causes harm or distress to older people, thus contributing to decreased quality of life, increased morbidity, reduced survival and possibly death[1, 2]. The use of different definitions, as well as sampling and survey methods, applied to different populations makes it difficult to compare studies, describe elder abuse and estimate its prevalence[2-5], with values ranging from 3.2% to 27.5% in general population studies from different countries[5]. Some experts believe that the incidence and prevalence of elder abuse may be increasing, but it is not known if this growth is due to better recognition and report or to an actual escalation in the number of cases. What is certain is that elder abuse cases will become more frequent with the aging of the world population. In Portugal, from 2001 to 2011, the population under the age of 15 decreased from 16% to 15% of the total population, with a simultaneous increase in the population over the age of 65 from 16% to 19%[6], marking a shift in the age pyramid which had already been predicted and is expected to worsen considering the higher longevity and decreased birth rate. Although most elders are autonomous and independent, it is known that older populations have higher prevalence of health disorders and added consequences of accidents. According to elder abuse literature, mental illness[7-11], poor physical health[12-14] or poor health in general[15] constitute risk factors for abuse. Elders with physical and/or mental disability are at even higher risk as they have inherent limitations in daily living activities[12, 16, 17] that make them completely or partially DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 4 dependent[5], and in many cases isolated from society. Lower physical resistance to violence, lower capacity to escape from it and/or higher difficulty to understand and report the abuse[2, 13, 18] are also possible explanations for the increased risk of abuse in elders with disabilities. Abuse against these elders is, thus, an expected event in the aging population, with 50% of people 65 years of age or older, in Portugal, declaring to have much difficulty in performing at least one of six activities of daily living (seeing, hearing, walking, memory/concentration, bathing/dressing up, understanding/making themselves understood)[6]. Elder abuse is most frequently perpetrated by family members[2], which may constitute domestic violence cases. This may be partly explained by higher levels of violence, stress, burnout and financial problems affecting the caregivers[1, 3, 4], that may even lead to deadly consequences[19]. Notwithstanding the fact that elders with health problems frequently visit their physicians, these being in a privileged position to detect and report cases of elder abuse, only 2% of suspected cases are reported by physicians[20]. In Portugal, domestic violence constitutes a “public crime”, so the Public Prosecutor Office may institute criminal proceedings even though the victim does not express will to press charge; in these cases, public employees have the legal obligation to report every suspected case that they come to acknowledge during their professional activity. Moreover, according to the 53rd article of the Ethics’ Code of the Portuguese Medical Association, physicians have the obligation to report these situations to the authorities. However, in addition to the difficulty of distinguishing symptoms and signs of abuse from those age-related or of other disorders, physicians fail to report due to a variety of reasons that might include, among others[2, 3, 21]: (a) unawareness of the obligation to report; (b) DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 5 unawareness of available victim support associations, thus considering that the victim may be more endangered if the abuse is reported; (c) time limitations that make them choose solving other of the patient’s problems; (d) preference to keep the patientphysician relationship, when the patient does not want to report the abuse; and (e) fear of implication in a legal process. Among cases involving a moderate or severe disability, these patients being frailer and at increased risk, there may be greater difficulty in making the correct diagnosis and, consequently, the report. Due to their characteristics, these cases deserve special attention for the detection of abuse. The aim of this study is to promote a better knowledge about domestic violence perpetrated against elderly people presenting physical and/or mental disabilities that make them dependent and/or without autonomy, in order to promote the detection and prevention of these cases, namely by health professionals. Methods A retrospective analysis of clinical forensic medical reports was performed. Cases’ inclusion criteria were: (a) alleged victim 65 years of age or older presenting, prior to the suspected episode of abuse, a moderate or severe physical and/or mental disability, corresponding to a rate disability superior to 60% (determined according to the Portuguese National Table of Disabilities – annex 1 of the Decree-Law 352/2007, of 23rd of October) or to a disability that conditioned dependency or loss of autonomy for daily living activities; (b) allegedly abused by a family member (with or without cohabitation); (c) having been submitted to a forensic medical evaluation in the scope of criminal law; (d) at the north branch of the National Institute of Legal Medicine and Forensic Sciences of Portugal, in Porto; (e) between 2005 and 2013. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 6 Data extracted from reports included characterization of: (a) the alleged victim’s and abuser’s socio-demographics; (b) the relationship between alleged victim and abuser; (c) the type of disability presented by the victim; (d) previous episodes of violence perpetrated by the same alleged abuser; and (e) the episode of abuse that motivated the report and consequent forensic medical examination, namely its type, the resultant lesions, the need for medical treatment and the existence of permanent physical consequences. It was considered that for all types of abuse, psychological abuse exists simultaneously, so this type of abuse is only referred when it occurred in isolation. Victims were divided in 2 groups depending on their disability degree: (a) moderate (when they had autonomy with some dependencies, excluding third person dependence); (b) severe (when they were dependent on a third person). Victims’ disabilities were categorized in 5 groups, corresponding to: (a) mental; (b) motor; (c) sensorial; (d) other disabilities; and (e) multiple disabilities (when more than one type of disability was present). Findings were recorded in a database and studied using SPSS (Statistical Package for Social Science - SPPS INC, Chicago, Illinois, USA) version 21.0, for Windows. Descriptive statistics was performed using frequency analysis for categorical variables and descriptive analysis for continuous variables. Contingency tables were created to study the relationship between categorical variables and Chi-Square or Fisher’s test were used to verify the independence and non-existent relationship between variable categories. Variables were considered to be related when p<0.05. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 7 Results A total of 1278 forensic medical reports related to alleged intrafamilial elder abuse were analyzed, of which 70 (5.5%) were selected according to the above criteria. Victim’s and abusers socio-demographic characterization Victims’ and abusers’ socio-demographic characterization is presented in table 1. Victims were mostly female (n= 26, 62.9%), married (52.9%) and retired (94.3%), the majority presenting moderate disability (55.7%). Mean age was 76.94 years old (SD=7.689; median=76; Min.=65; Max.=95), and male and female victims had approximately the same mean age (mean=75, SD=8 vs. mean=78, SD=8). The proportion of severe disability was higher among female victims (56.8% vs. 23.1%; p=0.006), and victims older than 74 years of age (57.5% vs. 26.7%; p=0.010). Abusers were male in 62.9% (n=44). There was no significant relation between abuser’s and victim’s sex (p=0.087). Their mean age was 52.53 years old (SD=16.626; median=50; Min.=20; Max.=88). In the 28 cases with available information, none of the abusers had a professional activity. Information about substance abuse was included in 24 reports, of which 75% referred to its presence, alcohol being the most frequent (n=13). Information about psychiatric disorders was included in 11 reports, with 72.7% victims referring their abusers as having some sort of this type of pathology. Table 2 presents the relationship between alleged victims and abusers in the total sample and in married victims (n=37). Though when considering the totality of cases the majority had been allegedly perpetrated by victim’s children (47.1% vs. 32.4% for partners), within married victims, partners corresponded to 48.6% of cases (vs. 28.6% for children). In 46 cases for which there was information, 89.7% (n=52) of abusers were living with the victims. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 8 Victims’ disability characterization Proportion and description of the different types of disabilities is presented in Table 3. Motor disability was the most frequent disability presented by the victims, corresponding to 48.6% of cases, followed by multiple disabilities (30%), sensorial disability (8.6%), mental disability (7.1%) and other types (5.7%). Overall, the proportion of victims with motor disabilities was 77.1% (n=54), with mental disabilities was 24.3% (n=17), with sensorial disabilities was 22.9% (n=16) and with other types was 11.4% (n=8). Description of previous episodes of abuse by the same alleged abuser Information about previous episodes of abuse by the same alleged abuser was present in 74.3% (n=52) of forensic medical reports. It was not described whether there was a background of abuse in 15 (21.4%) cases. Table 4 presents descriptive statistics of the previous episodes of abuse. The periodicity of abuse was specified in 29 forensic medical reports, with 93.1% of victims referring to have been frequently abused, 25 specified its duration, with 40% mentioning it was superior to 10 years, and 42 stated the occurrence of previous reports with 69% (n=29) denying its occurrence. Of those which had history of previous reports (n=13), in 8 the report had been made by the victim. There was no significant relation between the victims’ background of violence and the victims’ sex (p=1.000) or the disability degree (p=0.611). In 51 cases for which it was possible to determine the category of abuse and considering the association between multiple types of abuse, the most frequent type was physical abuse (n=41), followed by financial (n=11), psychological (when isolated; n=8) and sexual (n=1). Among these cases, neglect was observed simultaneously with 9 cases of physical abuse, 4 of physical plus financial abuse and 1 of financial abuse, DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 9 corresponding mostly to nutritional and hygiene neglect, followed by medication, health care, rest, affection and housing/safety neglect. Description of the episode of abuse that motivated the report The types of abuse that motivated the report were physical abuse in 85.7% (n=60) of cases, physical and financial abuse in 8.6% (n=6), and psychological abuse in 5.7% (n=4). Similarly, in these cases, neglect was identified in 6 cases of physical abuse and 4 cases of physical plus financial abuse, involving nutritional, hygiene, rest, health care, medication and affection neglect. Physical abuse corresponded to an aggression only by means of body strength (excluding attempted asphyxiation) in 72.9% (n=43) of cases, to aggression through use of blunt objects in 8.5% (n=5), to aggression with resource to body strength (excluding attempted asphyxiation) and to a blunt object in 13.6% (n=8), to attempt to strangle in 3.4% (n=2) and to privation of basic needs in 1.7% (n=1) of cases. Among cases of aggression only by means of body strength the most frequently involved types (not always occurring in isolation) were: pushing (n=27, 51.9%), pounding (n=25, 48.1%), grasping (n=8, 15.4%), slapping (n=8, 15.4%), kicking (n=8, 15.4%), scratching (n=6, 11.5%), hair pushing (n=1, 1.9%) and biting (n=1, 1.9%). There was no significant relation between the occurrence of physical abuse and the victims’ (p=0.800) or abusers’ (0.800) sex, or the victims’ disability degree (p=1.000). Physical abuse resulted in pain in 5.6% (n=3) of cases, minor injuries in 24.1% (n=13) and minor injuries with pain in 70.4% (n=38). In only 6.8% (n=4) an organic permanent consequence was found (scar). Consequences of physical abuse were not described in 12 forensic medical reports, either because they had evolved to cure at the time of the forensic evaluation or because no physical consequences resulted. Injury distribution is DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 16 psychological abuse as a significant or serious form of abuse by many people, especially when compared to physical abuse. It is also possible that psychological abuse is not as predominant over physical abuse as self-reported by caregivers, since people may tend to hide behaviors considered most reprehensible, thus disclosing psychological abuse more easily than physical abuse. Literature mentions financial abuse as more prevalent than physical abuse among elders[1]. However, it was present in only 8.6% of our cases. It is possible that these cases are not referred as the victim may feel that the forensic expert is not the appropriate person to whom they should denounce this type of abuse as it is not directly associated with their health. Another explanation may be that the police might not direct financial abuse to a forensic medical examination. Sexual abuse was reported in only one of the cases of our sample, and as an event occurring in the distant past. This type of abuse may be hidden as sex is still seen as a taboo topic in the eldest groups of our society. However, the reported prevalence of this type of abuse is also low among European countries (0.7%)[1], thus being difficult to represent in a sample such small as ours’[28]. Among cases in which a preliminary report was written, less than half were concluded. That may reflect withdrawal from complaint (when the public prosecutor does not see the case as a domestic violence one), denial of charges (when the victim is blackmailed by the abuser to do so, or when the report is presented against the victim’s will) or death of the victim. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 17 Conclusions From this study, we can conclude: a) The proportion of 5.5% of victims with disability observed among all cases of elders allegedly abused by family members presented to forensic medical evaluation at the north branch of the National Institute of Legal Medicine and Forensic Sciences of Portugal, in Porto, seems clearly underestimated; b) The victims are predominantly female (63%); c) Motor disability (49%) appears to be much more frequent than mental disability (7%) in our sample of abused elders; however, there may be more significant underreporting in the last group; d) Elders with severe disability have reports presented by a third person more frequently than elders with moderate disability; the same happens when comparing elders with and without mental disability; e) The abusers are predominantly male (63%) and living with the victims (90%); f) Although most abusers are victims’ children (47%), married victims are most frequently abused by their partners (49%); g) Most victims have previous history of abuse by the same abuser (74%), in multiple cases for many years and with frequent episodes (93%); h) Physical abuse is the most frequently reported type of abuse (86%); i) Abused elders frequently present with multiple superficial injuries (64%), mostly in the head and neck (75%). Since this was a retrospective study of forensic medical reports, caution must be taken in the generalization of our results to the general population of elders with moderate or severe disability. DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 18 Declaration of Conflicting Interests There were no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research or preparation of this article. Ethical approval This study was carried out in accordance with ethical rules. It has not been submitted to Ethical Approval since it was a retrospective review in which no invasive studies were carried out nor identification of the individuals was given. References 1. Sethi, D., et al., European report on preventing elder maltreatment, 2011, World Health Organization: Denmark. 2. Bond, M.C. and K.H. 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DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 22 Tables Table 1: Victims’ and abusers’ socio-demographic data (n=70) Victims n (%) Abusers n (%) Marital status Married 37 (52.9) - Widowed 25 (35.7) - Divorced 5 (7.1) - Single 3 (4.3) - Professional activity Retired 66 (94.3) 9 (32.1)* Without activity 4 (5.7) 1 (3.6)* Unemployed 0 18 (64.3)* Without information 0 42 (60) Degree of disability Moderate 39 (55.7) - Severe 31 (44.3) - Substance abuse Yes - 18 (75.0)* No - 6 (25.0)* Without information - 46 (65.7) Psychiatric disorders Yes - 8 (72.7)* No - 3 (27.3)* Without information - 59 (84.3) *Valid percent DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 23 Table 2: Relationship between victim and abuser. Relationship Total (n=70) n (%) Married victims (n=37) n (%) Partner 20 (28.6) 18 (48.6) Children 33 (47.1) 12 (32.4) Children-in-law 10 (14.3) 3 (8.1) Grandchildren 5 (7.1) 3 (8.1) Other 2 (2.9) 1 (2.7) DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 24 Table 3: Victims’ disability characterization (n=70) n (%) Type of disability Mental 5 (7.1) NSD (3); Alzheimer’s disease (1); Aphasia (1) Motor 34 (48.6) MSP (18); MSP and hemiparesis (3); MSP and monoparesis (1); MSP and ataxia (1); Hemiparesis (4); Monoparesis (3); Parkinson’s disease (3); Hemiparesis and dysarthria (1) Sensorial 6 (8.6) Decreased visual acuity (3); Decreased hearing acuity (1); Amaurosis (1); Bilateral deafness (1) Other 4 (5.7) Renal failure (2); Respiratory failure (2) Multiple 21 (30) NSD and MSP (4); NSD with aphasia and ataxia (1); Alzheimer’s disease and MSP (1); Parkinson’s disease with dementia and MSP (1); Alzheimer’s disease and decreased hearing acuity (1); Hemiparesis and decreased visual acuity (2); MSP with decreased hearing acuity (2); MSP with bilateral blindness (1); MSP with decreased hearing and visual acuity (1); MSP, loss of sphincter continence and neoplastic pathology (1); Parkinson’s disease with MSP and pneumonia (1); MSP and renal failure (1) NSD with MSP, hemiparesis, loss of sphincter continence and decreased hearing acuity (1); Cognitive impairment with aphasia, MSP, loss of sphincter continence and decreased hearing and visual acuity (1); Parkinson’s disease with dementia, MSP and decreased visual acuity (1); NSD, MSP and epilepsy (1) MSP: Musculoskeletal pathology; NSD: Non-specified dementia DOMESTIC VIOLENCE AGAINST ELDERLY WITH HANDICAP 25 Table 4: Background of abuse (n=52) n % Periodicity Frequently 27 93.1* Sporadically 2 6.9* Without information 23 44.2 Duration < 1 month 3 12.0* 1 month-1 year 8 32.0* 1-5 years 4 16.0* >10 years 10 40.0* Without information 27 51.9 Type of abuse Psychological 8 15.7* Physical 31 60.8* Financial 2 3.9* Physical + Financial 9 17.6* Physical + Sexual 1 2.0* Without information 1 1.9 Report Yes 13 31.0* No 29 69.0* Without information 10 19.2 *Valid percent