"Too Grey To Be True?" Sexual Violence in Older Adults: A Critical Interpretive Synthesis of Evidence

Healthcare experiences of pregnant and postnatal women and healthcare professionals when facing child protection in the perinatal period: A systematic review and Critical Interpretative Synthesis

BACKGROUND

The perinatal period is known as time of transition and anticipation. For women with social risk factors, child protection services may become involved during the perinatal period and this might complicate their interactions with healthcare providers.

AIM

To systematically review and synthesise the existing qualitative evidence of healthcare experiences of women and healthcare professionals during the perinatal period while facing child protection involvement.

METHODS

A systematic search of databases (Web of Science, MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, MIDIRS, Social Policy and Practice and Global Health) was carried out in January 2023, and updated in February 2024. Quality of studies was assessed using the Critical Appraisal Skills Programme. A Critical Interpretative Synthesis was used alongside the PRISMA reporting guideline.

RESULTS

A total of 41 studies were included in this qualitative evidence synthesis. We identified three types of healthcare interactions: Relational care, Surveillance and Avoidance. Healthcare interactions can fluctuate between these types, and elements of different types can coexist simultaneously, indicating the complexity and reciprocal nature of healthcare interactions during the perinatal period when child protection processes are at play.

CONCLUSIONS

Our findings provide a novel interpretation of the reciprocal interactions in healthcare encounters when child protection agencies are involved. Trust and transparency are key to facilitate relational care. Secure and appropriate information-sharing between agencies and professionals is required to strengthen healthcare systems. Healthcare professionals should have access to relevant training and supervision in order to confidently yet sensitively safeguard women and babies, while upholding principles of trauma-informed care. In addition, systemic racism in child protection processes exacerbate healthcare inequalities and has to be urgently addressed. Providing a clear framework of mutual expectations between families and healthcare professionals can increase engagement, trust and accountability and advance equity.

"In the End You Keep Silent": Help-Seeking Behavior Upon Sexual Victimization in Older Adults

Sexual violence is considered a prominent mental health problem. Exposure to sexual victimization during lifetime has been linked to mental health problems in old age. Research in adult victims has shown that they experience many barriers for disclosure and seeking professional help upon sexual victimization. However, information on help-seeking behavior in older victims of sexual violence is non-existent. With this study we aim for a better understanding of help-seeking behavior upon sexual violence in older adults. We used a mixed methods approach with an explanatory sequential design. Data were collected through structured face-to-face interviews with a random sample of 227 sexual violence victims of 70 years and older living in Belgium. Quantitative data were triangulated with qualitative data from 15 in-depth interviews with older victims. We found that up to 60% of older sexual violence victims never disclosed their experiences and 94% never sought professional help. Help-seeking is a complex process comprising several phases, which are affected by strong feelings of shame and self-blame, ageist premises and taboos about sexuality. In the end, most victims choose to cope on their own. Occasional disclosure only happens decades after the sexual violence took place. Older victims do not spontaneously disclose to healthcare workers but expect professionals to initiate the conversation. In conclusion, few older victims disclose or seek professional help upon sexual victimization. Healthcare professionals working with older adults need capacity building through training, screening tools, and care procedures to initiate conversation on sexual violence, and to detect signs, prevent, mitigate and respond to sexual victimization in older adults.

"Just something that happened?": Mental health impact of disclosure and framing of sexual violence in older victims

INTRODUCTION

Despite the important impact of sexual violence (SV) on mental health, few victims disclose their experiences. Although research in adult victims suggests that SV disclosure could protect against long-term mental health problems, studies in older adults are lacking.

OBJECTIVES

To establish the prevalence of depression, anxiety, posttraumatic stress disorder (PTSD), suicide attempts, and self-harm, their association with SV disclosure, and the moderating effect of sociodemographic characteristics and SV framing in the relation between SV disclosure and the different mental health outcomes in older SV victims.

METHODS

Data on sexual victimisation, mental health, SV framing, and disclosure were collected through structured face-to-face interviews with 171 randomly selected sexually victimised adults of 70 years and older living in Belgium. SV was measured using behaviourally specific questions based on a broad definition. Mental health outcomes were measured using validated scales.

RESULTS

Depression, anxiety and PTSD were reported by 34%, 33% and 9% of participants respectively, 5% had attempted suicide and 1% reported self-harm during lifetime. SV framing was associated with the kind of help victims consulted. SV disclosure was not linked with depression and anxiety, but was associated with an increase of PTSD symptoms in older victims with care dependency (p = 0.004) or a chronic illness and/or disability (p = 0.025).

CONCLUSIONS

SV disclosure in itself does not protect against adverse mental health outcomes in old age. Capacity building of professionals trough training and development of clinical guidelines and care procedures may increase appropriate response to SV disclosure by older victims.

Relationship between Sexual Violence and the Health of Spanish Women-A National Population-Based Study

BACKGROUND

Health consequences are likely to be different when sexual violence is analysed independently from other types of violence. It is also likely that different health consequences will result in the cases of partner or ex-partner sexual violence, non-partner sexual violence and sexual harassment.

METHODS

This study is based on the 2019 Macro-survey of Violence against Women conducted by the Spanish Ministry of Equality on a sample of 9568 women aged 16 years or older. Odds ratios were calculated, and multinomial logistic regression analyses were performed.

RESULTS

The present study estimates that 4 out of 10 surveyed women had experienced some form of sexual violence in their lifetime. Sexual harassment is the most frequently reported form of this violence, while intimate partner sexual violence is the form with the most unfavourable sociodemographic characteristics and the worst health impact indicators, such as a greater likelihood of suicidal behaviour.

CONCLUSIONS

Sexual violence is a widespread, under-studied problem with negative health impacts. Women exposed to intimate partner violence are the most vulnerable and at risk. It is advised that responses and comprehensive care plans be developed that place special emphasis on the protection of victims' mental health.

Forms of sexual assault against older women in the context of acquaintance relationships: An intersectional perspective

This study addresses forms of sexual assault against women in late life (SAWLL) from an intersectional perspective, focusing on acquaintance relationships. Qualitative research was conducted, using in-depth interviews with 18 welfare and healthcare professionals who treated sexual assault survivors. Five forms (themes) emerged, relevant to the identification of SAWLL: (1) Coercive sexual assault in the context of changes brought on by old age, (2) contempt and sexual humiliation based on ageist and sexist social constructions, (3) violation of the older women's dignity in the multigenerational context, (4) life-long incestuous relationships and sexual assault against older women and (5) erotic touching and exhibitionism in caregiving relationships. The revealed forms emphasise the vulnerability of older women who are sexually assaulted in domestic relationships by perpetrators whom they know. These forms can contribute to filling the existing gap in knowledge on SAWLL and promote the visibility of sexually assaulted older women in the justice system. In addition, they can aid law enforcement, health and welfare professionals and policymakers to advance the general understanding of SAWLL as well as improve the response to this phenomenon.

Neighborhood-Level Predictors of Sexual Violence Across Intimate Partner and Non-Intimate Partner Relationships: A Case-Control Study

Ample research explores individual factors associated with sexual violence, yet individual, dyadic, and environmental influences on intimate partner sexual violence (IPSV) occurring in the larger context of non-intimate partner violence (NIPSV) remain relatively unexplored. The current study aimed to determine the extent to which county-level indicators in combination with individual and dyadic factors are associated with sexual violence across relationship types. Reported IPSV and NIPSV cases were obtained from the Tennessee Bureau of Investigation's (TBI) online incident-based reporting system. County-level variables indicative of neighborhood physical disorder, violent crime, income inequality, firearm prevalence, and community alcohol use patterns were retrieved from the online resource County Health Rankings and Roadmaps. Using a nested case-control design, we determined significant sexual violence risk within younger cohorts and across relationship types, finding three significant county-level factors: 1) income inequality, 2) rate of firearm fatalities, and 3) percentage of female residents. Suggested prevention and intervention efforts include targeting younger age groups for IPSV and NIPSV education, developing resources for a range of relational partners, improving legal access and law enforcement training for reporting, and continued examination of the role of firearms.

Challenges in Conducting Sexual Health and Violence Research in Older Adults Beyond the General Data Protection Regulation: A Belgian Case Study

Because of a growing older population, the sexual health (SH) of older adults, including sexual violence (SV), is becoming an increasingly important public health concern. Yet, reliable SV prevalence rates and risk factors are lacking, due to methodological shortcomings in current studies. SV research involves challenges regarding safety and disclosure, especially in older adults. In this paper, we reflect on the methods used in a sexual health and violence (SH&V) study in older adults balancing between privacy rules imposed by the General Data Protection Regulation (GDPR) and ethical and safety guidelines.To ensure the acceptability of the questionnaire, it was tested in a two-phase pilot study. To maximize SV disclosure, the questionnaire built up gradually towards the more sensitive SV modules. Interviewers were trained to approach participants in a non-judgmental manner. Due to GDPR, our data collection method was changed from a random sampling via the National Register to a cluster random probability sampling with a random walk finding approach.Older adults were willing to discuss SH&V during a structured face-to-face interview with trained interviewers. Following strict safety guidelines, no major incidents were reported. The cluster random probability sampling with random walk finding approach provided an adequate sampling frame, but was inefficient and time-consuming.Doing research on SH&V in older adults is feasible but requires a substantial investment of time and the challenges involved may incur greater costs. In order to guarantee further research on sensitive topics in older adults, we recommend that an interdisciplinary expert group consisting of researchers, donors, and policymakers investigates how GDPR and public health research in hard-to-reach populations can be better matched.

"Time Does Not Heal All Wounds": Sexual Victimisation Is Associated with Depression, Anxiety, and PTSD in Old Age

Sexual violence (SV) has an important impact on mental health. Childhood sexual abuse is linked to internalising disorders in later life. In older adults, SV occurs more often than previously believed. Moreover, health care workers lack the skills to address SV in later life. Studies researching the mental health impact of lifetime SV, i.e., SV during childhood, adulthood, and old age, are lacking. Between July 2019 and March 2020, 513 older adults living in Belgium participated in structured face-to-face-interviews. Selection occurred via a cluster random probability sampling with a random walk finding approach. Depression, anxiety, and posttraumatic stress syndrome (PTSD) were measured using validated scales. Participants were asked about suicide attempts and self-harm during their lifetime and in the past 12 months. SV was measured using behaviourally specific questions based on a broad SV definition. We found rates for depression, anxiety, and PTSD of 27%, 26%, and 6% respectively, while 2% had attempted suicide, and 1% reported self-harm in the past 12 months. Over 44% experienced lifetime SV and 8% in the past 12 months. Lifetime SV was linked to depression (p = 0.001), anxiety (p = 0.001), and PTSD in participants with a chronic illness/disability (p = 0.002) or no/lower education (p < 0.001). We found no link between lifetime SV and suicide attempts or self-harm in the past 12 months. In conclusion, lifetime SV is linked to mental health problems in late life. Tailored mental health care for older SV victims is necessary. Therefore, capacity building of professionals and development of clinical guidelines and care procedures are important.

Sexual violence in older adults: a Belgian prevalence study

Background

Sexual violence (SV) is an important public health problem which may cause long-lasting health problems. SV in older adults remains neglected in research, policies and practices. Valid SV prevalence estimates and associated risk factors in older adults are currently unavailable. In this study we measured lifetime and past 12-months sexual victimisation in older adults living in Belgium, its correlates, assailant characteristics and the way that victims framed their SV experiences.

Methods

SV was measured using behaviourally specific questions based on a broad definition of SV. Participants were selected via a cluster random probability sampling with a random route finding approach. Information on sexual victimisation, correlates, assailant characteristics and framing was collected via structured face-to-face interviews with adults aged 70 years and older living in Belgium (community-dwelling, assisted living and nursing homes).

Results

Among the 513 participants, the lifetime SV prevalence was 44% (55% F, 29% M). Past 12-months prevalence was 8% (9% F, 8% M). Female sex and a higher number of sexual partners were associated with lifetime SV (p < .05), non-heterosexual sexual orientation with past 12-months SV (p < .05). Correlates identified to be linked to elder abuse and neglect in previous studies were not linked with SV in our sample. ‘Someone unknown’ was identified as most common assailant.

Conclusions

Sexual victimisation appears to be common in older adults in Belgium. Both correlates and assailant characteristics seem to differ from previous studies on elder abuse and neglect. Recognizing older adults as a risk group for sexual victimisation in research, policies and practices is of the utmost importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02485-3.

'Breaking the silence': Sexual victimisation in an old age psychiatry patient population in Flanders

BACKGROUND

Sexual violence (SV) is linked to mental health problems in adulthood and old age. However, the extent of sexual victimisation in old age psychiatry patients is unknown. Due to insufficient communication skills in both patients and healthcare workers, assessing SV in old age psychiatry patients is challenging.

AIMS

To assess lifetime and sexual victimisation in the past 12-months, correlates and SV disclosure in an old age psychiatry population.

METHODS

Between July 2019 and March 2020, 100 patients at three old age psychiatry wards across Flanders participated in a face-to-face structured interview receiving inpatient treatment. The participation rate was 58%. We applied the WHO definition of SV, encompassing sexual harassment, sexual abuse with physical contact without penetration, and (attempted) rape.

RESULTS

In 57% of patients (65% F, 42% M) SV occurred during their lifetime and 7% (6% F, 9% M) experienced SV in the past 12-months. Half of the victims disclosed their SV experience for the first time during the interview. Only two victims had disclosed SV to a mental health care professional before.

CONCLUSIONS

Sexual victimisation appears to be common in old age psychiatry patients, yet it remains largely undetected. Although victims did reveal SV during a face-to-face interview to a trained interviewer, they do not seem to spontaneously disclose their experiences to mental health care professionals. In order to provide tailored care for older SV victims, professionals urgently need capacity building through training, screening tools and care procedures.

The Elephant in the Room - A Critical Interpretive Synthesis of Older Adults' Sexuality

Objectives

This study aimed to explore past studies that have focused exclusively on the sexuality of adults older than 65 from a positive public health approach.

Methods

We performed a critical interpretive synthesis, starting with the literature review on sexual behaviors in later life, adding policy documents on aging sexuality, and bringing new perspectives.

Results

Older adults continue to be sexually active. Healthcare professionals lack knowledge and communication skills surrounding aging sexuality and no policies before 2013 mention aging sexuality.

Conclusions

We posit that society's view of later life sexuality reflects on practice, policies, and research on this topic, which influence back society's view.