Elder abuse and oppression: voices of marginalized elders

© The Author 2007. Published by Oxford University Press on behalf ofThe British Association of Social Workers. All rights reserved.

British Journal of Social Work (2007), 1 of 24doi:10.1093/bjsw/bcm022

Violence Across the Lifespan: Interconnections Among Forms of Abuse as Described by Marginalized Canadian Elders and their Care-giversChristine A. Walsh, Jenny Ploeg, Lynne Lohfeld, Jaclyn Horne, Harriet MacMillan and Daniel Lai

Christine A. Walsh is an Assistant Professor of Social Work at the University of Calgary. Herresearch interests include the examination of violence across the lifespan, child maltreatment,intimate partner violence and elder abuse, and participatory action research and community-based research with populations affected by issues of poverty or violence.Jenny Ploeg is an Associate Professor at the School of Nursing of McMaster University. Herresearch interests include qualitative and quantitative research related to high-risk elderlypersons and their care-givers. Dr Ploeg holds a CIHR/St Joseph’s Healthcare Hamilton inves-tigator award.Lynne Lohfeld is an Assistant Professor in the Department of Clinical Epidemiology andBiostatistics at McMaster University, as well as a faculty member in the Program for Educa-tional Research and Development (PERD), and an associate member of the Department ofFamily Medicine and the School of Geography and Life Sciences, also at McMaster University.Her research interests include aging and health, qualitative research, community-based partici-patory action research, ethics and programme evaluation. Jaclyn Horne is a Masters of Social Work student at the University of Calgary. Her researchinterest is in gerontology, with focuses on driving cessation, dementia, care-giver burden, long-term care seniors’ housing and elder abuse.Dr Harriet MacMillan—a member of the Offord Centre for Child Studies—is a psychiatristand pediatrician conducting research on the epidemiology of violence against children andwomen. She is a Professor in the Departments of Psychiatry and Behavioural Neurosciences,and Pediatrics at McMaster University and holds the David R. (Dan) Offord Chair in ChildStudies. Daniel Lai is Professor of Social Work and Alberta Heritage Health Scholar at the Univer-sity of Calgary. His research interest is in gerontology and social work with older adults,with special focus on health, well-being and culture in the aging population. He was theSocial Policy and Practice Section Editor of the Canadian Journal on Aging. Currently,Daniel is also on the Institute Advisory Board of the Institute of Aging of the CanadianInstitutes of Health Research.

Correspondence to Christine A. Walsh, PhD, Faculty of Social Work, University ofCalgary, 2500 University Drive NW, Calgary, Alberta, Canada T2N 1N4. E-mail:[email protected]

British Journal of Social Work Advance Access published March 23, 2007

2 of 24 Christine A. Walsh et al.

Summary

Elder abuse is recognized as a major problem, with profound effects on the health andquality of life of older persons. In our aging population, elder abuse represents anescalating clinical issue for social workers and health care professionals who provide careto older people. A major gap in our examination of elder abuse is the potential contribu-tion and application of knowledge developed within research derived from other formsof family violence. This paper explores the interconnections among various forms of viol-ence across the lifespan, and the experiences voiced by marginalized elders and their careproviders. We interviewed seventy-seven rarely consulted older adults and forty-threeformal and informal care-givers of older adults in focus groups in Ontario and Alberta,Canada. Study findings revealed four major themes that describe interconnections amongtypes of abuse: (i) intergenerational cycles of abuse; (ii) violence across the lifespan; (iii)exposure to multiple subtypes of elder abuse; and (iv) ongoing spouse abuse that shiftedinto elder abuse. The results from this study indicate that victims often ‘suffer in silence’and cultural factors, ageism and gender are ubiquitous to elder abuse. Recommendationsto reduce elder abuse include education, formal and informal supports and services.

Keywords: aging, elder abuse, marginalized elders, family violence

Violence has been recognized as a major problem that is continuing to growworldwide (Krug et al., 2002). The abuse of older adults is a common type ofviolence, recently identified as an area requiring urgent action in the WorldHealth Organization (WHO) International Plan of Action on Ageing (2002).The WHO and the International Network for the Prevention of Elder Abuse(INPEA)—Missing Voices Study (2002) employed focus group methodologyto gather the views of older persons and primary health care providers on elderabuse in developed and developing countries (Argentina, Brazil, Canada,India, Kenya, Lebanon and Sweden). Commonly identified types of elderabuse include: structural and societal abuse (e.g. inadequate government pol-icies, health care cuts and inadequate pensions), disrespect and ageist attitudes,legal and financial abuse (e.g. violation of human, legal and medical rights),psychological, emotional and verbal abuse, and physical abuse (WHO/INPEA,2002). In addition, some experts and practitioners include neglect and aban-donment, although others view it as a form of maltreatment rather than abuse.

Abuse and neglect can have a profound impact on the health and quality oflife of older persons (Fulmer, 2002). Maltreatment is associated with variousadverse health and life outcomes, including depression, increased likelihood ofplacement in nursing home, increased morbidity (Lachs et al., 1998, 2002) andelevated risk of death (Lachs et al., 1997). Increasing numbers and proportionsof older adults in Western societies, together with the increased demand forfamily care-giving (Schiamberg and Gans, 2000), have led some to speculatethat a rise in all forms of abuse of older adults is likely (Fulmer et al., 2000). Forthese reasons, elder abuse represents a major issue for social workers andhealth care professionals working with older people.

Interconnecting Forms of Abuse 3 of 24

A large gap in our understanding of elder abuse is the potential contribution tobe made by applying knowledge acquired through research into other types offamily violence. Considerably more research has been done on child maltreat-ment and intimate partner violence than on elder abuse. Although findings inthese areas have contributed much to our understanding of the nature and impactof these forms of abuse, the ‘different forms of interpersonal violence historicallyhave had their own literature and focus’ (Hughes et al., 2005, p. 32), providing fewinsights into the theoretical underpinnings of abuse across the lifespan. A growingbody of evidence suggests that different types of violence from childhood to olderage share similar etiologies, risk and protective factors (Korbin et al., 1995; Harris,1996). Victims of one form of violence are at greater risk of experiencing otherforms (Hughes et al., 2005). Furthermore, different forms of violence may occursimultaneously in the same family and so the presence of one form of violencemay be a strong predictor of the existence of other forms in that setting (Appeland Holden, 1998). Such knowledge can be used by researchers and clinicians tohelp develop effective interventions to prevent or reduce the impact of violence,as well as treat its consequences (Tolan et al., 2006).

This paper will explore the interconnections among various forms of viol-ence across the lifespan, and the experiences voiced by marginalized elders andtheir care providers.

Interconnections among forms of abuse

To better understand the effects, impact and mechanisms of family violence,researchers have identified the need to consider data derived from all forms ofabuse (Wolf, 1996; Daro et al., 2004) because there are some important similari-ties among all forms across the lifespan. First and foremost, family violence, des-pite its different forms, is often associated with circumstances of power imbalance(Brandl and Cook-Daniels, 2002; Penhale, 2003). Despite the differences inwomen’s experiences in violence across the lifespan for example, similaritiesbetween spouse abuse among young and older couples have been identified(Korbin et al., 1989), including the abuser’s need to maintain control over victims(Harris, 1996; Brandl, 2000). Thus, an unequal power relationship between abuserand victim has been posited as the basis of all forms of family violence (Bergeron,2001). Other factors that are similar between forms of family violence includegender roles, stress of care-givers, isolation of abuse victims and the lack ofresources to reduce the effects of these factors (Penhale and Kingston, 1997).

To date, the least clearly understood form of family violence is elder abuse,particularly violence against older women (Wolf, 1996; Straka and Montminy,2006). Literature attempting to link elder abuse with other forms of family viol-ence has been described as immature (Wolf, 1996). Slep and O’Leary (2001) sug-gest that ‘by considering one form of family violence within the context of what isknown about the other, the etiological and causal relations among the specificforms of family aggression can be examined, thereby allowing us to develop


more powerful models of each form of family aggression’ (p. 89). They propose,however, that initial integrative models of family violence should focus on childphysical abuse and partner violence because these literatures are more mature.

Theoretical explanations for abuse across the lifespan

Several theoretical models have been advanced to explain the transmission offamily violence. The ‘cycle of violence’ or, more correctly, the intergenera-tional transmission of family violence has been the predominant model in theliterature (Widom, 1989; Murphy and Blumenthal, 2000). It posits that abuse ofchildren is an inevitable mechanism for the transmission of family violence(Murphy and Blumenthal, 2000). Although early research has shown thatabused children are at risk for later becoming abusive parents (Kaufman andZigler, 1987; Oliver, 1993), almost two-thirds of abused children do not go onto become abusive parents (Kaufman and Zigler, 1987; Narang and Contreras,2000). A host of factors such as parenting under twenty-one years, history ofmental illness or depression, and residing with a violent adult (Dixon et al.,2005a, 2005b) are thought to influence the relationship. Further, much of exist-ing research on the intergenerational transmission of violence is plagued withfundamental weaknesses (Ertem et al., 2000; Newcomb and Locke, 2001),resulting in limited empirical evidence to support this claim (Widom, 1989;Korbin et al., 1995). A prospective longitudinal birth cohort study, for example,found no association between exposure to inter-parental violence in childhoodand increased risk of physical inter-partner violence perpetration or victimiza-tion (Fergusson et al., 2006). Although Harris (1996) found confirmation forthe transmission of child maltreatment to violence in young adulthood, this didnot extend to the older adult participants in the study. Further, the intergener-ational transmission model is better able to explain child abuse than abuse ofelders (Korbin et al., 1995).

The social learning theory proposed by Bandura (1973) is one of the mostwidely accepted explanations for the intergenerational transmission of violence(Egeland et al., 1988) in the child maltreatment literature. This theory states thatphysical aggression and abuse are behaviours that children learn in the family inresponse to stressful situations or the need to control other people (Kalmuss,1984). Although this model has been used to explain abuse of older adults byadult children (Barnett et al., 2005), it is not well supported by empirical evidenceabout elder abuse (Korbin et al., 1995). The following section reviews literaturelinking specific major forms of family violence with elder abuse.

Child maltreatment and elder abuse

Research on elder abuse emerged in the 1980s, nearly two decades after childmaltreatment and spouse abuse research had become well established


(Pedrick-Cornell and Gelles, 1982; Korbin et al., 1989). As research on elderabuse developed, findings pointed to many of the same correlates that hadbeen previously established in child maltreatment research, such as care-giverstress and victim dependency (Korbin et al., 1989; Wolf, 1996) and physical,emotional or cognitive impairment of the victim (Dyer et al., 2000; Heilpornet al., 2006; Jayawardena and Liao, 2006; Vandeweerd et al., 2006). Despite thepredominant use of the intergenerational model of transmission of abusedeveloped as an explanation for child abuse within the earlier literature (Wolf,1996), the limited empirical research available suggests that this model may notoffer explanatory value for elder abuse (Korbin et al., 1995).

Spouse abuse and elder abuse

Much of the family violence literature has emphasized the effects of abuseagainst women on females of child-bearing and child-rearing ages, therebyexcluding domestic abuse against older women (Phillips, 2000; Rennison andRand, 2003; Straka and Montminy, 2006). This is an important gap in ourknowledge because we cannot assume that the needs of abused older womenare the same as those of their younger counterparts. Recent studies haveshown that women who have been abused by their partner when younger aremost at risk for abuse in later life (National Committee for the Prevention ofElder Abuse (NCPEA), 2006)—as shown by studies documenting that half ofspouse abuse involves couples that have experienced abuse earlier in life(Pritchard, 2001; Penhale, 2003). Canadian data show that older women areat less risk of domestic violence than younger women and, with advancingage, the risk continues to decline (Statistics Canada, 2005). This may resultfrom either women outliving their abusive spouses, or that the abusivespouses are no longer physically capable of violence. Male perpetrators ofviolence against seniors were often sixty-five years or older (30 per cent),reflecting the finding that a significant proportion of senior violence wasspousal violence (Statistics Canada, 2005). The lack of sufficient data, how-ever, means we cannot assume that abuse of older women is ‘wife abusegrown old’ (Phillips, 2000; NCPEA, 2006).

Studies have also shown that there are some older women who have experi-enced ‘late onset domestic violence’ that either intensified or began later in life(NCPEA, 2006). Some of the primary causes for this abuse include unexpecteddisability, retirement, other family role changes, such as becoming a care-giver,or starting new relationships that result in new abuse (NCPEA, 2006).

Despite these parallels, some authors acknowledge that the exact extent towhich elder abuse is linked with spouse abuse is indeterminable (Penhale,2003). There are qualitative differences between younger and older adult vic-tims of abuse that suggest the need to examine elder abuse as a separate, dis-tinct phenomenon (Wilke and Vinton, 2005). Socialization processes have beenattributed to differences that exist between younger and older victims of


spouse abuse (Zink et al., 2003). Cohort effects result in older women who aremore likely to be socialized to be submissive and to view abuse within the familyas a private matter than younger women, reducing the likelihood that olderwomen will report incidents of abuse or seek help in order to hold the marriagetogether (Zink et al., 2003; Wilke and Vinton, 2005). Individual and environmentalchanges, including health, finance, employment roles and social support foraging women, may lead to increased dependency, which may make them lesslikely to leave a situation of abuse (Buchbinder and Winterstein, 2003).

Other generational effects that differ between younger and older adults includetraditional gender roles (Rennison and Rand, 2003), attitudes towards marriage andfear of being alone after many years of marriage, making it more likely that olderwomen will stay in abusive relationships (Zink et al., 2003; Vinton, 1999; Wilke andVinton, 2005). Older women tend to have less knowledge about and access to serv-ices for abuse victims (Wilke and Vinton, 2005), as well as limited resources andenergy needed to leave such situations (Buchbinder and Winterstein, 2003).

According to Patterson and Malley-Morrison (2006), while ‘cross-culturalresearch on domestic violence and abuse generally has expanded, elder abuse,as a subtype of domestic violence, remains poorly understood cross-culturally’(p. 73). Cross-cultural differences have been noted in the perceptions of andrisk for abuse (Moon and Williams, 1993; Hudson et al., 1998; Buchwald et al.,2003; Patterson and Malley-Morrison, 2006). Some investigators have positedthat cultural differences place older women at greater risk of abuse thanyounger ones (Malley-Morrison and Hines, 2004). Family solidarity and prideof older adults within specific cultures have been documented to increase therisk for abuse of older adults (Moon, 2001). Other research indicates that reli-gious beliefs, social class and acculturation also play a role in elder abuse (Kos-berg et al., 2003). However, methodological issues such as sampling size andtechniques limited the ability in drawing conclusions regarding the role of cul-ture in elder abuse (Moon, 2001).

Purpose of study

The purpose of the Elder Abuse Study is to build upon the work of theMissing Voices Study (WHO/INPEA, 2002) and the report from Canada(Podnieks, 2001) to explore the perceptions of elder abuse held by groups ofolder adults and care-givers. We purposively sampled from groups of olderpersons and care providers who had not been consulted in these previousstudies and who traditionally have not been widely consulted when definingor discussing elder abuse. It was anticipated that an enriched conceptualiza-tion of elder abuse would emerge from these ‘additional’ missing voices.This paper is based on secondary analysis of the transcripts of focus groupinterviews with study participants in the larger project in order to betterunderstand the interconnections among different forms of violence acrossthe lifespan.


Methods

We conducted a descriptive qualitative study using data from sixteen focusgroup interviews (Brown, 1999; Drabenstott, 1992) and one key informantinterview to explore the concept of elder abuse from the perspectives of rarelyconsulted older adults and their care-givers in Ontario and Alberta, Canada. Apurposeful sampling strategy was used. We interviewed seventy-seven olderadults in ten focus groups, each with six to eleven participants, and one individ-ual. Inclusion criteria were that the participants were members of selectedgroups of marginalized groups of older adults (women, diagnosed with mooddisorders, lesbians, immigrant and Aboriginal, or survivors of abuse), able toconverse easily in English and to give informed consent (See Table 1). We alsoconducted six focus groups with forty-three formal and informal care-givers ofolder adults, with four to ten members per group.

The usual means of recruiting participants was to contact facilitators of pre-existing groups. Participants filled out brief demographic questionnaires andreceived CAD $20 as compensation for their time. All interviews were con-ducted by two trained facilitators in a private setting within the communitybetween February 2003 and July 2005. Translation was provided for the Chinese,Farsi and Punjabi groups by certified translators who were staff members of alocal immigrant-serving agency. A semi-structured interview guide was used.The areas of inquiry included the definitions and scope of elder abuse, indica-tors or risk factors associated with elder abuse, consequences of elder abuseand interventions. Each interview was audio-taped and lasted between ninetyminutes and two hours. Ethics approvals were received from the research eth-ics boards of McMaster University (Hamilton, Ontario) and the University ofCalgary (Calgary, Alberta).

Data analysis

Audiotapes were transcribed by a professional typist, who removed all identi-fying information and produced verbatim copies of the interviews (tran-scripts). The transcripts were downloaded into a software program designedto assist qualitative researchers in managing and retrieving specific coded pas-sages of text (NVivo). Codes were developed by two or more researchers whoeach read a transcript independently, identified themes and subthemes in thetext, and then compared their findings until consensus was reached (Patton,1990; Guba, 1981; Denzin and Lincoln, 2000). The composite version of theircodes was given to a member of the research team, who entered the codes andlater retrieved coded sections of text, as needed. Codes and themes were vali-dated through discussion in larger team meetings in which consensus wasreached for each theme and linked to transcript excerpts that best exemplifiedthe theme.


Results

Study findings revealed four major themes that describe interconnectionsamong types of abuse across the lifespan from the perspectives of older adultsand care-givers: (i) intergenerational cycles of abuse; (ii) violence across thelifespan; (iii) exposure to multiple subtypes of elder abuse; and (iv) ongoing

Table 1 Description of focus groups by participant type and group size (n = 15)

*Percentages do not add up to 100 because of rounding.

Focus groupnumber Participant type Percentage (count)* Description

1 Aboriginal elders

15% (11) Older Aboriginal adults who meet regularly for social support (Ontario)

2 Elders with mood disorders

11% (8) A hospital-based group of older adults with mood disorder who meet regularly for social support (Ontario)

3 Latvian seniors 11% (8) Older adults who meet regularly at their church for social support (Ontario)

4 Farsi-speakingimmigrants

13% (10) Farsi-speaking immigrant women identified by a resettlement agency (Ontario)

5 Punjabi-speaking immigrants

11% (8) Punjabi-speaking immigrant men identified by a resettlement agency (Ontario)

6 Chinese-speakingimmigrants

12% (9) Chinese-speaking immigrant women identified by a resettlement agency (Ontario)

7 Older Wiser Lesbians (OWLS)

8% (6) Older adult lesbians who meet regularly for social support (Ontario)

8 Seniors HelpingAdvance Research Excellence (SHARE)

9% (7) Older adults who provide advice on gerontological research (Ontario)

9 Survivors of elder abuse

12% (9) Survivors of elder abuse who meet regularly for formal support (Alberta)

Total Older adults 100% (76)

10 Family care-givers

21% (9) Family care-givers for older people with dementia (Ontario)

11 Personal support workers

14% (6) Personal support workers employed by a local nursing agency (Ontario)

12 Elder peer support group

21% (9) Older volunteers who provide support for other seniors through an aid agency (Ontario)

13 Aboriginal case managers

23% (10) Aboriginal case managers from First Nations reservations (Ontario)

14 Case managers (Ontario)

9% (4) Health care professionals providing services for seniors via an aid agency (Ontario)

15 Case managers (Alberta)

11% (5) Case managers who provide support for seniors at a centre offering services for older persons (Alberta)

Total Care-givers 100% (43)


spouse abuse that shifted into elder abuse. In addition, several participantsspoke about the suffering abuse in silence, which is quite common for child andyounger adult victims of abuse. The results from this study indicate that cul-tural factors, ageism and gender are ubiquitous to elder abuse. This associationis further described in the discussion.

Presentation of findings

The majority of older adults and care provider participants were female (77and 89 per cent, respectively), married (41 and 66 per cent, respectively), Eng-lish Canadian (37 and 71 per cent, respectively), with English as their first lan-guage (51 and 83 per cent, respectively). The mean age of the older adults wassixty to sixty-nine; the majority had less than high-school education (41 percent) and almost half reported their annual income between $10,000 and$29,999 CAD (49 per cent). Care-givers were younger (mean age fifty to fifty-nine), had university or college certificates (67 per cent) and reported annualincomes of $30,000 to $49,999 CAD (35 per cent). A description of the sampleby focus group is found in Tables 2 and 3. The individual interview (II)—anEnglish-speaking, high-school educated, disabled woman in her eighties—isnot included in the summary tables.

Typical views expressed by participants (excerpted statements from tran-scripts) are presented along with the focus group number (1–16) of the speaker.Following qualitative research guidelines (Krueger, 1997), we have minimallyedited statements as needed in order to preserve their meaning while ensuringreadability. Ellipses (. . .) indicate where irrelevant information was removed,and non-italicized words in square brackets show where we have added text.

Intergenerational cycles of abuse

Some participants clearly acknowledged an intergenerational pattern of famil-ial violence and abuse, as one woman stated that ‘[when the] grandparents areabusive, the kids . . . become abusive’ (FG15). Other statements supported thecyclic nature of family violence:

. . . abusive families turn into abusers of older people and the cycle goes aroundand around . . . . [Abuse within families is] just one big vicious circle . . . [soabuse that has] existed in the past just continues, and perhaps become moreprofound because of the fact the person becomes more vulnerable (FG15).

A care-giver attributed the neglect and emotional abuse of an older client byher adult children to the neglect the adult children had experienced whengrowing up:

. . . when those kids were young and growing up and needed her, she wasout in the hotels with men and everything . . .. A lot of times you have to


Tab

le 2

Ch

arac

teri

stic

s o

f fo

cus

gro

up

mem

ber

s, b

y g

rou

p (

eld

ers

and

oth

er n

on

-ser

vice

pro

vid

ers)

(n

= 9

)

Dem

og

rap

hic

info

rmat

ion

FG1

FG2

FG3

FG4

FG5

FG6

FG7

FG8

FG9

Gen

der

(%

fem

ale)

73 (

8)63

(5)

71 (

6)10

0 (1

0)0

(0)

100

(9)

100

(6)

86 (

6)10

0 (9

)

Mar

ital

sta

tus

per

cen

tag

e (c

ou

nt)

36 (

4)13

(1)

14 (

1)11

(1)

0 (0

)11

(1)

0 (0

)0

(0)

0 (0

)27

(3)

50 (

4)57

(5)

33 (

3)88

(7)

33 (

3)33

(2)

29 (

2)22

(2)

0 (0

)13

(1)

0 (0

)11

(1)

0 (0

)0

(0)

67 (

4)29

(2)

67 (

6)36

(4)

25 (

2)29

(2)

44 (

4)13

(1)

56 (

5)0

(0)

43 (

3)11

(1)

Ag

e ra

ng

e p

erce

nta

ge

(co

un

t)9

(1)

0 (0

)0

(0)

44 (

4)13

(1)

0 (0

)0

(0)

0 (0

)0

(0)

9 (1

)13

(1)

0 (0

)33

(3)

13 (

1)0

(0)

67 (

4)0

(0)

44 (

4)46

(5)

25 (

2)14

(1)

22 (

2)63

(5)

33 (

3)17

(1)

29 (

2)44

(4)

27 (

3)25

(2)

86 (

7)0

(0)

13 (

1)67

(6)

17 (

1)71

(5)

0 (0

)9

(1)

38 (

3)0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

0 (0

)11

(1)

Mea

n a

ge

ran

ge

60–6

970

–79

70–7

950

–59

60–6

970

–79

60–6

970

–79

60–6

9

Eng

lish

fir

st la

ng

uag

e, p

erce

nta

ge—

yes

(co

un

t)82

(9)

100

(8)

0 (0

)0

(0)

13 (

1)0

(0)

100

(6)

100

(7)

67 (

6)

Leve

l of

edu

cati

on

, per

cen

tag

e (c

ou

nt)

Less

th

an h

igh

sch

oo

l82

(9)

50 (

4)29

(2)

78 (

8)38

(3)

78 (

7)0

(0)

0 (0

)11

(1)

Co

mp

lete

d h

igh

sch

oo

l0

(0)

25 (

2)0

(0)

22 (

2)13

(1)

22 (

2)17

(1)

29 (

2)33

(3)

Tech

nic

al/t

rad

e/vo

cati

on

sch

oo

l9

(1)

13 (

1)14

(1)

0 (0

)13

(1)

0 (0

)0

(0)

29 (

2)33

(3)

Som

e co

lleg

e/u

niv

ersi

ty0

(0)

0 (0

)14

(1)

0 (0

)0

(0)

0 (0

)33

(2)

29 (

2)0

(0)

Co

lleg

e ce

rtif

icat

e/u

niv

ersi

ty d

egre

e co

mp

lete

d9

(1)

13 (

1)43

(3)

0 (0

)13

(1)

0 (0

)50

(3)

14 (

1)22

(2)

Oth

er0

(0)

0 (0

)0

(0)

0 (0

)25

(2)

0 (0

)0

(0)

0 (0

)0

(0)

An

nu

al f

amily

inco

me,

p

erce

nta

ge

(co

un

t)Le

ss t

han

$10

,000

13 (

1)13

(1)

0 (0

)33

(3)

80 (

6)10

0 (9

)0

(0)

0 (0

)44

(4)

$10,

000–

29,9

9963

(7)

75 (

6)57

(5)

67 (

7)20

(2)

0 (0

)33

(2)

83 (

6)44

(4)

$30,

000–

49,9

9925

(3)

13 (

1)29

(2)

0 (0

)0

(0)

0 (0

)33

(2)

17 (

1)11

(1)

$50,

000–

69,9

990

(0)

0 (0

)14

(1)

0 (0

)0

(0)

0 (0

)17

(1)

0 (0

)0

(0)

$70,

000

plu

s0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

0 (0

)17

(1)

0 (0

)0

(0)

Eth

nic

gro

up

per

cen

tag

e (c

ou

nt)

Ab

ori

gin

al91

(10

)0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

13 (

1)En

glis

h C

anad

ian

9 (1

)10

0 (8

)0

(0)

0 (0

)0

(0)

0 (0

)10

0 (6

)86

(6)

38 (

3)Fr

ench

Can

adia

n0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

0 (0

)0

(0)

0 (0

)13

(1)

Euro

pea

n0

(0)

0 (0

)10

00

(0)

0 (0

)0

(0)

0 (0

)14

(1)

38 (

3)Fa

r Ea

ster

n0

(0)

0 (0

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know the whole story . . . and a lot of our clients are like that. Because oftheir past and what they have done in the past (FG11).

Another care provider stated that ‘the elder that’s being abused may have beenan abuser in earlier years. So now either the children have abandoned them, orthere has been no counseling or resolution to the family dynamics. So it justrepeats the cycle’ (FG13). One participant noted that she had a client whose‘daughters used to beat him up every time they used to drink and then I foundout that it was because that he [had sexually] abused the daughters’ (FG13).

Members of the Aboriginal focus group linked forms of family violence totheir experiences of abuse perpetrated in the context of the residential schoolmovement:

Because there is a lot of generations lost there with residential school stuff.Like my grandmother went to residential school. She raised my mom whoraised me and even my mom says to this day that she did an awful job (FG13).

One participant described at length how abusers should be aware of the poten-tial consequences of their abuse, noting that ‘they’re going to be in that eldersituation [someday], and most likely if they have children, they’re going to beabused, too, because that’s a cycle’ (FG13).

Several participants attributed the continuing cycle of familial abuse toageism that is part of a family. As one person explained, ‘I think it’s howthey’re brought up. If they’re not brought up to respect their elders, that’s theway they’re going to treat them when they get older’ (FG1). In another focus

Table 3 Characteristics of focus group members, by group (service providers) (n = 6)

Demographic information FG10 FG11 FG12 FG13 FG14 FG15

Gender (% female) 78 (7) 100 (6) 78 (7) 100 (1) 100 (4) 80 (4)

Marital status (%) Single/never married 0 (0) 0 (0) 0 (0) 10 (1) 50 (2) 60 (3)Married/common-law 78 (7) 67 (4) 89 (8) 90 (9) 50 (2) 20 (1)Divorced/separated 11 (1) 33 (2) 0 (0) 0 (0) 0 (0) 20 (1)Widowed 11 (1) 0 (0) 11 (1) 0 (0) 0 (0) 0 (0)

Age range (%) Less than 30 0 (0) 0 (0) 0 (0) 0 (0) 50 (2) 20 (1)30–39 0 (0) 0 (0) 0 (0) 10 (1) 0 (0) 40 (2)40–49 11 (1) 50 (3) 0 (0) 50 (5) 25 (1) 20 (1)50–59 22 (2) 17 (1) 11 (1) 40 (4) 25 (1) 20 (1)60–69 33 (3) 33 (2) 33 (3) 0 (0) 0 (0) 0 (0)70–79 33 (3) 0 (0) 56 (5) 0 (0) 0 (0) 0 (0)

Mean age range 60–69 50–59 60–69 40–49 30–39 30–39

English first language (% yes) 100 (9) 67 (4) 78 (7) 80 (8) 75 (3) 100 (5)Level of education Less than high school 44 (4) 17 (1) 22 (2) 0 (0) 0 (0) 0 (0)

Completed high school 11 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)Technical/trade/

vocation school22 (2) 17 (1) 0 (0) 0 (0) 0 (0) 0 (0)

Some college/university 0 (0) 17 (1) 11 (1) 11 (1) 25 (1) 0 (0)College certificate/

university degree completed

22 (2) 50 (3) 67 (6) 90 (9) 75 (3) 100 (5)


group, a similar view was expressed: ‘. . . the children are not taught ethics, religion,moral values . . . from generation to generation . . . that is why the older immigrantcommunities they have these ethical values—respect their elders!’ (FG3).

Others linked abuse to societal ageism. One older adult described that ‘youare no longer respected. You’re just considered an old person with nothing tocontribute’ (FG8). Another added ‘I think sometimes elderly abuse perhapsstarts with society view of older people, and their perception that as, when youget to be older, you’re not important in society. So that people don’t even . . .realize that elders are being abused because they don’t think we’re importantenough in people’s minds’ (FG9). Some focus group members linked ageismwith the failure of police to investigate in suspected cases of elder abuse: ‘Ifthey’re old it’s not really your problem. That’s the message we’re giving. Theyare old, they are not really that important. There is nothing we can do about itand how can we follow through on all this investigation’ (FG13).

Violence across the lifespan

Focus group participants linked exposure to one type of abuse to increased vul-nerability for other types of abuse across the lifespan. A care providerdescribed a client whose ‘mother victimized her. She went into the system[institutional care]. She got victimized in the system. And they decided thatnow you’re going to come out from here, go into homes . . . . And then her sis-ter finally got in touch with her, brought her up here and then didn’t her sisterabuse her’ (FG11). Another older adult stated that ‘a lot of people abuse theirkids, when they’re small’ (FG1). He further elaborated that the maltreatmenthe experienced as a child, including physical, sexual, emotional abuse andneglect, had made him vulnerable to abuse as an older adult, primarily finan-cial abuse by family members. One woman described the types of violence shehad experienced, which included witnessing domestic violence as a child: ‘I canremember my father when he had a knife, and I was ahh . . . eight years old’;experiencing intimate partner violence in two successive marriages: ‘I findmyself in a abusive situation’; and financially abused as an older person: ‘I wasin the hospital I had a nervous breakdown and we had to sell the house and the. . . realtor was driving me here and there and he talked in the car about suicideall that time. So, he helped us to move and he stole five hundred dollars fromthe money order’ (FG9).

Exposure to multiple subtypes of elder abuse

Participants suggested that the typical pattern of elder abuse consisted of expo-sure to multiple subtypes. As one formal care-giver illustrates:

I have a woman whose son beat her up. That’s pretty straight forward. Andof course with that, as in any other type of abuse there is all kinds of other


types of abuse going on along with it. I don’t really think any kind of abuseever happens just by itself. I think that there are always other typesinvolved with it. She’s being financially abused. There is no food in herhouse. She’s dirty. Things like that (FG13).

Another care provider described a ‘situation where there is a 90 year old ladyand her son is in his 50’s and he once lived with her for a while but is notallowed and somehow she couldn’t get him out’ (FG11). She further describesthat in addition to financial abuse, the son was ‘verbally abusive’ and ‘was beat-ing her [the woman] up’.

Participants in the older Chinese women’s focus group described multipleinstances of both neglect and emotional abuse by their children. Theyexplained that older adult women who were new immigrants to Canada and/orsponsored by their family are treated as if they were a burden. Often they areignored or told they are ‘old, worthless . . . and not important’ (FG6). The olderwomen expressed feeling ‘grateful that the children brought them here, [but]most of the time they have to endure whatever they are facing [neglect andemotional deprivation]’ (FG6).

In the context of domestic violence, other subtypes of elder abuse seemed toemerge, ‘be it physical, financial, whatever . . . that type of, of abuse is lumpedin with spousal abuse that has been going on for thirty, forty, fifty years’(FG15).

Many participants identified that in addition to the traditional forms ofelder abuse, government-regulated health care and social assistance wereabusive to seniors. ‘Well the government itself is abusing us elders, becausewe’re not getting enough money to keep going. You know, once you pay yourrent, you haven’t got hardly anything left for your groceries for the month’(FG1):

It’s like health care at 60. They don’t want to be bothered with you. You’rea drag on society and doctors don’t have time. They just don’t want to takethe time with an older person. And it gets back to health care. Every timethey have to cut healthcare back, the seniors seem to get it . . . . We’re justliving week to week to week (FG2).

Ongoing spouse abuse shifting into elder abuse

One of the most common interconnecting forms of abuse described by partici-pants, particularly women, was ongoing spouse abuse shifting into elder abuse.For example, a Farsi-speaking older woman stated ‘I got married. From thattime my abuse started until now, but in different shapes’ (FG4). Another Farsi-speaking woman agreed that abuse continued into older age: ‘I got married,but after one month he started to bother me, to abuse me, to kick me, to punchme. . . . and I didn’t have anyone to talk to’ (FG4). A further woman added that‘[I] don’t know anything else other than abuse’ (FG4). The following quoteillustrates the continuity of domestic violence into older age:


When I was young I had physical abuse a lot, a lot. Always I had bruises inmy body, even my husband just punched me and he just broke my arms.But I couldn’t tell anyone anything because they the men are so strong andthey don’t think that we should say no because they don’t believe thatwoman is something, that they are the owner of the woman (FG4).

Spouse abuse among older adults was described by some participants as abuse thathas occurred over many years of marriage. In one group of formal care-givers, aparticipant noted that many abused older female clients have told her aboutsituations ‘where the abuse has been going on for twenty, thirty, forty years in amarriage’ (FG15). Women with long-term exposure to domestic violenceexpressed a type of acceptance ‘because it had gone on so long you mean thatshe just kind of accepts that this is how life is’ (FG8).

Cultural expectations also played a role in domestic violence. Women voicedthat according to tradition, a woman ‘should obey whatever your husband says. . . you should be in your husband’s home until you die’ (FG4). One participantdescribed visiting her married daughter and finding her with a black eye:

I was so angry I wanted to go up to him and go someplace and complain.This man did something on my daughter. I raise my daughter from veryhard time and I don’t want anybody just abusing her. My husband just takemy hand and said ‘Sit down. It is not your business. She should be hereuntil she dies. . . . This is her husband’s right to punish her. Maybe she didsomething wrong’ . . . . It is not right. You shouldn’t accept it. But this is theculture (FG4).

Suffering abuse in silence

The theme ‘suffering in silence’ emerged from many of the focus group ses-sions. In the USA, it was estimated that for every reported case of elderabuse, five cases remain unreported (National Center on Elder Abuse, 1998).In this study, participants suggested that victims of elder abuse are reluctantto talk about familial abuse because of fear of ‘retaliation’ (FG14), ‘the fearfactor, but it’s also the shame factor too’ (FG13), ‘they were ashamed orembarrassed’ (FG4), or for the ‘love of your children’ (FG12), not wanting to‘put blame on their families’ (FG13). For this reason, some care-giversreferred to elder abuse as a ‘hidden problem, or hidden abuse’ (FG13). Olderadults and care-givers described the reluctance to disclose intra-familialforms of mistreatment:

If you have an elderly person living at home with a family member of a car-egiver, and perhaps through the frustration of the caregiver or fatigue orwhatever, their own personal needs of the caregiver are not met, and there-fore the elderly client or parent, when they go to the doctor and their needsare not being met, whether it’s physical or their medication, or yourhygiene or whatever, they are not going to rat on their family member,because they are the caregiver (FG11).


Another respondent suggested that the oldest adults may have the most diffi-cult time disclosing experiences of abuse: ‘I think the older are more fright-ened. More susceptible to [elder abuse] or afraid of talking about it’ (FG11).

Connected with this is the larger issue of deference to authority/power figures bythe older generation; in this situation, the power differential between the elder andhis/her care-giver (formal or informal) means that often elders won’t speak.

For some participants, ‘suffering in silence’ was linked to culture. It wasmentioned within the Catholic Family Services group that one participantbelieved ‘most seniors do experience at least one form of elder abuse’ (FG15)and ‘the difficulty with people from various cultures is the language barrier andunderstanding how to get help’ (FG15). Another suggested that one problemwith individuals from other cultures dealing with situations of abuse is that‘they are very isolated. Especially those who immigrate here later in life havebeen taken away from their little social networks’ (FG13). One participantstated that ‘the ethnic component is a very, very big [risk factor, because] theyhave language barriers’ (FG15), for example.

Among older adults from different cultural backgrounds, there is a strongtendency to avoid reporting abuse in general, despite the fact that they areaware there is something wrong with the situation. One participant explained,‘there is a saying in Chinese community that says if bad things happen in familyyou don’t go outside and spread it to other people’ (FG6). There is also a reluc-tance to talk about their ‘relation with their husband’ (FG6), and unfortu-nately, within other cultures (e.g. Afghan or Iranian), it is the ‘husband’s rightto punish’ (FG4) his wife. It is difficult to deal with abusive situations because‘even if there is certain evidence of abuse, very often the person may not wantto talk about it or admit it because it is a son or a daughter that is involved per-haps and unless it gets really severe. There is obviously an embarrassment’(FG3).

Among gay, lesbian and trans-gendered older adults, abuse may be experi-enced as a result of ‘extreme isolation, a lack of support and societal violence’(FG7). For instance, dealing with abuse is ‘harder for lesbians simply becausethey have a smaller pool [of support]’ (FG7) because the community is smallgenerally. Another lesbian woman talked about the lack of culture, communityand support with aging contributed to social isolation and vulnerability toabuse:

I mean I have wonderful non-lesbian friends whom I adore. But it’s one ofthe things that does scare me now as I am getting considerably older, thatwill I meet lesbians of my age with whom I can make contact? With whom Ican talk (FG7).

Discussion

Our findings, based on the perceptions of older adults as well as formal andinformal care-givers, identified four types of interconnections among different


forms of violence across the lifespan. Participants perceived that: (i) abuse iscyclical and occurs from generation to generation; (ii) abuse occurs throughoutthe lifespan; (iii) exposure to multiple forms of elder abuse is common; and (iv)spouse abuse continues in older life. Study findings also highlight that gender,ageism and cultural factors play important roles in elder abuse experiences.

The perceptions of older persons and care providers in the present studylend support for the explanations of intergenerational transmission of violencein families that have been promulgated in the literature (Widom, 1989; Murphyand Blumenthal, 2000). Participants provided illustrative examples of childphysical, sexual and emotional abuse and neglect, which led to the perpetrationof elder abuse on their parents, consistent with the cycle of violence theory.Participants cautioned against abusive parenting since perpetrators could facefuture abuse themselves. Aboriginal participants noted that the cycle of viol-ence involved at least three generations. Children abused in the residentialschool system had subsequent difficulties in parenting their own children; thesedifficulties in parenting also affected the second generation in their parenting.Findings also provide support for other explanations of elder abuse such as sit-uational explanations associated with care-giver stress, for example, as anumber of participants described care-giving situations linked with abuse. Lon-gitudinal studies are needed that specifically examine pathways to elder abuseto further test the intergenerational transmission of violence model as well asother models.

Older adults and care providers suggested a link between different forms ofviolence across the lifespan. As participants indicated, abuse that occurs ‘in thepast just continues’ into later life because it is a ‘vicious circle’. That is, expo-sure to one form of family violence places an individual at risk for further vic-timization at different stages in the lifespan and for multiple forms ofvictimization at any one stage of development (Wolf, 1997; Butler, 1999;Marshall et al., 2000; Levine, 2003; Hughes et al., 2005; Renner and Slack, 2006).

Participants clearly identified that multiple forms of abuse were common.The vulnerability of older adults was proposed as a risk factor for exposure tomultiple subtypes of abuse. Abuse ‘becomes more profound because . . . theperson becomes more vulnerable’.

Spouse abuse has been consistently recognized as one of the more commonforms linked to elder abuse. It is viewed as an extension of spouse abuse thathas been experienced earlier in life within the marriage (Phillips, 2000). Thisis supported by findings from Wilke and Vinton (2005), who reported that 94per cent of their sample listed an intimate partner as an abuser. Otherresearch has yielded similar findings; Lundy and Grossman (2004) found thatone-third of the participants reported experiencing abuse at the hands oftheir spouse. The findings in this study echoed the findings in previousresearch in that elder abuse is often spouse abuse grown old. Participants sug-gested that spouse abuse that began in older age was usually precipitated bythe introduction of a new partners or a change in the physical or mentalstatus of a spouse.


Themes related to situational patterns consistent with the care-giver stresstheory (O’Malley et al., 1983; Schiamberg and Gans, 2000; Brandl, 2000;Bergeron, 2001; Daro et al., 2004; Lundy and Grossman, 2004; Straka andMontminy, 2006) were also identified in the analysis and belongs to a paperwith a different focus.

Older women were portrayed as the primary recipients of abusive behaviourin the examples provided by the participants, confirming findings from the lit-erature that older women are more likely to be abused than older men, andthat men are more likely to abuse older women than are women (Penhale,1998; Fulmer et al., 2004; Straka and Montminy, 2006). There is a beginningrecognition that abuse of older adults reflects the gendered nature of attitudes,behaviour and expectations in society (Neysmith, 1995). The lack of empiricalresearch examining gender differences in experiences of older abused men andwomen seriously hampers the development of effective prevention and inter-vention strategies and should be addressed (Fulmer et al., 2004; Weeks et al.,2004).

The family violence literature is replete with examples of the failure to rec-ognize, detect and appropriately intervene in cases of abuse (Punukollu, 2003;Ullman, 2003; Daniels, 2005; Hornor, 2005). Participants in this study con-firmed findings in the literature related to problems in recognition and report-ing elder abuse (Levine, 2003; Nelson et al., 2004; Geroff and Olshaker, 2006).Study informants described fear of retaliation, loss of family relationships,shame and embarrassment as well as lack of knowledge about or access to serv-ices prevented disclosure of victimization.

In this sample, culture seems to be implicit in many situations of abuse. Someparticipants described an absence of elder abuse within their community whileothers alluded to cultural beliefs and practices which contributed to abusiveexperiences. Findings in the present study also suggest that challenges in com-plying with traditional cultural expectations and practices, such as filial pietyand the demands of Western society for dual income earners, may pose a riskfor elder abuse. Limitations in cross-cultural research on elder abuse, however,suggest caution in interpreting these findings and offer a promising avenue forfuture research (Malley-Morrison and Hines, 2004).

What can be done to reduce elder abuse? The literature on preventing fam-ily violence emphasizes understanding and awareness of the problem as thefirst steps toward reducing its occurrence (Ryan, 2005). The same principle canbe applied to elder abuse. The findings from this qualitative study suggest thatmany of the participants were aware of elder abuse. Although not all of themhad personally been abused, many of them were able to articulate the familyand interpersonal dynamics of family violence, particularly the interconnec-tions in violence across the life course of a family. Participants identified thatelder abuse was rooted in societal beliefs such as ageism (Ward, 2000), suggest-ing general education for the public was needed. An exploratory study of pro-fessional and volunteers’ perceptions of elder abuse reported similar findings,including the ‘lack of respect for elders as a type and cause of abuse, [and]


changing societal norms as a cause of abuse’ (Erlingsson et al., 2006, p. 156).Ageism is also suspect in seniors’ hesitation to report abuse, the lack of avail-able supportive services and the resulting consequence of suffering in silence.

Specific education needs were identified for health care and social serviceproviders. Participants suggested that ‘a lot of professionals are very unawareof what we are talking about’ (FG15) and that physicians, pharmacists andother health care professionals need ‘special classes, I think sometimes are sobusy . . . they don’t have time to learn enough about it’ (FG8). The literatureconcurs, suggesting that few social workers, physicians and other health careprofessionals are trained to recognize the different forms of elder maltreat-ment and that additional education is needed (Danis and Lockhart, 2003;Bond, 2004; Collins, 2006; Erlingsson et al., 2006; Stinson and Robinson, 2006).

The ultimate goal of education is to reduce the risk associated with ageismand other societal beliefs that contribute to elder abuse, to reduce the stigmaassociated with disclosing abuse and to increase the detection of elder abuseamong professionals to reduce the harm associated with elder abuse. As oneAboriginal care provider describes:

I think the key is to just to keep educating our kids. Keeping them aware ofwhat it is and what they can do. And try in some way to empower them ifwe can. I don’t think we can wait twenty years though. We need to be act-ing now and I think the governments need to be acting on this too. I meanthey do a lot for child abuse, but you know, they seem to be not botheringabout the elder abuse, but as our population in this country grows older, Ithink they are going to start putting things into place (FG13).

Study participants talked about the need for family and other informal forms ofsocial support. They also identified general supports to maintain theirindependence and quality of life, including adequate pensions and social assist-ance, subsidized housing, physical and mental health services. Specific servicessuggested for elder abuse included an advocate/ombudsman, access to crisissupport, shelter services for elders and specific reporting legislation for elderabuse similar to child abuse. The literature certainly describes a range of exist-ing elder abuse interventions, such as multidisciplinary teams including socialworkers, professional training, policies in nursing homes, shelters, and supportor empowerment groups for abused seniors (Pritchard, 1999).

Harbison (1999) identified six possible models for intervention in situationsof elder abuse and neglect and concluded that one of these models—the partic-ipatory model—holds the most potential to address the ageist context in whichabuse occurs. Such a participatory model would provide opportunities for olderadults themselves to take ownership of responses to elder abuse and neglect,rather than the current reliance on professional expertise. There are a numberof instances in which older adults, working in seniors’ organizations, providepeer counselling to other older adults, in some cases related to situations ofabuse (Harbison, 1999). However, elder abuse interventions must go beyondindividual level actions to initiatives targeting seniors’ organizations, servicedelivery agencies, and governmental policy and legislation (Harbison, 1999).


Recent reviews of the elder abuse literature indicate that there has beenlittle rigorous research to evaluate the impact of existing interventions (Wolf,1997; Chalk and King, 1998; National Research Council, 2003; Lachs and Pillemer,2004). For example, one recent review found only two quasi-experimental eval-uations of elder abuse interventions compared with seventy-eight in the area ofchild maltreatment (Chalk and King, 1998). A number of clinical practiceguidelines related to elder abuse have been developed (American Medical Asso-ciation, 1993; Canadian Medical Association, 1994; Daly, 2004). While the guide-lines provide valuable direction for professionals in assessing and intervening insituations of elder abuse, they reflect the current state of the elder abuse inter-vention research, with many recommendations based only on observationalstudies or on expert opinion. The Canadian Medical Association (1994), forexample, concluded that there was poor evidence to include or exclude casefinding for elder abuse in a periodic health examination. Clearly, there is aneed for rigorous research based on theoretical frameworks to examine theeffects of elder abuse interventions.

Family violence, as described by marginalized older adults and their careproviders, occurs in complex, synergistic ways throughout the lifespan andacross generations. Efforts directed at prevention of elder abuse and neglectneed to be informed both by the experiences of older adults and evidencederived from other forms of family violence.

Accepted: February 2007

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Acknowledgements

We wish to thank members of the focus groups for their honesty and willing-ness to share their opinions with us. We wish to express our gratitude to DrChristopher Patterson, the principle investigator of the Elder Abuse Study. Wealso thank Michelle Webb for project co-ordination, Lois Freeman-Collins fordata analysis and Dr Emily Vella for the preparation of tables. This researchwas supported by the Canadian Institutes of Health Research Institutes ofGender and Health; Aging; Human Development, Child and Youth Health;Neurosciences, Mental Health and Addiction; and Population and PublicHealth.

Elder abuse and oppression: voices of marginalized elders

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