Women With Disabilities’ Experience With Physical and Sexual Abuse

Abstract

While studies suggest that the rate of abuse of women with disabilities is similar or higher compared to the general population, there continues to be a lack of attention to this issue. Women with disabilities are at particularly high risk of abuse, both through typical forms of violence (physical, sexual, and emotional) and those that target one’s disability. In an effort to highlight the need for increased attention to this issue, this article reviews the current peer-reviewed research in this field. The authors outline recommendations for future research goals and provide implications for research, practice, and policy.

Keywords

abuse women with disability physical disabilities domestic violence

Introduction

Over the past three decades, there has been ever increasing attention to the abuse of women, yet there continues to be a dearth of research on the abuse of women with disabilities. The voices and experiences of this population have largely been missing in the research focused on violence against women. This lack of representation as research participants has further slowed the creation of adequate policies and accessible service provision for this population in the field of violence and abuse.

The scarcity of information about abuse of women with disabilities suggests a continued reluctance of society to acknowledge that violence toward this population may be occurring. This is compounded by the overall devaluation of those with disabilities, and the categorizing of women with disabilities as dependent and asexual (Curry et al., 2009). Historically, attitudes toward people with disabilities have been negative, dismissive, resulting in marginalization and oppression (Chenoweth, 1996; Mackelprang & Salsgiver, 1996). Researchers suggest that cultural biases and negative societal views toward those with disabilities that include such behaviors as dehumanizing, depersonalizing, and devaluating adds to the continuation of abuse of these individuals (Chenoweth, 1996; Hassouneh-Phillips & McNeff, 2005; Sobsey, 1994). Due to the absence of attention to the abuse of women with disabilities, those who want to reach out for assistance are met with little to no support, resistance, and even insensitivity by law enforcement, social services, and the health care system in general (Swedlund & Nosek, 2000).

Research in this area has shown some pockets of activity around the country, but the topic is not a leading agenda item despite the fact that it is known, from earlier limited research, that women with disabilities experience abuse at similar or increased rates as compared to the general population (Brownridge, 2006; Martin et al., 2006; Powers, Curry, Oschwald, & Maley, 2002; Powers et al., 2009; Smith & Strauser, 2008; Young et al., 1997; Young, Nosek, Howland, Chanpong, & Rintala, 1997). In an effort to gather a broad perspective of the work that has been done, this current study is a comprehensive literature review of studies focused on the issue of violence against women with disabilities. This review of both the quantitative and the qualitative research within this field sheds light on commonly derived themes and research findings.

Method

Search Protocol

A search for relevant articles was made using the following databases: Psychinfo (including PsyARTICLES), Sociological Abstracts, Pubmed, Social Science Index, Medline, Social Work Abstracts, Social Science Full Text, Criminal Justice Abstracts, Family and Society Studies World Wide, and Google Scholar. The search words included combinations of “physical abuse,” “sexual abuse,” “domestic violence,” “women and disabilities,” “women with physical disabilities,” “women with physical limitations,” “women with cognitive disabilities,” and “women with cognitive limitations.” Articles were reviewed and the reference sections of the pertinent articles were combed for additional articles of relevance.

The definition of disability for the purposes of this study was restricted to one that reflects the intent of the Americans with Disabilities Act definition of disability (Jones, 2001):

The term “disability,” with respect to an individual, is defined as (A) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment.

Thus, we used a broad definition that would allow the individual to define their limitations rather than a definition that is part of program policy, which defines disability as it relates to a specific social function, such as inability to work, as does the Social Security Administration (2011).

Inclusion and Exclusion Criteria

Our review focused on women and on studies that were completed in the United States with subjects/data from the United States. We restricted our studies to those with acquired disabilities rather than congenital. We felt this was important since these are two very different populations in how they may experience having a disability. Moreover, while there have been some studies of individuals with developmental and intellectual disabilities and their experience with violence and abuse (Barger, Wacker, Macy, & Parish, 2009; Carlson, 1997; Freeborn & Curry, 2009; Sobsey, 1994; Thompson, 1997), the lack of reliable and valid measures of abuse and trauma in individuals with intellectual disabilities makes any comparisons or grouping difficult with those with physical disabilities (Clegg, 2006; Wigham, Hatton, & Taylor, 2011). The field of research in the area of violence against individuals with disabilities is fairly new. Therefore, we did not limit our search to solely randomized controlled trials, as the field has not advanced to that level of science. It is clear that there is much more to be learned, therefore, we reviewed both quantitative and qualitative studies of varying research design to broaden the perspective as possible on the current state of the science in this area.

Analysis

After collecting all relevant articles, the studies were categorized into qualitative and quantitative research methodologies. The current study’s two authors reviewed the studies based on their strength of methodological focus (i.e., quantitative vs. qualitative). Careful cataloguing of the studies by study design, sample as well as source of that sample, study objectives, and the results was made. An evaluation of the discussion and implication for practice was also reviewed for each of the studies.

Results

We reviewed all of the articles and excluded ones that did not fit our criteria. We excluded ones that were more theoretically focused (Barranti & Yuen, 2008; Jones, 2001; Mays, 2006; Murray & Powell, 2009; Nixon, 2010), discussed policy recommendations (Nosek, Howland, Rintala, Young, & Chanpong, 2001; Nosek, Howland, & Young, 1997), or used samples from outside of the U.S. population (e.g., Brownridge, 2006, 2009; Mays, 2006; Pascall, 1998). We present the findings in Table 1 that provides the listing of the articles reviewed that met our inclusion criteria. To aid in the presentation of the findings, we reviewed and categorized the findings by methodological focus (i.e., qualitative vs. quantitative).

Table 1.

Published Works in Disabilities and Abuse.

Author (Year of Publication)	Study Design	Sample	Study Objectives	Study Results
Curry et al., (2009)	QT	Community sample of women who utilized social services (n = 305)	The purpose was to develop measures to assess violence and abuse among women with disabilities and to characterize their perpetrators. This was based on the Safer Stronger Program (SSP; an audio-computerized self-administrated interview) with audio computer-assisted self-interview program, which was created for women with disabilities	Latent class analysis revealed four distinct classes of abuse experiences: sexual abuse, physical abuse, multiple forms of abuse, and minimal abuse. Three classes of perpetrator risk characteristics were also identified including: controlling characteristics, noncontrolling characteristics, and minimal risk characteristics
Oschwald et al. (2009)	QT	Community sample of women who utilized social services (n = 305)	This article includes a description of the development and evaluation of the Safer and Stronger Program (SSP), an audio computer-assisted self-interview program, which was created for women with disabilities. It was compared in a randomized comparison with a Health Awareness module	Most of the participants preferred answering questions about abuse via a computer mechanism than directly to a health care provider, or family and friends. Some difficulties with reaching individual who have hearing loss were noted.
Powers et al. (2009)	QT	Community sample of women who used social services (including disability services and domestic violence services; n = 305)	The SSP (an audio-computerized self-administrated interview was created for women with disabilities) was used to assess safety promoting behaviors of women with disabilities and the characteristics of their perpetrators	Most participants (36%) learned about abuse safety behaviors from books, magazines, radio, and television. Ninety-two percent reported they had someone they could speak to about abuse. An exploratory factor analysis of safety behavior items revealed factors related to seeking abuse-related safety information, building abuse-related safety promoting skills, using relationship support, planning for emergencies, taking legal action, and managing safety in personal assistance relationships
Casteel, Martin, Smith, Gurka, and Kupper (2008)	QT	National Violence Against Women Survey 1995–1996 (n = 6,273)	Examine whether individuals with disabilities are more likely to be victims of physical and sexual assault	Women with severe physical disabilities were 4 times more likely to report sexual assault than women without disabilities
Grossman and Lundy (2008)	QT	Individuals (male/female, adult/child) who sought assistance from state-funded coalitions against sexual assault (Illinois; n = 1,093)	The goal was to expand the knowledge of the experiences of individuals with disabilities who experience violence	Individuals with disabilities were more likely to be victims of assault, less likely to be self-referred to the rape center, and more likely to receive social services than those without disabilities
Smith and Strauser (2008)	QT	Secondary data (2005 BRFSS; n = 4,574)	The goal was to examine the effect of physical and sexual abuse on employment patterns of women with disabilities in the United States	This study used data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) to explore the significance of the relationship between the experience of abuse and employment status for women with disabilities. These researchers found that women with disabilities who have been abused had higher levels of unemployment than women without disabilities who were not abused. They also found that women with disabilities who have been abused have higher levels of unemployment than women without disabilities who have not been abused. Over, they found that being physically and sexually abused increases the likelihood of unemployment for women with disabilities
Thomas, Joshi, Wittenberg, and McCloskey (2008)	QL	Community sample of women who had experienced physical and emotional abuse in last 12 months (n = 40)	Explore the impact of abuse on women’s health, the risks, and vulnerabilities for women with preexisting health conditions, and how women describe the impact of abuse on their health	Researchers suggest that intimate partner violence (IPV) leads to adverse health effects (including physical disability, chronic pain and health conditions, impaired mobility disfigurement, anxiety, and relapse). IPV worsens already compromised health and illness (due to stress and partners who undermine treatment) and disability increase dependency on abusive partners (fear of not finding another partner, dependency on partner for caretaking, financial dependence, and fear of relapse)
Copel (2006)	QL	Community sample (n = 25)	The purpose of the study was to create a model to depict the abuse experience of women with disabilities through a comparison with Walker’s Cycle of Violence theory	Five themes emerged through qualitative interviews, including: accumulation of stressors, stress exceeds ability to cope, abuse episodes, separation, and distraction periods, return to superficial normal. A cyclical model for understanding IPV of women with disabilities was proposed utilizing these five themes
Martin et al. (2006)	QT	North Carolina Behavioral Risk Factor Surveillance System (NC-BRFSS; n = 5,326)	Comparison of a statewide representative sample of noninstitutionalized women with and without disabilities in terms of the prevalence of physical and sexual assault perpetrated by a variety of individuals (e.g., intimate partners, other persons known by the victim)	Women’s violence experiences were classified into three groups: no violence, physical assault only (without sexual assault), and sexual assault (with or without physical assault). Multivariable analysis revealed that women with disabilities were not significantly more likely than women without disabilities to have experienced physical assault only within the past year; however, women with disabilities had more than 4 times the odds of experiencing sexual assault in the past year compared to women without disabilities. Young women were more likely than older women to have experienced both physical assault only and sexual assault, non-White women were more likely than White women to have experienced sexual assault and women who were not married were more likely than married women to have experienced physical assault only
Nannini (2006)	QT	Women who sought state-funded sexual assault survivor services in Massachusetts 1987–1995 (n = 16,672)	The primary research questions were (1) how do sexual assault patterns differ for women with disabilities as compared with women without disabilities and (2) how do patterns differ among women with different disabilities?	More than 10% of survivors reported more than 1 disability. If a woman had a history of a previous assault or was over 30 years old at the time of assault, she was significantly more likely to report a disability as compared to the referents. Among women with a single disability, a survivor who delayed seeking services more than 6 months was more likely to have a mental health disability. A survivor with a cognitive disability was more likely to report sooner than 6 months compared with a survivor with other single disabilities. Women with disabilities were less likely to confide in a friend than those without disabilities
Nosek, Hughes, Taylor, and Taylor (2006)	QT	Community sample of women with physical disabilities recruited from five private and public outpatient clinics (n = 415)	Explored abuse of women with disabilities within the past 12 months	Logistic regression analyses suggest age (women who are younger), education (more educated), decreased mobility, increased social isolation, and higher rates of depression predicted increased likelihood of having experienced abuse
Coker, Smith, and Fadden (2005)	QT	Community sample attending family practice clinics from 1997–1998and had Medicaid or managed care insurance (n = 1,152)	Explore the association between IPV by type (physical, sexual, and psychological), timing (current or past), and disabilities preventing work as reported in a clinical population of women attending primary health clinics	Of the 1,152 eligible women surveyed, 54% experienced some type of IPV and 24% were currently in a violent relationship. Women who had experienced IPV were more than twice as likely to report a disability. The most commonly reported disabilities were those associated with heart or circulatory disease, followed by back problems, chronic pain, arthritis, nerve system damage, asthma or another respiratory problem including emphysema, and either depression or another mental illness. Women ever experiencing IPV were more likely to report a disability due to generalized chronic pain and mental illness
Hassouneh-Phillips and McNeff (2005)	QL	Community sample (n = 37)	This study sought to learn about the participants’ experiences of abuse, the impact abuse has on their emotional, social and physical well-being, and the participants’ suggestions on how to assess and intervene in order to prevent and eliminate the abuse of women with disabilities	Women with high degrees of impairment, particularly those who acquired their disability later in life were more likely to accept negative societal messages about individuals with disabilities. Furthermore, overall societal devaluation, low body esteem, lack of sexual esteem, a preference for a nondisabled partner, and the overall desire to form and maintain an intimate relationship negatively impacted the women’s decision making regarding choosing a partner and staying in an abusive relationship. Women who were afraid to be alone, expressed low body and sexual esteem and had a strong desire to be in a relationship (particularly with an able-bodied man) said they lowered their standards when choosing a mate. Once in that relationship these women were more likely to tolerate abuse from their partner rather than leave and be single
Oktay and Tompkins (2004)	QL	Community sample of men and women ages 19–78, mean age 43 who obtain PA services (n = 84)	Explore the prevalence of abuse and neglect experienced by community-based adults with disabilities obtaining PA services; identify the characteristics of the recipients and PAs associated with abuse	Results showed that 30% reported one more types of maltreatment by primary PA and 61% reported maltreatment by other PAs. Verbal abuse was the common form of abuse reported. Eighteen percent reported they experienced verbal abuse by their primary PA and 29% said they were verbally abused by other PAs. 6% reported neglect by primary PA and 26% by other PAs. 5% reported they received “poor care” from their primary PA and 21% received the same type of care from other PAs. 10% experienced physical abuse by primary PA and 9% from other PA. 3% experienced sexual abuse by primary PA and 8% reported sexual abuse by another PA. 9% reported their PA sole from them and 29% said another PA did the same. 8% reported extortion by primary PA and 15% from another PA. Cross tab results indicate there was a significant inverse relationship between income and abuse. Male PAs were more likely to exhibit abusive behaviors. Length of employment was also found to be a significant correlate with those employed for shorter lengths of time were more likely to be abusive. Alternatively those who worked 40 hr or more were more likely to be abusive compared to those who worked fewer hours
Chang et al. (2003)	QL	Domestic violence programs in North Carolina (n = 72)	To describe the services that domestic violence programs in the state of North Carolina provide to women, including those with disabilities; to document the limitations and challenges faced by domestic violence programs in their attempts to provide services to women with disabilities; and to learn what strategies domestic violence programs have utilized to overcome the challenges they faced in providing services to women with disabilities	Of the participating programs, 99% provided services to at least one woman with a physical or mental disability in the preceding 12 months; 5% offered shelter services to women with physical or mental disabilities. Most respondents (94–99%) reported that their programs were either somewhat able or very able to provide effective services and care to women with disabilities. The respondents also described challenges to serving women with disabilities, including lack of funding, lack of training, and structural limitations of service facilities. Strategies used by the programs to overcome these challenges were networking and coordinating care with organizations that specifically serve disabled populations
Cramer, Gilson, and DePoy (2003)	OL	Community volunteers recruited through a center for independent living and disability advocacy organizations. Four focus group were interviewed (n = 24)	Individuals with disabilities and those without who were either professionals or survivors of abuse	Two major themes emerged from data analysis: vulnerable beginnings and complexity of abuse. They also report three subthemes regarding abuse: active abuse, abuse through image, and contextual abuse by social service/legislative systems. The results are presented in a person-in-environment perspective for women with disabilities
Milberger, Israel, and LeRoy (2003)	QL	Community sample (n = 177 women completed initial screening, 85 completed interviews)	The research questions include: what is the prevalence of violence among a sample of women with physical disabilities? What risk factors for violence exist among women with physical disabilities? What types of actions do women with physical disabilities engage in to escape abusive situations?	Of the 85 women interviewed, 87% reported they had experienced physical abuse, 66% sexual abuse, 35% were refused help with a personal need, and 19% were prevented from using an assistive device. The majority (89%) had experienced multiple incidents of abuse. The most common perpetrator was male. Thirty-one percent stated the abuser was a family member, 15% said it was an acquaintance, 12% said it was a caretaker or health professional, and 8% reported it was a stranger. While 33% sought help for abuse, only half of those individuals had a positive experience obtaining that help. Those who did not seek help gave the following reasons: feeling they could handle it on their own, having other forms of support, lack of knowledge about services, feeling embarrassed, feeling guilty about being a burden or at fault, fear of retribution, fear of not being believed, and concern about lack of accommodations at shelters. Experiencing abuse was positively associated with lack of employment, being divorced, having more than one disability, and being hearing impaired.
Powers, Curry, Oschwald, and Maley (2002)	QL	Community sample from independent living centers and disability services agencies (n = 200)	The purpose was to explore abuse by PAS workers, the barriers to stopping abuse and the strategies perceived to prevent abuse	The overall results suggest that those with physical and physical and cognitive disabilities experience abuse at twice the rate of those without disabilities. Barriers to reporting the abuse included embarrassment, fear of retaliation, lack of experienced workers, shortage of backup providers, and the low wages that are paid to PAS workers
Gilson, DePoy, and Cramer (2001)	QL	Participants were recruited through Centers for Independent living, other providers of disability services and domestic violence agencies (n = 16)	Exploratory study to better understand the types of abuse experienced by women with disabilities, the relationship between victim and abuser, identify attempts to obtain services and the victims’ experiences with those services.	The authors identified two overarching themes, the nature of abuse experienced by this population and their response to this abuse. Three subthemes addressed the nature of abuse experienced by these individuals, and included assault, neglect, and use of control and restraint—all related to disability. Three categories emerged and related to how the women felt about themselves as a result of the abuse. The categories included “bad self,” “stuck,” and “movement.” Poverty and isolation were identified as factors that intensified the abuse and impacted the victims’ response to that abuse. Limitation was identified as the factor that distinguishes abuse of women with disabilities from those who are nondisabled, as it turns ordinary circumstances into abusive situations
McFarlane et al. (2001)	QT	Community sample of women attending private and public clinics (n = 511)	Explore the prevalence, type, and perpetrators of abuse toward women with disabilities	Of the 511 participants, 9.8% reported they had experienced abuse within the last 12 months. The most common perpetrator of abuse were individuals identified as intimate partners; however when looking at incidents of disability-related only, this type of abuse was equally perpetrated by intimate partners, care providers, and health care professionals
Nosek, Howland, Rintala, Young, and Chanpong (2001)	QT/QL	Community sample (total N = 881, 475 women with disabilities and 406 without disabilities; n = 31 qualitative interviews with women with disabilities)	Exploratory study to understand various issues from the perspective of women with disabilities	Women with disabilities experienced the same rate of abuse as women without disabilities (62%); they experienced common types of abuse also experienced by women without disabilities, but also reported disability related abuse (i.e., withholding orthotic equipment and medications). For both groups, husbands were the most common perpetrators of emotional and physical abuse, while strangers were the most common perpetrators of sexual abuse. Women with disabilities were much more likely to be abused by a health care provider compared to women without a disability. Women with disabilities also experienced abuse for significantly longer periods of time and experienced barriers to accessing services to address abuse
Milberger, Israel, and LeRoy (2001)	QL	Community sample who used PAS services 3 times or more a week (n = 72; 49 in focus groups and 23 individual interviews)	Explore how women define personal assistance abuse, the barriers they face in handling abuse, strategies they recommend to prevent and or stop abuse	Themes that emerged: social and personal boundary confusions with PAS workers, difficulty recognizing, defining, and describing abuse in the PAS relationship, challenges of using family and friends as PAS workers, the barriers to address abuse (self-blame, difficulties finding and replacing PAS workers, lack of police understanding), strategies to prevent abuse (i.e., emergency backup PAS workers, support groups, the creation of a crisis line, increase wages and training for PAS workers, provider screening, and police training)
Swedlund and Nosek (2000)	QL	Staff at Centers for Independent Living (CILs) were mailed a survey and those who responded to the survey were then interviewed over the phone (n = 36)	The purpose of this study was to gain preliminary information on the services CILs are providing their clients who have experienced abuse	The majority of CIL staff (31 of 36 interviewed) identified abuse an important issue for their clientele. Issues related to assisting consumers with abuse concerns included, lack of physical accessibility to shelters and domestic violence outreach programs, lack of disability related knowledge and training of domestic violence workers, and the impact of client dependence on the abuser for daily care and economic needs
Young, Nosek, Howland, Chanpong, and Rintala (1997)	QT	General community sample (n = 439 with physical disabilities; n = 421 without physical disabilities)	Explores the prevalence of abuse of women with physical disabilities compared to women without physical disabilities	Sixty-two percent of individuals with and without physical disabilities reported they had experienced some form of abuse in their lifetime. Thirteen percent of women with physical disabilities experienced abuse within the last 12 months. Husbands and live-in partners were the most common perpetrators of emotional and physical abuse, while male strangers most commonly perpetrated sexual abuse for both groups. Women with physical disabilities were more often abused by a health care provider or attendant

Prevalence of Abuse

Women with disabilities experience abuse at similar or increased rates compared to the general population (Grossman & Lundy, 2008; Martin et al., 2006; Nosek et al., 2001; Powers et al., 2009; Smith & Strauser, 2008; Young et al., 1997). One study comparing rates of lifetime prevalence of emotional, physical and sexual abuse of women with disabilities to women without disabilities found that that 62% of both groups had experienced such abuse. The proportion of women with disabilities to women without disabilities who reported emotional abuse was 51.7% versus 47.5%, for physical abuse 35.5% versus 35.6%, and for sexual abuse it was 39.9% versus 37.1% (Young et al., 1997). In this study, significant differences were not found in the percentage of women abused, whether or not the individual had a disability, nor by type of abuse. In a more recent study comparing risk of physical and sexual assault prevalence among women with and without disabilities, the authors found that women with disabilities experienced similar rates of physical abuse and were 4 times more likely to have experienced a sexual assault (Martin et al., 2006). In a study of 1,152 women interviewed at family practice clinics, women who reported experiencing some type of abuse (physical, sexual, and emotional) in their current relationships were more than twice as likely to report having a disability (Coker, Smith, & Fadden, 2005).

Additionally, women with disabilities suffer from multiple forms of abuse, including disability related abuse and neglect such as withholding medications, denying access to mobility devices, neglecting personal care, and preventing attendance at doctor’s appointments (Copel, 2006; Gilson, DePoy, & Cramer, 2001; Oktay & Tompkins, 2004; Powers et al., 2009; Saxton et al., 2001). Abuse can also be contextual, as Cramer, Gilson, and DePoy (2003) point how legislative and social service agencies differ in how they define abuse, and how difference translates into differences in assistance that can be offered to these women with disabilities who have experienced abuse. Studies also suggest that women with disabilities experience abuse for longer periods of time compared to individuals without disabilities (Nosek et al., 2001; Young et al., 1997).

Potential Risk Factors

Gilson et al. (2001) suggest that in general, any limitation to one’s ability to tend to activities of daily living (ADLs) severely increases the risk of abuse and neglect. Further, researchers have identified a number of specific factors as possible contributors to the increased risk of abuse of individuals with disabilities. Some of these factors include increased risk of isolation (Nosek, Hughes, Taylor, & Taylor, 2006; Powers et al., 2009), contact with multiple potential perpetrators (Nosek et al., 2001), increased physical, emotional, and economic dependency as a result of a disability (Swedlund & Nosek, 2000; Thomas, Joshi, Wittenberg, & McCloskey, 2008), the incorporation of learned helplessness (Saxton et al., 2001), difficulties identifying disability related abuse (Saxton et al., 2001), and cultural/societal barriers that impede their ability to find and obtain assistance (Gilson et al., 2001; Hassouneh-Phillips & Curry, 2002; Nosek et al., 2001; Oschwald et al., 2009; Swedlund & Nosek, 2000).

Isolation

Increased risk of abuse has been attributed to a lack of accessibility, lack of mobility and social isolation (Gilson et al., 2001; Nosek et al., 2006; Powers et al., 2009). In a study of 415 women with physical disabilities, Nosek et al. (2006) found participants who were less mobile and more socially isolated had a higher likelihood of having experienced abuse. Gilson et al. (2001) identify isolation as factor that could intensify the abuse and further restricts the victim’s ability to respond to the abuse. Individuals may be isolated through multiple forms including restrictions to communication devices such as phone, Text Telephone (TTY), and the Internet, rendering a person incapacitated and unable to reach out for help.

Role of Perpetrators

Women with disabilities are exposed to multiple potential abusers, including intimate partners, family members, health care provides, and personal assistance service workers (PAS; Curry et al., 2009). Although the most commonly identified perpetrators of abuse against this population are husbands, live-in partners, and men (McFarlane et al., 2001; Milberger, Israel, & LeRoy, 2003; Saxton et al., 2001; Young et al., 1997), abuse by personal assistance providers remains a significant issue due to its prevalence and impact (Saxton et al., 2001). Individuals with disabilities are in a unique and potentially dangerous position of being in physical contact with many different professionals, of various responsibilities and experience, on a daily or weekly basis. These individuals will likely be at higher risk of abuse, compared to the general population, just by the sheer increased number of interactions necessitated by medical care for their disability. In a cross-sectional study of women with and without disabilities, those who identified as having a disability were found to be more likely to be abused by health care providers (Nosek et al., 2001). Further, environments that provide services to individuals with disabilities, such as large hospitals, institutions, and group homes, offer multiple opportunities for interactions with potential perpetrators (Nosek et al., 2001).

Furthermore, the very nature of the relationship between a PAS provider and women with the disability is also viewed as a risk factor. Due to the ongoing contact (many hours spent in the individuals’ home) and intimate nature of that contact (bathing, toileting, and feeding), the risk of abuse in the form of infantilism and boundary confusion is common (Saxton et al. 2001). Boundaries can also waver when friendship and a business relationship are unclear, or when touching through caretaking is highly personal and intimate. Saxton et al. (2001) investigated perceptions and experiences of abuse by PAS of disabled women. Seventy-two women between the ages of 19 and 70, diagnosed with physical disabilities or physical and cognitive disabilities who utilized PAS services at least 3 times a week were interviewed. Findings revealed that the participants experienced continued abuse at the hands of their personal care assistants. Similarly, Powers et al. (2002) utilized information from previous research to further identify the incidence of abuse by PAS workers and the barriers to obtaining assistance. The sample of 200 women with either physical disabilities or combined physical and cognitive disabilities, reported a lifetime rate of physical abuse at 67%, and a lifetime rate of sexual abuse at 53%.

Individuals with disabilities may also be a target by perpetrators due to perceived vulnerabilities. Certain predatory individuals may view a romantic or professional relationship with a person with a disability as an opportunity for exploitation, mistreatment, and abuse. Perpetrators of abuse may intentionally seek out women with physical and cognitive impairments with the assumption these individuals may be easily overpowered physically or manipulated emotionally (Martin et al., 2006). Some women with disabilities seem to be aware of this risk and increased vulnerability. Utilizing focus group interviews, Thomas et al. (2008) found that women who had experienced intimate partner violence in their relationships reported they believed their chronic health conditions actually made them more vulnerable to abuse.

Dependency

Physical, emotional, and financial dependency on an abuser has also indicated increased risk for individuals with disabilities. A diagnosis of a disability has been found to lead to increased dependency on an abuser due to a sheer need for assistance (Martin et al., 2006; Nosek et al., 2001; Swedlund & Nosek, 2000; Thomas et al., 2008). Perpetrators of abuse are not only partners of the victim but can also be the primary caregiver. The perpetrator may be responsible for cooking, cleaning, and attending to the victim’s daily living needs (i.e., bathing, toileting, etc), thus creating a dichotomous relationship of abuser and caregiver. Leaving an abusive relationship or alerting the authorities to abuse and neglect may lead to a loss of one’s primary caregiver. This perpetrator/caregiver relationship adds an additional layer of dependence, leaving a victim likely concerned about the source of continued care. This type of relationship might also place an individual in a situation in which she feels she needs to compromise or accept the abuse in order to obtain the positives or benefits she might obtain as a result of this relationship (Hassouneh-Phillips & McNeff, 2005). Intimacy, being in a relationship and having one’s daily needs cared for may outweigh the experiences of abuse. Finally, women with disabilities are less likely to be financially independent, often relying on their partner for economic stability. Women with disabilities who are unemployed have been found to be at increased risk of all types of abuse (Smith & Strauser, 2008).

Another type of dependence that has been identified as a potential risk is the integration of learned helplessness and overcompliance as a result of one’s disability. Individuals with disabilities are often taught to comply with other’s wishes and demands; this compliance is then often generalized by the individual to various situations and environments. Lifetime incorporation of behaviors that typify being overly agreeable and accommodating can create an atmosphere of fear and a reluctance to “rock the boat” when attempting to state one’s needs and wants (Saxton et al., 2001). They may either stop trying to fight or resist abuse, because their attempts offer no results due to the power of the abuse or the disability itself may limit one’s ability to defend oneself (Milberger et al., 2003; Nosek et al., 2001). Lifetime experiences of abuse by multiple perpetrators may instill in victims a belief that abuse is an expected part of one’s life (Nosek et al., 2006).

Lack of Identification

Women with disabilities and service providers do not always recognize abuse and neglect due to its insidious nature, often perpetrated through the exploitation of one’s particular disability (Gilson et al., 2001). Often the abuse experienced by individuals with disabilities exploits specific disabilities and are actions that are not necessarily defined as abuse by state law. Behaviors such as removing the battery from an electronic scooter, or moving furniture around so an individual with limited sight might fall are not actions that will result in arrest or an order of protection. Others may fear being met with disbelief if they come forward with their experiences of abuse. Additionally, the perpetrator is often in a position of power and authority that may be viewed as a trustworthy and caring person who provides support and help to the very person who is accusing them. The individual with the disability may be fearful to report abuse due to a dependent relationship that is born from a perpetrator/caregiver relationship, fear of not being believed, or the uncertainty of where she might live if she leaves an abuser. They also report a lack of knowledge about victimization and how to report such experiences (Saxton et al., 2001).

System and Cultural Barriers

Women with disabilities who want to reach out for services are met with a lack of accessible resources (Hassouneh-Phillips & McNeff, 2005; Milberger et al., 2003; Oschwald et al., 2009; Swedlund & Nosek, 2000). Those individuals that do attempt to report abuse are often met with insensitive behavior by service providers and first responders (Swedlund & Nosek, 2000). In a study of 36 Independent living centers (ILC), staff reported referral for assistance when abuse was indicated and was restricted due to a lack of ADA compliance by domestic violence shelters and agencies. Accessibility was further impaired by a lack of coordination by agencies to obtain personal care assistance and sign language interpreters at these facilities (Swedlund & Nosek, 2000). Lack of attention to abuse in the disabled population on all levels, including policy, theory, and practice, causes an environment that not only creates barriers to services but actually enables the abuse of individuals with disabilities (Gilson et al., 2001).

Oppression and devaluation of women with disabilities adds to the increased risk of abuse (Hassouneh-Phillips & Curry, 2002; Hassouneh-Phillips & McNeff, 2005; Saxton et al., 2001). Women with disabilities have been oppressed and marginalized due to society’s ableist and sexist view points. The impact of societal negative valuations about those with a disability is clear. Women born with disabilities are consistently reminded of their limitations, while simultaneously being prepared for lifelong dependence, and those individuals disabled in adulthood have unconsciously accepted lifelong messages of disability stereotypes that are entrenched in society (Nosek et al., 2001).

Furthermore, cultural factors such as societal discrimination may be internalized by the individual, translating into self-devaluation, poor self-esteem, and feelings of self-blame related to the abuse (Hassouneh-Phillips & McNeff, 2005). The use of stereotypes (women with disabilities are asexual and undesirable) negatively impacts disabled women’s self esteem and body image (Hassouneh-Phillips & McNeff, 2005). Women with disabilities have expressed high rates of low self-esteem (Gilson et al., 2001), which may translate into a fear of being alone and strong doubts whether they will find another partner who would accept their disability (Thomas et al., 2008) or even blaming themselves for the abuse (Saxton et al., 2001). Lack of self-esteem, fear of being alone, or unable to find another partner, compounded by the risk factor of physical dependency, may impact a woman’s decision to stay with an abuser. Women with disabilities have expressed overwhelming thoughts of being unworthy of a relationship and lack of feeling sexually desired (Hassouneh-Phillips & McNeff, 2005). These thoughts and feelings could propel an individual to stay in a relationship they know is abusive, tolerating actions and behaviors out of fear of being abandoned and alone.

Future Directions/Suggestions for Research

Scholars in this field continue to ask the same or similar research questions—what is the prevalence of abuse among women with disabilities? As the research in the field began its inception back in the mid- to late 1990s starting with the seminal article by Young et al. (1997), we continue today to pose the same question, how often does abuse occur in this population compared to individuals without disabilities? While research in this field is still in its infancy, we need to continue to identify prevalence rates. Studies now need to stretch beyond general occurrence and begin to focus on specific subpopulations and/or groups within the disability community.

Researchers must explore whether specific groups are at higher risk of abuse. For example, are individuals with traumatic brain injury at higher or lower risk for abuse compared to individuals with spinal cord injury? And if so what makes them more at risk? Are they at risk of specific kinds of abusive and neglectful acts by perpetrators? To date there are no studies that have compared experiences of abuse among individuals with specific types of disabilities. Only two studies have compared the experience of abuse by disability subgroup. Nannini (2006) included comparisons among disability groups when she studied their experiences of sexual assault and help-seeking behaviors after an assault, and Martin et al. (2006) similarly compared prevalence rates of physical and sexual abuse utilizing data from the NC–BRFSS survey of 2000–2001. While this is an important first step, the categories of disability were largely general (i.e., physical disability, cognitive disability/impairment, mental health, etc.) and overly encompassing. Notable though was Nannini’s inclusion of subgroups that have been largely ignored in this field: the hearing and visually impaired.

It is our estimation that prevalence rates have actually not been clearly established. Current rates of abuse have been based primarily on questions that only inquire about general types of abuse (physical and sexual) previously established as commonly experienced by individuals without disabilities. Most recent studies such as Martin et al. (2006), Casteel et al. (2008), and Coker et al. (2005) have established equal or high rates of sexual assault and physical abuse among this population, but all have neglected to include items specifically targeting disability-related abuse. It is in our estimation that studies that include disability related abuse tactics will actually suggest vastly higher rates of abuse. This hypothesis is supported by the results presented by McFarlane et al. (2001), in which only the use of two disability-related abuse items (included in the Abuse Assessment Screen-Disability [AAS-D]) detected an additional 2% of women abused.

Furthermore, through qualitative research, participants have described in detail their experiences of abuse that goes beyond what has been historically measured by scales that are albeist in nature. Narratives that include descriptions of abusers targeting particular disabilities clearly support the need for disability centered and disability sensitive measures. Inclusion of these items will greatly improve research ability to identify the true severity and frequency of abuse of this population. Neglecting to incorporate items that address abuse tactics targeting specific disabilities, “will invalidate the lived experience of many women with disabilities and result in an underreporting of the problem” (Curry et al., 2009). It is also recommended that disability-related abuse items should be tailored to the specific population that is being studied and focus on the identified vulnerabilities of that disability. Additionally, items inquiring about the relationship between victim and perpetrator should be inclusive and expansive. Women with disabilities are most commonly abused by their intimate partner/significant other, but remain at high risk of assault and neglect by other potential perpetrators such as doctors, PAS workers, nurses, and strangers. It is essential to include a range of potential perpetrator choices when asking about abuse. Discussions with individuals with various disabilities about potential disability-related abuses would provide a great amount of information and guidance when constructing these items.

Identifying Risk and Protective Factors

Although prevalence rates need to be established among certain groups as mentioned, the field of abuse and disabilities must take steps to go beyond the incidence rates and begin to address this issue by identifying risk and protector factors. This will result in much needed information in order to offer prevention and intervention strategies to those who work in the disability field. Studies need to include and test suggested risk factors that have thus far been largely anecdotal. Factors reported in both qualitative and quantitative studies need to be tested with multiple disability populations, settings, and contexts in order to confirm or reject their saliency. To date the only risk factors that have been identified quantitatively include unemployment (Smith & Strauser, 2008), isolation, age, education, and mobility (Nosek et al., 2006). Nosek et al. (2006) found individuals who are younger, more highly educated, and less mobile were at a higher risk of abuse.

One step toward identifying this population in order to better list risk and protective factors is the implementation and study of universal screening for this population. Although screening tools to identify abuse are available and easy to use, most women in contact with the health care system are not asked about abuse (Oschwald et al., 2009). Yet research suggests that the regular use of a screening tool encourages disclosure of abuse as compared to relying on self-initiated discussions of abuse (Oschwald et al., 2009). The use of a screening tool created specifically for individuals with disabilities will promote the identification of disability-related abuse (Curry et al., 2009; Gilson et al., 2001; Martin et al., 2006). The creation and use of instruments to identify disability specific abuse tactics will better establish prevalence and detection of abuse among this population. A screening tool will increase the awareness and knowledge of what constitutes abuse of women with disabilities, thereby possibly increasing their safety and reducing risk of continued abuse (Oschwald et al., 2009). Furthermore, disclosure will provide the necessary communication that will begin the process of referral to services for safety planning, emotional support, and other concrete services.

Mainstream abuse screening scales do not incorporate disability related abuse tactics, therefore a number of researchers have created disability specific instruments to address this need. Believing the current abuse assessment scales were lacking in ability to identify the range of abuse experienced by women with disabilities, McFarlane et al. (2001) created the first disability abuse scale, titled the Abuse Assessment Screen-Disability (AAS-D). This instrument includes four items total: two standard abuse questions taken from the AAS, and two disability related questions (has anyone prevented you from using a wheelchair, cane, respirator, or other assistive devices, and has anyone you depend on refused to help you with an important personal need, such as taking your medicine, getting to the bathroom, getting out of bed, getting dressed, or getting food or drink?). Curry et al. (2003) created an 8-item scale that combines the AAS with 6 disability-related abuse items. Finally, Oschwald et al. (2009) created a program called the Safer and Stronger Program (SSP) that utilized computer-assisted self-interviews (A-CASI) to both educate and screen for abuse among women with disabilities. The abuse screening section included 18 yes/no items, assessing the women’s experiences with physical, sexual, and disability-related abuse. These scales confirm Gilson, DePoy, and Cramer’s (2001) recommendations for the development and utilization of an assessment tool that identifies both abuse and level of functioning or ADL to better address the uniqueness of this issue. Researchers can collaborate with local hospitals, physical rehabilitation centers, medical offices, and so on, to test the impact of screening and referral on rates and experiences of abuse.

Consequences of Abuse

To date little research has been completed on the health effects of abuse on women with disabilities. Some suggest that abuse and violence against women with disabilities may exacerbate current health issues or cause additional injuries. This may be a as a direct result of the violence and abuse or due to partner interference with needed health care (Thomas et al., 2008) or through personally decreased attention to health issues (Powers et al., 2002). Psychological effects that have been identified include depression, anxiety, increased feeling of stress, and suicidal ideation (Hassouneh-Phillips, 2005). Negative physical effects of abuse include physical injury and overall decrease in physical functioning (bowel, skin, and nutritional issues; Hassouneh-Phillips, 2005). Longitudinal studies to examine the potential impact of abuse on the participant’s physical and mental health would provide insight into the effects of physical, sexual, and disability-related violence.

Include Disability in all Domestic Violence and Sexual Assault Studies

Finally, we strongly encourage the inclusion of disability as a category in all future domestic violence and sexual assault research studies to enable the field to truly recognize the significance of this issue. Social workers involved and knowledgeable about the field of domestic violence and sexual assault must collaborate and initiate research in this field. The majority of research in the field of domestic violence and sexual assault and individuals with disabilities has been largely done by those in the field of nursing, barring the work of Gilson, Depoy, and Cramer, Grossman and Lundy, and Oktay and Tompkins, who are from the field of social work. Utilizing social work values, theories, and ethics, our profession can provide a unique perspective to understand this important and often ignored issue. This would be an important step not only in identifying risk and protective factors but also may assist in the creation of a theoretical base to view this issue. Some previous researchers and scholars have framed the issue by placing partial culpability onto the victims and provided excuses or explanations for abusers’ behaviors. We suggest the use of the empowerment perspective, strengths perspective, and feminist theory to frame this issue. Additionally, much of the scholarship that is published is presented by the same groups of individuals who have dominated this field. Although previous work has been a positive step toward uncovering this issue, articles that restate the same or similar information does not encourage progression and innovation.

Limitations

We sought to examine a wide range of literature in our study from ten separate search engine/databases. There are many instances of less rigorous information being disseminated as advocacy groups, such as independent living organizations, try to bring this issue to the forefront (Meyers, 2010). In the process of reviewing the literature, we found researchers that reused a single data set for multiple articles (i.e., Curry et al., 2009; Oschwald et al., 2009; Powers et al., 2009). Therefore, much of the scholarship written on abuse and individuals with disabilities is repetitive and redundant.

Conclusion

Although statistics vary, it is clear that at the very least women with disabilities experience abuse at the same rate as nondisabled individuals and at worst they experience higher rates of abuse, incidents of disability-related violence, and sexual assault. Consistently, studies suggest that individuals with disabilities are abused for extended periods of time, are at greater risk of abuse by multiple types of perpetrators, and experience abusive tactics that target one’s disability. The risk of abuse and neglect of women with disabilities has been attributed to a number of identified factors. These risk factors include increased risk of isolation, abuse by multiple potential perpetrators, dependency as a result of disability, difficulties identifying and naming disability related abuse, and cultural/societal barriers.

It should also be noted that the discipline and background of researchers doing this type of work is not necessarily social scientists (i.e., social workers); the majority of research appears to be completed by nurses. Whereas nursing has the training to work with victims of domestic violence as well as social workers, social workers are trained in the interventions for long-term care needs and ongoing adjustment issues. This presents an opportunity for creating an agenda for social work for a more comprehensive inclusion of curriculum directed at the prevention and treatment of domestic violence, particularly for those with disabilities, as well as the opportunity for the inclusion of ongoing research in this area. Furthermore, it was noted in the location of the published research the pockets of research going on within the United States. This begs the question of how does this fragmentation affect service provision? This is another area where social work and other community-level workers could address the lack of services as well as the training of service providers in regions that are not as well developed.

Finally, the role of cognitive abilities of the individuals with disabilities needs to be considered in how research and training being conducted. In fact, the definition of “disability” itself and how the term is used needs discussion in the field of domestic violence. There is an abundance of literature in the rehabilitation field that addresses disability from a strengths-based perspective that promotes community integration and reduction of physical and social barriers (World Health Organization, 2001), whereas the medical field frequently views disability from the medical model with the individual exhibiting deficit (Lin, 2003). The approach of the worker with the individual with disability should include exploration of the workers’ understanding and feelings regarding disability to address myths or misunderstandings that do not support a strengths-based perspective. Future research will offer guidance to relevant interventions and policies that need to be introduced to protect these individuals.

Implications for Review for Practice, Policy, and Research

Investigators should be encouraged to include individuals with all forms of disabilities in their work concerning women with disabilities to increase the representativeness of those studies.

Existing scales that assess for abuse or violence should include the broader range of abuse that might occur in individuals with disabilities including neglect (e.g., leaving a wheelchair or other assistive device out of reach of the user).

Services for individuals who are victims of violence and/or abuse need to be linked with agencies that provide services for those with disabilities to increase sensitivity to the needs of individuals with disabilities in order to assist them at the highest levels possible (e.g., educate staff on the more common disabilities and how abuse many occur).

Research now needs to move beyond the epidemiology of the problem of women with disabilities that experience violence and abuse; research needs to explore the ability of the social service and medical sectors to respond to their issues.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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