Violence and People with Disabilities: A Review of the Literature

by
L'Institut Roeher Institute
For the
National Clearinghouse
on Family Violence
 

Family Violence Prevention Unit
Health Canada
August 1994
Prepared by Miriam Ticoll

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Family Violence Prevention Unit
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Health Canada
Ottawa, Ontario
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La violence et les personnes ayant des incapacités analyse de la littérature

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©Ministry of Supply and Services Canada 1994
Cat.  H72 - 21/123/1994E
ISBN: 0-662-22712-3

Table of Contents

       Summary

1.    Introduction and Methodology

2.    Defining Violence against
       People with Disabilities

3.    Extent of the Problem

4.    Where Violence Occurs

5.    Factors Contributing to Violence

6.    Effects of Violence and Abuse

7.    Disclosure

8.    Patterns of Response

9.    Preventing Violence against
       People with Disabilities

10.  Conclusion

11.  Biobliography
 
 

SUMMARY

People with disabilities - like other marginalized groups - are particularly vulnerable to violence and abuse.  There is now a small but growing body of literature that addresses the particular issues faced by people with disabilities with respect to their experience of violence.  This document is a review of that literature.  The document analyses how violence against people with disabilities is defined, the kinds of violence to which people with disabilities are subject, the contributing factors/causes of violence, the incidence of violence, issues relating to disclosure and responses to violence and prevention issues.

Violence against people with disabilities has been characterized as:
 

• occurring in the context of systemic discrimination against people with disabilities in which there is often an imbalance of power, and

• including both overt and subtle forms of abuse which may or may not be considered to be criminal acts.

Although people with disabilities are susceptible to the same forms of violence as the population at large,  the circumstances in which they find themselves may also make them more vulnerable to particular types of abuse.  People with disabilities may be more likely to experience the following forms of abuse:
 

• physical abuse, which can include hitting, shaking, burning, the administration of poisonous substances or inappropriate drugs; inappropriate handling, personal or medical care; over-use of restraint or inappropriate behaviour modification, experimental treatment;

• sexual abuse, including unwanted or forced sexual contact, unwanted touching or displays of sexual parts, threats of harm or coercion in connection with sexual activity; denial of sexuality, denial of sexual education and information, forced abortion or sterilization;

• psychological and emotional abuse, including the lack of love and affection, verbal attacks, taunting, threats (of withdrawal of services or of institutionalization, for example), insults and harassment;

• neglect and acts of omission, including ignoring nutritional, medical or other physical needs, the withholding of the necessities of life, the failure to provide required medical care or appropriate educational services;

• financial exploitation, including the denial of access to, and control over, individuals' own funds and the misuse of their financial resources.

Problems have been noted by researchers with regard to obtaining accurate incidence statistics about violence and disability.  Varying definitions of abuse and reporting rates, for example, make it difficult to measure the difference in risk faced by people with and without disabilities.  However, there is an accumulation of independent findings which suggests that there is a problem of considerable magnitude.

A number of psychological, cultural and social factors have been noted as contributing to a climate in which violence occurs.  These general factors have an impact on the extent to which people with disabilities experience violence.  In addition, several factors have been identified which may precipitate the exposure of people with disabilities to violence and abuse, including:

• negative public attitudes towards disability;

• social isolation of people with disabilities and their families;

• reliance of people with disabilities on others for care;

• lack of support for care-givers;

• lack of opportunity for people with disabilities to develop social skills through typical social interaction;

• nature of the disability;

• gender;

• poverty;

• lack of control or choice of people with disabilities over their personal affairs;

• perceived lack of credibility of people with disabilities when they report or disclose abuse;

• socialization of people with disabilities to be compliant;

• alcohol and drug abuse by perpetrators;

• ineffective safeguards.

Although there is a considerable volume of research examining the effects of violence in the population at large, relatively little research has been conducted focusing particularly on the effects of violence and abuse on people with disabilities.  Most of the literature which does exist looks at the effects of sexual abuse.

The literature suggests that people with disabilities may be reluctant to report abuse for many of the same reasons that non-disabled children and women do not report abuse, including fear of retaliation, dependency and shame.  A number of studies suggest that for children or adults with disabilities the difficulties of disclosing abuse are further compounded due to the situations they find themselves in because they are disabled.  Some of the factors identified as influencing a person's decision to report or not to report abuse include:

• the significance the victim attaches to the incident;

• whether the individual has the physical means of communicating with others;

• whether the individual has or perceives there to be anyone to whom to report;

• the receptivity and perceived trustworthiness of the person to whom the victim discloses;

• the probability of being believed;

• the perceived consequences to the victim's and others' safety as a result of disclosure;

• whether the victim feels sympathy for a perpetrator;

• the perceived probability of receiving a just and efficient response to the complaint.

A number of issues emerge in the literature with respect to the nature of the responses of the various systems to acts of violence against people with disabilities, and how they can intervene more effectively.  Some of the issues highlighted are summarized below:
 

• Service environments: It has been noted that the response patterns vary greatly within services and agencies, and even within the same agency.  To a large extent, in the absence of effective and well implemented protocols, the responses to abuse often depend on the attitudes, knowledge and skills of the individual staff person who comes into contact with the victimized person.

• Community support services: A number of studies indicate that there is limited access to community support services for people with disabilities who have been abused.  However, there is an emerging recognition of the need to provide accessible and appropriate counselling services for children and adults who have been sexually abused.

• Police: The literature suggests that the police may have certain attitudes towards persons with disabilities that may impede investigations.  Interactive training of the police with face-to-face encounters with disability organizations, and inter-disciplinary training with social workers, advocacy groups, medical personnel and police officers, are required to improve police responsiveness to people with disabilities.

• Judicial system: The lack of physical and social access to the courts, rules of evidence, courtroom procedures that unfairly impinge on the rights of people with disabilities and the lack of willingness to make reasonable accommodation to individual differences were identified as barriers to be addressed by the judicial system.

The need for a multi-faceted approach to responding to and preventing the abuse of people with disabilities emerges repeatedly in the literature.  Effective intervention requires the collaboration between systems, including the police, the judiciary, residential and support services, and community-based generic services.

A number of recommendations emerge from the literature regarding the prevention of violence against people with disabilities.  They involve:

i.     Systemic changes to eliminate the conditions that make it likely that people with disabilities will be subject to abuse, including:

• better access of persons with disabilities to the labour market so they are not so widely impoverished;

• more adequate levels of income support that would help reduce economic reliance on care-giver-perpetrators;

• disability-related support services that are more widely available, affordable, portable and subject to consumer control so that people with disabilities are not required to participate in delivery sites that may involve risks (e.g., sheltered workshops, group homes, special care homes, multi-service institutions) in exchange for essential services;

• deinstitutionalization of people with disabilities and integration into the community;

• changing attitudes regarding disability, through public education;

• ensuring the availability of adequate supports to families.

ii.    Specific preventative measures within a variety of settings to make it less likely that people will be harmed, including:

• ensuring that people with disabilities know their rights and how to report abuse;

• clear definitions with respect to abuse and neglect, the requirement that reporting be made to the police or the child welfare authorities, that investigations happen quickly and that the safety of the individual from the perpetrator be ensured;

• sex education and clearer guidelines with respect to sexual activity within residential settings;

• assertiveness training and empowerment of people to resist abuse;

• the screening of new employees for past criminal records;

• risk assessment approaches used in child protection agencies that include the child's specific disability as a risk factor;

• education of service providers/professionals on the relationship between abuse and disabilities, and on making appropriate referrals for children with disabilities;

• educating professionals who come into contact with children and adults with disabilities on the relationship between maltreatment and disabilities, on identifying possible abuse, and on making appropriate referrals.

iii.      Measures to ensure effective responses to abuse when it happens, including:
 

• effective internal protocols in health, social service and educational settings for identifying, reporting and responding to victimization;

• reforms to the judicial system to ensure that people with disabilities have recourse to the courts;

• affordable, accessible counselling and other support for people with disabilities;

• strong advocacy support.

The literature suggests that there is an increasing recognition of the need to address the issue of violence against people with disabilities and that some progress has been made in terms of raising public awareness and developing more effective intervention strategies.  However, much remains to be done to eliminate the systemic causes that create a climate in which the abuse of people with disabilities is tolerated, as well as to ensure that safeguards are in place and that systems and agencies work collaboratively to respond appropriately when violence occurs.
 
 

1. INTRODUCTION

i.      Framing violence and disability

This document is a review of the literature pertaining to people with disabilities and violence.  Through an examination of the literature it analyses how violence against people with disabilities is defined, the kinds of violence to which people with disabilities are subject, the contributing factors/ causes of violence, the incidence of violence, issues relating to disclosure and responses to violence, and prevention issues.

There is a large body of literature on violence.  The literature includes philosophical examinations which attempt to explain the causes of violence, studies looking at the characteristics of perpetrators and victims for purposes of identification and treatment, case studies, personal accounts, statistical information, analysis of factors which contribute to violence and discussions of the effectiveness of the responses to violence.

Analyses of violence focus both on individual and on systemic issues.  Much of the literature looks at violence resulting from the actions of individuals and examines the biological and environmental factors which contribute to understanding their actions.  Some of the literature also analyses the systemic inequalities which contribute to violence.  Feminist analyses, for example, point to institutional inequities and power imbalances as critical to understanding violence against women.  In this review, an effort is made to focus both on the individual and systemic issues and the interaction between them with respect to how people with disabilities experience violence in their lives.

Whereas a considerable amount has been written about violence generally, the body of literature on violence and people with disabilities - the particular focus of this review - is still relatively small.  An effort was made to concentrate on material relating to violence and disability in the Canadian context.  However, other sources were consulted, particularly in the United States and Great Britain.
 

ii.     Methodology

Literature searches were conducted on several databases, including Psych Lit, Sociofile and Abstracts in Criminology and Penology.

The Psych Lit and Sociofile databases were searched by combining all derivatives of the descriptors handicapped or disability and violence.

Additional searches on Psych Lit were conducted using the following descriptors: behaviour modification, aversion therapy, institutionalization, institutionalized mentally retarded, time out, nursing homes, residential care facilities, physical abuse, child abuse, elder abuse, emotional abuse, sexual abuse, patient abuse, physical restraint, child neglect, informed consent, quality of care, mental health services, mental health personnel, psychiatric hospitals, group homes.

Additional searches on Sociofile were conducted using the descriptors child abuse, sexual abuse and handicapped, human service organizations, group homes, hospitalization, access to employment, recreation, public transportation, sheltered workshops, community mental health, deinstitutionalization, abuse and mental patients, mental illness, mental health services, mental hospitals, justice, human rights, health services.

Abstracts in Criminology and Penology were examined with special regard for sections on special groups, psychopathology/psychiatry, penology, criminal procedures and the administration of justice, special offences and prevention.  Some work was found with regard to psychiatric populations and elder abuse.  Little was found relating to other kinds of disabilities.

Extensive use was made of the resources of l'Institut Roeher Institute's Information Services.

The bibliography appearing at the end of this document includes material specifically referred to in the literature review as well as a number of documents retrieved through the database searches which would likely be of interest to those concerned with the issue of violence and people with disabilities.

Where possible, the literature review focuses particularly on material pertaining to the Canadian context.
 
 

2. DEFINING VIOLENCE AGAINST PEOPLE WITH DISABILITIES

i.     Issues in defining violence

This review looks specifically at the issue of violence as it affects people with disabilities.  However, it is worth noting some of the ways in which violence is defined more generally and the implications of these definitions for understanding the particular ways in which people with disabilities experience violence.

A review of the literature reveals that violence has been defined in a variety of ways over the course of history.  The way in which violence is defined depends both upon who is "doing the defining" and the social and historical context in which people are operating.

The legal-judicial system plays a significant role in terms of defining what constitutes violent crime.  In Canada, under the Criminal Code, crimes of violence include murder, attempted murder, manslaughter, sexual assault, non-sexual assault, other sexual offences, abduction and robbery.  Property crimes include breaking and entering, theft, possession of stolen goods and fraud.

Legal definitions not only reflect societal values, but also play a role in shaping public opinion.  The impact of the legal definition of violent crime on public opinion is illustrated in comments by researchers who worked on a survey of violence against women recently conducted by Statistics Canada:

In recent years, criticism has been directed toward survey research that defines "abuse " or "violence " against women more broadly than social consensus would allow.  It was considered important in this survey to restrict measures Of violence against women to Criminal Code definitions of assault or sexual assault in order to capture 'violence 'as it is legally understood.  There was a need to develop descriptions of violent acts that could be understood by a random sample of women across the country as reflective of their own personal experience and still be consistent with Criminal Code definitions. (Johnson and Rodgers, 1994)

In a survey conducted by the Native Family Violence Counselling and Community Service Training Program with members of seven home communities in 1988 about their understanding of family violence, respondents included not only wife battering, sexual abuse, child neglect and verbal and emotional abuse as forms of violence, but also residential school violence, spiritual abuse and addiction (Nadeau, 1990).

A proposed United Nations Declaration defines violence against women in terms that go beyond legal definitions of violence.  It suggests that violence against women includes:

Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life. (United Nations, 1993)

In their discussion of how to define violence against women, the authors of the final report of the Canadian Panel on Violence against Women stress that violence against women is socially structured - that all social institutions, from the family to the legal-judicial system, are characterized by unequal power relations between men and women.  They suggest that each individual experience of violence must be seen in this larger social context (The Canadian Panel on Violence against Women, 1993).

The question of how violence is defined, and the need to situate acts of violence in a broader context, have also been raised in literature on violence and people with disabilities.
 

ii.     Issues in defining violence against people with disabilities

In one study on violence and people with disabilities, research participants perceived violence against people with disabilities as including the range of acts that are widely considered by the public, the law and social policy as unacceptable ones against which all members of society should be safeguarded - in other words, acts proscribed under Canada's Criminal Code.   However, various acts were identified during this research that are not widely construed by the public at large as forms of violence.  These acts, it was noted, are ones to which persons with disabilities are particularly vulnerable and which people with disabilities are perhaps more likely than others to construe as acts of violence (The Roeher Institute, 1994).

How acts of violence are defined has a significant impact on how or whether victimization is perceived and reported.  One author suggests that the victimization of people with disabilities is often classified as abuse and neglect rather than as crime (Luckasson, 1992).  Luckasson notes that the specific acts that may occur - for example torturing and perhaps killing an individual, violating an individual's body, hitting, yelling, withholding food, subjecting someone to dangerously unsanitary living conditions, depriving an individual of necessary medical care - are similar, if not identical to, the acts that occur in what tend to be regarded as more serious crimes such as rape.

Another researcher comments that more subtle forms of violence or abuse affecting people with disabilities are often ignored or denied:

Over the past two years there has been an opportunity to witness countless abusive incidents.  Many people would deny that these situations or scenarios could be called "abusive " and be deemed humiliating, degrading, oppressive or discriminatory due to the fact that they would feel their personal actions, their status or their corporate practices were being challenged or threatened. (Macfarlane, 1994)

iii.      Forms of violence perpetrated against people with disabilities

As noted above, the identification of the various forms of violence against people with disabilities depends to some degree on whether one includes systemic discrimination and other forms of abuse which are not necessarily criminal offences.  As one researcher notes:

Definitions of abuse include physical, sexual and emotional abuse and neglect... Also, disabled people are discriminated against in their everyday lives -for example, by lack of appropriate services, lack of access to public facilities -and many would view such discrimination as abusive itself. In order to set 'boundaries' for the current study, however, discrimination was viewed as a secondary form of abuse. (Westcott, 1993)

Attempts have been made to identify the various forms of abuse, incorporating power differentials or systemic discrimination.  For example, in a discussion paper on family violence against woman with disabilities, family violence was described as "physical, psychological or sexual maltreatment, abuse or neglect of a woman with disabilities by a relative or care-giver.  It is a violation of trust and an abuse of power in a relationship where a woman should have the right to absolute safety.  In many cases, it is also a crime" (Health and Welfare Canada, 1993a).

Another study defined violence broadly, in an effort to capture the scope and the various forms of violence experienced by people with disabilities.  It suggested the following definition:

Violent acts against people with disabilities may involve any combination of:

• physical force (e.g., beating);

• physical actions that take the form of "care" (e.g., administration of medications or restraint);

• physical actions of a sexual nature (e.g., rape or fondling);

• denial of rights, necessities, privileges or opportunities by persons who are in a position to promote or safeguard the individual's well-being;

• patterns of communication that may not involve physical contact but which are nonetheless perceived by victims as threatening (e.g., explicit threats or stalking), as tormenting (e.g., harassment), or as insulting (e.g., "speaking down" to or using derogatory terms when speaking to the individual);

• lack of proper action, such as neglect or the failure to respond effectively to incidents that have compromised the victim's well-being.

Typically, acts of violence against people with disabilities involve a power differential between the victim and the perpetrator for any of the following reasons:

• the victim depends on the perpetrator for physical, psychological or economic support or for other necessities;

• the victim lacks control over the actions of others who have the potential to invade, disrupt or negate well-being;

• the victim lacks status, credibility or "voice" in relation to persons or systems that are in a position to inflict, prevent or ameliorate harm (The Roeher Institute, 1994).

A number of broad categories of violence perpetrated against people with disabilities can be identified through the literature.  These may or may not involve acts that are recognized as criminal acts of violence or abuse.  These forms of violence are discussed below with particular reference to how people with disabilities may be at risk to them.

Physical abuse involves an individual being physically hurt, injured or killed.  This includes hitting, shaking, squeezing, burning, biting, as well as the administration of poisonous substances, inappropriate drugs and alcohol, and attempted suffocation or drowning (The Roeher Institute, 1994; Sobsey, 1994; Westcott, 1993).  It can also include inappropriate handling, inappropriate personal or medical care, over-use of restraint, and inappropriate behaviour modification (Health and Welfare Canada, 1993b).  Certain therapies prescribed for people with disabilities, such as electroshock and aversive behaviour modification techniques, have been described as violent acts similar to torture (Weitz in Burstow and Weitz, 1988; Stainton in The Roeher Institute, 1988b).

Another form of physical abuse discussed in the literature and to which people with disabilities may be particularly susceptible is that of experimental treatment.  Hudson, in Hanmer and Maynard (1987), discusses the lack of regulations underlying psychosurgery within the mental health field.  The literature of personal accounts relates the damaging experiences of women who underwent physical and psychological experimental treatments.  Examples include lobotomies and experiments in which electroshock, drugs and deep sleep were combined at the Allan Memorial Institute and which resulted in complete memory loss (Sager in Browne, Connors and Stern, 1985; Macdonald in Burstow and Weitz, 1988).

Sexual abuse includes any unwanted or forced sexual contact such as rape or forced oral sex; unwanted touching or unwanted displays of sexual parts; threats of harm or coercion in connection with sexual activity (The Roeher Institute, 1993).  For people with disabilities sexual abuse has also been identified as including the denial of sexuality, denial of sexual information/ education, forced abortion or sterilization (Health and Welfare Canada, 1993a).

Sobsey notes that, although there are some areas of discrepancy, certain patterns are emerging with regard to the sexual abuse of people with disabilities:

Both children and adults with disabilities experience risk of sexual abuse.  The abuse that these individuals experience is often chronic and severe.  While they may be abused by many of the same perpetrators as other victims of sexual abuse (e.g., family members, neighbours, babysitters), they appear to experience additional risk from offenders with disabilities and caregivers with whom they come in contact through disability services. (Sobsey, 1994)

Psychological and emotional abuse includes lack of love and affection, threats, verbal attacks, taunting and shouting which leads to the victim's loss of confidence and self-esteem (Westcott, 1993).  Psychological abuse frequently accompanies other forms of abuse, but also occurs independently (Sobsey, 1994).  Sobsey notes that while there is little research on the psychological abuse of people with disabilities, research studies have revealed the prevalence of negative and ambivalent attitudes towards people
with disabilities, and that it can be assumed that psychological abuse is a particular concern for people with disabilities.

Recent research supports the view that threats, insults and harassment are constants in the lives of many people with disabilities (The Roeher Institute, 1994).  Included in the range of threats cited by respondents are: threats by attendant care providers that they will withdraw their services, threats by social workers to persons labelled with intellectual or psychiatric disabilities that their children will be taken away; threats by family members that the individual will be institutionalized or reinstitutionalized if they do not comply.  Insults and harassment to which people with disabilities may be subject include: verbal taunts from strangers on the street; being yelled and shouted at by neighbours; belittling, verbal onslaughts and lack of respect by care-givers; verbal and emotional abuse by boyfriends and husbands.  According to one respondent in this study "the climate of insult is present all the time, everyday" (The Roeher Institute, 1994).

Psychological and emotional abuse can also be manifested in the internalization by people with disabilities of the attitudes of their care-givers and their families that they cannot look after themselves.  Emotional dependency can be combined with economic and physical dependency, and threats of withdrawing support.  This may lead an individual to be reluctant to reveal abuse or leave a situation where she or he may be experiencing physical and sexual abuse as well (The Canadian Panel on Violence against Women, 1993).

Neglect and acts of omission have been described as ignoring the nutritional, medical or other physical needs of people with disabilities (Williams, 1993).  Neglect may be seen as "the intentional failure to provide, or the withholding of the necessities of life" (Ontario, Ministry of Citizenship, 1991), or "an act of omission, through ignorance or oversight" (Dubowitz and Egan, 1988).  The failure to provide required medical care or appropriate educational services have also been identified as forms of neglect to which people with disabilities may be particularly susceptible (Sobsey, 1994).

The debate in the United States regarding the Baby Doe case of 1982 in which a newborn with Down syndrome was not given medical treatment on the grounds of poor expected quality of life and subsequently died, is illustrative of some of the issues pertaining to failure to provide medical care.  Questions arose with respect to the civil rights of the child, who makes the decision whether or not to provide treatment, and on what grounds (Gerry, 1985; Gostin, 1985; Merrick, 1989; Nicolson et al., 1986; Rhoden and Arras, 1985; Rue, 1985).  In the United States, failure to treat these infants is now viewed as neglect.  Hospitals are advised to establish infant care review boards to guide decision making and the local child protection agencies are responsible for investigation (Dubowitz and Egan, 1988).

Financial exploitation includes the denial of access to, and control over, individuals' own funds and the misuse of their financial resources (The Canadian Panel on Violence against Women, 1993; Health and Welfare Canada, 1993a; The Roeher Institute, 1994).

The Panel on Violence against Women describes the experience of women with disabilities with respect to financial violence as follows:

Financial violence is often experienced by women with disabilities who may have to beg for money because they have been stripped of the dignity to control their own financial world. We heard of instances where women with disabilities lost their support or pay cheques to controlling family members, partners and 'friends ". We also were told of situations where women with disabilities were coerced into signing over control of their funds, sometimes in "exchange "for care. (The Canadian Panel on Violence against Women, 1993)

Problems have been noted by researchers with regard to obtaining accurate incidence statistics about violence and disability.  Differences in definitions of abuse, reporting rates, contextual variables, and sampling strategies make it likely that no single figure will reliably express differences in risk between people with and without disabilities (Sobsey, 1994).  Furthermore, even if one restricts the definition of abuse to criminal acts, it is difficult to obtain data.  As one research study notes, national crime statistics provided by police departments to Statistics Canada concerning complaints, arrests and convictions have not been classified according to whether the victims have disabilities and so do not lend themselves to statistical analysis.  In addition, few police departments have the means to systematically draw data from crime incident reports that might shed incidental light on the problem and few departments have set about to collect such data by other means (The Roeher Institute, 1994).

Many small-scale studies have reported that children with disabilities are more frequently abused than other children.  There are, however, inconsistencies in the estimates of the extent of increased risk, along with a few studies that fail to demonstrate a relationship.  This does leave some uncertainty about the nature and the magnitude of the relationship (Sobsey, 1994).

Nonetheless, as the table on the next pages demonstrates, there is an accumulation of independent findings strongly suggesting there is a problem of considerable magnitude.

A study examining the maltreatment of children with disabilities in the United States, based on data collected from 35 Child Protective Services agencies selected to be nationally representative, found that the incidence of maltreatment among children with disabilities was 1.7 times higher than the incidence of maltreatment of children without disabilities (Crosse, Kaye and Ratnofsky, 1993).

It has been suggested that people with disabilities may be less vulnerable to certain types of crime experienced more frequently by the population at large, and more vulnerable to other forms of violence.  In a discussion of the victimization of adults with an intellectual disability, it was noted that in the U.K. about one-third of crime concerns cars and 95 per cent of the total recorded offences involve property (Williams, 1993).  In Canada, 60 per cent of all Criminal Code offences known to the police were property crimes, while 10 per cent were crimes of violence.  The remaining Criminal Code offences include mischief, bail violations, disturbing the peace, etc. (Statistics Canada, 1992).  As Williams notes, people with intellectual disabilities rarely drive and usually own little more than personal effects.  However, Williams (1993) cites the following as more typical incidents experienced by people with an intellectual disability harassment in public places, verbal abuse, simple assault, murder, abduction by car, arson at a group home, sexual assault by a taxi driver.

A study by Ulicny et al. (1990) suggests that people with disabilities face elevated levels of physical assault and theft.

The cumulative results of a range of studies examining violence and people with disabilities suggest that the risk of only a single incident of abuse for people with disabilities appears to be at least one-and-a-half times as great as the risk for other people of similar age or gender (Sobsey, 1994).

However, since the forms of violence that have received attention in the research tend to conform to a definition of violence that coincides with the definition embedded in criminal law, the statistics do not reflect acts which people with disabilities might perceive as violent which are not criminal offences (The Roeher Institute, 1994). Some examples of violence not reflected in the statistics noted in The Roeher Institute study are:

• the ways in which "care" is distorted into acts of malevolence or acts which compromise physical or

• psychological well-being while retaining the outward form of "care";

• acts by means of which people with disabilities are denied family life (child apprehension and the pressure not to conceive);

• acts and circumstances that effectively compromise the economic security of people with disabilities.

4. WHERE VIOLENCE OCCURS

"Place" emerges as an important factor in discussions about violence in the population at large.  Sacco and Johnson (1990) reveal how general incidents of violence change according to place.  For example, 50 per cent of all assaults take place in a private residence while robberies were more frequent in public spaces (42 per cent) than in private homes (36 per cent).  Participation in evening activities and alcohol consumption also increased the risk of violence.  Newcomer and Stone (1985) also indicate that neighbourhoods and dwellings in which large groups of marginalized people are congregated due to poverty may leave individuals vulnerable to violence.

The literature identifies the following as places where violence may occur:

• social groupings such as the family, or some other personal relationship (Armstrong, 1983; Hanmer and Maynard, 1987; Health and Welfare Canada, 1988; Finkelhor and Yllo, 1988);

• residential settings such as homes, apartments, boarding homes (Newcomer and Stone, 1985; Sacco and Johnson, 1.990);

• services settings such as hospitals, group homes, institutions (Groze, 1990; Mutchnick and Fawcett, 1990; Nibert et al., 1989);

• public spaces (Sacco and Johnson, 1990).

• family members;

• paid care-givers;

• Other people with disabilities, especially those clustered with their victims in services settings (Sobsey and Doe, 1991).

i.      Family as a place of risk

In the literature on disability "family" is sometimes understood to include not only parents, husbands, boyfriends and other relatives, but to encompass friends, neighbours and care-givers.  It has been suggested that the notion of family includes the range of people (paid and unpaid) upon whom individuals may often depend to provide them with assistance in carrying out their everyday lives.  According to this definition, the family of a person with disabilities would include a range of service providers, such as attendants, interpreters, homemakers, drivers, doctors, nurses, teachers, social workers, psychiatrists, therapists, counsellors, and workers in hospitals and other institutions (Health and Welfare Canada, 1993a).  The particular issues pertaining to paid care-giving and services are discussed in the section following this one.

Generic literature on violence identifies the family as a site where violence occurs, particularly against women and children:

• Information collected by the Badgley Committee through a National Population Survey found that about one-third of males and just over one-half of females surveyed reported that they had been the victims of at least one unwanted sexual act (Badgley, 1984).

• According to a recent Statistics Canada report, 29 per cent of never-married females have been physically or sexually assaulted by their partners (Statistics Canada, 1994); this same study indicates that 39 per cent of never-married females with disabilities have been physically or sexually assaulted by their partners (The Roeher Institute, 1994).

• It is estimated that between 75 and 90 per cent of the women in some northern Aboriginal communities are battered (The Canadian Panel on Violence against Women, 1993).

• isolation (which may be increased by the demands of care-giving);

• being overwhelmed by the demands of caretaking;

• lacking the opportunity to gain effective coping skills;

• individuals who are particularly difficult to care for;

• lack of respite;

• additional stresses such as unemployment;

• their own history which leads them to reproduce the violence they experienced;

• use of physical punishment as a form of discipline;

• substance abuse;

• negative social attitudes towards disability which may be lived out, or struggled with, in parents' reactions and attitudes.

(Fulmer, 1988; Gnaedinger, 1989; Groce, 1988; Rogers, 1990; Sobsey, 1994; Wachtel, 1989)

ii.     Services and institutional settings as places of risk

Whether or not one includes paid service providers in the definition of family, services have been identified clearly as a place of risk for people with disabilities (Berkman, 1984-86; Luckasson, 1992; The Roeher Institute, 1994; Sobsey, 1994; Stimpson and Best, 1991).  Each of these studies provides examples of physical, sexual, psychological, and financial abuse of people with disabilities in service settings.

The large numbers of people involved, the intimate physical and emotional contact involved in the care they provide, and the power imbalance between the service provider and recipient of care are cited as factors which increase the risk of abuse to people with disabilities in service settings.  These settings might be within the context of community or institutional care.

Much of the research and statistical data pertaining to violence against people with disabilities in services settings examines victimization in institutional or residential settings (including psychiatric hospitals and nursing homes).  Sobsey notes that there is an extensive record of institutional abuse extending over the past two centuries, and provides numerous examples of institutional abuse in Canada, the United States, Australia, Romania, England and Wales (Sobsey, 1994).

The literature indicates a high incidence of physical and sexual assault on individuals with disabilities in psychiatric facilities, perpetrated by both fellow patients and by staff (Nibert et al., 1989; Pillemar and Moore, 1990).  Nibert interviewed 58 residents of a psychiatric institution.  Seventy-one per cent of the residents interviewed revealed they had been threatened with violence within the institution.  Fifty-three per cent said they had been assaulted the most by other residents, while 39 per cent reported that staff members had assaulted them.  Fifty-five per cent reported sexual assault by other residents and 27 per cent by staff.  Jacobson and Richardson (1987) found that 81 per cent of psychiatric in-patients reported experiencing major physical and/or sexual assault.  In terms of injuries to staff by residents, Carmel and Hunter (1989) found in a one-year study of a hospital that nursing staff sustained 16 injuries per 100 staff; 9.9 per cent of these incidents occurred while staff were containing violence, and 6.1 per cent were assaults.

The literature written by consumers describes their experience in psychiatric institutions as emotionally abusive/ degrading.  Kingston outlines how any attempt on her part to exercise personal choice left her open to judgements by staff of "inappropriate behaviour".  This potentially left her vulnerable to treatments such as electroshock (Kingston in Burstow and Weitz, 1988).  The restriction on wearing one's own clothes in favour of drab hospital pyjamas, as well as being confined to a ward, are also described as dehumanizing by former psychiatric inmates (Burstow and Weitz, 1988).

Violence in nursing homes has been documented in the literature as well (Pillemar, 1988; Pillemar and Moore, 1990).  These studies have focused primarily on violence perpetrated between residents and from care-giver to resident.

Pillemar and Moore (1990) conducted a study on the types of violence in nursing homes through interviews with 477 nurses and aides in 32 nursing and intermediate care facilities in the state of New Hampshire.  Their findings indicated that 10 per cent of respondents admitted to engaging in physical abuse and 40 per cent to psychological abuse.  Care-givers most frequently observed other staff abusing patients by over-restraint, pushing, yelling, and swearing.  Furthermore, staff-patient conflict and level of staff burnout was most strongly related to the presence of physical abuse.  Levels of burnout and patient aggression were most strongly related to the presence of psychological abuse.

Hoefkens and Allen (1990) found that 56 per cent of clients admitted to a hospital-based unit for people with "mental retardation and challenging behaviour" received anti-psychotic drugs although they did not have a diagnosis of psychosis or related disorders.
 
 

5. FACTORS CONTRIBUTING TO VIOLENCE

Although place emerges as an important consideration in any discussion about violence, other factors have been identified in the literature that relate to violence or that increase the likelihood that violence will take place.  Psychological, cultural and social factors have been noted as contributing to a climate in which violence may occur.  In addition, specific factors which increase the vulnerability of people with disabilities to violence are also discussed in the literature.
 

i.     General factors

The literature suggests that the existence of violence can be attributed to psychological, cultural and social factors which may interact with one another.

Psychological factors include unresolved childhood conflicts within individuals, or individual pathology or deviance (Edwards in Hanmer and Maynard, 1987).

Some of the cultural and social factors which are seen as contributing to violence and which have an impact on people with disabilities include:

• cultural, historical and social conditions which lead to the marginalization of certain groups which then become targets of violence for those with more power and control;

• cultural support for violence;

• the construction of private and public spheres which result in reduced community responsibility in areas of private ownership;

• social and economic stresses within the life of an individual such as poverty, unemployment, previous experiences of violence, drug and alcohol abuse that contribute to violence.
 

(Garbarino in Garbarino, Brookhouser and Authier, 1987; Straus, 1990; Young, 1990)

ii. Specific factors which increase the vulnerability of people with disabilities

Researchers have identified a number of factors that can place people with disabilities at particular risk of abuse.  In examining risk factors, several researchers have emphasized that it is not the disability itself that may put people with disabilities at risk, but the social condition s in which people with disabilities are likely to find themselves that makes it more likely that abuse will occur (The Roeher Institute, 1988b; Sobsey, 1994; Westcott, 1993).

A number of studies address in some detail the risk factors associated with sexual abuse and other forms of violence affecting people with disabilities, several of which are mentioned below.

The Roeher Institute study (1994) discusses in depth the risk factors perceived by people with disabilities and others interviewed for its study on violence and people with disabilities.  Stimpson and Best (1991) address the factors putting women with disabilities at risk of sexual abuse.  Crossmaker (1991) looks at the factors placing people who have been institutionalized at risk of sexual abuse.  Sobsey (1994) proposes an integrated ecological model of abuse in which the physical and psychological aspects of interacting individuals are considered within the context of environmental and cultural factors.

The main risk factors presented in the literature are:

• negative public attitudes about disability;

• social isolation of people with disabilities and their families;

• reliance of people with disabilities upon others for care;

• lack of support for care-givers;

• lack of opportunity for people with disabilities to develop social skills through typical social interaction;

• nature of disability;

• gender, particularly with reference to sexual abuse (where women face very high risk of victimization);

• poverty and other economic factors affecting people with disabilities;

• lack of control or choice of people with disabilities over their personal affairs;

• perceived lack of credibility of people with disabilities when they report or disclose abuse;

• socialization of people with disabilities to be compliant, and learned helplessness;

• alcohol and drug abuse by perpetrators;

• ineffective safeguards.

(Crossmaker, 1991; The McCreary Centre Society, 1993; The Roeher Institute, 1988a and b, 1994; Sobsey, 1994; Westcott, 1993)

There is a considerable volume of research examining the effects of violence in the population at large.  However, relatively little research has been conducted focusing particularly on the effects of violence and abuse on people with disabilities.  Most of the literature which does exist looks at the effects of sexual abuse.

Westcott (1993), who interviewed a number of people with disabilities, suggests that "by far the most fundamental effect of being abused was for interviewees to experience great difficulties in forming relationships with people, particularly in developing trust".

In a discussion of sexual abuse in institutions, Crossmaker (1991) notes that the following have been identified as the effects of sexual abuse on the population at large:

• the diagnosis of mental illness or the label of developmental disability or mental retardation;

• social withdrawal;

• problems with identity formation, self-protection, intimate relationships and self-esteem;

• overly compliant behaviour;

• alienation and dissociation;

• isolation and problems with trust.

The effects of sexual abuse on people with disabilities have also been discussed in the context of post-traumatic stress disorder (Cohen, 1993).  Cohen notes that people with disabilities are often victims of sexual abuse by care-givers and health professionals, and that the abuse mirrors the trauma experienced by childhood victims of sexual abuse.  He suggests that the betrayal of one who is dependent on another for survival represents a "monumental misuse of position of power".  He also suggests that for people with disabilities the abuse may constitute a re-enactment of childhood trauma, given that such a large percentage of the population has been sexually abused prior to reaching adulthood. Stimpson and Best (1991) identify the following effects of sexual assault on women with disabilities:

• physical harm;

• alienation from self;

•  alienation from others;

• fear and nightmares;

• anger and guilt;

• negative responses by others;

• revictimization (by repeated sexual assault or by people not believing or questioning the woman's credibility);

• harmful psychiatric and medical responses.

Flynn (1989) also indicates some of the outcomes of victimization of people with disabilities.  She suggests that when people with disabilities are victimized:

• personal debts are significantly more likely to occur;

• people are unable to trust others and do not or cannot take the necessary steps to form relationships;

• some people are too frightened to leave their homes;

• the quality of people's lives is lowered and restrictions are imposed upon them.

7. DISCLOSURE

A number of issues are discussed in the literature with respect to the likelihood that people with disabilities will disclose abusive incidents and under what circumstances they are most likely to tell someone they have been abused.

It was noted that people with disabilities may be reluctant to report abuse for many of the same reasons that non-disabled children and women do not report abuse, including fear of retaliation, dependency, and shame (Ontario Women's Directorate, 1993; Westcott, 1993).  These and other studies suggest that for children or adults with disabilities the difficulties of disclosing abuse are further compounded as a result of the situations people find themselves in because they are disabled.  The literature suggests that people with disabilities may:

• feel ashamed or feel that they are somehow to blame;

• fear retaliation from their abuser if they report,

• be afraid because they are unsure of the consequences of reporting (fear of losing privileges, removal to a more restrictive ward of a unit, seclusion or restraints, increased medication, being labelled a problem, deportation, or removal of children);

• may be dependent financially, physically and emotionally on the person who abuses them, which can make it difficult to report the violence against them;

• may feel isolated and are unaware that many other people with disabilities have experienced violence;

• may be seen as attention-seeking, out of touch with reality, lying, manipulative or seeking revenge;

• may have difficulty "telling on" or challenging the actions of an able-bodied authority figure, given the compliance and obedience instilled in children who are disabled.



(Crossmaker, 1991; Ontario Women's Directorate, 1993; The Roeher Institute, 1994; Westcott, 1993)

• the significance the victim attaches to the incident;

• whether the victim has the physical means of communicating with others;

• the victim's confidence and strength of purpose;

• the communication skills of the victim and of the respondents to the disclosure;

• whether the victim has or perceives there to be anyone to whom to report;

• the receptivity and perceived trustworthiness of the person to whom the victim discloses;

• the probability of being believed;

• the perceived consequences to the victim's and others' safety and well-being as a result of disclosure;

• whether the victim feels any sympathy for a perpetrator;

• the perceived probability of receiving a just and efficient response to the complaint.

There is a considerable volume of literature which examines the ways in which society attempts to respond to violence.  Responses occur through the legal and judicial systems on the one hand, and through service systems which provide protection, support, treatment and preventative education on the other hand (Bourne, 1988).

The need for a multi-faceted approach to responding to and preventing the abuse of people with disabilities emerges repeatedly in the literature.  Wagner (1987) outlines the importance of a multi-disciplinary team to deal with child abuse which would include medical and legal professionals as well as police and social workers.  Straus (1990) and Rogers (1990) suggest that effective responses require interdisciplinary, multi-faceted approaches to address the underlying economic and social contributors to violence.  Aiello (1984-86) outlines the importance of collaboration between all types of services in dealing with cases involving women with disabilities who have been sexually assaulted.  The Roeher Institute (1992b) and Sobsey (1994) discuss the need for collaboration between various systems in order to respond effectively to abuse.

The following section reviews the literature on violence against people with disabilities with respect to specific issues pertaining to the responses of the police, the judicial system, service settings and community support services.  It looks at some of the barriers to effective response in each of these areas, as well as recommendations to improve responsiveness emerging from the literature.
 

i.      Responses in service environments

The literature suggests that there is a wide range of responses to the abuse of people with disabilities in residential and in other service settings.

It has been noted that the response patterns vary enormously within services and agencies - and even within the same agency.  To a large extent, in the absence of effective and well-implemented protocols the responses to abuse often depend on the attitudes, knowledge and skills of the individual staff person who comes into contact with a person with a disability who has been victimized (The Roeher Institute, 1994).

Some of the literature suggests that institutional settings by definition may create a climate of abuse and an environment in which abuse will not be reported (Crossmaker, 1991; Sobsey, 1994).

Sobsey, for example, suggests that an abusive subculture often exists among staff in institutions and sometimes predominates:

Within such an abusive subculture, abuse is not viewed as either deviant or socially unacceptable.  It is viewed as normal, and becomes expected of one socially, with peer pressure to encourage abuse ... individuals who report on or otherwise attempt to thwart abuse become the targets of social outrage and administrative retaliation ... The subculture often intercepts any reports of abuse; thus, even when reported incidents clearly fit the criteria for mandatory reporting to outside agencies, studies suggest that 80 to 90 per cent never reach the proper authorities. (Sobsey, 1994)

In discussing responses to abuse within institutions, reporting procedures emerge as an important area in the literature.  Rindfleisch and Bean (1988) discuss the factors which affect reporting by staff within institutions. The two most powerful factors included the type of incident and the commitment of the respondent to the resident.  Other factors include: staff position; contextual factors regarding the incident such as other witnesses; severity of the incident; organizational support for reporting; and the individual's affiliation with residential care.

Sundram (1986) found that minor occurrences of abuse are often not reported because of the working conditions which contribute to the abuse occurring.  Major occurrences of abuses are not reported due to administrative and disciplinary structures within institutions.  Maibaum (1985) found that staff may hinder the efforts of patient advocates for fear of abuse being discovered or prosecuted.

Responses to the abuse of people with disabilities in the community or within community service settings also vary greatly.  However, it has been noted that, for example, within housing and support services in the community, there are difficulties with responding to residents or parental complaints of neglect and abuse (The Roeher Institute, 1990, 1994).  These difficulties include: the lack of national guidelines or standards regarding the provision of services; inadequate monitoring; and the lack of recourse available to victims of abuse or neglect.
 

ii.     Access to community support services

The degree to which people with disabilities have access to crisis centres and transition homes in the community has also been addressed in the literature.  The following comments about the access of women to community services were made in the report from the Canadian Panel on Violence against Women:

Women with disabilities who find themselves suffering the aftermath of sexual assault or abuse often have nowhere to turn.  Indeed, emergency shelters, rape crisis centres, sexual assault centres and counselling programs that are physically accessible to women with disabilities and which are experienced with their needs are still rare.  These inadequacies are a direct result of funding shortages and a failure to account for the needs of women with disabilities... It is important to acknowledge that some organizations have worked very hard to provide accessible services despite the lack of financial support from governments.  Others are well aware of the specific issues of women with disabilities but are unable to do anything about them because of lack of funding.  (The Canadian Panel on Violence against Women, 1993)

In a discussion of the community service requirements for women with disabilities who have experienced violence, the following were noted as necessary to improve access to services:

Accessibility does not just mean physical access to services.  Accessibility includes a broad range of issues such as, but not limited to: the provision of educational information in formats accessible to women who are blind or vision impaired, TDD service and personnel who are able to sign for women who are deaf or hearing impaired and more interpreter/intervenor services and outreach to let women knoll, that services are available.  Women emphasized that their needs varied widely according to their particular disability. Therefore, women with hidden disabilities (e.g. epilepsy, chronic pain), women with multiple disabilities and women with developmental disabilities all have particular service requirements that need to be addressed. (Ontario Women's Directorate, 1993)

iii.      Police response

Although people with disabilities are likely to face elevated levels of risk for abuse, for a variety of reasons (many of which have been discussed above), many crimes never come to the attention of the police (Sobsey and Doe, 1991).  A study conducted in Australia, for example, indicates that "40 per cent of crimes against people with mild and moderate mental retardation went unreported to the police, and 71 per cent of crimes against people with more severe mental retardation went unreported" (Wilson and Brewer, 1992, cited in Sobsey, 1994).  A study conducted in Canada found that almost 75 per cent of sexual abuse cases were not reported (Sobsey and Varnhagen, 1988).

The literature highlights a number of barriers to bringing complaints to the police as well as obstacles to fair treatment of people with disabilities in the event that they do register a complaint.  It has been noted that:

• Women with disabilities rarely encounter the police and when they do, they often have a negative experience making it unlikely that they would want to contact the police again (Masuda and Ridington, 1990; Ontario Women's Directorate, 1993; Stimpson and Best, 1991).  Several authors suggest that many of the attitudes, stereotypes and myths about women with disabilities held by the public at large are also prevalent among members of police forces (The Roeher Institute, 1993; Stimpson and Best, 1991).

• A perceived lack of credibility of women with disabilities acts as a barrier to reporting incidents of abuse to the police (The Canadian Panel on Violence against Women, 1993; Stimpson and Best, 1991).

• An absence of protocols relating to handling complaints concerning victims with disabilities suggests that the policing system as a whole cannot equitably respond to the complaints of victims with disabilities.  It has been noted that a great deal is left to individual police knowledge about what steps to be taken and who to turn to for assistance (The Roeher Institute, 1993).

• Because they may have internal procedures in place for fielding complaints, abusive incidents occurring in group homes, institutions and other care-providing agencies may not come to the attention of the police.  This has been noted to be the situation both by the police and those involved in social services.  This may have the effect of decriminalizing acts of abuse against people with disabilities (The Roeher Institute, 1993).

• The police are currently playing the role of the id gatekeepers" to justice, by exercising discretion to screen cases from coming to the attention of the courts.  In effect the police are in a position to prevent the court and legal system from perceiving the need for reform of the judicial system to ensure justice for those who are most vulnerable to victimization (The Roeher Institute, 1993).

In a report on police training and family violence by the Canadian Association of Chiefs of Police, barriers to investigation were identified with respect to people with disabilities:

Certain victims may not be able to adequately communicate with investigators due to their particular disability others may be limited in mobility and may have difficulty in making court appearances. [and] ... Police officers ... may have certain attitudes towards persons with disabilities that may impede the investigation.  This may be particularly acute with respect to persons with cognitive disabilities. (Canadian Association of Chiefs of Police, 1993)

• interactive training of the police, with face-to-face encounters with various disability organizations;

• interdisciplinary training bringing together social workers, advocacy groups, medical personnel and police officers;

• computer-based information systems and computer--based training.

iv.     Response of the judicial system

A number of issues have been raised in the literature with respect to access to justice for people with disabilities who have experienced abuse.  It has been suggested that people with disabilities remain one of the groups least well-served by the justice system (Sobsey, 1994).  Barriers include the lack of physical and social access to the courts, rules of evidence, courtroom procedures that unfairly impinge on the rights of people with disabilities, and the lack of willingness to make reasonable accommodation to individual differences (The Roeher Institute, 1994; Sobsey, 1994).

In a survey of service providers in Ontario, respondents were asked to choose from a list the three most important areas of the justice system that need revision with respect to women with disabilities.  The most important factor that emerged was the need to train judges, Crown attorneys and court personnel on meeting the needs of women with disabilities.  Service providers also highlighted issues such as the accessibility of the court room, communication and assistance for women with disabilities.  A significant number of service providers called for reexamination of the rules of evidence, contained in both the federal and provincial evidence acts, to see how they discriminate against people with disabilities in terms of giving evidence and in being believed (Ontario Women's Directorate, 1993).

In 1988 amendments (Bill C-15) were introduced to the Criminal Code of Canada and the Canada Evidence Act that either directly or indirectly affect complainants/witnesses who have communication disabilities in criminal proceedings.  A study conducted in 1992 on the impact of this legislation on people with disabilities concluded that "Bill C-15 included some useful first steps towards more equitable treatment of victims/ complainants, especially by removing the requirement that all adult witnesses must first demonstrate that they are capable of being sworn or making a solemn affirmation.  This has opened the door to persons with communication disabilities, and resulted in a significant number of cases being prosecuted that would not have gone to court in the past because the key witnesses could not or would not have been permitted to testify" (The Roeher Institute, 1992a).  This study suggests, however, that despite the reforms introduced by Bill C-15, the law continues to impose barriers to the participation of people with communication disabilities in the criminal justice process.  The study concludes with ten recommendations, eight of which propose further amendments to the Criminal Code and the Canada Evidence Act.

In a discussion of the concerns particular to people with disabilities which may require considerations beyond the typical victim issues, Luckasson (1992) suggests a number of strategies to improve the response of the justice system to the issues of victimization of people with an intellectual disability, including:

• civil damage actions seeking large financial awards could be used for "routine abuse" such as verbal abuse, leaving the person in excrement, or failure to provide physical therapy;

• sentence enhancements could be implemented for the victimizers of people with disabilities;

• specialized victim assistance services could be provided;

• recruiting "disability advocates" to assist the police and the judicial system with these cases;

• alternative dispute resolution, such as non-court mediation, could be used in some cases in which people with disabilities are victims of crime;

• further research on victimization issues;

• inappropriate reliance on the "abuse and neglect" classifications should be reduced; the actual actions in individual cases could often be identified as more serious offences such as rape, homicide, and battery;

• policymakers should explore the possibility of special criminal statutes when victims have an intellectual disability;

• consideration be given to the possibility that the impact of victimization may be especially severe for persons with disabilities.

The prevention of violence against people with disabilities is treated in various ways in the literature.  Recommendations pertaining to prevention can be characterized as involving:

• systemic changes to eliminate the conditions that make it likely that people with disabilities will be subject to abuse;

• specific preventative measures within a variety of settings to make it less likely that people will be harmed or make them less vulnerable to abuse;

• measures to ensure effective responses to abuse when it happens.

i.     Systemic changes

A number of general societal reforms have been suggested in the literature to reduce the risk of victimization, including:

• better access of persons with disabilities to the labour market so they are not so widely impoverished;

• more adequate levels of income support that would help reduce economic reliance on care-giver-perpetrators;

• disability-related support services that are more widely available, affordable, portable and subject to consumer control so that people with disabilities are not required to participate in delivery sites that may involve risks (e.g., sheltered workshops, group homes, special care homes, multi-service institutions) in exchange for essential services;

• deinstitutionalization of people with disabilities and integration into the community;

• changing attitudes regarding disability, through public education;

• ensuring the availability of adequate supports to families.

• Ensuring that people with disabilities know their rights and how to report abuse;

• clear definitions with respect to abuse and neglect, the requirement that reporting be made to the police or the child welfare authorities, that investigations happen quickly and that the safety of the individual from the perpetrator be ensured;

• sex education and clearer guidelines with respect to sexual activity within residential settings;

• assertiveness training and empowerment of people to resist abuse;

• the screening of new employees for past criminal records;

• risk assessment approaches used in child protection agencies that include the child's specific disability as a risk factor;

• education of service providers/professionals on the relationship between abuse and disabilities, and on making appropriate referrals for children with disabilities;

• educating professionals who come into contact with children and adults with disabilities on the relationship between maltreatment and disabilities, on identifying possible abuse, and on making appropriate referrals.

• Effective internal protocols in health, social service and educational settings for identifying, reporting and responding to victimization;

• reforms to the judicial system to ensure that people with disabilities who have experienced abuse have recourse to the courts;

• affordable, accessible counselling and other supports for people with disabilities;

• strong advocacy support.
  
  (Crosse, Kaye and Ratnofsky, 1993; Crossmaker, 1991; Docherty, 1989; Ombudsman of British Columbia, 1987; The Roeher Institute, 1988c, 1992b, 1994; Sobsey, 1994; Westcott, 1993; Whittaker, 1987)

The literature suggests that, while the degree of victimization of people with disabilities is unacceptably high, there is an increasing recognition of the problem and some indication that progress has been made in terms of raising public awareness and developing more effective intervention strategies.  However, much remains to be done to eliminate the systemic causes that create a climate in which the abuse of people with disabilities is tolerated, as well as to ensure that safeguards are in place and that systems and agencies work collaboratively to respond appropriately when violence occurs.
   

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