Many have suggested that a decline in hygiene is a marker of neglect (Aravanis et al., 1993; Lachs and Pillemer, 1995; Butler, 1999; Marshall et al., 2000). Individuals may present with dirty clothes that reek of animal excrement; multiple insect bites due to mosquitoes, scabies, or fleas; or other signs of poor hygiene. For some persons, poor personal care is a matter of lifestyle or choice, and should not be blamed on age. Thus, this finding requires investigation of previous habits and any recent decline as well as screening for dementing or psychotic illness.

Sexual abuse is characterized by sexual contact or exposure without the person’s consent, including those cases in which persons are not able to consent (American Medical Association, 1996). Mickish (1993) categorized sexual abuse as the least perceived, acknowledged, detected, and reported type of elder abuse. Although the least frequently reported type of elder mistreatment (Tatara, 1993; Pavlik et al., 2001), it is nonetheless heinous. Several studies have demonstrated that the overwhelming majority of victims have cognitive impairment (75 percent to 77 percent) and/or have functional limitations (67 percent to 92 percent) (Ramsey-Klawsnik, 1991; Holt, 1993; Teaster et al., 2000). In the study by Teaster and colleagues (2000), which includes APS reports from 1996 to 1999, the most common form of sexual abuse was sexualized kissing and fondling but ranged from unwelcome sexual interest to rape.

Women experience a number of physiologic changes in the genital tract as they age. Both progesterone and estrogen levels decline with aging (American Geriatrics Society Review Syllabus, 1998). Decreased estrogen levels result in changes in the shape of the vagina, increased vaginal dryness, and thinning of the vaginal walls. These changes may cause pain and bleeding during sexual intercourse. Such age-related changes as altered acidity of the vaginal secretions and decreased estrogen levels make older women more prone to spontaneous vaginal and bladder infections (Butler and Lewis, 1998). Note, however, that there is never a situation in which sexual abuse is considered normal, regardless of the age or functional status of the individual.