Recognising Abuse in Adults

Physical injuries can occur through abuse. There may be no satisfactory explanation, definite knowledge, or a reasonable suspicion that injury was inflicted with intent caused by lack of care by the person having custody, charge or care of that person.

The following are examples of physical abuse:

• Assault, hitting, slapping, punching, kicking, hair-pulling, biting, pushing
• Rough handling
• Physical punishments
• Inappropriate or unlawful use of restraint
• Making someone purposefully uncomfortable (e.g. opening a window and removing blankets)
• Involuntary isolation or confinement
• Forcible feeding or withholding food
• Unauthorised restraint, restricting movement (e.g. tying someone to a chair)

 This could be indicated by:

• History of unexplained falls
• Unexplained bruising in well protected areas or soft parts of the body
• Bruising in different stages of healing
• Unexplained burns - unusual location / type
• Unexplained fractures to any part of the body
• Unexplained lacerations or abrasions
• Slap, kick, punch or finger marks
• Injury shape similar to an object
• Untreated medical problems
• Over and under medication
• Weight loss due to malnutrition or dehydration

Domestic violence and abuse includes any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been, intimate partners or family members regardless of gender or sexuality. It also includes so called 'honour-based’ violence, female genital mutilation and forced marriage. See later sections on FGM and Forced marriage.

Coercive or controlling behaviour is a core part of domestic violence. Coercive behaviour can include:

• acts of assault, threats, humiliation and intimidation
• harming, punishing, or frightening the person
• isolating the person from sources of support
• exploitation of resources or money
• preventing the person from escaping abuse
• controlling everyday behaviour

Sexual abuse is the involvement of vulnerable adults in sexual activities, which:

• they do not fully comprehend
• they cannot give consent to
• they object to, or
• may cause them harm.

The following are examples of sexual abuse:

• Rape, attempted rape or sexual assault
• Inappropriate touch anywhere
• Non- consensual masturbation of either or both persons
• Non- consensual sexual penetration or attempted penetration of the vagina, anus or mouth
• Any sexual activity that the person lacks the capacity to consent to
• Inappropriate looking, sexual teasing or innuendo or sexual harassment
• Sexual photography or forced use of pornography or witnessing of sexual acts
• Indecent exposure

The following list may indicate sexual abuse. They must be viewed in the context of the situation, taking account of other factors. Often more than one indicator may be apparent. There may be other causes for the indicators listed below but a combination of several factors is often found in sexual abuse cases:

• An adult discloses that they have been sexually abused or raped, or subjected to sexual assault or sexual harassment
• Sudden change in behaviour; sudden onset of confusion, or withdrawal
• Incontinence
• Overt sexual behaviour/language by the vulnerable adult
• Self-inflicted injury and self-harm
• Disturbed sleep pattern/poor concentration
• Difficulty in walking
• Torn, stained underwear
• Love bites
• Pain or itching, bruising or bleeding in the genital area
• Sexually transmitted disease/urinary tract/vaginal infection
• Bruising to upper thighs and arms
• Frequent infection
• Severe upset or agitation when being bathed etc.
• Pregnancy in a person unable to consent
• Sexual exploitation

Emotional or psychological abuse can include intimidation, humiliation, shouting, swearing, emotional blackmail and denial of basic human rights, as well as using racist language and preventing someone from enjoying activities or meeting friends.

The following are examples of emotional abuse:

• Enforced social isolation – preventing someone accessing services, educational and social opportunities and seeing friends
• Removing mobility or communication aids or intentionally leaving someone unattended when they need assistance
• Preventing someone from meeting their religious and cultural needs
• Preventing the expression of choice and opinion
• Failure to respect privacy
• Preventing stimulation, meaningful occupation or activities
• Intimidation, coercion, harassment, use of threats, humiliation, bullying, swearing or verbal abuse
• Addressing a person in a patronising or infantilising way
• Threats of harm or abandonment
• Cyber bullying

This may be indicated by:

• Ambivalence about carer
• Fearfulness, avoiding eye contact, flinching on approach
• Deference
• Insomnia or need for excessive sleep
• Change in appetite
• Unusual weight loss / gain
• Tearfulness
• Unexplained paranoia
• Low self esteem
• Confusion, agitation
• Coercion
• Possible violation of human and civil rights
• Distress caused by being locked in a home or car etc.
• Isolation - no visitors or phone calls allowed
• Inappropriate clothing
• Sensory deprivation
• Restricted access to hygiene facilities
• Lack of personal respect
• Lack of recognition of individuals rights
• Carer does not offer personal hygiene, medical care, regular food/drinks
• Use of furniture to restrict movement

Financial or material abuse can take the form of fraud, theft or using the vulnerable adult’s property without their permission. This could involve large sums of money or just small amounts from a pension or allowance each week.

The following are examples of financial abuse:

• theft of money or possessions
• Fraud, scamming
• Preventing a person from accessing their own money, benefits or assets
• Employees taking a loan from a person using the service
• Undue pressure, duress, threat or undue influence put on the person in connection with loans, wills, property, inheritance or financial transactions
• Arranging less care than is needed to save money to maximise inheritance
• Denying assistance to manage/monitor financial affairs
• Denying assistance to access benefits
• Misuse of personal allowance in a care home
• Misuse of benefits or direct payments  in a family home
• Someone moving into a person’s home and living rent free without agreement or under duress
• False representation, using another person's bank account, cards or documents
• Exploitation of a person’s money or assets, e.g. unauthorised use of a car
• Misuse of a power of attorney, deputy, appointeeship or other legal authority
• Rogue trading – e.g. unnecessary or overpriced property repairs and failure to carry out agreed repairs or poor workmanship

These may be indicated by:

• Sudden inability to pay bills
• Sudden withdrawal of money from an account
• Person lacks belongings that they can clearly afford
• Person’s relatives are not receptive to necessary expenditure
• Power of attorney is obtained when the person is unable to understand what they are signing
• Extraordinary interest by family members in the vulnerable adult’s assets
• Recent change of deeds to the house
• Carer’s main interest is financial with little regard for the health and welfare of the vulnerable adult
• The person managing the finances is evasive and uncooperative
• Reluctance to accept care services

The Modern Slavery Act was introduced in 2015 and categorises the offences as - human trafficking, slavery, servitude, forced and compulsory labour. Victims of Modern Slavery are unable to leave their situation of exploitation, controlled by threats, violence, force, coercion and deception. In addition, many individuals do not see themselves as victims and there are a number of barriers to disclosure.

Types of modern slavery:

• Human trafficking
• Forced labour
• Domestic servitude
• Sexual exploitation, such as escort work, prostitution and pornography
• Debt bondage – being forced to work to pay off debts that realistically they never will be able to

The following may indicate modern slavery:

• Signs of physical or emotional abuse
• Impingement on human rights, removal of personal ID, passport etc. and substantial control of one person by another
• Appearing to be malnourished, unkempt or withdrawn
• Isolation from the community, seeming under the control or influence of others
• Living in dirty, cramped or overcrowded accommodation and or living and working at the same address
• Lack of personal effects or identification documents
• Always wearing the same clothes
• Avoidance of eye contact, appearing frightened or hesitant to talk to strangers
• Fear of law enforcers

The Home Office provides information on identifying and reporting modern slavery.

Discriminatory abuse is often on the grounds of age, gender, race, culture, religion, sexuality or disability.  This type of abuse and others can be perpetrated through grooming.  This can be called ‘Mate crime’ and it occurs when vulnerable adults are "befriended" with the intention to abuse. See later section on ‘Mate crime’.

In 2011, Mencap launched the "Stand by Me" campaign to eradicate Hate and Mate crime.

The following are examples of discriminatory abuse:

• Unequal treatment based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex or sexual orientation (known as ‘protected characteristics’ under the Equality Act 2010)
• Verbal abuse, derogatory remarks or inappropriate use of language related to a protected characteristic
• Denying access to communication aids, not allowing access to an interpreter, signer or lip-reader
• Harassment or deliberate exclusion on the grounds of a protected characteristic
• Denying basic rights to healthcare, education, employment and criminal justice relating to a protected characteristic
• Substandard service provision relating to a protected characteristic

 This may be indicated by:

• Derogatory, offensive and racist comments and actions, graffiti, trolling etc.
• harassment and bullying due to a personal attribute
• being made to move to a different resource/ service based on age
• being denied medical treatment on grounds of age or mental health
• not providing access

Organisational abuse may include neglect and poor care practice within an institution or specific care setting such as a hospital or care home, or in relation to care provided in one’s own home. This may range from one-off incidents to on-going ill-treatment, including acts of omission leading to harm. It can be through neglect or poor individual professional practice or as a result of the structure, policies, processes and practices within an organisation or lack of effective joined working.

The following are examples of organisational abuse:

• Discouraging visits or the involvement of relatives or friends
• Run-down or overcrowded establishment
• Authoritarian management or rigid regimes
• Lack of leadership and supervision
• Insufficient staff or high turnover resulting in poor quality care
• Abusive and disrespectful attitudes towards people using the service
• Inappropriate use of restraints
• Lack of respect for dignity and privacy
• Failure to manage residents with abusive behaviour
• Not providing adequate food and drink, or assistance with eating
• Not offering choice or promoting independence
• Misuse of medication
• Failure to provide care with dentures, spectacles or hearing aids
• Not taking account of individuals’ cultural, religious or ethnic needs
• Failure to respond to abuse appropriately
• Interference with personal correspondence or communication
• Failure to respond to complaints

This may be indicated by:

• No flexibility in bedtime routine and/or deliberate waking
• People left on the commode or toilet for long periods of time
• Inappropriate care of possessions, clothing and living area
• Lack of personal clothes and belongings
• Un-homely or stark living environments
• Deprived environmental conditions and lack of stimulation
• Inappropriate use of medical procedures e.g. enemas, catheterisation
• 'Batch care' - lack of individual care programmes
• Illegal confinement or restrictions
• Inappropriate use of power or control
• People referred to, or spoken to with disrespect
• Inflexible services based, on convenience of the provider rather than the person receiving services
• Inappropriate physical intervention
• Service user removed from the home or establishment, without discussion with other appropriate people or agencies, because staff are unable to manage the behaviours 

A person can suffer because their physical and/or psychological needs are being neglected by a carer. This could include failure to keep them warm, clean and well-nourished or neglecting to give prescribed medication.

The following are examples of neglect/acts of omission:

• Failure to provide or allow access to food, shelter, clothing, heating, stimulation and activity, personal or medical care
• Providing care in a way that the person dislikes
• Failure to administer medication as prescribed
• Refusal of access to visitors
• Not taking account of individuals’ cultural, religious or ethnic needs
• Not taking account of educational, social and recreational needs
• Ignoring or isolating the person
• Preventing the person from making their own decisions
• Preventing access to glasses, hearing aids, dentures, etc.
• Failure to ensure privacy and dignity

 This may be indicated by:

• Poor environmental conditions
• Inadequate heating and lighting
• Poor physical condition of the vulnerable adult
• Person’s clothing is ill fitting, unclean and in poor condition
• Malnutrition
• Failure to give prescribed medication properly
• Failure to provide appropriate privacy and dignity
• Inconsistent or reluctant contact with health and social care agencies
• Isolation - denying access to callers or visitors

Self-neglect is any failure of an adult to take care of himself or herself that causes, or is reasonably likely to cause within a short period of time, serious physical, mental or emotional harm or substantial damage to or loss of assets.

Types of self-neglect:

• Lack of self-care to an extent that it threatens personal health and safety
• Neglecting to care for one’s personal hygiene, health or surroundings
• Inability to avoid self-harm
• Failure to seek help or access services to meet health and social care needs
• Inability or unwillingness to manage one’s personal affairs

The following may indicate self-neglect:

• Very poor personal hygiene
• Unkempt appearance
• Lack of essential food, clothing or shelter
• Malnutrition and/or dehydration
• Living in squalid or unsanitary conditions
• Neglecting household maintenance
• Hoarding
• Collecting a large number of animals in inappropriate conditions
• Non-compliance with health or care services
• Inability or unwillingness to take medication or treat illness or injury

These are crimes committed against someone because of their disability, gender-identity, race, religion or belief, or sexual orientation and should be reported to the police.

Hate crimes can include:

• threatening behaviour
• assault
• robbery
• damage to property
• inciting others to commit hate crimes
• harassment

This involves procedures that intentionally alter or injure female genital organs for non-medical reasons. The procedure has no health benefits for girls and women. The Female Genital Mutilation Act (2003) makes it illegal to practise FGM in the UK or to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in another country. There is additional guidance available on safeguarding women and girls at risk of FGM.

A forced marriage is where one or both people do not (or in cases of people with learning disabilities, cannot) consent to the marriage and pressure or abuse is used. It is recognised in the UK as a form of violence against women and men, domestic/child abuse and a serious abuse of human rights. The pressure put on people to marry against their will can be physical (including threats, actual physical violence and sexual violence) or emotional and psychological (for example, when someone is made to feel like they’re bringing shame on their family). Financial abuse (taking your wages or not giving you any money) can also be a factor.

Information for people directly affected by forced marriage is also available.

The police define Hate Crime as ‘any incident that is perceived by the victim, or any other person, to be racist, homophobic, transphobic or due to a person’s religion, belief, gender identity or disability’. It should be noted that this definition is based on the perception of the victim or anyone else and is not reliant on evidence. In addition, it includes incidents that do not constitute a criminal offence.

A ‘mate crime’ as defined by the Safety Net Project is ‘when vulnerable people are befriended by members of the community who go on to exploit and take advantage of them. It may not be an illegal act but still has a negative effect on the individual.’ Mate crime is should be reported to the police who will make a decision about whether or not a criminal offence has been committed. Mate Crime is carried out by someone the adult knows and often happens in private.

This is the unlawful or inappropriate use of restraint or physical interventions. Someone is using restraint if they use force, or threaten to use force, to make someone do something they are resisting, or where an adult’s freedom of movement is restricted, whether they are resisting or not. Restraint covers a wide range of actions. It includes the use of active or passive means to ensure that the person concerned does something, or does not do something they want to do. An example of this might be the use of keypads to prevent people from going where they want from a closed environment.

This involves exploitative situations, contexts and relationships where adults at risk (or a third person or persons) receive 'something' (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. It affects men as well as women. People who are sexually exploited do not always perceive that they are being exploited. In all cases those exploiting the adult have power over them by virtue of their age, gender, intellect, physical strength, and/or economic or other resources. There is a distinct inequality in the relationship. Signs to look out for are not being able to speak to the adult alone, observation of the adult seeking approval from the exploiter to respond and the person exploiting the adult answering for them and making decisions without consulting them.