Content warning:
This passage includes sensitive content about sexual violence and may be triggering for some readers.
I’m a GP, and my work takes me into aged care facilities as well as general practice. When it comes to sexual assault of older women, I’m interested in all settings—residential aged care, hospitals, and the broader community.
I look at recent assaults and also historical ones, because things that happened long ago can resurface later in life, particularly during times of transition such as retirement or after significant losses.
I have one patient in residential aged care whose behaviour has really highlighted these issues for me. She is in a mixed dementia ward and reacts strongly and fearfully when a man comes near her—not in an obviously inappropriate way, but even just passing close.
I don’t know what happened to her earlier in life because her dementia means she can no longer explain it, but she clearly becomes triggered. She is fine with women and with her husband.
The staff struggle to understand that what they’re seeing is not a behavioural problem to medicate but an emotional reaction rooted in something she cannot verbalise.
In an understaffed ward where residents wander freely, it’s extremely difficult for nurses to prevent these encounters. They sometimes suggest medication, whereas I try to explain that she is responding to fear that she cannot control or articulate.
At one point, I sought help from the Dementia Behaviour Management Advisory Service. They came out several times, and staff began to understand the situation a little better.
There was even a discussion about moving her to a unit that, at the time, had only female residents. This might have helped her feel safer, but it would have meant moving her far away, which would have made it almost impossible for her husband—who visits several times a week—to see her. We ultimately didn’t move her.
Over time, as her dementia has progressed, she wanders less, and she now stays mostly in her room, which has reduced the distressing incidents.
Sexual assault, in the broader context of my practice, is significantly underestimated and under-recognised. I also teach about domestic violence and sexual assault to GPs and practice nurses, and I see how little inquiry actually occurs.
Like domestic violence, sexual assault is surrounded by shame. People feel as though they somehow should have prevented it. I’ve seen this even in patients who wouldn’t fit the societal myths about who gets assaulted.
One of my patients with schizophrenia, who had lost weight on new medication, told me she now felt unsafe because she looked more “attractive.” That was the first time she hinted at something traumatic in her past.
I didn’t ask further—partly because we were in a standard 15-minute appointment and partly because I didn’t feel confident I could manage a severe emotional reaction in that moment. This is a real limitation of the system.
Most disclosures happen indirectly, during appointments for something unrelated. For example, one older woman came in for a urinary tract infection. I noticed she used to have them frequently until her husband died.
When I asked whether he had insisted on sex when she didn’t want it, she said yes—every day. That is sexual assault. She looked surprised when I told her she shouldn’t have had to put up with that. I gave her support numbers and encouraged her to come back.
She hasn’t yet, but sometimes older women return years later and say, “Remember when I told you that? Now I want to talk about it.”
A small percentage of my patients disclose sexual assault—less than 10 percent—and I know that is a vast underestimate. Many older women living in abusive relationships still don’t feel safe to talk about it. They may not see a viable alternative to their situation.
Residential aged care might be an option, but only if they can afford it, and there are family dynamics and financial entanglements that make disclosure extremely complicated.
To help older women disclose, I know I need to ask more. I also have to accept that I may not be able to “fix” anything and learn to live with that discomfort. Just being present, available, and open to hearing them can be helpful. They may choose to act later, or they may never act—but the door has to stay open.
Systemically, the 15-minute consultation model is completely inadequate for trauma issues. GPs are under huge pressure, fewer are entering the profession, and workload is increasing.
Other health professionals, such as pharmacists, can take on some tasks, but they cannot replace the relational continuity needed to uncover sexual assault.
For example, a pharmacist treating a UTI would never ask the question I asked that older woman. Long-term therapeutic relationships matter.
In the training I deliver, I work with domestic violence workers who have taught me not to jump to “fixing.” Health professionals tend to want to tell people what to do, even well-meaning things like calling a helpline. But that can take autonomy away.
People need to feel empowered, not directed. Shifting from a top-down model to true collaborative care is difficult, but it’s necessary.
Training in universities is insufficient. When I taught sexual assault and domestic violence, we had only three hours in total for both topics. Over time, even that got reduced.
Students received almost no teaching on the context, dynamics, or early warning signs—only biomedical content, such as which swabs to take. There was nothing on older women, nothing on ageism, nothing on how trauma affects behaviour.
Many medical students simply don’t imagine sexuality or sexual assault in older age groups. It’s invisible in the curriculum.
What doctors need to understand is that sexual assault in older women is not rare. Older women, including those with cognitive impairment, can feel shame, fear, terror, violation, and loss of safety just as anyone else would. These experiences profoundly affect their emotional wellbeing, their physical health management, and their relationships. It affects quality of life in later years.
I have also cared for a few care leavers—men and women who lived in institutions as children. Some disclosed sexual abuse. I’ve seen how trauma in childhood affects functioning across generations. In one family, the effects showed up not only in the survivor but in their spouse, their children, and even the next generation. These impacts continue long after the original harm.
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