Categories and Indicators of Abuse

1. Introduction

The different types of abuse described in this chapter may in some cases be criminal offences, for example assault and sexual offences. Where a criminal offence is suspected the Police will be notified and should a formal complaint be made, the Police will take primacy in leading any enquiry.

Remedies through the courts are one form of redress but safeguarding adults is also about prevention and part of everyday practice. For example, effective assessment and care planning, being aware of responsibilities and powers available, engaging service users by seeking consent and participation in decision-making are all essential tools in minimising risks and vulnerability to abuse.

The UK Care and Support Statutory Guidance (2022 recently amended) identifies types of abuse, but also emphasises that organisations should not take a limited view of what constitutes abuse or neglect.

The categories below are taken from the Care Act Guidance:

Here is a list of types of abuse with examples and potential indicators. In all examples there may be other signs as each person has unique needs and circumstances which cannot be captured within a single list.

2. Physical Abuse

This includes: hitting, slapping, pinching, pushing, misuse of medication and inappropriate holding or restraint. It may also include inappropriate sanctions or punishment and rough handling.

Possible indicators:

• History of unexplained falls;
• Unexplained bruising in well protected or soft parts of the body e.g. ears or buttocks;
• Multiple bruising in different stages of healing;
• Unexplained burns unusual location or type;
• Unexplained fractures;
• Unexplained lacerations or abrasions;
• Slap, kick punch or finger marks;
• Injury shape similar to an object;
• Untreated medical problems;
• Weight loss due to malnutrition or dehydration.

3. Sexual Abuse

Examples: rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, sexual acts or indecent exposure to which the adult has not consented or was pressured into, including revenge porn and sexting.

Possible indicators:

• Sudden change in behaviour;
• Sudden onset of confusion;
• Incontinence;
• Withdrawal;
• Overt sexual behaviour/language by the adult;
• Self-inflicted injury;
• Disturbed sleep pattern/poor concentration;
• Difficulty in walking;
• Torn, stained underwear;
• Love bites;
• Pain/itching/bleeding or bruising in genital area;
• Sexually transmitted disease/urinary tract/vaginal infection;
• Bruising to upper arms and thighs;
• Frequent vaginal and urinary tract infection;
• Severe upset or agitation when bathing;
• Pregnancy in a person who is unable to consent.

4. Financial Abuse

Examples: fraud, theft, taking property without permission, assuming ownership of money or items, scamming (which can be in person, by letter, phone and internet), coercion in relation to an adult s financial affairs including the writing of or changing a Will, and misuse of benefits. Financial abuse can involve small and large amounts of money or value of property. Financial abuse can be a criminal act. Financial abuse can be insidious and be perpetrated by people well known to the adult at risk.

Possible indicators:

• Sudden inability to pay bills;
• Sudden debt;
• Unexplained or unusual patterns of cash withdrawal from an account;
• Lack of belongings that the adult can clearly afford;
• Resistance by family to give explanation for unusual financial activity;
• Extraordinary interest by family in an adult s assets;
• Purchase of items that the adult would not usually buy or need;
• Personal items going missing;
• The main interest shown by a family member is financial and not the in relation to the care of the adult.

5. Discriminatory Abuse

Examples: discriminatory abuse is often on the grounds of age, race, gender or gender identity, culture, religion, sexual orientation or disability.

Other examples of abuse include:

• Hate crime (acts of violence or hostility directed at people because of who they are or who someone thinks they are);
• Mate crime (sometimes used to describe a crime committed against an adult by someone who has befriended them);
• Derogatory comments;
• Harassment;
• Being made to move to a different resource/service based upon an adult's age;
• Being denied medical treatment on grounds of age or mental health.

6. Emotional/Psychological Abuse

Examples: threats of harm or abandonment, blackmail, deprivation of contact, humiliation and ridicule, blaming, controlling, intimidation, coercion, harassment, isolation, cyber bullying, shouting and swearing, unreasonable support of services or support networks, denial of cultural or religious needs, denial of access to the development of social skills.

Possible indicators:

• Change in appetite, weight loss or gain;
• Low self esteem;
• Upset and tearfulness;
• Confusion and agitation;
• Insomnia;
• Avoiding eye contact, withdrawal;
• Isolation, unable to make contact;
• Distress;
• Poor hygiene, resulting from restricted access to facilities;
• Uncharacteristic behaviour.

Psychological abuse is often linked to other types of abuse, such as financial abuse and neglect as predominant aspects.

7. Neglect (and acts of omission)

Examples: ignoring medical, emotional or physical needs; failure to provide access to appropriate health, care and support or educational services; withholding the necessities of life including medication, adequate nutrition and heating.

Possible indicators:

• Poor environmental conditions;
• Inadequate heating and lighting;
• Poor physical condition of the adult;
• Malnutrition;
• Clothing is ill-fitting, unclean or in poor condition;
• Isolation of the adult;
• Withdrawal, unhappiness or change in demeanour;
• Carer's reluctance to engage with professionals;
• Carers not allowing contact by professionals with the adult.

8. Self-Neglect

Examples: self-neglect covers a wide range of behaviour including neglect to care for one s personal hygiene, health, medical needs or surroundings and can include hoarding when it becomes extreme (including animal hoarding). In these circumstances there is no third-party abuser.

Possible indicators:

• Living in unsanitary conditions;
• Suffering from untreated illness or disease/condition;
• Inability or unwillingness to take medication or treat illness or injury;
• Non-compliance with health or care services;
• Creating a hazardous situation that would likely cause risk to self and neighbouring or adjoining others (public safety).

*It is important that staff from all organisations read and understand the Safeguarding Board's Multi-agency Self-Neglect Procedural Guidance.

9. Organisational/Institutional Abuse

Organisational or Institutional abuse is the mistreatment of people brought about by poor or inadequate care or support, or systematic poor practice that affects the whole care setting. It occurs when the individual's wishes and needs are sacrificed for the smooth running of a group, service or organisation. Organisational abuse is often an indication a poorly led service, or may exist in care settings where there is a delinquent or bullying culture within the staff group.

It is important not to jump to the wrong conclusions too quickly: but the following list may be possible indicators of institutional abuse:

• No flexibility in bedtime routine and/or deliberate waking;
• People left on a 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 such as enemas, catheterisation;
• Batch care - lack of individual care programmes;
• Illegal confinement or restrictions;
• Unauthorised restrictions on liberty;
• 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 behaviour.

Abusive behaviours may include:

• Treating adults like children;
• Arbitrary decision making by staff group, service or organisation;
• Strict, regimented or inflexible routines or schedules for daily activities such as meal times, bed / awakening times, bathing / washing, going to the toilet;
• Lack of choice or options with food and drink, dress, possessions, daily and social activities;
• Lack of privacy, dignity, choice or respect for people as individuals;
• Unsafe or unhygienic environment;
• Lack of provision for dress, diet or religious observance in accordance with an individual's belief or cultural background, including dietary needs.

Organisational/Institutional abuse enquiries will require a formalised safeguarding approach with the contribution of relevant partners.

Abuse, neglect and poor practice may take the form of isolated incidents of poor or unsatisfactory practice, at one end of the spectrum, through to pervasive ill treatment and gross misconduct at the other. Repeated instances of poor care may be an indication of more serious problems.

Not all abuse that occurs within settings that provide health or social care will be institutional; incidents between service users or actions by individual members of staff may occur without any failings on the part of the organisation.

There is a need for assessment and judgement in determining when poor practice becomes an adult safeguarding issue leading to potential concerns of organisational abuse. Addressing four key questions will support the decision to initiate a formal response to institutional/ organisational abuse:

• Does the type of incident indicate organisational abuse?
• Does the nature of the incident indicate organisational abuse?
• Is the incident of a degree to indicate organisational abuse?
• Relating to these three questions, is there a pattern and prevalence of concerns about the Service and/or Organisation.

10. Modern Slavery

Modern slavery refers to the offences of human trafficking, slavery, servitude, and forced or compulsory labour. Victims of modern slavery are exploited in a range of ways. Both adults and children can be trafficked for the purposes of exploitation, with sexual exploitation, labour exploitation or criminal exploitation being the most common types reported in the UK. Other types also exist, including domestic servitude.

These crimes also include facilitating a person s travel with the intention of exploiting them soon after. Although human trafficking often involves an international cross-border element, it is also possible to be a victim of modern slavery within your own communities. It is also possible to be a victim even if consent has been given to be moved. Children cannot give consent to being exploited therefore the element of coercion or deception does not need to be present to prove an offence.

It should not be assumed that the Isle of Man is a safe place where modern slavery cannot exist. The UK has seen significant growth in terms of referrals being received on suspected reports of modern slavery.

Any information relating to concerns about modern slavery should be reported to the Isle of Man Constabulary and the Adult Safeguarding Team.

11. Hate and Mate Crime

Hate and mate crime involves acts of violence or hostility directed at people because of who they are, or who someone thinks they are. Hate crimes happens because of prejudice or hostility based on a person s disability, race, religion, sexual orientation or transgender identity. Mate crime is a form of crime in which a perpetrator befriends a vulnerable person with the intention of exploiting them financially, physically or sexually.

Mate crime explained

Mate crime happens when someone makes friends with a person and goes on to abuse or exploit that relationship. The founding intention of the relationship, from the point of view of the perpetrator, is likely to be criminal. The relationship is likely to be of some duration and, if unchecked, may lead to a pattern of repeat and worsening abuse.

Learning disability and mate crime

People with learning disabilities may be situationally vulnerable to mate crimes. They may be living very isolated lives, but like everyone need friends. This need is easily exploited. In addition, many people with learning disabilities haven t had the usual opportunities to become streetwise when growing up. Incidents can therefore be more likely to take place when they are in the community, on public transport or using services without support.

Features of mate crime

Mate crimes are likely to happen in private, often in the victim s own accommodation. They can also happen via social media, where victims are financially or sexually exploited after being befriended online. Mate crimes often occur within long-term relationships, which may have started out as genuine friendships. They can appear to be real friendships to many observers.

Identifying mate crime

Indicators of mate crime can be similar to other forms of abuse. Potential signs include:

• Bills not being paid, a sudden lack of money, losing possessions, changing their Will;
• Changes in routine, behaviour, appearance, finances or household (new people visiting or staying over, lots of new friends, increased noise, neighbourhood complaints or rubbish than normal);
• Cutting themselves off from established networks of friends/family and support, missing weekly activities;
• Secretive internet or mobile phone use.

Cuckooing

Cuckooing is a practice where people take over a person s home and use the property to facilitate exploitation. (It takes the name from cuckoos who take over the nests of other birds).

There are different types of cuckooing, including:

• Using the property to deal, store or take drugs;
• Using the property to sex work;
• Taking over the property as a place for them to live;
• Taking over the property to financially abuse the tenant.

The most common form of cuckooing is where drug dealers take over a person s home and use it to store or distribute drugs. People who choose to exploit will often target the most vulnerable in society. They establish a relationship with the vulnerable person to access their home. Once they gain control over the victim - whether through drug dependency, debt or as part of their relationship larger groups will sometimes move in. Threats are often used to control the victim.

Signs of cuckooing:

• An increase in people entering and leaving;
• An increase in cars or bikes outside;
• Increase in noise and anti-social behaviour;
• Increasing litter outside;
• Signs of drugs use or paraphernalia;
• Increased refusal of visitors to the person in need of support at the premises e.g. health supports.

See also: Research in Practice, County lines, criminal exploitation and cuckooing.

12. Female Genital Mutilation (FGM)

Female Genital Mutilation (FGM) is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death (WHO, 2020).

Female Genital Mutilation involves removing and damaging healthy and normal female genital tissues and interferes with the natural functions of girls and women s bodies. It is primarily, though not exclusively, carried out on minors. On average, girls are subjected to FGM between birth and age 15. FGM is not prescribed by any religion and has no health benefits. The practice can cause life-lasting physical and psychological trauma. Adult Safeguarding issues may arise where there is re-infibulation (where a woman is reclosed).

Prevalence of FGM

FGM is a deeply rooted tradition, widely practiced mainly among specific ethnic populations in Africa and parts of Asia. While the exact number of girls and women worldwide who have undergone FGM remains unknown, at least 200 million girls and women have been cut in 31 countries with representative data on prevalence. However, the majority of girls and women in most countries with available data think FGM should end and there has been an overall decline in the prevalence of the practice over the last three decades, but not all countries have made progress and the pace of decline has been uneven (Unicef, 2020).

In Africa, around 50% of girls undergo FGM between birth and the age of 5 years. The remainder usually undergo FGM between the ages of 5 and 15 years. This will vary between countries and cultural background.

The terminology used for FGM varies between communities and individual s may only recognise the term used in their community. It is sometimes referred to as female circumcision, cutting, Sunna and initiation. It has over 50 names, based on what part of the world you are. FGM or Cut is commonly used but still not known in many practising communities because it is an English term.

Types of FGM

The four major types of FGM, and their subtypes, are (WHO, 2018):

• Type I. Partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals, with the function of providing sexual pleasure to the woman), and/or the prepuce/clitoral hood (the fold of skin surrounding the clitoral glans). When it is important to distinguish between the major variations of Type I FGM, the following subdivisions are used:
  • Type Ia. Removal of the prepuce/clitoral hood only;
  • Type Ib. Removal of the clitoral glans with the prepuce/clitoral hood.
• Type II. Partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva). When it is important to distinguish between the major variations of Type II FGM, the following subdivisions are used:
  • Type IIa. Removal of the labia minora only;
  • Type IIb. Partial or total removal of the clitoral glans and the labia minora (prepuce/clitoral hood may be affected);
  • Type IIc. Partial or total removal of the clitoral glans, the labia minora and the labia majora (prepuce/clitoral hood may be affected).
• Type III. (Often referred to as infibulation). Narrowing of the vaginal opening with the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora. The covering of the vaginal opening is done with or without removal of the clitoral prepuce/clitoral hood and glans (Type I FGM). When it is important to distinguish between variations of Type III FGM, the following subdivisions are used:
  • Type IIIa. Removal and repositioning of the labia minora;
  • Type IIIb. Removal and repositioning of the labia majora.
• Type IV. All other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterization.

Why is FGM Done?

FGM is carried out for various cultural, religious and social reasons within families and communities in the mistaken belief that it'll benefit the girl in some way (for example, as a preparation for marriage or to preserve her virginity). FGM usually happens to girls whose mothers, grandmothers or extended female family members have had FGM themselves, or if their father comes from a community where it's carried out.

It is believed to have started hundreds of years ago and originally began because men wanted to control women's sexuality. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. Despite the harm Female Genital Mutilation causes, it is a complex issue as many women from FGM practicing communities consider FGM a normal part of their cultural identity.

People who perform FGM are usually older women within the community known as cutters. The procedure usually involves the child being held down by several women and the procedure carried out without medical expertise, attention to hygiene or anaesthesia. The instruments used are unsterilised knives, razor blades, broken glass and sharpened stone.

Medicalisation of FGM

Some who support the practice have sought to eliminate risks of infection (by, for example, carrying it out in a medical environment) in order to legitimise FGM. However, in addition to the immediate risks associated with FGM being carried out, it can have serious and harmful long-term psychological and physical effects, regardless of how the procedure was done.

Some who support the practice have sought to eliminate risks of infection (by, for example, carrying it out in a medical environment) in order to legitimise FGM. However, in addition to the immediate risks associated with FGM being carried out, it can have serious and harmful long-term psychological and physical effects, regardless of how the procedure was done.

Many women in practicing communities appear to be unaware of the relationship between genital mutilation and its harmful health and welfare consequences. There is increasing awareness of the severe psychological consequences of FGM which can be lifelong. There is evidence to suggest that girls having undergone FGM have a wide range of physical and psychological health concerns such as anxiety and mood disorders, and suffer from post-traumatic stress disorder with flashbacks. The feeling of betrayal, incompleteness, anger and regret are also themes reported by young women who have undergone counselling.

FGM offers no health benefits and causes significant short-term and long-term complications. Women are most likely to be identified through maternity services and will require specialised care during pregnancy and delivery. They may also present throughout the health system. It is essential that health professionals know how to identify and support FGM survivor s and refer appropriately. Females born within communities practicing FGM are at risk of the practice. All pregnant women should be asked about FGM and appropriate safeguarding steps must be taken.

FGM is often seen as a natural and beneficial practice carried out by loving family member who believe that it is in a girls or woman s best interests. The type of mutilation practiced, the age at which it is practiced and the way in which it is done, vary according to a variety of factors.

These include:

• The women or girls ethnic group;
• What country they are living in (whether in a rural or urban area);
• Their social economic background.

There are no acceptable reasons that justify FGM. It's a harmful practice that has no health benefits and often happens against a girl's will without her consent, and girls may have to be forcibly restrained.

Reasons given for FGM include:

• Preservation of virginity and chastity;
• Religion, in the mistaken belief that it is a religious requirement;
• Custom and tradition;
• Fear of social exclusion;
• To ensure girl is marriageable and improve marriage prospects;
• Increase sexual pleasure for the male;
• Family honour;
• Social acceptance;
• Enhancing fertility, status and respect;
• Hygiene and cleanliness;
• Clitoris connotes maleness;
• Part of becoming a woman.

Risk Factors for FGM

The family comes from a community that is known to practice FGM; any female child born to a woman who has been subjected to FGM must be considered to be at risk, as must other female children in the extended family; the girl is unexpectedly absent from school; any female who has a relative who has already undergone FGM; the socio economic position of the family and the level of integration within society can increase risk.

Girls may be particularly vulnerable during summer holidays when they are taken out of the country to a practicing country for FGM to be performed. Parents may withdraw children from Personal, Social and Health Education lessons at school as a way of the parents keeping the girl uninformed about FGM, her rights and her body.

The child is usually told they are to have a special celebration or party and a relative may visit from a practising community. Professional should be alert to this and use their professional curiosity to ask questions.

Immediate Consequences of FGM can include (WHO, 2020):

• Severe pain;
• Excessive bleeding (haemorrhage);
• Genital tissue swelling;
• Fever;
• Infections e.g., tetanus;
• Urinary problems;
• Wound healing problems;
• Injury to surrounding genital tissue;
• Shock;
• Death.

Long-term complications can include (WHO, 2020):

• Urinary problems (painful urination, urinary tract infections);
• Vaginal problems (discharge, itching, bacterial vaginosis and other infections);
• Menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.);
• Scar tissue and keloid;
• Sexual problems (pain during intercourse, decreased satisfaction, etc.);
• Increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby, etc.) and newborn deaths;
• Need for later surgeries: for example, the sealing or narrowing of the vaginal opening (Type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks;
• Psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.)

FGM has been a criminal offence in the Isle of Man since the prohibition of the Female Genital Mutilation Act 2010. This Act came into force in July 2011 and makes it an offence for Isle of Man Nationals or permanent Isle of Man residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where practice is legal. All agencies on the Isle of Man have a duty according to the FGM Act 2010 to report FGM to the Isle of Man Constabulary whether it is planned or has been completed.

Information-Sharing and FGM

When dealing with FGM, organisations and professionals should continue to have regard to their wider responsibilities in relation to the handling and sharing of information. To safeguard children and vulnerable adults in line with relevant statutory requirements and guidance, it may be necessary to share information with other agencies or departments.

Children and Families Division will undertake Section 46 Enquiries jointly with the Police if they have reason to believe that a child is likely to suffer or has suffered FGM. A Strategy Discussion / Meeting should include the relevant Health professionals and, if the child is of school age, the relevant school representative.

Where a child has been identified as having suffered, or being likely to suffer, significant harm, it may not always be appropriate to remove the child from an otherwise loving family environment. Parents and carers may genuinely believe that it is in the girl s best interest to conform to their prevailing custom. Professionals should work in a sensitive manner with families to explain the legal position around FGM. The families will need to understand that FGM and re-infibulation (the process of resealing the vagina after childbirth) is illegal.

It cannot be assumed that all families from practising communities will want their female children to have FGM performed and support should be offered to them. Professionals must take into consideration that by alerting the girl s or woman s family to the fact that she is disclosing information about FGM may place her at increased risk of harm. Interpretation services should be used if English is not spoken or well understood and the interpreter should not be an individual who is known to the family.

If there is an immediate risk of harm, legal advice should be considered.

See Female Genital Mutilation Procedure.