The Role of Gender in Violence Experienced by Adults With Developmental Disabilities

Abstract

Violence against people with developmental disabilities is a highly prevalent yet understudied phenomenon. In particular, there is a paucity of literature surrounding the role of gender and the experiences of men. Using a cross-sectional study design, we surveyed 350 people with diverse developmental disabilities about experiences of abuse, perpetrators of abuse, and their physical and mental health status. These data were analyzed to determine whether gender influenced these domains. Statistical methods included chi-square, independent t tests, logistic regression, and hierarchical multiple regressions. Male and female participants reported abuse at high rates, with 61.9% of men and 58.2% of women reporting abuse as children and 63.7% of men and 68.2% of women reporting abuse as adults. More women than men reported adult sexual abuse, but there was no gender difference in the prevalence of any other form of abuse. Women were more likely than men to identify an intimate partner as their abuser, although intimate partners represented the minority of abusers for both men and women. Violence was associated with worse health status regardless of participant gender. These findings confirm that violence is an important issue for both men and women with developmental disabilities. Although some expected gender differences arose, such as higher rates of adult sexual abuse and intimate partner violence against women, these differences were less pronounced than they are in the general population, and the overall picture of abuse was one of gender similarities rather than differences.

Keywords

gender developmental disability intimate partner violence sexual assault caregiver abuse community based participatory research

Introduction

Issues surrounding violence are highly relevant to people with developmental disabilities. There is strong evidence that both men and women with disabilities are at equal or greater risk for violence compared with their nondisabled peers (Cohen, Forte, Du Mont, Hyman, & Romans, 2006; Harrell, 2012; Horner-Johnson & Drum, 2006; K. Hughes et al., 2012; R. B. Hughes, Lund, Gabrielli, Powers, & Curry, 2011; Powers & Oschwald, 2004; Smith, 2008). In addition to being at an increased risk of the forms of violence experienced by the general population, people with disabilities are also subject to unique forms of violence and perpetrators as a product of their disability. For example, people with disabilities may be subject to destruction of assistive devices, over- or underadministration of medications, theft, and neglect or rough performance of personal care, all of which constitute disability-specific abuse (Nosek, Foley, Hughes, & Howland, 2001; Oktay & Tomkins, 2004). In addition, people with disabilities may experience abuse by people they encounter as a result of their disability, such as personal assistance providers, disability service providers, or transportation employees (Oktay & Tomkins, 2004; Powers et al., 2008; Saxton et al., 2001; Saxton et al., 2006). However, the few population-based studies exploring violence against people with disabilities limited their scope to forms of abuse experienced by the general population such as sexual abuse (Rand & Harrell, 2009), violent crime (Harrell, 2012), and intimate partner violence (Cohen et al., 2006; Smith, 2008).

Violence in general should be understood as a health issue. Several studies have demonstrated a strong association between violence and poor health outcomes in the general population (Bonomi et al., 2006; Campbell, 2002; Coker et al., 2002). A large-scale literature review of the mental and physical health outcomes associated with intimate partner violence showed the consequences of violence can range from direct trauma to chronic gastrointestinal, gynecologic, cardiovascular, and mental health sequelae (Campbell, 2002). While much research on the health consequences of violence focuses specifically on intimate partner violence, other forms of violence such as child abuse and violent victimization by community members have also been shown to have negative health consequences (Nicolaidis, Curry, McFarland, & Gerrity, 2004). For people with disabilities, it is possible the association between violence and health is even stronger and more complex; for example, violence may involve manipulation of medical equipment, and vulnerability to abuse may increase with the severity of one’s disability. However, the impact of violence on the health of people with disabilities has received little formal attention.

Within the understudied topic of violence against people with disabilities, there is a particular paucity of research exploring the role of gender on the prevalence and nature of abuse and its impact on health and well-being (R. B. Hughes et al., 2011). Qualitative studies on the subject have examined some ways in which gender influences the abuse experiences of people with disabilities. In a study of the abuse of women by personal assistance providers, Saxton et al. (2001) described how the socialization of women with disabilities, with an emphasis on female vulnerability and the need to be agreeable to receive needed care, contributed to women remaining in abusive situations. In their subsequent study of men, Saxton et al. (2006) found that male socialization, with its emphasis on masculinity and control, also impacted experiences of abuse by leading to more frequent escalation of violence. This same study found that due to a societal emphasis on male independence, little support was available when abuse of men with disabilities arose.

Quantitative studies analyzing the role of gender in violence against people with disabilities found inconsistent results. Some studies highlighted that women with disabilities experience higher rates of abuse than men with disabilities (Mitra, Mouradian, & Diamond, 2011; Smith, 2008; D. Sobsey & Doe, 1991). However, Smith (2008) noted that the gender difference in rates of intimate partner violence is less pronounced among people with disabilities than it was among people without disabilities. A Canadian population-based survey of women and men with and without disabilities found that gender differences in rates of intimate partner violence were not statistically significant when controlling for demographic confounders (Cohen et al., 2006), and the Bureau of Justice Statistic Crime Victimization Survey did not show a gender difference in the rates of violence victimization between men and women with disabilities (Harrell, 2012).

The larger project from which these data are derived is a multisite effort to explore many aspects of the association between violence and health among people with developmental disabilities. This article focuses on the impact of gender on these associations. Specifically, we examine gender similarities and differences in lifetime prevalence of various forms of violence, perpetrator identities and behaviors, and health status associated with abuse.

Method

Community Academic Partnership

This project used a community-based participatory research (CBPR; Israel, Schulz, Parker, & Becker, 1998) approach to explore issues of violence and associated health status experienced by people with developmental disabilities. The research team consisted of academic researchers, community members with developmental disabilities, and other community stakeholders. Research took place at two sites. Academic and community partners were integral to each phase of research. The project sought to equitably share power and knowledge. Further details about the CBPR process can be found elsewhere (Nicolaidis et al., 2015).

Subjects

To be eligible for participation, participants had to be at least 18 years of age, have a developmental disability (defined as a disability that began before the age of 22, likely to persist for life, and causing at least three major functional limitations), understand English or American Sign Language (ASL), and be able to provide informed consent with reasonable accommodations. Participants were recruited from one metropolitan city in one state as well as urban and rural areas in a second state. To reach a large number of participants, a variety of recruitment methods were utilized, including letters sent to individuals receiving government disability services, postings on community listservs, fliers in student disability offices, announcements at community events, and word-of-mouth. Further details about recruitment and study participants can be found elsewhere (Oschwald et al., 2014).

Measures

Study participants completed a self-administered survey about demographic information, disability status, mental and physical health status, and childhood and adult abuse experiences. During the survey creation, community advisory boards reviewed all questions and helped to adapt existing health measures to ensure they would be meaningful and accessible to the community. Adapted health measures included one measure of physical health and three measures of mental health. Physical health was measured with the Patient Health Questionnaire–Physical Symptom Scale (PHQ-15), an assessment of physical symptoms. Adapted mental health measures included the Center for Epidemiologic Studies Depression Scale (CESD-10), PTSD Checklist–Civilian Version (PCL-C), and the 4-item Perceived Stress Scale (PSS-4). The PHQ-15 is a 15-item survey that asks about the most common physical complaints seen in the outpatient setting, and is scored from 0 to 30 (Kroenke, Spitzer, & Williams, 2002). The CESD-10 is a 10-item depression screening tool, adapted from the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). It is scored from 0 to 30 (Andresen, Malmgren, Carter, & Patrick, 1994). The PCL-C is a 17-item measure of PTSD, with items corresponding to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for post traumatic stress diosrder (PTSD). It is scored from 17 to 85 (Ruggiero, Del Ben, Scotti, & Rabalais, 2003). Finally, the PSS-4 is a 4-item measure assessing subjective levels of stress. Its scores range from 0 to 16. For all health measures, higher scores indicate greater symptomatology. In their adapted forms used in this study, all but the PSS maintained good to excellent internal consistency reliability. The adapted version of the PSS had lower internal consistency (α = .52), and conclusions drawn from this measure are thus limited. The process and outcomes of measurement adaptation are described in more detail elsewhere (Nicolaidis et al., 2015).

The survey contained questions related to diverse childhood and adult abuse experiences. Half of the items related to childhood abuse were adapted from the Adverse Childhood Experiences Scale (Felitti et al., 1998), whereas the rest were added based upon prior research or community advisory board input regarding forms of abuse experienced by youth with developmental disabilities. Items related to adult abuse were adapted from prior work by Curry et al. (2009). Exploratory factor analyses were conducted on the responses to these abuse items to create variables representing categories of abuse. Childhood abuse experiences were reduced into three factors: physical abuse, disability abuse, and sexual abuse. Adult abuse questions were reduced into two factors: sexual abuse and mixed (physical and disability-specific) abuse. During this process, we eliminated two items representing a person’s perception of feeling unsafe or vulnerable and an item pertaining to being held down because they loaded heavily on both the sexual and physical abuse factors. Factor scores represent the extent to which individuals endorsed different abuse experiences, with higher scores arising when one endorsed a greater number of experiences.

To better understand the context of abuse, participants were also asked about their relationship to the perpetrator, as well as several perpetrator behaviors and characteristics. Questions about perpetrator identity and behaviors were asked only if individuals reported adult abuse. Examples of perpetrator relationships included intimate partners, family members, disability services providers, acquaintances, or strangers. Perpetrator behaviors /characteristics included 10 items that were adapted from the Danger Assessment, a frequently used measure of lethality in heterosexual intimate partner relationships (Campbell, Webster, & Glass, 2009). Many of these questions focus on the presence of controlling behaviors.

Data Collection

To best facilitate disclosure of abuse histories, we provided an anonymous survey that could be completed independently. This was important given that nonanonymous disclosure of violence would in many cases necessitate mandatory reporting. Data collection was completed using an audio-computer assisted self-interview (ACASI), developed in partnership with community advisory boards to be accessible to people with diverse developmental disabilities. The ACASI provided various accommodations, including read-out-loud and video ASL translations. Details about the ACASI development can be found elsewhere (Oschwald et al., 2014).

Research staff met participants in a location of their choosing. Assistants introduced the research topic, described their role as mandatory reporters, and introduced the ACASI with its accessibility features. Research staff provided clarification and support as requested, and often assisted with demographic questions to ensure participants were comfortable with the ACASI. An effort was made to provide as much comfort and privacy as possible during the survey, and only anonymous data were saved. Each study participant was provided a US$40 stipend and a pocket card with information about resources for people experiencing violence. Institutional Review Boards approved this study.

Data Analysis

We used Pearson’s chi-square analyses to compare gender differences in demographics, disability characteristics, childhood and adult abuse prevalence, and abuser identity and behaviors. We used logistic regression to calculate the adjusted odds ratios (ORs) of abuse for men and women when controlling for demographic confounders. These regressions controlled for demographic factors that have been previously reported in the literature as having associations with abuse (gender, age, number of limitations, minority status, education, employment, relationship status, and history of child abuse; Nosek, Hughes, Taylor, & Taylor, 2006; Smith, 2008). The number of functional limitations a participant reported was used as a proxy for disability severity. Due to relatively low numbers of individuals endorsing each specific racial and/or ethnic minority status, we collapsed race/ethnicity information into a dichotomous variable (minority vs. non-Hispanic White).

Finally, we tested gender differences in the associations between adult abuse and health status using hierarchical multiple regression. We conducted a separate regression predicting each of the four health measures by abuse experiences and gender. We then tested for a moderation effect of gender using interaction terms for dichotomous adult abuse variables. If the addition of interaction terms significantly changed the predictive capacity of the regressions, interaction terms were removed one at a time until only statistically significant variables remained. Regressions were controlled for participant age, disability severity, and minority status. All analyses were conducted using SPSS software.

Results

Sample Demographics

In total, 350 eligible participants completed the survey. An additional 2 people began the survey but discontinued before eligibility was determined, and 9 people began the survey but did not meet eligibility criteria. Demographics and disability characteristics are detailed in Table 1. Of the 350 participants, the mean age was 38.6 years (SD = 13), 177 (51%) identified as female, 172 (49%) identified as male, and 1 identified their gender as Other. The only significant demographic difference between males and females was in the number of Hispanic participants with a greater number of males than females identifying as Hispanic (7.1% and 2.3%, respectively; p = .031). Participants reported diverse disabilities and a variety of functional limitations. The most common disability category reported was intellectual/cognitive (65%).

Table 1.

Sample Demographics.

Variable	All (n = 350)	Males (n = 172)	Females (n = 177)	P Value
Age (M)	38.59 (SD = 13.4)	38.35 (SD = 13.8)	38.85 (SD = 13.2)	.727
Race				.144
Black or African American	11.2% (n = 38)	10.7% (n = 18)	11.7% (n = 20)
White	75.9% (n = 258)	76.8% (n = 129)	75.4% (n = 129)
Other	12.9% (n = 44)	12.5% (n = 21)	12.9% (n = 22)
Hispanic				.031
Yes	4.7% (n = 16)	7.1% (n = 12)	2.3% (n = 4)
Rural or urban				.285
City or suburb	68.6% (n = 240)	72.1% (n = 124)	65% (n = 115)
Small town/country/reservation	31.4% (n = 110)	27.9% (n = 48)	35% (n = 62)
Living circumstances				.077
Own home or apartment	56.9% (n = 199)	51.7% (n = 89)	62.1% (n = 110)
Family/someone else’s home or apartment	26.3% (n = 92)	26.2% (n = 45)	26.6% (n = 47)
Group home, assisted living, or other group care setting	15.4% (n = 54)	19.8% (n = 34)	10.7% (n = 19)
Homeless shelter/domestic violence shelter	0.6% (n = 2)	1.2% (n = 2)	0% (n = 0)
Other	0.9% (n = 3)	1.2% (n = 2)	0.6% (n = 1)
Level of education				.558
Less than high school	22.6% (n = 79)	22.7% (n = 39)	22.6% (n = 40)
High school	56.3% (n = 197)	59.3% (n = 102)	53.1% (n = 94)
Some posthigh school	21.1% (n = 74)	18% (n = 31)	24.3% (n = 43)
Employment status				.668
Full-time or part-time	57.1% (n = 200)	43.6% (n = 75)	42.4% (n = 75)
Unemployed		56.4% (n = 97)	57.6% (n = 102)
Relationship status				.464
Married or marriage-like	14.5% (n = 49)	12.2% (n = 20)	16.7% (n = 29)
Not married	85.5% (n = 290)	87.8% (n = 144)	83.3% (n = 145)
Functional limitations
Harder to speak or be understood	46.3% (n = 162)	45.9% (n = 79)	46.9% (n = 83)	.857
Harder to hear	19.7% (n = 69)	16.9% (n = 29)	22.6% (n = 40)	.178
Harder to see	20.9% (n = 73)	19.2% (n = 33)	22.6% (n = 40)	.433
Harder to learn or remember	74% (n = 259)	71.5% (n = 123)	76.8% (n = 136)	.256
Harder to understand or process	74% (n = 259)	73.8% (n = 127)	74.6% (n = 132)	.875
Harder to walk	28.6% (n = 100)	26.2% (n = 45)	31.1% (n = 55)	.310
Daily personal needs harder	28.3% (n = 99)	30.2% (n = 52)	26.6% (n = 47)	.446
Harder to live independently	52.3% (n = 183)	56.4% (n = 97)	48.6% (n = 86)	.144
Harder to make decisions and plans	54.9% (n = 192)	53.5% (n = 92)	56.5% (n = 100)	.572
Socialize differently	47.7% (n = 167)	51.7% (n = 89)	44.1% (n = 78)	.151
Harder to work independently	62.6% (n = 219)	62.2% (n = 107)	62.7% (n = 111)	.923
Harder to manage money	55.4% (n = 194)	57.6% (n = 99)	53.7% (n = 95)	.465
Disability categories
Intellectual/cognitive	64.6% (n = 226)	65.1% (n = 112)	64.4% (n = 114)	.890
Autism spectrum	13.1% (n = 46)	16.3% (n = 28)	10.2% (n = 18)	.092
Deaf or hearing loss	11.4% (n = 40)	12.8% (n = 22)	9.6% (n = 17)	.345
Mobility/physical disability	22.0% (n = 77)	21.5% (n = 37)	22.6% (n = 40)	.807
Blindness or vision loss	8.9% (n = 31)	9.9% (n = 17)	7.9% (n = 14)	.517
Speech	20.3% (n = 71)	18.6% (n = 32)	22.0% (n = 39)	.426
Mental health	41.1% (n = 144)	40.7% (n = 70)	41.8% (n = 74)	.833
Ongoing health condition	36.6% (n = 128)	32.6% (n = 56)	40.7% (n = 72)	.116
Other	1.7% (n = 6)	1.7% (n = 3)	1.7% (n = 3)	.972
Functional disability status
Mean number of functional limitations	5.65 (SD = 2.82)	5.65 (SD = 2.782)	5.67 (SD = 2.858)	.959
Needs assistive devices	25.7% (n = 90)	25.6% (n = 44)	26% (n = 46)	.931
Needs personal assistance	62.3% (n = 218)	61.6% (n = 106)	62.7% (n = 111)	.835

Note. Statisitically significant results are in bold font.

Abuse Prevalence

Among study participants, 76.6% reported at least one instance of abuse in their lifetime, with many of these individuals endorsing more than one form of abuse; 60.1% reported any childhood abuse, and 66% reported being abused as an adult. The prevalence of overall childhood and adult abuse was not significantly different for men and women. There was no significant difference between men and women’s responses to the 12 childhood abuse items. Among the 14 adult abuse items, there were 5 items that women endorsed at significantly higher rates, 1 pertaining to financial abuse and 4 pertaining to sexual abuse (Table 2). When categorized as specific abuse categories, 38.9% of participants reported physical abuse as a child, 26.9% reported disability-specific abuse as a child, and 34.5% reported sexual abuse as a child; 62.7% of the sample reported mixed (physical and disability-specific) abuse as an adult, and 24.3% reported sexual abuse as an adult. Among the five abuse categories, the only significant gender difference in abuse prevalence was for adult sexual abuse, which women reported almost 3 times as often as men even after controlling for confounders (unadjusted OR = 2.91, p < .001; adjusted OR = 2.89, p = .001; Table 3).

Table 2.

Prevalence of Childhood and Adult Abuse Experiences.

Abuse Experiences	All (n = 350)	Males (n = 172)	Female (n = 177)	p Value
Childhood abuse experiences
When you were growing up, how often did an adult threaten to hit you or throw something at you?^a				.378
Never, rarely, or sometimes	267 (78.8%)	129 (76.8%)	138 (80.7%)
Often or very often	72 (21.2%)	39 (23.2%)	33 (19.3%)
When you were growing up, how often did an adult push, grab, shove, slap you, or throw something at you?^a				.444
Never, rarely, or sometimes	277 (81.7%)	140 (83.3%)	137 (80.1%)
Often or very often	62 (18.3%)	28 (16.7%)	34 (19.9%)
When you were growing up, how often did an adult hit you so hard that you had marks, bruises, or were hurt badly?^a				.565
Never	219 (64.6%)	106 (63.1%)	113 (66.1%)
Rarely, sometimes, often, or very often	120 (35.4%)	62 (36.9%)	58 (33.9%)
When you were growing up, did an adult ever touch or feel your body in a sexual way?^b	99 (29.2%)	43 (25.6%)	56 (32.7%)	.148
When you were growing up, did an adult ever have you touch or feel their body in a sexual way?^b	72 (21.2%)	37 (22.0%)	35 (20.5%)	.726
When you were growing up, did an adult ever have any type of sex with you?^b	71 (21.0%)	35 (20.8%)	36 (21.2%)	.938
When you were growing up, did an adult ever try to have sex with you?	83 (24.6%)	37 (22.0%)	46 (27.1%)	.282
When you were growing up, did an adult refuse to help you or ignore an important personal need such as using the bathroom, dressing, eating, communicating, or going out in the community?^c	79 (23.4%)	43 (25.6%)	36 (21.2%)	.337
When you were growing up, did an adult purposely break or keep you from using important things such as a wheelchair, breathing machine, communication device, or service animal?^c	15 (4.4%)	6 (3.6%)	9 (5.3%)	.442
When you were growing up, did an adult keep you from taking your medicine or give you more medicine than they were supposed to?^c	29 (8.6%)	18 (10.7%)	11 (6.5%)	.164
When you were growing up, were you ever taken from your home because adults were hurting you or not taking care of you?	57 (16.9%)	28 (16.7%)	29 (17.1%)	.923
When you were growing up, were you bullied by other children or teenagers?	194 (57.4%)	98 (58.3%)	96 (56.5%)	.729
Adult abuse experiences
As an adult, has anyone you know made you feel unsafe?	143 (42.3%)	71 (42.3%)	72 (42.4%)	.986
As an adult, has anyone you know yelled at you over and over again or hurt your feelings on purpose?^d	166 (49.1%)	77 (45.8%)	89 (52.4%)	.231
As an adult, has anyone you know ignored or refused to help you with an important personal need such as using the bathroom, banking, dressing, eating, communicating, or going out in the community?^d	59 (17.5%)	29 (17.35)	30 (17.6%)	.926
As an adult, has anyone you know purposely broken or kept you from using things such as a wheelchair, breathing machine, communication device, or service animal?^d	16 (4.7%)	7 (4.2%)	9 (5.3%)	.626
As an adult, has anyone you know kept you from taking your medicine or given you more medicine than they were supposed to?^d	24 (7.1%)	9 (5.4%)	15 (8.8%)	.215
As an adult, has anyone you know stolen or misused your money, bank account, or debit/credit cards?^d	91 (26.9%)	33 (19.6%)	58 (34.1%)	.003
As an adult, has anyone you know made you afraid they would hit, kick, slap, shove, or otherwise physically hurt you?^d	123 (36.4%)	56 (33.3%)	67 (39.4%)	.246
As an adult, has anyone you know hit, kicked, slapped, shoved, or otherwise physically hurt you?^d	90 (26.6%)	37 (22.0%)	53 (31.2%)	.057
As an adult, has anyone you know physically handled you in a rough way?^d	94 (27.8%)	43 (25.6%)	51 (30.0%)	.366
As an adult, has anyone you know held or tied you down or made you stay someplace when you did not want to?	50 (14.8%)	21 (12.5%)	29 (17.1%)	.238
As an adult, has anyone you know made you afraid they were going to touch you in a sexual way that you did not want?	69 (20.5%)	22 (13.1%)	47 (27.8%)	.001
As an adult, has anyone you know touched you in a sexual way that you did not want?^e	62 (18.4%)	18 (10.7%)	44 (26.0%)	<.001
As an adult, has anyone you know made you touch them in a sexual way that you did not want?^e	42 (12.5%)	11 (6.5%)	31 (18.3%)	.001
As an adult, has anyone forced you to have sex?^e	60 (17.8%)	12 (7.1%)	48 (28.4%)	<.001

Note. Statisitically significant results are in bold font.

Used in childhood physical abuse factor.

Used in childhood sexual abuse factor.

Used in childhood disability abuse factor.

Used in adult mixed abuse factor.

Used in adult sexual abuse factor.

Table 3.

Abuse Prevalence.

Abuse Factor	All (n = 350)	Male (n = 172)	Female (n = 177)	Unadjusted Odds Ratio	p Value	Adjusted Odds Ratio^a	p Value
Child physical abuse	38.9% (n = 132)	40.5% (n = 68)	37.4% (n = 64)	0.89	.565	0.87	.579
Child sexual abuse	34.5% (n = 117)	31.5% (n = 53)	37.4% (n = 64)	1.30	.255	1.25	.356
Child disability abuse	26.9% (n = 91)	29.8% (n = 50)	24.1% (n = 41)	0.75	.242	0.60	.063
Any childhood abuse	60.1% (n = 203)	61.9% (n = 104)	58.2% (n = 99)	0.86	.491	0.78	.298
Adult mixed abuse	62.7% (n = 212)	60.1% (n = 101)	65.3% (n = 111)	1.25	.325	1.12	.654
Adult sexual abuse	24.3% (n = 82)	14.9% (n = 25)	33.7% (n = 57)	2.91	<.001	2.54	.001
Any adult abuse	66.0% (n = 223)	63.7% (n = 107)	68.2% (n = 116)	1.23	.378	1.08	.757

Note. Statistically significant results are in bold font.

Adjusted for age, number of limitations, minority status, rural/urban, level of education, employment, and relationship status. Reference group = Male.

Perpetrator Relationships and Behaviors

Consistent with published literature in the general population, the most common perpetrator identified by women was an intimate partner, and women were significantly more likely than men to identify an intimate partner as their abuser (30.5% and 15%, respectively; p = .001). However, men were more likely than women to identify disability service providers as perpetrators of violence (10.8% and 4.8%, respectively; p = .041). Many males and females identified a family member as a perpetrator of adult abuse (28.1% for both). A large number of survey respondents selected “other” to describe their relationship with their abuser. These results are outlined in Table 4.

Table 4.

Perpetrator Characteristics and Behaviors.

Perpetrator Characteristic	All (n = 219)	Male (n = 106)	Female (n = 113)	p Value
Perpetrator identity
Husband, wife, boyfriend, girlfriend	34.2% (n = 75)	22.6% (n = 24)	45.1% (n = 51)	<.001
Parent, sibling, other family	41.6% (n = 91)	41.5% (n = 44)	41.6% (n = 47)	.990
Disability service provider	11.0% (n = 24)	16.0% (n = 17)	6.2% (n = 7)	.020
Friend, neighbor, coworker, or classmate	30.6% (n = 67)	34.0% (n = 36)	27.4% (n = 31)	.295
Professional (e.g., teacher, police officer, minister)	13.7% (n = 30)	15.1% (n = 16)	12.4% (n = 14)	.561
Stranger	23.7% (n = 52)	28.3% (n = 30)	19.5% (n = 22)	.125
Other	31.1% (n = 68)	24.5% (n = 26)	37.2% (n = 42)	.043
Perpetrator behaviors
Depend on perpetrator for personal assistance or support	27.4% (n = 60)	26.4% (n = 28)	28.3% (n = 32)	.752
Control services or health care	28.8% (n = 63)	27.1% (n = 29)	30.1% (n = 34)	.656
Control access to friends and family	36.5% (n = 80)	31.1% (n = 33)	41.6% (n = 47)	.107
Control daily activities	41.1% (n = 90)	35.8% (n = 38)	46.0% (n = 52)	.126
Try to choke	19.2% (n = 42)	10.4% (n = 11)	27.4% (n = 31)	.001
Hurt or threaten with a weapon	24.2% (n = 53)	25.5% (n = 27)	23.0% (n = 26)	.671
Hurt or threaten loved ones	24.2% (n = 53)	17.9% (n = 19)	30.1% (n = 34)	.036
Use alcohol or drugs	42.0% (n = 92)	38.7% (n = 41)	45.1% (n = 51)	.219
Get jealous or very angry	59.8% (n = 131)	53.8% (n = 57)	65.5% (n = 74)	.156
Hurt nonrelatives	25.1% (n = 55)	23.6% (n = 25)	26.5% (n = 30)	.656

Note. Statisitically significant results are in bold font.

To gain a better picture of the nature of abuse and the role of power and control, we asked 10 questions about perpetrator behaviors and characteristics. Two of these behaviors (choking participants and harming their loved ones) were significantly more common among perpetrators of violence against women than against men. Questions that directly pertain to controlling behaviors (control access to services or health care, control daily activities, control access to friends or family) tended to be endorsed more by women than men, although these trends did not reach statistical significance.

Abuse and Associated Health Status

Although childhood and adult abuse were significantly associated with poor health status, this association was not affected by gender. Physical symptom burden, as measured by the PHQ-15, was significantly higher for people who experienced childhood disability abuse and adult mixed abuse. On average, PHQ-15 scores were 2.01 points higher for people who experienced disability-specific abuse in childhood (p = .02) and 1.85 points higher for those who experienced adult physical or disability-specific abuse (p < .003). Depression, as measured by the CESD-10, was significantly higher for people who experienced childhood disability abuse and adult mixed abuse. On average, CESD-10 scores were 3.19 points higher for those who experienced disability-specific abuse in childhood (p < .001) and 2.89 points higher for those who experienced physical or disability-specific abuse as an adult (p < .001). Stress, as measured by the PSS, was significantly higher for people who experienced childhood disability abuse, adult mixed abuse, and adult sexual abuse. Among those who experienced disability-specific abuse as a child, the average PSS score was 1.17 points higher (p = .005), whereas those who experienced physical or disability-specific abuse as an adult had an average PSS score of 1.33 points higher (p = .001), and those who experienced sexual abuse as an adult had an average PSS score of 1.22 points higher (p = .006). Finally, PTSD, as measured by the PCL-C, was significantly more common for people who experienced childhood physical abuse, childhood disability abuse, and adult mixed abuse. Participants endorsing childhood disability-specific abuse had PCL-C scores that were 6.37 points higher (p < .001), whereas those who endorsed adult physical or disability-specific abuse had scores that were 6.04 points higher (p < .001). We did not find a significant moderation effect of gender in any of these instances.

Discussion

By and large, our study demonstrated similarities rather than differences between men and women. Rates of overall abuse were similar for men and women. Although sexual abuse as an adult was more common for women than it was for men, rates of all other forms of abuse were not affected by gender. Women were more likely than men to be abused by intimate partners; however, intimate partners represented the minority of abusers for both men and women. There was no significant gender difference in the association between abuse and health status. This striking picture of gender similarities among study participants underscores the importance of reconsidering issues of gender among people with disabilities. Although some gendered aspects of violence and health frequently seen in the general population were replicated here, this study demonstrates that when considering people with developmental disabilities, one must have a more nuanced approach to these issues.

As previous studies have acknowledged, one is not susceptible to violence solely because of their gender; the presence of a disability also increases the risk of violence (R. B. Hughes et al., 2011; Nosek et al., 2001; Powers et al., 2008). Our findings extend a growing trend in the literature toward a view of violence that considers vulnerabilities beyond those related solely to gender and urges responses and services accommodating of people with developmental disabilities, including males. This highlights the importance of utilizing an intersectional perspective when considering violence and disability. One’s vulnerabilities to and experience of violence are shaped by multiple, interlocking life experiences; neither disability nor gender alone determines the existence or outcomes of violence. To further our understanding of the impact of violence on people with disabilities, we must account for the relevant intersecting social, political, and cultural dimensions of gender and disability.

Furthermore, gender as commonly understood in the medical literature neglects important aspects of the conversation. Discussions regarding gender, which often become synonymous with “woman” (Moore, 2010), may neglect the needs and experiences of men with disabilities. Expanding our gaze to focus on masculinities and femininities as opposed to binary notions of sex and gender helps make sense of the prevalence, severity, and outcomes of violence for men and women with disabilities.

We found that participants reported childhood and adult abuse experiences at staggeringly high rates. Overall, 68.2% of women and 63.7% of men reported adult abuse, and 58.2% of women and 61.9% of men reported childhood abuse. Many studies have found that rates of physical and sexual abuse exposure among persons with developmental disabilities are high and exceed those for general population samples (R. Sobsey, 1994; D. Sobsey & Doe, 1991). Findings from a systematic review of research involving persons with diverse disabilities, and examining exposure to both typical and disability-related forms of abuse, suggest that persons at highest risk of violence often experience multiple, concomitant disabilities, a component of which could include cognitive or mental health disabilities (R. B. Hughes et al., 2011). The high rates of violent exposure may be related to several factors, such as an increased dependence on others, a perception by abusers that violence will not be reported or believed, lack of accessible violence services, and an exposure to new settings and situations in which abuse can arise. These factors affect both men and women, and may thus explain the overwhelming similarities between men’s and women’s reports of violence in this sample.

Women were nearly 3 times more likely than men to report an experience of sexual abuse as an adult (OR = 2.91, p < .001). These results are largely consistent with existing evidence. For example, in their study of 782 men and women with severe mental illness, Goodman et al. (2001) found that women experienced higher rates of sexual abuse than men did, while physical abuse and overall childhood and adulthood abuse occurred at similar rates. Likewise, the Bureau of Justice Statistics showed comparable rates of violent victimization against men and women with disabilities (Harrell, 2012).

It is worth highlighting, however, that although men in this sample reported less sexual abuse than women, the prevalence of both adult sexual abuse (14.9%) and rape (7.1%) were higher than the prevalence reported by men in the general population. A population-based study of 941 participants found that only 3.8% of males reported experiences of sexual abuse as an adult (Elliott, Mok, & Briere, 2004), and the National Violence Against Women Survey, administered to 16,000 individuals, found a 0.8% prevalence of rape among adult males (Tjaden & Thoennes, 2000). Furthermore, although women in this sample experienced greater rates of sexual abuse than men, that gender difference was less pronounced in this sample than what has been reported in studies of the general population (Tjaden & Thoennes, 2000). In their population-based study of 25,756 adults, Mitra et al. (2011) also found that men with disabilities experienced significantly more adult sexual abuse than men without disabilities, and that the gender difference in the prevalence of adult sexual abuse was less pronounced among people with disabilities compared with those without. The narrowed gender difference in rates of sexual abuse could be related to decreased power and an increased dependence on others experienced by men with disabilities (Saxton et al., 2006). Furthermore, men with disabilities are often less likely to enact stereotypical forms of masculinity that emphasize strength and independence (Powers et al., 2008). This change in power dynamics, described as “feminization” by some, has been suggested to result in men with disabilities experiencing oppressions and abuses more typically experienced by women (Shakespeare, 1999). Their disability status, thus, makes them more vulnerable to certain acts of violence. The diminished association between gender and rates of sexual abuse of people with developmental disabilities forces a view of violence, especially sexual violence, which considers the impact of vulnerabilities beyond those inherent to one’s gender identity. As Thomas Gerschick (2000) puts it, “having a disability erodes much, but not all, masculine privilege” (p. 1265).

Women were more likely than men to identify an intimate partner as their abuser, whereas men were more likely than women to identify a disability service provider as a perpetrator. The finding that men were more likely to identify a disability service provider as an abuser should be interpreted cautiously, as the overall number of people reporting this type of perpetrator was small. Furthermore, men may have experienced abuse by service providers more than females simply as a product of having greater exposure, as 20% of male participants lived in a group home or assisted living setting, compared with only 11% of female participants. Previous studies of intimate partner violence among people with disabilities have shown inconsistent results. Of the two population-based studies of intimate partner violence against people with disabilities, both found that women experienced intimate partner violence more frequently than men, although one demonstrated that this gender difference was less pronounced than it was among people without disabilities (Smith, 2008), and the other found that after controlling for demographic confounders, the gender difference no longer existed (Cohen et al., 2006). It is perhaps more important to note that only 18% of perpetrators were identified as intimate partners. By comparison, 22% of perpetrators were identified as family members and 16% were identified as acquaintances (friends, neighbors, classmates, or coworkers). This underscores the need to expand the scope of investigation beyond intimate partner violence, which is often the focus of interest in the general population. Finally, it is noteworthy that more than 30% of the participants who reported abuse selected “other” to identify their abuser. This suggests that more research should be done to better understand who perpetrates abuse against people with disabilities.

Among the 10 perpetrator behaviors or characteristics that we studied, women were significantly more likely to endorse two of the items (perpetrator tried to choke participant and perpetrator hurt or threatened their loved ones). Although not statistically significant, all but one of the other behaviors were reported more often by women than men. Some of these behaviors and characteristics are strongly associated with higher lethality in intimate partner violence in the general population (Campbell et al., 2009). That women endorsed more of these items could suggest more severe violence. It is also possible that these behaviors are more characteristic of intimate partners than other abusers and are thus more commonly reported by women because they are more likely to experience intimate partner violence. Although items such as choking clearly suggest a higher severity of violence, it is also worth noting that the abuse factor scores did not show differences in the severity of abuse experienced by male and female participants.

With respect to health status, we found that several forms of abuse were independently associated with worse health, and these associations were not moderated by gender. Previous studies on the impact of gender on the association between violence and health have been mixed. Data from the National Violence Against Women Survey of 8,000 men and 8,000 women found that child abuse had a stronger association with poor health for women than men (Thompson, Kingree, & Desai, 2004). However, this same survey showed the association between intimate partner violence and poor health was unaffected by gender (Coker et al., 2002). Elliott et al. (2004) found that among participants who had not experienced sexual abuse, females had a worse severity of trauma-related symptoms than males. However, among those who had been sexually abused, males had worse trauma symptom severity than females (Elliott et al., 2004). By not showing a significant gender difference on the association between violence and health, our study supports the argument that services for people with developmental disabilities must be sensitive to the needs of both men and women.

A major strength of the study was its survey administration format, specifically designed to be meaningful for and accessible to people with diverse developmental disabilities. This format allowed participants to anonymously report experiences of violence, thus circumventing the need for proxy reporting or mandatory reporting of researchers, both of which have likely limited disclosure of violence in previous studies. Another strength was the broad scope of abuse considered and the inclusion of men as participants in a survey about violence. One limitation of this study is its nonrandom sampling method, which limits the generalizability of its results. As with all cross-sectional studies, we are also limited in our ability to draw conclusions about causality in associations. As with all studies based upon self-reporting, recall bias is a concern, which may lead to under- or overreporting of abuse. Finally, although peer victimization is a major issue for children with developmental disabilities, only one of our survey items addressed this topic. Future research efforts should include extending anonymous and accessible survey methods for use in a population-based study to provide for more generalizable information. Prospective cohort studies could also shed important light on this topic by providing a temporal understanding of the association among abuse, disability, and health. Further research surrounding the prevalence and impact of peer victimization in children with developmental disabilities is also needed.

Despite the limitations, the findings of this study have several important implications. Overall, violence against men in this sample was as common as violence against women. Although more women reported sexual violence than men, the men who experienced sexual violence had comparable levels of abuse severity and no difference in associated health status. These findings have implications for programs and services designed for addressing abuse in the lives of people with developmental disabilities. Services and interventions built solely on notions of gender-based violence may be incomplete when considering the context of disability. To be most effective, these programs must be aware of abuse experiences outside of intimate partner relationships, and they must be sensitive to the experiences of men with developmental disabilities.

There is a documented dearth of services for men with disabilities who experience violence (Lund et al., 2015; Powers et al., 2008). These reasons are multifaceted but again can be seen in light of the social context of hegemonic masculinity that assumes (a) men are not victims, only perpetrators; (b) men can (and should) protect themselves; (c) men are capable of dealing with their problems on their own. As noted by Powers et al. (2008), the lack of services for men may also in turn reinforce the invisibility of the problem.

In the health care arena, while current guidelines exist for screening women for intimate partner violence and screening older patients for elder abuse, no guidelines or recommendations exist for people with developmental disabilities. Based on the results of this study of people with developmental disabilities, as well as previous research demonstrating high levels of abuse among people with disabilities in general, such screening guidelines may be beneficial in increasing the likelihood that abuse would be detected among these populations.

Footnotes

Authors’ Note

The content of this material does not necessarily reflect the views and policies of Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities (NCBDDD), nor Association of University Centers on Disabilities (AUCD). The Research Topic of Interest (RTOI) award was made to the University of Montana in Missoula.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities (NCBDDD) under Cooperative Agreement U01DD000231 to the Association of University Centers on Disabilities (AUCD).

Author Biographies

Laura Platt received her BA in religion from Reed College in 2008. In the community, she worked for 3 years at a domestic violence shelter in Portland, Oregon. She received her MD from Duke University School of Medicine in 2015. While a student at Duke and in partnership with the Portland State University School of Social Work, she participated in community-based participatory research (CBPR) projects focusing on violence and the health of people with developmental disabilities.

Laurie Powers, PhD, is emerita associate dean for research, director of the Regional Research Institute for Human Services, and professor at Portland State University. Her work focuses on interpersonal violence, self-determination enhancement, transition to adulthood, and health and wellness for youth and adults with diverse disabilities as well as other disparity populations.

Sandra Leotti received her BA from Prescott College in 2002 and her MSW from the University of Montana in 2006. She is currently a PhD student in social work and social research at Portland State University. Her practice experience includes community mental health, violence education and prevention, community case management for adults and children with disabilities and long-term illnesses, clinical practice with youth, and leadership development. Her research interests include the criminalization of women, reproductive justice, disability, and feminist methodologies. She is also interested in antioppressive practice and social work education with a specific focus on the infusion of critical and feminist theories in education and practice.

Rosemary B. Hughes, PhD, is the principal investigator of several federal grants and subcontracts on research related to the health and safety of adults with disabilities. Her current research projects address interpersonal violence, weight management, and smoking cessation. She holds a PhD in counseling psychology from the University of Houston, an MS in education from the University of Houston–Clear Lake, and a BA in sociology from St. Mary’s College, Leavenworth, Kansas. She is a licensed psychologist with clinical, teaching, and research experience in disability, health, and mental health. She is the former director of the Center for Research on Women With Disabilities at Baylor College of Medicine in Houston, Texas. She has served as principal investigator on research grants investigating health promotion, stress, depression, and self-esteem in the context of disability. Her projects have been funded by the Centers for Disease Control and Prevention, the National Institute on Disability and Rehabilitation Research, the Christopher Reeve Foundation, and the National Institutes of Health. Her primary research focus is interpersonal violence in the context of disability, and her methodological approach is primarily CBPR. She has published more than 50 articles or book chapters and has presented nationally and internationally on issues related to the health and safety of people with disabilities.

Susan Robinson-Whelen, PhD, is a current investigator at the Center for Research on Women With Disabilities and an assistant professor in the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine. She received her PhD in clinical psychology and geropsychology from Washington University on St. Louis, Missouri, in 1993. She has since been a principal investigator on several research projects, many of which are focused on the health and wellness of people with disabilities.

Sherri Osburn is a self-advocate, community-advocate, and community researcher with an intellectual disability. She is currently serving her second term as a vice chair on the Oregon Council of Disabilities where she focuses on unemployment policy. She has also worked with Self-Advocates as Leaders and has served on the Board of Inclusion at her local disability brokerage firm. She has participated as a Community Advisory Board Member on multiple research projects related to the health of people with developmental disabilities.

Elesia Ashkenazy is an autistic, deaf, multicultural, and multiracial disability rights advocate committed to improving the lives of autistic individuals and their families. She has served in a leadership capacity for several agencies and organizations. She collaborates on the development and implementation of self-advocacy curricula and training tools. While working for the Autistic Self-Advocacy Network (ASAN), she served as both the editorial coordinator and project lead for several published anthologies. She also served as the director of Community Outreach at the National Youth Leadership Network (NYLN) where she focused on educating, inspiring, and mentoring youth with disabilities. She has participated in the Academic Autistic Spectrum Partnership in Research and Education (AASPIRE) as a community partner since 2008. During this time, she has partnered on several research projects, serving as an equal partner in the development, implementation, and dissemination of the research. She also has served on the Community Advisory Board for the Partnering with People With Developmental Disabilities Against Violence Consortium, led by the University of Montana in conjunction with AASPIRE. She serves as the chair of AASPIRE’s Community Council.

Leanne Beers, MSPR, is currently a PhD candidate in human services and family strategies combined with a master’s in public relations and health communications. She has been working with individuals with disabilities for more than 20 years. She continues to specialize in human relations, health communications, body image, and intimacy among individuals with disabilities. Through her expertise in leadership skills and education of others, she promotes the divine right to be recognized and accepted. Currently living in Missoula, Montana, she serves as president on the Summit Independent Living Center Board of Trustees as well as serves on various Community Advisory Boards regarding disability research. She prides herself as a professional, class facilitator, and advocate for topics such as assertiveness, self-esteem, safety awareness for women, nonviolent communication, disability, sexuality, and healthy relationships.

Emily M. Lund, MEd, is a student in the Disability Disciplines PhD program at Utah State University pursuing dual specializations in rehabilitation counseling and special education. She holds bachelor’s degrees from the University of Montana and a master’s degree from Texas A&M University. Her primary research interests are interpersonal violence, bullying, and peer victimization, with a focus on individuals with disabilities. Her secondary research interests include suicide and nonsuicidal self-injury, especially as they relate to disability and trauma, and the experiences of psychology trainees with disabilities.

Christina Nicolaidis, MD, MPH, is professor and senior scholar of social determinants of health in the School of Social Work at Portland State University and adjunct associate professor of medicine and public health at Oregon Health and Science University. As an internist and health equity researcher, she has led numerous CBPR projects in partnership with people with developmental disabilities, intimate partner violence survivors, and members of ethnic or racial minority communities. Her research interests include participatory approaches, interpersonal violence, mental health, and primary care services. She is the codirector of the Academic Autism Spectrum Partnership in Research Education and was a coprincipal investigator on the Partnering With People With Developmental Disabilities to Address Violence Project. She served as Ms. Platt’s primary mentor and the senior author for this analysis.

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