Systematic Review Overview: Violence Against Adults with Disabilities

Abstract

This study aimed to conduct an overview of systematic reviews in the field of violence against adults with disability. Eight electronic databases as well as gray literature from January 2022 to April 2023 were searched to identify systematic reviews that focused on violence against adults with disabilities. A total of 13 high-quality systematic reviews were included in the overview. Findings show that adults with disabilities experience a higher rate of emotional and physical violence than the general population. Sociodemographic, financial, and cultural risk factors, prevention, and treatment approaches were discussed. Although the large body of studies on disability and violence have explored different aspects of the issue, there are some limitations and gaps in the literature that need further attention. The most important gap in the literature is the lack of attention to diversity. Accordingly, there is little knowledge about disability and violence in a variety of geographical locations. In addition, studies on violence based on ethnicity/race, age, gender identifications, and some types of disabilities such as hearing impairments or severe disabilities were scarce. There is a need to reach diverse populations of adults with disabilities, through employing a variety of data collection methods and qualitative research methodology. Prevention and treatment programs should be developed with attention to types of disability, and they should be culturally and linguistically sensitive.

Keywords

Disability violence overview systematic review

Every year, violence in its various forms, such as physical, sexual, and psychological, influences the lives of billions of people and leads to physical or psychological injury or even death. In 2019, about 475,000 deaths were reported due to interpersonal violence around the world (WHO, 2022). Similar to the general population, persons with disabilities face physical, sexual, and emotional violence. Hughes et al. (2011) found that the prevalence of violence against adults with disabilities (AWD) ranged between 2% and 70%. The wide variation in the prevalence rate of violence against AWDs reflects the diversity of methods and definitions used to measure violence, the heterogeneity of the study populations, and the multiplicity of disability types. The significant point according to epidemiological studies is that the risk of violence against AWDs is higher than their counterparts without disabilities (Hughes et al., 2012).

In addition to the common types of violence, AWDs may also face disability-related violence. For example, Araten-Bergman and Bigby (2020) reported that AWDs may be deprived of accessing assistive technologies, medication or medical care, and assistance or support. Such violence may have adverse short-term and long-term effects on the survivors, such as substance abuse, depression, post-traumatic stress disorder, suicidal ideations, and even death (Cadwallader et al., 2018; Meyer et al., 2022). Furthermore, the low rate of disclosure of violence among AWDs may be attributed to fear of the perpetrators who are often the formal or informal caregivers, communication barriers, and limited access to authorities. This may result in re-victimization and entrapment in a cycle of violence.

The topic of disability and violence has been explored for decades, leading to the generation of several systematic reviews. This study aims to conduct an overview of systematic reviews around disability and violence in the last decades, to provide a comprehensive overview of the existing literature, and to pave the way for more informed research and policy making in the future. Accordingly, the main research questions were:

What are the types and prevalence of violence against AWDs?

What are the risk factors for violence against AWDs?

What preventive/treatment strategies have been employed?

What are the gaps and limitations in the literature?

Method

The Preferred Reporting Items for Systematic Review and Meta-Analyses (Moher et al., 2009) was employed to identify high-quality papers (Figure 1). Narrative synthesis methodology as described by Ferrari (2015) was used to synthesize the data.

Figure 1.

The Preferred Reporting Items for Systematic Review and Meta-Analyses flowchart.

Search Strategy

Eight electronic databases, including PubMed, Web of Science, CINAHL, PsycINFO, Embase, Cochrane Library, Google Scholar, and Scopus, were searched from 1990 to April 2023 using keywords including “systematic review,” “violence against people with disabilities,” “abuse against people with disabilities,” “disability,” “abuse,” “neglect,” “trauma,” and “neglect.” The Boolean operators AND, OR, NOT, and truncations were utilized to find the relevant articles. A further search was undertaken manually based on the reference list of articles to find gray literature.

Inclusion Criteria

Reviews were included if they: (a) were systematic reviews, (b) reported any kind of violence against adults with any type of disability, (c) were written in English, and (d) had a full text. Reviews that contained qualitative, quantitative, or both methods were included.

Quality Assessment

Full-text systematic reviews were assessed for quality by the AMSTAR (Shea et al., 2017) measurement tool developed to assess the methodological quality of systematic reviews (Shea et al., 2017). High-quality reviews were required to provide at least six of the 11 requirements of the AMSTAR measurement tool. The first and second authors conducted an initial electronic database search, and the quality assessment of the papers was carried out by all authors independently. The evaluators discussed their disagreements on quality ratings to reach a consensus. The initial electronic search generated 106 references, and the manual search revealed 10 more studies. Fifty references remained after removing duplicated studies. In the next stage, 37 papers were excluded because they did not meet the inclusion criteria. Finally, 13 systematic reviews were included in the analysis (Table 1).

Table 1.

Descriptive Information for Included Papers.

No	References	Methodology	Main Findings	AMSTAR Score
1	Fettig et al. (2023) (Risk factors studies)	• Scoping review • 29 papers (2010–2020) • Population: Older adults with/without disability, caregivers • N = 155,688 • Gender: Female and Male • Types of abuse/violence: emotional, physical, financial, sexual abuse/neglect, self-neglect Country: USA	• Moderate to large effect size between age and emotional/physical abuse and neglect • Low income, low social support, depression, and physical disability = most consistent results	11/11
2	Amborski et al., (2022) (Sexual violence and disability studies)	• Meta-analysis • 68 papers (1970–2018) • Population: Persons with physical, sensory, or intellectual disabilities/without disability • N = 12,427 • Gender: Female and Male • Types of abuse/violence: sexual • Countries: USA (35), UK (13), Canada (4), Australia (2), Israel (2), South Africa, Ghana, Nepal, Sri Lanka, Taiwan, Norway, Germany, and Italy (1 each)	• Higher risk of sexual victimization (SV) • Higher rate of SV in adults with disability • Highest risk of SV among people with sensory disabilities	11/11
3	Trundle et al. (2022) (Prevalence studies)	• Systematic review/meta-analysis • 34 papers (2005–2019) • Adults/children with autism • N = 633,051 • Gender: Female and Male • Types of abuse/violence: bullying, cyberbullying, sexual, physical maltreatment, crime, emotional and medical neglect • Countries: USA (17), UK (3), Canada (3), Australia (3), Taiwan (3), Sweden, China, South Korea, South America, Netherlands, France (each country one paper)	• Rate of victimization= 44% Children and adolescents (39%), • Adults (66%) • Subgroup analysis = higher rates of bullying and SV than cyberbullying	11/11
4	Araten-Bergman and Bigby (2020) (Prevention studies)	• Scoping review • Six papers (2007–2017) • Adults/intellectual disabilities/service providers • N = 71 intellectual disabilities/131 service providers • Gender: Female and Male • Types of abuse/violence: mainly sexual abuse, also physical, financial, and verbal • Countries: USA (4), UK, Netherlands (1)	• Prevention programs included: Training programs for service providers, educational workshops, behavioral skills training, training using cognitive-oriented decision-making Psychoeducation training • Focus on specific impacts over a short period of time • Not focusing on broader context • No intervention for severe or profound ID	10/11
5	McGilloway et al. (2020) (Experiencing sexual abuse studies)	• Systematic review and meta-synthesis • 13 papers (2000–2020) • Adults with intellectual disabilities/deaf, all disabilities/stakeholders • N = 768 • Gender: Female and Male • Types of abuse/violence: sexual • Countries: USA (6), Australia (3), Ireland (2), Scotland (1), UK (1)	Three main themes: • Interpersonal context (fear, communication, sexual knowledge) • Professional context (ID identification, lack of collaboration between service providers, presumption of capacity and credibility) • Social context (myths, misconceptions, and attitudes)	11/11
6	Alhaboby et al. (2019) (Cybervictimization)	• Systematic review • 10 papers (1990–2016) • Children and adults with disabilities • N = 3,070 • Gender: Female and Male • Types of abuse/violence: cybervictimization Countries: USA (4), Australia (2), UK (1), Sweden (2), Netherlands, Switzerland, Taiwan (each 1)	• Prevalence 2%–41.7% based on different definitions/duration and methods • Consequences: psychological/psychiatric mainly depression, anxiety, distress, Post Traumatic Stress Disorder, self-harm	11/11
7	Bowen & Swift (2019) (Prevalence studies)	• Systematic review • Six papers (before 2017) • Adults with intellectual disability • N = 93 • Gender: Female and Male • Types of abuse: physical, sexual, and emotional abuse by partner or against partner • Country: UK (3), Alaska, Australia, The Netherlands (each 1)	• Prevalence of physical Intimate partner violence 60% men, 57% women • Prevalence of emotional Intimate partner violence 90% men, 79% women • Prevalence of sexual Intimate partner violence • 20% men, 4.2% women • 37% never sought help	11/11
8	Hughes et al. (2012) (Prevalence studies)	• Systematic review and meta-analysis • 26 papers (1990–2010) • Individuals with Mental, intellectual, physical, and sensory disabilities • N = 21,557 • Gender: Female and Male • Types of abuse/violence: physical/sexual abuse by intimate partner/caregiver • Countries: USA (15), UK (5), Taiwan (2), Canada, Australia, New Zealand, South Africa (1 each)	• Higher risk of victimization • Higher vulnerability for people with mental illness	11/11
9	Khalifeh et al. (2016) (Experiences of physical and Sexual abuse studies)	• Systematic review and meta-analysis • 30 papers (2000–2015) • Adults/People with severe mental illness • N = 16,140 • Gender: Female and Male • Types of abuse/violence: domestic physical/sexual • Countries: USA (11), Europe (8), UK (5), Australia (3), Ethiopia (1)	• high prevalence of lifetime victimization (physical, sexual, and domestic violence) for people with mental illness • Risk factors: demographic, social, clinical, substance misuse, violence perpetration and childhood abuse	11/11
10	Plummer and Findley (2012) (Experience of physical and Sexual abuse studies)	• Comprehensive literature review • 24 papers (1997–2009) • Adults/Physical, mental disability • Gender: Female only • N = 39,034 • Gender: female • Types of abuse/violence: physical/sexual • Country: USA	• Similar or higher rate of victimization • Experiencing multiple forms of abuse • Risk factors: isolation, role of perpetrators (partner, caregiver, healthcare providers), dependency, learned helplessness, fear of report, system and cultural barriers, lack of self-esteem	10/11
11	Hughes et al. (2011) (Prevalence studies)	• Comprehensive literature review • 21 papers (2000–2010) • Adults/Physical, Mental disability, and Chronic illness • N = 22,260 • Gender: Female (mainly) and Male • Types of abuse/violence: mainly physical and sexual, also emotional, financial, disability-related • Countries: USA (18), Canada (3)	• Prevalence of any types of violence 2%–70% • Higher rates with expanding the definition of violence • The highest rate: women with mental illness • Female life time experience of abuse: 26%–90% • Male life time experience of abuse: 28%–86%	11/11
12	Lund (2011) (Intervention/prevention studies)	• A scoping review • 16 papers (1995–2010) • Adults/intellectual/physical, vision and hearing disabilities • N = 416 • Gender: Female (mainly) and Male • Types of abuse/violence: mainly sexual, physical, psychological, financial, disability-related • Countries: USA (13), UK (3)	• Intervention and Prevention Programs: • Behaviorally based abuse prevention programs, • Cognitively based abuse prevention programs, • Psychoeducational-based abuse prevention programs	11/11
13	Barger et al. (2009) (Prevention studies)	• Comprehensive literature review • Four papers (1999–2000) • Female only/intellectual disabilities • N = 61 • Types of abuse/violence: sexual • Countries: USA/Australia	• Prevention programs • Decision making training, knowledge of abuse, empowerment program • Pre-, post-test of attitudes and knowledge about sexual assault • No real-world practice	10/11

Data Extraction/Primary Coding of Systematic Reviews

The identified references were downloaded into Endnote software and deduplicated by the first reviewer. Afterward, the irrelevant articles were removed by initial screening. Subsequently, titles and abstracts were independently dual-screened for inclusion, and authors discussed disagreements. Full-text articles were retrieved for remaining records and independently dual-screened, with discrepancies resolved in biweekly meetings. The following information of each study was recorded for review: methodology (e.g., study design, sample, country, types of disabilities, types of abuse, and types of interventions), the effectiveness of interventions (extracted from the results, discussion, and conclusion), and other study characteristics (e.g., date of publication and quality of included studies).

Data Synthesis

A narrative synthesis approach (Ferrari, 2015) was adopted to synthesize data since different methodologies (qualitative, quantitative, and mixed-methods) were employed in the 13 included systematic reviews, and statistical pooling was not possible or suitable, as suggested by Higgins et al. (2019). Content or thematic analysis can systematically be employed in the narrative synthesis approach to extract the main themes from multiple studies (Ferrari, 2015). Here, a six-step thematic analysis approach was employed (Braun & Clarke, 2022). Extracted information was exported into the last version of MAXQDA software to organize and analyze the key themes (step 1). All authors participated in the analysis, read all the included articles (step 2), and generated initial codes (step 3). Codes with similar content were grouped into potential subthemes (step 4). Then, subthemes were categorized into themes (step 5). Finally, the thematic network was created and approved by the authors (step 6). The authors repeatedly checked and updated the list of codes, subthemes, and themes by re-reading the articles and discussing themes in biweekly meetings. During these sessions, discrepancies were discussed and the final results that were agreed by all authors are reported here.

Findings

The 13 included papers covered the period between 1970 and 2023 and contained 287 articles with at least 904,767 participants (ranging from 61 to 633,051). Over 90% of articles (n = 264) were conducted in the USA, the UK, the European countries, Australia, and Canada. Countries such as Ethiopia, South Africa, Ghana, Nepal, Israel, Sri Lanka, Taiwan, China, and South America had a small number of studies. Different definitions of disability were adopted in studies; however, they often covered physical, sensory, mental, and intellectual disabilities as well as chronic illnesses. One study focused on older adults with some disabilities. Intellectual disability received the highest research interest (n = 7), followed by physical (n = 5) and sensory (n = 4) disability. The majority of studies employed a quantitative methodology (n = 219) to collect and analyze the data.

Types and Prevalence of Abuse

The first research question was: What are the types and prevalence of violence against AWDs? Several types of violence were mentioned in the systematic reviews, including common types of violence such as physical, sexual, and emotional violence and neglect, as well as other types such as financial abuse/neglect, cybervictimization, disability-related abuse, medical neglect, and self-neglect. The main types of violence in most studies were sexual violence, mentioned in 12, and physical violence, which was reported in nine systematic reviews. Emotional/psychological violence was reported in five systematic reviews. Disability-related violence and bullying/cyberbullying were reported in two studies.

Different prevalence of violence was mentioned in the six systematic reviews (Table 2). However, the general conclusion was that AWDs were at greater risk of experiencing violence than the general population. Lifetime sexual violence prevalence was reported to be 11%–68% for females and 9.3%–24.7% for males with disabilities in Hughes et al. (2011), 9.9% for females and 3.1% for males with disabilities in Khalifeh et al. (2016); and 20% for females and 4.2% for males with disabilities in Bowen and Swift (2019). In Trundle et al. (2022), 40% of adults with autism faced sexual violence, which was sixfold higher than the general population.

Table 2.

Types and Prevalence of Violence Against Adults with Disabilities.

References	Types of Disability	Types and Prevalence of Violence (Summary)
Trundle et al. (2022)	• Autism spectrum disorder	• Bullying victimization (47%) • Abuse (physical, sexual, emotional, neglect and medical neglect) (16%) • Sexual victimization (40%) • Cyberbullying (13%) • Multiple victimization (84%)
Alhaboby et al. (2019)	• Chronic conditions (asthma, diabetes, epilepsy, allergy, intestinal disease) • Disabilities (intellectual, developmental, physical, psychological, sensory)	• Cybervictimization (2%–41%)
Bowen and Swift (2019)	• Intellectual disability	• Intimate partner violence in just one study: • Physical violence against men 60%, against women 57% • Emotional violence against men 90%, against women 79% • sexual violence against men 4.2%, against women 20.8%
Hughes et al. (2012)	• Mental illness • Intellectual disability	• Any type of violence against people with mental illness (24.3%) • Any type of violence against people with intellectual disability (6.1%) • Any type of violence against nonspecific disability (3.2%)
Khalifeh et al. (2016)	• Severe mental illness	• Domestic violence (15%–22% against women) • Domestic violence (4%–10% against men) • Sexual violence (9.9% against women) • Sexual violence (3.1% against men)
Hughes et al. (2011)	• Physical, mental, psychological disability, communication issues	• Women’s any type of violence lifetime (26%–90%) • Sexual violence (3.1% against men) • Men’s any type of violence lifetime (28%–86%)

Physical violence prevalence was reported in four systematic reviews. Hughes et al. (2011) found that 14%–82% of women and 28%–86.1% of men with disabilities suffer from lifetime physical abuse. In Bowen and Swift’s (2019) systematic review, 57% of women and 60% of men with disabilities experienced physical abuse. Hughes et al. (2012) and Khalifeh et al. (2016) explore the experience of violence in different disability populations. Khalifeh et al. (2016) focused on individuals with severe mental illness (SMI) and found that 20.7% of females and 17.8% of males with SMI suffer from physical violence, and the rate is higher than the general population. Similarly, Hughes et al. (2012) found that individuals with mental illness suffered from physical abuse at a higher rate (21%) than those with intellectual disabilities or without disability.

Emotional violence was reported in two studies, with a very high prevalence of 90% for males and 79% for females with disabilities (Bowen & Swift, 2019). Hughes et al. (2011) reported 35.5%–52% physical violence against women with disability. The rate of experiencing financial abuse in men and women with disabilities was 24% and 35%, respectively. It was found that men with activity limitations experienced a higher rate of financial abuse by their partners (Hughes et al., 2011).

Disability-related abuse prevalence rate was reported in only one systematic review (Hughes et al., 2011). Lifetime disability-related abuse such as medication/equipment abuse or neglect occurred for 13.5%, 14%, and 19.5% of females, respectively. Men with SMI also reported manipulation of medications (13.7%) and denial or destruction of assistive technology (4%).

Alhaboby et al. (2019) focused on the prevalence rate of cybervictimization among AWDs and people with chronic conditions such as epilepsy. As reported 2%–41% of participants experienced cybervictimization through email, phone messages, and social network platforms like Twitter or Facebook. In the same vein, Trundle et al. (2022) reported that 13% of people with autism experienced cyberbullying.

Variable definitions, measurements, duration of the experience, and diverse methodology lead to different prevalences in these studies. In general, AWDs experience different types of violence higher than the general population; moreover, as Hughes et al. (2011, 2012) suggested taking more than one type of abuse and multiple disabilities into account, the rate would rise sharply (2011, 2012).

Risk Factors

The second research question was: What are the risk factors of violence against AWDs? It seems that disability could be a risk factor for experiencing violence as the prevalence of victimization was higher among AWDs than the general population. Higher needs for personal assistance may infringe on their autonomy and privacy and could place personal boundaries in danger (Plummer & Findley, 2012). Other factors such as demographic, financial, cultural, and social factors and failure to report violence increase the risk of violence against people with disabilities.

Demographic Factors

Demographic factors related to violence included the type and severity of disability, gender, and individual characteristics. In a subgroup comparison, Hughes et al. (2012) found that individuals with SMI might experience higher rates of physical, sexual, or any violence. Khalifeh et al. (2016) also mentioned that individuals with mental illness were at higher risk of violence experience; however, their study focused only on individuals with mental illness, not other disabilities. Gender is another demographic factor that was the focus of some systematic reviews. It is noteworthy that in all 13 systematic reviews, gender was defined as a binary male/female concept. Several systematic reviews focused on only females (Barger et al., 2009; Plummer & Findley, 2012) or mainly had female participants (Hughes et al., 2012; Lund, 2011). Males as a separate population appeared merely in two studies (Araten-Bergman & Bigby, 2020; Hughes et al., 2011). Hughes et al. (2011) reported that women with SMI were more vulnerable than men. The rate is higher for sexual violence in studies where participants could report their experience through anonymous computerized methods. Similarly, Plummer and Findley (2012) claimed that women with disabilities might experience a higher violence rate than women without disability, but they merely reviewed studies with female participants. Khalifeh et al. (2016) found no association between gender and physical victimization, but they found that the rate of sexual violence among females with disabilities was higher than among males. They concluded that in the general population, males experienced physical violence more than females, and females experienced sexual violence more than males. However, among AWDs, both genders reported higher rates of physical violence, and females experienced a higher rate of sexual violence than the general population. There is insufficient information about domestic violence against males with disabilities; accordingly, gender comparison is impossible. Amborski et al. (2022) stated that gender comparison of sexual violence against AWDs is impossible as many studies did not report findings by gender.

Financial Factors

Financial problems such as poverty, living in socially disadvantaged neighborhoods, homelessness, and lack of employment increase exposure to violence (Araten-Bergman & Bigby, 2020). Fettig et al. (2023) also reported low income and unemployment as risk factors for physical violence against AWDs.

Cultural and Social Factors

Prejudices and cultural stereotypes are another threat to the lives of people with disabilities. They often suffer from a stigma that damages their dignity (Araten-Bergman & Bigby, 2020; McGilloway, et al., 2020; Plummer & Findley, 2012). Isolation and low social support (Fettig et al., 2023; Plummer & Findley, 2012) are other social factors that increase the risk of violence experience.

Failure to Report Violence

A history of violence or trauma is associated with revictimization (Fettig et al., 2023). Some studies explained why AWDs might not report violence and stay in an abusive relationship. Bowen and Swift (2019) stated that 37% of AWD had never sought help. Several studies claimed that if the caregiver was also the perpetrator, it was less likely that AWDs report violence as they might fear losing their caregivers, being blamed, experiencing more violence, not being believed, or losing their freedom. The communication barrier is another factor that hinders AWDs from verbalizing the incident and making themselves understood and believed (McGilloway et al., 2020). Fear and communication barriers might create learned helplessness and acceptance of violence as part of daily life (Plummer & Findley, 2012).

Prevention and Intervention Strategies

The third research question was: What preventive/treatment strategies have been employed? Two of the 13 systematic reviews (Araten-Bergman & Bigby, 2020; Barger et al., 2009) included papers focusing on prevention studies. Only one study (Lund, 2011) reviewed prevention as well as post-violence intervention studies.

Preventive Strategies

Araten-Bergman and Bigby (2020) reviewed six papers about the effectiveness of violence prevention against people with intellectual disabilities between 2007 and 2017. Half of the prevention studies focused only on women and mainly on preventing sexual violence. The majority of programs were individualized and offered educational workshops, behavioral skills training, and psychoeducation training for women with disabilities. Increasing the quality of life of AWDs was the primary objective of these programs; however, none evaluated long-term results or actual violence prevention. None of the prevention strategies were practiced in populations with severe or profound intellectual disability. Barger et al. (2009) also reviewed four studies on sexual violence prevention for women with intellectual disabilities between 1999 and 2000. One of the programs focused on decision-making, and the results revealed the beneficial effects of the program on promoting decision-making in abusive situations. One program was supposed to affect knowledge, attitudes, and skills, yet the others did not evaluate knowledge or skills and merely assessed participants’ satisfaction with the program.

Lund, (2011) reviewed 16 papers about violence treatment intervention and prevention strategies. Training to recognize abusive settings, assertiveness skills, cognitive-based programs, psychoeducation, or leaving the situations through role-play or in situ were among the prevention strategies. Transferability of learnings to the real world, long-term effects of the programs, behavior change, and the reduction of sexual violence were not evaluated in most programs.

Post-violence Intervention

Only two papers in Lund, (2011) systematic review focused on post-violence interventions. Person-focused group therapy to discuss coping, body image, painting, sculpturing, and role play after sexual violence of AWD showed that nonverbal tasks and activities significantly reduced anxiety and depression and raised their self-esteem after sexual violence. The 3-month follow-up, however, showed increased anxiety and depression. In the second study, sexually abused adults with intellectual disability underwent solution-focused therapy. Furthermore, art-based techniques such as bodywork were included in the therapy. Both studies were limited in scope and sample size and did not focus on various violent situations.

Literature Gaps and Limitations

The fourth research question was: What are the gaps and limitations in the literature? Over 280 studies addressing violence against adult disability have been published since the 1970s, and several vital aspects of the topic have been explored; however, there are still some gaps and limitations in the studies that need further research, practice, and policy attention.

One of the limitations in the literature on disability and violence is the unequal geographical distribution of the studies. Most studies were conducted in high-income countries such as the USA, the UK, European countries, Canada, and Australia (Amborski et al., 2022; Hughes et al., 2012; Trundle et al., 2022). The information about some parts of the world is almost nonexistent in the literature. Similarly, there is less focus on rural and remote areas (Hughes et al., 2011). Regarding sampling, the majority of publications focused on AWDs from white, Caucasian backgrounds, and little information exists on diverse groups. Diversity in general seems to be not the focus of many studies. Accordingly, as mentioned in some systematic reviews, the comparison is difficult because there is little information about different types of violence for different types of disabilities or chronic conditions. When studies focused on any type of violence or a variety of disabilities, the rate of violence was higher (Alhaboby et al., 2019; Amborski et al., 2022; Hughes et al., 2011; Plummer & Findley, 2012). Violence against adults with disability in the LGBT group is almost nonexistence in the literature, and almost all studies selected a binary female/male position concerning gender, and even among them, only a few studies dealt with men with disabilities. There is also little and inconsistent information about the relationship between age, disability, and violence experience (Alhaboby et al., 2019; Fettig et al., 2023).

Data collection methods may also create some limitations. The lack of universal measures of violence and disability created difficulties for comparison studies. For example, as Amborski et al. (2022) mentioned, some studies used self-report measures to select AWDs, some others used certain diagnoses while others used utilizing assistive devices to define people with disability. Self-report of disability or violence is considered a limitation by Hughes et al. (2012) because this data collection method might exclude people with communication barriers or severe disabilities such as SMI or severe intellectual disability. When the perpetrator is also the caregiver, data collection would be difficult, and studies often failed to manage this. Another limitation is the almost exclusion of some types of disability from the literature, mainly because of communication barriers. For example, there is insufficient information about adults with sensory disability, especially from the deaf community, about their experiences of violence (Hughes et al., 2012). While there are communication barriers, less attention has been given to diverse data collection methods, such as qualitative interviews (Alhaboby et al., 2019), clinical interviews, nonverbal data collection methods, and tailored measures for different disability communities. In addition, while AWDs seem vulnerable to extra types of violence compared to the general population (Fettig et al., 2023), little data about disability-related violence is another limitation of the literature.

In risk factor studies, as Fettig et al. (2023) claimed, information about contextual risk and protective factors is scarce. Lund, (2011) and Khalifeh et al. (2016) mentioned that insufficient information exists about the consequences of violence against adult AWDs.

While prevention/treatment interventions assisted AWDs in gaining more knowledge and skills, there are a few evidence-based prevention/treatment studies, and they are mainly prevention studies that did not target diverse types of disability or violence. The majority of prevention studies focused on the prevention of sexual violence against women with intellectual disabilities, and while they showed some positive outcomes, the long-term effects of the programs were not often evaluated. The transferability of prevention strategies to the real world is not certain. The interventions are often not accessible for people with diverse disabilities, especially for the deaf community that has communication problems. The few intervention studies were not culturally or linguistically competent, which causes further difficulties in terms of accessibility. Many intervention studies had small sample sizes of individuals with specific disabilities and explored the short-term impacts of the programs. There is little data about the effectiveness of the programs in the long term and real life because there is no longitudinal prevention/treatment study (Araten-Bergman and Bigby, 2020; Barger et al., 2009; Lund, 2011).

Discussion

The current study synthesizes the results of 13 systematic reviews about violence against AWD. Four main questions were addressed: What are the types of violence against people with disabilities? What are the risk factors of violence against AWDs? What kinds of prevention/treatment strategies were employed? And what are the gaps and limitations in the literature?

Concerning the first question, persons with disabilities experience similar types of violence to the general population, including physical, sexual, emotional, and financial violence and neglect. They also experience disability-related violence, such as destroying their assistive device or medical neglect. Several studies showed that AWDs are at higher risk of victimization compared to the general population (Hughes et al., 2012; Plummer & Findley, 2012) and for some reasons such as communication barriers or dependency on the caregivers and power imbalance when the caregiver is also the perpetrator, reporting violence may be difficult. This may cause continuation of violence and revictimization (McGilloway et al., 2020). This is similar to the violence reoccurrence in the general population (Alaggia et al., 2019; Heron & Eisma, 2021); however, AWDs are at greater risk and need special attention.

The second question explored the risk factors of violence. The results revealed that demographic factors such as type and severity of the disability, gender, financial problems such as low income, homelessness, unemployment, and cultural and social issues such as stigma, social isolation, and lack of social support were among the risk factors of violence against AWDs. The majority of these factors are similar to the general population; for example, there is a link between low income, unemployment, homelessness, and victimization in the general population (Tertilt & van den Berg, 2015). There is also a link between social stigma against people from minority groups and violence experienced in the general population (Herek, 2009). However, it seems that AWDs often suffer from the intersectionality of disability, financial issues, social isolation, and stigma that place them at risk of violence. Gender as an influential factor of victimization revealed inconsistent findings. While some studies showed that women with disabilities are at greater risk of violence than the general population, in-group comparisons between men and women with disabilities presented inconsistent results.

As mentioned above, people with disabilities might be dependent on their caregivers to meet their daily needs. This level of dependence can be a risk factor, especially when the perpetrator is also the caregiver. This is also similar to literature about child abuse when a child is entirely dependent on their caregiver (Alaggia et al., 2019). The same was found in literature about domestic violence and the unresolved question of why women stay in abusive relationships (Heron & Eisma, 2021). In addition to the common reasons people stay in an abusive relationship, such as learned helplessness, some AWDs have extra reasons, such as dependency on caregivers to save their lives at home or institutional settings. For some types of disabilities, such as hearing difficulties, SMI, or intellectual disabilities, even if there is a willingness to disclose the violent situation, communication barriers may create fear of misinterpretation leading to more violence and freedom restriction (McGilloway et al., 2020).

The third question focused on prevention/treatment strategies. There are various programs to prevent violence against people with disabilities with positive and promising results. Programs that use nonverbal techniques to teach skills and knowledge about preventing sexual violence situations seem to work best for people with intellectual disability. The same was found in other studies with people with intellectual disability who responded better when speaking and verbal interaction were not required by the program (Bailey, 2015). The reviewed prevention and treatment strategies had some limitations that need further research. Gaps and limitations discussed in systematic reviews were explored, and the following implications are suggested based on the literature gaps.

Limitation

We faced some limitations in our overview of systematic review. Focusing on English-only studies limits our findings and conclusions on the available data in English and there might be studies in other languages with important results that we did not review. Registration will provide a public record of the planned methodologies, preventing deviations from the proposed analysis and ensuring a transparent research process; however, we did not register this study on the respected websites.

Conclusion: Implications of the Review for Practice, Policy, and Research

Findings could be used by professionals and policymakers to develop research and strategies to monitor the prevalence of violence against AWDs and respond to it by creating prevention and therapeutic interventions for caregivers at home and in institutional settings, for other professionals in the fields as well as AWD. There are some recommendations to address the literature gaps mentioned above. Future research should address violence among people with various disabilities and chronic conditions and focus on hard-to-reach populations such as people with severe disabilities or communication problems. Researchers should also expand the geographical coverage of the studies and add rural and remote areas. There is a need for studies to focus on the intersectionality of violence, subgroup disabilities and severity, gender, race, ethnicity, and socioeconomic status. The need for a universal definition of violence and disability is addressed in some studies. Conducting comparison studies will be difficult without having agreed-upon definitions and measurements. Considering the increasing application of artificial intelligence, the Internet, and social media, more studies need to be conducted on the cybervictimization of AWDs.

While quantitative studies are of high importance, future research should focus on qualitative methodology exploring personal experiences of violence against AWD in general and also populations that are already underrepresented such as adults with disability who belong to the LGBT community or in rural settings. Such groups often have small sample sizes, which is not sufficient for quantitative studies. Similarly, measures and data collection methods should be tailored based on the types of disabilities and participants’ cultural and linguistic specifications. There is also a significant gap in violence prevention and treatment strategies for AWD. Developing culturally and linguistically competent interventions to prevent violence or treat affected people is a critical global need. In addition, longitudinal studies are needed to find the actual effect of interventions in the real world.

Critical Findings.

1. Adults with disability experience abuse/violence at a higher rate than the general population.
2. Adults with disability experience common types of abuse/violence such as physical, sexual, and emotional abuse/neglect. They also experience disability-related abuse such as medical neglect, damaging assistive device, and restrictive access to assistive devices, and cybervictimization.
3. Risk factors for abuse/violence against adults with disability include demographic factors (e.g., types and severity of disability); financial factors (e.g., poverty, living in a disadvantaged neighborhood, homelessness, unemployment); cultural and social factors (e.g., stigma, isolation, and lack of social support); and failure to report abuse/violence due to communication difficulties and fear of not being believed or supported, or losing support when the abuser is also the caregiver.
4. There are some prevention programs mainly for preventing sexual abuse against women with intellectual disabilities.
5. Treatment programs to increase abuse consequences are mentioned in only two studies out of over 200 studies.
6. Diversity is a neglected issue in the literature on disability and abuse.
7. Low attention to geographical diversity: The majority of studies are conducted in high-income countries such as the USA, the UK, European countries, Australia and Canada.
8. Low attention to Demographic diversity: The majority of studies focused on a binary definition of gender as female/male and less attention has been given to other gender identification as well as the LGBT community.
9. Low attention to Demographic diversity: The majority of studies focused on the adult population with disability from white, Caucasian backgrounds.

Implications of the Review for Practice, Policy, and Research.

1. There is a need to expand access to hard-to-reach populations and diverse populations with disability with a more diverse geographical coverage of studies.
2. There is a need to develop data collection methods that are tailored to a variety of disabilities with different severity.
3. Researchers and policymakers should consider the intersectionality of abuse/violence with subgroup disabilities with different severity, gender identification and sexual orientation diversity, race/ethnicity, and socioeconomic status.
4. There should be more attention to cybersecurity and cybervictimization of adults with disabilities especially for adults with communication difficulties (e.g., people with hearing impairment or autism spectrum disorder).
5. Prevention and treatment programs should be developed with attention to types of disability, cultural, and linguistic backgrounds.

Footnotes

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Azam Naghavi

Author Biographies

Samira Sadat Badakhshiyan is a PhD candidate in the field of counseling in the Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran. She holds an MA in Rehabilitation Counseling and in the last 5 years has been working with people with disabilities.

Azam Naghavi is an Associate Professor in the Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran. She received her PhD from Monash University, Australia. Since 2015, she has run the MA program in Rehabilitation Counseling in this department and since then has worked extensively on disability studies.

Rezvan Alsadat Jazayeri is an Associate Professor in the Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran. She has worked on the area of abuse and violence in the last 20 years.

References

Alaggia

Collin-Vézina

Lateef

(2019). Facilitators and barriers to child sexual abuse (CSA) disclosures: A research update (2000–2016). Trauma, Violence, & Abuse, 20(2), 260–283. https://doi.org/10.1177/1524838017697312

*Alhaboby

Z. A.

Barnes

Evans

Short

(2019). Cyber-victimization of people with chronic conditions and disabilities: A systematic review of scope and impact. Trauma, Violence, & Abuse, 20(3), 398–415. https://doi.org/10.1177/1524838017717743

*Amborski

Bussieres

E. L.

Vaillancourt-Morel

M. P.

Joyal

C. C.

(2022). Sexual violence against persons with disabilities: A meta-analysis. Trauma, Violence, & Abuse, 23(4), 1330–1343. https://doi.org/10.1177/1524838021995975

*Araten-Bergman

Bigby

(2020). Violence prevention strategies for people with intellectual disabilities: A scoping review. Australian Social Work, 76(1), 1–16. https://doi.org/10.1080/0312407X.2020.1777315

Bailey

(2015). Art therapy and developmental disabilities. In Gussak

Rosal

M. L.

The Wiley handbook of art therapy. (pp. 317–328).Wiley Online Library.

*Barger

Wacker

Macy

Parish

(2009). Sexual assault prevention for women with intellectual disabilities: A critical review of the evidence. Intellectual and Developmental Disabilities, 47(4), 249–262. https://doi.org/10.1352/1934-9556-47.4.249

*Bowen

Swift

(2019). The prevalence and correlates of partner violence used and experienced by adults with intellectual disabilities: A systematic review and call to action. Trauma, Violence, & Abuse, 20(5), 693–705. https://doi.org/10.1177/1524838017728707

Braun

Clarke

(2022). Thematic analysis. A practical guide. SAGE.

Cadwallader

J. R.

Spivakovsky

Steele

Wadiwel

(2018). Institutional violence against people with disability: Recent legal and political developments. Current Issues in Criminal Justice, 29(3), 259–272. https://doi.org/10.1080/10345329.2018.12036101

10.

Ferrari

(2015). Writing narrative-styles. Medical Writing, 24(4), 230–235.

11.

*Fettig

Mitchell

Gassoumis

Nizam

Whittier Eliason

Cory

(2023). Adult maltreatment risk factors: Adding community-level factors to an individual-level field. Trauma, Violence, & Abuse, 25(1), 5–12. https://doi.org/10.1177/15248380221137659

12.

Herek

G. M.

(2009). Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample. Journal of Interpersonal Violence, 24(1), 54–74. https://doi.org/10.1177/0886260508316477

13.

Heron

R. L.

Eisma

M. C.

(2021). Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research. Health & Social Care in the Community, 29(3), 612–630. https://doi.org/10.1111/hsc.13282

14.

Higgins

J. P.

Thomas

Chandler

Cumpston

Page

Welch

V. A.

(2019). Cochrane handbook for systematic reviews of interventions. WileyBlackwell.

15.

*Hughes

R. B.

Lund

E. M.

Gabrielli

Powers

L. E.

Curry

M. A.

(2011). Prevalence of interpersonal violence against community-living adults with disabilities: A literature review. Rehabilitation Psychology, 56(4), 302. https://doi.org/10.1037/a0025620

16.

*Hughes

Bellis

M. A.

Jones

Wood

Bates

Eckley

Officer

(2012). Prevalence and risk of violence against adults with disabilities: A systematic review and meta-analysis of observational studies. The Lancet, 379(9826), 1621–1629. https://doi.org/10.1016/S0140-6736(11)61851-5

17.

*Khalifeh

Oram

Osborn

Howard

L. M.

Johnson

(2016). Recent physical and sexual violence against adults with severe mental illness: A systematic review and meta-analysis. International Review of Psychiatry, 28(5), 433–451. https://doi.org/10.1080/09540261.2016.1223608

18.

*Lund

E. M.

(2011). Community-based services and interventions for adults with disabilities who have experienced interpersonal violence: A review of the literature. Trauma, Violence, & Abuse, 12(4), 171–182. https://doi.org/10.1177/1524838011416377

19.

*McGilloway

Smith

Galvin

(2020). Barriers faced by adults with intellectual disabilities who experience sexual assault: A systematic review and meta-synthesis. Journal of Applied Research in Intellectual Disabilities, 33(1), 51–66. https://doi.org/10.1111/jar.12445

20.

Meyer

S. R.

Stöckl

Vorfeld

Kamenov

García-Moreno

(2022). A scoping review of measurement of violence against women and disability. PLoS One, 17(1), e0263020. https://doi.org/10.1371/journal.pone.0263020

21.

Moher

Liberati

Tetzlaff

Altman

D. G

(2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

22.

*Plummer

S. B.

Findley

P. A.

(2012). Women with disabilities’ experience with physical and sexual abuse: Review of the literature and implications for the field. Trauma, Violence, & Abuse, 13(1), 15–29. https://doi.org/10.1177/1524838011426014

23.

Shea

B. J.

Reeves

B. C.

Wells

Thuku

Hamel

Moran

Moher

Tugwell

Wlech Welch

Kristjansson

Henry

D. A.

(2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, 358, j4008. https://doi.org/10.1136/bmj.j4008

24.

Tertilt

van den Berg

G. J

(2015). The association between own unemployment and violence victimization among female youths. Jahrbücher für Nationalökonomie und Statistik, 235(4–5), 499–516. https://doi.org/10.1515/jbnst-2015-4-510

25.

*Trundle

Jones

K. A.

Ropar

Egan

(2022). Prevalence of victimization in autistic individuals: A systematic review and meta-analysis. Trauma, Violence, & Abuse, 24(4), 2282–2296. https://doi.org/10.1177/15248380221093689

26.

World Health Organization. (2022). World Health Organization Violence Prevention Unit: Approach, Objectives and Activities, 2022–2026. https://cdn.who.int/media/docs/default-source/documents/social-determinants-of-health/who_2022_plv_strategy_2022-2026_finalfile.pdf?sfvrsn=c819ff54_3&download=true