Elder Abuse in Singapore

What Can We Do?

This article deals with elder abuse in Singapore, and suggests some ways forward in tackling the issue.

A Workgroup on Elder Suicide Prevention in Singapore was established in April 2002. It brought together a total of 19 stakeholder-organisations, including the government, voluntary welfare organisations, social organisations, as well as individuals.

Is there a need to deal with elder abuse differently from other types of crimes or social phenomena? The answer is ‘yes’, for three reasons.

First, within the context of the family, we already differentiate crimes against two vulnerable categories, namely, children and women. Another vulnerable category is older adults. Second, they have special needs. Third, the consequences of abuse on older adults can be devastating. They have less physical reserves with which to recover and bounce back. Once down, they may stay down. Older adults are more prone to depression, which is aggravated when they suffer abuse. Furthermore, older adults have their working years behind them, so that recovery from financial abuse is often impossible.

Victims of elder abuse may lose faith in people and become distrustful and fearful. They may never enjoy their ‘golden years’ that society proclaims is their due and for which they have worked hard.

As we age — and we are a fast ageing population in Singapore — a small but significant minority of the very old and venerable adults will become frail of body or mind. Their frailty will cause them to be dependent on others, physically, financially or psychologically. Some will be unable to take care of themselves and to handle their own affairs. This minority is vulnerable to abuse. And they can be found in families, institutions (such as nursing homes and hospices), and elsewhere in the community.

The Workgroup builds on precedents. In September 1999, the Ministry of Community Development and Sports (‘the MCDS’) published an ‘Integrated Management of Family Violence Cases in Singapore Manual’. In 1999, after the deliberations of two Inter-Ministerial Committees, comprising many Workgroups, the government released two Reports, the first on ‘Health Care of the Elderly’, and the second on ‘The Ageing Population’. In February 2001, the MCDS produced a ‘Manual For Professionals & Service Providers Working with Children’. In late 1999, Mrs Helen Ko, then Director of the Singapore Action Group for Elders (‘SAGE’) Counselling Centre, established a ‘GoldenLife’ Workgroup comprising 14 agencies, that in August 2001 released its ‘Elderly Suicide in Singapore, Management and Intervention Training Manual’. It also organised public education and intervention programmes. This Workgroup serves as a model, and the Elder Abuse Workgroup also uses the ‘GoldenLife’ name.

Definitions of Elder Abuse

The Elder Abuse Workgroup and its five committees are currently examining what constitutes elder abuse in the Singapore context. They have not concluded their discussions.

In 1986, an expert conference in the United States ended in ‘definitional disarray’ and found ‘no generally accepted definitions of elder abuse and neglect’.¹ Commenting on the situation, Frank Glendenning wrote in 1997, ‘A clear difficulty has been that investigators have approached elder abuse from different perspectives: the victim, the carer, the physician, the nurse, the agency, the social worker, social policy; and, as a result, there has been a lack of clarity’.²

The Workgroup, however, can look for guidance from the Report of the UN Secretary-General dated January 2002, entitled ‘Abuse of Older Persons: Recognising and Responding to Abuse of Older Persons in a Global Context’,³ which was presented at the Second World Assembly on Ageing. After noting the absence of an accepted universal definition, the Report tends towards this:

A single or repeated act, or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.

The Report highlights four categories of elder abuse: physical abuse, emotional or psychological abuse, financial exploitation and neglect. It also refers to self-neglect — ‘a set of behaviours that threaten the health or safety of an older person’, as well as about a dozen other types of elder abuse.

Prevalence and Causes of Elder Abuse

Assuming that the Workgroup comes up with a definition of elder abuse, how prevalent is the problem?

Two Singapore doctors, WM Cham and E Seow, tell us, ‘A Medline search from 1966 to 1999 for local data revealed six articles dealing with child abuse, four on spousal violence and two on family violence in general, but none had any data on elderly abuse’.⁴ They examined the records of elderly (65 years and above) attendances at the Emergency Department in Tan Tock Seng Hospital from May 1994 to December 1997. Commenting on their article, geriatrician Pang Weng Sun observed in 2000, ‘Elder abuse is seldom reported, and even less so in an Asian society where filial piety and respect for the elderly is traditionally highly regarded. ... the relatively low figure of 17 cases of elder abuse out of 62,826 elderly attendances at the Emergency Department is likely to be the tip of the iceberg’.⁵

We can examine that iceberg by mounting a scientific survey of our population. That, however, would require manpower, resources and sensitivity. Another way is to use focus groups. Doctors, nurses, medical social workers, police officers, counsellors, community workers — basically people who are likely to encounter elder abuse — can be tapped for knowledge on the prevalence of the problem. They can also be approached for their views on the causes of elder abuse.

But we still need some hard data.

The Law and Elder Abuse

There are no laws specifically addressing elder abuse as such. Nevertheless, there are some laws which help in dealing with elder abuse.

First, the provisions in the Penal Code (Cap 224) that pertain to ‘causing hurt’, ‘wrongful restraint’, ‘wrongful confinement’, and rape can be invoked to protect older adults who suffer physical and sexual abuse. Provisions that pertain to theft, extortion, and criminal breach of trust can protect older adults who suffer financial abuse.

The second provision is the Women’s Charter (Cap 353) (‘the Charter’), which was introduced in 1961 to ‘protect the rights of women and family members’. It was amended in 1997 to deal with ‘family violence’. Its scope was expanded in three ways so that the Charter applies to older adults. One, it included the parents and parents-in-law of the person (perpetrator). These parents are often older adults. Two, it went beyond physical violence, so that older adults can be protected against psychological or emotional abuse. The Charter is directed against perpetrators who seek to put them ‘in fear of hurt’, ‘wrongfully confining or restraining’, and ‘causing continual harassment with intent to cause, or knowing that it is likely to cause, anguish to family members’. Three, it added teeth by providing for the Protection Order (‘PO’). Even third parties can apply for a PO on behalf of incapacitated adults and children. This provision can be invoked to protect older adults against physical abuse.

The third law is the Maintenance of Parents Act of 1996, which provides for parents to file a complaint against their children for their maintenance. Thus, older adults who suffer financial neglect have some form of redress.

What Can We Do About Elder Abuse?

Public education

A racist society discriminates against some members of society on account of their race. A sexist society discriminates against women on account of their sex. In a more just and equal society, we condone neither.

An ageist society discriminates against the old. Is there ageism in Singapore? Ageism can breed elder abuse. Through public education, we can reduce, if not, eliminate, ageism. When elder abuse has been defined and surfaces, we should have zero tolerance for it.

Legislation

We can ask what laws other countries have to deal with elder abuse. There are two laws that we might consider. Both have advantages and disadvantages. One law is for an Adult Protective Service (‘APS’), for vulnerable older adults. The APS is characterised by special legally mandated powers of investigation, intervention, and mandatory reporting. An APS worker would assess whether an older adult is at risk of abuse or neglect and deliver the required services. Under certain circumstances, the APS worker can even intervene without the older adult’s consent. Among the people who are mandated to report elder abuse are health practitioners, police officers and social service workers.

The second law is Guardianship. The court could declare an older adult to be incompetent on grounds of mental incapacity. The court entrusts his care to a Guardian who is appointed by the court. There are three types of guardianship: personal (affecting his person), plenary (affecting a whole range of matters) and limited (affecting specific matters).

In some countries, a person gives instructions, in advance, as to what he wants done for him at some future date when he can no longer make decisions. He executes an Enduring Power of Attorney (‘EPA’), which deals with his property, and a Living Will, which deals with his person.

In Singapore, the Advance Medical Directive (‘AMD’), passed in 1997, addresses such issues. We ought to ask whether this is adequate or more needs to be done.

Social services

While legislation is more interventionist, the provision of social services is less obtrusive. One way is to provide social services to both parties in a case of elder abuse. This is based on the view that elder abuse is often attributed to stress, and that the parties involved may continue to live together. The two parties are separated for a cooling-off period. Then the older adult is assisted to become less dependent on the carer, through training in self-care, and to have greater knowledge of resources available, and to increase the number of social contacts. The carer can be supported in his responsibility by home nursing and other services, by skills training, financial and counselling, and by participation in support groups.

Another form of support is a variation of the first, by providing social services through case management. This is based on the view that few carers and fewer older adults know enough about the services available and how to access them. This is where the Case Manager comes in, to manage the older adults’ needs by sourcing for required services from service providers.

But what about the recalcitrant carer? Can we provide the abused older adult with alternative accommodation? Do we have sufficient nursing and residential homes for this? How long can he stay? How do we ensure that elder abuse does not occur in these institutions? There are four crisis shelters for elders in Singapore, but they normally only accommodate an abused elder for up to three months. If the abused older adult is financially dependent on the perpetrator, can we finance his needs? If we can’t, and the older adult has to return to live with the perpetrator, and to depend on him financially, can we say that the older adult is better off because we intervened? Or is the older adult, in fact, worse off?

Thus, we need to have appropriate social services in place so that we can intervene.

Abridgement of Rights

Earlier we referred to self-neglect. It is a form of risk, not abuse, for an older adult. Self-neglect may lead to the abridgement of his rights, even though it may be done with the best of intentions. Suppose there is an older adult who does not care for himself, lives in unsanitary conditions, and neglects to take the necessary medication. Does he have the right to live his preferred lifestyle, perhaps at risk to himself? Or does the state have the right to do for him what he does not do for himself? If his preferred lifestyle puts the older adult’s neighbours at risk, does the state have the right to intervene? If the older adult is not mentally able to make decisions, should the state make them for him?

Where do we draw the line to balance the rights of an older adult and the responsibility of the state to this older adult and to society as a whole?

Conclusion

We should be cognisant of, and be sensitive to, the fact that the largest majority of carers of older adults are their family members, most of whom provide care at great sacrifice to themselves and the rest of the family. These carers must also be protected. It is the small minority of unfortunate, venerable and vulnerable older adults, who are abused, and who need our protection.

It is said that in life we can be sure of only two things: death and taxes. If we are fortunate, we can be sure of a third, namely, old age. If we can keep elder abuse at bay, older adults WILL enjoy their ‘Golden Years’.

Chiang Hai Ding
Director, SAGE Counselling Centre

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