Practices Used in Health and Social Services for the Management of Mistreatment Situations towards Adults in a Context of Gender and Sexual Diversity: A Scoping Review

Mélanie Couture ^1,2,*, Julien Gauthier-Mongeon ², Pearce Simamonika ², Rosalie Bernard ¹, Kevin St-Martin ¹, Rosalie Lacasse ¹, Sarita Israel ²

1. Research Chair on Mistreatment of Older Adults – Université de Sherbrooke, 2500, Université Blvd, Sherbrooke, Québec, Canada

2. Center for Research and Expertise in Social Gerontology – Integrated University Health Center and Social Services (CIUSSS) of West-Central Montreal, 5800, Cavendish Blvd, Côte Saint-Luc, Québec, Canada

* Correspondence: Mélanie Couture

Academic Editors: Gloria Gutman, Jennifer Marchbank and Claire Robson

Special Issue: Elder Abuse in the LGBT Community: A Hidden Problem

Received: December 18, 2023 | Accepted: July 11, 2024 | Published: July 17, 2024

OBM Geriatrics 2024, Volume 8, Issue 3, doi:10.21926/obm.geriatr.2403282

Recommended citation: Couture M, Gauthier-Mongeon J, Simamonika P, Bernard R, St-Martin K, Lacasse R, Israel S. Practices Used in Health and Social Services for the Management of Mistreatment Situations towards Adults in a Context of Gender and Sexual Diversity : A Scoping Review. OBM Geriatrics 2024; 8(3): 282; doi:10.21926/obm.geriatr.2403282.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

1.1 Mistreatment Situations in the Context of Gender and Sexual Diversity (GSD)

Older adult mistreatment is an important public health issue and is described as: “a single or repeated act or lack of appropriate action occurring within any relationship in which there is an expectation of trust that causes harm or distress to an older person” [1]. Mistreatment can be perpetrated by different types of people (spouses, family members, friends, care providers, etc.) and can occur in various contexts (at home, in residential care, in hospitals, etc.). In recent years, many jurisdictions around the world have broadened their commitment to counter mistreatment by also addressing this problem in adults in vulnerable situations. For example, with this population in mind, the national assembly of the province of Quebec (Canada) adopted law 6.3, the “Act to Combat Maltreatment of Seniors and Other Persons of Full Age in Vulnerable Situations” in 2017 (https://www.legisquebec.gouv.qc.ca/en/document/cs/L-6.3). It is estimated that - 14 to 16 percent of older adults living in the community experience mistreatment [2,3]. In institutional settings, more than three out of five staff members admit to having mistreated residents in the last year. While other forms of staff-to-resident mistreatment are also common, psychological mistreatment is the most often experienced by residents, with one in three residents reporting it [4].

Unfortunately, studies have shown that adults in the context of gender and sexual diversity (GSD) are more likely to experience violence and discrimination than the rest of the population [5,6]. GSD refers to all the diversities of sexual characteristics, sexual orientations and gender identity of a person or a group. Adults within a context of gender and sexuality diversity include, but are not limited to, lesbian, gay, bisexual, and trans (LGBT) as well as queer, intersex, asexual and aromantic, two-spirited, and pansexual people. For instance, LGBT people are nearly four times more likely to be victims of violent crime than non-LGBT people [7]. The prevalence of intimate partner violence (IPV) between gays and bisexual men is reported to be equal or higher than for heterosexual women [8].

In addition, the health and social services system in charge of managing mistreatment situations can also mistreat people of GSD. For example, care providers can have biased opinions about the person’s biology, gender or sexual orientation that can lead to wrong assumptions and discriminatory attitudes and practices toward the person. The individual in turn will feel mistreated which could result in the reluctance to seek help [9,10]. These forms of mistreatment undermine trust in the system and divert people from health and social services [11,12,13]. Consequently, it is crucial to describe practices used in health and social services for the management of mistreatment situations involving adults in a context of GSD to improve quality of services. The term GSD is used in this article as it is more inclusive than LGBT as it encompasses all the diversities of sex characteristics, sexual orientations, and gender identities, without the need to specify each of them [14].

1.2 Management of Mistreatment Situations in Health and Social Services

Health and social services institutions are greatly involved in the management of mistreatment situations. Most adults who are mistreated are already clients of this system [15], which places care providers in a privileged position to detect and respond accordingly. However, lack of knowledge on mistreatment and lack of training hinder detection [16,17]. Furthermore, many care providers report feeling uncertain about how to respond [18]. Institutions must therefore ensure that professionals in health and social services are trained appropriately on how to detect and manage mistreatment situation.

According to the Model for the Management of Older Adult Mistreatment Situations, an evidence-based Canadian conceptual model implemented in Quebec’s institutional policies and trainings to counter mistreatment, five main care events are important for responding to mistreatment situations: identification, reporting, needs assessment, investigation, and intervention [19]. Care events are steps or activities accomplished within the continuum of care [20]. The management process starts with identifying potential mistreatment situations using screening instruments and/or clinical judgment to analyze risk factors, signs, and indicators of mistreatment. Harden et al. (2020) [21] noted a lack of framework for identifying violence in the context of same-sex relationships, thus contributing to the invisibility of the violence experienced by these populations. Once the (suspected or confirmed) situation of mistreatment is identified, it can be reported to the proper authorities according to the legal framework, including mandatory reporting, if applicable [19]. An investigation process can be undertaken to determine whether mistreatment has occurred or not by thoroughly collecting and analyzing data regarding the mistreatment situation. Also, an in-depth assessment of the person’s needs and capacities in an interdisciplinary manner is necessary to provide a clear and complete portrait of the situation that will enable professionals to develop a personalized and adequate intervention plan [22,23]. Interventions encompass any activity undertaken or services offered (including referrals) with the objective of lessening the consequences of the mistreatment, reducing the risks of reoccurrence and, if possible, resolving the mistreatment situation [19]. Follow-ups should be planned to ensure the situation is under control.

1.3 Existing Reviews

To our knowledge, most existing reviews synthesize data regarding manifestations of mistreatment situations in the context of GSD, but not how to manage them. Some reviews explore mistreatment within health and social services [11,12,24,25,26,27] and the barriers to accessing these services [26,28,29,30,31,32]. Other reviews [33,34,35,36,37,38] describe the lack of knowledge and training needs of care providers regarding the realities of GSD communities and/or look at ways of adapting practices to their specific needs [9,36,39,40,41,42]. Finally, a recent review by West et al. [43] explored continuing nursing education actions regarding homophobia and concluded that these types of initiatives can successfully raise awareness.

To our knowledge, only two existing reviews explored interventions to manage mistreatment situations in the context of GSD. A systematic review by Layland and colleagues [44] examined 37 behavioral and psychological interventions aiming to reduce stigma in GSD populations. Most interventions identified were for sexual minority men and targeted proximal stressors, including internalized and anticipated stigma. Subirana-Malaret and colleagues [45] examined IPV treatment programs for LGBT couples and found no studies describing programs for sexual orientation and gender-minoritized populations. These two reviews only looked at two specific forms of mistreatment, namely stigma and IPV. It is still unclear how other types of mistreatment situations are managed within health and social services. This scoping review aimed to 1) describe how people working in health and social services manage mistreatment situations in the context of GSD; and 2) map existing evidence to inform on knowledge gaps and priorities for future research.

2. Materials and Methods

2.1 Design

A scoping review is a systematic approach used to map the available evidence on a topic in which key concepts and knowledge gaps are identified. Scoping reviews are more exploratory and address broader issues than systematic reviews, which are used to synthesize research findings to inform practice and policy [46]. For this scoping review, the study design is informed by the 2015 Johanna Briggs Institute manual, which provides recommendations for conducting a scoping review [47]. In addition, data will be reported using the PRISMA-ScR guidelines [48].

We searched for studies describing practices used by people working in health and social services to manage situations of mistreatment in the context of gender and sexuality diversity (GSD) in adults. These individuals can be employees as well as administrators. This scoping review is structured as follows [47]:

1. Identifying the research question
2. Identifying relevant studies
3. Study selection
4. Charting the data
5. Collating, summarizing, and reporting the results

This review did not involve the participation of humans, animals, plants, or subjects, and thus, no ethical approval was required.

2.2 Identifying the Research Question

The following question was used in the present scoping review: “What are the practices used in health and social services described in the scientific literature regarding the management of mistreatment situations in adults within the context of GSD?”. To define the research question of this scoping review, the population, concept, and context acronym were used (see Table 1).

Table 1 PCC acronym used to define the eligibility of the primary research question for this review.

2.3 Identifying Relevant Studies

Preplanned comprehensive search strategies were developed and tested by the two first authors (MC and JGM), the last author (SI) and reviewed by an information scientist. Because the information scientist and one of the authors (MC) had worked on other reviews regarding GSD [40] and mistreatment, most of the key words had already been identified and tested. The strategies were designed to search eight databases (MEDLINE, PsycInfo, CINAHL, Social Sciences Abstracts, LGBT life, Gender studies, Érudit and Cairn) for all studies published in French and English. Keywords were in both languages. The search was based on keywords related to mistreatment (e.g., neglect, discrimination), GSD (e.g., lesbian, gay, trans*), health and social services (e.g., long-term care, hospital, home care) and management (e.g., support, assistance, report, reveal). EndNote X9 reference software manager was used to compile all relevant references. An example of search strategies using the keywords are included in Appendix 1 at the end. The literature search was first conducted until December 21st, 2021. It was updated in early 2024 by the same information scientist to include published papers up to March 18^th, 2024.

2.4 Study Selection and Eligibility Criteria

The eligibility criteria for the articles are presented in Table 2. Prior to the evaluation process, two authors tested the applicability of these criteria on 10 percent of all selected publications.

Table 2 Eligibility criteria.

In total, 2139 references have been retrieved at the end of the initial search. After the removal of duplicates, titles, and abstracts of all 1347 remaining references were screened independently by two authors based on inclusion criteria. Then, the full texts of the 73 remaining references were read integrally and assessed independently by two authors using the same criteria. All disagreements between reviewers were resolved by consensus or by consulting a third author. Sixteen articles were excluded based on exclusion criteria 1, 42 were excluded based on exclusion criteria 2, one according to criteria 3 and 2 according to criteria 4. Finally, twelve studies were included in the scoping review. The PRISMA [48] flowchart was adopted for reporting screening results (see Figure 1) to ensure transparency and replicability of the process.

Figure 1 The flowchart of the identification and the selection processes.

2.5 Charting Data

An extraction form inspired by Noyes and Popay [49] was used to identify the characteristics of the studies and relevant results regarding the management of mistreatment situations. As recommended by the JBI Reviewer’s manual, the extraction form includes the following information: 1) author’s name, 2) year of publication, 3) country, 4) aims/purpose, 5) respondents 6) methods, 7) key findings. The charting form was tested, reviewed, and discussed by the research team prior to the implementation to ensure comprehensiveness and completeness. For each study, an extraction form was filled out independently by two reviewers (third and fourth authors). Their forms were combined by the first author to obtain a final version.

2.6 Collating, Summarizing and Reporting Results

The extracted data were collated and analyzed using a descriptive method [50]. The results are presented in an aggregate and visual form (e. g. using tables and charts as appropriate) and in a descriptive format that aligns with the objective of the review. The descriptive format consists of a presentation of broad themes that describe the strategies used to manage situations of mistreatment in the context of GSD. Consistent with our theoretical framework, references will be grouped according to the key care event to which they refer, i.e., strategies used for identification, reporting, investigation, needs assessment, and interventions [19]. As recommended by Levac and colleagues [50] (2010), the authors will discuss the implications of the findings on future research, practice, and policy.

3. Results

3.1 Characteristics of the Studies

A summary of the twelve studies included in this scoping review is provided in Table 3. Studies were almost all conducted in North America including eight in the United States [51,52,53,54,55,56,57,58] and three in Canada [10,59,60]. Only one European study was found, from Serbia [61]. Studies were published between 2006 and 2024 with only three of them published before 2015. Three types of mistreatments in the context of GSD were addressed in the selected references: intimate partner violence (IPV) [51,54,55], discrimination [10,52,53,56,57,58,61] and sexual assaults [59,60].

Table 3 Summary of the studies included.

Participants in included studies (n = 368) were either adults in the context of GSD (n = 180) or service providers (n = 188). No studies specifically aimed at obtaining the perspectives of older adults. Seven studies included the perspectives of individuals representing GSD such as LGBTQ+ people [57], sexual minority men [52,53], transgender and non-binary (TGNB) people [55,58,61] and LGBT people living with depression [10]. It must be noted that some studies specifically included members of the Latino population in the United States [52,58] and HIV positive individuals [52,53]. Six studies described the perspectives of service providers working in queer-allied organizations that offer IPV services [51,54], community organizations and sexual assault/domestic violence treatment centers [59,60], as well as organizations providing services for Transgender and Gender Non Conforming (TGNC) community members [56].

Many studies used a qualitative design that collected data using individual interviews to have a better understanding of the perspectives of either care providers or adults in a context of GSD. Only three studies evaluated interventions to manage mistreatment situations, and none used a comparison group. Bogart and colleagues [52] assessed a cognitive behavior therapy group intervention to cope with discrimination using a community-based participatory research design to assess anticipated acceptability and a single-arm process evaluation (pre-post design without control) to assess acceptability, feasibility, and preliminary effects of the intervention. Hellmuth and colleagues [55] used a single case study design to examine the effects of partial hospital alcohol treatment on alcohol consumption and IPV in one gay couple. Finally, Ross and colleagues (2007) [10] tested using an experimental uncontrolled intervention trial a cognitive behavioral therapy-based group intervention for LGBT people living with depression based on anti-oppression principles.

3.2 Practices Used in Health and Social Services for the Management of Mistreatment Situations

Synthesis of the data revealed that identified studies describing practices in health and social services only presented data on two care events to manage mistreatment situations in context of GSD: identification of mistreatment situations and interventions. None of the studies directly addressed reporting, needs assessment or investigation of mistreatment situations. See Table 4 for examples of practices used.

Table 4 Examples of identified practices in health and social services for the management of mistreatment situations.

3.2.1 Identification of Mistreatment Situations

Only two studies comprised data regarding how to better identify mistreatment situations in the context of GSD. More specifically, Bermea and colleagues [51] and Helfrich & Simpson [54] called for a better understanding of queer IPV by care providers. Some care providers in the study by Bermea and colleagues [51] explained that it is important to understand queer IPV to be able to better identify this type of mistreatment as it is mostly conceptualized as a dynamic that can be found in heterosexual couples. In addition, the more “masculine” person in same-sex couples may be more easily perceived as the perpetrator even if this is not the case [51] (Bermea et al., 2019), thus attributing the role of the victim to the more “feminine” partner. Furthermore, care providers in Helfrich & Simpson [54] study called for identification tools that help to understand who the perpetrator is and who is being mistreated without reference to gender. This type of tool should be implemented in an environment where care providers receive education to develop cultural competency about lesbian culture.

3.2.2 Interventions for Mistreatment Situations

Identified studies in this scoping review collected perspectives of care providers or people of GSD on how to improve interventions to manage discrimination [53,56,57,58,61], IPV [51,54] or sexual assaults [59,60]; or evaluated the preliminary effects of an intervention [10,52,55]. Overall, data synthesis produced six main themes regarding interventions to manage mistreatment situations: recognizing the impact of prior stigma and discrimination on help-seeking behaviors and use of services; implementing an intersectional approach; addressing risk factors; providing psychological support; and fostering advocacy.

3.3 Recognizing the Impact of Prior Stigma and Discrimination on Help-Seeking Behaviors and Use of Services

In Bermea and colleagues [51], it is highlighted that actions should be put in place to consider the unique experiences of this population and acknowledge prior difficulties encountered in other organizations. The health and social services system can induce fear if stigma has been experienced in this environment [56]. In fact, people of GSD can find it hard to trust care providers and may try to conceal information including their gender identity [56]. As Vidić & Bilic [61] report, members of a self-help group for TGNB persons shared knowledge about how to present themselves to medical authorities to successfully access services such as gender-affirming surgery as it must be approved by a psychiatrist. Having to fit the “performance” expected by those who have the power to make decisions. Participants also discuss having to educate professionals in health and social services about GSD as they are trying to get the services they need, and this results in a feeling of being used by the system [61].

As stated in Holt and colleagues [56], the relationship with the client must be gender-affirming to avoid further complicating mental health issues. As a one care provider states, “ensuring we’re attending to... queer as an identity and stressors of being queer in a heteronormative world.” [51] (Bermea et al., 2019; p.535). Transgender participants in Rhodes and colleagues [58] suggested that “the stigma associated with being transgender affected sexual health and required more understanding, appreciation and sensitivity” (p.10). In Paschen-Wolff et al. [57], some LGBTQ+ people said they appreciate when care providers stand up for them when they witness discrimination by staff or other patients as it can provide them with an additional a sense of safety. This heightened awareness of the impact of stigma can be acquired by care providers through work with other marginalized populations [56]. Mandatory training is also promoted as a way to acquire cultural sensitivity, a healthy therapeutic relationship and foster an inclusive environment [53].

It is also important to create a “safe space” [56] or an “aura of inclusiveness” (Helfrich and Simpson, 2006). For example, a care provider in Holt and colleagues [56] deliberately chose not to display any religious objects in her office to make clients feel more comfortable. Visual cues to indicate a supportive environment can also be more inviting such as rainbow flags [57]. There is an actual need for staff training [54,57,58,59], standard protocols/guidelines [57,58,59]; and policies [54,57] in organization providing services in a context of GSD. Having an intake form representing GSD [57,58] provides a more inclusive space and as one client said, “I know I am in the right place” [56] (p.9). Helfrich and Simpson (2006) [58] participants add that “using gender-neutral language to screen, assess, and describe the dynamics of domestic violence is imperative.” (p.355). Daniels et al. (2022) [53] goes even further by suggesting that having telehealth appointments can help to overcome the anxiety and stigma that can come with obtaining services and being seen in an HIV/AIDS clinic.

According to care providers, it is important to let the client lead and try to understand where they are regarding their identity and heading to provide personalized services [56]. Additionally, care providers express this by supporting exploration and being comfortable with shifts in gender or sexuality as well as providing an individualized approach. Care providers in Helfrich and Simpson (2006) [58] noted that staff should acknowledge their own biases and self-evaluate to improve their approach. Furthermore, clients should be invited to evaluate the quality of services in organizations. Overall, a trauma- and -violence informed approach should be considered by organizations managing mistreatment situations [53,59].

3.4 Implementing an Intersectional Approach

Intersectionality as also been brought forth in multiple studies to include identities outside of GSD and influencing experiences. In Bogart and colleagues [52], participants “felt it would be helpful to discuss coping with discrimination, especially regarding immigration status, HIV status.” (p.4). For HIV-positive Latino SMM and care providers, facilitators in group activities should not only be professionally trained to facilitate group learning, but also have characteristics in common with the participants [52]. In Bermea and colleagues [51], it is stated that “a diversity approach was attentive to representing their unique needs through service providers’ shared backgrounds and experiences.” (p.531) This includes mirroring other identities such as race and age [51]. Du Mont and colleagues [59] also note that diversity should also be reflected by “the organizations’ diverse nature of supports offered will be critical in addressing the complex needs of trans survivors who may be experiencing multiple intersecting issues (e.g., housing instability, immigration status) that affect their vulnerability to experiencing sexual assault” (p.249). Still, some of the care providers in Daniels et al., 2022 [53] think that the quality of the relationship with the patient is more important than care providers presenting characteristics similar to the clientele. Furthermore, cultural competency of the care providers can also be acquired through engaging in social activities of BMSM.

3.5 Fostering Advocacy

Care providers in the study by Bermea and colleagues [51] stress the importance of highlighting the person’s strengths when supporting people of GSD, but also to empower them to become an advocate for themselves and their community [51]. Striving to make changes in society is important as they have lived multiple situations of mistreatment and are at higher risk of experiencing more. These care providers go even further by promoting a social justice approach aiming at structural changes to improve access to services for their clients [51]. In Rhodes and colleagues [58], immigrant Latina transgender women also call for collective action for change and to reduce stigma. They also express need to access services about legal issues including workplace discrimination and options for having and adopting children. Power differences must be addressed in the care relationship, but also in helping clients gain access to services in other organizations [51]. In their study with BMSM with HIV, Daniels et al. 2022 [53] found that this clientele expressed difficulties in accessing services regarding housing, transportation, employment, and medication and suggested that administrative changes be made so their health care setting could also support them in getting nonclinical resources. In Du Mont and colleagues [59], organizations wanted to be involved in an organized network to not only share information and resources, but also to improve quality of care and bring needed changes to the systems. Kosa et al. 2024 [60] reported that community organizations were more likely than hospital-based centers to see their lack of capacity for advocacy as impeding on collaboration. Community-based expertise is undervalued, and community organizations are excluded from key opportunities (for ex. Committees). Thus, the development of a network is necessary to foster collaborations between these sectors. As Holt and colleagues [56] explain: “Several barriers to care complicated how providers reach and work with TGNC clients such as economic insecurity, geographic distance, and limited community resources, often described as being magnified because of the Great Plains location. These barriers caused providers to operate as advocates and case managers to help their clients navigate barriers and connect with available resources, going beyond the scope of a traditional therapeutic alliance.” (p.14).

3.6 Providing Psychological Support

Participants in Rhodes and colleagues [58] explicitly expressed a desire for more psychosocial support as it is difficult to find trustworthy people to confide in and provide needed help. In Daniels et al., 2022 [53], BMSM suggested that more attention to the mental health of patients during regular checkups would be beneficial. Furthermore, counselling is also needed for families so they can have information and education about GSD to improve acceptance and additional support [58]. Care providers believe that support from family and the community can help to deal with stigma [56].

Two studies evaluated the use of cognitive behavior therapy (CBT) to address discrimination with positive results. Bogart and colleagues [52] assessed a CBT group intervention using mindfulness, including attentiveness to reactions to stressful situations. Most participants saw their participation in this type of group as an opportunity to increase knowledge and connection with other people experiencing GSD. The first study indicated high acceptability among potential clients and care providers of the CBT intervention to address coping with discrimination. Still, one participant stated that he did not believe that discrimination was a problem, so he did not see the relevancy of the program. This highlights the idea that the participants must value the main outcome of the program for it to be relevant for them. The second study described in the paper focused on acceptability and preliminary efficacy did show promising results as the “intervention participants showed higher emotion-focused coping at follow-up compared to the baseline, in that they were less likely to react negatively, such as with anger or anxiety, to discrimination.” [52] (p.7)

Ross and colleagues (2007) [10] tested using an experimental uncontrolled intervention trial a CBT-based group intervention for LGBT people living with depression based on anti-oppression principles. About 77% of participants said that the intervention fulfilled multiple of their needs and 91% said it was helpful with their depression. It was important for participants that the group was for LGBT people only and moderated by LGBT professionals.

3.7 Addressing Risk Factors

Hellmuth and colleagues [55] conceptualize alcohol as a contributing factor to IPV in same-sex couples as well documented in heterosexual couples. These authors used a single case study design to examine the effects of partial hospital alcohol treatment on alcohol consumption and IPV in one gay couple. The hypothesis was that partial hospital alcohol treatment would reduce alcohol consumption and in return acts of IPV. For the 12-month duration of the study, results showed a decrease in the frequency of physical aggression, physical injury, and psychological aggression. Relationship satisfaction did not change as it was already high at the beginning of the project. Authors caution that more studies are needed as this experiment was performed on only one couple, but the results are promising.

4. Discussion

This scoping review explores critical elements related to the management of mistreatment situations in the context of GSD. First and foremost, there is an obvious lack of scientific data regarding the management of mistreatment situations in the context of GSD, especially for older adults. The reality of the elderly remains largely unknown, as most studies focus mainly on younger populations. As high rates of victimization in the context of GSD are consistently found [7] and the WHO considering older adult mistreatment as an important public health issue [1], more studies are warranted. It would be important to gain a better understanding of how mistreatment occurs in the context of GSD among older people living in institutions, given that these populations sometimes must hide or conceal their true identity and sexual orientation, generating complex dynamics of vulnerability and social isolation [62,63]. It should also be noted that most studies make recommendations based on the perspective of stakeholders rather than that of survivors [51]. Future research should consider the perspective of marginalized people to identify the most relevant approaches adapted to their needs and realities.

Moreover, with many studies concentrated in the US and Canada, the applicability of these findings to regions with distinct socio-cultural, legal, religious, and healthcare frameworks remains uncertain. It is essential to explore the identification and intervention challenges within GSD communities in countries where their rights are overlooked or violated. Access to resources may also be restricted in some parts of the world. This affects people's ability to seek help, limits the options available for effective intervention and, in so doing, increases the isolation and vulnerability of marginalized groups. Future research should address this issue by studying the questions and challenges related to GSD in populations outside North America.

As mentioned above, the selected studies do not address the key care events other than identification and intervention, i.e., reporting, needs assessment or investigation. Future research should include recommendations for these key care events to ensure a comprehensive response adapted to the reality and needs of people experiencing mistreatment in the context of GSD. Data regarding identification of mistreatment situations emphasize the need to provide an inclusive space and identification tools in health and social services. This is important as stressful events associated with aging, such as illness and severe incapacities, may lead to an escalation of violence within a couple already experiencing conjugal violence, or may even engender violence in a previously harmonious couple [64]. Some of the existing tools to identify mistreatment show moderate to good internal consistency [65], but are not specific or validated for a context of GSD.

There is little evidence regarding the effectiveness of interventions to manage mistreatment situations in the context of GSD. In fact, none of the studies used a control group to evaluate interventions. It would also be relevant to conduct studies that monitor the long-term outcomes of interventions. This approach will help ascertain the sustainability and effectiveness of practices designed to manage mistreatment in GSD contexts. In addition, a recent systematic review of reviews of interventions to prevent or stop older adult mistreatment [66] calls for more robust research design for stronger evidence including randomized controlled trials and mixed methods and increasing sample size.

The findings highlight the importance of enhancing the training of care providers in matters related to GSD, to ensure that they have a better understanding of the needs and realities of the people involved. It must also be recognized that past experiences of discrimination and victimization affect the help-seeking behavior of people marginalized because of their sexual orientation and gender identity [67,68]. Educational programs for social and health care professionals have been associated with increase in knowledge about mistreatment as well as identification and reporting of mistreatment situations [69,70].

Finally, Collaborative efforts that include policymakers, health and social services providers, advocacy groups, and the GSD community are also crucial to foster systemic change. There is a need to improve access to health and social services for people experiencing mistreatment situations in a context of GSD within an intersectional and intersectoral approach. Mistreatment situations are usually complex and multifaceted and require the involvement of resources and professionals from different disciplines [71,72]. At an organizational level, lack of organizational priority and competing priorities is one of the current challenges associated with implementing practices to counter mistreatment [73]. As it is reported in Helfrich and Simpson [54]: “it is important to note that, although agency policy must clearly dictate the expectations of service delivery, each individual staff member must ultimately strive to implement these policies with fidelity and must remain dedicated to the missions of the institution in which he/she provides services.” (p.359).

4.1 Strengths and Limitations of the Scoping Review

To our knowledge, this is the first review describing practices used in health and social services for the management of mistreatment situations towards adults in a context of GSD. A total of eight databases were used to identify relevant studies in English, but also in French. No studies were excluded because of language. Still, our search terms might not have been fully exhaustive. In addition, we search for studies up to March 2024 and new studies might have been published since.

5. Conclusions

Our scoping review is one of the first looking at mistreatment situations in the context of GSD. In conclusion, a multifaceted research approach that encompasses the voices of marginalized individuals, considers the variances in global contexts, and evaluates the long-term impact of interventions is necessary. Such an approach will not only fill the existing research gaps but also contribute to the creation of a more inclusive and just environment for all individuals, regardless of their sexual orientation, gender identity, or age. Potential solutions for the management of mistreatment situations include development and implementation of identification tools, staff training, GSD sensitive protocols, guidelines or policies, but also an overall recognition of that mistreatment situations occur, and that better support and advocacy is needed.

Acknowledgments

We thank Rym Zakaria for her support during the comprehensive search strategies.

Author Contributions

MC, JGM and SI contributed to the study conceptualization. MC, JGM, PS, KSTM, RL conducted the selection of papers. PS, RB, KSTM, and RL extracted the data and MC combined and validated the extraction form. Themes analysis was performed by MC and validate by JGM. MC and JGM wrote the first draft of the manuscript and revised the manuscript based on feedback from PS, SI, RB, KSTM. All authors reviewed and approved the article before submission and provided final approval of the article.

Funding

This scoping review was financed by the Ministry of Health and Social services (Government of Quebec) for a governmental mandate given to the Integrated University Health Center and social services (CIUSSS) of West-Central Montreal as part of its designation as an affiliated university centre in social gerontology. The Research Chair on Mistreatment of Older Adults who also contributed to this review is funded by the same government instances.

Competing Interests

The authors have declared that no competing interests exist.

Additional Materials

The following additional materials are uploaded at the page of this paper.

1. Appendix 1: Example of Search Strategy.