A woman who had been in a coma for more than a decade gave birth at a private nursing facility in Arizona last week, in a case that highlights a vulnerable population that advocates say have received far less attention in the #MeToo era: people with disabilities and in long-term care.

The patient, whose age and identity has not been made public, was left in a persistent vegetative state after nearly drowning 14 years ago. She’s since depended on around-the-clock care at Hacienda Healthcare, a private facility based in Arizona that treats chronically ill and developmentally disabled patients. But the staff there were reportedly unaware that she was even pregnant until she went into labor on December 29 and gave birth to a healthy baby boy, according to KTVK, the CBS News affiliate that was the first news outlet to report the case Thursday.

“From what I’ve been told she was moaning,” an unidentified whistleblower told KTVK. “And they didn’t know what was wrong with her.”

The Phoenix Police Department has launched a sexual assault investigation into the case, and a Hacienda spokesperson said the facility has promised to get to the bottom of what they called “an unprecedented matter.” In the meantime, state regulators have demanded that the facility step up its safety measures, asking that male employees be accompanied by another person while treating female patients.

While many crucial details remain unknown, news of the case was met with outrage online, with women’s advocates questioning why staffers reportedly remained unaware of the patient’s pregnancy for so long, and why authorities were treating it as a “possible sexual assault” rather than calling it outright rape. The patient had been in a vegetative state for more than a decade. She could not consent to any sexual contact or defend herself during an attack, nor did she have the power to report inappropriate behavior or assault.

Patients like the one at Hacienda are particularly vulnerable

Though the scope of the problem is hard to assess — research on abuse of patients living in long-term care facilities lags decades behind research for other populations — experts say those patients are particularly at risk of becoming victims of abuse or sexual violence because of how often they’re at the mercy of others to live their lives.

“People who need total care are very, very vulnerable,” says Regan Smith, an ombudsman with Area Agency on Aging, based in Maricopa County, Arizona. “And nobody wants to believe that things are happening to them — they’re our most vulnerable population.”

Some may have cognitive disabilities, while others may be tied to ventilators or feeding tubes, and require hands-on care around the clock. Patients unable to communicate obviously can’t give consent, while those who are physically incapacitated are unable to protect themselves from an attack.

Add to those circumstances the fact that many patients are isolated from older support networks or their families, and experts say that can make patients easy targets.

“Opportunistic assailants are common, and we see them show up in all kinds of environments where there are inherent vulnerabilities,” said Kristen Houser, spokesperson for the National Sexual Violence Resource Center.

According to Smith, instances of abuse as extreme as the Arizona case — in which a patient without the ability to consent to sex is impregnated while receiving around-the-clock care — are relatively rare within the industry of long-term care and nursing homes. But the circumstances aren’t unheard of: Over the last few decades, there have been several high-profile cases involving women who were impregnated against their will while they were in a coma.

Less extreme cases are more common. There have been other complaints of sexual misconduct, for example, at the same Arizona facility where the latest pregnancy occurred. A 2013 complaint filed against the facility alleged that a male employee directed sexually explicit comments toward patients. In one instance detailed in a report from the Arizona Department of Health Services, the employee made explicit comments while bathing a patient, saying he was going to have a “happy morning” due to his semi-erect penis.

The employee was eventually fired, and the facility’s operators promised the state it would implement new training on how to report patient abuse.

But stories of abuse like that patient’s and others in long-term care facilities often don’t get as much attention as they deserve.

Advocacy groups complain that studies on elder abuse lags “as much as two decades” behind similar research on child abuse and domestic violence. The scale of abuse complaints inside long-term care facilities is also largely obscured from the public eye. Federal agencies frequently catalog these complaints into overly broad categories, where data on “abuse” could be a catch-all for everything from neglect to sexual assault.

A 2017 investigation by the Kansas City Star sorted through the data and found that sexual abuse allegations in long-term care facilities were on the rise nationwide. More than 20,000 complaints of sexual abuse were filed over the course of a 20-year period, the report found. But there’s reason to believe that at best, the statistics paint an incomplete picture of the scale of the problem.

Assault allegations made by elderly or disabled victims are often met with skepticism or disbelief

Rates of reporting sexual abuse or violence are already notoriously low nationwide — but advocates believe only a fraction of individuals who experience violence within a long-term facility come forward. By some estimates, only one in five do so.

One of the primary concerns is whether victims who have physical or cognitive disabilities are believed if they do come forward, Smith says: “Do staff always believe what they hear from patients? If they can communicate at all, are they heard, are they listened to — is everything taken seriously?”

Working against victims are false assumptions that the elderly or disabled could never be victims of abuse or sexual assault — people simply don’t want to believe that such vulnerable groups would be taken advantage of. As Houser points out, our society tends to think of people with disabilities as asexual, and are therefore “infantilized” and less likely to be taken seriously when reporting abuse.

“Our nation is very much in denial about how widespread the problem of sexual abuse is — especially when you have a population that does not fit the mainstream criteria as a sexual being,” Houser said.

In one case in Minnesota in 2014, nursing home administrators said they believed an elderly woman was “making up” her rape allegations, and even blamed her for being a “flirt.” Their testimony was captured by the Star Tribune:

... an administrator at Edgewood Vista appeared to defend the rapist even after his admission to police. According to court testimony, Marilyn Moore, clinical services director at the home, asked Flesvig, “Did she tell you that this was consensual? Did she tell you that she flirts with this boy mercilessly?”

#MeToo changed our understanding of sexual assault. But the culture shift isn’t over.

The story of the Arizona case — and the systemic issues that enable abuse in long-term care facilities — follow a similar narrative arc to the stories unearthed since #MeToo entered our cultural lexicon. Victims are often the most vulnerable. They face many barriers in their ability to come forward with allegations of abuse. And even if they report, often they’re not believed.

Thanks to the countless number of victims who have come forward with stories of assault and violence since the start of the #MeToo movement, challenging power structures and the unequal application justice, there’s been a shift in our culture’s understanding of just how widespread sexual assault and abuse truly is.

But what happened in Arizona is an important reminder: Not all victims may be able to speak out on their own.