One only needs to turn on the TV or open any popular magazine to be confronted with a plethora of ads selling products to "mature" adults to enhance their continued sexual expression. It is now well understood that human sexuality and the desire to engage in various forms of sexual contact continues well beyond the prime reproductive years. This desire to remain sexually active does not end when a person enters a nursing home. In fact, it may actually be heightened by issues as serious as dementia, or as simple as an aid to the boredom of institutional living.
Unfortunately, many nursing homes do not have formal policies regarding the issue of sexuality among their residents, and some have not seriously considered it at all. This can result in significant problems for the nursing home.
While the nursing home field is more highly regulated than any other, there are almost no rules regarding sexuality. As a result of several high-profile cases, facilities are eager to avoid liability and have begun to develop guidelines that preserve residents' rights to pursue sexual pleasure in privacy, while protecting the resident from unsafe, unwanted or abusive situations. However, according to a 2013 survey by the Society for Post-Acute and Long-Term Care Medicine, only about a quarter of facilities have policies on intimacy and sexual behavior. Approximately one half said that developing a policy was "planned" or "uncertain."
Sexual expression among residents can be anything from compliments through touching to sex. Attraction, hugging, flirting, fondling and sexual relations know no expiration date. It is a way that seniors can still generate excitement in their lives. Social connections and human touch can help ward off the depression and loneliness that old age and institutional living can bring.
More than half of nursing home residents experience some form of cognitive impairment, such as dementia or Alzheimer's disease. Frequently, with this impairment, some individuals will become disinhibited sexually. In frontotemporal dementia, this disinhibition shows up before other cognitive issues, so the person can still think reasonably well. Are people able to consent to sex when their mental faculties are diminished? Is sex more an impulse akin to eating, a pleasurable appetite that one retains an ability to indulge in? Who gets to decide what is safe and appropriate?
Sexual activity in a nursing home seldom involves just two people. Nonresident spouses and adult children often make decisions for the person and many simply do not like to think about an elder's sexuality. Family members are usually the ones who make a fuss. It is not uncommon that a spouse with dementia who was living in the moment and, in their mind, is 20 and not married, will find a new nursing home romance that leaves the nonresident spouse in the lurch. This new romance may leave the healthy spouse distraught or upset adult children. Problems particularly occur when the family finds out about the situation unexpectedly.
There can also be institutional and personal biases. Staffers sometimes disapprove or are repelled by the idea of sex among older adults. Administrators often decide that it is easier to ignore or proactively discourage sexual expressions. This can result in citation of the facility by the state for failure to report possible abuse and for not having staff training or policies in place. There needs to be a way to evaluate each situation. Guidelines are warranted for behaviors as innocuous as a kiss on the cheek. There is a problem if the person kissed feels uncomfortable.
Compassionate policies acknowledge that older adults still have sexual needs, including the very basic human need for touch. Policies must distinguish between crime, sexual abuse, inappropriate sexual activity (such as hypersexuality in someone with dementia) and a real relationship. Cognitive impairment should not be considered an automatic reason to deny a relationship.
For a resident with dementia, one of two principles is usually applied in determining the appropriateness of sexual contact. The most widely used standard "substituted judgment" looks at the person's previously held values and decision-making in determining what they would choose now. The other principle, "best interests", which is preferred by ethicists and dementia experts, considers what is good for the person as he or she is now, ignoring past values and taking into account that personalities can change dramatically in dementia. It is not unusual for someone with Alzheimer's disease to develop a comforting, beneficial attachment to a fellow resident and forget the non-resident spouse. However, conundrums can abound. One example would be a gay man who has lived his life in the closet and begins a gay relationship with a fellow resident after developing dementia. He seems happy, but his wife and children are confused. What happens when the interests of a cognitively impaired resident collide with the interests of his or her family? Generally, the family will have the final say if they are the responsible party and have a power of attorney.
Having the same staff consistently care for small number of residents is very helpful. They get to know the residents and can act as their advocates. They can tell distress from happiness, even when someone is nonverbal. This facilitates determining consent.
Examples of privacy accommodations and assistance include offering a double bed rather than two singles to a married couple, placing mattresses on the floor, and using "do not disturb" signs. Staff members are taught to knock and pause before entering a room. Prescriptions for Viagra, personal lubricants and vaginal estrogen creams are filled.
An in-service of as little as one hour on this once unspoken topic can work miracles with the staff. Something as simple as a decision tree to help determine if someone has the ability to consent to and participate in a relationship can be a starting point. Bringing families into the conversation is very important as well, even if they do not want to hear it. Orienting families in advance regarding sexual policies of the institution helps to plant the seed if the issue comes up later.
Consulting a healthcare lawyer to assist an institution in the drafting of a policy regarding resident sexual activity that conforms to the Resident's Bill of Rights can be the first step in addressing this issue.
If you have questions regarding this article, please contact Gerald V. Burke, MD.,Esq. at gburke@barmak.com or by telephone at (609) 454-5351.
