Consenting Adults: Making Sex Safer for Senior Residents

Abstract

No one wants to talk about grandma and granddad having sex. But a recent court case involving a man having an intimate relationship with his cognitively impaired wife may convince nursing homes to find a way to have constructive conversations about an uncomfortable topic. In reality, elders – even those in nursing homes – are more sexually active than ever, and the numbers are growing as baby boomers age. According to various surveys, up to a third of seniors older than 75 years report being sexually active; not coincidentally, sexually transmitted diseases in the elderly are on the rise. “Sexuality is part of being human. Even when people get dementia, things that bring them joy, intimacy, and closeness don't disappear,” said Zachary Palace, MD, CMD, medical director of the Hebrew Home at Riverdale in Bronx, NY. Yet, despite the statistics about seniors and sex, a survey of AMDA members suggested that only about 30% of nursing homes have formal policies addressing sexual activity. According to geriatric psychologist and AMDA communications committee member Patricia Bach, PsyD, RN, who conducted the survey, the topic simply has not been a priority or even on the radar screen of most providers. Part of this is due to a sociocultural stereotype of elders as being asexual, she noted, while cognitive dissonance – a sense of discomfort on the part of society in general to discuss sex among elders – also contributes. The court case that has brought public attention to this often ignored issue involved a 78-year-old man charged with raping his wife, who has Alzheimer's disease and is in a nursing home. Facility staff told the husband that his wife couldn't consent to sex because of her illness. However, experts testified that some people with Alzheimer's disease can still be willing sexual partners, and the man was acquitted. The case has brought national attention to the issue of sex in nursing homes, especially regarding residents with dementia. “It has created a heightened awareness and sense of vulnerability on the part of facilities,” Dr. Bach said. This is a good thing, she suggested, as awareness is an important step. Now, providers and team leaders “are on notice that they can't ignore this issue.” Although facilities now realize that they must address their residents' sexuality, it still is difficult for people to talk about. “Caregivers often are embarrassed about this. We hear, ‘What should I do if a resident says this or does that?' It's easier for them to stay in denial,” said Dr. Bach. Even practitioners aren't always comfortable. However, in her survey, she found that more experienced physicians were more at ease talking about sex with residents and their families. “That was somewhat surprising. I would have expected younger people to be more confident. I think part of the reason is that this isn't woven into the fabric of geriatrics. It's an outlier issue that practitioners have to learn on their own as they go along. It takes time to develop a comfort level.” Assessing Consent1.Ability to express choices/consentAsk: ▸What are your wishes about this relationship?▸Does your sexual partner make you happy?▸Do you enjoy sexual contact?Consider: ▸Observations and non-verbal clues when older adult is unable to verbalize choices (facial expression and body language)▸Emotion and mood, before and after sexual contact2.Ability to appreciate sexual activityAsk: ▸Do you know what it means to have sex?▸What does it mean to you/your partner?▸What would you do if you wanted it to stop?▸What if your partner wanted it to stop?Consider: ▸Nature of the relationship (monogamous)▸Emotion and mood, before and after sexual contact3.Personal quality of life choices in the here and nowAsk: ▸Was and is intimacy important in your life?▸What are your social and companionship needs?▸What brings happiness or fulfillment to your day?Consider: ▸Past and present relationships (including family)▸Impact of cognitive impairment (not an automatic reason to deny relationships)▸Privacy and intimacy rights▸Responsibility to uphold older adults’ choices▸Policies for staff education and practices▸Impact of third party objectives or values on assessment processSource: The Weinberg Center and The Hebrew Home. Abuse or intimacy: Older adult sexuality. 2011. Available at: www.riverspringhealth.org/uploads/ckeditor/files/sexualconsentguidelines.pdf. 1.Ability to express choices/consentAsk: ▸What are your wishes about this relationship?▸Does your sexual partner make you happy?▸Do you enjoy sexual contact?Consider: ▸Observations and non-verbal clues when older adult is unable to verbalize choices (facial expression and body language)▸Emotion and mood, before and after sexual contact2.Ability to appreciate sexual activityAsk: ▸Do you know what it means to have sex?▸What does it mean to you/your partner?▸What would you do if you wanted it to stop?▸What if your partner wanted it to stop?Consider: ▸Nature of the relationship (monogamous)▸Emotion and mood, before and after sexual contact3.Personal quality of life choices in the here and nowAsk: ▸Was and is intimacy important in your life?▸What are your social and companionship needs?▸What brings happiness or fulfillment to your day?Consider: ▸Past and present relationships (including family)▸Impact of cognitive impairment (not an automatic reason to deny relationships)▸Privacy and intimacy rights▸Responsibility to uphold older adults’ choices▸Policies for staff education and practices▸Impact of third party objectives or values on assessment process Source: The Weinberg Center and The Hebrew Home. Abuse or intimacy: Older adult sexuality. 2011. Available at: www.riverspringhealth.org/uploads/ckeditor/files/sexualconsentguidelines.pdf. Policies addressing sexual behavior should be designed to protect residents' rights to express themselves sexually while ensuring everyone's safety. “Every situation is unique and has to be evaluated specifically,” Dr. Palace said. “However, the policy gives us a baseline from which to work and puts everyone on the same page.” It also allows staff to feel more comfortable tackling a delicate topic. This is especially important, said Dr. Palace, as “staff come from many different ethnic and cultural backgrounds, and have many different views about sex. They may feel that a person doesn't have the ability to consent and worry that their patients are being taken advantage of. We need to give them policies that help guide them, and we need to give them opportunities to discuss their questions and concerns.” Hebrew Home's policy states that it “recognizes and supports the older adult's right to engage in sexual activity, so long as there is consent among those involved.” It explains that consent may be demonstrated by the words and affirmative actions of an older adult who has intact decision-making ability, who has intact decision-making ability but who is non-verbal, or who has Alzheimer's disease or dementia. One way to handle the question of consent is to address sexual consent in an advance directive, said David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, TX. “It is possible to anticipate this and document it. For example, people can document that intimacy has been an important part of their relationship with a significant other and that they would like this to continue even if they no longer are able to consent verbally.” This can be especially useful, he said, with blended families in which adult children don't like a parent's spouse and disapprove of their relationship. Dr. Smith stressed that family relationships can be complicated and affect how people feel about mom or dad having an intimate relationship or even getting married. “We had one incidence where two people were incapacitated but affectionate and wanted to marry. Their children objected, but we discovered that their real objection was that they didn't want to muddy up their parents' estates. Once we addressed and resolved this issue, they gave their blessing.” Sometimes when there is mutual consent, practitioners or facility staff may not approve of the relationship, but they need to respect residents' rights and remain non-judgmental. Developing a policy regarding sexual activity and consent is just the beginning, said Dr. Bach. “This is just one of multiple layers. The cost of developing policies isn't that big, but training staff and creating cultural competency to support these policies takes considerable time and money.” Staff training should be didactic and experiential in nature, Dr. Bach suggested. “It is more difficult and more challenging than simply teaching them how to bathe or provide physical care for residents.” Training should address areas such as “humanizing” residents' needs for intimacy and sexuality; capacity for sexual consent; appropriate and inappropriate behavior related to patients, families, and staff; sensitivity training for best practices by staff; and myths and misunderstandings about senior sexuality. Elsewhere, physical environment changes may be necessary to maximize privacy and enable conjugal visits with spouses or significant others. Handling Inappropriate BehaviorAbout 15% of people with dementia exhibit some sort of sexually inappropriate behavior, and this can put residents and staff in awkward situations or even put them in danger. Staff needs to watch for signs of improper behaviors and address them promptly and thoroughly. “You need to find out what is happening and when,” Dr. Smith said. “You need to conduct a mental status exam, then a physical to determine if anything – such as medications – might be causing or exacerbating the problem.”Some people have normal libido and dementia, and they approach others inappropriately; they need to be directed so they express libido in appropriate ways. “Then there are sexual pedators who figure they can get away with it because they are old,” Dr. Smith said.“There are also people with libido caused by psychopathology. People develop mania, and hypersexuality goes with that. If I have someone acting out sexually, and I don’t know if they have capacity or not, I have a [staff] person of the same sex counsel the resident for 3 consecutive days about expectations for appropriate behavior and explain that he or she has to deal with these feelings in private and not affect others,” said Dr. Smith. On the fourth day, the team spokesperson asks the resident to repeat back what he or she has been told the past 3 days. “If they can’t tell us, we can conclude that they are unable to learn and unable to be accountable.” If the person can repeat what he or she has been told, then he or she can be held accountable. Then the team watches the individual to be sure he or she is willing to behave in accordance with expectations.Sometimes, the best solution is to fix the environment rather than the person, Dr. Smith said. A resident may need to be moved to a location where he or she has limited contact with the opposite sex or the individuals he or she is most likely to target. For example, a heterosexual man who is harassing women may be restricted to a male-only floor or wing.There is limited evidence to support drug therapy to treat sexually inappropriate behavior, but if the behavior is caused by psychopathology, then “antidepressant, anti-androgen, antipsychotic, and mood-stabilizing medications might be helpful. In every situation, the team needs to work together and document their efforts to address inappropriate sexual behavior and keep residents and staff safe.”—Joanne Kaldy About 15% of people with dementia exhibit some sort of sexually inappropriate behavior, and this can put residents and staff in awkward situations or even put them in danger. Staff needs to watch for signs of improper behaviors and address them promptly and thoroughly. “You need to find out what is happening and when,” Dr. Smith said. “You need to conduct a mental status exam, then a physical to determine if anything – such as medications – might be causing or exacerbating the problem.” Some people have normal libido and dementia, and they approach others inappropriately; they need to be directed so they express libido in appropriate ways. “Then there are sexual pedators who figure they can get away with it because they are old,” Dr. Smith said. “There are also people with libido caused by psychopathology. People develop mania, and hypersexuality goes with that. If I have someone acting out sexually, and I don’t know if they have capacity or not, I have a [staff] person of the same sex counsel the resident for 3 consecutive days about expectations for appropriate behavior and explain that he or she has to deal with these feelings in private and not affect others,” said Dr. Smith. On the fourth day, the team spokesperson asks the resident to repeat back what he or she has been told the past 3 days. “If they can’t tell us, we can conclude that they are unable to learn and unable to be accountable.” If the person can repeat what he or she has been told, then he or she can be held accountable. Then the team watches the individual to be sure he or she is willing to behave in accordance with expectations. Sometimes, the best solution is to fix the environment rather than the person, Dr. Smith said. A resident may need to be moved to a location where he or she has limited contact with the opposite sex or the individuals he or she is most likely to target. For example, a heterosexual man who is harassing women may be restricted to a male-only floor or wing. There is limited evidence to support drug therapy to treat sexually inappropriate behavior, but if the behavior is caused by psychopathology, then “antidepressant, anti-androgen, antipsychotic, and mood-stabilizing medications might be helpful. In every situation, the team needs to work together and document their efforts to address inappropriate sexual behavior and keep residents and staff safe.” —Joanne Kaldy Even when a facility has strong policies and educated staff, it is important to stay alert to residents' actions and behaviors. “We had a cognitively impaired female resident whose male guardian, a family friend, would take her out of the ward for outings. She would be [highly agitated] when she returned. We investigated and discovered that he was molesting her. This was a clear case of lack of consent,” said Dr. Smith. If staff approaches the issue with sensitivity to and respect for residents' rights to have and express sexual feelings, it will help residents feel more at ease. At the same time, Dr. Palace said, “They have to be vigilant and recognize if two people are spending time together and there is more than casual friendship involved. Regardless, if the people involved are cognitively intact, or if one or both have dementia, a thoughtful discussion about appropriate sexual behavior is in order.