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Sex & Long-Term Care

Nurses play a key role as advocates for the rights of older adults to express their sexuality

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

Learning Scope #375
1 contact hour
Expires Jan. 2, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide current information to nurses that will help them advocate for the rights of older adults to express their sexuality in the long-term care environment. After reading this article, you will be able to:

1. Describe a realistic view of sexuality in older adults.
2. List ways nurses can facilitate the expression of sexuality among long term care residents.
3. Take appropriate action if a long-term care resident's action merits intervention.

  • The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Older adults, just like younger adults, have a need for intimate relationships because they are important for the quality of one's life as well as for physical and mental health. A study by the University of Chicago concluded older people, given the opportunity, are as sexually active as younger adults. The researchers report that a substantial number of men and women engage in vaginal intercourse, oral sex, and masturbation into their 80s and 90s.1

Older adults living in long-term care facilities experience barriers to the expression of their sexuality. The facility, professional nurses and all staff working with long-term care residents share in the responsibility to help them overcome these barriers.

Facility's Responsibility

The Nursing Home Reform Act of 1987 requires that to continue to receive federal funding, long-term care facilities must maintain an environment in which every resident can "attain and maintain his or her highest practicable physical, mental and psychosocial well-being." The act's Residents' Bill of Rights includes the right to privacy and the accommodation of personal needs, sexual expression being one of them. Long-term care facility residents are entitled to express themselves sexually as long as it is done in private, is consensual and does no harm.2

Many long-term care facilities are taking steps to move away from institutional models of care in an attempt to improve the quality of life for those receiving care. This concept of "culture change" encompasses a variety of philosophical and practice models that all view the facility as an older person's home, implying the facility is a place of choice, a place where needs are met, and a place of personal enjoyment and pleasure.3 Two well-known advocacy groups for culture change are the Pioneer Network and the Eden Alternative. Both are dedicated to creating an environment where older adults can thrive in all aspects, including their sexual lives.4,5

Nearly a decade ago, the Hebrew Home in Riverdale, NY, became the first long term-care facility to develop policies that recognize and protect the sexual rights of its residents, distinguishing between intimacy and sexually inappropriate relations. Through a grant from the New York State Department of Health, the Hebrew Home created a comprehensive staff training DVD entitled, "Freedom of Sexual Expression: Dementia and Resident Rights in Long Term Care Facilities." The Hebrew Home's policies have become the standard of practice for many residential healthcare facilities across the nation.6

Long-term care facility governing staff members need to grapple with serious questions when it comes to expression of sexuality in their facilities:7,8

• How does a facility balance patient safety and the need for privacy?

• If family members object to their loved one's sexual activity, are long-term care facilities held accountable if this behavior occurs? Do staff members need to act as chaperones?

• What should staff do when sexual advances are made if one or both of the residents have Alzheimer's disease or other forms of dementia?

• How should staff determine matters of consent with residents who are confused or have lost their language skills?

• When is intervention necessary in the ongoing care of residents who are in intimate relationships?

Thoughtful discussion among all professional and administrative staff guided by the review of the latest evidence-based best practices and available training provides the opportunity to direct changes in facility practices and policy.

Ongoing staff education is important to make sure that staff are on board with the facility's policies about sexual expression for the residents. Even if there are many personal perceptions about sexual expression among staff members based on their religious and cultural beliefs, the facility needs only one policy that is upheld by all staff no matter their personal views. For example, if asked, any group of staff members could come up with many ways to handle a male resident who is found masturbating in public. If the facility policy states such, all staff members need to feel comfortable moving the resident to his own room where he can masturbate in private, thus supporting his right to sexual expression without offending other residents.

Each Nurse's Responsibility

Although nurses usually enjoy seeing friendships develop between long-term care residents, they are often uncomfortable if the relationship progresses to a sexual one. Some nurses might advocate celibacy. Others ignore the fact older adults have sexual thoughts and urges, or are surprised to learn older adults think about sex. People who live in long-term care are of both genders, living in close quarters, with lots of free time, and plenty of opportunity to interact with each other in close and intimate situations. So it should come as no surprise sexual urges and activity develops.

In many cases, simply spending time together, holding hands, kissing and hugging are the extent of sexual expression. When a relationship between residents progresses to sexual activities, nurses can help by assuring that both residents are able to consent. Nursing staff can support them by monitoring the relationship to make sure it remains a good experience and neither one becomes agitated or upset.

It is also important to counsel them on safe sexual practices, as many older adults do not believe they are at risk of getting a sexuality transmitted disease including HIV.

If the question of sexual exploitation arises, nurses cannot use the same rules as they would in the situation of sexual exploitation involving teens. Confused elders who are enjoying their sexual encounters may have no need to be protected from future anxiety and guilt as would teens and young adults. Nurses need to advocate on the side of residents and their well-being.

Concerns about the family's response or the possibility of a lawsuit brought against the facility by the family can cloud the issue. Expending energy on educating the family about the needs of their loved one may help them view the situation from a different vantage point.

The movie Away From Her portrays the challenges faced by a husband when his wife develops Alzheimer's disease.9 In the movie, the wife enters a "retirement home," no longer recognizes her husband, and develops a romantic relationship with a fellow resident. The movie is a beautiful portrayal of love focusing on the best interests of the person with dementia.

Basic Measures

Professional nurses usually are the ones who hold others accountable for following practices and policies on their units. In the case of healthy sexual expression, they are often the ones to assure residents are treated with respect and dignity. Nurses can help others understand handling residents' sexuality is often quite simple:7,8

• Always knock before entering a room.

• Discreetly close a resident's room door or privacy curtain if a resident is masturbating or two residents are found engaged in appropriate sexual activity.

• Provide residents with items they request to help them have satisfying sexual experiences.

• Refrain from negative verbal or facial expressions if you find a resident or residents engaged in sexual activity.

Working together, staff can eliminate certain barriers to privacy faced by long-term care residents. In most long-term care facilities, rooms are double occupancy, and private room time is difficult with a roommate. Staff members need to plan how to provide for private visitation during visiting hours for those with long-time partners. Another example of forward planning is to provide privacy for residents who develop an intimate relationship since coming to the facility.

Inappropriate Advances

We all are at risk of having inappropriate sexual behavior directed towards us. Prepare yourself with a response so when it occurs you are not taken by surprise. Sometimes the inappropriate behaviors start with innuendos or jokes and may lead to other more overt sexual advances.

First determine the etiology of the sexual advances. Some perceived sexual advances may simply be an expression the resident needs more physical contact. Perceived advances may also be an indication something is wrong, a way to "act out" feelings of frustration, neglect or loneliness. Nurses need to complete a thorough assessment to make sure all psychosocial needs of the resident are being met.

Then there is transference. It might be especially difficult for an older adult to refrain from acting upon feelings that may arise because a staff member reminds her of a past love. Michelle, a long-term care resident, could not believe who she saw walking toward her down the hallway. Although she knew it was Thomas, the new RN on evening shift, she could not help but be reminded of her late husband Jack. The way he walked and talked, and the gestures he used, were all reminders of Jack. She found herself following him around; had a hard time keeping her eyes off him. One day when Thomas was handing her some medication, she grabbed his hand and pulled him toward her. She burst into tears as she realized what she had done - the shame of an "old lady coming on to a young nurse."

Some older adults may display sexual behavior as a personality trait or as a result of mental illness. For example, those with a history of mania often have a history of hypersexuality. Certain medications may also increase the likelihood of sexual behavior in otherwise demure individuals, either by stimulating increased arousal or causing disinhibition. Cognitive impairment also may cause an enhanced sex drive or disinhibition. A person with memory loss may even forget he just had sex and desire more.

If approached in an inappropriate way, especially by a confused resident, display a neutral reaction and avoid saying anything that might devalue a resident, make him feel ashamed or punish him. Resist the urge to make a value judgment. Simply state what the unwanted behavior is and point out it is not acceptable. Then redirect the resident.

Ask for help rather than ignore inappropriate behaviors. Ignoring a behavior will not make it go away. And doing so might show tacit approval or subtle encouragement. Ask for help from a staff member you trust. If the behavior cannot be controlled, other arrangements need to be made to ensure your comfort.

Key Role for Nurses

Nurses can make important contributions to the sexual welfare of older adults in their care as decision makers and policy writers. Raising the question of how to handle sexual expression among the older adults you care for is the first step. Remind others "when we mistakenly view older adults as asexual - one of the most extreme forms of ageism - we in fact deny parts of their humanity, and for those who work with aging and elderly individuals, we fail to support their life choices."10

Focus on the needs of your residents, keep it simple and adopt practices that have been shown to enhance the quality of life of older adults. Doing this will prove to be beneficial to all - the residents, their families and the entire staff.

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

References for this article can be accessed here.

Joan M. Lorenz has worked in long-term care, palliative care and hospice, and is president of Clearly Stated, Gainesville, FL.

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