Sexuality in Long-Term Care

Objectives • Discuss prevailing perceptions about sexuality and older adults as well as the capacity of elders with dementia to consent Sexuality in Long-Term Care to sexual activity • Open Your Mind (And Close the Door, Please) Examine the challenges faced by long-term care providers in facilitating safe sexual expression among residents and for managing inappropriate sexual expression • Consider ways to preserve residents’ rights to intimacy and sexuality while complying with regulatory requirements Kathleen Weissberg, OTD, OTR/L Education Director -- Select Rehabilitation [email protected] Definitions Definitions • Sexuality • Sexual expression o A part of personality that encompasses o Kissing, fondling, masturbation, oral sex, sexual beliefs, attitudes, values, behavior, intercourse, touching, hugging and knowledge • Expressions • Intimacy o Sending flowers, providing comfort and warmth, dressing up, expressing joy, maintaining beauty o Interpersonal relationship between two and physical experience, flirtation, affection, people who may or may not be engaging passing compliments, proximity and physical in sexual activity contact 1 Domains of Sexuality By the Numbers … • 45% of older men and 8% of older women Biological think of sex at least once a day (Fisher, 2010) • 28% of men aged 66-71 living in the community report having intercourse at least once a week (Marsiglio & Donnelly, 1991) • 60% of men and 43% of women ages 80-91 Psychological Cultural remain sexually active (Starr & Weiner, 1981) Physical Changes in Women Physical Changes in Men • Lower libido or slowing of sexual arousal • Longer time to obtain erection • Hot flashes and/or night sweats • Inability to maintain erection • Sleep disturbances • Increased time between erections • Emotional changes • Vaginal dryness and itching • Increased sensitivity to sounds • Dry skin • Weight gain and/or food cravings 2 Sexuality in Long-Term Care Consider Their History … • Grew up at a time when sexual • 25% of people living in SNF say they behavior was never discussed are lonely • Sexual activity was suppressed • 40% saying they are sometimes lonely • Education was minimal o A major fear is that they’ll die alone • Modesty was an important value • Gender differences exist Obstacles to Sex in Residential Strategies to Address Needs Facilities • Lack of privacy • Touch • Negative attitudes toward alternative o For example, hair grooming, hand lifestyles massage, manicure or pedicure, ROM exercises, back rub, taking pulse • Lack of education of staff • Consistent staffing • Lack of education of adult children • Counseling and Education • Physical and mental limitations 3 Sexual Expression in LTC • Love and caring • Romance • Eroticism Staff Responses to Sexuality Inappropriate Responses • Standing guard • Placing notes on the medical record • Reporting sexuality at meetings • Reactive protection • Snickering or giggling • Guarding the guards • Discussing sexuality with colleagues • Reprimanding or otherwise scolding • Proactive protection • Praying over the person Roach (2004) • Invasion of privacy 4 SAID Survey (Kuhn, 2002) SAID Survey (Kuhn, 2002) • Competent and consenting residents who are single are • A resident is entitled to masturbate in private as entitled to be sexually intimate long as his or her personal safety is ensured • Competent and consenting residents who are married, but not • to each other, are entitled to be sexually intimate with one Two residents of the same sex are entitled to be another in a care facility sexually intimate as long as it is consensual • Residents with dementia are not capable of making sound • If family members object to a relative with decisions regarding sexual relationships dementia having sexual relations with others, it is • A spouse living in the community is entitled to become the duty of the staff to prevent such activity intimately involved with someone else if the spouse has • dementia and lives in LTC A resident displaying hypersexual behavior should be transferred out of the facility • A resident with dementia is entitled to be sexually intimate with two different residents as long as there is no sign of • No one should interfere in the sexual lives of coercion in these relationships residents as long as no laws are broken Training Programs Staff Training Program Elements • • Uncover staff bias, morals, thoughts Resources o Staff can direct the training and • Education individualize it to their population • Support • Debunk myths about older sexuality • Protection o Helps caregivers recognize that sexuality • Empowerment is a human need that does not disappear • with age Confidentiality • Tactfulness (Lorenz, 2009) 5 FTag 175 FTag 164 The resident has the right to share a • The resident has the right to personal room with his or her spouse when privacy and confidentiality of his or her married residents live in the same personal and clinical records. facility and both spouses consent to the o Personal privacy includes accommodations, medical treatment, written and telephone arrangement. communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident Ftag 241 FTag 460 The facility must promote care for residents in a manner and in an Be designed or equipped to assure full environment that maintains or enhances visual privacy for each resident each resident’s dignity and respect in full recognition of his or her individuality. 6 FTag 242 FTag 246 • Accommodation of Needs • Self-Determination and Participation o A resident has the right to reside and o The resident has the right to make receive services in the facility with choices about aspects of his or her life in reasonable accommodation of individual the facility that are significant to the needs and preferences, except when the resident health or safety of the individual or other residents would be endangered FTag 223 Reactions of Family Members • The resident has the right to be free • Supportive from verbal, sexual, physical, and • Angry mental abuse, corporal punishment, • Indifferent and involuntary seclusion. • Unsupportive • Humiliated • Embarrassed 7 Spousal Issues Adult Children • How am I obliged as a spouse or partner to someone who no longer recognizes me? • Feel the need to make decisions • How do I maintain a sexual or intimate relationship including separation when my feeling toward my spouse have changed? • Many not be aware of parent’s sexual • How to I handle my feelings of anger, frustration, behavior and entrapment? • How do I cope with my spouse’s changes in • Does the facility need to tell them sexuality? (e.g., hypersexual, accusations of EVERYTHING? unfaithfulness, suspicion) • How can I meet my spouse’s needs? I love my spouse, but I cannot bring myself to be intimate. Consider … In most cases, the facility will choose A “sexual power of attorney” because the direction of the family members without one, the adult children will feel over the wishes of the resident free to control the intimacy of loved ones 8 Ways Dementia Affects Sexuality Spouse/Partner Issues • Early stages: interest in sex, but • Female caregivers uncomfortable with performance issues partner’s increased sex interest; males • Partner with AD may have interest and do not experience the same (Duffy, 1995) capability; way to retain one normal • With loss of communication ability area of a relationship comes loss of reciprocal feelings • Partner with AD is hypersexual • Spouse may feel alienated and • Person with AD has no interest or withdraw affection that was once thinks sexual activity is unacceptable important to both partners The Move to LTC The Question of Consent • Affection often increases when the • MMSE score 14+ has been used as the spouse with AD is moved into LTC cut off for consent to sexual activity • Nursing homes can be places of • MMSE does not address emotional isolation and loss state • Physical contact from others and intimate relationships can be calming Is the MMSE enough? and reassuring 9 Interview for Consent (Lyden, 2007) Criteria for Sexual Capacity • Interviewer should have good and • Voluntariness comfortable relationship with client • Safety • Utilize someone familiar to assist if • No exploitation impaired speech or translator needed • No abuse • Explain the reason behind the meeting • • Ability to say “no” Assess rationality, knowledge, • Socially appropriate time and place voluntary agreement Determining Functional Competence For What? • Determine whether the resident has the ability to express his or her desires • Determine what critical interests or values might be Capacity/competence can only be affected by acting upon the desires assessed in relation to a specific • Determine if the resident can consider these demand or task interests when making a decision • If not, then the nursing home needs to consider or decide whether the value of the intimate relationship outweighs the value of the critical interest affected 10 Keep in Mind Dilemma of Adultery • Cognitive memory may be impaired, Is the nursing home’s obligation to the often times emotional memory is not resident or to his/her spouse? o Cognitive impairment does not erase the need for affection or intimacy Do we hold a person with dementia at a • If a person can consent to one higher standard than everyone else? relationship, that doesn’t mean they can consent to another o Each relationship must be approached differently System Bias? Helping to Decide • System bias relies

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