Resident Sexuality: Adapting Your Policy
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Resident Sexuality: Adapting Your Policy

Certain topics arise in everyday life, whether that be in a senior living facility or at home. Although these situations are taboo at times, they won't disappear by ignoring them. One of these sensitive subjects is the sexual needs of residents in your facility. After all, it was the Baby Boomer generation that created the famous slogan "make love, not war." Indeed, they still feel strongly that sexual expression is ageless.

A study by the New England Journal of Medicine reports that over 25 percent of seniors aged 75 to 85 are sexually active. This number rises above 50 percent for seniors aged 65 to 74. Research also shows that individuals who have enjoyed an active and healthy sex life throughout their adulthood are likely to continue doing so well into their later years. The majority of older adults in relationships say that sex and intimacy are still an important part of their lives.

Despite these facts, very few senior living facilities openly acknowledge and/or accommodate for the sexual expression or intimacy needs of their residents. This is likely due to the fact that the rights of residents to engage in sexual activities in senior living facilities have not always been clear or supported by the state survey team, family members and staff. However, with the advent of recent culture change, more facilities are adapting a person-centered model of care, striving to create a more home-like setting for their residents. Part of this overall change in philosophy includes paying more attention to a resident's right to sexual expression.

Consider the following steps to help acknowledge, provide and support these rights:

Research Available Resources – The Center for Practical Bioethics has produced a document to help assist long-term care facilities with guidance on how to address resident needs and desires for intimate relationships and sexual activity. The document, "Considerations Regarding the Needs of Long-Term Care Residents for Intimate Relationships and Sexual Activity" helps guide staff through this process. Another article, "Pioneering Change: Sexuality in Nursing Homes Education Module," was developed by Kansas State University, in collaboration with the Kansas Healthcare Associations, to promote excellent alternatives in nursing homes. It was created to help educate and train employees working in your senior living facility.

Prepare for Residents with Alternative Lifestyles – Chances are, your facility will be serving residents who identify themselves as being lesbian, gay, bisexual or transgender (LGBT). Gender expression is the physical manifestation of one's gender identification, usually expressed through clothing, mannerisms and chosen names. Experts estimate that roughly seven percent of Americans, aged 65 or older, are among the LGBT group. That number may be low, since this current generation of elders came of age when there was so much discrimination that they didn't want to be counted. They grew up when the potential to be arrested, to lose or not get a job, to not get housing, or even end up in a mental institution was immense. Their support system may be lacking, as LGBT seniors are:

  • Less likely to be connected to their biological family;
  • Four times less likely to have children;
  • More likely to live alone; and
  • Less likely to reach out to mainstream services.

Caregivers need to provide the same quality of care to LGBT residents as they do to others. All residents need to feel acknowledged, included, respected and understood. Admission forms should capture information about families of origin and families of choice, so that caregivers capture what is most important to the resident. Staff should acknowledge and respect their answers and avoid assumptions and judgment.

Minority stress is prevalent in the lives of some LGBT elders. Through the admission process and assessment interviews, caregivers can determine the resident's level of self-acceptance, support and social network available to better determine their needs. Some ways to achieve person-centered care include:

  • Maximize the resident's dignity, autonomy, socialization, privacy and choice;
  • Support their lifestyles;
  • Promote family and community involvement (including families of choice); and
  • Develop positive relationships with staff, residents, and the community.

Seek Legal Counsel – Allowing a resident to exercise their right to sexual expression, while safeguarding the physical and mental health needs of those involved, and determining what is communicated to concerned family members, can be a difficult task. Legally, and under federal regulations (i.e. 483.10 (e) Privacy and Confidentiality; as well as 483.10 (l) Married Couples), residents of long-term care facilities are entitled to express themselves sexually as long as sexual expression is not a public display, is consensual between residents, and does not harm the resident or others. These criteria may be challenging to discern when residents are not married to each other, and one or both have varying degrees of dementia and/or physical frailty. Legal counsel should be involved to provide general guidance, as providers develop policies and informed consents to assist residents in experiencing the intimacy they desire in a safe and private manner.

Develop Policies – These policies should address a residents' desire for an intimate relationship and sexual activity. According to the Center for Practical Bioethics, a long-term care facility's policy regarding their residents' intimate relationships need to address the advent, continuation and conclusion of those relations. To assist facilities, a copy of their policy can be found here. In addition, providers should develop a list of working definitions, such as: sexual intimacy, sexual activity, consenting resident, etc. Be sure to seek out other senior living facilities and health care associations that have already adopted policies regarding their response to the intimate and sexual needs of residents. See what they have in place and adapt their ideas to meet the needs of your facility. Along with legal counsel, involve the interdisciplinary team (IDT), medical director, pharmacist and psychiatric service members to assist with the development and review of your policies. Some facilities also have asked residents, clergy, family members, surveyors and Ombudsmen for their input and feedback. As reported by the Center for Practical Bioethics, if the facility has fully articulated written policies that support the intimate relationships of its residents, long-term care surveyors should respect the right of residents to accept the risks of their intimate relationships and sexual activities.

Conduct Pre-admission Tours – Tours should not only address the everyday concerns of the resident and their family members, but also discuss the realities of residents and their desire to have sexual expression. Families need to know what the facility's policy is, even if it's not an easy dialog for them to have. Family members want to protect their loved one, sometimes taking a paternalistic approach (likely due to safety concerns), and expect there will be no sexual activity. The staff should be prepared to provide educational materials to the family, including a resident's right to sexual expression. Even if their loved one is not able, or does not desire to, participate in sexual intimacy, it is important to educate the family. Even though their family member may not participate, there are other seniors within the facility who will be expressing their sexual identity and/or expressions. This allows the family to make an informed decision about admitting their loved one to the facility and know that residents' rights are supported by the caregivers.

Have Clear Standards for Assessment and Evaluation – This helps to determine the resident's desired sexual expression, activity and capacity to consent to sexual relations. To do this, caregivers need to incorporate sexual health assessments into the comprehensive assessment process. They should ask residents if they would like to talk privately or with loved ones regarding their sexual history and health. Once complete, determine if they are sexually active or wish to be in a sexual relationship once admitted. By assessing the resident's sexual history and personal quality of life choices, the staff will be able to better support the resident's desired sexual expression. Assessing a resident's consent to sexual activity is easy when he or she is alert, oriented and can voice their opinion. However, the question of consent becomes problematic when residents have dementia. Caregivers should have those residents evaluated by their physician, psychiatrist or psychologist to determine their ability to consent. There are multiple evaluation tools available to psychiatric practitioners to determine a confused resident's ability to consent. Additionally, many articles are available, stating that cognitive impairments do not preclude a person from recognizing their desire for intimacy and pursuing a meaningful relationship. These same articles also can be used to assist with educating family members.

Educate and Train Staff – The new policy regarding residents' rights to engage in appropriate sexual activity should be reviewed in detail. Some staff members may consider a senior's sexual preferences and behaviors to be wrong, perverted or embarrassing. Providers then should offer support to the staff and allow them to discuss their concerns, while reminding them that the rights of the residents are no different from other seniors who live in the surrounding community and engage in sexual expression privately. It is never acceptable to speak or gossip about the consensual sexual activities of any resident with others, inside or outside of the facility. For culturally diverse groups, ongoing sensitivity training (that includes sexual orientation) can help to decrease instances of potential discrimination. Additional training should include examples of consensual versus non-consensual consent, along with signs of abuse behavior. Providers should remind staff, if they are concerned that a resident may be involved in an unwilling, non-consensual, harmful or potentially abusive intimate relationship, they need to inform their supervisor immediately and follow the facility protocol for suspected abuse.

Educate Residents – By providing information on safe sex, such as the use of prophylactic products, residents in your facility can take the proper precautions. Baby Boomers became sexually active at a time when facts about sexually transmitted diseases and safe sex were not as readily available as they are today. Healthcare providers can mistakenly assume that all seniors are aware of the commonly known risks associated with sexual activity or think there aren't any risks past a certain age. CBS News recently stated that sexually transmitted diseases have more than doubled over the past decade in adults aged 50 to 90.

As the largest generation becomes senior citizens and moves into senior living facilities, it is imperative for providers to prepare for resident sexuality. Baby Boomers will expect and demand all of their rights, including those concerning sexual expression and intimacy, be upheld.

Sources and Additional Resources:

Kansas Department on Aging, Peak Nursing Home Initiative. Pioneering Change Sexuality in Nursing Homes Education Module. Retrieved September 22, 2014 from www.kdads.ks gov/long term care/PEAK/Modules/Sexualitymodulef.pdf.

Center for Practical Bioethics (2006). Considerations Regarding the Needs of Long-Term Care Residents for Intimate Relationships and Sexual Activity. Retrieved September 22, 2014 from

The International Longevity Centre (2011). The last taboo: A guide to dementia, sexuality, intimacy and sexual behavior in care homes. Retrieved September 22, 2014 from

Hebrew Home at Riverdale (2013). Policies and Procedures Concerning Sexual Expression. Retrieved September 22, 2014 from

Hebrew Home at Riverdale (2011). Assessing Consent to Sexual Activity in Older Adults. Retrieved September 22, 2014 from

State of Wisconsin Board on Aging and Long Term Care Ombudsman Program. Sexuality & Intimacy in Long Term Care. Retrieved September 22, 2014 from

Resident Intimacy and Sexuality Task Force with the CDPH and EMSD (2014). Investigative Guidelines for Resident Intimacy and Sexual Behavior. Retrieved September 22, 2014 from

Colorado Department of Public Health and Environment, Health Facilities Division (2004). Frequently Asked Questions and Answers Related to Resident Sexual Activity. Retrieved September 22, 2014 from

"Better Serving the Lesbian, Gay, Bisexual, and Transgender Populations in Long-Term Care." American Health Care Association, National Center for Assisted Living. 2014

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