1. Sexuality in Elder Care:
Toward a New Paradigm
Lois Stewart-Archer RN, MN, CPMHN(C)
Regional Clinical Nurse Specialist
WRHA Geriatric Mental Health
Susan Bernjak RN, BA, CACE, GNC(c)
Regional Educator
WRHA PCH Program

2. SHHHHHH, we’re talking about sex!

3. Sexuality in Elder
Care
Objectives:
• we will ask you to examine, and
maybe change, your attitudes and
beliefs regarding sexuality and the
elderly
• we will look at some challenging
behaviours related to sexuality
• we will look at policy development

4. Thoughts on
Sexuality
“In our experiences, old folks stop having
sex for the same reason they stop riding
a bicycle –general infirmity, thinking it
looks ridiculous, no bicycle.”
A. Comfort

5. Thoughts on
Sexuality
“Aging … is a metaphor for
asexuality”
H. Davies, et al

6. Thoughts on
Sexuality
What do the words “sex” and
“sexuality” mean to you?
What are some common attitudes
and beliefs held by staff?
Common staff reactions?

7. Staff attitudes
• residents aren’t interested in sex
• sexual behaviours are a problem
not an expression of a need
• staff are uncomfortable with
displays of affection/sexual
behaviours
• staff become paternalistic

8. Staff attitudes
• concerned about competency of
residents involved
• level of comfort with gay and
lesbian relationships
• may feel disgusted
• uncertain what to do or say

9. Staff attitudes
What influences our attitudes and
beliefs on sex and sexuality?
• cultural values
• personal beliefs
• lack of understanding
• inadequate training

10. Myths about
Sexuality and the
Elderly
• “old people don’t have sex”
• “old people have stopped
developing relationships”
• “old people aren’t interested in
sex”

11. STATISTICS
Of the1604 men and women ages
65-97 who responded to a survey:
• 40% reported that they had
sexual activity an average of
2.5x/month
• 69% of the men and 49% of the
women reported that sex was
important in their lives

12. STATISTICS
A recent study from the New England
Journal of Medicine reported that:
• more than half of those surveyed who
were between the ages of 57-75 stated
that they gave or received oral sex
• one third of those between 75 and 85
reported that they gave or received oral
sex

13. STATISTICS
Another study showed that:
• 74% of married men and 56% of
married women > 60 continued to
be sexually active
• 31% of unmarried men and 5% of
unmarried women > 60 continued
to be sexually active

14. STATISTICS
Among the most seriously
cognitively impaired elderly, 7%
are reported to exhibit sexually
disinhibited behaviour.

15. Sexuality &
Intimacy

16. SEX & INTIMACY
“Sex and intimacy encompass a
kaleidoscope of feelings and activities;
from the deepest longings for mutual
affection to the simple enjoyment of the
company of a loved one” (Sherman, 1998).

17. SEXUALITY
Sexuality also covers a gamut of
behaviours – touching, kissing,
caressing and cuddling, genital
intercourse with mutual orgasm and
feelings of closeness and being wanted
and valued as a human being.” (Sherman , 1998).

18. Sexuality Defined
“Sexuality is a central aspect of being human
throughout life and encompasses sex, gender
identities and roles, sexual orientation, eroticism,
pleasure, intimacy and reproduction. Sexuality is
experienced and expressed in thoughts, fantasies,
desires, beliefs, attitudes, values, behaviours,
practices, roles, and relationships. While sexuality
can include all of these dimensions, not all of them
are always experienced or expressed (WHO, 2003).

19. Intimacy
The need and ability to experience
emotional closeness with another
human being and to have that
emotional closeness predictably
reciprocated (Denis Dalley).

20. Sexuality: What
does it mean?
• Close companionship
• Touch and be touched
• Body image
• Synonymous with sexual activity and
intercourse.
(Deacon, Minicheiello, Plummer, 1995)

21. Sexually Dysinhibited
Behaviour
Incidence 4% - 7%
Occurrence: both males and females
Both long term care and acute care
Particularly high with those with a
dementing illness

22. Changes secondary to
Dementia
Of Note:
Existing relationships →adapt
New relationships → form
Desires → fluctuate

23. Dementia: Sexuality
& Intimacy
Changed sexual Diminishing sexual
behaviours interest
• Uncharacteristic? • Withdrawn, non-initiate
Illness related
• Sexual desire – what,
when, where Increased sexual demands
• Unreasonable, exhausting
Loss of inhibitions • “Objectified”
• Advances towards
others

24. What Does Not Change?
The right to be sexually alive, should adults
wish - regardless of age, ability, or sexual
preference.
Intimacy is a basic need, which people with
Dementia and their carers should be able to
express, WITHOUT FEAR OF DISAPPROVAL!

25. Causes of SDB
• Underlying Medical Problems
Labial Cancer Vaginitis
Prolapsed uterus UTI
Colorectal cancer Scabies

26. Causes of SDB
• Aggressive response
to stressor of
institutionalization
• Threat, fear, loss
• Structure
• Tasks exceed ability etc

27. Causes of SDB
• Dementia/Depression
- misunderstanding of environmental cues
- not adhering to social norms
- disturbance in memory, judgment
- psychological conflicts acted out through
sexual behaviour
- frustration, confusion
- boredom, inability to concentrate

28. Causes of SDB
• Need for
Intimacy
Desperation
for human
contact

29. Causes of SDB
• Panic associated
with death
– helps mask

30. Causes of SDB
↓ impulse control
Age-related
Changes

31. Medication Adverse
Effects
A/D (tricyclics - ↓desire, SSRIs - delayed ejaculation, Trazodone –
↑desire
Antihypertensives (analapril, diuretics)
Antianxiety (inhibition of orgasm)
Narcotics (↓ desire)
Antifungals (ketoconazole – erectile dysfunction)
Anticoagulants (Heparin – priapism)
H2 antagonists (Ranitidine – gynaecomastia)
Anti-lipid (Niacin - ↓ desire)
(Finger et al, 1997; Thomas et al, 2003; Rizvi et al, 2002)

32. SDB: Theoretical
Framework
Habits,
Personality SDB
Satisfies the need
Current condition
Physical SDB
Unsatisfied Communicates
Mental Need needs
Environment
SDB
Physical
Due to Frustration
Psychosocial
Negative Effects
Cohen-Mansfield, 1990

33. General Suggestions for
Basic Intervention

34. Disturbance in Memory and
Judgment
Reorient to person and place as possible
Use short simple instructions to direct to
room or redirect behaviour
Label rooms to help locate privacy
If SDB persists, use alternative clothing
• Pull-over shirt
• Elasticized pants
• Back-closing shirts etc.

35. Unmet Need for
Affection
Assign same caregiver consistently
Spend time with Resident/Pt.
Provide tactile stimulation e.g. touch, toys,
texture
Encourage verbalization re: sex and sexual
frustration
Reward for appropriate requests for
attention e.g. smile, hug, spend time

36. Death Anxiety
Spend time with Resident/Pt.
Encourage to verbalize feelings
about illness, end of life
Engage in life-review or reminisce
therapy as appropriate
Reinforce that he is not alone

37. Age-related changes
with
↓ impulse control
Provide with limits for behaviour, outlining
acceptable and unacceptable behaviour in the
present environment
Reassure of acceptance
Problem solve to determine ways to manage
(situation triggers, alter situation)
Reward for appropriate requests for attention e.g..
Smile, hug, spend time

38. Misinterpreting
Environmental Cues
Behaviour Possible Explanation
Clothing removal Clothing - hot, itchy, tight
Self exposure Need to use bathroom
Masturbation Boredom, frustration
Inappropriate touch Mistaken identity
Requests for kisses Expressed need to touch
Attempts to fondle Misinterpret others

39. Principles
• Observation
• Assessment of past and present
• Identification of unsatisfied needs
• Adaptation of intervention to needs, personal
characteristics, environment
• Trial of several alternatives
• Assessment of approach used
(Groul, 2005)

40. Defining Capacity to
Consent to Sexual Relations
Ability to Avoid Exploitation
• Is the behaviour consistent with formerly held beliefs and
values?
• Does the person recognize the concept of choice and
voluntariness?
• Does the person have the information needed to make a
decision?
• Does the person have a guardian?
(Alzheimer Mb., 2006)

41. Defining Capacity to
Consent to Sexual Relations
Awareness of Potential Risks
• Does the person realize that sexual contact may be
time limited?
• Can the person describe how she/he will respond if
and when contact ends?
• Is the person aware of any potential physical and
emotional harm?
• Can the person take precautions against risks?
(Teitelman, 2002)

42. Our Approach

43. Our Approach to
Sexual Behaviours in
LTC
A Problem-Solving Approach
We need to ask ourselves:
• is the behaviour really sexually motivated?
• is this “normal” behaviour for this
individual?
• is there a trigger for the behaviour?
• who is this really affecting?
• staff? other residents? families?

44. Steps in a problem
solving approach
1. Define the problem
• is there a problem?
• whose problem is it?
• who is it affecting?
• the resident? the family? other
residents? staff?

45. Steps in a problem
solving approach
2. Assess the person
• what is behind the behaviour?

46. Steps in a problem
solving approach
3. Develop a plan
• what is the desired outcome?
• as a team, decide on the interventions and
recommendations you want to put into
place
• work with the resident, the family, other
residents, the interdisciplinary team and
staff on all shifts

47. Steps in a problem
solving approach
4. Evaluate and monitor

48. Challenges
Masturbation
• video clip
• applying the problem solving
approach

49. Challenges
Consenting Adults
• video clip
• applying the problem solving
approach

50. Policy Development
Having a policy in place provides guidance
for looking at a situation in a more
objective way.
What do you need to take into
consideration when trying to develop a
policy on sexuality?

51. Policy Development
• a statement of purpose
• definitions of sexuality and intimacy
• a definition of sexual expression
• a definition of capacity

52. Policy Development
• what individual rights do you want to
include in the policy?
• the resident’s rights
• the rights of other residents, families and
staff

53. Policy Development
• resident rights you may want to
consider include:
• the right to seek out and engage
in sexual expression

54. Policy Development
• the right to obtain materials with legal
but sexually explicit content for personal
use
• the right to privacy in support of sexual
expression

55. Policy Development
• the impact on other residents, family, staff
• who is the recipient of the sexual
expression?
• what if a cognitively impaired resident is
the recipient of the sexual expression?

56. Policy Development
• what will you do if there is no consensus
among the resident, other residents, staff
and family?
• include a reminder that each incident needs
to be considered individually
• what is your commitment to on-going
staff/family education?

57. Ethical Considerations
Some thoughts on ethical considerations:
• views on sexuality and the elderly are often
not a reflection of the values of the resident,
but rather the values and attitudes of staff
and the facility

58. Ethical Considerations
• at what point do we, as staff, have the
right to decide what is inappropriate
touching?
• how do we tell the family?
• how do we decide whether a relationship
will continue?
• determine capacity?

59. Ethical Considerations
• how do we determine that we are “caring”
for a resident, not “controlling” a resident?
• how do we decide whether the “then” self
controls the destiny of the “now” self?

60. Organizational Support of Sexual
Expression in LTC Facility
Area Interventions
Policy Development of policies incorporating the sexual needs of
residents into care plans
Education Staff education tailored to the defined level of staff
Access Access to beauty salon, manicurist, cosmetics
Privacy Offering married couples own room
Do not disturb sign
Requiring knocking prior to entering room
Facilitation of conjugal/home visits to spouse
Environment Provision for locked doors
Availability of a double bed

61. Responsibilities of Nursing Home
Staff Regarding Sexual Expression
Issues Responsibilities
Environment Maintain awareness, support sexual expression
Privacy Needs Assist in maintaining privacy for sexual activity
Materials Permit access to sexually explicit materials (magazines,
videos, etc)
Risk Identify situations requiring intervention, such as:
• involvement of those with impaired cognition
• presence of medical condition that might limit or require
adaptation of sexual activity
• risk of communicable disease – STDs
• public expression offensive to others
• emotional distress, possibly requiring counselling

62. KEY POINTS
People with dementia have lived with their sexuality for much longer than they
have lived with Dementia.
Not everyone with Dementia is heterosexual
Not everyone chooses to exercise his right to be a sexual being
Couples who work on their relationships can keep them stronger for longer
Maintaining a healthy sex life can improve overall quality of life for caregivers
and those with Dementia
Caregivers need to consider their own needs along side those who have Dementia
The risk of sexual infections does not diminish with age
Sexual abuse of a person with Dementia can constitute a criminal offence

63. Video Clip
Backseat Bingo
6 min

64. Questions/
Comments

65. References
Archibald, C. “Sexuality and Dementia: The Role Dementia Plays When Sexual Expression
Becomes a Component of Residential Care Work” Alzheimer’s Care Quarterly Apr./June
2003
Barnes, I. “Sexuality and Cognitive Impairment in Long Term Care” Canadian Nursing Home
Oct. 2001
Bonifazi, W. “Somebody to Love” Contemporary Long Term Care April 2000
Cohen-Mansfield, J. Theoretical Frameworks for Behavioural Problems in Dementia. Alzheimer’s
Care Quarterly, 1(4):8-21. (1990)
Groulx, B. Screaming and Wailing in Dementia. Canadian Alzheimer Disease Review,7-11.
(2005)
Hajjar, R. & Kamel, H. “Sexuality in the Nursing Home, Part 1: Attitudes and Barriers to
Sexual Expression” Journal of American Medical Directors Association Mar./Apr. 2004
Lindau, S. et al “A Study of Sexuality and Health among Older Adults in the United States”
New England Journal of Medicine August 2007

66. References
Loue, S. “Intimacy and Institutionalized Cognitive Impaired Elderly”, Care Management
Journals Winter 2005
Roach, R. “Sexual Behavior of Nursing Home Residents: Staff Perceptions and Responses”
Journal of Advanced Nursing 2004
Robinson, J. & Molzahn, A. “Sexuality and Quality of Life” Journal Of Gerontological
Nursing March 2007
Teitelman, J. & Copolillo, A. “Guidelines for Recognition and Intervention” Alzheimer’s
Care Quarterly Summer 2002
Wallace, M. “Sexuality and Aging in Long Term Care” Annals of Long Term Care February
2003
WHO Definition of Sexuality and Intimacy. Geneva: Author. (2003)

67. Reference (Modules)
“Intimacy, Sexuality and Sexual Behaviour in Dementia: How to Develop
Practice Guidelines and Policy for LTC Facilities” (McMaster website)
Sex and Sexuality in Long Term Care: Mod. 2: Sexuality and Dementia
“Staff Education Manual: Resident Sexuality in the Nursing Home”
The National Alzheimer Centre of the Hebrew Home for the Aged at
Riverdale

68. References
Videos:
Freedom of Sexual Expression
Backseat Bingo