Sexuality in Nursing Homes: Preserving Rights, Promoting Well-being
By Jennifer Sisk, MA

Sexual desire does not disappear with age. Professionals play a key role as advocates for the rights of nursing home residents to express their sexuality.

For many older Americans, entering a long-term care facility means giving up their independence, their homes, their livelihood, and many of their favorite possessions. Often adding to these major losses is the perception that the freedom and privacy to express their sexuality has also been lost. Because society tells us that sex is for the young and healthy, it is mistakenly assumed that sexual desire dwindles after a certain age. Sexual expression by residents in long-term care facilities is often misinterpreted as a behavioral problem, but it may be a sign that an important basic need—the need for human touch, closeness, and intimacy—has been overlooked.

Legally, 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. However, barriers remain, and for many residents, appropriate sexual expression may be prevented by lack of privacy, physical and mental health status, lack of institutional policies and procedures, and staff or family intervention.

Responsibility for Residents’ Rights
In response to the often-sensitive issue of geriatric sexual expression, some facilities have established firm policies and procedures to ensure that staff supports residents’ rights.

In the early 1990s, the research department at the Hebrew Home for the Aged in Riverdale, NY, decided that it needed to formalize resident rights to sexual expression and created a sexuality workgroup composed of social workers, psychiatric nurses, therapeutic recreation specialists, researchers, residents’ family member representatives, and religious representatives to establish policies and procedures related to sexual expression and residents’ rights. The current policy specifically outlines residents’ rights to privacy, sexual expression, and intimate relationships, as well as delineates staff and facility responsibilities in upholding these rights. With the aid of a $250,000 grant from the New York State Department of Health, the Hebrew Home also produced a training video, “Freedom of Sexual Expression: Dementia and Resident Rights in Long-Term Care Facilities,” which presents both appropriate and inappropriate sexual expression and has since been sent to all long-term care facilities in New York State. The video introduces the importance of each facility having residents’ rights policies related to sexual expression and the responsibility of staff in upholding them.

The rights of residents in a long-term care facility to engage in appropriate sexual activities have not always been clear cut and supported by staff. According to Robin Dessel, LMSW, assistant director of social services at the Hebrew Home, supporting the sexual rights of geriatric residents is keeping with the relatively recent movement to deinstitutionalize long-term care facilities. This holistic movement involves changes in facility design, creative programming, and individualization of resident care. For example, at the Hebrew Home, a patient floor previously referred to as “The Alzheimer’s Unit” is now called a “Special Care Neighborhood.” The Hebrew Home recently constructed a new resident-centered pavilion with private rooms and bathrooms called households. This change in the culture and philosophy of long-term care has the ultimate goal of making the end-of-life experience more appealing, says Dessel, and the new attention to residents’ rights to sexual expression is part of the overall change in philosophy. “The facility is now viewed as the resident’s home. The term home implies a place of choice, a place of pleasure,” says Dessel, where appropriate sexual expression can occur.

Additionally, the health benefits of sexual expression and intimate relationships for geriatric residents are being realized. “As people age, they do not lose their need for intimacy, and in fact, because of losses due to nursing home placement, declining health, and lifestyle changes, the need for intimacy may even be greater,” notes Catherine C. Bradley, MSW, LCSW, ACSW, a long-term care social work consultant for nine years. “An intimate relationship with another resident can enhance self-esteem and well-being.”

The resident’s happiness and quality of life is important. Dessel adds, “Warmth, closeness, and touching with another resident can alleviate the profound loneliness that affects many long-term care residents.”

And, residents are not necessarily seeking only sexual gratification. “They are seeking comfort, companionship, and human touch to combat feelings of loss and isolation,” says Janis Lyons, LCSW, a geriatric social worker at the Motion Picture & Television Fund (MPTF) long-term care facility in Woodland Hills, CA. “This expression is vital for their emotional and mental health. It enhances the quality of the remainder of their life.”

As more facilities realize that sexual expression is essential to their residents’ quality of life, the role of the geriatric social worker has grown to include daily interaction about this issue with both nursing home residents and staff.

Professionals as Advocates
When an appropriate consensual relationship develops between two residents, professional staff can support the residents by monitoring the relationship to make sure that it remains consensual and residents do not become agitated or upset. 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 that require privacy, social workers can often help arrange private space and time for the couple. “It is important to make sure that both residents are able to consent and have been counseled on safe sexual practices and understand that sexual activity should be in private,” says Bradley.

In most nursing homes, rooms are double occupancy, and private room time is difficult with a roommate. “There are limited options for privacy in such a structured environment,” says Doreen Delgado, MSN, ANP, a nurse practitioner and educator at the MPTF. At the Hebrew Home, Dessel says, “When possible, we will find a private room for one member of the couple. If that is not possible, we can arrange private time in a shared room when the roommate is participating in a chosen recreational activity elsewhere.”

“Ongoing staff education is needed to ensure rights to sexual expression in the geriatric population,” Bradley says. Clinical staff may view nursing home residents more as patients, focusing primarily on their medical needs rather than personal and emotional needs. “Clinical staff need to understand that elderly long-term care residents have very real sexual needs that might exceed what staff would consider their clinical needs,” Dessel observes. “These are people, not just patients,” she emphasizes at regular monthly orientation meetings for new staff.

Personal beliefs about sex can also influence how clinical staff deal with sexual expression. At the MPTF, staff members enjoy seeing companionship between residents, but they often find it difficult to deal with sexual expression, Lyons notes. “On a consistent basis, our staff are distressed about resident sexual behavior, even when it is appropriate. Their religious and cultural beliefs affect how they view sexual expression between residents,” says Delgado. Same-sex relationships and residents who are still legally married to a spouse outside MPTF are especially problematic for most staff members, even though residents have the right to engage in such sexual expression, according to Delgado. “Some staff members remain uncomfortable with residents’ sexual behavior,” she says, “mostly due to their own cultural issues related to sexuality.” In the Hebrew Home’s “Freedom of Sexual Expression” video, the narrator says, “A hundred staff members can have 100 different personal, moral, and religious approaches to sex, but there can only be one institutional approach.”

When the Hebrew Home introduced its policy on sexual expression, Dessel and a psychiatric nurse did multiple in-service trainings to introduce the new policy and its importance to all staff members—from nurses to housekeeping staff. “We explained that we were not looking to challenge or change a staff member’s personal beliefs or to offend them. We are simply asking them to uphold the rights of residents and not deny them appropriate sexual pleasures,” Dessel explains. At the in-service trainings, methods of dealing with different sexual expression scenarios should be discussed. Often, simple, non-threatening, and nonconfrontational actions—such as discreetly closing a resident’s room door or privacy curtain if they see a resident or residents engaged in appropriate sexual activity—are effective, says Bradley. However, in many cases, clinical staff cannot determine whether sexual expression is appropriate or beneficial to the resident(s). The geriatric social worker then acts as a resource for staff members.

While the staff of a nursing home may consider certain sexual behaviors to be aberrant or perverted, as long as the behaviors are safe for the resident or others and are not performed in public areas, residents have the right to engage in those behaviors. These rights are no different from those of older individuals who live in their own homes and engage in such sexual expression privately. For example, a staff member may be personally offended by homosexuality or masturbation while viewing sexually explicit materials. However, staff members do not have the right to impose their sexual preferences and views on any resident. Frequently, male residents, especially those with dementia, can become less inhibited in public. How does a staff member handle a situation where a male resident begins masturbating while watching television in a public area with other residents? Moving the resident to his own room, where he can view pornographic materials and masturbate in private, supports the resident’s right to sexual expression without offending other residents. “The sexual expression is not wrong, only its public display,” says Dessel.

Progress for the Future
Based on communications and questions from staff at other facilities, Dessel believes there is a greater recognition of geriatric sexuality, and a move toward understanding that sexual expression is a reality in long-term care. “It is prudent to acknowledge resident sexuality to plan for these situations,” she says.

Bradley says most facilities she works in do not have specific policies for residents’ sexual expression. Delgado and Lyons both note that there has been a rise in consciousness about residents’ rights to sexual expression at MPTF, but there is also continued embarrassment and discomfort among the clinical staff. “We are not anywhere close to actively promoting sexual expression,” says Delgado. “For residents to thrive in long-term care, we do need to look at every aspect of well-being, and that includes intimacy with other residents,” she adds.

— Jennifer Sisk, MA, is a suburban Philadelphia-based freelance writer with 15 years of experience as a writer and a research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.