University at Buffalo (UB)
In a recent article concerning the sexual abuse of one nursing home resident by another, the failure of the staff to fully recognize the responsibility to supervise and protect residents from harm leads to a tragic outcome. Not only does the victim suffer irreparable damage, but the perpetrator suffers as well for the ignorance of the staff about dementia and issues of sexuality and sexual expression.
The issue of sexuality is often taboo in the institutional environment. Either the staff lack any understanding and consideration for the very human emotions and needs we all share, or they are uncomfortable with sexuality and would rather avoid having to address it at all. In extreme cases, staff may see themselves as the moral police, imposing their personal feelings and beliefs about sexuality on the dependent population.
When complicated by dementia, sexual expression becomes more complex. Experts tell us that the person with dementia will experience changes in their sexuality. “As the ‘control center’ for behavior and emotion, the brain determines sexual feelings, good manners and inhibitions. This means that in a person with dementia, sexual feelings can change unpredictably.”[1]
The person with dementia may experience an increase or decrease in sexual interest, engage in uncharacteristic self-stimulation or other public displays or make sexual advances toward someone they mistake for a spouse. In each of these situations the person is without fault as his or her ability to comprehend why the behavior is inappropriate is lacking. The manner in which intervention is applied may serve to intensify agitation if not done with sensitivity for the person’s dignity and lack of understanding.
Staff often struggle to balance residents’ rights with their duty of care, and negative attitudes towards older people’s sexuality can lead to residents’ sexual expression being overlooked, ignored, or even discouraged.[2] The criteria for establishing the capacity to consent to sexual behavior is varied and should be evaluated on an individual basis. There are different levels of capacity and the team should look at all aspects of the ability for informed consent before making a determination about the care path.
Sometimes the actions or a comment a resident may make to staff or other residents is misunderstood as sexual. What appears to be sexual may actually be an indication of something quite different, such as:
As with any mood and behavior issue, a thorough and complete investigation into the circumstances leading up to the event is essential. Without identification of the things that trigger certain reactions and feelings the team will be hard-pressed to address them successfully.
Federal regulations addressing a variety of topics under the umbrella of Abuse Prevention impact our response to issues of sexual expression generally and, specifically, with regard to residents with dementia or other diagnoses or conditions affecting their capacity to make informed decisions. Under the Abuse Prevention guidelines (F223-F226) issues of resident-to-resident abuse are addressed relative to the caregiver’s responsibility to identify the risk and develop a plan to prevent the abuse from occurring.
In F323 addressing Accidents the responsibility for supervision of residents to prevent incidents, accidents and circumstances that can lead to abuse, neglect, mistreatment or misappropriation of property is stressed. The effectiveness of the supervision will make all the difference in preventing events and maintaining a safe, quality living environment.
The first challenge to long term care facilities is improved staff education and training on the subject of human sexuality. Staff should be able to recognize these needs and plan proactively to not only protect residents from each other, but to ensure the dignity and well-being of residents is protected and maintained.
The second challenge is that of developing meaningful, satisfying activities for all residents to engage them, distract them, delight them and keep them safe. With the right activity offered in the right environment the job of protecting, supervising and caring well for all residents will be more easily achieved. True person-centered care begins with caring enough to be well-educated and well-prepared to efficiently and successfully navigate the very delicate task of caring for another human being, completely and in a manner that is satisfying for all concerned.
Barbara Speedling, Quality of Life Specialist ©2012
[1] Sex and Dementia, Alzheimer’s Society UK, http://www.alzheimers.org.uk/site/scripts/documents info.php?documentID=129
[2] Dementia, Sexuality and Consent In Residential Aged Care Facilities; Laura Tarzia, Deirdre Fetherstonhaugh, Michael Bauer; J Med Ethics doi:10.1136/medethics-2011-100453
[3] Sex and Dementia; Alzheimer’s Society, UK,http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=129