© Springer International Publishing Switzerland 2017
Angela Georgia Catic (ed.)Ethical Considerations and Challenges in Geriatrics10.1007/978-3-319-44084-2_1010. Intimacy in the Long-Term Care Setting
(1)
Department of Family and Community Medicine, Texas Tech University School of Medicine, Lubbock, TX, USA
(2)
Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
(3)
Family and Community Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
Keywords
IntimacyLGBTCognitive impairmentIntroduction
Sexual needs of the elderly have historically been misunderstood and ignored. Younger, healthier people tend to believe that sexual desire and activity normally cease with advancing age [1]. In reality, the sexual needs of the elderly are similar to those of younger individuals, but with variations in frequency, intensity, and mode of expression [2]. Social connection and human touch are essential ways of avoiding the depression and loneliness that inevitably abound when an elderly individual becomes isolated by losses or illness in advancing age [1]. Sexuality is often considered in the context of youth when, in reality, intimacy in the long-term care environment often takes the form of affection, romance, companionship, touch, and the need to feel attractive, even in the absence of overt sexual or coital activity [2]. Admission into a long-term care facility does not automatically diminish these basic needs and desires, although it often includes the loss of personal freedom, especially involving sexual fulfillment [3]. The communal atmosphere and environment necessarily leads to additional restrictions to individual autonomy, privacy, and expression of these behaviors. However, it is important to recognize that the Patient’s Bill of Rights mandates that a resident has the right to associate and communicate privately with persons of his or her choice, including other patients [4].
The architectural features of a long-term care facility are specifically designed to allow for easy access and observation. Although federal regulations mandate privacy as a given right of residents, interviews with staff indicate that there is general agreement that compromising resident privacy is justifiable if physical health can be enhanced [5]. Privacy of information is an often overlooked concern when it relates to a resident’s personal activities. Regulations require that private resident information may not be discussed, documented, or judged, unless it is directly required to the provision of care [2]. The evolution of the long-term care environment has created a resident-centric culture in which the facility may be viewed more as a home, where privacy permits an individual to function within “a place of choice, a place of pleasure” [1]. Individual choice includes both aspects of a resident’s previous life, such as cultural and religious beliefs, and a resident’s current sexual needs and expressions. It seems only logical to recognize and respect the highly individualized character of sexuality [6].
In the majority of long-term care facilities, the medical model receives emphasis, while the basic human right of loving and being loved is overlooked. This, in turn, determines operational norms and values of the community. In such a model, the nursing staff plays a central role in the care of institutionalized elderly. Sexuality is often not considered to be part of the primary caregiving role, largely because it is not vital to the maintenance of bodily functions [7]. In their desire to provide care, staff may inadvertently treat adult residents in an infantilized manner, making it difficult to contemplate them as sexual beings [8]. Additionally, many staff members have only a vague understanding of the sexual needs of their elderly residents. As the typical curriculum provided in healthcare professional education sends a message that sexuality is not an important aspect of geriatric health, there is often a sense of unease among physicians, administrators, and staff when considering these issues [9]. There is often a perception that residents’ sexual interests represent behavioral problems, rather than expressions of need for love and intimacy, and staff indirectly determine whether and which sexual acts are tolerated [10]. The most commonly observed sexual behaviors in nursing homes include hand-holding, kissing, petting, and masturbation. The impetus for policies concerning intimate relations in the long-term care facility setting is often a sexual violation, or perceived “inappropriate behavior,” committed by a resident [11].
In order for long-term facilities to care for each resident in a holistic fashion, they must expand their definition of basic human needs including the need for sexuality and touch. Regardless of whether this topic is brought to the forefront of societal and medical discussions, residents are finding ways to meet these needs. Studies have found that 25 % of patients were seen as “causing problems” due to sexual behavior or talk [12]. Staff felt uncomfortable in the face of what they considered to be “problem” sexual behavior and were unsure of what to do or say. Therefore, they typically fail to acknowledge residents’ sexual comments, touching, self-exposure, or masturbation [11]. The tension between an ethical responsibility to provide privacy, autonomy, and self-expression, while meeting the requirement to ensure a safe living environment that respects family values and cultural beliefs of each resident, creates a challenge for administrators and staff which must be considered on a case-by-case basis.
A Culture of Intimacy in Long-Term Care
Two nursing home residents with no cognitive impairments become attracted to one another and would like to initiate a relationship, including an intimate sexual component. While both are currently married, neither spouse has maintained an intimate relationship and they rarely visit. Their families are opposed to their relationship based upon differing cultural and religious beliefs and their intact marriages. Several staff members have expressed concern based upon their personal belief systems and point out that both residents have multiple debilitating illnesses and functional disabilities.
Benefits and Challenges of Intimacy in Long-Term Care
Essential to the ethical treatment of sexuality in long-term care is a process that allows the complex situation to be reduced into its basic components. Provided that all safety concerns are identified and addressed, residents of long-term care facilities should not be made to feel as if they “are being forced to hide in fear of having the enjoyment of sexual activity taken away from them” [1]. Residents retain a right to privacy and to express themselves as autonomous adults. In addition to the sense of control provided by their right to expression, developing and maintaining an intimate relationship has additional benefits. In an interview of residents of a long-term care facility, 73 % of the residents reported that sexual activity improves quality of life and 95 % viewed sexual expression as a way to promote a sense of well-being [13]. These health benefits can ease feelings of loneliness and despair that may lead to depression, clinical decline, and even suicidal ideations. Most long-term care residents also view sexual activity positively as a stress reliever [13]. It is likely that being involved in an intimate relationship makes residents feel more connected to their surroundings and allows them to confide in another, sharing similar joys and challenges of living in a long-term care setting.
While advantages have been noted, an intimate relationship can also be challenging for older adults. Only 1 of the 13 residents believed that “sexual activities are common in long-term care facilities,” and, therefore, they may feel isolated in their desire for intimacy [13]. The significant shift in cultural norms over the lifetime of many current nursing home residents contributes to the uncertainty around intimate relationships. Most residents began their sexual experience at a time of conservative norms and double standards when “Pleasurable sex was for men only, and women engaged in sexual activity to satisfy their husbands and to make babies” [9]. Additional feelings of guilt can arise when either or both partners are married. However, residents may wish to pursue intimacy outside of their marriage for a variety of reasons including physical separation from their spouses as well as significant differences in cognitive and physical function. The decision to remain faithful or not to the spouse, whatever the conditions of the relationship, lies exclusively on the resident. Regardless of the beliefs or opinions of staff or family members, the long-term care facility has an obligation to “address residents’ needs and interests and uphold residents’ legitimate rights” [14].
Cultural Support of Intimacy
In order to meet the needs of residents in a long-term care facility, the cultural circumstances of each individual should be recognized and respected by all interdisciplinary professionals. A popular nursing theory states that “culture is the broadest, most comprehensive, holistic, and universal feature of human beings; and care is embedded in culture.”[15] In the context of intimacy, this concept extends its meaning to include the fact that human touch and intimacy are expressed differently in individual cultural contexts. Interdisciplinary professionals should engage themselves in an active process of attempting to understand why residents hold certain beliefs or act in a particular manner. It is only through this process of understanding that long-term care staff will be able to address the unique background and basic human needs of each resident [2]. An important part of understanding intimate relationships in long-term care is determining what benefits are being provided by the relationship. For example, an individual’s selection of a specific partner is often based upon a need that is missing in their life at the facility, be that a desire for quiet conversation, human touch, or someone with whom to share activities. If residents express feelings of guilt regarding intimate relationships, these should be addressed in a manner that examines the cause and identifies methods by which it may be productively managed [16].
Due to the complex interaction between facility staff, residents, and family members in situations of intimacy in long-term care facilities, it is helpful to consciously consider facility culture and policy regarding these issues. Currently, over two-thirds of facilities do not have any policy regarding sexual activity between residents and only one in five has written policies [17]. However, written facility policies can be very useful as they help to guide the actions of administration and staff, provide an awareness and openness to the sexual health of residents, and encourage an atmosphere where privacy is respected. Such policies should be reviewed through regular trainings, and interdisciplinary case discussions regarding issues around sexuality should be encouraged. When a couple begins an intimate relationship, it is appropriate for interdisciplinary professionals within the facility, including administrators and physicians, to initiate a dialogue concerning how the couple intends to proceed with their relationship. This conversation is meant to facilitate a safe place for the residents to express themselves and their desires [18]. Occupational therapists, who often interact with patient’s function, and other staff members closely involved in care can also help elicit a patient’s sexual goals and desires. Intimate encounters can be planned for a time of day when energy levels are highest or physical symptoms are less troublesome. In addition, trained assistants can assist couples in experimenting with different sexual positions and assistive devices (i.e., pillows) to maximize comfort [19].
There is ongoing debate regarding the need to involve family members in intimate relationships within long-term care facilities. A survey of directors of nursing at skilled facilities indicated that more than half require family or a designated representative to approve sexual activity between residents, regardless of cognitive status, and one in eight still requires permission even when both individuals are cognitively intact. Less than 5 % require a physician order [17]. In general, even in cases where residents have cognitive impairment, it is not always necessary to require permission from family members if the partners are deriving benefit from the relationship.
Intimacy and Cognitive Impairment
An 82-year-old male nursing home resident with mild cognitive impairment is flirtatious and often makes sexually provocative comments to female staff, indicating that he likes to “play the field.” He has been observed spending increasing time with a 79-year-old female resident with mild to moderate dementia. She is largely independent for most ADL’s but requires assistance with dressing and toileting. She has severe osteoarthritis of the hips and is largely wheelchair-bound. The couple has frequently been observed in a quiet corner of the facility, and their intimacy has advanced to hugging and kissing. Although most behavior is initiated by the male resident, his advances are encouraged by his female partner. He tells staff that they need a private place where they can “make love.” He adds that he understands that he must be gentle with her due to her arthritis pain. She independently assures staff that she desires to be intimate in a private place and that they are in love. She adds that she does not want her family to be informed because “they will not approve.”
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