What is sexuality and sexual expression for older people?
Sexuality is a core part of the human experience. People of all ages have their own experience of their own sexuality, and ways of sexually expressing themselves. Sexuality is diverse and individual to each person, and can include one’s own ‘sexual feelings, thoughts, attractions, and behaviours towards other people’. [1]
A person’s discovery of their own sexuality is unique to them, and can be shaped by biological, psychological, emotional, and social aspects. Intimacy relates to sexuality and sexual expression, as it involves physical touch and emotional connection. [2] Sexuality and sexual expression can also change through life. [3]
In residential aged care, sexual expression by residents reflects ‘a spectrum with everything from daydreaming, touching, hugging, being able to share a bed with another person, kissing and masturbation on one end, to sexual intercourse at the other end.’ [4]
Why does this matter for rights-based care?
Older people have the right to their own sexuality and to sexually express themselves. Sexual expression is seen as a basic need for older people, which should be supported. [5] Quality care also involves respecting sexual rights. In Australia, the strengthened Aged Care Quality Standards recognise this.
- Standard 1, Outcome 1.1 highlights that ‘1.1.3 The provider and aged care workers recognise the rights, and respect the autonomy, of individuals, including their right to intimacy and sexual and gender expression.’ [6]
- Outcome 7.1 of Standard 7 is specific for residential aged care. Service providers need to ensure that ‘7.1.6 Individuals can maintain relationships of choice free from judgement, including intimate relationships, and engage in sexual activity.’ [7]
Balancing sexual rights in practice
Sexuality and sexual expression should be considered as part of care planning. [8] In aged care, intimacy is often understood as part of a person’s right to dignity and autonomy. At the same time, worries about possible abuse can create tension and uncertainty around how intimacy is supported. [4] Aged care staff can find it challenging to balance protecting residents against harm with enabling their sexual rights and autonomy. [9] It is important to understand different views about sexuality and how they relate to residents’ rights and duty of care. [10]
Residents’ rights around choice, privacy, and sexuality can be restricted even when not intended. Staff can find it challenging to support older people’s rights for sexual expression. [11] Staff can feel uncomfortable, confused or embarassed when it comes to the topic of sexuality, and some may wish to avoid addressing sexual expression in their role. [10] Sexuality may not be addressed even though it is important to residents, [8] and the emphasis on doing no harm may take priority over upholding sexual rights. [2, 9] Sexual intimacy that takes place behind closed doors may raise concerns about how resident safety is ensured. [10] Different and/or discriminatory responses to LGBTQ residents’ sexual expressions can also happen. [5]
Ensuring the older person’s sexual needs are supported can be challenging, as the older person’s previous relationships can change, and perspectives of family members and aged care staff can frame how the older person’s intimacy is viewed. [4] Staff may see preventing disagreements about sexual intimacy as an important part of the care environment and try to discourage intimacy. [9] Residents have a right to privacy about their sexual expression, including when information is shared with families.
Around the world, many RACFs do not have specific policies that comprehensively address sexuality or sexual rights. [5, 9] Residential aged care facilities may need to review and change practices that limit privacy or prevent residents from sexually expressing themselves. [4] Staff training can also support a positive change in attitudes, boost sensitivity when discussing sexuality and sexual expression with older people, and address knowledge and practice gaps.
What should be considered when it comes to sexuality and older people with dementia and/or cognitive impairment?
Views about sexuality, dementia, and consent can vary, and this can affect how decisions are made between supporting autonomy and putting limits in place. [10] Staff can take on different roles that range from enabling and supporting sexual expression in dementia to blocking intimacy and sexual interaction. [10] While some may see sexuality as a fundamental part of ageing and quality of life, others may see dementia as something that affects the older person’s ability to express sexuality. [10] Sexual expression of residents with dementia may also be labelled as inappropriate sexual behaviour. [2]
Staff feel responsible for protecting older people from sexual abuse which they may prioritise over residents’ sexual needs when there is concern about dementia or cognitive impairment. [9] Family attitudes and beliefs about the older person’s sexuality can also influence how staff behave; for example, staff may distract residents with dementia from sexually expressing themselves, which may limit their autonomy. [10]
It can be difficult to understand what is needed for a person with dementia to give consent, which can make these situations harder to manage. [4] Rather than completely losing the ability to consent, a person with dementia may be able to consent to some forms of sexual expression but not others. [4] Aged care services should consider how sexual rights can be upheld for older people with dementia in ways that promote autonomy, safety, and privacy.
Want to learn more?
- palliAGED have also collated evidence on Intimacy and Sexual Expression in aged care.
- The #ReadyToListen Charter of Residents’ Rights and Responsibilities outlines 9 sexual rights and 3 related responsibilities for residents. It also has staff rights and responsibilities. The charter can be used to support service providers in responding to and preventing sexual assault within residential aged care.
- Resources like Sexuality And People In Aged Care Facilities: A Guide For Partners And Families can help partners and family members understand key points about expressing sexuality in a residential aged care context.
What can be done?
Appropriate communication and consent for sexual expression and intimacy
Care teams:
- Encourage sexuality and intimacy to be discussed within broader care teams, which includes relevant support people.
- Proactively discuss sexuality and sexual expression directly with older people. Identify their individual needs and any supports required. This also involves understanding their relationships, preferences, and relevant history. Consider asking older people about their sexual history and using models such as Ex-PLISSIT (Permission, Limited information, Specific suggestions, Intensive therapy) to enable conversations. [8]
- Create a plan, as part of care delivery, to ensure that these needs are met where possible.
- Ascertain and regularly review older people’s capacity to consent to (and refuse) sexual intimacy. This can change over time and with the ways in which sexuality is expressed. Consider how cognitive impairment can impact the older person’s ability to consent.
Organisations / service providers:
- Ensure aged care staff, residents, and their families are aware of relevant sexuality, sexual expression, and intimacy policies for older people in aged care.
- Have processes in place that help staff better document discussions with older people about needs, supports, and strategies relating to sexual expression.
The evidence:
- It is important to normalise conversations around sexuality and sexual expression in aged care. [8, 12] Sexual expression may not be a comfortable topic for everyone, so it can be avoided or glanced over. [12]
- Staff have an important role in starting conversations and recording sexual wishes as needs, which supports residents’ ability to embrace their sexuality. [12]
- Care plans can include the sexual needs of residents. [12] However, staff do not know enough about how and when to document sexual expression. [11] If not enough was documented, it was seen to get in the way of nursing care and impact person-centred care. [11]
- Residents’ capacity for sexual decision-making over time and how it changes can be useful to follow and regularly document. [13]
- The capacity to refuse is imperative especially if there is a power imbalance, for instance when one person is cognitively impaired and the other is not. [13] This may be challenging for older people with dementia. [13] Clear sexual expression guidance is needed to determine what would be harmful physically, socially, or emotionally. [13]
- Family concerns can shape how staff and service providers respond, and in some cases this can lead to residents’ sexuality rights not being upheld. [9] Staff may not be clear on how best to balance privacy and protection, or when to contact family members about residents sexually expressing themselves. [13]
Training and education
Organisations:
- Provide staff with training opportunities to broaden their understanding of sexuality, sexual expression, intimacy, and older people. Training on sexuality in the context of ageing (e.g., physiological changes), older people’s rights to sexual expression, sexual abuse and how to report it, and how to meet the needs of LGBT residents specifically can help to promote person-centred care and build a more inclusive environment. [14]
- Ensure that training supports care staff to implement relevant guidelines about sexual expression in older people.
- Identify existing assumptions, stereotypes, prejudices, or discriminatory views that staff may have about sexuality. Find ways to discuss and address them to improve the organisational culture and reduce any potential negative impact on care delivery.
Care teams:
- Educate older people, their families / relevant supporters and substitute decision-makers about sexuality and sexual expression in aged care. This can help normalise discussing sexuality and sexual expression for staff, older people, and their families.
Aged care workers:
- Reflect on attitudes and views about sexuality and how they may impact how older people’s rights are upheld when providing care.
- Identify knowledge gaps and seek relevant training to broaden your understanding of sexuality, sexual expression, and how it relates to older people.
The evidence:
- Training has a role in helping to overcome barriers such as negative staff perspectives, prejudices and/or discrimination within residential aged care. [2] Cultural and religious aspects can also have an influence. [2, 15] Training can help support sexual expression for residents and change staff attitudes to promote healthy intimate relationships in residential aged care. [4]
- Sexuality and dementia can raise complex issues, and opportunities to talk through how to respond appropriately are needed. [5]
- Staff need training and a clear understanding of the laws and policies that apply to their work. [5] Staff training in sexuality has been lacking in residential aged care settings. [9] It can also be centred around liability issues. [5]
- Because of a lack of policies and training, staff have reported everything because of uncertainty. [9] Lack of staff training can also lead to avoidant actions like ignoring private space or distracting residents, which can have negative impacts. [9]
- Knowledge and skills are important for staff to distinguish and respond to safe and unhealthy or unsafe sexual expression. [14] This includes how to talk about and record residents’ sexual preferences over time. [13] Training staff across different levels within the organisation should be considered. [14]
- Registered nurses have called for more tools such as discussion forums, educational resources and guidelines, to help support them to work with aged care staff and families around sexuality. [11]
Environments and policies that support sexual expression and intimacy where able
Organisations / service providers:
- Design residential aged care environments that enable residents to sexually express themselves in safe and inclusive ways. Consider the physical layouts of RACFs that impact residents such as private areas, shared spaces, and personalised environments. For example, organisations can provide larger beds as well as layouts and signs (e.g., do not disturb) that promote privacy.
- Develop and implement policies that help uphold older people’s sexual rights and minimise risks such as sexual abuse and spread of sexually transmitted infections. Consider utilising tools or resources like the #ReadyToListen Charter of Sexual Rights and Responsibilities in Residential Aged Care and the Sexuality Assessment Tool (SexAT) to identify areas of the organisation that need improving.
- Consider the balance between the level of monitoring of older people receiving aged care services and providing opportunities for privacy and sexual expression.
Aged care workers:
- Understand and apply relevant policies regarding older people and sexuality.
The evidence:
- Training, policies and guidelines, as well as a physical design that allows for intimacy and privacy to be respected can help address organisational barriers and negative attitudes among staff, supporting residents’ sexual expression. [2]
- Leadership plays an important role in shaping staff and resident attitudes about sexuality. [16] Policies factoring in potential staff biases that can affect aged care are needed. [13]
- Examples of RACFs that have taken a proactive approach to having policies protecting residents’ sexual rights highlight the value of clear organisational policies. [14]
- The physical environment of RACFs do not always allow residents to comfortably express themselves sexually. [2, 4]
- Ongoing surveillance in aged care can reduce privacy and limit sexual expression. [9] This includes, for example, staff knocking and entering rooms quickly. [4]
- A lack of privacy can make sexual expression more difficult. [2, 4, 9] RACF layouts and a lack of larger beds are some elements of aged care that contribute to this. [4] Addressing these issues can also support older people with dementia to express themselves in a RACF context. [10]