When training in dementia care the issue of sexuality will often come up. One overriding principle of my training is about the power, and importance of human connection, whatever shape or form that might take. I believe that sexuality, and intimacy is an important part of that. Yet often sexualised behaviour activity in care homes is labelled as problem behaviour. Despite these practices being common place in many services, some staff struggle to understand why two people who enjoy, and benefit from an intimate relationship should be separated. Many staff battle balancing priorities; safeguarding, capacity, rights, often alongside an overwhelming pressure from families. Exploring this in training often takes the conversation down many multi-facetted dimensions, often creating a good opportunity to tackle issues which fundamentally place barriers to many aspects of wellbeing in older people’s services.

 

Ageism and sexism have been successful in portraying sexuality as the preserve of young people and stereotyping older people as asexual. Older people sometimes collude with this, worried about how people might respond if they ‘come out’ (Gott et al. 2004).

 

The need for intimacy does not diminish with age, but often increases. However many services are not equipped to support this.  There are often physical barriers in place, such as lack of privacy, or the availability of couple bedrooms. Sometimes these barriers are as a result of poor attitudes, such as myths about sexuality. It may also be as a result of poor assessment frameworks that fail to include the whole person. To truly embrace person centred planning we need to consider the whole person, and this includes assessment and planning of how to support a person’s sexuality.

 

Our sexuality is an integral part of our identity, and therefore should be nurtured. Self-identity as a construct is well researched in dementia care. Sexuality incorporates intimacy, romance, sensuality, eroticism and relationships.  Emotional connectedness is fundamentally important to wellbeing.

 

“…a central aspect of being human throughout life 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. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” (WHO, 2006a)

 

 

Certain medications, pain or surgery might affect sex drive/libdo. Conditions such as diabetes, Parkinson’s (Mott et al., 2005), rheumatoid arthritis (Hill et al., 2003), and depression can all impact on sex and relationships (Rosen et al., 2004). Sexual dysfunction does not preclude a sex life. Services should be able to offer support and advice with this, as well as information on safer sex.

 

Capacity to participate in intimate relationships should be assessed (Berger, 2000), and not automatically precluded. The Mental Capacity Act 2005 offers limited support with such matters, and actually precludes an option to give consent to sex on someone’s behalf. The Sexual Offences Act 2003, may provide a more fit for purpose framework. However neither alone, provide a sufficiently robust framework to work through what amounts to a very complex, and often emotive subject. My feeling is that people should be provided with the right to freedom of sexual expression, as long as this does not impinge on the rights of others. We need to consider what should happen if someone does not have capacity, yet is clearly benefitting from mutually intimate relationships, and this activity is also doing no harm.

 

Tenenbaum (2009) suggests a four-step approach:

 

1. Determination of whether the individual has the ability to express a choice,

capable or otherwise;

2. Determine the interests or values that might be affected by acting on these desires,

including the effects on the feelings of others;

3. Determine whether the resident can consider these interests in making a

decision. If so, the relationship should be allowed to continue.

4. If not, determine whether the values of the relationship outweigh the critical

issues.

 

Clearly intervention is only acceptable if the person lack capacity, but in itself this may not be sufficient. Everett (95) argues that any interference should not create more harm that it prevents.

 

Sexual behaviour activity has been actively discouraged, sometimes using threats (Roach, 2004), punishment and in some cases people have been given medication to control what is determined as a problem behaviour (Archibald, 2003). This is more likely if someone has dementia (Chandler et al., 2004). This practice clearly has to stop. Who are we to deny people intimate human connection, or a person’s right to enjoy their own body? Ward (2005) suggests that it is now time to move beyond a focus on sexual expression in care services, but instead to consider strategies that may facilitate and enhance this aspect of the lives of people with dementia residing in care.

 

Organisations should have; a policy in place that addresses how their operational procedures will meet desired outcomes around wellbeing. This will include the appropriate scope to their assessment to include sensuality, identity, sexuality and levels of intimacy to enable people time, and opportunity to discuss and plan. Organisations also need to consider their building design, to ensure that there are enough private spaces. Training should be provided to tackle myths about ageism, as well as unhealthy, and dangerous practices which restrict human connection. Sadly limited funding is made available to tackle such issues. Many service providers see this as a low priority, opting instead to spend their budgets on mandatory training. However forward thinking services that are driven by outcomes do commission and advocate the importance of this training. As a service we embrace working with these movers and shakers in the social care world. However, individual action is not enough, public policy also needs to embrace this, by broadening their sexual health policies to focus on those over 60. The media also needs to play its part in portraying positive images.

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