Lisa P.L. Low, RN, RHV, BN, MPhil 1 *
May H.L. Lui, RN, BN, MPhil 2
Diana T.F. Lee, RTN, RN, RM, PRD(HCE), MSc, PhD 3
David R.Thompson, RN, PhD, FRCN 4
Janita P.C. Chau, RN, BN, MPhil 5
Lisa P.L. Low, RN, RHV, BN, MPhil 1 *
Affiliations: 1. Professional Consultant Postal addresses:
2. Assistant Professor
4. Director and Professor of Clinical Nursing
5. Associate Professor
All at The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
Lisa P.L. Low (*Corresponding author)
The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
Tel: (852) 2609 8182, Fax: (852) 2603 5269
1. Professional Consultant
Addressing sexuality of older people is a neglected area and has received insufficient attention in residential care practice. This paper presents an urgent need to address this sensitive, potentially embarrassing but important health issue. It concludes that much work is still needed in this area, particularly to understand sexuality from older peoples’ perspectives and how their sexual needs and concerns can be addressed by those caring for them in residential care homes. Not until we truly know what older people want and understand what sexuality means to them can it be possible to plan individualized care that will meet their specific sexual need.
As the number of older people moving to residential care home continues to increase, there is a growing expectation that the care they receive will be of the highest quality. Yet to actively engage in discussion about how older people live in residential care homes conjures up unpleasant images that may make people uneasy and prefer not to think about it (Kane, 2000). Then what about broaching the subject of sexuality of older people in residential care homes? It is important, no doubt, but also sensitive and potentially embarrassing.
Even though sexual health has been acknowledged as an important component of quality of life for many older people (Miller, 2004), it has not been easy to either encourage or respond to older people expressions of sexual interest, attitudes, activity and satisfaction. Not surprisingly, there appears to be scant knowledge on how best to address the sexual needs of older people in residential care homes. As such, sexuality of older people is a neglected area that has received insufficient attention in residential care practice. In a selective review of the literature, this paper aims to offer insights into how sexuality of older people is expressed and addressed in residential care homes. It also suggests that more work should be undertaken to promote awareness of sexuality in residential care, particularly understanding what sexuality means from older people’s own perspectives. In this way, they may be supported to express their sexuality in appropriate forms across culturally diverse societies.
Sexuality is a complex and multi-dimensional concept covering the desire for sex, the sexual act and values, and beliefs about sex (Kaiser, 1996). Sexuality also involves the whole experience of a person’s sense of self, and includes a person’s ability to form relationships with others, feelings about themselves, and the impacts of the physiological changes of ageing on their sexual functioning (Kamel, 2001; Russel, 1998). Other dimensions of sexuality such as a person’s level of self-esteem, type of clothing worn, type of sexual activity one chooses to engage in and with whom, and the nature of the sexual act may also be considered (Peate, 1999). This suggests that a person’s sexual experience and their ability to enjoy it is very personal and individualized, and is related to age and degree of disability or ill-health (Russell, 1998). It would seem that when effort is put into promoting an understanding of a person’s sexuality, numerous benefits such as having a healthy self-image, psychological refueling and re-energizing, an outlet for personal anxieties, and a means of preventing social disengagement and avoiding depression results (Heath, 1999). Engaging in a sexual relationship can also bring love, intimacy and closeness that can further improve older people’s general well-being (Wallace, 1992). It is therefore important to promote sexual awareness of older people.
Many sexual myths and stereotypes work against older people and challenge whether the expression of sexuality in old age is appropriate. Despite studies reporting that older people can be potentially sexually active into later life (Marsiglio & Donnelly, 1991), the society still continues to devalue older people’s sexuality with humor, ridicule and distaste (Spurgeon, 1994).
One major challenge is trying to change people’s attitudes towards sex in later life and to outgrow the deeply embedded beliefs that sexuality is only the province of a youthful society (MacRae, 1999). As people age it is generally believed that they no longer look physically attractive and thus do not have sexual needs and, if they have any, they would need to suppress them. This is somewhat consistent with findings from older people who reported that they no longer felt physically attractive and thereby felt sexually unattractive (Richardson & Lazur, 1995). This commonly held misconception has unnecessarily coerced and socialized sexual older people into becoming asexual beings - who have lost their physical attractiveness, have no sexual needs, thoughts or desires to engage in any forms of sexual behavior (Kessel, 2001) - in order to comply with societal expectations and social values.
Few would deny victimizing older people for their overt sexual behaviors and labeling them as socially unacceptable. Indeed, such assumptions would deny older people the right to express their true sexual feelings verbally and behaviorally, for fear of being labeled as disgusting with unrestrained indulgence of lust (Archibald, 1998). Until these ingrained and longstanding myths are dispelled, older people’s sexuality will continue to be concealed, viewed with shame, and discouraged from the freedom of sexual expression by those caring for them (Bauer, 1999). So instead of working towards accepting older people’s sexuality as an indispensable part of human existence (Nay, 1992), society has further diverted needed attention to understand older people’s sexual needs and rendered their sexual behavior as insignificant.
Despite some progress made to challenge the prominent sexual myths of older people in residential care homes, supporting and allowing older people to freely express sexuality in acceptable forms is still a challenge for residential care home staff. The following will discuss different ways in which older people express their sexuality, and how residential care staff respond, understand and interpret older people’s sexual acts.
Older people’s expressions of sexuality
Studies demonstrating different types of sexual expression among older people in residential care homes found that, in terms of physical aspects, sexual intercourse, masturbation, caressing and touching have been reported – with the latter two being more prevalent among women than men (Lichtenberg, 1997). Limited contacts such as kissing foreheads, hugging, petting or holding hands were important social expressions of sexuality among women (Steinke, 1997). In terms of gender differences, there was a preference for women to enjoy social intimacy and strive for love and companionship, as opposed to sexual-physical acts. When allowed to engage in relationships with others, these positive experiences enabled them to feel joyful, special, loved and attractive again (Miles & Parker, 1999).
In contrast, there are older people in residential care homes who would deny any interest in sexual expressions. Notably, loss of interest has been demonstrated among older people with chronic illness and disability, when they experienced changes in body image and sexual dysfunction (Pangman & Seguire 2000). Additionally, not having able partners, lack of privacy to engage in sexual activities, and being confronted with negative attitudes of staff were barriers to sexual expressions (Kessel, 2001; Hajjar & Kamel, 2004).
Although sexual activities bring gratification and enable older people to have greater locus of control and increase self-esteem, expressions of physical intimacy have not received favorable responses and are widely viewed as ‘abnormal or inappropriate behaviors’ among the elderly (Miles & Parker, 1999). In a survey eliciting residential home managers responses to elders sexual expressions (Archibald, 1998), behaviors were only encouraged when they were privately expressed (e.g. holding hands between residents), considered culturally ‘safe’ and not difficult to manage by staff. However, the same behavior would be considered less acceptable and interpreted as sexual when performed in public, or where a carer was involved. The author speculated that holding hands was discouraged so as to protect the carers’ feelings or prevent potential altercation between the parties involved. The findings also revealed that sexual expressions directed towards staff and public sexual expressions were also unacceptable and were major concerns for staff.
Furthermore, a study on hyper-sexuality of eight residents in nursing care facilities found that the demonstration of extremes of problematic sexual related behaviors triggered the greatest concerns and distress among staff (Nagarathnam & Gayagay, 2002). Cuddling, touching of genitals, grabbing and groping, use of obscene language, masturbating without shame, aggression and agitation were cited as inappropriate sexual behaviors. Interestingly, this study used illustrative cases to set older people’s sexual behaviors and their presenting symptoms in the context of their daily lifestyles, clinical and neurological histories in order to individualize the sexual issues and better understand their situations. These elders were subsequently referred to the Geriatrician for expert advice and management, and labeled as ‘diseased’ or had an ‘illness’.
In the restricted residential care home environments (Nagarathnam & Gayagay, 2002), the freedom of elderly people to move on from acceptable behaviors (e.g. caressing and touching) to greater physical intimate relationships between residents was often inhibited and discouraged by staff, who would intervene when they perceived behaviors to be unacceptable and inappropriate. In these settings, the concerns of staff and their abilities to handle the sexual expressions were more important considerations in determining whether older people’s desires and wishes to express themselves sexually should be recognized, acknowledged and met.
An understanding of how residential home care staff respond and interpret older people’s sexual acts would be important, particularly when staff plays a prime role in facilitating what and how sexuality of older people should be expressed in the home. Although the review highlighted issues on staff responses to older residents’ sexual expression and strategies to address sexual needs, these have largely been the subject of speculation and opinion, with little research-based findings. More recently, however, there has been an interest to examine strategies to assist staff to make decisions about handling ethical dilemmas concerning sexuality of institutionalized elders with dementia (Ehrenfeld et al., 1997).
Despite the fact that some sexual behaviors are easier to accept than others, sexuality of older people emerged as a concern and a burden to staff. Consistently the literature supports the limited insights and vague understanding of residential care home staff in handling older residents' sexual acts – often construing sexual behaviors as behavioral problems, rather than elders’ expressions for love and intimacy (Miles & Parker, 1999). Against a set of negative attitudes reported by staff, earlier studies found that older people’s sexual expressions were met with apprehension, disapproval, judged as misbehavior, and punished using restraints or segregation (Butler & Lewis, 1987). It was not unusual for staff to feel threatened, awkward and uncomfortable, and to react by ignoring the expressions. Not surprisingly, these reactions are not too different from what is happening today.
In response to male masturbation, interviews involving 18 nurses working in nursing homes demonstrated reactions of shock, horror and uncertainty about how to deal with it (Nay, 1992). Although nurses expressed disgust at the image of men acting sexually, what was more disturbing was their belief that women would be excluded from such behaviors (Nay, 1992).
Similarly, Ehrenfeld, Tabak, Bronner & Bergman (1997) demonstrated that staff expressed mixed emotions of confusion, embarrassment and helplessness when older people acted sexually. In making sense of the negative reactions of staff, a categorization system was developed to help staff understand different sexual expressions displayed by older people (Ehrenfeld et al., 1999). It was found that staff were able to accept and support loving and caring behaviors but were hostile, angry and disgusted when older people’s behaviors were openly erotic.
Additionally, sexual behaviors that were linked to romance brought on reactions of humor, ridicule and tease from staff (Bauer, 1999; Ehrenfeld et al., 1999). This was supported by Bauer’s (1999) phenomenological study investigating nursing home staff experiences of elderly residents sexuality, which found that the use of humor enabled staff to communicate sexuality easily by firstly assisting them to relieve the stress of the situation, and then to understand the meaning behind the situation and the role they should play in it. If used with understanding and sensitivity, humor would be a useful strategy to safely deal with emotional and socially unacceptable incidents that would normally be uncomfortable to address directly (Robinson, 1983). However, humor could also have an opposite effect and be seen as another sanction measure used by staff to coerce residents to conform to asexuality, and thereby concealing their genuine needs in the nursing homes (Bauer, 1999).
The lack of knowledge and experiences of staff in handling sexuality in old age is one main reason for not being able to promote awareness of older people’s sexuality in residential care homes (Lyder, 1994). Undoubtedly, the attitude and mind-set of staff remain an influential factor inhibiting sexual expression of older people, particularly when staff cannot comfortably talk about sexuality and hesitate when venturing into intimate discussions with older people and dealing with their sexual responses. If older people are discouraged from expressing sexual interests and activities, this can impede them from becoming fully accepted into residential living. Those elders who choose to lead a relatively active sexual life will continue to conceal their true sexual needs and desires.
The way ahead
Although slow, there appears to be a shift with staff being more receptive towards older people’s need for sexual expressions. This is a positive move forward in acknowledging the importance of sexuality in later life. In promoting awareness of older people’s sexuality in residential care, three strategies will be discussed: (1) re-emphasizing staff awareness of sexuality issues through education and training, (2) compromising on a tolerant environment for sexual expression and, (3) conducting research aiming to conceptualize the meaning of sexuality from older people’s perspectives.
Re-emphasizing staff awareness of sexuality issues through education and training
Part of the answer lies in the recognition of the benefits of sexual education and sexual training, which should be aimed at appropriate levels for different ranks of residential care staff to increase their knowledge about sexuality of older people. Whilst educational initiatives have helped to dispel myths and raised awareness of older people’s sexuality (Steinke, 1997), it would be helpful to re-emphasize key features of some educational programs in terms of course content, venue and ranks of staff participating.
In a formal and systematic approach to respond to the need for training programs, Walkers et al (1998) examined the process of developing a comprehensive sexuality training curriculum upon which training for staff could be based. This process involved conducting a systematic needs assessment by reviewing the literature, forming an advisory team and conducting focus group discussions with professionals, residents and family members. Program goals, objectives and modules were then established, with the aim of attracting participants whose desire is to increase their own knowledge base and be better equipped to deal with residents sexual concerns. Although curriculum development is time-consuming work, reviewing it on a regular basis to update the content in the light of new knowledge and recommendations will be needed.
Steinke (1997) described an educational intervention lasting for two one-half day sessions on knowledge and attitudes of sexuality and aged-related changes, conducted on front-line care staff in the classroom of one nursing facility, with the aim to sensitize staff to sexual issues and to correct misinformation. Although an initial reluctance of staff to discuss sexual issues was witnessed, they later claimed to have benefited from the program and the strategies discussed for dealing with elders’ sexuality were useful in the workplace. Although not mentioned in the study, the value of this type of education session can be speculated. Firstly, conducting sessions within the home’s premises not only acknowledged the home manager’s support of this important topic, but the program was also supported by relieving staff to attend the sessions. Secondly, this training mode could be further developed into an in-service training initiative, whereby front-line staff together with the home’s managers would be motivated to generate their own agenda for regular discussion of sexual issues that were specific to the residents residing in the home. In this way, staff would take ownership of the training program and strategies proposed for dealing with older people’s sexuality would be individualized to the homes concerned.
The way in which educational materials are presented to staff need to be relevant, appropriate and applicable to the sexual dilemmas they encounter on a daily basis. In an attempt to formulate a systematic way of presenting sexual incidents encountered (either between older people or the carer-older person), a decision-making worksheet was introduced to four institutions catering for people with dementia (Ehrenfeld et al., 1997). The worksheet served to document specific sexual problem(s), carers' personal beliefs towards the problem, and offered choices on a course of action suggested by colleagues and supervisors. Although part of a research study, the idea of systematically working through sexual dilemmas and problems with staff, and coming to an agreement on the most appropriate way of coping with the sexual problem could be transformed and applied to the practice settings, thus arousing greater awareness among staff that issues were being addressed.
Compromising on a tolerant environment for sexual expression
Promoting open, comfortable and safe discussion of sexual concerns among staff would be an important first step to creating a tolerant environment for accepting elders’ sexual expression. Indeed, it would also facilitate staff to confront and review their personal beliefs about sexual concerns by encouraging them to talk through their disturbing experiences, if they are to be of help to the residents concerned (Lyder, 1994). While a helpful strategy to compromise values would be to pursue discussion of sexual concerns in staff meetings or during change-of-shift report (Steinke, 1997), having protected and reserved time solely devoted to this purpose would be a better suggestion, particularly when priorities of other agenda items could take precedence over discussion of sexual issues if pressed for time and detract from the efforts already achieved.
Indeed, the gradual involvement of residents in the discussion would raise the profile of the necessity to foster ‘tolerable’ sexual freedom in the homes, without necessarily overriding the constraints of homes and causing disturbances to other residents. One way of compromising conflicts of interests would be to directly elicit residents’ sexual expectations and whether staff were able to meet them. Although a rather formal approach, a survey on 1500 men and women aged 50 was conducted to provide specific suggestions on how health care providers could discuss sexual concerns and questions with them (Johnson, 1997). Staff possessing specific personal characteristics such as open-mindedness, a willingness to talk and spend time listening, answering questions and providing accurate information and suggestions to resolve sexual problems were more appropriate in initiating conversation on sex (Johnson, 1997). This approach documented useful information about older people’s sexuality and enabled issues to be followed up later.
Unless residential care staff take an active and initiated stance in wanting to promote holistic, personal and autonomous sexual health of older people, it will be impossible to cultivate a home environment that would support older people to openly and comfortably discuss sexual concerns and have their sexual issues resolved (Johnson, 1997).
Indeed, the experience of living in residential care homes is a vulnerable one as older people come from different backgrounds with their own specific sexual needs. It is not unusual for older people to succumb to the routines of homes and be influenced by the power exerted by staff (Heath, 2002). Rather than making the older person the culprit of undesirable sexual behaviours, staff will need to acknowledge normalcy and confront their own attitudes toward older people’s sexuality. In addition, they must recognize how their responses can either inhibit or encourage older people to express themselves sexually (Drench & Losee, 1996).
Conducting research to conceptualize sexuality of older people
In truly understanding sexuality in residential care, it is prime time to take a step forward and seek older people’s views about their own sexuality in terms of, for instance, views on sex in old age, expressing oneself sexually, and thoughts and meanings underlying their sexual motives. This important information will assist staff to appreciate the need for sexuality in later life, and also to be extremely sensitive when they reconsider how they would best respond to older people’s sexual interests, attitudes and activities in residential care homes. When older people are given opportunities to conceptualize and interpret the meaning of sexuality using their own words, they are being legitimately encouraged to talk about sex and express sex as it should be - a normal part of an older people’s everyday life. Older people will no longer need to feel ashamed, repressed and denied about wanting to exhibit sexual feelings and acting sexually. Indeed, it must not be forgotten that conceptualizing sexuality is itself a very complex phenomenon. The topic also is fraught with embarrassment and taboo in cultures with collectivist social pressures and concerns for social hierarchy (Bond, 1991). Careful interpretation of what sexuality means and how it should be appropriately expressed among older people in culturally diverse societies should be considered in future research.
Human sexuality is a natural, unique and integral part of every person’s identity (Heath, 1999; Kessel, 2001). It is clear that the number of people moving into residential care homes is increasing. The selective review of the literature summarizes studies that have attempted to identify different forms of sexual expressions among older people and some helpful interventions to guide residential care home staff to deal with these sexual expressions. However, there is a paucity of research available concerning effective strategies that will meet the specific sexual needs of older people. With only a few exploratory studies examining older people’s knowledge, attitudes and sexual behaviour, current information is insufficient to inform residential care practices about older people’s sexuality. Much work is still needed to understand sexuality from older people’s perspective and how their sexual needs and concerns can be addressed by residential care staff caring for them. Not until we truly know what older people want and understand what sexuality means to them will it be possible to plan individualized care that will meet their specific sexual need.
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