The following question was asked of the readers of the Journal of Cerontological Nursing: What do you identify as problems with sexuality for patients, families, and staff in nursing homes or long-term care facilities? What type of interventions have you found useful?
Our society believes that sexual desires decline with age; however, sexual patterns remain throughout the life span. Older adults not only needs to express their sexuality through traditional sexual methods, they also must fulfill their need to touch and to be touched. The importance of touch is not seen as a significant component in older adults' lives, but it can be an alternative sexual expression when intercourse is not desired or possible.
Society views the sexual behavior of older adults in a negative manner, and these views inhibit the expression of sexuality among older adults. Sexual relationships provide love, intimacy, closeness, and physical stimulation which serve as motivation for continuing or improved quality of life.
Health care professionals may have a discomfort with sexual issues and this may change his or her perception of what the older adult needs. Opposing moral values, lack of knowledge and training may also interfere with professionals' ability to intervene and facilitate sexual satisfaction of older adults.
Institutionalization offers minimal opportunities for intimacy and sexuality. Some things that health care workers may want to consider to maintain intimacy for this population follow:
* Be aware of isolation and sensory deprivation.
* Remember that older adults need more touch for social reasons: hugging, kissing, hand-holding, massage.
* Build sexuality into spiritual and emotional well-being.
* Remember that meaningful sexual relations may not be all heterosexual - be helpful, not punitive.
* Accept masturbation as an expression of sexuality... do not punish this act.
* Provide touch and offer "feeling" objects to handle, fondle, and hold such as stuffed animals or baby dolls.
* Live pets provide sensory stimulation.
* Encourage music that is romantic, sentimental, and sensuous.
* Encourage the opportunity for older adults to meet, mingle, and spend time together.
* Provide privacy for couples who share a room or who want to be with one another.
* Promoting sexuality in older adults provides them with opportunities to live the remainder of their lives in the joy of human relationships.
Diane Marinaro, RN, MSN
Geriatric Nurse Practitioner
Wayne General Hospital
Wayne, New Jersey
The staff has misconceptions that because residents are older, they have lost their sexuality or sexual urges. Instruct staff that it is normal for residents to have sexual urges. It is okay for husband and wife to be intimate in the privacy of a room, as long as it doesn't infringe on a roommate.
Lynn Bendi, RN
Community Care of America at Muscatine
Lack of privacy /availability of a private room for intimacy is a problem. Staff and family acceptance are all problems. We addressed these problems with the needs of two younger residents. We made arrangements for them to spend 2 nights per week together in a designated empty room. We inserviced staff and spoke to families many times to help them adjust to the idea. We monitor emotional behavior because the woman has cognitive deficits, but we do our best to maintain the delicate balance between resident rights and the family's desires. This has been a success story that was a challenge.
Social Services Director
Parkview Acres Care & Rehabilitation Center
I try to train staff to think of sexual behavior not as a "problem," but as an unmet need the resident is trying to express or satisfy. Sometimes this need can come out in inconvenient or inappropriate ways. Sexually expressive behaviors can range from simple hugs and handholding to inappropriate sexual remarks and/or public exposure or masturbation. Depending on the staff's beliefs and attitudes, any behavior in that range can be considered "problem" behaviors. The "cure" to the behavior is to look for the reason behind it (that unmet need). Often, when the need is satisfied, the behavior will resolve itself. Ask yourself, is the behavior based on a need for a feeling of intimacy, lack of pleasurable stimulation or touch, boredom, loneliness, etc.? The list of unmet needs that manifests itself this way can seem endless. The interventions then address the unmet need rather than the behavior. It can include encouraging and assisting residents to cultivate friendships and relationships, providing appropriate stimulation and activities that the resident enjoys, providing uninterrupted "private time" for a couple that is alert and consenting. The interventions are as varied as the residents and the needs.
Often I find that the resident's behavior is not the "problem," but rather the staff's feelings about the behavior is a problem. Many younger staff members view intimate or sexual contact between elderly as repulsive. You hear comments like, "older people shouldn't do that," or "older people don't feel that way, there's something wrong with..."
Educating staff about sexuality and sexual needs across the lifespan can change some of this. Then, although the behavior doesn't disappear, it is no longer viewed as a "problem" that must be resolved. This education also provides staff understanding so they can guide residents to express their sexuality in appropriate ways, times, and places. Guidance is sometimes necessary because the resident is functioning in a new environment, under new rules. This is similar to what parents do with young teenagers as the teens discover their sexuality.
E. Reed-Lewis, RN
Infection Control /Quality
Assurance/ 'Inservice Education Coordinator
Anna Sunderman Homes
Lack of privacy, opposition from staff, and questions of ethics are all problems. Education is essential in this situation.
Susan Senger, RN, MSN
Hospital-Based Adult Day Care
The problem lies in the staff's own personal comfort level in talking about sexuality. Admit that elderly patients with dementia, post-cerebrovascular accident, etc. still have sexual drives. Allowing the patient/family privacy and respect is the most useful intervention I've found.
Lois Huffman, RN, BA
An elderly gentleman diagnosed with dementia and frontal lobe disinhibition used constant verbal abuse and grabbed female residents and staff.
At a care conference 2 weeks after being re-admitted to the nursing unit from a geropsychiatry unit, where attempts to control his behavior with medication failed, a plan of care was initiated and 6 months later the behavior decreased to four or six advances per day.
The plan of care follows:
Problem: Resident makes both physical and verbal sexual advances toward female residents and staff.
Goal: Resident will have decreased number of inappropriate sexual incidents each day per behavior flow record.
1 . When the resident makes sexual advances, inform him that his behavior is not appropriate. Remove the resident's hand and leave the room.
2. Place the resident in a social eating setting, away from female residents.
3. During activities of daily living, tell him ahead of time what is expected.
4. If unable to redirect advances, offer sexually explicit material in his room with the door closed and a curtain pulled between beds. Allow him time and privacy with the material.
Cali E. Jackson, RN1 C
West Park Retirement Community
Skilled Nursing Unit
1. Involve family members as soon as problems regarding sexuality are recognized.
2. Council residents regarding natural sexual feelings and privacy.
3. Avoid situations and activities that promote sexual attentions.
I try to train staff to think of sexual behavior not as a "problem, * but as an unmet need the resident is trying to express or satisfy.
4. Educate staff on interventions that have worked in the past.
5. Encourage residents to discuss their sexual concerns and desires.
6. Have an RN discuss sexuality and masturbation (i.e., technique) for visual and manual stimulation.
7. Narrow the group to include those that show an interest.
8. Direct activities away from sexuality if resident is obsessed.
9. Male and female sexual dysfunction due to illness or that is health-related should be assessed and treated, and education should be provided by an RN.
10. Review prostate education with residents.
11. Review urinary incontinence with residents.
12. In view of the fact that interest in sex after 70 exists, it should be part of admission assessment and care planning.
13. Educate staff on age-related sexual changes in men and women.
14. Pap smears and testicular examinations, breast examinations and self-examinations should be taught.
15. Make a double bed available to consenting residents.
Hazel Whttty. KN, BSN
Sterling Center Adult Day Services
Wayne, New Jersey
This question was submitted by Beverty K. Johnson, PhD, RN, of the University of Washington, Bothell campus. Dr. Johnson authored the a/tide, "Older Adults and Sexuality: A Multidimensional Perspective" in the February 1996 issue of the Journal of Gerontological Nursing. Dr. Johnson's commentary follows.
Sexual interest and activity between residents in long-term care (LTC) facilities can provoke an array of reactions and discussions among the LTC triad: residents, family members, and staff. Society has generally seen older adults as sexually undesirable, uninterested, and then incapable even if they were desirable and interested. One myth for older men can be described as "Virile at 16 but lecherous at 60." Research has found, however, that although sexual activity declines with age, patterns of sexual interest, participation, and satisfaction do continue for both older men and women in the later years, even in the presence of health concerns (Johnson, 1996).
Specific interventions for sexual problems are clearly stated by readers' responses to this question about sexuality and long-term care: a) educate both staff and residents about topics related to sexuality and aging; b) provide a supportive environment such as privacy and permission to be sexual; c) encourage staff to examine their attitudes on sexuality and aging; and d) recognize the increased need for touch to increase sensory input for LTC residents. Richardson and Lazur (1995) similarly suggested interventions to remove barriers to sexual activity in nursing home residents: a) promote privacy for residents ("do not disturb" signs, closed doors, staff education); b) educate staff about sexuality in the elderly; c) allow conjugal visits or home visits; d) assess decision-making capacity for cognitively impaired adults; e) encourage alternate forms of sexual expression, such as kissing and hugging; f) assess residents' sexual concerns; and g) provide sexual information and counsel to interested residents.
Education for staff and residents can include discussion about the normal changes of aging and the effect of illness and medications on the sexual response cycle, sense of self, and intimate relationships, as well as societal and personal beliefs about sexuality and aging. Nurses can facilitate this education for residents as illustrated by the concept of the "Intimacy Group" (TunstuII & Henry, 1996). Butler & Lewis' 1993 text as well as recent articles on health issues and sexuality and aging can be valuable educational resources for nurses in long-term care facilities (Badeau, 1995; Ballard, 1995; Garden & Schramm, 1995; Holzapfel, 1994).
Including a sexual history and ongoing sexual assessment in care planning can allow nurses to intervene earlier to respond to their clients* sexual concerns (Johnson, 1996; Smedley, 1991; Wallace, 1992). An important question to consider is "What is the meaning of a particular sexual behavior to the older adult?" especially a behavior to which others have negative reactions. As E. Reed-Lewis described in her response, the meaning is "an unmet need the resident is trying to express or satisfy." Possible appropriate interventions could include the need for more social interaction, touching, or a need for privacy alone or with a partner. The PLISSIT model continues to be a relevant guide for nurses in their interventions for older adults' sexual concerns to provide permission (P) to talk about sexuality, limited information (LI), specific suggestions (SS), and intensive therapy (IT)(Annon, 1976).
Older adults themselves have provided suggestions to health care providers to assist them with their sexual concerns (Johnson, 1997). These suggestions include spending time with older adults, using easyto-understand words, being openminded and talking openly, listening, being respectful and nonjudgmental, encouraging discussion, and providing advice or suggestions. Most clearly the adults (age 50 and older) in this study stated that health care providers must realize that sex is not just for the young. These suggestions add another perspective to the readers' responses in "Your Turn."
Annon, J.S. (1976). The PLISSIT model: A proposed conceptual scheme for behavioral treatment of sexual problems. Journal of Sex Education Therapy, 2(2), 1-15.
Badeau, D. (1995). Illness, disability, and sex in aging. Sex and Disability, 13(3), 219237.
Ballard, E.L. (1995). Attitudes, myths, and realities: Helping family and professional caregivers cope with sexuality in the Alzheimer's patient. Sexuality and Disability, 13(3), 255-270.
Butler, R.N., & Lewis, M.I. (1993). Love and sex after 60. New York: Ballantine Books.
Garden, EH-, & Schramm, D.M. (1995). The effects of aging and chronic illness on sexual function in older adults. Physical Medicine and Rehabilitation, 9(2), 463-486.
Holzapfel, S. (1994). Aging and sexuality. Canadian Family Physician, 40, 748-766.
Johnson, B.K. (1996). Older adults and sexuality: A multidimensional perspective. Journal of Gerontological Nursing, 22(2), 6-15.
Johnson, B.K. (1997). Older adults' suggestions for health care providers regarding discussion of sex. Geriatric Nursing, 18(2), 6566.
Richardson, J.P., & Lazur, A. (1995). Sexuality in the nursing home patient. American Family Physician, Sl(I), 121-124.
Smedley, G. (1991). Addressing sexuality in the elderly. Rehabilitation Nursing, 16(1), 9-11.
Tunstull, P., & Henry, M.E. (1996). Approaches to resident sexuality. Journal of Gerontological Nursing, 22(2), 37-42.
Wallace, M. (1992). Management of sexual relationships among elderly residents of longterm care facilities. Geriatric Nursing, 14(12), 308-311.