Late-Life Sexuality Presents Problems, Rewards: Nursing Homes Face Competing Values and Principles Involving Safety, Dignity, and Decision Making

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SALT LAKE CITY -- Most Americans find it difficult to accept late-life sexuality, according to Dr. Andrew S. Rosenzweig.

"Our culture still has this pervasive negative attitude about late-life sexuality in terms of discreet silence, distaste, and tunnel vision," said Dr. Rosenzweig, an assistant clinical professor of psychiatry at Brown University, Providence, R.I.

Nevertheless, sexual desires among residents are normal and should be accepted, he said at the annual symposium of the American Medical Directors Association.

Not only family members of residents, but health professionals also have biases and can be judgmental on the topic, said Rosenzweig, medical director of MedOptions, a company based in Old Saybrook, Conn., that provides behavioral and primary care consulting services to nursing homes and assisted living facilities.

For instance, one Israeli study observed that nursing staff caring for Alzheimer's residents at a nursing home categorized residents' sexual behaviors in three ways: love and care, romance, and eroticism (Nursing Forum 2006;41:158-66).

The nursing staff showed acceptance and support of love and care, mixed reactions to romance, and strong reactions of anger and resentment to erotic behavior. That some staff found romance between residents troublesome and that most were appalled by erotic behavior reflects narrow biases, Dr. Rosenzweig said. "So clearly there's a lot of staff confusion and ignorance, and lack of training about late-life sexuality.... We should not underestimate the need for affection, for touch, for a connection with someone else."

The goal for nursing facility professionals should be to create an environment that will help residents fulfill their sexual needs and desires while maintaining dignity and protecting rights of competent and incompetent residents. Some of the competing principles and values include the right to privacy, the right to experience a loving relationship, and the right to make one's own decision. Beyond that, however, staff members need to refrain from being judgmental. "It's very easy to project one's own religious, cultural, and personal beliefs on another," Dr. Rosenzweig said.

Sexually inappropriate behavior may include genital exposure, masturbating in public, propositions to others for sexual intercourse, fondling another resident's genitals or breasts, requesting unnecessary genital care from staff, touching a caregiver in a sexually suggestive manner, and openly reading pornographic material. Sexually provocative but less problematic behaviors in nursing home and assisted living settings may include flirting, excessive flattery, commenting on a caregiver's behavior or appearance, and asking staff members personal questions.

The prevalence of sexual-behavior reports among dementia patients in nursing homes ranges from 3%-15% of reports of inappropriate behaviors, "but there have been very few studies," Dr. Rosenzweig said. However, some evidence has linked those behaviors to frontal and temporal lobe pathology, especially disinhibited types of behaviors, he said. Acute onset of sexually inappropriate behaviors may follow stroke, vascular insult, and head injury. Differential diagnosis includes delirium, mania, seizure disorder, dopaminergic drugs, social isolation, and boredom.

Dr. Rosenzweig urged those attending the meeting to consider the barriers that nursing facilities residents face in making intimate human connections.

"Imagine your typical nursing home or assisted living facility, where the amount of privacy is zero and opportunities for expressing sexual desires are zero," he said. "The literature on geriatric sexuality is showing that even with all these obstacles, there is a high amount of sexual desire in our residents, regardless of medical or psychosocial comorbidities. …