Sexual Consent Capacity: Ethical Issues and Challenges in Long-Term Care

From Gatekeeper to Facilitator: Balancing Between Sexual Rights and Protection From Harm in Dementia Adults

OBJECTIVE

The assessment of sexual consent capacity has been a challenge due to its dynamic nature, influenced by factors such as time, environment, individuals involved, and the nature of activities. Particularly in people living with dementia, the complexity is intensified with the interplay of the disease's impact, residential care setting, and legal constraints. This amplifies the dilemma faced by practitioners-whether to prioritize protection or encourage and support sexual expression. This article aims to provide a sensible approach to uphold the sexual autonomy of people living with dementia while mitigating the potential risks of them being involved as either perpetrators or victims.

METHODS

In this narrative review, a literature search spanning from 1990 to 2023 was carried out on PubMed. Relevant articles on people living with dementia and topics related to sexuality were scrutinized.

RESULTS

41 relevant articles identified themes related to the impact of cognitive impairment on sexuality, challenges in residential care facilities, sexual consent capacity assessment models, and ethical frameworks regarding sexual rights and law.

CONCLUSION

Discussions highlight the often neglected influence of prolonged suppression of sexual expression and the benefits of actualization of sexual autonomy, especially in people living with dementia, whose sense of identity is fading. It scrutinizes the limitations of existing sexual consent capacity evaluation models, emphasizing ethical concerns, practical challenges, and the need for a more balanced approach. Proposed strategies advocate for a shift from a gatekeeper to a facilitator role, offering principles for setting educational programs and policies to mitigate obstacles, supporting sexual rights, and safeguarding vulnerable groups.

Adults' Understandings and Experiences of the Capacity to Consent to Substance-Involved Sexual Activity

Most research on capacity to consent to substance-involved sex has focused exclusively on the implications of alcohol with little attention given to other or additional psychoactive drugs. This study aimed to explore people's understanding and experiences of the capacity to consent to alcohol- and/or drug-involved sexual activity. UK adults (N = 354) completed an online mixed-methods survey on sexual consent during sober, alcohol- and/or drug-involved sex. Qualitative data were analyzed using thematic analysis. Themes for capacity to consent were: (1) "There is no normative understanding of substance-involved sexual consent," (2) "Moving beyond the binary of consciousness versus incapacitation" and (3) "Substance-involved sexual decisions are viewed as irresponsible." The findings illustrated that capacity to consent is nuanced and multidimensional, and that people's understandings and experiences of capacity to consent to substance-involved sex are not solely individual, but rather, they are also shaped by their environment. We call for a multidimensional view of capacity to consent, where a standard of "unimpaired," rather than sober, is used and modeled by academics, legislators, and educators.

Is Sex Good for Your Brain? A National Longitudinal Study on Sexuality and Cognitive Function among Older Adults in the United States

Using a life course approach, we examined how sexuality is related to cognitive function for partnered older adults. We utilized longitudinal data from two rounds of the National Social Life, Health, and Aging Project (NSHAP) to analyze 1,683 respondents. Cognitive function was measured using a continuous Montreal Cognitive Assessment (MoCA) score. We considered both sexual frequency and sexual quality (i.e., physical pleasure, emotional satisfaction). We estimated cross-lagged models to consider the potential reciprocal relationship between sexuality and cognitive function. Results indicated that sexuality was not related to later cognitive function in the total sample, but the pattern varied by age and gender. For adults aged 62-74, better sexual quality (i.e., feelings of physical pleasure and emotional satisfaction) was related to better cognitive functioning, while for those aged 75-90, more frequent sex was related to better cognitive functioning. Feelings of physical pleasure were related to better cognitive functioning for men but not women. There was no evidence of cognitive functioning being related to later sexuality. The findings highlight the importance of age and gender in modifying the link between sexuality and cognition in later life.

Using the Intersectionality-Based Policy Analysis Framework to Evaluate a Policy Supporting Sexual Health and Intimacy in Long-Term Care, Assisted Living, Group Homes & Supported Housing

Sexuality is an integral part of being human throughout life. This does not change when moving into long-term care (LTC). However, the sexual health of persons living in LTC is often overlooked. This paper presents an analysis of the recently released health organizational policy: Supporting Sexual Health and Intimacy in Long-Term Care, Assisted Living, Group Homes & Supported Housing. The Intersectionality-Based Policy Analysis Framework is used to outline the policy problem, examine how this policy was developed, and evaluate its potential to address the problem. Key findings are that both the development process and the policy constructs align with principles of intersectionality, such as equity, reflexivity, and diverse knowledges. In conclusion, this analysis suggests this policy is feasible, equitable and could effectively address sexual health for persons living in LTC, while leading to an improved workplace for staff. We recommend that this policy be more widely adopted across Canada.

Approaches to Determine and Manage Sexual Consent Abilities for People With Cognitive Disabilities: Systematic Review

BACKGROUND

This review focused on how sexual consent ability was determined, managed, and enhanced in people with cognitive disabilities, with the aim of better understanding the recurring themes influencing the design and implementation of these approaches. If a person's consensual ability becomes compromised, owing to either an early or late-onset cognitive disability, the formal systems involved must establish plans to balance the individual's rights and restrictions on sexual expression. This review identified these plans, focusing on how they promoted the intimacy rights of the individual.

OBJECTIVE

This study aims to identify approaches that determine sexual consent ability in people with cognitive disabilities, identify the means of managing and enhancing sexual consent ability in people with cognitive disabilities, and note the recurring themes that influence how these approaches and management systems are designed and implemented.

METHODS

A systematic literature review was performed using EBSCOhost (Social Gerontology, CINAHL Plus, MEDLINE, and SocINDEX), Embase, PsyInfo, and Scopus to locate reports on terms expanded on sexual consent and cognitive disability.

RESULTS

In all, 47 articles were identified, featuring assessment practices, legal case studies, and clinical standards for managing sexual consent capacity in people with cognitive disabilities. A total of 8 studies (5/8, 63% qualitative and 3/8, 38% quantitative) were included out of the 47 articles identified. Approaches for determining sexual consent included functional capacity and person-centered, integrated, and contextual approaches. Management of sexual consent ability included education, attitude, and advanced directives and support networks. The recurring themes that influenced these approaches included the 3 legal criteria of consent, American Bar Association and American Psychological Association Model, Lichtenberg and Strzepek Instrument, Ames and Samowitz Instrument, Lyden approach, Mental Capacity Act of 2005, and Vancouver Coastal Health Authority of 2009.

CONCLUSIONS

Determining sexual consent takes a holistic approach, with individuals judged in terms of their adaptive abilities, capacities, and human rights. The attitudes of those using this holistic approach need to be balanced; otherwise, the sexual rights of assessed people could be moved either in favor or against them. The ideal outcome, after person-centered considerations of those living with cognitive disabilities includes the people themselves being involved in the process of personalizing these approaches used to facilitate healthy intimate relationships.

Effectiveness of a Sexuality Workshop for Nurse Aides in Long-Term Care Facilities

BACKGROUND

In long-term care facilities, there are frequent conflicts related to elderly residents' sexual expression. Nurse aides usually handle such conflicts with negative or negligent attitudes; therefore, elderly sexuality is considered "problem behavior" and is stigmatized.

OBJECTIVES

This study aimed to improve elderly residents' quality of sexual life by enhancing nurse aides' knowledge and attitudes toward elderly sexuality through sexuality workshops.

METHODS

A quasi-experimental study was conducted with 64 nurse aides and 58 residents, who were divided into two groups, i.e., an experimental group and a control group, according to the floor where the residents resided. The nurse aides in the experimental group participated in sexuality workshops and were compared with those in the control group with respect to their knowledge of and attitudes toward sexuality; the residents' quality of sexual life was also compared between groups.

RESULTS

Compared with the control group, in the experimental group, the nurse aides' knowledge of and attitudes toward elderly sexuality as well as the residents' quality of sexual life significantly and continually improved after the sexuality workshops.

CONCLUSION

The four-week sexuality workshop is effective and may be used as an example in developing occupational education programs regarding elderly sexuality in long-term care facilities.

Sexuality and the Older Adult

PURPOSE OF REVIEW

This paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia.

RECENT FINDINGS

Sexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

Quantitative assessment of sexual knowledge and consent capacity in people with mild to moderate intellectual disability

While it is well known that people with an intellectual disability experience the same needs for intimacy as those without an intellectual disability, a number of developmental, structural, environmental, and attitudinal barriers circumvent the expression of sexuality in people with an intellectual disability – particularly in institutional and residential health care settings. People with an intellectual disability generally have lower levels of sexual knowledge than those without an intellectual disability, and sexual exploration and expression is frequently viewed with concern by mental health care practitioners and caregivers, who may regard people with an intellectual disability as being ‘nonsexual’ or ‘hypersexual’. However, the rights of people with an intellectual disability to sexual expression have been established in policy and legislation. Service providers are required at times to make determinations regarding the ability of people with an intellectual disability to consent to sexual intercourse in a number of health care settings. There is a dearth of published literature on psychometric instruments to assess sexual knowledge and consent capacity. This article briefly reviews the more commonly used sexual knowledge and consent assessments for people with mild to moderate intellectual disability and advances recommendations in this regard.

Content analysis of public opinion on sexual expression and dementia: Implications for nursing home policy development

Purpose

We examined public opinion of sexual expression and dementia to inform nursing home policy and practice.

Design and Methods

A content analysis was conducted on public comments (N=1194) posted in response to a New York Times article about a highly publicized legal case involving a husband engaging in sexual acts with his wife who had dementia, living in a nursing home. Researchers utilized constant comparative analysis to code the comments; reliability analysis showed moderately strong agreement at the subcategory level. Data were also coded to indicate whether the commenter thought the couple should or should not have been allowed to be sexual.

Results

One primary theme was identified: conditions necessary for someone to be sexual. Six categories were identified within this theme, with the public commentary considering factors such as marital relationships, intimacy needs and several sexual consent‐related issues as key conditions necessary to be sexual in a nursing home setting. Overall, the majority of commenters were in support of sexual expression for an individual with dementia in the described situation.

Discussion

This study revealed sexual expression among individuals with dementia is a contentious issue with strong public opinions about how this should be managed in a nursing home setting. These opinions should be considered as policy related to sexual expression in nursing homes is developed.

Sexual Consent Capacity Assessment with Older Adults

Many healthcare providers have a limited knowledge of sexual and intimate expression in later life, often due to attitudinal and informational limitations. Further, the likelihood of an older adult experiencing cognitive decline increases in a long-term care (LTC) setting, complicating the ability of the providers to know if the older adult can make his or her own sexual decisions, or has sexual consent capacity. Thus, the team is left to question if and how to support intimacy and/or sexuality among residents with intimacy needs. Psychologists working with LTC need to be aware and knowledgeable about sexual consent capacity in older adulthood to be prepared to conduct evaluations and participate in planning care. Limited research is available to consult for best practices in sexual consent capacity assessment; however, models of assessment have been developed based on the best available evidence, clinical judgment, and practice. Existing models will be discussed and an integrated model will be illustrated via a case study.