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.

Intimate relationships in residential aged care: what factors influence staff decisions to intervene?

Intimacy contributes to our well-being and extends into older age, despite cognitive or physical impairment. However, the ability to enjoy intimacy and express sexuality is often compromised-or even controlled-when one moves into residential aged care. The aim of this study was to identify what factors influence senior residential aged care staff when they make decisions regarding resident intimate relationships and sexual expression. The study used vignette methodology and a postal survey to explore reactions to a fictionalised case study of a couple-Norm and Carol-who develop a close, mutually satisfying relationship. Staff were first asked whether they would intervene in the relationship. Using an innovative approach, several variations to the case study were then presented to explore whether views about intervening changed according to varying contextual factors. Findings indicated that over 90% of respondents initially agreed that the relationship should continue, and only 10% indicated they would intervene. However, when the case study was varied, respondents indicated they were more likely to intervene, particularly if Norm was exhibiting distress in Carol's presence (89%), but also if Norm was married and his wife was living in the community (40%). Other factors including level of cognitive impairment and family disapproval were also found to influence staff views. This study provides insight into how residential aged care staff make decisions regarding the intimacy and sexuality of older people living in residential aged care and how personal views and values likely guide practice in the absence of formal policies.

Value pluralism about sexual intimacy in residential care

BACKGROUND

The existing literature on sexuality and intimacy in residential care tends to focus on either the question of rights, or the value of autonomy. Where the literature does reference values other than autonomy, such values are considered in the context of being a guide to whether or not a resident is autonomous, rather than being important values in their own right.

OBJECTIVE

This paper draws on qualitative data gathered as part of a larger study in order to inform practice on how care workers respond to intimacy issues that arise with residents with dementia and to inform a general ethics of sex and sexuality, demonstrating that an approach which permits value pluralism can be appropriate in certain contexts.

RESEARCH DESIGN

The qualitative data referred to in this paper was gathered from semi-structured interviews undertaken as part of a larger mixed-method research project. The interview text was analysed using Thorne's methodological approach, interpretive description.

PARTICIPANTS AND RESEARCH CONTEXT

The qualitative arm of the project consisted of semi-structured interviews conducted between October 2018 and October 2019 with participants (staff, residents and family members) recruited from 35 residential care homes in Aotearoa New Zealand.

ETHICAL CONSIDERATIONS

Participation was informed, voluntary and written consent was gained before interviews. The project was approved by the Massey University Human Ethics Committee (Northern), number NOR 18/25.

FINDINGS

Analysis of the scenarios presented in this paper shows that decision-making around sexual intimacy involving people with dementia in a residential care setting is complex and requires recognizing and weighing the different values that may be a in play.

CONCLUSION

A focus on safety and consent to the exclusion of other values which matter morally in this context is a mistake which prevents care workers from providing appropriately person-centred care to residents, as policies which focus on the goal of care allow space for critical examination of issues which are likely to be highly context-sensitive.

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.

Sexual Expression, Policies, and Practices in Skilled Nursing Settings Serving Older Adults: An Updated Assessment in the State of Kansas

Doll assessed sexual expressions, policies, and practices in Skilled Nursing Facilities (SNFs) in the state of Kansas. This study provided an updated and expanded assessment. A mixed-methods survey was distributed to administrators of all SNFs in the state of Kansas. Among 60 administrations, 84% reported any sexual expression among residents in their community within the past year and 55% reported expressions involving an individual with cognitive impairment. In response to sexual expressions, 70% of administrators believe staff would treat residents with dignity and respect and about 40% anticipated staff discomfort. About 40% of administrators reported having a policy related to sexual expression. Attitudes and responses of staff and administrators appear to be shifting in a sex-positive direction. While policies related to sexuality are more common than a decade ago, there is room for additional uptake, standardization, and infusion of person-centered language and practices.

Iatrogenic loneliness and loss of intimacy in residential care

BACKGROUND

There is an international trend for frail older adults to move to residential care homes, rather than ageing at home. Residential facilities typically espouse a person-centred philosophy, yet evidence points to restrictive policies and surveillance resulting in increased loneliness and diminished opportunities for intimacy and sexual expression. Residents may experience what has been termed social death, rather than perceive they are related to by others as socially alive.

AIM

To consider how the loss of intimacy and sexuality in residents' lives contributes to iatrogenic loneliness experienced in residential care, and the importance of considering these issues together.

RESEARCH DESIGN

The study utilised a constructionist methodology, investigating the meanings associated with intimacy, loneliness, and ageing.

PARTICIPANTS AND RESEARCH CONTEXT

Qualitative data used in this study are drawn from a larger dataset of a mixed-methods study. Interviews were completed as follows: staff, 21 individual interviews, and two groups with a total of 13 additional people; residents, 26 interviews with 28 people; and family members, 12 interviews with 13 people.

FINDINGS

Five key themes were identified in the data analysis: loneliness and relational identity, loneliness and functional relationships, loneliness and disrupted intimacy, loneliness and liminality, and loneliness and the built environment.

ETHICAL CONSIDERATIONS

The study was approved by a University Human Ethics Committee. Participation was voluntary. Consent was gained and confidentiality upheld.

DISCUSSION

Residents' expression of intimacy and sexuality can be compromised through paternalism, ageism, restrictive policies, care-rationing and functional care, alienating residents from sustaining and developing significant relationships. Attitudes and cultural beliefs of staff and family members about ageing and intimacy, compounded by architectural design, may intensify loneliness.

CONCLUSIONS

Nurses have a pivotal role in ensuring policies and practice enhance social citizenship.

Nurses' experiences and reactions towards intimacy and sexuality expressions by nursing home residents: A qualitative study

OBJECTIVES

To better understand how nurses experience and react to intimate and sexual expressions of nursing home residents.

BACKGROUND

Although many nursing home residents continue to desire intimacy and sexual expression, they commonly perceive negative attitudes of nursing staff towards them as a major barrier to their sexual well-being. To eliminate this barrier, it is crucial to gain a more in-depth understanding of nurses' personal experiences and reactions towards intimacy and sexuality in aged care.

DESIGN

Our study used a qualitative design, rooted in grounded theory.

METHODS

Semi-structured interviews with 15 nurses between 34 and 59 years of age were conducted. Participating nurses were recruited from seven different nursing homes in Flanders, Belgium. We used the Qualitative Analysis Guide of Leuven (QUAGOL) for data analysis. We followed the COREQ guidelines to ensure rigour in our study.

RESULTS

Nurses experienced and dealt with intimate and sexual expressions of residents in an individual way, which was focused on setting and respecting their own sexual boundaries and those of residents and family members. Depending on their comfort level with residents' expressions, nurses responded in three ways: active facilitation, tolerance and termination. Nurses' responses depended on contextual factors, including their personal experiences with sexuality, the nature of their relationship with the residents involved, the presence of dementia and the organisational culture of the facility.

CONCLUSIONS

Nurses face a wide range of experiences and emotions when confronted with residents' expressions of sexuality and intimacy. A supportive approach is needed to guide nurses in dealing with these highly sensitive situations. This approach can be promoted at the institutional level through continuous educational programmes.

RELEVANCE TO CLINICAL PRACTICE

This study advocates a contextual and interpretative ethical approach to sexuality in older adults, taking as starting point nurses' own vulnerability and that of residents and relatives.