Supporting residents' expression of sexuality: the initial construction of a sexuality assessment tool for residential aged care facilities

Utilization of the Intimacy and Sexuality Expression Preference tool in long-term care: a case study

Introduction

Sexual wellness plays a crucial role in an individual's quality of life, interpersonal relationships, and self-concept, particularly among older adults residing in residential aged care facilities, including those with dementia. However, there is currently a limited person-centered approach to understanding the unique preferences of each older person regarding their intimate and sexual behaviors. To address this gap, the Intimacy and Sexuality Expression Preference (ISEP) tool was developed to facilitate meaningful discussions between healthcare professionals or workers and older individuals about their intimacy and sexuality needs and preferences. This paper explores the use of the ISEP tool with residents in long-term aged care, including those with dementia via a user-centric case study.

Methods

ISEP tool interviews were conducted with 14 residents in a single residential aged care facility in Queensland, Australia.

Results

The study presented valuable insights and contextual information from using the ISEP tool, including an example of a resident's response, which provided recommendations for better supporting the resident. This involves engaging in supportive conversations to facilitate the exploration, implementation, and assessment of practical and actionable strategies to meet intimacy and sexuality needs and preferences.

Discussion

The ISEP tool shows promise in improving care practices and addressing the intimacy and sexuality needs of older individuals in aged care facilities. However, it is important to acknowledge that the study was conducted in a single aged care facility with a small group of residents, potentially limiting the generalisability of the findings. Further large-scale studies are necessary to establish the tool's broader applicability across different care settings.

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.

Sexuality and the Human Rights of Persons With Dementia

We explore barriers to enjoyment of human rights to sexuality of persons with dementia and remedies for addressing these. Enjoyment of sexuality is contingent upon actualization of rights to dignity, autonomy, respect for will and preferences, abuse safeguarding and equitable access to highest standards of sexual health. Persons with dementia living at home or in care face systemic barriers to enjoyment of sexuality fueled by ageism, apathy and ignorance, compounded by complex legal barriers in relation to consent. Such challenges can be tackled with awareness raising and education of care staff, families and physicians, including training for capacity assessment with dimensional, noncategorical conceptualization of capacity, leaving room for supported decision-making. These measures, together with strengthened legislative and human rights frameworks to cater to the specific needs of older people, may allow people to live well with dementia and exercise their human rights to enjoy sexuality in a safe and lawful manner.

Sexuality, sexual expression in long-term care and the law

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.

Challenges faced by residential aged care staff in decision-making for residents with dementia

Care staff in residential aged care facilities (nursing homes) in Australia are obligated, under the Australian National Framework for Action on Dementia 2015-2019, to support residents to exercise choice and make decisions. Research indicates, however, that care staff are often given little guidance regarding which residents' decisions should be supported or how to make decisions on their behalf. This lack of guidance can result in a denial of residents' rights and inconsistent treatment by staff, placing residents' wellbeing at risk. Through providing an analysis of the responses of staff at RACFs in Victoria and Queensland to two case scenarios, this study seeks to provide some understanding of the difficulties staff face in supporting residents' self-determination and their own need for greater organisational support.

'I do it my way': long-term care staff's perceptions of residents' sexual needs and suggestions for improvement in their management

This study is aimed at exploring to what extent staff perceive older residents in long-term care facilities (LTCFs) as still having sexual needs, and how they think care in relation to sexual issues could be improved. The sample was self-selected and comprised 2115 staff members (including managers, technical and care assistants) employed at 152 Spanish LTCFs. Data were collected in the second half of 2016. Participants were asked to estimate the proportion of older residents who had sexual needs in their institution and, by means of open-ended questions, they were also asked about how they satisfied such needs and how to improve care in relation to sexual issues. Responses to the open-ended questions were analysed using content analysis. Differences were assessed according to participants' work position. Results showed that most participants did not see sexual needs as being present in many (or even any) older people living in LTCFs. Masturbation was the most common way staff thought residents' sexual needs were being satisfied. The participants mentioned a broad range of measures to improve care regarding sexual issues, including providing more training opportunities for staff, guaranteeing privacy and improving negative attitudes held by family, residents or staff members. Work position influenced participants' responses: managers and technical staff were more likely to recognise sexual needs among residents, perceived a greater need for training, and proposed more ambitious and far-reaching improvements than care assistants.

Influence of Sexuality on the Health of the Elderly in Process of Dementia: Integrative Review

Objective: this work sought to inquire on the influence of sexuality on the health of the elderly during dementia. Materials and Methods: this was an integrative review. A careful search was conducted in nine databases; however, only five databases provided articles fulfilling the scope of the study: Medline, Lilacs, BDENF, Scopus, and Web of Science (WoS). The health science descriptors (DeCS) were adopted: “sexualidad”, “demencia” and “anciano”, and the descriptors cataloged in the Medical Subject Headings (MeSH): “sexuality”, “dementia” and “aged”. After applying the inclusion criteria, eight articles were selected to comprise the study sample. Results: the practice of sexuality influences upon the health of the elderly with dementia with some beneficial effects, given that it provides, especially, better perception of quality of life and wellbeing. Nevertheless, it cannot be generalized due to methodological insufficiency evidenced in the studies found to construct this review. Conclusions: due to the limitation of studies addressing the theme and the methodological insufficiency of those included in this review, it is necessary to conduct research that shows in depth the influence of sexuality on this population, given that it can be constituted as another approach for the promotion and protection of health in the elderly with dementia.

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.

The nursing team's performance towards the sexuality of institutionalized elderly women

OBJECTIVE

Analyzing how the nursing team performs in facing the sexuality in the daily lives of institutionalized elderly women.

METHOD

A qualitative and descriptive study carried out in a Nursing Home in the southern region of Brazil. Data were collected from April to July 2016 through a semi-structured interview and submitted to the French Discourse Analysis of Michel Pêcheux. The study complied with the norms of the Brazilian legislation for research on human beings.

RESULTS

Eighteen (18) nursing professionals participated in the study. Ideological and imaginary formations permeated the subjects' discourse, evoking the understanding of sexuality, its institutional conformation and the performance demanded under manifestations of this sexuality. Thus, considering the professionals' performance, it became possible to identify difficulties such as embarrassment, discomfort or prevalence of personal beliefs and strategies. These strategies have diversified ranging from the use of humor to direct repressive actions.

CONCLUSION

Understanding the dynamics of professionals' performance towards sexuality allows us to glimpse the need for comprehensiveness in care related to social, ideological and imaginary formations which demand an imperative strengthening of academic and professional training.

Staff members' perceived training needs regarding sexuality in residential aged care facilities

The purpose of the article is to ascertain if staff members of residential aged care facilities (RACF) perceive the need for training regarding residents' sexuality, and what, if any, benefits from the training were perceived, and to compare perceived benefits of training between care assistants and professional/managerial staff. Interviews were conducted with 53 staff members of five different RACF in Spain. Their responses to two semistructured questions were transcribed verbatim and submitted to content analysis. Results show that most interviewees said they lacked training about sexuality and aging. Two potential highlighted benefits of the training are knowledge/attitudinal (countering negative attitudes regarding sexuality) and procedural (developing common protocols and tools to manage situations related to sexuality). Care assistants and professional staff agreed on the need for training, though the former emphasized the procedural impact and the latter the knowledge/attitudinal benefits. The results suggest that RACF staff should have an opportunity to receive training on residents' sexuality, as sexual interest and behavior is a key dimension of residents' lives.

Old(er) care home residents and sexual/intimate citizenship

Sexuality and intimacy in care homes for older people are overshadowed by concern with prolonging physical and/or psychological autonomy. When sexuality and intimacy have been addressed in scholarship, this can reflect a sexological focus concerned with how to continue sexual activity with reduced capacity. We review the (Anglophone) academic and practitioner literatures bearing on sexuality and intimacy in relation to older care home residents (though much of this applies to older people generally). We highlight how ageism (or ageist erotophobia), which defines older people as post-sexual, restricts opportunities for the expression of sexuality and intimacy. In doing so, we draw attention to more critical writing that recognises constraints on sexuality and intimacy and indicates solutions to some of the problems identified. We also highlight problems faced by lesbian, gay, bisexual and trans (LGB&T) residents who are doubly excluded from sexual/intimate citizenship because of ageism combined with the heterosexual assumption. Older LGB&T residents/individuals can feel obliged to deny or disguise their identity. We conclude by outlining an agenda for research based on more sociologically informed practitioner-led work.

Recommendations for sexual expression management in long-term care: a qualitative needs assessment

AIMS

To conduct a qualitative needs assessment of Directors of Nursing regarding challenges and recommendations for addressing sexual expression and consent.

BACKGROUND

Sexual expression management among long-term care residents is a complex issue for nursing home staff. Little guidance is available for those wanting to follow a person-centred approach. Policies and procedures are needed, and must be usable across long-term care settings.

DESIGN

Qualitative design for in-depth exploration.

METHODS

Semi-structured interviews were conducted with 20 Directors of Nursing in the spring and summer of 2013, representing a range of regions, facility sizes and resident populations. Interview questions prompted them to identify recommendations that address challenges to improving sexual expression management in long-term care settings.

RESULTS

Comparative thematic analysis resulted in several codes, which were grouped into eight overall categories. Recommendation categories that addressed key challenges included: address the issue, make environmental changes, identify staff expertise, provide education and training, assess sexuality initially and recurrently, establish policies/procedures for sexual expression management, develop assessment tools for sexual expression and consent, and clarify legal issues. The recommendation to develop national guidelines was observed across categories.

DISCUSSION

Directors of Nursing report several challenges to sexual expression management in their facilities, and perceive their current methods to be ad hoc. A proactive approach to policy and procedure development is needed.

The challenges and opportunities in researching intimacy and sexuality in care homes accommodating older people: a feasibility study

Aim

To explore the challenges of conducting research on sexuality and intimacy among older care home residents.

Background

Sexuality and intimacy are neglected in care policies and practices.

Design

Qualitative analytical study drawing on poststructuralist theorizing.

Methods

Semi‐structured interviews were conducted with residents and spouses (n = 6) and care staff (n = 16) in two care homes in Northwest England in 2014. The sample was obtained through a network of ‘research‐ready’ care homes. Thematic analysis was used to make sense of narratives with the aid of NVivo10.

Results

Participant responses highlight the workings of ageist erotophobic discourse that undergirds the assumption of residents (and old people generally) as postsexual. This materialized in reservations about the research ranging from opposition on moral grounds to doubts about its feasibility given the age‐group concerned. However, residents and care home staff can also draw on counter‐discourses that resist/challenge ageist erotophobic thinking, which materialized in methodological and ethical recommendations.

Conclusion

Participants generally agreed with the principle of the research and made recommendations that could counter/resist ageist erotophobic governance and guide researchers on sampling, style of questioning and communicating with (prospective) study participants on a sensitive subject.

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.

Intimacy between care home residents with dementia: Findings from a review of the literature

BACKGROUND

There is limited research on what family members and frontline care home staff consider to be the best responses to the sexual expression of a person with dementia, whilst at the same time respecting relatives' feelings, managing their possible distress and conflict, and how good practice should be reflected in care home policy and practice guidance.

METHODS

This literature review explored what is known of the views of relatives and care workers of new relationships or sexual intimacy between care home residents with dementia, whilst still married to another person. It reports the findings of searches of three databases undertaken in August 2014 (Medline, Embase and PsychINFO).

FINDINGS

Nine papers were found relevant to the research question. The following themes emerged from a synthesis of the papers located: sexuality in old age, dementia and sexuality, hyper-sexuality, views regarding sexuality of older people living in care homes, the law, ethics and consent, relationships and communication between care home and relatives, and new relationships or intimacy between residents with dementia.

CONCLUSION

While studies of residents' expression of sexuality and their engaging in sexual behaviour with other resident(s) may be challenging to manage in care home settings and can be emotionally painful or uncomfortable for families, the review found that studies are few in number and span emotional intimacy and distressing behaviour.

Ageing fears and concerns of gay men aged 60 and over

Purpose

– In light of the fact that the “baby boomer” generation is moving into early old age, the purpose of this paper is to examine what aspects of ageing and old age concerned an age cohort of 25 gay men aged 60 plus.

Design/methodology/approach

– The primary data for this paper came from interviews with 25 men aged 60 and older who were recruited in Auckland, London, Manchester, Melbourne, and New York. Interviewees were contacted by a variety of means, such as by e-mail introductions, advertisements placed on social media, and recommendations of mutual friends or acquaintances. Once contacted, the men were sent a plain-language statement outlining the purpose of the study and the intention to publish the results and were asked to sign and return a consent form. Narrative identity was central to understandings of the men’s lives got from analysing their interview transcripts.

Findings

– Analysis of extracts from their life stories showed the men interviewed for this paper drew on two principal narratives when discussing their apprehensions about growing old. The first related to general fears or concerns about old age that would be fairly common among members of the general population. The second narrative related to gay-specific fears or concerns. Significant claims: that class affects gay men’s experience of old age just as it does for everyone else; and that fears of being ostracised because of their sexuality were strongest when the men spoke about aged-accommodation settings.

Research limitations/implications

– More research is needed on gay men’s experience of in-home supported care and residential care to see if the reality of the heterosexism and/or homophobia matches the fears of some in this sample.

Originality/value

– This is a relatively new field and there is a growing number of researchers examining the ageing concerns and experiences of the GLBT population. The originality of this paper lies in the international sample on which it is based, its use of narrative analysis, and its relevance to policy makers as well as to members of the GLBT population, carers, and owners/managers of aged-care accommodation facilities.

Bonds, bridges and ties: applying social capital theory to LGBT people’s housing concerns later in life

Purpose

– The purpose of this paper is to contribute to debates about lesbian, gay, bisexual and transgender (LGBT) housing later in life by placing these in a theoretical context: social capital theory (SCT).

Design/methodology/approach

– After a discussion of SCT, emanating from the works of Robert Putnam and Pierre Bourdieu, the paper draws on existing studies of LGBT housing later in life, identifying key concerns that are identified by this body of literature.

Findings

– The paper then applies SCT to the themes drawn from the LGBT housing later in life literature to illustrate the usefulness of putting these in such a theoretical context.

Originality/value

– Hence, overall, the paper fills an important gap in how the authors think about LGBT housing later in life; as something that is framed by issues of social networks and connections and the benefits, or otherwise, that accrue from them.