Sex: A Matter of Policy?

by Duncan S. MacLean, MD, CMD

Sex in nursing homes is like the weather--everyone talks about it, but no one does anything about it.

This tongue-in-cheek quip is all too true in many nursing homes. More to the point, sex is not even talked about in some nursing homes. It is taboo. However, sex is a fact of life in nursing homes that should not be ignored. This column will look at some approaches to sexuality taken by different facilities. It will also describe an innovative approach that has met with some preliminary success.

The Role of Leaders

How the issue of sexuality and privacy is handled in nursing homes is highly influenced by leadership, including that provided by the medical director. If the leaders treat sex as taboo, facility staff will not address sexual issues openly.

On the other hand, if leaders permit open handling of sexual issues, staff will manage problems before they become crises.

In some facilities, leaders must encourage more formal management of sexual issues. This may be especially true in facilities with a significant number of residents who:

• Are younger than age 60
• Have acquired brain injury
• Have serious chronic mental illness or mental retardation
• Have premorbid antisocial personality features

In such facilities, sexual activity is likely to be a recurring concern. A written medical policy can help organize a process for addressing sexuality, no matter what the age or characteristics of a facility's residents.

Sexuality in Nursing Homes

Sexual urges do not end with either advancing age or admission to a nursing home. One study of healthy community-dwelling individuals ages 80 to 102 found that among women, 72% fantasize, 38% have coitus, and 40% use self-stimulation (Bretschneider JG, McCoy NL. Arch Sex Behav 1988;17:109-129). Among men, 88% fantasize, 66% have coitus, and 72% use self-stimulation.

A study of 63 nursing home residents found sexual interest continues despite considerable barriers (Wasow M, Loeb MB. J Am Geriatr Soc 1979;27:73-79). These barriers include:

• No available partner
• Lack of privacy
• Inability to perform (men only)
• Poor health

According to sex therapist William Kelly, sexual activity in nursing homes is more likely to take the form of manual or oral stimulation of genitals than coitus (Kelly WA. Nursing Home Medicine 1995;3:56-61).

Among cognitively impaired residents, inappropriate sexual behaviors occurred in 7% in one study (Burns A et al. Br J Psychiatry 1990;157:86-94). According to Leopold Liss, MD, CMD, who spoke on sexuality at AMDA's 2001 Annual Symposium (see the April 2001 issue of Caring, p. 1), such dementia-associated behaviors require staff education and, in some cases, specific behavior management.

Researchers on sexuality in nursing homes observe that all too often staff attitudes are "oppressive." One survey found that nursing home staff members commonly misunderstand use of foul language or exposure of genitals by demented residents as being sexual threats rather than simply uninhibited, non-purposeful behaviors (Szasz G. J Am Geriatr Soc 1983;31:407-411). In another study, two-thirds of staff considered resident sexuality unimportant--not something that nursing homes need to address (Saretsky K. Provider 1987;13:20-23).

On the other hand, there is a growing recognition that healthy sexuality promotes self-esteem, dignity, and well-being. For instance, one CNA training curriculum (Pulliam J. The Nursing Assistant. Upper Saddle River NJ: Prentice-Hall, 1998) includes specific information about geriatric sexuality. It encourages CNAs to use an approach consistent with the resident's age and gender. For example, it suggests that CNAs put cologne or perfume on residents when grooming them for special occasions, and compliment residents on their appearance.

Approaches to Sexuality

Several approaches to sexuality in nursing homes have been reported:

Religious & Ethical Many nursing homes are operated by religious groups as ministries of service, and many nursing home staff, even in non-sectarian nursing homes, see their work as religiously motivated. They draw support from their beliefs for their sometimes thankless efforts. These staff may approach sexual issues from the standpoint of the moral teachings of their faith or from a general ethical perspective.

Clinical Some nursing homes, especially those with academic affiliations, approach sexuality from a clinical standpoint. They seek to understand biological, psychological, and sociological aspects of sexuality. They promote behavioral interventions, and recommend drug treatment when necessary for intractable, disruptive behaviors. The clinical approach to sexuality, including drug therapy, was recently reviewed by Hosam Kamel, MD, of St. Louis University's Division of Geriatric Medicine (Ann Long Term Care 2001;9:64-72).

Advocacy Some nursing homes and professionals frame sexuality as a matter of resident rights. They emphasize an approach that seeks to reduce the restrictive effects of institutions and staffs on sexual expression (Kelly WA. Nursing Home Medicine 1995, cited above). Staff Education Most approaches identify a key role for staff knowledge and attitudes, and thus rely heavily on staff education. Dr. Kamel's review outlines strategies that can be used by facilities--and reinforced with staff education--to protect the sexual rights of residents. These strategies include such simple practices as always knocking before entering a resident room. Studies have demonstrated the effectiveness of education on staff's ability to handle sexual behaviors (Steinke EE. Journal of Continuing Education in Nursing 1997;28:59-63).

A Risk Management Approach

Our facilities in Delaware have been trying out a risk-management approach to managing resident-to-resident sexual activity. We address dementia-associated sexual behaviors in a separate policy.

The risk-management approach does not try to be "values-free." Rather, it seeks to acknowledge and affirm the values of all stakeholders. It does so by clearly identifying potential risks entailed in sexual activity between residents, including potential clashes of values. In turn, the interdisciplinary team addresses risks in an individualized care plan to which the resident or responsible party consents.

Although we have not finalized a policy as yet, this approach has had some initial success in helping the team address these complicated issues:

Regulatory The only specific federal regulation related to sexuality is Tag F 175 (42 CFR 483.10 m), which requires the facility to allow married spouses to share a room if they wish. This right is contingent upon room availability and financial arrangements. Other regulations could be construed as pertaining to sexuality, but I have not seen them interpreted this way:

• Tag F 164 deals with privacy. This is interpreted as pertaining to bodily privacy, communication, visits, and clinical information.
• Tag F 279 deals with highest practicable level of function. This is interpreted to include psychosocial skills but not necessarily gender role or sexual functioning.
• Tag F 280 deals with the comprehensive care plan. This is not interpreted as a requirement to assist the resident with sexual functioning.

Any move to expand interpretation of these federal tags to include sexuality would undoubtedly encounter controversy and political resistance. But at least one state (New York) does require privacy for visitation by a spouse or partner (Codes, Rules, and Regulations Ch. V, Part 415.3).

Legal On the other hand, there are a number of Supreme Court decisions recognizing a constitutional right to privacy, specifically in the context of sexual rights. I am not aware of any instance in which this right has been asserted in a nursing home setting.

A more pertinent legal issue is that of competence to consent to sexual activity. Technically, sexual contact with a person incapable of consent is statutory rape, a crime. Forensic psychologists note that from a strictly legal standpoint, the standard of competence to consent to sexual activity is lower than that to marry. Marriage under the law is a contract requiring a full understanding of all the responsibilities and rights entailed. Consent to sexual activity, by contrast, requires only:

• Awareness of the relationship as intimate
• Mutual non-coercion
• Awareness of the risk of future termination of the relationship (Lichtenberg PA. A Guide to Psychological Practice in Geriatric Long-Term Care. New York: Haworth Press, 1994).

Health Health risks of sexual activity include communicable diseases, cardiopulmonary stress, and physical trauma. The physician is the best one to assess the actual risks in each case and the ability of individuals to exercise appropriate precautions.

Safety Safety risks are primarily those related to physical mobility. Mental Health The team should assess the psychosocial benefits and risks. Specific vulnerabilities such as underlying chronic mental illness, potential for violence, or intolerance for interpersonal stress should be identified.

Welfare The team should consider the effect on previous relationships, including spouse and family. The team should also identify risks to dignity. In the case of residents of reproductive age, the possibility of pregnancy is an issue.

Human Resources Nursing home staff members become involved in the most intimate aspects of their care recipients' lives, including their sexuality. Caregivers' values and sensibilities must be considered.

Administrative Beyond legal, regulatory, and managerial issues, administration must attend to public relations, organizational dynamics, and facility mission, including the moral or religious sensibilities of the governing board.

Drug therapy If the use of drugs to modulate sexual behavior is contemplated, the medical director should ensure accountability for off-label or investigational uses.

AMDA is posting in its On-Line Model Policy Manual a draft policy on privacy and sexuality based on this risk-management model. For more information, or to offer comments or suggestions, send e-mail to webmaster@amda.com.

The opinions expressed by Dr. MacLean are his own and not necessarily those of the American Medical Directors Association.

Dr. MacLean is Medical Director of Delaware's state-operated system of nursing homes. He was founding President of the Pennsylvania Medical Directors Association and served as an Issue Expert on Long-Term Care for the 1995 White House Conference on Aging. He has directed a private non-profit nursing home, a hospital-based subacute unit, and a private personal care facility. He has served on AMDA committees, presented at the AMDA Annual Symposium, and conducted Symposium discussion groups.

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