Sexuality in Elder Care: Toward a New Paradigm

1. Sexuality in Elder Care:Toward a New Paradigm • Lois Stewart-Archer RN, MN, CPMHN(C) • Regional Clinical Nurse Specialist • WRHA Geriatric Mental Health • Susan Bernjak RN, BA, CACE, GNC(c) • Regional Educator • WRHA PCH Program

2. SHHHHHH, we’re talking about sex!

3. Sexuality in Elder Care • Objectives: • we will ask you to examine, and maybe change, your attitudes and beliefs regarding sexuality and the elderly • we will look at some challenging behaviours related to sexuality • we will look at policy development

4. Thoughts on Sexuality • “In our experiences, old folks stop having sex for the same reason they stop riding a bicycle –general infirmity, thinking it looks ridiculous, no bicycle.” •   A.Comfort

5. Thoughts on Sexuality • “Aging … is a metaphor for asexuality” • H. Davies, et al

6. Thoughts on Sexuality • What do the words “sex” and “sexuality” mean to you? • What are some common attitudes and beliefs held by staff? • Common staff reactions?

7. Staff attitudes • residents aren’t interested in sex • sexual behaviours are a problem not an expression of a need • staff are uncomfortable with displays of affection/sexual behaviours • staff become paternalistic

8. Staff attitudes • concerned about competency of residents involved • level of comfort with gay and lesbian relationships • may feel disgusted • uncertain what to do or say

9. Staff attitudes • What influences our attitudes and beliefs on sex and sexuality? • cultural values • personal beliefs • lack of understanding • inadequate training

10. Myths about Sexuality and the Elderly • “old people don’t have sex” • “old people have stopped developing relationships” • “old people aren’t interested in sex”

11. STATISTICS • Of the1604 men and women ages 65-97 who responded to a survey: • 40% reported that they had sexual activity an average of 2.5x/month • 69% of the men and 49% of the women reported that sex was important in their lives

12. STATISTICS • A recent study from the New England Journal of Medicine reported that: • more than half of those surveyed who were between the ages of 57-75 stated that they gave or received oral sex • one third of those between 75 and 85 reported that they gave or received oral sex

13. STATISTICS • Another study showed that: • 74% of married men and 56% of married women > 60 continued to be sexually active • 31% of unmarried men and 5% of unmarried women > 60 continued to be sexually active

14. STATISTICS • Among the most seriously cognitively impaired elderly, 7% are reported to exhibit sexually disinhibited behaviour.

15. Sexuality &Intimacy

16. SEX & INTIMACY • “Sex and intimacy encompass a kaleidoscope of feelings and activities; from the deepest longings for mutual affection to the simple enjoyment of the company of a loved one” (Sherman, 1998).

17. SEXUALITY • Sexuality also covers a gamut of behaviours – touching, kissing, caressing and cuddling, genital intercourse with mutual orgasm and feelings of closeness and being wanted and valued as a human being.” (Sherman , 1998).

18. Sexuality Defined • “Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed (WHO, 2003).

19. Intimacy • The need and ability to experience emotional closeness with another human being and to have that emotional closeness predictably reciprocated (Denis Dalley).

20. Sexuality: What does it mean? • Close companionship • Touch and be touched • Body image • Synonymous with sexual activity and intercourse. (Deacon, Minicheiello, Plummer, 1995)

21. Sexually Dysinhibited Behaviour • Incidence 4% - 7% • Occurrence: both males and females • Both long term care and acute care • Particularly high with those with a dementing illness

22. Changes secondary to Dementia • Of Note: • Existing relationships adapt • New relationships  form • Desires  fluctuate

23. Changed sexual behaviours Uncharacteristic? Illness related Sexual desire – what, when, where Loss of inhibitions Advances towards others Diminishing sexual interest Withdrawn, non-initiate Increased sexual demands Unreasonable, exhausting “Objectified” Dementia: Sexuality & Intimacy

24. What Does Not Change? • The right to be sexually alive, should adults wish - regardless of age, ability, or sexual preference. • Intimacy is a basic need, which people with Dementia and their carers should be able to express, WITHOUT FEAR OF DISAPPROVAL!

25. Causes of SDB • Underlying Medical Problems • Labial Cancer Vaginitis • Prolapsed uterus UTI • Colorectal cancer Scabies

26. Causes of SDB • Aggressive response to stressor of institutionalization • Threat, fear, loss • Structure • Tasks exceed ability etc

27. Causes of SDB • Dementia/Depression • - misunderstanding of environmental cues • - not adhering to social norms • - disturbance in memory, judgment • - psychological conflicts acted out through sexual behaviour • - frustration, confusion • - boredom, inability to concentrate

28. Causes of SDB • Need for Intimacy • Desperation for human contact

29. Causes of SDB • Panic associated with death • – helps mask

30. Causes of SDB • impulse control Age-related Changes

31. Medication Adverse Effects • A/D (tricyclics - desire, SSRIs - delayed ejaculation, Trazodone – desire • Antihypertensives (analapril, diuretics) • Antianxiety (inhibition of orgasm) • Narcotics ( desire) • Antifungals (ketoconazole – erectile dysfunction) • Anticoagulants (Heparin – priapism) • H2 antagonists (Ranitidine – gynaecomastia) • Anti-lipid (Niacin -  desire) • (Finger et al, 1997; Thomas et al, 2003; Rizvi et al, 2002)

32. SDB: Theoretical Framework Habits, Personality SDB Satisfies the need Unsatisfied Need Current condition Physical Mental SDB Communicates needs Environment Physical Psychosocial SDB Due to Frustration Negative Effects Cohen-Mansfield, 1990

33. General Suggestions for Basic Intervention

34. Disturbance in Memory and Judgment • Reorient to person and place as possible • Use short simple instructions to direct to room or redirect behaviour • Label rooms to help locate privacy • If SDB persists, use alternative clothing • Pull-over shirt • Elasticized pants • Back-closing shirts etc.

35. Unmet Need for Affection • Assign same caregiver consistently • Spend time with Resident/Pt. • Provide tactile stimulation e.g. touch, toys, texture • Encourage verbalization re: sex and sexual frustration • Reward for appropriate requests for attention e.g. smile, hug, spend time

36. Death Anxiety • Spend time with Resident/Pt. • Encourage to verbalize feelings about illness, end of life • Engage in life-review or reminisce therapy as appropriate • Reinforce that he is not alone

37. Age-related changes with  impulse control • Provide with limits for behaviour, outlining acceptable and unacceptable behaviour in the present environment • Reassure of acceptance • Problem solve to determine ways to manage (situation triggers, alter situation) • Reward for appropriate requests for attention e.g.. Smile, hug, spend time

38. Clothing removal Self exposure Masturbation Inappropriate touch Requests for kisses Attempts to fondle Clothing - hot, itchy, tight Need to use bathroom Boredom, frustration Mistaken identity Expressed need to touch Misinterpret others Misinterpreting Environmental Cues Behaviour Possible Explanation

39. Principles • Observation • Assessment of past and present • Identification of unsatisfied needs • Adaptation of intervention to needs, personal characteristics, environment • Trial of several alternatives • Assessment of approach used (Groul, 2005)

40. Defining Capacity to Consent to Sexual Relations • Ability to Avoid Exploitation • Is the behaviour consistent with formerly held beliefs and values? • Does the person recognize the concept of choice and voluntariness? • Does the person have the information needed to make a decision? • Does the person have a guardian? (Alzheimer Mb., 2006)

41. Defining Capacity to Consent to Sexual Relations • Awareness of Potential Risks • Does the person realize that sexual contact may be time limited? • Can the person describe how she/he will respond if and when contact ends? • Is the person aware of any potential physical and emotional harm? • Can the person take precautions against risks? (Teitelman, 2002)

42. Our Approach

43. Our Approach to Sexual Behaviours in LTC • A Problem-Solving Approach • We need to ask ourselves: • is the behaviour really sexually motivated? • is this “normal” behaviour for this individual? • is there a trigger for the behaviour? • who is this really affecting? • staff? other residents? families?

44. Steps in a problem solving approach • 1. Define the problem • is there a problem? • whose problem is it? • who is it affecting? • the resident? the family? other residents? staff?

45. Steps in a problem solving approach • 2. Assess the person • what is behind the behaviour?

46. Steps in a problem solving approach • 3. Develop a plan • what is the desired outcome? • as a team, decide on the interventions and recommendations you want to put into place • work with the resident, the family, other residents, the interdisciplinary team and staff on all shifts

47. Steps in a problem solving approach • 4. Evaluate and monitor

48. Challenges • Masturbation • video clip • applying the problem solving approach

49. Challenges • Consenting Adults • video clip • applying the problem solving approach

50. Policy Development • Having a policy in place provides guidance for looking at a situation in a more objective way. • What do you need to take into consideration when trying to develop a policy on sexuality?