Promoting awareness of sexuality of older people in residential care.
Low, Lisa P.L. ; Lui, May H.L. ; Lee, Diana T.F. 等
Abstract
Addressing sexuality of older people is a neglected area and has
received insufficient attention in residential care practice. This paper
presents an urgent need to address this sensitive, potentially
embarrassing but important health issue. It concludes that much work is
still needed in this area, particularly to understand sexuality from
older peoples' perspectives and how their sexual needs and concerns
can be addressed by those caring for them in residential care homes. Not
until we truly know what older people want and understand what sexuality
means to them can it be possible to plan individualized care that will
meet their specific sexual need.
Introduction
As the number of older people moving to residential care home
continues to increase, there is a growing expectation that the care they
receive will be of the highest quality. Yet to actively engage in
discussion about how older people live in residential care homes
conjures up unpleasant images that may make people uneasy and prefer not
to think about it (Kane, 2000). Then what about broaching the subject of
sexuality of older people in residential care homes? It is important, no
doubt, but also sensitive and potentially embarrassing.
Even though sexual health has been acknowledged as an important
component of quality of life for many older people (Miller, 2004), it
has not been easy to either encourage or respond to older people
expressions of sexual interest, attitudes, activity and satisfaction.
Not surprisingly, there appears to be scant knowledge on how best to
address the sexual needs of older people in residential care homes. As
such, sexuality of older people is a neglected area that has received
insufficient attention in residential care practice. In a selective
review of the literature, this paper aims to offer insights into how
sexuality of older people is expressed and addressed in residential care
homes. It also suggests that more work should be undertaken to promote
awareness of sexuality in residential care, particularly understanding
what sexuality means from older people's own perspectives. In this
way, they may be supported to express their sexuality in appropriate
forms across culturally diverse societies.
Defining sexuality
Sexuality is a complex and multi-dimensional concept covering the
desire for sex, the sexual act and values, and beliefs about sex
(Kaiser, 1996). Sexuality also involves the whole experience of a
person's sense of self, and includes a person's ability to
form relationships with others, feelings about themselves, and the
impacts of the physiological changes of ageing on their sexual
functioning (Kamel, 2001; Russel, 1998). Other dimensions of sexuality
such as a person's level of self-esteem, type of clothing worn,
type of sexual activity one chooses to engage in and with whom, and the
nature of the sexual act may also be considered (Peate, 1999). This
suggests that a person's sexual experience and their ability to
enjoy it is very personal and individualized, and is related to age and
degree of disability or ill-health (Russell, 1998). It would seem that
when effort is put into promoting an understanding of a person's
sexuality, numerous benefits such as having a healthy self-image,
psychological refueling and re-energizing, an outlet for personal
anxieties, and a means of preventing social disengagement and avoiding
depression results (Heath, 1999). Engaging in a sexual relationship can
also bring love, intimacy and closeness that can further improve older
people's general well-being (Wallace, 1992). It is therefore
important to promote sexual awareness of older people.
Sexual myths
Many sexual myths and stereotypes work against older people and
challenge whether the expression of sexuality in old age is appropriate.
Despite studies reporting that older people can be potentially sexually
active into later life (Marsiglio & Donnelly, 1991), the society
still continues to devalue older people's sexuality with humor,
ridicule and distaste (Spurgeon, 1994).
One major challenge is trying to change people's attitudes
towards sex in later life and to outgrow the deeply embedded beliefs
that sexuality is only the province of a youthful society (MacRae,
1999). As people age it is generally believed that they no longer look
physically attractive and thus do not have sexual needs and, if they
have any, they would need to suppress them. This is somewhat consistent
with findings from older people who reported that they no longer felt
physically attractive and thereby felt sexually unattractive (Richardson
& Lazur, 1995). This commonly held misconception has unnecessarily
coerced and socialized sexual older people into becoming asexual beings--who have lost their physical attractiveness, have no sexual
needs, thoughts or desires to engage in any forms of sexual behavior (Kessel, 2001)--in order to comply with societal expectations and social
values.
Few would deny victimizing older people for their overt sexual
behaviors and labeling them as socially unacceptable. Indeed, such
assumptions would deny older people the right to express their true
sexual feelings verbally and behaviorally, for fear of being labeled as
disgusting with unrestrained indulgence of lust (Archibald, 1998). Until
these ingrained and longstanding myths are dispelled, older
people's sexuality will continue to be concealed, viewed with
shame, and discouraged from the freedom of sexual expression by those
caring for them (Bauer, 1999). So instead of working towards accepting
older people's sexuality as an indispensable part of human
existence (Nay, 1992), society has further diverted needed attention to
understand older people's sexual needs and rendered their sexual
behavior as insignificant.
Sexuality of older people in residential care
Despite some progress made to challenge the prominent sexual myths
of older people in residential care homes, supporting and allowing older
people to freely express sexuality in acceptable forms is still a
challenge for residential care home staff. The following will discuss
different ways in which older people express their sexuality, and how
residential care staff respond, understand and interpret older
people's sexual acts.
Older people's expressions of sexuality
Studies demonstrating different types of sexual expression among
older people in residential care homes found that, in terms of physical
aspects, sexual intercourse, masturbation, caressing and touching have
been reported--with the latter two being more prevalent among women than
men (Lichtenberg, 1997). Limited contacts such as kissing foreheads,
hugging, petting or holding hands were important social expressions of
sexuality among women (Steinke, 1997). In terms of gender differences,
there was a preference for women to enjoy social intimacy and strive for
love and companionship, as opposed to sexual-physical acts. When allowed
to engage in relationships with others, these positive experiences
enabled them to feel joyful, special, loved and attractive again (Miles
& Parker, 1999).
In contrast, there are older people in residential care homes who
would deny any interest in sexual expressions. Notably, loss of interest
has been demonstrated among older people with chronic illness and
disability, when they experienced changes in body image and sexual
dysfunction (Pangman & Seguire 2000). Additionally, not having able
partners, lack of privacy to engage in sexual activities, and being
confronted with negative attitudes of staff were barriers to sexual
expressions (Kessel, 2001; Hajjar & Kamel, 2004).
Although sexual activities bring gratification and enable older
people to have greater locus of control and increase self-esteem,
expressions of physical intimacy have not received favorable responses
and are widely viewed as 'abnormal or inappropriate behaviors'
among the elderly (Miles & Parker, 1999). In a survey eliciting
residential home managers responses to elders sexual expressions
(Archibald, 1998), behaviors were only encouraged when they were
privately expressed (e.g. holding hands between residents), considered
culturally 'safe' and not difficult to manage by staff.
However, the same behavior would be considered less acceptable and
interpreted as sexual when performed in public, or where a carer was
involved. The author speculated that holding hands was discouraged so as
to protect the carers' feelings or prevent potential altercation
between the parties involved. The findings also revealed that sexual
expressions directed towards staff and public sexual expressions were
also unacceptable and were major concerns for staff.
Furthermore, a study on hyper-sexuality of eight residents in
nursing care facilities found that the demonstration of extremes of
problematic sexual related behaviors triggered the greatest concerns and
distress among staff (Nagarathnam & Gayagay, 2002). Cuddling,
touching of genitals, grabbing and groping, use of obscene language,
masturbating without shame, aggression and agitation were cited as
inappropriate sexual behaviors. Interestingly, this study used
illustrative cases to set older people's sexual behaviors and their
presenting symptoms in the context of their daily lifestyles, clinical
and neurological histories in order to individualize the sexual issues
and better understand their situations. These elders were subsequently
referred to the Geriatrician for expert advice and management, and
labeled as 'diseased' or had an 'illness'.
In the restricted residential care home environments (Nagarathnam
& Gayagay, 2002), the freedom of elderly people to move on from
acceptable behaviors (e.g. caressing and touching) to greater physical
intimate relationships between residents was often inhibited and
discouraged by staff, who would intervene when they perceived behaviors
to be unacceptable and inappropriate. In these settings, the concerns of
staff and their abilities to handle the sexual expressions were more
important considerations in determining whether older people's
desires and wishes to express themselves sexually should be recognized,
acknowledged and met.
Staff understanding of sexual acts
An understanding of how residential home care staff respond and
interpret older people's sexual acts would be important,
particularly when staff plays a prime role in facilitating what and how
sexuality of older people should be expressed in the home. Although the
review highlighted issues on staff responses to older residents'
sexual expression and strategies to address sexual needs, these have
largely been the subject of speculation and opinion, with little
research-based findings. More recently, however, there has been an
interest to examine strategies to assist staff to make decisions about
handling ethical dilemmas concerning sexuality of institutionalized
elders with dementia (Ehrenfeld et al., 1997).
Despite the fact that some sexual behaviors are easier to accept
than others, sexuality of older people emerged as a concern and a burden
to staff. Consistently the literature supports the limited insights and
vague understanding of residential care home staff in handling older
residents' sexual acts--often construing sexual behaviors as
behavioral problems, rather than elders' expressions for love and
intimacy (Miles & Parker, 1999). Against a set of negative attitudes
reported by staff, earlier studies found that older people's sexual
expressions were met with apprehension, disapproval, judged as
misbehavior, and punished using restraints or segregation (Butler &
Lewis, 1987). It was not unusual for staff to feel threatened, awkward
and uncomfortable, and to react by ignoring the expressions. Not
surprisingly, these reactions are not too different from what is
happening today.
In response to male masturbation, interviews involving 18 nurses
working in nursing homes demonstrated reactions of shock, horror and
uncertainty about how to deal with it (Nay, 1992). Although nurses
expressed disgust at the image of men acting sexually, what was more
disturbing was their belief that women would be excluded from such
behaviors (Nay, 1992).
Similarly, Ehrenfeld, Tabak, Bronner & Bergman (1997)
demonstrated that staff expressed mixed emotions of confusion,
embarrassment and helplessness when older people acted sexually. In
making sense of the negative reactions of staff, a categorization system
was developed to help staff understand different sexual expressions
displayed by older people (Ehrenfeld et al., 1999). It was found that
staff were able to accept and support loving and caring behaviors but
were hostile, angry and disgusted when older people's behaviors
were openly erotic.
Additionally, sexual behaviors that were linked to romance brought
on reactions of humor, ridicule and tease from staff (Bauer, 1999;
Ehrenfeld et al., 1999). This was supported by Bauer's (1999)
phenomenological study investigating nursing home staff experiences of
elderly residents sexuality, which found that the use of humor enabled
staff to communicate sexuality easily by firstly assisting them to
relieve the stress of the situation, and then to understand the meaning
behind the situation and the role they should play in it. If used with
understanding and sensitivity, humor would be a useful strategy to
safely deal with emotional and socially unacceptable incidents that
would normally be uncomfortable to address directly (Robinson, 1983).
However, humor could also have an opposite effect and be seen as another
sanction measure used by staff to coerce residents to conform to asexuality, and thereby concealing their genuine needs in the nursing
homes (Bauer, 1999).
The lack of knowledge and experiences of staff in handling
sexuality in old age is one main reason for not being able to promote
awareness of older people's sexuality in residential care homes
(Lyder, 1994). Undoubtedly, the attitude and mind-set of staff remain an
influential factor inhibiting sexual expression of older people,
particularly when staff cannot comfortably talk about sexuality and
hesitate when venturing into intimate discussions with older people and
dealing with their sexual responses. If older people are discouraged
from expressing sexual interests and activities, this can impede them
from becoming fully accepted into residential living. Those elders who
choose to lead a relatively active sexual life will continue to conceal
their true sexual needs and desires.
The way ahead
Although slow, there appears to be a shift with staff being more
receptive towards older people's need for sexual expressions. This
is a positive move forward in acknowledging the importance of sexuality
in later life. In promoting awareness of older people's sexuality
in residential care, three strategies will be discussed: (1)
re-emphasizing staff awareness of sexuality issues through education and
training, (2) compromising on a tolerant environment for sexual
expression and, (3) conducting research aiming to conceptualize the
meaning of sexuality from older people's perspectives.
Re-emphasizing staff awareness of sexuality issues through
education and training
Part of the answer lies in the recognition of the benefits of
sexual education and sexual training, which should be aimed at
appropriate levels for different ranks of residential care staff to
increase their knowledge about sexuality of older people. Whilst
educational initiatives have helped to dispel myths and raised awareness
of older people's sexuality (Steinke, 1997), it would be helpful to
re-emphasize key features of some educational programs in terms of
course content, venue and ranks of staff participating.
In a formal and systematic approach to respond to the need for
training programs, Walkers et al (1998) examined the process of
developing a comprehensive sexuality training curriculum upon which
training for staff could be based. This process involved conducting a
systematic needs assessment by reviewing the literature, forming an
advisory team and conducting focus group discussions with professionals,
residents and family members. Program goals, objectives and modules were
then established, with the aim of attracting participants whose desire
is to increase their own knowledge base and be better equipped to deal
with residents sexual concerns. Although curriculum development is
time-consuming work, reviewing it on a regular basis to update the
content in the light of new knowledge and recommendations will be
needed.
Steinke (1997) described an educational intervention lasting for
two one-half day sessions on knowledge and attitudes of sexuality and
aged-related changes, conducted on front-line care staff in the
classroom of one nursing facility, with the aim to sensitize staff to
sexual issues and to correct misinformation. Although an initial
reluctance of staff to discuss sexual issues was witnessed, they later
claimed to have benefited from the program and the strategies discussed
for dealing with elders' sexuality were useful in the workplace.
Although not mentioned in the study, the value of this type of education
session can be speculated. Firstly, conducting sessions within the
home's premises not only acknowledged the home manager's
support of this important topic, but the program was also supported by
relieving staff to attend the sessions. Secondly, this training mode
could be further developed into an in-service training initiative,
whereby front-line staff together with the home's managers would be
motivated to generate their own agenda for regular discussion of sexual
issues that were specific to the residents residing in the home. In this
way, staff would take ownership of the training program and strategies
proposed for dealing with older people's sexuality would be
individualized to the homes concerned.
The way in which educational materials are presented to staff need
to be relevant, appropriate and applicable to the sexual dilemmas they
encounter on a daily basis. In an attempt to formulate a systematic way
of presenting sexual incidents encountered (either between older people
or the carer-older person), a decision-making worksheet was introduced
to four institutions catering for people with dementia (Ehrenfeld et
al., 1997). The worksheet served to document specific sexual problem(s),
carers' personal beliefs towards the problem, and offered choices
on a course of action suggested by colleagues and supervisors. Although
part of a research study, the idea of systematically working through
sexual dilemmas and problems with staff, and coming to an agreement on
the most appropriate way of coping with the sexual problem could be
transformed and applied to the practice settings, thus arousing greater
awareness among staff that issues were being addressed.
Compromising on a tolerant environment for sexual expression
Promoting open, comfortable and safe discussion of sexual
concerns among staff would be an important first step to creating
a tolerant environment for accepting elders' sexual expression.
Indeed, it would also facilitate staff to confront and review
their personal beliefs about sexual concerns by encouraging them
to talk through their disturbing experiences, if they are to be of
help to the residents concerned (Lyder, 1994). While a helpful
strategy to compromise values would be to pursue discussion of
sexual concerns in staff meetings or during change-of-shift report
(Steinke, 1997), having protected and reserved time solely devoted
to this purpose would be a better suggestion, particularly when
priorities of other agenda items could take precedence over
discussion of sexual issues if pressed for time and detract from
the efforts already achieved.
Indeed, the gradual involvement of residents in the discussion
would raise the profile of the necessity to foster 'tolerable'
sexual freedom in the homes, without necessarily overriding the
constraints of homes and causing disturbances to other residents.
One way of compromising conflicts of interests would be to
directly elicit residents' sexual expectations and whether staff
were able to meet them. Although a rather formal approach, a
survey on 1500 men and women aged 50 was conducted to provide
specific suggestions on how health care providers could discuss
sexual concerns and questions with them (Johnson, 1997). Staff
possessing specific personal characteristics such as
open-mindedness, a willingness to talk and spend time listening,
answering questions and providing accurate information and
suggestions to resolve sexual problems were more appropriate in
initiating conversation on sex (Johnson, 1997). This approach
documented useful information about older people's sexuality and
enabled issues to be followed up later.
Unless residential care staff take an active and initiated stance
in wanting to promote holistic, personal and autonomous sexual
health of older people, it will be impossible to cultivate a home
environment that would support older people to openly and
comfortably discuss sexual concerns and have their sexual issues
resolved (Johnson, 1997).
Indeed, the experience of living in residential care homes is a
vulnerable one as older people come from different backgrounds
with their own specific sexual needs. It is not unusual for older
people to succumb to the routines of homes and be influenced by
the power exerted by staff (Heath, 2002). Rather than making the
older person the culprit of undesirable sexual behaviours, staff
will need to acknowledge normalcy and confront their own
attitudes toward older people's sexuality. In addition, they
must recognize how their responses can either inhibit or encourage
older people to express themselves sexually (Drench & Losee, 1996).
Conducting research to conceptualize sexuality of older people
In truly understanding sexuality in residential care, it is prime
time to take a step forward and seek older people's views about
their own sexuality in terms of, for instance, views on sex in old age,
expressing oneself sexually, and thoughts and meanings underlying their
sexual motives. This important information will assist staff to
appreciate the need for sexuality in later life, and also to be
extremely sensitive when they reconsider how they would best respond to
older people's sexual interests, attitudes and activities in
residential care homes. When older people are given opportunities to
conceptualize and interpret the meaning of sexuality using their own
words, they are being legitimately encouraged to talk about sex and
express sex as it should be--a normal part of an older people's
everyday life. Older people will no longer need to feel ashamed,
repressed and denied about wanting to exhibit sexual feelings and acting
sexually. Indeed, it must not be forgotten that conceptualizing
sexuality is itself a very complex phenomenon. The topic also is fraught
with embarrassment and taboo in cultures with collectivist social
pressures and concerns for social hierarchy (Bond, 1991). Careful
interpretation of what sexuality means and how it should be
appropriately expressed among older people in culturally diverse
societies should be considered in future research.
Conclusion
Human sexuality is a natural, unique and integral part of every
person's identity (Heath, 1999; Kessel, 2001). It is clear that the
number of people moving into residential care homes is increasing. The
selective review of the literature summarizes studies that have
attempted to identify different forms of sexual expressions among older
people and some helpful interventions to guide residential care home
staff to deal with these sexual expressions. However, there is a paucity
of research available concerning effective strategies that will meet the
specific sexual needs of older people. With only a few exploratory
studies examining older people's knowledge, attitudes and sexual
behaviour, current information is insufficient to inform residential
care practices about older people's sexuality. Much work is still
needed to understand sexuality from older people's perspective and
how their sexual needs and concerns can be addressed by residential care
staff caring for them. Not until we truly know what older people want
and understand what sexuality means to them will it be possible to plan
individualized care that will meet their specific sexual need.
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Lisa P.L. Low, RN, RHV, BN, MPhil (1) *
May H.L. Lui, RN, BN, MPhil (2)
Diana T.F. Lee, RTN, RN, RM, PRD(HCE), MSc, PhD (3)
David R. Thompson, RN, PhD, FRCN (4)
Janita P.C. Chau, RN, BN, MPhil (5)
Affiliations:
(1.) Professional Consultant
(2.) Assistant Professor
(3.) Professor
(4.) Director and Professor of Clinical Nursing
(5.) Associate Professor
All at The Nethersole School of Nursing, Faculty of Medicine, The
Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
Postal addresses:
Lisa P.L. Low (*Corresponding author) The Nethersole School of
Nursing, Faculty of Medicine, The Chinese University of Hong Kong,
Shatin, N.T., Hong Kong.
Tel: (852) 2609 8182, Fax: (852) 2603 5269
Email: lisalow@cuhk.edu.hk