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Wednesday, 24 July 2013

Sex Among Residents of Care Homes

That's a scene from the 2006 movie, Away From Her, with Julie Christie and Gordon Pinsent. She is moving into a care home that day due to her Alzheimer's disease. The story gets more complicated from there but for now...

Let's talk about how old people with dementia and without are prevented from having sex in care homes of various kinds. In fact, according to reporter, Bryan Gruley, writing at Bloomberg.com this week,

Federal and state laws require elderly care facilities to respect residents’ rights to privacy and safety. Married couples in Iowa and 17 other states have legal rights to share rooms or have conjugal visits...”

The only acceptable response to that statement is: What's wrong with the other 32 states and why aren't the laws enforced everywhere?

There is no reason for anyone – federal or local governments, physicians, nurses, care home workers, adult children, etc. - to have a say in any person's sexuality no matter where they live.

But they do and it is another form ageism - prejudicial treatment of old people based on beliefs about how they should and should not behave.

In the first of his two-part report, Gruley relates the story of two residents at the Windmill Manor home in Iowa who were caught by nurses in December 2009, engaging in sex. Greatly abridged, here's what happened:

The encounter appeared to be consensual and when the woman's son was informed as well as the man's daughter, everyone seemed to agree that nothing needed to be reported to the state.

Nevertheless, the state did become involved, the man was discharged from the home, the administrator and the director were fired. The next year, the woman's family sued stating that she had been raped and it got more complicated from there even though both the man and woman died during the lengthy legal case.

Last May, a “veteran Iowa nursing home administrator” told the reporter,

”...the woman was 'confused to the extent that I don’t feel she was maybe realizing what was happening to her or she thought maybe it was her husband.'”

Let us count all the ways this incident is wrong:

  1. Why did the man and woman have no privacy from the nurses who walked in on them?
  2. Why would the staff call the adult children of the man and woman to report they were having sex?
  3. Why were the administrator and director fired over consensual sex of two residents?
  4. Since there is no way the woman's family could know if rape had occurred, why was the lawsuit allowed to proceed?
  5. How could the “veteran administrator” know the woman was “confused”?

These were adults – she age 87, he 78 - engaging in sex. They were deprived of their privacy, stripped of their dignity and forced to never be together again. Both had dementia but during the investigation a psychiatrist concluded that both parties had “the ability to consent.”

Although laws in most states would seem to assure care home residents their rights to privacy, dignity and self-determination, it doesn't necessarily work that way. In a 2009 piece in The Los Angeles Times, psychologist Ira Rosofsky explained why it is hard to remain sexually active in a nursing home:

”First, it's hard to find any privacy in nursing homes,” he wrote. “Doors are always open; a closed one is viewed with the suspicious eyes of a teenager's mother wondering what's going on in there.

“I recently had a resident referred to me for masturbating in front of an aide who had walked into the room. Why did she walk in without knocking? Well, you can't knock on an always open door. And in your room - typically shared with a total stranger after a lifetime of independence - you have only a curtain for privacy.

“When I'm having a session with a resident in a nursing home - even with the door closed - it's quite common for an aide to just walk right in and start making up the bed. The custodian might appear next with a mop, followed by the cable guy fiddling with the TV.

“Unless you're into exhibitionism, it's hard to imagine consenting adult residents having sex under these conditions.”

Here's what I have discovered in my research about many people who are in positions of authority in care homes: they think old people should not engage in any sexual activity and set up rules accordingly. As Gruley reports:

”A 2012 study by two Kansas State University researchers found sex among nursing home residents is often viewed as a behavior problem rather than an indication of an unmet need.”

There are exceptions and one of the best is the Hebrew Home in Riverdale just north of New York City which reporter Gruley writes about in part 2 of his elder sex story that includes this graphic about elders' sexual activity. (Click the image for a larger, readable version)

The Hebrew Home has had a rational, life-giving, respectful attitude toward the sexual life of its residents for nearly 20 years:

”The nurse was frantic,” as Gruley relates the story. “She’d just seen two elderly people having sex in a room at the Hebrew Home at Riverdale, New York. She asked Daniel A. Reingold, then the home’s executive vice president, what she should do.

“'Tiptoe out and close the door so you don’t disturb them,' he told her.

“In 1995, the home adopted a four-page policy - considered the first of its kind - stating that residents 'have the right to seek out and engage in sexual expression,' including 'words, gestures, movements or activities which appear motivated by the desire for sexual gratification.'”

Nowadays, Daniel Reingold is the president and chief executive officer of the Hebrew Home and I had the pleasure to meet him four years ago when I attended a week-long seminar presented by the International Longevity Center in New York City and we spent most of one day visiting the Hebrew Home. I can attest to Reingold's and the Home's enlightened policies throughout.

You can read the Hebrew Home's Sexual Expression Policy here [pdf] which is, as Gruley reports,

”...intended to comply with federal law giving residents essentially the same rights they’d enjoy outside the facility. Sex is as much a civil right as the right to vote, Reingold said.”

Not enough care homes are as enlightened as the Hebrew Home and there is a lot of work to do to ensure elders' freedoms, dignity and rights wherever they live. To not do so is ageist in the extreme.

As a study published in the Journal of Medical Ethics in 2011 concluded about dementia residents in particular but it applies to all:

”...while every effort should be made to ensure that no resident comes to harm, RACFs [residential aged care facilities] must respect the rights of residents with dementia to make decisions about their sexuality, intimacy and physical relationships.

Bryan Gruley's two stories on sex in care homes contain a lot more information and much worth your time to read in their entirety. You'll find them here and here.

There is also a good interview with Bryan Gruley about this reporting at NPR.


At The Elder Storytelling Place today, Sharon Ostrow: Thought for the Day


Posted by Ronni Bennett at 05:30 AM | Permalink | Email this post

Comments

As if old age isn't hard enough! The possibility of intimacy or privacy of any kind in the aged care facilities I have seen is virtually non-existent. Thank you for raising this issue - it has to be raised frequently and widely to change attitudes and practices.

Of course, old people in possession of their mental faculties should be able to have sexual relations if they choose to. I agree that some facilities are not solicitous of privacy as they should be.

However, for old people who have some measure of dementia or confusion, it is not so simple. How can you be sure informed consent is taking place, if the person does not recognize those around him/her? I'm not saying it can't happen, but the family should be consulted and/or it should probably be discussed by treatment professionals, or perhaps a patient advocate. Just my opinion.

When my beloved grandmother was in a nursing home (88), one day I visited her and instead of her usual morose demeanor, she was lively and talkative. Finally she called me over and whispered, "______ up the hall is flirting with me."

She winked at me, and then we changed the subject. Honestly, this went on for several months and frankly, I was happy to see HER happy. I am fairly sure no sex happened (though can't be certain) but the flirtation and communication between them made her life better -- and that's not easy in a nursing home.

I was so angered by this story I almost spit. It's one thing to be old and very, very infirmed, and perhaps to be assaulted by a staff member, and another completely to have a consensual relationship with another person while in a care facility. These two people aren't children, and they are not so "out of it" that they didn't know what they were doing and couldn't consent. I am shocked, too, by the attitude that, omgosh, they could actually *care* for one another (or that he could *care* for her.) You're old, but you haven't lost your conscience or emotions for god's sake! that the kids were called into it is so demoralizing and demeaning. People always seem "shocked" that "old people" have sex in "rest homes"--well, they're still human and sex is a human function/need. It doesn't go away as we get older. IMO, some of this has to do with our ideas about sex overall--it's an activity for young people,and once you stop being young, like when you reach 40, or become someone's parent, you're automatically rendered neuter and should never, ever have sex, lest it embarass the beautiful young people too much. Oh the hell with that! I've become so militant after turning 50 because I see how all of this might affect me somewhere down the line, and I'll be damned if someone's going to take away my right to screw whomever I choose, whenever I choose. Damned uptight protestant parent state of the United States! Grow the f-up, America!

I think the crux of the issue in question is the ability of the residents to consent. Patients are there for a reason, many with reduced mental capacity. It would be easy for one to take advantage of another whose mind is going or gone--just like the woman who later claimed "rape." This is a great liability for those in charge. I don't know what the answer here is.

Freedom sounds good to me.

This is simply a reflection of the divide in America. And 'enlightenment' is indeed the missing element. I'm continually startled by the number of people who think they have the right to pass judgement on other people's sex lives, however, I'm with Jean on this one. From what I've personally observed, a resident with mid-level dementia isn't truly capable of consenting, and end level - not at all. The vulnerability of this population creates a very fine line between 'consent' and 'no resistance'.

The nursing home opened themselves up for that lawsuit by bringing the adult children into the issue; which is probably why the administrator and director were fired.

I had no idea sex was considered off limits in nursing homes. Where do these people come from that institute such regulations. Legal issues could be addressed it seems in a simple document that residents sign that allows consensual sex.

A reminder:
It would be good if, before passing judgment on the people involved in the story, you read both stories as I urged above.

What I've written here is only the barest bones with important details omitted.

I've been in and out of care homes as part of my previous work for many years and have come across some very odd attitudes towards sexual activity, not only concerning older people but those with physical disabilities.

It was a small minority who behaved as if they were "in loco parentis" towards children and actively discouraged sex - usually they had some religious affiliation and they invoked ideas about morality. Others were more realistic and saw sex as an important and essential part of relationships and accorded the maximum privacy possible.

I was in Holland once visiting a sick friend in hospital and they were so enlightened that if a patient were expecting his/her partner to visit and they fancied some action, they merely had to hang a "do not disturb" notice on the door and the nurses respected that.

Of course, this is only possible when facilities provide single rooms, and many of them don't - I can just imagine the uproar in shared rooms if a couple were getting it on.

I can foresee a difficulty if older people are roaming corridors at night and if they are forgetful, wandering into the wrong room and getting into bed with someone. That might take a bit more supervision.

I remember helping someone out one weekend when an elderly man's live-in carer needed to go away. I moved in at the son's request to cook meals, supervise washing, dressing etc. and was told to lock my room at night as his father (aged 86 and very demented) sometimes got out of bed and tried to get into bed with his carer. Bless 'im, he didn't bother me at all!

Chagrined, I read the article after my comment, and indeed it was mismanagement by the state that caused so much grief for Willow Manor. Iowa ended up dismissing charges 3 years later because the evidence was very persuasive that the sex was indeed consensual, but of course the two who were fired suffered greatly, and the man and woman were denied a relationship that may have made their last months not only bearable, but joyful.

We can only hope this is the exception, and came about because of some state official's zealotry. The woman's family simply took an opportunity to make some money. An opportunity that was dropped in their lap by the state.

With the exception of rape the State should not be involved in making laws governing anyone's sexual activity. This is true at any age and doubly so when the adults are elders. Intimacy is a private act and should be respected.

Unless the patient in any care facility is a danger to him/herself they should have the right to ask that their doors be closed and that everyone should knock before entering. I think the right to privacy is manditory.

I'm still slack-jawed over the beginning of this post -- that there apparently are 32 states where married couples in homes do NOT have "legal rights to share rooms or have conjugal visits." Why on earth would would married couples not automatically have these rights!? Appalling. Followed by the tales of no privacy whatsoever. Honestly I'd rather be struck dead than "live" like that.

Too bad that morality has up and died. I'm still of the teaching that sex should be for married people. However, that being said, I understand that everyone is entitled to do as they please. The big issue I have is when there is such a potential for abuse in nursing homes. The mentally impared should be assured of a safe environment to live in and their families should also have that assurance. If a married couple shares a room, they should certainly be given privacy. If unmarried couples want to copulate, they should recognize that the nursing home is not a brothel and figure out how to make suitable arrangements for the peacefulness of all involved. I would hate to be in a home and feel like the men were out on the make. Call me old fashioned. I don't care. Perhaps a better word would be a Christian, living by biblical standards.

Sex per se won't be a big consideration for me if I'm ever forced to enter a nursing home, but the freedom to be an adult person will be! The loss of dignity and privacy is appalling to me. While there may need to be protections against sexual assault involving seriously demented or otherwise helpless individuals, treating older people like naughty teenagers (i.e., "reporting" them to their adult children) is simply not acceptable. Open doors and no-knock entry aren't O.K., either.

I understand that these establishments have a legal responsibility to keep inmates (oops, residents) safe, but few elders want to end their lives in jail!

A couple of years back when we had an Ombudsman in our town specifically for nursing and assisted living homes of various kinds many of the complaints to our office were about lack of privacy, freedom, sex, and lack of locked doors. The Ombudsman and volunteers interviewed the clients (no longer referred to officially as patients in Washington) and their families, and the caregivers. The results were good. Many of the living facilities rewrote their policies so that clients got locks on the door, the option of keeping their doors shut, of eating when and where they preferred, rather than communally at set times, privacy in sexual matters, appointments for bath times for those who needed help and so on. Sadly the program has lost much of its funding and consequently in Washington has slowed down, we lost our office here but the work keeps on with trained volunteers who still respond to complaints and investigate. How well it worked in larger cities I don't know but a lot of progress was made here in Walla Walla.

this will be no news to anyone paying attention, but this country is rife with racism, homophobia, and misogyny. and, safe to say, the puritanical world view of the first european immigrants is still rampant. i heard it said many, many years ago, and it rings truer now than ever: 'glad to be an american, but not proud to be.'


So, 32 states?

States of Nay Nay Nay?

I'd rather live in a tent. At least I can zip something up or down when I'm in the mood.

”A 2012 study by two Kansas State University researchers found sex among nursing home residents is often viewed as a behavior problem rather than an indication of an unmet need.”

I live in Kansas and, a few years ago, trained and served as a state-certified ombudsman for residents (the proper term) in a local nursing home. We were taught two things that are germane: 1) always knock before entering a resident's room - and wait for an answer (unless the resident is not capable of communicating), and 2) residents do not check their rights at the front door of the facility - they have a right to mutually consensual sexual relations.

As Brenda Berretta wrote above, "I think the crux of the issue in question is the ability of the residents to consent."

On the "open door" issue: some residents did keep their doors closed, as was their right.

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