Sexuality, care homes and dementia
We need to talk about sexuality, care homes and dementia
How might we think about sexuality in care homes?
Can people with dementia consent to sexual activities?
What is the guidance about sexual activities in care homes?
As part of my series on Taboos in Dementia (released on my Twitter and FaceBook pages), I asked people what they’d like me to address. One subject that came up frequently was sexuality in care homes where people have dementia.
The possible scenario
In 2015 I was asked to write a hypothetical scenario about sexuality in a care home for a publication called “Ethical Issues in Practice” by Alzheimer Europe. (You will find it under Activity three). The story was couched in general terms because of the international audience and it did not make any reference to the law or protection arrangements of any specific country. It is about an uproar in a nursing home where a widow, Mrs Brown is found in her bedroom, naked to the waist, snuggling into the arms of Mr Green and whispering endearments to him. She has Alzheimer’s disease, and he has alcohol related brain damage. The story unfolds with relatives and staff holding polarised views about whether this is a good thing, illegal, the residents’ choice, rape, therapeutic or just not what staff should have to put up with. It’s fiction, which allowed me to weave in themes based on many real stories, and it is followed by a long analysis by another ethics expert about what is really going on and why. It also asks what, if anything, should or could be done about it.
Problematic sexual behaviour in care homes
People with dementia in care homes sometimes have sexual behaviour that is problematic for the staff and the family. It may be sexualised behaviour that others think is at the wrong time or place, or it may be that any sexualised behaviour at all is judged unacceptable to those around. A resident who has a frontal lobe dementia that has taken away all their normal inhibitions may pester, annoy and embarrass people almost randomly. But there are also lonely people who seek the perfectly normal comfort of human intimacy. Or even people who fall in love with someone. There is a difference between crude or thoughtless behaviour stemming from uncontrollable urges and human tenderness. In preventing the former, we must not eliminate the latter. It is often said that in dementia all behaviour is a communication and you need to pay attention to the nuances.
No guidelines can simplify sexual behaviour responses in care homes
Dawne Garrett at the Royal College of Nursing has said that no guidelines can make this a simple matter. Consent is difficult to establish when there are communication difficulties and cognitive impairment. Sex without consent is illegal, and everyone has a responsibility to protect vulnerable people from abuse. Alex Ruck Keene, a barrister who specialises in mental capacity has pointed out that no one can consent to sex for another, not even if they have power of attorney. Care workers who enable sex could be committing an offence depending on circumstances. This situation is fraught.
But it is true that people with dementia can consent to sexual relations
The CQC guidance is clear though, that people with dementia can consent to sexual relations. Care homes would be right to support them in that light. But there is still a responsibility to look for signs of distress that might indicate there is a problem.
Many of the writers on this subject emphasise the importance of tackling this taboo, though openness, honesty and training for staff. But there are practical problems. What about the availability of a double bed, to avoid the risk of a fall during lovemaking? Sometimes care homes don’t even have a two-seater sofa where you can sit together. How do we ensure enough privacy for intimacy with the obsession we have with observation and supervision? How can a care home signal discretely to visitors and residents that same sex relationships are not taboo? And how can we ensure that staff, from a wide range of social, ethnic, religious and educational backgrounds are prepared to believe that older people with dementia are interested in sex and allowed to express that interest. How can we make it clear that sex is not a problem that needs to be managed, but rather part of normal life? There will be more on this topic soon.
If you would like more information, you can buy my book Dementia, the One Stop Guide or Care Homes: When, Why and How to Choose a Care Home. I am available for consultancy for families or organisations. And if you have any further queries or questions, or suggestions for something you’d like to see me write on, please contact me via the Contact Page
See my new course on Dementia the One Stop Guide on Policy Hub here
