Last week Bloomberg News published a two-part story about sex in nursing homes, which has sparked an interesting conversation among ethicists: Should the elderly living in a residential facility, particularly those suffering from dementia, be forbidden to have sex with other residents? The possibility of banning sex is controversial, as it is at odds with the fact that residents are not inmates under confinement, without basic rights and freedoms. As Americans are living longer lives, often spending their final years in nursing homes, we need to address their well-being and quality of life.
I don’t think sex should be prohibited; people living in nursing homes should be allowed to have sex, as long as it’s safe and consensual. Why would we want to keep the elderly chaste? They are adults after all, and many are quite capable of making their own decisions on these matters. Of course, as with all sexual relations among adults, the issue turns on consent. Consent may be difficult to determine. “Yes means yes” and “no means no,” but what if one or both adults are incapable of verbal consent because they have dementia? What are the implications and consequences of sex between them?
Before you get too squeamish about the idea of your grandmother or grandfather even wanting to have sex at their advanced age, consider this reality check: the young aren’t the only ones who have sexual desire and want to act on it. A recent survey about sexuality and health demonstrated that though libido decreases with age, almost 40 percent of women and 67 percent of men between the ages of 67-74 had partnered sex at least once during the past year. For the older set, ages 75-95, the percentages decreased (38.5% for men and 16.7% for women), yet some older couples are still enjoying physical intimacy. And why shouldn’t they?
Unfortunately, many nursing homes simply have not dealt with sex in a forthright manner. Unprepared staff members might stumble upon residents having sex (this happened at Windmill Manor in Coralville, Iowa a few years back) and be unsure how to handle the situation. Just as it’s useful for parents of teenagers to be prepared when they find evidence of their kids’ sexual activity, it’s important that nursing home staff anticipate the sexual liaisons of their residents. They should talk openly about such possibilities and set or clarify the rules and boundaries.
Bloomberg reported last week on the progressive policies of the Hebrew Home at Riverdale in New York, which might serve as a model for other old age facilities. All residents, even the demented ones, have the right to have sex there. After all, it’s their home, not a prison. Their rights and privacy are respected, yet the Hebrew Home has sought to offer protections as well. Its rules stipulate that the sex has to be consensual; it can’t be with minors, and it has to take place in private to respect the privacy and sensibilities of others. These are reasonable rules.
But how can one tell if sex is consensual if the residents aren’t completely capable of making cognitive decisions? Dementia might cloud the usual decision-making process, rendering a resounding “YES!” to sex unlikely. But there are other ways of ascertaining consent between adults: spending time together, holding hands, touching, communicating; these are all important signs. Sometimes there are moments of clarity. Author Lauren Kessler in Dancing with Rose: Finding Life in the Land of Alzheimer’s poignantly describes the spark of life that remains among those living with the disease. The human need to connect is still there, even at an advanced age.
Staff can and should be sensitive to signs of coercion in sexual encounters, and there are clues they can look for to see whether sexual encounters are (or were) mutual. For example, the Hebrew Home instructs its staff to watch for odd behavior that might indicate an aversion to the sexual relationship, which in turn triggers their intervention. One component of the Hebrew Home’s policies involves getting the patients’ views on sexual activity ahead of time. This knowledge no doubt helps guide nursing home staff in evaluating developing relationships.
Some ethicists have suggested a sort of advance directive approach; in other words, have residents sign a paper saying whether they want sex or not while they are living in a home. I caution against including these kinds of intimate questions in advance directives, which typically concern medical decisions at the end of life. Insisting on a decision about possible future sex is naïve. For one thing, an older person might be embarrassed to admit a desire for sex, fearing that the acknowledgment of such an interest might tarnish their reputation, make them an object of disgust, or even lead to illegal sexual predation by the staff itself. For another, before meeting Mr. or Ms. Right, a new resident might not be able to imagine wanting sex. And for a third, people change their minds. The nursing home staff would feel obligated to enforce an abstinence pledge despite a patient’s new wishes. Family members often remark that those living with dementia “are not the same person.” If one’s personality shifts with dementia, then the person he or she has become might want to make different decisions from those they previously would have, and that includes whether or not to become intimate with someone who has become dear to them in their new home.
Staff should try to communicate various possibilities, scenarios, and options to potential residents and their families, with a mind toward creating greater knowledge, openness, and flexibility. Personally, when I’m old (much older than I am now), I would rather live in a place that encouraged autonomy and granted me the freedom to continue all my bodily pleasures for as long as I liked, provided I neither harassed anyone nor showed signs of being harassed myself. At that point, I will have to depend on my caregivers for my wellbeing. I hope they will ensure I am neither abused nor unduly constrained in my life. Isn’t that what we all would want?