Introduction and Background
Challenges with Sexual Expression in Continuing Care Homes
A Sexual Rights Framework
Rights Related to Continuing Care Resident Sexual Expression
The Alberta Context
Methods and Procedures
Participant Recruitment
Data Collection
Data Analysis
Findings
The Tension Between How Sexual Expression Should Be Supported and How It Is Currently Addressed in the Care Home
These descriptions reflect how resident sexual expression includes physical intimacy as well as activities embedded in personal care and leisure practices. Our participants indicated that sexual expression is both a human right and a basic need and it should have a place in continuing care. At the same time, they acknowledged that resident sexual expression is fraught, particularly for residents with cognitive impairment, and the ideal of what it could look like was different from their experiences in practice.“It’s just part and parcel of who we are as people. I think it should have the same place as getting up and washing and dressing and eating your meal; it provides a deeper meaning to life” [Participant 8].“It’s not only sexual activity, independent or with a partner. It’s the way you present yourself to the world. How you do your hair, your makeup, your nails, the shows you go to, the activities that you participate in, the books you read. It’s a form of attachment that provides security and comfort, and it should be a basic need and basic right in care facilities. [Participant 21].
How Sexual Expression Should Be Supported
Such a policy establishes the place of sexual expression in the care home and creates an expectation for staff to honor peoples’ rights to non-discrimination, bodily autonomy, and healthy sexual expression (Barrett & Hinchliff, 2018; Lester, Kohen, Stefanacci, & Feuerman, 2016; Rowntree & Zufferey, 2015). In settings where there was no policy, participants indicated that one would be welcomed.We have a formal policy on privacy, intimacy and sexuality. We offer education, and we have conversations with the team as part of supporting our staff to support the residents. I’m thinking specifically of a situation where we had a resident in one area who was involved with a resident in another part of the building. We made sure to give them privacy, but we were monitoring as well to make sure it was all appropriate [Participant 11].
Some participants called attention to sexual orientation as a human right in general, and made particular reference to the needs of LGBTQ2S+ residents. There was agreement that continuing care homes should be inclusive spaces for persons from LGBTQ2S+ communities. Furthermore, “the incoming cohorts will have lived through the sexual revolution and same sex marriage. So [people] coming into care homes will be much more open, much more vocal” [Participant 22]. Several participants saw a role for guidelines on how to create a safe and welcoming environment for residents of all orientations. These guidelines would reinforce education and help to establish consistency of responses within and between care homes. We heard that a policy on sexual expression would also provide clarity for residents about expectations and supports with this part of their care.“I think the provincial health authorities could give us some guiding principles that everyone - even faith-based providers or private providers - would be accountable to. There should be some standards that are set as to, if you are a long-term care provider, this is a fundamental aspect of care, and you need to be able to address it in a compassionate and a forthright manner” [Participant 27].
How Sexual Expression Is Currently Addressed in Continuing Care
However, the talk about normalizing resident sexual expression does not necessarily translate into action. The attitudes of staff members about resident sexuality appear to undermine its place in the care home and temper managers’ efforts to support its safe expression. All participants acknowledged that without education and guidelines, the staff relied upon personal values when they encountered instances of resident sexual expression.There is the idea among staff that when people come into care the need for sexual expression is gone. So, it’s seen as abnormal. To be resident-centered, we have to realise sexual expression is natural and not a ‘taboo’ subject [Participant 14].The challenge is we haven’t found ways to comfortably acknowledge that sexuality has a place in the care home. We talk with staff about this as a healthy part of being human and we shouldn’t expect our residents to hide this because they are human beings who have some kind of sexuality and a sexual identity [Participant 13].
The staff’s personal views can influence their professional work and, in so doing, unjustly constrain residents’ rights to sexual expression. We heard that support for same-sex relationships in continuing care is also a ‘work in progress’. “A lot of LGBTQ2S+ people are fearful of being open in the long-term care setting. And a lot of elders have experienced extraordinary amounts of discrimination… there is a lot of fear when they disclose” [Participant 27]. A few participants spoke about some promising developments, but we also heard that many educational or supportive efforts are undertaken discreetly to avoid controversy. When these matters are not discussed openly, residents’ right to non-discrimination may be infringed upon:I hear comments that the staff find it really distasteful. They don’t understand it’s an important part of well-being and I think it’s because there is no education on this. I looked through their curriculum [for Health Care Aides] and this is missing [Participant 23].I notice the staff bring their own personal biases about what is right and wrong, which really influences how they manage the behaviours. When resident sexual expression comes to my attention, staff see it as a misbehavior [Participant 28].
The distinction between appropriate and inappropriate expressions of sexuality was described as a matter of perspective. For example, there was widespread agreement that unwanted groping was inappropriate, but there was less agreement about whether or not residents should be permitted to view pornography in their bedrooms. Typically, sexuality is only addressed when family, staff, or other residents considered particular expressions to be inappropriate. Residents are rarely provided with information about appropriate or healthy ways to express themselves in continuing care settings.We do have couples’ suites. So again, we’re just beginning the conversations of what defines a couple. Is it a heterosexual couple? Or is it a same-sex couple as well? I don’t think we’re having conversations about that. I don’t think we’ve moved to that direction where we would actually admit that same-sex couple into that particular suite [Participant 28].
The Tension Between the Care Home as a Private Home Space and a Public Work Space
The presence of multiple people in the care home, and the nature of their work with residents, creates an ambiguous boundary between private and public space. For example, if a person was in their own home and watched pornography, this could go unnoticed. However, in a congregate setting, the tension between private and public space surfaces because the care work intersects with the resident’s sexual expression. One participant provided an illustrative example of this common experience:You know, the amount of meaningful privacy that some of our residents have is pretty minimal…what’s at play is a difference in how people understand the space. So, do they see their room as essentially their home, like an apartment almost, like a little bachelor suite? Or is it a bedroom in a larger house? Or is it neither of those things – is it actually just a room and a bed in a health care facility? [Participant 13].
This example highlights the murky boundary because the resident behaves as if the bedroom is a home space, and the staff interprets viewing pornography as an inappropriate behavior in their workplace. The manager who shared this story indicated that care staff need not extinguish the resident’s right to expression. They can give residents space to express themselves privately instead.[W]e had a gentleman that wanted to view pornographic movies. The staff were very upset by that, they would walk in on him and find things that were offensive to them… So we had to get the team together and decide how we would go about this, allow him to have his freedom in his home, which was now the facility, and still manage to respect the rights of the other residents and the staff… [Residents] should have a right to sexual expression, but it should not infringe on the rights of others who are caring for them. So in doing that we need to find a balance. What we did was we talked to him and had a contract with him where he was allowed to [watch porn], but he needed to let the staff know in advance that that's what he was doing by pulling his curtains or closing his door so that anybody coming in would know what they might be walking into [Participant 1].
The tension between private and public space is heightened in rural continuing care homes. “There tends to be more discomfort around this in smaller towns because people talk” [Participant 15]. Participants noted that relationships between community members, longstanding histories among care home residents, and gossiping by visitors complicated these dynamics.We had two women who formed a relationship. They would go into each other’s rooms and pull the curtain, sit on the bed, and listen to music. The staff would walk into the room and catch the couple kissing and expressing their sexuality. The staff were shocked. I had to have a conversation with the staff about privacy. So now they notice the two walkers behind the curtain in the room and do not disturb. If staff have to disturb, they knock and say ‘can I come in?’ It’s becoming something that we consciously make an effort to live with because that is the reality [Participant 3].In a case where a resident wanted to masturbate in their room and needed some privacy, there was the staff just walking in on them without giving any notice. It takes a big culture change for staff to find some boundaries around privacy so they are not entering the room to check on people without knocking, without respect for what someone could be doing [Participant 10].
The nature of rural communities, where people are more likely to know one another and have opportunities to share information, make it more difficult to protect resident privacy. This can be a contentious issue for residents because their sexual expression may be judged or stigmatized by community members. Whether in a small town or a large city, participants indicated that it is reasonable to expect that employees and visitors will safeguard resident health information, exercise discretion in conversations about residents’ lives, and respect residents’ physical privacy. However, in small towns, this can be more difficult to ensure.I'm thinking of a scenario where a friend's father is admitted who then exhibits some sexual desires for somebody other than the mother, than his wife, and you knew the kids growing up. How do you talk about this or who does the family consult? [Participant 1].It's harder in these rural sites. The family can be embarrassed when they go and visit their husband or their wife and find out they've been doing something that was not part of their personality before because everybody they know and associate with may be related to the staff at the facility [Participant 8].
The Tension Between a Medical Model of Care and Sexual Expression as an Activity of Daily Living
The right to nourishing and safe sexual experiences goes unrecognized if there is no expectation of staff—or capacity within their work flow—to support sexual expression. Participants said that care staff could support residents by turning one’s back and drawing the curtain, providing physical inspections during care after intimacy, exercising discretion when witnessing expressions of sexuality, respecting autonomy and privacy, and upholding residents’ right to make choices about safe and healthy sexual expression, even when they may not align with one’s own preferences. Some participants suggested that institutional ambivalence about sexual expression as a legitimate aspect of resident life influences the extent to which staff are able to support it. The matter is further complicated when residents cannot independently meet their needs for sexual expression (e.g., applying makeup before a visitor arrives, acquiring romantic novels, opening a bottle of lubricant) and the staff do not see accommodating resident sexuality as part of their work.The things we have to focus on reflect the medical approach, the clinical approach. So where’s that balance with quality of life, which includes resident sexual expression? It’s easier to support the medical approaches to the resident’s clinical issues versus the sexual expression piece [Participant 19].There is a big focus on the personal and medical care needs - we don’t discuss sexuality with residents and families, the staff are not prepared for when residents express themselves, and the institution doesn’t bring this forward as a part of care planning. Everyone gets surprised by residents’ sexual behaviors [Participant 6].
When care is task-centered, sexuality is typically viewed as problematic and residents have no claim to engage in or have support for sexual expression as an activity of daily living. With the predominant focus on health care needs, it is no surprise that care staff rarely recognize or realize opportunities to proactively anticipate resident sexual expression.As a manager, my immediate response is to respect the resident’s wishes about sexuality, but I understand where the staff are coming from because they have tasks to do that are time-sensitive and, therefore, they can’t offer much support. They know that if tasks are not completed, there are consequence, so they’re task-oriented. [Participant 2].For the direct care staff, they get task-focused and there is no consideration of the resident’s sexual expression. And when it does show, the staff panic because they think this isn't something that’s in the scope of their job or part of the care plan [Participant 18].
As Participant 5 noted, even when sexual expression is anticipated, it is often pathologized. For the employer that had a policy and staff who were willing to support sexual expression, resident intimacy was still scheduled around unit routines.Some of the difficulty with resident sexual expression comes from our task-focused care. It is quite a challenge as facilities are so institutional – it’s a top-down approach to people. The time’s ten o’clock and lights out you know. ‘What’s John doing in with Mary? We can’t have this! We can’t let them do that because we have to do this, and this, and this by midnight’ [Participant 23].If we know up front that someone has a tendency to express himself or herself sexually, it would be considered as part of their disease condition and we would manage it accordingly using behavioral, environmental, or chemical restraints [Participant 5].
We heard that even when resident sexual expression is supported by a policy, it can be subordinated to the care home routines. Such an orientation can create an environment in which resident pleasure is treated as another scheduled task. Our participants did not suggest that care schedules ought to be organized around individuals’ personal sexual practices, rather that some flexibility and compassion can create a more home-like environment. This flexibility provides opportunity for spontaneity, for residents to feel good in and about their bodies, and to experience themselves as whole beings with desires and choices and not solely the recipients of medical care. The rights to bodily autonomy expressed through solitary or shared intimacy, as well as the privacy to engage in such pursuits, may be overlooked because sexuality is unrecognized as an activity of daily living.We still have to coordinate things around care. We’ll put the ‘do not disturb’ sign on the door with the understanding that if we have to go in, we’ll knock first. We talk about trimming the person’s nails and keeping them clean, making sure they have lubricant, and checking them afterwards – a visual inspection – to make sure everything’s okay. [Participant 22].