Long-term care (LTC) homes have received considerable media attention over the past year. This has led to many discussions about how we can improve and re-imagine long-term residential care post-pandemic.
Care staff navigate a wide variety of resident needs. One need that is often overlooked is sexual expression. By sexual expression, we mean a range of behaviours, practices, identities and relationships.
Sexual expression is associated with multiple benefits for resident health and well-being and is recognized as a human right. The need to address sexual expression in LTC has garnered more attention recently as sexually transmitted infections have been on the rise among seniors.
Navigating sexual expression in care homes
Most care staff do not receive education or training on how to anticipate and respond to sexual expression in care homes. In absence of related policies or standards, staff are left unprepared for residents’ sexual expressions and, as a research participant aptly described, they “just wing it” in response. In this context, individual beliefs, values and biases can play a significant role.
This haphazard approach can lead to outcomes that harm residents, frustrate and confuse health-care workers and family members, damage caring relationships and/or erode public trust. As scholars engaged in research on sexual expression in long-term care, we have seen this first hand in our interviews with residents, family members, managers and related health professionals.
What does “winging it” look like in practice?
A “just winging it” approach creates an unpredictable and uncertain environment. Forms of sexual expression are enabled and supported in some care homes or by some staff, while being stigmatized in and by others.
For instance, we heard about one care home that afforded residents privacy for masturbation and exercised discretion about these arrangements. This included keeping the door closed, the blinds shut and ensuring staff don’t enter unannounced.
In contrast, staff at another care home shamed a resident for her private use of a vibrator. She said that staff made her feel embarrassed and judged.
Approaches to residents dating also varied considerably. At one home, staff helped a resident prepare for a date. This required staff collaboration to provide the resident with emotional support in anticipation of the outing, assist with dressing and grooming and co-ordinate transportation. Whereas, at other care homes, dating and intimacy were discouraged or disparaged.
One of the more troubling inconsistencies we found was in the treatment of residents with dementia who displayed sexual behaviours. In some cases, staff/management reacted with hostility, while in others the response was one of compassion, empathy and communication.
In one case, a family member spoke about how her father experienced drastically different responses at two care homes. At the first home, he was vilified, punished and ultimately relocated because of his sexual expressions. At the second home, the staff worked with him to manage these expressions and redirect unwanted or public gestures.
“I don’t think my dad’s sexual expression was appropriate, but the way they handled it at [second care home] was to redirect and treat the man with respect. It removed the shame and … helped us get through this crisis and just see our dad as dad again, as opposed to this sick monster, which everybody made him seem like.”
“Just winging it” leads to inconsistent responses to similar situations and resident behaviour. This produces very different experiences for residents and family members and can lead to significant harms for all parties involved. To address this, we recommend the development of principle-based guidelines to support staff, residents and families in navigating sexual expression in LTC.
The case for a principle-based approach
Principle-based guidelines are instructional documents that guide users to make decisions on the basis of ethical principles. They don’t attempt to prescribe rules for every situation. Instead, they emphasize, and in some cases prioritize, central values that can be applied as cases arise.
The type of document we envision would highlight a set of principles such as autonomy, dignity and safety, provide a rationale for their inclusion, and offer examples of how to uphold them in practice.
The principles can include those already well established in bioethics such as autonomy, justice, beneficence and nonmaleficence (the principle of doing no harm). They can also include principles specific to organizations or professional regulatory bodies, such as respect for resident privacy or person-centred care.
Although different jurisdictions may have different legal, policy or cultural contexts, principle-based guidelines can incorporate these features and provide an excellent basis for decision-making.
Benefits of guidelines
Principle-based guidelines offer several potential benefits.
First, principle-based guidelines offer a more consistent approach to decision-making about sexual expression than currently exists. They provide shared concepts and language that can help care staff discuss complicated and “taboo” issues in a more systematic way, less prone to personal biases.
Second, the guidelines provide flexibility to address diverse expressions (for example hand-holding, new relationships, sexual acts) and varying degrees of complexity (such as matters of consent for residents with fluctuating cognitive capacity).
Third, such guidelines affirm residents’ sexual rights and encourage organizational accountability for addressing them. It communicates to all parties that this is something to be anticipated in care homes. This can help to destigmatize sexuality in older adulthood and for those with chronic health conditions.
As with any guidelines, how they are interpreted and applied — as well as who is given voice — will affect their outcomes. Principle-based practice guidelines should be accompanied by provincial policy implementation as well as staff training and education. Such guidelines better position care homes to anticipate and respond to sexual expression and support residents’ needs for intimacy, connection and pleasure.
This article was co-authored with Duncan Steele, Senior Consultant in Organizational Ethics with Alberta Health Services. His interests include values-based decision-making, resource allocation and priority setting/assessment in health care, and the intersection of health ethics and economics in value prioritization frameworks.