Defining intimacy and sexual expression
Intimacy and sexuality include a range of behaviours from talking, flirting, showing affection, hugging, kissing, and fostering emotional closeness in relationships such as friendships. They can also involve feelings of sexual arousal and engaging in sexual activity. [1]
Intimacy and sexual expression are personal experiences that hold different meanings for different people at various stages of life. [2] These experiences include physical, emotional, and social aspects that shape a person’s sense of self, connection, and belonging. In aged care, recognising and supporting intimacy needs can improve wellbeing, social connection, and quality of life. [2]
Why intimacy and sexual expression matter in aged care
For many older adults, intimacy and sexual expression remain important for identity and a sense of autonomy. [3,4] Within consenting relationships, they also enhance emotional and psychological wellbeing, [5,6] even when mobility, health, or cognitive challenges exist. [2,7] When older people are unable to express their sexuality, they may experience emotional distress, isolation, anxiety, or depression. Intimacy also plays a key role in strengthening close relationships, providing a significant source of support and happiness for older adults. [2,5]
In residential aged care, barriers such as shared living spaces, lack of privacy, and risk-averse policies can limit sexual expression. [8] Challenges include adjusting to shared living environments with unfamiliar people, difficulties faced by couples if double beds are unavailable, and the inability to lock bedroom doors due to staff access requirements. Additionally, people living alone may find it challenging to form new relationships or maintain existing ones within the care facility. [8]
Staff may also face challenges in supporting residents’ sexual expression. [9,10] These difficulties can stem from ageist attitudes that dismiss or undervalue sexuality in later life, insufficient training to address residents' needs, or the absence of clear organisational policies and guidelines. [4,6] Concerns about organisational risk management and issues of consent, particularly in cases involving dementia, can further complicate the level of support staff can provide. [8] Additionally, the physical design of care facilities may hinder sexual expression if it fails to accommodate residents' needs for intimacy and their rights to privacy. [11]
Standard 1 of the Aged Care Quality Standards (The Person) affirms the right of older adults to intimacy, including sexual and gender expression, as part of person-centred care. [12] Standard 7 (The Residential Community) reinforces this, stipulating that residents be supported to ‘… maintain relationships of choice free from judgement, including intimate relationships, and engage in sexual activity.’ (Outcome 7.1.6).
What the evidence tells us
Aged care facilities can support intimacy and sexual expression through clear policies and guidelines, staff training, and private spaces for residents.
Positively acknowledging sexuality
Older adults in residential care may worry whether their intimate and sexual needs will be respected. [8] Fear of judgement, stigma, or misunderstanding from staff and peers can discourage self-expression. [4] LGBTQI+ residents may face additional discrimination, particularly in facilities that fail to acknowledge or support their identities. [10]
Creating a non-judgmental and supportive environment where residents feel safe to express their needs is essential. [1] Clear policies on intimacy and sexuality, along with staff education, help address concerns. [6,9,13] They also help residents feel their intimate and sexual needs are respected, enhancing emotional wellbeing and satisfaction with care. [1]
The Intimacy and Sexuality Expression Preference (ISEP) tool facilitates conversations between staff and residents about personal preferences as well as gender identity, sexual orientation, intimacy, and trauma history. [14] By fostering understanding, the ISEP tool enables person-centred care, addressing residents' individual needs while promoting wellbeing and reducing adverse behaviours linked to unmet intimacy needs. [15]
Policy and guidance
Strong leadership and clear guidelines are essential for fostering a positive culture around sexual expression in aged care. [4] Yet many Australian facilities lack structured frameworks addressing residents’ rights to intimacy and sexual expression. [6] This can lead to inconsistent responses to intimacy-related issues within services. [16]
Comprehensive and flexible policies are crucial for fostering a supportive environment. [4,13] These policies should prioritise personal autonomy over risk avoidance, [4,16] and equip staff to address sexual rights and responsibilities in a respectful and inclusive way that does not overlook the rights of others. [13] Policies should also clearly define consent and provide guidelines for assessing the capacity to consent. [1,17]
Staff attitudes and training
Training enhances staff confidence and competence in supporting intimacy and sexuality. [2,9] Knowledgeable staff tend to have more positive attitudes and are better prepared to address sexual needs. [5,9] Nurse managers play a key role in fostering a culture of respect and inclusivity. [13]
Training should cover communication skills and the role of intimacy in older people’s lives. [2,13] It should also equip staff to handle issues of consent and inappropriate behaviours sensitively, ensuring the safety and dignity of all residents while managing concerns from family members. [1,8,17]
Without training, staff responses may be shaped by personal beliefs or cultural norms. [8] They might believe the ‘cultural myth’ that intimacy needs decline with age, feel uncomfortable discussing sexuality, or discourage and even hinder sexual expression because the resident's family disapproves. [4,6,8] Later-life sexual expression is then likely to be viewed as ‘problem behaviour’ rather than a normal part of life. [8]
Physical environment
Privacy is crucial for sexual expression and intimacy in aged care, [18] yet many facilities prioritise functionality for staff over resident autonomy. [4] Shared spaces, use of surveillance technologies, and lack of private rooms may reduce risk restrict opportunities for sexual expression [4,6,13,19] and disrupt longstanding intimate relationships. [1]
Aged care environments should privacy by including soundproof rooms, lockable doors, and designated private spaces. [5] The Sexuality Assessment Tool (SexAT) helps facilities evaluate and improve how they support and normalise residents’ sexual expression. [19]
Considerations for people living with dementia
More than half of older Australians in residential aged care have dementia, [20] which affects communication, relationships, and sexual expression. [7] Despite cognitive decline, many individuals continue to seek intimacy for emotional and psychological fulfillment and connection. [1,7,17] Due to communication challenges, however, they may express intimacy needs in non-verbal ways. [1] Staff may misinterpret these behaviours as inappropriate, leading to restrictive practices. [21] Some behaviours, such as public masturbation or unwanted advances, may indicate unmet intimacy needs rather than deliberate misconduct or a symptom of dementia. [1,8]
Families may struggle with the idea of sexual expression in people with dementia. [17] They may also share with staff concerns over consent capacity and vulnerability to exploitation. [8] Consent should be assessed individually as a person’s ability to consent can change over time or across situations. [17] It can also be difficult to detect what is and is not unwanted sexual contact as people with dementia may express distress in more subtle ways such as withdrawing. [8]
Staff training can equip staff to handle these issues sensitively. [1,7,17] Clear policies and guidelines are also necessary to support the person with dementia’s rights and dignity, avoiding overprotection while addressing concerns from both staff and family members. [1,7,8,17]
Considerations for LGBTIQ+ aged care clients
LGBTIQ+ older adults may fear expressing their sexuality due to past discrimination, stigma, or fear of judgement. Care providers need to create inclusive and affirming environments. [10,22-26] LGBTQI-specific training can help staff understand the issues and promote inclusive language and care. [10,22-27] Clearly communicated policies that explicitly support LGBTIQ+ rights to sexual expression should be available to potential clients or residents. [10,22-26] The Rainbow Tick certification helps aged care organisations develop safe and inclusive services for LGBTQI+ people by focusing on policies, training, and respectful practices.
Page updated 18 February 2025