Background / Definition
Sexual activity encompasses intercourse, emotional intimacy, close companionship, flirting, affection, hugging, kissing, arousal, desire and self-pleasure. Sexuality describes how a person experiences and expresses themselves as a sexual being. Sexuality encompasses biological sex, gender identity and roles, sexual activity and behaviours, sexual orientation and choices, eroticism, pleasure, intimacy, and reproduction. [3-9] A person may choose to express their sexuality through dress, grooming, styling, speech, actions, attitude, and sexual activity and behaviours. 
Intimacy is the emotional connection with another individual. Expressions of intimacy may include sitting close to someone; talking; holding hands; hugging; kissing; stroking someone’s face, hands, or arms; romance; and intercourse. [3,5,6] Relationships based on intimacy create a safe space for both people and actively try to maintain that sense of security for one another.
Closeness or intimate relationships are an essential human experience which can provide a person with security, support, and connectedness across the lifespan.  Intimacy, sexuality and sexual expression are basic human needs which can contribute positively to health and quality of life. [1-6]
Older people report varied interest in sex and frequency of sexual activity and place a varying importance on sexual activity and intimacy. [1,4,5,7] Sexuality remains important to older adults and this can provide physical and psychological benefits.  Sexual expression in later life encompasses a range of behaviours from sexual intercourse to emotional intimacy and proximity. [3,5-7]
Older people are commonly viewed as asexual. They are conscious of social norms on sexual activity and report awkwardness in expressing their sexuality and discussing sexuality with their peers, family and health care professionals. [1,4,7] Many older people feel that this is a very private matter and are hesitant to raise questions about sexual issues [1,4,7] despite wanting discussions about sexual health.  When these issues are also not raised by health professionals, older people are left without help to deal with changes in sexual function and to identity and manage expectations for a changing sexual life. [1,4,7]
With age, physical sexual activity can become increasingly difficult due to general physical health, emotion, psychological state, sexual dysfunction, the side-effects of medications, issues experienced by the person’s partner or the absence or loss of a partner. [1,5-7,23] Often intimacy becomes more important. [1,6]
Healthcare professionals often find sexuality and sexual activity a difficult topic to broach and may consider it out of their scope of practice. [2,4] Older people perceive health care professionals as uninterested or ill-equipped for discussions about sexuality and sexual health. [1,7] Although they may feel very hesitant or unable to start these discussions, older people feel more inclined and at ease in discussing sexuality and sexual health if health care professionals appear interested, understanding, concerned and empathetic and clearly accepting of all sexual orientations. 
Dementia is increasingly prevalent in Australia and other countries. Dementia brings changes to a person’s ability to think, communicate and behave which can affect the way that a person living with dementia receives, experiences and expresses intimacy and sexuality.  Couples may actively seek ways to maintain couplehood.  In all stages in life, relationships are dynamic, evolving with the influence of personal and contextual factors. Those looking after people living with dementia need to respond to changes with sensitivity and respond to perceived or actual problems by asking questions and communicating with relevant stakeholders.
The person with dementia may initiate sexual activity which may or may not be welcomed by the recipient of these advances or acts. More than half of the residents in Australian residential aged care facilities (RACFs) live with dementia and changes in sexual expression (lack of inhibition, inappropriate or aggressive behaviours) can pose challenges to staff and other residents.  The literature includes suggested ways that staff may approach these challenges. [26,27] The question of consent and consensual assent (acceptance or approval) is important to consider before responding.
Transition into a residential aged care facility (RACF) means adjusting to living in a shared space with new people in new surroundings. Residents find that the RACF environment is not conducive to sexual expression. Commonly cited reasons are the lack of privacy; constraints of the physical environment; staff unease at addressing and facilitating residents’ sexuality; and knowledge and attitudes of staff members, family members, and residents. [2,5] In this context, issues and concerns around expression of sexuality and intimacy are likely to differ in some respects from those encountered in a private dwelling.
In the Aged Care Quality Standards, Standard 1 part 3(c)(iv) requires that organisations demonstrate their capacity to support consumers to make connections with others and maintain relationships of choice, including intimate relationships.  Although some RACF staff believe that residents who have sexual needs should be supported, RACFs may not have policies dealing with resident sexual activity. [2,24]
LGBTI people have an increased risk of certain life-limiting conditions. [18,28] Stigma and fear of discrimination may delay entry into aged care and prevent access to care and support at the end of life. [18,19,28] LBGTI people accessing a RACF fear experiencing discrimination and that the status of their same-sex partner or family of choice may not be acknowledged. [19,28] LGBTI people look for services which are open, respectful, nonjudgmental and empathetic [18,19,28]
The Actions to Support for lesbian, gay, bisexual, trans and gender diverse, and intersex elders  developed under the Aged Care Diversity Framework  provides guidance for respectful, inclusive and culturally-safe care of LGBTI older people. It is noteworthy that relationships and intimacy are considered in the action plan for LGBTI people but are absent in the action plans for all diverse older people, older Aboriginal and Torres Strait Islander peoples, and older Culturally and Linguistically Diverse people. [13-16] The framework and action plans consider diversity in ageing in an aged care context without specific consideration to older Australians needing or receiving palliative care.
Some sexual contact may take the form of sexual abuse. Sexual abuse is defined as any sexual behaviour without a person’s consent. It includes sexual interactions and non-contact acts of a sexual nature. To help protect vulnerable residents whilst not restricting their sexual freedoms, the Aged Care Act 1997 has compulsory reporting provisions for unlawful sexual contact, that is, non-consensual sexual activity involving residents in aged care facilities.  When aged care staff consider reporting unlawful sexual contact, the capacity of the resident to consent to sexual activity be based on an assessment by a health professional and should be assessed on a case-by-case basis.
As part of the National Plan to Respond to the Abuse of Older Australians 2019-2023, the Australian Government has released a document (Everybody’s business) that describes the range of work already underway across Australia to prevent, intervene, respond to and mitigate abuse of older people. [11,12] Both documents look at sexual abuse in a general context without specific consideration to older Australians needing or receiving palliative care. The Directory of Key Services in Everybody’s business provides contact details for key national, state and territory services that can assist people seeking help with elder abuse including sexual abuse. 
The included papers were of acceptable to high quality. Most papers related to older people or aged care; those relating to palliative care were restricted to studies of people living with dementia and/or their spouse or partner.
Page updated 09 July 2020