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Intimacy and Sexuality

What we know

There is little published literature of intimacy and sexuality for older people in a palliative care context outside of dementia. Older people are commonly viewed as asexual, yet intimacy, sexuality, and sexual expression are basic human needs and continue to be important throughout life and can provide physical and psychological benefits. Older people and healthcare professionals often find sexuality and sexual activity a difficult topic to broach. Health care professionals can encourage discussion by appearing interested, understanding, concerned and empathetic and clearly accepting of all sexual orientations. Safe, respectful and inclusive care of older people should respect diversity and include sensitive assessment of and response to intimacy and sexuality needs. Dementia can bring changes in sexual expression (lack of inhibition, inappropriate or aggressive behaviours) and can pose challenges to staff and other residents. The question of consent and consensual assent (acceptance or approval) is important to consider before responding.

What can I do?

Recognise and respect:

  • That older adults can still be interested in sexual expression and be sexually active.
  • All relationships (existing and newly formed) without judgement or discrimination.
  • That sexuality takes many forms; some may have several partners, connections or romances.

Recognise and support the family of choice of clients and residents and involve them in care planning.

Respect a person’s right to privacy and knock on the person’s door, then wait for an answer before entering.

Treat clients and residents with respect and keep their sexuality needs confidential.

Support clients and residents if sexual harassment or abuse is suspected and report to appropriate staff.

Check if your organisation includes in its policy, matters related to sexual expression for clients and residents.

Be mindful that some older people may have experienced trauma in the past including that due to their sexuality, sexual choices or gender identity.

Use the Mosaic app for tips on more inclusive care of older LGBTI people.

Engaging in the conversation

Talking about sexuality requires sensitivity and training to have the capacity to understand a person’s experience and needs and respond to their questions. Social workers or counsellors may be suitably skilled to help.

You can start a conversation with ‘Has your illness changed your family relationships, your life as a couple, your ability to get physically close to your spouse/another person?’ This signals that you are open to these issues and the person can choose to focus on general family relationships or more intimate emotional and/or physical issues.

In a residential care facility, an initial conversation may include 'My name is xxx and you can call me xxx. How would you like me to address you? Each person is unique in this home. What things could we do to make you feel more included and part of this family? Here in this home, we feel sex is a normal part of ageing. Is there anything that we can do to assist you?'

Use guided and open-ended questions such as 'Many people at your age or with your medical problem report changes or difficulties with sex. Is there anything you’d like to ask me or check with me?' or ‘How has this illness affected the way you feel about yourself or your relationship with your partner?’

Care-related issues that might prompt a conversation

If you suspect the following care issues, it is advisable to talk to the person:

  • sexually transmitted infections (STIs)
  • suspected sexual abuse
  • changed or inappropriate behaviours.

Information and services

You can assist a person to access relevant information and services about:

  • sexual dysfunction
  • preventing and treating sexually transmitted infections (STIs)
  • identifying as older lesbian, gay, bisexual, trans and gender diverse, or intersex person
  • sexual harassment and abuse.

Consult the Stocktake of elder abuse awareness, prevention and response activities in Australia (905kb pdf) particularly its Directory of Key Services (p.107) if you suspect sexual abuse of an older person.

Dementia

Remember that sexual expression for a person with dementia may be a straightforward expression of sexual needs, but there are many other possible reasons for behaviour that seems sexual. For example:

  • A person might be expressing a need for closeness and comfort.
  • A person might be indicating that they feel bored or physically restless.
  • A person who seems to be exposing themselves might be indicating a need to go to the toilet or that they are too hot.

Note that people with dementia and their partners are unlikely to spontaneously raise their experiences of relationship and sexual difficulties. Ask about changes in their relationship to see if they need help expressing intimacy and sexuality.

Provide to older couples living with dementia in the community, practical information regarding services that can assist with daily tasks such as cleaning, cooking, shopping, managing finances etc. This can lessen the burden on the spouse carer and leave opportunity for the couple to do pleasurable activities together.

When working with couples living with dementia, ask them how if they have any challenges associated with communication, and how they manage conflict associated with communication. This can guide the types of support and coping strategies that will help them.

Pass on to families of residents living with dementia Sexuality and people in residential aged care facilities:  A guide for partners and families

Check out information and tips in this recorded presentation The Elephant in the Room: Sexual Expression of People with Dementia of Dr Cindy Jones.

 

What can I learn?

Check out the Oxford Textbook of Palliative Medicine (5 ed.) Chapter 8.8 (subscription required) for tips on: 

  • talking about intimacy and sexuality
  • managing realistic expectations
  • managing symptoms and side-effects that may interfere with sexual and intimate expressions
  • providing privacy in palliative care setting.

Read the following articles and webpages

Watch the video series Creating a safe environment for LGBTI people.

Check out the information on the ELDAC website: Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI)

 

What can my organisation do?

Ensure that your organisation can demonstrate capacity to support consumers to make connections with others and maintain relationships of choice, including intimate relationships as per Standard 1 part 3(c)(iv) of the Aged Care Quality Standards.

If your organisation wishes to normalise older age sexuality and/or has an attitude of openness, include this in assessments, consultations and marketing materials.

Keeping educational materials accessible and visible can promote an easier and more comfortable discussions.

Using the Rainbow Tick, your organisation can be independently assessed and formally accredited to demonstrate their commitment to LGBTI inclusive practice and service delivery.

If your organisation or service is accepting of all sexual orientations, make sure that this is clearly stated in service information and advertising.

Provide training and guidelines so that staff

  • understand their attitudes and views and become confident in supporting intimacy and sexuality with older clients and residents
  • normalise sexuality and provide information that appropriate sexual expression can include sex workers, online pornography, sexual aids and other expressions of sexuality
  • can provide differentiated care to couples living with dementia (person and spouse)
  • The Sexualities and Dementia program has resources for health professionals and train-the-trainer resources

For residential aged care:

Residential aged care facilities can use the Sexuality Assessment Tool (SexAT) (2.37MB pdf) to identify areas of good practice or need for improvement.

Provide a home-like environment with co-habitable spaces and private spaces which allow residents to have privacy.

Consider how your organisation can respond to the following questions from current or future residents:

  • Do staff always knock and ask permission before entering a resident’s room?
  • Are there rooms or provisions made for couples to share?
  • Can residents invite partners to stay overnight?
  • How are spiritual, cultural and sexual preferences positively acknowledged and accommodated?
  • Can residents or clients make choices, express views, be heard and responded to?
  • Does the facility have a policy about sexuality, including diverse sexualities and relationships, and sexual health and has this been communicated to staff?
  • Does the facility have a policy about the use of sex workers, sexual aids or the use of on-line ‘resources’ that a person living in the facility may wish to access?
  • Do staff welcome, respect and support people who are gay, lesbian or bisexual, trans and gender diverse or intersex?
  • What are the responsibilities of staff and those of the organisation with respect to supporting the sexual expression of the people living in the facility? For example, have the professional and care staff received education and training on sexuality including residents’ sexual rights, privacy, and the recognition of unwanted sexual contact?

Sexual expressions of elderly individuals with dementia is a complex issue that can lead to conflict between the rights of residents and their families’ desire to protect them. To minimise conflict, the sexual consent capacity of residents should be assessed regularly or as needed.

Page updated 11 June 2021