Sexuality Policy 1

Running Head: SEXUALITY POLICY FOR GERIATRIC RESIDENCE

Sexuality Policy Guidelines for a

Geriatric Residential Facility

Travis Sky Ingersoll & Shanna Scott

 Sexuality Policy 2

Mission Statement

The Ingersoll Scott Retirement Community provides services mainly to the aging

population with the vision of providing the best care available while maintaining the highest

ethical standards. We aim to provide rewarding professional relationships and a positive

employment and living experience.

The community will provide services and living facilities dedicated to quality retirement

living for any person in need, regardless of race, creed, color, religion, sexuality, or gender. As

advances are made in society, out community will advance with society, using the most

innovative and modern services available in order to provide the best quality of life and

continuum of care in all facets of our residential community.

We will strive for excellence in our nursing center as well, serving our community

residents and surrounding area aging population in need of skilled nursing services.

Intergenerational activities are beneficial to both the young and the old, and such activities will

be provided for our residents. We will be fair, honest, and respectful of all people, regardless of

their background, including both our residents and our employees. In order to provide the best

care to our residents, we aim to hire and train the most talented, dedicated and caring healthcare

professionals. The sexuality policy created supports the mission of the Ingersoll Scott Retirement

Community by allowing the residents of the community to express themselves fully and

appropriately in a sexual manner, thus providing them another avenue to assure an enhanced

quality of life.

Although many people do not associate sexual activities with following along with the

ideals of a spiritual atmosphere, in fact, in a survey of close to four thousand people, “67% say
 Sexuality Policy 3

sex needs to be spiritual to be satisfying, 59% say their spiritual beliefs open them to risk deeper

intimacy, 47% say they have experienced God during sexual ecstasy, and another 45% say they

have experienced sexual energy during spiritual ecstasy” (Ogden, 2006, 19). According to this

survey by Ogden, it appears that there is a strong connection between spirituality and sexuality,

and is even necessary in order to feel sexual satisfaction. Of course there may be parameters to

this sexual activity, such as being married, which is a common necessity for the elderly

population that typically resides in a nursing community, however, that still does not mean that

they do not have any sexual needs at all. It just means that there are values they have in place

before they feel they can engage in these relations with another person. These may or may not

have anything to do with religion.

Sexuality Policy

The following sexuality policy espouses the ideal that all people, of all ages, deserve and

are entitled to a superior quality of life. Creation of a sexuality policy which gives sanction to

sexual expression, while taking into consideration the realities of residents with different levels

of cognitive and physical impairment, would achieve such an ideal (Reingold, 1995). In our

society sex and desire are falsely believed to be solely the realm of the young and able. A

common misassumption is that older people are asexual (Benbow and Jagus, 2002), over-sexual

(primarily due to mental illness), and heterosexual by default (Callan, 2006; Mayers & and

McBride, 1998). For the benefit of our aging population’s wellbeing, such outdated belief

systems need to be challenged and changed. There is a long and on-going history of sexual

oppression within the United States. For many generations people have primarily associated

sexuality with physical attractiveness, procreation and marriage. Sex outside of marriage, and
 Sexuality Policy 4

for reasons other than breeding, have historically been criticized on moral grounds (Reingold &

and Burros, 2004).

Even though attitudes in America are moving toward a more positive and healthy outlook

on sexual development throughout one’s lifespan, there still exists a pervasive air of negativity

surrounding elderly sexuality (Aizenberg, Welzamn, & and Barak, 2002). These oppressive

attitudes toward elderly sexuality are commonly demonstrated by administrative policies,

children of residents, and by staff of residential communities and nursing homes (Brown, 1989;

Reingold & and Burros, 2004).

It is rare that very common for staff members in geriatric residential settings have

sufficient knowledge about elderly sexuality, and are often communities to be uncomfortable

with, and hold negative attitudes toward, the sexual interests of elderly clients (Eddy, 1986;

(Mayers & and McBride, 1998; Richardson &and Lazur, 1995). Based on their own moral

convictions, staff members often react in judgmental and punitive ways , based on their own

personal moral convictions, when encountering sexual activity amongst residents (Aizenberg,

Welzman, & and Barak, 2002). Despite a wealth of research demonstrating that physical and

emotional unions make for happier, healthier seniors (Bauer and Geront, 1999), staff may

discourage, or even prohibit sexual relations between residents (Richard, 2002). This onslaught

of negativity toward their sexuality directly impacts how elderly residents feel they can safely

express themselves sexually (Walker & Harrington, 2002). Staff restrictions also include privacy

violations in instances when residents are engaging in self-pleasure. In addition to this, “nursing

home staff simply deny the importance of sexual expression” (Holmes, Reingold, and Teresi,

1997, p. 695), believing that sexuality and the expression of it is not an issue in their facilities.
 Sexuality Policy 5

Surprisingly, this oppression may also come from the residents’ children who, perhaps

due to their own experiences of sexual oppression from their parents, utilized their powers of

guardianship to control and restrict the sexuality of their parents. Sometimes this control is

rooted in religious and moral convictions, and at other times is due to the child’s sense of loyalty

to a parent who is no longer alive, but for whom they feel their surviving parent should remain

faithful. Another possibility for the opposition to elderly parents becoming sexual with others

could be due to financial reasons (i.e., the chance that a remarriage may threaten the economic

position of children expecting to inherit parental assets, businesses, and/or property) (Reingold,

1995; Reingold & and Burros, 2004).

Much of this oppression appears to be coming from the younger generations, those that

are caring for the elderly in some capacity, whether it be as a care giver in a nursing home, or a

loved one of an elderly person, however, studies show that all of this oppression is unfounded, as

most of the aging population wishes to be sexual in some way. There are multiple surveys that

have been completed over the years, and each one of these surveys reports that men and women

over the age of 50 are very much interested in sexual relations of some sort, whether it be what

most of society regards as traditional sexual intercourse, or other romantic activities such as

holding hands, kissing, cuddling, or intimate fondling of one another. (Aizenberg, Weizman, &

Barak, 2002; Richardson & Lazur, 1995).

Elderly residents have expressed that they feel health care professionals should openly

discuss matters of sexuality with them. In addition, most have expressed interest in receiving

consultation services and treatment for sexual dysfunctions for them and their partners. Despite

all this, administrative rules and regulations concerning issues of elderly sexuality are created

regardless of the residents’ beliefs, views or attitudes (Aizenberg, Welzman, & Barak, 2002).
 Sexuality Policy 6

The following residential rights aim to ensure a positive and healthy atmosphere in which elderly

residents can freely explore and express their sexuality.

Resident Rights and Regulations Regarding Sexual Expression

► Residents have the right to seek out and engage sexual expression including: physical

affection, emotional intimacy, sexual intercourse and masturbation. They have the right to

develop relationships and make decisions pertaining to the nature of those relationships. Their

sexuality shall not be limited by the parameters of heteronormativity, and should include

alternative orientation and identity expressions such as gay, lesbian, bisexual, transgender, queer

and intersex.

► Residents have the right to live in environments that facilitate physical and emotional

privacy in the area of human relations and sexuality. This could simply be in the form of having

“do not disturb” signs hung onto room doors, which would need to be respected by staff.

Another option would be to allow conjugal visits within the residence, or through visitations

outside of the residence. When possible, providing residents with private rooms, with larger

beds may offer a solution. In addition there is the option of having spare rooms set aside for the

privacy of the residents.

► Residents have the right to engage in sexual activity without fear of punishment, and/or

public ridicule by residential staff. Sexual expression may occur individually (i.e.,

masturbation), between or among residents, or may include visitors. Encouragement for other
 Sexuality Policy 7

forms of sexual expression, such as hugging or kissing, should be permitted. However, sexual

acts including minors, those that are not consensual, and sexual activity between people who are

cognitively impaired to the point of being deemed unable to give consent are not allowed.

Furthermore, sexual expressions that negatively impact the residential community as a whole,

such as through public display, are prohibited. Any sexual contact between staff and residents is

also unacceptable and will be dealt with immediately and severely upon discovery.

► Residents have the right to access and/or obtain sexually explicit material for private use,

as long as they are considered legal by the states in which they are purchased. Such material

may include books, magazines, film, video, pictures or drawings. Residents also have the right

to sexual education by qualified and competent educators (i.e., AASECT certified), or by staff

trained by such educators, who can answer residents’ questions about topics such as sexuality,

sexual function, medication sexual side effects, Sexually Transmitted Infections,

contraception/STI prevention barrier methods, alternative sexual lifestyles, sexual orientation,

gender, sexual anatomy, and self-pleasuring.

Staff Role:

It is the role of the staff to uphold and facilitate resident sexual expression. This includes

the responsibility and wherewithal to not intervene with respect to sexual expression, unless

intervention is necessary due to previously mentioned prohibitions. The role of staff does not

include such acts as: sexually positioning clients; physically assisting masturbation; assisting in

acquiring illegal sex aids and pornographic material; and assistance in accessing the services of a

prostitute (Reingold & Burros, 2004).

 Sexuality Policy 8

Institutional Role:

As long as expressions of sexuality do not harm patients’ dignity, violate their privacy, or

negatively effect their physical well-being, the governing institution is responsible for improving

the residents’ quality of life by formulating sex-positive regulations and issuing guidelines for

residential staff. It is the institution’s responsibility to ensure that the residents’ sexual rights are

respected and supported, and when possible, necessary environmental changes are made

(Reingold & Burros, 2004). The governing institution should also be responsible for providing

on-going educational opportunities for staff at all levels of the corporate hierarchy. Such

education should focus on exploring, understanding, and aggrandizing empathy and compassion

toward the sexuality of geriatric institutional residents.

Procedural documentation guidelines should take into account the array of sexual

orientation and gender identity variances in existence. Intake paperwork should include the

option of “other” in the “gender” category, and gear questions to avoid heteronormative

assumptions. This could be accomplished in such ways as by asking potential and/or current

residents about their “partners” or “significant others” instead of the presumptuous options of

“husband, wife, boyfriend, or girlfriend.”

While it is also necessary for nursing home staff to document the daily behaviors of their

residents, it is not necessary to document in detail the behaviors of a sexual nature in the medical

chart of the resident. Certainly there will be documentation stating the positive or negative

reactions to the sexual activity, but the activity does not need to be described in detail, unless it

was abusive and was observed as being as such. As this documentation is part of the medical
 Sexuality Policy 9

record, it cannot be obtained by anyone else without prior written permission by the resident or

the power of attorney, or if summoned by a judge.

Sexuality Education

Including Stake-holders

There may be some residents of the community that are against this policy for a variety of

reasons, and for that population, a support group may be offered, as well as an open forum for

them to express their concerns before this policy is officially placed into practice within the

facility. If it should happen that the reason for their resistance is due to ignorance of their own

sexuality, one on one intervention and support can and will be provided for them to assist them

in being educated about their bodies and their abilities to still enjoy the use of their bodies.

In order to entice our board of directors, administration, staff members, and families and

loved ones of our residents to accept this new policy, there will be much education provided to

them through team meetings, in-service opportunities, reading materials, and guest speakers from

the Center for Sexuality and Religion in order to help them see the connection between sexuality

and spirituality. There will also be guest speakers from Widener’s Human Sexuality program to

calm any fears about the residents not being able to fully benefit from this new policy. Many

family members of the elderly are in denial that their mom, dad, grandma or grandpa are still

sexually active, as this is the general thought of most of society. Much of the education to be

provided will be based on the need for American society to accept that sexuality does not

diminish with age, it only changes.

There are common barriers that the majority of residential care communities share, and

they are: lack of privacy, lack of available partners, chronic illness, attitudes of the staff, a loss
 Sexuality Policy 10

of interest in sexual activities, feeling unattractive, and the residents’ lack of knowledge about

sexuality (Richardson & Lazur, 1995). Most of these barriers can be overcome through adequate

and necessary education for the staff, physicians, family members, and the residents themselves.

As mentioned above, this education will be based upon the idea that sexuality does not diminish

over time, it only changes.

The residents will be offered individual and group education from a certified sexuality

educator about how their bodies have changed over the years, and what steps they can take to

work with the changes to increase their feelings of desire and attractiveness. It is likely that

some residents will benefit from individual therapy, and for that reason, there is a therapist on

staff to assist them with any self-esteem or adjustment issues that may arise from exploring their

sexuality.

The staff, both direct care staff and administrative staff, will receive extensive training on

the importance of recognizing how sexuality impacts upon all parts of our lives, even well into

the golden years. Staff may need to examine their own sexuality, and thinking about their

residents being sexually active may naturally lead to think of their own parent’s sexuality, which

of course may be a rather difficult scenario for some of the staff. As with the residents, there is a

program available for the staff, an employee assistance program, to assist those staff in working

through various difficult issues that arise as they learn about and explore their own sexuality.

There will also be a council established that will assist in eradicating the barriers to

sexuality expression. This council will consist of the sexuality educator, the social services staff,

a member of the administration, nursing representative(s), and residents. One of the first barriers

to be addressed will be the lack of privacy, as this is one of the easier and cheaper barriers that

can be fixed.
 Sexuality Policy 11

Determining Capacity to Consent

Many residents in nursing facilities show signs of memory problems or progressing

dementia. There is a wide continuum of severity with dementia and how it affects a person’s

abilities to choose various things throughout a day. In someone with mild dementia, sexual

behaviors may be something that is not a major decision for them, and based on questioning and

conversations, it may be easy to determine of the resident is understanding what they are

deciding to do and giving consent to do with another person. However, as their dementia

progresses, as it naturally will with or without medications, the line becomes more difficult to

see as to at what point the resident is no longer able to make the decision to have sexual relations

with another person.

One way to determine how oriented a person is to reality is the Mini-Mental State

Examination (Folstein, Folstein, and McHugh, 1975), which asks a series of questions based on

time and place, and then proceeds to other questions that require more thought and organized

thinking and recall. This test is best used as a screening tool for cognitive impairment with older

adults living in a community setting such as a retirement community, or in a hospital or other

institutionalized setting (Kurlowicz, Wallace, 1999). This is a nice tool to use, as it is quick,

taking only about five or ten minutes to complete from start to finish, and it covers five areas of

cognitive functioning (orientation, registration, attention, calculation, recall and language) in

only eleven questions.

Another method to determine how capable someone is to consent to an activity is to

practice these situations through a role play scenario. A social worker on the unit can talk with

the resident and interested individuals and discuss how to make appropriate choices. If the

resident is having trouble making even simple decisions, such as what to wear that day, then
 Sexuality Policy 12

perhaps it is best that this person not engage in sexual activities with another person, but it would

still be appropriate to allow them to find pleasure alone with themselves. Education and positive

reinforcement may need to be provided, depending on the severity of the dementia, to help the

resident learn to have sexual relations with themselves in private places, not in the dining room

or living room of the facility.

If the capacity to consent is still questionable, a psychiatric evaluation can also be

employed, as well as a consult with a physician. The psychiatrist can perform other assessments

to ascertain how cognitively aware the resident is and make a professional decision about

whether or not it is possible for this individual to make a major decision concerning their health

and well-being. The physician that is involved in this individual’s care would ideally be one that

has followed this resident’s care for an extended period of time and has therefore created a

relationship with them and has seen the changes, or lack of changes, in their cognitive

functioning over time. As with the psychiatrist, the physician can perform their own assessments

of the individual’s abilities to make decisions concerning their body, and offer their professional

opinion about whether or not this resident truly understands what they would be consenting to

do. One of the barriers that may arise is in regards to choosing medical professionals that have

an unbiased or sex positive approach to the elderly and those with various mental functioning

impairments. As there are many “social myths and stigmas that surround sexuality in the

elderly…this may account for the medical professional often ignoring sexuality in this

population” (Bouman and Arcelus, 2001, p.27).

The attending physician can also play an important role in educating the residents on the

need to use condoms or some other form of barrier method in order to keep themselves safe from

sexually transmitted infections. The number of our elderly contracting HIV/AIDS is rising, and
 Sexuality Policy 13

there are some theories on why that may be. First, with all the new medical advances, people

with HIV/AIDS are able to live longer. Another thought is that since medical science has been

so effective at treating HIV/AIDS, the fear factor of imminent death is fading. Lastly, and

perhaps most importantly, our older population usually only thinks of sex ed for their

grandchildren and great grandchildren, not for themselves.

A study was conducted by Emory University in Atlanta, Georgia, where they asked a

group of women over the age of 50 nine questions about HIV risks. “Only 13 percent said

condoms were effective prevention; 63 percent inaccurately stated kissing is a mode of

transmission; about half believed vasectomies provide protection; and most surprising, 44

percent said abstinence was not at all or only somewhat effective in preventing HIV”

(Gottesman, 2005). It is obvious by this study that a large part of the education to be provided

to the residents will need to be about how to keep themselves safe. While they may not be

thinking about using protection since they are no longer able to procreate naturally, they need to

see the necessity of using barrier methods in order to protect themselves from sexually

transmitted infections. This education would best be provided by the attending physician, as

many of the elderly population believe very firmly in whatever the doctors tell them, as they see

them as the source of accurate medical information.

Protection From Harm

It is common knowledge that long-term and profound harm can result from sexual abuse

and exploitation. Researcher Ramsey-Klawsnik defined “elder sexual abuse as coercing an older

person, through force, trickery, threats, or other means, into sexual contact against his or her

will” (Quinn, 1995, p.1). Based upon this definition, anyone can be the perpetrator, although the
 Sexuality Policy 14

majority of the reports made state the perpetrator as male (Brodwater, 2007; Quinn, 1995; Jeary,

2004). Many people equate children and the elderly population with one another because of their

level of abilities, whether it be physical or cognitive, however, this is not the case when it comes

to sexual abuse of these populations. Often times, the older population is not taken as seriously

or believed at all when a report as made (Jones and Powell, 2006), perhaps because of the

aforementioned denial of sexuality in old age. However, Jones and Powell (2006) state that the

age of the victim of sexual abuse should not reduce the societal response to the problem. When a

report is made, all consideration should be given to it, and the report should be followed through,

even if there is a question about the victim’s mental abilities.

As there are times when residents may not feel comfortable or are unable to voice their

concerns over a suspected abuse, the signs to look for possible sexual abuse, by a staff member

or anyone else are: genital/urinary irritation, an otherwise unexplained sexually transmitted

infection, vaginal tearing or bleeding, repeated vaginal infections, extreme upset when being

assisted with bathing, changing, or toileting, fear of a particular individual or people in general,

nightmares or other sleep disturbances, frequent and unexplained illness or complaints, self-

destructive or suicidal behaviors, prolapsed uterus, or any other signs of physical abuse or

restraints, such as any unexplained bruises, rope marks, burns, etc (Quinn, 1995). Of course,

each of these symptoms taken either individually or together can be explained by other

diagnoses, however, it is important to keep these in mind when behaviors change with a resident.

In order to keep our residents as safe as possible and free from harm, all of our staff will

have to have three references from previous employers or educators supporting their good faith

efforts to care for the elderly, in addition to a criminal background check before being allowed to

interact with residents unsupervised. As Jeary (2004) noted, sexual abuse by a staff member is
 Sexuality Policy 15

doubly abusive, not only in terms of the act itself, but also in terms of the betrayal of trust. Our

residents are putting their health and well-being into our hands with trust and confidence, and as

part of our mission, we aim to never disappoint them in that way. In addition to the background

checks prior to employment, there will be continued abuse training required throughout their

employment with Ingersoll Scott Retirement Community, so that the importance of these issues

is never forgotten.

Discussion

Although societal attitudes toward elderly sexuality are still quite oppressive in nature,

times are evidently changing. Recent studies indicate that older Americans increasingly view

sexual expression to be a positive aspect of their lives (Clements, 1996). A lack of

understanding from health professionals may coerce our elderly to conform to society’s

oppressive expectations, particularly so for older women. With the current population of elderly

living in nursing homes to be around 1.6 million and rising (Richardson & Lazur, 1995), geriatric

care will have to adapt to the ever changing characteristics of the people it serves.

The new generation of people entering long-term care facilities will likely demand more

from their service providers, especially with regards to personal privacy. We will also likely to

have more residents coming to geriatric residential facilities for which cohabitation was a

suitable prelude or option to marriage, and for whom sexual relationships outside of marriage is

more acceptable (Reingold, 1994; Reingold & Burros, 2004). In addition there is a growing need

for residential facilities to recognize and accommodate the needs of gay, lesbian, bisexual,

transgender, and intersex clients (Callan, 2006). The challenge will be for residential care

facilities to properly educate their employees about elderly sexuality in all its forms, and to have
 Sexuality Policy 16

policies in place which will ensure optimum sexual, physical and spiritual health for their

residents.

We owe it to our aging population to provide them with a sense of comfort and peace in

their final years. The last days of our aging population, who have built the foundations on which

we all stand, should be free from oppression of any kind. It is our duty to put aside our

moralistic judgments about sexuality, our adherence to negative ageism, and to think about

what’s best for the aging people which we serve. The research has demonstrated time and time

again, what our elderly have consistently communicated to us, which is that sexuality continues

throughout the lifespan and is an important part of human health and wellbeing. It’s time we all

began to listen.
 Sexuality Policy 17

References

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nursing home residents. Sexuality and Disability, 20, 3, 185-189.

Bauer, M, and Geront, M. (1999). The use of humor in addressing the sexuality of elderly

nursing home residents. Sexuality and Disability, 17(2), 147-155.

Benbow, S., and Jagus, C. (2002). Sexuality in older women with mental health problems.

Sexual and Relationship Therapy, 17(3), 261-270.

Brodwater, T. (2007). Male nurse faces sex abuse charges. The Spokesman-Review.

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Callan, M. R. (2006). Providing aged care services for the gay and lesbian community.

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 Sexuality Policy 18

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 Sexuality Policy 19

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