Sample Geriatric Residence Sexuality Policy

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

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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.

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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.

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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.

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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, selfdestructive 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 Aizenberg, D., Weizman, A., and Barak, Y. (2002). Attitudes toward sexuality among 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. Brown, L. (1989). Is there sexual freedom for our aging population in long care institutions? Journal of Gerontological Social Work, 13, 750-793. Callan, M. R. (2006). Providing aged care services for the gay and lesbian community. Australian Nursing Journal, 14, 4, 20-20. Clements, M. (1996). Sex after 65. Parade Magazine, 7, 4-5. Eddy, D. M. (1986). Before and after attitudes toward aging in a BSN program. Journal of Gerontological Nursing, 12, 117-122. Ehrenfeld, M., Bronner, G., Tabak, N., Alpert, R., Bergman, R. (1999). Sexuality Among Institutionalized Elderly Patients with Dementia. Nursing Ethics, vol 6(2)

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Folstein, M., Folstein, S.E., McHugh, P.R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198. Gottesman, N. (2005). HIV over 50. AARP, The Magazine, July/August issue. Holmes, D., Reingold, J., and Teresi, J. (1997). Sexual Expression and Dementia, View of Caregivers: A pilot study. International Journal of Geriatric Psychiatry, vol. 12, 695- 701.

Sexuality Policy 18 Jeary, K. (2004). Sexual abuse of elderly people: would we rather not know the details? The Journal of Adult Protection, vol. 6(2), 21-30. Jones, H. and Powell, J.L. (2006). Old age, vulnerability, and sexual violence: implications for knowledge and practice. International Nursing Review, vol 53, 211-216. Kuhn, D. (2002). Intimacy, sexuality, and residents with dementia. Intimacy, Sexuality, and Residents, 3(2), 165-176. Kurlowicz, L., and Wallace, M. (1999). The Mini Mental State Examination. Try This: Best Practices in Nursing Care to Older Adults, issue 3. Mayers, K. S., and McBride, D. (1998). Sexuality training for caretakers of geriatric residents in long term care facilities. Sexuality and Disability, 16, 3, 227-236. Ogden, Gina. (2006). The Heart and Soul of Sex: Making the ISIS Connection. Boston, MA: Trumpeter Books. Quinn, K. (1995). Identify elderly victims of sex abuse. Psychotherapy Letter, 7(3), 1-2. Reingold, J. et.al. (1995). Creation of a training program regarding residents sexuality. Paper Presented at the Eleventh Annual International International Conference of the Alzheimer’s Disease, International, Buenos Aires, Argentina. Reingold, D., and Burros, N. (2004). Sexuality in the nursing home. Journal of Gerontological Social Work, 43(2/3), 175-186. Richard, D. (2002) New York nursing home sets policy, precedent for sexually active residents. Contemporary Sexuality, 36, 9, 7-7. Richardson, J. P., and Lazur, A. (1995). Sexuality in the nursing home patient. American Family Physician, 51, 1, 121-124. Tabak, N., and Shemesh-Kigli, R. (2006). Sexuality and alzheimer’s disease: Can the

Sexuality Policy 19 two go together. Nursing Forum, 41, 4, 158-166. Walker, B. L., and Harrington, D. (2002). Effects of staff training on staff knowledge and attitudes about sexuality. Educational Gerontology, 28, 639-654.