In an intimate relationship we have the opportunity to feel valued and connected. The relationship may be one of a sense of closeness only, a deeply caring experience, or it may include acts of physical intimacy like hugging, hand-holding, or sensual adoration (or what we call sexual relations). The biological source of yearning for any form of intimacy is not really understood. Fulfilment of the yearning depends on socialized opportunities, and negotiating intimate activities requires skills and experience, as well as some courage to establish the required relationship. Physical and emotional safety issues may also be important in some circumstances.
In our society we can largely blame our lack of clarity, mixed signals, and awkwardness or shyness for any difficulties communicating our desires and intentions for emotional or physical intimacy in a relationship, and that seems to be the case even more so in later life, specifically in lonely living circumstances, institutional settings, or assisted-living accommodations.
In response to a request from nursing and caring staff of a 400-bed extended care facility for men, I conducted a survey in 1983 to find out what patient behaviors staff identified as annoyingly sexual in nature and how staff reacted to the behaviors.[1] Staff identified sex talk (explicit language), provocative acts as touching, grabbing staff members or exposing genitalia, and implied sexual behaviors such as openly reading magazines with sex-related content as sexual and as causing problems. Staff emphasized that such incidents were a daily occurrence, the majority of which were caused by 20% to 25% of residents. Supervisors of two mixed male and female extended units collected additional information from their staff members. While reported incidents concerning men were similar, sexual incidents about women residents were fewer and more sympathetically reported. The survey and follow-up meetings raised questions about the nature and cause of different types of sexual behaviors and about the potential roles of nursing staff, physicians, and administrators to defuse unwanted situations. Further studies were suggested to address epidemiological, medical, and administrative questions. Such studies would help medical, nursing, and administrative personnel respond rationally and effectively to the people in their care.
Forty years later, an article from the UK reviewed fifteen relevant studies by asking two questions: what are the intimacy concerns of people over the age of 50, and which interventions are effective in promoting well-being in this complex and sensitive area.[2] The reviews confirmed that older people may prefer to view sex as expressions of physical and emotional intimacy and recognize the importance of intimacy in one’s identity and healthy aging. Health issues as well as cultural factors significantly impact the quality and frequency of intimate experiences in later life, such as long-term health conditions, hormonal issues, prostate problems, diabetes, general fatigue, and dementia. In care homes and residences, barriers include a lack of privacy, fear of judgment from co-residents, and prohibition by staff.
Regarding interventions, older people reported a fear that their intimacy-related concerns would be dismissed by health professionals as part of normal aging. Both men and women expressed their desire for health professionals to raise questions about intimate needs. Most health professionals in the surveys recognized the importance and appropriateness of discussing intimacy with their older patients but admitted their lack of knowledge and some degree of discomfort as inhibiting factors in raising the subject. Care home professionals also expressed concerns over residents’ safety, ethical issues, and pressures from family members.
My study from 40 years ago focused primarily on how to assist staff to deal with unwelcome or unwanted intimate interactions in extended care units. The recent UK survey article looked for descriptions of the nature of intimate concerns presented by older persons and searched for evidence of effective interventions. Neither study provided effective strategies to promote or safeguard the intimacy-related well-being of the elderly in the home or in residential or long-term care settings.
In 2009 the Vancouver Coastal Health Authority published a document titled, Supporting Sexual Health and Intimacy in Care Facilities: Guidelines for Supporting Adults Living in Long-term Care Facilities and Group Homes in British Columbia, Canada.[3] Research for the document included an international literature search and provincial focus groups. In 2006 the findings had been presented to and the recommendations supported by the Public Health Agency of Canada, the BC Ministry of Health Services, Vancouver Coastal Health, and GF Strong Rehabilitation Centre. These guidelines, which pertain to adults 19 years and older, clearly state that facilities have an ethical and legal obligation to respect and support clients’ sexual lives. This represented a significant turn away from former attempts to manage and control residents’ perceived sexual health and intimacy issues. Addressing sexual behavior and related issues in care facilities may improve residents’ health and emotional state while safeguarding staff and all clients, including those with compromised cognitive functions. The guidelines compellingly identify opportunities to support and promote the sexual and intimate well-being of residents in assisted residential settings in BC.
Providing suggestions for consistent standards of care in long-term care facilities and group homes, the guidelines recommend directions for supporting sexual expression and management of problematic sexual behaviors. In essence, the guidelines recognizes that what is a private aspect in a person’s life must be addressed in a nonprivate environment. As such, ongoing education for staff is essential, including case reviews, discussions on sexuality and caregiving, responsibility to be respectful about clients’ intimate lives, and an obligation to support the facility’s policies.
In 2013 a user-friendly pamphlet called Supporting Sexual Health and Intimacy in Long Term Care Homes: A Pocket Reference Guide was first published by the Vancouver Coastal Health Authority for staff and caregivers (updated in 2023).[4] Using case examples, it outlines the values that underpin the clinical recommendations and responsibilities related to sexual health issues that may occur in long-term care. Included are suggestions about assessing risk of harm to a person where sexual activity may occur, guides to caregivers about how to determine if a person is capable of making the decision to engage in sexual activity, and if necessary, how to intervene when there is a risk of harm. The Pocket Guide ends with practical suggestions for cases where persons may need physical assistance to engage in sexual activities.
By 2021 Vancouver Coastal Health and Providence Health Care released a decision support tool based on the guidelines.[5] In the past 2 years, resources were developed to provide educational support to staff around the topics covered in the tool, including a series of interactive e-learning modules to help health care workers build their confidence and competence to support sexual health and intimacy for persons living in care.[6] Supporting, instead of controlling, sexual health and intimacy requirements of persons living in long-term care, assisted living, group homes, or supported housing is a unique, humanistic approach to ensure that moving into a care home will not result in the loss of opportunities to engage in intimate and sexual behaviors.
A 2017–2018 environmental scan of long-term care and group homes in Vancouver Coastal Health and Providence Health Care found that 85% of persons living in care had questions or concerns related to sexuality, intimacy, and related issues.[5]
Will these sophisticated initiatives result in a dramatic reduction in questions and concerns from residents in care facilities, and evidence of them feeling valued and needed in intimate relationships? The proof will be in the pudding in the next 5 to 10 years.
—George Szasz, CM, MD
Acknowledgments
The author acknowledges valuable help from Kate McBride, MSN, clinical nurse specialist, in leading him through the initiatives and guidelines of Supporting Sexual Health and Intimacy in Care Facilities.
References
1. Szasz G. Sexual incidents in an extended care unit for aged men. J Am Geriatr Soc 1983;31:407-411.
2. Stowell M, Hall A, Warwick S, et al. Promoting sexual health in older adults: Findings from two rapid reviews. Maturitas 2023;177:107795
3. Breen S, Carlson M, Clements G, et al. Supporting sexual health and intimacy in care facilities: Guidelines for supporting adults living in long-term care facilities and group homes in British Columbia, Canada. Vancouver Coastal Health Authority. July 2009. Accessed 21 November 2023
4. Carlson M, Clements G, Everel B, Young J. Supporting sexual health and intimacy in long term care homes. A pocket reference Guide. Vancouver Coastal Health Authority. May 2023. Accessed 21 November 2023. https://vch.eduhealth.ca/en/permalink/phem4152.
5. Carlson M, Everett B, Villaos VG, Salazar L. Sexual health and intimacy: A decision support tool as a model of care and advocacy. Vancouver Coastal Health. 2021. Accessed 21 November 2023. www.vch.ca/sites/default/files/import/documents/COP-sexual-health-and-intimacy-resources-poster.pdf.
6. PHSA LearningHub. Supporting sexual health and intimacy in LTC, assisted living, group homes and supported housing. 2023. Accessed 21 November 2023. https://learninghub.phsa.ca/Courses/25808/supporting-sexual-health-intimacy-in-Itc-assisted-living-group-homes-and-supported-housing.
Additional reading
Wajngarten M. Lessons from the longest study of happiness. Medscape. 12 July 2023. Accessed 21 November 2023. www.medscape.com/viewarticle/994286_print.
This post has not been peer reviewed by the BCMJ Editorial Board.
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