Sexual self-determination is considered a fundamental human right by most of us living in Western societies.
While we must abide by laws regarding consent and coercion, in general we expect to be able to engage in sexual behaviour whenever, and with whomever, we choose.
For older people with dementia living in residential aged care facilities (RACFs), however, the issue becomes more complex. Staff often struggle to balance residents' rights with their duty of care, and negative attitudes towards older people's sexuality can lead to residents' sexual expression being overlooked, ignored, or even discouraged.
In particular, questions as to whether residents with dementia are able to consent to sexual activity or physically intimate relationships pose a challenge to RACF staff, and current legislation does little to assist them.
This paper addresses these issues, and will argue that, while every effort should be made to ensure that no resident comes to harm, RACFs must respect the rights of residents with dementia to make decisions about their sexuality, intimacy and physical relationships.
Safety fears and agism denying care home residents right to consensual sex
But sex is good for health and wellbeing; formal policies are needed, say specialists
Concerns about safety, and ageism, are needlessly denying elderly care home residents what is often one of their few remaining pleasures - the right to consensual sex - say specialists in the Journal of Medical Ethics.
Older people, including those with early stage dementia, often continue to enjoy a sexual relationship in their own homes, but once they move into residential care, lawful and consensual sexual expression is frequently frowned upon, argue the authors from the Australian Centre for Evidence Based Aged Care.
Lack of privacy, safety fears, concerns about duty of care, anxieties about potential repercussions from relatives, and ageism all get in the way of what is "a basic human right" and "a normal and healthy part of ageing", they say.
"Since it has been well established that sexuality and intimacy continue to be important in later life and are central to an individual's health and wellbeing, the lack of attention paid by aged care facilities to residents' sexual needs is concerning," they write.And the existing research indicates that residents do want their sexual expression to be acknowledged and believe that healthcare professionals should ask them about their sexual needs, they say.
But many residential facilities lack formal policies or guidelines or appropriately trained staff to address this, they contend. And they are not helped by existing frameworks for assessing mental capacity and consent, which apply primarily to high stake decisions, such as treatment and power of attorney.
There are some frameworks to assess decision making capacity around sex, say the authors, but they are unsuitable. A person may perform badly on a mini mental state test (used to assess cognitive impairment), but is often still able to express a preference for a friend or lover.
The authors acknowledge that it is important to protect the vulnerable from harm and to ensure that sexual behaviour is not harmful, abusive or illegal, but that should not prevent people with dementia from making their own decisions about sex, they argue.
They may indeed be exposed to emotional distress if a relationship ends, they write. "However, these are risks that any sexually active person faces throughout his or her life, and we should not confuse a bad or unwise decision with incompetence."
"Seeking to 'protect' individuals with dementia by not allowing them to express their sexual needs, thereby stifling their autonomy and personhood, is a far greater failure of duty of care. It is also, we would argue, a violation of the fundamental right of a person with dementia to be recognised as a person before the law."These issues are likely to become more relevant and pressing as the population ages and more and more residential care homes will be needed, say the authors.
"At present, rather than engaging with the delicate balancing act between resident autonomy and duty of care [residential care homes] are choosing to ignore the issues and tread on the side of caution." they conclude.[Dementia, sexuality and consent in residential aged care facilities Online First doi 10.1136/medethics-2011-100453]
Journal of Medical Ethics -- Dementia, sexuality and consent in residential aged care facilities
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Original content Bob DeMarco, the Alzheimer's Reading Room