October 18, 2019

On the Horns of a Dilemma

I've got a lot on my mind this morning and I'm sorry, but today's post is going to reflect that. I'm going to be going in a more serious direction so if you are looking for something to make you laugh, you might want to quit reading right now. I'm not in a bad mood, mind you, just really thinking about and struggling with a very uncomfortable subject. 

Also, we lost another resident yesterday before breakfast was even over. Another is in the hospital and we learned yesterday that she won't be back, she is expected to pass very soon. She is the first resident I got close to and I will really miss her.

Now on to the uncomfortable subject...sex in nursing homes. People this is a thing. It happens. It might not be going on all the time, but it does happen and it's something facilities and staff members have to figure out how to deal with. Making it especially difficult and tricky is that there is no clear-cut, approved-by-everyone plan for this. There is no consensus among the "experts" that I could find. (Update. The home's dementia expert told me today the state does have laws about this, but didn't clarify other than if we don't comply we will get called on it during inspections. I would be interested to know if the state's laws specifically deal with "sexual expression" or just the subject of rights and dignity.)

About the only thing everyone agrees on is that those who are not competent must be protected, but that's also where it gets a little lot murky. Throw in a resident with dementia or better yet an entire unit of dementia residents all in differing levels of the disease. Then what? From what I've read the "experts" agree that a diagnosis of dementia does not have to mean the end of an active sex life. I would agree with that in the early stages. Beyond that I've read so many things my head is spinning.

Most articles say a dementia resident who wants to engage in sexual activity should have their cognitive ability evaluated to see if they have the ability to make an "informed choice." Do they know who they are engaging in sex with? Do they understand the risks involved (STD's, injuries from falls, etc.)? 

That sounds reasonable...unless you keep digging. You run into all kinds of thinking about why sex should be allowed among dementia residents.

  • Touch brings comfort and that includes sexual touch so they shouldn't be kept from that comfort.
  • It shouldn't matter if the resident still has a living spouse. Dementia residents often forget their spouse. The resident's happiness and well-being is all that matters.
  •  It doesn't matter if the behavior is completely out of character with who the resident was before the disease, because personalities change with dementia. (This includes residents who have been heterosexual all their lives and now engage in homosexual acts.)
Some "experts" say the family should be informed, but not necessarily given the power to say no to such things....which brings up the whole question of who exactly decides if a resident has the capacity to consent to sexual activity. The facility's doctor? The resident's doctor? The family? The staff? Administration? 

It's scary, but the overwhelming majority of nursing homes have no official policy on the subject. There are no hard and fast rules or laws concerning it. Families and staff struggle to cope with it.

Everyone's personal morals and feelings don't seem to count. In fact, some of the articles warn of the risk of staff who are not okay with what's going on treating the residents involved differently than the other residents. (I'm happy to say that though I know nearly all the staff is not okay with what is going on, I saw no evidence of any staff treating anyone differently. And I didn't, either. I'd never hold that sort of thing against a resident, they can't help it. It's the administration I have problems with.) 

I have to tell you that this subject is keeping me awake at night and raising my stress levels all day. The home I work at has no official policy, but that is changing as we cope with just such a situation. The biggest struggle for me is that the question of whether the residents are competent or not has a clear answer to me. No, they are not. Their competency is sufficiently reduced that they have to be housed in the lock-down unit of a skilled nursing facility. They can't drive a car, hold a job, live alone, remember to do (or not do) normal life things, use the bathroom...so how are they able to decide intelligently about sex? If they are deemed competent to make decisions about sex then hey, lets unlock the doors and give them the car keys!

In the situation at work, the woman chases after all the men in the unit, thinking each is her husband at varying times. She just wants attention and love and has been known to show affection to women once in a while. The man is very crude and inappropriate with all females, residents and staff alike. I really don't think it matters to him who he is with as long as he gets what he wants. The entire staff is uncomfortable as all get out with this. Both use walkers and are fall risks. There is the morality issue, but also the physical danger of one of them falling during the act and getting hurt. 

Official policy is being formed as we go forward. Our dementia "expert" is definitely in the let-them-do-whatever-makes-them-happy camp of thinking and she has the home's administrator on board with her. The residents have already been intimate, but now they are going back and covering their bases.

The families of both have been contacted and we've been told both are okay with it so we are to allow it to happen. (We've been told another resident's family was okay about incidents with this same woman in the past...and they definitely are not!) As long as they both enjoy it and neither one resists we are to ignore it.

Yeah, about that. What if one of them gets hurt? Someone has to clean up after the act, because they don't know enough to do that any longer. What if they start getting inappropriate in front of the other residents? What if the woman who is prone to jealous fits of rage as it is, gets jealous or angry and harms another resident? What if either one decides to be intimate with a different resident? Both share a room with another resident, what about those residents and their rights?

We are having an official training on the subject the 28th of this month. I suspect that it isn't going to change the fact that none of the staff is okay with this, but it will, at least be official and on paper.

So, this is our policy thus far:
  • Residents who are both agreeable may engage in sexual activity.
  • Families will be informed.
  • Care plans will be written up.
  • They will not be allowed to have sex with other individuals unless the families of those individuals have been contacted and care plans have been put in place.
  • The staff is not liable if the residents injure themselves during the activity.
  • It does not matter if either party has a living spouse.
I know many of you have been down this dementia journey with a loved one. Has this ever been an issue? How do or did you feel? It feels so totally and completely wrong to me...just another symptom of our slipping moral fiber. I know I would be devastated if it was my husband or my parent. It seems that the only real recourse a family that disagrees would have is removing the resident from the facility.


  1. I am shocked that this behavior is allowed to go on (although I probably shouldn't be with the way this world is going). If it were a member of my family, I would be pulling them out of that facility. It seems the only way changes are made these days are by hitting the owners in the pocketbook. I'll be praying for you. This is a tricky situation for sure.

    1. I need to learn more because our "expert" has told me things before that have proved to be untrue, but as of today she is making it sound like families can say no and we will enforce that. I'm not really getting the point of calling the families now and getting the doctor to evaluate them next week. It's a case of shutting the barn door after the horse is already out.

  2. Wow! This actually blows my mind. I never even considered that dementia patients would be having sex. I guess that shows how naive I am.

    In my opinion, this should not be going on. If it was a husband and wife, sharing a room together, that is one thing. But considering that both of these people share rooms with others, no way. How disrespectful to those other patients to be in a room with that stuff going on. I think those patients' families should be informed as well.

    We talk about dying with dignity. In my opinion, the vast majority of dementia patients would be mortified to learn of their behavior. They wouldn't feel dignified at all to learn that they are having sex with someone they aren't married to and that facility personnel have to clean up after them.

    You've gone from driving a school bus to working in a nursing home. You've seen both ends of the age spectrum. Which age group is easier?

    Have a blessed day,

    1. Honestly, I'd still rather work with the seniors than elementary age children. It's the stupid policies administration puts into play that drive me nuts, not the residents. I get what's going on with the residents, but I don't get the thinking that allowing them to do certain things is giving them respect and their dignity. Seriously, how competent are they if we have to direct them to go somewhere private or close the door?

  3. My father had dementia and was in a rest home before he died. Mom and dad both roomed together until mom passed from cancer. As far as I know, this topic never came up. Or if it did, no one contacted the family. I know I for one would have been upset. It would have been so far out of character for my father to be involved in something like this. I can't even imagine. But I agree with you, if they are in a locked facility and can't leave or drive or take care of themselves, then how could they legitimately make a decision like this. It's rather scary that anyone would think this is okay.

  4. What a tough subject. Before I met Joe he had a neighbor whose wife had early onset Alzheimer's. She was put in a home when she got to be too hard for her husband to manager her behavior (leaving the house in the middle of the night, for example). He walked in on her making out with another man at the facility where she lived. He was hurt beyond comprehension but he also knew the woman doing that was not the woman he had married. She didn't know him anymore. I can't imagine the hurt this would cause me but how do you stop it? Locks? That seems awful too. Let us know what you learn on the 28th. Interesting subject.

  5. The policy made me laugh... sorry... the Families will be informed. OH MY GOSH.. .its like they say, you revert to your childhood... I can imagine getting a call about grandpa... which knowing my grandpa, it wouldnt have surprised me one bit!! I laugh about it but I can imagine the confusion of it all too.
    & I'm so sorry you lost another resident. I can only imagine how you take your job home with you.

    1. And that's why some of the stuff I read said maybe the families shouldn't be involved because no one wants to hear this stuff about their parent, let alone discuss it. Like, seriously, can you imagine? EWWWWWW!

  6. Took care of my grandfather for two years.

    Enrolled him in an adult daycare for two days a week. I work third shift and was running on fumes.

    One morning the daycare called. Grandfather had been transported to the hospital.

    At the hospital I was greeted by the doctor and a nurse. I was too sleepy to follow most of what they were saying until "...and when he is well enough we'll send him back to his nursing home."

    What nursing home? He lives with me.

    Worst idea ever. You could see the daily decline.

    And inappropriate comments.

    Never had that happen at home. But that was the home he where he spent sixty years of his life and could go into his workshop and make things. Such as an engine block or a blunderbuss-type black powder gun. Or take a walk around the neighborhood and all the neighbors greeted him.

    1. Well, God bless you. Being a caretaker is a tough job no matter how much you love the person. We offer respite care at our facility so families can get a break.

  7. Thank God the facility has people like you, with values and caring, working there.


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