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.