Home' Australian Ageing Agenda : AAA Nov-Dec 2017 Contents Julie Letts
motional and physical intimacy,
including sexual expression is a
profound and universal human need.
And most people’s desire for intimate
human connection becomes increasingly
important as end of life nears. Yet when it comes
to acknowledging within aged care settings that
residents have a normal need for intimacy, this is
often seen as a problem to be managed, or simply
ignored, especially sexual expression.
Expressions of intimacy by aged care residents
may take many forms, as they do in the wider
world, ranging from handholding, quiet shared
confidences, kissing, being held or holding
another, caressing, intimate skin-skin time in a
bed, masturbation, use of sex aids or porn, to
intercourse. And there will be enormous variation
in what kind or intensity individuals desire in line
with personal values and histor y, impact of illness,
and proximity of death.
In his 1999 paper Sexuality in the Nursing
Home: Iatrogenic Loneliness, bioethicist Professor
Steven H Miles argues that understanding
intimacy and loneliness are a foundation for
interpreting the experience of sexual relationships
of those in aged care. He says intimacy is the sense
accompanying being in an intense relationship in
which one has a confidante for safe self-disclosure
while the converse of intimacy is loneliness. It is
essential then that sexual expression be understood
in this relational sense, rather than merely about
personal genital pleasure.
Ageist attitudes partly contribute to aged care
facility staff discomfort about sexual intimacy
between residents. Society generally views older
people as post sexual. Residents may also be
infantilised – consider staff use of endearments
like ‘sweetie’ or ‘darling’ – making it harder to
see them as potential sexual beings. Younger staff
members’ attitudes may also reflect the typical
generational discomfort that adult children
experience thinking about their parents as sexual.
Perceptions about organisational risk and
possible complaints, or litigation from families
disapproving of a parent’s sexual or other
intimate activity are also a driving factor.
However, it is not clear that staff have either
an ethical or legal duty to supervise apparently
consensual sexual intimacy, or why staff may act
on family requests to intervene and disrupt such
relationships, notwithstanding the motivation
is the desire to protect. Misperceptions by staff
and managers about what duty of care requires
probably clouds this complex issue.
Needs, culture and policy
Entering an aged care facility is essentially a
marker of approaching end of life. The average
stay now being 18-24 months in many Australian
facilities. While there is much focus on residential
aged care as being a place to live well, it is critical
that facilities also be a place to die well.
A major fear of the dying is dying alone, or
disconnected from those they choose to have close.
After potentially a lifetime together, being
constrained to holding the hand of a dying
partner through a bed rail is a sad substitute. This
is certainly seen in hospitals. Healthy intimacy is
important for the ongoing process of creating and
recreating one’s personal identity that continues
into old age. This telling and retelling of one’s
story, confiding about who one is and what one’s
life has been about is an essential part of facing
the end of life. Intimacy, sexual or otherwise, is
integral to facing death and this process.
Affection, touch, quiet confidences are
soothing to most people who enter their dying
time. But there will be some for whom sexual
activity is desired and beneficial in the last year or
so right up until that point.
Sound ethically informed policy and resources
can help engineer an environment where residents’
healthy expression of intimacy and sexuality
is considered part of the cultural fabric of an
organisation. Abandoning ‘no locked door’ policies,
signage to ensure respect for private time and
space, and less intrusion by staff in new intimate
connections between residents are a start. Doing
so will also better position aged care providers to
respond to the probable increase in demand for
intimacy-enabling spaces and attitudes as the baby
boomer generation begins to move into residential
care. Their sexual mores were developed in a
different time to those currently in aged care whose
attitudes to sex were formed in the 1940s and 50s.
The uptake of institutional policy to date
by Australian aged care providers is patchy, in
part because it is challenging to create intimacy
enabling environments while stepping through
the ethical, legal and social complexities that
inevitably arise. This is a task made more sensitive
in the current environment where legitimate
concerns prevail about protection of some
vulnerable older people at risk of abuse.
The Opal Institute has developed model
policies on sexual wellbeing and safety and sexual
boundaries that can be adopted and modified
for local conditions. A resource to support staff
training Sexualities and Dementia – Education
Resource for Health Professionals is being further
developed by Dr Cindy Jones.
A good end of life setting is one in which
someone feels understood, empowered and cared
for as an individual in a way that is right for
them. This must also include more opportunities
to seek out and pursue the possibility for intimacy
and what this deeply human need craves as we
face the last years of life. n
Julie Letts is director of LettsConsulting where
she specialises in ethics and end of life issues.
‘The converse of
intimacy is loneliness’
A good end of life must include opportunities for intimacy, writes JULIE LETTS.
to aged care
62 | NOVEMBER – DECEMBER 2017
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