1. Seniors, Sex and Elder Care Ann Wilder, LCSW UNT Doctoral Teaching Fellow & RA Sociology of Aging and Applied Gerontology

2. Learning Objectives 1. Participants will gain knowledge on current issues related to Senior adults living in dependant care settings including stereotypes and myths of sexuality and sexual expression. 2. Participants will be presented with clear information on issues regarding sexual expression of older adults that range from easy to difficult to address in dependant care settings. 3. Participants will be given general guidelines for respecting privacy, understanding consent and evaluating competency for Senior adults in dependent care.

3. Myths & Stereotypes Objective 1: Participants will gain knowledge on current issues related to Senior adults living in dependant care settings including stereotypes and myths of sexuality and sexual expression.

4. Myths & Stereotypes Myth 1: Older adults are not sexual Fact: Sex is considered to be a basic human need

5. Myths & Stereotypes Myth 2: Older adults are immune to contracting HIV or other STD’s Fact: The DHHS Administration on Aging 2013 states… Over 1 million Americans are living with HIV and the number is growing. According to the Centers for Disease Control and Prevention, 31% percent of people living with HIV nationwide are over the age of 50. Moreover, research indicates that by 2015 half of the people living with HIV in the U.S. will be over more than 50 years old. With the advent of the 21st century, prevention of HIV has become an important issue for older Americans. Today, 17% of all new HIV/AIDS cases occur among people who have lived to the half century mark and beyond. It is clear that more needs to be done to inform individuals and aging network providers about the importance of educating older Americans about HIV prevention. Source: www.aoa.gov

6. Myths & Stereotypes Myth 3: Equipment stops working as we get older Fact: Erectile functioning can decrease and change for men but there is still the capacity for pleasurable experiences. In an AARP survey of men over 70 years of age, 75% of the respondents reported having never had erectile dysfunction. There are currently 3 prescriptions drugs on the market that enhance sexual performance and several aids that can be incorporated into sexual activity (i.e. pumps, implants, shots) For women, vaginal walls may thin and expand but the clitoris maintains functionality throughout a lifetime. Sometimes a little more foreplay is necessary because of the decrease in blood flow to that area. A wide variety of sexual lubricants are available to help with vaginal dryness that sometimes occurs at menopause. Source: www.aarp.org

7. Myths & Stereotypes Myth 4: Older people should not be having sex Fact: Sex is not just for reproduction. Sex is a pleasurable experience that is healthy and important throughout an entire lifespan. An active sex life has been found to be linked with healthy aging. In fact, studies show that an active sex life is linked to higher levels of marital satisfaction, better health outcomes and improved stress management. Even though sex drive may decrease based on health or medical issues, it is not healthy to stop wanting sex. We are clearly designed to keep our sexual connectedness vibrant and alive throughout the entire lifespan. Source: www.aarp.org

8. Myths & Stereotypes Myth 5: Older bodies are not sexy Fact: Sexy is in the eye of the beholder and as we age those who are also aging can see the beauty that each person holds. Laws of human attraction hold true throughout a lifespan and bodies that show age are still considered to be attractive to many people. Sex and healthy aging is not all about how you look either, there is an emotional and spiritual aspect associated with pleasure and being able to have a body that still experiences pleasure is worth celebrating! Source: www.aarp.org

9. Sexual Expression Objective 2: Participants will be presented with clear information on issues regarding sexual expression of older adults that range from easy to difficult to address in dependant care settings.

10. Sexual Expression Sexuality is a health issue ! Studies have identified significant gap in what occurs sexually for older adults and what they talk about with their care providers (Lindau, et al. 2009). Role of nursing staff in assisting patients to meet their needs for sexual expression is very important. Nurses are key in opening communication about health issues and the need for sexual expression is a health issue. Sex as pain reliever, provider of pleasurable sensations and relief from stress. Some doctors will prescribe masturbation as an activity to help with chronic pain.

11. Sexual Expression Sex re-education provided by nurses and or social workers with support and encouragement for healthy sexuality later in life is critical. Continuum of sexual expression exists– not just the act of intercourse but talking, emotional intimacy, cuddling, making out, fore play, masturbation How is this encouraged or handled in your facility? * Older, Wiser, Sexually Smarter provided by New Jersey Planned Parenthood

12. Sexual Expression Sex drive and expression can increase with the progression of dementia. Agitation becomes an issue, agitated when unable to express sexuality and agitated sometimes when over stimulated. How are spouses handled in dementia and Alzheimer’s care facilities? Are conjugal visits allowed? If so, what works and what doesn’t work?

13. Sexual Expression Common and Easy issues… No sexual relations between staff and residents. There needs to be a differentiation between acceptable and unacceptable touching and expressions of affection that are caring but non sexual. Why? Confusing for residents, may develop a crush or be aroused and unable to fulfill needs, can result in complaints from family members or reports needing to be made if there is suspected abuse or neglect. This can reflect negatively upon the facility and state rating system if reports are made and corrections are required.

14. Sexual Expression Common but more moderate issues… Residents who have the capability to engage in sexual expression have the right to do so as long as it is not offensive or harmful to others. Reasonable expectations of privacy must be provided for residents by law that reside in a care facility. Issues become about assessing capability, family attitudes and privacy arrangements being made available for residents.

15. Sexual Expression Occasional but more difficult issues… How much say do family members have if a resident is determined capable, competent and consensual to make decisions? Do policies exist in your facility on how to handle issues of sexual expression when they arise? Alternative lifestyles and accommodations for these needing to be made at facility without complaints from other residents or discrimination from staff. Need to determine consensual capacity and who does this at a facility…interdisciplinary staffing needed to review prior to referral for formal evaluation. Residents falling in love and wanting to get married or share a room with a companion that they have met at facility are some examples where family and/or staff would be involved in decision making process with resident.

16. Privacy, Competency & Consent Objective 3: Participants will be given general guidelines for respecting privacy, understanding consent and evaluating competency for Senior adults in dependent care.

17. Privacy, Competency & Consent Privacy Definition The condition of being free from observation or of having unsanctioned intrusion. What does privacy look like in dependant care? * roommates, attendants, bathing, increased interaction between people that did not exist when living at home * increased opportunities for sexual interaction that is very different from living at home, more opportunities for arousal to occur creating behavioral challenges * awareness of how this effects people is critical to successful care (i.e. bias and judgment of older generation toward younger staff or staff that lead alternative lifestyles)

18. Privacy, Competency & Consent Examples of how privacy needs are handled facilities that promote sexual expression… What works and what doesn’t?  C ompanion rooms  Adult movie nights  Library of adult films, magazines and videos available  Outings to adult entertainment  Private access to a computer for online encounters( note: * safety issues related to online dating)  Private visitation of spouse or adult companions allowed in patient room or designated private area  Provide condoms and lubricant for residents that request or demonstrate a need and encourage use

19. Privacy, Competency & Consent Competency Generally this is referred to as how well you are able to do something or how capable a person is. Very often based on the ability to exhibit good judgment. Definition- the quality of being adequately or well qualified physically and intellectually How determined? In state of Texas this is determined through need for guardianship. It is based on an evaluation and a series of Psychological tests designed to determine a persons level of competency. Many people come into care competent and situations change and health declines. It is possible that a guardian may be necessary later on. Source: www.acelaw.cawww.acelaw.ca

20. Privacy, Competency & Consent Consent The three main areas of sexual consent capacity are rationality, knowledge and voluntariness. Definition- a voluntary agreement by an individual to engage in a sexual activity How obtained? * Individual, family, guardian * Person has to have the capacity for consent and this is determined in multiple ways through psychological testing (i.e. MMSE > 14) and interviewing to determine patients understanding of potential for exploitation, knowledge that a relationship exists and what the potential risks might be. Sometimes legal involvement is necessary for final determination. Source: www.acelaw.cawww.acelaw.ca

21. Privacy, Competency & Consent How best to protect against abuse and exploitation? Regular training provided for staff that includes discussion on sexual expression and policies for handling this in facility. Most importantly, everyone needs to feel comfortable discussing sexual expression. Situations are bound to arise and each one has a unique set of circumstances. Being able to handle each of these situations with compassion, dignity and respect begins with open dialogue about this sensitive topic. Who is responsible for doing this in your facility? Administrator * Social Worker * Nurse * Rehab Therapists * CNA* Food Service * Housekeeping

22. Conclusion Sex is a basic human need… Older adults have sex and there is a wide variety of sexual expression that human beings engage in. Creating an open atmosphere in a facility for staff to speak openly about what is going on in a care routine is critical. If people do not feel comfortable discussing sexuality in ways that are non judgmental and are not shaming then it is becomes more difficult to keep residents safe from harm.

23. Conclusion Sex re-education is of particular importance to older adults. HIV and other STD’s are currently on the rise in older adults This current generation of older adults did not receive sex education in HS or college and basic condom awareness may be not exist (i.e. notion of birth control vs. STD prevention may preclude condom use)

24. References Alagiakrishan, K. Lim, D. Brahim, A. Wong, A. Wood, A. Senthilselvan, A. Chimich, W.T.. Kagan, L. (2005). Sexually inappropriate behaviour in demented elderly people. Postgrad Med Journal, August 23: (81): 463-466. Brick, P., Lunquist, J., Sandak, A. and Taverner, B. (2009) Older, Wiser, Sexually Smarter; 30 Sex Ed Lessons for Adults Only. Planned Parenthood of Greater Northern New Jersey. Morristown, NJ Benbow, Susan M. and Beeston, D. (2012) Sexuality, Aging and Dementia. International Psychogeriatrics 24: 7, 1027-1033. Hirayama, R., Walker, A. (2010, March 9.) Who Helps Older Adults With Sexual Problems? Confidants Versus Physicians. The Journals of Gerontology Kontula, O., & Haavio-Mannila, E. (2009). The Impact of Aging on Human Sexual Activity and Sexual Desire. Journal of Sex Research, 46(1), 46-56. Lindau, Stacy T., Schumm, L. Phillip, Laumann, Edward O., Levinson, Wendy O’Muircheartaigh, Colm A. and Waite, Linda J. (2007). A Study of Sexuality and Health among Older Adults in the United States. New England Journal of Medicine, Aug 23: 357(8): 762-774.

25. References Moore, K., Boscardin, J., Steinman, M., & Schwartz, J. (2012). Age and sex variation in prevalence of chronic medical. The American Geriatrics Society, 60(4), 756-764. Rheaume, Chris, Mitty, Ethel (2008) Sexuality and Intimacy in Older Adults. Geriatric Nursing, Sep –Oct: 67040. Wahl, Judith B.A., L.L.B. Sexuality in Long Term Care Homes- the Legal Issues. Advocacy Center for the Elderly; Toronto, Canada (www.acelaw.ca)www.acelaw.ca Online Websites: 1.www.aasect.orgwww.aasect.org The American Association of Sexuality Educators, Counselors and Therapists provides names of certified professionals for people seeking help. 2. www.sexualhealth.comwww.sexualhealth.com An good site providing reliable information and links to other sites, good for professionals and lay persons alike, special focus on disabilities. 3. www.menopause.orgwww.menopause.org Good information on sexual issues that often occur at menopause 4. www.aarp.orgwww.aarp.org American Association of Retired Persons has a helpful Sex & Intimacy blog

26. Thank you!