A bit of the other - Older People in Care Homes: Sex, Sexuality and Intimate Relationships; an RCN discussion and guidance document

Dr. Dawne Garrett is Professional Lead Older People and Dementia Care at the Royal College of Nursing. She has committed her career to the care of older people in a range of clinical, academic and entrepreneurial roles. Her doctoral research is on sexual intimacy. She maintains a clinical role and publishes widely. She tweets @profleadolder

We are getting better at difficult conversations - cancer, dementia, end of life care, advance directives, deprivation of liberty - for those of us who work with older people all these thorny issues are common. They’re personal, individual but frequent.

But now here’s the elusive one. Sex. Or to be exact, sexual intimacy. Many older people don’t have penetrative hetero-normative sex, but they do engage in sexual intimacy. That said, many older people do have penetrative hetero-normative sex - whatever floats your boat.

So what, I hear you cry! I always ask the sex question as part of CGA, it’s a holistic assessment for goodness sake.

Now here’s the rub… do you ask the sex question when visiting residents in care homes?

As nurses we know some of the complex, intimate and sensitive conversations we have with residents, staff, visitors and families. Frequently we are left wondering how to help and support their activity, particularly where there are issues of capacity or unexplored sexual health needs.

The Royal College of Nursing has produced a new discussion document

Older People in Care Homes: Sex, Sexuality and Intimate Relationships, written by Hazel Heath (Independent Nurse Consultant), Dawne Garrett, (RCN Professional Lead Older People and Dementia Care), Victoria Butler-Cole, (Barrister, 39 Essex Chambers) and Lynne Phair (Independent Nurse Consultant and Expert Witness).

It suggests care home service providers should strive to develop policies which support the rights of all the people who live, visit or work in care homes. They should offer environments which facilitate individual rights and choices in sexuality, expression and intimate relationships. Care homes should offer support and appropriate education for staff in dealing with issues of sexuality.

These aspirations are underpinned in the document by the current evidence about what older people may want in later life, highlighting the barriers to sexual expression and explaining the principles of good practice and relevant legislation. Additionally we provide a framework for action when sex is seen as a problem.

The guidance ends with real and tricky case studies. These start with some easier decisions, such as consenting adults in a new relationship where one is married, and consenting adults in a new same sex relationship facing family objections. Fine and dandy from a professional and legal perspective, but who prescribes the viagra and how do they access the lubricant or have a sexual health check?

The guidance then ramps up the complexity moving on to professional dilemmas for staff - the resident with mental capacity asking to watch pornography in his bedroom but who is unable to access it. An individual with mental capacity asking to bring a sex worker into the home. A resident requesting help with masturbation. We provide some answers from our professional regulator and considered suggestions.

Finally the case studies explore legal questions, including support when someone with intermittent mental capacity is in a partnership and is sharing sexual intimacy, scenarios where residents’ mental capacity is unclear or deteriorating and they are seeking sexual activity, and issues relating to prior predatory sexual behaviour.

It is a discussion of life, real life and the things sometimes we would rather avoid and instead frequently leave to others. So do have a read, it might make you smile, hope for the future and ask the question…

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