Intimacy in Institutions
by Yuri J. Koszarycz, Senior Lecturer in Religion (Ethics)
Australian Catholic University, McAuley Campus.

In my last presentation I dealt with broader issues that related to the topic of sexuality and the elderly. In that lecture I outlined how, historically and culturally, our society had developed negative and stereotypic attitudes that viewed sexual expression in prohibitive terms. Our ethical world-view was, and in some cases still is, colored by perspectives that unconsciously perpetuate negative myths and misinformation about the elderly. Contemporary gerontological nursing must be at the fore-front of re-evaluation and re- education in unlearning detrimental and damaging misconceptions.

In our culture, in this last decade of the 20th century, too often this misinformation comes from the media and the generational gap that disallows positive contact between the youthful and the aged. Let me illustrate by example: In Japan, 75% of people over 65 live with their children. The Chinese have a wonderful proverb, "If you wish to succeed, consult three old people." Yet in our industrialized and highly technologized world, where 10% of the general population is over 65, why is it that frequently the elderly are seen as surplus stock, unproductive and helpless?

Coupled with advances in medicine and science, there has been much geriatric research in understanding the significance of ageing for the individual and for the community. It is recognized that, though sexual response is a complex reaction of physiological, psychological, and social factors at any age, older persons, because of chronic disease conditions, societal attitudes, and lack of partners, are particularly at risk in unhealthy sexual functioning.

So the question must be asked: how can nurses and care-givers help? Should carers become involved in assisting elderly people to appropriately express their sexuality? And what does "appropriate" mean? At a time when carers have so many duties and professional responsibilities how can they effectively take on the role of facilitator, educator, consultant, counselor, and advocate?

Older people have a right to sexual expression and unless we acknowledge their sexuality, we cannot give them the holistic care they appropriately deserve. Yet all too often while counseling older patients we act like embarrassed parents, obviously uncomfortable with the entire subject of sex. Unfortunately, many nurses seem to think that elderly patients do not have sexual needs. It is important to realize that a basic understanding of some of the insidious and negative effects of institutionalization on the elderly (lack of privacy, disorientation, depersonalization) could make a fundamental difference in respecting the sexuality of elderly residents and patients.

Sexuality matters because unresolved problems can cause needless misery, and carers who recognize their patients' sexual needs give full recognition to their humanity. "Of all the trends apparent in nursing, two in particular seem to be converging. One is the acceptance of "holism" as a basis of care; the other is the recognition of sexuality as a real part of the older person's life" (Booth 1990: 52). It must be recognized that it is impossible to give proper holistic care if a patient's sexuality is not accepted or acknowledged. It has been said that 'sexuality is far more about what happens to us above our neck than below our navel!' If we are to give suitable and sensitive advice to others about sexual issues, then it is imperative that we must scrutinize our own feelings and beliefs in these matters. What are our own personal attitudes, and how comfortable are we with our own sexuality?

Consider the following questions: "Have you ever nursed an elderly patient who exhibited 'unusual sexual behavior', such as masturbation, self-exposure, 'suggestiveness'? What was the response of the staff? Did the age of the nurse seem to have any bearing on the response? Did trained staff react differently from untrained staff? Did ancillary staff need special instruction? Were certain members of staff kept away from that person? Were sedative drugs prescribed? Was the word 'disgusting' used much? I have a feeling that quite a few nurses will have answered 'yes' to two or more questions. If so, should not we be looking at our attitudes?" (Booth, 52).

In the past, I have given numerous workshop tutorials to hospital and nursing-home staff where I use the following case to stimulate interactive and productive discussion. How would you respond to the issues raised in the ensuing situation?

Shirley is 78 years old. She is a charming and independent minded resident of a hostel for the aged administered under the auspices of a Christian denomination. Here, she has met and befriended Bill, an 80 year old resident, a widower, who has his own room at the hostel. After three months or so, Bill and Shirley's discrete sojourns to his quarters has caused considerable comment and reaction from other residents and staff. The director feels that Bill and Shirley's "life-style" possibly is inappropriate in the context of this particular hostel's ethos. A meeting of nursing staff is convened where a motion is put forward for discussion: that Bill and Shirley be asked to stop their cohabitation, modify their behavior, or leave the institution.

As a member of the staff, what issues would you want raised during this discussion? Would you support the motion or speak against it? Would you recommend any resolution or follow-up to the issue as it relates to other patients, the nursing staff, or the policy of the institution?

Let's take another instance: "Mr. Stevens, 75 years old, has been thrown out of a nursing home for having a sexual relationship with a woman resident his own age. Now he sits in a rocking chair on his daughter's porch, sad and lonely. 'They made me feel ashamed of myself,' he says. 'But it was a normal, natural thing'" (Pollard & Barker 1985: 17).

It is important to realize that our attitudes and decisions affect real people - and that imprudent decisions can have a devastating effect on a person's well-being. As nurses, professional carers, or administrators of homes for older people, it would be profitable to reflect on these personal questions regarding our own sexuality:

Do I accept my own body, my own sexuality? Am I at peace and relaxed with the physical body that I own in such a way that I can enjoy my own sexuality and that of others? How important is my own sexuality and how comfortable am I with it? How do I maintain my own positive image?

What are my particular strengths in helping my older patients to re-claim their own bodies? How can I help them to be mentally, emotionally and physically more positive in re-owning their bodies which they may have rejected as a process of ageing? Do I recognize my own apprehensions, negative inclinations, and possible prejudices that I may have in dealing with my own sexuality and that of others? How do I relate to someone who may have a different sexual preference to my own? Can I see the person behind the sexual preference?

Do I have a sufficient knowledge-base in the field of sexuality? Can I talk about sexual matters sensitively in a competent and responsible manner? Do I know who to turn to if I am confronted by issues that need specialized knowledge or treatment? Do I treat people differently only because they are older? For example, would I give a 35-year-old mother-of-two different advise about resuming sexual activity after an illness, than to a 65-year-old grandmother after a similar illness? If so, why?

Such a critical re-examination of our own values, beliefs and attitudes can be an affirmative and positive growth experience. Steinke and Bergen also ask the following questions that could be added to the above: "How do I feel about my elderly parents having sex? Do I consider sexual activity in the aged to be shameful or perverse? How do I react when I see two elderly people kissing and fondling each other? Is sexual activity in the nursing home setting acceptable to me? Is it okay for unmarried, widowed, or divorced elderly to engage in sexual activity?" (1986: 9).

It is obvious that in a pluralist society there are many differing view-points ranging from the conservative to more liberalized attitudes towards sex. In our responses to the above questions, we reveal a lot about ourselves, our personal values, and beliefs about our own sexuality. So how do we reconcile possible value-conflicts that may arise? One suggestion is that "staff members have to be encouraged to ventilate their attitudes and feelings toward residents' sexual expressions. This could occur within the parameter of a staff group facilitated by an objective professional who is knowledgeable on the subject of aged sexuality. The goal of this group would be (1) to assist the staff members in coping with their attitudes and feelings about residents' sexual expression and (2) to identify strategies and approaches for allowing nursing home residents to express their sexuality in appropriate ways" (Allen 1987: 81-82).

How much do we, or should we, know about the sexuality of our clients in the nursing home situation? Generally, such information is difficult to find as a sexual assessment often is uncommon as part of admission history. It is true that some hospitals and care centers (e.g.: Mater Hospital in Brisbane & the Blue Nursing Service) do make such an assessment using Marjory Gordon's Functional Health Patterns which lists eleven health domains (Gordon 1982). No. 9 deals with sexuality and reproduction - and certainly nursing students at the Australian Catholic University at the Queensland Campus are made aware of how such a history is taken with respect and sensitivity to the in-coming patient/client. I also recommend the viewing of a most informative videotape entitled "Taking a Special History." Miriam Glasgow, in this film, outlines the procedures and questions that would be part of noting a sexual history of the patient. The following typical questions could be used for such a history-taking process:

Females:

1. Do you have any pain during vaginal penetration? If so, in what situations?

2. Do you have any difficulty having an orgasm when you want to? If so, in what situations?

Males:

1. Do you have any problem achieving or maintaining an erection? If so, in what situations?

2. Do you have any trouble ejaculating when you want to? If so, in what situations?

Both:

1. Are you currently sexually active? With more than one partner? With men or women or both?

2. Has your present illness affected your sexual function?

3. Do you have any question or concern about your sexual function?

Clarification of Problems:

1. How much of a problem is this?

2. How long has it been a problem?

3. When was it better? When was it worse?

4. Do you have any idea about what causes the problem? Have you ever sought help for this or any other sexual concerns?

5. How do you feel about getting help now?

6. How do you feel about discussing this with your partner? (1986).

It must be pointed out that some sexual problems among older patients may arise, not so much from a debilitating illness, or the effects of a degenerative disease, but from the fact that many of the older patients simply may be living in a state of sexual ignorance due to a lack of appropriate education. Many of the elderly, during their schooling in their youth, when sex was a taboo subject, did not receive an appropriate opportunity to acquaint themselves with sexual matters. A fascinating study was done by M. Sviland who notes that the following sexual facts are frequently unknown by the elderly, adding to the myths and misinformation too often existing even in the wider community:

1. The clitoris is an important component of orgasm.

2. Some postmenopausal women are multiorgasmic.

3. Many females require some form of clitoral contact and stimulation for arousal and to this end touch or oral genital contact are socially acceptable.

4. The improved ejaculatory control found in ageing males allows for longer intercourse before orgasm, which can enhance the female's pleasure.

5. There is no physical evidence that ageing males cannot continue sexual expression with small or even negligible reduction in frequency.

6. The ageing male requires increase in direct genital contact for arousal or orgasm and to this end touching or oral genital contact are socially acceptable techniques.

7. Intercourse positions can be varied for maximum enjoyment and all positions are socially acceptable.

8. Afterplay enhances satisfaction in the emotional component of sexuality, especially for the female.

9. Alcohol consumption prior to the sexual act is a major cause of performance failure.

10. Masturbation is a socially acceptable alternative form of sexual release for adults whether or not one has an active partner (1978).

You will note that I have used the term "socially acceptable" on four occasions in outlining some of the above concerns. It must also be said that there are some private, cultural, and particularly, religious perspectives that may color certain practices for the individual as being either ethical and proper or condemned as unethical and immoral. Pluralism in a multicultural democratic society necessitates the existence of a multiplicity of moral standards. For example, there are some religious denominations, and some individuals of a 'puritanical Victorian heritage' that view masturbation in a negative light as an 'unacceptable' or even as an 'abnormal' form of sexual expression. Contrast this with advice from Ebersole & Hess, two nurse educators: "Masturbation is a common and healthy practice in late life". Persons without partners or with spouses who are ill or incapacitated by long-term health problems find that masturbation is helpful. Self- stimulation is steeped in myth and fear. As children, today's aged population were stopped from practicing this pleasurable activity with stories of the evils of fondling one's genitals. Masturbation provides an avenue for resolution of sexual tensions, keeping sexual desires alive, physical exercise, and preserving sexual function in those individuals who have no other outlet for sexual activity and gratification of their sexual need" (1990: 446).

So what guidelines should staff follow that will provide for an appropriate recognition of possible problems, and allow for positive expression of a holistic sexuality within the nursing home environment? How can careers assist the elderly to express sexuality? Here are some suggestions compiled by Dr. Anne Roberts:

"Make it easy for them to talk about any problems and ask for help. This seems easiest

- when you are alone together
- when you have got to know each other
- while helping with personal care.

Sometimes you may have to ask specific questions - for example, 'Some of my patients find having a catheter interferes with their sex life; how do you feel about it?' Do not probe if patients are reluctant to talk - they have a right to be reticent.

Gather information about the likely physical and psychological effects on their sex lives of your patients' illnesses, disabilities and treatment. Where appropriate, give information to patients as a routine so that they don't have to ask for it. Handouts are useful both for patients to refer to and helps them broach the subject.

Remember that different ethnic and religious groups have different beliefs and practices.....when staff and patients come from different cultures, they will have different words for sex organs and acts, so be prepared for possible misunderstandings.

Do not assume that a person is heterosexual. Recognize that, after the death of a long- standing gay partner, bereavement is as real as that of a widow or widower.
Don't wait to start talking with patients until you don't feel embarrassed any more; coping with sexual problems gets gradually more comfortable only with practice" (1989: 68).

It is feasible that nursing homes should give their elderly residents the opportunity to express their sexuality in private. It would be a great pity and disappointment, if the scathing criticisms made 20 years ago by Leopold Bellak were still an existing reality in contemporary nursing homes. This is what he wrote in 1975: "Institutional rules are often absurdly inappropriate to the people they serve. An example of this is the lack of privacy accorded people in many old-age homes and hospitals. In such settings, any kind of intimacy, particularly for forming sexual relationships is impossible... even doctors, nurses and administrators are still quite oblivious to the fact that their charges have need for love and sex. They actively abhor the idea or discourage it, or at the very least make no provision for it" (1975). Things had not changed by 1982 as we see from an American study in the United States, where residents in 15 nursing homes were interviewed, and it was found that an astonishing 91% of them were sexually inactive (White, 1982). What would the statistics reveal in the nursing-care situation in which you find yourself?

In summarizing Eliopoulos' holistic view of geriatric nursing (1980), June Andrews relates that "nurses may witness subtle or blatant violations of respect to the sexual identity, citing some common examples:

- Belittling an aged person's interest in clothing, cosmetics and hairstyles.

- dressing men and women residents of an institution in similar and asexual clothing.

- forgetting to button, zip or fasten clothing when dressing the elderly.

- unnecessarily exposing aged individuals during examination or care activities.

- joking about two aged persons' interest in and flirtation with each other" (1988: 16).

You can see the hand of a practical and practicing nurse as Andrews continues with some solid and positive advice on how care-givers can help: "Recognize the importance of clothes for men as well as women. A decent collar and tie, and trousers that fit (with flies that close), will make all the difference. Proper underwear including a bra, slip and stockings or tights are essential prerequisites for the self confidence of any woman in public. Beware of infantilizing old people. It is insulting and depressing.

Make it possible for old people in care to mix with the opposite sex in social groups, for eating and other social activities. Encourage visits home if possible, for partners to be alone together. Make possible for individuals to have time alone in the home or hospital, providing single rooms, and allowing the elderly person to refuse entry to staff. Hold and touch your patients and residents. Let them hold your hands or arms and don't discourage them, for example, from resting against you when you are looking after them. Be aware of inappropriate touch. Respond to inappropriate sexual advances in a therapeutic way, reorienting the old person to reality gently and discreetly. Avoid ridicule and condemnation" (1988: 16).

The provision of privacy, and allowing the aged to exercise control over their sex lives, conforms to ethical principles that should govern all nursing care. Among these, there is the principle of respect for individuals and their privacy, in the recognition of the client's autonomy which asserts a right of non-interference, allowing competent patients to make decisions for themselves and be self-determining. As a nurse or an administrator, keep your approach "confidential, private, and personal."

Carers are bound by principles of beneficence and non-maleficence, by which they are called to exercise positive action and conduct, that is aimed at the good and well-being of their patients. Equally importantly, are the principles of veracity and confidentiality, by which nurses can establish a relationship with older adults in which both feel comfortable talking about sexual matters in an atmosphere of trust, truthfulness, and confidentiality.

One important concern, that often arises for carers is the question of "how does one handle inappropriate sexual activity?" The commonest profile of such activity takes the form of public masturbation or self-exposure by (usually) mentally-frail men. How should staff cope? Firstly, it is important that the client has opportunities to masturbate in private - explain to him that "though he has a right to self-gratification, others have a right not to watch" (Roberts 1989: 68). Make sure that the behavior is not caused by some other factor, such as itching or pain in the genital area. Roberts also make these suggestions:

1."Think about the patient's life situation - does he manage his own life as far as possible? Where care is poor, an orgasm may be the only nice thing he can make happen for himself.

2. Resist the temptation to sedate the patient. This tends to worsen the situation by removing any remaining inhibitions. It also adds problems such as incontinence and a tendency to fall. Sometimes the use of anti-androgen drugs is suggested; these are chemical castrators and abolish libido in men. The ethical implications are considerable, and carers' opinions differ as to when, if ever, chemical castration is appropriate.

3. More importantly "staff may have strong feelings about behavior of this sort, and will need to express them among themselves... Educate new members of staff to recognize the sexuality of older patients" (p.68).

In my concluding remarks, I would make an appeal to all those involved in the field of gerontological care. It is true that, for most, there has been little educational opportunity to acquire the necessary skills and knowledge to provide appropriate health care for the older person with sexual concerns. Coupled with the reality that some staff are uncertain and may themselves be influenced by negative attitudes, sexual guidance for the elderly is usually avoided. Now is the time that it is "necessary to change the beliefs and attitudes of people who care for the aged in order that they might understand and accept the aged individual's sexual problems, concerns, frustrations, and disappointments" (LaTorre & Kear, 212). Too often, expressions of sexuality in the nursing home environment had been seen as a 'behavioral management problem."

Now is the time for change. In Nursing Programs at the Queensland Campus of the Australian Catholic University, it has been recognized that positive classroom and clinical experiences are a 'must' if students are to develop constructive attitudes and high levels of knowledge about aged sexuality. In terms of on-going in-Service courses for registered staff, nurses and administrators have a challenging role in creating attitudinal changes within the workplace, in re-evaluating the societal stigmas and myths concerning sexuality in the elderly. This is not an easy task, but it is a vital and necessary one in on-going nurse education. I leave you with one of my favorite quotes from the poet and playwright, Paul Green: "The sun setting is no less beautiful than the sun rising."

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