How can care home staff support residents' sexual needs?

Intimate relationships are rarely discussed in residential care, but staff can provide opportunities for couples to connect

 ‘Being worthy of touch is important when we consider that older, frailer and sicker bodies are touched largely for the purposes of care.’ Photograph: Alamy

 ‘Being worthy of touch is important when we consider that older, frailer and sicker bodies are touched largely for the purposes of care.’ Photograph: Alamy

Little is known about sexuality and intimacy among older care home residents, but with more than half a million people aged over 65 living in a care home, the chances are that many could be missing out on these basic needs.

Care home residents are often assumed to be prudish and “past it”, yet neglecting such needs – which are commonly designed out of care systems – can impact self-esteem and mental health. This might be doubly complicated for lesbian, gay, bisexual or trans people who can feel obliged to “go back into the closet” when they enter care.

The Opus (Older People’s Understandings of Sexuality) project of health care academics and representatives of older people’s organisations, began an investigation into these concerns. With funding from the Economic and Social Research Council’s Transformative Research initiative, we conducted a study involving people living in homes, female spouses of men with dementia who lived in a home and 16 care staff in north-west England, between May and August 2014.

The accounts we gathered are more diverse and complicated than any stereotypes of older people’s sexuality. Care home residents and spouses spoke in ways that either denied their sexuality, expressed nostalgia for something they considered as belonging in the past, or spoke of openness to sex and intimacy given the right opportunity and conditions. 

Tales of intimacy

The most common story among study participants reflected the idea that care home residents – and older people generally – have moved past a life that features or deserves sex and intimacy. One 79-year-old male participant said that nobody talks about sexuality, suggesting a reluctance to address such needs. But this was not the whole story. One female participant, aged 80, said that some women might wish to continue with sexual activity if they had an opportunity with the right person.

For spouses, cuddling and affection featured as a basic human need and could eclipse sexuality in importance. Being worthy of touch is important when we consider that older, frailer and sicker bodies are touched largely for the purposes of care, and commonly through the protective barrier of plastic gloves. 

Care workers’ accounts

Because intimacy and sexuality are rarely discussed, care home staff were enthusiastic to be trained in ways to help them enable residents to meet their own sexual and intimacy needs. Care home staff also raised the issue of the grey areas around consent within long-term relationships, perhaps where one or both partners showed declining capacity. Staff also spoke about how sexualised expressions could pose ethical and legal dilemmas, especially where people with dementia project sexual feelings towards another, or receive such attention inappropriately. The challenge was to balance safeguarding welfare with needs and desires for intimacy. Besides, nobody would want an essentially human experience to be turned into a bureaucratic procedure. 

Some problems are built into care home environments and modes of care; most care homes only have single rooms and provide few opportunities for people to sit together. A “no locked door” policy in one home caused one spouse to describe the situation as “like living in a goldfish bowl”.

But not all accounts were problematic. Many care home staff wished to support the expression of sex, sexuality and intimacy but felt constrained by the need to safeguard those in their care. One manager said their home managed this issue by placing curtains behind the frosted glass window in one room, enabling a couple to enjoy each other’s company in privacy. Such improvisations suggest a more measured approach to safeguarding while enabling intimacy – one determined more by the observable reactions of residents than anxieties about ageing sexuality. 

What does this mean for care providers?

In light of our findings, we offer three recommendations.

1. Service providers should engage with the existing guidance on recognising and meeting the intimacy needs of older people made available by the Care Quality Commission, Independent Longevity Centre, Local Government Association and the Royal College of Nursing. Our own study, and a separate survey by Nottingham and Oxford Universities on care home staff knowledge of the needs of older LGBT people, have revealed a distinct lack of awareness of these resources. In the latter case, 71% of respondents said they had some training on sexualities as part of generic equality training, but just over a half reported experience of specific training on such issues, which was usually a one-off experience. 

2. Relevant policies and practices should recognise the diversity of residents and avoid “treating them all the same” – an approach that risks reinforcing inequality and falls short of meeting different needs relating to sex, sexuality and intimacy. The views of non-white, working class and LGBT individuals are commonly absent from research and knowledge on ageing sexuality and service provision. For example, one care worker spoke of how her home’s sexuality policy (a rare occurrence) was effectively a “heterosexuality policy”. We should not forget that differences of identity are not discrete and can combine to produce multiple disadvantages. It may be harder for an older, working-class, black, trans-identified person to identify sexuality needs compared with an older white, graduate, heterosexual, cisgender male.

3. Care homes need to provide awareness raising events for staff and residents on intimacy and sexuality, which should address stereotyping, moral concerns, safeguarding vulnerable individuals, and achieving a balance between enabling choices, desires and rights. Indeed, there is a need for nationally-recognised training on such issues, though some organisations have begun to provide such training, including Dementia Care Matters, the Older Lesbian, Gay, Bisexual and Trans Association and the Opening Doors project.