Management of Sexual Expression in Long-term Care

Ombudsmen's Perspectives

Laci J. Cornelison, MS, LSW; Gayle M. Doll, PhD


Gerontologist. 2013;53(5):780-789. 

In This Article

Abstract and Introduction


Purpose: This study investigates sexual expression management in long-term care settings based on cases requiring intervention from ombudsmen. Although the literature frequently mentions a lack of policies governing sexual expression in these settings, there is little information available on management of situations when they occur. This study addresses these missing elements through the perspective of resident advocates.

Design and Methods: 31 in-depth interviews using a multiple case study approach were conducted with long-term care ombudsmen in 6 states. A thematic analysis was performed on the interview transcripts.

Results: Ombudsmen intervened in cases based on dilemma or conflict due to risk, risk associated with dementing illness, limited knowledge, privacy, and values. The theoretical framework of the total institution was utilized to interpret the results.

Implications: The results underscored the importance of resident advocates to support residents' rights. This research also highlights the importance of workforce training and examination of the institutional impact on resident sexual expression. Formulation of standards of practice for ethically complex situations is also critically important.


Older adults have long been considered asexual in American culture, particularly those individuals living within institutional care (Langer, 2009; Walz, 2002). Contrary to this cultural belief, older adults have been found to be sexual throughout life wherever they are living (Lindau et al., 2007; Miles & Parker, 1999; Reinisch, 1991). Literature investigating sexuality in long-term care suggests that sexual expression occurs in facilities, but few care facilities have implemented policies or training programs directing staff response to residents' sexual expression (Ehrenfeld, Bronner, Tabak, Alpert, & Bergman, 1999; Fairchild, Carrino, & Ramirez, 1996; Low, Lui, Lee, Thompson, & Chau, 2005; Shuttleworth, Russell, Weerakoon, & Dune, 2010; Tabak & Shemesh-Kigli, 2006). Because nearly 46% of adults aged 65 and older will spend time in nursing home care (Spillman & Lubitz, 2002), it is important to have a holistic picture of elders' needs, including intimate needs, and their support in these settings.

Sexuality can be broadly defined as the quality or state of being sexual. Drench and Losee (1996) conceptualized sexuality as a combination of sex drive, sexual acts, and the psychological aspects of relationships, emotions, and attitudes. Expressions of sexuality in long-term care have encompassed a broad range of actions, including sexual intercourse, flirtation and affection, passing compliments, proximity and physical contact, and maintenance of physical appearance (Hubbard, Tester, & Downs, 2003).

A study done by the American Association of Retired Persons (AARP, 2005) among people aged 45 and older found that 86% of respondents, in the 6 months prior to survey, engaged in sexual activities: kissing, hugging, sexual touching/caressing, sexual intercourse, self-stimulation, or oral sex. Seventy-five percent of those aged 70 and older reported engaging in these same activities (AARP, 2005). In this study, increasing age predicted decreased sexual activity and was related to declining health and lack of partner (AARP, 2005).

People living in nursing home care have reported sexual desires in equal proportions to noninstitutionalized older adults (Hubbard et al., 2003; Lichtenberg & Strzepek, 1990). Though sexual intercourse is infrequent in nursing homes, intimate relationships and sexual feelings are often experienced. Intimacy, a sense of closeness and familiarity with another, has been closely tied to the experience of sexuality (Robinson & Molzahn, 2007). Residents with dementia have also continued to express sexual feelings and frustrations (Hellen, 1995; Kuhn, 1994). A study on sexuality and women in nursing homes (Nay, 1992) found that sex in late life is associated with pleasure, tension reduction, communication, mutual tenderness, passion, affirmation of one's body and its function, a sense of identity, and security when facing hazards and losses.

There are a number of hindrances for older adults in long-term care who wish to express their sexuality. Elders in nursing homes often face challenges such as lack of partner, health concerns, limited privacy, negative staff attitudes, loss of self-esteem, cognitive loss, mental illness, family concerns, and legal/liability potential for the facility (Hajjar & Kamel, 2003; Lantz, 2004). Reasons for lack of privacy have included roommates, staff failing to knock on doors, or resident gossip (Hajjar & Kamel, 2003; Reingold & Burros, 2004). In many cases, staff members have construed sexual acts as behavioral problems rather than expressions of love and intimacy (Miles & Parker, 1999). However, behaviors may be encouraged by nursing home management when they are privately expressed, considered culturally safe, and are not difficult to manage. When these same behaviors are expressed in public or when caregivers are involved, they have been viewed as less acceptable and interpreted as problematic (Archibald, 1998).

Long-term care facilities, particularly nursing homes, have much in common with total institutions. Goffman (1961, p. xiii) defines a total institution as "a place of residence and work where a large number of like-situated individuals, cutoff from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life." Within this framework, residents of these facilities comply with an institutional regime. Their whole lives, including their sexuality, are under observation (Parkin, 1990). Nursing homes have been described as "homes," which may suggest that personal expressions, such as sexuality, are private concerns. However, these facilities have been considered a part of both the private and public domains (Parkin, 1990). Though sexuality is a private issue and one of personal self-determination, the characteristics of the total institution within care settings have stripped people of their "freedom of action" (Goffman, 1961). Sexuality has been an issue within these settings because of the close proximity in which people live (Parkin, 1990).

Management of sexual expression may be further confounded by multifaceted resident needs. When sexual expression intersects with issues of consent and avoidance of abuse or moral and ethical issues (Tarzia, Fetherstonhaugh, & Bauer, 2012), it often produces complex situations. There has been little guidance concerning decision-making capacity to enter into intimate relationships (Tenenbaum, 2009). For staff members and the facility, there has been conflict between honoring a resident's autonomy and ensuring that a resident is not exploited (Tabak & Shemesh-Kigli, 2006). In the context of individuals with intellectual disability and cognitive impairment, Lyden (2007, p. 5) stated that there are "no universally accepted criteria regarding capacity to consent to sexual behavior." Criteria for assessing consent have varied in different states and in common law, as well as within nursing home regulations (Lyden, 2007). This lack of uniformity in the definition of consent means the needs of sexually active cognitively impaired residents may not be addressed. It has been easier to believe that older adults are asexual than to handle the complexity of the issues (Lyden, 2007; Mayers & McBride, 1998).

The literature related to sexuality in nursing homes has several consistent messages. The first is the lack of clear policies or regulations directing response to residents' sexual expression in formal care settings (Tabak & Shemesh-Kigli, 2006). In addition, numerous articles recommended that facilities implement training programs to help sensitize staff members to this subject (Ehrenfeld et al., 1999; Fairchild et al., 1996; Low et al., 2005; Shuttleworth et al., 2010) though there was little evidence that this is common practice. Evaluation research on newly initiated staff training suggested that staff members' attitudes changed with education (Mayers & McBride, 1998). Literature supported that sexuality training and policies for staff are not the norm in long-term care; thus, it is unclear how sexual expression is managed overall.

The purpose of this study was to initiate an in-depth investigation of the management of sexual expression in institutional care based on interviews with long-term care ombudsmen. Ombudsmen are an understudied group and provide unique perspectives on the issue of sexuality in care settings. Unlike past research looking at the issue at the facility level, this study examines cases requiring ombudsman intervention. This study contributes to the discussion of person-centered care regarding the issue of resident sexual expression.