Older Adults and Sexuality… and Does Your Nursing Home have a “Pornography Policy”?

Okay, first – disclaimer. This may or may not be a NSFW (Not Safe For Work) posting (I think it is, though). I will be talking, at times, somewhat explicitly about sex here. First – onto the more general topic of sexuality and older adulthood.

There are a lot of misconceptions about older adults and sex.

First:

  • Older adults aren’t interested in sex.

Of course, that’s hooey. I am reminded of a centarian (that’s someone who is 100+ years old, BTW) who I worked with and who was a patient at one of my facilities, who was wheelchair-bound, demented, had multiple medical issues, but still found the time to occasionally (cheerfully) sexually proposition his nursing staff, and, at times, would still find the time to masturbate in his room. Of course, since his memory and executive functioning was so poor, he required the assistance of nursing staff to maintain his privacy (staff would draw his blinds for him). As an aside – there is not much difference between older adult females and males in that regard, in case you’re wondering. Sexual desire does not diminish with age.

  • Older adults can’t have sex.

While it’s true that older adult males may have trouble achieving and maintaining erections the way they did when they were younger, and older adult females may have more trouble with vaginal lubrication, these issues are surmountable and frankly aren’t really that pronounced for older adults. For example, apparently 75 percent of older adult males surveyed over the age of 70 report little or no issues with erective dysfunction as they age. They’ve still got it!

  • Older adults shouldn’t have sex.

I think there are people who actually do actually think this. Obviously there’s an ageist bias at work here. The idea is that sex is something only appropriate for the youth, and that it’s somehow unseemly or inappropriate, or perhaps even unhealthy for older adults to be engaging in sexual activity (you know, might give grandpa a heart attack or something). The fact is all the things you heard about sexual activity for us young people (relatively young people, anyways) is true for older adults. It lowers blood pressure, it makes you happier, it helps you relax – heck, it’s good exercise – all true. Like anything, if you have medical issues that specifically precludes sexual activity, that’s something that shouldn’t be ignored. However, older adults can, and if they want to – should – have sex!

  • The older adult body isn’t sexy.

Says who? Younger people?

Pornography and Sex in Long Term Care

Let’s talk about pornography. Which is really what inspired this post of mine in the first place.

One thing that’s been clear to anyone who hasn’t been living under a rock for the past 20 years is that the availability, consumption, and production of pornography in the Western world, particularly the United States, has skyrocketed.

Depending on who you ask, porn is a 10 billion dollar a year industry in the United States, making it larger than major league baseball, and even possibly Hollywood. It’s “no longer a sideshow to the mainstream…it is the mainstream,” according to NY Times columnist Frank Rich.

With the much greater accessibility of pornography, and the advent of mobile technology (tablets, smartphones, and soon – wearable technology), pornography will soon be a real issue to be grappled with in long term care. Is pornography use a normal variation in human sexual behavior, is it more akin to a ‘kink,’ ‘fetish,’ or paraphilia, or is it something else? I’ll leave that to the side for now. Suffice it to say, it’s something that’s here to stay. Pornography is something many, many adults use, both males and even a significant chunk of females. Most seem to use it without becoming addicted to it (certainly a concern), or without gravitating towards illicit forms. In many ways, pornography seems analogous to drugs and alcohol. Used responsibly, it seems to be fairly harmless to most. Arguably, I suppose. Again, to be debated at another juncture, perhaps.

A recent issue that came up in my nursing home involved an older adult male in his late 60s who is being cared for due to complications secondary to stroke. This resident, we’ll call him Bob, is wheelchair-bound, essentially paralyzed on his left side, incontinent of bowel and bladder, and requires extensive assistance with his activities of daily living (ADLs).

Bob also has been known to exhibit some behavior issues in the past, approximately a year ago he distinguished himself by being combative with nursing staff (primarily during ADL care, e.g., such as when he has been cleaned up). Although I worked with him a bit more extensively in the beginning of his time with us at the nursing home, for approximately the last year I haven’t had much contact with him, and by all indications Bob seemed to have adjusted to being at our nursing home.

However, recently I began to hear some interesting information about Bob. First, I began to hear about how Bob had begun shredding his incontinence briefs (which are basically large adult diapers) – he was doing this, of course, to access his private parts for the purposes of masturbation. Well, no big deal – we just replace the briefs after he’s done, correct? Otherwise, nursing staff were encouraged to continue to maintain Bob’s privacy when he needed it (e.g., to draw his blinds for him, that kind of thing).

Then, I heard some accounts of Bob engaging in some sexually explicit language with nursing staff, and, most recently, with one of our recreation therapy staff, e.g., asking staff members to sleep with him, things of that nature. Some of this was documented.

Shortly after this, I learned that Bob had made a specific request of his physician to obtain a portable DVD player so that he could watch “his (pornographic) movies.” This request was communicated to our recreation therapy staff (who handle offering loaner DVD players to residents) and this caused a minor controversy / uproar amongst them.

I should say that the prospect of nursing home residents accessing and using pornography is not in fact new at our VA nursing home. In fact, in doing some research on this issue (which was sparked by the case of Bob), I found out about a few of our past and current residents at the nursing home who used porn (overwhelmingly via use of portable DVD players), and was amused to find that there was an informal trade in these materials that goes on between a small subset of our patients.

That being said, in all of the cases of porn use in other residents that I found out about, all of them involved veterans who were, for the most part, *independent* in their use of pornography. They were able to place DVD discs in players, cue them up, hit the play, pause, rewind, and stop buttons, and adjust the volume (and use headphones where necessary). Aside from cues, reminders, and perhaps some assistance in drawing their blinds for privacy, these were veterans who did not require “setup assistance” in using pornography.

So, here was the difficulty with Bob. He apparently expressed an interest in using porn. Let’s say his family even supplied him some pornography. RT has an existing policy of loaning out DVD players to residents who wants them. Who’s to say that this veteran can’t access porn if he wants to?

Well, the answer was, he would need assistance with it – in other words, with this resident we would be faced with the prospect of nursing staff setting up his porn, pressing play, and perhaps even pause and rewind on his porn videos; adjusting the volume, et cetera. This is not exactly what I consider to be the job of professional nursing staff, but perhaps my view is old-fashioned and unfairly restrictive.

Of course, other issues came into play with Bob as well. He had some significant dementia, which seemed pretty clearly to result in some disinhibition leading to inappropriate behavior with our younger, female staff members – not cool. And so the question was raised (prominently by me), would facilitating Bob’s use of sexually explicit materials somehow inadvertently be fueling his sexually inappropriate behavior? Would we want to risk more of that by effectively supercharging his access to porn (e.g., by upgrading his capabilities from magazines to full-length porn videos)?

What do you think – is actively facilitating the use of porn by nursing home residents a job for nursing or ALF staff?

Before you say a horrified NO!, consider the movement towards patient-centered, individualized care and the provision of a “homelike environment” for long-term care residents. Why isn’t the use of legal pornography a recreational preference to be respected just like any other recreational preference? What makes it special unlike any other recreational activity? In my research for this blog post, I was forwarded a 1992 article from “Advance for Occupational Therapists” (sorry, haven’t figured out how to link to it – but I can email the article to you on request) where apparently an assisted living residence actually had taken it upon themselves to sanction and help run a ‘porno night’ at their facility. Which I found a bit boggling, particularly for the early 90s!!! So, attitudes on this issue can certainly range.

I could take this further – wouldn’t we consider it a form of discrimination to allow patients who are independent enough with their functioning to use porn in a nursing home, but those who are impaired in some important way, say, a quadriplegic resident – they are *not* allowed to access their pornographic materials, because they require substantial assistance from nursing staff?

So this is the quandary we were faced with. Here’s what I did – as I indicated earlier (like any dutiful VA Community Living Center geropsychologist) I queried my VA nursing home psychologist listserv, and got a number of responses.

One of the most notable included this– it’s one of the few nursing homes out there that has developed a specific protocol for addressing “sexual expression” amongst their residents, and to their credit, it spells out much more than I’ve seen from nursing homes out there on average. However, even then it’s somewhat vague as to how to treat the use of sexually explicit materials by nursing home residents:

“Residents have the right to access and/or obtain, for private use, materials with legal but sexually explicit content: books, magazines, film, video, audio, pictures, or drawings.”

So what does “access” mean, in practice? What does “private use” mean? Et cetera?

As internet use becomes more and more ubiquitous amongst older adults, and sexual attitudes continue to liberalize – I think that nursing homes will need to all have their own “sexual expressions” policies – and moreover, it will need to specifically address pornography use. I can’t see how we’ll be able to avoid it!