Everything you need to know about the physical state and dementia, and how to manage your charge.

Sex In Assisted Living

Sex In Assisted Living


Trulah Goin Mills had developed dementia and couldn’t be left alone in the house, but when she and her husband, Lewis, moved into an assisted living facility in Boise, Idaho, in 2012, one lifelong quality remained intact.

“She was a sexual kitten,” said her daughter, Glenna Mills. “She loved her man. She sat on his lap. They held hands all the time.”

One night a staff member heard a thunk from their studio apartment, went in to check, and found Mrs. Mills, then 89, on the floor. “It was clear that they’d been doing something sexual,” said her daughter. “The whole staff heard about it and thought it was hilarious.”

Luckily, the senior Millses thought the incident was pretty funny, too. And because they’d been married since 1941, there was no question of trying to discourage their sexual behavior, separate them or report them to a disapproving family — all actions that administrators and staff have been known to take with couples in assisted living who aren’t married (at least, not to each other), especially if one person shows signs of cognitive decline. The Millses treasured their intimacy almost until they died last year.

Yet, Glenna Mills said, her parents’ experience shows the difficulty of maintaining, let alone developing, a sexual relationship in assisted living.

“One thing they really hated was, they didn’t have any privacy,” she said. “Anybody taking care of them could walk in.” She still wonders about that nighttime topple. “Did someone deliberately enter their space because they heard something they didn’t like hearing?”

Moreover, the staff members could be condescending to couples, finding ardor cute as long as it didn’t go too far. “When it amused them – ‘It’s so sweet!’” Glenna Mills said. “When people said, ‘I can’t believe they’d still be Doing It,’ you knew what the undercurrent was, what they were visualizing: ‘Old bodies, ewww.’”

Much as their families and caregivers might prefer to see older adults as asexual, more than half of men over age 60, and 40 percent of women, remain sexually active. In 2007, a federally funded survey found that nearly a third of sexually active 75- to 85-year-olds gave or received oral sex. Rates of sexually transmitted diseases among older people are climbing.

True, assisted living residents are often less physically and cognitively healthy than those living independently. And the population skews so female that a simple lack of male partners can create, for heterosexuals, a barrier to sex. But any assisted living administrator can tell you stories, from the delightful (because love knows no age limits) to the disturbing (exploitation doesn’t either).

Ascertaining whether encounters are consensual, who is capable of consent, how to balance couples’ privacy with that of other residents — “these issues have not been thought through,” said Ann Christine Frankowski of the Center for Aging Studies at the University of Maryland, Baltimore County. “But people are beginning to talk about it.”

Some assisted living complexes have done more than talk. The Hebrew Home at Riverdale, in the Bronx, developed the first sexual rights policy for older adults in its care in 1995. The Sunrise chain, with nearly 300 facilities nationwide, adopted a policy in 2008, though the company declined to let me read it.

But most such centers have yet to grapple with such questions, said Karen Love, a longtime advocate for improvements in assisted living. Dr. Frankowski has conducted observational studies in 23 Maryland assisted living complexes in the past few years. “None of them have formalized policies to deal with sexual behavior,” she said.

That leaves the response up to the staff, mostly aides who’ve had little to no training in this sensitive matter. And to families who may be, well, “still shocked that their parents are having sex,” said Daniel Reingold, president and chief executive of the Hebrew Home.

He recalled the reaction of the families when two residents fell in love. “A daughter on one side thought it was great that Mom was happy, and a daughter on the other side was appalled and disgusted and thought we needed to keep these people apart.”

But the Hebrew Home’s policy declares that “emotional and physical intimacy” remains “a normal and natural aspect of life,” and requires staff to set aside “personal biases” and support consensual sexual behavior. On occasion, administrators have moved people into single rooms for privacy or provided condoms or drugs like Viagra. The policy forbids non-consensual acts or a “public display” that has a “negative impact” on the community.

“The greatest number of complications come up with cognitive impairment,” Mr. Reingold said. In assisted living, a significant proportion of residents have some degree of cognitive loss, even if they’re not diagnosed with dementia. Can they consent?

Yes, the Hebrew Home has decided. It trains staff to ask people about their relationships — how they feel, whether they are comfortable — and to rely on body language and facial expressions when people are non-verbal. “You can tell when an older adult wants something or is repulsed,” Mr. Reingold said.

At the same time, dementia can cause sexual aggression or reduce inhibitions. The Hebrew Home required one family to hire a round-the-clock aide to prevent a serial exhibitionist from flashing women. In another complex, Dr. Frankowski reported, a man accustomed to masturbating on his couch had to be led from the communal living room to the privacy of his own apartment.

This kind of measured response requires not only policies and leadership but also, given high staff turnover, continuing education. The Sunrise in Old Tappan, N.J., retrains its staff in sexual guidelines twice a year, said its executive director, Colleen Varnum. “They understand that this is O.K., this is good, this is what residents want, this is what we want.”

Elsewhere, however, administrators and staff still show discomfort with sexual activity beyond hand-holding or cheek-kissing, Dr. Frankowski has found. “I hear the word ‘appropriate’ a lot,” she told me.

She has seen aides separate couples, move them to different dining tables or floors, steer them to different activities. She met a married couple required to have separate beds in their apartment. She has heard staff members joke about walking in first and knocking later, or threaten to call residents’ families when they see sexual expression. Gay and lesbian residents, she said, remain “an invisible population.”

Yet sex goes on anyway, of course, in a population whose sexual values were formed in the 1940s and ‘50s. You hope the industry recognizes that the people who will move in 20 years from now may have different ideas.

At the complexes where she does research, Dr. Frankowski said, “Staff members already laugh about it: ‘Oh my God, when the boomers get here, what a place this is going to be.’”

Reprinted with permission from New York Times Syndicate.

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