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Assessing Consent to Intimate Sexual Relations Among Nursing Home Residents with Dementia

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Living with Dementia

Part of the book series: Advances in Neuroethics ((AIN))

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Abstract

Some of the most sensitive and controversial issues in nursing homes today involve intimacy and sex among nursing home residents with dementia. Due to longer life expectancies and the many baby boomers in their 60s and 70s, these issues are likely to arise with increasing frequency. This chapter focuses on the inherent difficulties faced by nursing homes in deciding whether dementia patients have capacity to consent to intimate sexual relationships. The difficulties are rooted in the very nature of both dementia and sex. Patients with dementia have fluctuating cognitive abilities, sometimes during a single day, and sexual acts—such as caressing and sexual intercourse—have differing cultural and social significance. In addition, nursing homes must protect patients from sexual exploitation and harm, while also protecting their right to enter into satisfying, self-affirming, intimate sexual relationships. Due to these complexities, nursing homes need clear standards for determining whether residents with dementia have capacity to consent to sexual relations. In order to support patient autonomy and make the best decisions for patients, nursing homes must also determine whether to follow the patients’ precedent values and advance directives or give priority to their current well-being.

This chapter reviews the varying approaches to consent to sexual activity by dementia patients and concludes that patient consent should include determining whether the patient wants the sexual relationship, can communicate a request to stop, and can respect a partner’s request to stop. The chapter also analyzes the continuing scholarly discussion of whether decision-making regarding sexual relationships should take prior values into account. This analysis includes a discussion of the philosophical and legal bases for using substituted judgment, best interests, and functional competence approaches and recommends a balancing approach that takes both the patient’s experiential and critical interests into account.

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Notes

  1. 1.

    Malone states “Existing policies on sexuality in [long-term care] have been heavily criticized in the literature, mainly due to their absence” (p. 34).

  2. 2.

    Spece notes that “nursing homes often discourage ongoing intimate relationships because of logistical, financial, and other considerations” (p. 909).

  3. 3.

    Lyden notes that individuals with severe disabilities may “require assistance from another person to have sexual intercourse” (p. 18).

  4. 4.

    Spece Jr., Hilton, and Younggren comment that the “[o]ver-blown fear of lawsuits from family members and of criminal liability for encouraging sexual activity that may be interpreted as abuse, influence[] administrator’s judgment” (p. 919).

  5. 5.

    Casta-Kaufteil notes that guiding nursing home policies are essential to ensure that staff and families do not disregard the residents’ sexual preferences.

  6. 6.

    Wilkins phrases this requirement as whether “the resident [is] aware of potential physical and emotional harm” (p. 719).

  7. 7.

    Spece, Hilton and Younggren state, “[A] competent resident’s prior directive, if any, that intimacy should not continue should she be incompetent, shall not be disregarded” (p. 931).

  8. 8.

    Boni-Saenz notes that individuals can also choose proxy directives, in which they specify a surrogate to make medical decisions for them should they become incompetent, and hybrid directives “which designate a proxy decisionmaker but also provide written guidance about the principal’s beliefs in varying levels of mandatory language” (p. 12).

  9. 9.

    See Evelyn M. Tenenbaum, To Be or To Exist: Standards for Deciding Whether Dementia Patients in Nursing Homes Should Engage in Intimacy, Sex, and Adultery, 42 Ind. L. Rev. 675, 714–719 (2009) for a more in-depth discussion of critical values relating to sexual activity.

  10. 10.

    Wilkins suggests “a committee approach [that] can be utilized where residents, the nursing home, and family members can convene to advocate for residents’ autonomy, dignity, and right to sexual expression while working to minimize harm.”

References

  1. World Health Organization. Sexual health. 2019. Retrieved from https://www.who.int/health-topics/sexual-health#tab=tab_1

  2. Foxx J. Dementia sex culture: out with the old, in with the new. J Ame Acad Matrimon Lawy. 2016;29:187–219.

    Google Scholar 

  3. Malone M. “All Power to Them”: exploring perspectives and experiences of intimacy and sexuality among older long-term care residents (Unpublished master’s thesis). Dalhousie University, Halfax, Nova Scotia. 2016.

    Google Scholar 

  4. Spece RG Jr, Hilton JK, Younggren JN. (Implicit) consent to intimacy. Indiana Law Rev. 2017;50:907–42.

    Article  Google Scholar 

  5. Dresser R. Missing perceptions of incompetent patients. Rutgers Law Rev. 1994;46:609–719.

    PubMed  Google Scholar 

  6. Miles SH, Parker K. Sexuality in the nursing home: iatrogenic loneliness. Generations. 1999;23:36–43.

    Google Scholar 

  7. Mattiasson A, Hemberg M. Intimacy – meeting needs and respecting privacy in the care of elderly people: what is a good moral attitude on the part of the nurse-carer? Nurs Ethics. 1998;5:527–34.

    Article  CAS  Google Scholar 

  8. Bentrott MD, Magrett JA. Taking a person-centered approach to understanding sexual expression among long-term care residents: theoretical perspectives and research challenges. Ageing Int. 2011;36:401–17.

    Article  Google Scholar 

  9. National Center for Health Statistics. Long-term care providers and services users in the United States (DHHS Publication No. 2019–1427). Washington DC: U.S. Government Printing Office; 2019.

    Google Scholar 

  10. Joy M, Weiss KJ. Consent for intimacy among persons with neurocognitive impairment. J Am Acad Psychol Law. 2018;46(3):286–94.

    Google Scholar 

  11. Wilkins JM. More than capacity: alternatives for sexual decision making for individuals with dementia. The Gerontologists. 2015;55(5):716–23.

    Article  Google Scholar 

  12. Boni-Saenz. Sexual advance directives. Alabama Law Rev. 2016;68:1–47.

    Google Scholar 

  13. Doll GA. Sexuality and long-term care: understanding and supporting the needs of older adults. Baltimore: Health Profession Press; 2012.

    Google Scholar 

  14. Pellegrino ED. Toward a reconstruction of medical morality. Am J Bioeth. 2006;6(1):65–71.

    Article  Google Scholar 

  15. Lindsay JR. The need for more specific legislation in sexual consent capacity assessments for nursing home residents: how grandpa got his groove back. J Legal Med. 2010;31:303–23.

    Article  Google Scholar 

  16. Hill E. We’ll always have Shady Pines: surrogate decision-making tools for preserving sexual autonomy in elderly nursing home residents. William & Mary J Race Gend Soc Just. 2014;20:469–90.

    Google Scholar 

  17. Gruley B. Boomer sex with dementia foreshadowed in nursing home. BloombergBusiness. July 22, 2013. Retrieved from https://www.bloomberg.com/.

  18. Bartlett P. Sex, dementia, capacity and care homes. Liverpool Law Rev. 2010;31:137–54.

    Article  Google Scholar 

  19. Lyden M. Assessment of sexual consent capacity. Sex Disabil. 2007;25:3–20.

    Article  Google Scholar 

  20. Tarzia L, Fetherstonhaugh D, Bauer M. Dementia, sexuality and consent in residential aged care facilities. J Med Ethics. 2012;38:609–13.

    Article  Google Scholar 

  21. Casta-Kaufteil A. The old and the restless: mediating rights for intimacy for nursing home residents with cognitive impairments. J. Med Law. 2004;8:69–86.

    Google Scholar 

  22. Cornelison LJ, Doll GM. Management of sexual expression in long-term care: Ombudsmen’s perspectives. The Gerontologist. 2012;53(5):780–9.

    Article  Google Scholar 

  23. Tenenbaum EM. To be or to exist: standards for deciding whether dementia patients in nursing homes should engage in intimacy, sex and adultery. Indiana Law Rev. 2009;42:675–720.

    Google Scholar 

  24. Dessel R, Ramirez M. Policies and procedures concerning sexual expression at the Hebrew Home at Riverdale. Riverdale: The Hebrew Home at Riverdale; 2013.

    Google Scholar 

  25. Chin NM. Group homes as sex police and the role of the Olmstead integration mandate. New York University Review of Law and Social Change. 2018;42:379–450.

    Google Scholar 

  26. May R. The courage to create. New York: W.W. Norton & Company; 1994.

    Google Scholar 

  27. Koppelman ER. Dementia and dignity: towards a new method of surrogate decision making. J Med Philos. 2002;27:65–85.

    Article  Google Scholar 

  28. Dworkin RM. Life’s dominion: an argument about abortion, euthanasia, and individual freedom. New York: Alfred A. Knof, Inc.; 1993.

    Google Scholar 

  29. Tenenbaum EM. Sexual expression and intimacy between nursing home residents with dementia: balancing the current interests and prior values of heterosexual and LGBT residents. Temp Polit Civil Rights Law Rev. 2012;21:459–84.

    Google Scholar 

  30. Dresser R. Dworkin on dementia: elegant theory, questionable policy. Hast Cent Rep. 1995;25(6):32–8.

    Article  CAS  Google Scholar 

  31. Dresser R. Precommitment: a misguided strategy for securing death with dignity. Texas Law Rev. 2003;81:1823–47.

    Google Scholar 

  32. Coombs M. Shiavo: the road not taken. Univ Miami Law Rev. 2007;61(3):539–94.

    Google Scholar 

  33. Kayser-Jones J, Kapp MB. Advocacy for the mentally impaired elderly: a case study analysis. Am J Law Med. 1989;14(4):353–76.

    CAS  PubMed  Google Scholar 

  34. Kothari S, Kirschner K. Decision-making capacity after TBI: clinical assessment and ethical implications. In: Zasler ND, Katz DI, Zafonte RD, editors. Brain injury medicine: principles and practice. New York: Demos; 2007. p. 1205–22.

    Google Scholar 

  35. Barnes AP. Beyond guardianship reform: a reevaluation of autonomy and beneficence for a system of principled decision-making in long term care. Emory Law Rev. 1992;41:633–760.

    Google Scholar 

  36. Jaworska A. Advance directives and substitute decision-making. 2009. Retrieved from https://plato.stanford.edu/entries/advance-directives/

  37. The President’s Council on Bioethics. Taking care: ethical caregiving in our aging society. Washington, DC: Author; 2005.

    Google Scholar 

  38. Quinn KP. The best interests of incompetent patients: the capacity for interpersonal relationships as a standard for decisionmaking. Calif Law Rev. 1988;76:897–937.

    Article  Google Scholar 

  39. Harvey M. Advance directives and the severely demented. J Med Philos. 2006;31(1):47–64.

    Article  Google Scholar 

  40. Swartz M. Living the good lie. The New York Times Magazine. June 16, 2011. Retrieved from: https://www.nytimes.com.

  41. In Re M.R., 135 N.J 155 (N.J. 1994).

    Google Scholar 

  42. Hugo V. Les misérables (Fahnestock L, MacAfee N, Trans). New York: Signet Classics; 1987.

    Google Scholar 

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Acknowledgment

A special thanks to my fantastic, creative, and reliable research assistant Emily Gray.

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Authors and Affiliations

  1. Albany Law School, Albany, NY, USA

    Evelyn M. Tenenbaum

  2. Albany Medical College, Albany, NY, USA

    Evelyn M. Tenenbaum

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  1. Evelyn M. Tenenbaum
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Correspondence to Evelyn M. Tenenbaum .

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Editors and Affiliations

  1. Department of Philosophy and Religious Studies, and Science Technology and Society (STS) Program, North Carolina State University, Raleigh, NC, USA

    Veljko Dubljević

  2. Department of Philosophy, University of North Carolina, Greensboro, NC, USA

    Frances Bottenberg

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Tenenbaum, E.M. (2021). Assessing Consent to Intimate Sexual Relations Among Nursing Home Residents with Dementia. In: Dubljević, V., Bottenberg, F. (eds) Living with Dementia. Advances in Neuroethics. Springer, Cham. https://doi.org/10.1007/978-3-030-62073-8_8

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  • DOI: https://doi.org/10.1007/978-3-030-62073-8_8

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