12. Focus on sexual expression

Sexual interest and capacity to enjoy sex are not lost with old age however the cultural expectation is for older people to become asexual. Therefore when confused people exhibit sexual needs our response may be shadowed by our own prejudices and values.

Task: Download and compete the exercise about sexual expression from the Social Care Institute for Excellence website http://www.scie.org.uk/publications/dementia/difficult/activity7.asp

As the brain is the ‘control centre’ for behaviour and emotion, this determines sexual feelings, good manners and inhibitions. This means that in a person with dementia, sexual feelings can change unpredictably and sometimes inhibitions related to sex can be reduced.

For example of all the people with Alzheimer’s type dementia:

  • 87% will experience decreased sexual activity
  • 13% will experience increased sexual activity
  • A minority will exhibit a decreased sense of decency or do embarrassing things

(Derouesnee et al 1996)

Sometimes a person with dementia may appear to lose their inhibitions and make sexual advances to others or undress or touch themselves in public. Sometimes they might make sexual advances to someone who they mistake for their partner and this can be staff or other family members. Although sexual disinhibition is a relatively infrequent problem it can have a disproportionate impact on staff and carers.
Sexual expression from a person with dementia may be a straightforward expression of sexual needs and staff can give sensitive support to help people express their sexuality appropriately. But there are many other possible reasons for behaviour that seems sexual. For example:

  • A person might be expressing a need for closeness and comfort.
  • A person might be indicating that they feel bored or physically restless.
  • A person who seems to be exposing themselves might be indicating a need to go to the toilet or that they are too hot.

Identifying needs that the person is communicating through apparently sexual behaviour is very important, because we may be able to meet many of these needs – for example by helping the restless person get some physical exercise or by providing the comfort that someone is missing.

Managing sexually inappropriate behaviour depends upon the intent of the perpetrator and the perception of the receiver. Effective management depends upon staff maintaining the resident’s dignity and responding to their behaviour calmly and objectively. Management will also depend on what ‘gains’ the person is getting from this behaviour. The impact of this behaviour on the person/people who are affected by, or the subject of this behaviour needs to be considered, and handled sensitively.

What may help?
Staff may have a key role to play in assisting people with dementia to express their sexuality and need to respond with sensitivity and empathy respecting people’s feeling and their dignity. In particular, staff should be aware that they need to compensate for difficulties that have arisen due to symptoms of the dementia. For example:

  • Establish if masturbation or sexual fondling are a need for sexual gratification. Provide privacy and quietly redirect the person away from public areas. Maintain the person’s dignity. For example if a person exposes themselves or begins to masturbate in the lounge of their care home, a staff member should discreetly advise the person to go to their bedroom, and guide them there if necessary.
  • If a person mistakes another member of their day centre for their spouse, staff may need to gently remind them who the person is and let them know when they will be seeing their husband or wife.
  • If a person has misunderstood the situation for example when a carer is helping them with intimate personal care, and they then believe that they are having a sexual encounter, the carer needs to calmly explain the situation to the person and be aware that this person may need frequent reminders during personal care of exactly what’s happening.
  • Recognise that behaviour may not be sexually directed but may be a result of infection (e.g. urinary tract infection or thrush); or pain which needs to be investigated by a doctor.
  • Establish toileting routines; provide orientation cues to toilet
  • Check if the person has discomfort: for example are they disrobing due to tightness of clothing or because they are too hot?

(adapted from SCIE 2011)

Further learning

Further learning resources «