What issues surround sexual intimacy among older patients/residents?
Sexual intimacy is not discussed very much in society today, and even less so for older people where the subject is quite a taboo. People’s perception is that sex stops when you are 10 years older than you are now, and nobody thinks that their parents are sexually active.
Healthcare practitioners are notoriously bad at discussing sexual intimacy, but there is evidence that older people would like to talk about it, and are waiting for permission to bring it up. We know that one in three over 65s are having very regular sexual intercourse, and 60 per cent of over 80s have sexual intimacy.
In reality it is younger people with young children who are having the least sex, while many of the older generation are getting married for the second or third time, and there are more inter-generational marriages – so there is the need to talk about STDs and also the possibility of having children.
Messaging on STDs and pregnancy is still targeted to younger people, and many of those in their 80s won’t even have heard any of this messaging when they were younger – for example, those in their 80s now would have already been in their 50s when the AIDS campaigns were so high profile in the 1980s.
Is this an area which is discussed openly and if not, why not?
People can feel awkward about discussing sex with anyone, and this can get even more ingrained the older you get. Many healthcare staff almost need to be professionally required to consider talking about it – for example sex will be discussed where it has to be at particular outpatient appointments (such as prior to prostatectomy) or when new medication is prescribed which affects libido. It seems a great shame that many will be comfortable going into great detail about bowel movements, but not discussing sexual intimacy, which is something that is life-affirming.
There is also an issue with many older people being chaperoned by their family when attending appointments, so the opportunity to discuss sexual intimacy doesn’t arise.
How best can healthcare staff support their patient/resident?
It’s crucial to talk about sex and recognise that it is an essential part of being human. If you genuinely want to deliver person-centric holistic care then it is a subject that needs to be raised. Most sexual behaviour is not a problem and can be easily managed when both patients/residents have mental capacity. It’s important to facilitate opportunities – for example discussing medication such as Viagra with men if it has been previously prescribed. We know simple things like men being giving opportunity to masturbate can reduce the risk of distress.
Some care homes offer the opportunity for spouses to stay in double beds. These may be guest rooms which can be booked by residents as well. It’s important for couples to have the opportunity for privacy. Also, to be open to setting the scene for intimacy – to give couples the opportunities to have a meal together or watch a film, to help create romance.
How can healthcare staff ensure they are adopting a best practice approach and protecting themselves?
The situation can be a bit more complicated if a person is sexually intimate with someone other than their spouse, who is still alive and aware of the situation, but it is often the children of the couple who find this more difficult than the spouse. There need to be open and honest conversations about the subject. During the pre-assessment process is the perfect opportunity for a new patient/resident to be asked if they would like a spouse or partner to stay and if they have any issues. Also giving them privacy to discuss this away from family members could result in a more frank discussion.
It’s also a more complex issue when one or other of a couple lack mental capacity, but it can still be managed well. If a healthcare worker is unsure of what process to follow then I would recommend they bring it up with their organisation’s most senior clinician, or indeed the person’s social worker to find out about policies that support the individual’s needs.
The RCN’s publication ‘Older people in care homes: Sex, sexuality and intimate relationships’ is an excellent resource, and will also be updated again this summer.
You led an RCN twitter debate on sexual intimacy in care homes earlier this year. Were there any areas of the discussion which you found surprising?
It was a very interesting and lively discussion. One of the things that came up which I was surprised about was the reluctance of courts to make decisions on this subject.
We were very pleased to have an eminent barrister online and nurse consultant expert and she said that courts have not seen cases, particularly where partners both lack capacity, actually reach the court. Really this is not so surprising when you consider how little sexual intimacy among older people is discussed in general and the complexity of the subject.
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Are there changes that you would like to see that you think would help healthcare staff and patients/residents to approach this matter more effectively in the future?
I think the best approach is two-fold. Good and robust training and preparation for nurses to discuss sexual activity is essential.
There also needs to be an acceptance from wider society that sex among older people should be discussed in positive terms. In the media there is a ‘gold standard of sex’ perpetuated where you have to be young, blond and beautiful to have sex. Otherwise sex is not portrayed in a normal way – it is salacious or about safeguarding. For example, there are 35 stories in the media about affairs or clandestine relationships compared to one of those within a marriage or civil partnership, or stories about older people focus on areas such as cross-dressing, fuelling the ‘naughty’ aspect of sex. This completely skews perceptions.
There are some new stories filtering through, such as through the film Best Exotic Marigold Hotel, but the portrayal of older people having sex is still more constrained than passionate. We need more positive mainstream stories.
How can RCN members find out about updates in older people’s care?
The RCN Older People's Forum is a group and network of individuals within the nursing family who focus on and promote the care and support of older people within their daily practice.
One of the many benefits of being a member is the ability and opportunity to be involved in a number of consultations, working groups and focus events on a local and national basis. Members can get involved by visiting the forum's webpages at or by asking for information from RCN Direct.