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Inappropriate Sexual Behaviour | Doctor's Diary

In many cultures, few areas provoke as much difficulty as inappropriate sexual behaviour. The inappropriateness often can stir up deep feelings. These can go beyond just the 'usual' shame that people feel about sex, but can especially wound people who have been sexually abused, and who now find themselves having to deal with behaviour in which they are obliged not to respond as forcefully as they would if the offending person was capable of doing otherwise.

In general, older adults engage in sexual activity less often, but while activity decreases, sexual interest does not always. When a person is autonomous - when they can dress as they please, and go where they want - their sexual activity is a private matter between them and their partner(s). But, as autonomy becomes compromised, what was once private is now someone else's business, and this extends even to intimate aspects of one's life. This is a consideration for people whose dementia advances while they remain in their own homes, but it is much more acutely felt when they must live with other people in institutional care.

Being constantly involved with many intimate aspects of others' daily lives, nursing home staffis not always as fully aware as they should be of the need of older people for privacy. Like many young people, they can operate as though they believe that their generation discovered sex - or in any case, that it is for the young and fit, and not for the old, especially older people with dementia. Worse, they can view sexual interest as deviancy.

In short, a real problem in this area is to know what constitutes inappropriate behaviour. Especially when a person moves to a new setting, there is a need to adapt to the norms of that setting, but these too can vary substantially. For example, one of the nursing homes that I used to visit - it has since been renovated - was designed so that the bathroom doors opened into the resident's room door, which of course opened into the corridors; in this way, the nursing home staff had ready access to the bathroom, and could 'safely' leave the resident on the toilet while attending to other chores - or at least, that is how it was explained to me. It reminded me more of an otherwise happily forgotten army barracks, in which toilets sat side by side in a row, all part of an attempt to break down the recruit's mores before building them up in a new model. Each was a shocking denial of the need for privacy. I have no doubt that people exposed to such environments behave differently, so it should be no surprise to the nursing home staff that elective public masturbation can quickly follow enforced public defecation. Even so, the alarm expressed over the former seemed out of keeping with the lack of alarm expressed over the latter. Even among caring health professionals, local norms about intimate behaviours can vary widely.

From the nursing home's point of view, they face significant ethical, procedural and legal issues. All need to be considered when formulating institutional policy and procedures to address the sexual needs of the people they care for. In general, being risk averse, most opt for officially being very strict, but operationally turning a blind eye, and hoping for "common sense" on the part of the staff.

Usually the sexually inappropriate behaviour consists mostly of disinhibition, which is often precipitated by an external stimulus - a typical example would be a male patient who will sit quietly while alone, but will call out or grab at any woman who comes near by. Sometimes the inappropriate sexual behaviour will be part of a more general delusional disorder - fully formed erotomania (in which the person has the delusional belief that another person is sexually attracted to him/her) seems to be comparatively rare. In consequence, it is usually inappropriate to use antipsychotic medications as the first line of drug therapy to treat sexual disinhibition.

I have seen nursing staff use humour very effectively to deflect a patient's verbal or physical inappropriateness (e.g. "You'd never be able to handle me" or "I'd spoil you for all other women"). In their view, they give as good as they get, and they are not bothered by the behaviour. Sometimes though, I have observed what appears to be humour used as a means of them coping with something that they find troubling. It is impossible to expect that a nurse whose own attitudes towards sexual activity and desire are not fully resolved to have a fully resolved attitude towards sexual behaviour - especially inappropriate behaviour - on the part of others. Those nurses needed to be supported, but practically, it would seem to me to defy policy-making; this is where a skilled and sensitive nursing unit manager is of the greatest importance. If it is not available, there is little that a family can do to make it so; it becomes another aspect of the dementia caregiver's journey which must be accepted with a certain equanimity. I have often counselled family members who have been obliged to move a loved one to long term care that "no one can give the sort of care that you gave - not even you". It is times such as these that make the journey difficult, and where the old theological dictum that "if you cannot bend the world to your will, you must bend your will to the world" seems most apt. But everyone should recognize that for a nurse, nursing assistant or personal care worker to provide intimate care to a person who is sexually disinhibited is a difficult task that requires a high degree of skill. This is often an example where we require some of our least trained - and least rewarded - people to do some of the most highly skilled tasks.

Nursing staff must also recognize that the same standard of sexual harassment cannot be applied to a patient who is incapable of knowing what he is doing. I have seen cases where a nurse will strenuously assert "he knows bloody well what he is up to" for patients who have no real idea of themselves as having any capability - they barely have an organized sense of self, much less a sense of self-control. At the same time, people with a lifelong tendency towards sexual aggression can also become demented, and it can be a fine line between lacking insight and continuing a lifelong pattern of manipulation and bullying. In my experience, this is one of the most challenging areas for skilled nursing care. Also in my experience, there is considerable variation between settings and between nurses about what is and is not acceptable. To the extent possible, consistency needs to be the rule - it is too difficult for demented patients otherwise to learn how to adjust their behaviour.

Finally, it is worth considering that not all the difficulty in this area comes about as a consequence of the person with dementia being disinhibited. A common, but often hidden problem, is the husband who no longer knows whether his wife wants to have sex with him, and who feels tremendously guilty if part way through intercourse she behaves as if she does not want to - or even as if she does not know what is going on. This can feel deeply shameful and thereby set up other difficulties in the relationship. Many people with dementia have an all too acute sense of when they have in some way offended, however unintentionally.

Although this area is very tricky, it is not always doom and gloom. What was embarrassing at the time can become humorous in the re-telling - once sufficient time has passed, and if some care reframing is done. And sometimes caregivers surprise themselves with how well they have learned to cope. I was consulted to see a patient who had become gravely unwell, with an unclear diagnosis . His nurses told me that they had known something was wrong the day before, when he suddenly stopped making sexual comments. They were certain that he was gravely ill when they inserted a tube in his bladder and he made no comment. They surprised themselves at how relieved they felt when, a few days later, he began to "harass" them again. Over time, these nurses had come to accept this man's disinhibited behaviour as part of his dementia, and of his express of the need to be cared for and to express his care. While they remained firm with him, they were not accusing - they could see beyond the dementia, to the man.

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Last updated December 4, 2018
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