Sexual interest and activity continue, despite the many physical, social and emotional changes that accompany the aging process. Nonetheless, sexuality is the one aspect of health that is often ignored when an elderly person enters an institution for long term care. Within institutions, sexual behaviours are likely to evoke segregation, limit-setting and disapproval. As a result, the elderly individuals who reside in these facilities may be denied the benefits of a healthy and intact sexual identity. These benefits include companionship, improved self-esteem and physical release.

There is evidence that this situation is changing, however. Since the beginning of the 1990s, there has been a steady increase in the publication of articles, commentaries and even books in which authors discuss the role that sexuality continues to play in the lives of many of the elderly. These authors argue that health care professionals have a responsibility to ensure that they respect and support the sexual needs of the elderly whom they serve. The elderly who reside in nursing homes and other care facilities are included in the appeal for greater understanding.

Sexual beliefs and behaviours develop as a result of one's personal history, in combination with the social influences to which one is exposed, especially in early life. The values about sexuality that existed in the Victorian era when today's elderly were born were quite different from the values that held sway in subsequent eras such as the fifties and sixties, when caregivers were born. It is perhaps not surprising that caregivers and their elderly clients have difficulty openly discussing sexuality. Indeed, well-meaning caregivers who have heard the message that they ought to be willing to accept and prompt sexuality in the elderly may be at a loss as to what the elderly themselves would consider helpful, versus what they would consider inappropriate or an invasion of privacy.

We have addressed this problem within our facility by developing a combined service, research and education program to promote sexual health for our elderly clients. At all stages of the program, the elderly have had input. We would advocate that individuals and couples who are considering entering a long term care institution include questions about sexuality in their assessment of the facility, if sexual issues are a concern to them. It is unsafe to simply assume that privacy, intimacy and understanding about sexuality are part of the culture of the institution. While every program will differ, this description of our program will help to alert potential consumers of long term care to the types of services and educational initiatives that provide the foundation for the promotion of sexual health.

Parkwood Hospital
Parkwood Hospital is a chronic care hospital which includes within its mandate 410 beds for the care of Canadian war veterans. The veterans are mostly men in their seventies and eighties. Many have wives who reside in the community, but visit regularly.

Approximately five years ago, the first two authors (a Psychologist and Clinical Nurse Specialist, respectively) decided to spearhead the development of a program to better address sexual issues within our facility. We had become aware that conflict over sexual behaviours sometimes existed between staff and residents. Staff had expressed concern about residents who behaved inappropriately. Specifically, some residents would make unwelcome sexual comments to staff and touch or grab staff during care delivery. Staff members wanted these problematic behaviours to stop so that they could deliver care and develop supportive relationships with their patients, unencumbered by the embarrassment and anger they felt in these situations.

In considering how to respond to the issue of "sexual inappropriateness", we were mindful that elimination of all expression of sexuality was not a satisfactory goal. We realized that we had heard only half of the story. We did not know how our residents felt about these behaviours, or what they felt we could change so that sexual needs were better accommodated and understood. We recognized that we needed a much broader and better informed appreciation of what a culture supportive of residents' sexuality would "look" like. Fortunately, efforts were already underway within our facility to implement a client-centred approach to other behavioural issues, such as wandering, agitation and social isolation.

Within this approach to care, the contributions of all participants are valued. We work together to improve quality of life for residents, families and staff. We decided that sexual behaviours would be addressed within this framework as well.

Service
Since this program was initiated, there has been a gradual change in the nature of referrals for assistance with sexual issues that we have received. Referrals now are more likely to originate in concern for a resident's sexual well-being rather than only in staff discomfort. For example, a resident who is struggling emotionally because he is no longer intimate with his wife is likely to be identified as a candidate for both counselling and practical assistance, and will be offered help accordingly.

One of the most important factors that has contributed to this change, is that assistance with sexual issues is offered in a non-threatening, non-judgmental manner. Research has documented the lack of self- esteem the elderly may feel with respect to their own sexuality. The elderly who reside in institutions may be particularly sensitive to how their caregivers react to the suggestion that they have sexual interests or needs. Residents who feel they are viewed as "dirty old men" are likely to hide their true feelings behind jokes and inappropriate comments. Residents who are mourning the loss of intimacy that can accompany the relocation of one spouse to long term care will be unwilling to share their feelings with staff if they perceive that romance and intimacy among the elderly is viewed as nonexistent, or as a source of humour.

In our facility, clinical resources, including psychology, nursing, social work and occupational therapy are available to address sexual issues as needed. For example, a couple can book private time in the "independent living unit" (a small self-contained apartment on site). A cognitively impaired resident who masturbates in public or exposes himself is more likely to be redirected than reprimanded. Caregivers and family members receive support for their efforts to understand the motivations underlying behaviours. A concentrated effort is made to include even cognitively-impaired residents in problem-solving when expectations about sexual behaviours are different for residents, family members and staff. Efforts to revise clinical practices have benefited immeasurably from unwavering administrative and managerial support.

A spouse of one resident recently commented that one of the hardest things she had to adjust to following her husband's move to the institution was learning to sleep alone after 50+ years of marriage. Her husband's Alzheimer's disease had progressed to the point where intimacy between them was not longer a possibility, but she was grateful for the opportunity to discuss her feelings with a caring professional. Importantly, she felt respected and supported by staff in the occasional moments of togetherness her husband was able to tolerate.

Research
We believed that sexual behaviours could be addressed ethically only if we understood how participants in our setting perceived various behaviours, and how they felt these behaviours should be addressed (or if they should be addressed at all). Our need to better understand these perspectives led to a research study, generously funded by the Parkwood Hospital Foundation. Previous research has documented differences in attitudes towards and knowledge about sexuality between staff and nursing home residents (Kaas, 1978; Wasow and Loeb, 1979). Research comparing opinions about the acceptability of specific behaviours among participants within a setting has not been published. Our study, which is in preparation for publication, compared opinions about residents' sexual behaviours among staff, residents, and community-dwelling spouses.

We found both similarities and differences of opinion among the three groups (residents, community-dwelling spouses and staff), as well as among subgroups within the staff category. Our findings have provided an scientific basis for care planning at the individual level. Instances where differences in expectations underlie conflict between residents and staff are more readily identified and investigated. For example, situations where residents have thought they were being complimentary to staff, but staff have considered the comments made by residents inappropriate, have been resolved through dialogue rather than censure.

Our research has also provided direction for continuing education efforts with staff. The complexities inherent in attempting to create an institutional culture in which the rights and needs of all participants are respected is captured in this quote from one of the staff study participants: "My comfort level [with resident's sexuality] is connected to my own feeling or lack of esteem and comfort with my own sexuality, which varies from time to time".

Education
Education can be effective in changing staff knowledge about and attitudes toward sexuality in the elderly. Education sessions are held with staff on an as-needed basis. These sessions are structured as opportunities to compare perspectives, raise issues, and learn. Discussions have ranged from philosophical debate about sexual value systems, to information exchange about the impact of aging and institutionalization on sexual health, to brainstorming about how to respond appropriately and effectively to situations encountered in daily clinical practice. Just as residents have expressed appreciation for the opportunity to explore their sexual issues in individual counselling, staff have been grateful for the opportunity to openly express their concerns and opinions. Occasionally, open discussions have lead staff members to identify personal sexual issues which have required therapeutic intervention. These individuals have been assisted to access resources such as the Employee Assistance Program.

Summary
In our experience, an integrated program of service, research and education has been essential for the development of an institutional culture more supportive of sexual health for residents, spouses and staff. A willingness to identify, investigate and educate about sexual issues has replaced a general tendency to feel uncomfortable and to avoid the issues. Our experience attests to the responsibility that all participants in a setting share for the promotion of sexual health. The success of our initiative reflects the contributions of many people. We believe, as leaders of this initiative, that we have had an obligation to both solicit and be responsive to input from all those with a stake in the outcomes. It is our hope that the next decade will see continuation of a concentrated effort on the part of health care professionals to promote sexual health for the elderly, parallelled by the development of a stronger voice from the elderly themselves.

Recommendations
Not all facilities will have an integrated program of service, research and education in place to promote sexual health. However, the interested consumer should feel welcome to inquire as to what steps the facility has taken towards this end.

Questions might include:

0. what is the general attitude towards sexuality in the facility?
   
1. is privacy respected? how?
   
2. what counselling or intervention resources are available should sexuality become an issue?
   
3. is there a mechanism for residents to have input on any policy decisions around sexuality?
   
4. do staff training and continuing education activities include a focus on promoting sexual health?
   

Author Note: Margaret Gibson is a Psychologist, Nancy Bol is a Clinical Nurse Specialist and Gail Woodbury is an Epidemiologist, all at Parkwood Hospital, London Ontario.

Correspondance: Dr. Maggie Gibson, Veterans Care Program, Parkwood Hospital,
801 Commissioners Road East, London, Ontario, N6C 5J1
Phone: 519-685-4292 x 2708
Fax: 519-685-4031
e-mail: m.gibson@parkwood.london.on.ca

Suggested Readings:
Butler, R.N. & Lewis, M.I. (1993). Love and Sex After 60. New York: Ballantine Books.
Jones, H. (1994). Mores and Morals. Nursing Times, 90(47), 54-59.
Kaas, M.J. (1978). Sexual expression of the elderly in nursing homes. Gerontologist, 18, 372-378.
Kaplan, L. (1996). Sexuality and institutional issues when one spouse resides in the community and the other lives in a nursing home. Sexuality and Disability, 14(4), 281-293.
McLean, A.H. (1994). What kind of love is this? The Sciences, September/October, 36-39.
Wasow, M. & Loeb, M. (1979). Sexuality in nursing homes. Journal of the American Geriatrics Society, XXVII( 2), 73- 79.