Supporting Intimacy and Sexuality Needs of Older Adults: The Development of Person-Centered Guidelines

Being intimate and sexual are basic human needs throughout life, not limited to certain living environments, including for those older adults living in their private home or in long-term care. However, many older adults, loved ones and healthcare professionals (HCPs) still indicate that intimacy and sexuality are often taboo topics, even though one should be able to freely talk about it [1]. This hinders the provision of person-centred support if needed.
During the first three-months of the project, 27 interviews were conducted in private homes and long-term care environments, consisting of eleven (n=11) HCPs, eleven (n=11) older adults (OAs) and five (n=5) close relatives/loved ones (Rs). The preliminary results of the project show that intimacy plays a major role in the older adults’ lives, even if it has become ‘remote’ or unattainable for some. For older adults, intimacy means holding each other, putting an arm around one another, having a conversation, drinking coffee together, walking together, socializing, the presence of children, going somewhere together, feeling secure, and feeling the warmth of another human being. Many older adults became emotional during the interviews when thinking about the intimacy they lack. In long-term care settings, problems pertain to the physical environment and design of the home, including older adults not having sufficient privacy. Furthermore, the design and policies of the homes only allow for the use of single beds. This can be challenging for partners who have always shared a bed before entering the home. Personal connections with HCPs are also limited due to time restrains and restricting policies. Older adults would like to receive more personal/intimate attention, putting an arm around the older adult’s shoulder and asking what their night was like.

Examples of older adults’ responses:

a) “You cannot hug each other or express feelings of sadness. You can, but you don’t do it automatically, because there are always people around you”. (OA-2)
b) “People always seems to have been happy together and suddenly they seem to become strangers to each other”.
c) “They could ask, tell me, why are you so emotional?”
d) “We have been together for so many years, why should intimacy and sexuality not be possible anymore? It’s an important part of human life”.

Healthcare professionals generally accept and recognize the need for intimacy and sexuality in later life. They know it is a normal part of the entire lifespan. Yet they often find it difficult to talk about or deal with intimacy. For example, only a few HCPs consider it normal for a partner to spend the night in long-term care with their loved one. In addition, there is often still ‘giggling’ about the subject and older adults in long-term care are given little privacy to express their need for intimacy and sexuality. HCPs are often only involved when intimacy and sexuality are considered to be a problem. “Care is much more than treating wounds, dressing well or showering, care is paying attention to people who are alone”.

An essential and often first step for a person-centered approach to intimate and sexual care is a conversation between HCPs, older adults and those close to them. “People are made lonely because they don’t talk. Ask the question: What makes you happy or sad?” In order to provide person-centred care a number of basic conditions must be met, as became apparent from the preliminary results of this project. One of these basic conditions is trust. Both older adults and HCPs need trust in each other to be able to have an open conversation. In addition, the conversation about intimacy and sexuality must be problem free and easy going. It is also imperative to tailor the conversation to each older person individually. It is crucial to understand who the older person is as an individual and what this conversation can evoke in that person. For example, with whom can someone joke about intimacy and sexuality and with whom one cannot. Paying attention to the reaction and behavior of the older adult is also important. Observing, listening and asking questions is essential for a conversation about this subject. In addition, many HCPs believe that older adults and their loved ones should start the conversation themselves, while older adults and their loved ones think that HCPs should initiate it. Some HCPs find that the intake interview can be used to introduce the conversation. Furthermore, the culture of an organization or team also plays an important role when it comes to intimacy and sexuality. In the project, HCPs indicate that it is important to engage as a team including the support of the manager. For instance, one HCP talked about the fact that the entire team knows that one older adult in their care regularly watches pornography. People laugh about this together, but it is never discussed further. It is clear, that culture change must take place in the team’s attitudes towards intimate and sexual needs in later life and only than can supporting tools be introduced.

Tools must be aligned with the context of the organization and follow a person-centred approach. In order to be truly personcentered, tools must be developed through a co-creation process between older adults and their loved ones and HCPs. As basis for this person-centered approach, the organization has to provide specific conditions. For instance, in long-term care privacy must be provided to older adults and their loved ones. Furthermore, HCPs working with older adults must be knowledgeable/competent in the area of intimacy and sexuality. Finally, older adults, their loved ones as well as HCPs themselves are very diverse with different personalities, cultural and religious backgrounds, morals and experiences. A person-centred approach would contain tools that fit the culture of the organization and the team, HCPs and the older adults and their loved ones, so that the right tool can be selected in the right context with the aim of reducing the reluctance to support intimate and sexual needs of older adults. Several tips have been developed through the preliminary data analysis.

Health Care Professionals

a. Show interest in the person who is dependent on your care. Ask about a picture on their side table or ask about their youth.
b. Be empathic and open-minded.
c. Make time: the investment in time to get to know someone is earned back by improved wellbeing.
d. The organization:
e. Provide extra beds for spending the night, and other conditions that are necessary to address the intimate and sexual needs of older adults.
f. Be clear about your philosophy (e.g., everyone is welcome, no judgment about gender, religion, colour).
g. Make it possible for the employees, and support them, to be able to talk with the older adults about their need for intimacy and sexuality.
h. Make it a structural recurring theme in care.
i. Provide knowledge to improve skills regarding intimacy and sexuality.
j. Be aware of the lack of privacy older adults experience in long-term care on a daily basis.

During the next months of this project, concrete and detailed descriptions of major personalities amongst HCPs and older adults will be developed (personas). Students and researchers of the Saxion University of Applied Sciences in the Netherlands will investigate if these identified “personas” fit the existing health care team members and older adults they have encountered. HPCs will be able to identify with one specific persona and will be able to recognize particular personas of older adults in their everyday practice. Making use of this person-centred approach, HPCs will be able to match the right tool with the older adults’ and their own persona. This will ultimately lead to a person-centred guideline supporting HCPs in their intimate and sexual care for older adults.

1. Mahieu L, Ankcaert L, Gastmans C (2017) Intimacy and sexuality in institutionalized dementia care: clinical-ethical considerations. Health Care Analyses 25(1): 52-71.