Why Older People’s Sexuality Remains Invisible Within Long-Term Care Facilities

Research indicates that the expression of sexuality and intimacy remains relevant to many older people as a source for physical and mental wellbeing within long-term care facilities (LTCFs). Nevertheless, despite knowledge available and recommendations suggested, these needs stay unsupported within LTCF settings. This article suggests a gap in research literature on the subject and presents a novel, overlooked reason that explains why progress in the support of older people’s expression of sexuality is and will continue to lack momentum. This article comprises the findings of two literature reviews. Chapters 1 to 3 represent the findings of an implicit literature review, chapters 4 to 5 the findings of an explicit literature review.

1) Introduction

Albert Schweitzer famously determined ethics as being the “reverence for life” (Schweitzer, 1949, xviii). Reflecting this ideal, in Finland every graduating professional nurse commits oneself under oath to a set of nursing ethics, which includes goals such as the alleviation of unnecessary suffering, the respect for human rights and the maintenance or the betterment of perceived quality of life (Sairaanhoitajaliitto, 2014). One factor influencing the perceived quality of life is sexuality. It is widely accepted that sexuality is “a central aspect of being human throughout life”. Sexuality belongs to every human being regardless of, for example, age. (WAS, 2014, p. 1; WHO, n.d.) The consensus is that sexual rights are derived from human rights (WHO, n.d.), which in turn today are often juristically anchored within nations state laws. At least as far back as the 1970s, geriatric and sexological publications repeatedly and in growing numbers acknowledge that the need for and the expression of sexuality and intimacy remains relevant to older peoples physical and mental well-being, including to those dwelling in geriatric long-term care facilities. (Kontula, 2010, p. 242; Kiviluoto, 2000, pp. 307–316; Wasow & Loeb, 1979)

One could argue that the above presented picture alone should yield enough gravity and reason as to expect that the health care sector acknowledges in words and respects in actions the older people’s need for knowledge on sexual health related issues (such as sexually transmitted diseases) and support on their natural need to verbally or physically express their desire for affection, intimacy and sensuality. But it appears to be very far from truth. In “Invisible sexuality”, Korhonen and Ridanpää conclude that the sexuality of the aged, and especially of the demented is invisible. Next of kin and staff do neither dare to see it, nor to speak about it. (Korhonen & Ridanpää, 2014, p. 129) This holds to be true also for the non-demented residents in LTCFs. Amongst other things, taboos, biased opinions and negative attitudes as well as the lack of knowledge, education, policies and guidelines are identified as typical causes for the existence of barriers to the sexual expression of the aged by professional literature and scientific studies on the matter (Bauer, Haesler, & Fetherstonhaugh, 2016, p. 1238; Martin, 2004, pp. 1–2; Rautiainen, 2006, pp. 228–230; Ritamo, 2008, p. 49). In the recommendations and suggestions in these publications, they for a rather long time now repeatedly call for action and betterment in a variety of ways, but it appears as if the implementation and integration of suggested ideas is significantly lagging behind and lacking momentum. The question arises as if to why this is so? To the best of my knowledge, both literature and scientific studies about older people’s sexuality in long-term care institutions have omitted to provide a satisfiable answer to this question.

This article suggests that the beforementioned causes are but symptoms. It is suggested that the concept of social norms, as the possible underlying but overlooked root factor for many of the identified causes, has not been consciously identified by scientific publications that concern themselves with the topic of older people’s sexuality in LTCFs. As it is in the nature of norms to resist change and development, the lack of awareness or understanding of the underlying workings of social norms is of relevance as to explain why older adults’ sexuality has persistently remained a low- to no-priority area of care-taking interventions.

This article attempts to present the reader with a different thinking angle and approach rather than claiming to provide a comprehensive, definite answer. Raising the awareness on the dynamics of social norms as a form of power relations could help to more effectively produce, launch and integrate already suggested or novel recommendations into practice. The goal of this article is to facilitate and inspire new discussion and research on the topic, suggest novel thoughts and ideas and as a result to hopefully challenge the current status quo for the better.

2) A reality of supporting residents’ sexuality in LTCFs

Kenneth Plummer (1975) states that “Nothing is sexual, but naming it makes it so”. Underlining the complexity and “slipperiness” of the term sexuality, Weeks (2003, pp. 4, 19) says that “the more expert we become in talking about sexuality, the greater the difficulties we seem to encounter in trying to understand it.” A particularly narrow way of interpreting the term would be to equate sexuality with sexual intercourse only. Others name sexuality to include intimacy, pleasure, eroticism, sexual orientation, gender identities and roles, manifesting not only in sexual practices but also “in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, roles and relationships” (WHO n.d.). One might think that ultimately one’s sexuality cannot be defined by any other (Bildjuschkin & Ruuhilahti, 2010, p. 13), that one’s sexuality belongs to oneself.

On the other hand, sexuality is always interconnected and hence influenced by many variables (such as norms and attitudes) that surround and shape our lives. Literature typically categorises these variables into the biological, psychological and sociocultural dimensions. In their definition of the term sexuality, the WHO states that “Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” (Bildjuschkin & Ruuhilahti, 2010, pp. 35–45; Greenberg, Bruess, & Oswalt, 2014, pp. 4–10; Santalahti & Lehtonen, 2016, pp. 17–18; WHO, n.d.). Oxymoronically, it seems one can argue that one’s sexuality is and is not one’s own at the same time.

Sadly, within the confinements of LTCFs, it appears as if one’s own sexuality is very much so not one’s own. Literature and scientific publications repeatedly confirm that the topic of sexuality remains problematic, although the importance of sexuality and intimacy to the wellbeing of the aged has been repeatedly confirmed: Taboos, unawareness, biased opinions, negative attitudes and practices around elderly persons’ sexuality are not only widespread within the society at large but also within the healthcare sector. Ageism is normatively present, as residents are often perceived and treated as nearly non-sexual entities. The expression of sexual attraction and desires is often belittled, negated and denied (Barrett & Hinchliff, 2018, p. 18; Ritamo, 2008, p. 49): “Somehow it seems indecent for two 70-year-old people to have sex with each other, and even more for a 70-year-old to masturbate. These negative attitudes become particularly obvious in nursing homes, where staff members may frown on sexual activity among residents. Somehow what is ’virility’ at 25 becomes ’lechery’ at 75.” (Hyde & DeLamater, 2008, p. 277)

It seems clear, that this behaviour diminishes residents’ trust in a non-judgemental relationship, for example within the context of not fitting into expectations of heteronormativity. Denying the right on sexuality and sexual fulfilment by keeping silent as well as a lack of physical spaces enabling intimacy are portraying the overall stance of stricter behavioural norms and policies, which often dominate in institutional care settings. (Bauer et al., 2016, p. 1238; Rautiainen, 2006, pp. 228–230; Ritamo, 2008, p. 49) Especially within the context of dementia, the perceptions on sexual, sensual and intimate expressions appear to be undereducated and narrow. Opinions range from dementia equalling asexuality to categorically declaring sexual behaviour as being pathological, needing to be managed and controlled. (Martin, 2004, pp. 1–2). The lack of policies, guidelines and management support implies that encountering a resident’s sexuality consequentially becomes a very personal experience to a nurse. In this situation, the nurse must rely upon her/his own personal experience and world view in order to make decisions. (Elias & Ryan, 2011, p. 1673)

In the context of the above portrayal, it is apparent that social norms are of significance to the existence and persistence of the current situation.

3) What are social norms and why do they matter in nursing

Social norms and its interconnected parts are an important and huge part of a society’s fabric. Humans benefit from social norms as they guarantee cohesion and coherence of communication, behaviours and actions by creating a set of collective behaviours. Metaphorically speaking, they are both glue and lubricant for the smooth running of the societal machinery. Bicchieri, Muldoon, and Sontuoso describe the regulatory and decision-making functions of social norms as being the grammar of a society’s social interactions. Much like the grammar of a language specifies how it is composed and properly used, a system of social norms determines what behaviour is either expected or not accepted within a society or group and within a particular situation. (Bicchieri & McNally, 2015, p. 2; Bicchieri, Muldoon, & Sontuoso, 2011) According to Honkanen (2016, pp. 140–143), social norms can be seen as thinking-shortcuts or rule-of-thumb heuristics, which provide a quasi-automated and at least in parts unconscious framework of behavioural decision-making. Crucial to the existence of any social norm is that a set of expectations exists and that these expectations do matter. Social expectations are essentially beliefs about what we expect others to do or beliefs about other people’s normative beliefs (what we belief others think we ought to do). Personal beliefs which represent an evaluation of a behaviour are called attitudes. Hence, also attitudes are inherently linked to the formation of expectations and social norms. A norm can change or even cease to exist when the normative basis (expectations) changes. (Bicchieri, 2017, pp. xi, 8, 11, 142) Under normal circumstances, one is rather unaware of the surrounding norms, as they are so deeply embedded and internalised. Awareness is only raised when one of these norms is violated, e.g. when a person in a certain situation diverges from the typically expected “social script”. (Bicchieri et al., 2011) In this instance, social norms activate the imposition of appropriately severe social sanctions upon the deviator(s) (Bicchieri, 2017, p. xiv).

Despite their apparent benefits to the regulation of human interactions, social norms do come with trade-offs, disadvantages and challenges. Norms and social scripts possess the ability and power to hinder and harm individuals as well as groups of people in a variety of very tangible ways. They can distort people’s thinking and create and maintain rigid attitudes and operating modes (Honkanen, 2016, pp. 56–58). Most people might continue to follow a disliked norm, because individually they belief to be the sole “deviants”, whilst in fact they might not be alone. This is called “pluralistic ignorance”. (Bicchieri, 2017, pp. 43, 73) Taboos, when understood as a strong, even sacred form of social norms (Fershtman, Gneezy, & Hoffman, 2011, pp. 139–142) are especially exemplary in representing such negative connotations. Sigmund Freud highlights the rather peculiar opposing duality of meanings of the word taboo: on the one hand, it stands for things sacred and consecrated, on the other hand it does also represent things scary, dangerous, forbidden and impure. Anyone who either intentionally or unintentionally breaks a taboo runs the risk of becoming taboo him/herself (Freud, 1922, pp. 24–25, 27). According to Laitinen, the social function of a taboo is to restrict certain phenomena related to social life by prohibition in order to preserve a normative social order. She concludes that especially within the context of professional health and social care it is in the nature of taboos to isolate, to put and keep in a particular box and to form a confrontational rather than a conciliatory atmosphere. Taboos produce deafening silence, truculent and hostile behaviour and make it hard or even impossible to encounter someone truly. To share, feel and pass on sympathy and empathy or to offer assistance and care to someone are all hindered. This includes also taboos on sexuality. (Laitinen, 2009, pp. 9–15). It can be argued that the above statement can hold true not only to taboos (as a special form of social norms) but also to social norms in general. Enforcing a social norm implies the either aware or unaware execution of certain power relations upon a person or a group of persons, so does the attempt to challenge a social norm (Foucault, 1984, p. 95). In a nutshell, good or bad, social norms influence both nursing ethics, nursing intervention quality and ultimately the wellbeing of the human being to be taken care of.

The question arises whether and to what degree scientific articles on the subject of LTCF sexuality are aware upon the relevance of social norms to the support of residents’ expressions of sexuality.

4) Methodology

In order to be able to answer this question reliably, a second descriptive literature review was undertaken. The review was done explicitly, leaning on the principles of a systemised review as much as possible. A total of 41 peer-reviewed papers was included and analysed. All 41 articles were read through thoroughly and possibly relevant passages were outlined, written out into a spreadsheet and re-analysed. All passages were analysed and evaluated according to their possible degree of social norm awareness. The correctness of the initial evaluation was confirmed by re-reading the complete passages within the original texts itself. The process flow of selection criteria and data collection can be seen in Figure 1.

Figure 1. The process flow of selection criteria and data collection.

5) Findings

The analysis resulted into the synthesis of three separate sets of findings: a) a list of commonly mentioned barriers to the expression of sexuality and its support; b) a list of recommendations for the betterment of sexual expression and its support and c) a list of selected articles grouped according to the amount of social norm awareness (no awareness, partial awareness, direct awareness). Both a) and b) are not further discussed within this article as they represent merely by-products to the third finding which answers the research question. They are presented though within the thesis on which this article is based upon. Out of the 11 selected articles, five papers qualified as being partially aware of norm awareness, all identifying some aspect related to social norms and norm change. One paper concentrates on discussing heteronormativity as the root source for silence and invisibility of sexual diversity, including aspects such as ageist attitudes (ageism), social hierarchy and power imbalance (Leyerzapf, Visse, Beer, & Abma, 2018, pp. 367–373). The role of group pressure as a tool of informal control of other people’s sexual behaviour is identified and changing attitudes as the first step to bring about change are suggested (Villar, Celdrán, Fabà, & Serrat, 2014, pp. 2524–2525). In a literature review, the authors discuss as to why available guidance fails to translate into awareness and practice of professional care. Whilst identifying barriers which can be attributed to values and norms, the review itself does not provide an answer to this question (Simpson et al., 2017, pp. 252–260). Additionally, two papers identify that despite sexual-positive beliefs on the individual level of nurses and shifts in social attitudes, taboos and other barriers continue to overwhelm and stay in place. Again, these studies fail to connect this phenomenon to social norms and related concepts such as “pluralistic ignorance”. (Elias & Ryan, 2011, p. 1673; Gilmer, Meyer, Davidson, & Koziol-McLain, 2010, pp. 21–22)

No paper indicated directly the need to deepen the understanding of the workings of social norms and to interconnect social norms theories to the context of barriers to the expression of older people’s sexuality. No paper with direct awareness was identified.

The findings indicate that scientific articles, which consider LTCF residents’ sexuality and support of sexual expressions, are largely unaware of the relevance of social norms. In consequence, the result can serve as an argumentative answer to the question as to why older people’s sexuality has and might remain largely invisible and unsupported.

6) Discussion, conclusion and recommendations

For many years, literature has demonstrated that sexuality is important to the aged. One train of thought goes as far as suggesting that the need for sexual intimacy of LTCF residents is of even enhanced importance, in an attempt to compensate for the cumulation of biological, psychological and sociocultural losses (Doll, 2012, p. 24). Despite this fact, elderly persons’ sexuality does not receive the respect nor the support it deserves. It is very much so still a topic of invisibility. Typically, scholars try to explain this discrepancy by identifying barriers to the support of sexuality as the reasons for as to why rigid behaviour and bad practice still prevail. Some authors even wonder why so little change for the better is happening despite the identification of barriers and suggestions made. One such major obstacle is the prevailing of ageism and ageistic beliefs. Whilst societies are generally very aware of discriminative behaviours such as racism and sexism, the discriminative nature of ageism seem to elude the collective consciousness of society. Ageistic beliefs are accepted as truths without questioning not only by the young but are internalised also by the aged themselves. It is the norm to see the elderly as asexual beings. In this sense we fail to see the person holistically. In terms of nursing ethics, this is of vital relevance. If nurses fail to recognise LTCF residents as sexual beings, they are inevitably both unable to recognise sexuality-related sufferings and unable to alleviate it in the best possible ways. These sufferings might be related to shame on a sexual health matter or to gender identity, plain physical loneliness and many others.

Present literature has given the impression that tackling the identified barriers (such as negative attitudes, lack of education, heteronormativity, gerontophobia, lack of privacy, lack of communication) is the way to improve current shortcomings. However, as changes do not appear to happen, it becomes obvious that something more is going on. The common denominator here is the concept of social norms. By its very nature, the grid of social norms keeps normative societal behaviours in place, even despite better knowledge. Without realising it, tackling a barrier (such as working on rigid attitudes and biases) might constitute an attempt of changing an underlying existing social norm, challenging the grid in place. There is no guarantee that changing specific barriers will by and of itself result in desired positive normative changes. In the worst case, an attempt to change can even backfire, producing defiant and stonewalling behaviours, as Bicchieri (2017, pp. 156–158) points out. Changing social norms is much more complex than this.

If we want to succeed in enhancing the support of older people’s sexuality more effectively, we need to consider social norms theory and familiarise us with how norms are and are not successfully changed. Only equipped with this data will it be possible to envision strategies that more successfully enable changes in social norms. Ignoring the relevance of social norms increases the risk of inefficiency or even failure. The literature review within this article demonstrated that, largely, such mental connections have not been made yet. Still, I am not alone with this view, as also Gott (2007, p. 148) suggests the consideration of societal norms as focal to the perceived incompatibility of old age and sexuality. Scrutinising already identified barriers within the new context of social norms theory might improve the way we will be able to bring to fruition suggestions to the betterment of the sexual expression of older people.

Considering social norms can also produce new recommendations. This being said, as a signalling tool for normative change, I recommend the creation of a customised sexual rights declaration for the aged, addressing specific challenges, concerns and needs that come with increased age. Barret & Hinchliff are pioneering here. They meticulously dissect and discuss as to why a separate sexual rights framework in this context is needed and suggest how it could look like. (2018, pp. 20–185) A institutionally supported and advocated separate declaration would carry a clearer and stronger signal to the whole society to embrace a more holistic and supportive stance and abandon today’s negative normative. In Finland, a customised version for the young already enlightens society on the specific concerns of young people’s sexuality (Family Federation of Finland, n.d.). So why don’t we just lead the way and do the same for the elderly?