**3. Nursing care professionals' attitudes towards sexuality among elderly in nursing homes**

### **3.1. Stereotypes about sexuality in elderly**

Sexuality is an intrinsic part of human being, but evidence still suggests that in elderly this area of life is often overlooked, particularly in long-term care settings [36]. Madsen [37] argue that society is a barometer for how majority feels about a certain topic such as sexuality in later life, so the societal views can be used as a guide for where changes may be needed or should be done. We may assume that society indicates, but at the same time determines the point of view about sexuality in later life. Sexuality is still stereotypically seen as something normal, desired, acceptable and meaningful when it comes to young people, but in older sexuality is perceived as unnecessary, pointless, embarrassing and even disturbing [13, 37-39]. Such a stereotypical viewing arises from reflecting on the elderly as unattractive, asexual and unable to get involved into intimate and sexual relationships [7] and leads to the misconception and wrong conclusion that elderly have no such needs.

### **3.2. Impact of stereotypes about sexuality in elderly on a perception of elderly, their relatives and nursing staff**

Stereotypes about sexuality in elderly (mentioned above) may have several effects. They may affect the perception of older people themselves but also the perception of others that coexist with the elderly in the same environment (e.g. caregivers, relatives). How the elderly in nursing homes feel about their own sexuality is similar to older adults in general: interest in sex does not necessarily diminish with admission to a nursing home but engagement in sexual behavior often does [36]. According to Villar et al. [39] a large proportion of elderly pushed the sexuality aside and do not think about it anymore. Social taboos associated with sexuality in older age predominate even because many older people are still caught between their own need for intimacy but also the need to fulfill societal expectation [36]. Today's elderly still belong to the generations that were raised up in a restrictive and repressive way, but also under the influence of religion and religious education [39]. These generations think about sex as a topic that should be hidden and shall not be spoken about, because it only makes sense in terms of procreation, otherwise it can be socially and morally inappropriate in old age. This contributes to the invisibility of sexuality in old age in general. Sexual needs of older people are often ignored and overlooked by society in general and particularly in long-term care settings so the nursing care professionals have difficulties distinguishing between appropriate and inappropriate sexual expression and behavior by elderly in nursing homes [36].

Such a stereotypical point of view has an impact on the perception and consequently on attitudes of those who live nearby elderly (e.g. relatives caring for old parents in domes‐ tic environment) or are professionally involved with elderly (e.g. nursing care professio‐ nals in institutional care units or residential care facilities). Villar et al. [39] argue that a group pressure which partly derived from elderly and partly from relatives and nursing care professionals on the other side is an important factor of inhibiting sexual interest and expression. That pressure contribute to controlling behavior of elderly – the importance of what other people think about someone's sexual behavior might cause in elderly feelings of being judged and ashamed or even guilty. Roach [9] in Mahieu [13] state that percep‐ tion of nursing care professionals and the ethos in the organization where they work are the main factor influencing nursing staff' attitudes toward older adults' sexuality in institutional care settings. Roach [9] points out that nursing staff perceptions and respons‐ es to residents' sexual behavior were influenced by their own level of comfort related to sexual issues as well as organizational ethos. Furthermore, nursing staff attitudes influ‐ ence vice versa their own perceptions about sexual expression of elderly and the extent to which the expression is considered to be problematic or not [36]. At this point it should be noted a reverse impact of nursing care professionals' attitudes and the organizational ethos not just on well-being and self-image of residents but also vice versa on nursing staff themselves. If nurses often feel embarrassed and helpless about resident's sexual behav‐ ior (especially when uninhibited sexual behavior occurs in elderly with dementia) it might be detrimental for their self-image and causes negative experiences among them [13]. As stated previously, nursing staff experiences are affected by their own level of comfort related to sexual issues and the organizational ethos, but this in turn has an impact on staff' emotional and behavioral responses to the resident' sexuality [36]. We could conclude that there is a complex and reciprocal interaction between experience, perception and atti‐ tudes of nursing care professionals on the one side, then organizational culture of nurs‐ ing home on the other side, but also the perception of what is wright and what is considered to be wrong among residents and their relatives. All these factors should be considered when exploring the effects on sexual expression among old people living in nursing homes.

### **3.3. Impact of institutional environment**

va" in the later period of life. Another important sociocultural aspect is the religion which has also a great impact on individual's attitude toward sexuality, especially among older adults in western societies [17]. During the middle Ages, the European church decreed that sexual intercourse was solely for the purposes of procreation. In fact, older individuals who have more conservative religious beliefs are looking at the sexual intercourse and masturbation in the postmenopausal period as something with negative connotation; because this kind of sexual activity does not include the possibility of procreation they perceive it as a sin [17]. Others social aspects can also have a great influence on the sexual activity in older people, like socioeconomic status (individuals with lower socioeconomic status are more sexually active) or ethnicity (among older adults, African Americans are more sexually active than Caucasians) [17] as well as environmental restrictions, in case of communal living environment (e.g. nursing homes), where the lack of privacy may force some residents to express their sexuality

**3. Nursing care professionals' attitudes towards sexuality among elderly in**

Sexuality is an intrinsic part of human being, but evidence still suggests that in elderly this area of life is often overlooked, particularly in long-term care settings [36]. Madsen [37] argue that society is a barometer for how majority feels about a certain topic such as sexuality in later life, so the societal views can be used as a guide for where changes may be needed or should be done. We may assume that society indicates, but at the same time determines the point of view about sexuality in later life. Sexuality is still stereotypically seen as something normal, desired, acceptable and meaningful when it comes to young people, but in older sexuality is perceived as unnecessary, pointless, embarrassing and even disturbing [13, 37-39]. Such a stereotypical viewing arises from reflecting on the elderly as unattractive, asexual and unable to get involved into intimate and sexual relationships [7] and leads to the misconception and

**3.2. Impact of stereotypes about sexuality in elderly on a perception of elderly, their relatives**

Stereotypes about sexuality in elderly (mentioned above) may have several effects. They may affect the perception of older people themselves but also the perception of others that coexist with the elderly in the same environment (e.g. caregivers, relatives). How the elderly in nursing homes feel about their own sexuality is similar to older adults in general: interest in sex does not necessarily diminish with admission to a nursing home but engagement in sexual behavior often does [36]. According to Villar et al. [39] a large proportion of elderly pushed the sexuality aside and do not think about it anymore. Social taboos associated with sexuality in older age predominate even because many older people are still caught between their own need for intimacy but also the need to fulfill societal expectation [36]. Today's elderly still belong to the

in semiprivate or public places [21].

**3.1. Stereotypes about sexuality in elderly**

wrong conclusion that elderly have no such needs.

**nursing homes**

194 Sexology in Midwifery

**and nursing staff**

Due to a complex interaction of various factors (mentioned above) the institutional care settings, where elderly could live for many years, represent an important and challenging area if we want to respect a right of elderly to express their sexual needs [13, 39]. Expression of sexual needs among elderly in nursing homes could be also a very sensitive subject for many nursing care professionals and family members due to a variety of ethical issues and concerns, especially when dementia residents are involved because it might easily be perceived as a behavioral problem rather than the expression of human need to love and intimacy [38]. Skoberne [7] and Ziherl [6] argues that environmental factors which could have a significant impact on sexual expression among institutionalized elderly, are sometimes much more difficult to cope and change than other factors (e.g. age-related changes or diseases). According to their experience the people's view might be so deeply embedded and persistent that changing it can be a very long process.

According to Madsen [37], the institutional environment is for the elderly in many ways very restrictive. Nursing home could be an environment which may directly or indirectly limit elderly or even makes them unable to establish and maintain intimate relationships with another person. Causes of such limiting effect are many, but at the end they all lead to lack of privacy which is essential in intimate relationship. The opportunities for institutionalized old people to express their sexual needs are determined both by architectural features and institutional policy. The most common barriers to sexual expression of elderly in nursing homes derived from facility design and how the work processes are performed (institution policy, organizational protocols, rules, guidelines, instructions etc.) The result is an organized, structured and in some way directed daily life of residents. All the facts shown in Table 2 are recognized as important elements in restricting old people rights for privacy by various authors [10, 37, 39, 40].

It seems that the main causes which are indicating a denial of sexuality among elderly by nursing care professionals are the lack of privacy and restriction of the individual person in different ways, both pointing to negative nursing staff attitudes. Personal beliefs, embarrass‐ ment and thinking that sexual expression may potentially have a disruptive effect on life in nursing homes seemed to be reasons why sexual expression of elderly is sometimes considered unacceptable [36]. Barriers mentioned in a Table 2 could be indirect indicators of negative attitudes toward sexuality in elderly. It is not only nursing staff members who may act in a negative way toward sexual expression of elderly but also managers of the institution. They may have an even greater impact on how the sexuality of elderly is accepted because of providing working conditions in the institution. As Table 2 shows one could think about listed barriers that major responsibility for attitudes toward sexuality in elderly lies on factors which seem to be dependent just on a nursing home policy and how the working processes must be carried out. But if you think about listed barriers more accurately, we can conclude that the listed causes are, after all, a result of individual's attitudes that subsequently influence the institutional culture and policies about sexual behavior in nursing homes. From that point of view the listed factors are indirect indicators of attitudes toward discussed topic, but have a direct impact on how nursing staff deals with sexual desires and needs for intimacy of residents in nursing homes.

### **Facility design**

• semi-private rooms (even more than two residents together in the same room)

• absence of individual rooms or bathrooms

• common living areas for residents

if we want to respect a right of elderly to express their sexual needs [13, 39]. Expression of sexual needs among elderly in nursing homes could be also a very sensitive subject for many nursing care professionals and family members due to a variety of ethical issues and concerns, especially when dementia residents are involved because it might easily be perceived as a behavioral problem rather than the expression of human need to love and intimacy [38]. Skoberne [7] and Ziherl [6] argues that environmental factors which could have a significant impact on sexual expression among institutionalized elderly, are sometimes much more difficult to cope and change than other factors (e.g. age-related changes or diseases). According to their experience the people's view might be so deeply embedded and persistent that

According to Madsen [37], the institutional environment is for the elderly in many ways very restrictive. Nursing home could be an environment which may directly or indirectly limit elderly or even makes them unable to establish and maintain intimate relationships with another person. Causes of such limiting effect are many, but at the end they all lead to lack of privacy which is essential in intimate relationship. The opportunities for institutionalized old people to express their sexual needs are determined both by architectural features and institutional policy. The most common barriers to sexual expression of elderly in nursing homes derived from facility design and how the work processes are performed (institution policy, organizational protocols, rules, guidelines, instructions etc.) The result is an organized, structured and in some way directed daily life of residents. All the facts shown in Table 2 are recognized as important elements in restricting old people rights for privacy by various

It seems that the main causes which are indicating a denial of sexuality among elderly by nursing care professionals are the lack of privacy and restriction of the individual person in different ways, both pointing to negative nursing staff attitudes. Personal beliefs, embarrass‐ ment and thinking that sexual expression may potentially have a disruptive effect on life in nursing homes seemed to be reasons why sexual expression of elderly is sometimes considered unacceptable [36]. Barriers mentioned in a Table 2 could be indirect indicators of negative attitudes toward sexuality in elderly. It is not only nursing staff members who may act in a negative way toward sexual expression of elderly but also managers of the institution. They may have an even greater impact on how the sexuality of elderly is accepted because of providing working conditions in the institution. As Table 2 shows one could think about listed barriers that major responsibility for attitudes toward sexuality in elderly lies on factors which seem to be dependent just on a nursing home policy and how the working processes must be carried out. But if you think about listed barriers more accurately, we can conclude that the listed causes are, after all, a result of individual's attitudes that subsequently influence the institutional culture and policies about sexual behavior in nursing homes. From that point of view the listed factors are indirect indicators of attitudes toward discussed topic, but have a direct impact on how nursing staff deals with sexual desires and needs for intimacy of residents

changing it can be a very long process.

196 Sexology in Midwifery

authors [10, 37, 39, 40].

in nursing homes.

• facility designed as a hospital with quick access to residents and living areas

**Institution policy, organizational protocols and working procedures**

• unlocked-door policy and removal of keys by staff because of safety and surveillance (residents are forced to hide and lock in bathroom for some privacy)

• absence of not disturbing signs

• lack of roommate choice

• separation from partner

• enforced selection of the company for spending most of day time in common dining room and other places for socializing

• structured daily life, standardized schedules and emphasizing communal activities (rather than resident decides how to spent their free time)

• structured ways how to do stuff by self in nursing home facilities - predetermined way to do something or perform something (e.g. when and how to do a bath or a personal hygiene)

• restrictive clothing (in a way to restrict an access to the body or parts of the body)

• constant presence of nursing staff and attendants

• supervision of daily activities and relationships of elderly (by nursing staff and attendants)

• day and night checks by nursing staff

• regulation requiring residents to remain indoors between specified hours (especially at evening or at night)

• sharing the personal data of residents among nursing staff (data may become the subject of discussions, gossip, mocking and laughing or other ways for the inappropriate use of humor as a means of social control)

• informing relatives and adapting things to their expectations to avoid problems

• making decisions in consent of relatives but without resident permission or regardless of her / him wishes

• using a medical model approach to care where staff assume the role of decision-maker and establish routines that facilitate working processes without disruption, but also with little or none consideration about what residents' needs about sexual expression are

**Table 2.** Barriers to residents' sexual expression in nursing homes [10, 37, 39, 40]

At this point we must also consider the aspect of residents' safety. According to Madsen [37] the reason that most current policies and procedures are restrictive about sexual expression of elderly is that of ensuring safety. This seems to be especially important when it is about to protect a cognitive or physically impaired residents which may not be able to make decisions about any sexual activities. In addition there is a possibility of sexual abuse or exploitation by other resident, even partner. This is supported also by Mahieu et al. [38] who claim that principle of respecting the autonomy is most mentioned factor in assessing the permissibility for sexual behavior in institutionalized elderly persons, but only when elderly person is still capable to make decisions. If elderly suffer from mental and/or physical deterioration their need and desire for sexual fulfillment and intimacy is being denied – resident is seen only as a patient [38] in which we think that the physical needs must be fulfilled first and that only physical needs should be met. This (medical) point of view does not support a holistic approach in nursing care of elderly. It shows that nursing staff is thinking about sexuality in elderly as unimportant and useless and consequently would not promote this area of life of the elderly. Even more, caregivers think that nothing bad happens if this area remains neglected [1, 11]. This avoidance is consistent with the findings of Villar et al. [39] that under the pretext of "ensuring safety" lays tendency to avoid problems regarding sexual behavior and to satisfy expectations of relatives.

### **3.4. Nursing care professionals' attitudes towards sexuality among institutionalized elderly**

It is already clear that the sexuality among institutionalized elderly is a delicate topic from many aspects. Therefore, at the beginning we must always ask, what is our position on the topic – and therefore what is the point of view about sexuality in nursing homes among employees. In nursing homes residents and staff are in constant contact so they both develop strong interpersonal relationships which affect sexual expression in elderly [13]. In the field of exploration the nursing care professionals' attitudes towards sexuality among the elderly in nursing homes suggest a certain discrepancy between different authors. Bouman et al. [8] have found both positive and negative staff attitudes. More likely to have a positive attitude are employees with higher educational level, higher socio-economic status and many years of work experience. But on the other side, a predictive of negative attitude to late life sexuality are younger staff, less than five years experiences of working in nursing home, working with high dependent residents and also in the case of strong religious beliefs [41]. On the other hand, Madsen [37] finds no relationship between staff age, years of working experience and attitudes, although it considers that this could be expected because of similar life-stage and consequently experiencing to be peers by age. Nevertheless Mahieu et al. [13] draw attention to the potential impact of methodological approaches in research-studies with a quantitative approach show more positive attitudes and those with qualitative approach more negative attitudes. On their opinion the negative climate and the lack of privacy is typical for a nursing home environment, but in spite of this the methodological approach is the factor that need to be considered as a possible cause for discrepancy in the results. In this context Bouman et al. [41] point out the inconsistency in attitude-behavior relationship as the important phenomenon that must be kept in mind when we talk about discrepancy in results. Elias and Ryan [36] emphasize that research about sexuality in elderly is not so much focused on late life sexuality as well, but rather in sexuality and dementia because of concerns and ethical dilemma nursing staff is faced with.

Nevertheless, many authors [13, 37, 38] are uniform in the claim that nursing care professionals still have a rather negative attitudes toward sexual behavior of elderly in institutional care settings, especially in western cultures where ageism and stereotypes are still prevailing. Particularly it is the case in situations where nursing staff experience difficulties in distin‐ guishing between healthy and unhealthy sexual behavior, like in elderly with dementia [13, 37]. The sexual interest of elderly might be perceived as a behavioral problem rather than an expression of basic human needs [38], so the care is focusing on preventing and solving problems emerging from unwanted and unknown sexual behavior rather than the provision of holistic care to elderly, especially in those with dementia [36].
