180
HEALTH AND SOCIAL WORK
The Nursing Home: Death of Sexual Expression HEDI MCKINLEY AND BELLE DREW
"Aren't the lovebirds cute?" asked the young nursing home aide, pointing to a couple who were holding hands. "They do it whenever they think nobody is looking." The "lovebirds" were a 79-year-old woman suffering from cardiovascular disease and an 82-yearold man who was partially paralyzed as the result of a stroke. Although this nursing home was a superior one run by an enlightened administrator and staffed by professionals, any expression of sexual feelings was unacceptable there. In most nursing homes, ridicule, bed checks, medication, and even threats of discharge are used against patients who violate this basic taboo. Some nursing homes even segregate their inmates by sex in order to avoid any "problems." These are illustrations of the great schism that exists between the scientific findings regarding the sexuality of older persons and the attitudes of physicians, .
Hedi McKinley, MSW, is Director of Community Service, School of Social Welfare, State University of New York at Albany. Belle Drew, MSW, is Assistant Professor of Psychiatry, Albany Medical College, Union University, Albany, New York.
PROGRAM NOTES
181
social workers, nurses, and the general public.1 Most people see sexuality as a need that starts with adolescence and ends when reproduction is over. Older persons are considered neuter, sexless, without desires or passions. This simply is not so, according to several recent studies that show that sexual appetites and capabilities remain with many men and women until late old age and death. According to Kinsey, 95 percent of the males he studied were sexually active at age 60; at age 70 the number declined to 70 percent.2 A longitudinal study carried out at Duke University of men ranging in age from 60 to 94 indicated that men retained their sexualt interest into their 80s.3 Masters and Johnson report working successfully with sexually dysfunctional men and women in their 80s.4 The nursing home is a fairly new, rapidly expanding institution serving not only the old, but adults of all ages who suffer from a wide range of debilitating physical and emotional disorders. The staff members are usually totally lacking in training in human sexuality. Some have minimal education and others have strong religious biases or limited life experiences. Nursing home beds are in great demand, and it is a seller's market. Patients are therefore forced to conform to
1 Harvey Gochros, "The Sexually Oppressed," Social Work, 17 (March 1972), pp. 16-23; and Harold I. Lief, "Sex Education of Medical Students and Doctors," Pacific Medicine and Surgery, 73 (February 1965), pp. 52-58. 2 Alfred C. Kinsey, W. B. Pomeroy, and C. R. Martin, Sexual Behavior in the Human Male (Philadelphia: W. B. Saunders Co., 1948). 3 Eric Pfeiffer, Adriaan Verwoerdt, and Hsioh-Shan Wang, "Sexual Behavior in Aged Men and Women," Archives of General Psychiatry, 19 (December 1968), pp. 753-758. 4 William H. Masters and Virginia E. Johnson, "Geriatric Sexual Response," Human Sexual Response (Boston: Little, Brown & Co., 1966), pp. 223-260.
182
HEALTH AND SOCIAL WORK
staff's expectations. The existence of sexual problems is frequently denied by the staff. "We have no such problems here," said an administrator of a large, religiously oriented home. "When they arrive here we tell them that we expect them to conduct themselves as ladies and gentlemen and that they can stay here as long as they behave." Although we know from Kinsey and from many other reports that almost 100 percent of males in the United States have used masturbation as one sexual outlet, masturbation is actively discouraged in nursing homes through threats, restraint, and ridicule. The expectation of a sexless, passive, neuter old age is strongly supported by the families of nursing home residents. Children are generally unable to handle thoughts of their parents' sexuality. Having dismissed this disturbing topic from their minds when they reached adulthood, they are unwilling to reactivate the anxieties the subject kindles in them. Frequently they even discourage an enlightened administrator from making any kind of sexual release available to the elderly. In some homes where a room was set aside for privacy, families complained that males might attack their mothers, that the home was experimenting with their parents, or that such a room was physically dangerous since it was not immediately supervised. Although the calming effects of physical closeness are well known—we hold crying babies, hug upset children, embrace sick adults—older persons have hardly any pleasurable physical contact. Since many old persons are physically unattractive, especially to the young nursing home staff, touching is kept to the absolute minimum. To counteract this Jack, many nursing home patients demand back rubs, enemas, and physical ministrations of all sorts to take the place of
PROGRAM NOTES
183
normal physical contacts. No physical communication exists among the nursing home residents themselves. Mutely they sit, side by side, day after day, never touching, rarely speaking, following the agile nursing home staff with their eyes and watching visitors come and go. REACTIONS OF MEN AND WOMEN
Men and women react differently as they leave their sexuality behind to concentrate on the role of nursing home resident. The American male, who has been raised to judge his ego by the multiple successes—real and imaginary—of his sexual contacts, often feels that he has been reduced to infant status. He is addressed by his first name or by the ambiguous "Grandpa" and is surrounded by sexually attractive young persons who, were he to touch them, would show intense disgust at the "dirty old man." He is asked to undress in front of others, but he must refrain from displaying any sign of sexual excitement. More than one confused nursing home resident has mistaken the females ministering to his needs as prostitutes and was harshly treated for his mistake.5 No matter how inadequate the aged male's sexual past might have been, he will attempt to see himself as a sexual being to his death and will resent being neutered by society. One example: Mr. J was an 85-year-old Italian man who became acutely paranoid in a nursing home where he was recovering from surgery of a cancerous prostate
5 Ruth Pease, "Female Professional Students and Sexuality in the Aging Male," Gerontologist, 14 (April 1974), pp. 153157.
184
HEALTH AND SOCIAL WORK
gland. He did not speak English well, and although he was small and thin the intensity of his anger was frightening to the staff. Staff members would avoid him as much as possible, but they noticed that his fury intensified whenever his wife visited. It was learned that prior to his hospitalization he had enjoyed an active sex life with his wife. He was now impotent and murderously angry with his wife and his surgeon, both of whom he blamed for his impotence. He was treated with medication and released to go home. There, although he could not resume intercourse, he was able to enjoy the physical closeness of his wife, and his paranoid symptoms disappeared.
The reactions of women to their asexual status in nursing homes are not all the same, just as they differed in attitude toward sex during their earlier years. For many sexuality is a loving part of life, and if their partners are alive and well they continue their sexual involvement into their 80s or tilt their death. Others have seen sex simply as part of their marital duties and feit relieved when menopause allowed them to plead exhaustion, headaches, and other symptoms to excuse them from continuing an active sex life. Many elderly women have never been married. It should not be assumed that they have had neither lovers nor children. These women would find an opportunity to speak about their past a very relieving experience, and any sexual history must contain some gentle questions in this area. The following case illustrates one such situation: Mrs. H had lived in a common-law marriage and had an illegitimate daughter. Her common-law husband died tragically, and Mrs. H went to work in
PROGRAM NOTES 185
a local store. There she formed a liaison with another woman with whom she then shared a home and a large part of her life. This friend died and Mrs. H's job was terminated soon after when the store closed. She became severely depressed. The daughter tried caring for her but found her mother's symptoms too disturbing for her active household and placed her in a nursing home. In no way was Mrs. H ever given an opportunity to work through her grief at the losses she had experienced. She fought being in the nursing home, refusing to remain in bed, climbing over the bars at the side of her bed, and breaking her hip in the process. A catheter offended her deeply and she became mute. She died within a short time. An autopsy revealed no physical cause for her death.
Not all residents of nursing homes are old. There are men and women who have had lengthy illnesses or who require special services. A number of retarded persons are being transferred from state institutions to nursing homes closer to their homes. Many of these people have sexual problems, which are usually ignored. Paraplegics and quadraplegics have drawn attention to their plight, and there is presently a flurry of interest in the sexuality of postcoronary patients.° But nursing homes rarely consider their patients' sexual needs in planning management programs. It must be remembered that entering a nursing
6 Wanda Sadoughy, Martin Lesherner, and Herbert L. Fine, "Sexual Adjustment in a Chronically Iii and Physically Disabled Population: A Pilot Study," Archives of Physical Medicine and Rehabilitation, 52 (July 1971), pp. 311-317; and Herman K. Hellerstein and Ernest H. Friedman, "Sexual Activity and the Post Coronary Patient," Archives of Internal Medicine, 125 (June 1970), pp. 987-991.
186
HEALTH AND SOCIAL WORK
home does not mean the death of sexuality. In one case, a woman of 72, whose 73-year-old husband was recuperating in a nursing home from eye surgery, requested privacy for physical intimacy since her husband would be staying several months and she visited frequently. The staff met her request first with incredulity, later with anger and ridicule, and finally avoided her completely. It is clear that the "sexual revolution" does not at this time include the sick, retarded, or the aged. Persons living in nursing homes must abide by a set of unrealistic rules and are targets of prejudice and punitive morality. MAKING CHANGES
What steps can professionals working in nursing homes take to combat this situation? The first might be to demand some education about the facts and realities of sexual life in order to change attitudes among the staff. There must be a more accepting way of looking at men and women as human beings who have varying sexual practices that must be respected. Any laws that cause married couples to be separated against thar will are antitherapeutic and should be changed. It should be illegal to rupture a marriage, even if one member requires full-time nursing and the other does not. This could be handled by having a different pay scale for persons who wish to enter a nursing home to be with their spouses, but who would not make use of nursing care. Health-related f acilities could accept both partners if the one who was not ill was allowed to help care for his or her spouse. Furthermore, is it really necessary to separate a couple who have been living together for many years, because they
PROGRAM NOTES
187
are not married? Medicaid and Medicare laws must be amended to humanize this degrading bureaucratic interference with people's lives and relationships. For all people who are able to participate in the process, a sexual life history should be taken with the same gentleness and care as is taken with all parts of the social history. It should be accepted that many men and women are sexually alive and active, and they must be given reasonable opportunities for continuing their sexual activities in private. Staff members need information about the effect of certain medications on sexual expression. For example, L-Dopa or testosterone may increase sexual desires in some persons while other medications may produce impotence. A better educated staff can handle inappropriate expressions of sexuality such as public nudity or masturbation with understanding and creativity.7 Nursing home residents might welcome opportunities to meet with staff to discuss sexual problems, even though they might not always have solutions. Social workers are in the unique position to take the lead and bravely consider nursing home residents not as emotionally and sexually dehydrated but as whole, alive people. With creative efforts on the part of the staff, many of the emotional and physical problems of the patients might be eased and the gloomy tone of the nursing homes lightened. 7 Joshua S. Golden, "Sexuality and the Chronically III," The Pharos of Alpha Omega Honor Medical Society, 38 (April
1975), pp. 76-79.
HEALTH AND SOCIAL WORK
The Nursing Home: Death of Sexual Expression HEDI MCKINLEY AND BELLE DREW
"Aren't the lovebirds cute?" asked the young nursing home aide, pointing to a couple who were holding hands. "They do it whenever they think nobody is looking." The "lovebirds" were a 79-year-old woman suffering from cardiovascular disease and an 82-yearold man who was partially paralyzed as the result of a stroke. Although this nursing home was a superior one run by an enlightened administrator and staffed by professionals, any expression of sexual feelings was unacceptable there. In most nursing homes, ridicule, bed checks, medication, and even threats of discharge are used against patients who violate this basic taboo. Some nursing homes even segregate their inmates by sex in order to avoid any "problems." These are illustrations of the great schism that exists between the scientific findings regarding the sexuality of older persons and the attitudes of physicians, .
Hedi McKinley, MSW, is Director of Community Service, School of Social Welfare, State University of New York at Albany. Belle Drew, MSW, is Assistant Professor of Psychiatry, Albany Medical College, Union University, Albany, New York.
PROGRAM NOTES
181
social workers, nurses, and the general public.1 Most people see sexuality as a need that starts with adolescence and ends when reproduction is over. Older persons are considered neuter, sexless, without desires or passions. This simply is not so, according to several recent studies that show that sexual appetites and capabilities remain with many men and women until late old age and death. According to Kinsey, 95 percent of the males he studied were sexually active at age 60; at age 70 the number declined to 70 percent.2 A longitudinal study carried out at Duke University of men ranging in age from 60 to 94 indicated that men retained their sexualt interest into their 80s.3 Masters and Johnson report working successfully with sexually dysfunctional men and women in their 80s.4 The nursing home is a fairly new, rapidly expanding institution serving not only the old, but adults of all ages who suffer from a wide range of debilitating physical and emotional disorders. The staff members are usually totally lacking in training in human sexuality. Some have minimal education and others have strong religious biases or limited life experiences. Nursing home beds are in great demand, and it is a seller's market. Patients are therefore forced to conform to
1 Harvey Gochros, "The Sexually Oppressed," Social Work, 17 (March 1972), pp. 16-23; and Harold I. Lief, "Sex Education of Medical Students and Doctors," Pacific Medicine and Surgery, 73 (February 1965), pp. 52-58. 2 Alfred C. Kinsey, W. B. Pomeroy, and C. R. Martin, Sexual Behavior in the Human Male (Philadelphia: W. B. Saunders Co., 1948). 3 Eric Pfeiffer, Adriaan Verwoerdt, and Hsioh-Shan Wang, "Sexual Behavior in Aged Men and Women," Archives of General Psychiatry, 19 (December 1968), pp. 753-758. 4 William H. Masters and Virginia E. Johnson, "Geriatric Sexual Response," Human Sexual Response (Boston: Little, Brown & Co., 1966), pp. 223-260.
182
HEALTH AND SOCIAL WORK
staff's expectations. The existence of sexual problems is frequently denied by the staff. "We have no such problems here," said an administrator of a large, religiously oriented home. "When they arrive here we tell them that we expect them to conduct themselves as ladies and gentlemen and that they can stay here as long as they behave." Although we know from Kinsey and from many other reports that almost 100 percent of males in the United States have used masturbation as one sexual outlet, masturbation is actively discouraged in nursing homes through threats, restraint, and ridicule. The expectation of a sexless, passive, neuter old age is strongly supported by the families of nursing home residents. Children are generally unable to handle thoughts of their parents' sexuality. Having dismissed this disturbing topic from their minds when they reached adulthood, they are unwilling to reactivate the anxieties the subject kindles in them. Frequently they even discourage an enlightened administrator from making any kind of sexual release available to the elderly. In some homes where a room was set aside for privacy, families complained that males might attack their mothers, that the home was experimenting with their parents, or that such a room was physically dangerous since it was not immediately supervised. Although the calming effects of physical closeness are well known—we hold crying babies, hug upset children, embrace sick adults—older persons have hardly any pleasurable physical contact. Since many old persons are physically unattractive, especially to the young nursing home staff, touching is kept to the absolute minimum. To counteract this Jack, many nursing home patients demand back rubs, enemas, and physical ministrations of all sorts to take the place of
PROGRAM NOTES
183
normal physical contacts. No physical communication exists among the nursing home residents themselves. Mutely they sit, side by side, day after day, never touching, rarely speaking, following the agile nursing home staff with their eyes and watching visitors come and go. REACTIONS OF MEN AND WOMEN
Men and women react differently as they leave their sexuality behind to concentrate on the role of nursing home resident. The American male, who has been raised to judge his ego by the multiple successes—real and imaginary—of his sexual contacts, often feels that he has been reduced to infant status. He is addressed by his first name or by the ambiguous "Grandpa" and is surrounded by sexually attractive young persons who, were he to touch them, would show intense disgust at the "dirty old man." He is asked to undress in front of others, but he must refrain from displaying any sign of sexual excitement. More than one confused nursing home resident has mistaken the females ministering to his needs as prostitutes and was harshly treated for his mistake.5 No matter how inadequate the aged male's sexual past might have been, he will attempt to see himself as a sexual being to his death and will resent being neutered by society. One example: Mr. J was an 85-year-old Italian man who became acutely paranoid in a nursing home where he was recovering from surgery of a cancerous prostate
5 Ruth Pease, "Female Professional Students and Sexuality in the Aging Male," Gerontologist, 14 (April 1974), pp. 153157.
184
HEALTH AND SOCIAL WORK
gland. He did not speak English well, and although he was small and thin the intensity of his anger was frightening to the staff. Staff members would avoid him as much as possible, but they noticed that his fury intensified whenever his wife visited. It was learned that prior to his hospitalization he had enjoyed an active sex life with his wife. He was now impotent and murderously angry with his wife and his surgeon, both of whom he blamed for his impotence. He was treated with medication and released to go home. There, although he could not resume intercourse, he was able to enjoy the physical closeness of his wife, and his paranoid symptoms disappeared.
The reactions of women to their asexual status in nursing homes are not all the same, just as they differed in attitude toward sex during their earlier years. For many sexuality is a loving part of life, and if their partners are alive and well they continue their sexual involvement into their 80s or tilt their death. Others have seen sex simply as part of their marital duties and feit relieved when menopause allowed them to plead exhaustion, headaches, and other symptoms to excuse them from continuing an active sex life. Many elderly women have never been married. It should not be assumed that they have had neither lovers nor children. These women would find an opportunity to speak about their past a very relieving experience, and any sexual history must contain some gentle questions in this area. The following case illustrates one such situation: Mrs. H had lived in a common-law marriage and had an illegitimate daughter. Her common-law husband died tragically, and Mrs. H went to work in
PROGRAM NOTES 185
a local store. There she formed a liaison with another woman with whom she then shared a home and a large part of her life. This friend died and Mrs. H's job was terminated soon after when the store closed. She became severely depressed. The daughter tried caring for her but found her mother's symptoms too disturbing for her active household and placed her in a nursing home. In no way was Mrs. H ever given an opportunity to work through her grief at the losses she had experienced. She fought being in the nursing home, refusing to remain in bed, climbing over the bars at the side of her bed, and breaking her hip in the process. A catheter offended her deeply and she became mute. She died within a short time. An autopsy revealed no physical cause for her death.
Not all residents of nursing homes are old. There are men and women who have had lengthy illnesses or who require special services. A number of retarded persons are being transferred from state institutions to nursing homes closer to their homes. Many of these people have sexual problems, which are usually ignored. Paraplegics and quadraplegics have drawn attention to their plight, and there is presently a flurry of interest in the sexuality of postcoronary patients.° But nursing homes rarely consider their patients' sexual needs in planning management programs. It must be remembered that entering a nursing
6 Wanda Sadoughy, Martin Lesherner, and Herbert L. Fine, "Sexual Adjustment in a Chronically Iii and Physically Disabled Population: A Pilot Study," Archives of Physical Medicine and Rehabilitation, 52 (July 1971), pp. 311-317; and Herman K. Hellerstein and Ernest H. Friedman, "Sexual Activity and the Post Coronary Patient," Archives of Internal Medicine, 125 (June 1970), pp. 987-991.
186
HEALTH AND SOCIAL WORK
home does not mean the death of sexuality. In one case, a woman of 72, whose 73-year-old husband was recuperating in a nursing home from eye surgery, requested privacy for physical intimacy since her husband would be staying several months and she visited frequently. The staff met her request first with incredulity, later with anger and ridicule, and finally avoided her completely. It is clear that the "sexual revolution" does not at this time include the sick, retarded, or the aged. Persons living in nursing homes must abide by a set of unrealistic rules and are targets of prejudice and punitive morality. MAKING CHANGES
What steps can professionals working in nursing homes take to combat this situation? The first might be to demand some education about the facts and realities of sexual life in order to change attitudes among the staff. There must be a more accepting way of looking at men and women as human beings who have varying sexual practices that must be respected. Any laws that cause married couples to be separated against thar will are antitherapeutic and should be changed. It should be illegal to rupture a marriage, even if one member requires full-time nursing and the other does not. This could be handled by having a different pay scale for persons who wish to enter a nursing home to be with their spouses, but who would not make use of nursing care. Health-related f acilities could accept both partners if the one who was not ill was allowed to help care for his or her spouse. Furthermore, is it really necessary to separate a couple who have been living together for many years, because they
PROGRAM NOTES
187
are not married? Medicaid and Medicare laws must be amended to humanize this degrading bureaucratic interference with people's lives and relationships. For all people who are able to participate in the process, a sexual life history should be taken with the same gentleness and care as is taken with all parts of the social history. It should be accepted that many men and women are sexually alive and active, and they must be given reasonable opportunities for continuing their sexual activities in private. Staff members need information about the effect of certain medications on sexual expression. For example, L-Dopa or testosterone may increase sexual desires in some persons while other medications may produce impotence. A better educated staff can handle inappropriate expressions of sexuality such as public nudity or masturbation with understanding and creativity.7 Nursing home residents might welcome opportunities to meet with staff to discuss sexual problems, even though they might not always have solutions. Social workers are in the unique position to take the lead and bravely consider nursing home residents not as emotionally and sexually dehydrated but as whole, alive people. With creative efforts on the part of the staff, many of the emotional and physical problems of the patients might be eased and the gloomy tone of the nursing homes lightened. 7 Joshua S. Golden, "Sexuality and the Chronically III," The Pharos of Alpha Omega Honor Medical Society, 38 (April
1975), pp. 76-79.
