When Kansas State University sent researchers into nursing homes to find out how the topic of sex was being addressed, they initially found silence.
"Nobody was talking about it; it was a really hush-hush subject," said Gayle Doll, director of the university's Center on Aging. "I guess it's hard enough for people to think about their parents having sex, let alone their grandparents."
In response, the researchers have produced seminars and training aids to encourage nursing home caregivers to discuss and accommodate sexual desires.
The effort brings Kansas into a national discussion that advocates say will only grow as baby boomers age and take their beliefs about sexual freedom and civil rights into the nation's nursing homes.
One of the first Kansas seminars was held at Schowalter Villa in Hesston, where many staff first reacted with, "We're going to talk about WHAT?" said Lillian Claassen, vice president of health services at the villa.
Claassen said residents' sexuality had always been a difficult subject for nursing homes and the Kansas State training affirmed her earlier efforts to address the topic.
"It wasn't like we hadn't cared for these needs in the past, but it was liberating to some folks to have an open discussion with university researchers," Claassen said. "It empowered people to think about how they could help folks."
Doll said the training focuses on explaining what sexuality means for older adults, identifying barriers to fulfilling the sexual needs, finding strategies to help residents and how to discern appropriate from inappropriate sexual behaviors.
Solutions can be as simple as providing "do not disturb" signs or making sure staffers don't barge into residents' rooms without knocking. Claassen said her nursing home provides a discreet room for residents and has staff work through possible scenarios they may encounter.
Sometimes, it's as simple as arranging a bed for someone who needs physical therapy in a way that also allows that patient to be with his or her companion, she said.
"My greatest interest is to promote dignity in a situation that can be very challenging," Claassen said. "We all need touch, kindness and companionship. We try to enable that in this setting, which can be very public but where there is still a need for privacy."
Sexuality doesn't always mean intercourse. Many lonely or depressed residents are simply looking for ways to relieve loneliness and depression, Doll said.
For example, she told of one resident who had asked for pornography but dropped the request when the staff started spending more time with him.
"The staff can help with the loneliness and need for connection that residents often have," Doll said. "Some sexual expressions that might be seen as inappropriate will go away when they simply get the attention they deserve."
When the need does include sexual activity, the issue becomes more difficult if one of the residents is suffering from dementia, advocates say. That can manifest itself in a resident making passes at a staff member.
Claassen said her staff is trained to respond politely and to understand that the impaired resident may be mistaking the staff member for a spouse or reacting as he or she has in the past, which is often more vivid than the present for those suffering from dementia.
If a resident with dementia becomes involved with another resident, the issue becomes determining if the sexual activity is consensual, said Robin Dessel, a national expert on dementia who is the director of memory care at Hebrew Home in Riverdale, N.Y.
Dessel said people with dementia, even those who can no longer speak, have wants and desires and the ability to express them. It takes a trained and educated staff to recognize if a sexual overture or relationship involves abuse or is borne of real need, she said.
Dessel said she has seen a growing awareness that the aging do not forfeit their rights as they become infirm, and that includes the right to express sexuality. She expects that trend to increase as baby boomers, with more liberal attitudes toward sex than their parents, continue to age.
"No matter what we see, even if someone needs total care or is incontinent, they still feel," Dessel said. "If there's a bonding with someone else, I think it's a time of celebration at that point that there's something left, something good and pleasurable for that person."
To meet that challenge, clinicians and providers need some standardized parameters to use to assess patients' consent, Dessel said.
The Kansas State researchers say federal guidelines should be developed to help nursing homes deal with sexuality in a positive way.
"Nursing homes are the second most regulated industry in the country, behind nuclear power plants," Doll said. "But none of those regulations address sexuality. So, consequently, no one knows how to handle it."