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Managing Inappropriate Sexual Behaviors

badsmellThe topic of inappropriate behaviors is one that comes up quite frequently among caregivers and others who commonly associate with persons who have dementia.  Of particular concern is those behaviors which are sexual in nature.  These may range from a man who pats his nurse on the bottom, to inviting her into his bed, to forcing his sexual attentions on another resident.  There are a number of ways to deal with these matters, and many of these strategies relate directly to why the person has engaged in the problematic behavior.

One of the things we need to examine here is that our own personal beliefs regarding sexuality may differ from those of another person, particularly those we are caring for.  For example, we may have some deeply-held beliefs that a sexual relationship outside of marriage is wrong, but asserting those beliefs when dealing with two residents who are engaging in a consensual and mutually-satisfying relationship may not be appropriate on our part.  But, as is often the case with any kind of relationship, we often need to look at where and how this activity is carried out.  For example, it might be totally appropriate for a woman to unzip her partner’s trousers and pleasure him with her hands — IF this takes place in the privacy of their bedroom.  However, if this behavior occurs while lunch is being served in a crowded dining room, within clear view of other residents, it might indeed be considered inappropriate.

Another factor that needs to be taken into consideration is WHY a person is engaging in a specific behavior.  Often, a person with dementia may be completely innocent in his/her motivations, regardless of the behavior involved.  The disease processes that produce changes in physical, cognitive, and functional changes may include alterations in inhibitions or memory, for instance, that might cause the person to do things that might previously have been considered inappropriate.

For example, let’s say that a nurse in a long-term care facility is walking down the hall and sees Mr. Jones sitting in his wheelchair engaging in public masturbation, where anyone who walks by can see him.  If she were to publicly scold him, he might become defensive and argue with her or become aggressive.  Or he might be confused, because he does not understand what he is being scolded for.  Or he may simply forget her correction thirty minutes later, and engage in the behavior all over again.

Many long-term care facilities dress their residents in sweat pants with elastic waistbands, which are easy to put on or take off, especially when toileting the resident or changing him if he has been incontinent.  But if he wears a more standard pair of trousers, he may find it more difficult to manipulate the buttons or zipper.  This may allow the staff more time to distract him, either verbally or by interesting him in more appropriate forms of behavior.  The staff also needs to be aware that this behavior may be prompted by a need to urinate, or the person may feel pain or discomfort associated with a topical fungal infection or a urinary tract infection.  It may be more appropriate, in this case, to ask the man if he needs to go to the bathroom.

When assessing the appropriateness of sexual behavior, it is important for a caregiver to look at the following:

  • What form does the behavior take?
  • In what context does it take place?
  • How frequent is it?
  • What factors contribute to it?
  • Is it a problem?  To whom?
  • Are the participants competent?

If the behavior occurs with another person, then things become somewhat more complicated, with the issue of consent entering into the equation.  Here are some useful guidelines to consider when looking at sexual behavior(s) between two or more persons:

  • The patient’s awareness of the relationship.  Is he/she aware of who is initiating sexual contact?  Is delusion or misidentification affecting his/her choice?  (For example, does she think the other person is her husband?)
  • Can the person state what level of sexual intimacy he/she would be comfortable with?  (For example, can she avoid exploitation?  Is her behavior consistent with previously held beliefs and values?  And does she have the capacity to say no to unwanted sexual contacts?)
  • Is the person aware of potential risks?  (For example, if the other party is discharged from the facility or becomes incapacitated?)

If the behavior becomes a consistent problem, and does not respond to interventions such as redirection or gentle dissuasion, there are other steps that can be taken to determine why it occurs.  This can include a review of medical history (to include an interview of family members, regular interviews, and other nursing home residents), a physical examination, and laboratory testing.  Evaluations should attempt to determine presence or absence of a mood disorder, psychosis, substance abuse, attention-seeking behavior, and long-standing hypersexual personality traits.  Also included should be the specifics of the demonstrated behavior, including potential precipitating factors and consequences.  These precipitating factors can include environmental or emotional triggers, misinterpretation of nonsexual acts, or side effects of medications.

Other factors which should be taken into consideration when attempting to determine motivations for behaviors include those which are dementia-specific.  For example, a person with dementia may not wear appropriate clothing for a number of different reasons related to memory or problem solving deficits.  It may also be that the person is no longer able to fasten her clothing, and not know how to ask for help.  I recall one particular instance where a woman would come to the dining room unclothed from the waist down.  When we looked into the situation, it was determined that she would become incontinent of bladder and remove her clothing appropriately, and then become distracted by the activities associated with other residents making their way to the dining room for lunch.  Hence, she would forget that she had no clothing on below the waist.

If a person suddenly begins behaving sexually, when such behavior is out of character, then caregivers should examine the possibility of delirium.  The presence of a urinary tract infection, fecal impaction, or other medical condition that could produce such a change should be considered.

Management of such inappropriate sexual behaviors should be consistent with that for other types of behavioral issues.  The first step should include nonpharmacological approaches such as discontinuing medications that might promote disinhibition, removal of precipitating factors, distraction, and providing opportunities to relieve sexual urges more appropriately.  If these behaviors are directed toward a particular resident, separation or removal of the other resident to another unit may be sufficient (if the other resident is not desirous of such attention).  Giving the person something else to do with his hands may be helpful, as may directing the person’s attention toward something else such as a television.

There are a few instances where medication may be required in order to effectively manage inappropriate sexual behavior.  It should be noted that all such treatments are off-label, and should be closely monitored by the individual’s physician as well as approved by family members and other approved decision-makers.  Limited, and mixed, results have been noted with the use of antidepressants, hormones, antipsychotics, anticonvulsants, cholinesterase inhibitors, and others.

To summarize, inappropriate sexual behaviors must be evaluated carefully, with consideration given to the person observing the behavior as well as the one doing it.  The person, and behaviors, should be carefully evaluated.  Preference should be given to nonpharmacological methods of intervention.  If medical means of management are used, this should be done carefully and with the understanding that there has been very little evidence-based research into this area.

For more information:  http://www.cfp.ca/content/59/3/255.full

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