Management of Sexual Expression in Long-term Care
Management of Sexual Expression in Long-term Care
Interpretation of the data in this study is influenced by the particular positionality of the investigators. The primary investigator is a white, female social worker and long-term care administrator. The coinvestigator is a white woman with a PhD in life-span development. These factors played a role in the interpretation of the information in this study. Through these lenses, the investigators found that ombudsmen's cases related to residents' sexual expression in long-term care settings are initiated based on conflict or dissatisfaction due to risk, risk associated with dementing illnesses, limited knowledge, privacy issues, and values. Study results support the literature that found long-term care facilities do little workforce training and that few organizations have policies to support and respond to residents' sexual expression (Ehrenfeld et al., 1999; Fairchild et al., 1996; Low et al., 2005; Shuttleworth et al., 2010; Tabak & Shemesh-Kigli, 2006). Limited workforce training and policy in these settings contribute to the primary findings of conflict and dissatisfaction, and initiate the need for advocacy from long-term care ombudsmen.
Goffman's (1961) total institution theory has lent further understanding. Long-term care settings, particularly nursing homes, have much in common with total institutions (Goffman, 1961) and "people processing organizations" (Hasenfeld, 1972) where residents must comply with an institutional regime (Parkin, 1990).
A key principle of the total institutional framework is the recognition that the institution suppresses residents' civil liberties. Total institutions restrict people's rights to self-determination, autonomy, and freedom of action (Goffman, 1961). Sexuality and intimacy are human needs, which continue throughout life (Lindau et al., 2007; Miles & Parker, 1999; Reinisch, 1991), thus are considered civil liberties. Placement in an institutional setting and the vulnerabilities residents face (such as physical frailty and cognitive losses) further complicate their sexual expression. The role of the ombudsman is critical to advocate for the residents' rights.
Restrictions on residents' autonomy can be clearly seen in the example of a resident who felt that having a boyfriend was not allowed. Institutional cues resulted in the impression that an intimate relationship was against the rules. Goffman (1961) found that the total institution establishes an authority over the residents, directing their behavior, and this authority is emphasized by regulations and judgments by staff members. The results support that staff values and related judgment influence the management of residents' sexuality. Staff's attitudes and opinions on sexual expression or sexual orientation fuel conflict that may lead to ombudsman intervention. Conflicts can also arise from the values and attitudes of family members, as well as their expectations of the institution's response to residents' sexual expression.
Lack of privacy is a further institutional barrier that deters residents from being intimate. Within Goffman's (1961) total institutional framework, people's actions are under constant surveillance. In a care facility, surveillance may include the building's construction, video cameras, and periodic staff checks. Lack of privacy has been identified as a consistent barrier to residents' sexual expression (Hajjar & Kamel, 2003; Lantz, 2004; Reingold & Burros, 2004), and this study supports that finding. Staff failure to knock before entering private living quarters, semiprivate rooms, and gossip all serve as reminders of constant surveillance. Institutions justify the need for high levels of surveillance to comply with strict regulations, reduce organiza tional risk, and ensure residents' safety.
Risk and threats to residents' safety are difficulties within these settings. It is challenging to balance these threats with the ombudsman's obligation to advocacy. Protecting residents from sexual abuse or mistreatment (especially when residents have cognitive losses), working with sexual offenders living in institutions, preventing the spread of infectious disease, and the collective rights of residents in a community continue to be areas of difficulty that further support the need for third party advocates.
Discussion
Interpretation of the data in this study is influenced by the particular positionality of the investigators. The primary investigator is a white, female social worker and long-term care administrator. The coinvestigator is a white woman with a PhD in life-span development. These factors played a role in the interpretation of the information in this study. Through these lenses, the investigators found that ombudsmen's cases related to residents' sexual expression in long-term care settings are initiated based on conflict or dissatisfaction due to risk, risk associated with dementing illnesses, limited knowledge, privacy issues, and values. Study results support the literature that found long-term care facilities do little workforce training and that few organizations have policies to support and respond to residents' sexual expression (Ehrenfeld et al., 1999; Fairchild et al., 1996; Low et al., 2005; Shuttleworth et al., 2010; Tabak & Shemesh-Kigli, 2006). Limited workforce training and policy in these settings contribute to the primary findings of conflict and dissatisfaction, and initiate the need for advocacy from long-term care ombudsmen.
Goffman's (1961) total institution theory has lent further understanding. Long-term care settings, particularly nursing homes, have much in common with total institutions (Goffman, 1961) and "people processing organizations" (Hasenfeld, 1972) where residents must comply with an institutional regime (Parkin, 1990).
A key principle of the total institutional framework is the recognition that the institution suppresses residents' civil liberties. Total institutions restrict people's rights to self-determination, autonomy, and freedom of action (Goffman, 1961). Sexuality and intimacy are human needs, which continue throughout life (Lindau et al., 2007; Miles & Parker, 1999; Reinisch, 1991), thus are considered civil liberties. Placement in an institutional setting and the vulnerabilities residents face (such as physical frailty and cognitive losses) further complicate their sexual expression. The role of the ombudsman is critical to advocate for the residents' rights.
Restrictions on residents' autonomy can be clearly seen in the example of a resident who felt that having a boyfriend was not allowed. Institutional cues resulted in the impression that an intimate relationship was against the rules. Goffman (1961) found that the total institution establishes an authority over the residents, directing their behavior, and this authority is emphasized by regulations and judgments by staff members. The results support that staff values and related judgment influence the management of residents' sexuality. Staff's attitudes and opinions on sexual expression or sexual orientation fuel conflict that may lead to ombudsman intervention. Conflicts can also arise from the values and attitudes of family members, as well as their expectations of the institution's response to residents' sexual expression.
Lack of privacy is a further institutional barrier that deters residents from being intimate. Within Goffman's (1961) total institutional framework, people's actions are under constant surveillance. In a care facility, surveillance may include the building's construction, video cameras, and periodic staff checks. Lack of privacy has been identified as a consistent barrier to residents' sexual expression (Hajjar & Kamel, 2003; Lantz, 2004; Reingold & Burros, 2004), and this study supports that finding. Staff failure to knock before entering private living quarters, semiprivate rooms, and gossip all serve as reminders of constant surveillance. Institutions justify the need for high levels of surveillance to comply with strict regulations, reduce organiza tional risk, and ensure residents' safety.
Risk and threats to residents' safety are difficulties within these settings. It is challenging to balance these threats with the ombudsman's obligation to advocacy. Protecting residents from sexual abuse or mistreatment (especially when residents have cognitive losses), working with sexual offenders living in institutions, preventing the spread of infectious disease, and the collective rights of residents in a community continue to be areas of difficulty that further support the need for third party advocates.
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