Sexuality and consent in senior centers

When we care for and accompany lives, we often have doubts about how to act in certain situations. We have been taught to take care of people's physical health and provide safe environments, but this often clashes with values such as people's autonomy to make their own decisions and live according to their own preferences and values.

It is in day-to-day life that ethical conflicts, situations or decisions arise that we do not know how to deal with. In those moments, we feel that we do not have a “right” option, and that any of the alternatives to offer seems to harm some important value of the person we are accompanying.

The nature of these situations is very diverse, for example, that diabetic people eat sweets, that a person with cognitive impairment wanders and may become disoriented and lost, the use of restraints or physical and chemical restraints to prevent falls, the refusal of medication, the use of erotic toys, consent in people with dementia, etc. Situations in which we are not clear how to act.

As there are no magic recipes or established protocols, it is important to have spaces for reflection in the teams so that decisions on these conflicts do not arise from improvisation, nor depend on the values and beliefs of one or another professional, but are argued decisions, the result of a shared reflection, and taken in a responsible and prudent manner.

When the teams consider it necessary, a good option may be to seek the advice of an ethics committee.

This is the case of the CEIS, the Ethics Committee of Social Intervention of Matia-Hurkoa, which, among its functions, offers support to the professional teams of the Matia and Hurkoa centers, and to whoever is interested, in making prudent and optimal decisions, taking into account each specific case, its context, the people involved and the values in conflict, in short, the use of deliberation as a method for making prudent decisions.

Although sexuality is something inherent to human beings, in the residential setting it continues to be an invisible subject that has hardly been discussed until very recently. This is also a new subject for those of us who make up this Committee, so in order to be able to deliberate on ethical problems related to this issue, we received basic training on sexuality and enjoyed the opportunity to consult Nerea Almazán, an expert psychologist in this area.

One of the aspects that most challenges professionals in residential centers is related to consent in sexual relations, especially when at least one of the people has dementia.

This is a very challenging and difficult issue where different key aspects need to be addressed and reflected upon:

• Protection vs sexual freedom: when faced with the doubt of whether or not there is consent the first key is the protection of the most vulnerable person, in this case the person with dementia. If there is no consent, there is sexual abuse. There is a duty of beneficence and good professional practice to prevent such situations, but, at the same time, it is important to inquire about the values of this person, to know if the relationship provides welfare and is pleasurable for him, in this case, not to limit their sexual freedom.

• Capacity to give consent: this is a very complicated point, it is very difficult to determine whether a person with dementia has the capacity to understand the situation and give consent. In this case, skills and tools are needed that are not always available to the people accompanying the person. It is essential to know the people and have communication and observation skills.

• Information, communication and confidentiality. Sexuality is still a taboo subject that is difficult to talk about naturally. The education received, or rather not received, with respect to sexuality, and its identification with genitality and coitus, means that we do not know how to start talking about the subject. Thus, we encounter professional difficulties in dealing with sexuality in the formal setting (it is argued that it is something intimate and personal). But, at the same time, it can become the center's joke, the topic of the hallway, a motive for laughter and mockery. For all these reasons, formal communication must be worked on, guaranteeing confidentiality and respecting the dignity of the people involved at three levels:

• With the persons themselves.
• With family members, even when the person with dementia has a guardian.
• Among professionals.

We can hardly accompany people if we have not worked on the issue and there is no position of the organization as a result of knowledge and reflection. We need training and tools to help us get started.

In this sense, we encourage you to discover a free training available in Matia Eskola, which invites you to reflect on the look around the sexuality of the elderly and people with functional diversity.

In short, the fact that sexuality is invisible does not mean that it does not exist. Sexuality is an important dimension of people that we have to incorporate naturally into our daily lives. Knowing the values and preferences of the people we accompany is important to be able to support them in their life project, including their sexual identity and preferences.