Conflicting agendas: the politics of sex in aged care.

• Jurisdiction: Australia
• Date: 01 January 2016
• Author: Rahn, Alison,Jones, Tiffany,Bennett, Cary,Lykins, Amy
• Published date: 01 January 2016
• Author: Rahn, Alison

2. INTRODUCTION

   Sexuality in aged care environments is a fraught topic. Traditionally, aged care providers have determined moral standards and 'acceptable' behaviours in their facilities. However, some politicians and professionals have argued that aged care residents have the same civil rights as all citizens (1) and have advocated for residents' sexual relationships to be respected and accommodated. (2) Some contend that cultural change is long overdue and will only happen if the Government legislates for providers to actively protect residents' sexual relationships by training staff to respond appropriately and compassionately to residents' sexual expressions. (3) What prevents this from happening?

   A review of the literature suggests entrenched cultural patterns in aged care practice have their roots in colonial institutions. This article begins by briefly reviewing current problems faced by partnered residents, followed by an historical overview of institutional aged care in Australia, tracing recurrent themes and persistent problems for couples. With this background, discussion turns to the history of attempted reforms to protect couples and the corresponding political debates in the period 1974 to 2015.

2. Partnered residents--the current situation

   Some Australian residential aged care facilities still segregate sexes, including married couples (4) and many ignore the needs of lesbian, gay, bisexual, transgender and intersex residents. (5) The experience of de facto couples is unclear, however, one might reasonably assume they face similar discrimination.

   In 2011, 21 per cent of women and 44 per cent of men in residential aged care facilities self-identified as being married or in a de facto relationship. (6) It is unknown how many couples entered care together. The majority of facilities lack formal policies or practice guidelines stating their position on residents' expressing themselves sexually. (7) Research also indicates that the physical environment within facilities influences residents' ability to freely conduct their intimate relationships by either enabling or restricting intimate activities. (8)

   Currently, no government policy addresses the sexual needs of aged care residents, especially couples. Some experts believe the aged care sector is unlikely to address this situation without proscriptive legislated measures in place to direct them. (9)

   Van den Hoonaard (10) has identified systemic ageism in Australia's aged care system. Butler (11) defines 'ageism' as a combination of three connected elements: prejudicial or derogatory attitudes; discriminatory practices; and institutional practices and policies perpetuating ageist stereotypes. This article considers all three elements.

   Ageism is evident in the lack of attention to residents' privacy needs, which manifests in invasive practices by some providers. Examples include 'open door' policies (where residents' doors are kept open at all times), housing partners either in separate rooms or in single beds only (refusing to push couples' beds together), staff entering residents' rooms without knocking, ignoring 'do not disturb signs', management refusing to put locks on doors, and staff gossiping about residents. (12) These practices originate from conservative ageist attitudes and past paradigms of aged care.

2. Historical Context

   The Australian residential aged care facility is a post-World War Two phenomenon. (13) Previously, institutions mainly took the form of large generic asylums for society's refugees, predominantly funded by churches and charitable organisations. (14) They were places of 'overcrowding and misery' where 'incarceration almost invariably meant the separation of married couples'. (15) People of all ages were fed and housed in military-like barracks. (16) Asylums operated as totalitarian regimes (17) or 'total institutions', (18) exercising social control through 'rules, routines, and the fabric of the institutions' (19) in tandem with systems of surveillance and discipline. (20)

   By the 1930s, dedicated institutions for the aged had emerged. Asylums evolved into 'nursing homes', 'geriatric hospitals' and 'convalescent homes'. The discourse shifted from 'incarceration' and 'inmates' to 'care' and 'patients'. Old age became medicalised, requiring nurses in attendance 24 hours a day. (21)

   For couples, aged care began emerging from the 'dark ages' in the 1950s. A new political narrative was winning favour--that institutions be more 'homelike'. By 1952 there were '140 semi-charitable organisations providing pensioner housing'. (22) Hostel accommodation emerged as an alternative to nursing homes, offering supported housing for those not requiring nursing care. As Dargavel and Kendig note: ' [c]ouples as well as single aged persons were eligible, thus overcoming the problem of couples being separated by admission to an institution, many of which separated males and females'. (23)

   Services offered included meals, cleaning, bathing, and dressing. (24) Demand outstripped supply, (25) resulting in the Aged Persons' Homes Act 1954, which provided capital funding for not-for-profit 'churches and recognized charitable bodies and institutions to assist them in providing homes for aged people'. (26) This legislation remains unique by explicitly seeking to protect married couples:

   The purpose of this Act is to encourage and assist the provision of suitable homes for aged persons, and in particular homes at which aged persons may reside in conditions approaching as nearly as possible normal domestic life, and, in the case of married people, with proper regard to the companionship of husband and wife. (27) II. RECURRENT SYSTEMIC PROBLEMS

   From this brief historical review, we now turn to four recurrent historical patterns that continue to interfere in residents' intimate relationships.

2. Dehumanisation

   Dehumanisation means to 'deprive of human characteristics' or to 'make impersonal or machinelike'. (28) Residents may become dehumanised in a myriad of ways. Examples include being viewed as objects rather than people; negative staff attitudes or ageist beliefs; rigid routines that dominate daily life in the institution; and rosters and staff ratios that allow little time for staff to develop relationships with residents. (29) The likelihood of dehumanisation tends to increase in larger institutions.

   Some argue that the language we use, such as 'facility' and 'care recipient' dehumanises older people. (30) There have been disturbing national and international examples of dehumanisation of aged care residents in recent years. In the period 2012 to 2015, there were at least 35 reported instances in the United States of staff sharing degrading photos on social media, in which residents were partially or totally naked. (31) A recent example in Australia involved staff photographing residents' genitals and deriving amusement by guessing which resident the genitals belonged to. (32) Other dehumanising practices in some Australian institutions include photographic documentation of residents' wounds without regard to their bodily privacy and one particular style of bed bath (where, for convenience, residents are reportedly stripped off, placed in a defenceless position, stark naked, on their back, in an inflatable bath on a trolley and hosed down by a staff member, sometimes in view of other people). (33)

2. Surveillance

   Surveillance in modem nursing homes often resembles the 'disciplinary space' of 19th century institutions, allowing staff 'to be able at each moment to supervise the conduct of each individual'. (34) In such institutions individuals were isolated and distributed with gatekeepers strategically placed to surveil their activities. (35) Currently, many staff characterise residents as 'frail, dependent, and in need of constant supervision'. (36) Rooms are often shared, distributed along long corridors, with doors kept open. Hallways busy with residents, staff, and visitors are visible from a central nursing station (37) or from surveillance cameras. (38) A disturbing trend in America is the increasingly common practice of installing surveillance cameras in residents' rooms. (39) Some are calling for similar measures in Australia, (40) resulting in ethical guidelines having been formulated. (41) In such an environment 'couples can encounter difficulty when trying to find a time and place to be intimate'. (42) They are limited by lack of privacy (43) or private space, especially 'couple space'.

3. Management and social control

   Institutions exercise social control through management structures and building design. The term 'facility' speaks of this, meaning 'a place, amenity, or piece of equipment provided for a particular purpose', which derives from the French facilite, or Latin facilitas, meaning 'easy'. (44) In other words an aged care facility is designed to make care of the aged easy to manage.

   Sexuality is one of the most controlled aspects of human behaviour within institutions. As a result, it has been actively repressed and silenced 'to constrain severely the powerful sexual impulse in order to maintain social stability'. (45) Given that a person's sexuality is fundamental to their identity, (46) denying it creates one of two reactions: (1) a compliant, withdrawn, non-person who is easy to manage, (47) or (2) a person who acts out in 'inappropriate' ways due to sexual frustration. Experts report that assessing people's sexual and physical contact needs and including solutions in their care plan reduces unwanted behaviours and leads to happier outcomes for both residents and staff. (48)

   In residential aged care facilities, sexuality is controlled largely through various preventative measures, including leaving residents' doors open, (49) separation of couples, (50) and chemical restraint to reduce sexual desire (examples include oestrogen injections, androgen reducing medications, and antipsychotics). (51)

4. Contested spaces

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