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Attitudes about Sexuality & Aging

Episode #74August 31, 2021


Our attitudes about sexuality & aging may influence an older adults’ sexual health.

Researchers¹ have found that sex among older adults is often viewed as stereotypically “shameful, disgusting, laughable, and nonexistent”, which can lead to internalized stigma and increased sexual problems for older adults. To date, much of the research on aging sexuality issues has been conducted with healthcare providers who serve an aging population, including long-term care staff, and have found mixed results on permissive versus restrictive attitudes of staff.  Current research¹ and healthcare policies also suggest that aging stigma is present within healthcare institutions where aging sexual concerns are often underreported, ignored, and left untreated.

In fact, a recent survey² of more than 1,000 adults between 65-80 years old, found that 50.9% of men and 30.8% of women reported being sexually active. In this same survey, when it came to discussing sexual health with health care providers, however, only 17.3% of adults aged 65–80 reported speaking to their health care provider about sexual health in the past two years and of those, the vast majority (60.5%) initiated the conversation².

On the contrary, research conducted in community samples of older adults¹, are finding that sexual stigma beliefs may NOT be as prevalent among the general population as cohorts become more sexually liberal over time. For example, as the Baby Boomers move into older adulthood and replace previous generations, they bring a more sexually liberal belief system that also places a higher importance on sexual well-being¹

So, in an effort to help mental health, senior care, and health care providers reflect on our own values and attitudes, I interview sexual health and aging expert, Dr. Maggie Syme.

In this interview Dr. Maggie Syme and I discuss:

  • What it means to be a sexual citizen
  • Attitudes about sexuality and aging
  • Current research on intimacy and aging
  • Benefits of sexuality and intimacy in older adulthood
  • Dementia and sexual expression
  • What sexual liberation looks like for older adults

About Maggie Syme, PhD, MPH

Maggie L. Syme, PhD, MPH is currently a Project Director at Hebrew SeniorLife Marcus Institute for Aging. Her research has focused on sexual health and wellness in later life, specifically on issues related to sexual consent and ageism. Prior to her current Project Director role, Dr. Syme was an Associate Professor and Associate Director of Research at Kansas State University Center on Aging. Contact Dr. Syme at [email protected]

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References & Articles Mentioned in Episode

  • ¹Syme, M. L., & Cohn, T. J. (2016). Examining aging sexual stigma attitudes among adults by gender, age, and generational status. Aging & mental health20(1), 36–45.
  • Allison G. Smith, Shoshana H. Bardach, Justin M. Barber, Andrea Williams, Elizabeth K. Rhodus, Kelly K. Parsons & Gregory A. Jicha (2021) Associations of Future Cognitive Decline with Sexual Satisfaction among Married Older Adults, Clinical Gerontologist, 44:3, 345-353, DOI: 10.1080/07317115.2021.1887420
  • Hillman, J. (2017). Sexual consent capacity: Ethical issues and challenges in long-term care. Clinical Gerontologist: The Journal of Aging and Mental Health, 40(1), 43–50.
  • Henry Rayhons Case:
  • Hebrew Home Life: Sexual Health policy:

Dr. Maggie Syme 0:00

It's a worthwhile conversation, right? Because we're hoping that we encourage and empower a group of folks who have benefits there on the table to take them up, right. And some of those benefits are social connection and a way a particular way in which you can connect socially which has been found to be different than just friendship, there are additional benefits that social connection of sexuality or sexual intimacy has even on longevity, right. So we know that the more socially connected you are, the longer you live in, there are probably a million different pathways in which that mechanism happens. But I wouldn't doubt that some of them are biological. So there are a lot of protective factors among that that can be captured by having these sexual intimate relationships with other folk. Also, there are some tangible physical benefits. Or there have been studies that have shown that even pain sensitivity decreases, the more frequently someone engages in what I would consider healthy sexual experiences, which are chosen, you know, reciprocated experiences that are wanted, and beneficial, mutually beneficial. There are also mental health benefits. So there have been studies shown that your well being or your positive mental health qualities increase your quality of life, self reported quality of life can increase, certainly your relationship quality with whomever you have a sexual relationship with in can be enhanced by that intimate connection. So and there are a lot more I mean, there's some really interesting studies about even the potential for cognitive reserve and cognitive. Sort of, I don't know if it I wouldn't say it's gross, but protection against cognitive deficits that you can have from a longer term, both intimate and physically intimate relationship.

Dr. Regina Koepp 2:05

I'm Dr. Regina Koepp. I'm a clinical geropsychologist, which means that I'm a psychologist who specializes with older adults and families. And this is the psychology of aging podcast, your go to resource for mental health, and aging.

Dr. Regina Koepp 2:24

Today's podcast episode is all about attitudes about sexuality and aging, and some facts about intimacy and aging and sexuality and older adulthood. It's important to know that our attitudes about sexuality and aging might actually influence and older adults sexual health. So researchers have found that sex among older adults, is often viewed very stereotypically as shameful, disgusting, laughable, and even non existent. And of course, these views are wrong, and can lead to internalized stigma and increased sexual problems for older adults. Even during this episode, in this interview with Dr. Maggie Syme, I share an example of a clinical example of a sex being denied to an older adult, even in their own personal, private sex life as an example of non existent sex, or you shouldn't be thinking about that at your age. And of course, when we internalized stigma, stigma related to later life, sexuality actually has harmful effects for older adults. Much of the research has been done in healthcare systems and long term care communities related to sexuality and aging. And what research has found is that there are incredibly mixed results on permissive versus restrictive attitudes about sexuality and aging. Current research and health care policies also suggest that aging stigma specifically related to sexual expression is present within healthcare institutions. We're aging sexual concerns are often under reported, ignored and left untreated. And that gives us some information about what is valued among staff as it relates to older adults. So are older adults actually having sex in a recent survey of more than 1000 adults between 65 and 80 years old, and this was published in 2021. And today's guest and I talked about this. This survey found that close to 51% of men and close to 31% of women report being sexually active and this same survey when it came to discussing sexual health with health care providers. Only 17.3 of adults 65 to 80 reported speaking to their health care provider about sexual health in the past two years. And of those, the vast majority like close to 61% initiated that conversation.

Dr. Regina Koepp 5:22

Okay, so now researchers and one of those researchers is today's guest conducted a community sample of older adults to see so do older adults in the community, not staff, not health care providers, just general older adults living in the community. What sort of sexual stigma beliefs do they hold? And what researchers found? One of those researchers, like I said, being today's guest found that beliefs that stigmatize sexuality and aging might not be as prevalent in the general population of older adults, as it is in healthcare systems and in long term care communities. And that's an interesting phenomenon. Researchers are attributing this to baby boomers moving into older adulthood and replacing previous generations. And of course, baby boomers, bringing a more sexually liberal belief system that places higher importance on sexual well being. And of course, that's a broad generalization about a cohort, right? But we know with the hippie movement, I was a child of the hippie movement. my middle name is moon, it was born in Switzerland, in the Alps to American parents. It was an interesting time, there was a lot more sexual liberation. Okay, now, let me tell you about today's guest, and what we're going to talk about today. So today's guest is Dr. Maggie Syme. She's currently a project director at Hebrew senior life Marcus Institute for aging. Her research has focused on sexual health and wellness and later life and specifically on issues related to sexual consent and ageism. Prior to her current project director role, Dr. Sign was an associate professor and Associate Director of Research at Kansas State University Center on Aging. Today, Dr. Syme I talk about what it means to be a sexual citizen, attitudes about sexuality and aging, current research on intimacy and aging benefits, we talk about the benefits of sexuality and intimacy and older adulthood. We talk about my favorite topic, which is dementia and sexual expression, and what sexual liberation looks like for older adults. All right, let's jump into this interview with Dr. Maggie Syme. Can you share a little bit about where you come from and where you're at now?

Dr. Maggie Syme 8:01

Absolutely. So I am a farmer's daughter. I grew up in the rural list of rural Montana's that you can get in the corner up by Canada and North Dakota. I think there's less than 2000 people in the town that was seven miles away right now. I graduated one of six from a private high school in the area. So humble beginnings, maybe. But it makes a lot of sense to me when I think about my journey to Jarrow, because that's who our people were right. Like I spent most of my younger life in the spaces of older adults at my grandmother's house. It was a gathering place for the community. She had coffee ladies, who would come over probably at least once a week, if not just drop in periodically. And you know, our community events were centered around the older generation. There's just a sense of comfort, ease and really simpatico way of communicating for me and older adults. And I think it goes all the way back to that. So for 18 years, I lived in small town, Montana, and then moved to Spokane, Washington for college and from there just got bigger and bigger. No la San Diego Boston. Man I did spend some time back in small town America and Kansas for sure. Rock Chalk and landed back here in Boston after I was in fellowship here. Really just chasing the aging world. I mean, there are a few spaces in I think the US where aging is kind of the place to be. And Boston was one of them for me. So that's really where I ended backup and I'm really happy to be here because they're, I mean if you want it's like a candy store for aging professionals. If you want to work at it oh Fenway health and get into LGBT older adult work, I mean, Nick community clinics and or if you want Harvard, you know, and it's just all levels. So

Dr. Regina Koepp 10:14

tell us about your current position, because you said you're a project director. Tell us a little bit about being in Boston, in your current position.

Dr. Maggie Syme 10:24

Yeah. So I'm a project director right now at the Marcus aging Institute. In Hebrew senior life, I was shortly before this associate professor and decided that that wasn't the life for me in work, I think, who I am professionally is part researcher, but bigger part advocate. And being an aging, that's a perfect fit, right, because we're constantly talking about rights of older adults and values and recognition for a group of folks who are really under appreciated and recognized and discriminated against in a lot of spaces. So I didn't get enough of the advocacy part, a little bit of the research and too much bureaucracy. And I decided I wanted to do more research, but feel like it had more of an advocacy bent like working for research institute that was moving the dial forward for older adults who were underserved. And these folks specifically work in the nursing home setting. So that will, the one of the most vulnerable places we could get, let's do it. So...

Dr. Regina Koepp 11:34

and where rights need to be honored and protected.

Dr. Maggie Syme 11:38

Exactly. And it was during COVID. So even more, so a stark contrast between who matters and who doesn't. And even in aging. The folks that matter the least, were the folks in the nursing home. So that was a good place for me to be professionally.

Dr. Regina Koepp 11:56

Well, thank you for doing this important work. And I hope it meets your your professional and personal goals and needs,

Dr. Maggie Syme 12:05

You know, someday I don't think I'll do research at all. And I'll just be in a nonprofit somewhere, using those skills, those analytic skills, you know, to look at patterns in existing data and tell people like this is what you should be doing to making your agenda more visible and getting more rights for hopefully older adults.That would be like a dream job.

Dr. Regina Koepp 12:29

And speaking of research and advocacy and rights, one of your areas of specialty and research and which may be culminated maybe didn't but was represented at least in a recent clinical gerontologist journal was on sexual health rights and sex rights for older adults. So the clinical gerontologist is a scientific journal that is peer reviewed, I've reviewed some of the cannabis articles, actually, so many caregivers are using cannabis and wanting more information. And I didn't have that information. So I said, Well, I'll review and look, keep learning. But so there was a recent special issue, which is volume 44, that came out just last month or in 2021. And it's called a sexuality in later life. And you were the editor of this particular journal. And I wanted to highlight something that you you opened that that journal saying, which was talking about sexual citizens, and so if it's okay with you, I'm going to just quote you, and I think quoting somebody else, so yeah, quote of a quote, a quote of a quote, yeah. It's like a parentheses within a parentheses. Yes. Okay. So here we go. And, and it was one of the first times I had and maybe I just have skipped by it before, but the term sexual citizen, and I really enjoy it, and I wanted, I want to just to share it with everybody. So you write in in even the first paragraph here, sexual wellness is part of the tapestry of mental health and covers psychological, cognitive and physical benefits throughout older age. However, wellness is unattainable without first granting sexual rights that are integral to being a sexual citizen in this culture, defined as, quote, control over one's body feelings, relationships, access to representations, relationships, public and public and socially grounded choices. And that was the end quote by Plummer from 1995. Anybody can get access to this first page, and I'll make sure that there's a link to it in the show notes, but can you talk a little bit about how important it is or sexual citizenship, how important it is for older adults and and maybe start this conversation around sexuality and aging and advocacy?

Dr. Maggie Syme 14:55

Yeah, absolutely. I think if we look at The research that's been done the scant amount that's been done probably in the tour maybe three decades before this, I think a lot of it was just descriptive like, oh, wow, let's just this is happening. And here's a little bit of information about who's engaging and what, what's hot, what kinds of things predict, like function or not. And they, they're, they're small but growing section, and people said, We wait a minute, like you're describing a phenomena that is couched in a context of oppression, right, like, older adults are not seen as sexual citizens, if you take the the definition that I have, and you're describing something that is a proxy of what it could be, because we put these constraints around it. So let's talk about those constraints, and how they've shaped what we view as, you know, acceptable older adult sexuality in this box, in what it could be, if we actually opened up their rights to full citizenship in the different spaces that they occupy. So I think that's where I began in the descriptive zone too, because that's, you know, what everybody was doing. And I think one of the first articles I published was literally like what predicts this type of experience or not, and a bunch of different factors, but then you run into people in your life and different experiences that you have, and you're like, wow, I missed the boat on that, I better back it up. And then you find out that other people are doing that, too, which is what I found, and there was some folks at the University of New Zealand or Massey University in New Zealand, Paul Simpson, in particular, who's been publishing more sociological or socio cultural criticisms about how we view aging sexuality, and in particular, in a nursing home context. And he used the sexual citizenship as kind of that this is what everybody should have, and put that frame around. And it really made sense to me. And all of the things that I was reading about ageism, and internalized ageism, outside of the sexuality literature. It just everything started to fit in this narrative of, well, what don't? What constraints are there that are producing these snapshots that we have? And how can we alter the context? And what might that do for what we really could achieve?

Dr. Regina Koepp 17:38

Let's talk about some of those ageist... where the sexuality and ageism intersect. What are some of those snapshots? So some that I'm aware of are unfamiliar with our older adults are no longer sexual, like people being repulsed by imagining older people having sex? What other snapshots (stereotypes) come to mind?

Dr. Maggie Syme 18:01

Well, it's definitely older people shouldn't be having sex. So there's a value judgment on that, like you said, there's an you factor or just uncomfortable No, no, no, no around that. There's that they can't write that they're physically incapable Endor mentally incapable, because that sort of edges on that myth of all older adults are frail and demented. And, you know, those kind of fit together with they don't have sex, they can't have sex, and then they don't want to have sex, right? So your desire is gone. Nobody finds older people attractive. That's definitely one of those circles of myths in aging sexuality, and that there are these only certain acceptable ways, right? That older adults can be sexual, and that is mostly to be laughed at, made fun of or be disgusted by. So we have kind of these tropes, right of the older, dirty old man, right, and the cougar woman, which you might think would have been empowering, but the way in which it's depicted is not empowering, right? These women are predators. They're doing things they shouldn't be doing it their age, their sexuality isn't being celebrated. It's being mocked. So...

Dr. Regina Koepp 19:22

And dehumanized. Equating it to animal behavior.

Dr. Maggie Syme 19:27

Yeah. And the other sort of intersection. That's pretty stark, I guess you have it a little bit is that women older women are very much more like double, triple jeopardized in these ways because they're held to a different sexual standard in life, but also an older age, right? So we have Viagra for men. We have no such thing for woman for women. They after reproductive age, right aren't supposed to enjoy sex, because that's not more acceptable. And so we have a lot of those who have already existing gender depictions that just amplify into old age. So women tend to be at a higher disadvantage than older men, although, you know, name your disadvantaged group intersect that with aging. And it's probably not great for them. They're, you know, this many ticks back behind the charmed circle of sexuality

Dr. Regina Koepp 20:28

Right, which is heterosexual men. Cis-gender

Dr. Maggie Syme 20:31

Yep, cisgender cisgender, young, fit, beautiful, you name those. And, you know, you don't ever really get close to old, when you think about acceptable ways that society to find sex, there are acceptable ways for women to have sex or acceptable ways for men to have sex most of the time. It's as you defined in those spaces of hetero normative, says, normative age young normative and beauty norms in then, and often, I mean, getting a little less so but it used to be marriage, right, like, or a committed relationship was the way in which it had to be defined, which checks out quite a large number of folk who weren't interested in either second relationships or any part long term partnerships. And that might be more the case for some older groups and others too.

Dr. Regina Koepp 21:29

Right. So then they're left entirely out of the conversation in the journal that we were mentioning early on one of the articles, which was entitled interest in sex and conversations about sexual health with health care providers among older US adults. they surveyed more than 1000 people between the ages of 65 and 80, and found that 50.9% of men and 30.8% of women reported being sexually active, yet 17.3% of those surveyed, reported speaking to their health care provider about sexual health and the past two years. And of those people of that 17.3%. They're their providers, were not the person who would initiate the conversation 60.5% of the time, patients initiated the conversation. And so I like to give statistics about how often older adults are indeed having sex. So those are adults between 65 and 80. There are other studies that show that yes, you know, older adults remain sexually active. And so I'm wondering if we could have a conversation about what some of the benefits of sexual activity are in older adulthood. And and then maybe talk about what older adults and health and mental health and senior care providers can do to initiate these kinds of conversations, so that the ball is not always in the older adults' court.

Dr. Maggie Syme 22:58

Yeah. Well, you're right. It's, it's a worthwhile conversation, right? Because we're hoping that we encourage and empower a group of folks who have benefits there on the table to take them up, right. And some of those benefits are social connection and a way a particular way in which you can connect socially which has been found to be different than just friendship, there are additional benefits that social connection of sexuality or sexual intimacy has even on longevity, right. So we know that the more socially connected you are, the longer you live in, there are probably a million different pathways in which that mechanism happens. But I wouldn't doubt that some of them are biological. So there are a lot of protective factors among that that can be captured by having these sexual intimate relationships with other folk. Also, there are some tangible physical benefits. Or there have been studies that have shown that even pain sensitivity decreases, the more frequently someone engages in what I would consider healthy sexual experiences, which are chosen, you know, reciprocated experiences that are wanted, and beneficial, mutually beneficial. There are also mental health benefits. So there have been studies shown that your well being or your positive mental health qualities, increase your quality of life, self reported quality of life can increase, certainly your relationship quality with whomever you have a sexual relationship with in can be enhanced by that intimate connection. So and there are a lot more I mean, there's some really interesting studies about even the potential for cognitive reserve and cognitive. Sort of, I don't know if it's, I wouldn't say it's growth but protection against cognitive deficits that you can have from a longer term, both intimate Physically intimate relationship? Again, exact mechanisms not known yet. But we do know that folks who don't do those things tend not to have these benefits at the highest level, that folks who do have these sexual experiences still do.

Dr. Regina Koepp 25:18

There was an article from another gerontology journal, maybe a year and a half or two years ago, reported that people who were sexually active also scored better on cognitive screeners. Yes, you know, the healthier our heart is, the healthier our brain is, generally, there's so much correlation, if you're physically able to have intercourse and engage in a physical sexuality, then, you know, might be healthy for your heart, and then that also is healthy for your brain. What are your thoughts about that?

Dr. Maggie Syme 25:52

Well, I would say absolutely, I think that there are so many ways in which sex sex is like a cacophony of experiences for your body and mind, right, it's not just increased blood flow, which could help with all kinds of different cardiovascular conditions, which has also been found right to increase your cardiovascular health or be associated with increased cardiovascular health, it's, it has bet you get better sleep, you know, for your brain, which is intensely good for your brain, your social relationships, again, you get those positive benefits from so you've got I want to say chemicals in your brain to make it at least accessible for people chemicals in your brain that are pumping through there, that increase your wellness, and your physical wellness and your brain health. And there's motional and intimate connection, and feelings of sexual self esteem, that are feeding into all of these different parts of your brain, in your body in your mind, and that are likely going to produce long standing benefits. So it doesn't surprise me that folks who are able to enjoy and engage in healthy sexual experiences for longer across their lifespan are building better brain health, or at least potentially benefiting from a baseline good brain health and then being able to build on to that. Yeah.

Dr. Regina Koepp 27:20

Another article from the journal that you edited. Thank you. Entitled associations of future cognitive decline with sexual satisfaction among married older adults reported that it was a 10 year study. And so over the 10 year study period, 33.5% of individuals developed cognitive impairment, but participants with greater sexual satisfaction scores at baseline, at the beginning of that 10 year study, were statistically less likely to convert from cognitively intact to mild cognitive impairment, or dementia in the future. And so that, again, was people with greater sexual satisfaction scores. And the study at the beginning of 10 years, were less likely to convert to mild cognitive impairment or dementia, just some other benefits. And yeah, back to that. And I wonder about like, having a purpose filled life and this sense of connection and desirability, and I'm lovable I'm, and what are your thoughts about that?

Dr. Maggie Syme 28:26

I would agree that that's a key factor in that. So it's not just all of those physical ways in which you know, your blood, your brain chemicals, and all of those things, and I'm sure that they're involved. But there is this huge faction of things about sexuality that is psycho sexual, right, so cognitive, and cognitive conceptions of yourself. And if you're sexual and desirable, and seen as that, and lovable, all of those things make a huge deal to our lives and the way in which we live them as a result, right. So we know that depressed individuals or individuals who have less mental health, don't, aren't as active, don't do as many things for themselves that are protective. So building up those psychosexual various things in your life is going to be highly protective because I think when you have experiences that poke a little bit at that, the stronger it is, the more resilient you are to those and then the more likely you are to continue those healthy experiences or pursue another healthy experience. If you didn't just tank your sexual self esteem because it was tiny, because you've never heard in your life that older women are beautiful, or older men are lovable. You know, it's, I think that you have to build those things up. You have to build those muscles in your life to keep them going because you're gonna get an onslaught of you don't belong here. This isn't an experience for you. coming out from society. So the stronger intra-individual things that we can build up, the better off we're going to be for sustaining sexual health across the lifespan.

Dr. Regina Koepp 30:12

And even you know, getting those messages from society, including young people in society, I worked with a family, once where, I was embedded in a primary care clinic. So I only saw this family once. The old an older man had come to live with his adult daughter, and from another state. And I was meeting with him one on one, he was telling me he was lonely. And, you know, I inquired about his sexual satisfaction, I think that was relevant to what we were talking about. And he said that he would like some magazines or something to help with his own personal sex life. And, and I asked him if he would like for me to help him have a conversation with his daughter about that he didn't drive he didn't have access, it was a new community for him. He said, Yes, please, would you and I asked, Would you like to be there in that conversation? Would you like me to talk with her privately? How would you like that to go? He wanted me to talk with her privately. I presented it to her, she refused. And I asked him, you know, I went back and shared with him the results. They had different levels of religiosity and values in that regard. And I shared with him, you know, can I help you brainstorm other ways to get access to this material? And he, I think, was defeated, and and said, No, I asked, Would you like to come back and see me? No. And, and then I never saw the family again. And I, and I just think, you know, so many, there's so many transitions in his life, to move from one state to another to move from independent living to living with an adult child. And then now from moving from a sexual being to, this is no longer an option for you, or we don't value it anymore. And, and just these, the sort of litany of losses and transitions for him. And, and then I didn't know what came up. But my hope is that somehow it worked out for him. But but at times, I'm cynical, so I don't know that it did. But that was my wish anyway, that he would find a way to have you encountered other situations like that.

Dr. Maggie Syme 32:29

Yeah, not as much personally, clinically, as I have through stories of folks that I've worked with in different caretakers, actually in care homes, who've bless their hearts been very proactive and wanting to do what they could but came up against kind of the machine, right, the system who either said no, or you run into very paternalistic folks who want their wishes to be their parents wishes or their residents wishes, depending on the setting you're in. And it is very frustrating, because it's another one of those experiences where we've stripped rights for or failed to give sexual citizenship to people in in in, you know, in an age liberated world, that wouldn't be the case, right? Because people wouldn't have conceptions about those things. You know, but also, I think part of it has to be the sort of culture that is America, you know, and when you think about this, in places that potentially where you grew up in Switzerland, and were folk in like Amsterdam, you know, talk to people who are caregivers in work in nursing homes there. And I know they'll hire sex workers for folks and they'll not blink an eye about buying a magazine or getting it to people because they don't see a value in consistent thing there there isn't this a just overlying conception, that this should not be done? Or whatever is, you know, you're going to layer on top of ages. So think that's another hard take on this is that we live in a particular context in which we're further away from those realities than a lot of other places in the world. And it really is those individuals like yourself and like the folks who tell me these stories who are fighting the good fight, right, trying to find ways to empower folks and have them live out their values versus live someone else's value system. Yeah.

Dr. Regina Koepp 34:39

I know before the call we were also talking about sexual expression in the context of dementia. And with that in the context of diminished capacity, because as the illness course of dementia progresses, people often will lose capacity to make certain decisions about their lives and maintain Other access to other decision making and often sexual decision making can maintain even after we lose capacity to drive or lose capacity to, you know, manage our finances or, or vote. And so we can. And so I know you and I both have a real shared passion in that topic of sexual expression in the context of diminished capacity, even dementia. And this is where I think ageism and ableism also really intersect. But some research shows that adult children tend to be less encouraging or affirming of their parent with dementia, engaging in a sexual relationship than a spouse, even. And, and, and I think that's just a kind of another example of that paternalistic sort of point of view and removing some of the citizenship from the person,

Dr. Maggie Syme 36:00

it's a difficult place to be navigating a nursing home and rights. And we know that they're extremely highly regulated organizations and often get dinged for things that I would have told them to do in terms of pricing people's sexual citizenship, or social or intimate citizenship. And I know that that's a difficult place to be. And I have a lot of respect for folks who go into that and try to live the Person Centered Care life with for their, with their residents. And sex is a really sticky issue in in a lot of nursing homes. But, you know, I think it's partially as you said, the way we think about it, it's not, can you have sex? Or can you not have sex code that coincides with Can you make decisions versus Can you not make decisions? I think what I'm trying to help people understand is that you can answer those questions differently for everybody. And there is always some level of intimacy in which the risk is low enough to be able to let someone engage. So maybe they have diminished capacity, as you mentioned, and like you said, I mean, I don't think that it's the same level of decision to say, I'd like to take away my life saving medications versus I'd like to kiss that guy, you know, I mean, those are different decisions with different timings and very premeditated on one end, and not at all in in the moment on one. So how can we say that the same exact capacities rule over those types of decisions would be like, well, I guess they can't decide what they want to eat either, even though they're sitting in front of the hamburgers, like, so. We need to think about this in a little more malleable sense. If they can't, if they're losing cognitive capabilities that maybe keep them from making the highest level of risk decisions, the things that probably should be slightly more premeditated, like, should I have unprotected sex with him? Because I think we've talked about our sexual history. And we're both have tests and we're clean. Okay, that's something that might happen in the real world. That's risky, but people reason through it. But oftentimes, we're just talking about things like holding hands, or seeking out intimate contact. And I don't think that that requires the same capability. So if you're found to not have these capabilities, fine. But what can you do on the spectrum that's low enough and risk in terms of expression, that fulfills the need to connect and to be intimate with someone, maybe yourself, but it's at low enough risk, and that's what we're about here is the most, you can do at the least at the most manageable level of risk. Now, we say this, there is no no risk situation, I know that a nursing home doesn't want to hear that because they want there to be a no risk situation. There's a risk in getting out of bed, there's a risk in picking up before there's a risk in getting into the assisted bath. There are no no risk situation. So why are you holding sex to this standard? Or intimacy? There is a more nuanced way to think about this. And these two ideas of can they engage in this or what can they engage in? And what kind of capacity Do they have cognitively are, you know, affect each other, but they're not like this, which most people want? And I think there is no black and white either yes or no, it's okay. Well, they can't maybe make this complex decision, but they could make this complex of a decision. So in that level of expression, where might the risk be most manageable That they're that they're seeking out an expression. And that's a harder question to answer, right? It takes a team, it takes loads of observation, it takes nuance, it isn't as easy as Nope, move him to the other wing so that those two can't get together. That's an easier decision. But it's not a resident centered decision, it is not affording people sexual citizenship, it is revoking sexual citizenship, which most nursing homes tend to do by default.

Dr. Regina Koepp 40:33

And so cruel. I mean, there are so many benefits even with and there are certainly risks with dementia and sexuality, of course, especially if there's hypersexuality, with dysregulation because of the disease process and all of that. But, you know, there are also studies that show that it decreases behavioral agitation, that intimacy promotes quality of life for people living with dementia, all sorts of benefits, in addition to risks.

Dr. Maggie Syme 41:00

Yeah. And we're not asking people to become experts in how to do this. But I would argue that you already have the skills to assess risk, and to mitigate risk and manage behavior. You do it in other realms, this is just the most difficult because it involves so many. And it is harder to do. But everybody has the capability to do it. And I'm just asking you not to just say, No, I'm asking you to think about it before you and make a individualized plan as opposed to nobody not in this place. I can't deal with it, you know?

Dr. Regina Koepp 41:45

Right. Right. Right. Yes, I've heard that before. I even think you know, people have, and I do appreciate that in the context of diminished capacity. This, this is a wish, but my, you know, even highly educated physicians, I know, have had unprotected sex, you know, knowing that it's high risk. And I think that, you know, we are all we all make risky decisions driving, you know, if we don't snap our seatbelt right away, or if we eat a doughnut with diabetes,

Dr. Maggie Syme 42:20

If you drink a coffee, while you're driving in the car, you've just heightened your risk

Dr. Regina Koepp 42:27

So I think we do also hold these standards that are like, well, I suspect most of the people sitting around the table have done something risky sexually. Maybe you're not disclosing that, but but, you know, we all have our own histories with this. And, and that we're allowed to make bad decisions or unhealthy decisions and learn from them. I think, sometimes, you know, we have so much of a desire and the regulatory, you know, the system is real in terms of regulation and citations and for for long term care communities or nursing home communities. So I don't want to I don't want to minimize that, because I also know, you know, I don't know, a place to lose their license or, or something. Sure. And then they have a responsibility to protect the safety of other residents. And if somebody is hyper sexual, and, and is non consensual, because of impaired judgment or something with dementia, you know, that's also complicated. So I, I also was thinking I was presenting on this, and my husband had the idea, well, maybe we should just have a sexual Advanced Directive, like if people just created their advanced directives before they had dementia. Wouldn't that be cool? And then I was reading, do you know, hilman? damage? The reset? Yeah, I don't know her personally. But I was reading one of her articles from 2017. And she mentioned this, I think it was in her article, and she said, Well, you know, that seems like a good idea on the surface. But, but one of the challenges is with sexual consent is then you're in the middle of it. And maybe you're okay with this particular person touching you in this particular place. But maybe you're not okay, with this particular person touching you in this other place. And that happens, you know, in an instance, not an advanced directive.

Dr. Maggie Syme 44:14

Yeah. You know, I think there has been often on this idea thrown around right about a sexual advance directive. And there been a couple of pieces, interestingly, by in the legal arena about like their feasibility and things like that, particularly after the re hands case in Iowa. And that being such a high national profile case, and I think the bottom line is, you're correct, there's so much nuance to it, that it would be difficult in advance directives, in general are a bit of a sticky wicket legally, sometimes anyway to enforce. But I think where they probably have the most bang for your buck is if you're in a committed relationship, and one of you becomes incapacitated. Sort of Having that this is my life partner, this is whom I'd want to be physical with. These are my values around sex. And if if one of us becomes incapacitated, we agree to allow this relationship to continue in a sexual way. Within, you know, and you can even say, within certain limits of, you know, obviously, if I'm being physically abused or something like this person turns into somebody, I don't know, or something. But I think there's a potential for a more limited application in those situations, because those like Henry Rayhons, become very tricky when someone from the outside gets to make a decision about your already existing long term sexual, intimate relationship based on sort of the changes that one of you has cognitively. And that's tricky. Particularly obviously, if one's an institution, it's a lot more under the table if you're both at home, right. So, but I think that in those cases, it kind of gives us some tool to be able to use However, I'm pretty skeptical of that holding up in court until we actually get a case where it worked. But it doesn't, it doesn't mean it stops you. I had a did a presentation once to a group of faculty in a psych department about my research on this. And one of them actually contacted me afterwards and said, my wife and I are redoing our wills. And I'm interested in putting something like this. Were interested. It wasn't like he was saying, I want this. And he did they changed their well to have some language around that if one of them became incapacitated, it was living outside the home and I thought, well, good for you. Try to do it. I mean, what can I hurt? hopefully people will take that as substituted judgment, you know, and say, yes, that's, you know, what they intended.

Dr. Regina Koepp 46:58

And just for some background information, the Rayhon's case was in Iowa or Idaho, I get those states. It was an Iowa phi, sorry, Iowans are in Idaho. And so in Iowa, he was a state legislator or something, and he and his wife had dementia moved to a long term care memory care community, they remained intimate her adult children were opposed to this, or thinking that he was sexually assaulting her, charged him with rape, the adult children became his her legal guardians, then charged him with rape, and he was tried and found not guilty. And so it's this sexual expression in the context of diminished capacity and dementia. So that's, that's the case, it was all over the New York Times A few years ago, I'll link to it in the show notes of the episode if people want to learn more, it's an important case. And and, in my opinion, tragic for both Henry irons and the wife who was separated from him and I think died. And while they were separated because of the adult children, that's I think, painful indeed. And one of my wishes is for all Long Term Care communities, assisted living communities, memory care communities have a sex health policy, kind of like Hebrew home life has in Riverside, New York or something, they have a sexual policy. And it's very simple. It's basically like we honor sexual citizenship, like you're talking about. And if we're concerned that judgment might be impaired, or there might be exploitation, or there might be, you know, shifts in, in an illness process that's impairing judgment. This is our process for investigating if this is a consensual relationship or not, but it at the outset, it honors sexual expression and sexual citizenship. And then it's very simple. And my wish is that every community would have something like this and then have a way of introducing the family and the old and the people moving into the residence to this health policy so that it's already on the table. So that if there are concerns there already as sort of a conversation started.

Dr. Maggie Syme 49:11

Yeah, I think that that's got to be the way to go is to present preemptively talk about these issues with someone coming in, whether it's a spouse or partner who's bringing another their their spouse or partner to the table or adult children, etc. Bringing in a family member, is to just say, oh, and among these other policies that we have, here's our policy around sexual expression. And it's written here, let me give you a brief explanation. If this ever comes up, we can have conversations about this know that we these are the guidelines that we follow. And feel free to address any concerns that you have. And depending on who is at the table and who takes up the question. My sense is is that most people be like, cool, cool, let's not talk about that. Yeah. But you know, my hope to is that we will stay true to this idea of sexual citizen and amplify the rights of the resident as much as possible. Because, as you know, Regina, you don't have to do everything a family member says there is no legal recourse that they have for saying, I don't want my parent to do this. So they can't, what they can do is take their parent out of the home and withdraw, obviously, the financial compensation. But even if they're a guardian, over a parent, there is no specific legal action around if you loud something to happen, that was protective of harm and risk rate. And if they are a guardian, there is no dependent power or power, there is no durable power of attorney for sex, it does not exist. So technically, it's sort of one of those gray areas that no one has jurisdiction over in specific and we have too few court cases to like know, what would happen if we took this to the bricks, right. But in most cases, they're just getting what they want, because they speak the loudest. And that doesn't cut it with me, a resident is is your consumer, you are there to provide them with resident centered care that is the best for them. And if this is the best care protected from harm and reduction, reduced risk to the point of high benefit. I think that your arguments pretty strong for allowance up and particularly if like you said, you have said at the outset, this is how we roll at this facility. Given this particular area. I think it's it's good. And I know that that doesn't give a lot of folks very much to go on because they want something hard and fast. And they can you know, say okay, well, if this then I'm protected. But we just got a great a big gray area in terms of sex in the law in nursing homes.

Dr. Regina Koepp 52:28

Well, I'm back to your point about teamwork, and, and observation and interview and making decisions as a team. Also ombudsman can be helpful and being an advocate for the resident, and in making some of these decisions.

Dr. Maggie Syme 52:44

And it doesn't mean that we cut the family out either they get to weigh in, they get to provide information, because how else would we know a history and hopefully accurate because hopefully, they're not, you know, reinventing their parents history to keep them from doing things. But you want to have the family be as large of an advocate as you can, there may come a time when you need to push back on the paternalistic attitudes and the boundaries that you've set around what adult children get to say and don't get to say about their own parents care. But that goes for every other thing. I want my parent not to be able to have ice cream, well, they want it and it's not going to, you know, produce a lot of harm. I'm sorry, like they're choosing it for them. You can't police that you're more than welcome to take your parents to a place that doesn't allow them to have it.

Dr. Regina Koepp 53:43

Of course. Also have physiological physical, emotional. That's right. What is sexual liberation for older adults? And and then where can people learn more about you?

Dr. Maggie Syme 53:56

sexual liberation for older adults. I think in the future, if we had set if we were sexually liberated, for older adults, we wouldn't have these tropes of older adults as comical or disgusting, if they were engaging in sex. That would be one cue, right? We would still have them in our history. But we wouldn't have this porting of those myths and those stereotypes that are currently governing, aging sexuality, including that they're asexual, they can't do it. They're physically incapable, but also that is disgusting and dirty, like all of those things would be sort of, really, nobody really thinks that. I know I don't even you know, now, we would feel liberated to if you were a 65 year old and 85 year old, a 75 year old, whatever. You wouldn't have age as a hang up. You would feel your sexual self if you so chose. You would have a choice of partner. If you want You will be able to openly be older and gay, older and lesbian, older, and by older and trans, you know, black, older and trans, whatever it was, we would be able to be out and about and feel confident, but safe, also safe in those spaces. I think those things would key me into, I feel like we're becoming liberated, and people are safe and confident and proud and not oppressed. And the opportunity is out there for them to have safe, chosen experiences, regardless of who you are as an older adult, you are no longer fettered to, it must be heterosexual it must be with same age person, it must be only cute expressions, if those things would be gone.

Dr. Regina Koepp 56:02

And a sense of security and where you are choosing to express these aspects of your life.

Dr. Maggie Syme 56:09

Yeah, I wouldn't have to worry if I was a new and potentially like an older trans woman or an older trans man of going into spaces and expressing that with my partner in being either at least denigrated, but most harmed physically, because of my expressions, there would be a sense that I feel confident in the spaces I'm in of being who I am expressing it, the way I feel is authentic for me. You can feel free to contact me at my personal email at MAGGIE dot n a i dot two [email protected]. And I'll be the most likely to respond from that one. So please do ask questions. Give comments. I like this stuff. So...

Dr. Regina Koepp 57:03

Its my all time favorite. Well, thank you so much for sharing your perspective on sexual citizenship and sexual liberation with us and here is to a more empowered and less oppressed. more authentic life for all of us. That's right. You're here. Yeah. Welcome to make the world secure for everybody.

Dr. Regina Koepp 57:31

For all of the references and resources that Dr. Syme and I mentioned in this podcast, check out the show notes page. For all the details. You can link to the show notes page wherever you listen to podcasts. Now, are you a mental health or senior care provider, I have a free guide just for you. called the mental health professionals guide to working with older adults. In it, you'll learn the five facts that every professional working with older adults must know. To download this free guide which is filled with lots of helpful resources. Go to All one word, all lowercase. Alright, that's all for today. If you like this episode, please subscribe and leave a review because subscriptions and reviews help other people to find this show. And the more people listen and the more people hear the lived experiences of older adults and hear from experts working with older adults in the mental health field, the less stigma there will be and the more resources there will be in this world. All right. That's all for today. I'll see you next week, same time, same place.Bye for now.

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