Sexual Health and Sexual Expression in Women Transitioning to Long Term Residential Settings: Challenges and Individual Rights

Sexual health and sexual expression can be controversial topics at any age. Ageism in Western society makes this discussion, as it pertains to the elderly, even more taboo because sexual health is not usually a focus for healthcare providers serving the geriatric population (Bauer et al., 2015). However, sexual rights are human rights fully acknowledged by the World Health Organization, through its Department of Sexual and Reproductive Health (2021). The ability to fully express one’s sexuality is part of the human experience across the lifespan and any barrier to this expression will have an impact in one’s quality of life. 
Considering this, how do elderly women transitioning to long-term residential facilities (assisted living or nursing homes) rate their sexual health and their opportunities to express their sexuality? This presentation will describe the current state of affairs in these facilities as it pertains to services and supports related to sexual health, how residents rate the current sexual health related services and support, and current barriers to services that are more person-centered, dignified, and respectful of older people’s sexual expression, with specific emphasis on the LGBTQIA+ aging population.  
 


Settings: Challenges and Individual Rights
Sexual health and sexual expression can be controversial topics at any age. Ageism in Western society makes this discussion, as it pertains to the elderly, even more taboo because sexual health is not usually a focus for healthcare providers serving the geriatric population (Bauer et al., 2015). However, sexual rights are human rights fully acknowledged by the World Health Organization, through its Department of Sexual and Reproductive Health (2021). The ability to fully express one's sexuality is part of the human experience across the lifespan and any barrier to this expression will have an impact in one's quality of life.
Considering this, how do elderly women transitioning to long-term residential facilities (assisted living or nursing homes) rate their sexual health and their opportunities to express their sexuality? This literature review will describe the current state of affairs in these facilities as it pertains to services and supports related to sexual health, how residents rate the current sexual health related services and support, and current barriers to services that are more personcentered, dignified, and respectful of older people's sexual expression.

Main concerns related to sexual health and intimacy in the elderly population
There is currently no consensus in the literature about what constitutes sexual intimacy.
Research to expand our knowledge base under these circumstances is difficult. Garrett (2014) notes this conundrum and discusses many barriers related to sexual intimacy and sexual expression among older adults living in nursing homes. According to the author, this topic in this specific population is "under-researched, under-discussed, and poorly understood". The published articles that pertain to the sexual health of older women in residential facilities focused 3 on the reduced partner availability (for women), centering the research on a heteronormative view of sexuality; the media portrayal of older adults as asexual; and physiological changes affecting sexual health.
Another important topic addressed in this study is the concern with financial implications of relationship development for women at this stage in life and the potential of becoming caregivers to their aging partner. These concerns seem to affect the level of satisfaction with their intimate relationships. From the woman's perspective, a re-marriage or cohabitation could mean a decrease in autonomy, financial concerns and risk of overextending themselves taking care of a new but elderly partner.
The author acknowledges the lack of assessment for sexual health concerns across the lifespan, but particularly with this population. Although there is resistance on the part of the patients to discuss these topics due the cultural norms of their generation, Garrett also notes a lack of training on the part of the health care providers to approach these topics. This is concerning because older people are less likely to use protection during intercourse, making themselves more prone to sexually transmitted diseases.

Non-heteronormative sexual expression : LGBTQIA+ aging population
One of the concerns of elderly people moving into residential settings is the loss of autonomy that is represented by their home. For the aging LGBTQIA+ population, this preoccupation is compounded by the fear of not being accommodated in the residential setting (Westwood, 2016). The locus of this study was the UK and the author notes a scarcity of residential placement for elderly people. This lack of options is more pronounced if the person is 4 part of the LGBTQIA+ community. The author emphasizes that this problem is worse for women, as they are expected to live longer and spend more years in residential facilities. Westwood (2016) states that the main concerns reported by this population include lack of visibility (as if their sexual expression didn't exist), or risks associated with visibility (fear of being more isolated due to sexual expression), lack of opportunity to express affection, and "compulsory co-occupation", where the physical accommodations do not support nonheteronormative sexual expression. (Westwood, 2016). The author seems to conclude that providers are not cognizant and respectful of non-heteronormative sexual expression.

Current accommodations
According to Bauer et al. (2015), residents in long term care facilities report that providers do not consider the sexual health of their patients as a priority in the overall health management responsibilities towards them. The authors report overall dissatisfaction with services and lack of interest from providers regarding this topic. This lack of interest can also be attributed to lack of training in the topic, which leads to the staff not being comfortable approaching the subject. Garrett (2014) reports on sexual intimacy in the elderly not currently living in residential facility, which contrasts with what Bauer et al. report. This can lead to the hypothesis that there is a decrease in autonomy and satisfaction when elderly patients more from their own homes to a residential facility.

Recommendations
Clear communication is paramount. Garrett (2014) unequivocally advocates for it as the basis for better understanding of older patients' needs in the sexual health arena and improving 5 the supports offered by healthcare providers. It is recommended that healthcare providers talk about sexuality with elderly patients, as sexual health monitoring is part of their role. However, the author warns us about potential biases and suggest that the providers assess their own bias, specifically of ageism, when providing medical advice to this population. Healthcare providers should receive training to familiarize themselves with most common healthcare concerns related to sexuality to provide a variety of solutions based on the patient's needs, including pharmacological and non-pharmacological interventions, including psychosocial education. This could be a good opportunity for a DBH focusing on gerontology and interested in sexual health. Westwood (2016) emphasizes that creating welcoming residential facilities that will serve the LGBTQIA+ population will only occur is public health official take into account aging, sexuality, and gender as intersectionalities that need to be addressed when planning residential facilities for the LGBQIA+ population. Choices should be provided to ensure the elderly person's quality of life.
As mentioned in the WHO report (2021), sexual rights are human rights, and they should not be infringed upon due to the prejudices or lack of planning of nursing homes administration.
This shift in the way healthcare providers address these concerns will not happen naturally. It should be planned and systematic, starting with training opportunities at all levels: in schools of medicine and nursing, but also in-service training opportunities in group homes, for instance.
Putting patients' rights and dignity at the heart of decision-making, through a person-centered approach, will benefit all aspects of quality of life, including sexual health. It is incumbent upon us to "be the change we want to see in the world".