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Case study

The names of the service users mentioned in this article have been changed.

Situation: Rose Marshall is 82 and has occasional dementia along with regular periods of lucidity. Albert Chambers is 77 and has a drink-related illness. They both live in a council-run home for older people and have been in a relationship for about six months. Although the families are unhappy about the situation, the home has been working positively with them over residents' choice, privacy and dignity. Rose has said, in times of lucidity, that she is happy to have a relationship - including sex - with Albert. She has joked that he is her "toyboy".

Problem: Rose's dementia is becoming increasingly problematic for her. Staff became concerned after Rose started complaining about being "hurt" by Albert. She would cry out in considerable pain when using the toilet. Her bottom was also very sore and raw. An examination by the doctor suggested that Rose had been having anal sex. Rose refuses to talk about it. Albert, however, said it was something they both wanted to do and was an agreed part of their relationship. The home is struggling with what action to take, if any. Concerned that the families, who have taken six months to come to terms with the relationship, will "hit the roof" and blame the home may be at the root of its decision to have not yet informed the families of the development.

Panel responses

Mick Ryan
There are clear issues around consent and mental capacity, a person's right to privacy and choice and possible issues around abuse. Life for an older person in residential care, such as Rose, is in many ways controlled by the environment and a dependency on staff to help fulfil the tasks of daily living. Privacy is often difficult to attain and life becomes open to the scrutiny of members of that residential community. Sex and sexuality are to most of us a private aspect of our lives. Rose's relationship with Albert due to their individual needs is not.

The question as to whether this constitutes abuse arises. On the face of it there appears to be consent on both sides but is there consent to anal intercourse, an act which clearly causes pain for Rose? In my view, this is abusive only if she is not consenting or is unable to consent due to a lack of mental capacity.

As she suffers from dementia, it is important to check this with further assessment through a psychiatrist, if necessary, and to engage with her directly to find out her views. This must be done in an extremely sensitive way by a female practitioner. Advice would need to be sought from professionals who have expertise in the field of sexuality whether from within a health and social care setting or from outside agencies that could offer sexual counselling and therapy.

There also needs to be careful discussion with Albert. Depending on his level of understanding and cognitive ability, advice and help need to be given to him also. It would seem sensible to ask him to limit this particular aspect of their sexual relationship in view of the obvious discomfort it is causing his partner.

If this situation remains within the realms of a consenting relationship and the appropriate help and advice can be offered so that the couple can engage in safe practices, it is my opinion that adult protection procedures would not be necessary.

It therefore follows that I feel the home should continue to respect the couple's privacy, not inform relatives without the couple's permission and continue to work with the relatives in a positive way.

Kathryn Evans
Anal sex is legal between consenting adults. Rose's capacity to consent needs to be established initially. However, Rose's dementia and refusal to complain complicates the situation. If she does not have the capacity to consent this could be classed as rape. Advice could be sought from learning difficulties services staff. Moreover, it could be discussed with a police sexual offences unit, which may be able to advise on the appropriate course of action.

Clarification on how experienced the doctor is at diagnosing anal sex is important because the pain and soreness could be due to other causes. It may be that Rose has been constipated and has been performing self-evacuation, which has caused trauma. Or she may have an infection which has caused irritation and scratching. Close observation needs to be carried out and discussion with care staff.

As Rose's dementia has deteriorated it is important to establish whether her complaints are unusual and whether she is particularly sensitive to being approached. For example, does she complain about staff members helping her in her daily living activities?

Careful and gentle questioning from an appropriate person whom Rose trusts may establish whether she is consenting to anal sex. It may be appropriate to offer advice from a qualified person to discuss other ways and methods of expressing sexuality.

Is Albert telling the truth, or has he agreed to the allegation because he sees it as a sign of virility? It would be prudent in this situation to suggest to Albert to stop sexual activity until Rose is able to confirm or deny her consent.

In terms of the families being informed of the development, knowing the initial objections that the family had to the relationship could help. Until it is possible to establish Rose's ability to consent to anal sex, it may not be appropriate to inform them, and what right have they to be informed if the activities are consensual?

The risk may be that the families move or expect Albert to be moved within the home or into another home - and this could turn out to be distressing for all parties.

Relative's view 

This case raises a number of issues and taboos, with which many workers, residents and relatives feel ill-at-ease, writes Judy Downey. People do not take kindly to discussion or admission of the sexual needs of older people, particularly dependent older people. This is hardly surprising, when questions also arise about consent, competence and capacity. 

It is clear that, even though Rose may have consented initially, her subsequent complaints, her pain and other symptoms suggest that the physical relationship is no longer a consensual or pleasurable experience on her part. Her intermittent dementia may also make her more fearful and vulnerable and frightened of possible threats or repercussions. 

On the consideration to be expected from a partner, it does not seem reasonable for a loving friend or companion to insist on such a relationship if it caused harm, pain or upset to the other party. Is Albert's attitude sufficiently sensitive and tender towards his partner, or is he, too, perhaps suffering from the lack of inhibition which often accompanies dementia? He certainly should not be allowed to follow his needs and feelings at Rose's expense due to misguided interpretations about sexual needs and freedoms. 

 It is crucial to try to establish Rose's feelings and wishes in this matter during her lucid moments. Perhaps a trusted staff member or an independent advocate could undertake this role. The assumption should be that there are good reasons, in the absence of Rose's positive corroboration, to stop their physical relationship.

It is unclear from her current attitude or responses that the relationship with Albert has any advantages for her.  It is also important to consider the importance of love and warmth and the expression of affection and attachment. The lack of tenderness and overt expressions of any sentiment, let alone sexual or  non-sexual physical contact, characterises the lives of many people in residential care.  

Many have no close friends or relatives, which must leave a gap in their lives. An awareness of the emptiness that remains for many older people can encourage a distortion of values in care settings about what is and is not appropriate compensation for this shortfall. 

Judy Downey is a trustee of the Relatives and Residents Association.  

- None of our contributing older service users felt able to comment on this case study