PLEASE NOTE: This is a minimally-edited transcript that originates from a program that uses AI.
Anita Rao
This is Embodied, from PRX and WUNC. I’m Anita Rao.
Sex has no age limit, but having a robust intimate life into your 80s and beyond comes with challenges, especially when you no longer live in your own home.
Jane Fleishman
Some of the major issues are around, do people have the cognitive, um, ability to make a decision that is really about sexual consent.
Anita Rao
Today, a conversation about making good sex possible in residential long term care. We’ll meet two people breaking down barriers to sex and intimacy — including training staff to check their own biases.
Maggie Syme
I think you walk in the room, as you know, nursing assistant and you get shocked at first, but you teach a pause, which is check in with yourself, right? Like first.
Anita Rao
Why we need to be talking MORE about sex in nursing homes...Just ahead on Embodied.
Anita Rao
Jane Fleischman was visiting an assisted living community to give a talk on older adults and sex. When a young nursing assistant approached her with an earnest question.
Jane Fleishman
He said to me, I've got a couple, and they sleep in separate beds, and there's a little nightstand between them, and he looked at me and said, they're not having sex right.
Anita Rao
Jane is a sexuality educator who also happens to be in her seventies. Her answer?
Jane Fleishman
And I said, you never know. You don't know if they sleep in different beds because she pulls the covers or he doesn't like her toenails, but they might find that after they take their meds. And their ts are working really well and they're feeling good. They might have fun hopping into one of the beds.
Anita Rao
What the nursing assistant said next was both simple and profound.
Jane Fleishman
I never thought about it that way, and I guess that's the thing that for many young people, older adults, having a sexual life is unimaginable.
Anita Rao
This is Embodied our show about sex, relationships, and health. I'm Anita Rao.
As a sexuality educator, Jane's first mission is to make it known that people well into their eighties need and want sex. The second is to break down the barriers to doing so, especially for older folks who no longer live in the privacy of their own homes. Jane often works alongside staff and residents in long-term care facilities, ing them through both cultural and practical questions about the sexual wellness of older adults.
She's forged relationships with other professionals doing this work, one of whom will meet in just a moment. But when Jane got started on this path 10 years ago, there weren't many people talking openly about sex and aging. In fact, it wasn't even something on her mind.
So when you were in your mid fifties, you came to the end of a 30 year career in education and consulting, and many folks in this moment in life would embrace a leisurely retirement. You did not.
Jane Fleishman
Oh, no, no, no.
Anita Rao
You decided to get a PhD in human sexuality. So why did you decide to start an entirely new career?
Jane Fleishman
It was probably the hardest thing I'd ever done. Well, except for maybe childbirth, but it was really hard. And you're right, it was a, it was a crazy idea. I was 55 years old, but I wasn't ready to really retire. I was ready to retire from that particular job. I was really happy to be done with it, but I wasn't ready to stop. I wanted to make more trouble. I wanted to make more change. I've always been a kind of a activist and so. I thought, what's more complicated in this world than sexuality and what's more fundamental to so many crises of this world than sexuality?
Anita Rao
Tell me about a moment when you were in your work, when it became clear to you that you needed to better understand the sexual experiences of older adults in particular.
Jane Fleishman
I didn't set out to study older adult sexuality. I just was looking for. A dissertation topic that would grab my attention for as long as I was able to do the work and needed to do the work, but also I wanted to do something that was a little bit different. And that's when it became clear to me that looking at the sexual satisfaction of older adults. It was clearly under-researched and really underfunded research, and there was very little about the possible pleasures and joys of sexuality for older adults, it was more about what I call the problematizing. It's the risks and challenges and difficulties.
Anita Rao
So you had a special interest in sex and intimacy for older adults and throughout graduate school and beyond. You spent a lot of time in various long-term care facilities and communities. As we begin to talk more about the specific challenges that arise in those spaces, I wanted to first clarify what you mean when you say the words intimacy, insects in the context of older adults.
Jane Fleishman
Yeah. Um, the question of, you know, what is sex is a great question, right? And what is sex as you get older can really change. And in my classes that I teach in senior living communities and in senior centers and councils on aging, I remind people that sex is not just penetration or intercourse as we often hear, and it doesn't always include an orgasm. And it can be anything from cuddling to really heavy make out. Great massage arousal, close on or close off. It's in the eye of the people who are having that moment together. And if it is to someone else's view, it doesn't look like sex. Ask those people involved what it feels like. That's the most important definition of what sex is.
Anita Rao
So you graduated with your PhD in human sexuality in 2016. You were 62, and a couple of years after that, your own parents moved into a long-term care community. I'd love to know about some of the changes that occurred in their romantic and sexual lives as they made this transition.
Jane Fleishman
Yeah. Well first of all, they're my parents, so, so
Anita Rao
You only know so much,
Jane Fleishman
So well also there, there's only so much I wanna ask about. So, so when you asked me that question, here's what happened. My dad, um, because of his Parkinson's, he had some difficulty with mobility and we were concerned that, um, he might just, uh. Inadvertently have a, an unconscious reaction in bed and, and might, uh, hurt my mom. And so we were wondering about, you know, what do we do? How do we handle this? And I loved it that the social worker said to me, you know, let's preserve their intimate life. As long as we can, and I said, you're absolutely right. You know, like, let's make sure that they can still have their time in bed. Because one of the things that happened as his Parkinson's got worse was they would hold hands and they'd share. A little bit of conversation before they went to sleep, and that was something that was a throwback from, you know, their 70 years of, uh, marriage that they had had. They, they used to write a love letter to each other every day, and then they'd share it right before bed. Hmm. And they still had that intimate emotional time together, which I loved.
Anita Rao
What kind of guidelines or policy did your parents' care community have in of intimacy and sexual wellness for their residents?
Jane Fleishman
Oh, good question. Very, very little. Um, I can count on one or maybe two hands, the number of senior living communities who have sexual wellness policies. The building that my parents lived in did not have any. They had a very caring and comionate staff and management, but there was nothing codified. There were conversations but nothing codified. And often it's not in the culture of an assisted living community to even have a conversation. In their case, I think, uh, they really benefited from incredibly comionate staff, but I would say in some communities the culture doesn't allow for that.
Anita Rao
At this point in the conversation, I wanna bring in research psychologist and licensed clinician, Maggie Syme, to talk more about the broader landscape of sexual health policy in residential long-term care. Maggie, we have been talking with Jane about how older adults are having and are enjoying sex into their eighties and beyond, but this transition into residential communities can bring about some new and unexpected challenges. Jane mentioned that policies. And and guidelines are really lacking. To what extent do facilities around the country have policies and guidelines around sex and intimacy?
Maggie Syme
You know, Jane is probably one of the people that is responsible for the less than 20% of facilities that have some kind of sexual consent or sexual policy around expression. As Jane mentioned, a handful probably across the entire us. And inclusive of Canada. Probably have something that's more robust that actually does talk about what is sex, what is sexual expression, how do we it, um, in any really comprehensive or even small manner that isn't just, we'll give you private space if you ask. So not many. And even less than that, somewhere around 10% say that they have any kind of training for their staff around sexual expression, which as. Jane pointed out could be STI prevention. Hmm. Or could be as rich as attitudes. Right? And how they affect our approach to sexuality of, and sexual rights of every individual. And the various ways that we can reduce risk, but enhance autonomy, um, for sexual and intimate expression. Like those are the kinds of things we hope and wish for. Um, but those are the very few gems that are hidden around, I think in very forward-thinking homes.
Anita Rao
This is so surprising to me because I think about residential facilities as such a highly regulated, highly controlled space. I know as a little kid I spent a lot of time volunteering in in a nursing home, and there was like. Such specific guidelines about like when I could deliver the orange juice and how much orange juice could be in the cup, and like it just all seemed very planned out and regulated. So can you explain that, uh, apparent contradiction?
Maggie Syme
I guess you're not wrong. I think. Uh, someone once told me that nursing homes are the second most regulated industry in the US and the first one is nuclear plants. Oh, wow. And one of the reasons right, is because the centers for Medicare and Medicaid, uh, are. Sort of overseeing the operations of these licensed facilities, and they have a lot of regulations that are related to a lot of injustices and a lot of infractions, and a lot of things that happened that were abusive. I think one of the issues that Jane potentially alluded to earlier is that sex isn't seen as a necessary element of quality of life, right? It's seen as unimportant and potentially super high risk for these facilities, both in of their. Licensure at the CMS level and potential infractions, but also just legal suits. Um, so I think it's really just been this, let's not touch it or go there and just blanketly say it's not available or Okay. And that will keep us out of the fire.
Anita Rao
Just ahead. We'll talk through some common questions that come up around sex and intimacy in long-term care facilities and hear how Jane and Maggie advise staff residents and their family you're listening to Embodied from North Carolina Public Radio, a broadcast service of the University of North Carolina at Chapel Hill. You can also hear Embodied as a podcast. Follow and subscribe on your platform of choice. We'll be right back.
This is Embodied. I'm Anita Rao. We've been talking with research psychologist Maggie Simon, and sexuality educator Jane Fleischman about the lack of explicit policies around sex in long-term residential care communities. This void creates a lot of gray area, leaving it up to individual staff to make game time decisions. We're gonna hear from Jane and Maggie about specific times. They've helped long-term care communities work through that murky territory. And to start that conversation, I asked Jane about some of the most common gaps she sees in how residential care communities are thinking and talking about sex.
Jane Fleishman
When I go to a senior living community, Anita, it's because they've invited me in and when I first started doing this work about 10 years ago, I felt as if I was trying to. Cajole people to bring me in. I said, you know, this is really important stuff. You need to learn about it. And now, 10 years later, I feel like it's turned a bit and assisted living community executive directors or nursing s will, will call me and say, we heard about your work. People are having sex in our community, and I'm so glad to hear that they realize that and. We wanna know how we can them. And so now people are really more interested in how do we older adults who are finding love, finding relationships, finding sex, and they're not always the same. Right? And what, how do we respond? Some of the major issues are around, do people have the cognitive ability? To make a decision that is really about sexual consent. I'd love to hear some of the work that you've been doing lately on this, Maggie, because it's so important.
Anita Rao
Maggie, let's go into that example around consent capacity, and specifically for residents who have dementia. I'd love to start first with kind of the observations that you've made around. Folks with dementia's needs and desires for sex and and, and how that can inform how we think about capacity for decision making.
Maggie Syme
Yeah, so folk with dementia have the same desires of needs as folk without dementia of folk who are of any age. So the need and the desire to fundamentally connect to someone else in an intimate way is always gonna be there. I think we know that in of what we see, right? As you alluded to Jane, right there. People are engaging in intimate acts in all levels. Assisted living, skilled care, where it's the most physically frail and cognitively impaired folk. They need physical touch. They need presence. They need intimacy and connection. And think that alone is something that. We don't appreciate, right? So once someone crosses a magical threshold, whether it's cognitive or physical incapacitation, we just assume that they don't need anything at that high sort of belongingness connection, intimacy level, and everything is about keeping them alive, right? And keeping them from harm. And I think that's one of the pitfalls of this is that. You may not have a high enough cognitive capacity to reason through to understand all the risks and the benefits of a sexual relationship to make a fully verbal, voluntary decision about it. But that doesn't mean that you don't need touch or that you don't respond to massage a manicure, a you know, a sponge bath in a way that isn't sexual per se, but is intimate and a connection. And I think we get caught up in the, can they consent or not on a very black and white level. When for me that question. Might be one of the first questions, but it's certainly not the last question I want answered. I first may want to know what is their ability to understand the potential harms or risks of this type of relationship. But if the answer is, you know, they probably don't have the highest level capacity needed to be a reasoned person, and I say, okay, well. They need something because they're showing that to us. They're getting in bed with this person, or they're holding this person's hand, or they're kissing them and they're responding and they're not hiding. They're not showing highly anxious behaviors or refusing to eat or something that would indicate to us that they're not okay. But what can we provide that meets that need in a way that enhances the need as much as we can, but reduces the risk to just enough that that's reasonable. They're safe.
Anita Rao
I hear you saying like finding that sweet spot between maximizing someone's ability to have sexual agency and minimizing harm and how it is a, it's a gray area that needs to be super personal.
Maggie Syme
Absolutely. And that's why. Sexual expression policies like the one, I think it's at the Hebrew home at Riverdale. They have this nuanced policy that is for cognitively intact folks. These are the things that we are and are not going to intervene on or help with for cognitively impaired folks. Really what we're just gonna do is make sure that we understand their risk and then. Do our interdisciplinary team planning to try to make the best plan to meet their needs, and we'll continue to monitor that so that we know that they're safe and that's what we need to move toward, not a yes no decision, right? A yes and or no, and right. And that starts it. And then we get into the, the nuances of what this person's care plan can look like to their need.
Anita Rao
Jane, I'd love for you to talk about the example of the Hebrew home at Riverdale. I spent some time looking at their sexual expression policy. They have it on their website, and they're very clear in there about, you know, what they encourage staff to do, what residents should know if they move in there about how the facility thinks about sexual expression. Tell me about this policy as, as an example and, and how it's being used as an example for homes who don't have one.
Jane Fleishman
Sure. In Riverdale, which is in the Bronx in New York, the Hebrew home developed this policy because, and here's how the story goes in it, it's a wonderful story. One of the nursing assistants, uh, walked in on a couple in the middle of having a sexual moment with each other and kind of got anxious and nervous and got a little worried and went right over to the executive director's office and said, what do I do? And the executive director, I thought, rightly so, said. You close the door. Mm. And you leave them alone. Wow. Which I thought was just beautiful, but it's that nanosecond that we have to make a, make a decision or, or create an intervention that may not need to happen. And so their policy allowed their staff to not have to make those ad hoc moment to moment nanosecond decisions, which I thought was brilliant. What they did was they created an umbrella around. All of their wellness. Put sexual wellness within it. And so when we talk about what it means to be a healthy human being at the end of our lives, what we often forget is the sexual side of their wellness. We think about physical health and emotional health. We think about financial health. We think about. Environments, but we don't often allow ourselves to think about sexuality as part of this umbrella of wellness. And I think that's what they were able to do there in of their sexual expression policy. And it was the first, and it was very exciting, and I was thinking. Gee, this is gonna be great for me. I have a background in organizational development before I became a sex educator. I'll go right into these facilities and help them develop their policies. Boy was I wrong. I just, yes, a handful of people have called me and expressed interest, but really it's very, very rare, and I think it goes back to that kind of sex is all about. Guilt and pain and shame and, and how hard it is for most of us to have conversations about sex to begin with, let alone have conversations about sex when it comes to our older adults. And so that's where I think we have a. A bit of work to do. I do wanna say, we have to , Anita, that sex is good for our health. Yeah. So it does allow us to put it within that wellness category. Right. It, you know, we've, there's been some really good research, you know, Beverly Whipple and her colleague Barry Kaa. Looked at the ability to increase your pain threshold through touch and sexual arousal. There's been some really interesting work on neuro and cognitive functioning as a correlation to sexual involvement. And so there's so many others. There's even kissing. I love this one, Anita Kissing can alleviate some of the allergic symptoms people have. That was, uh, kamata in 2006.
Anita Rao
Oh, that's fascinating.
Jane Fleishman
I love it. And so I think there's, you know, there's many different pieces of research now that we can look to, to say that sex is good exercise and it's good for keeping us connected. Together, which of course is really the the biggest issue I think most older adults face, which is isolation.
Anita Rao
I'd love to talk with you both about some specific examples and how this decision tree model that Maggie mentioned could be used to kind of find that line between ing older folks, sexual agency, and minimizing harm. So Maggie, maybe we can go to the example of. Uh, a staff member opening a door similar to, to the story that led to the Hebrew home policy and. What they might be wondering or potentially the question of how can we enable intimacy while protecting people from unwanted touch or potential harm? So like what does a staff member need to be trained on to do to make that distinction and help facilitate decision making in that moment?
Maggie Syme
This is a great question, something that I've thought a lot about. When we think about then, what elements do we train for, right? So I think you walk in the room, as you know, nursing assistant and sort of. You get shocked at first, but I think Jane's, uh, point of moment of surprise and then a pause, right? You teach a pause, which is check in with yourself, right? Like first. So there's an attitude check that sort of happens, which is, oh, okay, I see what I'm seeing and who I, I feel my feels, and let me now take. My, you know, more analytic brain that can turn on and look and see what's happening. One of the harms is certainly physical harm. You know, do I see any potential for physical harm? Is there a mobility issue or a fall risk that I see? Is there a guardrail there? You know, so you're looking, you may be teaching them to look for things that are about the built environment that can reduce physical harm risk. Right? And then you're also, you wanna think about. Cognitive capacity too. So what do I know about Mr. X and Ms. X or Ms. And Ms. X, whomever it might be, and their, their capacities here. So I do a quick like, oh, I know that Ms. X has dementia. Is that something that certainly needs to go in the decision maker? Right? Which is, is this an activity that she's able to show she accepts and is not afraid of? Right? Maybe Mr. X is in, or Ms X is intact, the other partner. So we wanna be thinking about, oh, there's could be a possibility for coercion here. So what do I know about them? Do they have a relationship outside of this moment? Have I seen them in the hall together holding hands? Right. So you're building this sense of what. Are the potential risks emotionally and or cognitively in this relationship. A lot of times you're looking for like behavioral indicators of an acceptance when someone isn't able to voice it out loud or to reason through something. Now, that's sort of an extreme example, given that. Most of the time we don't see folk in mid intercourse, right? When we walk in the room, they might be in the bed together cuddling or maybe hands underneath the shirt or, you know, the, the behavior is also something you wanna pay attention to. So what is the potential risk in the behavior, right? So all the way up to potentially like some kind of intercourse is probably the highest risky behavior that we can think of. But holding hands, kissing, fondling. Just being together, that's pretty low risk behavior. So we're paying attention to the like sort of what's the escalated risk of this behavior as well.
Anita Rao
That's so helpful and so clear, and I think gives a, a really good sense of all of the, the factors and also the need for staff to be able to kind of take that pause and, and take that moment. And, and, and Jane, I kind of wanna put. To you, 'cause I know you've had, you're on call so often for facilities and helping people work through specific examples. Did hearing that decision tree from Maggie bring any stories or examples to mind of a situation that you have encountered and helped folks work through?
Jane Fleishman
I did think of one. That was so great, Maggie. Thank you. I, I was thinking about an assisted living community where the executive director called me and she said, Jane, I've got a problem. I've got this guy. Let's call him Joe. He's got cognitive impairment. He lives in our community in the building. His wife, let's call her Mary. She still lives at home at there. Um, at their residence, Joe has been having sex with another woman in the community, in the building, and when Mary comes to visit, everybody scrambles, they try to find Joe. They try to make sure he is not in this woman's apartment, or if this woman is in his apartment, everybody goes a little bit nuts. What do I do? How, what do I tell her? You know? So I said, wait, wait, wait. Slow down. Let's think more broadly about this. Like for instance, can we talk to Joe, can we talk to Mary? Can we find out what their relationship boundaries are? Do we know that they have always had a situation where they were in a a monogamous relationship or. Were there times where it was an open relationship? We can't assume that we know we need to talk to the other resident. We might need to talk to the neighbors because people on either side of his apartment or her apartment might be feeling some kind of dis unease or not. We need to know that and we might wanna talk with the staff and educate the staff about sexual intimacy. That may be going on in different parts of the building and what their role, as Maggie was saying, what their role would be. And there may be a need to educate the family as well. And I've done some trainings for family and it's been very interesting to find out what their concerns are. The executive director who called me was wonderful and she was really concerned and she didn't wanna shut it down. She just wanted to know what to say to his wife when she came to visit. And what we ended up talking about, and I had some really good meetings with her whole multidisciplinary executive team, was we need to really open up the conversation to think about how we all have to be educated around this and not just one individual and certainly not. You know, play this game where we try to hide Joe or his new lover from his, um, partner.
Anita Rao
In of the conversations with kids, I'm really curious about any examples you have there and, and strategies that you employ to align the sexual needs and wants of older adults with their younger kids who may be the ones paying for the facility or, or who may have, you know, a sense of stake in what happens.
Jane Fleishman
Sure. Very often. I think of the kids of these older adults as really allies because I want them to see their parents or sometimes in some cases, their grandparents as people who. Have sexual needs just as they have, and that they don't go away because they're in their sixties, seventies, or eighties. And so I, I consider family as allies because I want them to that they want what's best for their parents or their grandparents. And what they want is for people in their last days. Months and years to have as much joy as they possibly can. But often that doesn't include sexual joy. Right? Yeah. Because that's a little bit removed. That's a bit taboo. And as, as we all know, it's a little scary to think about sometimes. So the strategies I use are really. To remind people of the research, to remind them that in these communities, people are really concerned about safety, right? Risk is a very important issue and that we will do all we can to make sure that your parent or grandparent is as safe as possible when they're engaging in a sexual activity. And so I talk with family about how important it is for their elders. To be able to be in connection with someone else because after all, isn't that the great project of life to find connection.
Anita Rao
Just ahead, we'll talk more with Jane and Maggie. We'll hear about their desires and plans for sexual wellness in older age, and talk to Maggie about mitigating conflict around sex and intimacy decisions in residential facilities. As always, you can hear the podcast version of this show by following embodied on your platform of choice. We'll be right back.
This is Embodied. I'm Anita Rao. Research shows that older adults want and need sexual intimacy well into their later years, but when they move out of their homes and into long-term care communities, they have a lot less privacy and autonomy to seek it out. So what can be done? We've been talking about that with research psychologist Maggie Syme and sexuality educator, Jane Fleishman. They're both leading cultural and policy conversations about the sexual lives of older adults. They've outlined that the effort is layered. One step is recognizing that we all have stakes in this conversation, no matter our current age. They'll tell us more about that piece in a moment. But first, the trickier step is developing guidelines, training and practices to get everyone on the same page. I asked Maggie about how residential long-term care communities can bridge the gap between residents and their adult kids On the topic of sex.
Maggie Syme
I think dealing with the family unit around these kinds of decisions has to be also a staff intervention, right? Like because they're the ones who are going to be having the first, the second, the third conversations with them. I think it's part of how we should preface any tricky, risky situation with a family member, right? Which of which they are well versed in. Sex is similar. Intimacy is similar. I think the best thing you can do. The best absolute thing you can do is have an upfront guideline, right? Like the Hebrew home at Riverdale, because it's on the front page of their website, right? Like, here's our sexual expression policy. Take a look. And it's part of a discussion of when families onboard to say, here are all of the things that we provide. Here are the things that we live by. And. The sexual expression policy is one of them. So certainly the best possible world is to include it in your issions kind of discussions with family is, and this is how we approach it and have things like even. An ombudsman or if everybody had a Jane, wouldn't that be great to be able to have these beginning conversations and invite a family member to, to ask a question, you know, well, what happens if, you know? And I think that prevention is always the best approach, so that when you get into a situation where an adult child feels like their parent is either. Being violated or doing something that they are not comfortable with, let's be honest. Uh, and then you can kind of say, okay, right. We've got this expression policy that we're gonna go back to and we're gonna talk you through this, but it makes these decisions and these discussions around how are we going to care plan for this particular intimate situation. Broader, right? You include when. Necessary and needed, and hopefully they're willing the family to say, this is what we've come up with and this is how we would like to go about ing your dad's relationship with Person X. We'd love your input on this. And I think a lot of. A lot of it is what Jane is trying to preempt, which is attitudes, right? Yeah. About my parent having sex, and not just sex, but sex with someone who isn't my other parent, right? Like I think that. Is, uh, almost like a triple whammy that you're headed into. And there are some larger societal issues around that, certainly that I wish we, we had a better, um, sex education system for people to understand that sex is a need and a want and a connection across the life course. And they also need to. Get their hand held a little bit, right? When it comes to that really personal situation that is their own parent and bringing it back. I love that, Jane, bringing it back to the importance and the need for connection and the benefit that this brings to your parent, I think really helps with motivation to continue the discussion.
Anita Rao
I know we've been talking in this conversation about. Sex and intimacy as a spectrum and, and making sure to kind of keep that spectrum in mind when we're having these conversations that, you know, intercourse is at one end, but we're also talking about responses to cuddling and holding hands. But one of the, I guess, biggest cultural narratives around older adults and sex. Recently, at least in the news, is around STIs and STI rates in nursing homes and assisted living facilities. I know the CDC estimates that STIs for adults 55 or older, more than doubled in the US from 2012 to 2022. So. Maggie, I'm curious about that piece of it, like what role does staff have in making sure residents are practicing safe sex, and how do STI rates inform how this conversation is taking place in these spaces?
Maggie Syme
Yeah. Well, I think the one thing which you hit the nail on the head, Anita, is that people are realizing it, right? Yeah. Like. We have more ability to test and to treat and to understand what is actually happening in nursing homes now and are starting to pay attention both sort of skilled facility level and assisted living to know like this is an issue. So that's one of the first important things that like the public health actually has it on their radar. Right. That's important. And then I think we. Have to have safer sex in general as a conversation, especially in more independent living situations where folk have much more sort of alone, private, independent time and can make a lot of, I know healthcare decisions and. Choices of the day-to-day on their own. And that includes having things available to them like condoms and dental dams and the right kind of cleaning for your solo sexual equipment. Right. Because you also don't wanna have problems in that level. Yeah. And staff, if I. Let's just say if I walked into a nursing facility and had to do that and was just, you know, someone who had a bachelor level education, how would I know how to help another person have safer sex? Like and in older adulthood where there's some particular differences in challenges. So part of it is education for the staff , right? And that 13% of facilities that say they educate staff about sexuality needs to be more like. 85%, right? We hope for a hundred, but we're realistic so that your staff can really. Put these practices in place and feel confident in these decisions to say, oh, I see this is happening. Let's talk and provide some options. And that's part of the care plan is a safer sex plan, right, for older adults. And if you have, how to, you know? Cook safely. You should have how to have sex safely, right? And that should be part of your facility's approach to providing good care for your residents, right? Is how to access these things and how to negotiate these things and have people come in and talk about it. If you don't have the expertise within your own walls.
Anita Rao
I would love to turn to asking you all to personalize this conversation a little bit. Jane, you are now in your early seventies. You have been doing this work around aging and sexuality. How has it shaped your own thinking about your sexual wellness in this moment of your life?
Jane Fleishman
Just recently I learned about, uh, some senior housing in a city near us in Boston for L-G-B-T-Q seniors. It was the first one in Boston and one of the first in the country, and of course it's LGBTQ Friendly Housing. I was very excited about it because I thought for many people like myself who are part of the LGBTQ community. We have some concerns about what happens to us when we decide that we want to continue to be who we are. Yeah. But for various reasons. Move to an assisted living community or perhaps a, a nursing home. For many people being gay could be a very scary, uh, in a new community because they've been really comfortable where they live. But now. They're not quite sure what it's going to be like, and they feel as if they have to come out again. And so personally for me, I've been really just thinking, you know, I'm in my seventies now, you know, I'd like to live in a, in a, uh, assisted living community that had a sexual wellness policy, that had a real robust conversation about sexuality and that really understood that people are sexual, you know, until they decide not to be in their older age. And so. You know, I'm kind of looking around Anita. I'm, I'm wondering where am I gonna end up? I'm not sure. My partner and I are kind of, um, talking about it. I'd like to be right in the, in an apartment in the middle of the floor and she'd like to be right at the end. 'cause she's more of an introvert and she thought, you know, that way nobody will stop in. Just, you know, like, uh, kind of spontaneously. But I, I really, I really am starting to think about my own. Uh, next step and what it will be like. We'd like to stay in our own home as long as possible, but when that's not the case, we live in a really old house in New England. I think I'd really enjoy living in a senior living community where people really did take sexuality seriously.
Anita Rao
Maggie, I know that you are younger, not in, in the age of maybe more imminently thinking about a, a potential transition, but I'm curious about how this work has informed your thoughts about what you want for yourself as you think about older age.
Maggie Syme
Yeah, I mean, even in my mid forties, it, maybe it's an occupational hazard, but it definitely. Think about it, but potentially differently, right? Than someone who is like maybe making the decision in the next few years of what the next step is. But for me, Anita, I think the thing that strikes me the most is the willingness of people to view this as a me issue versus a them issue. And I think until. Myself included, that impacts me. But like until we all start to think of ourselves as. This is me, and these decisions that will be made in these facilities are affecting me just down the road and that my sexuality is affected right now, by the way, these things are happening. I think that to me is where I. Put a lot of my effort is like helping turn on light bulbs for people who feel like that's that other person, that other group, right? That's not me. That's for them, and that's not true. We're all a. Right where along the life course I am becoming who I'm going to be as a person in my seventies, eighties, and nineties, every moment and the decisions that I make, the relationships that I have now are going to shape the decisions and the relationships that I have then, and. One of the things that I really would love to see is more people thinking about what do I want? And making some of that sort of like sexual advance directive kind of plans for themselves because we need to start thinking about this as a we, you know, and a me instead of an them. And I think that will. Help us also feel personal about these decisions, but it will help us have a greater empathy for everyone else who's, who's. In the thick right now. Right.
Anita Rao
Are people making sexual health advanced care directives? Tell me about that concept.
Maggie Syme
Probably not. Okay. Um, not in a formal way. There have been some rumblings in some of the more legal literature about a sexual advanced directive and whether or not that would hold weight and essentially all advanced directives are just as good as. The location that they're held in. Right. Like, I'm not gonna travel to Arizona and have my advanced directive that's sitting on my fridge. Yeah. Honored. Right, right. If I go to the er and I think that there's, there's something to that. There isn't a concept right now legally of a sexual advanced directive, but. Advanced directive is also a discussion you have with your family, and that's where the power comes from, right, is, Hey everybody, here are my five wishes, right? If you're using the five wishes document, here are the things I want for myself when I'm no longer able to say it for myself. And why isn't sex a part of, or intimacy a part of that conversation? You know, when I am on my deathbed and unable to move, I want there to be a. Big enough bed for my partner to be in and to be next to me if that person is still there. Or my kids, I wanna be touched, you know, I want people to surround me. I mean, and maybe it's more of a sexual and intimate advanced director, but I want my, I wanna be kissed still. You know? Like those things I think can be said in conversation and potentially written down for your family to see. I think we're pretty far away from that being like a hold up in court kinda situation. I hear you. Yeah,
Anita Rao
yeah, yeah. Jane, what, what would you put in a sexual health advanced care directive if you made one? I know you have older, uh, you have adult kids.
Jane Fleishman
Great question. I, okay, let me step back a bit. Let me say that I think in an advanced directive, what we really need around our own sexual wellness. Is to do exactly what we never do, which is to talk about how change. Our sexuality means that we want to continue to love our own bodies and to love whomever we're close with in whatever way that makes sense for us. And so I think if I were to write one for myself, I would wanna make sure that my kids got it, that. As long as I'm capable, I wanna have the privacy that I can to either embark on a sexual pleasure alone or with my partner in ways that make sense for us at that time, and that my kids may not understand what. Those ways are, but that they need to allow that to happen. Now, can I imagine having those conversations with my kids? I think so. I think it's gonna be awkward. I think it's gonna be weird. I think they're gonna say, oh no, please do. We have to keep talking about this. But I think they would. They're both incredible human beings and I think they would really want to do what's best for their mom. So I think, yeah, that would be incredible and it would be change as an opportunity to explore. And just as you were saying, Maggie, that it's not a them or an us, it's. It's not a you or me, it's all of us thinking about what we would like as we get older. And you know, when I talk with young staff, I often say, if you are lucky enough, this may be you in the future. So think about what you want and think about doing that. Now,
Anita Rao
Maggie and Jane, thank you both so much for this conversation and for your work in this realm. I so appreciate it.
Jane Fleishman
Mm. Thank you Anita.
Maggie Syme
Thank you.
Anita Rao
You can find out more about Jane and Maggie at our website, embody w unc.org. You can find all episodes of Embodied the Radio Show there and make sure you're subscribe to our weekly podcast. You can also find more about Embodied and all of our guests on Instagram. Our handle is @embodiedwunc. Today's episode was produced by Kaia Findlay and edited by Amanda Magnus and Wilson Sayre. Nina Scott is our intern. Jenni Lawson, our technical director. Quilla wrote our theme music. This program is recorded at the American Tobacco Historic District. North Carolina Public Radio is a broadcast service of the University of North Carolina at Chapel Hill. I'm Anita Rao.