Sex In Aged Care, Where’s The Line? with Dr. Catherine Barrett

Transcript

Ash de Neef: Awesome, Catherine, thank you so much for joining us on the show.

Dr. Catherine Barrett: Thank you, Ash. It’s a pleasure to be here. 

Ash de Neef: I’m wondering for our listeners who don’t know who you are. Can you tell us, who are you? What do you do?

Dr. Catherine Barrett: My name is Catherine Barrett and I’m the founder and director of Celebrate Ageing, which is a charity, challenging ageism and building respect for older people. And at the moment I’m also coordinating a project called Ready To Listen, which is preventing sexual assault in residential aged care. That’s being led by OPAN, the Older Women’s Network and funded by the Department of Health.

I started my career as a nurse in residential aged care and worked for a decade as a Nurse Unit Manager and I love that work. And that was where I first really took an interest in sexual rights of older people. And then I went across to academia and when I was at La Trobe University, I did some research work as a senior research fellow and focused on sexual rights again.

Then I thought, you know what? I did amazing research work in academia, but it didn’t result in change, cultural change. So I stepped out of that and set up Celebrate Ageing because I want to see more change happen directly. It’s not enough to do amazing research. I think we need to create change as well.

So I’m sort of bringing to this podcast and the work I do now, a passion for change, a passion for older people, a background as a nurse in residential aged care and a bit of academia thrown in. 

Ash de Neef: Yeah, that’s great. So you’ve been on the floor. You’ve been researching and now you’re advocating. Nice little combo there.

Dr. Catherine Barrett: Yeah. 

Ash de Neef: Well, that’s great. We did want to talk today about sex and sexual activity in aged care. 

And there’s a lot to talk about here, but maybe just to start with a very obvious question, which I’m sure most of our listeners will know the answer to. Are aged care residents, having sex?

Dr. Catherine Barrett: Well look, absolutely they are. Absolutely. And you know, I think that anybody out there listening to this could say, at what age do they expect that they would no longer be sexual? What birthday do you think that you would wake up on and allow people to label you as asexual and take away your sexual rights? And most people in response to that are younger people sometimes.

Or the oldest was 40 or 60, but anyone who’s middle or mature age will just go well, that’s outrageous, I would never let someone take away my right to intimacy, sexuality and sex.

So we remain sexual our whole life. It changes the way we express – our sexuality changes. And I think the thing that’s really important is that sexuality is about sex.

Sex is an important part of sexuality, but it’s not the sum total. And, you know, one of the things that people talk about as they grow older is that the reality, the other parts of sexuality, other than sex, become increasingly important and that’s touch and intimacy and human connection and, feeling like a sensual person or a sexual person. And the ways we express our gender as well too. They’re all really important parts of our sexuality as well. 

Ash de Neef: Yeah, that’s great. Lots of nuances to dig into there. Before we do, I think there’s probably a lot of coverage over sexual assault in aged care, which undoubtedly happens. Are there instances of consensual sexual activity in aged care as well? Just to be clear.

Dr. Catherine Barrett: Yeah look, there are. Absolutely, absolutely. There are people who are having consensual sex in residential aged care. There are new relationships that are formed, which is really wonderful, you know. Having to be in a residential aged care service, and then meeting someone that you want to have sex with or that you love is a really beautiful thing. There are stories of people getting married in residential aged care. So absolutely, there are stories and plenty of them are about older people expressing their right to sexual expression and having sex in residential aged care. Absolutely.

Ash de Neef: Yeah, fantastic. 

Dr. Catherine Barrett: Yeah. I think that most of us, if we were told that we weren’t allowed to hug anybody, that we weren’t allowed to touch anyone, most of us would resist and say well, that’s not something that we’d agree to. But you know, imagine being in a loving relationship and having to go into residential aged care and you know, your partner can still visit or you can still go home and you can have sex or cuddles or whatever it is that you want to have. It’s an incredibly life affirming, joyous, celebratory part of life. And then I think if you don’t have a partner and you go into residential aged care.. you know, some people meet the love of their life. And to be able to then have a new intimate or sexual relationship. To have sex or cuddle or touching or whatever it is that you want to have. That’s a really beautiful thing to be able to have and it’s the right of older people to be able to have that. 

Ash de Neef: Awesome. So when you were working on the floor and you said you were quite interested in the sexual rights of older people, were there moments that kind of peaked your interest like -hang on, there’s something here that we’re not talking about. What was the experience that was getting you interested? 

Dr. Catherine Barrett: Yeah, look I think probably, where it started or where I remember it started was, there was a resident who was masturbating in the shower every morning. And the staff were embarrassed and angry and outraged and said that wasn’t part of what they expected they signed up for.

And they thought it was really quite inappropriate for him to be doing that while they were assisting him in the shower. And they were right. That it wasn’t. That wasn’t the appropriate place for him to masturbate, but he had the right to masturbate. And he was a person who had cognitive impairment.

And so what we needed to do was to find ways for him to express that in a private way, rather than a public way. And so we had conversations about it and what we realized was happening was we had these new fantastic continence pads that you could put on for eight hours, and then you take them off and put another one on.

And so he had actually lost contact with his genitals. He wasn’t able to masturbate. He didn’t have the cognitive function to be able to fight his way through a continence pad to access his genitals. And the only time that happened was in the mornings. The staff got him out of bed, took him up to the shower.

He then woke up and went, “there’s my genitals, I’m going to masturbate.” So what we realized we needed to do was that the night staff at 6:00 am would take his continence pad off and then he could have that private time. He could have his dignity and the staff could have theirs as well too. So they were able to then get him up and assist him in the shower.

And that private activity was done. So that was successful. I mean, sexual expression in residential aged care is often complex. Not just because of what’s happening for residents, but also because staff have their own values and beliefs and that’s okay.

And most people have not had education on older people’s sexuality. So there are so many different responses and a lot of them are quite explosive and highly emotive. But what we did was we talked about it. So, you know, let’s come up with a strategy or the night staff will do this and then let’s have another meet.

So then someone said the next day we talked about it and yes, it’s working. And so someone said, well, if you’re going to do something about that, you need to do something about this. And then there was another story that came forward. And so we did something about that.

And then people said, well, what about this? You know so what happened was, we created a culture or context where it was okay to talk about sexual expression. And then what we did was we were able to educate staff – support staff so they knew how to respond to the sexual expression.

And that’s what got me interested. That and then the sexual assault in residential aged care. I realized that it’s kind of the work that I do with older people is about respect for older people. You know, why sexual rights is the canary down the coal mine. If you don’t have respect for older people, it’s like, there’s no oxygen in the cave.

The canary is going to die. So promoting sexual rights is really addressing that problem of ageism. So that’s what got me interested.

A couple of years ago, I edited a book on the sexual rights of older people with an academic from the UK. And I think that’s a really important contribution because we took these global rights that human beings have and we applied them to the lives of older people. And so it’s debunking the myths of ageism that say this doesn’t matter for older people. We’re saying it does matter. And not only does it matter, but older people have rights. 

Ash de Neef: Hmm, if we take a step back towards the residence, sexual rights and responsibilities as well. As you said, there is a responsibility from both residents/older adults and from staff. But number one, the right to engage in a sexual activity is paramount. That everybody has that right. No matter their age, no matter their living circumstances. 

Dr. Catherine Barrett: Yeah, they do. Absolutely. The example I gave you is potentially one of the simplest ones. So, an older person asserting their right to masturbate – there’s not another person involved other than staff and it can be relatively straightforward. Where it starts to get more complex is when you got, for example, that resident who had a cognitive impairment, perhaps he has dementia for example, and then maybe he’s moved into the room of another resident and he’s touching a female resident.

Then it starts to get really complex because. if it’s not clear what his cognitive function is, well particularly if what happens much more often is, the female resident has a cognitive impairment. The female resident has dementia and she’s being touched by someone and there’s a discussion about whether this is her right to form a new relationship. Or does she think this man is her husband, or maybe she’s enjoying some affection and there’s a new relationship and she’s enjoying the affection. Then it crosses over into sex and staff aren’t sure whether she’s consenting and there are some indications that she’s not comfortable.

And so that’s when it becomes really complex because there are then often discussions about, is she consenting or not? And if she’s not consenting, then that’s called sexual assault. So then the lack of consent for sexual activities by definition, is sexual assault. So that’s when it becomes difficult and then there are layers and layers. You speak to aged care service providers and the people they’re looking after are as complex as the rest of the community. So then there might be a male resident who’s doing this and he may be a serial offender and it may be a pattern that he’s had all his life.

And so he’s only doing this when staff aren’t watching. And so staff are unsure of what’s happening and maybe the female resident has family members who like that she has a companion because her husband has died. But now that handholding is starting to progress to something more sexual and the family are just going, “we’re not happy with this”. For male residents, the families are saying “we’re happy”. And then the staff get really conflicted. These are some of the real life challenging situations that staff are finding themselves confronted with.

Ash de Neef: Well, in that instance if it’s a clear cut case of consent. That everybody has the ability to provide consent and the families have an opinion, the family’s opinion is irrelevant. Isn’t it? 

Dr. Catherine Barrett: Yeah, if the residents have capacity to make their own decisions. We are guided by the residents, not by the family members. Because sometimes, the family members, they may be having all kinds of other difficulties. You know, a mum has formed a new relationship and she can consent, but the family are still grieving the loss of their dad, for example. Or sometimes what happens is, a female resident has formed a new relationship, and the husband hasn’t died. So then families get really conflicted. But yes, it’s being guided by what the resident wants and ensuring that the resident is able to provide informed consent. Incredibly important. And so that’s some of the work that we are doing with this charter of residents – sexual rights and responsibility.

Ash de Neef: Hmm okay. So it sounds like the way that you’ve set it out there, is though the question of whether or not someone can give consent is a tricky one, depending on the individual. If you deem that they cannot give consent, then it is classed to sexual assault. And if it’s deemed that they can give consent, then everything’s fine.

Dr. Catherine Barrett: Yeah, everything’s fine. But it becomes really difficult for people. For staff particularly, if they feel someone’s been taken advantage of. So there can still be inequalities in a new relationship between two residents, perhaps both the residents are consenting. But the staff, it’s not sitting well with them.

And you know, one of the things that happens actually is, people might be in a country town and the staff members know the new couple really well.

Perhaps the female resident’s husband has just died and the family is saying, “we don’t want this relationship”, but the two residents are consenting and the staff are really conflicted because the residents have children that are their friends and they’re in a country town and all those layers that are just really very human, as complex as any other human, get brought into it. So it’s rarely simple because we’re not just providing guidelines for staff and residents. We need to educate families as well and sometimes when families get really upset or angry or hurt, they might make complaints. They get really agitated and some staff will default to responding to the family rather than the older person. 

Ash de Neef: Yeah, it sounds like there’s so many different factors to consider. Something that would probably come up a lot is the opinions of the staff or what they’re comfortable with or what they think is appropriate that might be put on to the residents, regardless of issues of consent or comfort of anybody else. There’s probably a need for some training or some discussions around how to remove your own bias, right? 

Dr. Catherine Barrett: Yeah, absolutely. There is. And I think that traditionally that staff have responded from a position of their own values and beliefs because there have been no other guidelines. There’s still no generic program of education on the sexual rights of people in residential aged care. So what have staff got to draw on other than their own values and beliefs?

It’s really interesting that often when we have these conversations; people will say, “oh yes, we’ve got a culturally diverse workforce”. And I say to people, well hang on a minute. If you think about culture, culture is about our values and beliefs and traditions. And we’ve all got those.

We’ve all got those. And so we need to put them on the table. And when you do that, you open up conversations. People go, “well, I think that’s wrong. And I don’t think that’s not what older men should be doing. And I see this man as my grandfather and this shouldn’t be happening”. And so you can actually put that all on the table and acknowledge the difficulty for staff and actually say to them, I know this is difficult for you, and then you need to develop organizational guidelines that really clearly delineate what is acceptable and what is not acceptable, what are the residents rights and what are their responsibilities in relation to sexual expression as well too. And really be clear about those and give staff education around those so that they understand them.

And I think then the other thing that we’re doing with this charter of sexual rights and responsibilities in that we’re saying, staff also have rights and responsibilities in relation to this. And staff, you know, again and again and again, tell me that when they’re caring for people who might be sexually disinhibited, for example, or hypersexual, that the residents might be sexually harassing staff. So where’s the education for staff on how to respond to that? You know, that needs to be part of the same policy process. And so to recognize that staff have the right to a harassment-free workforce is about taking a step back and going, “well we need policies for our organization and we need education for our organization because we’re violating staff rights to a safe workplace”. But also when it comes to sexual assault there is this belief that people who perpetrate- I think 50, the Royal commission estimated 50 sexual assaults in residential aged care each week.

I think that’s an underestimate. We know that most of the perpetrators are male, we know that most of the victims are female residents with dementia. And I think one of the things that’s really difficult for staff to understand is when you have a really valued colleague that perpetrates sexual assault, and then you’ve got a resident who says “I’ve been sexually assaulted”, then names a staff member, it can be really, really difficult for staff to get their heads around that because often it’ll be a male and he’d be a valued staff member. We trust him. This service is about caring for residents. Why would anyone in our team do that? 

Ash de Neef: Because of the cognitive dissonance there, right?

Dr. Catherine Barrett: Yeah, yeah, yeah, absolutely. Actually it’s wonderful to have that reflecting back. So what happens with that cognitive dissonance? 

Are people distancing themselves from it? And the first one is discrediting ; “oh she must be confused, she must be remembering a childhood sexual assault, he must have cognitive decline, she must have dementia or a urinary tract infection”. But then the other thing that some service providers are doing is minimizing ; “oh it wasn’t that bad or it wasn’t really a sexual assault”. A family member rang me the other day and described walking into a room and seeing their mother being sexually assaulted and it was really clear to them and to me, listening to the story, that it was a sexual assault.

But the staff said, “oh they were just having a cuddle”. So there’s this minimizing because it’s so difficult for people to believe that anyone would do that. Particularly if they’re caring people and they really care about the residents and it’s like “that person in my care has just been sexually assaulted. What does that mean?” And Jim Mars has been talking about this thing called ‘Monster Myth’.

He said when he went to court for his wife, the person who was accused of his wife’s rape and murder- he said he expected to see a monster walk into the room and there wasn’t one.

We think that we will be able to tell if someone would perpetrate sexual assault. We’ll know, we’ll know what they look like, we’ll know the minute they walk into the room that that’s a perpetrator, but it doesn’t work that way. So what we do with he Ready To Listen program that we’re doing for preventing sexual assault is we say to people, this is the research on the victim survivors, these are their characteristics, these are the characteristics of the perpetrators. And what we know you need to do is, we know you need to have policy, not just on sexual assault, but on sexual rights. And you need to be able to tell staff where the line is and you need to have that policy backed up with education for staff, because otherwise you’re expecting people to put out a bush fire with a garden hose.

You know, it’s quite unfair to residents and to staff, really, if you’ve not got policy and education.

Ash de Neef: Yeah, well, a lot of that sounds very kind of reminiscent of the Me Too movement that’s been coming out over the last couple of years where women are coming forward with allegations and being dismissed. And if you ever need a sort of clarifier on if there’s a power imbalance, it’s probably somebody’s accusations being dismissed as shifting cognitive abilities.

As you said, we need something to clarify where the line is and the charter of  residential sexual rights and responsibilities that you’re putting out very shortly through your website, opalinstitute.org does just that. 

One of the things that really tacks onto what we’re just saying there is any sexual interaction between a volunteer or a staff member and a resident should be considered as sexual assault. 

Dr. Catherine Barrett: Yeah, absolutely. We’re doing some work at the moment with the Aged Care Quality and Safety Commission with a serious incident response game. Because there is a gap at the moment between their fact sheet that says that’s sexual assault, and then the supported decision tree that they have, which gives staff the opportunity to say “sexual assault by a staff member, no adverse impacts, didn’t report it” to place priority to. So there’s a real gap there. And there is a community expectation that if there is an allegation of sexual assault by staff member or a disclosure of sexual assault by staff member that it’s reported to the place and taken absolutely seriously. 

Dr. Catherine Barrett: And you’re right about Me Too. I mean, not everybody’s a fan of Me Too, but what I liked about Me Too was that it brought this issue into focus. And two years ago I did some work with Margarita Solis who was sexually assaulted when she was 95. At the age of 97, I worked with her and she launched a national campaign called She Too, and it was about “please don’t forget older women, and please listen to us”.

And Margarita was an ex nurse. When she reported her sexual assault, she was discredited in so many different ways. And then she went to a residential aged care home. She was in a retirement village and in the residential aged care home, she found security. She found safety. She found people that listened and she was empowered enough to have him charged and convicted.

To the assistant manager and also then to launch a national campaign. Calling for service providers to listen to older women and to listen with their eyes and their ears and to ask “how are you?” and then ask again. That was Margarita’s campaign. And so I think that we think that old age is a protective factor against sexual assault and it so isn’t, but talking about sexual assault is education policy. Talking about sexual rights and sexual assault can help to stop sexual assaults.

Ash de Neef: Yeah. Great, great point. Talking about it does help to prevent it. Now we’re moving through a lot of topics here, but we’ve moved through quite quickly the idea that staff might be experiencing sexual assault from residents, which I’m sure is quite common and that they have a right to be working in a place where they’re free from that assault and harassment.

What steps can be taken? What can be done if a staff member is experiencing sexual harassment or assault? 

Dr. Catherine Barrett: Well, I think one of the first things that if somebody reports that they’re experiencing that I think the first thing to do is to say to them, “I’m sorry that happened to you” and just to have that empathy and compassion. And I’ve done that in workshops where I’ve been brought into a service where things have gone terribly wrong and everybody’s sat there and the room is so loaded and someone starts to tell their story and I’ve said to people, “I’m sorry that happened to you” and the people, you know, service providers just wailing because that’s the first time they’ve had that recognition, that it was a really difficult thing for them and saying to people “it’s not your fault, you’ve done nothing wrong”.

You know, let’s talk about it. So acknowledging that hurt, employee assistance, sexual assault, counseling, giving that person the support they need, and then addressing that issue ; that there’s a resident who’s crossed a boundary. And so one of the things, in terms of working out how to manage that situation, the first thing I think you need to find out is, what’s happening for the resident? Is the resident trying to express their sexuality and is disinhibited or has lost capacity to judge that this is an appropriate way to express it? Like, so a neuro, psych or a geriatrician assessment can find out what’s happening in that person’s heart and in their head, and then that will give you the clues you need on how to respond. And it may be that something is done to meet their need, in whatever form that takes. But then there needs to be really clear messaging from staff about what’s appropriate and what’s not, and almost every time I go into a service in that context and if there’ll be 10 people in a room and I’ll say to them now “tell me if he does that, how do you respond?” And you work around the room. 

Dr. Catherine Barrett: Everyone will have a different response and invariably it will be younger staff members who will say “I’m really embarrassed and I just can’t go there anymore”.

And the older staff members will say, “I said to him, don’t do that again. I’ll tell your daughter or stop that”. But then some people will make a joke of it and shrug it off. And so if you’ve got a resident who’s got a cognitive impairment, they’re getting a different message from each staff member.

So what we do then is agree on a strategy and often that will be giving the resident a really clear warning and saying, “hey, stop that now. I’m not going to assist you to have a shower if you do that again”. So giving that person some warnings and then leaving if you need to, but everybody’s doing the same thing, giving a really clear message. And then I think the other thing that needs to be acknowledged too – because people in residential aged care are diverse and a broader community – sometimes you get someone who doesn’t have a cognitive impairment. This is something they might have done all their lives. So what needs to happen is to contract with that person and just actually say, “please don’t do that again, and if you do do that again, these will be the consequences”. And you know, it can be withdrawing a service, if somebody doesn’t stop. 

Ash de Neef: To bring it back to 2018, you published the Declaration of Sexual Rights of Older People and there are 15 specific rights there. There’s a couple that I wanted to chat about, specifically the right to privacy. Is there some concern for privacy when discussing with other staff members? 

Dr. Catherine Barrett: Well, sometimes it might be necessary and sometimes it might not. I mean, talking to others about it in a way that’s titillating, that robs him of his dignity, it’s not okay. But, it can be really important to talk about resident sexuality.

But you’re right. There’s some times having conversations about residence sex or sexuality can be demeaning. But sometimes if we’ve got staff who feel really confident and comfortable with older people’s sexuality. They understand this is a sexual right. They know where the boundaries are.

They know what they’re expected to do and not to do, then sometimes having communication about residents sexuality is a way of promoting better resident care. So I think that it’s incredibly important that we have these conversations, so that everybody starts to build a level of confidence and comfort. 

Ash de Neef: Absolutely. How does this work with the family’s involvement? Does the family have a right to know or need to know if their family member is being sexually active?

Dr. Catherine Barrett: No, no they don’t. If you’ve got consenting adults, then the care has contracted with that resident and it’s their business. You wouldn’t expect to tell your parents, if you are having sex with your partner. We just wouldn’t do that. So why would we do that the other way round? I think the only time it happens is when you’ve got a resident who doesn’t have capacity to make decisions. So the family’s engaged in making those decisions for the resident. Or sometimes if you’ve got residents who are in consensual relationships and the families just go, “well, that’s not okay”.

Then we’ve got to let them know that the person who’s in our focus, the resident, is whose needs we’re responding to, not yours. 

Ash de Neef: Hmm, I can see that being a very challenging conversation. Hey Catherine this has been such a great conversation. There are so many intricacies in this topic. Before we sign off, is there anything else you’d like to talk about?

Dr. Catherine Barrett: The only thing that I’d like to say is that I know that this is a topic that a lot of aged care service providers want to know about. And a lot of people struggle with it because they’ve never had education. There are no policies or guidelines. And so that’s the work that we’re doing with this Ready To Listen project led by OPAN, funded by the Department of Health, Older Women’s Network – is saying, here is a charter of sexual rights and responsibilities that looks at what residents need and what staff need as well too. And I think this is a really positive step forward in really trying to be much more affirmative in our responses to sexuality.

Ash de Neef: Hmm, absolutely. And there are some resources included at the end of the charter as well. Maybe you can help us here. Where can people find this charter when it’s released? 

Dr. Catherine Barrett: They can go to opalinstitute.org and then go to the map and have a look at the Ready To Listen map and the charters there. It’s free and there’ll be some education modules.

Ash de Neef: Perfect. Well Catherine, thank you so much for your time today. Thanks for touching on this delicate, very intricate topic. 

Dr. Catherine Barrett: Hey, well thank you for the amazing questions. Your questions were very astute. Thank you.