Hypersexuality and dementia: dealing

with inappropriate sexuai expression

Agnes Higglns, Philip Baricer, Cecily M Begley
Abstract
Sexuality is always a difficult and challenging issue for nurses to address
with older patients. This is particularly the case in relation to responding
to incidents of hypersexuality or inappropriate sexual expression
as a result of dementia. Although research suggests that hypersexuality
is a rare occurrence, when it happens it has the potential to jeopardize
the quality of life of all concerned. The focus of this article is on
exploring the literature on hypersexuality in people with dementia
in the residential care setting. Information and principles of care
are offered that may help nurses respond in a sensitive manner
that protects the rights, dignity and autonomy of all concerned.
Key words: Alzheimer disease Dementia
Education: interprofessional Elderly: attitudes Sexual behaviour
exuality is generally a challenging issue for many
healthcare workers. It is a sensitive, emotive and taboo
) topic, often shrouded in misinformation and fear
(Kautz et al, 1990; Gamel et al, 1995; Cort, 1998). In
a society and culture that seems to be confronting its taboos,
sexuality and older people is an issue that is rarely discussed in
an open and constructive manner. Indeed, in earlier research
on sexuality, few older people of either gender were included
in the sample (Kinsey et al, 1948,1953; Hite, 1976). Regardless
of our reluctance to notice or talk about it, many older adults
are sexually active (Steinke, 1994;Trudel et al, 2000) and the
onset of cognitive dysfunction does not diminish the desire for
sexual intimacy, love and affection (Harris and Wier, 1998).
The body of literature and research on sexuaHty and people
with dementia is in its infancy, and what is available tends to
ignore the clinical and ethically challenging aspects of how to
respond to inappropriate sexual expression. Addressing issues of
sexuality in this group, including consensual activity as well as
'forced' sexual encounters, is an area that merits serious
attention (Archibald, 2002).

age is thus equated with sexlessness. Mayers and McBride

(1998) suggest that it is not unusual for healthcare staff to
discuss issues of sex and older people in a demeaning manner,
view older people as asexual, consider older people's sex lives
as a non-issue or label sexual conduct with a variety of value
judgments that impose their own moral assessments. Denial of
the existence of sexual activity in older people can result in
attitudes that sexual conduct between older adults is
inappropriate, laughable, and shameful (Ehrenfeld et al, 1999;
Clifford, 2000). Indeed, the stereotypes of the 'dirty old man'
and sexually predatory old woman still exist. The media
continues to portray older person's sex as a joke, or limit the
portrayal to hugs and kisses (Mayers, 1998). This dilute
depiction contrasts with the passionate,flesh-revealingscenes in
films portraying young people's sexual activity (Mayers, 1998).

Table 1. Examples of negative

misconceptions about older people
and sexuality

Sex is unimportant to older individuals

It is abnormai for oider people to be interested in sex
Older people have no desire for intimacy
Older persons are not physically attractive and are not
desirabie
Sex is for the young and fit
Source: Bauer and Geront (1999a), Weei<s (2002), Peate (2004)

The older person living in institutional settings who seeks

out intimacy is often in a difficult situation as in many
inpatient settings sexual interactions are prohibited, if not in
written policy then through the attitudes and values held by
staff. Older people find themselves under what Foucault (1976)
terms the constant 'clinical gaze' of staff, with very little
'backstage' space in order to meet their intimacy or sexual
needs in privacy. First, the environment is constructed as a
public space and, second, the staff handover legitimizes what
could often be considered 'gossip' about people's behaviour
Sexuality and the older person
and conversations (Bauer and Geront, 1999a).
There are a variety of common negative attitudes and
When older individuals express themselves sexually in any way
misconceptions about older people and sexuality {Table 1). Old
that is deemed by staff to be socially acceptable, such as holding
hands, they are often patronized with phrases such as 'isn't it
Agnes Higgins is Student/Health Research Board Fellow, Philip Barker
is Visiting Professor, and Cecily M Begley is Professor of Nursing
lovely to see'.There is also a tendency to infantiUze older people.
and Midwifery/Director, School of Nursing and Midwifery Studies,
For example, Mayers and McBride (1998) suggest that if the
Trinity College Dublin, Ireland
person is attractive and is not aggressive sexually staff may engage
in actions such as asking the person for a kiss, calling the person
Accepted for publication: October 2004
by affectionate names in baby-talk, kissing the person on top of

1330

British Journal of Nursing, 2004, Vol 13, No 22

OLDER PEOPLE
the head, hugging the person without permission and displaying
other such behaviour. Although affectionate and well meaning,
behaviour of this type may demean the person. This
infantiUzation of the person may make it difficult for staff to
contemplate these 'children' as sexual beings (Archibald, 1998),
Indeed, for people who have a cognitive impairment and are
already having problems interpreting the world, this type of
behaviour may lead to mixed messages and a blurring of
boundaries. However, if behaviour goes outside the limits of what

Table 2. Manifestations of iiypersexuaiity

Touching the breasts, buttocks and genitals of staff
and other residents
' Kissing and hugging that exceeded mere affection
' Exposing genital arecis
' Mai<ing sexuaily suggestive remari<s
' Attempting intercourse and oral sex
' Public masturbation
Source: Burns et al (1990), Devanand et al (1992), Miller et al
(1995), Archibald (1998), Mayers (1998)

The literature suggests that staff, patients and family may

disagree as to what constitutes appropriate behaviour (Gibson
et al, 1999), For example, depending on the healthcare staffs',
residents' and families' values and beliefs, two older women or
two older men holding hands may be considered
inappropriate. For others, the viewing of sexual material may
be considered a form of hypersexuality.
From a review of the literature, hypersexuality typically
involves inappropriate or uninhibited sexual behaviour
directed at oneself or another. Usually the behaviour is
directed to a number of people and is not confined to one
particular relationship (Kuhn et al, 1998), but this may not
always be the case (Mayers, 2000), In studies on sexuality and
dementia, hypersexuality manifested itself in the ways listed
in Table 2. The rates of sexual disinhibition reported in the
literature in people diagnosed with Alzheimer's disease living
both in the community and residential care range from
2,9-8% (Burns et al, 1990; Devanand et al, 1992; Miller et al,
1995; Archibald, 1998; Mayers, 1998),
It might be expected that people suffering from a dementia
that affects the frontal lobe, e,g. Pick's disease, would
demonstrate more problems related to hypersexuality as the

staff define as acceptable, people are often separated, moved to

different areas of the service, scolded, chastised, or labelled as
'perverts' or'dirty old men/women' (Kuhn et al, 1998),

Aizheimer's disease
Plaque
Neurofibrillary tangle
(twisted nerve cell fibres)

Sexuality and dementia

Dementia is a progressive condition that affects the brain and
consequently memory personality and behaviour. The most
common form of dementia is Alzheimer's disease, followed by
Lewy body dementia and vascular dementia (Baikie, 2002)
(Figure 1).As dementia progresses and the person's cognitive
ability declines, sexual and intimacy desires and needs do not
necessarily disappear. As Harris and Wier (1998) suggest, the
emergence of grey hair, wrinkles, or progressive cognitive
dysfunction does not automatically signal the end to sexual
desire and sexual behaviour. While sexual apathy and decline
in sexual interest generally accompanies dementia
(Wright, 1998), a rare yet disturbing behaviour outcome of
dementia for some sufferers is hypersexuality or inappropriate
sexual expression (Kuhn et al, 1998),
This issue presents many challenges to caregivers and has the
potential to disrupt family and professional relationships
because of its antisocial nature; it may give rise to a range of
conflicting emotions from anger, shame, embarrassment,
frustration through to helplessness. If occurring in a residential
setting it may pose a threat to the entire fabric of life for
residents, family and staff (Kuhn et al, 1998), Thus, caregivers
have an extremely challenging task to ensure emotional,
physical and sexual safety while optimizing the environment
and opportunities for intimacy, touch and sexual expression.
Indeed, the expression of physical affection and touching
becomes even more important to people for whom verbal
communication may be difficult.
Defining hypersexuality is not easy. There are no clear
criteria on what constitutes hypersexuality in terms of types
or frequency of behaviour. Also, what constitutes
'inappropriate' is subjective and dependent on the observer.

British Journal of Nursing, 2004,Vol 13, No 22

Frontal lobe
Temporal lobe

Lewy body dementia

(Lewy bodies present
in brain stem
and cortical areas)

Frontal lobe
Judgement and behaviour

frontal lobe of the brain is considered to be involved in the

control of the libido (Kuhn et al, 1998), However, Miller et al
(1995), in a comparative study involving 14 people with frontal
lobe dementia and 14 people with Alzheimer's disease, found
no statistically significant differences in increased or decreased
sexual drive between both groups.
In a small survey in Australia involving 33 nursing and therapy
staff working in a long-term care facility for people with
dementia and mental illness, 61% reported incidents of both
male and female patients displaying 'inappropriate' sexual
behaviour towards either staff or other patients in the previous
year (Mayers, 1998), Most of the sexual behaviour reported
involved victimization of another patient, with male patients
being described as more aggressive with forceful actions and
sexual grabbing. Some caregivers believed that behaviours such
as verbalizing about sexuality, engaging in self-stimulation and
scrutinizing private body parts of others were predictors for
possible future sexual aggression (Mayers, 1998), Similar levels of
inappropriate sexual behaviour was reported by the 33 Scottish

Figure 1. Diagram
showing the main
causes of dementia
and sites of
neurological damage
with respect to the
frontal and temporal
lobes of the brain.

1331

nursing homes managers surveyed by Archibald (1998). Despite

the fact that most of the residents were female, the majority of
incidents reported by managers related to male residents.

Possible causes of hypersexuality

Reasons for hypersexuality in dementia are unclear. The
expression of sexuality involves complex brain function and
many physical, psychological, and environmental factors may
account for the person's behaviour. It has been suggested that
disruption to the neural pathways related to sex drive may play
a role (Baikie, 2002). Kuhn et al (1998) also point out that sexual
manners are learned behaviours that may be forgotten as a result
of the dementia. In other cases, hypersexuality may be related to
a psychological need for intimacy that has been sexualized.
People with dementia may feel disconnected from others, and
they may have lost the ability to speak, or to communicate their
desires and needs. Consequently, they may be acting out a strong
need for human connection and touch as a result of what Miles
and Parker (1999) term 'iatrogenic loneliness' loneliness
induced by staff attitudes and organizational structures that
discourage or fail to accommodate any form of intimate
relationship within the institutional setting. The part of the
person's body being touched may be irrelevant to the person with
dementia, who just craves the touch itself. The occurrence of
inappropriate sexuality also does not occur in a vacuum. People
with dementia may confuse staff and other residents with a much
loved partner or may misinterpret the interest of another resident
and respond out of that misinterpretation (Mayers, 2000).

Psychological and beliavioural approaches

to care
In responding to hypersexuality in people who have dementia
there is a fine line between appropriate concern, safety and the
patient's basic human rights. It is much easier to take the view that
no sexual behaviour is allowed in the facility, with one rule for aU.
It is much more challenging to uphold a holistic approach to care.
This approach requires that the person is viewed as a unique,
complex individual with specific needs and desires (Heath, 2002).
It requires that staff accept sexuality as a continuing part of
people's lives, appreciate the importance of sexuality in relation to
the individual's identity and self-worth, and consider the rights
and needs of residents within the sexual realm (Mayers and
McBride, 1998). The aim should not be to eliminate all sexual
expression, but to accept and promote 'appropriate' expression.
Harris and Wier (1998) draw our attention to the fact that
healthcare professionals tend to focus on cognitive ability in their
assessments and fail to seek input specifically regarding sexual
functioning. Many reasons have been put forward for this
inattention including lack of education, staff discomfort and
embarrassment (Mayers, 1998) and a belief that aU people with
dementia suffer sexual apathy (Harris and Wier, 1998). The
minefield of ethical dilemmas raised by such issues as consensual
sex in long-term care facilities may also cause staff to ignore
patients' sexual health needs (Harris and Wier, 1998).
Underlying many of these reasons is the often pervasive bias of
ageism and the stereotyping of older persons as asexual (Heath,
2002). A person-centred approach that acknowledges cognitive
impairment and also takes account of the person's environment,
health status, previous sexual behaviour, response to stress and

1332

personality is required (Archibald, 2002). A detailed assessment of

the person's behaviours, including all possible precursors, is
necessary. This includes a systematic examination of the
environment, including the behaviour of staff and other residents
that might have influenced the patient's behaviour. Behaviour of
people ^vith dementia may be misconstrued as sexual when in
fact it may have an entirely different meaning or purpose. It may
be a case of mistaken identity, misinterpretation of environmental
cues, or simply the need for human contact (Kuhn et al, 1998).
Nurses need to be guided by the principle that all human
behaviour is purposefiil and communicates, thus the key
questions to consider are: why is this behaviour occurring? What
is the person trying to communicate?
The typical educational, counselling and behavioural
approaches include education about social norms,
exploring feelings and antecedents to behaviour,
challenging dysfunctional thinking, setting boundaries and
behaviour targets in relation to impulse control, and using
contracts. However, approaches that are taken to solve the
problems with people who do not have a cognitive
impairment are not very useful when caring for people
who have a continued deterioration in learning ability
(Harris and Wier, 1998).
In many situations what is required is a 'low-key' approach. For
example, for patients who get into another resident's bed, all that
may be required is a calm reminder and direction to the location
of their own room, as this behaviour may be more the need to
'snuggle' and be close to another human being, as opposed to a
sexual advance (Ehrenfeld et al, 1999). Redirecting the person
who is masturbating in public to a private area, or pulling curtains
around the bed, is advocated (Kuhn et al, 1998). Other
techniques reported in the literature include putting restraining
clothing such as pants or belts on backwards and using zipperless
jumpsuits (Mayers, 1998; Miles and Parker, 1999). While these
may appear to be simple solutions, one needs to be circumspect
about the outcomes and ethics of such practices.
The intimate nature of some of the care given by nurses
and other care staff makes sexuality an ever-present issue
(Archibald, 1998). Thus, staff need to consider when a man
gets an erection during bathing or other intimate contact,
whether or not it is merely a physiological reflex to being
touched. The ability to set limits in a confident and discreet
manner, without offending the person, is required
(Mattiasson and Hemberg, 1998). When staff are
propositioned, simple, assertive, neutral comments such as 'I
don't do that' or 'Don't touch my breasts', while removing
the person's hand, may suffice. If such behaviour persists it is
easy to see why staff would resort to caring for the person on
a rota basis, in an attempt to reduce each individual nurse's
burden of care; however, this is not helpful if the behaviour is
arising from a need for human connectedness and affection,
as simply rotating carers may heighten the residence's sense of
loneliness and isolation.
Bauer and Geront (1999b) found that staff used a form of
joking, witty replies and titillating dialogue to deal with
sexual incidents and elicit patient cooperation. In most
situations the humour acted as a 'smokescreen', which
concealed the patient's real need. While humour is an
important form of communication, and is helpful when

British Journal of Nursing, 2004, Vol 13, No 22

OLDER PEOPLE
dealing with sensitive issues, it needs to be used in a
therapeutic manner to open up conversation and not merely
to conceal staff discomfort.
While staff and family members can usually respond to sexual
approaches in a direct manner, people with dementia may have
lost the verbal ability and skill to refuse unwanted affection or
sexual advances (Mayers and McBride, 1998). Archibald (2002),
in a case study of one residential home, found that staff were
often unaware of the extent of sexual harassment occurring
between clients, and depended on clients to inform them or

Table 3. Possible staff responses to an

older person initiating affection with
another older person
Strong anger
Disgust and rejection of the perceived offender
Giving the person a 'dressing down'
Moving the person to another part of the service
ignoring the behaviour
From Mayers (1998)

simply discover it by accident. This suggests that there is a need

for staff to be more aware of the potential for such harassment,
while at the same time acknowledging the right of older
residents to form mutually consenting relationships.
Respondents in Mayers' (1998) study suggest that in most
cases where a resident made a sexual advance to another
resident, there was a stable relationship between both residents
before the incident; they often sat together and talked together,
with the initiating patient frequently mistaking the victim for
his/her spouse. Staff response to such behaviour varies.
Examples are given in Table 3. Some staff reported difficulty in
broaching the subject with both the 'aggressor' and the victim
(Mayers, 1998). Nurses in other studies have also reported
similar difficulties in discussing sexual behaviour with residents
(Ehrenfeld et al, 1999; Archibald, 2002). In such situations it is
imperative that the rights of both parties are respected, the
right of the victim to be protected mentally and physically and
supported emotionally, and the right of the other person to be
treated in a professional manner. Simply moving the person to
another part of the service is not the answer. It is important
that staff meetings, involving all members of the
interdisciplinary team, are held to discuss such issues in an
open and constructive manner and a plan of care is devised for
both residents involved (Ehrenfeld et al, 1999).
Displays of inappropriate sexual behaviour can be distressing
for family members and visitors. Family members of a person
who is the object of another's sexual attentions may fear for the
safety of their relative; if the person who is engaging in the
behaviour is a relative, family members may feel stigmatized,
ashamed, angry or may fear that their relative will be
victimized, isolated or sent home (Kuhn et al, 1998; Mattiasson
and Hemberg, 1998). Therefore, involving family members in
discussion and education is a core aspect of the nurse's role.
Having family participate with staff in problem solving is an

British Journal of Nursing, 2004, Vol 13, No 22

effective way to build constructive and supportive relationships

with family members (Kuhn et al, 1998).

Pharmacological approaches to care

Most writers agree that behavioural, psychological and
environmental interventions are preferable to the risks of
pharmacology (Alessi, 1991; Kuhn et al, 1998; Harris andWier,
1998). However, Harris and Wier (1998), in a review of the
literature, found that in many cases the pharmacological model
of treatment for hypersexual behaviour is often the preferred
first-line treatment because of its ease of administration,
perceived efficiency and decreased use of staff time. Many
drugs, such as the neuroleptics and antidepressants, are known
to possess the adverse side-effects of decreased sexual desire,
decreased sexual excitement, diminished or delayed orgasm,
erection and delayed ejaculation problems (Milner et al, 1999;
Rothschild, 2000; Smith et al, 2002).
Given the lack of evidence supporting positive outcomes, the
documented side-effects of neuroleptics, antidepressants and
benzodiazepines and the age profile of these patients, Harris and
Wier (1998) concluded that all possible environmental and
psychological causes should be assessed and treated before
consideration of the use of these medications. However, they do
report that drugs that impact on hormonal production, such as
antiandrogens, have been found to be effective in decreasing

Table 4. Expressions of sexuaiity

that need to be covered in education

Affection
Touch
Erotic and non-erotic intimacy
Attitudes of caregivers
Sexuaily inappropriate behaviour
Recisons for behaviour, inciuding cognitive and emotionai
factors
The importance of a team approach to care

frequent masturbatory behaviour in men and women. Practitioners

also need to consider whether chemical restraints are ethically and
cUnically justified for behaviour that might be an expression of a
need for human contact. There is a big difference between
eliminating all sexual expression and finding ways to limit and
restrict behaviour to appropriate locations and frequency.

Education of staff and management

While education on sexuality is offered in many staff education
programmes, the needs of older people and more particularly
the needs of people with dementia are often ignored within
such courses. If education and advice is given, it is often reactive
and after the event. Studies have shown that some staff feel guilt,
confusion and shame, with a sense of having done something
wrong to elicit sexual responses from patients (Mayers, 2000;
Archibald, 2002). Mayers (2000) suggests that this response is
similar to the response of some rape victims, who believe that
the rape was the result of the way they dressed, spoke or
behaved. In some institutions staff have been made to feel
responsible by colleagues and management for the patients'

1333

sexual behaviour. As a consequence, junior staff often failed to

report subsequent incidents to management (Archibald, 2002).
Education needs to focus on the various expressions of
sexuality {Table 4). Mayers' (2000) and Archibald's (2002)
studies highlight the need for education to ensure that staff
do not feel guilty or responsible for such behaviour. There is
also a need for education to ensure that staff respond
appropriately by not encouraging or reinforcing the
behaviour or by labelling the person in a derogatory or
demeaning manner.
Some statff may be uncomfortable and feel too ashamed
when reporting incidents or discussing them with other clinical
or academic staff. For this reason staff should take the initiative
by introducing the topic into discussions and by teaching
coping strategies. Training programrries have been devised to
address other aspects of patient behaviour such as physical
aggression, but sexually inappropriate behaviour is seldom
addressed in education. Using role play, senario discussion or
developing education programmes along the Balint approach
(with its emphasis on the role of psychology in medical care and
on the interpersonal relations between group members and
their patients) (Selby, 2000) is important as these will increase
staff members' confidence, self-assurance and skill in responding
to the needs of this population in a sensitive and dignified
manner (Fitzpatrick, 2000; Selby, 2000).
Where education has been offered, findings indicate that staff
feel more aware of their attitudes towards older people's
sexuality, are more comfortable raising issues and talking to
residents and other staff about sexuality, and reported a greater
willingness to use residents' terminology rather than using
medical terms with which the residents may be unfamiliar
(Mayers and McBride, 1998).

Conclusion
Addressing issues of sexuality is challenging, irrespective of care
environment or patient group. However, no issue carries such
emotional weight and conflicting vie\vs as hypersexuality, thus
it needs to be responded to in a way that protects the right,
dignity and feelings of all concerned.
Caring for people who challenge us
with sexual behaviour that is
KEY POINTS
considered 'inappropriate' always
I Although rare, hypersexual behaviour
demands reflection and assessment as
is a distressing outcome of dementia.
each person and situation is unique.
I Hypersexuai behaviour presents
The lack of training, the
the nurse with difficuit clinical, ethical
existence
of a culture that fails to
and practicai chaiienges.
allow
an
open and informed
I Nurses responding to hypersexuai
discussion,
and
the continued belief
behaviour need to pian care in a way
that
it
is
the
responsibility
of the
that respects the rights and dignity
staff
not
to
place
themselves
at risk
of aii patients, famiiy and heaithcare
in
relation
to
sexual
advances,
may
workers.
mean that inappropriate sexual
I There is an urgent need to include
expression to staff or other patients
issues of sexuality and older people
is not addressed in a sensitive and
in education programmes and create
constructive manner. Thus, there is
a cuiture within organizations where
a need for education to develop a
issues of sexuaiity can be spoken about
culture where staff feel comfortable
in an open and constructive manner.
to express their concerns, acknowledge their emotions without fear

1334

of being blamed and ridiculed and support one another in

the interests of holistic patient care.
IBS
Agnes Higgins holds a Clinical Nurse Research Fellowship from the Health Research
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