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European Journal of Ageing logoLink to European Journal of Ageing
. 2019 Nov 25;17(2):197–205. doi: 10.1007/s10433-019-00546-6

‘I do it my way’: long-term care staff’s perceptions of residents’ sexual needs and suggestions for improvement in their management

Feliciano Villar 1,✉, Rodrigo Serrat 1, Montserrat Celdrán 1, Josep Fabà 1, Teresa Martínez 2, Jos Twisk 3
PMCID: PMC7292849  PMID: 32549873

Abstract

This study is aimed at exploring to what extent staff perceive older residents in long-term care facilities (LTCFs) as still having sexual needs, and how they think care in relation to sexual issues could be improved. The sample was self-selected and comprised 2115 staff members (including managers, technical and care assistants) employed at 152 Spanish LTCFs. Data were collected in the second half of 2016. Participants were asked to estimate the proportion of older residents who had sexual needs in their institution and, by means of open-ended questions, they were also asked about how they satisfied such needs and how to improve care in relation to sexual issues. Responses to the open-ended questions were analysed using content analysis. Differences were assessed according to participants’ work position. Results showed that most participants did not see sexual needs as being present in many (or even any) older people living in LTCFs. Masturbation was the most common way staff thought residents’ sexual needs were being satisfied. The participants mentioned a broad range of measures to improve care regarding sexual issues, including providing more training opportunities for staff, guaranteeing privacy and improving negative attitudes held by family, residents or staff members. Work position influenced participants’ responses: managers and technical staff were more likely to recognise sexual needs among residents, perceived a greater need for training, and proposed more ambitious and far-reaching improvements than care assistants.

Keywords: Sexuality, Long-term care, Nursing homes, Person-centred care

Recent research has shown that living in a long-term care facility (LTCF) for older people is an experience that may impose constraints on the expression of sexual behaviours (Aguilar 2017; Bauer et al. 2007; Lichtenberg 2014; Mahieu and Gastmans 2012). Residents may continue to have sexual needs which remain unfulfilled (White 1982). More recently, Bauer et al. (2013) showed that most residents see themselves as sexual beings who still experience sexual needs. In addition, managers of LTCFs acknowledge that issues regarding sexual activity frequently arise in this setting (Lester et al. 2016), and most staff are able to mention at least one sexual situation that had caused them discomfort (Villar et al. 2018a).

In this context, staff’s attitudes towards residents’ sexuality are key to determining whether residents’ sexual rights will be upheld or, on the contrary, curtailed. Consequently, it is important to establish the extent to which staff working in LTCFs are aware of residents’ sexual needs and what kind of policies they would implement to manage these needs. This study addresses these issues and, in contrast to most of the research in this area, explores them in a large sample of LTCF staff. Specifically, we take into account participants’ work position (i.e. whether they are directors and managing staff, technical staff, or care assistants) in the organisation, as their responsibilities and tasks within the institution are radically different. This approach should allow us to identify distinct views and assess the practical implications for different working positions.

Barriers to expression of sexual needs in LTCF

Most literature on sexuality and older people living in LTCFs has revolved around the many barriers that they might face with regard to the expression of sexual needs. Such barriers can be grouped into three types. The first type relates to the cognitive, mental and physical health and medication use of older people living in such settings, with a high prevalence of chronic diseases (including cognitive impairment), dependency and polypharmacy (Dwyer et al. 2010) that could potentially impair sexual drive and the ability to engage in sexual activities. A second type of barrier relates to the lack of privacy in most LTCFs, which are designed to give quick access to residents’ rooms and, in most cases, provide a standardised and highly regulated program of activities, most of them undertaken in groups (Villar et al. 2014a, b). These environments and practices, as well as making it hard to find the private moments and spaces needed for sexual expression (Bauer 1999a), contribute to the desexualisation of older residents and to curtail their sexual rights (Hafford-Lechfield 2008, Simpson et al. 2017a, b).

However, most attention has been given to a third type of barrier, the attitudinal one. In this respect, although the attitudes of relatives (e.g. Wiskerke and Manthorpe 2018) and peer residents (Mahieu and Gastmans 2015; Villar et al. 2015) seem to be important, there are many studies highlighting the significance of staff attitudes and practices as a key to facilitate or, conversely, hinder, sexual expression in LTCFs. Staff attitudes to residents’ sexual expression have been found to be very diverse, ranging from acceptance and non-interference (Villar et al. 2015, 2016) to condescending and paternalistic views that sometimes include gossiping, joking and mocking (Bauer 1999b). When demonstrations of sexual arousal are judged to be too explicit, or when people with dementia are involved, such infantilising attitudes give way to more restrictive or even punitive attitudes (Villar et al. 2014a, b; Ehrenfeld et al. 1999).

Such attitudes towards specific sexual expressions appearing among older people living in LTCFs are likely to be grounded in a more general view about the extent to which sexual needs are still present in that collective, and how they manage (or not) to express such needs in an institutional setting. Attitudes towards sexual needs and means to satisfy them in an institutional setting may influence staff’s sensitivity towards residents’ sexuality, their willingness to talk openly about (or on the contrary, hide) sexual issues, and their specific response (supportive or restrictive) when older people try to express their sexuality. Although, as reviewed above, there are some studies on staff’s attitudes towards sexuality in LTCF, few of them have explored to which degree staff consider residents still have sexual needs and how such needs should be managed in an institutional context.

Managing sexual needs in LTCF

The wide range of staff attitudes towards residents’ sexual expressions suggests that, in most cases, sexual issues in LTCFs are managed in an ad-hoc way, without relying on explicit and previously agreed institutional policies, which leads to uncertainty among both professionals and residents. Although issues regarding residents’ sexual expression in LTCFs are frequent (Lester et al. 2016) and studies have concluded that implementing policies designed to deal with residents’ sexual rights are urgently required (e.g. Doll 2013), most LTCFs do not have specific policies or guidelines on these issues (Lester et al. 2016; Shuttleworth et al. 2010).

Policies on sexual issues could also be very diverse. In this respect, Bauer et al. (2014) designed an instrument, called Sex-AT, which identified several areas where further improvements may be required. These include: (a) institutional policies addressed at the recognition of sexual rights and sexual diversity; (b) determining the needs of older people living in LTCFs; (c) staff education and training; (d) information and support for older people; (e) information and support for families; (f) improvements regarding the physical environment, and (g) safety and risk management. Using a similar classification and based on a sample of directors of nursing (DONs) in Spanish LTCFs, Celdrán et al. (2018) found that explicit recognition of sexual rights and diversity was most frequently included in policies, whereas training and information were frequently excluded.

In any case, taking into account staff’s views about what could be done to improve the management of sexual issues occurring in LTCFs is essential, since they are the ones who are going to design, implement and enact such policies. However, considering staff in an undifferentiated way, as most of the research in this field has tended to do (e.g. Aguilar 2017; Mahieu et al. 2011) would be misleading, since the position within the organisation of different professionals may influence their views on policies. Thus, while DONs and managerial staff are mainly responsible for designing policies in coherence with the philosophy and values of the organisation, the enactment of these policies in everyday situations tends to fall on care assistants, who are the ones providing front-line care and, in consequence, are also the ones facing sexual situations directly. Located in the middle ground, technical staff, coming from both health and social fields, are better suited to supervising and supporting the application of policies, assuring that they are useful for dealing with the most frequent and challenging sexual-related situations in LTCFs. Care assistants, who are ultimately responsible for supporting or restricting residents’ sexual expression in situations that frequently involve sensitive ethical dilemmas, are the members of staff with the least formal training in these issues, and do not feel that they receive sufficient support from technical or managerial staff (Villar et al. 2017).

Despite the potential influence of the work position held on sexual issues in LTCFs, few studies have specifically explored this factor. Such studies have been exclusively focused on knowledge or attitudes towards older people’s sexuality (e.g. Bouman et al. 2007; Mahieu et al. 2016; Villar et al. 2014b), generally finding that care assistants have less knowledge about sexuality, and more conservative attitudes towards it, than technical or managerial staff. Simpson et al. (2018) reported similar results in relation to LGBT issues in nursing homes. However, to the best of our knowledge, no published study to date has explored views on residents’ sexual needs and policies regarding sexuality in LTCFs according to the work position held.

Objectives

In the light of the above, the present study had two aims. First, we explored the staff’s views on the extent to which older people living in LTCFs have sexual needs and how they usually express them in institutional settings. Second, we ascertained staff views on what should be done to improve care for residents with sexual needs. In both cases, we analysed the influence of work position (differentiating among managers, technical staff and care assistants) on staff member’s views.

Methods

Participants

A purposive and self-selected sample of 2115 professionals working in Spanish LTCFs voluntarily participated in the study. Participants comprised 161 professionals working in managerial positions (7.6%), 614 technical staff (29.0%) and 1340 care assistants (63.4%). Data were collected in the second half of 2016.

Most participants in each group were women, which reflects the degree of feminisation of residential care staff in Spain (Tobaruela 2003). Around 50% had secondary studies; education was strongly related to working position, with technical staff being the respondents with the most formal training. On average, our participants had 10 years of experience in the field, and only 8.4% reported a high level of religiosity. Some descriptive characteristics of the sample are shown in Table 1.

Table 1.

Description of the sample, by work position

Total (N = 2115) Directors/managers (n = 161) Technical staff (n = 614) Care assistants (n = 1340)
Age (M, SD) 39.64 (10.95) 45.42 (8.61) 36.52 (9.65) 40.42 (11.36)
% Females 87.9 82.6 80.4 91.9
Education (%)
 Primary studies 10.1 1.9 0 16.1
 Secondary studies 52.4 21.1 3.7 78.7
 University studies 37.5 77.0 96.3 5.6
Religiosity (%)
 Very 8.4 7.5 5.1 10.0
 Quite 28.7 29.8 24.1 30.7
 Little 41.0 37.9 39.6 42.0
 No religious 21.8 24.8 31.2 17.1
Years of experience (M, SD) 10.00 (7.23) 15.30 (8.11) 9.03 (6.94) 9.80 (6.98)
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Technical staff included doctors, nurses, physiotherapists, psychologists, social workers, social educators and occupational therapists

To participate in this study, LTCFs had to meet the following inclusion criteria: (a) be officially registered residential centres; (b) be long-term centres for care-dependent older people; and (c) agree to participate in the study and abide by the conditions stipulated in the protocol. Since our aim was to explore issues regarding sexuality in facilities where people actually lived, palliative care units, acute care or convalescence centres, and day-care or short-stay units were excluded from the study.

Professionals participating in our sample worked in 152 different LTCFs, distributed across 15 of the 17 Spanish autonomous regions. The mean size of facilities was 86.56 residents (SD = 45.71). Most were public institutions (42.1%), while 38.8% were private for-profit institutions. The remainder (19.1%) were private not-for-profit institutions.

Procedure

The first author corresponded by e-mail or telephone with 200 LTCFs meeting the inclusion criteria. After outlining the objectives of the study, 152 LTCFs (76%) agreed to participate and returned valid data. Some of the LTCFs that did not take part mentioned a lack of time or a lack of interest as the reasons for their non-participation, while others simply did not respond to our e-mails.

Each participating centre was asked to appoint a member of staff to coordinate the administration and collection of questionnaires. Coordinators were contacted by the researchers to explain the objectives of the study and were asked to estimate how many staff members in their institution met the inclusion criteria. The researchers mailed that number of blank questionnaires in an envelope to the centre coordinator. Included were written instructions specifying which professionals should be invited to complete the instruments; how to facilitate participation, maintain confidentiality and ensure that each questionnaire was completed individually; and, finally, how to store and subsequently return the questionnaires once completed. The researchers remained in regular contact with the centre coordinators to check on the delivery and administration of questionnaires, and to resolve any issues that arose.

The first page of the questionnaire included the aim of the study, how data collection would be managed to guarantee anonymity and confidentiality, and a consent form that each participant had to sign. Questionnaires were answered individually at home, and then had to be placed in a locked box to which only the centre coordinator had access. Participation in the study was voluntary.

The researchers sent out 3627 blank questionnaires by post, of which 2261 were returned (a response rate of 63.3%). Among the questionnaires returned, 146 did not respond to any of the questions analysed in this study. Thus, the study was based on a final sample made up of 2115 questionnaires (58.3% of the questionnaires initially sent out). The project received approval from the Bioethics Committee of the University of Barcelona (institutional review board IRB000003099).

Measures

A self-administered questionnaire designed by the authors was used to gather data. The first section asked participants to answer socio-demographic questions regarding age, gender, religiosity, work position within the organisation and years of experience in the care field.

The second section included both Likert-type and open-ended questions about sexuality in LTCFs and some multiple-choice questions aimed at exploring how staff reacted towards various sexual expressions by older people living in LTCFs. Since presenting the whole data set exceeds what is possible in a single paper, we have limited our analysis to participants’ answers to one Likert-type and two open-ended questions related to the goals of this study. These questions were as follows:

  • ‘How many older people living in long-term care facilities have sexual needs?’ (possible responses within a 5-point scale were: (1) ‘None of them’, (2) ‘Just a few of them’, (3) ‘Some of them’ (4), ‘Most of them’, and (5) ‘All of them’.

  • ‘Regarding those with sexual needs, how do you think they satisfy these needs?’

  • ‘To improve the care that my institution is providing, what should be done regarding residents’ sexual needs?’

Data analysis

Participants’ responses to open-ended questions were transcribed, entered into a database and content-analysed by the first and second authors. We applied a conceptual content analysis and, accordingly, for each open-ended question, the researchers grouped responses based on repetitions or similarities between them (Krippendorff 2013). To increase the reliability of the results, the process of categorisation was undertaken independently by two researchers. They compared the groups of responses (categories) obtained, and differences were discussed until consensus on the system of categorisation was reached.

The researchers independently re-read the answers and assigned them to categories (or more than one, if the response contained more than one meaning) according to the system previously established. They created a hierarchically structured categorical system, comprising primary categories that in some cases included additional secondary categories, for each of the two open-ended questions. The primary and secondary categories selected by each researcher were compared, and disagreements were used to refine categories, define their limits and adjust their definition until the researchers reached consensus on each category system.

The last step involved an independent rater (researcher 3) who had not participated in the previous process. She was given the final version of the categories (including category definitions), and her task was to assign a randomly selected sample (20%) of the answers into categories. The Kappa reliability index was used to estimate to what extent this independent categorisation was similar to the one previously agreed upon by the other two researchers. The Kappa index was .97 for the first system of categorisation (how older people living in LTCFs satisfy their sexual needs) and .94 in the second (what should be done to improve care regarding sexual-related issues). These Kappa indexes indicated very good inter-observer reliability in both cases (Landis and Koch 1977).

Chi-square tests were used to ascertain differences in response rates according to work position. We also tested the relationship between predictive variables (gender, work position, experience on the field and religiosity) and (a) the number of residents thought of as having sexual needs and (b) secondary categories regarding what should be done to improve care for residents with sexual needs. Intraclass correlation (ICC) for the criteria variables was calculated taking LTCFs as grouping factor, based on a model without any predictors. As ICCs were statistically significant in all cases, we applied a multilevel multinomial lineal regression (for the case of perception of sexual needs) and multilevel logistic model (separately for each category if strategies related with measures to improve care), taking LTCFs as a grouping factor. We did not perform any centring for the predictor variables or added random slopes to the models, as they were not necessary regarding the research question. All the quantitative analyses were performed using STATA.

Results

The average score obtained in response to the question about how many older people living in LTCFs have sexual needs was 2.93 (SD = 0.82, range 1–5). While 26.2% of the participants thought that none or just a few residents have sexual needs, 19.1% attributed such needs to most or all residents. A multilevel multinomial linear regression (taking LTCF as grouping factor) showed that work position significantly predicted the estimation of sexual needs (z(2) = − 3.66, p < .001), with directors and technical staff being more likely to attribute sexual needs to residents than care assistants. In addition, the more experienced participants tended to think that older people living in LTCFs have sexual needs (z = 3.35; p < .001). On the contrary, less experienced participants were more likely to recognise sexual needs among LTCF residents (z = − 3.53; p > 0.001). The predictive value of gender and religiosity, variables which were also included in the regression model, did not reach statistical significance.

As to how participants think that sexual needs are satisfied in LTCFs, 651 participants did not know or did not answer that question (30.8%). Care assistants were more likely to not give an answer (36.7%) than technical staff (21.3%) or managers (17.4%), such differences being statistically significant (χ2 (2) = 61.41, p <.001). A further 181 participants thought that such needs were not satisfied at all, with this response being less common in care assistants (n = 70; 5.2%) than among managers (n = 17; 10.6%) or technical staff (n = 94; 15.3%). These differences were also statistically significant (χ2 (2) = 34.87, p < .001).

A total of 1283 participants specified one or more ways to satisfy sexual needs. Among them, illustrated in Table 2, self-stimulation (and particularly masturbation) was, by far, the most frequently mentioned way to satisfy sexual needs, according to 8 out of 10 participants who responded to the question. In contrast, satisfying sexual needs in a relationship involving other people was cited by only 30% of participants, most of them mentioning sexual relationships with other residents. Less sexually explicit behaviours (such as kisses and hugs or courtship) or sexual advances towards staff were also mentioned, but far less often. Finally, almost 10% of the participants said that residents do satisfy their sexual needs, but without specifying how. The majority of such responses implied that such satisfaction is not easy (they satisfy their needs ‘as they can’, ‘with difficulties’ or ‘taking advantage of the few opportunities they have’).

Table 2.

Frequencies and percentages of the categories resulting from the content analysis of answers to the question ‘How do they satisfy their sexual needs?’

Category n %
Sexual self-stimulation 1007 78.5
 Masturbation 986 76.9
 Visual stimulation/imagination 64 5.0
Sexual expressions involving other people 361 28.1
 Sexual relationships in the centre 245 19.1
 Sexual relationships outside the centre 72 5.6
 Kisses and hugs 57 4.4
 Talk/courtship 42 3.3
 Inappropriate sexual advances towards staff 34 2.7
Non-specific ways 118 9.1
Other 26 2.0
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Percentages were calculated on the basis of the 1283 participants giving one or more ways to satisfy sexual needs. Categories do not add up 100% because one participant could mention more than one category. Likewise, secondary categories do not add up to the total shown in each primary category

Managers and technical staff mentioned two primary categories significantly more often than care assistants: self-stimulation (χ2 (2) = 21.43, p < .001) and relationships involving other people (χ2 (2) = 23.59, p < .001), whereas care assistants mentioned non-specific ways of satisfying sexual needs more than their workmates (and, especially, more than technical staff) (χ2 (2) = 18.32, p < .001).

In response to the question about how to improve care in relation to sexual issues, 535 participants out of the 2115 (25.3%) did not answer or did not know what to answer. These answers were far more frequent among care assistants (32.6%) than among technical staff (13.5%) or managers (9.3%). Such differences were significant (χ2 (2) = 104.78, p < .001). Additionally, 34 participants (1.6%) thought that there was nothing to improve. In total, 1546 participants mentioned at least one action to improve the care provided to residents in relation to their sexual needs. Such mentioned actions were distributed in three main primary categories (Table 3).

Table 3.

Frequencies and percentages of the categories resulting from the content analysis of answers to the question ‘What should be implemented to improve the way your centre deals with residents’ sexual expression?’

Category n %
Training and information 745 48.2
 Non-specific target 226 14.6
 Staff 420 27.2
 Users 136 8.8
 Families 39 2.5
Specific facilitative resources 620 40.1
 Providing private time/space 396 25.6
 Human resources/experts 136 8.8
 Explicit protocols 51 3.3
 More time and attention from staff 17 1.1
 Other facilitative resources 35 2.3
Culture change 380 24.6
 Change stereotypes/normalise 237 15.3
 Understand user needs/personalisation 174 11.3
Control/surveillance 19 1.2
Other 7 0.5
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Percentages were calculated on the basis of the 1546 participants giving one or more ways to deal with residents’ sexual expression. Categories do not add up to 100% because each participant could include more than one category. Likewise, secondary categories do not add up to the total shown in each primary category

The most frequent one was training and information, which accounted for 48.3% of responses. Although sometimes the participant did not specify the target to be trained or informed, most often this was not the case, with professionals being named as the most frequent target (27.2% of the total responses), followed by residents (8.8%) and families (1.8%).

In a multilevel binomial regression analyses (with LTCF as grouping variable), work position was significantly related to mentioning any response under the category ‘Training and information’ (z (2) = − 3.53, p < .001), since care assistants mentioned this category less often than managers or technical staff. As for the predictive value of the rest of variables entered in the model (gender, religiosity and years of experience), none of them was statistically significant.

The second most frequent primary category was ‘Specific facilitative resources’. Mentioned by 40.1% of participants, this suggested a way to improve care of sexual issues. In most cases, the specific solutions included the provision of spaces and moments private enough for residents’ sexual expressions to manifest. Although not as frequent, making professionals expert in sexual issues, having specific protocols to manage sexual situations, and making sure that staff have more time to care adequately for residents’ needs were also given as answers by some participants.

Work position predicted the mentioning of ‘Specific facilitative resources’, according to a multilevel binomial regression analysis. As with the category ‘training and information’, in this technical staff (z = 2.53; p < 0.05) and particularly care assistants (z = 3.97; p < 0.001) mentioned ‘specific facilitative resources’ significantly more often than managers. As for the rest of the variables included in the model, none of them (gender, years of experience and religiosity) reached statistical significance.

Some participants mentioned more overarching and deeper changes in beliefs and practices as a way to improve care regarding sexual issues. Such changes, grouped in the primary category ‘cultural change’, involved two aspects: (a) avoiding the view that residents’ sexual expression was something abnormal and modifying stereotypes about the lack of sexual needs or sexual capacities of residents and (b) trying to understand the needs and beliefs of people living in LTCFs and, accordingly, provide more personalised care.

According to a multilevel binomial logistic regression, there were statistically significant differences in the references to ‘Cultural change’ according to work position (z(2) = − 2.44; p < 0.05), with managers and technical staff mentioning these kinds of changes more than care assistants. The rest of the variables included in the model (gender, years of experience and religiosity) did not reach statistical significance.

Other suggested ways of improving care, such as increasing control and surveillance of residents, were much less common.

Discussion

The present study aimed to explore LTCF staff’s perceptions of the extent of LTCF residents’ sexual needs and means of expression, according to their work positions, as well as what they think could be done to improve care related to sexual issues.

Regarding the first objective, our results show that most staff working in LTCF do not see sexual needs as something still present in many (or even any) older people living in LTCF. This inability to conceive of sexual needs as basic, universal needs, could explain why (a) sexuality does not seem to be a priority in LTCFs and (b) explicit policies for managing sexual needs and guaranteeing sexual rights are usually absent (Lester et al. 2016). It could also explain why most staff members do not facilitate or give active support to residents’ sexual expression (Villar et al. 2018b). The fact that care assistants were particularly likely to ignore residents’ sexual needs is consistent with some previous studies suggesting that the lower the position in the organisational hierarchy, the more negative and conservative the view of sexuality in LTCF (Bouman et al. 2007, Mahieu et al. 2016).

Self-stimulation (basically masturbation) is by far the most common way perceived by staff for residents to satisfy their sexual needs, when they exist. This perception differs from the more common sexual behaviours among older people living in the community, in whom sexual activities involving a partner, such as sexual intercourse or hugging/kissing, are more frequently reported than masturbation (e.g. Lindau et al. 2007; Palacios-Ceña et al. 2012). This difference supports the idea that masturbation could act as a compensation for the impossibility of involving oneself in partnered sex (Das 2007), or it could simply reflect staff attitudes and beliefs. Since the availability of partners in LTCFs is scarce and the limitations of private space are high, there is little opportunity for partnered sex, which makes masturbation a relatively more accessible way of satisfying sexual needs. So, the attitude of staff towards masturbation is critical. Previous research has found that a non-interference approach predominates among staff, but also that reprimanding or gossiping/joking are relatively common and more frequent than proactively supporting self-stimulation as a way to express sexual needs (Villar et al. 2016).

Regarding the second objective, some of the difficulties and barriers that challenge the normalised expression of sexuality in LTCFs are reflected in the improvements in care practices mentioned by our respondents. In this sense, the actors involved in care (staff, residents, relatives) and how they deal with sexual issues are aspects that could be improved. Thus, many members of staff, and particularly those occupying positions further up the organisational hierarchy, indicated that the difficulties in managing sexual issues well are due to a lack of or inappropriate training and information in the aged care sector. Such a lack of knowledge and skills was attributed to residents and relatives, but fundamentally refers to themselves as professionals, a lack that has also been highlighted by previous studies (Di Napoli et al. 2013; Gilmer et al. 2010; Villar et al. 2017). The awareness of limitations was not as high among care assistants, i.e. those who had received less training. This difference suggests that having more formal training leads to a greater awareness of both their own limitations and the importance of further training in some areas, such as sexuality, to solve such limitations. In contrast, care assistants, who have received less formal training, seem to be less aware of their own weaknesses in this area. According to our results, they seem to favour quicker, more specific solutions to improving care related to sexual issues.

Some of these solutions, such as increasing privacy by providing more time and particular spaces to be far from public view, have already appeared in studies focused on barriers for sexual expression in LTCFs (Villar et al. 2014a, b; Bauer 1999a; Rahn 2018). The availability of specific experts to which the management of sexual situations could be transferred, or the presence of explicit protocols guiding step-by-step what to do in complex situations, has been less frequently mentioned (Steele 2007). Despite this, such responses suggest that some staff members perceived sexual issues as a problematic domain in which they do not feel comfortable. As a consequence, a source of additional security, in the form of an expert or guidelines, is needed.

Beyond these specific measures, which could be easily implemented, some respondents also mentioned a more far-reaching and deeper solution, which involves the transformation of social and institutional practices. Such responses, included in the category ‘cultural change’, imply that there is a background hampering the normalisation of sexual expressions of older people living in institutional settings, one that consists of ageist attitudes and stereotypes that condemn sexuality in older age, as the previous literature has shown (Gewirtz-Meydan et al. 2018), but also refers to institutional practices that hinder personalised care for institutionalised older people. In this respect, the implementation of a person-centred care model, which takes into account residents’ rights and tries to tailor care to residents’ life stories and priorities, has been proposed as a necessary step towards including and supporting sexual needs in LTCFs (Tarzia et al. 2012; Villar et al. 2018b). Such strategic and in-depth cultural changes were mentioned more frequently by managers and technical staff, i.e. the members of the organisation that are able to define the organisation’s values and aims. However, the risk of this type of solution is that by blaming the lack of appropriate care relating to sexual issues on forces needing transformation could be perceived to be beyond one’s control (societal changes regarding sexuality, institutional change of care models), resulting in nothing being done in everyday practice.

Our results also suggest that factors such as religiosity, which in previous research were found to have an impact on attitudes towards residents’ sexual expressions in LTCF (Bouman et al. 2007; Di Napoli et al. 2013; Mahieu et al. 2016), have no influence on participants’ proposed measures; in fact, only work position (as discussed above) and years of experience in the field exerted any influence. Maybe the fact that we did not ask about attitudes (e.g. conservative, restrictive vs open, supporting), but about ways to improve care could account for the divergence with previous studies.

Finally, it is also worth noting the high percentage of ‘don’t know’ or no responses in both open-ended questions analysed in the study, reaching 30% in one case (how to express sexual needs) and 25% in another (ways to improve care). Although there is no straightforward way to interpret such a lack of response, it is consistent with a topic in which taboos still exist and that could raise some discomfort for LTCF staff (Gilmer et al. 2010; Villar et al. 2018a), which makes it rarely assessed or openly discussed. Some professionals might even consider residents’ sexual expression as an issue that over-complicates their work and, consequently, is better concealed (Ward et al. 2005). Non-response was particularly frequent among care assistants, the professionals who occupy the front-line care positions where they are more likely to deal with sexual situations. Simultaneously, they have the most diverse educational and cultural background and the least sexuality training. Such differences according to work position could be grounded on a more negative attitude and more entrenched taboos towards residents’ sexuality in this collective (e.g. Mahieu et al. 2016), but also to other factors, such as more apathy and burn-out, or a fear of reprisals.

Any interpretation of the results should take into account the study’s limitations. First, although we gathered a large and more diverse sample than most previous studies on sexuality in LTCF settings, the participants were recruited using a non-probability sampling procedure, which limits the generalisability of the results. Second, our questions focused on some interesting aspects of sexuality, but there are other factors or approaches that were not included. For instance, it would have been interesting to ask about factors that, from the staff’s point of view, influence the presence or absence of sexual needs among residents. Similarly, in our study we conceptualised sexuality as a need, when other approaches are also possible (e.g. taking it as a right, as proposed by Rowntree and Zufferey 2015), which could have led to different results. Such alternative approaches certainly deserve further research attention. Finally, our participants were staff working in institutions in a specific country, Spain. As attitudes and practices towards sexuality in older age, and specifically in LTCFs, are likely to be influenced by cultural and historical factors (e.g. Villar et al. 2015), our results cannot automatically be generalised to other countries.

Our study contributes to the literature on sexuality in residential settings by highlighting how sexual needs go unrecognised by staff as intrinsic attributes of older residents living in LTCFs. It stresses the importance of staff’s views, a factor frequently neglected in research on sexuality in LTCFs. Work position seems to modify views on sexuality and priorities for improvements in care, being managers and technical staff more likely to recognise sexual needs among residents and identify training and other ambitious, far-reaching strategies as ways of improvement in this area. In the light of our results, providing training tailored according to work position and changing organisational values and practices in line with person-centred care may be the best ways to guarantee and support residents’ rights and needs.

Footnotes

Responsible editor: Marja J. Aartsen and Guest editor: Bente Træen.

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