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The assisted living industry provides residential, medical, nutritional, functional, and social services for approximately 1 million older adults in the United States. Also presented are practical recommendations and policy implications for addressing the sexual and intimacy needs of current and future cohorts of assisted living residents. Data for this article were drawn from 3 National Institute on Aging—funded ethnographic studies conducted in 13 assisted living settings over 9 years.

The assisted living industry, a form of long-term care primarily marketed to older populations, currently provides residential, medical, nutritional, functional, and social services for approximately 1 million older adults in the United States National Center for Assisted Living, Assisted living settings are unique in that they are not subject to the same federal rules and regulations that govern the operation of nursing homes in the United States.

Although each state has a set of regulations specific to assisted living, these vary widely because no single, national policy defines what comprises assisted living.

However, all assisted living regulations are hallmarked by ideals of privacy, autonomy, and quality of life Assisted Living Workgroup, ; Mollica, Furthermore, there is a dearth of research investigating resident experiences, practices, and expressions of sexuality and intimacy in assisted living.

Future cohorts of older adults are expected to have even higher sustained interest in sex, as well as higher frequencies of participating in sexual acts, as generational acceptance and perception that sexuality is normal for elders increases Hillman, Our purpose here is to contribute to an understanding of how sexuality and intimacy are experienced within the social models of care provided in assisted living communities.

In this article, we examine the discourse of sexuality, the impact of institutional structure and the role of oversight on sexual attitudes and behaviors, and the relationship of assisted living values to sexual expression. For residents living in long-term care settings such as assisted living, these factors are likely to be highly relevant.

Cultural factors dictate that, compared with older men, members of this group are less likely to report engaging in sexual activity Lindau et al. Furthermore, a majority of the women in assisted living are widowed or single National Center for Assisted Livinga situation that sharply limits partner availability for heterosexual women. Additionally, medications used to treat these and other common conditions can decrease sexual drive, reduce sensitivity to stimulation, and result in other side effects detrimental to sexual experiences Hillman, Dementia is another condition present among assisted living residents.

One study of assisted living settings in Maryland Rosenblatt et al. It is important to note that consequences of dementia can be, at times, increased sexual expression, sexually inappropriate behavior, or sexual aggression Alagiakrishnan et al. Thus, even though dementia can complicate the understanding of sexuality and intimacy within the context of assisted living, it is possible to differentiate between healthy and unhealthy or wanted versus unwanted sexual behavior.

In addition to issues relating to gender, marital status, and health status, sexual interest and behavior may be influenced by the realities of living within a structured environment that provides oversight, rules, and monitoring. Privacy is also a major barrier to sexual expression in long-term care settings. Collectively, these studies show that sociocultural and health biases may be present against older adults residing in long-term care who participate in sexual activity, even though current cultural attitudes are shifting to encourage individuals to remain sexuality active over the life course.

Qualitative data from three studies funded by the National Institute on Aging formed the basis for this analysis.

Transitions in Assisted Living was a 5-year ethnographic study of entry into, through, and out of assisted living settings; Quality in Assisted Living focused on a mixed methods approach to determine elements of quality important to residents, staff, and family over 3 years; and the Cultural Context of Residential Settings is a 5-year ethnographic study of multi-residential housing types including assisted living that is investigating many topics, including social relations and the experience of stigma. The basic research de consisted of sequential ethnographies, lasting 6 to 18 months each, in 13 diverse assisted living facilities.

The majority of residents across the settings were White middle-class females, with an average age of Two homes of residents each were predominantly African American and three had religious affiliations. Across the grants, one assisted living setting was rural, one urban, and the remainder suburban.

Direct care staff were primarily White, African, and African American; few Hispanics were employed at these research sites. Following the Collaborative Studies of Long Term Care typology of assisted living facilities, our ethnographies were conducted in small settings i.

All assisted living facilities included in our sample were located in the mid-Atlantic region of the United States, and were selected for size, profit status, level of care offered, assisted living type, religion, ethnicity, and affiliation independent or corporate chain. Using ethnographic methods, the research team studied daily life in these settings, exploring interactions among residents, their family members, direct care staff, and administrators.

Ethnography involves research on individuals and groups within their own sociocultural or physical environments, the place where they live or work.

Literature review

Information is collected primarily through participant observation and in-depth interviewing. By immersing themselves in the setting, researchers are able to both observe and participate in daily activities hence the term participant observation and, thereby, come to understand the nature and meaning of interactions and ideas through the eyes of those who live and work in a specific place.

Ethnographers visited the research sites at various periods of the day and evening over a 7-day week, going to lounges and suites, patios and smoking alcoves, lobbies and dining rooms—in other words, wherever people in a particular home gathered. Descriptive and interpretive fieldnotes of one to 12 s in length were written at the end of each field visit and circulated to the research team.

In total, seven project ethnographers conducted research over 9 years. In ethnography, open-format in-depth interviews provide essential information from the perspective of the individuals in a study, including their daily lived experiences and the processes involved in formal and informal decision making Charmaz, s of interviews at each site varied, depending on the size of the setting, level of dementia in the resident population, and stipulations of the grant.

However, over the course of the fieldwork, conversational interviews were also held with a larger proportion of people who live, visit, and work in each site. These data are embedded in fieldnotes.

The narrative data collected for the three grants were entered into Atlas. For each of the three projects, initial analyses involved collaborative coding of each transcript and fieldnote by project personnel; codes were ased to sections of every document based on a coding scheme inductively developed by each respective research team's thorough review and discussion of the data for its project. It must be noted that the research studies on which this analysis is based were not deed specifically to collect data on sexuality and intimacy but rather, as ly stated, to explore transitions and quality of life within assisted living, and examine social relations among older adults in senior housing.

However, the nature of ethnography lends itself to collecting a host of information not directly connected to the research questions. The amount of time spent at the field site interacting in the setting, as well as the flexibility inherent in using an interview guide as opposed to a structured instrumentproduced a volume of data tangential to the fundamental question.

Data on sexuality and intimacy surfaced in fieldnotes, for example, when residents casually discussed sex or a staff member related her story of finding a couple being intimate in a public space.

Booze, sex & stds in senior living facilities

Interviews also produced such data. The Transitions and Quality grants yielded, respectively, and fieldnotes and interviews. The Social Relations grant, at the end of its 1st year, produced documents. These fieldnotes and interview transcripts are stored centrally in a text base.

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To explore resident experiences, attitudes, and behaviors related to sexuality and intimacy, we used three analytical techniques to search these rich and numerous data. First, we identified narrative passages that had been coded, for example, as culture, emotions, social contact, and friends within the larger databases.

From these data, we identified instances in which residents, staff, or family members discussed issues relevant to sexuality and intimacy within the assisted living settings. In the second strategy, we developed a list of key terms that were embedded within these passages to find additional data that had not been apparent in the first analysis. Finally, two other project ethnographers were interviewed to identify exemplary cases, passages, and fieldnotes encompassing any aspect of sexuality, sexual behaviors, intimacy, or sexual interest that we may have missed.

Presented subsequently are thematic findings related to the experiences of sexuality and intimacy among residents within our sample of assisted living settings. All sites and participants are referred to by pseudonyms. Our coding analysis, coupled with a search through Atlas. The findings are suggestive, because the original research questions had distinct foci other than sexuality; they provide a baseline for future study. We have included exemplars from fieldnotes and interviews to illustrate each finding.

Several exemplars illustrate more than one idea or theme, which we elaborate within the finding. When asked directly, assisted living managers acknowledged that sex occurs in their assisted living settings.

What happens when a new nursing home romance leaves a spouse in the lurch?

It's happened here quite often. Although sexuality and intimate relationships of varying degrees and manifestations occur among couples, instances of solo masturbation also occur. At Huntington Inn, for example, one female resident asked her physician if he could recommend sex toys she could use for masturbation; he replied that he could not because he was not an expert in that area.

Another resident in the same assisted living community had been found by staff on multiple occasions in what they called awkward positions after she had fallen asleep while masturbating.

Facilities are finally grappling with the fact that residents have sex lives

Sexuality and intimacy are manifested in various ways, including intercourse, but our findings overwhelmingly revealed that intimate touch, hand holding, and other less physically intense expressions were common. For example, Mr. Sidney and Ms.

Perkins, an intimate couple who were acknowledged as such by the staff, were comfortable with and cared deeply for each other. They met for meals, attended activities together, supported each other through illnesses, and slept in each other's rooms when loneliness set in, he in his wheelchair and she in her recliner. In another assisted living community, Ms. Keeps saying it's beautiful. He says when he touches my ponytail, he gets an orgasm. In some cases, sex is assumed but intimacy is the reality.

I get my morning kiss and my nighttime kiss, and that's all. Residents also discussed preferences.

Catherine at the Chesapeake spoke of her friendships with two male residents, one who was a kindred spirit, as educated and intellectual as she was, and the other who sent flowers and talked of t vacations and marriage, but was also domineering and verbally abusive. His speech was filled with sexual innuendoes, she said.