Behind closed doors in nursing homes across the country, thousands of seniors are denied sex—and some are even chastised for holding hands. Lesbian, gay, and transgender seniors face ridicule and hostility. Why advocates, residents, and staff are mad as hell and fighting for change
“How can somebody be like that?” The words wafted down the hall of the nursing home, accompanied by furtive glances. “How can anything like that exist?”
These were the sorts of questions that Christine Sherman would sometimes overhear.
They were questions about her.
Born in Ireland and raised in Winnipeg, Sherman discovered that she was intersex at the age of 10 and publicly came out as a lesbian at 16. In 1969, at the age of 20, she moved to Toronto to work as a nurse. More than 30 years later, in 2001, Sherman entered a private long-term care (LTC) facility in Toronto for her own health reasons. There, her unique anatomy and sexual orientation made her the subject of antipathy and gossip that she had rarely encountered during her nursing career. “It was just like they were living back in the 1950s,” says Sherman. While some members of the nursing staff were accepting and supportive, others were “way off the wall.” In such homes, says Sherman, anyone who was perceived as being different, especially sexually or in sexual orientation, is a target: “[They’re] not to be accepted—not even to be tolerated.”
Sherman transferred from that facility when it closed in 2006. At the next facility, the discrimination was present, she says, but more subtle—“you just got the impression that they knew.” Finally, in 2009, Sherman arrived at Wellesley Central Place, a 150-bed nursing home in eastern Toronto, which has a fully developed lesbian, gay, bisexual, transgender, and queer (LGBTQ) policy, and where Sherman feels welcome. It is one of only five nursing homes out of 83 in the Toronto area with LGBTQ-friendly policies.
In fact, many nursing homes in Canada don’t have any concrete policies when it comes to seniors’ sex and sexuality. In 2011, I conducted a survey with a master’s student at the University of Regina that examined resident sexuality and intimacy policies in select Canadian nursing homes. Its chief aim was to determine whether facilities had any policies on resident intimacy or sexuality. The study had a number of shortcomings: it only covered homes in the Vancouver Coastal Health Authority and provincial capital districts, and excluded Quebec. Of the 248 facilities contacted, only 64 responded to repeated requests for information.
Despite these limitations, the results of the survey are revealing, especially because so few have addressed intimacy in Canada’s LTC homes. Of the 64 respondents, 13 facilities had sex-positive policies, 47 had no policies, and 5 actively declined to participate. Homes in cities with large gay and lesbian communities, it seems, are no more friendly than those in less diverse towns. Toronto’s city-run Long-Term Care Homes and Services had no clear-cut policy for LGBTQ residents until 2008. Other interview-driven studies have repeatedly revealed that nurses and staff who believe intimacy is incompatible with old age regularly bar residents from pursuing healthy relationships. In some homes, staff sniff out intimate situations with the fervour of an old-fashioned witch hunt.
Lois Horath is a senior registered nurse at St. Joseph’s Integrated Care Centre, a 10-bed LTC facility in Lestock, Saskatchewan. When asked about suppression, she tells the story of a woman who had separated from her husband. The widowed fellow across the hall from the woman wanted to pursue a relationship. He went to her room a few times. There, they held hands—until staff hustled him out one evening, saying he wasn’t allowed in her room. Horath pleaded the would-be couples’ case with staff members, but many were adamant: the two couldn’t have a relationship. Administration later released a memo affirming the rights of residents to engage in relationships. Yet, out of fear, both residents said they were just good friends. “Because [the man] thought that he was going to get in trouble,” Horath says, “he actually denied that there was anything going on.”
As research (or an uncomfortable conversation with your grandmother) shows, though, people do not become asexual when they enter a nursing home—resigned to a life of “just good friends” after age 60. This is news to many nursing homes. Some staff feel that they need to protect residents from themselves; others think those who express sexual urges after a certain age are misguided or deviant. Even staff who want to support healthy sexual relationships often find themselves stumbling without any official policies or guidance. While awareness is slowly growing, thanks to the work of sex-positive policy advocates throughout the country, many more homes simply leave the issue unspoken. As a result, seniors are separated for flirting, scolded for holding hands, and threatened with disciplinary action for pursuing healthy relationships. When it comes to LGBTQ individuals, treatment only often gets worse—turning a supposed home into something that feels more like an institution.
In 2002, Dalhousie University professor Robin Stadnyk quipped: “Nursing home care across this country has developed as if the provinces were 10 separate countries.” Homes are administered and funded by each individual province’s government. They are not insured by the Canada Health Act, which principally covers care delivered in hospitals or by physicians. The result is widely different policies and levels of coverage across the country, making it difficult to discuss Canada’s nursing home system as a whole.
As of 2010, there were 2,136 residences for the aged—including nursing homes, homes for the aged, and other facilities that provide services and care—in Canada. Together, they serve 204,008 residents, accounting for 0.6 percent of the population, or roughly four percent of seniors, based on Statistics Canada estimates from 2009. As baby boomers age over the next 25 years, the number of Canadians over 65 is expected to double to roughly 10.4 million. While the vast majority of nursing home residents are above the age of 65, there is also a significant population of younger people with disabilities who live in LTC facilities alongside older residents.
The roots of the modern nursing home lie in nineteenth-century Great Britain, when women’s and church groups established special homes to shelter the impoverished elderly. The marginalized elders of previous centuries were often relegated to almshouses and poorhouses, where they would be mixed with the poor, the insane, and the disabled. By the end of the 19th century, poorhouses had evolved into dumping grounds for the sick and elderly—“a place for the destitute pauper to die,” as gerontological historian Thomas R. Cole wrote in 1987. Staff generally assumed the “inmates” were unworthy. “That is,” Cole adds, “chronically and illegitimately dependent on the state.”
The appearance of modern-day nursing homes in the 1930s in Western society parallels the emergence and development of the mental hospital. Indeed, as many elders suffer from dementia, the clientele of the mental institution and the nursing home often overlapped until the 1960s, when the role of the nursing home as a long-term residence for the elderly became clearer. Hospitals became increasingly concerned with acute, short-term care, while asylums were principally reserved for younger patients with the potential to be treated and returned to society.
Insane asylums—institutional cousins of the nursing homes—experienced a seismic shift in the late 1950s and 1960s, when a movement towards deinstitutionalization was mobilized by damning accounts of overcrowding, abysmal living conditions, and widespread abuse. Nursing homes became swept up in the same anti-institutional zeal and underwent a number of reforms, especially after a cascade of scandals in the 1960s and 1970s. These revealed widespread negligence, physical and emotional abuse, and financial mistreatment, including embezzlement and extortion. While stricter government scrutiny has largely banished these practices to the scrapheap of history, the nursing home culture is still struggling to emerge from a century of silence and stigma.
Judith Wahl is the executive director of the Toronto-based Advocacy Centre for the Elderly. Founded in 1984, this community legal clinic is funded by Legal Aid Ontario, and offers a range of legal services to seniors. It also engages in public legal education and law reform activities. Wahl, who has directed the centre since it was founded, is a frequent speaker at various conferences on elder law issues. There, she often discusses the murky legal issues surrounding LTC resident intimacy. Passionate, experienced, and full of energy, Wahl is not someone you’d want to contend with in front of the judge.
While she is now one of Canada’s foremost advocates for elder rights, Wahl first became aware of resident intimacy issues by following cases of sexual assault in LTC facilities in the 90s. From there, she began looking more broadly at senior sexuality in homes, completing anecdotal interviews with residents and talking to staff and managers. She discovered Canadian nursing homes have a range of approaches to the issue of sexuality, and that most have no written policies on the subject. Since then, Wahl has given numerous presentations on elder sexuality at various universities. Wahl, and others like her, believe that nursing homes should have policies that explicitly affirm the rights of residents to engage in intimacy, while also untangling difficult questions about consent and capacity.
Without such policies, Wahl says many nursing homes are “no sex” zones that forbid all types of sexual expression. Several years ago, she even had one personal support worker (a person who performs routine caretaking tasks) in an Ontario facility tell her that sex was holding hands. That worker, she says, continued to rationalize that holding hands leads to cuddling, which leads to petting, which leads to more intimate behavior, which leads to sexual intercourse. Wahl now deploys this anecdote in conferences and training seminars, grasping the hand of the person next to her.
Such restrictive policies and interventions have caused some advocates and academics to liken nursing homes to total institutions. One of the seminal works of the deinstitutionalization movement over the past 50 years is Canadian-born sociologist Erving Goffman’s Asylums. In his collection of essays, Goffman outlines four key components of the total institution: daily life occurs in the same place and under a single authority; a large group of inmates or residents are similarly situated; daily schedules have rules established by an official group; and all of the scheduled activities are part of a plan to further the goals of the institution.
Examples of total institutions, Goffman argues, include insane asylums, prisons, and military bootcamps. Such organizations, he says, thrive on the social distance between supervisory staff and inmates. In Goffman’s final analysis, people in total institutions undergo a process of self-mortification, in which the roles that they held in civil society—husband, wife, lover, even flirt and womanizer—are stripped away.
American author Renee Rose Shield echoes Goffman’s arguments in her 1988 book Uneasy Endings: Daily Life in an American Nursing Home. People, Shield says, draw their sense of self-worth from reciprocal relationships with others. This often takes the form of gift-giving, but can also include physical affection—a gift in itself. Residents in LTC facilities who are unable to give gifts, she adds, can only perceive themselves as helpless children, or even useless. They are denied all means of meaningful expression and become interchangeable.
While many, if not most, contemporary homes for the aged have managed to divest themselves of many of the elements of the total institution—such as isolation from the outside world, impersonal rituals of admission and daily routine, and a lack of intellectual stimulation—repressive sex policies remain the last bastion of institutional culture in many facilities. Part of the reason for this, says Wahl, is that saying no is easy. Restrictive policies, in other words, are simply easier to manage; no one needs to think. “I’ve had staff say to me, ‘Everyone in a long-term-care home is incapable,’” says Wahl. “That’s not true.”
Facilities that fail to incorporate a sex-positive approach into their policies face a number of pitfalls, she adds. Sexuality policies are vital in preventing sexual abuse and assault, in controlling the spread of sexually transmitted infections, and in allowing the expression of a fundamental aspect of residents’ humanity. In the absence of such policies, the potential for abuse from staff, spouses, and other residents often goes unchecked. Repressed residents can lash out in destructive or unexpected ways.
Nursing homes that deny capable adults of making their own sexual decisions could also reasonably be accused of violating Charter rights. Specifically, Wahl says, the ability to engage in consensual sexual activity, which can be interpreted as a right under Charter section 12: “Everyone has the right not to be subjected to any cruel and unusual treatment or punishment.” Consensual sexual activity is generally legal throughout Canada; the only exception is public places, which nursing homes are not.
Unfortunately, there is little legal literature or case law in Canada on these issues. Common misconceptions among staff include the notion that residents with dementia can pre-consent to sexual activity, or that the family of a capable resident can determine that resident’s sexual practices. To have sex without breaking the law, each party must provide consent and have the capacity to provide that consent. Nursing home staff often invoke both these factors as reasons for suppressing sexual activity, especially with residents living with various forms of dementia. While issues of consent may be difficult to determine in these cases, Canadian law involves making judgements on a case-by-case basis.
Wahl admits consent and capacity can be murky territory for seniors, especially those living with dementia. Questions to consider, she says, include: Does the person understand that they’re engaging in a relationship and what that means? Do they appreciate the risk of being involved in that relationship? Do they understand what’s going on? Do they understand who that person is? If the answer to all these questions is yes, then any type of intervention is ethically and legally unjustifiable, Wahl says. “Capable adults, wherever they live, can decide to do what they do,” she adds. “That’s their right. If a couple wants to get together in a long-term-care home and they’re in their nineties, that’s their business in their home. When you’re capable of consent, you can make decisions yourself.”
While heterosexual activity is often suppressed in Canadian nursing homes, same-sex partnerships and transgendered individuals are frequently met with outright hostility. Many nurses and staff oppose LGBTQ individuals and relationships on religious or moral grounds. In fact, plenty of nursing homes in Canada are religiously or ethnically centred. As a result, these homes can create an environment where gay and lesbian issues are not respected, says Dick Moore, a prominent Toronto activist who advocates for LGBTQ rights. Even homes and staff that are open-minded and well-intentioned may be unaware of the issues surrounding these residents.
Moore has worked with retired people and their families for more than 30 years, and served as the coordinator of the Older LGBT Program at the 519 Church Street Community Centre for nine years. During that time, he started the Seniors Pride Network, which works to expand programs and services for older LGBTQ individuals. He also worked with Toronto Homes for the Aged to establish LGBTQ-friendly nursing homes. There is a common attitude among staff, Moore says, that LGBTQ “people are sinners and [they] don’t want to have anything to do with them.”
The reasons for those feelings can be complex. According to Moore, many nursing home workers come from conservative backgrounds or are recent immigrants, and some can be less accepting of sexual expression. He recognizes that LGBTQ-positive sex policies can clash against such staff members’ values and religious beliefs, and that training must be done sensitively. Even so, he says, the point is not to change religious values or beliefs, but to assert residents’ human rights.
In part, Moore and his fellow advocates are also letting residents know what their human rights are. While the sixties generation was also involved in the gay liberation movement, says Moore, not everybody coming into care—or who is already in care—was on the front lines of social change. “Some people are going to be coming in waving the pride flag, saying ‘We’re here, we’re queer, get used to it,’” says Moore. “Many other people are going to be closeted, because that’s the way they were able to survive.” The challenge for nursing homes, he says, is to make homes comfortable for those who are out and proud and also those who are closeted. “This is where they live,” he adds, “and they’re entitled to privacy and intimacy.”
Alan Raeburn, a 76-year-old nursing home resident, agrees. A former actor/dancer who lived through the Stonewall Riot of 1969, Raeburn spent much of his professional career performing in New York City in roles such as Mr. Sowerberry in the musical Oliver! and as a homosexual Piers Gaveston in Christopher Marlowe’s Edward II. He says that the latter role may have been “the first time that two males had smooched in a play in New York.” Now retired and living with Parkinson’s, Raeburn has never experienced animosity at his home, Fudger House, which lies within Toronto’s east end—most likely because the facility has had LGBTQ-friendly policies since 2004. Raeburn participates without discrimination in Fudger House’s various programs, which include weekly movie nights. He’s been lobbying for weekly showings of LGBTQ-themed movies such as Trick and Normal. Yet while Fudger House is a welcoming environment, Raeburn suspects some residents may still be keeping their sexuality secret. Old survival mechanisms die hard.
Unfortunately, transgendered and transsexual residents are almost inevitably subject to the judgment of staff and other residents, says Anna Travers, director of Rainbow Health Ontario, a province-wide program that aims to improve access to services and promote the health of Ontario’s LGBT communities. This is one area where training for staff is invaluable. Many trans people, says Travers, choose to present in a certain way, but not to have surgical procedures. Some may use hormones instead. Others choose to have top surgery, but not bottom surgery.
“Unlike lesbian and gay people, who are in a vulnerable situation because of relationships and history,” says Travers, “Trans people are actually at risk because of their bodies.” The same can also be said for intersex individuals, like Christine Sherman. Intersex and trans residents often face shame and humiliation during bathing, dressing, and using the bathroom. It isn’t long before gossip carries down the hall, and daily life becomes a series of dirty looks and sour whispers.
Despite these challenges, there are grounds for optimism. “People are talking about it more,” says Wahl. “Even before people like me are getting into the home.” In the past five years, elder rights advocates across Canada—including lawyers, activists, nurses, and bureaucrats—have managed to make piecemeal progress. In 2008, Travers and Moore, along with many others, contributed to the creation of the Toronto Long-Term Care Homes and Services LGBT toolkit. In 2009, the Vancouver Coastal Health Authority developed a comprehensive set of guidelines for supporting sexuality and intimacy in LTC facilities. Other changes are coming: Baby boomers will soon enter the nation’s nursing homes in force and are less likely to tolerate the older culture of repression. The “free love” generation will hit these homes like a tanker truck. Through struggle and work, more change will come. Until then, however, most of Canada’s nursing homes have a long way to go.