The underestimation of sexual risk due to ageism

To the Editor: Sexual incidents involving patients in hospitals are prevalent and are distressing for patients and staff alike, but they are poorly managed.1 Such incidents are frequently perpetrated by people with acute mental illness (eg, mania, psychosis), substance misuse, personality vulnerabilities, and cognitive impairment (eg, delirium, dementia). Sexual incidents span the age range, although lack of staff's understanding of sexuality and sexual behaviour in older adults2 mandates practice improvement.

Sexual safety is defined in health care settings as “recognition, maintenance and mutual respect of the physical [including sexual], psychological, emotional and spiritual boundaries between people”.3

Sexual incidents include sexual offences (criminal offences such as sexual assault) and inappropriate sexual behaviour, ranging from suggestive language to removing clothing, exposure, and public masturbation. State public mental health services have sexual safety policies and guidelines, but no such policies exist for general hospitals. The scholarly literature is similarly limited. Our experience of sexual safety in health care can be described as “a neglected area, there is no training, no one is talking about it and there seems little interest until something happens,” particularly involving older people.1

A hypothetical case based on clinical experience (Box) demonstrates the trivialisation and minimisation of sexual incidents in health care and the associated risks and ramifications. This phenomenon is aligned with the “dirty old man” stereotype, a reflection of ageist societal attitudes towards sex in older people as inappropriate, shameful or funny.4 Consequences of these attitudes for clinical management include poor documentation and communication, inconsistent responses to patient behaviour, and multiple victims, particularly staff. Sexual harassment is both under‐reported by staff5 and dealt with superficially, despite having significant effects on physical and psychological health and burnout.6

These issues are compounded in aged care, where staff ignore or minimise the impact of sexual behaviour, which is often excused by cognitive impairment4 or dismissed as harmless due to frailty or advanced age.5 Aged care staff may feel shame, guilt, confusion and even responsibility for causing the behaviour.5 Conversely, a tension exists between a cognitively impaired person’s right to sexual expression and the health care worker’s right to a safe workplace.

Education of health care staff and development of guidelines with response pathways are needed to ensure sexual behaviour is understood and dealt with consistently and respectfully.4 In this situation, ageism trivialises risk and harm, which may have an adverse impact on a safe health care environment.