Love Endures

That was the case with a Fairfax County woman whose husband was diagnosed in his early fifties, a few years after they married. During a subsequent visit from her mother and father, her husband asked her at the dinner table, "Do you want to go to bed and make babies?" Even though the parents knew he was ill, recalled the woman, "I was just mortified."

Even when he could no longer work, drive or have regular conversations, he wanted to have sex, she said. For a while she went along. "I felt as if I was giving him a gift," she said. "But in the middle of being intimate he'd start speaking gibberish" or ask, "What are all these people doing in our room?"

Eventually, she moved him to a nursing home, and sex became a thing of the past.

Away From Home

When intimate relationships form between residents at dependent-care facilities, managers there face three big issues: the residents' right to privacy, ability to consent and safety. Responses differ. There is no industry-wide standard for handling intimacy at assisted-living facilities, half of whose residents have some form of dementia, said David Goldberg, vice president of communications at the Assisted Living Federation of America, an industry group.

In most cases, the law deals with the matter only implicitly. Federal law dictates that residents retain all of their legal rights when they enter a nursing home or other residential facility, says Zita Dresner, a lawyer for the office of the District's long-term care ombudsman. In the Washington area, no state laws address how facilities must deal with sexuality among their residents with dementia, though institutions are obligated to report any case of abuse, sexual or otherwise. The problem is that, particularly with residents who have dementia, it's not always clear when sex is abusive and when it's consensual. When in doubt, social workers and others are advised to ask their state's long-term care ombudsman to investigate, said Jerry Kasunic, the District's ombudsman.

Texas, one of the few states that does have guidelines, adopted them in 1999 in response to family members' complaints of alleged sexual abuse at residential facilities; what actually was taking place was consensual sex, said Marc Gold, state director of long-term care policy in Austin. The guidelines clarify what constitutes sexual abuse that must be reported to state authorities.

Arbor Place, a small group home in Rockville for people with early and mid-stage dementia, supports residents' relationships, which may or may not include sex, as part of a philosophy that people with dementia benefit greatly from connecting emotionally with others. It encourages residents to join in organized activities and interact with other residents for much of the day. When a couple gets together, staff members allow them to be intimate in private, while monitoring the situation for safety and alerting the families of the new friendship, said the home's owner, Walter Fanburg, a geriatric psychiatrist.

"There's a lot of pairing-up here," said Fanburg. "I'd say that all of our male residents and most of our female residents have exhibited an interest in sex." They reveal their interest not necessarily in any overt way -- though that happens, too -- but in their conversations, gestures and responses to others.

But Fanburg's facility is unusual, as few institutions have plans in place to promote relationships or to educate staff on the sexual behavior of residents. At residential facilities, it's no longer "politically correct" to forbid sex between residents, said Halina Williams, director for mental health services at Potomac Valley Nursing and Wellness Center in Rockville. Administrators, she said, "just don't know what to do about it."

Some call her for advice on dealing with problematic sexual behavior, from masturbation to pinching nurses. She also takes patients, including residents from other facilities, for psychiatric evaluation. Treatment often includes supplementing or just fine-tuning medications.