Marie-Therese Connolly -- When the Mind Falters, Is Sex a Choice?

By Marie-Therese Connolly
Sunday, September 20, 2009

The 96-year-old woman with mild-to-moderate dementia pinned a piece of paper to her clothing each day to remind herself of the date. She posted scores of notes throughout the house to remember other details of life. "Cut toenails" and "take medication" read notes in her bathroom. And in the kitchen: "Cook the food [daughter-in-law] brought over."

But the notes that detectives later found in her home contained other, more complex reminders: Thur jan 8 2:40 pm sitting on side of bed. Thinking of [the gardener] and how I love him and it is returned. Friend love.

And: think it is Tues, Jan 12 9:15 PM can't think what has happened has happened. [The gardener] is unbelievable Is all a dream so much sex! sex! sex! Wonder what will happen next. Think he comes on Tuesdays. Help! . . .

For more than 20 years, the gardener had tended her yard. When he finished, she had often invited him in for a glass or two of wine. Each considered the other a friend. The woman's son and daughter-in-law lived nearby and helped her with finances, meals and transportation; the daughter-in-law said the woman often talked of the gardener, who was in his mid 50s, as if he were a long-lost son.

But that changed Jan. 13 of this year when, according to a police report, she alleged that he had raped her.

Page Ulrey, the elder-abuse prosecutor in the King County prosecutor's office in Seattle, wasn't sure what she was looking at: Was it sexual assault, or consensual physical intimacy that hadn't worked out as intended? Was the woman capable of making a decision about intimacy? Was she a victim? Had a crime been committed?

The tension between preserving freedom and assuring safety is not the exclusive domain of old age, nor is it limited to matters of sex. The challenges of the teenage years, when independence waxes, are well-known: Driving, drinking, sex and curfews are just a few of the battlegrounds. The balancing acts at the other end of life, when independence wanes, are not so dissimilar: driving, living independently and making decisions about care. But we are perhaps in greatest denial about issues that lie at the intersection of intimacy and dementia. Until a note on the wall, or a police report, or the surge in the number of people with dementia confronts us.

Already, 5.3 million Americans have Alzheimer's disease or other types of dementia, and the number will rise as the nation's population ages. At current rates, it's projected that 7.7 million people will have dementia by 2030 and 11 million to 16 million by 2050. A 2007 New England Journal of Medicine study confirms that for most older people, sex remains an important part of life. And some organic brain changes of old age are characterized by increasingly sexualized behavior. The disability rights community has grappled with issues of consent and intimacy. But issues relating to sex in old age, whether consensual intimacy, or sexual assault, or the nettlesome netherworld in between, receive scant attention. They should receive more.

Earlier this year, two teenage girls, whose newspaper photos looked less like mug shots than like glam yearbook pictures, were charged with physical, sexual and emotional abuse of seven Alzheimer's patients over four months at the Good Samaritan Society nursing home in Albert Lea, Minn., where they worked. Four other girls younger than 18 were charged with failing to report the conduct. The girls allegedly poked residents' breasts, hit their genitalia, stuck gloved fingers in their noses and mouths until they screamed, spit into their mouths, rubbed men until they became erect and laughed about their exploits later at school or driving around town. According to the detective's report, the girls saw their conduct as "something fun to do at work." They believed they wouldn't be caught, the detective wrote, because the "residents did not have their minds."

Elder sexual assault, although largely hidden, takes many forms: the Florida grandmother raped by her drunk grandson; the Wisconsin minister who regularly came to the nursing home to have sex with his comatose wife; sexual predators in facilities among the most vulnerable people; elder sexual homicides; and more.

Contrast these horrors with the situation at the Hebrew Home for the Aged in Riverdale, N.Y., where nurses and aides have grown accustomed to walking in on residents in flagrante delicto and respectfully excusing themselves. The facility is one of the few in the country to accept and facilitate consensual physical intimacy among residents. "Intimacy and sexual expression are fundamental human and civil rights, which must be encouraged and protected," says Daniel Reingold, the Hebrew Home's president and chief executive. "Sexual consent begins as an affirmation of these rights . . . . Our society must uphold these last vestiges of adulthood, rights and life pleasures."

Unlike most facilities, the Hebrew Home has rigorous procedures to determine consent. But there are challenges. For example, the resident who no longer recognizes her husband of 50-plus years but is physically intimate with a new (also demented) boyfriend in the facility. (Not all family members come to terms with new affections with the equanimity of former justice Sandra Day O'Connor.)

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