Dementia and sexually inappropriate behavior can be challenging to manage, and can make it difficult to provide quality care.
Sexually inappropriate behaviors are among the most distressing behavioral changes for family members and caregivers of people with dementia. Sexual behaviors can leave care partners rattled by a range of emotions, from shock and fear to embarrassment and shame.
Sexually inappropriate behaviors, sometimes called hypersexuality or sexual disinhibition, encompass a range of activities from lewd or suggestive comments to non-consensual touch.
Sexually inappropriate behaviors may interfere with the rights of others or with a person’s activities of daily living.
Some sexual behaviors are not inappropriate in and of themselves, but rather in context. They are pursued at inappropriate times or places, or with the wrong people.
Examples of sexually inappropriate behavior include:
- Disrobing or exposing one’s genitals
- Masturbating or looking at pornography in public
- Sexually suggestive comments, language or stories
- Touching others’ private areas, or touching others in a sexually suggestive way
- Requesting unnecessary genital care
Sometimes these behaviors aren’t actually motivated by sexual desires.
Is it Actually Sexual?
There are a number of reasons people with dementia display behaviors that might be construed as sexual. In some cases, they are driven by a desire for sexual gratification, but not always. For example, a person who exposes himself may actually be seeking a place to urinate. A person who is disrobing may simply be overly warm.
The first step in managing sexual behaviors is to determine the cause behind them.
Common Causes Behind Dementia and Sexually Inappropriate Behavior
Some inappropriate sexual behaviors are due to dementia-related brain changes. Confusion, disorientation, misinterpretation, and impulse control are all common in dementia, and are frequent culprits behind sexual behaviors.
There are also a number of needs that may be unmet, which can lead to sexual behaviors.
Disorientation to Place
When someone with dementia doesn’t realize where they are they may behave “inappropriately”.
The solution may be to provide privacy. For example, if they wish to masturbate or look at sexually explicit materials, provide them with a private area to do so.
Disorientation to Person
Sometimes the person with dementia mistakes one person for another. For example, it’s not uncommon for a father to mistake his daughter for his wife.
It can help to leave the room for a few minutes, and then come back in with a big greeting such as “Hi, Dad!” to clear up any confusion while sparing any embarrassment.
Misinterpretation of Signals
People with dementia commonly misinterpret signals or environmental cues. For example, a man who sees his pants are down, and then notices a young lady in the room with him, may come to the conclusion that she is interested in him sexually – not that she is here to provide incontinence hygiene care.
This can be especially pronounced if the person giving care is smiling, giggling nervously, or otherwise emitting signals that might be misinterpreted as flirtatious behavior. If she is also wearing somewhat revealing clothing – including scrubs that may not fully cover the chest when bending over, for example – there ends up being a lot of hard-to-read signals and room for misinterpretation.
Exerting an air of confident, no-nonsense professionalism during personal hygiene assistance can be helpful. If the behaviors exist more with caregivers of one gender, try using caregivers of another.
Putting on a lab coat or bulky jacket, tucking long hair up into a hat, or wearing dark glasses will sometimes alter a caregiver’s appearance enough to change the environmental cues, or signals – and the behavior.
Impulse Control
Somewhere between 7-25% of men and women with dementia exhibit sexually inappropriate behaviors to some extent. About 60% of these instances are comments. Sexual behaviors tend to be less frequent in people with Alzheimer’s-type dementias (7-8%), and higher in other types, with vascular dementia having the highest prevalence.
Researchers theorize that this may be related to the areas of the brain affected by various types of dementia. Damage to certain areas of the brain, such as the frontal and temporal lobes, is likely to decrease inhibition, making it more difficult for a person to control their impulses and actions.
When helping someone with impulse control issues, reasoning is generally ineffective, and may create unnecessary negative feelings. Instead, try to avoid situations or images that trigger the unwanted behavior.
It may help to avoid alcohol, change caregivers (or their attire) and remove potentially stimulating television programing from the environment. In some cases, it may help to strategically substitute other pleasant distractions – such as providing a small lollipop during personal care.
Environmental Triggers
The person may disrobe due to environmental triggers, such as feeling too warm, or wearing clothing that is tight or itchy.
Improving the environment and assisting them to become more comfortable should resolve these behaviors.
Unmet Needs
People with dementia often have a hard time recognizing and communicating what they need, and their behavior becomes a form of communication.
When their need is identified and met, the behavior resolves.
Physical Discomfort
“Indecent exposure” or touching one’s genitals may actually be a sign of needing to use the toilet. Urinary tract infections, yeast infections or prostate problems can also contribute to genital discomfort and “inappropriate” touching.
Assist the person to the toilet, or take measures to make it easier for them to find it on their own.
Look for changes in urination patterns, new incontinence, difficulty passing urine, and signs of rash or redness in the genital area. If noted, report to the person’s doctor.
Sexual Expression
While some seniors may naturally lose interest in sexual activity as they age, others do not. Some seniors enjoy healthy and evolving sex lives well into their advanced years. Older adults – as well as those with young-onset dementia – may continue to feel a desire for sexual expression, sexual contact and intimacy.
Dementia may affect a person’s sex drive – as well as that of their partner. In some cases, the person with dementia may experience an increased interest in sex, while the caregiving spouse is less sexually attracted to them (or simply too exhausted to be interested).
While it can be uncomfortable to discuss, sexual health is an important part of holistic wellness. If the person with dementia has a need for sexual expression, it’s important to find ways to meet it appropriately.
Sexual expression isn’t limited to intercourse, and these needs can sometimes be met by cuddling and exchanging loving touch with a romantic partner. If there is no romantic partner, some find masturbation to be a suitable alternative. Provide privacy and materials as needed.
Intimacy, Affection, Companionship and Social Connection
People need companionship, affection and connection in their lives. While they may seek to meet these needs through sexual expression, there may also be alternate ways to do so.
The term intimacy refers to the need for trusting connections and shared vulnerability in a relationship. Intimacy can be sexual, but it isn’t always. It can also refer to an open emotional, mental or spiritual connection. Intimacy is usually cultivated over time, through a process of communication and patience. When someone lacks intimate connections, they may feel isolated, lonely or disconnected.
Supporting positive, healthy friendships, heartfelt conversations, and meaningful relationships may help meet the need for companionship and close connection.
A cuddly pet can be a very affectionate companion.
Touch
Every human being needs touch. Some people with dementia have very little opportunity to share positive, appropriate touch with other humans.
Look for ways to increase appropriate touch in their lives. Foot, hand or back massages, manicures, pedicures, or even combing their hair can offer satisfying tactile stimulation. Find excuses to offer handshakes throughout the day. Holding hands may also be appropriate.
Sucking on lollipops or popsicles can offer alternative sensory stimulation.
Responding to Sexual Behaviors in the Moment
Encountering a sexual behavior from someone with dementia can evoke uncomfortable feelings of stress, embarrassment or even fear in many family members or caregivers. It’s easy to be overcome with shock or disbelief, especially if it’s the first time it has happened.
Keep in mind these simple steps:
- Remain calm
- Ensure the safety of all involved
- Step back, or out of the room, if needed
- If possible, determine the cause behind the behavior
Depending on the situation, it may help in the moment to…
- calmly and firmly tell them not to touch you
- respectfully remind them why it’s inappropriate
- look them in the eye and ask them to stop because it’s making you uncomfortable
- ignore comments or behaviors that aren’t harming anyone
- step out of the room
- redirect with humor
- provide privacy
Managing Ongoing Sexual Behaviors
If the person with dementia has begun to demonstrate a pattern of sexual behaviors it is essential to determine the unmet need. Once the need is fulfilled, the distressing behavior will resolve.
It’s important that people caring for someone with dementia are educated about potential sexual behaviors, so they can be handled successfully should they arise. In addition to education, emotional support and reassurance for family members and caregivers may be necessary.
If the person can understand, it may help to have a frank, respectful conversation about their needs and behavior. Sometimes this is better received if it comes from someone the person holds in high regard, such as a doctor or religious leader.
Sometimes the behavior occurs more with a particular gender, or with younger (or older) caregivers.
Switching caregivers can help.
Gather Information, Track the Behavior and Look for Patterns
It can help to have basic information about the person’s lifelong sexuality, if possible. It can also be very helpful to keep a log of challenging behaviors in order to discover patterns, and develop interventions to prevent unwanted behaviors.
Track details about each episode to identify any patterns or trends.
- Who else is around or involved?
- What are they doing? What have they been doing recently? And what else is happening in the area?
- When is it occurring? Note the time of day, the date, and day of the week
- Where is it occurring?
You may notice that the behavior is occurring, for example, after visiting with a particular family member, when a certain television program is on, at a certain time of day, or primarily during personal care.
Keep a log of these details, and, if possible, sit down to discuss them with another care partner of the person with dementia. Plan to debrief with some regularly for as long as the behaviors occur.
Medications for Sexually Inappropriate Behaviors
At this time, there are no good drugs for managing sexual behaviors in people with dementia. Sometimes sedatives, or drugs that reduce testosterone or libido are used, but their success is hit or miss, and many have serious side effects.
Drugs can make it harder for the person to communicate or function, and they can increase the risk of falls or health complications. Medications should be used only as a last resort when the situation is serious, and the need clearly outweighs the risks and drawbacks of the drug.
Note that alcohol or certain medications can increase sexual behaviors in some cases.
Refer to the doctor or pharmacist for questions about medications.
Keep Calm and Uncover the Cause
There are many reasons that people with dementia may exhibit sexually inappropriate behaviors, which can be very impactful on the people around them. Understanding the cause or need behind behaviors is essential for resolving them.
When encountering sexually inappropriate behavior in a person with dementia:
- Remain calm and respectful at all times.
- Ensure the safety of all involved.
- Determine the need or cause behind the behavior. (Tracking behaviors and discussing with the person directly, other care partners, or medical providers may be necessary.)
- Try an intervention. If it doesn’t work, try another. Keep trying until you figure out a solution.
Education about the nature of sexual behaviors in dementia is helpful for family members – and essential for professional caregivers – so they aren’t caught completely off guard if it happens.
