More Than Capacity: Alternatives for Sexual Decision Making for Individuals With Dementia

Sexual expression can be an important aspect of well being for older adults with dementia living in nursing homes. There is a tension in the nursing home, however, between ensuring autonomy of residents for sexual expression and protecting residents from harm. To alleviate this tension, nursing homes can conduct an assessment of residents' capacity for sexual consent. This article argues that although such assessments can be useful in the initial evaluation of capacity, this is a somewhat flawed approach to sexual decision making and a finding of incapacity should not necessarily preclude sexual expression. In instances where residents are found to lack capacity but continue to express interest in sexual expression, a committee approach can be utilized where residents, the nursing home, and family members can convene to advocate for residents' autonomy, dignity, and right to sexual expression while working to minimize harm. Such advocacy decisions can be based on substituted judgment, a best interest standard, or some combination of the two. Although committee decision making for sexual expression seems intrusive, it at least allows for continued discussion of the right to sexual freedom for residents in the face of significant counterbalancing forces.