A Scoping Review on Attitudes towards Sexuality in Residential Aged Care

Le, Klara; Bennich, Maria; Strandberg, Thomas

doi:https://doi.org/10.1155/2024/1478395

Health & Social Care in the Community

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Abstract Introduction Background Methods Results Discussion Conclusion Conflicts of Interest Authors’ Contributions Acknowledgments References Copyright Related Articles

Review Article | Open Access

Volume 2024 | Article ID 1478395 | https://doi.org/10.1155/2024/1478395

A Scoping Review on Attitudes towards Sexuality in Residential Aged Care

Klara Le,¹Maria Bennich,¹and Thomas Strandberg^1,2

Academic Editor: Helen Skouteris

Received02 Feb 2024

Revised23 Mar 2024

Accepted29 Mar 2024

Published09 Apr 2024

Abstract

Objectives. Sexuality in residential aged care is a complex and often overlooked aspect of aged care. The attitudes of both staff and residents significantly influence how sexuality is perceived and addressed in these settings. This scoping review aims to compile, analyse, and identify gaps in the existing research concerning the attitudes of residents and staff towards sexuality within the context of residential aged care. Methods. The scoping review involved a systematic search across eight databases, yielding 469 unique articles, with 29 included studies. Results. Thematic synthesis within the selected studies disclosed three themes: hollow attitudes, postsexual residents, and organizational setbacks. Discussion. The results emphasize the significance of treating sexuality as a fundamental right, emphasizing that it should be not only acknowledged in theory but also implemented in practice.

1. Introduction

Sexuality is widely acknowledged as a fundamental aspect of overall well-being, spanning the entire lifespan [1]. However, discussions about sexuality are often centred on younger individuals, influenced by Western society’s youth-centric culture [2]. Rooted in the belief that ageing involves continuous physical and cognitive decline, the sexuality of older adults is frequently disregarded, particularly in aged care [3]. Research indicates that some older adults in residential aged care (RAC) maintain an interest in sexuality, recognizing the positive impact on overall well-being [3, 4].

RAC settings present a unique blend of private and public norms. Transitioning from a private home to RAC transforms personal spaces into areas of professional caregiving, influencing perceptions and attitudes towards sexuality [2, 5]. The attitudes of RAC staff and residents towards sexuality, therefore, play a pivotal role in either facilitating or constraining sexual expression. Previous research [6–8] has highlighted the correlation between a lack of clear guidelines addressing sexuality in RAC and staff often relying on their personal moral beliefs, which can significantly impact the residential environment and organizational culture. A critical aspect to consider when exploring sexuality in RAC is, therefore, the impact of the individuals’ residential environment. RACs are designed to provide comprehensive care and support for older adults who can no longer live independently in their own homes. This highlights the importance of not only studying attitudes as an individual factor but also considering how organizational and societal norms influence attitudes towards residents’ sexuality. Understanding these broader influences is essential for developing comprehensive strategies that support the sexual needs and rights of older adults in RAC settings.

Recent research by Aguilar [9] indicates a growing acceptance and a more permissive view among RAC staff towards residents’ sexuality. However, the real meaning and practical implementation of these changing attitudes remain unclear. This lack of clarity highlights the need to explore how these attitudes are reflected in the day-to-day care of older adults and their overall well-being. Furthermore, prior reviews have identified a gap in understanding residents’ perspectives on sexuality in RAC [9–11]. Emphasizing person-centred care, Mahieu and Gastmans [11] have called for more research focusing on residents’ views. This scoping review aims to fill these gaps, particularly by shedding light on how organizational conditions influence attitudes towards sexuality within RAC and prioritizing research that concentrates on residents’ perspectives. Unique in its approach, this review utilizes a scoping methodology not commonly employed in previous studies [9–13]. By systematically mapping the research landscape, this study provides an overview of existing knowledge and its limitations.

1.1. Objectives

This scoping review aims to compile, analyse, and identify gaps in existing research concerning the attitudes of residents and staff towards sexuality within the context of residential aged care (RAC).

The review is guided by the following research questions:(1)What are the prevailing attitudes towards sexuality in residential aged care among both residents and staff?(2)What can influence residents’ and staff’s attitudes towards sexuality in residential aged care?(3)What are the gaps in the current literature regarding the attitudes of sexuality in residential aged care?

2. Background

The term “sexuality” refers to a wide spectrum of behaviours, interactions, and connections [14]. It encompasses sexual feelings and thoughts; personal grooming and self-expression; romantic partnerships; expressions of affection such as handholding, kissing, shared bed arrangements, and self-pleasure [3]. Sexuality, in this study, is, therefore, not limited to intercourse; it can also encompass aspects of intimacy and the sense of being a sexual individual. Research in the area found that sexuality had a continuing meaning for residents, and sexuality was closely linked to intimacy and was manifested in various ways such as holding hands, hugging, and engaging in joint activities [4, 15].

Ageing can present specific challenges when it comes to sexuality. These challenges can affect the physical and mental well-being of older adults in different ways [16]. Older adults can encounter health issues that impact their sexuality, with physical conditions such as diabetes, cardiovascular disease, or musculoskeletal disorders, as well as mental health challenges such as depression and anxiety [17]. However, this does not imply that an older adult should be considered asexual or lacking sexual desire. Studies have shown that sexuality continues to be important to some people who have health problems related to ageing [16, 18]. Moreira et al. [19] found that some older adults in palliative care were sexually interested and active despite reported health problems and sexual physiological dysfunctions. Even individuals with life-limiting illnesses who had a few weeks to live reported that sexuality remained important. Furthermore, the perceptions of older adults as frail and in need of care tend to overshadow research results that indicate the importance of sexuality [2, 16]. Therefore, it should not be assumed that health problems automatically reduce individuals’ sexual desire.

Kellett and Oppenheimer [14] identified three societal attitudes that can affect the view of sexuality in later life. The first attitude, labelled “discreet silence,” suggests a preference for avoiding open discussions on such matters. This approach values privacy and allows individuals to make personal choices without attracting interference. However, challenges that arise may remain concealed due to embarrassment, leading to distress and anxiety. The second attitude is characterized by “distaste.” In this perspective, sexuality in older adults is deemed unattractive and out of place. The third attitude can be defined as “tunnel vision,” restricting the concept of sexuality as exclusively heterosexual [14].

One aspect often noticed in research about older adults is loneliness [20, 21]. Loneliness among older adults can affect their well-being in several ways, and it can create a sense of detachment that reduces opportunities to initiate and maintain relationships. Studies have pointed out that the lack of a partner is often cited as one of the main reasons for a decrease in sexual activity [7]. Individuals who have lost their partner may experience a complex sense of loyalty towards their deceased partner. They may feel that they have a moral obligation not to engage in new sexual relationships out of respect for and loyalty to their former partner [7].

Attitudes towards the sexuality of older adults are a primary factor influencing individuals’ sexuality within the context of RAC [22, 23]. The literature highlights issues related to negative staff attitudes, which may be rooted in ageism and can lead to older adults’ sexual or intimate expressions being unfairly labelled inappropriate [24]. These attitudes wield considerable influence over how both staff and residents approach sexuality. Consequently, cultivating positive attitudes among staff and residents has emerged as a fundamental element in promoting respect for sexuality within RAC. Fostering such attitudes necessitates the implementation of education and guidelines concerning sexuality within the framework of RAC. Regrettably, the field suffers from a dearth of comprehensive guidelines and training, and staff must rely on their moral compass when deciding how to act and respect an individual’s sexuality [3, 8]. Research findings suggest that staff employed in RAC do not regard sexuality as a topic that merits active promotion or proactive discussion with residents. In certain instances, staff perceive sexuality as inconsequential or even potentially disruptive to the institution’s operations [25, 26].

3. Methods

The method is a scoping review conducted using the program Covidence, which is an online software platform that simplifies the review process, making it easier for researchers to manage study selection, data extraction, and risk of bias assessment. The scoping review is registered on Open Foundations Commons [27].

3.1. Design

The scoping review was designed and performed with the support of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and checklist [28]. The use of PRISMA in this scoping review ensured a systematic and comprehensive approach to the review process.

3.1.1. Inclusion Criteria

This research primarily centres on residential aged care (RAC), encompassing both residents and staff. The timeframe is from 2000 to 2023, as this period has witnessed an upsurge in interest regarding sexuality. Numerous studies have been published during this time, exploring the intricate relationship between sexuality, health, and overall well-being in older adults. These studies often include individuals who came of age during the sexual revolution of the 1960s and 1970s, making this period particularly relevant [29]. The included studies must have adhered to ethical guidelines or received ethical approval.

In contrast, studies that exclusively concentrate on sexual violence, harassment, or sexual abuse were excluded. Research examining inappropriate sexual behaviour, which encompasses a range of behaviours such as exposing body parts, disrobing, and public masturbation, falls beyond the research’s scope. In terms of population, studies involving people with dementia are incorporated only if they feature a minimum of 50% cognitively healthy participants, with separate data extraction for this subgroup. The decision to exclude studies predominantly involving people with dementia is based on the condition’s association with behavioural changes such as “hypersexuality,” which significantly alters sexual behaviour. This differs from cognitively healthy older adults’ experiences [30]. Furthermore, the research does not encompass studies solely focused on sexual orientation, to keep the focus on the central theme of the scoping review. Many of the studies that address LGBTQ-related issues highlight aspects such as the possibility of maintaining queer identities, making them less relevant to the current research question [31].

Lastly, we distinguished between “assisted living arrangements” and “residential aged care” by their care intensity and environment, excluding the former for its different care model. Assisted living arrangements were omitted as they involve a less intensive care model than residential aged care [4]. Additionally, the research excludes studies focused solely on educational or training programmes and those centred on policy or regulatory issues. Studies focused solely on educational or training programmes and those centred on policy or regulatory issues were marked as beyond the scope of the review. Excluded formats were grey literature such as opinion pieces, editorials, and literature reviews without primary data.

3.2. Search Strategy

The search was developed with the support of Örebro University’s librarian. The search process was initiated by identifying relevant keywords in previous research. The selected databases for the scoping review were PubMed, Scopus, CINAHL, PsycINFO, and Web of Science, as they are comprehensive platforms encompassing a wide range of relevant publications. Additionally, AgeLine, Gender Studies Database, and Social Service Abstracts were selected as they are specialized databases in the research subject areas related to ageing and sexuality. The search process took place between April and May 2023. The search methodology began with a thesaurus search in PubMed MeSH, to identify a range of synonyms pertinent to “Sexuality” and “Residential aged care” [32]. The search strategy was further refined by synthesizing the terms, culminating in the refined search query: “Sexuality” AND “Residential aged care” (see Table 1).

Out of an initial pool of 1098 references imported for screening, 629 duplicates were identified and removed by the first author. Following this initial screening, all authors independently and blindly screened the 469 studies by titles and abstracts, with dual review to ensure consistency. During this stage, 362 studies were excluded from further consideration. Out of the remaining 107 studies, a full-text assessment was conducted blinded by all authors to determine eligibility for inclusion in the research. To enhance methodological rigour, meetings were held to discuss articles where disagreements arose. In these sessions, each study was jointly reviewed against inclusion and exclusion criteria, ensuring collective understanding and agreement before final decisions. This collaborative approach further solidified the review process’s reliability. After this review, 78 studies were excluded. The reasons for exclusion were diverse, with 24 studies having the wrong study design, 16 not aligning with the population, 14 not following the required format, 13 not being conducted in the relevant setting, and 10 falling beyond the defined scope of the research. One study was eliminated due to language issues. The outcome of this screening and assessment process left us with a final set of 29 studies that met the inclusion criteria (see Figure 1).

An extended search was performed in September 2023. This search found one new hit that was excluded because it was an overview written in Spanish. Although a quality assessment is not required in a scoping review, this study considered the quality of the studies [33]. This process was carried out individually and blindly in Covidence, where the researchers rated the studies as low, moderate, or high quality [34]. All studies but one [35] were assessed as of high or moderate quality, due to methodological limitations. However, Gilmer et al. [35] were included due to the study’s empirical value.

3.3. Data Extraction and Analysis

The data extraction was conducted individually and blinded in Covidence, ensuring a systematic and unbiased process. Covidence provides a systematic and blinded process, ensuring that researchers do not have access to the data entered by their peers. Data extraction was conducted individually for each selected study. Key details from each study, such as methodology, participant characteristics, outcomes, and significant conclusions, were rigorously catalogued. This structured approach ensured comprehensive and consistent data capture across all included studies, allowing for an accurate and reliable synthesis of the findings.

Additionally, a thematic synthesis was employed, encompassing three key stages [36]:(1)Coding Text: Initially, the text from primary studies was examined and coded, focusing on its content. This crucial step facilitated the identification of key concepts and ideas in the data. The analysis focused exclusively on the primary result sections of the studies, omitting text from the introductions and discussions. The coding of qualitative data was performed at both the thematic level and the level of primary data, including quotes. The decision to incorporate the quantitative data into the thematic analysis stemmed from its rich, descriptive nature rather than quantitative metrics.(2)Developing Descriptive Themes: Following the initial coding, codes were grouped into related areas to form descriptive themes (see Table 2). This involved synthesizing and summarizing the primary data while staying closely aligned with the original studies.(3)Generating Analytical Themes: In the final stage, the analysis extends beyond the primary studies’ content to create new interpretive constructs, explanations, or hypotheses. Here, three themes emerged: hollow attitudes, postsexual life, and organizational setbacks. Although the studies encompassed both quantitative and qualitative data, thematic analysis emerged as particularly suitable. The quantitative data, primarily gathered through multiple-choice and open-ended surveys, often contained rich, descriptive elements conducive to qualitative analysis. Instead of depending solely on numerical analysis, this data format facilitated a deeper and more nuanced understanding of the subject.

4. Results

The study results are organized in tables alphabetically, with Table 3 detailing qualitative findings and Table 4 showing quantitative outcomes. Most of the studies (n = 19) used qualitative methods, primarily semistructured interviews, while quantitative studies (n = 10) mainly employed surveys. Geographically, most research occurred in Oceania, especially in New Zealand (n = 5) and Australia (n = 4), followed by Europe with notable contributions from Spain (n = 7), the UK (n = 2), Belgium (n = 2), Poland (n = 1), and Portugal (n = 1). North America is represented by studies from Canada (n = 2) and the USA (n = 3), with additional studies from Israel (n = 1) and Brazil (n = 1). Notably, some studies, like those by Cook et al. [42, 43] and Villar et al. (2014–2017), utilized the same datasets. The research fields varied, with 13 studies in medicine, nine in psychology, five interdisciplinary (combining psychology, medicine, law, and social work), two in social work, and one in sexology. Many studies were published during the periods 2010–2019 (n = 19) and 2020–2023 (n = 8), with only two studies dating back to 2000–2009.

A significant number of study participants were women. This observation can be linked to the fact that the field of healthcare, which includes RAC, is often female-dominated [63]. Among 29 studies, the most common methodology was constructivism (n = 7), followed by grounded theory (n = 3). One study employed phenomenology. The remaining studies did not specify a particular methodological stance (n = 18). Furthermore, this field is predominantly empirical, with many studies lacking theoretical frameworks. Out of 29 studies, only four incorporated theories. These theories included Foucault’s Panopticon (2), organizational theory (n = 1), and ageism (n = 1). Most of the research (n = 17) was conducted from the staff’s perspective, with nine studies involving both staff and residents and four studies exclusively focused on the residents’ perspectives.

4.1. Results from the Thematic Analysis

After analysing the selected articles, three themes emerged: hollow attitudes, postsexual life, and organizational setbacks.

4.1.1. Hollow Attitudes

The prevailing trend among the studies indicates that staff within RACs tend to exhibit positive attitudes regarding the sexual needs of residents [13, 46, 57]. In some studies, staff and residents portrayed sexuality as a fundamental right or a basic need for the residents and linked it to well-being [35, 50]. For example, over half of the participating staff in Schouten et al.’s [50] study concurred that sexuality should be recognized as a lifelong human right.

While previous studies suggest positive staff attitudes towards residents’ sexuality [13, 46, 57], this review indicates that certain attitudes in RAC may lack depth, reflecting a potential disconnect from genuine perceptions in terms of supporting residents’ sexuality. The theme of “hollow attitudes” highlights situations where attitudes towards sexuality can be superficial or reflect socially accepted norms rather than being genuine and deeply rooted in respect for residents’ sexuality. This is further developed with the help of two subthemes: Sexuality is a right, right? and Sexual expression within boundaries.

(1) Sexuality is a Right, Right? Although many studies found that staff had positive beliefs about residents’ sexuality and viewed sexuality as a right, it was rarely something that was talked about in the workplace, and there were no policies regarding the residents’ sexuality [38, 43, 61]. In some studies, staff reported that they had guidelines and policies for residents’ sexuality; however, when asked to state these, the majority stated, “the right to privacy” and nothing specifically related to sexuality or intimacy [37, 45]. Despite the staff’s awareness that sexuality is a fundamental human need and should be regarded as a resident’s right, a significant number of staff expressed a distinct discomfort when it came to addressing this issue in practice [52, 53, 64]. In the literature exploring the resident’s perspective, several residents noted that staff often seemed uncomfortable with matters related to sexuality [40, 43, 55]. Many residents emphasized the correlation between staff’s negative attitude and limited education as barriers to sexuality in RAC. In a study by Villar et al. [56], a resident described the following: “Their sexual education has been very repressive. They couldn’t talk about sex: they’ve been very limited and coerced” [56].

Various studies [46, 48, 51, 52, 56] have called for the establishment of explicit guidelines for sexuality within RAC. These guidelines would serve as essential tools to provide clear directives for the staff and influence staff attitudes towards residents’ sexuality, promoting a more respectful and open-minded approach. However, the existence of guidelines alone is not a solution. Their effectiveness depends on the willingness of staff to embrace and adhere to them. This complexity is exemplified in a study by Jen et al. [37], who found that only half of the staff felt they would follow policies on residents’ sexuality.

While many studies reveal that staff generally hold positive beliefs regarding residents’ sexual rights, there is a significant gap between those beliefs and recognizing these rights in practice. This disconnect is evident in the absence of formal discussions and specific policy documents addressing residents’ sexual rights [38, 43, 61]. Even though staff acknowledged sexuality as a fundamental human need, many expressed discomfort when faced with this issue in practice.

(2) Sexual Expression within Defined Boundaries. In the studies, staff described the residents’ sexuality as a natural human need regardless of age [42, 46, 48, 49, 51, 60]. Nevertheless, it is noteworthy that specific forms of sexuality were often more tolerated than others within RAC [45, 53, 58]. In several instances, sexual expressions that contained erotic or more explicit elements were subject to more severe condemnation [35, 55] than expressions of tenderness. Many of the most common sexual expressions among the residents, such as masturbation, kissing, and intercourse, were also the ones that staff found most discomforting [40, 52, 62].

Masturbation was one of the most common sexual expressions among the residents and one that staff most believed the residents needed to be satisfied [52, 59, 61, 64]. Despite this, masturbation was also one of the sexual expressions that created the most discomfort among staff [54, 62]. Villar et al. [54] found that staff saw masturbation in the RAC as an unexpected event, and they did not know how to react. Some mentioned that they would be embarrassed, while others would joke or start gossiping about the residents. A respondent described colleagues’ reactions: “Some of them would make a fuss about it … some of them certainly would, joking about dirty old men and things like that” [54].

Another aspect is the question of who is permitted to engage in sexual activity. Staff often regarded individuals with multiple illnesses or those experiencing challenges in daily self-care as unable to engage in sexual activity [37, 46, 48]. Research has further illuminated that the level of acceptance is primarily contingent on whether the sexual activity occurs within a heterosexual relationship [50, 53]. In comparison, same-sex couples often faced more severe judgment and, in some cases, were not even recognized as couples at all. For instance, Venturini et al. [53] highlighted an example that underscores the challenges and consequences faced by same-sex couples in these institutional settings where a relationship between two women was prohibited. This led to the administrative decision to relocate the couple to separate departments, to dissolve the relationship.

4.1.2. The Postsexual Life

Residents in RAC are commonly viewed as postsexual—both by staff and by the residents themselves [35, 38, 45, 55]. This is conceptualized using four subthemes: staff perceptions of postsexuality, self-perceptions of postsexuality, the postsexualizing institution, and challenging norms in expressing sexuality.

(1) Staff Perceptions of Postsexuality. When staff were asked about the sexuality of the residents, a recurrent response was that they believed the residents had no sexual needs [39, 45, 48, 56]. Staff often perceived that residents’ sexual needs waned with age, leading them to disregard the existence of these essential aspects of well-being [37, 39, 52, 65]. For instance, Villar et al. [56] found that the staff’s attitude posed a significant barrier to addressing residents’ sexual needs. Some staff believed that it was morally inappropriate for older adults living in RAC to engage in sexual activity. Villar et al. [54] highlighted an example where staff question whether sexuality is appropriate for the residents due to their age: “I’d be taken aback … because it seems that at that age you can’t do it anymore” [54].

(2) Self-Perceptions of Postsexuality. Research focusing on the residents’ perspectives on sexuality within RAC has revealed that residents tend to downplay their sexuality [43, 50]. Numerous residents mentioned that they had abandoned sexuality when they moved into RAC [38, 43, 50]. Some residents believed that their sexual life ended following the death of their partner, deliberately abstaining from engaging in sexuality as a means of honouring their deceased partner [18, 41, 47].

In the exploration of residents’ attitudes, a prevailing narrative surfaces wherein residents frequently detach themselves from discussions around sexuality, often ascribing this distancing to their age [38, 50]. In line with the staff, some individuals express the belief that engaging in sexual activity is deemed inappropriate. Simpson et al. [38] discovered residents expressed the opinion that sexuality within RAC was deemed irrelevant because nobody engaged in it. When asked about sexuality, one resident replied, “Nobody talks about it … Nobody practises it. We just live as we are—We’ve had our sex life way back” [38].

(3) The Postsexualizing Institution. In navigating discussions on their sexual lives, residents consistently conveyed an awareness of the specific conditions within RAC that would enable or constrain their ability to engage in sexuality [43, 44, 49, 50]. This awareness stemmed from the limitations imposed by the communal living environment and the potential intrusion into their privacy. Residents often found themselves adapting to the schedules set by the staff, conscious that staff could enter their living spaces at any given moment. One resident stated, “You’re very self-aware in a place like this. You don’t do anything unless you double-check it” [43].

Several residents emphasized that they still desired sexuality, but they pointed out constraints within RAC that hindered its expression [40, 41, 44, 49]. A recurring concern was the perceived inadequacy of privacy, with many residents asserting that even their personal rooms felt too exposed for intimate activities [40, 44, 45, 55]. Some residents mentioned that they did not feel that the RAC was their own home [41, 43, 49, 55]. As a resident in Rowntree and Zufferey’s [49] study said, “You’re always telling me this is my home. If I were at home, there would be no way that I would entertain a doctor while I was in the shower” [49].

Another aspect raised by the residents and staff was the conflict between the desire to feel like a sexual being and the fear of rumours [41, 42, 47, 49]. A resident in Palacios-Ceña et al.’s [47] study mentioned that she wished to dress a certain way but refrained from doing so to avoid potential gossip. While the majority of residents experienced sexual desire, a significant number chose to overlook it due to the constrained environment [18, 47, 55]. Mroczek et al. [18] found that only 39% of the residents said that they were able to satisfy their sexual needs. Instead, many residents focused their attention on activities such as walking or attending church.

(4) Challenging Norms in Expressing Sexuality. Some residents challenged the prevalent narrative of postsexuality [38, 40, 41, 50]. This perspective portrays sexuality as a spectrum, ranging from intimate relationships to acts of self-expression, such as enhancing one’s appearance. In Mroczek et al. [18], many of the residents stated that they felt sexual tension, but 71% claimed that sex for older adults was taboo. Residents also associated sexuality with feeling like a sexual being, which could involve dressing or grooming oneself to evoke that feeling [18, 44, 45, 47]. One resident in a study by Bauer et al. [40] articulated that, despite concerns about being noticed, they consciously chose to engage in a sexual relationship: “She said ‘Oh I’ll take you in my room’, and I said, ‘I don’t think I better, I’ll get caught’, … but oh she was … hot!” [40].

4.1.3. Organizational Setbacks

One of the key barriers identified in RAC settings is the staff’s attitude towards residents’ sexuality, a complex issue shaped by more than just individual perspectives. Various explanatory models have been explored, including the importance of an individual’s culture, religion, and age [13, 39, 58–60]. However, the predominant factors identified in most research are the level of education and professional experience. More importantly, these attitudes are not formed in a vacuum. They are influenced by the broader organizational framework, including the structure and policies of the RAC organization. These setbacks can be attributed to organizational factors, highlighting how the structure and policies within the RAC organization influence the staff’s permissive or restrictive attitudes towards the sexuality of residents. Research investigating factors that can influence staff attitudes towards residents’ sexuality consistently highlights a notable correlation concerning educational levels and the development of permissive attitudes [13, 39, 58–60]. Studies in this domain suggest that individuals with higher education within RAC tend to exhibit more open and accepting attitudes towards the sexual expression of residents [13, 39, 57–61]. This observation underscores the substantial impact of education levels on staff perspectives regarding the residents’ sexuality and their right to express their sexuality within the context of RAC.

Moreover, the data reveal a notable correlation between limited work experience with older adults and the manifestation of negative attitudes towards sexual expression in later life [13, 39, 57–61]. This implies that staff with fewer years of experience working with older adults tend to exhibit more restrictive views regarding the sexual rights and expressions of older adults. Notably, the statistical analyses by Bouman et al. [57] showed that staff with less than 5 years of experience demonstrated a more negative outlook on later-life sexuality.

The significance of education and professional experience emerges as a crucial organizational challenge within the realm of aged care. The literature in the field underscores the critical need to address this issue, particularly due to the high turnover rate prevalent in aged care and the fact that a substantial number of individuals embark on their careers in this field [40, 44, 51].

5. Discussion

This article presents the results of a scoping review investigating the attitudes of residents and staff concerning sexuality within the context of RAC. The review was guided by three research questions concerning (1) the prevailing attitudes towards sexuality among both residents and staff, (2) what can influence residents’ and staff’s attitudes towards sexuality in RAC, and (3) the gaps in the current literature regarding the attitudes of sexuality in residential aged care. Exploring attitudes towards residents’ sexuality in RAC reveals a complex landscape, where it is crucial to acknowledge the broader context that shapes these attitudes. It is important to recognize that these attitudes are not solely individual issues but are also formed and influenced by cultural, organizational, and societal factors.

Looking at the prevailing attitudes, this study found that there seems to be a discrepancy between considering residents’ sexuality as a right and treating it as a right. The prevailing attitudes seem to be marked by what this study has termed “hollow attitudes.” Staff working in RAC generally express moderately positive attitudes concerning the sexual needs of the residents [13, 35, 46, 57]. However, the question arises as to whether these positive attitudes are superficial. Monteiro et al. [46] mentioned this aspect in their discussion, noting that positive beliefs may not translate into permissive attitudes and behaviours. Although the majority of staff may express positive beliefs about residents’ sexual rights, their discomfort in addressing the issue in practice reveals a deeper challenge that needs attention [35, 37, 52, 62, 66]. The theme “Sexuality is a right, right?” underscores the disconnection between the theoretical acknowledgment of sexual rights and the application in practice. Within this context, the absence of explicit discussions and policy documents contributes to the discomfort expressed by staff when faced with residents’ sexuality. It is insufficient to examine attitudes merely; it is vital to analyse how these attitudes are manifested in practice [8].

The reserved perspective held by residents regarding their sexuality can be influenced by several factors. Pervasive societal norms contribute significantly, with ageism playing a particularly impactful role [24]. The stereotype associating older adults with asexuality or reduced sexual desire pervades societal views of ageing [38, 43, 50]. This stereotype, in turn, affects how residents are perceived and treated within RACs. This can be explained through Kellett and Oppenheimer’s [14] second attitude towards sexuality in later life, which can be characterized as “distaste.” In this perspective, sexuality in older adults is considered inappropriate. This viewpoint reflects societal attitudes that find the expression of sexuality in older adults displeasing and out of sync with accepted norms associated with the ageing process. Moreover, if staff perceive residents through the lens of postsexuality, it creates a self-fulfilling prophecy. The environment within RACs, shaped by both societal norms and institutional constraints, may not provide the necessary privacy for residents to express their sexuality. Staff, influenced by these preconceptions, can unintentionally contribute to a cycle where residents feel compelled to see themselves as postsexual due to the conditions imposed by the RAC. Another attitude that can affect residents’ sexuality is Kellett and Oppenheimer’s [14] third attitude, “tunnel vision,” that is, a narrow focus that sees relationships as exclusively heterosexual. This is shown in the research when same-sex sex is usually condemned or when same-sex couples are seen as friends [53].

The transition to RAC brings an awareness of privacy constraints and altered personal dynamics, significantly impacting residents’ attitudes towards their sexuality. The communal living arrangements and the constant presence of caregivers, who are involved in various aspects of daily life, contribute to a heightened awareness of these constraints. In response to these factors, residents may consciously modify their behaviour, often becoming more reserved in expressing their sexuality, reflecting a shift in their attitudes [43, 49, 50]. This change in attitude is further reinforced by the institutional environment itself, which typically plays a role in shaping a “postsexuality” mindset. RACs, structured predominantly for medical and functional care, often overlook intimacy and sexual expression [5, 7]. This unintentionally contributes to the perception among both staff and residents that older adults are no longer sexual beings. This institutional emphasis on physical and medical care, coupled with a lack of attention to emotional and relational needs, reinforces a prevailing attitude that sidelines sexuality in older adults. Therefore, understanding residents’ perspectives on sexuality within RACs requires a nuanced examination of both the broader sociocultural context and the specific institutional environment. This approach will reveal how attitudes towards sexuality are not just individually based but are also significantly shaped by the organizational culture and societal norms.

The exploration of residents’ sexuality in the context of residential care settings has revealed research gaps. The first one is the lack of clear methodologies and theoretical frameworks in numerous studies within the domain. This suggests a gap in the integration of existing theoretical knowledge into the field, and this absence can hinder a comprehensive understanding of the intricate dynamics and patterns inherent in the subject matter. The research landscape concerning sexuality in older adult care primarily includes studies from similar regions, with a notable emphasis on Western countries. This review highlights a lack of research from other diverse geographical areas, especially regions in Africa and Asia. Furthermore, a significant gap identified is the limited research emanating from the Scandinavian region, particularly from countries like Sweden, which are known for their open and progressive attitudes towards sexuality [48]. Another noteworthy aspect of the research field is the predominant influence of the medical domain, with less prominence given to social work and sociology. If the research is mainly focused on the medical field, it may limit the understanding of wider social and societal aspects of sexuality in aged care. Social work and sociology can contribute important perspectives on relationships, norms, and social structures.

5.1. Limitations

One limitation of this study is the fact that certain studies are based on the same dataset. This may introduce a level of redundancy in the findings, potentially limiting the diversity of perspectives. Another noteworthy potential limitation is the diverse countries of the included studies. There are variations in age care across countries, influenced by cultural, regulatory, and structural differences, which affect how older adults are cared for. Therefore, our findings should be interpreted considering these varied organizational contexts and the influence of cultural and systemic factors on attitudes and practices regarding sexuality in these facilities.

6. Conclusion and Further Research

This scoping review arrived at the following conclusions:(i)Prevailing attitudes towards sexuality in RAC: Even though there has been a shift towards more positive attitudes regarding residents’ sexuality, these attitudes may be superficial, mirroring socially accepted norms rather than genuine respect for individual sexuality.(ii)Factors influencing attitudes towards sexuality in RAC: Institutional policies and cultures significantly impact attitudes, often leading to the characterization of residents as “postsexual.” The perceived restrictiveness of the RAC environment influences the attitudes of both residents and staff.(iii)Identified gaps in research on sexuality in RAC: In line with previous studies [9–11], this study highlights a gap in the current literature where the voices of staff are predominantly represented over those of residents. The study also identifies a lack of clear methodologies and theoretical frameworks in many studies within this domain.(iv)The study identified the gaps in research on sexuality in residential aged care (RAC), confirming previous findings [9–11]. These gaps primarily involve the predominance of staff voices over those of residents and the absence of clear methodologies and theoretical frameworks in many studies within this domain. Moving forward, future research in the field of sexuality in RAC should prioritize addressing the underrepresentation of residents’ perspectives to provide a more balanced view. Additionally, there is a clear need for studies to employ clearer methodologies and theoretical frameworks, integrating existing theoretical knowledge more effectively to understand the complex dynamics of sexuality in these settings. This would contribute to a deeper understanding of how cultural, societal, and organizational factors interact to shape the experiences and attitudes of residents and staff alike.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

All authors contributed to the study. The first author conducted the literature search and thematic analysis. All authors participated in article screening and the data extraction process. The first author had a central role in conceptualizing the study and writing significant parts of the text. The second and third authors substantively edited the manuscript.

Acknowledgments

This study was funded by the Örebro University’s faculty budget. Open access funding was enabled and organized by Bibsam 2023. This study was accomplished within the context of the Swedish National Graduate School on Ageing and Health (SWEAH).

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