Case Study

Gladys and George

Gladys is 73 years old with mid-stage dementia, who has been living in the residential aged care facility for the past year. Gladys is widowed, and has a sister who regularly visits her in the residential care home. Gladys frequently experiences forgetfulness, and often has trouble identifying people who are familiar to her, including her sister.

George is 79 years old and has early-stage dementia. George has been living in the residential aged care facility for the past six months. George is divorced and has three adult children. Whilst his two older children do not regularly visit him, his youngest son visits weekly. In the past three months, Gladys and George have formed a relationship. Although Gladys generally has trouble recognising people, she is easily able to recognise George and often seeks him out within the residential care home.

Note. The names and images in this case study are used in a fictional context, and are not intended to represent the real persons pictured.

Gladys

1 PREFERRED NAME AND PRONOUN: Gladys prefers to be addressed by her first name, Gladys, using the pronouns ‘she, hers, and her’. She believes it is very important to be addressed by her preferred name and pronoun.

2 GENDER IDENTITY: Gladys identifies her gender as female, and that her gender identity is not different from the sex she was assigned at birth. She believes it is somewhat important that her gender identity is acknowledged.

3 INTIMACY: Gladys defines intimacy as “a bit of romance”. She identifies intimacy as very important in her life. Gladys prefers or enjoys the following forms of intimate behaviour: touching, holding hands, talking/whispering, cuddling or hugging, and kissing (on the cheek, mouth, and hand).

4 SEXUALITY: When asked to how Gladys would define intimacy, she responded “I am not sure…I don’t really know”. She believes it is not very important to be able to express her sexuality in her life.

Gladys prefers or likes to express her sexuality through the following forms:

  • Appearance (i.e., clothing, makeup, hair)
  • Being in intimate casual and/or committed relationships with others

5 SEX: Gladys appeared uncomfortable when asked to define sex, and declined to provide an answer. Gladys identified engaging in sexual behaviour/activity in her life as not important at all.

6 SEXUAL ORIENTATION: Gladys identifies as heterosexual and believes that it is somewhat important for her sexual orientation to be acknowledged.

7 ROMANTIC AND/OR SEXUAL RELATIONSHIP: Gladys believes that it is somewhat important to be in a romantic and/or sexual relationship with someone. Gladys is currently in a romantic and/or sexual relationship with someone (George), who is currently living inside the nursing home.

Over the course of her life, Gladys has not been married more than once, but has been involved in a romantic and/or sexual relationship with more than one person.

Gladys believes that it is very important for her spouse/partner/significant other/special friend to feel comfortable visiting and spending intimate and private time with her in her place of residence.

Gladys believes that she and her spouse/partner/significant other/lover/special friend would like to be supported in having intimate and private time together by having a private room. Gladys also noted that she “would like to be left in peace when she is spending time with George”.

8 SAFE SEX: Gladys has not heard of the expression safe sex.

Gladys understands what a sexually transmitted infection means, knows how to protect herself (“getting him to wear protection”), and has not had a sexually transmitted infection in the past.

9 OTHERS: Gladys knows what the term consent means in the context of sexual expression with another person. Gladys defines consent as “saying yes”. She has not had any type of sexual encounter that was not mutually consensual.

10 SUPPORTING INTIMACY AND/OR SEXUAL NEEDS AND PREFERENCES: Gladys believes that intimacy and/or sexual needs and preferences should be supported in long term care. Gladys elaborates on this by saying “everyone should be allowed a bit of privacy”.

Gladys and George, another resident in the care home, are in a relationship. Although Gladys often forgets people who are known to her, she was able to recognise George and displayed warmth and affection towards him.

Gladys mentioned that her and George regularly eat their meals together, go for walks, and engage in leisure activities together. Gladys also acknowledged that her and George engage in intimate behaviours, such as kissing, cuddling, and holding hands. When enquired if she would consider sex with George, Gladys responded, “No…that’s not something we want to do…we’re far too old.”

During the visit to the care home, Gladys and George were observed to be completing a jigsaw puzzle together. There was nothing to suggest that either person did not enjoy the relationship, or that any non-consensual interactions had occurred.

RECOMMENDATIONS:

  • Presently, no action is required. There is no immediate concern with the romantic relationship between Gladys and George, which is characterised by them spending time together (i.e., eating meals together, talking walks together, and participating in leisure activities together). Whilst there is physical intimacy (e.g., kissing, cuddling, holding hands), there is no sign of ill-being in this relationship. Gladys displayed positive wellbeing where she smiled and displayed happiness when speaking about George.
  • A meeting may be required to discuss if and when Glady’s and George’s families need to be informed of their relationship. Points of consideration:
    • Possible opposition from Gladys and George’s families with regards to their relationship
    • Different levels of cognitive impairment in Gladys (moderate) and George (mild), although currently Gladys appears to be aware and understands her relationship with George, and appreciates the physical intimacy in their relationship.
  • Continuing observation in the coming weeks of Gladys and George’s relationship. In particular, be observant for any:
    • Signs of ill-being by either party in relation to their relationship
    • Increase in level of intimacy
    • Increase in cognitive impairment for either Gladys or George
    • There may be concerns over Gladys and George’s ability to understand and/or provide verbal consent/dissent and/or show behaviour assent/dissent to the relationship when there are changes to their cognitive awareness and level of intimacy, particularly if sexual intimacy becomes present

Note. Please refer to the Interviewer Observation and Reflection and Recommendations for George.

George

1 PREFERRED NAME AND PRONOUN: George prefers to be addressed by his first name, George, using the pronouns ‘he, him, his’. He believes it is somewhat important to be addressed by her preferred name and pronoun.

2 GENDER IDENTITY: George identifies his gender as male, and that his gender identity is not different from the sex he was assigned at birth. He believes it is very important that his gender identity is acknowledged

3 INTIMACY: George defines intimacy as “having a close friendship with a lady”. He identifies intimacy as somewhat important in his life. George prefers or enjoys the following forms of intimate behaviour: touching, holding hands, talking/whispering, cuddling or hugging, and kissing (on the cheek, mouth, and hand).

4 SEXUALITY: George defines sexuality as “showing that you’re looking for a close friendship with someone”. He believes it is somewhat important to be able to express his sexuality in his life.

George prefers or likes to express his sexuality through the following forms:

  • Appearance (i.e., clothing, makeup, hair)
  • Being in intimate casual and/or committed relationships with others (i.e., intimate touching, cuddling/hugging, kissing, flirting and/or romantic gestures)
  • Engaging in sexual behaviour/activity (i.e., with someone of the opposite sex and gender)

George noted that, in relation to maintaining his appearance, he prefers to “look like a man, and keep shaved and tidy”.

5 SEX: George defines sex as “the physical private act, but it’s not that important now since [Gladys] isn’t bothered about it”, and believes that it is not very important for him to engage in sexual behaviour/activity in his life.

George prefers or enjoys the following forms of sexual behaviour: penetrative sex with someone of the opposite sex.

George believes that “his partner” prevents him from being able to engage in sexual behaviour/activity that he enjoys. George further elaborates by saying that “Gladys doesn’t want to do it so I’m not that worried. I’m too old anyway.”

6 SEXUAL ORIENTATION: George identifies as heterosexual and believes that it is very important for his sexual orientation to be acknowledged.

7 ROMANTIC AND/OR SEXUAL RELATIONSHIP: George believes that it is very important to be in a romantic and/or sexual relationship with someone. George is currently in a romantic and/or sexual relationship with someone (Gladys), who is currently living inside the nursing home.

Over the course of his life, George has not been married more than once, but has been involved in a romantic and/or sexual relationship with more than one person. He is currently in a romantic and/or sexual relationship with someone [Gladys], who is currently living inside the nursing home.

George believes that it is very important for his spouse/partner/significant other/special friend to feel comfortable visiting and spending intimate and private time with him in his place of residence.

George believes that he and his spouse/partner/significant over/lover/special friend would like to be supported in having intimate and private time together by having: a private room, a lock on my room’s door.

8 SAFE SEX: George has not heard of the expression safe sex, however indicated “it probably means not having sex”.

George understands what a sexually transmitted infection means, knows how to protect himself (“a condom”), and has not had a sexually transmitted infection in the past.

9 OTHERS: George knows what the term consent means in the context of sexual expression with another person. George defines consent as “making sure the person you are with is keen”. He has not had any type of sexual encounter that was not mutually consensual.

10 SUPPORTING INTIMACY AND/OR SEXUAL NEEDS AND PREFERENCES: George believes that intimacy and/or sexual needs and preferences should be supported in long term care. George elaborates on this by saying “it’s not really any of my business what other people want to do”.

George appeared to be friendly and articulate. He spoke about his previous career as a firefighter and interest in woodwork. George also spoke about his family, and expressed sadness that his older son and daughter do not visit him often. He believes that his eldest son “cannot be bothered making the trip”, and that his daughter is “too busy with her own family”, however he spoke positively about his youngest son, and indicated that they were very close. He did not wish to speak about his marriage, however stated that he “doesn’t know what [his ex-wife] is doing now and doesn’t really care.”

George displayed affection towards Gladys, another resident within the care home, who he has formed a relationship with. George disclosed that he has become “much happier in the care home since meeting Gladys”. George expressed concern about older son and daughter finding out about his relationship, and stated that he “knows they won’t approve”. George has introduced his youngest son to Gladys on a visit to the care home, and is pleased that his son is friendly towards Gladys, and approves of the relationship.

When asked whether George desires to engage in sexually intimate behaviours with Gladys, George responded that he was not particularly concerned, as he did not think Gladys was interested. He elaborated on this by stating “I just like spending time with her”.

RECOMMENDATIONS:

  • Presently, no action required. There is no immediate concern with the romantic relationship between George and Gladys, which is characterised by them spending time together (i.e., eating meals together, talking walks together, and participating in leisure activities together). Whilst there is physical intimacy (e.g., kissing, cuddling, holding hands), there is no sign of ill-being in this relationship. Gladys displayed positive wellbeing where she smiled and displayed happiness when speaking about George.
  • A meeting may be required to discuss if and when George and Gladys’ families need to be informed of their relationship. Points of consideration:
    • George expressed that his older son and daughter may not approve of the relationship
    • Different levels of cognitive impairment in George (mild) and Gladys (moderate), although currently George appears to be aware and understands his relationship with Gladys, and appreciates the physical intimacy in their relationship.
  • Continuing observation in the coming weeks of George and Gladys’ relationship. In particular, be observant for any:
    • Signs of ill-being by either party in relation to their relationship
    • Increase in level of intimacy
    • Increase in cognitive impairment for either Gladys or George
  • There may be concerns over George and Gladys’ ability to understand and/or provide verbal consent/ dissent and/or show behaviour assent/dissent to the relationship when there are changes to their cognitive awareness and level of intimacy, particularly if sexual intimacy becomes present

Note. Please refer to the Interviewer Observation and Reflection and Recommendations for Gladys.