Texas developing sexuality guidelines.

The Texas Department of Human Services is drafting guidelines to help providers establish policies and determine when to report residents' sexual activity.

Its task force, including providers, consumer advocates, and health professionals, is defining sexual abuse, inappropriate behavior, and consensual sex, and will develop best practices ranging from least to most intrusive.

Facilities are required to have policies on abuse, neglect, and exploitation, and report occurrences to the state. Since the old system grouped all abuse, nobody knows how much sexual abuse occurred or was reported.

Providers say they're willing to comply, but it's unclear what they should stop, report, or permit, particularly when residents are cognitively impaired.

"We believe in strong regulations to protect residents," says Jim Lehrman, LMSW, AP, deputy commissioner for long term care regulations. "We also believe in fairness by providing clarity on our expectations."

The initiative is not a crackdown on intimacy. "Although sexual activity in nursing homes focused us on giving guidance, the impetus is abuse, not sexuality," says Lehrman. "Abuse and inappropriate sexual behavior must be stopped and reported immediately. Providers must deal with cognitively intact consensual intimacy by providing privacy and respecting dignity. You shouldn't have to give up any part of your humanity to go to a nursing home, but we do not want anyone victimized by inappropriate behaviors."

Some advocates question residents' ability to consent, particularly when partners aren't married.

"If a husband and wife are there, that's their prerogative," says Beth Ferris, co-founder of Texas Advocates for Nursing Home Reform. "Our main concern is residents who are not related. Residents with dementia can't make a choice."

The state expects the interdisciplinary professional team to assess cognitively impaired residents' ability to make decisions, and decide what activities they may engage in. When facilities don't do an evaluation and sexual behaviors occur, surveyors are forced to make their own assessments. "We're rule enforcers, but we end up making the decisions," says Lehrman.

When patients with dementia lose social and sexual inhibitions, facilities are caught between providing care with maximum freedom and protecting other residents from offensive and abusive behaviors. "Many facilities report anything and everything to avoid action," says Lehrman. "Others say their first choice is to discharge the resident, when it should be the very last choice. We don't want to see the system label residents as sex offenders."

Providers in other states should share problems and best practices, then present strategies to their representatives, Lehrman advises.