Senior moments Love me tender ... John Bradshaw with his wife Joan, who has dementia. The elderly don't have sex? Carers in nursing homes are seeing otherwise and often butting heads with families and the law over how to deal with it. He's asleep now, curled to one side in bed, his lower half covered with a blanket. Lying there with the television on and the door to his nursing home room open, he is the picture of an aged man, grey hair and eyes closed in the early afternoon. He has put away his blow-up sex doll. Time was, before his dementia advanced, they would be together in his room all day with the door closed. Away, too, is the pornography he owned before leaving his home for full-time aged care. Hard though it is to conceive of this elderly man as a sexual being, as he lies there snoring, he has enjoyed the kindness of strangers over many years, and continues to do so. Lately, a sex worker has visited his nursing home in south-west Sydney, to sit with him, talk and touch his hair and more. His carers say he has been calmer since the visits and less sexually suggestive to staff. "It's part of his care, like showering him or giving him something to eat or making sure he is warm," says one. Sweet memories ... "The staff gave us privacy and we spooned, more or less." Wilma Traas treasures the photo of herself with her husband John as young lovers. Here, where many might expect days are filled with soup and sleep and no sex, please, I spy by the reception desk a story in The Senior newspaper, headlined: "Boomers' Hep C timebomb." Sex and sexuality do not stop at the front sliding doors, no matter the age of the occupants. Two residents here have recently started a relationship with each other, kissing and spending time in each other's room. At last year's Christmas party she sat on his lap, running her hands through his thinning hair. Other residents opt for the professional touch. Senior staff have helped organise sex workers for two men with dementia in recent months, in consultation with their families. "This is going to become more common, but it's a taboo subject," says the home's executive care manager, Be Valenzuela. One of my staff said to me, 'People shouldn't be having sex over 40, they should all be neutered.' This is the general perception of what sex should be - it should be for the young. There's the "ick factor," of course: that distaste at the thought of your parents or grandparents having sex. Ageing is seen as a time of decline, impotence and isolation. On the face of it, nursing homes are about as unsexy as life gets. Walking frames are parked in front of enormous television screens. Residents snooze in armchairs by the front door. The expression of sexuality changes with age, says Sydney sexologist Patricia Weerakoon. Our body functions slow down and sexuality slows down with it - from the penis-in-vagina-orgasm-fireworks experience to quiet intimacy. We reach a time in our life when sitting side by side and holding hands may be the ultimate in sexual intimacy. People are sexual beings their whole lives, she says. We call it womb-to-tomb sexuality. Yet about a quarter of Australians aged 18-24 believe older people don't have sexual relationships. Even the meaning of "old age" is skewed: younger respondents reckon you're old at 56; for older people it is 67. "As a society broadly we don't think of old people as sexual," says La Trobe University sexual health researcher Catherine Barrett. Greeting cards will laugh at it, with pictures of older women with their breasts hanging on the ground. We have for a long time not considered old people as sexual, so [aged care] service providers have just been a microcosm of the broader society. Silence and neglect of such issues has contributed to sexual assault in some homes, Barrett says, as well as surprisingly high levels of sexually transmitted infections among old people. But change is coming. Nursing homes say residents are increasingly engaging in sexual behaviour, aided, in some cases, by drugs such as Viagra. Australia's ageing population is turning society's focus towards the needs and desires of the elderly. There are more than 220,000 people in aged care, according to the Department of Health and Ageing, and demand is expected to treble by 2056. The gradual progression of "free loving" baby boomers into aged care will shake things up further, says Weerakoon, 67. Our generation is going to demand that we be given the opportunities to remain sexually intimate, if not sexually active, into old age. Nursing homes would be wise to sit up and notice, because we are a generation used to getting what we want. "If I still have a libido at that stage I would like to be cared for," says Anita Pitt-Owen, 56. We meet at a cafe in Bondi Junction to discuss why she booked a sex worker for her 93-year-old father, Andrew, who was a resident at the south-west Sydney nursing home. "My brother and I knew sex was important to him," she says. He was very proud of his achievements in that area. When I was emptying his desk at home, I found a draft of a book he had written titled What Pleases Women. Andrew, who had dementia, lived at the home from August 2012 until his death in March. One day he asked Pitt-Owen, who is a disability care support worker, "to find me a woman." After much discussion with her dad and his care manager, Pitt-Owen went online and found the organisation Touching Base, which provides sex workers for the disabled and elderly. Nursing home care manager Barbara Whittall helped arrange two visits for Andrew before he died. He was ecstatic, just glowing. The smile on his face was priceless," she recalls. Pitt-Owen says her father was happier and more settled afterwards. I don't want people viewing it as a quick, callous decision or that he is a dirty old man. It wasn't like he was sitting there saying, 'I want sex, I want sex, I want sex.' He wanted someone to hold and touch him," she says. He has lost everything else, does he need to lose that as well? Later, I speak to his sex worker, Emma, whose clients have included four men in aged care facilities in the past six months. Not everybody has intercourse. Some can't sustain erections so I will accommodate that," she says. With some people it's really going to be a whole lot of hugging and human warmth, body-to-body, and not much more than that. Indeed, many men I speak to in aged care can no longer sustain an erection. Some residents have simply lost interest. In a La Trobe University survey of aged care residents in Victoria and Queensland, respondents highlighted that sexuality and intimacy continued to matter to them, whether intercourse or something less strenuous: hugging, touching, companionship or simply looking their best. But they felt care staff had little or no understanding of their needs. Some staff didn't knock before entering their room. The layout of the nursing homes didn't help, with residents sleeping in single beds in shared rooms. The Parramatta Nursing home, in western Sydney, has 152 residents but only 12 single rooms. Nursing director Rodney Carroll tells me about a 43-year-old resident with a traumatic brain injury and his own collection of pornographic movies. Staff help him to be able to watch the movies in private by arranging outdoor activities for his roommate, Carroll says. I probably have quite a few residents who masturbate so we make sure the curtains are drawn. It is not something we say they can't do, just not in a public area," he says. He encourages staff to sit with residents, hug them or hold their hand. Personal touch - removed from the daily care regime of washing, and dressing - can often reduce problematic behaviours such as masturbating in public, he says. The touch they typically get is very clinical. One street over from the nursing home, I meet Wilma Traas to talk about her husband John, a retired teacher who was in care there from 2001 until his death in 2004. Over tea and biscuits on her riverside balcony, Traas says they were married in 1950 after a three-year engagement, during which they abstained from sex. Now I think, what a bloody waste of time that was," she says, laughing. She visited John at the nursing home every day until his death. They often sat in the garden and held hands. Sometimes she lay next to him in his single bed in his shared room, with their clothes on, the curtains drawn and classical music on the radio. "I think it meant a lot to him, someone to hug him and kiss him," she says. The staff gave us privacy and we spooned, more or less. It meant that he was still mine. When the Alzheimer's took hold we couldn't have intercourse, really. But you get to the stage where you just want to be together and sex doesn't matter anymore that much. She shows me their old photographs in an album: one that John took of their wedding night hotel and their big bed in Holland; and, later, of John on stage in an amateur production of My Fair Lady. He was a dashing man with thick black hair, a goatee and glasses. When I leave, Traas hands me a bag of homemade cookies for my young children. As you get older you just cuddle more, I suppose. Touch is still important, maybe even more important," she says, holding my arm and kissing me on the cheek. More than half of those in aged care facilities have dementia. Some suffer from frontal lobe dementia, which can affect the part of the brain that stops people from acting on sexual urges. Sometimes they can't tell the difference between their spouse, a care worker or another resident. Paula Trood, general manager of residential services for Benetas, which has 13 aged care homes in Victoria, says family members need to be involved in cases where residents start new relationships or engage in sexual behaviour. "If that person would not have behaved that way before the onset of dementia, we would try to protect them and talk to their family and doctor about medication, perhaps," she says. If we have identified that they can't really make an informed decision, then we would look at alternatives to try to channel their energies. As a last resort, there are medications, for men in particular, that dampen arousal. Rodney Carroll says he sometimes reminds residents who form new relationships that they already have a partner outside the nursing home. "I have had to approach families where an elderly lady has hooked on to an elderly man and we caught them in a room together," he says. A lot of families are quite happy their father or mother has found someone they like. Some partners respond quite angrily and don't visit for a while. Others understand they are separated from them and they still have that drive. Dr Chris Hatherly, national research manager for Alzheimer's Australia, argues that in most cases people with dementia can consent to sexual activity, without the intervention of family members. Where people are engaging in sexual activity in a mutually consenting way, probably it's not such a serious issue. It can be treated in the same way as any other issue in residential care, such as choices as to what to eat that day, what clothes to wear or what channel to watch on TV. I visit a new dementia facility run by HammondCare at Miranda, in Sydney's south. It's nicer than the hospital ward-like older homes I have been to. Each cottage is laid out like someone's home, with a large kitchen and living area by the front door and private en suite rooms off to each side. Residents sleep in king-size single beds and have their own glass-encased memory box outside their room; a reminder of where and who they are. "I don't see [sex] as a big issue unless somebody is being manipulated or abused or hurt in some way," says general manager Angela Raguz. Families don't always see it that way. They see that Mum in her young age would never have held hands with someone like that, so you need to do whatever you can to stop that. Sometimes families will move their mother. The compulsory reporting guidelines for aged care providers consider consent only in terms of the worst-case scenario. Providers are exempt from having to report alleged assaults by residents with cognitive impairment. People with dementia are vulnerable to exploitation and abuse. There were 344 reports of "alleged or suspected unlawful sexual contact" in residential aged care in 2011-12. In May, La Trobe University started studying the factors that make older women vulnerable to sexual assault as part of Norma's Project, named in honour of an 84-year old woman with early dementia who was sexually assaulted by a staff member while in respite care. Some older women who report sexual assault are not believed because they have dementia, says Catherine Barrett. The silence surrounding older people and sex makes it harder for victims, she says. People don't know how to respond or how to prevent sexual assault because there isn't even a conversation about it. "A lot of service providers we have spoken to say sexual assault wouldn't happen because older people aren't sexual," she says. In many cases, nursing homes are not sure where to set boundaries around sexual behaviour or how staff should respond. Some providers will separate residents. But Dr Michael Bauer, from La Trobe's Australian Centre For Evidence Based Aged Care, says a person's capacity to consent to sexual behaviour should be assumed unless proven otherwise. People with dementia regularly make decisions about aspects of their daily lives, such as their clothing or meals. Consent to sexual behaviour should be determined similarly, he says. If someone is given medication and doesn't want to swallow it, they will spit it out or try to push your hand away. Or they will show it in their facial expression. I think those kinds of indications could be applied to whether someone wants to be in the company of someone else. Happiness should be one of the guiding principles when assessing sexual expression, whether by a person or mutually consenting couple, he says. The question is: are staff the moral guardians in aged care facilities or are they there to look after older people and do what is in their best interests? Only one in five nursing homes has a policy relating to sexual health or sexuality. Most cases are dealt with in an ad hoc manner. Gay and lesbian residents have spoken about having to "go back into the closet" when they move into aged care. The Federal Parliament, in June, passed legislation to outlaw discrimination against gays and lesbians by faith-based aged care providers. But sexual stigma continues beyond the front door - some same-sex partners say they are not always consulted about care decisions concerning their loved one, even when they have power of guardianship. Protection can descend into paternalism. UnitingCare insists on having a media officer present while I interview two residents at its facility in Leichhardt, in Sydney's inner-west. At the end of the interview the media officer stops one of the residents from willingly giving me her phone number for later reference. Later, he tells me she is "not 100 per cent" and that she is "frail and nervous" despite her showing little sign of either. My attempt to visit the Garden Suburb nursing home in Newcastle, with the consent of the facility manager, is similarly thwarted by head office on "duty of care" grounds. I settle for speaking by phone to John Bradshaw, whose wife Joan is a resident. "Your world is turned upside down in your old age," he says. He visits his wife, who has dementia, each morning, holding her hands and bringing her sweets. He asks her: "Who am I?" "The lolly man," she replies. "She knows I'm there because she squeezes my hand every now and then," he tells me. I could think of nothing nicer than to be able to lie with her and just put my hands around her, but it's bloody hard in a single bed. Some nights, alone at home, he dreams that she has gone missing and he can't find her. Other nights, he has erotic dreams. "I couldn't get it up anyways, but sometimes I do think about it," he says. I was like a bloody rabbit when we were younger. Many aged care facilities fear legal action from families or the removal of the resident if they allow sexual expression. "In general we manage it fairly poorly and don't advocate for people's right to maintain their sexual identity," admits Paula Trood. One of the biggest barriers has been family acceptance - children don't like to think of their parents being sexually active. Psychologist Julie Bajic, who has clients in 23 aged care facilities in Sydney, says the denial of sexual expression can cause symptoms of depression and anxiety. A year ago, one nursing home asked her to counsel a resident who was found repeatedly masturbating in his room. Instead, Bajic counselled staff to knock on his door before entering. The focus is so much on illness. Everything is clinicalised and all behaviours are documented as being challenging," she says. I visit her client Simon at the nursing home where he lives in Sydney's north. His wife lives in the same facility, but recently moved to a single room on the ground floor because of her reduced mobility. "It used to be five paces from my door to her door, now it's 132," says Simon. There is a soft knock and the door is opened by a female staff member who takes his dinner order (a tomato sandwich, no cheese). Do they always knock? They used to just walk in. I would be sitting on the toilet and they would walk in and have a discussion with me. I abuse them and they don't do it again. He takes me on a tour, past the empty "entertainment room" to see his wife, who is sitting on her bed doing a crossword. Beside her television is a rough patch of bare wall she reckons won't be repainted until she dies, or is moved into the dementia ward. Later, I tell Simon that I find it hard to imagine sex in such a place. "I suppose if a couple wanted to get up to high jinks here they could lock the door and put a chair under the doorknob, because the staff have all got pass keys," he says. But more than the sex, it's the loss of intimacy he mourns. He gestures to his single bed by the wall in his narrow bedroom. You certainly miss being half awake, rolling over, putting your arm around your wife and going back to sleep again.