Can People with Alzheimer's Give Consent to Sexual Activity?

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Once upon a time, a couple fell in love and married each other. Several years later, one of them developed Alzheimer's disease. Here's the question that followed, became a matter of great debate and made national news:

Can a spouse with dementia give consent for sexual activity?

In this particular instance, the couple- Henry and Donna Rayhons- lived in Iowa and were married in 2007 after meeting later in life.

Henry Rayhons, age 78, was accused of sexually abusing his wife on May 34, 2014, in the nursing home where she resided due to her dementia.

Rayhons contended that he did not have intercourse with his wife on that particular night but stated that they had kissed and touched each other. He also reported that she initiated sexual interaction from time to time. The nursing home where his wife resided, however, felt that she could not consent to sexual activity and reported the issue to the police after hearing that sexual activity had occurred between the two.

After testimonies and deliberation, the jury found Rayhons not guilty.

The Challenge of Determining Consent

Can someone with dementia understand the decision they're making and the potential consequences? Clearly, the answer is not an easy yes or no.

The goal in asking, and attempting to answer, the question of ability to consent is two-fold:

1) Prevent the sexual abuse of a vulnerable person who may be unable to report it.

Due to the memory problems and communication difficulties that can develop in dementia, it is imperative to guard against the potential victimization of someone who is involved in sexual activity against their will. Older adults, and especially those who have cognitive problems, are an easy target for abuse of all kinds, including sexual.

2) Protect the rights of a vulnerable person to engage in mutual, consensual sexual activity that promotes quality of life.

Dementia care has come a long way in acknowledging that simply because Alzheimer's disease (or a different type of dementia) is present, the desire for intimacy is not automatically removed.

Instead, research has identified the many benefits of touch for people with dementia, and dementia professionals have emphasized the importance of person-centered care in dementia. Some nursing homes and assisted living facilities have written policies on recognizing the physical, emotional, mental, spiritual and sexual needs of those in their care.    

What Factors Should Be Considered in the Question of Consent?

If two people- one, or both, of whom have dementia- indicate interest in pursuing a sexual relationship with each other, what questions should be asked? While there's not a comprehensive list that has been agreed upon by experts, here are questions that may help in this decision:

1) Do they consistently recognize each other? Do they know the name or room location of each other? Does one person mistakenly think the partner is her spouse when he's not?

2) Do they seek each other out?

3) What do their verbal and non-verbal communications say? When asked, does each person express a desire to spend time with each other? When you observe them interact, are both engaged with each other and appear happy? Can they answer questions about their relationship and indicate a desire for physical intimacy?

4) Does either person display any signs of distress, such as emotional withdrawal, fear, tearfulness, decrease in appetite or physical recoiling from touch?

5) Are both people able to say "No" (verbally or non-verbally) to unwanted sexual contact? Can each person indicate "how far" they wish to proceed with sexual interaction? For example, is one person content with kissing and touching, and the other attempting to progress to more intimate activities?

6) To what extent are those involved susceptible to exploitation?

6) Does the relationship appear to improve the quality of life for both people?

Complicating Factors

  • Inability to Participate in Medical Decisions

What if one or both individuals have been determined to be unable to participate in medical decisions, thus activating the power of attorney? Does that automatically make them unable to consent to sexual activity?

Based on my clinical observation and that of others as well, a person might be unable to completely understand the complexities of a medical decision but yet clearly and consistently be able to indicate that they wish to be in a relationship with each other.

  • Family, Guardian and Healthcare Power of Attorney

What if family members, a court-appointed guardian or a healthcare power of attorney are against the relationship?

It's not uncommon for family members to have significant and understandable concerns about their loved one's physical safety and ability, the potential for exploitation, embarrassment that their parent is interested in a sexual relationship, faith-based concerns about their parent's behavior and a desire to protect the dignity of their loved one. 

Some policy writers and researchers advocate for the complete protection of the right to a relationship in dementia and thus feel it's a privacy breech to inform families.

Others stress that since the facility is responsible for the care of those potentially involved in the relationship, the responsible parties should be informed of the situation in order to maintain open communication about its development, especially if it's a newer relationship.

The Hebrew Home at Riverdale policy (a facility that has led the way in discussing this issue) suggests educating family members about the needs of the resident and advocating for the resident to maintain quality of life, potentially through a sexual relationship, in addition to other avenues.

For facilities, the risk in this situation is that family members who are concerned may file a lawsuit or a complaint with the department in the state that oversees compliance in nursing homes if they disagree with how the facility handles the relationship. Rather than seeing the relationship as a choice that improves quality of life, they may feel the facility failed to protect a vulnerable resident by limiting interaction or preventing a relationship from occurring.

  • New Relationship vs. Established

The case earlier referenced is one of a reportedly happily married couple, making it an established relationship that both people willingly entered into and remained. In my opinion, the establishment of the relationship prior to the presence of dementia makes the decision a little easier-- not because abuse can't occur within a marriage (or established relationship), but because her decision to be in a sexual relationship was made while her cognitive ability was not in doubt.

When new relationships are developed after dementia is present, the question of, "Would they be doing this if they didn't have dementia?" is often asked. Or, "She wouldn't have pursued an intimate relationship before her memory loss. She'd be so embarrassed."

If it's a new relationship, should the person's past decisions and preferences be taken into account? While some experts suggest that a person's past preferences and beliefs should impact today's decisions, others advocate for evaluating the person in light of identifying what their current choices,  preferences and needs are, and what contributes to their present well-being.

  • Interpretation of Regulatory Compliance by State or Federal Surveyors

One of the difficulties in responding to these relationships if they take place in a nursing home is that of how the surveyors (those who are in charge of monitoring compliance with healthcare regulations) will interpret the situation.

Due to the subjective nature of the survey process, two different surveyors can reach two very different conclusions about the same situation, each thinking she is doing the right thing in protecting the residents and honoring their rights to choose.

One surveyor may conclude that the facility failed to protect the resident from sexual activity based on the lack of proof that the resident can consent, thus concluding the resident was sexually abused. Another surveyor may conclude that the facility failed to protect the resident's right to choose and to enjoy quality of life through maintaining a meaningful, intimate relationship. Facilities are often placed in a guessing game of how the surveyors might interpret a situation.

Some suggest that the right to engage in a sexual relationship should be maintained unless evidence is present to suggest it is non-consensual. Others maintain that those involved need to prove that they are specifically consenting to the relationship.

The Take Away?

This dilemma highlights the need for nursing homes and other care facilities to write well-researched, articulate and resident-driven policies about relationships between persons where one, or both, have dementia. These policies can then guide facilities in their decisions and provide insight for surveyors to understand the rationale for decisions as they review these situations.

It's more than policies, however. Having an open-door approach for communication with family members is also critical in processing each resident's changing needs and the challenging dilemmas that develop, such as consent for intimate relationships.

Most importantly, facilities need to know their residents- including their cognitive functioning and what activities specifically enhance their quality of life- so that when these situations arise (and they will), each decision is intentionally focused on the individual and is clearly based on his or her best interest.


This article should not be misconstrued as consisting of legal advice. See an attorney who specializes in this area for legal advice.


Alzheimer's Society. Sex and Dementia. Accessed April 26, 2015.

Annals of Long Term Care. Volume 12 - Issue 9 - September, 2004. Sexuality in Long-Term Care: Ethics and Action.

Bioethics Forum. Sex, Consent and Dementia. April 15, 2015.

The Hebrew Home at Riverdale. April 2013. Policies and procedures concerning sexual expression at the Hebrew Home at Riverdale.

New York Times. April 22, 2015. Iowa Man Found Not Guilty of Sexually Abusing His Wife with Alzheimer's.

The International Longevity Centre. 2011. The Last Taboo: A guide to dementia, sexuality, intimacy and sexual behaviour in care homes.

Sexuality and Disability. March 2007, Volume 25, Issue 1, pp 3-20. Assessment of Sexual Consent Capacity.

The Weinberg Center and The Hebrew Home at Riverdale. 2011. Abuse or Intimacy. Older Adult Sexualtiy.

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