In certain cases, ensuring that there is in fact affirmative consent will require privacy tradeoffs in the context of institutional care. Further, Hillman provides a comprehensive set of questions to guide the functional capacity assessment portion of the clinical interview and illustrates the model with two case examples. To ensure that contemporaneous consent is voluntary, the individual must verbally or nonverbally express consent to sexual contact. To ensure that prospective consent is authentic, the sexual advance directive must be executed with the heightened level of formalities required of wills — a writing, signature, and attestation of two witnesses. The man then choked the woman, something which they had done before, and she passed out for approximately three minutes. They are often based on ethical decision-making see Everett, , legal expertise see Tang, or practical considerations for LTC settings see Doll, Other key considerations for the clinician include the level of risk of the proposed intimate relationship, the potential to mitigate risk, and ultimately if the relationship can be supported regardless of the determination of capacity i.
Unfortunately, this is not a hypothetical issue. Important areas of assessment include relevant medical, cognitive, social, and psychological history as well as the older adult's sexual values, considerations of potential risk, and the functional capacity assessment. As with other models, it is guided by the three major legal standards for sexual consent and suggests a team-based, clinical-interview approach that is supplemented through patient records, neuropsychological testing, and collateral information. An interdisciplinary team process is well established in nursing home settings, where the psychologist is likely to conduct sexual consent assessment. To ensure that prospective consent is authentic, the sexual advance directive must be executed with the heightened level of formalities required of wills — a writing, signature, and attestation of two witnesses. Further, Hillman provides a comprehensive set of questions to guide the functional capacity assessment portion of the clinical interview and illustrates the model with two case examples. This effort represents an initial step in the complex process of validating an adapted SCEA tool for use in sexual consent assessment with older adults. Psychologists working with LTC need to be aware and knowledgeable about sexual consent capacity in older adulthood to be prepared to conduct evaluations and participate in planning care. This allows the psychologist to provide relevant, practical recommendations for team members e. The law currently provides a tool for advance decision-making in the face of expected incapacity: There is a fourth criterion that is applied in nine states—appreciating the moral quality of the sexual activity in question. In other words, silence or inaction should not be taken to constitute consent, as it risks being the product of a cognitive or communicative impairment instead. She illustrates this with a hypothetical case and provides an ethical decision-making framework with additional questions addressing key areas of assessment to help guide team discussion. The team process is designed to be collaborative, with the psychologist consulting the team prior to the evaluation, presenting the evaluation results, and the team providing additional insights from multiple perspectives, including collateral information from the family. Tests assessing executive functioning skills planning, problem-solving, utilizing environmental information, goal-directed behavior, and impulse control memory, and instruction following were key in discerning true positives Beyond prevalence, studies have also attempted to identify ISB patterns. Objectivity is key when considering harm reduction and autonomy, and the psychologist should remain attentive to the potential influences of each while not favoring either. Finally, to protect the individual with cognitive impairments against harmful consequences of sexual activity, long-term care institutions that house said individual and agents acting under a sexual advance directive must comply with a duty of care, taking reasonable steps to shield the person with cognitive impairments from objective welfare threats stemming from the sexual activity. In a review of ISB, Tsatali and colleagues cited a study of patients with dementia showing that intimacy-seeking sexual behaviors e. To date, no empirical studies have been published that test these models on an older adult population, though they provide psychologists with much-needed guidance for addressing sexual consent. Research on sexual activity among couples in which one partner has dementia may provide additional insight into these sexual patterns. The first is awareness of the relationship, indicating the individual's choice and understanding of that choice. Adaptation of the SCEA items for an older adult population has potential to provide further guidance for the clinical interview process. Similar to Lichtenberg , the author suggests additional measures be taken to allow safe intimate expression when an older adult is found to be incapable of consent to sex by a formal evaluation i. Functional capacity assessment is embedded within a comprehensive clinical interview, cognitive assessment, records review, and interdisciplinary discussion that address limited capacity. These formalities provide courts with good evidence of prospective consent and protect individuals in memorializing their sexual wishes.
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