Sexual predators

Media representations of men with dementia portray them as violent sexual predators whose sexuality is excessive and constitutes a threat to public safety. These representations produce an image of the person with dementia 'in the guise of the human, to show how the less than human disguises itself, and threatens to deceive those of us who might think to recognize another human there' (Butler 2006, 146). Often, it is their disability, as signified by a diagnosis of dementia that is highlighted as a mark of their sexual deviancy within news articles. Although in some cases the crime has occurred many years prior to the diagnosis of dementia, articles often explicitly link the sexual crime to dementia by citing it in the headlines and opening paragraphs of the articles. This is evident in the headline of an article about the 2014 arrest of an U.S. man for committing molestation in 1977: 'Judge dismisses child sex abuse charge against priest, citing his dementia' (Funk 2014). Another example is the 2015 article about the arrest of U.K. man: 'Serial abuser who carried out more than 200 sexual attacks on boy avoids jail because of his DEMENTIA' (Dubuis and Wright 2015; original emphasis).

The justification for media attention to the sexualities of persons with advanced dementia is often not the sexual crime itself, but rather in response to the judicial decision not to criminally charge a person with dementia, or barring them from standing trial due to their mental incapacity or physical frailty. By implying that these judicial decisions are inappropriate, and that persons with dementia maliciously use their diagnosis to avoid criminal sanctions, such representations mobilize public outrage and disgust towards persons with dementia. For example, in the U.S. article, the victim's lawyer stated that the perpetrator is 'allegedly incompetent' questioned why he wasn't tried for four years after his arrest and 'before dementia ever became an issue.' Similarly, the 2015 article from the U.K. describes the accused living with dementia as a 'child rapist' who 'avoided a lengthy jail sentence because of his age and poor health' and that this means that 'the most that can be imposed' is psychiatric institutionalization, or conditional or unconditional release (Dubuis and Wright 2015; emphasis my own). The emphasis placed on suggesting that a diagnosis of dementia enabled individuals to evade criminal liability for actions that happened prior to their diagnosis makes it unlikely that dementia was used to generate public sympathy, rather than disgust.

Moreover, many articles actively suppress public sympathy for the person with dementia by moralizing the issue using a melodramatic narrative (Wright 2015) that incites fear and panic in audiences; emphasis in particular is placed on the 'evilness' of the person through representations of their duplicity and the innocence and suffering of their sexual victims. For example, the photograph of the man with dementia from the U.K. article cited above is subtitled: 'An 86-year-old man who repeatedly raped a young schoolboy over a seven-year period has avoided a jail sentence because he has dementia' and reports that after the assault the man would take the schoolboy out for ice cream as 'a treat.' The same article also reports that the 'ordeal' of the 'young victim' lasted seven years and suggest that the man with dementia gained access to his victim by tricking the victim's mother ('turn[ing up at] the youngster's house to offer his mother a break by taking her son out to the park or arcade'). Similarly, another article reporting on the release of a U.K. man convicted of raping his two daughters titled 'Sisters raped by paedophile dad warn of "dementia defence" loophole in echo of Lord Janner case' stated that the they 'wept after a judge freed him because he has dementia' (Macaskill and Rawlins 2015). The article goes to report that the abuse started in 1962 when they were toddlers and lasted for twenty years, but that while he was found guilty, he was deemed unfit to stand criminal trial and released into a care home. The two sisters are quoted as saying that his release is 'devastating' and 'an insult to the abused who are made victims a second time,' and warn that 'other attackers could use the same legal loophole as their dad' to 'escape' criminal punishment and 'walk free.' Through such representations of sexuality dementia becomes associated in the popular imagination with a tendency towards horrific violence and criminality, adding to the broader cultural stereotypes of persons with mental illness as violent and dangerous (Wahl 2003).

Even articles that focus on assentual sex in residential long-term care settings (e.g. nursing homes) tend to use sensationalist and stigmatizing language in their headlines and the bodies of the articles. Although such articles purport to broaden the dominant narrative by seeking to represent sexuality with more complexity, they ultimately efface the very conditions that would make such broadening possible by invoking 'the language of fear'. For example, articles use war metaphors (e.g. bomb) and apocalyptic warnings about the rising number of persons with dementia, or their unruly sexualities. One article that reported that the sexualities of persons with dementia raise 'legal, ethical and moral' issues has a headline that implies that such sexualities are a 'rape case time-bomb' for nursing homes who face legal fines and criminal sanctions in the future (Nye 2013). This article describes the case of Windmill Manor, a nursing home where two residents with dementia developed a sexual relationship. Although the couple were forcibly separated and restrained based on the desires of their families and the nursing home's fear of criminal liability, the nursing home still incurred civil and criminal penalties (Nye 2013). The article notes that the relationship was 'mutual' and that the woman 'tried to attack the staff' when they interrupted their sexual encounter. However, it does not report on the consequences of the intervention by staff into this relationship which began with the staff 'keeping them away from each other' and attempting to 'soothe' the woman with Oreo cookies, and medicating the man ('prescribing drugs to curb the man's sexual urges'). Instead, the article focuses on the monetary and occupational consequences of this sexual relationship for the nursing home and staff ('horrific case', 'a legal time-bomb', 'fired with no reason given') and for the suffering of the couple's families ('heart-break'). Similarly, an article in the health section reports that 'better training is needed for dementia carers to deal with issues around relationships, intimacy, and sex' also includes a warning about of the 'dangers' of such sexualities (Better sex-and-dementia care call, 2014; emphasis my own). The article begins by describing how staff members at one home found it 'very difficult to manage' after two residents with dementia developed a relationship and cuddled and hand-held because they felt that this was 'wrong' and because one of the spouses was 'very distressed' by this. This is despite the fact that the article goes on to report that a senior staff member said that the home supports such intimacies stating that in general sexuality is 'not a problem to us'. However, there is a proviso: a geriatric psychiatrist in this article also warns that some sexual behaviours may not be so 'benign' as persons with dementia may become aggressive, and that such aggression can 'show itself in terms of sexual behaviour.'

Media representations that instil fear and disgust in relation to the sexualities of persons with dementia reflect biomedical discourses on sexuality that operate across empirical research on persons with dementia, professional care, and clinical literature. For example, empirical research on provider's reactions and perceptions has shown that they tend to respond to the sexualities of persons with dementia with expressions of disgust, denial, and discouragement (Ward et al. 2005; Roach 2004; Syme 2014; Cornelison and Doll 2013). This is most apparent in the context of institutional settings where the sexuality of persons with dementia becomes a matter of public concern due to the congregate nature of the living environment and the lack of privacy accorded to residents of institutions (Benbow and Beeston 2012; Taylor and Gosney 2011). Care providers have also been shown to hold negative and patronizing attitudes toward the sexualities of persons with dementia, and the sexualities of men in particular are perceived as threatening to both providers and other residents (Ward et al. 2005; Parker 2007; Roach 2004; Yelland and Hosier 2015). When confronted with overt sexual desires or erotic activity, providers report feeling shame and discomfort, as well as the need to intervene in the sexual expression (Roach 2004; Shuttleworth et al. 2010; Villar, Fabà, et al. 2015).

The sexualities of persons with dementia have also recently emerged as an object of surveillance within the psychiatric clinical literature. Through the establishment of pre-diagnostic categories such as 'improper' or 'inappropriate sexual behaviour' (ISB), the sexualities of persons with dementia have become constructed as mental pathologies and thus subject to medical assessment and intervention (Mendez and Shapira 2013; Guay 2008; Stubbs 2011; Cipriani et al. 2016). The pathologization of sexual expression in the context of dementia is part of a broader history of medicalization of sexuality that legitimates the authority of psychiatry over the treatment of mental illness through diagnostic categories that establish 'sex as a cause, symptom and form of madness, particularly when sexualities contested heteronormative and patriarchal discourses' (Tosh 2011, 3). There are multiple problems with the discourse of ISB, including the lack of consensus on terminology or classification criteria, as well as the lack of a universally accepted definition of what makes such sexualities 'inappropriate' or 'harmful' and thus necessary to curtail (Gibson et al. 1999; Tsatali et al. 2011). Definitions of 'inappropriateness' are both expansive and circular, and cited examples can include everything from handholding to physical assault, the use of pornography, masturbation, sexual interest in someone other than one's spouse, or a 'change' in sexual preference (Cipriani et al. 2016; Guay 2008; Black, Muralee, and Tampi 2005). Take the following description of ISB from a literature review (Mahieu, Van Elssen, and Gastmans 2011): [D]ementia might be accompanied by uninhibited sexual behaviour or hypersexuality. Such behaviour is beyond the person's control… and mostly arises due to dementia. It may include touching intimate body parts of care providers and bystanders, kissing and hugging that exceeds plain affection, disrobing oneself and others, using sexually suggestive language, attempting intercourse, and compulsive masturbation in both public and personal areas (Mahieu, Van Elssen, and Gastmans 2011, 2; emphasis my own). As can be seen from this expansive description, the sexualities of persons with dementia are considered 'inappropriate' because they are thought to be 'beyond their control' or 'unintentional,' that is, not the result of agentic desires but rather symptoms of dementia-related neurodegeneration that causes disinhibition. Definitions of ISB in dementia further emphasize lack of sexual agency by describing the sexualities of persons with dementia as 'repetitive,' as 'inconsistent' with the person's personality and/or their life-history pre-diagnosis (Cipriani et al. 2016; Torrisi et al. 2017; Kaplan and Krueger 2010). However, exactly what is 'appropriate' or 'normal' sexuality is left undefined within descriptions of ISB. As a result, it is not the sexual activity per se that is inappropriate, but rather how it is perceived by the individuals who observe it. The reliance on subjective values and judgement in diagnoses of ISB is problematic given the dominance of ageism and ableism, and empirical research that suggests that determinations of appropriate sexuality in the context of dementia by observers reflect and perpetuate ageist and heteronormative gender norms (Archibald 1998; Ward et al. 2005; Simpson et al. 2017).

Finally, the diagnosis of some variants of ISB (e.g. hypersexuality) often includes the criterion that the sexual behaviour is inappropriate because it causes personal distress or another form of 'impairment' to the person (Mendez and Shapira 2013). And yet, in the context of dementia, sexual behaviour may also be judged to be inappropriate because it is perceived to be accompanied by a lack of 'concern,' 'shame' or awareness about the public 'consequences of the behaviour,' including the social prohibition against public displays of sexuality. Such sexualities are thus primarily judged inappropriate and undesirable because they are distressing for informal caregivers and staff, rather than to the individual with dementia (Black, Muralee, and Tampi 2005; Mendez and Shapira 2013). Thus, the sexualities of persons with dementia are restricted primarily because they are perceived as socially disruptive or because they 'interfere' with the work of care providers (Black, Muralee, and Tampi 2005; Mendez and Shapira 2013). This is often articulated explicitly in professional literature on ISB that recommends treating (e.g. suppressing) sexual expressions for the purpose of decreasing caregiver burden and/or delaying or preventing nursing home placement (Cipriani et al. 2016; Tucker 2010). In this way the diagnosis of ISB 'domesticates' the distress caused by such sexualities by recasting them as an internal and personal problems of persons with dementia, rather than the result of broader sexual norms and organization of care (Butler 2004, 99). This broader biomedical discourse of pathology underpins the dominant practice of representing the sexualities of persons with dementia in the media as mental pathologies that are burdensome to individuals and society. These types of representations invite public terror and disgust by implicitly and explicitly positioning persons with dementia as the cause of public 'grief.' Through such negative representations biomedical intervention to restrict these sexualities become 'sustained as an ongoing object of [public] survival' (Ahmed 2004, 79).

Asexual victims of violence

Unlike men with dementia, women with dementia are constructed in the media as having no sexuality (asexual) and as vulnerable victims to men's sexual desires. The most common examples of this are news articles that report on criminal sexual assault charges filed against a long-term care resident or a staff member (Trotter 2016; Ellis and Hicken 2017). More recently, news articles have also featured husbands accused of sexual misconduct, or barred from engaging in sexual activities with their wives who are living with dementia. For example, there is the now infamous case of Henry Rayhons, who was charged and acquitted in 2015 of sexually assaulting his wife Donna Lou (Allen 2015), and the case of Thomas Middleton from the U.K. who has a protection order that restricts his sexual interactions with his wife who lives in a long-term care home (Lindsay 2015). The focus of these types of articles is often on describing the fundamental vulnerability of the woman with dementia to sexual victimization, who is often described as 'suffering' from dementia. Regardless of the individuals involved, all articles reflect the assumption that women with dementia are inherently asexual or are not interested in sex by virtue of their diagnosis, cognitive capacity, functional dependence, or advanced age. For example, an article about the trial of Henry Rayhons reported that "Dr. John Brady, medical director of the nursing home, told the jury that if [Donna Rayhons] responded positively to hugs and affection from her husband, it was a 'primal response' and not an 'informed decision' (Allen 2015). Such articles also portray men's desire towards women with dementia as morally suspect or as reflective of criminal sexual intent. For example, the headline of an article about a sexual interaction involving a resident and a friend who was a frequent visitor described the visitor as an '82-yer old sex beast' and a 'pervert' who 'attacked' the resident (Clements 2016). Headlines of other articles about the Henry Rayhons case have similarly included the following: 'Was Henry Rayhons a loving husband or selfish abuser?' (Leys 2015); 'Can a wife with dementia say yes to sex?' (Gruley 2014); 'Rape case asks if a wife with dementia can consent' (Gruley 2014); 'Should Alzheimer's Patients Be Allowed to Have Sex?' (Syngal 2015). All of these articles implicitly or explicitly suggest that without legal control over their own care, persons with dementia are incapable of assentual sexual expression as this is 'a decision that requires two fully consenting partners' (Should Alzheimer's Patients Be Allowed to Have Sex?').

News articles reporting on sexual victimization of women with dementia emphasize their vulnerability, characterizing them as children or as dependent on others, and thus especially susceptible to sexual exploitation. For example, one article about the Rayhons' trial stated that a physician likened Donna Rayhons' response towards her husband as 'the instinctive response of a baby to affection shown by a mother' (Volokh 2015). Other articles on the Rayhons trial emphasized the severity of Donna Lou Rayhons' cognitive impairment in an attempt to discredit the defence's claim that this was not assault as Donna expressed sexual desire towards her husband. For example, one story reported that 'Mrs. Rayhons had scored zero on a standard test for Alzheimer's when a score below eight counted as severe impairment" and that 'staff described her as being "in her own little world"' (Allen 2015; emphasis my own). In another it stated that 'Donna Rayhons' Alzheimer's disease had worsened dramatically in the months before last May's incident [date of suspected sexual encounter]. She washed her hands in dirty toilet water, [and] forgot how to eat a hamburger.' (Leys 2015). Similarly, the article on the case involving a resident and visitor describes the female resident with dementia as a 'frail OAP (old age pensioner)' and as having 'severe dementia' (Clements 2016).

News articles both implicitly and explicitly link the disability of women with dementia with asexuality by portraying them as both incapable of expressing sexual desire or lacking such desire all together. Such representations collapse ethical complexity and context in an effort to construct an unequivocal boundary between 'good' and 'evil' (Wright 2015). Ultimately, this serves to normalize sexual violence towards women with dementia by locating their vulnerability to violence in their disability, rather in broader structural conditions and disabling practices. For example, news articles do not consider how sexual violence towards women with disabilities is supported by their lack of access to knowledge that supports sexual self-determination (e.g. information about sex, their right to refuse unwanted contact, how to protect themselves or report unwanted sexual contact), as well as providers' lack of training around how to gauge wanted and unwanted sexual expression in the context of disability (Fish 2016; Ballan, Burke and Freyer 2012; Hollomotz 2009).

The belief that women with dementia are inherently asexual is most apparent in articles that report on sexual encounters between two older adults. These articles rarely mention the female resident's sexual expression, her reaction to the sexual encounter, or to its discovery. The primary criterion used by the media (as well as the experts cited within these articles) to demonstrate that such sexual encounters are involuntary, rather than assentual, is the cognitive disability of the woman with dementia. For example, one article reports that a police spokesperson stated that the female resident was 'considered unable to consent because of her condition' and that she 'could not consent to sex because she suffers from dementia,' as she is 'not really able to decide things on her own' (Zauzmer 2015). To explain how it was determined that there was a sexual assault, the article reports that nursing home staff went to search for the female after she did not attend lunch, unlocked her locked room to 'find' her and the other resident 'together.' Staff' actions are left unproblematized in the article, thus implicitly justifying both their interpretation of the encounter as sexual abuse as well as their right to surveil and curtail the sexual freedom of women with dementia. Similarly, the article on a sexual encounter between a female resident and her male visitor does not describe how the female resident responded to his sexual advances. Instead the article simply states that the care providers determined that the interaction was 'sexual assault' and reported it as such to the police. Although the article notes that the man was a 'regular visitor,' it is noted that staff understood that 'the man and woman were friends and not in a romantic relationship.' Yet it does not mention how the nature of the relationship was determined.

The assumption that women with dementia are asexual is perpetuated by the dominance of the biomedical model of dementia and the neurobiologization of selfhood; both discourses disqualify the actions and expressions of persons with dementia based on the belief that dementia fundamentally erodes selfhood. This discourse is prevalent among care providers who often consider persons with dementia as lacking in capacity to be sexual, or as compromised by their cognitive impairment (Grigorovich and Kontos 2018; Kontos, Grigorovich, Kontos, and Miller 2016; Roelofs, Luijkx, and Embregts 2015). Although currently there is no consensus on the definition of 'sexual capacity' or how to best evaluate this, it is often assumed to be similar to the capacity for deciding on medical treatments and is assessed as such. Such ableist and cognitivist forms of judgements privilege self-reflection and rationality and require that persons with dementia verbally articulate their expectations regarding desired sexual intimacy, as well as demonstrate awareness of potential sexual risks and ability to avoid exploitation (Wilkins 2015; Gill 2010). The lack of explicit and established polices regarding the sexual rights of persons with dementia, along with the prevalence of mandatory reporting policies regarding sexual abuse, prompt providers to view the sexualities of residents with as being especially 'risky,' and thus as necessary to restrict (Villar, Celdrán, et al. 2014; Wilkins 2015).

The dominant affect produced by media representations of women's sexuality is that of an 'empty sympathy'; a form of superficial caring about the pain of others that precludes a collective identification with the humanity of the sufferer (Ahmed 2010; Berlant 2014). Sentimentalized narratives turn the personal pain of women with dementia into a form of entertainment that allows us to experience compassion passively and at a distance, without acknowledging our own complicity in the social relations of power that sustain violence (Kaplan 2011; Berlant 2014; Ahmed 2010). As Ahmed (2004; 2010) and Butler (2006) remind us, detached and depoliticized forms of 'feeling bad' for the Other 'do something'; melodramatic narratives of public crisis that elicit sentimentalized sympathy for an imagined and distant other re-establish the distance between valued and devalued bodies and allow for the exercise of sovereign power in the name of national security or defence. Sentimental 'scenes of suffering' (Woodward 2014, 13) invoke sympathy based on discourses of charity, which ultimately works to sustain rather than resist the socio-political structures that enable vulnerability to violence. Such affective responses are limited as they do not invite a critical questioning of how the social treatment of persons with dementia contributes to their precariousness to experience violence in long-term care. Nor do such representations challenge the prevailing cultural assumption that persons with dementia do not have legitimate sexual desires or needs that should be supported in and through social entitlements (Grigorovich and Kontos 2018; Kontos, Grigorovich, Kontos, and Miller 2016). Instead, such conditional forms of recognition become a way to demonstrate a charitable identity through spectatorship, rather than a commitment to collective social action. As Berlant argues, the sentimental narrative of compassion is 'an emotion in operation' (Berlant 2014, 4) that enacts privilege; feeling compassionate places 'the sufferer…over there' while also making them subject to our form of 'rescue' (Berlant 2014, 5). Representations of sexual violence towards women with dementia thus serve to further justify the dominant practices of curtailing the sexual expressions of persons living with dementia in the name of their protection from harm.

Highlighting the excess of emotionality around these representations is not to deny that sexual assault is traumatic or the need for collective efforts to prevent such forms of violence. Instead my aim is to draw critical attention to the affective power of sensationalizing such acts of violence. Writing about white teachers' 'professions of care and love towards people of color' (331), Matias and Zembylas (2014) suggests that sentimentalized caring can mask hidden disgust towards racialized persons under a politically correct emotional performance. Such performances ultimately allow white teachers to project their disgust onto racialized persons rather than to acknowledge their own complicity in racism and white supremacy. Extending this to consider representations of sexuality and dementia allows us to see that expressions of compassion that deny women with dementia sexual subjectivity allow for a performance of caring that is based on fear and disgust towards persons with dementia. Constructing the sexualities of women living with dementia as horrific causes of violence and suffering reinforces the popular belief that dementia is essentially a tragic and intolerable state of being and that 'death [is] preferable to a life lived with' dementia (Behuniak 2011, 16). Dementia thus becomes further preserved as the 'threat to life itself' (Ahmed 2004, 64), or as a collective hazard that requires containment.

Ahmed (2010) cautions us to be suspicious of cultural narratives that attempt to idealize and elevate 'other people's unhappiness' (95). Often such attempts to elicit sympathy are conditional, in that sympathy is used to justify state-sanctioned forms of violence in the form of heroic intervention, or 'liberation from abjection' (127). Protectionist narratives of violence teach persons with dementia 'how to be happy' (128) by turning them away from the structural causes of their unhappiness. In doing so, they also support unnecessary and inherently unjust attempts to reduce their sexual freedom and sexual agency. By positioning the desire for sexual expression as a 'kind of death wish' (Ahmed 2010, 104) or as an imagined threat to the potential for happiness, media representations redirect persons with dementia 'toward the [asexual] norms, values, and practices of the colonizer' (128). Such representations thus justify professional intervention into the sexual lives of women with dementia as the means for decreasing their future suffering.