The Science and Sexism of Man-Flu

I don’t remember when I first heard the expression “man-flu,” but it has been around a few years now. Generally, it expresses the view of many women that men whine and complain when felled by the flu, but women soldier on undaunted by a little thing like a flu virus. Even women who consider themselves feminists will trot out man-flu as evidence that women are stronger and more resilient than men.

After this went on for some time, men rejoiced when a study published in the American Journal of Physiology claimed that women’s stores of estrogen spared them the worst effects of flu and helped them fight off the virus. Men could stop apologizing for theirIMG_0398 suffering and just continue whining and demanding attention, because the man-flu was real after all.

But, of course, some researchers pushed back. An article in STAT in March 2017 boldly asserted that the scientific evidence for man-flu was overblown. If women have stronger immune responses, it said, they will have more severe symptoms, as it is the immune system that causes sneezing, coughing and other flu symptoms. More telling, though, is the final statement in the article. The article quoted immunologist Laura Haynes of the University of Connecticut, who said, “Maybe men just get whinier.”

“Whiny” is a rough scientific category to pin down, but in this case I guess “whiny” means a man expressing pain out of proportion to his suffering. For any study to determine whether men suffer from flu more than women, it would have to quantify and measure the subjective experiences of men from across the globe. I’m not saying it can’t be done, but I am saying it has not been done.

Given the fact that we can’t actually know who suffers more from the flu and the fact that we actually don’t know who complains about it more (anecdotal evidence from women who just happen to live with men lacks a bit of rigor, I think you will agree), I propose to blame another culprit: patriarchy.

It just might be true that men seem to complain more because they are expected to never complain at all. Men are expected to be stoic and unaffected by pain and suffering. This may be at least one reason women take 50 percent more sick days than men. When men show any crack in their invulnerability, they are mocked by other men, by women, and even by feminists.

So, the term “man-flu” may just be another way of saying someone failed the test of the patriarchy to fulfill the demands of sacrificial masculinity. If you support gender equality, phrases such as “man-flu” and “man-up” can only hurt your cause.

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Manchester, Abolitionism, and Frederick Douglass


by Dr Natalie Zacek, English and American Studies, University of Manchester

Manchester had since the seventeenth century been a centre for radical movements, and many of its people in the late eighteenth and nineteenth centuries devoted themselves to the abolition of slavery. Although it was never a slaving port, Manchester was tightly linked to the African slave trade because, beginning in the seventeenth century, the “coarse check” cloth and the silk handkerchiefs its mills produced were one of the principal goods which English traders exchanged for captives on the West African coast. Moreover, as the global demand for cotton clothing boomed in the eighteenth century, traders brought ever more slave-grown cotton in to be processed in the Manchester mills.

Visiting abolitionist activists found Manchester a fertile ground in which to spread their message and raise funds for their cause; important visitors included Thomas Clarkson, the founder of the British…

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Why patients go do the doctor too much


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Wittgenstein, Shame, and the Nazi Problem

“Hate between men comes from cutting ourselves off from each other. Because we don’t want anyone else to look inside us, since it’s not a pretty sight in there.” (Ludwig Wittgenstein, Culture and Value, 1945)

Philosopher Ludwig Wittgenstein hated himself. If you described him as a self-loathing ludwig-wittgenstein-2aristocrat, a self-loathing Jew, or a self-loathing homosexual, you would probably be right, but it is anyone’s guess which of the three descriptions is most accurate. He gave his money away, responded ambiguously to race and religion, and necessarily kept his sexual and romantic inclinations as private as possible.

Ludwig was reared in a Roman Catholic home and did not have a strong Jewish identity as a young man despite having three Jewish grandparents. By coincidence, Ludwig and Adolf Hitler attended the same grammar school; although they were about the same age, they were two years apart as Ludwig was advanced a year and Adolf was held back a year in school. Some believe Ludwig is the Jewish boy who first provoked Hitler’s anti-Semitic rage as described in Hitler’s Mein Kampf. Others point out that Hitler probably wouldn’t have known Ludwig was Jewish at the time. Either way, it is likely Ludwig would not have thought much of his less accomplished contemporary at the school. If they met, it is doubtful Ludwig would have shown any sort of camaraderie to the young Adolf, and Adolf probably would have resented Ludwig on reflection even if he did not during their time at school together. Throughout his life, Ludwig could be brash, even to his friends, so it is easy to imagine how he may have treated those he saw as his inferiors. Bertrand Russell once wrote that Ludwig could be “destitute of the false politeness that interferes with truth.”

Regardless of whether Ludwig provoked Hitler, we can’t help but wonder the source of Ludwig’s own anti-Semitism. He identified as a Catholic but also deprecated himself in terms of his Jewishness, saying, for example, “Amongst Jews ‘genius’ is found only in the holy man. Even the greatest of Jewish thinkers is no more than talented. (Myself for instance.)” (Culture and Value, 1931). All writers and thinkers are plagued by self-doubt, and sometimes a free-floating anxiety seems to just hover around us waiting for a place to land. Perhaps this was a convenient way for Ludwig to explain his doubts and insecurities to himself, even if his assertion is demonstrably false, but he certainly had a complicated relationship with his own racial identity.

Ludwig similarly seemed to feel guilty for his staggering wealth. Thanks to his father’s ruthless business strategies, Ludwig was one of the richest people in Europe. He seemed to find his wealth problematic. Perhaps he believed money itself is corrupting or maybe he was ashamed of how his wealth was acquired. Whatever the case, he gave his money to his siblings and lived in famously stark accommodations.

His father, Karl Wittgenstein, was a wealthy industrialist who amassed much of his wealth through aggressive business dealings during the war between Russia and Turkey in 1878 (my info here is largely based on an essay by Jorn K. Brammann and John Moran, which can be found here). He emerged from his war dealings as the leader of the iron and steel industry with one of the greatest fortunes in Austria. Once established as a leader in industry, Karl pursued greater power through vertical integration and control, establishment of cartels, and gaining influence with financial institutions. Karl opposed government protection of consumers but sought government protection of entrepreneurs from foreign competition. His strike busting activities were described in Arbeiter-Zeitung, by declaring that the director evicted workers “with a lot of policemen, and the latter began the expulsion. The head of a family with four children was expelled late at night, when the children were already asleep in their beds. Sergeant Werner, a well-known enemy of the workers, mercilessly dragged them out of their beds, and they were made homeless.” Karl’s only apparent political ideology seemed to be to promote policies that would aid industrialists like himself in the search for wealth and power.

As an ostensibly Catholic family with seemingly limitless wealth and power, the Wittgenstein family might understandably feel insulated from the effects of world affairs. They may have felt that Hitler’s advance was no threat to them personally, but their safety was more precarious than one might expect, and protecting the sisters from Nazism required a significant bribe. In 1939, Ludwig and his only surviving brother, Paul, managed to convince Hitler to grant half-breed status to the daughters of Karl Wittgenstein in exchange for the gold and foreign currency held in Switzerland by a Wittgenstein trust (for more information, see here). At the time, Ludwig and Paul were both safely outside Austria. The amount of money transferred to the Nazis was significant and surely aided the continued advance of the Reich to one degree or another. Ludwig distanced himself from his own race, used his extreme wealth to buy privilege for his family, and likely helped the Reich survive, and perhaps we do not blame him for it.

Ludwig’s brother Rudi committed suicide, it is thought, after fearing he could be identified as a homosexual in a published study.  Rudi left a suicide note that referred to his “perverted disposition.” Ludwig had every reason to hide his own homosexuality. It was illegal, and the punishment could be devastating. Ludwig was a contemporary of Alan Turing, who was subjected to “chemical castration” by the British authorities, and his “treatment” led inexorably to his death by alleged or supposed suicide.  Ludwig’s own sexuality was secret and remains a source of speculation. Depending on who is telling the story, Ludwig falls somewhere on a continuum between being a homosexual who almost never engaged in physical sex to being a promiscuous gay man scouting about for anonymous sex. Each of the most extreme descriptions seems motivated by homophobia, and his sex life was probably much less interesting than either virtual celibacy or promiscuity would suggest. The existential threat to gay men was real, though, so being homosexual robbed one of any sense of safety and security.

Given the circumstances and the fact that he contemplated suicide often, it is amazing that Ludwig did not kill himself. Bertrand Russell wrote of Ludwig: “He used to come to my rooms at midnight, and for hours he would walk backward and forward like a caged tiger. On arrival, he would announce that when he left my rooms he would commit suicide. So, in spite of getting sleepy, I did not like to turn him out. On one such evening, after an hour or two of dead silence, I said to him, ‘Wittgenstein, are you thinking about logic or about your sins?’ ‘Both,’ he said, and then reverted to silence.” We might be tempted to say that philosophy saved Wittgenstein, and perhaps it did, but his philosophy offers little comfort, frankly, for his followers who read him with the hope of alleviating their own discomfort. Believe me, I would know.

Wittgenstein’s shame was ambiguous. We can’t fault him for the behavior of his father, his inherited wealth, his desire to save his sisters, his Jewishness, or his homosexuality, but, still, we can understand his shame. Wittgenstein finds expiation in the same evidence that condemns him. He devoted much of his life to trying to overcome ambiguity and paradox and to atone for his stained being, but declared that nothing unambiguous could be said about ethics. In his “Lecture on Ethics,” he said, “Ethics so far as it springs from the desire to say something about the ultimate meaning of life, the absolute good, the absolute valuable, can be no science. What it says does not add to our knowledge in any sense. But it is a document of a tendency in the human mind which I personally cannot help respecting deeply and I would not for my life ridicule it.” Ethics could not ameliorate his torment.

Despite his despair regarding both religion and ethics, one of his most trusted, and arguably more accomplished, students was Elizabeth Anscombe, a Catholic and dedicated ethicist who saw ethical rules as both absolute and universal. Wittgenstein named Anscombe as one of the literary executors of his estate. In responding to Oxford University’s decision to award Harry Truman an honorary degree, Anscombe wrote an open letter denouncing the honor. After the bombing of Japan, she argued that the intentional killing of innocent people is never justified, even if it results in some good. She asked, “Come now: if you had to choose between boiling one baby and letting some frightful disaster befall a thousand people—or a million people, if a thousand is not enough—what would you do?”

Wittgenstein’s entire life was a kind of penance. He was rich but gave his money away to avoid its corruption. He taught school. He was a gardener. He worked in a hospital. He served in the military. He tried to guide and protect the ones he loved. In the end, he aided the Nazi apparatus, brutalized children, and made those around him miserable. Describing his own life, he said, “I sit astride life like a bad rider on a horse. I only owe it to the horse’s good nature that I am not thrown off at this very moment.” (Culture and Value,  1939-40). He spent his years on earth devoted to determining what can be said precisely or how it can be possible to communicate, but he left us only with the same ambiguity he found so tortuous to begin with. When we study Ludwig’s life and words, we see no way forward. As such, Ludwig’s shame seems to serve no purpose.

Then again, perhaps Ludwig leaves us with some comfort, after all. We all carry our private shame, but that may be exactly what connects us to the rest of humanity. Ludwig wrote, “Of course, you must continue to feel ashamed of what’s inside you, but not ashamed of yourself before your fellow men” (Culture and Value, 1945). We need not be ashamed before our fellow humans because we are all flawed and seeking our own redemption. Some people run from their shame, some try to suppress it, some try to atone for it, and some, like Ludwig, do all three, but everyone has to manage it one way or another.

Hannah Arendt, who infamously had an affair with her Nazi professor, Martin Heidegger, said she was tempted to respond to people who were ashamed to be German by saying it made her ashamed to be human (see “Organized Guilt and Universal Responsibility”). Surely, Arendt had to manage her own shame, but she wasn’t paralyzed by it. She went on to say, “For the idea of humanity, purged of all sentimentality, has the very serious consequence that in one form or another men must assume responsibility for all crimes committed by men and that all nations share the onus for evil committed by others. Shame at being a human being is the purely individual and still non-political expression of this insight.” In the end, Ludwig’s shame was a political act, even if unconscious.

As human beings, I’m amazed we can live with ourselves at all. For a moment, in the late 20th century, some of us were able to convince ourselves that humans were evolving to a better state. We thought humans were becoming increasingly humane. Ludwig and Arendt both lived in times of terror, and both engaged with evil in one way or another. Against terrifying odds, the holocaust eventually ended, and we slowly came to believe we would not make such mistakes again. However, nothing exists in the world now to remind us of our optimism. We must rely on our old crutch, hope, so that we can do better in the future. Arendt urges us to feel shame for all of humanity because if we feel no shame, we also lose hope. Those who are shameless will seek to destroy our world, and only those of us filled with shame can save it.

Our shame, like Ludwig’s, may be ambiguous, but it serves a purpose. It is the source of our humanity and our only hope for salvation.





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Review: John Gluck’s Voracious Science and Vulnerable Animals

The entire medical research enterprise is built on a foundation of intense and immense animal suffering. Most of the effective treatments we have now were previously tested on non-human animals before they were ever used on humans. On the other hand, most non-human animal research does not lead to an effective treatment or even publishable results.

In Voracious Science and Vulnerable Animals: A Primate Scientist’s Ethical Journey, John Gluck describes his glacially slow transition from primate researcher to animal welfare advocate. Early in his career, Gluck worked on the infamous monkey social-isolation experiments that provided the earth-shattering news that separating infants from their mothers and rearing them in isolation harms their emotional and intellectual development. Thanks to img_0327this ground-breaking research, mothers have learned not to raise their babies in small wire cages and occasionally perform painful surgeries on them.

In approximately the same amount of time it took for humans to evolve from other species, Gluck began to realize the great harm he was causing to his beloved monkeys. Gluck apprehended the harm he was doing after personally observing the excruciating suffering of the animals he was studying, seeing the shock in the eyes of non-scientists when he described his work and realizing that he could only describe his work to fellow scientists, having a student present him with Peter Singer’s accurate description of his work, having his lab broken into by animal rights activist, and, finally, talking with philosophers about the rights of animals.

The brilliance of his account is that he illustrates why it was so difficult for him to acknowledge the pain he was causing and why it is next to impossible to engage animal researchers in a debate over the welfare of research animals. Typically, animal researchers say they turn to non-human animals when it would be unethical to test on humans. When pressed, they will agree that animals should be used only when their use benefits the pursuit of scientific knowledge, should be given clean living quarters, should be fed appropriately, and should be given medical treatment when needed. Unless, of course, the scientist is studying the effects of food deprivation, lack of medical treatment, and so on.

The research is further justified by the fact that non-human animals have similar biological and neurological structures that ensure that results in non-human animals can be replicated in human animals. The human who doubts the similarity is scoffed at for being scientifically illiterate. Paradoxically, suggesting that non-human animals, similar to humans in other ways, are also similar to humans in terms of suffering or moral importance is accused of anthropomorphism. The argument is either that animals are not capable of suffering in any meaningful way or that their suffering is of no moral significance.

Gluck describes these arguments and explains that he himself held such seemingly contradictory views because they are taught and repeated ad nauseam until they become ingrained beginning with undergraduate study. Anyone who questions these basic beliefs is either met with laughter or denied entry and participation in research programs. People within the system become so closed off from contrary opinions that they are often surprised when descriptions of their work shocks and offends outsiders. The only explanation for the outrage many scientists will consider is that outsiders cannot understand the importance of their work.

One of the more fascinating events that led to Gluck’s change of heart concerned a human patient who was thought to be severely cognitively impaired. Staff in the patient’s room talked about the woman as if she were an object. Gluck was trying to solve a particular problem. At times, staff could feed the woman from a spoon but at other times she could not swallow. It turned out that she could swallow but was refusing to because she did not appreciate the way certain staff treated her. It was the only form of protest she had at her disposal. When Gluck realized how robust the conscious life of this patient was despite the appearance of minimal cognitive activity, he realized also that he could not say with certainty what thoughts, beliefs, or emotions non-human animals might experience.

Gluck eventually decided to get out of animal research and began teaching courses on research ethics that covered a variety of topics but included discussions of animal welfare. (If you care about the suffering of the animals in his lab, you will be disappointed by what happened to them.) Gluck’s educational programs on research ethics were successful in the sense that they attracted students from a myriad of disciplines and engaged both students and faculty in interesting and enlightening debate on the use of both human and non-human animals in research. Looking back, he is proud of his accomplishment to begin these discussions but admits that animal researchers were the one group that never engaged in the discussions.

Ethicists can attempt to change practices from inside or outside of institutions. Outsider ethicists have more freedom to make bold declarations of misconduct, express outrage, and threaten established practices. Insider ethicists have greater access and opportunity to speak directly with the people who have the power to change practices. Both kinds of ethicists are needed. Gluck is an insider whose thoughts and arguments were enhanced and supported by outsider ethicists. He says he was unable to effect a great deal of change inside research labs, but he was able to speak to researchers as an equal to engage in an ethical discussion. Sadly, insider ethicists who raise ethical alarms are often forced outside. It takes a great deal of courage to risk losing a privileged position inside the castle, and it also takes a great deal of courage to storm the castle gates.

If you are looking for a book with a detailed and comprehensive review of philosophical theory related to animals, you will be disappointed in Voracious Science and Vulnerable Animals; however, if you are looking for an insider’s perspective on the views and outlook of animal researchers, you will find Gluck’s insights and introspection fascinating, even if depressing. The book shows that it possible for researchers to be moved and gain compassion and understanding of the harm they are doing, but it also shows that such progress is slow and infrequent.





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Book Review: A cross-dresser explains The Descent of Man

In a world where a man who talks openly about kissing and grabbing women without consent can be taken seriously as a candidate for leader of the “free” world, you may wonder how toxic masculinity has spun out of control. As an antidote to all the bully posturing, perhaps the wisdom of a famous cross-dressing artist can help explain how we got here and how we can move forward, so it is time to pick up Grayson Perry’s The Descent of Man and begin to unravel the mystery of toxic masculinity.

If you have already spent some time pondering feminism, masculinity, and gender, you really have two choices as you read Perry’s screed: You can quietly applaud from the choir loft or utter a mild rebuke that it doesn’t go far enough to liberate us all from the shackles of rigid gender roles. On the other hand, if you have not really examined assumptions about gender and how they affect the world, prepare yourself for a brief but fairly inclusive overview of entertaining and insightful musings on gender, violence, fashion, and injustice.

If you aren’t already familiar with Grayson Perry, he is a celebrated artist, cross-dresser (he refers to himself as a transvestite and sometimes “tranny,” something I decline to do), and host of a television program titled All Man, which was also an exploration of masculinity. At the outset of the book, Perry says that some may think his cross-dressing gives him a better understanding of women, but he insists that it instead gives him a better understanding of men. Though he mentions cross-dressing a number of times in the book, it plays a relatively minor role in this overall thesis, with the exception of his emphasis on fashion.

For a man of a certain means and status, wardrobe options are limited. When doing any kind of business, a fairly bland suit with a fabric “penis,” as Perry says, wrapped around his neck is the default choice for what Perry describes as the Default Man. The Default Man represents all the power and privilege of being male, but Perry acknowledges that not all men share the power and privilege of maleness equally. Still, the Default Man is the assumed cultural archetype for Western society. His clothing is bland, Perry avers, because the Default Man is in a position to observe and objectify others, not to be observed and evaluated himself.

To care about fashion is decidedly unmanly, and, indeed, men who fuss about their appearance are often assumed to be gay by homophobes and self-appointed gender police. Men from other social classes may not be condemned to the prison of the gray suit, but are still considered effeminate in the event that they spend too much time worrying over hairstyles and clothing choices. This is why, of course, cross-dressing is so emotionally and, for some, erotically charged.

While noting that men are responsible for most of the violence in the world, Perry claims that aggressive masculine behavior is entirely, or almost entirely, the result of conditioning that begins even before birth as parents, family, and friends begin choosing clothing, toys, and decorations that “match” the gender of an expected child. Infants and children are treated differently according to their gender, so it would be surprising if boys and girls did not behave differently. Boys learn early to suppress their emotions, be fiercely independent, and solve problems with violence.

Perry gives many compelling and interesting examples of how boys and men experience violence and emotional isolation, but I wish he had spent a little more time talking to the men who seem immune from this conditioning and to people of all genders who fail to fill the role of stereotypical male. For example, if gender is all conditioning, why is it that at least some gay (and some straight) men fail to follow the dictates of the gender binary? What disruptions alter the course of the conditioning? If we are hoping to modify gender roles for future generations, we need to explore alternative paths to non-binary or, at least, non-destructive masculinity.

Though he gives some a passing mention, Perry mostly ignores the experiences of nurturing men such as at-home dads, male carers, transgender men, transgender women, and intersex people. Perry claims gender is a matter of performance in that we all perform behaviors, dress, and emotions that indicate our gender. In other words, we perform masculinity or femininity by taking on the attributes of either gender. In this sense it would seem that anyone would be free to change the mode of performance at any given time.

The use of the word “performance” in this sense recalls the work of Judith Butler, who img_2269distinguishes between “performance” and “performativity.” Butler explains here that performativity is about the effects our behavior as related to gender has while performance is a choice to take on a role. If gender were merely a performance, bullying and other forms of gender policing would probably not be such a problem. The shame people feel when they are unable to conform to gender expectations is related to what they are, not what they do. Perry is probably wise to avoid the treacherous philosophical waters of gender identity and deep linguistic analysis, but the question of how deep our inclinations run and can be modified haunts the discussion like the baggage of an old relationship.

In chapter four, he begins by declaring, “I think we like the idea that gender is in our genes because it is convenient, it lets us off the hook.” If he is correct and gender is not in our genes, is not biologically determined, then we have a much better chance at making changes. We can expand the emotional lexicon of boys and men. We can increase male capacity for empathy. We can end war and violence and finally bring peace on earth.

After declaring that we are free to change our gender expression, he paradoxically says this: “Men, bless ‘em, are tethered to a monster, a demon conjoined twin, a one-man ‘wrong crowd’ who will often drag then into bad behaviour. The penis is at once us and not of us.” He says a boy’s sex drive keeps him from understanding the importance of platonic relationships and forming adequate social support networks. Here, near the end of the book, he seems to be speaking of a kind of gender essentialism, which contradicts most of what comes before.

He says, “Men, particularly when young, view the world through a heads-up display of sexual desire.” I’ve never been a young girl or woman, but I have a suspicion that sexual desire also occasionally clouds female judgment and causes them to behave less rationally than they may otherwise hope. And some boys, I am certain, are not so driven by their sexual desires. Regarding biological determinism, Perry clarifies, “We may be genetically predisposed to be straight or gay, identify as male or female or in between, but I think the attitudes, cues, contexts, power relationships, props and costumes are supplied by conditioning.” This clarification is crucial.

While some men “perform” masculinity well and succeed throughout their lives, other boys and men (or people assigned male) find it impossible to “act like a man” and, further, have no desire to join the fraternity. Removing the toxic part of masculinity can make more room for varied forms of gender expression.

In the end, Perry seeks to liberate men from the confines of narrow gender conformity. Once men are freed from shame around weakness and vulnerability, perhaps they can have more compassion for themselves and for those around them. Perhaps, finally, boys who like My Little Pony can say so without fear of bullying. Perhaps, finally, men in the throes of grief can cry openly without being told they need to pull themselves together.


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Protecting the sexual rights of our grandparents

Bioethicists and experts on aging spend some time advising people on advance directives aimed at helping us make decisions about our medical care in the event of dementia or unconsciousness near the end of our lives. The idea is that we may give prior consent for decisions to be made when consent is not possible. We generally make decisions about what treatments should be offered or withheld in the event of fading autonomy.

Perhaps we should consider a broader range of choices as well. In some cases, a personGrowing-Old-Together-800px with dementia can consent to a variety of activities that might not have seemed appropriate previously. In Holding and Letting Go: The Social Practice of Personal Identities, Hilde Lindemann gives an example of a life-long vegetarian and animal rights activist who ends up in a residential care facility and desperately wants to eat the meat dishes offered his fellow residents. Should his earlier convictions be respected or should his later desires be sated?

Lindemann breaks down the problem by identifying a capacity for two types of volition: primary and secondary. Primary volition is simply the ability to want something. Secondary volition is the ability to want something but think better of it because of overriding desires, which could be based on moral, social, or health concerns (among others). Our resident is able to want a hamburger but not able to think about the ethics of eating meat and how it affects the animals, the environment, or the economy. People who eat meat tend to say it is harmless to give him a hamburger, so his current desires should be indulged. People who care about animals might take a different view.

But what if we weren’t talking about eating meat? Perhaps our resident never cared about animals, but did care about sexual behavior. He may have been prude or strict moralist. Now, however, he would quite like to masturbate frequently and doesn’t mind who sees or knows. In the past, of course, he would have been more discreet, but he has lost the ability to take such concerns into account. Still, it is his body, and he should be able to do what he wants, even if the comfort of other residents and staff must also be considered. When the occasion arises, Mr. X might gently be guided to a private room.

Or he may meet a fellow resident with similar desires. Surely consensual sexual activity, with allowances for the comfort of other residents and staff, should be respected. When younger people have limited autonomy, we are likely to say they are incapable of consent, making sexual relations with them problematic at the least. Such patients are “protected” from sexual advances of any kind, even if they may appear to be willing “victims.”

Rarely is this debate framed as a “right” to sexual pleasure, but sexual puritanism is the only reasonable explanation for the imbalance in the discussion. Surely sexual pleasure is a human drive and a human need. If it isn’t such a strong drive for older patients, it is certainly still a human good. Currently, even the most progressive attitudes toward sexual pleasure for older patients could only be described as polite tolerance rather than accommodation.

To actually accommodate the sexual needs and desires of older, and sometimes demented, patients would require conversations and actions that are sure to make us uncomfortable. It may be possible to discreetly make condoms available to residents in nursing homes, but asking residents whether they might want a vibrator or other sexual aid available is more of a challenge. Involving children and grandchildren in the discussions is likely to be an insurmountable model, at least without a sea change toward sexual behavior in general and among the elderly in particular.

A further difficulty is posed by the possibility of sexual assault or exploitation. Normal guidelines for consent won’t do. A demented patient might consent to sexual activity that would never have occurred in the absence of dementia. The only way to honor the wishes of a patient’s lifelong values is to have difficult discussions earlier in life. We would need to ask question of this nature: “In the event of dementia, what types of sexual pleasure if any would you like to be available to you? What types of sex if any would you consider appropriate with other people? What types of sexual aids if any would you want provided for your pleasure?”

I would caution any young people thinking of completing an advance directive now to reconsider often. As we age, our estimation of what kind of sex lives we will want in old age changes dramatically. Younger people tend to assume that older people naturally lose interest in sex, and I’m sure some do, but many older people find the opposite.

Sexual pleasure has many advantages for older people. It doesn’t cost a great deal of money or effort. While illness and disability can limit sexual options for people of any age, they do not eliminate it. Sexual pleasure doesn’t require one to leave a residential facility, isn’t inherently risky (especially when partners are not involved), and doesn’t necessarily strain the budget (expensive sex toys and porn addictions notwithstanding). In fact, for many older patients, sexual pleasure may be one of a handful of pleasures still available to them.

Some of the risks of sexual behavior are no longer of concern to older patients. While sexually transmitted diseases are still a distinct possibility, many of the diseases seem much less frightening to someone nearing the end of life. Further, pregnancy is no longer a concern, and people who have already lost their spouses are no longer concerned with issues related to fidelity. In ways the young rarely understand, old age is liberating.

Of course, sexual activity of patents has the possibility of creating discomfort for staff. Taking care of a patient should not mean providing sexual services for patients, unless one is specifically hired as a sexual surrogate. Staff must be protected from sexual assault or exploitation. However, feeling squeamish or embarrassed is not the same thing as enduring sexual harassment or assault, and staff must know the difference.

We can make staff more comfortable by becoming more comfortable ourselves with elder sexuality. Normalizing mature sexuality will go a long way toward opening frank and productive discussions of policy and procedures to protect the sexual rights of patients.

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