Sarah Mourra, MD

Of all the transferences that emerge in the consultation room, sexual feelings are by far the least talked about and the most challenging for therapists to manage. When sexualized transference occurs in work with older adults, these challenges are amplified. As the population ages, more older adults will require or seek out mental health treatment, and effective recognition and management of this issue will be an inevitable part of treatment.

Sexual transference expressed by older patients does not differ dramatically from that of younger adults, other than involving unique barriers to its recognition and management. As in younger adults, it can range from aggressive lustful longings to intimate and tender feelings. Some have made the distinction between erotic transference (in which the patient understands his or her fantasies as unrealistic; it does not present a barrier to the patient to gain insight into the transference) and eroticized transference (in which the patient has an irrational preoccupation with the clinician and makes overt demands for sexual fulfillment, avoiding insight into the transference).

The overall challenge with erotic transference lies in both the patient and the clinician recognizing it as a distraction or a disguise for a wide range of affective experiences as well as unresolved developmental difficulties and interpersonal conflicts.

 For this reason, it presents an opportunity for clinicians to address underlying issues that may be at play.

Erotic transference possesses many underlying meanings. Sexual feelings may provide a way for patients to defend against feelings of dependency or passivity, particularly when the age gap between the therapist and the patient creates a reversal of power dynamics that the patient feels uncomfortable with. In addition, focusing on lustful or “falling in love” feelings is an effective defense against dealing with grief over the loss of a loved one, which many older adults confront. It may also serve as a method of combating loss of sexual potency or physical strength and beauty.

 For older adults who have experienced sexual abuse– related trauma in childhood, the experience of being cared for and being sexual may be conflated. For patients who have fears of intimacy and for whom the process of growing to trust the therapist triggers these fears, expressing sexual feelings in a manner that repels the therapist may lessen feelings of vulnerability.

Many barriers impair recognition of these underlying dynamics. For instance, clinicians may have difficulty in acknowledging sexuality in older adults, often as a result of avoiding awareness of the intimate lives of parents and grandparents in their own families. Some theorists have suggested that Oedipal issues might be triggered, which prevent practitioners from considering sexual attraction coming from someone who resembles a parental figure.

 Moreover, because of having lived through different life roles, older adults have the capacity for a myriad of transferences that may surprise clinicians. Indeed, Patricia King

 has theorized that older adults have a complex experience of age that involves experiencing the self psychologically (the age they feel), biologically (their physical appearance and health), and chronologically (the age they actually are). Management of sexualized transference must consider all of these factors.

Media and pop culture influences also strongly perpetuate barriers to acknowledging sexual feelings in older adults. Many films and television shows portray older adults as either asexual or hypersexual, with very few portrayals in between. This may contribute to restrictive societal perceptions of sexuality in older adults and more intense or ambivalent responses from clinicians.

For many older patients, their “real” objects (spouses, parents, friends) may have passed away, enhancing the therapist’s role as both a transference object and a real object.

 It is not unusual for a patient to express that seeing the clinician is often one of the few “outings” or moments of human contact during the week. In this context, the patient’s expression of sexual feelings may create worries about dependency and feelings of suffocation on the part of the clinician, leading to distancing behaviors.

Cultural factors are also important for clinicians to consider. The culture of geriatric psychiatry in general tends to employ touch far more than general adult psychiatry. This is partly because of data that indicate that for patients with sensory or neurological impairments, or with dementia, physical touch can be reassuring and soothing.6 Other aspects of touch include positive familial countertransference toward older adults as well as actual or perceived loneliness and need for physical comfort. However, this lower threshold for touch in the therapeutic setting with an older adult may be an indicator that the clinician unintentionally subscribes to the stereotype of the older adult as asexual or “harmless.” Integrating physical touch into patient care may become challenging when sexual transference emerges in the therapeutic encounter. For this reason, it is prudent to carefully consider the risks and benefits of using physical touch in an older patient.

Comorbid cognitive dysfunction presents perhaps the biggest challenge in managing sexualized transference in older adults. Geriatric psychiatry’s strong focus on monitoring for disinhibited behavior or hypersexuality as indicators of cognitive impairment may lead clinicians to use these diagnoses as a method of unintentional avoidance.

Memory loss may be a result of dynamic conflict and situational stress, rather than impending dementia.

 Clinicians must recognize brain change effects, such as frontal lobe disinhibition, agnosia leading to misidentifications, and loss of ability to understand context. These cognitive impairments often co-occur with the patient’s psychological experience and reaction to brain disease, which may include sexual feelings or behavior. Making this determination requires close observation of the person’s behavioral patterns in a variety of contexts, including reports from family members and caregivers.

In patients with more prominent dementia and inappropriate sexual behaviors, clinicians must consider psychological factors, such as boredom, lack of physical closeness, and need for control and mastery of a situation.

 In a study of inappropriate sexual behaviors in a nursing home population, only 40% of perpetrators had cognitive impairment. This finding suggests that other factors must be considered during management.

Strategies for managing sexual transference

Ignoring sexual feelings or setting harsh limits around expression of feelings in the therapeutic setting can be hazardous. These actions can cause isolation, shame, guilt, and withdrawal in both the therapist and the patient.

 Clinicians who experience guilt over admonishing a patient for expressing sexual interest may overinvest in therapy to compensate-eg, extending session time or reducing fees. This behavior may send conflicting signals to the patient and complicate matters further.

Effectively dealing with and managing sexual transference in older adults involves 3 steps: conceptualizing, containing, and managing. Conceptualization requires obtaining supervision from superiors, colleagues, or peers and identifying the variety of factors that may be at play. These include your physical and emotional safety, psychological and transference factors, patient’s degree of cognitive impairment, environmental and cultural factors, and countertransference.

Containment primarily involves containing one’s own reaction, which may involve anxiety, alarm, disgust, withdrawal, or reciprocation.

 Clinicians should recognize that unless physical and emotional safety are at risk, they may not need to act right away. Setting an empathic limit is often useful; this depends heavily on the characteristics of the patient and the therapist. Often, simply observing the behavior can bring it into the patient’s conscious awareness.

 For behaviors or comments that threaten physical or emotional safety, clinicians may want to emphasize the need to be in a safe space so that treatment can be optimized, and that psychotherapy is a verbal treatment that does not involve physical contact.

Normalizing feelings can also be helpful. An example of this is a statement such as: “It is often normal to have sexual feelings that come up in our treatment together because we have done a lot of work on intimate and difficult things. It often takes a lot of courage to talk about these feelings. I would like to explore how these feelings may relate to what is going on in your life right now.” Other statements, such as “I am wondering if there is someone else in your life who you felt that way about at one time or another,” can help shift the focus toward the underlying meaning of these feelings and how they relate to the patient’s experience. Comments such as “maybe I make you think about the kind of relationship that you would like to have” can help the patient associate to current unmet needs and affective experience.

In older adults, as cognitive impairment progresses or occurs, a periodic reexamination of the underlying contributing factors and of how you conceptualize the case is warranted. Maintaining the delicate balance between a curious and empathic stance and setting boundaries will help therapy progress in a positive direction.

For psychiatrists who work primarily in a supervisory role on a team, being able to recognize and manage erotic transference is key. Often, patients may develop sexual feelings toward a member of a team, causing conflicts among other team members.

 An example of this may involve a patient who develops romantic feelings for one member of the team, yet perceives another member of the team as a romantic rival-manifesting kind and cooperative behavior with one team member and aggressive or challenging behavior with another. Psychiatrists can be helpful in identifying these dynamics and in educating other care providers about how to manage them. Recognizing these issues will greatly affect care for patients at all levels of functioning.

Sexual feelings in the elderly are like any other strong affect that emerges in treatment. These sexual feelings present unique challenges that if understood can enrich the therapeutic experience. Frequently, unmanaged or unrecognized countertransference in work with older patients can manifest as ageism or the determination that patients are “not appropriate” for treatment. Awareness on the part of the clinician can avoid these pitfalls and better serve the needs of this special population.

Dr Mourra is a Clinical Instructor in geriatric psychiatry at the David Geffen School of Medicine at the University of California, Los Angeles. She reports no conflicts of interest concerning the subject matter of this article.

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 Bridges N. Meaning and management of attraction: neglected areas of psychotherapy training and practice. 

The Race Against Time: Psychotherapy and Psychoanalysis in the Second Half of Life

 king P. The life cycle as indicated by the nature of the transference in the psychoanalysis of the middle-aged and elderly.

 Gussaroff E. Denial of death and sexuality in the treatment of elderly patients. 

Therapeutic touch and agitation in individuals with Alzheimer’s disease

 Robinson KM. Understanding hypersexuality: a behavioral disorder of dementia. 

 Harris L, Wier M. Inappropriate sexual behavior in dementia: a review of the treatment literature. 

 Hillman JL, Stricker G. Management of sexualized transference and countertransference with older adult patients: implications for practice. 

 Berman CW, Bezkor MF. Transference in pa-tients and caregivers. 

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Of all the transferences that emerge in the consultation room, sexual feelings are by far the least talked about and the most challenging for therapists to manage. This author talks about erotic transferences here.

Author | Sarah Mourra, MD

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