No one wants to talk about sex in nursing homes.

The need for sex doesn’t disappear as we age, yet many facilities for the elderly have no policy on sex at all and only acknowledge that it happens when there’s a problem, like concern that an Alzheimer’s or dementia patient is being abused. Whether it’s out of ageism or just discomfort with the idea of senior sexuality, nursing homes are not eager to raise the issue, leaving a massive gray area where the line of consent is blurry.

“We’ll ask them about their religion, the music they like, what kind of food they want to eat. We don’t dream of asking them about their preferences around sexuality and intimacy,” said Dr. Cheryl Phillips, a senior advocate at LeadingAge, an association of nonprofit senior services.

The risks of ignoring residents’ sex lives are real. The issue most recently came to light in Iowa, when Henry Rayhons, 78, a longtime state lawmaker, was charged with sexually abusing his elderly wife, an Alzheimer’s patient, while she was living in a nursing home. Rayhons was acquitted this week, after testifying that he and his wife had shared a loving, consensual relationship. The case, which involved family tension between Rayhons and his step-daughters, was complicated by questions of whether someone with dementia can give consent, and whether Alzheimer’s patients have the right to have sex or the right to be protected from it.

Mr. Rayhons could not be reached for comment, and the administrator for the nursing home where his wife resided in Iowa, Concord Care Center, declined to comment.

When Phillips was a practicing geriatric physician, she dealt with sex often. In one particularly thorny case, two residents of a nursing home who both had dementia had begun kissing and holding hands, even though they were both still married to spouses who lived elsewhere. The nursing home lovebirds, though, each believed the other was their spouse. After consulting with the families, the nursing home decided to allow the budding relationship to go forward, since it was bringing the two so much happiness.

“The lesson we took out of that is that it is good to talk with families and be open about values and preferences,” Phillips said. However, she added, “There’s a flip side. Elders deserve privacy. If I’m in a nursing home and I’m attracted to a man, do you have to get my son’s permission for me to be intimate? Where are the boundaries with intimacy? That is where we as a country are really struggling. We don’t have good answers.”

When it comes to managing the sex lives of nursing home residents, the problems are not going away. By 2030, nearly 20% of the U.S. population will be 65 or older, according to Pew Research Center. And according to the World Health Organization, there are 47.5 million people with dementia, a number that will nearly double by 2030.

Today’s aging Americans also grew up with fewer sexual limits than earlier generations and may be unwilling to live in nursing homes that don’t accommodate their sex lives, experts say. “Let’s be real. Baby boomers brought the sexual revolution to America in the ’60s—what are they going to bring to nursing homes?” Roberta Flowers, co-director of the elder law center at Stetson University College of Law, told TIME.

But elder advocates, physicians and nursing home experts say that there is no national standard of best practices for how nursing homes should accommodate residents who are sexually active. The policies that do exist are archaic, regressive and even ageist, and do not acknowledge that nursing home residents could happily have consensual sex with each other.

One exception is the Hebrew Home at Riverdale in the Bronx, which is cited by many as the leader in progressive policies on sex. The Hebrew Home has a Sexual Expression Policy, which “recognizes and supports the older adult’s right to engage in sexual activity.”

Daniel Reingold, the CEO of Riverspring Health, which operates the Hebrew Home, said they developed the policy in 1995 after realizing that residents were having sex and the home had no plan for dealing with it. The problem became clear to him one day when he was walking down the home’s hallway and a nurse came up to him and asked him what she should do about two residents having sex in one of the rooms. “Tiptoe out and close the door!” he replied.

Reingold says many of his colleagues in the nursing home community are reluctant to adopt policies because of liability, and also just plain nervousness around sex. The issue is also complicated by adult children who are uncomfortable with their parents’ sexual lives, particularly if there is adultery. “It reflects ageism at its worst. People don’t want to acknowledge that old people have sex,” he said. “Intimacy and sexuality is a civil right no different than the right to vote.”

The question of whether the elderly should be having sex is most troubling when it comes to dementia. But experts and elderly advocates say people with dementia are capable of consenting to sex, that they are able to express that consent, and that sex and touch can be good for them, which makes it difficult to know when it is appropriate to set limits. Hebrew Home’s policy is explicit that patients with dementia and Alzheimer’s can give consent to sex, either verbally or non-verbally.

“A 12-year-old can’t consent to sex with an adult today or tomorrow. You can’t have the same black-or-white rule for someone suffering from dementia,” said Flowers, the expert on elderly law. “Someone with dementia is not incapacitated all the time for all things. If they are not incapacitated at the moment of the sex act, they have a right to have sex.”

She added, “It’s a difficult issue and it’s not going away.”

Nursing homes must establish policies, and must be comfortable talking about sex with residents and their families, advocates said. “People want to have sex. That doesn’t change merely because you have gray hair,” Flowers said. “We have got to be willing to talk about it.”

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