Issues Regarding Sexuality and Nursing Understanding Sexuality and Sexual Health: Age-Related Sexual Issues, Their Assessment, and Nursing Care. Patient Views Toward Sexuality.
What Is Sexuality
Sexuality is an inherent quality present in all human beings and plays a crucial role in an individual’s self-identity and overall well-being (Wallace, 2008). According to the World Health Organization (WHO, 2010), sexuality is defined as “a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.”
Sexual Health
As a manifestation of sexuality, sexual health is described as “a state of physical, emotional, mental, and social well-being related to sexuality” (WHO, 2010). While sexual health contributes to satisfying physical needs, it is often not as apparent that sexual contact fulfills many social, emotional, and psychological components of life as well. This is evidenced by the fact that human touch and a healthy sex life can evoke feelings of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one’s sexuality (Kamel & Hajjar, 2003). When this occurs, sexual dysfunction—defined as impairment in normal sexual functioning—may result (American Psychiatric Association [APA], 2000).
It is frequently assumed that sexual desires and the frequency of sexual encounters begin to diminish later in life. Furthermore, the notion of older adults engaging in sexual activities has become taboo in today’s youth-oriented society (Kamel & Hajjar, 2003). Despite this stereotype, sexual identity and the need for intimacy do not disappear with increasing age, and older adults do not transform into celibate, asexual beings. In a study of 3,005 U.S. older adults, current sexual activity was reported in 73% of adults aged 57–64 years, 53% of adults aged 65–74 years, and 26% of adults aged 75–84 years (Lindau et al., 2007).
Sexual Problems and Age
Despite the persistence of sexual patterns throughout the lifespan, there is limited research and information to assist nurses in assessing and intervening to promote sexual health among older adults. The lack of research literature and insufficient clinical resources stem from the lack of societal recognition of sexuality as a continuing human need, which perpetuates the absence of sexual assessment and intervention among the older population.
In addition to the lack of literature, several factors further impact the sexual health of older adults. These factors include the presence of normal and pathological aging changes, environmental barriers to sexual health, and special problems of the older adult that interfere with sexual fulfillment, such as cognitive impairment.
Views Toward Sexuality and Aging
Nurses’ hesitancy to discuss sexuality with older adults has a significant impact on the sexual health of this population. Gott, Hinchliff, and Galena (2004) reported that general practitioners do not frequently discuss sexual health when providing primary care to older adults. Their study of 55 older men and women found that a major factor affecting sexual discussions between patients and their physicians included the hesitancy of discussing sexuality with a health care provider who was not the patient’s age or sex.
In this qualitative study, clients stated that sexuality discussions would be more comfortable and forthcoming with health care providers who matched their sex and age. Furthermore, attitudes toward sexuality later in life, making jokes about sexuality, feelings of shame or embarrassment, fear, perception of sexual problems as not serious, and lack of knowledge regarding available interventions were also seen as barriers to sexual discussions between older clients and health care providers (Gott et al., 2004).
General discomfort among nurses in discussing sexuality and lack of experience in assessment and management of sexual dysfunction among older adults often prevent nurses from addressing the sexual needs of this population. Furthermore, the sexuality of older adults is generally excluded from limited gerontological curricula. Without education and experience in managing sensitive issues around sexuality, health professionals are often not comfortable discussing sexual issues with older adults. Health care providers may lessen discomfort with addressing sexual issues by increasing their knowledge on the subject and routinely introducing this dimension of health into routine assessment and management protocols.
Nurses’ understanding of sexuality should be broadened beyond that of relationships between just men and women. Many clients within various health care systems are gay, lesbian, bisexual, or transgender (GLBT) adults, and these alternative sexual preferences require respect and consideration. In a focus group study, older gay and lesbian individuals reported extensive discrimination in accessing health care services due to exclusion from program planning (Brotman, Ryan, & Cormier, 2003). Discrimination among GLBT older adults is especially evident in the development of residential services to meet the needs of older adults. In a larger study of 400,000 GLBT adults, discrimination was observed among administrators, care providers, and other residents of retirement care communities (Johnson, Jackson, Arnette, & Koffman, 2005).
Normal and Pathological Aging Changes
The “sexual response cycle,” or the organized pattern of physical response to sexual stimulation, changes with age in both women and men. After menopause, a loss of estrogen in women results in significant sexual changes. This deficiency frequently leads to the thinning of the vaginal walls and decreased or delayed vaginal lubrication, which may cause pain during intercourse (Lobo, 2007). Additionally, the labia atrophy, the vagina shortens, and the cervix may descend downward into the vagina, causing further pain and discomfort. Furthermore, vaginal contractions are fewer and weaker during orgasm, and after sexual intercourse is completed, women return to the pre-aroused stage faster than they would at an earlier age.
The result of these physiological age-related changes in women is the potential for significant alterations in sexual health that have traditionally received little attention from research or individual health care providers. The pain resulting from anatomical changes and vaginal dryness may lead to the avoidance of sexual relationships to prevent painful intercourse.
Men also experience decreased hormone levels, mainly testosterone, yet this seems to have a limited impact on sexual functioning because only a minimal amount of testosterone is needed for sexual purposes. This reduction in testosterone, controversially labeled viropause or andropause and sometimes referred to as male menopause, generally begins between the ages of 46 and 52 years and is characterized by a gradual decrease in the amount of testosterone (Kessenich & Cichon, 2001). The loss of testosterone is not pathological and does not necessarily result in sexual dysfunction. However, men may experience fatigue, loss of muscle mass, depression, and a decline in libido. As a result of normal aging changes, older men require more direct stimulation of the penis to experience erection, which is somewhat weaker compared to that experienced at earlier ages. As with postmenopausal women, orgasms are fewer and weaker in older men, the force and amount of ejaculation are reduced, and the refractory period after ejaculation is significantly increased (Araujo, Mohr, & McKinlay, 2004).
Bodily changes such as wrinkles and sagging skin may cause both older women and men to feel insecure about initiating a sexual encounter and maintaining emotionally secure relationships. In addition, lack of knowledge and understanding among older adults about sexuality is common because sexual education is rarely provided in formal educational systems as older adults developed and was seldom discussed informally. Strict beliefs and values are likely to impact sexual action, freedom, and desires, potentially resulting in sexual frustration and conflict.
Physical changes in the sexual response cycle that occur with increasing age do not completely explain the extensive changes in sexuality that occur among older adults. Many individual psychosocial and cultural factors play a role in how older adults perceive themselves as sexual beings. Although sexual disorders have not been well addressed among the older population, they have been defined and fall into four categories: hypoactive sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorders (Walsh & Berman, 2004).
In addition to normal aging changes and pathological sexual disorders, there are a number of medical conditions that have been associated with poor sexual health and functioning in the older population (Morley & Tariq, 2003). Rosen et al. (2009) reported that the main predictors of sexual dysfunction are age, cardiovascular diseases, and diabetes.
One of the most frequently occurring medical conditions among older adults includes cardiovascular disease. In a study of 2,763 postmenopausal women, the presence of coronary heart disease was associated with lack of interest, inability to relax, arousal and orgasmic disorders, and general discomfort with sex (Addis et al., 2005). Diabetes is a significant problem among older adults, affecting approximately 14.7 million individuals in the United States each year. Approximately 40% of those with diabetes are aged 65 years or older (Centers for Disease Control and Prevention [CDC], n.d.). In a study of eight women aged 24–83 years, older women with diabetes reported lower sexual function, desire, and enjoyment than their younger counterparts (Rockliffe-Fidler & Kiemle, 2003). Furthermore, in a study of 373 men aged 45–75 years with Type II diabetes, 49.8% of men reported mild or moderate degrees of erectile dysfunction (ED), and 24.8% had complete ED (Rosen et al., 2009).
The presence of depression among older adults impacts sexual health, in that depression often causes a decline in desire and ability to perform due to the disease and its treatment. Korfage et al. (2009) reported in a study of 3,810 men aged 57–78 years that men with ED reported significantly lower mental health than men without ED. The presence of loss and depression should be assessed among older adults and considered for the impact of these emotional and psychological factors on sexual health (see Chapter 9, Depression in Older Adults).
Other medical conditions occurring among older adults also have the potential to impact sexual health. Older adults who have experienced strokes and subsequent aphasias reported alterations in sexual health due to communication difficulties (Lemieux, Cohen-Schneider, & Holzapfel, 2001). Additionally, Parkinson’s disease (PD), which is predominantly found in older adults, has the potential to negatively impact sexual health. In a study of 444 older adults with PD, sexual limitations were reported in 73.5% of the sample as a result of difficulty in movement (Mott, Kenrick, Dixon, & Bird, 2005). Benign prostatic hypertrophy (BPH) in older men may result in altered circulation to the penis, affecting erectile function and sexual arousal.
Derogatis and Burnett (2008) stated that sexual dysfunction is prevalent worldwide, and its occurrence and the frequency of symptoms that impact sexual health increase directly with age for both men and women. Pathological changes of aging, such as the conditions discussed, are major risk factors for sexual disorders.
Medications used to treat commonly occurring medical illnesses among older adults also impact sexual function. Two of the major groups of medications include antidepressants and antihypertensives. Causative antidepressants include the commonly used selective serotonin reuptake inhibitors (SSRIs). In a study of 610 women and 412 men, 59.1% of the individuals taking SSRI antidepressant medications reported sexual dysfunction (Montejo, Llorca, Izquierdo, & Rico-Villademoros, 2001). Although the use of monoamine oxidase (MAO) inhibitors and tricyclic antidepressants has decreased in favor of the SSRIs with lower side-effect profiles, these medications also impact sexual function by reducing sexual drive and causing impotence and erectile and orgasmic disorders.
Antihypertensives, including angiotensin-converting enzyme (ACE) inhibitors and alpha and beta blockers, also result in impotence and ejaculatory disturbances among older adults (Alagiakrishnan et al., 2005). Antipsychotics, commonly used statin medications, and H2 blockers also impact the sexual health of older adults.
Special Issues Related to Older Adults and Sexuality
Cognitively impaired older adults continue to have sexual needs and desires that present a challenge to nurses. These continuing sexual needs often manifest in inappropriate sexual behavior. Sexual behaviors common to cognitively impaired older adults may include cuddling, touching of the genitals, sexual remarks, propositioning, grabbing and groping, use of obscene language, masturbating without shame, aggression, and irritability.
In a study of 41 cognitively impaired older adults, 1.8% exhibited sexually inappropriate behavior manifesting in verbal and physical problems (Alagiakrishnan et al., 2005). In a study that used computed tomography (CT) scans of the head on 10 patients with these problematic sexual behaviors, cerebral infarction was seen in six of them, and severe disease in two others, supporting the organic basis for these symptoms (Nagaratnam & Gayagay, 2002).
Masturbation is a method by which cognitively impaired men and women may become sexually fulfilled. Nurses in long-term care facilities may assist older adults to improve sexual health by providing an environment in which the older adult may masturbate in private. Alkhalil, Tanvir, Alkhalil, and Lowenthal (2004) reported that the use of gabapentin to decrease sexual behavior problems (such as inappropriate sexual overtures and public masturbation) has demonstrated effectiveness anecdotally.
Accurate assessment and documentation of the ability of cognitively impaired older adults to make competent decisions regarding sexual relationships with others while in long-term care is essential. If the resident has been determined to be incapable of decision-making, then the health care staff must prevent the cognitively impaired resident from unsolicited sexual advances by a spouse, partner, or other residents.
Environmental settings may also influence sexuality among older adults. Normally, engaging in sexual intercourse occurs within the privacy of one’s bedroom; however, for some older adults, extended care facilities are the substitute for what was once called home. Residents of extended care facilities state that many of the obstacles they face regarding their sexuality include lack of opportunity, lack of available partners, poor health, feeling sexually undesirable, and guilt for having these sexual feelings. Furthermore, negative staff attitudes and beliefs regarding residents’ sexual activity bar the expression of sexuality in long-term care settings (Hajjar & Kamel, 2004).
Twenty-five percent of all HIV cases are developed in adults older than the age of 50 years, underscoring the significant risk of HIV transmission in the older age group. Older adults with HIV are more likely to be diagnosed late in the disease, progress more quickly, and have a shorter survival (Martin, Fain, & Klotz, 2008). The use of antiretroviral medications among older adults may be complicated by multiple chronic comorbidities and treatments (Magalhães, Greenberg, Hansen, & Glick, 2007). Sherr et al. (2009) conducted a study of 778 patients in an HIV clinic. Of the total population, 12% were aged older than 50 years. The findings revealed that older patients reported significantly lower psychological and global burden and were more likely to take antiretrovirals than their younger cohorts. Health care providers are in a unique position to assess and manage HIV among the older population, but greater education regarding the risk for HIV in the older population is needed.
A well-established model to guide sexual assessment and intervention, known as the Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model (Annon, 1976), has been effectively used among younger populations since the 1970s. The model begins by first seeking permission (P) to discuss sexuality with the older adult. Since many sexual disorders originate from feelings of anxiety or guilt, requesting permission empowers the client, placing them in control of the conversation and facilitating open communication between the healthcare provider and the client.
Permission can be obtained by posing general questions such as, “I would like to begin discussing your sexual health; what concerns would you like to share with me about this aspect of your life?” Many healthcare assessment forms include questions designed to guide the sexual assessment of older adults.
The next step of the model provides an opportunity for the nurse to share limited information (LI) with the older adult. In the context of older adults, this stage allows healthcare providers to dispel myths about aging and sexuality, discussing the impact of normal and pathological aging changes, as well as medications, on sexual health.
The subsequent part of the model guides the nurse to offer specific suggestions (SS) to improve sexual health. Nurses may implement several interventions recommended for enhancing sexual health, such as promoting safe sex practices, more effective management of acute and chronic diseases, removal or substitution of medications causing sexual dysfunction, environmental adaptations, or initiating discussions with partners and families.
The final component of the model calls for intensive therapy (IT) when necessary for clients whose sexual dysfunction exceeds the scope of nursing management. In such cases, referral to a sexual therapist is appropriate.
Sexual assessments are most effective when using open-ended questions like:
- “Can you tell me how you express your sexuality?”
- “What concerns do you have about your sexuality?”
- “How has your sexuality changed as you have aged?”
- “What changes have you noticed in your sexuality since you were diagnosed or treated for a disease?”
- “What thoughts have you had about ways to enhance your sexual health?”
The loss of relationships with significant, intimate partners is unfortunately common among older adults and often halts communication about the importance of self to the person experiencing the loss. This greatly impacts the older adult’s sexual health. Asking about past and present relationships in their life will aid this assessment.
Barriers to sexual health should be evaluated, including normal and pathological changes of aging, medications, and psychological problems like depression. Moreover, lack of knowledge and understanding about sexuality, loss of partners, and family influence on sexual practices often present substantial barriers to sexual health among older adults. Nurses should assess for physiological changes through health history, review of systems, and physical examinations to identify normal and aging changes impacting sexual health.
Older adults may perceive normal aging changes and their subsequent impact on appearance as embarrassing or indicative of illness. This may lead to a negative body image and reluctance to pursue sexual health. It is crucial for nurses to consider the impact of normal and pathological aging changes on body image and frequently assess their effects.
As previously discussed, several medical conditions are associated with poor sexual health and functioning, including depression, cardiac disease, diabetes, stroke, and Parkinson’s disease. Effective assessment of these illnesses using open-ended health history questions, system reviews, physical examinations, and appropriate lab testing will provide necessary information for proper disease management and improved sexual function.
Assessing the impact of medications among older adults, especially those commonly used to treat medical illnesses such as antidepressants and antihypertensives, is essential. Potential medications should be identified by reviewing the client’s medication bottles, and the client should be questioned about the potential impact of these medications on sexual health. If a medication is found to affect sexual health, alternative medications should be considered. The older adult should also be asked about alcohol use, as this substance can impact sexual response.
Interventions and Care Strategies
Following a thorough assessment of normal and pathological aging changes, as well as environmental factors, several interventions can be implemented to promote the sexual health of older adults.
These interventions fall into several broad categories:
- Education regarding age-associated changes in sexual function
- Compensation for normal aging changes
- Effective management of acute and chronic illnesses affecting sexual function
- Removal of barriers associated with difficulty in fulfilling sexual needs
- Special interventions to promote sexual health in cognitively impaired older adults
Client Education
The most crucial intervention to improve sexuality among the older population is education. It’s important to remember that sexuality was likely not addressed in formal educational systems as older adults developed and was rarely discussed informally. Older adults may hold outdated values that impact sexual action, freedom, and desires, leading to both sexual frustration and conflict.
In his seminal work on the sexuality of older adults, Masters (1986) reported that older women were raised to believe that when menstruation ceased, they would cease to be feminine. Knowledge is essential for the successful fulfillment of sexuality for all individuals.
The incidence of HIV and AIDS infection is rising among older adults, with 25% of new cases occurring in adults over the age of 50 years (Martin et al., 2008). This underscores the significant risk of HIV transmission in the older age group and the need for effective teaching regarding safe sex practices. Teaching about the use of condoms to prevent the transmission of sexually transmitted diseases is essential. In response to this rise in HIV cases and other sexually transmitted diseases, it’s imperative to provide older adults with safe sex information provided by the Centers for Disease Control and Prevention (CDC).
Compensating for Normal Aging Changes
Assisting older adults in compensating for normal aging changes related to sexual dysfunction will greatly lessen the impact of these changes on sexual health. Among women, discussing anatomical changes will help them anticipate how these changes affect sexuality. For example, decreases in the size of the vagina and increased vaginal dryness may require the use of artificial water-based lubricants or topical estrogen agents.
In a multicenter, double-blind, randomized, placebo-controlled study, 305 women with symptoms of vaginal atrophy were treated with a low-dose synthetic conjugated estrogen-A (SCE-A) cream twice weekly. The results showed that the cream significantly reduced symptoms of vaginal atrophy and pain during intercourse compared to the placebo (Freedman et al., 2009).
In men, delayed response and increased time needed for erections and ejaculations are normal aging changes of which older adults may be unaware. Understanding the impact of these changes helps them realize the need to plan for more time and direct stimulation to become aroused.
One of the most important preventive measures older adults can undertake to reduce the impact of normal aging changes on sexual health is to continue engaging in sexual activity.
Planning for more time during sexual activities, being sensitive to changes in each other’s bodies, using aids to increase stimulation and lubrication, and exploring foreplay, masturbation, sensual touch, and different sexual positions—along with education about these common changes associated with sex and aging—can help immensely.
By doing so, changes in sexual response patterns are less likely to occur. Eating healthy foods, getting adequate sleep, exercising, practicing stress-management techniques, and avoiding smoking are also very important for sexual health.
Effective Management of Acute and Chronic Illness
Effective management of both acute and chronic illnesses that impair sexual health is also important. Interventions that improve sexual health are framed within current disease treatment strategies. In other words, effective disease management using primary, secondary, and tertiary interventions will not only treat the disease but also result in improved sexual health. For instance, better glucose control among diabetics enhances circulation and may increase arousal and sexual response.
Appropriate treatment of depression with medication and psychotherapy will enhance desire and sexual response. Although treating depression may help improve libido and sexual dysfunctions such as orgasmic disorders, medications used to treat depression often impact sexual function by lowering libido and causing orgasmic disorders.
As a potential alternative to address libido problems during antidepressant management, Seidman and Roose (2006) conducted a study with 32 depressed patients averaging 52 years old. The participants were randomized to receive either Enanthate (testosterone) 200 mg or sesame seed oil (placebo). While self-reported sexual functioning improved in both groups, no significant differences were found between them.
Oral erectile agents like sildenafil citrate (Viagra), vardenafil HCI (Levitra), and tadalafil (Cialis) play a significant role in treating sexual dysfunction associated with aging and are effective and well-tolerated treatments for erectile dysfunction in older men (Wespes et al., 2007). In men treated for prostate cancer with radical prostatectomy, the use of oral erectile agents to manage erectile dysfunction immediately following surgery is also gaining support (Miles et al., 2007).
Medications used to treat diseases may result in sexual dysfunction among older adults (see NetDoctor for a list of these medications). Many medications can lead to decreased sexual drive and impotence, as well as orgasmic and ejaculatory disorders.
These medications are widely prescribed for chronic illnesses among older adults, including psychological disorders like depression, hypertension, elevated cholesterol, sleep disorders, and peptic ulcer diseases. Furthermore, due to hesitancy among older adults and nurses to discuss sexual problems, the effect of these medications on sexual function is often not addressed in clinical settings.
This may result in prolonged sexual dysfunction or noncompliance with the medication. Recognizing the continuing sexual needs of older adults is essential for initiating dialogue about sexual problems. Effective assessment will uncover medications affecting sexual function and lead to considering stopping the medication in favor of alternative disease management strategies or substituting the medication with another that has fewer sexual side effects.
Removal of Barriers to Sexual Health
One of the greatest barriers to sexual health among older adults lies in nurses’ persistent beliefs that older adults are not sexual beings. Nurses should be encouraged to open lines of communication to effectively assess and manage the sexual health needs of aging individuals with the same consistency as other bodily systems, treating alterations in sexual health with available evidence-based strategies.
An essential intervention to promote sexual health in this population is to educate nurses about the continuing sexual needs and desires persisting throughout the lifespan. Education regarding older adult sexuality as a continuing human need should be included in multidisciplinary education and staff development programs.
Educational sessions may begin by discussing prevalent societal myths around older adult sexuality. Nurses should be encouraged to explore their own feelings about sexuality and its role in the lives of older adults. Furthermore, developing policies and procedures to manage sexual issues of older adult clients is important across all care environments.
Environmental adaptations to ensure privacy and safety among long-term care and community-dwelling residents are essential. Arrangements for privacy must be made to protect the dignity of older adults during sexual activity. For example, nurses may assist in finding activities for a resident’s roommate to provide privacy or securing a common room for private visits.
Call lights or telephones should be kept within reach during sexual activity, and adaptive equipment like positioning devices or trapezes may need to be provided. Interventions such as offering private rooms and consultations for residents regarding evaluation and treatment of their sexual problems are among the many ways this can be accomplished (Wallace, 2008). Roach (2004) suggested that nursing home staff and administration work to develop environments supportive and respectful of older residents’ continuing sexual rights, promoting sexual health.
Families are an integral part of the interdisciplinary team. However, for older couples, especially those in relationships with new partners, it is often difficult for families to understand that their older relative may have a sexual relationship with someone other than the person they are accustomed to. A family meeting, with a counselor if needed, is appropriate to help the family understand and accept the older adult’s decisions about the relationship.
Special Interventions to Promote the Sexual Health of Cognitively Impaired Older Adults
Cognitively impaired older adults continue to have sexual needs and desires but may lack the capacity to make appropriate decisions regarding sexual relationships. Accurate assessment and documentation of the ability to make informed decisions about sexual relationships must be conducted by an interdisciplinary team. If the older adult is incapable of making competent decisions, participation in sexual relationships may be considered abusive and must be prevented.
Conversely, nurses should not attempt to prevent sexual relationships and can play an important role in promoting sexual health among older adults who are cognitively competent to make decisions regarding sexual relationships. In these cases, nurses should implement all necessary interventions to promote the sexual health of older adult clients.
Inappropriate sexual behavior such as public masturbation, disrobing, or making sexually explicit remarks to other patients or healthcare professionals may signal unmet sexual needs among older adults. A comprehensive sexual assessment should be conducted using clear communication and setting appropriate limits in these situations. Following this, a plan should be developed to manage the behavior while providing utmost respect and preserving the client’s dignity.
Providing an environment where the older adult can pursue their sexuality in private may be a simple solution to a complex problem. Medication management for hypersexual behavior may be considered. Tricyclic antidepressants and trazodone are two medications with antilibidinal and anti-obsessive effects that can be safely used to treat hypersexual behavior (Wallace & Safer, 2009). Levitsky and Owens (1999) reported that antiandrogens, estrogens, gonadotropin-releasing hormone analogues, and serotonergic medications may be successful when other methods are ineffective.