Response to Touch

The Touch model proposed by Hollinger and Buschmann (1993) proposes that attitudes toward touch and acceptance of touch affect the behaviors of both caregivers and patients. Two types of touch occur during the nurse-patient relationship: procedural and non-procedural. Procedural touch (task-oriented or instrumental touch) is physical contact that occurs when a particular task is being performed. Non-procedural touch (expressive physical touch) does not require a task but is affective and supportive in nature, such as holding a patient’s hand.

Nurses should recognize the influence of their own personality, cultural expectations, and early exposure to touching. Everyone has definite feelings and opinions about touch based on his or her own life experience. “Individuals learn the boundaries of tactual communication culturally” (Kim and Buschmann, 2004, p. 37). Touch only if it is comfortable, and do not assume that a person likes or wants to be touched (Rheaume and Mitty, 2008). Individuals quickly discern the discomfort of another if touch is not an integral part of behavior. It is important to remember that the comfort of touching depends on the location of touch, the situation, social status, culture, and age.

A test of the person’s readiness to be touched is to initiate a hand clasp or handshake. The person can feel the tension or the welcoming relaxation that occurs. Some people respond warmly to a firm touch and others to a light or casual touch. Useful information may be obtained through a handshake. Does the individual grasp firmly or hesitate? Does he or she relinquish quickly or hold on? Are the fingers intertwined or held together? Is the hand limp, passive, or responsive, or is it tremulous, sweaty, or cold?

Fear of Touching

Often a nurse will touch in a condescending way (a pat on the head or a tweak of the toe) or in a circumscribed nursing treatment. Of all health care professionals, nurses have the most frequent opportunities to provide gentle, reassuring, renewing touch. The intimacy of the nurse-patient contacts may influence a nurse to be overly circumspect. However, the use of touch involves risk and may be misinterpreted by the nurse or patient. Stirring sexual feelings, if that is a response to gentle touching, is a human response and need not frighten.

Nurses sometimes respond negatively to a breach in the “status” of touch. A status system of touch exists that is significant to health care. A person of higher status may touch an individual of an inferior status, but the reverse is discouraged. Similarly, name familiarity may be used by an individual in a superior position but is greatly resented if the lower-ranking person presumes the same liberty. Because this notion is embedded in many hierarchical structures, treating everyone with respect regarding their name and propensity for touch is prudent. Instant familiarity is seldom useful. It should not be surprising when a patient reciprocates with the same level of intimacy as the nurse initiates. Therapeutic, caring touch by the nurse is a potent healing intervention. It is important that touching be done with respect regarding the person’s comfort and with the nurse’s intention of providing a comforting and healing modality within the nurse-patient relationship.

Touch Zones

Hall (1969) identifies different categories of touching—expanding or contracting zones around which every individual extends the sensory experience of touching, smelling, hearing, and seeing. The categories of touching include the intimate, vulnerable, consent, and social zone (Figure 21-1). Entering the zone of intimacy, which is identified as being in an area within an arm’s length of the individual’s body and is the space used for comforting, protecting, and lovemaking, is part of the nurse’s function. The vulnerable zone is highly sexually charged and will be protected. The most intimate area, the genitalia, is the most personally protected area of the body and causes the most stress and anxiety when approached, touched, or viewed by the caregiver. The consent zone requires the nurse to seek out or ask permission to touch or initiate procedures to these areas. The social zone includes the areas of the body that are the least sensitive or embarrassing to be touched and that do not necessarily require permission to be handled.

Illness, confinement, and dependency seen in institutionalization are stresses on the intimate zone of touch. Just as caregivers enter a room without knocking, so they often intrude into the intimate circle of touch without asking. A person’s need for privacy and personal space is strongly related to acceptance and response to touch. If the need for privacy and distance is great, touch should be used judiciously. The parameters of the intimate zone of touch are examined in this chapter to emphasize the importance of understanding behavior that might occur when the nurse enters this arena.

Touch Deprivation

Montagu (1986) noted that “tactile hunger” becomes more powerful in old age when other sensuous experiences are diminished and direct sexual expression is often no longer possible or available. Furthermore, Montagu believes the cause of illness may be greatly influenced by the quality of tactile support received. Do older people suffer touch deprivation? Many elders do if they are separated from caring others. Older men, in particular, may find it hard to reach out to others for comforting and caring touch. The previous lifestyles of these men often discouraged touch, except in the intimacy of sexual contact, which may no longer be available to them (Montagu, 1986). Older women are allowed considerably more freedom to touch, although they may lack the opportunity. Studies have shown that older women have reduced access to nonsexual intimacy, such as greeting someone with a hug or kiss or playing or cuddling with a grandchild (Waite et al., 2009). Since older women are more often widowed, reduced access to these other forms of nonsexual intimacy can further deprive them of warm and loving contact.

In the cases of the isolated or institutionalized older person, higher death rates are more related to the quality of human relationships than they are to the degree of cleanliness, nutrition, and physical disabilities on which we focus. Sansone and Schmitt (2000) noted that older people in nursing homes experience touch every day as they are bathed, dressed, toileted, fed, and positioned. The type of touch they desire is not task-oriented touch but “gentle, patient, conscious touch of another person that says to them, ‘I’m here, I care, you are important to me.’ It’s the kind of touch that goes beyond routine and bonds one human being with another” (p. 304).

Therapeutic Touch

Touch is a powerful healer and a therapeutic tool that nurses can use to satisfy “touch hunger” of older people. Nursing has recognized the importance of touch and has the social sanctions to touch the body in the intimate and personal care of a person, an opportunity too often not fully used for the betterment of the older person’s adaptation to environment and location in time and space. Touch can serve as a means of providing sensory stimulation, reducing anxiety, relieving physical and psychological pain, and comforting the dying, as well as sexual expression.

Kreiger’s experiments with therapeutic touch (1975) demonstrate physiological and psychological improvement in patients who are exposed to consistent “doses” of touch. “Hands-on healing and energy based interventions have been found in cultures throughout history, dating back at least 5000 years” (Wang and Hermann, 2006, p. 34). “Laying on of the hands” and the power of touch to heal had largely disappeared with the scientific revolution. The phenomenon has reemerged as healing touch and therapeutic touch movements. A growing body of research supports the healing power of touch, and Energy Field, Disturbed is an approved nursing diagnosis (Wang and Hermann, 2006, p. 34). Many nurses have learned how to perform therapeutic and healing touch and use these modalities in their practice with people of all ages. Positive outcomes of interventions utilizing touch in nursing homes, particularly with people with dementia and agitated behaviors, have been reported (Box 21-1). Further research on the use of touch with older people is needed. Touch is a powerful tool to promote comfort and well-being when working with elders.

Acceptance and Companionship

Sexuality validates the lifelong need to share intimacy and have that offering appreciated. Sexuality is love, warmth, sharing, and touching between people, not just the physical act of coitus. Margot Benary-Isbert, in her book The Vintage Years (1968), expresses the essence of sexuality most eloquently (p. 200):

Femininity and Masculinity

Males and females possess characteristic behavioral traits, which Jung refers to as the anima (female) and animus (male). Past social pressures did not often allow the appearance of sensitivity, gentleness, and sentimentality in most men. Men were expected to be strong, to be in control of situations, and to handle their emotions. On the other hand, women were not viewed as aggressive or the major decision makers.

Often seen and perpetuated among older adults are socially accepted standards characteristic of masculine and feminine behavior, which reflect male and female role models dominant in their formative years. Jung’s work has shown this view to be so, indicating that strong attitude types (male and female) and roles and functions associated with these attitudes are developed as adaptations of the person to the demands of the environment.

Man believed that repressing his feminine traits was virtuous; and woman, until recently, repressed her animus. Both men and women, however, are not consciously aware that they possess the opposite sexual identity. Goldblatt (1972) contends that neither gonads nor chromosomal sex is a determinant of sexual behavior. Money and Tucker (1975), in their work Sexual Signatures, believe that social stimulation provides gender identity and limits the individual’s concept of self. In essence, society expects men to be men and women to be women.

In the latter part of life, self-knowledge deepens. People tend to discover traits in their nature that were previously suppressed or heretofore remained in the unconscious. At this time, the emergence of the anima (in men) and animus (in women) may be seen. Jung identified this experience as the expression of the psyche that in the first half of life was turned inward. In late life, directed outward, this expression becomes indicative of the capacity for fuller living. Men become more comfortable with tenderness, “more dependent on the marriage for their sense of well-being, and more willing to accommodate for the sake of preserving peace” (Huyck, 2001, p. 11). Women become more assertive and self-confident. The person’s ability to accord his or her other nature its due recognition will enhance sexuality.

A large number of cultural, biological, psychosocial, and environmental factors influence the sexual behavior of older adults. The older person may be confronted with barriers to the expression of his or her sexuality by reflected attitudes, health, culture, economics, opportunity, and historic trends. Factors affecting a person’s attitudes on intimacy and sexuality include family dynamics and upbringing and cultural and religious beliefs (Chapter 5). Older people often internalize the broad cultural proscriptions of sexual behavior in late life that hinder the continuance of sexual expression. Much sexual behavior stems from incorporating other people’s reactions. Older people do not feel old until they are faced with the fact that others around them consider them old. Similarly, older adults do not feel asexual until they are continually treated as such.

American society continues to struggle with open acceptance of sexual expression for the young but continues to remain hostile to the attempts of older people to do the same. Sexual interest and activity in older adults are sometimes regarded as deviant behavior and described in such terms as “dirty old man,” “lecher,” and “old biddy.” The same activity attempted by a younger person would be viewed as appropriate. An often quoted statement by Alex Comfort (1974) sums it up nicely: “In our experiences, old folks stop having sex for the same reasons they stop riding a bicycle—general infirmity, thinking it looks ridiculous, no bicycle.” Box 21-2 presents some of the myths about sexuality in older people that may be held by older people themselves and by society in general.

Biological Changes with Age

Acknowledgement and understanding of the age changes that influence sexual physiology, anatomy, and the stages of sexual response may partially explain alteration in sexual behavior to accommodate these changes and facilitate continued pleasurable sex. Characteristic physiological changes during the sexual response cycle do occur with aging, but these vary from individual to individual depending on general health factors. The changes occur abruptly in women starting with menopause but more gradually in men, a phenomenon called andropause (Kennedy et al., 2010). The “use it or lose it” phenomenon also applies here: the more sexually active the person is, the fewer changes he or she is likely to experience in the pattern of sexual response. Changes in the appearance of the body (wrinkles, sagging skin) may also affect the older person’s security about his or her sexual attractiveness (Arena and Wallace, 2008). Table 21-1 summarizes physical changes in the sexual response cycle.

TABLE 21-1

PHYSICAL CHANGES IN SEXUAL RESPONSES IN OLD AGE

FEMALE	MALE
Excitation Phase
Diminished or delayed lubrication (one to three minutes may be required for adequate amounts to appear)	Less intense and slower erection (but can be maintained longer without ejaculation)
Diminished flattening and separation of labia majora	Increased difficulty regaining an erection if lost
Disappearance of elevation of labia majora	Less vasocongestion of scrotal sac
Decreased vasocongestion of labia minora	Less pronounced elevation and congestion of testicles
Decreased elastic expansion of vagina (depth and breadth)
Breasts not as engorged
Sex flush absent
Plateau Phase
Slower and less prominent uterine elevation or tenting	Decreased muscle tension
Nipple erection and sexual flush less often	No color change at coronal edge of penis
Decreased capacity for vasocongestion	Slower penile erection pattern
Decreased areolar engorgement	Delayed or diminished erectal and testicular elevation
Labial color change less evident
Less intense swelling or orgasmic platform
Less sexual flush
Decreased secretions of Bartholin glands
Orgasmic Phase
Fewer number and less intense orgasmic contractions	Decreased or absent secretory activity (lubrication) by Cowper gland before ejaculation
Rectal sphincter contraction with severe tension only	Fewer penile contractions
	Fewer rectal sphincter contractions
	Decreased force of ejaculation (approximately 50%) with decreased amount of semen (if ejaculation is long, seepage of semen occurs)
Resolution Phase
Observably slower loss of nipple erection	Vasocongestion of nipples and scrotum slowly subsides
Vasocongestion of clitoris and orgasmic platform	Very rapid loss of erection and descent of testicles shortly after ejaculation
	Refractory time extended (time required before another erection ranges from several to 24 hours, occasionally longer)

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