Older Adults’ Sexual Needs

Until 2007 there was no comprehensive, nationally representative, population-based data available to inform health care providers’ understanding of the sexual norms and problems of older adults. Lindau, Schumm, Laumann, et al designed the National Social Life, Health, and Aging Project (NSHAP) to provide data on the sexual behaviors and problems of older adults. Aside from the NSHAP study, literature pertaining to the sexuality of older adults remains limited.

Sexuality is an important part of health, general well-being, and quality of life. Human sexuality includes various types of intimate activity, as well as the sexual knowledge, beliefs, attitudes, and values of individuals. Not only does sexual activity provide pleasure for older adults, it may also help maintain a sense of usefulness and self-esteem, aspects of life often diminished after retirement. Sexual activity can help each partner express love, affection, and loyalty. It can also enhance personal growth, creativity, and communication. Older persons, especially older women, who feel desirable and attractive often feel younger as well (Messinger-Rapport, Sandhu, & Hujer, 2003).

In the 2007 Lindau et al study, older adults regard sexual activity as an important part of life. Although the need to express sexuality continues among older adults, they face several barriers to sexual expression, including problems arising from low desire, aging, disease, and medications; societal beliefs; and changes in social circumstances (Lindau et al, 2007). Nurses are in a pivotal position to assess normal aging changes, along with those caused by disabling medical conditions and medications, and to intervene at an early point to enhance sexuality in older adults.

This chapter explores both normal and pathologic aspects of sexuality for older adults. The obstacles in assessing and managing sexuality in the various care settings in which older adults reside are discussed. Finally, this chapter proposes the application of the nursing process to older adults’ intimacy and sexuality needs.

The Importance of Intimacy Among Older Adults

Despite the fact that the literature supports the existence of sexual interest and practice in older adults, health care professionals carry out few interventions to facilitate older adults’ expression of sexuality. One reason for this is that society continually equates sexuality with sexual intercourse. However, according to the World Health Organization, sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. Although sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biologic, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors.

In fact, if sexuality among older adults is viewed as a need for intimacy, society and health care professionals may be more comfortable in helping older adults meet those needs.

The absence of male partners for older women propagates the stereotype that older adults should not participate in sexual relationships. The life span of men in the United States is shorter than that of women. In 2006, women accounted for 58% of the population age 65 or older and 68% of the population age 85 or older (Older Americans, 2008). This often leaves older women without sexual partners. The loss of a partner does not necessarily mean that the woman does not have continuing sexual needs. In a recent study, Lindau et al (2007) found that older women had a similar number of sexual concerns as younger women but were less likely to have the topic of sexual health raised during health care visits. It is imperative that health care professionals value the continuing sexual needs of older women as much as those of younger individuals and provide interventions for fulfilling sexuality.

At times, such interventions might include increasing socialization for older women to assist them with finding new partners. Older adults may be reluctant to begin dating, feeling unfamiliar with dating practices. How to date and make new relationships can be challenging (Butler & Lewis, 2000). Alternatively, masturbation is a method in which both men and women can be sexually fulfilled in the absence of partners. Lindau et al found that the prevalence of masturbation was lower at older ages but higher among older men than older women (2007). Assisting older adults with masturbation may appear beyond a nurse’s ability; however, there are excellent references available within commercial bookstores to help older adults use this method to become sexually fulfilled.

The literature has established that, in addition to older adults’ ongoing need to express their sexuality through traditional sexual methods, the human need to touch and to be touched must also be fulfilled. A person’s need for intimacy and closeness to another does not end at any age (Kaiser, 2000a, 2000b). There is little information about the role of touch as a substitute or addition to the sexual practices of older adults. It is known that touch is an overt expression of closeness, intimacy, and sexuality and is an integral part of sexuality.

The importance of touch is often undervalued by society. In fact, touch is often thought of as the invasion of a person’s space, and caregivers should not assume that a person likes and wants to be touched (Rheaume & Mitty, 2008). Non–task-related “affective” touching, such as simply stroking a person’s check or holding their hand, may be viewed as assaultive, erotic, comforting, or presumptuous, depending on a person’s culture, personal comfort level, and relationship with the one touching (Rheaume & Mitty, 2008). For legal as well as privacy reasons, many people have shied away from touching. To older adults experiencing touch deprivation, the social rules that govern touch may be devastating. It is important to remember that touch is a way in which older adults may fulfill their sexuality with each other. Touch may be both a welcome addition to traditional sexual methods and an alternative means of sexual expression when intercourse is not desired or possible.

When older adults are not able to participate in sexual relationships with others, the nurse’s use of touch is fundamental in preventing touch deprivation. Therapeutic touch is an alternative nursing intervention developed by Kreiger and Kunz. Based on Martha Roger’s Science of Unitary Human Beings, therapeutic touch has been widely used to diminish anxiety, accelerate healing, and decrease pain. The use of therapeutic touch in fulfilling the sexuality of older adults is an exciting yet understudied area of nursing.

Despite the continuing need for sexuality, older adults may have difficulty accepting and understanding their sexuality. Sexuality and sexual expression were not formally or informally taught during the developmental years of today’s cohort of older adults. In fact, sexuality was hidden behind closed doors for most of these older adults’ lives. Therefore the sexuality assessment of an older adult may be the first opportunity he or she has to openly discuss sexuality. Embarrassment, shyness, and apprehension in this area are common. In addition, the client may view the normal changes of aging as embarrassing or indicative of illness and may be reluctant to discuss these matters with a nurse. Some are misinformed about sexuality and may refuse to discuss sexual issues about which they harbor feelings of guilt and shame (Butler & Lewis, 2000; National Council on Aging, 1998). Understanding older adults’ attitudes and myths about aging will help the nurse assess and intervene to sensitively promote the expression of sexuality.

Nursing’s Reluctance to Manage the Sexuality of Older Adults

The thought of older and often disabled people engaging in sexual intercourse is not appealing to society. Nurses often share society’s ageist beliefs about the asexuality of older adults, which can lead to nurses discouraging sexual activity (Messinger-Rapport et al, 2003).

In long-term care settings, including assisted living facilities, a resident’s attempt at sexual expression is often viewed as a “problem” behavior (Rheaume & Mitty, 2008). In fact, more literature about the sexuality of older adults pertains to the inappropriateness of the behavior.

Older adults face many barriers to sexual expression. NSHAP found that low desire (43%), difficulty with vaginal lubrication (39%), and inability to climax (39%) were the greatest barriers among women. Among men, erectile difficulties (37%) were the most prevalent barrier (Lindau et al, 2007).

Acute care nurses are in a key position to address newly developed or potential sexual dysfunctions before discharge to a community setting or long-term care environment. However, because of discomfort, myths, and lack of training in the area of sexuality, these problems are often ignored. The end result is that older adults are discharged home or to another setting with a newly developed or chronic sexual dysfunction that prevents them from functioning sexually.

In the community setting, nurses have access to the client’s entire family unit in his or her natural surroundings. The information needed to make a sexual assessment is therefore readily accessible. However, nurses may feel intimidated or uncomfortable questioning older adults about their sexual desires and needs. Consequently, the information needed for proper intervention is not obtained.

As a result of these factors, nurses have recoiled from venturing into such uncharted territory. The end result is that sexually interested older adults are in a situation in which they may have multiple disabilities, no privacy, no support, and no appropriate way in which to express their sexual feelings (Wallace, 2007).

Normal Changes of the Aging Sexual Response

If nurses are to assist older adults in fulfilling their sexual desires most effectively, it is critical that they understand the normal changes of the aging sexual system. Knowledge about these normal changes enables the nurse to work more confidently with the client to compensate for these changes, to assist the client in understanding these changes, and to become aware of possible pathologic problems within the aging sexual system.

To assess sexual function in older adults, health care providers need to understand the sexual response cycle, which is a psychophysiologic cascade of events leading to orgasm (Wise & Crone, 2006). The two parts of the cycle include the desire phase and the arousal phase. Lowered levels of desire and hypersexuality are dysfunctions in the desire phase, and erectile dysfunction, vaginismus, and dyspareunia are dysfunctions in the arousal phase.

Orgasm

The orgasm response also changes with aging. Dysfunctions include anorgasmia, premature ejaculation, and retarded ejaculation. In addition, a longer period of stimulation is typically required for both men and women to reach orgasm. The refractory period after orgasm is also longer for both men and women.

In both genders the reduced availability of sex hormones in older adults results in less rapid and less extreme vascular responses to sexual arousal (Wise & Crone, 2006). Although some older adults view this gradual slowing as a decline in function, others do not consider it an impairment because it merely results in them taking more time to achieve orgasm (Butler & Lewis, 2000).

Common physiologic changes associated with aging men are an erection that is less firm and shorter acting, less preejaculatory fluid, and semen that is less forceful at ejaculation (Butler & Lewis, 2000; Messinger-Rapport et al, 2003). The refractory period between ejaculations is long. Andropause (male menopause) has several physical, sexual, and emotional symptoms. There is disagreement about which term should be used to accurately describe the phenomenon. Most endocrinologists now use the term ADAM, an acronym for androgen decline in the aging male (Blackwell, 2006). A decline in the concentration of testosterone is believed to be the cause of andropause (Blackwell, 2006). Serum sex hormone-binding globulin (SHBG) concentrations gradually increase as a function of age, making less free testosterone. Testosterone levels diminish with age from a reduction in both testosterone production and metabolic clearance. These hormonal changes lead to a loss of libido, decreased muscle mass and strength, alterations in memory, diminished energy and well-being, an increase in sleep disturbance, and possibly osteoporosis secondary to a decrease in bone mass. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli (Kaiser, 2000a; Messinger-Rapport et al, 2003). Despite these physiologic changes, aging men can still experience orgasmic pleasure (Messinger-Rapport et al, 2003).

An instrument such as the ADAM Questionnaire, created by Morley (2000), is a helpful screening tool that should prompt further workup, including determination of the testosterone level. Other laboratory studies should include a complete blood count, complete metabolic panel, and a prostate-specific antigen test (Blackwell, 2006).

Erectile dysfunction (impotence), the inability to develop and sustain an erection for satisfactory sexual intercourse in 50% or more attempts at intercourse, can occur at any age but does increase with age (Araujo, Mohr, & McKinlay, 2004). Causes of erectile dysfunction include structural abnormalities of the penis, the adverse effects of drugs, psychologic disorders, and vascular, neurologic, and endocrine disorders. It is most common to have more than one cause of erectile dysfunction (Wise & Crone, 2006).

Women usually do not have difficulty maintaining sexual function in older age unless a medical condition intervenes. The infrequency of sexual activity for older women is usually from their lack of desire, according to the NSHAP study. Most sexual changes occur with menopause, including atrophic vaginitis, with dryness of the vaginal mucosa leading to irritation or pain and bleeding during intercourse (Butler & Lewis, 2000; Messinger-Rapport et al, 2003). Urinary incontinence from detrusor insufficiency or stress can cause embarrassment during intercourse (Messinger-Rapport et al, 2003). The age-related shortening and narrowing of the vagina may further compromise pleasurable intercourse (Butler & Lewis, 2000). Women may also have increased facial hair from decreased estrogen levels, causing them to feel less attractive (Butler & Lewis, 2000).

Libido appears to be testosterone dependent in both men and women. Women experience a decline in both ovarian hormones and adrenal androgens in the years preceding menopause. This can cause a diminished sense of well-being, loss of energy, loss of bone mass, and decrease or loss of libido (Kaiser, 2000b). Some of the causes of decreased libido include low bioavailable testosterone, elevated prolactin, and, indirectly, decreased estrogen. Incontinence can also decrease libido and inhibit arousal (Kaiser, 2000b). Dyspareunia, painful intercourse or pain with attempted intercourse, is a condition older women often experience, resulting in a decreased desire to participate in sexual activity. About one third of sexually active women older than the age of 65 experience dyspareunia. Causes of dyspareunia include inadequate vaginal lubrication, irritation and dryness of the external genitalia, urethritis, improper entry of the penis, anorectal disease, altered anatomy of the female genital tract, vulvovaginitis, local trauma (e.g., episiotomy scars), and even arthritis (Kaiser, 2000b). Vaginismus, involuntary painful contraction (spasm) of the lower vaginal muscles, is also often experienced by older women, again decreasing their desire to participate in sexual activity. Causes may be related to dyspareunia, vaginal infections, or vaginal mucosal irritation. It may be triggered by fear of losing control or of being hurt during intercourse (Kaiser, 2000b).

Changes associated with the aging sexual system may have important consequences. It is common for older adults to be uncomfortable with the changes in their internal and external sexual systems.

Sexual function is a process that depends on the neurologic, endocrine, and vascular systems. It is also influenced by several psychosocial factors, including family and religious beliefs, the sexual partner, and the individual’s self-esteem (Wise & Crone, 2006). Several medical disorders common to older adults can affect sexual function (Box 13–1).

Surgeries can also affect an older adult’s sexual responses. Some of theses surgeries include coronary artery bypass surgery, hysterectomy, mastectomy, prostatectomy, orchiectomy, and removal of the anus and the rectum. In addition, many drugs adversely affect sexuality (Table 13–1).

Human Immunodeficiency Virus

Older adults continue to be a considerable proportion of the population infected by human immunodeficiency virus (HIV) (Lovejoy & Heckman, 2008). According to the National Center for HIV, STD and TB Prevention’s 2007 statistics, those older than the age of 50 with acquired immunodeficiency syndrome (AIDS) represent 17% of all AIDS cases (National Center for HIV, STD, and TB Prevention, 2009). This is a 2% increase from 2002. Statistics indicate older adults are more likely than younger persons to develop AIDS less than 12 months after a diagnosis of HIV infection. The estimated number of new diagnoses of HIV/AIDS has also increased among adults older than 65 years of age, from 696 in 2004 to 803 in 2007, and has almost doubled from what it was 5 years ago (Centers for Disease Control and Prevention [CDC], 2009).

Results from a 2007 study led by Travis Lovejoy along with Ohio University psychologist Timothy Heckman, revealed that one third of HIV-infected older adults who were sexually active have unprotected sex. Older adults may be at risk for HIV infections if they engage in sex (Lovejoy & Heckman, 2008). Despite the fact that older adults do engage in behavior that puts them at risk for HIV infection, they are less likely than younger persons to adopt safer sexual practices because they do not perceive themselves as being at risk. Some of the reasons older adults do not practice safer sexual behaviors are as follows:

• They see sexually transmitted disease (STD) as something that happens to somebody else because they were settled in marriages when the safe sex battles of the 1980s were raging.

• Older women do not fear pregnancy because they are postmenopausal, so having the man wear a condom is not a concern.

• Older women outnumber older men, which gives men many partners to choose from; therefore women try to please their male partners by agreeing to unprotected sex.

• Older adults grew up when men made most of the decisions in a relationship; thus if a man does not want to use a condom, then it is not used.

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