Emma, 82 years

The doctor carefully examined the stump where Emma’s leg had been amputated. He was particularly sensitive to the bruised areas where circulation problems might exist. He palpated the darkened area around the stump and asked how it felt. ‘Fine’, she replied. Then he examined the good leg, explaining that it was probable that if she had severe circulation problems in the amputated leg, one had to be especially cautious about the other leg. He searched her good leg from the ankle upward for existing bruises. With each touching of a possible sensitive area, he would ask her how it felt. ‘Fine’, she would say. By this time he had reached the upper interior of her thigh. He asked her once again how it felt. Emma replied, with a teasing glint in her eye, ‘Doctor, the higher you go, the better it feels’.

(Walz 2002: 105)

Introduction

Researchers first began to show an interest in the sexual lives of older people in the 1950s. Some 60 years later, the sexuality of older people still remains relatively obscure and in many cases misunderstood. It is an area that is largely ignored by the popular media, advertisers, health care practitioners and policy makers alike. This is despite compelling evidence that refutes any notion that sexuality ceases to be of importance beyond a certain age. On the contrary, sexuality is a natural expression of human need that continues throughout life and extends well beyond the reproductive years (DeLamater & Moorman 2007). While there may appear to be a growing acceptance in the literature of the importance of sexuality to an older person’s sense of wellbeing, in practice health professionals frequently fail to recognise its significance.

For health professionals working with older people, sexuality remains one of the last frontiers. In this chapter we aim to raise the consciousness of the reader about sexuality and the sexual needs of the older person. In doing so, we will explore a number of aspects related to sexuality that are significant to an understanding of this topic. Among these are the attitudes and beliefs we have about older people and sexuality, what we think we know about older people’s sexuality, the factors that impact on sexuality and sexual expression, and the role of the health professional. As has been noted elsewhere (Nay et al 2007), we are not advocating that all older people become ‘sexy oldies’ (Gott 2005b), or that health professionals lobby their older patients to become more sexually demonstrative. We do however urge all health professionals to confront their attitudes and prejudices, view sexuality of older people as a legitimate area of concern, and become more informed and more comfortable dealing with this topic.

Making the invisible visible: some challenges

As the population is rapidly growing older, the widely held view of ageing as a period of inevitable decline is slowly giving way to a more positive discourse of ageing where older people are encouraged and supported to age well and age productively. Growing old is being aligned more with prosperity than paucity and government policy encourages older people to live happy, healthy and independent lives while also remaining actively engaged with the community. The new discourse on positive ageing attempts to redefine the popular belief that old age is sexless and tackles the traditional boundaries of what it means to be old by incorporating sexuality and sexual health as essential components for successful ageing (Brock & Jennings 2007; Henry & McNab 2003; Katz & Marshall 2003).

For an older person, sexuality is a culmination of all the developmental processes and experiences in their life so far (Sharpe 2004). Given that some people live to be 100, their sexuality will not only be informed by a rich life history, but it may also continue to be a factor of some significance for their remaining life. For health professionals including doctors, nurses, social workers and other therapists, the acknowledgment of sexuality presents a number of challenges.

Firstly, relative to other aspects of ageing, there is a dearth of empirical data about the sexual lives of older people, their sexuality needs (Brock & Jennings 2007), and how they conceptualise sexuality (Minichiello & Plummer 2004), with specific cultural or ethnic groups within the population being particularly under-represented in the research (Willert & Semans 2000). Over the past 2 decades we have seen some significant changes in society including shifts in social values, improvements in health care and increases in life expectancy. Stancil (2003) notes, for instance, that there are now more divorces among older people and while marriage is still highly valued, changes in conservative attitudes have led to greater acceptance of a range of other lifestyle choices for people, including co-habitation, gay and lesbian relationships, and having multiple partners, in addition to not having a sexual partner at all. These developments, together with the increase in the longevity of people, challenge the relevance of much of the earlier research (Kinsey et al 1948; Kinsey et al 1953; Masters & Johnson 1970; Pfeifer et al 1968; Pfeifer & Davis 1972) to the sexuality of older people today (Sharpe 2004).

There is very little published research available to guide practice and policy in this area and guideline documents that can assist staff to address the sexuality needs of older people in the health care setting are rare and often inadequate (Bauer et al 2007a; Everett 2007; National Ageing Research Institute 2002; Nay 2004). In 2007 we conducted a survey and document analysis to obtain descriptive baseline data regarding the nature of the information residential aged care facilities (RACFs) had available that addressed the issue of sexuality. To maximise the response rate it was decided to conduct a census (as opposed to a random sample) of all 826 RACFs in the state of Victoria. The aim of the study was threefold:

Letters were sent to all facilities explaining the purpose of the study and requesting copies of any information such as promotional material and policy documents. After two reminder notices the response rate to our survey was less than 20%. An analysis of the material provided found that less than 3% of the information returned actually contained any references to sexuality, love, intimacy or relationships. The very low response rate prevents us from drawing any firm conclusions about the resources aged care facilities have available. It is noteworthy however that 64% of facilities indicated that they did not return any relevant information because they had none that addressed this issue for either staff or residents.

During the course of this research we were contacted by a number of RACF managers who were eager to explain that while they had no written information, they nonetheless did cater to residents’ needs in this area. Several facilities indicated that they obtained the services of sex workers when needed. Others allowed couples to bring in their double bed from home; connected adjoining rooms to form one larger room; or allowed couples to enjoy some uninterrupted privacy. Some facilities arranged for a resident to see a social worker or psychologist if needed, however the aims of such a consultation remain unclear. A few facilities reported that they were in the process of developing a policy and others indicated that the issue was verbally raised with residents, often as part of a general health assessment. While these responses are in some way encouraging that the issue of sexuality is at least on the radar, we were also contacted by a number of facilities wanting to express their disapproval of our research, which was seen to be inappropriate and intrusive. A number of the comments we received indicated that residents’ needs for sexuality and intimacy were also being interpreted in the narrowest terms; that is, sexual intercourse between two (heterosexual) people. This is in the light of estimates that around 3–8% of people in the developed world identify as gay or lesbian (Aids Council of New South Wales [ACON] 2006).

The second reason why sexuality poses a challenge to health professionals is because talking about human sexuality is still largely taboo, even though depictions of sexuality are often very public in Western society. Many health professionals are reluctant to initiate conversations related to the sexuality and sexual health needs of their clients because of embarrassment, fear, or discomfort (Andrews & Piterman 2007; Burd et al 2006; Gott et al 2004a, 2004b; Horden & Street 2007; Jones et al 2005; Magnan et al 2005). Many health professionals lack both knowledge and training in this area, so it is not surprising that the majority will avoid discussing this topic and will employ a range of avoidance strategies not to do so. If the subject does arise, many staff will try and limit the interaction to a level with which they feel comfortable (Horden & Street 2007).

Third, professionals who work with older people are also influenced by societal views (Gunderson et al 2005; Hillman 2000) and many share the prevalent stereotypical and erroneous beliefs about sexuality and the older person (McAuliffe et al 2007). These beliefs portray older people as either not having sexual needs, being interested but no longer capable, or having long outlived such desires (Walz 2002). It is arguable whether health professionals harbour such misconceptions because of the nature of their work, which exposes them on a regular basis to sick and disabled individuals, thereby contributing to a biased view of old age (Gibson 1992), or whether the association between ageing and death in our society is so strong that we fear and deny any aspect of old age (including sexuality) because it reminds us of our mortality (Nelson 2005). Gott (2005b) suggests that judgments about sexuality and older people are so entrenched in the fabric of society, and so powerful, that no-one is immune from the influence. Even government policy agendas and health researchers, she notes, have been known to overlook the sexual views of older people.

How, then, can health professionals begin to dispel any ageist attitudes that they may harbour and become more comfortable with the notion of sexuality and the older person? Brock and Jennings (2007) propose that a useful starting point is self-reflection of one’s own values, attitudes and beliefs. To be able to respond to the needs of older clients and be non-judgmental, the health professional first needs to become aware of his or her own feelings and attitudes. Consider the following questions (modified from Hillman 2000) and think about your attitudes and how you react. Would you feel any differently if these questions pertained to someone aged 20?

Sexuality: more than sex

Sexuality can be a slippery term and can mean different things to different people (Bauer et al 2007b). How we think about and experience our sexuality and ‘…what we “are” and “do” in relation to sexuality is socially, culturally and ideologically shaped’ (Heaphy 2007: 196). It is not uncommon to find the term used in the literature to refer to what is really only one aspect of sexuality; that is, intercourse or oral sex (Lindau et al 2007). Much of the research still uses intercourse as the gold standard by which to judge older people’s sexuality (Gott 2005b). Without detracting from the significance of sex, sexuality is much more than this.

According to working definitions that were elaborated as a result of a World Health Organization (WHO) convened international technical consultation on sexual health (and then revised by international experts), sexuality is a broad construct that is ‘experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships’ (WHO 2006: 5). Sexuality has many dimensions and includes intimacy, body image, self-esteem, romance, physical closeness, touch, cuddling, kissing, hugging, self-gratification and social relationships (National Ageing Research Institute 2002; Nay 2004), as well as sexual desire and gender-role identity (Zeiss & Kasl-Godley 2001). Older people have described sexuality as feeling masculine and feminine, looking nice through grooming and clothes, enjoying sexually explicit magazines or movies, and talking ‘dirty’, as well as spending time with the opposite sex (Nay 2004).

Sexuality and health care

While sexual gratification is usually a private matter, sexuality goes beyond the immediate gratification of sex. Sexuality is a legitimate area of concern for health professionals because it is a key component of quality of life (Robinson & Molzahn 2007) and is linked to our physical, emotional, mental and social wellbeing (WHO 2006). Sexuality is important to the maintenance of healthy interpersonal relationships, self concept and sense of integrity (Zanni et al 2003), and self-esteem and physical health (Zeiss & Kasl-Godley 2001), and it forms an essential component of how we feel about ourselves, even when close to death (Horden & Street 2007; Lemieux et al 2004). The preservation of self-identity as noted by the National Ageing Research Institute (2002: 5) ‘… may be one of the most important needs of older people, particularly those who are institutionalised’.

Because the ability to express one’s sexuality is closely associated with quality of life, health professionals are encouraged to adopt a health promotion approach in relation to sexuality and the older person (Henry & McNab 2003). The WHO now acknowledges that sexual health goes beyond the absence of disease and a ‘narrow reproductive health focus’ and includes the associated states of ‘physical, emotional, mental and social wellbeing in relation to sexuality’ (WHO 2006: 5). A health promotion focus is therefore about acknowledging and recognising the role that sexuality may play in an older person’s life and, where appropriate, incorporating this aspect of the person’s life into the plan of care. This means adopting a ‘… pro-active process of enabling older people to have the right to identify and realise their unique sexual and sensual preferences and needs without infringing on the right of others’ (National Ageing Research Institute 2002: 4). A failure to consider sexuality as a normal part of on older person’s health status is likely to lead to inequities in care (National Ageing Research Institute 2002) and potentially harm self-image, social relationships and mental health (Hajjar & Kamel 2003; Willert & Semans 2000).

Representations of sexuality: images and stereotypes

We live in a highly sexualised society. Our language is replete with sexual references and sexual expletives (Goldman & Bradley 2004) and we are confronted by images of scantily clad women, and to a lesser extent men, on television, at the movies, in magazines, on billboards and on the backs of buses. The salacious images that we see, however, reinforce the notion that sexuality is the domain of youth, since sexuality is nearly always represented in the context of the active young man or woman. These images help to shape and reinforce the beliefs society has about older people (Minichiello et al 2005) and make it difficult to imagine that sexuality could be associated with older people and that they may also have sexual needs and desires.

In the absence of narratives about the sexual lives of older people, stereotypes are known to fill the void (Walz 2002) and the research shows that ageism is widespread within the medical field, particularly against the very old and those residing in long-term care (Gunderson et al 2005). Kay and Neely (1982) point out five key stereotypes that underscore how the sexuality of older people continues to be perceived:

According to Huffstetler (2006), these depictions are embedded in our history where sexual activities were once deemed by the church to be exclusively ‘of the flesh’ and a private matter for purposes of procreation. Sexual activity beyond the menopause (or for men, past the age of 50) was once viewed as sinful and perhaps foolish at best (Huffstetler 2006) and for some unlucky women was likely to be associated with witchcraft, since no man could possibly find an older woman attractive by any other means (Hillman 2000). The idea that reproduction gives sexuality legitimacy is still ingrained in society today and, as Gott (2005b) reminds us, marginalises older people, since without the imperative of reproduction, sexuality in the context of the older person is not seen to have any real purpose.

Just as historical attitudes can influence societal attitudes (Huffstetler 2006), the way society views the sexuality of older people can, in turn, influence the way many older people themselves view their sexuality (Gott 2005b). For one, many older people in their 70s and 80s who were raised in an era of conservative Judeo–Christian values and social mores may find it very difficult to openly discuss sexuality. This generation grew up at a time when open discussion of sexuality was not the norm, sexual knowledge was not freely available, and the only form of appropriate sexual pleasuring was thought to be sexual intercourse (Brock & Jennings 2007). Older gay men and lesbians, it should be noted, may also find it difficult discussing sexuality, not only because of a general lack of acceptance of gay and lesbian people, but because homosexuality was illegal when they were growing up and secrecy became a part of their way of life (Fannin 2006).

Secondly, it is not uncommon for older people to internalise negative social attitudes and share the view that sexual needs and desires are unnatural and unnecessary in old age. Kass (1981) refers to this acceptance of the mainstream view by older people as Geriatric Sexuality Breakdown Syndrome since, when an older person subscribes to this view, over time their enjoyment of sexuality and arousal wanes, and in some cases disappears altogether. For the health professional this phenomenon may be significant, since it can in some older people lead to a loss of identity, social skills, and self-esteem, and result in feelings of apathy, guilt and depression (Kass 1981).