How do we define sexuality? Regardless of whether we're young or old, it's an integral part of who we are. Sexuality is a combination of the emotional, psychological, social, and spiritual makeup of an individual. It influences our thoughts, feelings, actions, and interactions and, therefore, our mental and physical health. Sexuality also encompasses gender identity; sexual orientation; and social norms as they affect physical, emotional, and spiritual life. Next to sleeping and eating, sexuality is one of the most important drives that we encounter as humans.
We're involved in a lifelong learning process about our sexuality. The right to sexual expression exists across the lifespan and should be supported. The expression of sexuality and desire for intimacy is complex, no less so for an older adult than a teenager. The expression of intimate and sexual behaviors also directly links to health and quality of life throughout our lifetime, making it an integral part of health as we age.
Many health benefits are linked to sexual expression, including increased relaxation, improved cardiovascular health, lower levels of depression, decreased pain sensitivity, increased self-esteem, and better relationships. More important, older adults who remain interested in a sexual relationship and intimacy with a partner find this to be an important source of well-being. As older adults age, they may shift their ideas of sexuality to include more intimate behaviors, such as kissing, touching, and hugging, redefining sexual relationships to emotional intimacy.
Myth busters
According to AARP, formerly the American Association of Retired Persons, anyone age 50 or older can receive benefits. Medicare eligibility begins at age 65 or older. Social Security benefits can be received beginning at age 65. The U.S. Census Bureau predicts that by the year 2050, there will be 83.7 million Americans age 65 and older. Whether someone is young-old (age 65 to 74), middle-old (age 75 to 84), or old-old (age 85 and up), sexuality is a natural part of what makes us human.
Today, broad assumptions about aging, including intimacy and sexuality in later life, are being challenged. It's increasingly clear from the most recent research that the desire for sexual contact and closeness can last for a lifetime, yet older adult sexuality is often ignored. Existing research on the sexual activity of older adults lacks adequate descriptions of who the older adult is, particularly across cultural and ethnic groups, as well as across economic and educational status. The current research is generalized and limited.
Sex and intimacy shouldn't be ignored, especially because people are living healthier and longer lives. Many older adults remain physically active and even old-old adults engage in intimate and sexual relationships. According to a survey conducted by AARP in 2010, sex and intimacy are still an important part of the older adult's life, with the majority of interviewees indicating that sex is actually critical for a good relationship and important to their quality of life.
Unfortunately, nurses are often unsure of the sexual needs and desires of older adults. Healthcare professionals may manifest conventional beliefs and behaviors, such as thinking that older adults are asexual, and worry about discussing sexuality with the older adult because of embarrassment and lack of knowledge. If we understand the issues concerning sexuality and aging, and challenge our own views on sexuality, we can assist the older adult to reach a satisfying level of sexual expression and intimacy.
Why's this topic so important?
The shift in attitudes about sexuality and aging, combined with advances in medicine that prolong a sexually active life, has led to the challenge of meeting the unique needs of older adults who want to stay sexually active. Rates of sexually transmitted infections (STIs), such as chlamydia, gonorrhea, and syphilis, have doubled for people in their 50s, 60s, and 70s in the last 10 years. On the other hand, the promotion of safe sex practices among older adults is practically nonexistent.
According to the CDC, there were 885 reported cases of syphilis in individuals age 45 to 65 in 2000; in 2010, there were more than 2,500 reported. The number of older people with HIV nearly doubled in those 10 years. In fact, the number of new HIV infections is actually growing faster in individuals over age 50 than those age 40 and younger. Researchers indicate that it's hard to know just why STI rates are on the rise among older adults because there has been so little research on their sex lives.
Some primary care providers surmise that erectile dysfunction (ED) drugs and biologic changes as women age may be responsible for the rise in STIs among this population. Easily attainable prescriptions for ED allow men to have intercourse at older ages than before. And postmenopausal changes to the vagina make older women more vulnerable to infections. During menopause, estrogen levels are reduced. As estrogen decreases, it alters the thickness of the female reproductive organs, including loss of elasticity, thinning of the vaginal tissue, and decreased lubrication (easily fixed by using a water-based lubricant).
A 2010 AARP survey found that longer lives and more divorces may be leading older adults to have more sex partners than in years past. The older adult generation's view of condoms and safe sex may also be less well informed than younger adults at present. Some older adults may never have used a condom. Others may think condoms are old-fashioned; they may not be informed about how condoms have changed, their availability, or how to use them. Older adult women don't worry about getting pregnant because they're postmenopausal and they may be more eager to please their partners.
Health education campaigns promote safe sex for teens and young adults, but they rarely target older adults. It's a common assumption that STIs only happen to young people; however, the older adult is just as vulnerable. Age doesn't protect a person from STIs. Strategies aimed at STI prevention include adequate health assessment, comprehensive screening, early treatment, education, and reeducation for both the patient and his or her partner.
Obstacle course
As impossible as it is to classify young and middle-aged people into one standard of behavior or level of health literacy, it's equally impossible to generalize when dealing with older adults. It's vital to remember that patients are people first before identifying them as a particular age or cultural group. Then we must investigate how patients' behaviors and values are shaped by variables of age, race, cultural identity, life experience, and sexual expression. To do this, we must understand our own beliefs and attitudes about sexuality and intimacy in older adult patients, and examine the barriers that may be preventing us from providing optimal care to these individuals.
Many nurses admit to feeling uncomfortable discussing sex with their older adult patients. Some fear that discussing sexuality with an older patient can be viewed as an invasion of privacy. And even nurses have biases because just as our patients are products of a specific upbringing, culture, and belief system, so are we. For example, if a nurse's religious belief is that sexual activity is only for the purpose of procreation, he or she may experience a conflict when addressing the needs of the older adult-heterosexual or lesbian, gay, bisexual, or transgender (LGBT)-whose views allow for sexual pleasure.
Although there are healthcare providers who are uncomfortable discussing sex with older patients, older adults may be just as uncomfortable talking about sex with their healthcare providers. Questions such as: "I'm old enough to be his grandmother, what will he think of me?" or "Will she think I'm perverted because I want to have sex with my 30-year-old girlfriend?" may cause the older adult to be afraid to seek information. Older adults may be uncomfortable sharing information regarding sexual orientation due to fear of being shunned by the healthcare provider.
An individual's health status may affect the ability to have sexual intercourse. For example, diabetes can lead to ED in men and decreased vaginal lubrication in women. If this information isn't presented, the older adult may not know that these are common effects of the disease. Medications, such as antidepressants, diuretics, and beta-blockers, may negatively affect a person's ability to have sex. Older adults may find certain sexual positions more comfortable than others. For example, if an older adult is experiencing chronic pain from osteoporosis or osteoarthritis, then a side-lying position may decrease discomfort for both partners.
Education is key; however, the healthcare provider needs to be comfortable sharing information first and not necessarily wait to be asked.
One step at a time
Let's now review the nursing process as we continue to explore sexuality and the older adult.
Assessment. It's important to complete a thorough assessment of the older adult, focusing on physical, psychological/emotional, social, and environmental components. Does your older patient wish to discuss sex and sexuality or is he or she too uncomfortable to address the issue? Begin your assessment with a clear definition of the concepts. How does the patient define sex? Is it intercourse, cuddling, kissing, caressing, and/or holding hands? What's the patient's past medical history? What acute or chronic illnesses are present? Are there comorbidities that prohibit sex? What medications is the patient taking (both prescription and over-the-counter)? Is his or her environment conducive to a sexual encounter? If an older adult lives in a family member's home, he or she may not be comfortable having a partner spend the night. What if the patient lives in an assisted living or long-term-care facility? How do other family members, especially adult children, feel about the patient having sex?
Plan. Based on your assessment, you can develop a care plan. What are reasonable short-term and long-term goals? Does the care plan need to be revised to allow the older adult to have sex safely? For example, can medications be changed that may decrease the chance of orthostatic hypotension during sexual intercourse? Is your patient in need of education about STIs? Men may still need to be educated about the risk of pregnancy in a younger partner. What nursing diagnoses are appropriate? Lack of knowledge related to misinformation? Anxiety related to intimacy or perhaps the fear of being unfaithful to a previous partner who has died? Pain related to decreased vaginal lubrication or a chronic health problem? Social isolation related to fear of family members' acceptance of the sexual experience?
Intervention. Selected interventions need to focus on the older adult's sexual needs. First, create a welcoming environment to allow for the patient to feel comfortable asking questions. As nurses, we must be willing to hear the question(s) and not feel embarrassed. Older adults may want to discuss same-sex relationships. Don't assume that the relationship is heterosexual. Whether you focus on safe sex, sexual positions that may decrease pain or shortness of breath, or medication use, education is vital. Bringing in other members of the interdisciplinary team may help, such as a physical therapist for positioning, a pharmacist for medication changes, or a social worker for counseling of family members. A mini mental exam may provide information regarding any cognitive changes in the patient. It's important to protect a cognitively impaired person from being sexually exploited. Was the sexual encounter nonconsensual? Supportive and legal measures need to be taken to protect older adults from being victims of sexual abuse.
Evaluation. Now you're ready to determine if your assessment, plan, and interventions have made a difference. Were the patient's goals met? Were his or her questions answered? Did the information you provided allow the older adult to experience a satisfying sexual encounter? If not, why not? What prevented it from being satisfying: the environment, physical positioning, family issues? During the evaluation process, communication remains important. Remember that the entire nursing process can repeat itself until current or revised goals are met.
A PATH to follow
Our job as nurses is to help guide our older adult patients who want to continue to experience active sexual lives down a safe PATH:
* Provide older adults with a safe and supportive climate for discussing sex.
* Advocate for a variety of services to be provided to the older adult.
* Take time to talk and listen regarding sexual issues.
* Healthcare providers must understand their own beliefs and look for opportunities to work supportively with older adults.
Every patient deserves appropriate health education and support. Provide opportunities for open communication when needed. Through listening, observing, and recommending healthy practices and behaviors, we can help maintain our older adult patients' quality of life.
consider this
Joyce and Tom met as neighbors and friends. Both of them married and the couples became good friends when they were all in their 20s. Eventually, Joyce and her husband moved away, had children, and ultimately divorced when her husband's drinking overpowered their marriage. Joyce took care of her three children and, at age 75, reconnected as friends with Tom after his wife, Joyce's best friend, died of cancer. Friendship led to romance and Joyce and Tom just married. Tom at age 79 and Joyce at age 76 are deeply in love and ready for the adventure of a full married life, including sexual expression.
Given Joyce and Tom's new relationship status and their older age, helping them manage their sexual health is a priority. As we age, we experience normal and pathologic changes that may affect our sexual health. Addressing older adults' sexuality can promote companionship, increase self-esteem, and restore function. Before beginning your sexual health assessment, ask Joyce and Tom if it's okay to discuss their sexual health, such as "Would it be all right if I asked some questions about your intimate relationship?" If they consent, begin the conversation with a series of open-ended questions to prompt any concerns Joyce and Tom may have.
For example, because Joyce and Tom have already been involved with other partners, you can start with, "Could you tell me if your intimate relationship is different with each other than your previous partners?" You can also ask Joyce and Tom about ways in which they were able to achieve sexual fulfillment in the past. These types of open-ended questions are an excellent way to get the conversation started and then progress to more specific questions, such as, "What thoughts have you had about enhancing your sexual relationship?" Finally, you can conclude with, "What information can I provide to help you fulfill your sexual relationship with each other?" Use their responses to guide your assessment and develop a care plan that focuses on interventions to improve their sexual health.
memory jogger
When discussing sexual health with your older adult patients, think stay on the safe PATH.
P Provide older adults with a safe and supportive climate for discussing sex.
A Advocate for a variety of services to be provided to the older adult.
T Take time to talk and listen regarding sexual issues.
H Healthcare providers must understand their own beliefs and look for opportunities to work supportively with older adults.
consider this
The graying of America isn't only occurring among heterosexual couples, but also LGBT couples. Kim and Charlotte have been together for 50 years. They met in the 1960s, becoming friends and then lovers. They kept their relationship a secret for the majority of their lives. They were finally able to publically express their love for each other and married shortly after the June 26, 2015, U.S. Supreme Court ruling on same-sex marriage. Now in their 80s, they're both frail but continue to enjoy each other's company.
Recently, Kim was diagnosed with inoperable bile duct cancer. For the first several days home from the hospital, she slept in a recliner and Charlotte slept in a chair at her side. When asked if the couple wanted a hospital bed for Kim, they empathetically responded "no." They've spent the better part of their lives sharing a bed and want to continue that aspect of their relationship for as long as they can. Charlotte remarked, "It isn't always about sex. Sometimes it's just about being physically close."
Quick tips
cheat sheet
* The patient's sexual history can have an impact on his or her quality of life and overall physical, emotional, and psychosocial health. Assess how the older adult patient perceives sex and how he or she feels about engaging in a new relationship, especially if it follows the death of a long-time partner.
* Communication is important! Ask open-ended questions and include both partners, if possible, so that all questions can be discussed and answered.
* The rate of STIs is on the rise within the older adult population. Educate older adult patients about STIs and how to protect themselves and their partners.
key points
Nursing considerations
* Older adults still have sex. Be aware that sexuality is important to the health and well-being of our aging population.
* Whether we encounter an older adult in the hospital, outpatient clinic, home care, or long-term-care setting, we need to be comfortable addressing questions or concerns about sex and sexuality.
* Addressing older adults' sexuality can increase their self-esteem and promote companionship. The expression of intimate and sexual behaviors can improve health and overall quality of life. For example, feeling attractive and needed by someone new following the death of a spouse or partner can eliminate or minimize feelings of depression. Going out to a restaurant with someone and sharing a meal can increase social interaction and decrease nutritional concerns.
* Using the nursing process allows you to assess, plan, implement, and evaluate opportunities to enhance sexual health in older adults.
* Be aware of barriers and challenges to sexual health in the aging population. As we age, there are normal changes that occur, such as increased arousal time, difficult or painful penetration due to decreased vaginal lubrication, and decreased hormonal levels. In addition, chronic conditions, such as diabetes, arthritis, and cardiopulmonary issues, can affect an older adult's ability to enjoy sex. Medications, such as antidepressants, diuretics, and beta-blockers, can also hinder sexual activity. Attitudes from others who oppose the relationship may be difficult, especially if the disapproval comes from family members.
REFERENCES