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Providing sexual awareness to older adults to enhance their sexuality in later life: breaking down taboos Torna agli editoriali

di Emine Meral Inelmen
Dipartimento di Medicina -DIMED
Cattedra di Geriatria -Direttore Prof. Enzo Manzato
Università di Padova

According to the Declaration of Sexual Rights (1) , sexuality is an integral part of the personality of every human being, and sexual rights are universal human rights based on the inherent freedom, dignity, and equality of all human beings. Unfortunately, although being aged is not sufficient reason for being denied the joys of affection and sexuality, stereotypes and myths still prevail that older adults are or should be sexless and loveless. Many people assume that older adults do not have sexual desires; are unable to make love even if they want to; are physically unattractive, and therefore sexually undesirable; are fragile physically and might harm themselves; or that sexual activity in old age is perverse (!) (2) . The perceived asexual status of later life is also known to influence clinical practice (3): in fact, growing research literature suggests that discussing later life sexual health issues within medical consultations both for patients and for professionals are embarrassing. Particularly general practitioners (GP) are likely to have the most opportunity to initiate discussions in this area. Another important figure who can discuss about sexuality with the older patient is, obviously, the geriatrician (Gr). Unfortunately GP and geriatricians (Gr) are reluctant to take sexual histories of their senior patients, in part for fear of embarrassing the patient, or more likely because it is more embarrassing for the GP - Gr. Besides, GP -Gr may not feel that the sexual issues in later age are important, although- as for example- HIV/AIDS are becoming a severe topic also in seniors (4).
There are currently no clear guidelines for GP - Gr on how to approach to the sexual activity in this period of life, and sexuality and old age are still seen by most of them as incompatible. Hence, the aim of this article is: 1) to assess the problems with regard to aging sexuality taking a glance to the literature findings; 2) to explore barriers and taboos to sexual expression in seniors; 3) to propose strategies to foster and help GP-Gr on getting a sexual history in later life.

Before the 20th century, individuals often did not live beyond the reproductive years, and sexuality of the older adults was not an issue (5). The cultural taboo was on believing that sex is for reproduction. Nowadays, aging baby boomers are progressing into their 60s and 70s with a life expectancy of an additional 16 to 20 years; however, increased longevity without quality of life is an unpleasant burden rather than a prize (6) (7). Thus, the hope is not only to live as long as possible, but to improve the quality of life. Sexuality has important implications for overall quality of life and remains extremely important throughout the life cycle. Nonetheless, health care providers are still biased by our ageist and sexist society; thus they are not aware or sensitive to the sexuality needs of older people.

Unfortunately, epidemiologic data about sexual activity in seniors are scarce, because research in this area has typically been youth focused (3), and it is unclear what changes can expected as part of the aging process (8) .This leaves health care professionals somewhat in the dark about what older adults want and need to satisfy their sexual interests (9). Research into such deeply personal area is fraught with difficulties including embarrassment in one-to-one interviews, self-reporting biases and poor response rates to postal questionnaires (10). In fact, in the study of Nicolosi et al, 2004 (11) in 29 countries, the percentages of response rates were very low (19%), although the authors did not use face-to-face interviews. Nonetheless, from the literature findings emerge that age per se does not led to a decrease in the importance placed on sex (3), and there is a greater desire among older individuals to love and enjoy sexual activity, although especially psychosocial factors, such as depression, anxiety, low self-esteem, and problems in relationships, are responsible for sexual dysfunction by various mechanisms in many cases in the development of erectile dysfunction (12). Thus, contrary to the stereotypes, myths, and societal ignorance, in the absence of social isolation and health issues, older adults remain sexual beings with desires, fantasies, and active sex lives: in 1382 older adults there was found that 67% of men and 57% of women indicated that satisfying sex is an important part of their lives (13) . Lindau et al, 2007 (14) found that in a sample of 3005 adults 57 to 85 years of age, the majority of the subjects were engaged in a spousal or other intimate relationships and regard sexuality as an important part of life. Hence, although older men are less likely than their younger counterparts to be sexually active, sex remains important to many older men, even in the 10th decade of life; in fact, 70% of healthy 70-year-olds continue to have regular sexual intercourse (15), although the prevalence of sexual dysfunctions is quite high and tends to increase with age, especially in men (11) , as confirmed by Albersen et al, 2012 (5). In a study by Hyde et al, 2010 (8) on men aged 75-95 years, a substantial proportion were sexually active and considered sex to be an important part of their life; sex remained at least somewhat important to one fifth of men aged 90 to 95 years, and of those who were sexually active, more than 40% were dissatisfied with the frequency of sexual activity, preferring sex more frequently. A recent review has confirmed the studies done in the past, suggesting that men and women remain sexually active into their 70s and 80s (16). In this study (16) the authors suggested that aging-related physical changes do not necessary lead to decline in sexual functioning, and that good physical and mental health, positive attitudes toward sex in later life, and access to a healthy partner are associated with continued sexual activity, in turn, regular sexual expression is associated with good physical and mental health. Sexuality seems to stop in the "very oldest old": an interesting study shows that centenarians are no longer interested in sex, in contrast to those aged 86-99 years (17), even if centenarians live in excellent health and remain functionally independent for most of their lives (6). However, research suggests that interest in sex among older men has increased over the last 10 years, possibly due to the effective and well-publicized drugs starting with sildenafil (Viagra) in 1998 (10) , the clinically effective oral medication for erectile dysfunction, so that a massive and growing market for drugs and devices to treat sexual problems targets older adults (14) . Thus it is important to focus that -from the research findings - seems not to be a "sexual retirement"; therefore sexual awareness among this age group may be promoted (3).

Barriers and Taboos
There are multiple causes which create barriers and taboos in aging sexuality. These include general physical health, psychological causes, sexual dysfunction, and social problems. With regard to social problems, loss of a partner through death or incapacity of a spouse is a common scenario in the lives of older adults. In fact, Gray and Garcia, 2012 (18) highlight the importance of the sociocultural context within which aging individuals express their sexuality. In reality, sexual life in older people is affected by a complex interaction between psycho-social factors and physiological functioning. Barriers in aging sexuality divided by gender are summarized in the following paragraph.

Barriers in men
Aging: Although men surviving into their 80s and 90s, continued sexual activity is no great rarity (19) , many of them believe that impotency is a natural consequence of the passage of time, have fear of poor performance and of confiding it to her spouse. Particularly those men who have had unsatisfactory sexual relationship, age per se may be an important barrier and taboo as it may offer an acceptable excuse to end their sex lives (19).
Depression: When an old man cannot discuss sex with her wife, a dysfunction is often the result; he loses self-esteem which can lead him to depression. Depression also reduces sex drive, sexual interest, and sexual function (20) (21).

Monotony of a repetitious sexual relationship: Another barrier for the aging men may be a routine, stereotyped approach to lovemaking (20).

Physical unattractiveness of the spouse: an older man may see her spouse "old and unattractive", convinced that the reason of his is impotence is to have sex with an old lady but forgetting that he also is "old and unattractive"(!). At this several of the aging men who concern low sexual drive have expressed the belief that if they were in a relationship with a young woman, their sex drive would be intact (20). That is why after a midlife divorce, men tend to marry women considerable younger than themselves (20).

Hormone variables: The decline of total and free plasma testosterone levels with advancing age roughly parallels a decline in sexual function, affecting the level of sexual activity, libido and potency measures. In contrast, some studies found that sexual enjoyment was not correlated with any hormone variables (19).Thus some authors (22) suggest that the question of "andropause" remains controversial, and that the term should not be used, in contrast with Werner AW, 1939 (23), who was the first author who believed in the development of a typical climaterium syndrome at about the age of 50, similar to that of women, usually in less severe but perhaps more prolonged form.

Illness: Illness steals the sex lives of many of the seniors. Fatigue reduces the enthusiasm for sex. Pain and deformity can interfere with the ability to have sexual intercourse. Concurrent medical illness is commonly a cause of sexual dysfunction for aging patients (15) , altering body image and decreasing attractiveness (12). Older men reported that elevated blood pressure, diabetes, prostate enlargement, and cancer inhibited their sexual activity and interest; according to these self-reports, impotency increases with each decade, starting at age 60 (9).

Iatrogenic factors: Older people are more sensitive to side effects of medications, in part due to underlying comorbid disease (12).The most common iatrogenic cause of sexual dysfunction is medications: sexual dysfunction caused by drug side effects increases as exponential function of the number of medications a patient is taking (15). Anti-psychotic medications, SSRI anti-depressants, monoamine oxidase (MAO) inhibiters, and sedative drugs may contribute to decreasing levels of sexual desire (24).

Low income: the preoccupation with economic pursuits may be a barrier: many of the adulterous or unmarried aging men are economically deprived and cannot afford sexual relationships (for example with sex workers).

Barriers in women
Lack of a healthy sexual partner: the greatest barrier to being sexual in aging woman is lack of a healthy sexual partner; in fact, the long expectancy of women have produced three times more widows than widowers, making it almost impossible for older woman to find another husband or a societally sanctioned partner (25) .Thus the sexual activity of aging women is determined to a large extent by the availability of a husband or sexual partner and his sexual capacity (19). Most healthy women older than 80 have no partner, and 30 % of those that do, have impotent partners (15) . Then there is the group of unmarried women who report a negligible amount of heterosexual intercourse, which does not necessary imply -however- an absence of other types of sexual behavior (19).
Self physical unattractiveness: many women look to their postmenopausal years as a time of forced asexuality, she no longer thinks of herself as sexually desirable, and she may lose all sexual desire and interest. Besides, a woman may misinterpret the normal male changes in arousal response as proof that her male partner does not find her desirable anymore (20). To confirm this hypothesis is the finding of a study : the 78 % of women felt they are unattractive versus the 58 % of men (19).

Hormone variables: there is a common that women lose their sexual desire during the climacteric; however the role of hormones and its effects of aging on women's sexuality remain less clear. The effect of menopause is complex, involving not only physiological changes, but also psychological, and interpersonal aspects of a woman's life and therefore could have profound effects, both positive and negative, on her sexuality (26). During the climacteric, women are more likely to present sexual dysfunction but there is insufficient evidence to determinate whether the sexual dysfunction occurring during this phase is due to the decrease in estrogen levels or to the effect of aging (27).

Illness : analysis based on 235 patients aged 60 years or less indicated sexual difficulties due to arthritis in two-thirds of the patients, these difficulties were relatively more common in women, and were usually due to hip pain and stiffness; one-quarter of these patients recognized this as a definite cause of marital unhappiness (28).

Communication with physicians: in the study of Nusbaum et al, 2004 (30), older women reported that it was easier to discuss sexual concerns if the physician raised the topic and to be interested in a follow-up appointment to specifically address sexual concerns. The 60% stated that they would feel more comfortable with a female physician, and 45% reported that having a younger-appearing physician hindered this discussion. The participants reported to have tried to raise the topic themselves but the physician did not seem to understand. They also reported that not having enough time and the physician appearing rushed and embarrassed hindered discussion.

Age of the physician: older women seem to find the perceived age of the physician (specifically, a young appearance) to be hindrance (29).

Barriers in both genders
Nursing homes: it is worth noting that institutionalized seniors are at risk of being stigmatized with regard to their sex life. The most pressing of the sexual needs of the older people in institutional settings is the right to privacy; in fact they are segregated, double beds are rare and few institutions provide bedrooms with locked doors (19).

Barriers and taboos in aging sexuality, divided by gender, are summarized in Table 1.
General patients group
Taking a sexual history in older people is a subject which has received little attention in the literature. Bouman & Arcelus, 2001 (21) indicate that taking a sexual history is often omitted also in the psychiatric assessment of older men. Particularly, a significant number of GP identifies that they feel uncomfortable discussing sexual health issues with non-heterosexual patients, as many of them believe that non-heterosexual relationships are not "normal" or "clean", indicating an underlying, perhaps subconscious prejudice (30). On the other hand, to admit to problems with sexual functioning may be humiliating for the old patients that see themselves too old for sex, even if 91 % of them thought taking a sexual history is an appropriate part of a medical examination (15). Hence, a sexual history has to be achieved keeping in mind the following barriers :

Time: time constraints are critical: for doctors, limited time available within consultations may be the key barrier to initiating discussions of sexual health issues (30).The time pressures they work within meant that their priority had to be diagnosing health conditions and prescribing medication, meaning little, if any, time available to discuss the impact condition upon the patient's life, including their sex life (30).

Language: particular concerns are expressed about choosing the language to use to address sexual issues and being up to date with the latest developments in the field (30).
Privacy: an old patient is often accompanied by their relatives (spouse, sons, daughters), so may be difficult to initiate such a hot topic in front of a "third person".

Embarrass: when the topic involves sexuality, doctor-patient "open" communication is embarrassing. Sexuality is a sensitive topic for many and is subject to various social, religious, and legal norms. Participants may therefore be reluctant to report "socially censured" behaviors (8).

Sexuality viewed not as a medical issue: sexual activity and function are often considered by either the GP-Gr or the patient as non-vital functions. Sexuality may be viewed not as an issue of health and illness but as an embellishment affecting the enjoyment of life and therefore not pertinent to discuss in the medical office.
Younger doctor: the problem also is that the geriatric patient is queried by a much younger physician, this can be a barrier to communicate his sexual dysfunction.

Gender of the doctor: a preference for same-gender consultations about sexual health issues have been identified; some GPs reported that their preference stemmed from feeling more comfortable discussing sexual issues with same - gender patients and concerns that patients of the opposite gender may sexualize the consultation (30).

Lack accurate information about sexuality by the seniors: many older people are not receiving information about sexual issues from their GPs-who refer that discussing with patients about sexual issues is as opening a "can of worms" or "Pandora box" (30).

Barriers in particular

Senior patient groups
There are specific concerns about addressing sexual issues with particular senior patient groups: these include homosexual, transgender and lesbian senior patients. One manifestation of the lack of knowledge or willingness to discuss sexual matters is the rising rates of HIV/AIDS diagnosis in older adults, so that the diagnosis of HIV/AIDS tends to be made later, the disease's course is faster, and prognosis is poorer. Older adults are less likely to reveal their HIV status than younger adults. In our case, not the patient but the social assistant reveals that he was homosexual (4).Then they do not perceive themselves to be at risk for HIV, and are reluctant to take preventive measures even after an HIV diagnosis; in fact, in our case-report the patient refused the therapy after the delivery of the diagnosis (4). In addition, older adults are not interesting in learning about HIV risk: late diagnosis as in our case (4), is thought to account for much of the initial excess morbidity and mortality of older adults. This delay may be partially due to stereotypes held by health professionals that led them to forgo testing their older patients for HIV and, possibly, to under-treat them once diagnosed (4), in according with Gott and al, 2004 (30), who identified specific concerns about addressing such issues with particular groups as the non-heterosexual patients.

Barriers to get a sexual history in later life are summarized in table 2.

Several recommendations on how to get the sexual history extend from this paper. Questions about sexual issues are more comfortable for both doctor and patient when the patient understands the relevance of such questions to his/her situation; once the subject of sex has been broached, a sexual history can be taken, focusing on the areas of patient concern (33). In the questionnaire the interviewer can break the ice starting with the health problems of the patient such as depression, diabetes, infection, urogenital tract conditions, or cancer: sexual problems may be a warning sign or consequence of a serious underlying illness. Then the interviewer can continue asking about the side effects of some medications which can lead to sexual problems, bearing in mind that patients may discontinue needed medications because of side effects that affect their sex lives (14).

However it is worth noting that privacy is important condition for obtaining an accurate and honest sexual history. It should be done routinely as part of the normal office visit, without intrusiveness or excessive zeal. To be alone at the visit may help the patient to open more comfortable his/her sexual issues. Each patient should be evaluated as their individual lifestyle, intellectual background, emotionality, sexual orientation, environment, and religious and cultural viewpoints (29).

At this point we can design a roadmap on how to approach to a sexual history of a senior patient.

The first goal is to build up openness, knowledge and frankness which can encourage the patient to discuss their sexual problems. Many aging men fear the loss of their sexual powers, but are reluctant to express their fear. GP-Gr can encourage older patients in the continued expression of sexuality if they committed to the care of the entire patient and, as such, deal with his/her sexual needs as effectively as they deal with other medical needs. If the GP-Gr are frank, open, and knowledgeable about both sex and aging, most older people are willing to discuss their sexual activity. Bauer and Geront, 1999 (34) suggest that humor is an integral part of our social system and it is notable that it is also a well-recognized phenomenon in the caregiving relationship; humorous conversation can, therefore, be a useful strategy to help reduce tension arising out of social conflicts and to galvanize relationships and manage "delicate" topics such as sex.

The second goal is to obtain important information about the physical health of the patient. In fact, sexual problems may be the result of the physical effects of the illness itself or may be secondary (19), as sexual problems may be a warning sign or consequence of a serious underlying illness such as diabetes, an infection, urogenital conditions, or cancer (14).

The third goal is the discovery of sexual misconceptions, concerns, or dysfunctions, which may then be directly addressed; may be that the real reason that the patient has come to seek medical care is his or her sexual dysfunction, but that the patient is reticent to volunteer spontaneously.

The fourth goal is to counsel and reassure the patients and spouses after dramatic events like myocardial infraction, stroke: studies have shown that sexual intercourse is roughly equivalent to climbing a flight of stairs, walking briskly or performing ordinary daily tasks; with this information at hand the GP-Gr can enhance them to go on with their sex activity (35).

Finally, physicians should not expect full disclosure, even if these strategies have been applied, but the benefits for both patient and physician far exceed the costs in timed and effort when a screening sexual history is obtained from a geriatric patient (36).

The four strategies to get a sexual history in later life are summarized in Tab. 3

The first lesson is that all of us -clinicians- tend to underestimate sexuality in our senior patients. Despite studies reporting that older people can be potentially sexually active in later life, the youth -oriented Western culture continues to devalue older people's sexuality. Stereotypical thinking and prejudice ignore the elders' need for sex, and inhibit discussion on this topic.

The second and very important lesson is that older people often mistake HIV/AIDS symptoms for the aches and pains of normal aging so, they are less likely than younger people to get tested for HIV/AIDS. They may be embarrassed, ashamed, and fearful of communicating their risky sexual behaviors to the physicians.
The third lesson is that, with the growth of the older adult population, physicians must become familiar with the multifaceted issues of aging sexuality. Physicians and society need to support, investigate, and encourage the sexuality of the old.

The fourth and final lesson is that, because many older people hesitate to initiate conversations with health care providers about sexual topics, a sensitive but proactive approach is warranted. An inability to interact with the patient will result in poor outcomes.

Nowadays, with respect to the past century, the emphasis is increasingly on the sexuality of older adults (37). The older adults of tomorrow, perhaps after having breaking taboos and prejudices, will request more knowledge and information for their sex lives. Internet makes scientific knowledge available to everyone, and transforms the traditional ways of teaching and learning about sexuality (38). Communications technologies and commercialization of the Internet bring about a new digital "sexual revolution" (38), which will influence people of all ages. There is no doubt that there are many problems and challenges that lie ahead, but GP-Gr cannot exclude this area from their visits anymore, and they have to prepare themselves not only professionally but also psychologically to this "new scenario"(!). Perhaps they should consider raising the topic of sexual health at the routine wellness examination and offer a follow-up appointment to discuss these concerns in greater detail (29).

The purpose of this paper was to explore why sexuality in older adults is often misunderstood, misrepresented, or simply invisible, although seniors must be considered as individuals who have desires and sexual needs. There are many barriers in the aging sexuality but adaptive coping strategies can mitigate their impact considerably. Information can play a vital role in dispelling the many myths that surround sexuality in old age, in order to foster and help the older individual in maintaining his/her sexuality, and also the GP-Gr in understanding the importance of sexual health in this vulnerable group. Much can be done by GP - Gr in cooperation, by showing sensitivity and by breaking down the taboos. However, why GP - Gr working with older people do not routinely discuss sexual problems still remains unclear. A check list developed on the basis of table 1 and 2 is relevant.


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Tab 1. Barriers and taboos in aging sexuality, divided by gender

Tab 1. Barriers and taboos in aging sexuality, divided by gender 























Tab 2. Barriers to get a sexual history in later life









Tab 3. The four strategies to get a sexual history in later life





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