Sexual health, wellness in seniors
As we are abundantly aware, our society routinely associates sex with youth, beauty, wellness, and vitality. Recent research findings as well as the common experiences of long-term care and assisted living providers make a compelling case for making sexual health and wellness part of overall resident care. To do this, we must correct the myths surrounding sex and seniors, educate staff and frontline caregivers, and implement strategies at the community level to create a comfortable environment that nurtures expressions of intimacy, sexual health, and wellness.
I recently lost my beloved father, who had complex medical conditions and died of terminal malignant melanoma. He was 85 years old and was married to my mother for almost 60 years. They remained deeply in love and, until shortly before his death, regularly enjoyed an intimate and sexual relationship.
I have been a clinician for many years, but firmly believe the intimacy and sexuality my parents shared gave my father great emotional comfort and periodic relief from his disease processes and the associated pain and suffering during the last years of his life. He was on home hospice and my mother was cradling him in her arms when he took his last breath. They were physically and emotionally connected to the end.
Grandma and Grandpa do what?
In most Western cultures, discussing personal sexual behavior and practices can be uncomfortable at best. When turning the focus to discuss sexual relations among older adults, reactions can range from uncomfortable to horrified. Many people would rather not talk or think about their own parents or grandparents engaging in sexual acts and, consequently, the topic of sex among seniors is often dismissed as a nonissue, a joke, or a conversation that many would rather avoid altogether.
Love, sex, and intimacy are ageless and can have many health and psychosocial benefits in our senior years. I believe that intimacy and a meaningful sexual relationship at any age involve a great deal more than the act of sexual intercourse. Seniors often “get this” and have improved intimacy and sexual relations as they reach their later years. For many seniors, a great deal of intimacy and emotional satisfaction can be derived from touching, kissing, embracing, sensual massage, or simply holding hands.
Research has demonstrated that individuals who have enjoyed an active and healthy sex life throughout adulthood are likely to continue doing so well into their later years. It is important that caregivers understand that a “sexuality light switch” is not flipped off when we turn 70 or 80 years of age. Although sexual expression and fulfillment may not involve penetration, a substantial number of seniors still engage in intercourse, oral sex, and self-stimulation even into the eighth and ninth decades of life.
According to Dr. Patricia Bloom, associate professor of geriatrics and palliative medicine at The Mount Sinai Medical Center in New York City, “The level of sexual interest and activity among people over 65 is as diverse as the individuals who make up that population.” Many older adults actually report that their sex lives improve as they age. There is no longer a fear of pregnancy or of children interrupting the sexual encounter. Sexuality remains a basic human need and sexual relationships have occurred and will continue to occur between residents in our communities.
Barriers to sexual expression
A New England Journal of Medicine study conducted in 2007 revealed that only 22% of women and 38% of men had discussed sex with a doctor since age 50. Given these statistics, physician communication may be poor, and many are uncomfortable broaching the topic of sexuality with their elderly patients. Nurses or social workers, who have established relationships with residents, may be in a better position to discuss sexual health issues, and then refer them to a physician as necessary or requested. It should be noted that many residents may be uncomfortable discussing sexual problems with caregivers because of guilt, shame, misinformation, or sexual dysfunction. Conversations should be conducted in private and with the utmost sensitivity to the residents’ identified concerns and issues.
Among the sexually active participants in the NEJM study, half reported at least one bothersome sexual problem, with many avoiding sexual activity as a result. In addition, negative attitudes still prevail about women’s sexuality and sex at older ages. This is very alarming in that many of the problems with sexual function in the later years are often associated with underlying physiologic problems resulting from disease processes. Research clearly indicates that both men and women in poor health are less likely to be sexually active in their later years. Clearly, many older adults could benefit from discussions and therapeutic interventions targeting sexual health.
Impact of history and medical conditions
Unlike older adults who have enjoyed healthy sexual expression in their younger years, an older adult whose sexual experiences have been linked to physical or psychological pain, rejection, humiliation, and guilt will likely continue to avoid sexual contact and intimacy as a senior. Although many individuals enjoy full and loving lives without the need to have frequent sex, it should be noted that physical health is more closely associated with sexual dysfunction than age alone.
Long-term care professionals help to treat and alleviate many health conditions and it is important to consider how these health conditions can impact a senior’s sexual activity and sexual function. For example, common health problems that can impact sexual health and wellness include diabetes, cardiovascular conditions, urogenital tract conditions, musculoskeletal problems and arthritis, neurovascular conditions, and decreased physical endurance. Hypertension and antihypertensive medications also can cause erectile dysfunction (ED). While medications like Viagra, Cialis, or Levitra have changed the face of sexual behavior for many individuals, ED is still a common sexual health issue among older men and one they may be uncomfortable discussing with their healthcare providers.
Among older women, cystitis, urethritis, and the hormonal effects of menopause are among the common conditions that can result in decreased sexual health or interest in sex. Vaginal dryness can often be easily eradicated with medication or over-the-counter lubricants that can make the difference between sexual abstinence for fear of pain and a fulfilling sexual experience. Changes in functional mobility may necessitate alternate sexual positions to prevent pain and discomfort in a senior.
For both older men and women, changes in sexual health and wellness can trigger feelings of decreased self-esteem and depression, making it imperative that caregivers include sexual health in the resident assessment process. As our body image changes with the aging process, we may feel less attractive to our partner. Stress, anxiety, and a lack of sexual interest or responsiveness can result at the appearance of gray hair, hair loss, increased wrinkles, and excess weight or cellulite. Body changes, decreased mobility, and the perceived lack of acceptance by a partner may result in performance anxiety that can lead to impotence in men and an inability to achieve orgasm in women at any age, and this is intensified in many seniors.
Providers should consider incorporating sexual health and well-being assessments into the comprehensive assessment completed by a licensed or registered nurse at their communities. Ask residents if they are sexually active and if they have related issues they would like to discuss privately. Issues can be addressed by an interdisciplinary team that may include physicians, nurses, social workers, pharmacists, psychologists, and/or clergy members.
When discussing sex with seniors it is important to stress healthy sex is also safe sex. While the older adult may not be concerned about pregnancy, sex with a new partner should include open, honest communication and a discussion about the possibility of contracting a sexually transmitted disease (STD). Older adults must be just as diligent as younger adults when practicing safe sex with new partners. Nurses and care providers should include the use of condoms as part of this conversation, as STDs, HIV, and Hepatitis viruses are realities in our society.
A common issue specific to residents of long-term care communities is lack of privacy, as some individuals may not have private accommodations or do not feel comfortable having sex in a congregate living environment. Providers should find creative ways to provide appropriate and private times and places to allow residents to express their sexual needs and preferences. For example, a continuing care community can develop privacy signs for the doorknobs, similar to what is provided by hotels. Caregivers must respect the privacy of the resident or couple in a room or apartment and not disturb them until the sign has been removed. Except in cases of emergency, caregivers should remember to always knock before entering a resident’s room or apartment. In some instances, it may be possible to arrange a “home visit” for the resident to spend private time with his/her spouse or partner in their familiar surroundings.
As part of the NEJM research study, seniors were queried about topics that are often considered even more taboo than merely discussing the sexual health and behaviors of older adults. These topics included self-stimulation, homosexuality, and alternate lifestyles, and some participants chose not to answer these questions at all. Of those who chose to answer questions regarding homosexuality, an astounding three of 1,198 men and five of 815 women reported homosexual preferences. Among older adults in particular, few have ever revealed their homosexuality, which can result in depression and feelings of isolation. As we are well aware, long-term care or residential communities serving gay, lesbian, and transgendered individuals are still virtually nonexistent in the United States. Providers must be prepared to address the needs and preferences of all residents with dignity, sensitivity, and respect, regardless of the individual’s sexual orientation.
Protecting the vulnerable
Providers have an obligation to intervene immediately to protect frail and vulnerable residents who may be victimized by sexually aggressive residents, staff, or visitors. Be prepared to quickly identify inappropriate sexual behavior that could lead to abuse and impact the health, welfare, and safety of residents and/or staff.
New employee training and orientation must include a component on sexual behavior among seniors and discussions should include examples of acceptable and healthy behaviors as opposed to unacceptable and unhealthy behaviors. The topic of consensual versus nonconsensual sex also should be clearly outlined.
And while it would seem it should go without saying, it is also important for staff to understand that sexual relationships between staff and residents, nonconsenting adults, or those who do not have the capacity to make the decision to engage in sex, are never appropriate and should be reported to the management team immediately. Allegations of rape or sexual assault warrant an immediate call to the facility leadership team and timely evaluation by a qualified healthcare provider, emergency room, or rape crisis center. Providers also must notify the appropriate law enforcement officials and licensing/regulatory agencies in such cases, as well as have a system in place to notify responsible family members.
It can get better with age
Years ago when I was a new director of nursing, a male resident who recently suffered a stroke became sexually aggressive with the female staff of our skilled nursing facility. During baths and linen changes he would grab the breasts and genitals of the caregivers, requesting a variety of sexual acts.
The resident’s wife was living in our assisted living community attached to the skilled nursing facility and visited him several times daily. After discussing this privately with the resident and his wife, I learned that prior to his CVA and hospitalization the couple had enjoyed an active sex life. I gently counseled the resident about his inappropriate sexual behavior toward the female caregivers, but reassured him we would provide private time for expressions of intimacy with his wife.
We provided a privacy sign and taught staff not to interrupt or enter the room when they saw the sign on his door. I discussed and taught the couple more appropriate outlets for both of their feelings, needs, and desires. Consequently, the sexually aggressive behavior stopped and the resident was better able to deal with his illness and the absence of his wife. Intimacy was re-established between the two seniors, positively impacting their overall health and wellness.
Like younger adults, seniors may view sex as an expression of passion, affection, admiration, or loyalty. It may be viewed as a renewal of romance, an expression of joy, or a continued opportunity for growth and development. It can also be viewed as an affirmation of life and an opportunity to maintain a sense of identity. Sex can also increase self-esteem and confidence, prevent or reduce anxiety, or just provide physical and emotional pleasure for the older adult.
By continuing to explore this important topic with residents and staff, providers can work together to positively impact the sexual health and wellness of seniors and provide individualized, resident-centered care for the “whole” person.
Sara Elizabeth Vadakin, MS, RN, NHA, is Corporate Vice President of Quality & Clinical Services, Assisted Living Concepts, Inc. For more information, call (262) 257-8820 or e-mail
firstname.lastname@example.org. Long-Term Living 2010 November;59(11):47-49