Sexuality in the Older Adult
Although it is generally believed that sexual desires decrease with age, researchers have identified that sexual desires, thoughts, and actions continue throughout all decades of life. Human touch and healthy sex lives evoke feelings of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one’s sexuality. Healthcare providers play an important role in assessing and managing normal and pathological aging changes in order to improve the sexual health of older adults.
BACKGROUND AND STATEMENT OF THE PROBLEM
- Sexuality is a central aspect of being human throughout life that encompasses intimacy, emotional expression, gender identities and roles, and sexual orientation, and is influenced by biological, psychological, cognitive, and other factors (WHO, 2017).
- Sexual health is a state of physical, emotional, mental, and social well-being related to sexuality, with a positive, responsible approach to sexuality and sexual relationships (WHO, 2017).
- Sexual dysfunction is an impairment in normal sexual functioning (Steinke, 2017b).
B. Etiology and/or epidemiology
- Many older adults continue to be sexually active, resulting in greater life enjoyment, quality of life, and sexual well-being (Flynn & Gow, 2015; Santos-Iglesias et al., 2016; Smith et al., 2018).
- Despite the continuing sexual needs of older adults, many barriers prevent sexual health among older adults.
- Healthcare providers often lack knowledge and comfort in discussing sexual issues with older adults (Bauer et al., 2016; Hughes & Wittmann, 2015; Maes & Louis, 2011).
- Older adults may be LGBT; alternative sexual preferences must be respected, and protective strategies discussed (Lim et al., 2014; See Chapter 33, LGBTQ Perspectives for Older Adult Care).
- The older population is more susceptible to many disabling medical conditions. A number of chronic conditions are associated with poor sexual health and functioning, including depression, cardiac disease, stroke and aphasia, chronic respiratory disease, cancer, and diabetes, that make sexuality difficult.
- Medications used among older adults, especially those commonly used to treat medical illnesses, also impact sexuality such as cardiac medications and antidepressants (Nicolai et al., 2014; Reichenpfader et al., 2014; Trenque et al., 2013).
- Normal aging changes, such as a higher frequency of vaginal dryness in women and erectile dysfunction in men, make sexual health difficult to achieve (Hsu et al., 2017; Levin, 2015; Spadt & Kusturiss, 2016; Syme, 2014; Yeap et al., 2012).
- Environmental barriers also present barriers to sexual health among older adults (Aguilar, 2017; Lichtenberg, 2014; Mroczek et al., 2013).
A. The PLISSIT model (Annon, 1976) begins by first seeking permission (P) to discuss sexuality with the older adult. The next step of the model affords an opportunity for the nurse to share limited information (LI) with the older adult. Specific suggestions (SS) and interventions to improve health are then provided. Referral to intensive therapy (IT) may be needed for those with more complex sexual problems.
B. Ask open-ended questions such as “Can you tell me how you express your sexuality?” or “What concerns you about your sexuality?” and “How has your sexuality changed as you have aged?”
C. Assess for presence of physiological changes through a health history, review of systems, and physical examination for the presence of normal and aging changes that impact sexual health.
D. Review medications among older adults, especially those commonly used to treat medical illnesses that also impact sexuality such as antidepressants and antihypertensives.
E. Assess medical conditions that have been associated with poor sexual health and functioning, including depression, cardiac disease, stroke, chronic respiratory disease, cancer, and diabetes.
NURSING CARE STRATEGIES
A. Communication and education
- Discuss normal age-related physiological changes.
- Address how the effects of medications and medical conditions may affect one’s sexual function.
- Facilitate communication with older adults and their families regarding sexual health as desired, including the following:
- Encourage family meetings with open discussion of issues if desired.
- Teach about safe-sex practices.
- Discuss use of condoms to prevent transmission of STIs and HIV (CDC, n.d.; Spadt & Kusturiss, 2016; see Chapter 32, HIV Prevention and Care for the Older Adult).
B. Health management
- Perform a thorough patient assessment.
- Conduct a health history, review of systems, and physical examination.
- Effectively manage chronic illness.
- Improve glucose monitoring and control among diabetics.
- Ensure appropriate treatment of depression and screening for depression (see Chapter 19, Late-Life Depression).
- Discontinue and substitute medications that may result in sexual dysfunction, or try lower doses or a different drug class (e.g., ARB instead of ACEI; antidepressants such as mirtazapine or bupropion).
- Accurately assess and document older adults’ ability to make informed decisions (see Chapter 7, Healthcare Decision-Making).
- Participation in sexual relationships may be considered abusive if the older adult is not capable of making decisions or sexual activity is not consensual (Lichtenberg, 2014).
C. Sexual enhancement
- Compensate for normal changes of aging, including engaging in regular sexual activity, being sensitive to changes in one another’s bodies, and the use of aids to increase stimulation and lubrication (Gillespie, 2017; Smith et al., 2018).
- Use of artificial water-based lubricants (Spadt & Kusturiss, 2016)
- Use of topical estrogen (Clayton & Harsh, 2016)
- Recognizing the possibility for more time and direct stimulation for arousal caused by aging changes; use of oral erectile agents for erectile dysfunction (Marchese, 2017)
- Environmental adaptations
- Ensure privacy and safety among long-term care and community-dwelling residents (Steinke, 2017a; Wallace, 2012; Yelland & Stanfield, 2018).
A. Patients will:
- Report high quality of life as measured by a standardized quality-of-life assessment.
- Be provided with privacy, dignity, and respect surrounding their sexuality.
- Receive communication and education regarding sexual health as desired.
- Be able to pursue sexual health free of pathological and problematic sexual behaviors.
B. Nurses will:
- Include sexual health questions in their routine history and physical.
- Frequently reassess patients for changes in sexual health.
C. Institutions will:
- Include sexual health questions on intake and reassessment measures.
- Provide education on the ongoing sexual needs of older adults and appropriate interventions to manage these needs with dignity and respect.
- Provide a supportive environment that facilitates sexual discussions among staff and clients.
- Provide needed privacy for individuals to maintain intimacy and sexual health (e.g., in long-term care).
FOLLOW-UP MONITORING OF CONDITION
Sexual outcomes are difficult to directly assess and measure. However, with the demonstrated link between sexual health and quality of life, quality-of-life measures, such as the Medical Outcomes Study SF-36 Health Survey (RAND Health Care, n.d.), may be used to determine the effectiveness of interventions to promote sexual health. Retrieved from https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html
ACEI Angiotensin-converting enzyme inhibitor
ARB Angiotensin receptor blocker
CDC Centers for Disease Control
LGBT Lesbian, gay, bisexual, transgender
PDE5-I Phosphodiesterase-5 inhibitor
PLISSIT Permission, limited information, specific suggestion, intensive therapy
SNRI Serotonin norepinephrine reuptake inhibitor
SSRI Selective serotonin reuptake inhibitors
STI Sexually transmitted infection
WHO World Health Organization
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Chapter 15: Steinke, E. (2021) Issues Regarding Sexuality in Older Adults. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 221 -240). New York: Springer.
Aguilar, R. A. (2017). Sexual expression of nursing home residents: Systematic review of the literature. Journal of Nursing Scholarship, 49(5), 470–477. doi:10.1111/jnu.12315. Evidence Level I.
Annon, J. S. (1976). The PLISSIT model: A proposed conceptual scheme for behavioral treatment of sexual problems. Journal of Sex Education Therapy, 2(1), 1–15. doi:10.1080/01614576.1976.11074483. Evidence Level VI.
Bauer, M., Haesler, E., & Fetherstonhaugh, D. (2016). Let’s talk about sex: Older people’s views on the recognition of sexuality and sexual health in the health care setting. Health Expectations, 19(6), 1237–1250. doi:10.1111/hex.12418. Evidence Level I.
Centers for Disease Control and Prevention. (n.d.). HIV and older Americans. Retrieved from https://www.cdc.gov/hiv/pdf/group/age/olderamericans/cdc-hiv-older-americans.pdf. Evidence Level V.
Clayton, A. H., & Harsh, V. (2016). Sexual function across aging. Current Psychiatry Reports, 18(3), 28. doi:10.1007/s11920-016-0661-x. Evidence Level V.
Flynn, T. J., & Gow, A. J. (2015). Examining associations between sexual behaviours and quality of life in older adults. Age and Ageing, 44(5), 823–828. doi:10.1093/ageing/afv083. Evidence Level IV.
Gillespie, B. J. (2017). Correlates of sex frequency and sexual satisfaction among partnered older adults. Journal of Sex & Marital Therapy, 43(5), 403–423. doi:10.1080/0092623X.2016.1176608. Evidence Level IV.
Hsu, B., Hirani, V., Naganathan, V., Blyth, F. M., Le Couteur, D. G., Seibel, M. J., … Cumming, R. G. (2017). Sexual function and mortality in older men: The Concord Health and Ageing in Men Project. Journal of Gerontology. Series A, Biological Sciences and Medical Sciences, 72(4), 520–527. doi:10.1093/Gerona/glw101. Evidence Level IV.
Hughes, A. K., & Wittmann, D. (2015). Aging sexuality: Knowledge and perceptions of preparation among U.S. primary care providers. Journal of Sex & Marital Therapy, 41(3), 304–313. doi:10.1080/0092623X.2014.889056. Evidence Level IV.
Levin, R. J. (2015). Sexuality of the ageing female—The underlying physiology. Sexual and Relationship Therapy, 30(1), 25–36. doi: 10.1080/14681994.2014.963984. Evidence Level V.
Lichtenberg, P. A. (2014). Sexuality and physical intimacy in long term care: Sexuality, long term care, capacity assessment. Occupational Therapy in Health Care, 28(1), 42–50. doi:10.3109/07380577.2013.865858. Evidence Level V.
Lim, F. A., Brown, D. V., Jr., & Justin Kim, S. M. (2014). Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. American Journal of Nursing, 114(6), 24–34. doi:10.1097/01.NAJ.0000450423.89759.36. Evidence Level V.
Maes, C. A., & Louis, M. (2011). Nurse practitioners’ sexual history-taking practices with adults 50 and older. Journal for Nurse Practitioners, 7(3), 216–222. doi:10.1016/j.nurpra.2010.06.003. Evidence Level IV.
Mroczek, B., Kurpas, D., Gronowska, M., Kotwas, A., & Karakiewicz, B. (2013). Psychosexual needs and sexual behaviors of nursing home residents. Archives of Gerontology and Geriatrics, 57, 32–38. doi:10.1016/j.archger.2013.02.003. Evidence Level IV.
Nicolai, M. P. J., Liem, S. S., Both, S., Pelger, R. C. M., Putter, H., Schalij, M. J., & Elzevier, H. W. (2014). A review of the positive and negative effects of cardiovascular drugs on sexual function: A proposed table for use in clinical practice. Netherlands Heart Journal, 22(1), 11–19. doi:10.1007/s12471-013-0482-z. Evidence Level V.
Reichenpfader, U., Gartlehner, G., Morgan, L. C., Greenblatt, A., Nussbaumer, B., Hansen, R. A., … Gaynes, B. N. (2014). -Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: Results from a systematic review with network meta-analysis. Drug Safety, 37(1), 19–31. doi:10.1007/s40264–013-0129–4. -Evidence Level I.
Santos-Iglesias, P., Byers, E. S., & Moglia, R. (2016). Sexual well being of older men and women. The Canadian Journal of Human Sexuality, 25(2), 86–98. doi:10.3138/cjhs.252A4. Evidence Level IV.
Smith, L., Yang, L., Veronese, N., Soysal, P., Stubbs, B., & Jackson, S. E. (2018). Sexual activity is associated with greater enjoyment of life in older adults. Sexual Medicine, 7(1), e1–e8. doi:10.1016/j.esxm.2018.11.001. Evidence Level IV.
Spadt, S. K., & Kusturiss, E. (2016). Female sexual function and ageing: Constructs for understanding sexual health and common medical issues. Topics in Geriatric Rehabilitation, 32(3), 193–198. doi:10.1097/TGR.0000000000000115. Evidence Level V.
Steinke, E. E. (2017a). Ineffective sexuality pattern. In B. J. Ackley, G. B. Ladwig, & M. B. Flynn Makic (Eds.), Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed., pp. 790–797). St. Louis, MO: Elsevier. Evidence Level V.
Steinke, E. E. (2017b). Sexual dysfunction. In B. J. Ackley, G. B. Ladwig, & M. B. Flynn Makic (Eds.), Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed., pp. 784–790). St. Louis, MO: Elsevier. Evidence Level V.
Syme, M. L., & Cohn, T. J. (2016). Examining aging sexual stigma attitudes among adults by gender, age, and generational status. Aging & Mental Health, 20(1), 36–45. doi:10.1080/13607863.2015.1012044. Evidence Level IV.
Trenque, T., Maura, G., Herlem, E., Vallet, C., Sole, E., Auriche, P., & Drame, M. (2013). Reports of sexual disorders related to serotonin reuptake inhibitors in the French pharacovigilance database: An example of underreporting. Drugs & Safety, 36(7), 515–519. doi:10.1007/s40264–013-0069-z. Evidence Level IV.
Wallace, M. (2012). Nursing standard of practice protocol: Sexuality in the older adult. New York, NY: Hartford Institute for Geriatric Nursing. Retrieved from https://consultgeri.org/geriatric-topics/sexuality-issues-aging. Evidence Level V.
World Health Organization. (2017). Sexual health and its linkages to reproductive health: An operational approach. Geneva, Switzerland: Author. Retrieved from https://www.who.int/reproductivehealth/publications/sexual_health/sh-linkages-rh/en/. Evidence Level VI.
Yeap, B. B., Araujo, A. B., & Wittert, G. A. (2012). Do low testosterone levels contribute to ill-health during male ageing? Critical Reviews in Clinical Laboratory Sciences, 49(5–6), 168–182. doi:10.3109/10408363.2012.725461. Evidence Level V.
Yelland, E., & Stanfield, M. H. (2018). Public perspectives toward long-term care staff’s interventions in the sexual relationships of residents with dementia. Dementia, 1471301218772915. doi:10.1177/1471301218772915. Evidence Level IV.