WHY: Older adults retain their sexuality even after they reach “later life” as studies done by Masters and Johnson (1986), Lindau and colleagues (2007) and, Smith and colleagues (2019) have demonstrated. Faced with acute and chronic illness, normal aging changing changes, emotional and functional losses, medication side effects and changes in living environments, older adults are able to adapt and discover new ways to express their sexuality (Smith et al, 2019; Lagana et al, 2020). At the same time, new issues may arise that further complicate the older adult’s life and require a nuanced approach by the nurse. The older adult may no longer identify with the same sexual identity as they did when younger (Lagana’ et al, 2020), the older adult may have symptoms of a sexually transmitted disease, the older adult may be HIV positive, institutional racism in health care may restrain both nurse and patient from discussing important issues (Lagana’ et al, 2020), and the older person with dementia may need advocacy to promote sexual health or to protect from sexual advances (Jones & Moyle, 2018). In 2018, the CDC identified an increase in syphilis of 28.6% in adults aged 65 years and older. Implicit in this rate increase is validation of sexual activity in older adults, along with need to both identify sexually transmitted infections and to educate older adults that they may still contract STIs. The nurse is pivotal to a careful sexual assessment of both emotional and physical needs within an environmental, cultural, societal and medical context. In addition to the assessment of sexual health needs, the nurse remains an educator to the older adult and/or informal/formal caregivers for discussion of sexual needs and for possible interventions to facilitate healthy sexual expression. With further assessment of functional needs, chronic health issues, and medications, the nurse can refer to interprofessional specialists as needed and accepted by the older adult.

BEST TOOL: The National LGBT Health Education Center offers an algorithm for conducting a sexual history that can be modified for use in older adults. By omitting questions about pregnancy, the algorithm enables a nurse to incorporate the sexual history into a routine admission or visit history. Landes adapted the algorithm into a 1 sheet “yes”/”no” questionnaire for use in a primary care practice and reported on its ease of use. (Landes, 2020).

TARGET POPULATION: The National LGBT Health Education Algorithm modified to exclude the questions about pregnancy can be utilized by nurses in any clinical setting including home visits. The Algorithm facilitates comfort for both the nurse and patient by offering a “set the stage”. It is important that the nurse explore their own thoughts, feelings and perceptions about sexuality and the wide range of sexual expression in older adults to engage the older adults in a sensitive topic.

VALIDITY AND RELIABILITY:  The National LGBT Health Education Algorithm for conducting a sexual history offers a framework and specific questions to ask patients. When modified to exclude questions about pregnancy, it is a tool to focus on the sexual history in older adults. The Algorithm is based on CDC’s Guide to Taking a Sexual History that includes asking about the five “P”s: partners, practices, protection from STDs, past history of STDs and prevention of pregnancy.  Face validity is present but specific reliability measures have not been researched.

STRENGTHS AND LIMITATIONS: The National LGBT Health Education Algorithm allows for the integration of sexual history into general history taking and can be modified for older adults by excluding the questions on pregnancy. The algorithm is a stepwise process that begins with “setting the stage” for nurses to engage the older adult. The next step with three screening questions enables the nurse to focus on more specific issues and then transitions to the more specific questions based on the sexual activity by the older adult. The final step of education, counseling, and referrals is based on the sexual needs of the older adult. While the algorithm is concise and gives specific areas to explore by the nurse, it does not provide the nurse with standardized questions. How the questions are asked is as important as asking the questions. This may be more of an issue in populations where culture and language are different.

MORE ON THE TOPIC:

Centers for Disease Control and Prevention2019). Sexually Transmitted Disease Surveillance 2018- Primary and Secondary Syphilis by Age.  Accessed 2/24/21 at cdc.gov/std/stats18/syphilis.htm.

Centers for Disease Control and Prevention, National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention. Taking a Sexual History. Accessed 2/24/21 at cdc.gov/aguidetotakingasexual history.

Emlet, C.A., O’Brien, K.K., & Fredriksen Goldsen, K. (2019). The global impact of HIV on sexual and gender minority older adults: challenges, progress and future directions. Int J AgingHum Dev, 89(1): 108-126.

Jones, C. & Moyle, W. (2018). Are gerontological nurses ready for the expression of sexuality by individuals with dementia?. Journal of Gerontological Nursing, 44(5):2-4.

Lagana’, L., Balian, O.V., Nakhla, M.Z., Zizumbo, J., & Greenberg, S. (2020). A preliminary model of health regarding sexual and ethnic minority older adults. Culture, Health & Sexuality,1464-5351.

Landes,C.(2020). Increasing Primary Care Provider Sexual Health Assessments in Older Adults. DNP Project at Oklahoma City University-Kramer School of Nursing. Accessed on Google Scholar; 2/24/21.

Lindau, S.T., Schumm, L.P., Laumann, E.O., Levinson, W., O’muircheartaigh, C.A., & Waite,

L.J.(2007). A study of sexuality and health among older adults in the United States, NEJM, 357, 762-744. Evidence Level IV: Non-experimental Study.

Master, W.H. (1986). Sex and aging-expectations and reality. Hospital Practice, 21(8), 175-198. Evidence Level VI: Expert Opinion. National Institute of Aging. (2017). Sexuality in Later Life.  Accessed 2/9/21

National LGBT Health Education Center & National Association of Community Health Centers (November, 2015). Taking Routine Histories of Sexual Health: A System-Wide Approach to Health Centers.

Smith, L., Yang, L., Veronese, N., Soysal, P., Stubbs, B., & Jackson, S.E. (2019). Sexual activity isassociated with greater enjoyment of life in older adults. Sexual Medicine, 7(1), 11-18.