Activity 13

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Chapter 13
Sexuality and Aging

Objectives (1 of 3)

Recognize the importance of intimacy in feelings of sexuality.

Differentiate between sex and gender.

Define sexuality.

Recognize complications from common diseases that can interfere with the expression of sexuality.

Objectives (2 of 3)

List techniques to ameliorate complications in the expression of sexuality.

Identify some approaches to deal with sexuality issues, including the PLISSIT model.

Recognize the role prescription drugs can play in sexual expression.

Understand the causes of inappropriate client/patient sexual behavior and be able to choose appropriate responses.

Objectives (3 of 3)

Describe gender differences, including those in lesbian, homosexual and transgender persons, in sexual functioning caused by aging.

Recognize the ethical and policy dilemmas for sexuality for institutionalized older adults.

Sex & Sexuality (1 of 26)

  • Sexual innuendo pervades our society
  • Little time or attention devoted understanding our sexuality
  • Exploring our sexuality
  • Lifelong process
  • Frames how we see ourselves
  • Can greatly influence how we act

Sex & Sexuality (2 of 26)

  • Circles of Sexuality model
  • Ring of overlapping circles that represent the five core components of sexuality:
  • Sensuality
  • Intimacy
  • Sexual identity
  • Sexual health
  • Reproduction and sexualization

Sex & Sexuality (3 of 26)

  • FORGE
  • National transgender anti-violence organization
  • Added “power” to the sexualization circle to address issues of power and control often experienced by the LGBTQ community

Sex & Sexuality (4 of 26)

  • Similar models suggest sexuality is influenced by:
  • Feelings and beliefs about what it means to be male or female
  • Relationship(s) with people of similar or other genders
  • How relationships are established
  • How feelings are expressed

Sex & Sexuality (5 of 26)

  • Family, culture, and religious environments influence the development of sexuality
  • Being loved and nurtured fosters and strengthens our sense of competence
  • Abuse can inhibit the development of a positive sense of self-worth

Sex & Sexuality (6 of 26)

  • Sexuality is also influenced by:
  • Our self-perception as sexual beings
  • How our first expressions of overt sexual feelings were received by others

Sex & Sexuality (7 of 26)

  • Aging and sexuality
  • Sexual identity does not disappear with aging
  • Sexual feelings and urges simply change
  • Older adults may have fewer sexual encounters, but may find more pleasure by linking sex and intimacy to quality of life
  • Pleasuring, cuddling, and touching have been found to be more important among older adults

Sex & Sexuality (8 of 26)

  • Lindau study on sexuality among older adults found:
  • The two people involved define the parameters of the sexual relationship
  • An infinite variety of possibilities may prove satisfying to one or both partners
  • Main challenge for women remains finding a partner with whom to be intimate

Sex & Sexuality (9 of 26)

  • Another study identified a strong association between physical health and sexual activity among older adults
  • Identified benefits of mutually agreeable sex:
  • Improved health
  • Increased life span
  • More solid relationships
  • Bona fide escape from reality

Sex & Sexuality (10 of 26)

  • Study participants reporting some sexual problems indicated:
  • Sexual activity only began to substantially decrease after the age of 74
  • Problems experienced included:
  • Erectile dysfunction for men
  • Low libido, vaginal lubrication, and climax difficulties for women

Sex & Sexuality (11 of 26)

  • Findings from an analysis of the 2005–2006 National Social Life, Health, and Aging Project:
  • Sexual problems occurred in response to multiple stressors, not biological aging
  • Sexual health was directly affected by the strength and quality of the intimate relationship

Sex & Sexuality (12 of 26)

  • British study by Gott and Hinchliff found:
  • Older adults identified sex as an important part of a close relationship
  • Health problems and widowhood often led to a reprioritization of the role of sex
  • Intercourse remained centrally important even when viewed as no longer possible

Sex & Sexuality (13 of 26)

  • Study of older adults with lower socioeconomic status found:
  • Participants wanted to engage in sexual activities more frequently than they did, but lacked a partner
  • Touching and kissing were most desired
  • Mutual stroking, masturbation, and intercourse were less desired and infrequently experienced

Sex & Sexuality (14 of 26)

  • Intimacy
  • Requires self-acceptance and risk taking
  • Reinforces feelings of self-esteem and trust
  • Important component of meaningful sexuality
  • Reconciling the differences between one’s masculine and feminine qualities may be a key to vital aging
  • Embracing gender changes can enhance sexual activity

Sex & Sexuality (15 of 26)

  • Physiologic changes in sexual functioning
  • Women
  • Physical changes do not need to preclude sexual activity
  • Reduced sexual hormones only affect response time and intensity of physical response
  • Knowledge and appropriate adaptations can enhance sexual satisfaction in late life

Sex & Sexuality (16 of 26)

  • Menopause
  • Physiologic marker for changes in sexual functioning
  • Medicalization has identified female sexual dysfunction as a new category of disease
  • Culture, religion, family experiences, and level of acceptance of the aging process impact how a woman approaches and manages menopause

Sex & Sexuality (17 of 26)

  • Estrogen replacement therapy (ERT)
  • Recommended to treat “deficiency disease” of menopause
  • Helps alleviate symptoms, but increases risk for conditions such as heart disease, breast and uterine cancer, stroke, and cognitive decline
  • Final decision must be made by the individual considering her own circumstances

Sex & Sexuality (18 of 26)

  • Older women continue to regularly engage in and enjoy sex
  • Can be affected by decreased hormone levels and coexisting medical and psychiatric illnesses
  • Studies have found:
  • Sexually active women report frequent arousal, lubrication, and orgasm into old age
  • Sexual activity was not necessary to attain sexual satisfaction

Sex & Sexuality (19 of 26)

  • Effects of decreased estrogen from menopause:
  • Vaginal changes
  • Vasomotor changes leading to hot flashes or flushes
  • Less rapid and extreme vascular responses to sexual arousal
  • Orgasm with fewer contractions

Sex & Sexuality (20 of 26)

  • Effects of decreased estrogen from menopause (continued):
  • Bladder and urethral changes
  • Diminished fatty tissue of mons
  • Increased susceptibility of clitoral area to irritation by forced manipulation

Sex & Sexuality (21 of 26)

  • Decrease in libido
  • Sexual desire and activity are not necessarily related
  • Women may participate in sexual activity primarily for intimacy
  • Libido may increase post-menopause
  • Decreased desire may be the result of health problems, medication, or lack of partners

Sex & Sexuality (22 of 26)

  • Men
  • Changes in sexual functioning are less dramatic
  • Physical changes are largely due to reduced circulating testosterone
  • Arousal is delayed with less firm erection and less clear sense of impending orgasm
  • Orgasms may involve abbreviated ejaculation, decreased urethral contractions, decreased force and amount of ejaculate

Sex & Sexuality (23 of 26)

  • Other changes in sexual functioning:
  • Rapid loss of erection postorgasm
  • Longer time needed between erections
  • Decreased swelling and erection of nipples
  • Absence of flush
  • Reduced elevation of testicles
  • Knowing about and accepting these changes can contribute to increased sexual pleasure

Sex & Sexuality (24 of 26)

  • Gender differences
  • Meaning of sexuality can change with age
  • Cultural changes for women may include:
  • Different sexual scripts
  • Engagement in role transitions
  • Increased self-esteem
  • Promotion of their own sexual agency

Sex & Sexuality (25 of 26)

  • Masturbation
  • Safe way to relieve sexual tension
  • Continues through life
  • May enhance feelings of autonomy
  • Viewed by many as a substitute sexual activity

Sex & Sexuality (26 of 26)

  • Study findings indicate that:
  • Many men remain sexually active into their 70s
  • Most women are not sexually active, primarily due to a lack of partners or a decreased libido in their current male partner

Raising the Subject of Sexual Functioning (1 of 4)

  • Sexual functioning and sexuality need to be included as part of functional evaluations across the life span
  • Time and practice are needed to normalize the conversation about sexual functioning
  • Recognize your own discomfort
  • Start engaging patients
  • Ask open-ended questions

Raising the Subject of Sexual Functioning (2 of 4)

  • Practitioners should demonstrate:
  • Sensitivity
  • Empathy and understanding
  • Knowledge of physiologic changes
  • Cultural competency and respect
  • Familiarity with potential intervention strategies
  • Knowledge of available referral resources

Raising the Subject of Sexual Functioning (3 of 4)

  • Common misconceptions:
  • Client will initiate discussion about sexual functioning if it is important
  • Client’s sexual preference aligns with practitioner’s views of sexuality
  • Client is monogamous
  • Client share’s practitioner’s views on morality
  • Client’s age explicitly correlates with libido

Raising the Subject of Sexual Functioning (4 of 4)

  • Discussing sexual functioning with older adults can provide them with many benefits
  • Feeling empowered and less alone
  • Decreased inhibitions
  • Accepting their physical changes
  • Increased comfort with their sexuality
  • Enhanced sexual responses
  • Better communication

Assessing and Addressing Sexual Functioning (1 of 15)

  • PLISSIT model
  • Helps practitioner identify the level of intervention needed
  • Assists practitioner in understanding the level at which he or she can provide the intervention
  • Each ascending level requires more expertise from practitioners than the previous level
  • Knowledge of available resources is necessary

Assessing and Addressing Sexual Functioning (2 of 15)

  • Levels of treatment in the PLISSIT model
  • Permission
  • Limited information
  • Specific suggestions
  • Intensive therapy
  • Practitioners only proceed to the level at which they are comfortable and prepared

Assessing and Addressing Sexual Functioning (3 of 15)

  • Recognition Model
  • Recommended for a team-based approach
  • Takes steps that:
  • Recognize the individual as a sexual being
  • Facilitate opportunities to communicate and engage
  • Explore sexual concerns and problems
  • Address issues of sexual problems
  • Refer individual to an appropriate level of treatment

Assessing and Addressing Sexual Functioning (4 of 15)

  • Third approach is to explore areas of concern with regard to sexual performance:
  • Self-esteem
  • Body image
  • Relationships
  • Family

Assessing and Addressing Sexual Functioning (5 of 15)

  • Practitioners are better positioned to treat problems with sexual functioning if they:
  • Are comfortable with their own sexuality
  • Have an interest in treating older adults

Assessing and Addressing Sexual Functioning (6 of 15)

  • Sexual functioning and health problems
  • Arthritis
  • Can affect sexual performance and quality of life
  • Regular sexual activity can increase production of cortisol and endorphins that can:
  • Reduce pain and discomfort
  • Lessen symptoms of depression

Assessing and Addressing Sexual Functioning (7 of 15)

  • Older adults with arthritis should:
  • Rest prior to sexual activity to prevent fatigue or engage at times when energy is greatest
  • Place a pillow under painful limbs
  • Use aspirin prophylactically, if medically allowed, for pain before sexual activity
  • Use a hot shower or other thermal heat sources before sexual activity

Assessing and Addressing Sexual Functioning (8 of 15)

  • Older adults with arthritis should also:
  • Experiment with alternative positions
  • Use alternatives to intercourse
  • Empty bladder before sexual activity
  • Exercise regularly
  • Communicate and discuss fears and discomfort with their partner

Assessing and Addressing Sexual Functioning (9 of 15)

  • Heart disease
  • Can lead to anxiety about and avoidance of sexual activity
  • Older adults with heart disease should:
  • Take a less active role in the sexual act
  • Learn and use relaxation or de-stressing techniques
  • Use masturbation as an alternative to intercourse
  • Use foreplay to enable the heart to warm up slowly

Assessing and Addressing Sexual Functioning (10 of 15)

  • Older adults with heart disease should also:
  • Avoid sexual activity when anxious or fatigued, or when the weather is extremely hot, cold, or humid
  • Use positions that conserve energy and are non-weight-bearing
  • Use an activity configuration to determine energy and desire to participate in sexual activity

Assessing and Addressing Sexual Functioning (11 of 15)

  • Cerebrovascular accidents (CVAs or strokes)
  • Can lead to:
  • Sensory losses
  • Perceptual problems
  • Loss of strength and mobility
  • Visual problems
  • Communication problems

Assessing and Addressing Sexual Functioning (12 of 15)

  • Older adults with a CVA diagnosis should:
  • Experiment with comfortable positions
  • Keep partner within the visual field
  • Use heated blankets or mattress pads to facilitate relaxation
  • Use a manual vibrator for stimulation to compensate for weakness or incoordination
  • Stimulate areas that remain responsive to touch

Assessing and Addressing Sexual Functioning (13 of 15)

  • Cancer
  • Coping with the aftermath of cancer and its treatments includes acceptance of emotional and physical changes that can alter body image and self-esteem

Assessing and Addressing Sexual Functioning (14 of 15)

  • Older adults adjusting to life with cancer should:
  • Use vaginal lubricants
  • Engage with fantasy and massage
  • Use sex toys or vibrators to increase arousal
  • Request medication changes to facilitate sexual functioning
  • Schedule sex during times with the most energy

Assessing and Addressing Sexual Functioning (15 of 15)

  • Older adults adjusting to life with cancer should also:
  • Be creative and open to trying new things
  • Assess how the body has changed and responds to sexual stimulation
  • Incorporate relaxation techniques
  • Engage in pelvic floor exercises
  • Use pillows, bolsters, and wedges

Medication Effects

  • Medications can affect sexual functioning
  • Prescribers, practitioners, and users must communicate about potential side effects
  • Different formulations of a required medication may be available and eliminate or reduce the identified sexual problem

Inappropriate Sexual Behaviors Toward Practitioners (1 of 3)

  • Inappropriate sexual behaviors (ISB)
  • Interferes with care and intervention services
  • Form of sexual harassment
  • Key challenges of reporting ISB:
  • Definitions vary
  • Practitioner’s interpretation can vary
  • Can range from flattery to asking for a date to exposure and attempts at sexual fondling

Inappropriate Sexual Behaviors Toward Practitioners (2 of 3)

  • Possible causes of ISB:
  • Disinhibition arising from neurological conditions
  • Long-term sexual dysfunctioning
  • Fear of losing sexual functioning
  • Attempt to gain power or control over the practitioner and the intervention process

Inappropriate Sexual Behaviors Toward Practitioners (3 of 3)

  • Practitioner’s options:
  • Ignore the IBS
  • May only weaken the therapeutic relationship
  • Refuse to accept behavior from a client that they would not accept from anyone else
  • Immediately report repeated behavior
  • Develop an interprofessional behavioral plan

Special Populations (1 of 16)

  • Older lesbians and gay males
  • Diverse group whose image is often portrayed negatively
  • Share some of the same issues as heterosexuals with their sexuality in late life
  • Tend to be well-adjusted, self-accepting, and adapting to the aging process

Special Populations (2 of 16)

  • Practitioners often ignore issues of sexuality with older lesbians and gay males
  • Clients may:
  • Become marginalized
  • Harbor concerns about confidentiality
  • Fear discrimination and lack of sensitivity
  • Practitioners need to be sensitive to and connect with their client’s agency and provide them with culturally safe services

Special Populations (3 of 16)

  • Today’s older lesbians and gay males have had to:
  • Construct the meaning of their sexual identity while living in a heterosexually dominated society
  • Declare their sexuality many times over

Special Populations (4 of 16)

  • Stages of self-identify:
  • Identity
  • Confusion
  • Comparison
  • Tolerance
  • Acceptance
  • Pride
  • Synthesis

Special Populations (5 of 16)

  • Reconstructing or developing sexual identities outside of the social norm often results in:
  • Conflicts with family and friends
  • Advocacy to initiate social change

Special Populations (6 of 16)

  • Efforts to find a niche in society can lead to the need to make many adjustments throughout life
  • Can facilitate older lesbians’ and gay males’ ability manage the aging process
  • Helps develop a “crisis competence”

Special Populations (7 of 16)

  • Recommendations for working with older lesbians and gay males:
  • Take a nonjudgmental approach
  • Assess for their stage of development with their sexual identity
  • Develop an awareness of a client’s culture
  • Develop an awareness of societal discrimination against the client

Special Populations (8 of 16)

  • Recommendations for working with older lesbians and gay males (continued):
  • Recognize the importance of sex in the lives of older adults
  • Accept that clients may need a variety of sexual behaviors to satisfy need
  • Nurture an open-mind and remain nonjudgmental of sexual activity in late life

Special Populations (9 of 16)

  • Transgender adults
  • Transgender is an umbrella term for persons whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth
  • Opposite term is cisgender—a person who identifies with the gender they were assigned at birth

Special Populations (10 of 16)

  • Transgender people communicate their identity through their outward appearance
  • Not every person who presents as gender non-conforming will identify as a transgender person
  • Gender is increasingly being viewed on a spectrum
  • Individuals may be male, female, transgender, non-binary, or agender

Special Populations (11 of 16)

  • Gender non-conforming persons continue to face challenges blending into society and obtaining the quality of life they seek
  • Older transgender adults are marginalized in society and are hesitant to seek medical assistance
  • Negatively impacts their health and stress level

Special Populations (12 of 16)

  • Healthcare practitioners need to:
  • Be straightforward in asking people how they wish to be addressed
  • Use sensitive questioning and language
  • Provide a supportive environment
  • Provide culturally safe services
  • Include families of choice in treatment and care

Special Populations (13 of 16)

  • Adults with physical disabilities
  • Study found that women with disabilities:
  • Were less satisfied with their frequency of dating
  • Were less likely to have friendships evolve into romantic relationships
  • Had experienced abuse as frequently as nondisabled women, but for longer periods of time
  • Had as much sexual desire as other women, but not as much opportunity for sexual activity

Special Populations (14 of 16)

  • Another study found that:
  • Men with physical disabilities devalued the lower parts of their bodies more than women
  • Body-esteem was most closely related to:
  • Self-esteem in women
  • Sexual-esteem in men

Special Populations (15 of 16)

  • Couple with one partner with a disability
  • Decline in frequency of sexual activity
  • Change in approaches used to engage sex
  • Decline in sexual satisfaction and interest
  • Fear, discomfort, and increased stress contribute to physical limitations

Special Populations (16 of 16)

  • Recognizing the importance of sexuality and sexual activity as vital aspects in the lives of older adults can help clients:
  • Maintain or enhance their self-esteem
  • Increase their options for intimacy

Adults Living in Institutions (1 of 7)

  • Need for intimacy and sexual expression does not disappear, and may increase
  • May suffer “emotional malnutrition”
  • Healthcare providers must acknowledge these needs and rights in order to provide truly person-centered care

Adults Living in Institutions (2 of 7)

  • Some institutions:
  • Set aside a room where couples may spend time alone to pursue intimate relations
  • Help coordinate private couple time for residents who have a roommate that is not their partner

Adults Living in Institutions (3 of 7)

  • Training goals for healthcare practitioners:
  • Be aware of myths and realities surrounding sex and sexuality in late life
  • Be educated about older adults’ sexual needs
  • Be responsible for shielding residents from abuse
  • Be aware of their own prejudices and biases

Adults Living in Institutions (4 of 7)

  • Other recommendations:
  • Provide older adults with alternate outlets for sexual expression that maintain and restore ego strength
  • Recognize and address the needs of the partners of adults who are institutionalized
  • Provide time and space for intimacy when it is desired
  • Offer counseling and understanding

Adults Living in Institutions (5 of 7)

  • Informed consent
  • Point of contention in regard to persons who are institutionalized
  • Crucial to ensure the older adult is not being taken advantage of by a partner
  • Capacity should be assumed until proven otherwise by staff using established institutional guidelines and conducting an assessment

Adults Living in Institutions (6 of 7)

  • Dignity of risk must be afforded residents as it is a fundamental human right
  • Institutions should adopt a specific process to prepare for addressing concerns about resident sexual activity before it occurs

Adults Living in Institutions (7 of 7)

  • Recommendations:
  • Assemble key stakeholders
  • Learn about the issues
  • Conduct focus groups for values clarification
  • Review sample policies
  • Create working definitions of key concepts
  • Identify interventions
  • Draft, implement, and evaluate a policy document

Adults Infected with HIV (1 of 6)

  • Incidence of HIV is rising faster among adults age 50 and older than in younger age groups
  • Largest risk factor for transmission continues to be unprotected sex
  • Atrophic vaginal tissue changes and decreased lubrication in older women make them particularly susceptible

Adults Infected with HIV (2 of 6)

  • HIV infection among older adults is associated with:
  • Faster disease progression
  • Higher rates of morbidity and mortality

Adults Infected with HIV (3 of 6)

  • Barriers to diagnosing HIV in older people:
  • Physicians not asking about sexual activity or drug use
  • Limited testing of older adults for HIV
  • Reluctance of older adults to share information about their sexual activity
  • Nonspecific symptoms may be overlooked

Adults Infected with HIV (4 of 6)

  • AIDS Dementia Complex (ADC)
  • Very common and clinically important
  • Source of great morbidity
  • Cognitive impairments can include:
  • Emotional changes
  • Impairments in attention, executive function, and memory
  • HAART medication may reduce cognitive issues

Adults Infected with HIV (5 of 6)

  • Safe sex practices
  • Often not discussed with older adults
  • Project ROADMAP (Re-educating Older Adults in Maintaining AIDS Prevention)
  • Focuses on reducing high-risk behavior among HIV-positive older adults

Adults Infected with HIV (6 of 6)

  • Recommendations for practitioners:
  • Routinely include sexual functioning and histories as part of medical examinations
  • Be aware of methods of transmission among older adults
  • Remain sensitive to how safe sex information is acknowledged and shared with partners
  • Offer non-judgmental, plain language information and responses to questions