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Section 14. Mens and Womens Health Issues
Chapter 114. Sexuality
Topics:    Introduction | Aging and Sexual Function | Effects of Medical Disorders on Sexuality | Effects of Surgery on Sexuality | Effects of Drugs on Sexuality

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Introduction

The quality or state that comprises sexual desire (libido), arousal, function, and activity; physical satisfaction; and emotional intimacy.

A comprehensive survey of sexuality in the elderly has never been done in the USA. The nature and frequency of sexual activity among the elderly are unknown, as is the association between sexual activity and marital status, health status, or any other variable. Available data are from the important but now historic and limited Kinsey studies (1948 to 1949), the physiologic investigations of Masters and Johnson, the Duke Longitudinal Studies, and the Baltimore Longitudinal Study on Aging. Questionnaire surveys of self-reported sexual activity have been conducted by mail (eg, by Consumers Union). The most important conclusion is that sexuality is important to many elderly persons.

The elderly often view sexuality as an expression of passion, affection, admiration, and loyalty; a renewal of romance; a general affirmation of life, especially the expression of joy; and a continuing opportunity for growth and experience. In addition, sexual activity is a means for the elderly to affirm physical functioning, to maintain a strong sense of identity and establish self-confidence, and to prevent anxiety. It remains a mode of pure physical pleasure as well.

However, not all elderly persons have positive attitudes about sexuality. Even healthy elderly persons may internalize the negative stereotypes of elderly persons as desexualized invalids or, at the opposite extreme, as "dirty old men" or "lecherous old women." Some elderly persons show prejudice against other elderly persons and refuse to associate with them, reject an elderly partner, or attempt to appear unreasonably and inappropriately young.

Like all persons, the elderly may experience sexual dysfunction due to boredom, fear, fatigue, grief, or other factors (eg, intrinsically low sexual desire, physical disability). Sexuality in the elderly is particularly affected by problems that are common in this age group: eg, depression, medical disorders, or incapacitation or death of a partner.

Partners are in short supply, especially for elderly women, who outlive and outnumber elderly men. Over 50% of elderly women are widows, 7% have never married, and 2% are divorced. Thus, about 60% of elderly women are without a spouse, in contrast to about 20% of elderly men. Elderly persons who have lost their partner may be reluctant to begin dating, an activity abandoned for decades, and feel unfamiliar with dating practices when opportunities arise. How to date and make new and enduring relationships can be challenging.

Negative generational attitudes about masturbation and homosexuality can interfere with sexual expression. Many elderly homosexual persons have not publicly revealed their sexual preference. Although their relationships and sexual problems are generally similar to those of heterosexual persons, homosexual persons may experience additional stress due to a perceived need to hide their sexual orientation. Those who are institutionalized may be particularly vulnerable to loneliness and isolation. Gay-oriented long-term care facilities are virtually nonexistent.

A sexual history is part of the general medical evaluation of all elderly persons. Inquiry about current sexual function and activity is especially important. However, some physicians are uncomfortable discussing sexual issues with elderly persons because of ignorance, personal anxieties, negative stereotypes about the elderly, or objections to expression of sexuality by some elderly persons.

Some patients are misinformed about sexuality, and some may refuse to discuss sexual issues, about which they may harbor feelings of guilt and shame. Even if their sexual dysfunction is obvious, these persons often are unlikely to accept help. However, reassurance and information from a physician may enable some persons to achieve a more positive self-image and to express their sexual needs.

The sexual needs of elderly persons who live in nursing homes and other long-term care facilities deserve respect. These persons may be isolated from their partner, and many have severe neurologic, cardiovascular, or other impairments. As a result, sexuality in these patients may be expressed aggressively or may be accompanied by depression, dementia, or delirium. Staff must strive to understand sexual behavior and provide privacy. Medicaid and the regulations of some states and municipalities establish minimally acceptable guidelines regarding such issues as privacy for institutions.

Interdisciplinary issues: Nurses, social workers, and other health care workers may encounter patients, especially men or demented or delirious patients, who express their sexuality aggressively. Such health care workers need training in dealing with sexual issues; they may also need to counsel sexually active patients on the appropriate time and place for sexuality and provide them the privacy to do so.

Caregiver issues: Sexual expression or activity by an elderly person may be misunderstood or unwelcomed by family members and caregivers. Family members and caregivers may benefit from information and counseling to better understand that elderly persons have sexual desires and to help the elderly meet such needs when possible (eg, by providing privacy).

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