Sexual health, wellness in seniors: expressions of intimacy

are beneficial for seniors and should be accommodated and

protected.
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 assisted living
n.
A living arrangement in which people with special needs, especially older people with disabilities,
reside in a facility that provides help with everyday tasks such as bathing, dressing, and taking
medication. 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.
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I recently lost my beloved father, who had complex medical conditions and died of terminal
malignant melanoma Malignant Melanoma Definition
Malignant melanoma is a type of cancer arising from the melanocyte cells of the skin. Melanocytes
are cells in the skin that produce a pigment called melanin. . 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 sexual behavior A person's sexual
practices-ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual
life. 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 horrify
tr.v. horrified, horrifying, horrifies
1. To cause to feel horror. See Synonyms at dismay.
2. To cause unpleasant surprise to; shock. . 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 nonissue
n.
A matter of so little import that it ought not to become a focus of controversy and comment: She felt
that the matter of her attire should have been a nonissue. , a joke, or a conversation that many
would rather avoid altogether.
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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 New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest
city in the U.S. , "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 The New England Journal of Medicine (New Engl J Med or
NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts
Medical Society. It is one of the most popular and widely-read peer-reviewed general medical
journals in the world. 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 misinform
tr.v. misinformed, misinforming, misinforms
To provide with incorrect information.
mis , 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 NEJM New England Journal of Medicine
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 urogenital /urogenital/ (-jeni-tal) genitourinary.
urogenital or urinogenital
adj.
Genitourinary. tract conditions, musculoskeletal musculoskeletal /musculoskeletal/ (-
skele-t'l) pertaining to or comprising the skeleton and muscles.
musculoskeletal
adj.
Relating to or involving the muscles and the skeleton. problems and arthritis, neurovascular
conditions, and decreased physical endurance. Hypertension and antihypertensive
antihypertensive /antihypertensive/ (-tensiv) counteracting high blood pressure, or an
agent that does this.
antihypertensive
adj.
Reducing high blood pressure.
n. 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 cystitis (s?st?`t?s), common acute or chronic inflammation of the
urinary bladder. The disease occurs primarily in young women and frequently results from bacterial
invasion of the urethra from the adjacent rectum, most commonly with , urethritis
Urethritis Definition
Urethritis is an inflammation of the urethra that is usually caused by an infection.
Description
The urethra is the canal that moves urine from the bladder to the outside of the body. , 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
cellulite
n.
A fatty deposit causing a dimpled or uneven appearance, as around the thighs.
Cellulite
Cellulite is dimply skin caused by uneven fat deposits beneath the surface. . 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.
Healthy interventions
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 sexually transmitted disease (STD) or venereal disease, term for infections acquired
mainly through sexual contact. Five diseases were traditionally known as venereal diseases:
gonorrhea, syphilis, and the less common granuloma inguinale, (STD (Subscriber Trunk Dialing)
Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix
codes are required and billing is based on call units, which are a fixed amount of money in the
currency of that country. ). 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 HIV (Human Immunodeficiency Virus), either of two closely related
retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of
HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. , 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
nonexistence
n.
1. The condition of not existing.
2. Something that does not exist.
non 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 Rape crisis centers evolved in order to help victims of rape, sexual abuse,
and other forms of sexual violence. Also referred to as Sexual Assault Centers, RCCs serve a number
of purposes. . 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.
Summary
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 NHA Nha Trang, Vietnam (airport code)
NHA Nantucket Historical Association
NHA National Hydrogen Association
NHA National Health Accounts
NHA National Housing Act (Canada)
NHA National Humanities Alliance , is Corporate Vice President of Quality & Clinical Services,
Assisted Living Concepts, Inc. For more information, call (262) 257-8820 or e-mail
svadakin@alcco.com.
by Sara Elizabeth Vadakin, MS, RN, NHA
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