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This offering expires in 2 years: June 4, 2009
The goal of this CE offering is to explore the area of sexual expression in older adults and encourage nurses to self-reflect on factors that would enhance the quality of care they provide to older patients. After reading this article, you will be able to:
1. Discuss the factors that impact sexual expression in older adults.
2. Discuss the effect living in a nursing home may have on sexual expression.
3. Use the RESPECT model to provide appropriate care to older adults related to their sexual expression needs.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for LPNs, Learning Scope, 3100 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the PA State Nurses Association (No. 008-O-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Southeastern States Board of Nursing (No. 3298).
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Let's talk sex - let's talk sex and the older adult. What's your reaction? Did you find yourself thinking "older adults don't have sex" or "even if they wanted to, they couldn't because they are too frail and weak to attempt it?
But wait a minute: A landmark study on sexual attitudes and practices of Americans ages 45 and older, commissioned by AARP and Modern Maturity magazine in 1999 and updated in 2004, found that although the amount of sexual activity generally decreases as one ages, the amount of sexual interest and ability remains fairly constant throughout the adult years.1-3 Older adults, ages 70 and older, reported participating in sexual activity. And that sexual activity, however it is expressed, is beneficial to the overall health of an elderly individual.
A classic survey conducted by Bretschneider4 with upper middle-class residents of 10 California life-care communities with an average age of 86 found:
70 percent of men and 50 percent of women thought "often" or "very often" about being close or intimate with the opposite sex; and
53 percent of men and 25 percent of women had regular sex partners, although only 29 percent of men and 14 percent of women were married.
On a more somber note, the CDC reports the HIV infection rate among adults over age 50 has continued to grow, emphasizing the fact older adults have the same risk factors for HIV infection and transmission as younger people.5
Although a discussion of sex may initially seem a topic more appropriate for teens and those in their childbearing years, it becomes clear it is also an important topic to discuss with older adults.
Sexual Expression Defined
Kaiser defines sexuality as "a complex interplay of needs for intimacy, affection, connection, self-pleasure and self-image."6 Intimate sexual expression takes many forms: those who participated in the AARP study reported that besides vaginal intercourse, other forms of intimate sexual expression includes holding hands, kissing, masturbation and oral sex.
Many nurses admit to feeling uncomfortable talking with older adults about their sexual needs. Some fear asking about sexuality will be viewed as an invasion of privacy. However, this is not a good reason to avoid the subject. As Wilton has stated, a "respect for privacy is not the same as ignoring people's needs."7 Older adults need to be able to talk about their sexual concerns and receive information pertinent to their needs. Older adults also need the opportunity to express themselves sexually and to satisfy their sexual desires.
Factors Influencing Sexual Expression
A person's personal values and views, including those of sexual expression, are usually shaped by cultural, religious and social values learned in youth, as well as social issues prevalent during the teen and young adult years. Parental statements, attitudes and actions also impact a youth's value system, including sexual attitudes and values.
Adults ages 70-80 today were teens in the 1940s and 1950s, a time of mixed signals about sex and love. Their parents may have been uncomfortable talking to them about sex, and discussions of sex often included the "horrors" of masturbation and premarital sex. Sex was saved for marriage.
Contrast that with adults ages 50-60 today, who were teens and young adults during the 1960s and 1970s, when there was a multifaceted sexual revolution: the "pill" became available; slogans like "If it feels good do it" and "Make love not war" rang through the streets; and the Masters and Johnson report Human Sexual Response was released.
Have you ever considered how your personal values and beliefs about sexual expression impact the way you view sexuality in older adults and the way you approach older adults about their sexuality?
Physical Changes of Age
All four stages of the sexual response cycle - excitement, plateau, orgasm and resolution - are affected by the aging process. Decreased estrogen in women and decreased testosterone in men are responsible for the majority of physical changes that impact sexual expression as one ages.
For postmenopausal women, a reduction in estrogen may cause vaginal dryness and thinning of the vagina. Older women also may experience shorter orgasms. On the other hand, they are often more relaxed and enjoy sex more once the burden of becoming pregnant is no longer a concern for them.
For men, a reduction in testosterone levels may require a longer period of stimulation to achieve an erection and climax. Older men have a longer refractory period, meaning they need more time to rest after sexual activity before they can perform again.
Erectile dysfunction is not a normal process in the aging male. However, if it occurs, the AARP study found men were not shy when it came to seeking help: 10 percent tried sex-enhancement treatments, nearly 50 percent tried sildenafil citrate (Viagra), 8 percent tried yohimbine/yohimbe (the bark of a tall evergreen tree that has been used for centuries in some western African nations for sexual enhancement) and 7 percent tried testosterone patches.
Other Factors
Research shows factors other than physical changes may have a greater impact on sexual expression in later life. These include factors that cannot be changed such as:
prescription drugs, such as antihypertensive agents, some psychotropics, digoxin, cancer chemotherapy and heparin;
illnesses such as hypertension, heart disease, osteoporosis, arthritis, incontinence, diabetes, emphysema and obesity; and
certain surgeries, including mastectomy, colonoscopy, prostatectomy, hysterectomy and heart surgeries.
They also include factors that can be changed with intervention, including:
life stressors such as career and/or financial stress, concerns about living arrangements and health issues;
fear of looking ridiculous, performance anxiety and feeling self-consciousness;
perceived or real attitudes of others, including family members and healthcare providers;
lack of a partner or lack of privacy;
fatigue, depression, body image concerns, sadness and loneliness;
feelings of unattractiveness, low self-esteem, guilt and a general reduced satisfaction in life; and
excessive food intake or alcohol use.
The Nursing Home Experience
About 1.6 million people live in approximately 20,000 nursing homes in the U.S. While a number of these people are there for only a short period of time (less than 6 months), many remain there for the rest of their lives. For these individuals, the nursing home becomes their home.
The current trend of culture change or transformation in nursing homes focuses on providing a homelike atmosphere for residents, changing care delivery from an institutional approach to one that is person-directed. "The culture envisioned is one of community, where each person's capabilities and individuality are affirmed and developed."8
Advocates of nursing home culture transformation suggest providing an environment that reflects the comforts of home, including accommodations for married couples and clients with significant others regardless of sexual orientation.9 This trend may lead to addressing barriers to sexual expression that have been identified in nursing homes: lack of privacy, nonsupportive attitudes of staff, feelings of unattractiveness and lack of knowledge about sexuality.
Imagine yourself many years from now living in a nursing home. How would you like the nursing home to be organized? How would you like to be treated, especially regarding your sexual needs?
Active Role for Nurses
Nurses provide quality patient care to older adults if they incorporate a discussion of sexual expression into routine care of this age group. One way to address the sexual needs of older adults is to use the RESPECT model.
Resources - Learn as much as you can about the factors that influence sexual expression in older adults. Check the bibliography included in this article to get you started. Provide accurate and current educational materials to older adult patients. Furnish written materials in waiting rooms so older adults can pick them up for reading, and as a sign that you welcome discussion about their sexual concerns.
Education - Ask your older adult patients if they are sexually active. Correct any misconceptions and answer any questions they might have about their sexual activities. Teach older patients about the physical changes of aging that may affect sexual functioning. Also include education about the importance of protection from STDs, including HIV. Many older adults are unaware they may be at risk for becoming infected and use no protection when engaging in sexual activity.
Support - Provide support for expression of older adult's sexuality and act as a patient advocate with other healthcare providers who may express discomfort. If an older adult's current beliefs interfere with contentment and sexual enjoyment, offer an alternative point of view. For example, some older adults who have lost a spouse may feel that they are violating their marriage vows by forming an intimate relationship with another person. Offer time for them to process this through discussion.
Protection - Sometimes, older adults fall prey to others who might take advantage of them. Always protect those who are unable to make their own decisions about engaging in sexual activity. Nurses also need to protect patients from themselves when they are not in control of their own behavior. Ignoring behavior does not lead to resolution; coming up with an action plan does.
Empowerment - Advocate for the healthy expression of sexual behavior. Help older adults feel physically attractive, such as by providing beauty salons and cosmetic services.
Don't assume sexual preference. Many nurses, without thinking, simply assume older adults are heterosexual. As a result, older gay men and lesbians may be reluctant to identify themselves as such. However, as they enter nursing homes or assisted living situations, many find that their previously private lives are now open for scrutiny. Nurses need to challenge their own preconceived notions, explore their own homophobic attitudes and advocate for those of all sexual orientations. As Kate Thomas, PhD, RN, FAACS, from the Center for Sexual Health and Medicine, Lutherville, MD, succinctly states: "Every individual, no matter how they define their sexuality or gender, is worthy of respect. Every individual has the right to determine their own course of action."10,11
Confidentiality - Encourage privacy and remove barriers to sexual expression. Allow conjugal visits, ensure privacy, allow doors to remain shut and arrange for home visits.
Many older people who have been celibate for a period of time may feel uncomfortable returning to a sexually active life. Sydney Youngerman-Cole suggests older adults who are uncomfortable with resuming sexual activity seek out other older adults who are in similar situations, make themselves available to others, and communicate openly about their fears and expectations.12
Tactfulness - Always ask questions about sexual expression in a casual way during the assessment interview. Leave the door open for discussion, and avoid hurrying and the appearance of prying. Many older adults may find it difficult to talk about their sexual needs with their children. Always get permission before sharing any information they have given you.
Support From Nurses
So, let's talk sex with our older adult patients. We might be surprised by what we learn. In addition, we also might open up an opportunity for older adults to ask questions they may have been reluctant to bring up. As adults are living longer, they need our support to live their lives as fully as possible.
References
1. AARP/Modern Maturity. (1999). What the 1999 AARP/Modern Maturity sex study found. (1999). Retrieved Jan. 15, 2007 from the World Wide Web: www.aarpmagazine.org/lifestyle/relationships/what_the_1999_aarpimodern_maturityi_sex_study_foun.html
2. Jacoby, S. (2005). Sex in America. Retrieved Feb. 15, 2007 from the World Wide Web: www.aarpmagazine.org/lifestyle/relationships/sex_in_america.html
3. Open University Press. (2005). Sexuality at midlife and beyond: 2004 update of attitudes and behaviors: Research report. www.aarp.org/research/family/lifestyles/2004_sexuality.html. Retrieved 1/15/07.
4. Bretschneider, J.G., & McCoy, N.L. (1988). Sexual interest and behavior in healthy 80- to 102-year-olds. Archives of Sexual Behavior, 17(2), 109-129.
5. CDC. (2005). HIV/AIDS surveillance report, 2005. (Vol. 17). Retrieved May 25, 2007 from the World Wide Web: www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/default.htm
6. Kaiser, F.E. (2003). Sexual function and the older woman. Clinics in Geriatric Medicine, 19(3), 463-472.
7. Wilton, T. (2000). Sexualities in health and social care: A textbook. Buckingham, UK: Open University Press.
8. Misiorski, S. (2007). Pioneering culture change. Retrieved Jan. 15, 2007 from the World Wide Web: www.nursinghomesmagazine.com/Past_Issues.htm?CD=323&ID=1518
9. Gibson, L., Thorson, G., & Thompson, B. (2005). Culture transformation: NHCU Summit in San Antonio. Retrieved Feb. 15, 2007 from the World Wide Web: www1.va.gov/geriatricsshg/docs/CultureTransformation-kellyVISN23.ppt
10. Price, E. (2005). All but invisible: Older gay men and lesbians. Nursing Older People, 17(4), 16-18.
11. Thomas, K. Center for Sexual Health and Medicine: Sex help online. Retrieved Feb. 15, 2007 from the World Wide Web: www.sexhelp.org/mdfol/thomas.htm
12. Youngerman-Cole, S. (2005) Sexuality and physical changes with aging. Retrieved Feb. 15, 2007 from the World Wide Web: http://health.yahoo.com/ency/healthwise/hw159186/hw159186
Joan M. Lorenz is a clinical specialist in psychiatric and mental health nursing, and works in nursing education at Bay Pines VA Healthcare System, Bay Pines, FL. <% footer %>
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