Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Sexuality and Intimacy Assessment
Sexuality and Aging
Human beings are sexual beings throughout their lives. In good health, a person may continue to be sexually active into the seventh, eighth, and even ninth decade (DeHertogh DA, 1994).
Some degree of sexual appetite is usually present throughout life (Brooks TR, 1993).
Persons aged 65 years and older can have satisfying sexual experiences throughout their senior years, and weekly sexual activity is common well past middle age (Janus SC, 2003).
Sex involves merging emotional, spiritual and physical intimacies. Quality, in a sense, is more important than quantity when it comes to sexual relations and it comes only with time as the couple get to know each other better (Rao TSS, 2011).
Any performance concerns makes the act only more difficulty The very act of experimenting can lead to failure at times which can be overcome easily in an intimate relationship (Rao TSS, 2001)
Opinions about sex differ across gender and age groups (AARP, 1999).
Having a partner influences a person’s feelings about the importance of sexuality to life quality.
Generally, older adults with partners feel that a satisfying sexual relationship is important, whereas those without partners do not feel such urgency.
Women over age 75 are less likely to have a partner than older men and, as such, seem to have a less positive attitude toward or interest in sexual activity than men of the same age.
Men with or without a partner have more frequent thoughts, fantasies, and feelings of sexual desire (and self-stimulation) than women, with or without partners (AARP, 1999).
Western culture places great value on youth, physical attractiveness, and vigor. The pervasive message, conveyed in countless subtle and not-so-subtle ways, is that aging and sexual desirability are mutually exclusive. We are bombarded with advertisements for skin creams, cosmetic surgery, and hair color formulas, with the underlying assumption that facial wrinkles, sagging breasts, and gray hair are the banes of aging. Older adults may consequently experience lowered expectations for sexual fulfillment and avoidance of intimate relationships due to a sense of unworthiness or shame.
Age-Related Changes and Medical Conditions in Men
Decreased desire (loss of libido) can be caused by medical problems, depression, medication side effects, or lack of information about the range of sexual activities that could be pleasurable.
ED is the inability to achieve and maintain an erection for successful intercourse.
It is the most prevalent sexual problem in men, and its incidence increases with age; approximately 75% of men have experienced difficulty achieving an erection at some time by the time they reach 70 years of age.
Some older men believe that they have erectile dysfunction (ED; once more commonly known as ‘impotence”) when they are actually experiencing an age-related change in physical response.
When compared with younger men, older men require more physical penile stimulation and a longer time to achieve erection, and the duration of orgasm may be shorter and less intense.
ED is commonly caused by blood vessel disease associated with hypertension, diabetes, high cholesterol, and smoking. Neurological causes of impotence include spinal cord injury and Parkinson’s disease. Impotence can also occur following prostate surgery. Anxiety, depression, and relationship issues may all be implicated in ED. Some men suffer from widower’s syndrome, that is, difficulty achieving erection because they harbor guilt about pursuing a sexual relationship after the death of their spouse.
Sexual response can also be adversely affected by alcohol consumption.
Testosterone levels have little to do with ED but can have a major influence on libido (sexual desire).
Medications associated with ED include antidepressants, antihistamines, antihypertensives, antipsychotics, and several over-the-counter preparations (e.g., for heartburn); in most cases, the mechanism for this side effect is unknown.
Age-Related Changes and Medical Conditions in Women
Aging also affects the female sexual response, including fewer and weaker orgasms, mainly due to hormonal changes, but also as a result of altered body image, relationship and family issues, and medical conditions that may arise in late life.
Postmenopausal changes in the urinary or genital tract associated with lower levels of estrogen can make sexual activity less pleasurable. The resulting vaginal dryness and thinning of tissue can cause pain and irritation during intercourse (dyspareunia) and leave fragile mucous membranes susceptible to infection.
Body image can be particularly important post-mastectomy, which for some women represents loss of a part of their femininity.
Any medical condition that adversely affects mobility and endurance, such as heart disease, diabetes, or arthritis can limit sexual activity and make some positions uncomfortable.
Many of the same medications that are problematic for men can adversely affect the female sexual response; these include antihistamines, antihypertensives, antidepressants, anti-psychotics, antispasmodics, antiestrogens, and alcohol.
Sexual behavior in dementia.
Sexual interest and activity does not disappear with onset of a dementing illness.
Those in the first stage of Alzheimer’s disease may experience heightened sexual desire or a complete loss of interest in such activity (Tabak N, 2006)
Hypersexuality is relatively rare but not uncommon in dementia and can be treated with medication.
Certain medications, such as benzodiazepines, are associated with loss of sexual inhibition (Tabak N, 2006).
Assessment of decision-making capacity is essential for care home residents involved (or potentially involved) in a sexual relationship, with particular focus on
comprehension of both parties’ intentions or interests
their understanding of physical intimacy and sexual activity and
their expectations of the relationship and of the activity
If there is evidence that understanding is lacking, then the demented person must be protected from sexual exploitation and abuse, including unwanted touching.
There is no simple answer to the dilemma of a demented person who really wants to be intimate or engage in sexual activity but is unable to foresee the consequences, for example, being abandoned, so to speak, after the sexual activity.
In situations like these, an interdisciplinary ethics committee meeting or consultation might be warranted (Kamel HK, 2003).
Among the questions that can be raised are those addressing
the impact of this new relationship on the spouse (in the event that one or both are married)
the facility’s role in judging the wishes and understanding of the 2 residents
the presence or absence of coercion, whether either resident (or both) is mistaking the other as his or her spouse
the extent to which this new activity reflects an authentic value expressed in the past by the resident(s).
It is critical to recognize the sexual needs of residents and to make accommodations for these while preserving the rights of others.
For example, masturbation is a normal (for men and women) way of achieving sexual pleasure in the absence of a partner.
Caregiving staff should receive support and education about how to respond when they discover a resident masturbating (i.e., they should take steps to ensure the resident’s privacy).
Sexual activities that are commonly problematic in long-term care facilities include masturbation in public spaces, disrobing in public, inappropriate or suggestive sexual comments, exposing private body parts, reaching out to fondle or grab body parts that are associated with sexual arousal, and attempting to kiss others.
These behaviors are distressing to other residents and staff and signal a need for an interdisciplinary sexual assessment. The purpose of this assessment is to determine the underlying need the resident is expressing and how it might be addressed. (The possibility of urinary, vulvar, or vaginal pathology should not be overlooked in a resident who frequently touches his or genital area.)
Boredom, loneliness, and the need for reassurance can all lead to sexualized behavior that others find objectionable.
A resident might be mistaking another person for his or her spouse and begin exhibiting unwelcome intimate behavior toward that person (Kuhn D, 2003).
On the other hand, sexual expression between residents could indicate development of a new legitimate and welcome relationship,
Overcoming Barriers to Sexuality and Intimacy in Residential Care
Staff misconceptions and negative attitudes about sexuality and aging may pose a barrier to sexual fulfillment for long-term care residents.
It is important to examine staff attitudes to sexuality and intimacy, to ensure that optimum responses and actions are taken in response to residents sexuality and intimacy needs.
Staff education about sexuality and intimacy of older adults encompasses recognition of cues, desires, and interest in sexual activity and intimacy. It also must address the use of and access to pornographic material, assisting expression of sexuality through masturbation, and discussion and debunking of stereotypes (e.g., the “dirty old man”).
In long-term care settings, supporting sexual health of older adults begins with an assessment of sexual history on admission. This includes obtaining information about the person’s sleeping habits (e.g., without sleepwear), sexual orientation, history of extramarital affairs, sleep pattern, current sexual activity (e.g., masturbation), and interests (Kamel HK, 2003).
It is useful to know the resident’s attitude toward sexual humor and entertainment, such as explicit magazines or movies. How does the resident meet his or her need for sexual expression and intimacy?
All residents should be offered a level of privacy commensurate with their individual needs.
Ways to promote privacy might include hanging a “do not disturb” sign during conjugal visits and arranging something for the roommate to do during this personal private time. For some residents, the opportunity to pet or stroke an animal may provide the sense of touch they are missing.
Gay and lesbian older adults may need support to maintain their relationship (if their partner lives in community) or starting one in the assisted living residence (Blando JA, 2001).
Sex education and counseling might be indicated for those residents who express an interest in pursuing or resuming sexual activity.
Residents’ families might also benefit from sex education or counseling, keeping in mind, however, that the resident’s privacy rights are paramount.
This Read More page is an extension of
Sexuality and Intimacy Assessment
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The Sexuality and Intimacy Assessment is one of 8 domains of the
Comprehensive Geriatric Assessment (CGA)
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