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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.

loving couple

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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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