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As Lindau et al. (2003) point out, sexuality involves the forming of a partnership and pertains to the behaviors, attitudes, function and activity of sexually active individuals. Sexual activity has been associated with health (Addis, Van Den Eeden and Wassel-Fyr, 2006; Laumann, Nicolosi and Glasser, 2005), and ailment and disease might significantly impair sexual health (Schover, 2000). Elderly people are recipients of a wide array of devices and medications which aim at treating problems of a sexual nature. While the demand for services and medication pertaining to sexual health is increasing, nevertheless not much is known about the sexual behavior of adults over 65 years of age.
In the developed countries, the chronological age of 65 years old is largely accepted as a cut-off point for classification of a person as ‘older’ or ‘elderly’. While common definitions of the third age such as this are indeed practically utilized, there exists no general consensus as to the point in time when one actually becomes old. Usually, the time in life when one becomes eligible for a pension is adopted as indicative of old age. The United Nations do not use a standardized criterion, but nevertheless agrees to 60+ years as referring to the elderly (WHO, 2010).
A definition of ageing is provided by Gorman (2000): ageing is a highly predetermined biological process which eludes human control. At the same time, ageing is defined in a constructivist world, where different societies assign different meanings to old age. Chronological age is seen as most important in developed countries. The age between 60 and 65 is taken to signify the onset of old age. By contrast, in many developing countries, age by years bears little relationship to the definition of old age. In such countries, the meaning of old age may depend instead on the roles that are been assigned to older people, or even on the loss of previously-held roles, which may come as a result of natural physical decline. In sum, while the developed world defines old age in a manner highly chronological, the same is often not true for developing countries, where people start to be perceived as elderly when their active role involvement is no longer possible (Gorman, 2000).
According to a definition by the World Health Organization (2001), sexuality is “a natural part of human development through every phase of life and includes physical, psychological, and social components” (p. 13). Another definition of sexuality provided by Rheaume and Mitty (2008) states that sexuality is a “core dimension of life that incorporates notions, beliefs, facts, fantasies, rituals, attitudes, values, and rights with regard to gender identity and role, sexual acts and orientation, and aspects of pleasure, intimacy, and reproduction” and involves biological, psychological, social, economic, religious, spiritual and cultural components (p. 342).
Health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2001, p. 8). In turn, sexual health “implies a positive approach to human sexuality and is therefore an essential component of reproductive health. It includes the integration of somatic, emotional, intellectual, and social aspects of an individual in ways which positively enrich and enhance personality, communication, love and human relationships” (p. 13). Sexual health, not unlike physical health, is viewed as a state of well-being where there is an expectation of pleasurable experiences without the intrusion of negative feelings such as shame, fear, pressure or violence. In keeping with this definition, Calamidas (1997) suggests that home or assisted-living nurses can play a crucial role in the quality of elderly people’s life through helping them attain and preserve a positive outlook toward the expression of their individual sexuality.
Historically, a large proportion of today’s elderly people grew up and lived during a time when social norms were both conservative and gender-biased. Broadly speaking, sexual intercourse was considered as a pleasurable experience primarily for the men while women were thereby expected to sexually satisfy their husbands and to make babies (Hajjar and Kamel, 2003). People that today are over 70 years old may have actually ‘missed’ the sexual revolution of the 1960s in the context and social conditions under which it took place, since they were already married and engrossed in their work and family life. This interesting analysis by Hajjar and Kamel (2003) proceeds to argue that the challenges to intimacy and sexuality faced by that age group may be partly due to the adoption of a rather conservative set of values and beliefs about sexuality, a limited availability and access to knowledge on sexuality, and a lack of feeling comfortable with their sexuality.
Rheaume and Mitty (2008) suggest that nowadays the traditional stereotypes regarding ageing, intimacy and sexuality are being reexamined; that is, the point of view is promoted that a desire for intimacy and for sexual contact does not have to cease at any point during the lifetime. Knowledge on the sexual activity of the elderly people however is far from complete, especially within a cross-cultural context as well as with reference to educational and financial status. In this light, the generalizability of research findings in this area is rather hindered. Oftentimes, this means that health professionals may be left “somewhat in the dark” concerning the wants and needs of older adults as to their sexuality (Rheaume and Mitty, 2008, p. 342).
Sexuality of the Elderly
The National Social Life, Health and Aging Project (NSHAP) has taken up the task of gathering data on the sexual activity, behaviors and problems of elderly people (Lindau et al., 2007). The findings of the national American sample of NSHAP show that while sexual activity tends to decrease with age, most older adults continue to enjoy intimate marital or other relationships, as well as consider their sexuality an important aspect of life. The majority of individuals aged 57 to 85 years old, and approximately one in three of individuals aged between 75 85 years old were active sexually. Even in their 80s or 90s, the elderly may practice sex and/or masturbation (Lindau et al., 2007).
There is evidence to suggest that some men and women retain their sexual desire and partnership during the whole of their life (Addis et al., 2006; AARP, 1999; Nicolosi, Laumann and Glasser, 2004; Bacon et al., 2003). Some of these studies however have relied on relatively small sample sizes, and have utilized non-random sampling methods. Taking into consideration the above criticisms, Lindau et al.’s (2007) study examined the occurrence of sexual activity in sexually active participants and did not find significantly decrease with old age. At the same time, the levels of reported sexual activity in respondents between 60 and 74 years old were comparable to the levels reported by adults from 18 to 59 years old, in a wide US survey (Laumann et al., 1994).
Adults aged 65 years and over can retain an active and satisfying sexual life throughout their years (WHO, 2002). Frequent sexual activity is commonly reported after middle age (Janus and Janus, 2003). In the survey of the American Association of Retired Persons (AARP, 1999) including 1384 elderly individuals, although sexual activity was reported as being pleasurable, no overarching agreement was reached as to the importance of sex toward maintaining a good relationship. The research by AARP (1999) also found that old adults who have partners tend to feel that a fulfilling sexual relationship is important, as opposed to old adults with no partners. Men older than 75 were more likely to have a spouse or partner and appeared to hold more favorable attitudes or more interest towards sex than did women of the same age. Men, whether they had a partner or not, reported a higher frequency of thoughts, feelings and fantasies related to sex than generally did women.
Steinke et al.’s (2008) research with healthy elderly people reported that the lesser health restrictions of the elderly helped them to retain their sexual activity throughout the course of their lives. Women in their third age usually demonstrate a larger diminution of sexual activity with time than do same-aged men (Lindau et al., 2007). According to the results of a multinational survey of persons 40 to 80 years of age (Laumann, Paik and Glasser, 2006), women tend to think of sex as a less important facet of life than do men, and they also tend to report more absence of pleasure from it.
The determination of the dynamics that are involved in sexual satisfaction are of particular importance here (Carpenter, Nathanson and Kim, 2009). Henderson-King and Veroff (1994) and Sprecher (2002) have found that sexual satisfaction enhances the individual’s well-being, while it promotes the stability of a marriage and of other personal relationships. A better knowledge of the factors that promote and lessen sexual satisfaction may help in the development of better-suited clinical and policy interventions against sexual problems (Bancroft, 2002). As populations age, a sound understanding of sexual activity in elderly people is becoming more and more relevant; people now enjoy longer and healthier lives, attitudes toward sexuality are being transformed and the importance of a fulfilling sexual life toward the attainment of personal happiness is being recognized (Seidman, 1991; Calasanti & Slevin, 2001).
Quality of life
A number of authors have suggested that doctors and policy-makers are becoming more and more aware of the importance of human sexuality for health and for good quality of life across the life span (Lindau et al., 2007; Satcher, 2001; WHO, 2002). In his description of the cross-cultural study of the World Health Organization, ‘Quality of Life/Older Adults’ (including such topics as autonomy, activity, functionality, intimacy, relationships, socialization, death, and dying, Robinson (2007) states that sexuality, health status and personal relationships were all significantly related to quality of life. Many studies have found that sexual activity bears a significant relationship to longevity and positive health outcomes (Palmore, 1982; Davey Smith, Frankel and Yarnell, 1997; Onder et al., 2003).
Since the beginning of the 21st century new and considerable attention has been paid to the sexuality of the elderly as a result of the creation of drugs that treat erectile dysfunction. Male erectile dysfunction, if treated effectively, can prolong the active sex life of the elderly of both genders throughout life (Lindau, 2010). As Cambois, Robine and Hayward (2001) point out, in many countries sexual problems comprise a major issue for elderly people; in the United States, approximately one in two 57 to 85 year olds who are sexually active report that they have at least one sexual predicament, and one in three mention at least two such afflictions. Accordingly, the majority of the elderly people in Lindau et al.’s (2007) study did report pestering problems of a sexual nature, and approximately one in four sexually active elderly participants of both genders refrained from sexual intercourse as a result of a sexual problem subject to therapeutic intervention.
During the transition to old age, changes in physiology can impair the sexual responsiveness of elderly women and men, while they may affect, either negatively or positively, their sexual function (Bachmann and Leiblum, 2004; Rosen et al., 2005). Different aspects of sexuality had been found to have a negative correlation with poor health and age (Laumann et al., 2005; Schover, 2000; Laumann, Paik and Rosen, 1999; Camacho and Reyes-Ortiz, 2005). Isselbacher et al. (1994) and Rosen et al. (2005) state that problems of a sexual nature may act as precursors or as epiphenomena to significant infections or diseases such as diabetes or cancer. Sexual problems that go unnoticed and/or untreated may lead to or co-occur with depression and social withdrawal (Nicolosi et al., 2004; Morley and Tariq, 2003, Araujo et al., 1998). Medication prescribed to the elderly may have an adverse effect on sexual life (Finger, Lund and Slagle, 1997); even medication which treats sexual problems may have adverse health effects (Lindau et al., 2006; Gott, Hinchliff and Galena, 2004).
Steinke et al. (2008) also found that elderly participants who were not active sexually showed a worsening of sexual self-concept, self-efficacy, and satisfaction. In Konstam, Moser and De Jong’s (2005) research, a heightened self-efficacy was demonstrated to improve on both sexual function and emotional functioning, not excluding depression.
Health and sexuality
Lindau et al.’s (2007) study found sexual activity to be positively related to the physical health of the elderly, particularly in elderly men. In general, healthy individuals of all ages were more likely to engage in marital or other intimate relationships and to be more sexually active. Furthermore, physical health was found to be related to different facets of sexual function, as well as sexual problems, regardless of age; similar findings have been reported by other researchers (Laumann et al., 1999; Bacon et al., 2003). It is advisable then that, when specific conditions apply, elderly people who have health problems or who are to receive treatment which may influence their sexual functioning may need to be evaluated based on their health status instead of their age (Laumann et al., 2005).
In a representative national analysis, Lindau (2010) assessed the relationship between sexuality, as measured per sexual activity and quality of sex life, and global self-reported physical health in mature and elderly adults. Lindau (2010) found that especially for older women, self-rated health was closely related to having a partner. Overall, participants who were of very good or excellent physical health were about 1.7 times more likely to show an interest in sex than did participants of less than good health.
As Lindau (2010) puts it, when compared to women, men tend to spend significantly more of their life being sexually active but, at the same time, miss out on significantly more years of sexual activity as a consequence of less than good health. This strong relationship between men’s health and expected duration of a sexually active life may be partly attributable to chronic diseases but also to treatment received for erectile dysfunction (Westlake et al., 1999; Solomon, Man and Jackson, 2003; Burke et al., 2007).
The United Nations (2007) have proposed that in the developed and developing nations, a projection of people’s sexual activity as they become older can be useful in predicting health needs and resources, sexual function-related services, the recovery from sexual dysfunction due to illness, as well as the treatment for commonly occurring health conditions in the third age. At the same time, the wish to prolong the duration of their sexual life can modify older people’s important health behaviors; mature adults may for example quit smoking or take their medication more seriously if they expect that their action will promote a lengthy and fulfilling sexual life (United Nations, 2007).
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