Sexuality and the Older Adult

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Sexuality is at the core of who we are and has an impact on our lives in so many ways. It does not stop once we hit the age of 60 or 70 or 90 or even 100 despite the myths and assumptions of society. Sexual desire does not necessarily dissipate with age, but the physical, cognitive, and psychosocial changes that can occur with aging may interfere with sexual outcomes. Issues of sexuality with older adults often become a taboo topic; whether it is the expression of desire or the inappropriate sexual acting out of the individual with dis-inhibition secondary to dementia.

In the long-term care environment, expressions of sexuality are frequently labeled as problem behaviors. The number of older adults testing HIV positive is on the rise thereby making safe sex practices a priority topic of discussion for health care professionals. Clearly sexual issues are fairly common among older adults, but the health care team infrequently addresses these issues. Student nurses are no different. They frequently report a level of discomfort with initiating discussions of sexual assessment with their patients in general but more so with their patients who are older adults. There are sexuality assessments that are often a subsection of general assessments, but are often glazed over secondary to the discomfort of the examiner or the hypothesis that it is not of importance to the examiner. Common sexual side effects of medications such as antidepressants are regularly discussed with younger patients but very rarely addressed with older adult patients.

The need to raise a student’s awareness of the complex issues surrounding sexuality of older adults is a focus of this teaching strategy. In addition, this teaching strategy is designed to increase the comfort level of the student and to routinely include an integration of sexuality assessment in the plan of care of older adults. The landmark Masters and Johnson study (1986) links increased quality of life with the fulfillment of sexual desire. Empowering nurses to advocate for the sexual needs of their older adult patients and to look at sexuality in the context of functionality may start to break down the taboos seen as a barrier to optimal quality of life for this population. This teaching strategy can be used for the pre-licensure nursing student or to address the complexity of the issue for current nurses achieving further degrees.

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Sexuality and the Older Adult

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Learning Objectives
Students will:
- Identify physical changes in older adults that can contribute to or inhibit the expression of sexuality.
- Identify the functional, psychosocial, cultural, and cognitive issues that can affect expression of sexuality.
- Develop a comfort level with assessing the sexuality of their older adult clients.
- Demonstrate an awareness of the link between fulfillment of sexuality and optimal quality of life.
- Identify the sexual risks and associated interventions of sexuality in the older adult population.
- Assess function in the context of expectations of sexuality of their clients.
- Discuss tactics for advocacy for the client’s expectations.
- Reflect on the impact their own beliefs regarding sexuality have on their perceptions about the needs and expectations of others.
- Understand the pathophysiology around disinhibited sexual behaviors as a residual effect of cognitive issues.
Learner Pre-Work
Have students:
- Watch the video that accompanies the Try This: Sexuality Assessment for Older Adults.
- Read the companion article on the PLISSIT Model of Assessment of Sexuality in Older Adults. This provides an excellent basis for students to incorporate a sexual assessment of their older adult patients. The model is applicable to clients they will see both in inpatient and outpatient settings as well as those seen in the community. The additional questions included as a resource to the tool Questions to Guide Sexual Assessment Among Older Adults is an excellent tool to aid students in the process.
- Highlight issues that are a priority concern and interventions that might be helpful once they complete the sexual assessment on their clients. Incorporate the reflection activity into this assignment to help students better understand the need to assess sexuality of older adults, and to perhaps help them to gather insights into their own level of comfort.
Suggested Learning Activities
1. Student reflection: This exercise asks students to reflect on their comfort level with talking about sexuality as well as their thoughts on the part sexuality plays in the lives of older adults. These questions can be used as a journal reflection assignment, as questions in an online forum activity, or in small group discussions. Please see the suggested reading section for additional resources regarding specific facts about sexuality and older adults.
- What are your thoughts about the importance of sexuality to your patients? Do you think differently about your older adult clients?
- What makes you uncomfortable when you talk with your clients about issues of sexuality?
- What are you comfortable talking about?
- What issues of sexuality do you feel you have a strong bias about? Infidelity? Sexual orientation? Sexual abuse? Sex outside of a committed relationship?
- What do you think are the main teaching points in educating older adults about sexual issues?
- How would you feel if you were not able to express your sexuality?
2. Sexuality Awareness questions/quiz are included as a PowerPoint file. There are two separate files; one is a simple PowerPoint slide show; the other is a PowerPoint presentation that incorporates Turning Technology software to use as an audience response activity for interactive teaching. These questions will help to initiate a discussion on sexuality and older adults. The audience response format allows students to answer questions anonymously. If this option is not available, use the PowerPoint file alone to initiate the discussion. The myths surrounding sexuality and aging may start to get debunked in this activity. The questions in this file are as follows:

1.   Older adults should not have sex.

a. Yes, I agree.
b.   No, I don’t agree.

2.   The physical changes that occur with old age make it difficult for older adults to have sex.

a.   Yes, this is true.
b.   No, this is not true.

3.   Older adults have little interest in sex at this stage of their lives.

a.   True
b.   False

4.   Sexually transmitted diseases are an increasing concern for older adults.

a.   True
b.   False

5.   Women are less likely than men to be sexually active as older adults.

a.   True
b.   False

6.   Sexuality is a low priority in terms of assessments with older adults.

a.   I agree.
b.   I disagree.

7.   When I think about assessing the sexuality of my older adult patients I:

a.   Avoid the topic at all costs
b.   Can’t even say the word sex in their presence
c. Just dive right in and ask away
d.   Would feel more comfortable if I had a set of questions to ask

8.   Medications can affect the sexuality of older adults.

a.   True
b.   False

9.   Older adults with dementia who act out sexually have some control of their behavior.

a. True
b.   False

3. Mini Case Studies:

Download the PowerPoint case studies with pictures of older adults and speaker’s notes. The notes for each slide include a mini case study and some notes for the faculty to guide the discussion of older adults talking about issues of sexuality. Stress to students that these are all real issues brought up in the practice environment to practitioners caring for older adults. The case studies are meant to elicit discussion on how the student would respond if their own patient discussed these issues with them. The case studies serve two purposes: 1) to expose students to questions and discussions clients may initiate and 2) to help build up the comfort level students need when discussing issues of sexuality with older adults.
Materials
The Try This:® Series from the Hartford Institute for Geriatric Nursing (HIGN) at the NYU Rory Meyers College of Nursing contains many evidence-based assessment tools. The tool, an article about using the tool, and a video illustrating the use of the tool, are all available for your use.

Below are tools that may be appropriate in assessing the sexuality of older adults. Included are the PLISSIT Model of Sexual Assessment discussed above, and the Geriatric Depression Scale, which can also be used if there is a concern that an affective decline may be contributing to issues of sexuality. Visit the Try This:® Series to access the Try This:® resources.
- The Geriatric Depression Scale (GDS)
- Sexuality Assessment for Older Adults
Suggested Reading

Bauer, M., Fetherstonhaugh, D., Tarzia, L., Nay, R., Wellman, D., & Beattie, E. (2013). ‘I always look under the bed for a man’. Needs and barriers to the expression of sexuality in residential aged care: The views of residents with and without dementia. Psychology & Sexuality, 4(3), 296-309. doi:10.1080/19419899.2012.713869

Di Napoli, E., Breland, G., & Allen, R. (2013). Staff knowledge and perceptions of sexuality and dementia of older adults in nursing homes. Journal of Aging and Health, 25(7), 1087-1105. doi:10.1177/0898264313494802

Doll, G. (2013). Sexuality in nursing homes: Practice and policy. Journal of Gerontological Nursing, 39(7), 30-37. doi:10.3928/00989134-20130418-01

McCord, L. R. (2013) Attention HIV: Older African American women define sexual risk. Culture, Health & Sexuality, 1-11. doi:10.1080/13691058.2013.821714

https://www.womenshealth.gov/patient-materials/health-topic/sexual-health
Author Information

Laureen Tavolaro-Ryley, MSN, RN
Community College of Philadelphia
Philadelphia, PA