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Sexual Health in Older Adulthood: Defining the Goals
posted 04.14.2015

By Maggie L. Syme

What does it mean to be sexually well or sexually healthy in later life? This question has not gotten much attention until recently, given the prevalence of stigmatic beliefs about aging sexuality and lack of understanding about aging sexuality. The reality is people express themselves sexually across the lifespan, and even though sexual scripts may change over time, sexual expression continues and it remains important in relationships and for overall well-being.

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The conversation about later life sex is changing and becoming more inclusive. Much of this is due to older adults themselves, who are expressing the importance of sexuality in their lives (for example, see the 2010 AARP publication, Sex, romance, and relationships: AARP survey of midlife and older adults (PDF)) and telling us they want their providers to talk about it. The discussion has also changed, in part, due to a shift in the conceptualization of sexuality in general. The historic and singular focus on medically relevant symptoms that defined sexual dys/function has evolved into a broader conceptualization that encompasses several dimensions of wellness. The World Health Organization (WHO) blazed this trail with its definition of sexual health in 2006 (PDF), which defines it as:

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

Let’s apply the components of the WHO definition to a diverse older adult population. First, is the biopsychosical conceptualization of sexuality, moving beyond physical symptoms to incorporate emotional, social, and cultural aspects of aging sexuality. This prompts us to consider body image, mental health, sexual self-esteem, partnership status, relationship satisfaction, and cultural sexual values along with physical functioning when we are discussing sexual expression. To illustrate, Anna is a postmenopausal female and has been experiencing some recent sexual problems. She now has some pain when she and her partner, Sue, are engaging in digital penetration. Her provider not only asks about the physical pain, but also addresses whether her sexual practices have changed recently, about aspects of her relationship with Sue, explores her sexual values, and asks if Anna has been experiencing any emotional issues (e.g., body image concerns) that might be contributing. This, in turn, may expand Anna’s treatment recommendations to include relationship and emotional concerns that are influencing her sexual health, as opposed to focusing solely on common treatments for sexual pain (e.g., lubrication).

Next in the WHO definition is the imperative to move beyond the dys/function narrative of sexuality and into a discussion of wellness. By changing the language, the goals and expectations of aging sexuality for older adult clients becomes about being healthy and well as opposed to dysfunctional. This will often include talking about sexual problems, but it is in the context of promoting and achieving wellness, while having sexual dysfunction. To apply this let’s consider Dan, a 67 year-old biological male who is a 6-year prostate cancer survivor. As a result of his treatments, he has had some lingering erectile problems that are affecting his intimate relationship with his partner Elaine. Before you ask about the biopsychosocial aspects of his sexual and intimate life, you talk with Dan about his goals for working with you. You are careful to frame it in a wellness narrative, expressing the importance of many aspects of sexual wellness that include but are not exclusive to physical symptoms. What aspects of his sexual and intimate life contribute to his sexual wellness? How does his ED affect his overall sexual wellness? Are there times when he feels fulfilled in his intimate life? How have they been able to achieve that together? Thus, the language centers on wellness goals while including the dysfunction. A key aspect to this interaction is impressing upon Dan that wellness is attainable even with physical dysfunction, setting up the expectation for healthy sexual expression.

According to the WHO definition, older adults need their pursuit of pleasure to be respected. Part of being respectful is being inclusive of all sexual and intimate experiences for older adults. We know that sexual scripts in older adulthood often include a spectrum of sexual and intimate behaviors, not just penile-vaginal intercourse, which is more consistent with a heteronormative conceptualization of (aging) sexuality. We may miss important data and opportunities if we assume that older adults are in married, monogamous, heterosexual, and sexless relationships, which fits with the stereotypes. Practically speaking, discussions of sexual health should be free of assumptions about what the older adult does or does not do sexually and reflect an attitude of openness and respect for the older adult’s sexual goals.

Additionally, the WHO definition reminds us that individuals should be able to secure their sexual rights in an environment that is free of discrimination. Ageism, heterosexism, racism, and other discriminatory attitudes are examples of ways in which peers and professionals have fallen short of this goal for older adults. Ageism has impacted older adults at an individual level, with providers often being unaware of or ignoring sexual health for their older adult clients (discussed by K. A. Ports and colleagues in their 2014 article). Further, in studies on sexual health discussions with older adults, doctors have reported reluctance and discomfort in having sexual health discussions with their “non-heterosexual” patients due to lack of knowledge and stigmatic attitudes (see this article by Gott and colleagues). On a societal level, we see ageism reflected in the lack of national policies for sexual health screening and counseling for older adults. To combat age and other types of discriminations for older adults there is work to be done in training educators, providers, and peers that many sexual experiences are valued and “normal” in older age and sexual health is a relevant conversation. Thus, creating a context where older adults feel safe to openly discuss their diverse sexual experiences.

Related to this, the WHO states that being a sexually healthy older adult means securing safety in sexual expression. Assisting with sexual safety may include asking about sexual risk, education about sexually transmitted infections (STIs), and building skills to negotiate condom use and/or other harm reduction techniques (e.g., prophylactic medication) that the older adult finds consistent with his or her sexual values. Safety may also denote protection for vulnerable elders who may be in danger of sexual coercion, such as those who are cognitively unable to make sexual decisions (for more on this, see this article by Connolly and colleagues, from Generations). This is especially relevant when working in a long-term care or in-home care context. Though determining the older adult’s capacity to make these decisions may be outside of your expertise or professional responsibilities, you can play a role in safety by being aware of potential coercive situations, alerting others of a safety issue, and reporting any violations of safety to appropriate channels (e.g., confidential abuse reporting).

Concluding the WHO definition is a call to respect, protect, and serve. For those who work with older adults we can do this by valuing their lived experiences and sexual values, creating an environment of openness where sexual health discussions can occur, and/or advocating for their sexual rights or empowering them to advocate for themselves. It begins by understanding that sexual health is a key part of well-being for many older adults. It continues when the conversation about sexual health is started with older adults, and by realizing there is more to it than the small box we have been shoving it in for years. Open the box; it is less scary than you think.

Maggie L. Syme, PhD, MPH, is a research psychologist for San Diego State University where she focuses on sexual health promotion for older adults, including sexual decision making for cognitively compromised older adults. She is also a practicing geropsychologist in the VA San Diego Healthcare System.

This article was brought to you by ASA’s LGBT Aging Issues Network

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