Abstract
Increased knowledge of how sexuality is expressed in older persons may create opportunities for healthcare professionals to perform care according to a person-centered approach. To describe older people’s experiences of sexuality concerning aging, a qualitative study was conducted. Eight persons aged 60 and above were interviewed, and the obtained data were analyzed using content analysis. The findings revealed that the participants were certain of being sexually active as they got older. Awareness of what old age can bring regarding illness and increased medication intake was clear, alongside the importance of discussing sexuality with friends or a partner. Age was not seen as an obstacle to continuously being sexually active, and new ways to maintain intimacy and sexuality were identified. According to our results sexuality in older people is about well-being and intimate relationships. Creating opportunities for a trusting, caring relationship can strengthen older people’s sexual health. Healthcare professionals must, therefore, make possibilities for trustful relationships to support and discuss sexuality with older people.
LAY SUMMARY
In this study, eight persons aged 60 and above were interviewed about their experiences of sexuality concerning aging. They described sexuality in terms of well-being and intimate relationships and spoke about the need for support and discussions about sexuality in meetings with healthcare personnel.
Introduction
Sexual health is widely understood as a state of physical, emotional, mental, and social well-being about sexuality. Sexuality is an integral part of human personality and a basic need and aspect of being human (World Health Organization, Citation2015). Studies on older people’s sexuality have mainly explored sexuality, focusing on diseases or drug use (Beckman et al., Citation2014; DeLamater, Citation2012; DeLamater & Moorman, Citation2007; Lindau et al., Citation2007), and quantitative approaches have primarily been implemented. To create an increased understanding of how older people view their sexuality regarding aging, a person-centered approach (McCormack & McCance, Citation2006) with a qualitative perspective is needed.
The benefits of sexual activity in older persons are well documented. Being sexually active has been associated with benefits regarding good physical and mental health (DeLamater, Citation2012), including increased cardiovascular health, improved relationships, better health, and decreased levels of depression and mortality (Brody, Citation2010; Lindau et al., Citation2007). However, poor physical health and the presence of chronic diseases, such as diabetes, have been associated with higher levels of sexual difficulties (e.g. erectile problems and reduced desire) and lower sexual activities (Lee et al., Citation2016; Tetley et al., Citation2018).
Society has a dismissive view of older people who express their sexuality (Papaharitou et al., Citation2008). Based on the traditional view of what is contained in a person’s sexuality, healthcare providers often fail to prioritize sexuality in older people (East & Hutchinson, Citation2013). While nurses and physicians are aware that sexuality should be discussed with patients and possible partners, studies have revealed that these discussions have rarely been performed (Saunamäki et al., Citation2010). Healthcare professionals’ reasons for not discussing sexuality with patients are often lack of time, poor knowledge of the subject, or expecting other professionals to take responsibility for that conversation. This approach often prevents older people from discussing sexual issues (Gott et al., Citation1999). Increased knowledge of how sexuality is expressed in older persons may create opportunities for healthcare professionals to perform care according to a person-centered approach. Psychological and physical aspects of health can be supported by emphasizing the significance of sexuality for older people’s health in caring encounters. Therefore, this study aims to describe older people’s experiences of sexuality regarding aging.
Method
Design
A qualitative approach was used to enable older people to share their own experiences. Data were collected through individual interviews and analyzed using content analysis.
Participants
The Swedish National Study on Aging and Care (SNAC) is a cross-sectional, national, and longitudinal interdisciplinary study conducted at four research centers in Sweden. The task of the longitudinal study is to describe the process of aging based on different aspects and to capture the aging and transition from work to retirement (Lagergren et al., Citation2004). In the current study, participants from the SNAC study were recruited purposefully based on the following inclusion criteria: 60 years or older and willing to share their experiences about sexuality. During the SNAC study examination, the research nurse verbally informed the participants about the current study and inquired about their interest in participation. The participants also received an information letter, and when the individuals agreed to participate by written consent, a time for the interview was scheduled. Eight participants were recruited, comprising six men and two women, aged 60–84 years (mean 70.25). One of the participants became a widower, while the other lived as a cohabitant or married (see ).
Table 1. Characteristics of participants.
Data collection
Individual interviews were conducted, and each interview lasted between 30 and 60 min. Being interviewed about one’s sexuality can be difficult and sensitive for some people, especially when an unfamiliar person asks questions. Therefore, the information letter that described sexuality was used to introduce the interviews, in which the older persons were asked to describe how they viewed their sexuality about getting older. The idea was to create a more encouraging atmosphere for developing the interviews to suit the set goals. During the interviews, follow-up questions were also asked: Can you give me an example or elaborate further? The interviews were conducted, recorded, and transcribed verbatim by the first author, a nurse and a sexologist with experiences met older people in hospital settings. Five of the interviews took place in the participants’ homes, and three interviews were conducted on the premises of the SNAC study.
Data analysis
The transcribed interviews were analyzed according to the qualitative content analysis described by Graneheim and Lundman (Citation2004). First, all the interviews were read several times to properly understand the whole content. Second, the sentences were highlighted based on the purpose of the study and condensed to obtain shorter and more manageable texts. Condensation is the process of shortening a text while preserving its essence (Graneheim & Lundman, Citation2004). After condensation, the text was coded and sorted into subcategories and sub-categories into categories. Although these descriptions point to a linear process, it is important to remember that the analysis process involves oscillation between the whole and the parts of the text (Graneheim & Lundman, Citation2004). To gain trustworthiness, the first and the last author handled the analysis, and the other co-author closely followed up on the process, as suggested earlier. Finally, two categories and five subcategories were formulated.
Results
The analysis resulted in two categories: meeting norms in society and the meaning of being in a relationship. The categories contained five subcategories: feelings of being normal vs. abnormal, treatment from healthcare professionals, feeling safe in the relationship, being sexually active, and continuous feeling of a desire for pleasure. provides an overview of the categories and subcategories. The content is presented below and illustrated with quotations from the interviews. The parenthetical number (P) after the quotation refers to the respective participant.
Table 2. Overview of categories and subcategories.
Category: meeting norms in society
This category described that the participants in many encounters felt normal and abnormal. The feeling was created because the people they met had an already predetermined perception of what was normal or not. Feeling normal was easier when they were together with family and friends in a secure relationship, while feeling abnormal was due to others or healthcare professionals disrespecting them or their needs. The content of the two subcategories exemplified by quotations is described below.
Subcategory: feelings of being normal vs. abnormal
Although it appears that older people express their sexuality in different ways, the participants talked in terms of being normal vs. abnormal when it came to their sexuality. They described that the boundary between what was normal and abnormal was unclear, considering older persons and sexuality. Being the sexual person, you feel you are and having the opportunity to live to the fullest were some of the participants’ strong wishes.
“The feeling of going out naked…so with the risk of being caught. Hmmm. And that risk is quite imminent…and maybe it’s a bit too…you also want to be caught…laughter…” (P 4)
Some described that norms are created from a society where words like normal and abnormal are common. The participants emphasized that what is normal or not depends on everyone’s environment and childhood conditions. Something that also emerged from the participants was that norms and values were included in their way of describing themselves as sexual persons. There was an ambition among the participants to be accepted in the social affiliation. Even though it was expressed that they did not consider what others thought about them, there were statements about what others had thought if they knew what was going on in their home.
Sexuality in older ages was pointed out as a difficult topic to discuss in encounters with others, and it was not a topic in the general debate in society. Therefore, lacking the opportunity to discuss sexuality in older age was described as a loss that created a concern about what was normal or abnormal. The participants described, therefore, experiences of being seen as both normal and abnormal when allowing themselves to be a person with sexual needs. Feeling normal was easier when being together with family and friends. Most participants described that there were sometimes discussions with friends concerning various sexual issues, especially what was normal and not. Although the discussions often had playful jargon, some participants felt that there was a serious and worried undertone about what was accepted as sexually normal.
“We have an outspoken relationship with friends and could discuss everything… but it is not easy to ask right on if someone else is sexually active in a normal way or not …” (P3)
Feelings of being abnormal were also common among the participants, and they explained that it was other people who labeled them as abnormal. A common experience was that other people with perceptions other than themselves decided what was normal or abnormal. This induces feelings of disrespect by others as an individual. An ambition existed among the participants to be accepted into the social affiliation. Although they ignored what others thought about them, there were statements about what others had thought if they knew about the sexual activities happening in their home. The participants mentioned that they wanted confirmation that they were within the framework of what was accepted as normal regarding sexuality and aging. However, a common experience among the participants was that it is a strong taboo in society to discuss sexuality and aging, which induces feelings of insecurity about what is normal or abnormal.
Subcategory: treatment from healthcare professionals
The participants stated that healthcare professionals shift responsibility for initiating conversations about sexuality or the sexual needs of the participants. These induced feelings of shame and guilt when they really wanted to discuss the subject. The inability to discuss sexuality and how aging affects it showed the participants’ ignorance regarding the expected changes. Ignorance also contributed to experiences of being treated with disrespect. The participants felt that healthcare professionals doubted their needs while disregarding their conversation request. Instead of discussing sexuality or sexual needs, healthcare professionals offer them prescriptions for potency-enhancing drugs. The participants, therefore, asked for information they could understand and that it should be given when there was time for conversation.
The female participants described that healthcare professionals chose to discuss their partner’s sexuality instead of theirs, indicating that discussing a person who was absent was easier. The participants also expressed uncertainty and ignorance about sexually transmitted infections. Although most participants lived with a partner at the time of the present study, they could still imagine solitude and maybe meet a new partner. Here, a concern was revealed about starting a new sexual relationship and being exposed to the risk of a sexual infection.
Some participants described that the few times they took the courage to seek help from the health service, due to their sexual concerns, a lack of care was experienced from the care staff. This is because the purpose of seeking help from healthcare often involves a discussion about prescriptions for potency-enhancing drugs. The participants felt that the opportunity for some deeper conversations about sexuality never was given space in connection with contact with healthcare. The participants’ experience then was that the problems raised were not taken seriously and were joked away. "Yes, you don’t want more children, do you? " (P 4). Someone said that they would rather read the doctoral column in weekly magazines instead of contacting the health service, as this felt embarrassing. Living as a woman in a relationship where the man has erectile dysfunction was experienced as grief where those as women were deprived of the opportunity to have intercourse due to the man’s problems. The participants also expressed that they had little or no knowledge and were poorly informed about sexually transmitted infections. This was a statement that was described as negative. Even though most of the participants were living with a partner at the time, they could still imagine the situation that they could be alone and maybe meet a new partner. Here, a concern was revealed about starting a new sexual relationship and then also being exposed to the risk of sexual infection.
Category: the meaning of being in a relationship
This category described that relationship is imperative regarding sexuality. The participants described that the core of their sexuality was often expressed through a partner, the relationship with another person induced security and trust, and sexuality was expressed in duality. Although variations seemed to occur among the participants, sexual activities often occur together with a partner, and masturbation appears to be uncommon in their sex lives. Considering aging, the participants stated that their sexual pleasure became less important. The primary thing is that the person you live with or meet temporarily should experience maximum pleasure.
Subcategory: feeling safe in the relationship
The participants described the importance of feeling safe in their relationship with their partner. This means that confidence is imperative for a relationship regarding sexuality. The experience of being in a secure sexual relationship largely depends on the duality. Another factor of success expressed by the participants was the importance of a mutual dialogue about sexuality. Communication becomes a central part in the relationship for discussing expectations of each other, curiosity about the future, sexual problems regarding aging, and, if needed, what help is available.
Some participants also described that their sexual activities became even better during their aging because their relationships with their partners were now deeper and more intimate. A prerequisite was also to have a partner who could perform sexually. A safe relationship contributed to maintaining sexual health among the participants, even when age had taken its toll.
“I think it (sexual activity) affects health and you feel more satisfied, and you do not feel old prematurely” (P5)
Even though the participants have different backgrounds and have lived different lengths of time in a relationship, they have one thing in common; they express that confidence is of great importance for the relationship when it comes to sexuality. The experience of being in a secure relationship where sexuality is given space largely depends on the duality. Another success factor that was reflected among the participants was the importance of communication in the relationship when it comes to sexuality. Communication in the relationship turned out to be a central part of the relationship, where curiosity about the future, expectations, and seeking help for sexual problems were important topics of conversation. During the interview, this was perceived as something that only got better in connection with aging.
Subcategory: being sexually active
Getting an outlet for their sexuality when getting older was expressed mainly by being sexually active, where the focus for some was on penetrating intercourse and where masturbation rarely occurred. The great focus among the participants was on the ability to get a sufficient erection for intercourse.
“If you see to age, my body works okay… and no one complains so that must mean that I pass” (P2)
The sexual act remained enjoyable for some but was not perceived as a prerequisite for having a common touch life or love life. The participants experienced a strong feeling of sexual satisfaction despite their lack of intercourse. Intercourse was not something that was perceived as a must to be happy as an individual. Closeness and common interests could often replace intercourse, but the participants also described the feeling of recalling the sex life you once had together with your partner or dressing up for a dance night and feel good. The participants expressed that it was common for women in the relationship to be deprived of their sexuality when the man’s potency failed. It was explained that when intercourse ceased, no other sexual practices occur for them. Then intercourse is the expected norm in sexual activity. Sexual activity then gets less space, and other interests, such as hanging out with friends, travel, and entertainment, have more place in the relationship.
Subcategory: continuous feeling of a desire for pleasure
Regarding the importance of age for sexual health, the participants agreed that they did not feel that sexuality depends on age. The participants emphasized that the desire does not disappear because you get older but is included as a part of life. However, the importance of the body being changed was mentioned as a woman going through menopause and that men’s ability to get an erection decrease. Some participants expressed that much of the sexual spontaneity disappears with aging but that it is not something negative. The ability to plan sexual activities instead had, in fact, induced an increased quality in which one’s partner’s pleasure was prioritized.
“… imagine being able to experience this still and almost optimally, if you say so. Because you care a lot about each other’s pleasures” (P8)
The participants further described that, with increasing age, they could feel increased desire and pleasure together with their partners in planned sexual activities. They no longer needed to focus on achievements and conquests, as in younger age. The participants described that they instead could focus together on giving each other satisfaction and pleasure. Living in a relationship was a strong contributing factor for living out of their sexuality, which was also, for some, a prerequisite for living out their sexuality. Although it is expressed that intimacy, such as seeing each other, hugging, kissing, and giving each other attention, is important for a workable relationship, the participants expressed that, in a relationship, intercourse was strongly associated with sexual activity, in which some do not see masturbation as part of the relationship. For example, one participant disregarded masturbation as part of sexual activity.
“When you see how your partner reacts, it’s not about your own satisfaction… there is nothing that is as wonderful as when your partner enjoys” (P7)
Discussion
This study aimed to describe older people’s experiences of sexuality concerning aging. Some main aspects emerged from the experience of sexuality regarding aging.
The participants described a strong taboo regarding the subject of sexuality and aging. Sexuality was perceived as a topic without general debate in society, and the participants perceived this as a loss. Hence, because sexuality is perceived as important for the health and well-being of older people, it seems difficult for society to accept and absorb this knowledge (Bouman et al., Citation2006; Gott & Hinchliff, Citation2003). Sexuality in older ages was pointed out as a difficult topic to discuss in encounters with others, and it was not a topic in the general debate in society. Lacking the opportunity to discuss sexuality in older age was therefore described as a loss that created a concern about what was normal or abnormal. How sexuality changes during life depends on the individual and how society expresses and allows basic needs for intimacy, lust, eroticism, and togetherness (Lindau & Gavrilova, Citation2010). The view of older people’s sexuality may be a contributing factor to some older people not being sexually active, rather than the biological changes they experience (DeLamater & Friedrich, Citation2002). To this also comes the notion of what are “normal” or “appropriate” sexual behaviors, and they remain firmly entrenched (Weeks, Citation2017). Although sexuality has been discussed more than ever, it remains sparsely described in the literature about older people’s sexual interests and sexual behaviors (Ménard et al., Citation2015). Furthermore, Beckman et al. (Citation2014) argued that the latter generation has become more positive about their sexuality at their own age compared to the previous generation, and that today’s older persons are more sexually active than previous generations. According to Beckman et al. (Citation2014), this is because there has been a dramatic change in attitudes about sexuality in society that has changed over a 30-year period. It proves that aging and sexual dysfunction do not have to be absolute and linked to aging. Concurrently, many men and women remain sexually active despite the increasing number of sexual dysfunctions (DeLamater & Friedrich, Citation2002).
The results showed that the participants hesitated to discuss sexuality with healthcare professionals, and feelings of shame and guilt were common when discussing sexuality in those meetings; therefore, it was perceived as a non-issue. This shows that the healthcare system, imperatively, should work further on this topic and that open-minded meetings contributed to a feeling of being a person, while a poor environment contributed to increased feelings of abnormality. Healthcare professionals should note that age-related physiological changes do not have to exclude a meaningful sexual relationship. Healthcare professionals can work further on this topic with, for example, interventions like education or discussion groups where older persons are invited. Health professionals should also include, if possible, the partner in the discussions about sexuality. Healthcare professionals who meet older persons need to have knowledge of how they can ask questions and discuss sexuality because it can be experienced as one sensitive topic. The participants described that considering aging, their own sexual pleasure became less important. The primary thing is that the person you live with or meet temporarily should experience maximum pleasure. Furthermore, the participants experienced a strong feeling of sexual satisfaction despite their lack of intercourse. A strong positive correlation exists between sexual satisfaction and well-being (Lindau et al., Citation2007). Hence, older people without the opportunity to affirm their sexuality may experience reduced well-being in life. In the long run, this can negatively affect mental and somatic health. There are good physical and psychological health effects of being sexually active: it can lead to reduced stress, help with relaxation and sleep, and relieve pain more easily (Brody, Citation2010; Peate, Citation2012). Consistent with this, older people who are sexually active to a much greater extent rate their health as good or very good compared to those who are not (Lindau et al., Citation2007). Sexuality, at an advanced stage of life, needs to be viewed in a manner that does not restrict it to physiological aspects. It is necessary to consider the needs imposed by older age and to search for less predetermined care possibilities.
This study used a qualitative design to explore the experiences of older people regarding sexuality and aging. Lincoln et al. (Citation1985) proposed criteria for trustworthiness in qualitative studies. To increase the credibility of this study, the results are presented with quotes. Both men and women of varying ages contributed to the sample variation; thus, the results can be viewed as credible. The reliability of the data collection was strengthened by having all interviews conducted by the same person using the same approach. The reliability was also strengthened by having all the interviews recorded and printed verbatim. However, some important information may have been lost due to limited experience in conducting interviews. Preconceptions about the answers possibly steered the narrative in some cases, as the interviewer had a preunderstanding of the work as an RN and sexologist. However, any effect of this type was not considered to have made the interviews unusable. Data were collected using an interview guide to strengthen the trustworthiness. For interpretation, the interviews were analyzed using content analysis, a technique that offers a useful qualitative approach. The transferability of the study concerns the extent to which the findings can be transferred to or applied in other units and groups. This is, in this study, ensured through the method being accurately described. However, transferability of the results should also be treated cautiously, particularly because our sample was generally highly educated and physically active, as well as homogenous in terms of ethnicity.
Conclusion
To conclude, older people are affected by societal norms when they express sexual needs and feel sexual health. Sexuality in older people is about well-being and intimate relationships. Creating opportunities for a trusting, caring relationship can strengthen older people’s sexual health. Healthcare professionals must make possibilities for trustful relationships to support and discuss sexuality with older people. It would be beneficial for the patient if discussions about sexuality were included in both medical treatment and nursing work. Healthcare professionals should treat the older as equals in care and give them opportunities to express their needs. The different professions involved in meetings in care situations must, together with the older person, plan sexual rehabilitation based on the individual’s needs and wishes. Therefore, taking a more person-centered approach to the sexual needs of older persons is imperative.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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