Sexuality is an integral part of every living creature. In humans of all ages, including older adults, sexual health is closely linked with health, quality of life, overall well-being, and connection and intimacy with others (AARP, 2010; Brody, 2010; Flynn & Gow, 2015). The World Health Organization defines sexual health or well being 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” (WHO, 2006).
Kolcaba’s theory of holistic comfort (Kolcaba, 1994) serves as the guiding framework for this appraisal of sexuality in older adults. The theory posits that in order for a person to experience comfort, the three states of relief, ease, and transcendence of a perceived need must be attained within the context of one or more of four domains. Pertaining to sexuality, Kolcaba describes these domains as: (a) physical, which includes physical activity and the impact of sexuality on physical health, (b) psychospiritual, which includes intimacy, closeness, and connectedness to others, (c) sociocultural, which includes family, community, and societal norms and influences, and finally (d) environmental, which includes the settings in which older adults reside. The domains interact synergistically meaning as actions are taken to meet needs in one domain, they indirectly enhance the success of meeting needs in other domains.
Purpose
The purpose of this session is to critically appraise and present research findings pertaining to sexuality in older adults and to translate these findings into useful processes and tools that can be used to support comfort in sexuality and sexual well-being of older adults.
Background
Despite the prevailing perception in Western culture that as people age they lose interest in sex, research has shown that many older adults continue to have active, pleasurable sex lives. Findings from the University of Michigan National Poll on Health Aging showed that 76% of older adults believe sex is an important part of a romantic relationship at any age. They also reported that 92% of sexually active participants believed that intimacy was an important part of their relationship and 83% stated it was important to their overall quality of life (Solway, Clark, Singer, Kirch, & Malani, 2017). Results of other studies examining sexual activity of older adults ranged from 40% (Solway et al., 2017) to 75% (Lindau, Schumm, & Laumann, 2007). Santos-Iglesias, Byers, and Moglia (2016) reported that over the past three months, participants engaged in genital sexual activities on an average of once a week. In their sample of community living older adults, Killinger, Boura, and Diokno (2014) found that 66% of participants reported being sexually active on a weekly basis.
Historically, the biomedical model has been the prevailing approach to addressing older adults and sexuality, with a major focus on sexual performance (Marshall, 2011). Predominate issues included male sexual performance dysfunction, effects of chronic diseases and medications, and increasing rates of sexually transmitted infections among older adults (CDC, 2016; DeLamater & Sill, 2005; Solway et al., 2017).
In recent years, a psychosocial perspective has been proposed for assessing and supporting sexuality for older adults (DeLamater & Koepsel, 2015; Maciel & Lagana, 2014). Factors such as quality of relationship, body image, (Maciel & Lagana, 2014), attitude toward aging, and sexual self esteem (Santos-Iglesias et al., 2016) have been shown to influence sexual well-being. Additionally, this perspective includes care and considerations of older adults who are in same-sex relationships and those who identify as LGBT who may have different needs compared to heterosexual older adults (Fredriksen-Goldsen, Kim, Shiu, Goldsen, & Emlet, 2015).
The beliefs and attitudes of health care providers can be a barrier to providing holistic care. Cultural norms and taboos and exposure to people who are not heterosexual were identified as factors that interfered with a holistic evaluation of sexuality in older adults (Haesler, Bauer, & Fetherstonhaugh, 2016).
The majority of older adults live in a community setting. However, the likelihood of living in a care facility increases with age. A facility environment can present challenges in how older adults’ sexuality is expressed, how it is perceived, and how it is preserved (Mahieu & Gastmans, 2015).
Method and Evaluation Strategies
The research evidence utilized for this presentation was identified using search terms related to older adults and sexuality. Evidence was critiqued through the lens of Kolcaba’s Comfort Theory. Studies were identified using the following databases: CINAHL Plus, Ovid Nursing Database, Joanna Briggs Institute, EBP Database, Cochrane Library, and PubMED. The search prioritized studies conducted within five years. Seminal and international studies were included. Each study was evaluated using the Johns Hopkins Nursing Evidence Based Practice Research Evidence Appraisal process.
Appraisal Findings
Review of the literature showed that there are strategies that hold promise for addressing older adults’ sexuality in a holistic way. An overarching need addressed repeatedly in the literature was the need to improve the knowledge of health care providers about sexuality (Bauer, Haesler, & Fetherstonhaugh, 2015; Hughes & Wittman, 2015; Manzer, O’Sullivan, & Doucet, 2018); not only the physical aspects, but also the psychosocial, sociocultural, and environmental influences on sexuality that are critical to providing holistic care. Education must also include how to introduce the topic during a patient encounter, and how to facilitate discussion in a way that allows all of the patients’ needs to be addressed satisfactorily. As part of their assessment, nurses could begin the process of care around sexuality by asking older adults to complete a Geriatric Sexuality Inventory (Wallace Kazer, Grossman, Kerins, Kris, & Tocchi (2013). The inventory contains 34 items and includes eight potential domains of sexuality. It can provide a starting point for revealing and discussing needs of older adults and their sexuality. Within Kolcaba’s physical domain, providers should discuss concerns about sexual performance, sexual satisfaction, co-morbid health conditions and their treatments. Identifying solutions for these concerns is essential.
Within the psychospiritual domain, recognizing and addressing the impact of relationships and psychological issues such as depression on sexuality is necessary (Taylor & Gosney, 2011). Sociocultural considerations promoting holistic sexuality require health care providers to examine their own values, biases, and attitudes toward their own sexuality as well as toward sexuality of older people (Haesler, et al., 2016). Within the environmental domain, older adults who live in their own homes have the freedom to express their sexuality how and when they wish. However, for older adults living in facilities, rules, regulations, and the need for efficient use of resources interfere with their ability to express their sexuality. Expression of sexuality in institutionalized older adults is often labeled as problem behavior and is dealt with punitively. Something as simple as wanting to hold someone’s hand or getting a hug can be misinterpreted (Bentrott & Margrett, 2011). Changes are needed at the policy level as well as at the bedside. Programs such as “Promoting Excellent Alternatives in Kansas Nursing Homes” (PEAK), where specific issues, including sexuality, have been addressed as part of a culture change, can be very helpful in preserving sexuality of institutionalized older adults (Kansas Department for Aging and Disability Services, 2018).
Implications & Conclusion
The evidence appraised and presented in this session has implications for nursing practice, patient comfort, health care outcomes, and organizational policy. Nurses are in an optimal position to support older adults’ attainment of holistic comfort related to their sexuality. By incorporating strategies focused on helping older adults relieve their concerns and needs and ease their anxieties, nurses will be instrumental in supporting older adults in reaching a transcendent state of comfort.