Sexuality in Older Adults
B. Renee Dugger, DNP, RN, GCNS-BC*
Acknowledgement
of Resources Utilized
*Special acknowledgement and thanks
to Meredith Wallace PhD, APRN, A/GNPBC and the Geriatric Nursing Education
Consortium (GNEC) for resources utilized
for this presentation
GNEC
 The Geriatric Nursing Education Consortium (GNEC)
is a national initiative of the American Association of
Colleges of Nursing (AACN) to enhance geriatric
content in senior-level undergraduate nursing
courses. This project is generously funded by the
John A. Hartford Foundation.
Further information about the GNEC program can be
found at www.aacn.nche.edu/gnec.htm.
Objectives
1.
Identify myths about sexuality in the aging
population.
2. Describe changes expected to occur as we age
and the barriers/challenges these changes
present to sexual health.
3. Discuss the impact of disease processes,
medications and environment on the sexual
health of older adults.
4. Identify ways to assess and promote the sexual
health of older adults.
Myth Busting
Sexual Health
 Is important to an individual’s selfidentity and general well-being.
 Contributes to the satisfaction of
physical needs.
 Fulfills social, emotional, and
psychological components of life.
 Evokes sentiments of joy, romance,
affection, passion, and intimacy.
Myth Busting
Many believe that older adults are asexual
There is a
general
discomfort
with sexual
issues in the
U.S.
Health care
professionals
are typically
not educated to
manage sexual
health issues of
older adults.
Sexual health is
often ignored
in the
assessment of
older adult
health.
Myth Busting
The beliefs and misconceptions about older
adult sexuality result in the attitude that
older adult sexuality is not worth
considering.
Lack of education, experience and negative
attitudes toward aging sexuality results in
an inability to meet sexual desires and
maintain sexual health.
Myth Busting
Many people believe that sexual
desires diminish and disappear
with age.
Others believe that sexual
activity in long-term care
facilities is against the rules.
Older adults are often assumed to be
heterosexual. The presence of
Lesbian, Gay, Bisexual and
Transgender (LGBT) older adults is
not often considered a possibility.
Myth Busting
Sexuality …
 provides for expressions of affection and passion.
 Enhances the life experience.
 Enriches connection and communication.
Sexuality is alive and well among older adults:
 Research conducted by Lindau et al (2007) revealed
that in a study of 3005 U.S. older adults current sexual
activity was reported in 73% of adults aged 57 to 64,
53% of adults aged 65 to 74 and 26% of adults aged 75
to 84.
(Lindau, et al., 2007)
Reality
Older adults continue to be sexual beings.
However, older adults may require assistance to
manage sexual health needs by examining:
 Barriers to sexual health.
 Impact of normal aging changes, as well as acute
& chronic illnesses, medications and
environmental issues on sexual health.
Why Should We Promote the
Sexual Health of Older adults?
The expression of sexuality among older adults results in a
higher quality of life achieved by fulfilling a natural desire. It
also may…
 Improve functional status.
 Improve mood.
Older Adult
Barriers to Sexual Health
Older adults may lack knowledge and comfort with
sexual health issues.
 Older adults are not always familiar with safe sex practices.
 Older adults may not be aware of alternative sexual acts
and positions to accommodate health needs.
(Baumgartner et al., 2008)
In a survey study of 81 older community dwelling outpatients,
more than half could not name any risk factors for Erectile
Dysfunction (ED). Patients preferred the internet and general
practitioners as primary sources for sexually-related
information.
Older Adult
Barriers to Sexual Health
 Old habits
 Negative experiences
 Fear of discussing sexuality
 Victorian attitudes toward sexuality
 Lack of opportunity (no partners or privacy)
 Cultural attitudes toward sexuality
Case #1
 Taken from: McNicoll, L. (2008). Issues of sexuality in the
elderly Geriatrics for the Practicing Physician, 91(10), 321-322.
Health Care Provider
Barriers to Sexual Health in Older Adults
A study of 100 patients
aged 39 to 86 and their
health care providers
revealed that less than 10%
of providers asked
patients about erectile
function, although over
90% of patients were
interested in treatment
(Chitale, et al., 2007)
Providers:
 Are subject to myths and attitudes
about sexuality and aging.
 May be insensitive to older
adults needs.
 Don’t know how to manage sexual health issues.
 Experience discomfort in managing sexual issues.
(Chitale et al., 2007)
Other Barriers to Older Adult Sexual Health
Physical Barriers to Sexual Health







Normal aging changes
Pathological changes
Chronic pain
Cognitive impairment
Environmental restrictions
Body image
Adverse medication effects
Societal discomfort with
issues of homosexuality
 Older people are
homosexual too!
 They may have not come
out yet
 LGBT may fear physical
harm for coming out
 Require great sensitivity
due to years of isolation
Normal Aging Changes
that Impact Sexual Health
The ‘sexual response cycle’, or the organized pattern
of physical response to sexual stimulation, changes
with age.
These changes impact sexual health in both:
 Women
 Men
Normal Aging Changes
Female Sexual Response
After sexual intercourse, women return to the prearoused stage faster than they would at an earlier age.
Normal Aging Changes
Female Sexual Response






Vaginal wall thinning
Decreased/delayed vaginal lubrication (may lead to pain)
Labia atrophy
Vagina shortens
Cervix may descend downward into the vagina
Loss of fat pad over pubic symphysis may lead to pain from
direct pressure over bone
 Vaginal contractions become fewer and weaker during
orgasm
 Many of these changes are a result of loss of estrogen after
menopause
Normal Aging Changes
Male Sexual Response
The Massachusetts male aging study of
1085 older men indicated that age was an
independent risk factor for decreased
sexual function in older men.
(Araujo et al., 2004)
Normal Aging Changes
Male Sexual Response
 Decreased testosterone hormone levels
 Weaker erection to erectile dysfunction (ED)
 More direct stimulation of the penis required for
erection
 Orgasms are fewer and weaker
 Reduced force and amount of ejaculation
 Increased refractory period after ejaculation
Other Age-Related Changes
that Impact Sexual Health
Many individual psychosocial and cultural
factors play a role in how older adults
perceive themselves as sexual beings,
such as:
 Life long beliefs about sexual health.
 General physical and psychological
well-being.
 Body image issues from aging
changes
 Cultural beliefs about sexual practice.
Sexual Dysfunction
Sexual disorders fall into four categories:
1. Hypoactive sexual desire disorder,
2. Sexual arousal disorder
Sexual dysfunction is
prevalent worldwide, and
3. Orgasmic disorder
the occurrence of sexual
4. Sexual pain disorders
dysfunctions increases
(Walsh & Berman, 2004)
directly with age for both
men and women.
(Derogatis & Burnett, 2008)
Pathological Changes
There are a number of medical conditions that cause sexual
dysfunction among older people, including:
 Heart Disease
 Diabetes
 Depression
 Breast and Prostate Cancers
 HIV/AIDS
 Cognitive Impairment/Dementia
Heart Disease and
Female Sexual Health
In a study of 2,763 postmenopausal women, the
presence of coronary heart disease was significantly
associated with:
 Lack of sexual interest
 Inability to relax during sexual activity
 Arousal and orgasmic disorders
 General discomfort with sex
(Addis et al., 2005)
Heart Disease &
Male Sexual Health
In a study of 1,357 men with heart
disease world wide, the prevalence
of ED in the sample was 50.7% and a
significant decline in sexual activity
was reported after the diagnosis of
cardiovascular disease.
(Bohm et al., 2007)
Diabetes & Sexual Health
Diabetes is a significant concern among older adults, effecting
approximately 10.9 million, or 26.9% of all people in this age
group in the U.S each year. American Diabetes Association, 2011 http://www.diabetes.org/diabetesbasics/diabetes-statistics/
Diabetes effects sexual health among older adults in a number
of ways:
– impacts sexual function.
– impacts arousal and pleasurable sensations.
Approximately 42%
of those with diabetes
are aged 65 years or older.
Diabetes & Sexual Health
In a study of eight women aged 24 – 83, older women
with diabetes reported lower sexual function, desire
and enjoyment than their younger counterparts.
(RockliffeFidler & Kiemle, 2003)
In a study of 373 men aged 45-75 with type II diabetes,
49.8% of the men reported mild or moderate degrees
of ED, and 24.8% had complete ED.
(Rosen et al., 2009)
Depression & Sexual Health
The presence of depression among older adults
impacts sexual health
 Decline in desire
 Decline in ability to perform
 Both the disease and treatment can impact sexual
health
A study of 3,810 men aged 57-78 years revealed
that men with ED had significantly lower mental
health scores.
(Korfage et al., 2009)
Female Reproductive System Cancer
& Sexual Health
Women with breast and other reproductive system cancers
may have difficulty adjusting to disease and treatment due to
their association with bodily changes in self image that impact
sexuality. Quintard, 2008
Prostate Cancer
& Sexual Health
Men with prostate
cancer who have
undergone surgical or
radiation treatments
may experience ED
following treatment.
The rate of erectile
dysfunction following
radical prostatectomy
has been reported to be
greater than 80%.
(Siegel et al., 2001)
HIV and Older Adults
 HIV cases among older adults in the US is
increasing, with ~25% of infections occurring
in adults over 50.
 Older adults with HIV/AIDS and other STDs
should be taught to follow CDC safe sex
practices, as this was not routinely covered
in formal education. (Martin et al., 2008)
 The use of antiretroviral medications may
be complicated by multiple chronic
comorbidities and treatments.
 HIV-infected patients need continuous
treatment with antiretroviral agents to
suppress viral replication and maintain
immune function. (Magalhaes et al., 2007)
Urinary Incontinence
& Sexual Health
While not well-studied, the presence of urinary incontinence
(UI) is theorized to interfere with sexual function among older
adults related to:
 Shame and embarrassment
 Avoidance of sexual activity for fear of incontinence
In a study of 2, 361 Community-dwelling women aged 55 to 95,
UI was significantly associated with alterations in sexual
activity. (Tannenbaum et al., 2006)
Other Medical Conditions
Impacting Sexual Health
 Strokes and subsequent aphasias impact sexual health via
difficulties in desire, function and communication (Lemieux et al., 2001)
 Parkinson’s disease (PD)
 In a study of 444 older adults with PD, sexual limitations were
reported in 73.5% of the sample as a product of difficulty in
movement. (Mott et al., 2005),
 Benign Prostatic Hypertrophy (BPH)
 In older men altered circulation to the penis may affect
erectile function, sexual arousal and ejaculatory dysfunction.
(Rosen, 2006)
Cognitive Impairment
& Sexual Health
Sexual needs among older adults with cognitive impairment
may manifest in inappropriate & hypersexual behavior.
In a study of older, cognitively impaired older adults, 1.8%
had sexually inappropriate behavior manifesting in verbal and
physical problems. (Nagaratnam, et al, 2002)
Sexual Behaviors Common to
Cognitively Impaired Older Adults
Sexual Behaviors
 Grabbing & groping
 Use of obscene language
 Touching genitals
 Masturbating in public
areas
 Sexual remarks
 Propositioning
 Aggression and irritability
Environmental Barriers
Older adults who live in long-term care facilities or
with family members may lack privacy for sexual
relations.
There is an absence of
male partners for older
women - 60% of older
women are partnerless
Effect of Medications and
Treatments on Sexual Health
Antidepressants including Selective serotonin reuptake
inhibitors (SSRI), Tricyclic Antidepressants, Monoamine
oxidase inhibitors (MAOI) impact libido and sexual function
 In a study of 610 women and 412 men, 59.1% of the
individuals taking SSRI antidepressant medications reported
sexual dysfunction. (Montejo et al., 2001)
 MAO inhibitors and Tricyclic Antidepressants have
decreased in favor of SSRIs leading to lower side effects,
but all can impact sexual function by reducing sexual drive
and causing impotence and erectile and orgasmic disorders.
Effect of Medications and
Treatments on Sexual Health
 Antihypertensives including: ACE inhibitors, Alpha
Blockers, Beta Blockers, Calcium Channel Blockers,
Clonidine, Methyldopa and Thiazide Diuretics can result
in impotence, decreased libido and ejaculatory
disturbances among older adults.
 Cholesterol lowering medications, including statins and
fibrates, may impact male sexual health via ED.
 Other medications such as antipsychotics
(Phenothiazine & Risperidone) seizure medications
(Carbamazepine) and H2 Blockers (Cimetidine) also
impact sexual health due to effecting libido &
ejaculation problems.
Case #2
 Taken from: McNicoll, L. (2008). Issues of sexuality in the
elderly Geriatrics for the Practicing Physician, 91(10), 321-322.
Assessment of Sexual Health
Assessment of sexual health is the first step in developing a
plan of care to fulfill the sexual needs of an older population.
OPENING THE DOOR:
Sexual Health History Questions
 Can you tell me how you
express your sexuality?
 What concerns do you have  In what ways has your sexual
relationship with your partner
about fulfilling your sexual
changed as you have aged?
needs?
 What interventions or
information can I provide to help
What questions do you
you to fulfill your sexuality?
have about your sexual
(Wallace, 2000)
needs and function?
PLISSIT MODEL
(Annon, 1976)
P
Obtaining permission from the client to
initiate sexual discussion
LI
Providing the limited information needed to
function sexually
SS
Giving specific suggestions for the individual to
proceed with sexual relations
IT
Providing intensive therapy surrounding the
issues of sexuality for that client
Elements of Assessment
 Health history & review of systems
 Drug review
 Physical assessment
 Assessment for cognitive impairment and impact on
sexual health decision making
 Labs - ? Testosterone levels
 CT/MRI ? For hypersexual behaviors
Assessment Essentials
 Find a quiet, private area.
 Perform assessment in a respectful manner that conveys
understanding of the continuing sexual needs of older adults.
 The more comfortable the healthcare provider is with the
assessment, the more comfortable the client will be.
 Role play assessment/management planning prior to actual
client encounter.
Diagnosis of
Sexual Health Problems
Diagnosis of sexual problems and development of a plan of
care to meet the sexual health needs of older adults is essential
to improved sexual health and quality of life.
Management of
Sexual Health Needs
1)
2)
3)
4)
5)
Promote a healthy lifestyle.
Compensate for normal age-related changes.
Manage diseases that impact sexual health.
Review medications that impact sexual health.
Modify environment to facilitate sexual health
functioning.
Health Promotion
What’s good for the head and heart
is good for the _____.
Eating healthy foods, getting
adequate amounts of sleep,
exercising, decreasing alcohol
intake, stress-management
techniques, and not smoking
are essential to sexual health.
Compensate for Disease &
Normal Aging Changes
 Provide patient teaching about normal aging changes
and impact of diseases on sexual function and image.
 Discuss need for longer fore-play arousal time to
compensate for normal aging changes.
 Consider alternative positions or forms of intimacy when
sexual intercourse is uncomfortable or not possible.
 Understand the principle of: “Use it or lose it.”
 Include safe sex practices in all client teaching
encounters.
Compensate for Disease &
Normal Aging Changes
Consider use of artificial water based
lubricants and estrogen gels/patches/creams
for vaginal dryness
In a multicenter, double-blind, randomized,
placebo-controlled study, 305 women with
symptoms of vaginal atrophy were treated
with a low-dose synthetic conjugated
estrogen A (SCE-A) cream twice weekly.
The results indicated that the cream was effective compared with
placebo in treating symptoms of vaginal atrophy, including pain.
(Freedman et al., 2009)
The Many Faces of ED Treatment*
(*The speaker does not recommend any particular drug treatment)
Compensate for Disease &
Normal Aging Changes
Options for normal aging changes to erectile
function:
 Vacuum pumps
 Injection therapy
 Implants
 Talk therapy
 Oral erectile agents
Compensate for Disease &
Normal Aging Changes
The use of oral erectile
agents such as sildenafil
Citrate (Viagra®), vardenafil
HCL (Levitra®), and tadalifil
(Cialis®) have greatly aided
management of ED.
(Wespes et al., 2007)
There are a number of
erectile agents available in
the form of injectable
treatments. These are
effective treatments for ED,
however some are preferred
more than others due to
pain from the injections.
(Shah et al., 2007)
Heart Disease Management
& Sexual Health
Many medications for the treatment of hypertension
and cardiovascular disease impact sexual function
 Provide patient teaching about these adverse
medication effects.
 Be sure to assess whether patient’s medication is
adversely impacting sexual function and consider
change in medications when appropriate and
possible.
Heart Disease Management
& Sexual Health
92 men; mean age 58 were studied after MI/acute coronary syndromes
&/or coronary artery bypass graft
Intervention group: (n=47) 1) patient education, 2) cognitive
restructuring, 3) emotional support, 4) guided imagery, and 5)
medication (Viagra)
Control group: (n=45) 1) cardiac rehabilitation without other
intervention elements
Results: Intervention group able to 1) resume sexual activity within 1
month of their cardiac event (87% vs. 50% in control), 2) greater
improvement in libido, 3) confidence to attain erection, 4)
satisfaction with sexual relationship, 5) frequency of erection, and
6) enjoyment of sex. (Klein et al., 2007)
Diabetes & Sexual Health
Effective management of diabetes will prevent
circulatory and sensory changes that impact sexual
health. Make sure clients:
 Test blood for elevated glucose levels.
 Manage diet and exercise.
 Manage blood sugar levels with hypoglycemic
medications and/or insulin.
Depression & Sexual Health
CATCH 22
• Treatment of depression may help to improve
libido and sexual dysfunctions such as
orgasmic disorders.
• However, medications to treat depression,
often impact sexual function by lowering libido
and causing orgasmic disorders.
bupropion – “found to have no sexual side effect and may have a pro-sexual
response effect” (McNicoll, 2008)
(brand names: Aplenzin, Budeprion, Buproban, Forfivo XL, Wellbutrin, Zyban)*
*Speaker does not recommend any specific medication
Cancer and Sexual Health
The experience of breast, prostate and other reproductive
system cancers mandates a program of individual &/or group
support to resolve self image issues r/t bodily changes that
impact sexuality.
Environmental Management
 Environmental adaptations to ensure privacy and safety among LTC and
community dwelling residents is essential.
 Arrangements for privacy must be made so the dignity of older adults is protected
during sexual activity.
 Call lights or telephones should be kept within reach during sexual
activity and adaptive equipment such as hospital beds, side rails, or
trapeze bars may need to be obtained.
 Privacy and safe environment for masturbation in cognitively impaired
older adults or those without partners.
 Develop a sexual “tool kit”
 Individual tubes of lubricants
 Condoms
 Erotic materials (movies, magazines).
Summary
 Older adults have continuing sexual needs and
interests that persist throughout the lifespan.
 There are barriers and challenges to sexual health in
the aging population including: 1) normal aging
changes, 2) disease processes, 3) medications and 4)
environment.
 It is necessary to conduct a sexual health assessment
on ALL older adults and develop plans of care to
manage sexual health needs.
Web Links
 Hartford Institute for Geriatric Nursing/ ConsultgeriRN.org.
Sexuality Issues in Aging.
http://consultgerirn.org/topics/sexuality_issues_in_aging/want_to_know_
more
 MedlinePlus
http://www.nlm.nih.gov/medlineplus/sexualhealthissues.html
 American Foundation for Urological Disease, Inc
http://www.impotence.org
 World Health Organization (2004). Sexual Health- A New Focus for WHO.
Progress in Reproductive Health Research, 67. 1-8.
http://www.who.int/reproductivehealth/en/
 American Association of Older Persons. Great Sex Well After 50.
http://www.aarp.org/family/love/articles/berman_sex_after_50.html
 Society for the Scientific Study of Sexuality. http://www.sexscience.org/
References
References with Levels of Evidence provided
as a handout
Taken from GNEC resources
www.aacn.nche.edu/gnec.htm
Contact Information:
rdugger@uscb.edu; 812-573-9146
Final Acknowledgement for
Resources Utilized in Presentation
*Special acknowledgement and thanks
to Meredith Wallace PhD, APRN, A/GNPBC and the Geriatric Nursing Education
Consortium (GNEC)