Nurses' perceptions of sexuality in institutionalized elderly: a literature review

Sexual Expression in Long-Term Care Institutions: Are We Ready for the Baby Boomer Generation?

Baby boomers were at the forefront of profound social changes in sexual attitudes and many have expressed a desire to remain sexually active throughout their life course. The purpose of this survey study was to assess the perceived preparedness of Ontario's long-term care (LTC) homes to meet the changing sexuality needs and expectations of LTC residents. We examined sexuality-related attitudes, including in the context of dementia, among 150 LTC administrators. Participants also completed a questionnaire assessing their experiences and perceptions regarding existing and anticipated supports, barriers, and priorities. Most participants demonstrated positive sexual attitudes; however, multiple challenges to meeting residents' sexuality needs were noted, including assessing capacity to consent, limited privacy, staff training, conflicting attitudes, and a lack of adequate policy and guidelines. Challenges are broad and significant and considerable attention is required to meet the expectations of the next generation of LTC residents, including gender and sexual minority elders.

[Sexuality among the elderly: understanding the weight of stereotypes]

Sexuality is an integral part of health and accompanies human beings throughout their lives. It contributes to well-being and improves quality of life. The social representations conveyed by Western society modulate sexuality and can play a decisive role in the expression of seniors' sexuality.

Promoting sexual health in older adults: Findings from two rapid reviews

BACKGROUND

Sexual health throughout the life course is increasingly recognised as important to maintaining one's overall health, wellbeing, and relationships. We aimed to provide an overview of the evidence on sexual health needs and sexual health promotion in later life.

METHODS

We undertook two rapid reviews, drawing on systematic review evidence. Searches were conducted in Epistemonikos. Studies were eligible if they reported evidence about the sexual health needs of, or sexual health promotion interventions for, people aged 50+ years. Evidence was quality assessed and summarised in a narrative synthesis.

RESULTS

Fifteen systematic reviews were included in Review 1 (sexual health needs) and 12 in Review 2 (interventions). Key concerns and needs of older adults included the impacts of cultural stigma/misperceptions, barriers to sexual expression, and a need for tailored support in a welcoming environment. Key concerns and needs of health and social care professionals included mixed attitudes towards and knowledge of later-life sexuality and a need for more training and education. Approaches to promoting sexual health in later life included training and workshops for care home professionals, education for older people at risk of/living with HIV, and interventions to address sexual health-related symptoms of menopause. Gaps in the evidence from current reviews and methodological issues in primary studies were identified.

CONCLUSION

Older people have specific needs relating to their sexual health. Health and social care professionals working with older people may benefit from education/training around sexuality in later life. Evidence on effective interventions and strategies is limited.

[Attitudes, knowledge and perceptions of care staff in long-term care homes about residents' sexual expressions. Systematic review]

The sexual manifestations of residents in long-term care facilities are often overlooked and even discouraged by care staff. The aim of this study was to conduct a systematic review of caregivers' attitudes, knowledge and perceptions of sexual expression. After consulting different databases, ten scientific articles published between 2012 and 2022 met the inclusion criteria to form part of this review. This work has made it possible to identify and structure the insufficient scientific literature on this specific area of sexuality in older adults. It is concluded that there is scarce scientific literature and that the areas reviewed are determinant in the daily care of institutionalised older adults. Expanding in this field of study will allow the creation of training programmes and the creation of programmes for the care staff to deal with the sexual behaviour of institutionalised older adults.

Discomfort in Discussing Sexual Issues: Developing a New Scale for Staff at Long-Term Care Facilities for Older Adults

Interviews reveal that many health professionals working with older adults are uncomfortable discussing sexual issues with those under their care. Nevertheless, to date, discomfort in discussing sexual issues with older adults has not been empirically investigated. To facilitate exploration of this subject, the current study evaluated the psychometric properties of a new measure: The Discomfort in Discussing Sexual Issues (DDSI) with Older Adults scale. The study was conducted via online survey among 127 long-term care staff (e.g., nurses, physicians, physical therapists, social workers, speech therapists, occupational therapists) serving older adults. A confirmatory factor analysis confirmed the DDSI scale's structure as a single, four-item construct. More conservative attitudes regarding sexuality in later life were associated with higher DDSI scores. In addition, DDSI scale scores were negatively correlated with knowledge about sexuality in later life and educational level. Findings indicate that the DDSI has good psychometric properties, as reflected by its high reliability and adequate validity, making it a useful assessment tool for future research. [Journal of Gerontological Nursing, 48(9), 27-37.].

Frailty and Differences in Self-Reported Sexual Functioning Among Older Females and Males in National Social life, Health and Aging Project

OBJECTIVE

To understand the association of frailty with females' and males' self-reported sexual functioning.

METHODS

Logistic regression on 5 domains of sexual function by frailty status (robust, pre-frail, frail) were analyzed from 2058 respondents to National Social Life, Health, and Aging Project (2010-2011).

RESULTS

Females had similar frailty profiles to males, but more often reported low overall sexual functioning (12.9% v. 4.0%). Compared to robust, pre-frail and frail males had higher odds of sexual function-related: anxiety (pre-frail OR 1.91 95% CI [1.33, 2.74]; frail OR 2.13 95% CI [1.03, 4.41]), negative changes (pre-frail: OR 1.40, 95% CI [1.00, 1.96]; frail: OR 2.42, 95% CI [1.51, 3.89]), and erectile dysfunction (pre-frail: OR 1.81, 95% CI [1.23,2.68]; frail: 2.00, 95% CI [1.00,4.02]); frail females had 1.69 times higher odds (95% CI [1.16,2.48]) of negative changes.

DISCUSSION

Frailty may be a clinical indicator of sexual functioning decline for males more than females.

Registered Nurses' experiences of caring for persons with dementia expressing their sexuality

Background

Sexuality is an integral part of human beings and persons living with dementia still perceive negative attitudes from caregivers in this regard.

Aim

This study aimed to explore registered nurses' experiences of caring for persons with dementia living in nursing homes and expressing their sexuality.

Methods

A qualitative inductive design was adopted; data were collected through semi‐structured interviews and analysed through content analysis.

Results

The analysis reflected three categories. (1) Dealing with different reactions and responding to nursing staff and relatives: The registered nurses experienced discomfort, insecurity, frustration, distress and embarrassment when confronted with sexual expressions in people with dementia. (2) Caring with a focus on the person: The registered nurses expressed the importance of protecting the integrity of the person and consequently their right to sexual expressions. (3) Needing more competence development: The registered nurses expressed the need to educate and inform not only themselves but also the nursing staff and relatives.

Health care professionals and care staff challenges and experiences of managing sexual expression among older adults ≥60 years in long-term care facilities: a qualitative review and meta-synthesis

Long-term care (LTC) facilities, in which older adults are institutionalised, have the responsibility to address their residents' rights, privacy and comfort in expressing themselves sexually in an acceptable manner. However, many older adults have reported barriers in their sexual expression, which is often a result of the care staff's attitudes in the facilities. This review synthesis evidence from qualitative studies on the challenges faced by care staff when supporting sexual expression of older residents in LTC facilities. The systematic review and meta-synthesis is reported according to the Enhanced Transparency in Reporting the Synthesis of Qualitative Research Statement. A systematic literature search for peer-reviewed studies was conducted on PubMed, Cochrane Library, EMBASE, Scopus, Web of Science, PsycINFO, CINAHL and ProQuest Theses and Dissertations from inception until December 2020. Sandelowski and Barroso's two-step approach was used to synthesise the evidence. Seventeen qualitative studies published between 2004 and 2020 were included. This review encapsulated the experiences and challenges of 4,387 care staff whose age ranged from 18 to 69 years. Through the meta-synthesis, four themes were identified: varying manifestations of sexual expression and situations encountered, a spectrum of care staff's attitudes, setting boundaries in dementia care and workplace support. Managing sexual expression can be challenging for the care staff, given the complex interplay between personal beliefs, social contexts, moral dilemmas, practical barriers and the lack of clear policies. This review highlighted the need to equip them with knowledge, skills and confidence in managing sexuality in LTC facilities.

Sexual Expression, Policies, and Practices in Skilled Nursing Settings Serving Older Adults: An Updated Assessment in the State of Kansas

Doll assessed sexual expressions, policies, and practices in Skilled Nursing Facilities (SNFs) in the state of Kansas. This study provided an updated and expanded assessment. A mixed-methods survey was distributed to administrators of all SNFs in the state of Kansas. Among 60 administrations, 84% reported any sexual expression among residents in their community within the past year and 55% reported expressions involving an individual with cognitive impairment. In response to sexual expressions, 70% of administrators believe staff would treat residents with dignity and respect and about 40% anticipated staff discomfort. About 40% of administrators reported having a policy related to sexual expression. Attitudes and responses of staff and administrators appear to be shifting in a sex-positive direction. While policies related to sexuality are more common than a decade ago, there is room for additional uptake, standardization, and infusion of person-centered language and practices.

Regulating, fostering and preserving: the production of sexual normates through cognitive ableism and cognitive othering

People with cognitive disabilities are commonly positioned as risky sexual subjects. This article discusses the discursive production of sexual normates in the form of desirable and normative able-minded sexual subjects, in scientific research on the sexuality and cognitive disabilities of younger and older individuals (in particular those with dementia). We identify three interrelated discourses: regulating sexuality; fostering sexuality; and preserving sexuality. The first of these, regulation, pathologises sexuality of people with cognitive disabilities as faulty and in need of restriction. The second discourse, fostering, is more affirmative and argues for educating for a 'healthy' sexuality of people with cognitive disabilities, to mitigate risks of abuse. This discourse is more salient with younger people. The third discourse, preservation, in contrast, is more visible with older people with dementia and affirms sexuality so long as it is consistent with a 'genuine' or 'authentic' sexuality of the past. In conclusion, scientific research reinforces the cultural ideal of the rational and autonomous individual (and as such the mature/adult) capable of making independent decisions and engaging in healthy, good sex, based on stable sexual identities. Findings demonstrate how age intersects with cognitive ableism to intensify the cultural anxiety that exists around the sexualities of people with cognitive disabilities.

Communicating with older adults about sexual issues: How are these issues handled by physicians with and without training in human sexuality?

Although sexuality is an important part of health and emotional well-being throughout the entire life cycle, including during old age, little is known about how physicians discuss or approach the topic of sexuality during later life. The present study examined the perspectives of two groups of physicians toward discussing sexuality with older patients: 17 physicians who did not have any training in human sexuality and 21 physicians who were certified as sex therapists. The interviews underwent thematic content analysis to identify and code major themes and patterns. Qualitative analysis of the interviews yielded three main themes: (a) discourse between physicians and older adults regarding sexuality, (b) diagnosing sexual dysfunction among older adults, and (c) treating sexual dysfunction among older adults. Physicians who were not trained in sex therapy did not regularly ask their older patients about sexual functioning and/or problems with sex, tended to diagnose sexual problems from a medical perspective, and offered medication as the main treatment for sexual problems. Physicians trained as sex therapists felt more comfortable discussing sex-related issues with their older patients and diagnosed sexual problems from a medical, social, dyadic and psychological perspective. Although they offered their older patients a greater variety of medication-oriented interventions than those without training in sexuality, they did not rush into such interventions and instead emphasised the importance of the psychological and relational aspects of sex. The present study highlights the importance of human sexuality training for physicians and points out the effects of such training on the discourse, diagnosis and treatment of sexual concerns in later life.

A scoping review of education and training resources supporting care home staff in facilitating residents' sexuality, intimacy and relational needs

BACKGROUND

Having positive intimate, sexual and relational experiences is an important issue for older adults in care settings, yet little is known on the extent to which nursing staff and care workers have received education or training in addressing and meeting these needs among older residents. This scoping review aimed to identify and examine what education and training resources exist to assist nursing staff and care workers to meet their residents' needs in this area.

METHODS AND ANALYSIS

Using the Arksey and O'Malley framework, we systematically searched papers and grey literature to identify education interventions and resources that aimed to facilitate care home staff to meet their residents' sexuality, intimacy and relational needs.

RESULTS

Eleven studies (one dissertation) and three education resources met the inclusion criteria; most were conducted in the USA and Australia. Across the studies and resources identified, the education content was mixed and the methodology, presentation, design and duration varied widely. The focus of the education interventions and resources was to increase knowledge and improve and/or change attitudes towards the: (i) sexual expression of older people living in residential aged care, (ii) sexuality and ageing and (iii) expression of sexuality in people with dementia.

CONCLUSION

Few education interventions and training resources were identified. The findings suggest that education interventions can improve knowledge and/or change care staff attitudes, in the short-term, towards older people's sexuality, intimacy and relational needs in care home settings, which can lead to facilitating staff to enhance person-centred care in this area of need.

Knowledge and attitude of nursing students regarding older adults' sexuality: A cross-sectional study

BACKGROUND

Although older adults are sexual, sexuality is infrequently discussed with them by health care professionals. Nursing students, as future professionals, can make an important contribution by developing competences in discussing intimacy and sexuality with older adults to increase quality of life and to prevent sexual problems. In order to improve these competences, current levels of knowledge and attitude need to be explored.

OBJECTIVES

To investigate i) knowledge and attitudes of nursing students regarding intimacy and sexuality of older adults, ii) the difference in knowledge and attitudes of nursing students in different years of study and iii) frequency of discussing intimacy and sexuality with older adults.

DESIGN

Cross-sectional.

SETTINGS

A University of Applied Sciences in the Netherlands.

PARTICIPANTS

Nursing students, ≥16 years who were able to read and write in Dutch.

METHODS

The Ageing Sexual Knowledge and Attitudes Scale was used among nursing students. Furthermore, demographic information and frequencies were collected. Data was analyzed using SPSS.

RESULTS

In total, 732 students participated. The mean knowledge-score was 43.9 (SD = 8.9), the mean attitude-score 64.3 (SD = 16.0). Unlike attitude, the level of knowledge differed significantly per year of study: first year students had the lowest and third year students the highest knowledge. Most students stated they 'never' (54.1%) or 'once' (13.2%) discussed intimacy and sexuality with older adults. Reasons to avoid talking about intimacy and sexuality were feelings of 'not being the right person' (17.3%) and 'incompetence' (14.0%).

CONCLUSIONS

Nursing students had moderate knowledge and positive attitudes toward older adults' intimacy and sexuality. The knowledge-level differed per year of study, the attitude level did not. Only a minority discussed intimacy and sexuality with older adults. Moderate knowledge and positive attitudes do not mean that intimacy and sexuality is discussed. To ensure students feel responsible and competent, interventions should focus on continuous knowledge dissemination, role clarification and role modelling.

'I do it my way': long-term care staff's perceptions of residents' sexual needs and suggestions for improvement in their management

This study is aimed at exploring to what extent staff perceive older residents in long-term care facilities (LTCFs) as still having sexual needs, and how they think care in relation to sexual issues could be improved. The sample was self-selected and comprised 2115 staff members (including managers, technical and care assistants) employed at 152 Spanish LTCFs. Data were collected in the second half of 2016. Participants were asked to estimate the proportion of older residents who had sexual needs in their institution and, by means of open-ended questions, they were also asked about how they satisfied such needs and how to improve care in relation to sexual issues. Responses to the open-ended questions were analysed using content analysis. Differences were assessed according to participants' work position. Results showed that most participants did not see sexual needs as being present in many (or even any) older people living in LTCFs. Masturbation was the most common way staff thought residents' sexual needs were being satisfied. The participants mentioned a broad range of measures to improve care regarding sexual issues, including providing more training opportunities for staff, guaranteeing privacy and improving negative attitudes held by family, residents or staff members. Work position influenced participants' responses: managers and technical staff were more likely to recognise sexual needs among residents, perceived a greater need for training, and proposed more ambitious and far-reaching improvements than care assistants.

Sexual harassment from older residents at long-term care facilities: is it really part of the job?

OBJECTIVES

To explore the extent to which staff members in long-term care facilities (LTCF) have experienced situations of sexual harassment, how they commonly and ideally manage the situation, and how their work position influences their responses.

DESIGN

Cross-sectional quantitative study, using the vignette technique.

METHOD

A total of 2,196 staff-members who were currently working in Spanish LTCF participated in the study. Data were collected using a self-administered questionnaire. Questions regarding sexual harassment were analysed by a vignette that described a case of sexual harassment. Participants had to choose common and best practices for dealing with the case, and report the frequency with which they had experienced similar situations.

RESULTS

The results indicate that 29.9% of participants had experienced an episode of sexual harassment in a LTCF similar to the one presented in the vignette. Responses to the situation were diverse and there were significant differences between common and perceived best practices. Differences were also found depending on the work position of the participant (manager, technical staff or nursing assistant).

CONCLUSIONS

There is a need for a fuller recognition of the sexual needs of older people. However, the presence of inappropriate sexual behavior must also be acknowledged. The right of staff to work in an environment free of harassment must be respected. The need for explicit institutional guidelines and training opportunities is discussed.

"Shades of Grey": Exploring Public Opinion about Later-Life Sexuality

Public opinion on later-life sexuality affects older people's sexual health, behaviour, and satisfaction. In this study, we explored public opinion on later-life sexuality by participants' responding to an open-ended question rather than rank their level of agreement or disagreement with different statements about older people's sexuality. Responses from 135 men and women reflecting on how sexuality changes in older age were thematically analysed. Five themes emerged, varying from positive to negative perceptions of later-life sexuality. Older people's sexuality was described as declining, non-existent, conservative, narrow, tedious, and boring, but also as encompassing more emotions and feelings; being better and more "complete". This study provides qualitative data and an opportunity to gain insights on valuable opinions on what young and middle-aged people think about later-life sexuality. Assessing what people think about later-life sexuality is the first stage in instilling more liberating views about the diversity of sexual expressions in old age.

How do community-dwelling LGBT people perceive sexuality in residential aged care? A systematic literature review

OBJECTIVES

To investigate what empirical studies report on the perceptions of community-dwelling LGBT adults regarding sexuality and sexual expression in residential aged care (RAC), and how their sexuality should be addressed in RAC.

METHODS

Relevant papers were identified through electronic searches in databases; and by reference tracking and citation tracking. Data were extracted using a standardized data extraction form and were compared, related, and synthesized using thematic analyses. We evaluated the methodological quality of the studies.

RESULTS

Eighteen articles were identified. Three major topics emerged regarding sexuality in RAC: (1) factors affecting LGBT people's perceptions, subdivided into (a) discrimination, (b) loss of sexual identity, (c) failure to acknowledge the same-sex partner, and (d) lack of privacy; (2) LGBT-specific RAC facilities; and (3) characteristics of LGBT friendly RAC facilities and caregivers.

CONCLUSIONS

LGBT people have clear perceptions about how sexuality and sexual expression is or should be managed in RAC. Despite the general increase in acceptance of sexual minorities, many community-dwelling LGBT people believe older LGBT residents are discriminated against because of their sexual orientation or gender identity. Taking into account these opinions is crucial for increasing accessibility of RAC to LGBT people and to ensure the quality of the provided care.

Organisational enablers and barriers to the recognition of sexuality in aged care: A systematic review

AIM

To identify organisational characteristics and practices that promote or inhibit the recognition of sexuality in the care of older people in health and aged care settings.

BACKGROUND

Sexuality in old age is poorly understood by health professionals and rarely addressed in care planning and delivery. Nurse managers are ideally placed to lead organisations in promoting a culture of acceptance that enables the expression of sexuality.

EVALUATION

A search for research/expert opinion papers published from January 2004 to February 2017 was undertaken. Two reviewers performed data extraction and appraisal of 34 included studies using Joanna Briggs Institute tools. The primarily qualitative research was analysed to identify 152 findings that were organised into 22 categories and combined into four syntheses.

KEY ISSUE(S)

An organisation's philosophies frame the way older people's sexuality is perceived. Cultivating a culture and environment of acceptance, engagement and knowledge and delivering care in a way that promotes opportunity for safe and private expression of sexuality are key enabling factors.

CONCLUSION(S)

Organisations and nurse leaders can support and facilitate older adults' expression of their sexuality through the review and development of philosophies, policies, procedures, staff attitudes and knowledge and the creation of a conducive environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers play a pivotal role in developing a sexuality-positive organisational ethos by ensuring policies, care practices, the environment and amenities are supportive of the expression of sexuality and by role modelling attitudes of respect and inclusivity.

Let's talk about sex: A feminist poststructural approach to addressing sexual health in the healthcare setting

AIMS AND OBJECTIVES

To explore the use of feminist poststructuralism (FPS) as a way to critique, understand and improve sexual health care and policy in healthcare settings.

BACKGROUND

Sexual health is an important aspect of health; however, in healthcare settings, it often goes unaddressed by both healthcare providers and patients due to stigma, taboo, fear of embarrassment or uncertainty. Lack of attention to sexual health has been stated as a legitimate concern for patients across the lifespan; there remain gaps in implementing sexual health care discussions into practice in healthcare settings.

DESIGN

A critical analysis will be presented to explore sexual health care and attitudes in the healthcare setting from patient and nursing perspectives using FPS.

METHODS

Feminist poststructuralism is used to examine the meaning of experience that is personally, socially and institutionally constructed through relations of power. FPS will also be applied to understand how sexual health discourses are negotiated in healthcare settings. SQUIRE guidelines were used in the preparation of this paper (See Appendix S1).

RELEVANCE TO CLINICAL PRACTICE

The application of a feminist poststructural lens to sexual health care in healthcare settings may be used by healthcare professionals to understand, question and challenge how social and institutional beliefs, values and practices surrounding sexual health, inclusive of a patient's sexual pleasure or sexual activity, are experienced by healthcare professionals and patients. This theoretical and methodological approach could lead to identifying possibilities for change in healthcare settings that are inclusive and supportive of sexual health care.

Nurses' experiences and reactions towards intimacy and sexuality expressions by nursing home residents: A qualitative study

OBJECTIVES

To better understand how nurses experience and react to intimate and sexual expressions of nursing home residents.

BACKGROUND

Although many nursing home residents continue to desire intimacy and sexual expression, they commonly perceive negative attitudes of nursing staff towards them as a major barrier to their sexual well-being. To eliminate this barrier, it is crucial to gain a more in-depth understanding of nurses' personal experiences and reactions towards intimacy and sexuality in aged care.

DESIGN

Our study used a qualitative design, rooted in grounded theory.

METHODS

Semi-structured interviews with 15 nurses between 34 and 59 years of age were conducted. Participating nurses were recruited from seven different nursing homes in Flanders, Belgium. We used the Qualitative Analysis Guide of Leuven (QUAGOL) for data analysis. We followed the COREQ guidelines to ensure rigour in our study.

RESULTS

Nurses experienced and dealt with intimate and sexual expressions of residents in an individual way, which was focused on setting and respecting their own sexual boundaries and those of residents and family members. Depending on their comfort level with residents' expressions, nurses responded in three ways: active facilitation, tolerance and termination. Nurses' responses depended on contextual factors, including their personal experiences with sexuality, the nature of their relationship with the residents involved, the presence of dementia and the organisational culture of the facility.

CONCLUSIONS

Nurses face a wide range of experiences and emotions when confronted with residents' expressions of sexuality and intimacy. A supportive approach is needed to guide nurses in dealing with these highly sensitive situations. This approach can be promoted at the institutional level through continuous educational programmes.

RELEVANCE TO CLINICAL PRACTICE

This study advocates a contextual and interpretative ethical approach to sexuality in older adults, taking as starting point nurses' own vulnerability and that of residents and relatives.

Examining the Attitudes and Knowledge of Social Work and Nursing Students on Later-Life Sexuality

Cette étude a examiné les croyances, les attitudes et les savoirs âgistes liés à la sexualité au grand âge chez 148 étudiants en sciences infirmières et 137 étudiants en travail social de première année. Les étudiants ont complété les questionnaires Fraboni Scale of Ageism et Attitudes and Knowledge towards Older Adult’s Sexuality Scale, ainsi que des questionnaires portant sur leurs contacts avec des personnes âgées, leur éducation sexuelle et des variables sociodémographiques. Les résultats ont montré que les étudiants en sciences infirmières avaient des attitudes plus conservatrices envers la sexualité des personnes âgées. Les croyances âgistes corrélaient positivement avec des attitudes plus conservatrices envers la sexualité des personnes âgées. Les attitudes conservatrices envers la sexualité des personnes âgées étaient négativement corrélées avec les connaissances liées à la sexualité au grand âge. Les étudiants plus âgés avaient davantage de connaissances sur la sexualité des personnes âgées et des attitudes plus permissives concernant cet aspect de la sexualité. Les étudiants plus religieux avaient moins de connaissances liées à la sexualité des personnes âgées et des attitudes plus conservatrices sur ce sujet. L’éducation sexuelle reçue par les étudiants n’était pas associée avec leurs attitudes et leurs connaissances liées à la sexualité des personnes âgées. Les implications de ces résultats pour l’élaboration de programmes d’éducation continue sont discutées.

Sexual culture in low-income older adult housing: norms, behaviours and risks

This paper explores the behaviours and meanings associated with intimacy and sexuality among older adults with diverse partners living in subsidised senior housing. It utilises survey and qualitative data from a mixed methods of ageing/HIV exposure to illustrate gendered views on sexual and intimate behaviours, and attitudes towards transactional/commercial sex. Data suggest that women were cautious about engaging in intimate relationships, while men sought them and the companionship they provided to address loneliness. Reasons for non-intimacy were age and health problems. Generally speaking, both men and women had positive attitudes towards sex. Men took risks by having multiple partners and using condoms irregularly; women believed they could avoid risks by taking time to get to know their partners, but never used condoms. Forty per cent of men who saw sex workers were not regular condom users. They traded risk of gossip, violence and infection for companionship with women seeking money and physical safety. Findings have implications for policies, counselling and interventions for older sexually active adults in institutional and residential settings.

Views of family physicians on heterosexual sexual function in older adults

Background

Sexual functioning among older adults has received little attention in research and clinical practice, although it is an integral part of old age. As older adults tend to consume health services and to visit family physicians more frequently, these care-providers serve as gatekeepers in the case of sexual concerns. The present study evaluated the perceptions of family physicians regarding sexuality in older adults.

Method

Qualitative interviews with 16 family physicians were conducted. We used in-depth, semi-structured interviews.

Results

Three main themes emerged: 1. Family physicians described having difficulty in raising questions about sexuality to older patients. 2. Family physicians tended towards the biological side of the spectrum, focusing on the patient’s medical problem and asking physiological questions. 3. Family physicians mainly related to medication administered to their male patients, whereas a minority also described the guidance they provided to older individuals and couples.

Conclusions

The study shows that family physicians tend not to initiate discourse with older patients on sexuality, but rather discuss sexuality mostly in conjunction with other medical conditions. Implications for research and practice are discussed.

Staff's reactions towards partnered sexual expressions involving people with dementia living in long-term care facilities

AIMS

To explore staff responses, in terms of common practices, towards partnered sexual relationships in long-term care facilities where one or both people involved have dementia. It also tries to determine personal and institutional factors influencing these responses.

BACKGROUND

Although some studies, mostly qualitative, have focused on reactions to residents' sexual expressions so far the issue has not been assessed in a study using large and diverse samples.

DESIGN

Cross-sectional quantitative study using vignette technique.

METHODS

Participants were 2,295 staff members at 152 Spanish long-term care facilities. Data were collected during 2016. A vignette describing sexual situations involving people with dementia was presented to participants. After the vignette, participants had to answer the question: "What do you think most of your colleagues would do in this situation?" with nine possible responses.

RESULTS

Results showed that relationships involving persons with dementia were perceived as potentially problematic by staff. In both conditions, discussing the case with a colleague or supervisor was the most frequently chosen reaction. More restrictive reactions were mentioned when only one person with dementia was involved in the relationship. Factors such as participants" age and years of experience, professional post and commitment to person-centred care practices were related with the frequency of common restriction practices.

CONCLUSION

Results highlight the importance of providing staff with clear guidelines regarding the management of specific sexual situations to avoid stereotyped restrictive reactions.

Communication of healthcare professionals: Is there ageism?

Elderspeak is often used when talking to older individuals and is characterised by a slower and/or louder speech, a patronising tone, etc. A part of the reason of such communication can be found in the actual context of negative view of ageing. However, the link between view of ageing and elderspeak has never been objectively studied in oncology. Therefore, 40 healthcare professionals (physicians and medical students) record a podcast where they have to explain an endocrine therapy to two fictional patients (40- vs. 70-year old). Results show that when participants explained the treatment to the older patient, they used shorter utterances and made more repetitions. They also evoked fewer side effects such as sexual issues. Moreover, reduction in length of utterances and of word-per-minute rate was observed for older patient when participants have a positive view of ageing but for both patients when they have a negative view of ageing. In conclusion, physicians and medical students used elderspeak when they explained a treatment to older patients. Participants with a more negative view of ageing also unconsciously talked slower and made shorter utterances to a 40 -year-old patient.

Intimacy and Sexuality in Institutionalized Dementia Care: Clinical-Ethical Considerations

Intimacy and sexuality expressed by nursing home residents with dementia remains an ethically sensitive issue for care facilities, nursing staff and family members. Dealing with residents' sexual longings and behaviour is extremely difficult, putting a burden on the caregivers as well as on the residents themselves and their relatives. The parties in question often do not know how to react when residents express themselves sexually. The overall aim of this article is to provide a number of clinical-ethical considerations addressing the following question: 'How can expressions of intimacy and sexuality by residents with dementia be dealt with in an ethically responsible way?' The considerations formulated are based on two cornerstones: (1) the current literature on older peoples' experiences regarding intimacy and sexuality after the onset of dementia, and (2) an anthropological-ethical framework addressing four fundamental pillars of human existence namely the decentred self, human embodiment, being-in-the-world and being-with-others. The resulting considerations are oriented toward the individual sphere, the partnership sphere, and the institutional sphere. The continuous interaction between these spheres leads to orientations that both empower the residents in question and respect the complex network of relationships that surrounds them.

How do formal caregivers experience the sexuality of older adults? Beliefs and attitudes towards older adults’ sexuality

Aim

The way caregivers experience the sexuality of older adults has implications to their identity and sexual manifestations. There are few studies that focus on the meaning of caring of older adults, taking into account their sexuality. This study aims to explore the experiences of formal caregivers (FC) towards sexuality among older adults, and to obtain a description of their experiences.

Method

Complete data were available from six caregivers working in a nursing home. We used a sociodemographic questionnaire and topic interview guide. The data was subjected to content analysis.

Results

The most prevalent response of the interviewed participants for ‘beliefs about the interest in sexuality’ was ‘health limitations despite the desire’, for ‘observed behaviours related to sexual expression’ was ‘masturbation’, and for ‘reactions/behaviours due to the demonstration of sexual expression was ‘using humour”.

Conclusion

Future educational and intervention programs in the institution should take into account our findings to improve their efficacy on discussing these issues and to ultimately promote sexual wellbeing.

"Behind Closed Doors with open minds?": A qualitative study exploring nursing home staff's narratives towards their roles and duties within the context of sexuality in dementia

BACKGROUND

Despite sexual expression being recognised as a fundamental human need, sexuality in old age is often ignored and frequently misunderstood, with residents with dementia in a nursing home often viewed as asexual or incapable of being sexually active.

OBJECTIVES

The current study aims to understand the views held by nursing care home staff towards dementia and sexuality and explore the roles they may adopt whilst responding and managing sexual needs and expression for residents with dementia.

METHODS

Face to face, in-depth, semi structured interviews were conducted with eight staff members working in two nursing homes in Greater London, United Kingdom. Data were analysed using Interpretative Phenomenological Analysis.

RESULTS

The findings suggest that representations of sexuality in dementia held by nursing home staff ranged from the perception that sexual expression in old age was part of human nature and a basic human right to others that proposed that with the loss of memory, people with dementia may also experience loss of interest in sexuality and intimacy. Based on the representation of sexuality held (personhood versus biomedical model), nursing home staff adopted a role or a combination of roles (a facilitator, an informant, a distractor, an empathiser, a safeguarder) that legitimised past and anticipated responses in managing sexual expression in the nursing home setting. Nursing home staff's responses varied depending on the severity of the condition, level of involvement of the resident's family and their own personal views on their duty of care, old age, sexuality and dementia.

CONCLUSION

The simplified binary labelling and classification of sexual behaviour in dementia as appropriate or inappropriate often applied in institutional settings, fails to account for complex factors that may influence staff's decisions on the ethical dilemmas raised by dementia. A role based continuum approach could help staff move away from rigid binary judgments and train them to adopt formal carer roles that promote a more contextualised rights based approach in the provision of dementia care.

Nurses’ knowledge and attitudes toward aged sexuality in Flemish nursing homes

Background:

Admission to a nursing home does not necessarily diminish an older person’s desire for sexual expression and fulfillment. Given that nursing staff directly and indirectly influence the range of acceptable sexual expressions of nursing home residents, their knowledge and attitudes toward aged sexuality can have far-reaching effects on both the quality of care they provide to residents and the self-image and well-being of these residents.

Research objectives:

To investigate nursing staff’s knowledge and attitudes toward aged sexuality, to determine whether certain sociodemographic factors of the nursing staff relate to their knowledge and attitudes toward later-life sexuality, and to examine the relationship between knowledge and attitudes.

Research design:

Descriptive cross-sectional survey study.

Research participants and research context:

The administered questionnaire collected sociodemographic data and data from an adapted, Dutch version of the Aging Sexual Knowledge and Attitudes Scale. Data were collected from November 2011 through April 2012. A total of 43 geographically dispersed nursing homes in Flanders, Belgium, participated. Out of a potential research sample of 2228 nursing staff respondents, 1166 participated.

Ethical considerations:

The study protocol was approved by the Ethics Committee of the Faculty of Medicine of the KU Leuven.

Findings:

Nursing staff appeared to be moderately knowledgeable about aged sexuality and displayed a rather positive attitude toward sexuality in older people. Significant relationships between various variables were found both at univariable and multivariable levels. Knowledge and attitudes proved to be positively related, indicating that a higher level of knowledge of aged sexuality is associated with a more positive attitude toward sexuality in later life.

Discussion:

Research findings are discussed within a broader international context.

Conclusion:

There is room for improvement for both nursing staff’s knowledge and attitudes toward aged sexuality. This might be aided by appropriate educational interventions. Our results identified different target groups of nursing home staff for these interventions.

Sexuality, sexual health and older people: A systematic review of research on the knowledge and attitudes of health professionals

OBJECTIVES

Sexuality remains important to older people and should be recognised as an important part of their overall care. However, this appears to be poorly understood and addressed by many healthcare professionals. This systematic review reports on knowledge and attitudes of health professionals towards sexuality and sexual health of older people, including factors that impact knowledge and perceptions.

REVIEW METHODS AND DATA SOURCES

The review, conducted using Joanna Briggs Institute methods, included 23 studies of varied methodology published between January 2004 and January 2015.

RESULTS

Findings indicated that healthcare professionals often consider older people's sexuality as outside their scope of practice and there is lack of knowledge and confidence in this area. Cultural norms and taboos, length of time spent working with older people, familiarity with the older person, previous training and degree of exposure to people who are not heterosexual were all identified as factors that impact knowledge and attitude.

CONCLUSIONS

Better role modelling and education are needed to improve knowledge and attitudes toward later life sexuality.

Staff attitudes and reactions towards residents' masturbation in Spanish long-term care facilities

AIMS AND OBJECTIVES

To explore staff attitudes and reactions towards masturbation in long-term care facilities.

BACKGROUND

Staff attitudes and reactions towards the expression of sexuality in long-term care facilities may be influenced by the nature of the sexual behaviour being expressed. Staff attitudes towards masturbation, a common sexual behaviour in such settings, have gone largely unexplored so far.

DESIGN

An exploratory, descriptive, qualitative research design.

METHODS

Fifty-three staff members working in five different long-term care facilities participated in the study. They were asked about what they would think, how they would react, and what possible reactions they might expect from workmates if they entered a room and found a resident masturbating.

RESULTS

The majority of participants considered that masturbation was acceptable and avoiding interference was by far the most common reaction, although other reactions also arose. When asked about reactions attributed to workmates, mentions to reprimanding the resident and gossiping/joking about the issue were more frequent than acceptance.

CONCLUSIONS

The discrepancy between professionals' own reported attitudes and those attributed to workmates suggests the existence of widespread negative reactions towards sexual activity in later life.

RELEVANCE TO CLINICAL PRACTICE

In the light of these results, we underline the necessity of developing explicit policies regarding sexual issues. Formal training offered to staff would also help to recognise and preserve resident's sexual rights and needs.

Public Attitudes Toward Sexual Expression in Long-Term Care: Does Context Matter?

The purpose of this study was to (a) examine how age and sex of long-term care (LTC) residents influence public attitudes toward sexuality in LTC and (b) understand how, in the absence of cognitive decline, residing in LTC influences the perception of sexuality as a basic human right. Attitudes were examined using a factorial vignette with a probability sample of 325 respondents from a southern state. Results indicate that attitudes were not statistically affected by a vignette character's age or sex; but respondent education level, parenthood status, and religious affiliation did have direct bearing on attitudes. The notion of sexuality as a basic human right for residents of LTC was ultimately challenged as 19% of respondents said that LTC residents should not be permitted to have sexual relations with their spouse in the facility.

Older residents' perspectives on aged sexuality in institutionalized elderly care: a systematic literature review

OBJECTIVES

The aim of this systematic literature review is to investigate older residents' thoughts on, experiences of and engagement in sexual behavior and aged sexuality within institutionalized elderly care.

DESIGN

Systematic literature review.

DATA SOURCES

We conducted an extensive search of the electronic databases Cinahl, Medline, Pubmed, Embase, Web of Science and Invert for papers published between January 1980 and October 2014 when the searches were closed. Additional papers were identified through forward and backward citation chasing.

REVIEW METHODS

Data from relevant studies were extracted by means of a data extraction form. Relevant data were isolated, summarized, compared, related and categorized according to theme. Quality assessment of the included studies focused on their adequacy of reporting the study's research aim, sampling, collection, and analysis procedures, ethical considerations and results.

RESULTS

Twenty-five appropriate studies were identified. These studies varied in research design (using surveys, vignettes, focus groups, interviews, or observation), objectives, quality of reporting, and sample characteristics (i.e. male and/or female long-term care residents with and/or without dementia). Yet, they all point to the relevance of sex and sexuality in old age and emphasize the highly individual character of both sexual interest and expression. Older residents who wish to sexually express themselves, might do this in a wide variety of ways, including, but not limited to, daydreaming, dressing-up, looking for emotional and intellectual intimacy, stroking, caressing, kissing, and engaging in sexual intercourse. Overall, residents appear to have a rather positive attitude toward aged sexuality as such. When it comes to specific sexual behaviors or homosexuality, however, attitudes tend to be more negative. The perceived appropriateness of the displayed behavior is a predominant factor in determining older people's reactions to the sexual behavior of co-residents, rather than the potential emotional discomfort brought on by witnessing this behavior.

CONCLUSIONS

Relatively little work has been published on older residents' perspectives regarding aged sexuality in institutionalized elderly care. If, however, we wish to devote ourselves to individualized or person-centered nursing care, we will have to gain more insight into the patient's perspective and take notice of the needs, expectations, attitudes, experiences and behaviors of residents with regard to (aged) sexuality. Hence more research is needed that depicts the issue of aged sexuality in institutionalized elderly care from a patient's and thus resident oriented perspective.

Staff Reactions Toward Lesbian, Gay, or Bisexual (LGB) People Living in Residential Aged Care Facilities (RACFs) Who Actively Disclose Their Sexual Orientation

Fifty-three staff members currently working in residential aged care facilities located in Barcelona, Spain, were asked about the way they would react if a resident told them that he or she felt sexually attracted and had maintained sexual relationships with another resident of the same gender. Acceptance of non-heterosexual sexual orientation was a frequent answer, and around one in four professionals stated that they would try helping the resident in question, by offering a private space or giving some emotional support. However, some reactions were not consistent with a respectful approach toward sexual diversity, as, for instance, informing the resident's family or advising the resident to keep his or her sexual orientation hidden. We highlight the importance of developing formal policies and offering formal training to staff in order to address the specific needs of older LGB people living in RACFs.

Young Adults’ Implicit and Explicit Attitudes towards the Sexuality of Older Adults

L’intérêt sexuel et la capacité sexuelle peut s’étendre loin dans la vie plus tard, entraînant de nombreux effets positifs sur la santé. Cependant, il y a peu de soutien pour l’expression sexuelle dans la vie plus tard, notamment chez les jeunes adultes. Cette étude a évalué et comparé les attitudes implicites et explicites de jeunes adultes face à la sexualité des adultes âgés. Un échantillon de 120 participants (18-24 ans, dont 58 pourcent femmes) ont rempli un auto-évaluation et une série de tests d’associations implicites, capturant les attitudes envers la sexualité parmi les personnes âgées. Malgré des rapports des attitudes explicites positifs, les jeunes ont révelé un biais implicite contre la vie sexuelle des personnes âgées. En particulier, les jeunes adultes ont montré des partis pris implicites favorisant les activités générales, par rapport aux activités sexuelles, et les jeunes adultes sur les adultes plus âgés. En outre, les biais favorisant les activités générales ont été amplifiées à l'égard de personnes âgées par rapport aux jeunes adultes. Nos résultats mettent en doute la validité de la recherche en s'appuyant sur les déclarations des attitudes sur la sexualité des adultes plus âgés.

The sexuality experience of older widows in Korea

Sexuality plays an important role in elders' lives. However, few studies exist concerning the essential meaning crucial for the overall understanding of sexuality in later life. In this study we explored the experience of what sexuality implied and meant to older widows using the descriptive phenomenological approach. Purposive sampling yielded 10 elderly women who were in sexual relationships. We collected data through in-depth interviews with participants and conducted a thematic analysis. The findings were classified into eight themes: trying to find another side of herself, starting a romantic relationship, invigorating life, displaying femininity, being concerned about the perceptions of others, enjoying sexual freedom, feeling the limit of sexual intimacy, and facing up to reality. The sexual lives of older widows entailed a process of recovering their femininity, self-achievement, and self-esteem, which helped them to live independent lives by developing more active and flexible attitudes.

Staff attitudes towards sexual relationships among institutionalized people with dementia: does an extreme cautionary stance predominate?

BACKGROUND

This study explores whether staff perceptions and reactions to sexual situations involving one or two persons with dementia (PWD) reflect an extreme cautionary stance (an overprotective and paternalist style) or a person-centered model of care (focusing on understanding the residents' perspective and their rights).

METHOD

Fifty-three staff members currently working in residential aged care facilities (RACFs) were purposively selected to participate in the study. Two vignettes describing sexual situations involving PWD were presented to participants. They were asked about their interpretation of the situation and how they would react. Data were analyzed using content analysis, aimed at identifying common themes in the responses.

RESULTS

When the sexual relationship involved a PWD and a cognitively intact resident, participants tended to define the situation as real (54.7%) or possible (35.8%) abuse, whereas when both parties had dementia it was more frequently conceptualized as a possibly abusive (39.6%) or non-abusive (37.7%) situation. The most frequent reaction to both situations was seeking the advice of other professionals.

CONCLUSION

The interpretation of the first situation is compatible with an extreme cautionary stance, whereas the second scenario is less clearly perceived as an example of abuse.

Patterns of help-seeking in women when problems arise in their sexual life: a discussion paper

AIMS AND OBJECTIVES

To explore patterns of help-seeking in women who have sexual dysfunction and the implications for nursing practice.

BACKGROUND

Female sexual dysfunction is a common problem that is under-reported and untreated. Barriers to help-seeking reported in existing literature relate to the perception among many women that sexual dysfunction is: part of the normal ageing process; not bothersome or does not exist; an issue that health professionals are reluctant to address; a taboo subject. However, little is known about patterns of help-seeking in women with sexual problems. This leaves a potential gap in nursing knowledge regarding appropriate, supportive strategies.

DESIGN

Discursive inquiry framed theoretically by Vogel's model.

METHODS

A literature review was undertaken by searching relevant databases. A combination of keywords was used to identify peer-review papers relating to women's help-seeking behaviour for sexual dysfunction. Vogel's model was used as a framework to extract relevant information from the papers and structure the discussion.

RESULTS

Vogel's model comprises four steps: encoding and interpreting, generating options, decision-making and evaluation of behaviour. Using this stepwise approach helped elucidate the complex mechanisms associated with help-seeking in a structured manner. The key issues associated with help-seeking intention are concerned with women's personal awareness of and interaction with the environment.

CONCLUSIONS

Vogel's model offers a new approach to understanding the dynamics that underpin women's decisions to seek professional help when sexual concerns arise and also provides a useful framework for nurses to consider women's specific sexual concerns.

RELEVANCE TO CLINICAL PRACTICE

Implications for nursing practice are focused on public awareness, women's empowerment and the provision of effective sexual health care. Because sexual dysfunction is a global phenomenon, it is likely that the discussion in this paper will be relevant to an international, nursing readership.