**1. Introduction**

Sexuality as a human need for belonging and being close with someone, as a need for affiliation and physical pleasure is typical for all ages in the life span development [1]. In regard to human needs sexuality is a goal (the need) and a mean through which individuals satisfy their needs. Sexuality has a significant impact on individual's self-esteem, well-being, and functioning; it includes personal, cultural and social identity, and not just sexual orientation and behaviour [2]. The need for sexuality and intimacy is maintained in old age [3], only modes of sexual expression can be different concerning individual's age. In addition to physical sexual relations elderly can express sexuality through hugging, fondling, kissing, holding hands, touching or physical closeness [3, 4], through demonstrating mutual tenderness, support, and under‐ standing, and through developing a new partnership relationship [5].

There are many factors that positively or negatively affect the expression of sexuality among elderly in nursing homes. Not only age-related changes and diseases [6] but also some psychosocial factor occurs. Skoberne [7] and Ziherl [6] argues, that these factors are widow‐ hood, separations, quality of partnership, self-esteem, health impact on partnership, economic situation and environmental influence. In fact, sometimes is easier to influence on age-related changes and disease than environmental influence which has a significant impact on satisfac‐ tion of sexual needs in older age. Moreover, in this case the environmental influence means other people views whether are already so deeply entrenched and changing them can be very time consuming process. Society still perceives older people without sexual needs or incapable of sexual activity. For that reason elderly suppress their sexual needs and start to behave in accordance with these beliefs [7].

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Institutional care is important and widespread form of care for the elderly who are no longer able to live independently. The attitude of nursing staff towards sexuality is very different and may vary from positive to negative or permissive and restrictive [8]. This can significantly inhibit the expression of sexuality among the elderly. Room designs which do not provide privacy [9], taking care just for the physical needs, avoid talking about sexuality because of the shame [1, 10, 11], failure to respect residents autonomy or the need to control their behavior [3], and letting families to take decisions instead of them [12] are the aspects which may have a significant impact on sexual or intimacy expression among elderly living in nursing homes. Moreover, nursing staffs day-to-day contact with residents often develops into strong rela‐ tionships, which also affect the sexual expression of the elderly in nursing homes [13]. Since satisfaction of needs has an important role in individual's satisfaction, happiness, and wellbeing, the study of nursing care professionals' attitudes toward sexuality and sexual needs of elderly is necessary for a comprehensive understanding of the determinants which influ‐ ences the quality of life among elderly in nursing homes. In the end of the chapter authors present the results of a study of nursing care professionals' attitudes toward sexuality of elderly in nursing homes which was performed on a sample of nursing staff from 5 Slovenian nursing homes. The authors developed a semantic differential scale, encompassing a list of adjectives, through which nursing care professionals described the meaning attached to sexuality of elderly in institutional care.

### **2. Physiological and psychosocial aspects of sexuality among elderly**

Older people continue to have need for maintaining their sexual activity and intimacy [3], they just change the ways of expression of their needs. However, in addition to physical sexuality, elderly express their sexuality also with hugging, caresses, kissing, holding hands, touching or by physical closeness [3, 4] as well as tenderness, partners support and mutual understand‐ ing [5]. There are many factors that positively or negatively affect the expression of sexuality among elderly which include not only age-related changes and diseases [6] but also some psychosocial factors.

Over the years, some *physiological* changes occur in aged population that affects their sexual activity. For example, men take longer to get an erection, which can be shorter, and women can perceive physiological changes as a vagina moistening problem. However, Walsh and Berman [14] observed that with age the desire for sexual activity and the possibility of experiencing orgasm do not decrease. Although, in the recent years, studies that describe sexual lives among older women become more frequently, we still trace down some prejudices that with the menopause sexual life is over or that sexuality during menopause is not appro‐ priate [15].

The level of estrogen in women after menopause is declining, but the body still produces enough testosterone to maintain interest in sex [15, 16]. Some women after 60 years may experience that the clitoris is somewhat reduced, but still remains very sensitive [17]. Also, due to dryness and vaginal atrophy women can experience pain during sexual intercourse (dyspareunia) [16]. Sexual excitement can be reduced or it is weaker, and therefore women require a longer petting to lead her to an orgasm [15]. There also may be some psychological symptoms that accompany menopause. The fact that women in menopause cannot have children any more, for some proves the inevitable aging [14, 18]. Distress in older women is also caused by other factors including urinary incontinence, removal of the uterus and some other chronic diseases [19], although the removal of the uterus usually does not affect sexual satisfaction [16]. However, all this have an impact not only on the sexual functioning, but also on emotional state, self-esteem and consequently interpersonal relationship [20].

Even older men are confronted with some changes that may affect the perception of sexuality and sexual desire, although most of them produce enough testosterone that is sufficient to maintain libido [16]. The most common sexual dysfunction in man is erectile dysfunction and hypogonadism [20]. In fact, erectile dysfunction in man increases with each decade, starting at age 60 [21]. Masters and Johnson [17] found that men aged between 50 and 90 years, usually state that their erection is slow and incomplete, and for its mainte‐ nance need more stimulation. In older men the stimulation should be of both, mental and physical nature in contrast to younger men which mostly require only mental stimula‐ tion. On the other hand, older men have the ability to have greater control over ejacula‐ tion, but the intensity and volume of ejaculate is smaller [22]. Same authors also indicate a shorter orgasms and prolonged interval between each ejaculation. For those aged more than 70 the interval can be extended up to 48 hours [16], but it rarely happens that a sex organ is completely unresponsive [23]. Even some health problems and chronic diseases may affect the sexual performance in older man. Diabetes, vascular disease, fear of heart attack, certain operations (for example prostatic surgery) and some medications (used to treat hypertension, depression, anxiety, cancer etc.) can affect sexual desire or ability to have sexual intercourse [14, 23]. Table 1 presents some of the key changes among elderly man and woman that affect their sexuality and sexual functioning.


**Table 1.** Physiological changes among elderly [19]

Institutional care is important and widespread form of care for the elderly who are no longer able to live independently. The attitude of nursing staff towards sexuality is very different and may vary from positive to negative or permissive and restrictive [8]. This can significantly inhibit the expression of sexuality among the elderly. Room designs which do not provide privacy [9], taking care just for the physical needs, avoid talking about sexuality because of the shame [1, 10, 11], failure to respect residents autonomy or the need to control their behavior [3], and letting families to take decisions instead of them [12] are the aspects which may have a significant impact on sexual or intimacy expression among elderly living in nursing homes. Moreover, nursing staffs day-to-day contact with residents often develops into strong rela‐ tionships, which also affect the sexual expression of the elderly in nursing homes [13]. Since satisfaction of needs has an important role in individual's satisfaction, happiness, and wellbeing, the study of nursing care professionals' attitudes toward sexuality and sexual needs of elderly is necessary for a comprehensive understanding of the determinants which influ‐ ences the quality of life among elderly in nursing homes. In the end of the chapter authors present the results of a study of nursing care professionals' attitudes toward sexuality of elderly in nursing homes which was performed on a sample of nursing staff from 5 Slovenian nursing homes. The authors developed a semantic differential scale, encompassing a list of adjectives, through which nursing care professionals described the meaning attached to sexuality of

**2. Physiological and psychosocial aspects of sexuality among elderly**

Older people continue to have need for maintaining their sexual activity and intimacy [3], they just change the ways of expression of their needs. However, in addition to physical sexuality, elderly express their sexuality also with hugging, caresses, kissing, holding hands, touching or by physical closeness [3, 4] as well as tenderness, partners support and mutual understand‐ ing [5]. There are many factors that positively or negatively affect the expression of sexuality among elderly which include not only age-related changes and diseases [6] but also some

Over the years, some *physiological* changes occur in aged population that affects their sexual activity. For example, men take longer to get an erection, which can be shorter, and women can perceive physiological changes as a vagina moistening problem. However, Walsh and Berman [14] observed that with age the desire for sexual activity and the possibility of experiencing orgasm do not decrease. Although, in the recent years, studies that describe sexual lives among older women become more frequently, we still trace down some prejudices that with the menopause sexual life is over or that sexuality during menopause is not appro‐

The level of estrogen in women after menopause is declining, but the body still produces enough testosterone to maintain interest in sex [15, 16]. Some women after 60 years may experience that the clitoris is somewhat reduced, but still remains very sensitive [17]. Also, due to dryness and vaginal atrophy women can experience pain during sexual intercourse

elderly in institutional care.

190 Sexology in Midwifery

psychosocial factors.

priate [15].

Sexuality among elderly has also some advantages. Master and Johnson [17] have stated that one of the advantages of aging, according to the sexual functioning is that the control of ejaculation in the man aged 50 to 70 is better than in man aged between 20 to 40. In other words, many older people retain the ejaculation longer and therefore the sexual intercourse last longer to orgasm. Furthermore, women are no longer afraid to become pregnant [23] and they no longer need the contraceptives, which can release libido and lead to an increased desire for sexual contact [18].

But in spite of this society still perceives older people without sexual needs or incapable of sexual activity. For that reason elderly suppress their sexual needs and start to behave in accordance with these beliefs [7]. Lindau et al. [24] found, that sexual desire and activity are widespread among elderly man and women; however those aged more than 70 placed less importance on sex than the younger population [25]. The same authors also found that there are some gender differences in attitudes toward sexuality, with the greatest difference being in the older age group (41,2 % of males aged 75 – 85 stated an interest in sex compared with 11,4 % of females of same age) [24]. Other studies also shown that not having sexual partner and having poor health status in the late period of life are associated with decreased sexual activity [26, 27], but this does not necessarily mean that sexuality is not important to older people. In fact, Gott et al. [25] found that only when the barriers to remain sexually active were too great to be overcome then sex assume no importance, regardless of age.

*Psychological* aspect may be as important as physiological aspect for sexual function because this aspect can impact the ways in which other determinants of sexual function are expressed [28, 29]. For example, emotional and interpersonal motivation mediates the effect of sexual desire which is produced by neuroendocrine mechanisms. In fact, motivation plays an important role regarding personal attitudes about sexuality [28] and in sexual functioning of the person because it may increase the desire for sexuality and affects on sexual inactivity due anxiety, or anger with partner [30]. Psychological problem such as depression also influence sexual function in all age group. Its pharmacological treatment is associated with sexual dysfunctions such as anorgasmia, erectile dysfunction, diminished libido that may persist even after medication use is discontinued [31]. However, sexual dysfunction in depressed older adults is often overlooked and less appropriately treated than in younger population [20]. Moreover, psychological aspect is independently related to sexual function. Self-perception theory argues that individuals make attributions about their own attitudes, feelings, and behaviors by relying on their observations of external behaviors and the circumstances in which those behaviors occur [30]. Self-perception theory can be applied to a situation in which a woman observes that she is receptive to her partner sexual initiations, but she is never the initiator. Consequently, the woman perceives that because she engages in sexual activity only in response to her partner, she has low sexual desire [16]. Also, many women because of selfperception theory and overjustification, experience sex as an obligation rather than as an enjoyable part of the relationship, and they consider themselves sexually inadequate. Low selfesteem or poor body image due to aging is also an important psychological barrier which affects the sexual activity of older adults [17]. Furthermore, many couples in long-term relationship perceive the natural decrease in excitement and passion as a symptom of failed marriage. But in every long-term relationship passion can decline over the time and comfort, security, and partnership step in [28]. In addition, relationship duration may affect sexual frequency. Call et al. [32] found that the habituation to sex occurred as relationship duration increased, resulting in a decline in sexual frequency. However, sexual frequency decline is not synonymous with the decline in sexual satisfaction. Gott and Hinchliff [7] also found, that in older adults age was seen as facilitating cooping when sex become less frequent, or stopped. It seems that for older adults in long-term relationship is normal that sex will become less possible with normal ageing and the cessation of sex is easier to cope.

many older people retain the ejaculation longer and therefore the sexual intercourse last longer to orgasm. Furthermore, women are no longer afraid to become pregnant [23] and they no longer need the contraceptives, which can release libido and lead to an increased desire for

But in spite of this society still perceives older people without sexual needs or incapable of sexual activity. For that reason elderly suppress their sexual needs and start to behave in accordance with these beliefs [7]. Lindau et al. [24] found, that sexual desire and activity are widespread among elderly man and women; however those aged more than 70 placed less importance on sex than the younger population [25]. The same authors also found that there are some gender differences in attitudes toward sexuality, with the greatest difference being in the older age group (41,2 % of males aged 75 – 85 stated an interest in sex compared with 11,4 % of females of same age) [24]. Other studies also shown that not having sexual partner and having poor health status in the late period of life are associated with decreased sexual activity [26, 27], but this does not necessarily mean that sexuality is not important to older people. In fact, Gott et al. [25] found that only when the barriers to remain sexually active were

*Psychological* aspect may be as important as physiological aspect for sexual function because this aspect can impact the ways in which other determinants of sexual function are expressed [28, 29]. For example, emotional and interpersonal motivation mediates the effect of sexual desire which is produced by neuroendocrine mechanisms. In fact, motivation plays an important role regarding personal attitudes about sexuality [28] and in sexual functioning of the person because it may increase the desire for sexuality and affects on sexual inactivity due anxiety, or anger with partner [30]. Psychological problem such as depression also influence sexual function in all age group. Its pharmacological treatment is associated with sexual dysfunctions such as anorgasmia, erectile dysfunction, diminished libido that may persist even after medication use is discontinued [31]. However, sexual dysfunction in depressed older adults is often overlooked and less appropriately treated than in younger population [20]. Moreover, psychological aspect is independently related to sexual function. Self-perception theory argues that individuals make attributions about their own attitudes, feelings, and behaviors by relying on their observations of external behaviors and the circumstances in which those behaviors occur [30]. Self-perception theory can be applied to a situation in which a woman observes that she is receptive to her partner sexual initiations, but she is never the initiator. Consequently, the woman perceives that because she engages in sexual activity only in response to her partner, she has low sexual desire [16]. Also, many women because of selfperception theory and overjustification, experience sex as an obligation rather than as an enjoyable part of the relationship, and they consider themselves sexually inadequate. Low selfesteem or poor body image due to aging is also an important psychological barrier which affects the sexual activity of older adults [17]. Furthermore, many couples in long-term relationship perceive the natural decrease in excitement and passion as a symptom of failed marriage. But in every long-term relationship passion can decline over the time and comfort, security, and partnership step in [28]. In addition, relationship duration may affect sexual frequency. Call et al. [32] found that the habituation to sex occurred as relationship duration

too great to be overcome then sex assume no importance, regardless of age.

sexual contact [18].

192 Sexology in Midwifery

As mentioning before, sexuality is affected by several aspects which plays a crucial role in sexual functioning among elderly. One of them is also *social* aspect which includes many factors, like gender, race, ethnicity, educational and environmental background, socioeco‐ nomic status, financial resource, and religion that affects the sexual activity in older adults [21, 28]. Huffstetler [17] emphasized that internalizing negative attitudes toward sexuality and the lack of available partners are the most important social barriers in older adults. In this context DeLamater and Karraker [30] also stated that for older adults the availability of a partner seems to be an important factor for sexual functioning. Although studies [25] indicate that man population is more sexually active, Lindau et al. [24] found that the difference in overall rates between man and woman is manly explained by the relative shortage of man which is in turn due to disparity in ages between partners. In fact, men tend to be older than their spouses but also there is present higher longevity among woman which in older ages results in a shortage of man in later life period [30]. Therefore, Gott and Hinchliff [25] found that older people who are not in relationship or are widowed plays lesser importance on sex. Relationships factors are important because it is difficult to isolate sexual function out of this context, and the presence or absence of partner affects sexual desire [30]. Most of older people think about sexuality as an important component of close emotional relationship in later life and express no interest in sex outside this context (for example in the form of "one night stands") [25]. Laumann et al. [33] found in their analysis of the Global Study of Sexual Attitude and Behaviors that sexual satisfaction and relationship satisfaction are highly related in older adults, which means that for aged population sex in companionate relationship also express the quality of the relationship. The same authors [33] also found that men reported higher levels of subjective sexual wellbeing regardless of sociocultural context than did woman. Older men are less likely than older woman to state that they do not enjoy in sex [21]. Besides, in the society still persist some double standards between the genders which can be explained by the cultural myth that men have greater sexual needs. In fact, when man engage in sexual activity outside the bounds of marriage it is much more acceptable, and it is often viewed as necessary for remaining healthy, whereas women adulterers are often viewed as selfish or whorish [17]. But most older adults still think that sexuality is something that is not appropriate in adult life. In fact, older adults' may internalize the stereotype of sex in older age being wrong [20]. One Finnish study [34] showed that although many older adults have an active sex life, more than half were of the opinion that sexually active life in older age is somehow inappropriate. Also cultural experiences and cohort effects are important factor in sexual expression. The oldest individuals borne before the sexual revolution are now 65 years or more and their sexual attitude differs from the generations born before them. So called "Baby Boom" generation in the period of adolescence enjoyed the sexual expression and many of them enjoy it even today [30]. Researcher [35] found a significant correlation between sexual power among the youth, middle and older man population which means that "Casanova" in the young age remains "Casano‐ va" in the later period of life. Another important sociocultural aspect is the religion which has also a great impact on individual's attitude toward sexuality, especially among older adults in western societies [17]. During the middle Ages, the European church decreed that sexual intercourse was solely for the purposes of procreation. In fact, older individuals who have more conservative religious beliefs are looking at the sexual intercourse and masturbation in the postmenopausal period as something with negative connotation; because this kind of sexual activity does not include the possibility of procreation they perceive it as a sin [17]. Others social aspects can also have a great influence on the sexual activity in older people, like socioeconomic status (individuals with lower socioeconomic status are more sexually active) or ethnicity (among older adults, African Americans are more sexually active than Caucasians) [17] as well as environmental restrictions, in case of communal living environment (e.g. nursing homes), where the lack of privacy may force some residents to express their sexuality in semiprivate or public places [21].
