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Introduction
Population aging has been growing rapidly both in our country and around the world. This could be occurring due to the decrease of mortality rates, diminished birth rates, better socio-environmental conditions, and technological advances in medicine 1.
This process, which occurs naturally, irreversibly, and globally, defines the change in the population’s age structure. Within said structure, the so-called “elderly”, “very elderly”, “elderly people in advanced age”, or “octogenarians” (>80 years of age) have also been increasing proportionately and faster, constituting the population segment of greatest growth in recent times 2.
However, as a result of the population increase, there is now a greater focus on studies on human aging and health 3. However, when it comes to sexuality in the elderly, the issue continues to be seen as taboo in a prejudiced manner by health professionals, family members, the community, and even the elderly themselves.
From this, it must be understood that there is no age limit for the elderly to relate to other people. In this sense, feelings, the display of affection, fondness, and the capacity to love do not end while aging 4.
It is imperative that the negative image of the elderly, which refers only to diseases, be dissociated, and promote the idea that there is freedom, accumulation of experience, maturity and wisdom, along with the right to express love, sexuality, and desire 5.
With this purpose, studies conducted in the United States, with elderly in the age range between 65 and 80 years, have proven that they maintain an interest in sexual activities. 6,7. Among the participants in the research, 76 % stated that sex is an important part of a love relationship at any age; 54 % are in a relationship and are sexually active 5. Still, in this same study, for 54 % of participants, sex is important to maintain the quality of life, which encompasses the domain of individual perception about sexuality, which is a complex variable due to its multidimensional nature 6,8.
Sexuality can be expressed from the interaction with another and manifested in social relationships through corporeity. Thus, sexuality can be distinguished from sex, which portrays only one of the forms of expression of human love 9,10. People want and need to be loved and love others; hence, sexuality is part of this love, this intimate relationship.
According to the World Health Organization, sexuality is the energy that motivates to finding love; it encompasses caressing, intimacy, feelings 11. It is a basic need of the human being and is intertwined with other aspects of life, going beyond the sexual act itself. It influences thoughts and, due to this, also influences the individual’s physical and mental health.
The possible causes of the scarcity of studies on the sexuality of the elderly and their attitudes are due to the omission of sexuality of the elderly by society and even by health professionals, besides the bias that remains in a technologically advanced century. Thus, this area of research remains largely neglected.
Therefore, understanding the attitudes of the elderly about sexuality is fundamental so that new proposals for intervention can be articulated with this population group 12. Given this, nurses have a fundamental role as educators and promoters of health and well-being for the elderly in all areas, including sexuality.
With regard to health education, it can be a strategy designed to build a new image of the elderly in society in which they can express their feelings and experience sexuality free from prejudice, myths, or taboos. Said actions can be put into practice in various scenarios available, for example, in nursing consultations or with elderly groups.
In this context, nursing is again highlighted, which promotes health education in different settings of professional activity and in different themes, including sex education 12.
According to the theme exposed and with the need to better know the attitudes of the elderly population regarding sexuality; this research had the objective of identifying the attitudes the elderly have with respect to their sexuality.
Methods
This was an exploratory and descriptive study, with a qualitative approach, about the attitudes elderly women have about their sexuality. Qualitative research allows analyzing the experiences of individuals or groups that may be related to biographical histories or educational practices, as well as analyzing the knowledge, reports and histories of the day-to-day population studied 13. Moreover, through it, it is possible to understand the universe of human relations established within the context of research, observation, and interaction of the researcher with study participants 14.
Thus, 19 elderly women from two cohabitation groups for the elderly located in the city of Rio Grande, Rio Grande do Sul, Brazil, participated in the study. The elderly groups, one of private nature and the other public, are focused on promoting the social well-being, active aging, and quality of life of their members aged 60 and over. The groups were selected for having the highest number of participants, as well as by the greater offer of activities to the elderly community. Thus, it is estimated that 150 elderly people participate in the actions promoted by these groups.
The participants were selected according to the following inclusion criteria: Elderly women 60 years of age or over; participation in one of the groups, for at least three months; authorization of the publication of the results in scientific works. The exclusion criteria were: Not participating regularly in the group’s activities, that is, if the group’s activities happened twice a week, it was not considered assiduous for the elderly women to attend once every two weeks.
Data collection, performed by the nursing student, author of the research, began in October 2018, after approval of the project in the Ethics and Research Committee of the Area of Health at Universidade Federal do Rio Grande, with number 218/2018, and after authorization by the groups. The data collection took place at each group’s headquarters, through individual, semi-structured interview and recorded in audio.
Before the interviews were carried out, a first contact was made, in person, with the participants to explain the research theme, its benefits to the elderly, and to ask if they would like to participate.
To maintain participant anonymity and adhere to the ethical precepts provided for by Resolution 466/2012 of the National Health Council/Ministry of Health (CNS/MS, for the term in Portuguese), each elderly woman interviewed was represented by the letter I, followed by the number corresponding to the interview sequence (for example: I1, I2, …, I19). The interviews were conducted individually in reserved rooms, to guarantee the privacy of the participants, and lasted between 15 and 20 min, on average. Before starting the interview, the researchers clarified the objectives of the study, the relevance of the theme, the guarantee of safeguarding the secrecy of the information, and the possibility of canceling participation at any time without personal prejudice. All participants signed the Informed Consent Form.
To gather the data, the study used a semistructured instrument, divided into two parts: The first part referred to participant characterization data, and the second part addressed questions on attitudes about sexuality, which encompass the changes observed after 60 years of age, feelings when talking about the subject, with whom they talk about it and the importance of affective relationships for the elderly. After conducting the interviews, the data were transcribed, organized, and tabulated to facilitate the analysis process. The technique used was the thematic analysis, according to Bardin 15, given that data collection becomes more concentrated and productive, and it is possible to formulate more specific questions, which helps systematize the data collected 15.
For Bardin, to perform a thematic analysis is to discover the “cores of meaning” that compose the thematic categories. To compose these nuclei, it is necessary to analyze whether the elements evidenced in the communication, the presence of significant meanings, or the frequency of their appearance can mean something for the analytical objective chosen. Thus, the stages of pre-analysis, material exploration, treatment of the results, of inference, and of interpretation are fundamental 15.
Analyzing the qualitative data means “working” all the material obtained during the research. The analysis task implied, initially, transcribing the audio recordings, organizing all the material, dividing it into parts, relating them, and identifying the relevant trends and patterns. Secondly, these trends and patterns were reevaluated to seek relationships and inferences at a higher level of abstraction. From the coding work, an initial set of categories resulted and these were reexamined and modified at a subsequent time. The classification and categorization of the data were prepared for a more complex analysis phase, which occurred as the research reported its findings 16.
In the pre-analysis, after the transcription of the data, an overall reading (leitura flutuante) of the interviews was made to visualize the particularities that contributed to the elaboration of the initial ideas about the traits of participant characterization. Thus, from the tabulation of the data collected, several readings were made of the contents of the interviews to try to visualize the particularities of each.
Further, a new detailed reading was made of the 19 interviews obtained, to identify the nuclei of meaning regarding the research objectives, which were transcribed in the Pages program and tabulated in the Numbers program, to have better visualization and organization of the data.
In the material exploration phase, coding operations were executed on the interviews with numbers and letters, so that the most important portions of the research were grouped into alike or similar “sense nuclei”, which gave rise to “themes” or “categories” 15.
In the results treatment phase, analysis and discussion of the responses were conducted, based on the already exposed reference and on the sensitivity and experience acquired in the research trajectory. After ending the analysis of the categories, the information was delivered to the participants for them to validate the results obtained.
Results
The study population was comprised by 19 elderly women; ranging in age between 60 and 85 years; of these, eight were between 60 and 69 years of age; 15 declared themselves white. Regarding marital status, eight were married and eight were widowed; 10 of those interviewed declared themselves catholic; seven had a monthly income of a minimum wage and seven received two minimum monthly wages. In relation to schooling, six reported incomplete basic education. Referring to pathologies, seven elderly women reported systemic arterial hypertension, while six carry out medication treatment to control the disease. Through data analysis, it was possible to elaborate three categories and their respective subcategories, described hereinafter.
Change in the expression of sexuality after 60 years of age
In this category, the participants reported changes due to age and physical conditioning, but nothing that could prevent them from actively following the expression of sexuality.
It changed a little, I’m not younger, I do not have the same wind, but that’s not why I cease to be sexually active. (I2)
Of course, we get some limitations with age, but nothing that prevents us from relating sexually, even because the flame does not extinguish, the will does not disappear with time [laughs]. (I3)
Other elderly women reported that the change in their sexuality occurred because they did not have a fixed partner or because they no longer had an interest in sexually.
People do not give much importance to sex, but when you have affection, it solves everything. But it has changed, too, because I do not have a fixed partner. (I5)
[…] and it will also depend on the person who is with us, the company... because if you have a companion that is affectionate, it suddenly happens. (I6)
Additionally, some elderly women report that the expression of sexuality changed prior to turning 60 years of age due to alterations resulting from menopause, which directly interfere with the desire to relate sexually. Besides this, another factor cited as the reason for the change was widowhood.
Oh, it changed. I am not the same. The doctor told me that my ovaries are withered, it’s normal, but there are people to whom this does not happen. I think this also takes away the person’s will. (I7)
It changes lots, after 60 years of age, it changes for any person. After the woman stops menstruating, when the hormones diminish, it changes for anyone. (I8)
For me, it changed before, when I became a widow, because I did not have more sexual relations. But it was not a bad thing, it was my decision. (I13)
For me, it changed before 60, when my husband died and I did not have anybody else since I was 37 years old. (I14)
Finally, some participants stated that they did not notice age-related changes that affected their sexuality.
No, I do not think so. It continued the same, for me it was always something satisfactory, when I was married to my husband; he was a very affectionate person. And, currently, my mate is very good in bed, and is younger than me. (I9)
No, I think it’s the same thing. I consider myself a 15-year-old girl, only more mature, I know how to take better advantage, and I no longer have that fragility, fear; it’s all normal. (I19)
Feelings shown when talking about sexuality
This category describes the reports about the feelings the elderly women revealed when questioned about their sexuality. Most of those interviewed stated that they deal with the matter with normality, given that it is something inherent to human beings.
I speak normally; I have no feelings of shame, of nothing. It is all normal for me. (I19)
No, for me it is normal, it is part of life. There are elderly people who do not like to talk, they are embarrassed, but not me. (I2)
Other participants said they do not feel any kind of embarrassment or other feelings, but do not like to talk about it.
Oh, I don’t feel anything, but sometimes I don’t even want to talk (laughs). Not to remember, do you understand? Leave it alone… (I10)
No, I am not ashamed to speak. But not that I think it’s good to talk [...]. (I11)
They also said that they do not feel shame or that they have other feelings, but that this neutrality or lack of feelings depends on the environment in which they are inserted and the people with whom they talk.
Oh, depending on whom you talk to, when you talk about certain things. But I would not feel ashamed. (I1)
I am not ashamed to talk, but it will depend on the setting and with whom I will speak. [...] Children, we are embarrassed, even more that I only have a man, and I don’t have much access to the daughter-in-law. (I6)
Yet, in this category, the feeling of shame arose because the theme was not naturally approached by the family, as a young person, culminating in a feeling that has prevailed throughout life. It was also mentioned that they would be embarrassed IF they had to talk about sexuality with someone from the opposite sex.
[...]I am embarrassed to speak, more so because of the most reserved upbringing of my time, of everything being forbidden, veiled. (I3)
We, the woman speaking, I am not embarrassed, but if I were a boy, I would be, yes. (I5)
With whom they talk about sexuality
This category emerged from the reports by the elderly women when asked about who they would look for in case they had some question about sexuality. Most stated that they would seek, first, support from their friends.
I have a friend; I learned many things with her [...] (I1)
With my girl friends. (I3)
I speak with a friend, she likes those things. [Laughs] (I7)
Regarding the search for professionals to clear doubts, some said they would seek help from health professionals, whether nurses or physicians.
I’d talk to my boss, nurse. We’re very close friends, so if I need to, I talk to her... (I5)
Look, I would, at the moment, go to the gynecologist, mainly because she is very much my friend, we talk a lot, [...] I have freedom with her. (I6)
With a physician or nurse, too. (I17)
However, on the other hand, some interviewees stated that they never talked about their doubts with anyone.
Look, in reality, I never talked about this with anyone; it is the first time. My mother was very strict, at that time you could not talk. I learned everything by myself. (I15)
With no one, after my myoma surgery, I never looked for anyone. (I12)
Maybe a friend, but I never mentioned it there. (I4)
The importance of affective relationships for the elderly
The elderly women stated, in this category, the importance of having someone to relate to both sexually and affectively.
Yes, even more so if you have a loving, caring partner. It is good to feel loved, cared, and alive; to feel pleasure. (I12)
Of course it should, it does well for the body, for the mind. (I2)
Only if you do not want to, but you can and should, because it is good and does well for the skin. (I5)
It should be related, yes, even to age more slowly. (I3)
In addition, some of the women expressed that the importance of having an affective relationship depends on the needs of each individual, of their health, whether they want to continue in a relationship with someone.
It will depend on the will and need of the person. (I13)
I think it should, yes, it goes from the person’s head, will, life, health, because there are people who want, but cannot do. (I17)
Others said that they may have a relationship again, but the family, especially the children and ex-husbands, become a major obstacle and do not accept their relating again for a variety of reasons, including jealousy and not accepting a companion.
A year ago I fought with my partner and it was enough, I did nothing else. But he was very good. He was my boyfriend and I miss him, but there is no way to go back, my family is also against, so I do not want it either, it was good while it lasted. (I10)
If someone shows up, my daughter will kill me. She already told me: If you show up here with an old man, you’ll see, I’ll get my things and I’ll leave [...] (I7)
I’m lonely, but I miss sex, because I’m healthy, so at night I keep thinking about these things and everything, but I cannot have anyone because my ex-husband is very jealous and in his head we’re still together, and he does not accept. (I17)
Discussion
Old age may present challenges to staying with an active and healthy sexuality 17. However, this study demonstrated that the majority of the elderly women did not present significant changes that interfered negatively in the expression of sexuality after 60 years of age. In some reports, it was possible to identify that sexuality became better and more pleasurable over the years, surpassing even the experiences of when they were young.
Some participants stated that they noted changes in physical condition, but that, not even due to this, stopped expressing their sexuality or being sexually active. A study evidences that the elderly continue sexually active until their 70 and 80 years of age, and that the physical changes associated with aging do not, necessarily, reduce the sexual capacity 18.
However, the elderly women reported that there were changes in their sexuality due to the absence of a steady partner and that this was a negative change in their lives. Others stated that the will to express their sexuality changed because there was no more interest in relating to someone again.
For many elderly people, sexuality may not play an important role in their lives, either by not having a partner, having some physical barrier, or not being interested in maintaining it 19. If the elderly make that decision, health professionals, friends, and relatives must respect it.
The rest stated that changes occurred much before 60 years of age, as they go through the menopause period and through all the hormonal changes triggered by it. During human aging, there may be intercurrences in relation to the health and illness process, which have significant and impacting repercussions on the lives of individuals, directly affecting the quality of life, relationships, and human sexuality. These include menopause, diminished sexual libido, urinary incontinence, some types of cancer, and use of medications, among others 20.
Besides the sexual activity, it should be noted that the manifestation of sexuality can be expressed by desire, by the possibility of being connected to some person or objects, ideas, and ideals 21.
At any age, there is always time to live, express feelings and the individuality that constitutes the human being. Love, affection, and intimacy are fundamental elements to promote the individual’s wellbeing and quality of life 22.
Regarding the feelings derived when talking about sexuality, the majority of the elderly women declared feeling normal and that there are no constraints, given that this topic is something inherent to the human being. According to this declaration, in another study, 66 % of the elderly interviewed were comfortable talking about said issue. They also believed that sexuality is something normal in the lives of humans and that it is no different because they are elderly 23.
However, the feeling of shame emerged when talking about this subject and that feeling would be enhanced if the interview was performed by someone of the opposite sex. Sexuality is such a private matter that the elderly can not openly discuss it with other people, not even with health professionals. The discomfort generated ends up inhibiting them from talking about their sexual lives, doubts, or difficulties 24.
Such action is very dangerous because, thus, individuals end up not having access to information and guidance; thereby, exposing their health to risks and aggravations that could be avoided with a simple prevention action. But in this research, most of the elderly women said that in case of doubts related to sexuality, they first sought out their network of friends to talk. Later, others verbalized that they sought the primary care nurse closest to their home or, then, they consulted the gynecologist.
This finding is in line with the study in which the authors state that, in case of doubts, 62 % of the elderly seek health professionals first to talk; then 36 % the partner; 17 % no one, and 10 % family, friends or others. Therefore, in most of the interviewees, health professionals were cited as the first source of support that the elderly sought to solve their doubts; different from this research, in which the elderly mentioned their friends as the first source of support.
Moreover, another fact that emerged was that, if the elderly women had any doubts, they would not seek someone to talk to because they believe that since they are older, they no longer have doubts or need not clarify them, either because their partner is no longer with them or because they have no interest in seeking new knowledge. According to this statement, a study showed that 53.3 % of the elderly also did not talk about sexuality issues and, in case of doubts, there was neither interest nor concern to cure them 25.
With this, it is inferred that this issue is still a taboo in society, for the elderly themselves, and even for health professionals. However, there are some professionals who recognize the importance of sexuality in the health of the elderly, but who do not consider themselves fully qualified to discuss specifically about it 26.
Considering that nurses play an important role regarding the promotion of a healthy sexuality during old age, it is fundamental to train them with specific knowledge in the area, sensitize them, and make them aware of the problem, which will allow them to provide excellent care to the elderly 27.
There is evidence that when nurses are better able to deal with the elderly person’s sexuality, they end up having clarity and honesty to talk about the issues that guide this theme more openly, without prejudice. And, with this, sociocultural taboos are eliminated, leading to the maintenance of the quality of life of the elderly 28,29.
Finally, the last category addressed in the results inquired about the importance of affective relationships for the elderly. Some participants mentioned that it is very important to have someone by your side, by virtue of the benefits to health, body, and mind, among others.
The importance of relating to someone was also quoted in another study, in which 40 % of respondents stated that it is quite important to have a partner, especially with regard to the continuity of sexual relations. These results show an overcoming of the stereotype, created and maintained by society over the years, that the elderly no longer have an interest in sex or other forms of expression of their sexuality 25. However, some participants said that to have a new affective relationship, it will depend on the need and willingness to have someone by their side. People have their way of experiencing sexuality and, to understand it, one must take into account and respect their culture, religion, and education, given that these values directly and intensely influence the development of sexuality 30,31.
From another point of view, the elderly women stated that they might have a new relationship, but the family and even the ex-spouses are against this desire and prohibit a new relationship, one of the reasons being jealousy. With this, they deprive the elderly from making their own decisions in life. The desire to have a new relationship continues being neglected by society, family, or health professionals, who maintain the idea that the elderly are asexual 31. Repression of sexuality by the family is one of the most difficult barriers the elderly face, given that, often, they are forbidden to experience their pleasures, having to accept the will imposed by the family, especially when they live under the same roof with their children, for example 32.
As for this family and social oppression, it triggers the reversal of roles in which the elderly lose control of their lives and needs to adapt and submit to the new reality. In addition, children see their parents’ sexuality as inappropriate and derogatory 33. Another study also evidenced that, in 53 % of the cases, the family interferes directly on the desire of the elderly to relate sexually, limiting them 25. This demonstrates that it is not considered that some elderly people remain sexually active in old age and that the desire for expression and sexual fulfillment does not disappear 34. Moreover, it is not taken into account that sexuality is an important component of human identity, built throughout the life cycle and that it cannot be suppressed by force from the life of the elderly person.
Study limitations: Few elderly people accepted to participate in the research, which reinforces the idea that sexuality during old age is still permeated by taboos and prejudices. Nonetheless, it is important to highlight that, even with a small number, the research objectives were achieved.
Conclusions
From the aforementioned, it can be concluded that the elderly women have shown favorable attitudes towards their sexuality. The principal findings in this research evidence that the participants, for the most part, noticed no significant changes in the expression of their sexuality after turning 60 years of age. It is perceived that the capacity to manifest sexually is not lost during the aging process; it is only transformed, given that a large part of the elderly continues to maintain active sexuality. For most of the elderly women interviewed, the affective, loving, and sexual relationship is extremely important due to the capacity to promote physical and mental wellbeing in the lives of humans, besides providing feelings of joy and happiness, giving them more vitality and more pleasure in living.
Lastly, it is important to emphasize the importance of nursing professionals in the promotion of health education, quality of life, and the creation of a new image of the elderly in society in which they can express their feelings and experience sexuality free from preconceptions, myths, or taboos. Such actions can be put into practice in the different scenarios of these professionals, such as in nursing consultations or in the elderly groups.
