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The silenced sexuality in dependent older adults

Konrad Gutterres Soares
Escola de Enfermagem, Universidade Federal do Rio Grande do Sul
konradgs@gmail.com

Stela Nazareth Meneghel
Escola de Enfermagem, Universidade Federal do Rio Grande do Sul


Abstract

Sexuality is a silent theme concerning the elderly population who is socially perceived as asexual. This qualitative approach paper is part of research on dependent older adults, which aimed to analyze their sexual experiences. The topic was retrieved from interviews with 26 of them, who talked about sex in their lives. The Thematic content analysis identified two main categories in the statements: gender differences in the treatment of sexuality and difficulty in talking about sex. Differences were observed in the perception and valuation of sexuality by gender. Older men give importance to sexual potency, and older women consider the cessation of sexual life in old age to be natural. Older men enunciate a sexuality concept based on biological satisfaction and sexual act, while women value partnership, affection, and fondness. Researchers were silent on the topic, although it was included in the research manual to guide the interview with older adults. However, while only 26 mentioned the subject, sexuality of older adults is modulated by gender perception. It is a poorly studied and challenging theme to approach in research and healthcare settings.

Key word: Dependent older adults; Sexuality; Gender; Qualitative research


Introduction

Sexual decline is something inevitable and marks a reflection on aging as a prejudice, under the assumption that individuals should adjust to this imperative to enjoy the moral benefits of post-sexual maturity. In the 19th century, it was believed that a prudent lifestyle would delay this decline, but accepting it was part of the moral exercise of adjusting to the effects of the vital process1.

However, in the current scenario, maintaining sexual activity in old age is already a consensus2,3. However, it remains in common sense, including researchers and health professionals, prejudice, and silences on this taboo subject, increasing the vulnerability of older adults to psychological and physical problems, such as sexually transmitted diseases and erectile dysfunction4.

Significant body changes occur in the aging process, including loss of desire or sexual potency2. However, how sexuality is perceived and the meaning that aging takes on are specific to each social background and historical moment5,6.

Sexuality can be broadly defined as the social construction of body use and, in particular, but not exclusively, genital organs to obtain physical and mental pleasure. It also includes sorting these activities, which determines a set of rules and norms that indicate, socially, the people with whom such activities may or may not and should or should not be practiced7.

The WHO8 affirms that sexuality is a central component of the human being. It manifests itself throughout life and encompasses sex, gender identities, and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. It is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships.

The complex social phenomenon, sexuality is an integral part of personality, and its development is completed as a basic human need such as the desire for contact, intimacy, emotional expression, pleasure, love, and affection9.

The societal concepts of gender operate as norms and standards that people must follow, including sexual activity. In patriarchal societies, the intergender relationships, marked by male domination10, determine what is considered normal and interpreted as natural. Cultural patterns in the form of stereotypes indicate that men need to ensure the right to violence and the domination of women to show their virility, and affirm their sexual potency through the exercise of an erectile and penetrating sexuality11. In this model, older men believe that they should or need to continue exercising sexuality as a practice of the sexual act and those who are unable to do so due to some limitations feel diminished and are affected by frustration and sadness, which may accelerate the aging process and harm physical and mental health12.

On the other hand, women are socialized to satisfy male desire, seconding their own, and can thus minimize the importance of sex and sexual pleasure. Attributes such as patience, empathy and compassion are considered natural and thus are socially responsible for reproductive and care work, activities that operate to uphold intergender hierarchy11.

The cult of the young body idealized by contemporary society perpetuates the conviction that sexuality is linked to youth and beauty13, which results in prejudice against sexuality in old age14, de-eroticizing the body and treating it as incapable of producing desire15. In this sense, women face a more considerable disadvantage in the symbolic field, as the social construction of their identities is strongly associated with body image5.

In the current society, a prejudice that considers older adults asexual remains, which, together with the difficulties of talking about sex, produces discomfort and embarrassment in social relationships and silence on this topic among patients and health professionals16. In health care, the sexuality of older adults has been neglected, and the possibility of an older adult being infected with HIV, until recently, was considered remote. However, national data indicates that the HIV rate in older adults already exceeds that of adolescents17, and among the explanations for these high rates is the increased sexual practice in old age18.

Despite its importance, older adults’ sexuality is a topic that needs research, and most studies focus on negative physiological aspects, such as sexual dysfunctions19. International research on the subject is scarce, and even rarer in Brazil20, although the need to include this issue21 has been emphasized in the research of which this study is part.

This paper aims to analyze the experiences of sexuality among dependent older adults as per their viewpoint in the research Situational Study of Dependent Older Adults living with their families to subsidize a Policy of Care and Support to Caregivers22.


Method

This work aimed to identify the experiences reported by dependent older adults about their sexuality after the state of dependence or during life. The data were produced through semi-structured interviews, which included a conversation about their sexuality and other aspects of daily life. The question was thus introduced: “Tell me, what is or was sex like to you?”. This question was part of a qualitative study with older adults living in eight Brazilian municipalities, aiming to get to know their opinions, beliefs, and representations regarding their state of dependence22.

Only 26 of the 64 older adults interviewed spoke about sexuality. Therefore, the study focuses on the expressions of this small group residing in the cities of Araranguá (3), Brasília (10), Manaus (3), and Porto Alegre (10).

The thematic analysis23,24 was used to understand what older adults said about sex in their lives, which considers the relevant structures expressed in the statements, information provided, arguments, and justifications on the subject.

The finding that the subject has not been addressed by most of the researchers who conducted the conversation with the older adults is an indicator of the difficulty they feel in talking about sexuality, which raised a question about the reasons for this difficulty and gave rise to a category of analysis explored in this paper, alongside “difficulty talking about sex with dependent older adults”.

Short reports were produced that contextualized the situation of the disease and dependence to better understand the life scenarios of these older adults and the possibilities of expressing sexuality. We observed that the speech content and the emphasis on enunciation varied by gender of the respondents, showing that the social construction of gender - masculinities and femininities - modulates the behaviors of older men and women concerning performance and expectations on sex life. Thus, we considered that gender is an essential category for analysis : “gender and sexuality in the lives of older adults and dependent older adults”.

This research was approved by the Research Committee of the Nursing School/UFRGS and the Research Ethics Committee of the Federal University of Rio Grande do Sul.


Gender and sexuality in the lives of older dependent men and women

In this paper, we worked with a sample of 12 and 14 dependent older men and women, respectively. Of these, 17 considered themselves white, eight brown or black, and one did not report on color. Seven of them had more than 11 years of study, and more than half were Catholic. Most of the older adults (16) lived with a partner, and reported maintaining social activities.

Interviews with the older males revealed that they express an appreciation of sex and sexuality related to biological aspects, therefore, the ability to perform the sexual act and the presence or not of penetration. For them, sex means sexual intercourse; sexual intercourse means vaginal penetration and vaginal penetration requires a penile erection.

The impasse experienced by some of them in situations with sexual desire and loss of sexual function causes feelings of anguish, disappointment, frustration, and fear of failure, while it generates sadness, suffering, and depression in others. This picture confirms the perception that erectile dysfunction highly affects the core of masculinity, making men feel that they have lost the vitality that makes them men25.

– I don’t know if women have this difficulty. As sexists, men are even worse, and it’s already been four years now. It’s cruel, boy! It’s cruel. It is the worst part of all (Older man, 65 years old, Porto Alegre).

This statement was made by a relatively young man with a degenerative neurological disease. Before the illness, he was the family’s provider, centered his life on work and financial gains. At the onset of the interview, he said that what most affected him was not working. However, when asked about the exercise of sexuality, he stated that it was not about work, sex was the most important in his life, placing the loss of sexual potency as the worst consequence of the disease. The sexual dysfunction of this older man and the loss of work made him feel worthless and depressed: a disabled person. Some older adults feel diminished in the reductionist cultural conception of sexuality’s experience only through coitus, as the sexual act is affected by inexorable bodily changes from age, such as erectile dysfunction and hormonal changes26.

– Our life is over. It’s over! (Older man, 72 years old, Araranguá).

– Everything’s over. I lived with my wife very well, but old age is coming… (Older man, 88 years old, Manaus).

The statements of these two older adults, living respectively in the south and north of the country, announce emphatically the end of sexual life, showing feelings of loss and irreversibility. The first one suffered a stroke and has little autonomy. The disease brought him erectile dysfunction and functional losses that interfered with his plans for the future. The second has a history of several morbidities. He reports that he and his partner no longer have sex and even sleep in separate beds. He associates distance in the relationship with the wife with the loss of sexual potency. He feels sad, isolated, and, as most of the older adults interviewed, physically impaired. Both consider sexuality a synonym for the sexual act and do not consider other forms of expression, whether verbal or through touching and other desiring and affective expressions. In a way, the statements corroborate that the presence of illness is related to the lack of or reduced sexual practice, mainly when the disease occurs in men and affects male potency27.

Regarding older adult asexuality’s stereotype, it can be said that society contributes older adults’ perceived worthlessness because they have always been imagined as those who are saying goodbye to life. It is deduced then that, as they retired from work, older adults also retired from life, including sexual life.

– Now it’s normal! Now I don’t even remember it anymore, but it is annoying. At first, it was hard, but now it’s stable. I already accept everything else (Older man, 75 years old, Porto Alegre).

– Well, I even accepted a little now, but in the beginning, it was worrying. I was on edge. It was barbaric (Older man, 65 years old, Porto Alegre).

Some older adults accept their functional losses, as indicated by the statements that refer to “the normality” of not having more sex in the marital relationship. These two older adults have a history of chronic illnesses, and both do not share a bed with their wives. One of them remains most of the time sitting in an armchair in the living room, where he usually sleeps. Both reported that they had not had sexual intercourse for many years. Faced with the reductionist view of sexuality as the practice of the sexual act, in the case of sleeping in separate beds or another room, physical withdrawal seems to have been an arrangement for them to experience the mourning of the end of their sexual life.

– Wow, a good thing (laugh)! God gave us a good thing! I say, if you didn’t have the greed and pleasure, you wouldn’t have the world, right? The world would not exist because greediness and pleasure are what make the world stand up! But let’s keep going. What can we do? (Older man, 82 years old, Porto Alegre).

This 82-year-old man seems to address the issue more openly and he remains sexually active despite age-related limitations. He reports a recent hospital stay, complications, and loss of autonomy, but with progressive gain in functionality. He attends seniors’ balls, has a good relationship with his wife, sleeps in the same bed, and has sex with her. It shows that he is aging healthily, even with dependence, keeping his sex life alive with a good mood.

This and other older adults, unlike most, show that sexuality continues in old age, lived, and enjoyed throughout life4. Although the aging process traverses physical, biochemical, and functional changes that interfere with sexual activity, they maintain sexual interest at 70, 80, and even 90 years of age28, which is shown through affection, touch, and companionship29.

The older women expressed a different view of sexuality, albeit in the same way as men, marked by culture and social conventions. These women were educated half a century ago, at a time when gender standards were stricter, dictating what would be appropriate or inappropriate for each sex. The conduct concerning sexuality was impregnated with norms, prejudice and moralism. Submission and subordination to the husband was more common30. In the interviews, the different meanings attributed by the older women who spoke about sexuality are observed, highlighting life stories marked by the repression of desires and affections31.

– It was normal because I didn’t do it with anyone anymore, and I don’t miss it (Older woman, 78 years old, Porto Alegre).

– I don’t feel a need. I don’t mind not feeling, because I don’t have a partner (Older woman, 72 years old, Porto Alegre).

– It is essential, but I don’t know if he was so important in my life because after him, I didn’t miss him anymore (Older woman, 74 years old, Porto Alegre).

The selected passages were enunciated by elderly widows, who, after losing their partner, did not allow themselves other experiences and affirmed that sexuality was never relevant in their lives and that they do not miss sex. Even those who assume they still feel sexual desire do not allow themselves other relationships. They consider that it would not be appropriate because they do not have a husband.

Gender socialization in conservative societies assumes that a woman without a man cannot or should not have sex, let alone enjoy it. In the case of the older adults, the bodily transformations, and the message of a culture that values ​​youth and makes the old invisible, sustains the impossibility of being seen as attractive and desirable30. Sociocultural aspects reinforce gender standards, as women’s expectations are submission, dependence, and care for others, and this is observed in the statements in which they incorporate behaviors that include the sexual abdication and self-abdication32.

– When we get old, we lose everything! (Older woman, 79 years old, Manaus).

– The problem is having nothing, you know? Staying like this, so useless. I consider myself a useless person, of no use. I stay here without a pot to piss in (Older woman, 67 years old, Porto Alegre).

The functional losses and changes that time imposes on bodies reap the masculine potency and, differently, but just as hard, they mean losses to the feminine potency. The 79-year-old female resident of Manaus, who has leprosy, mentions the losses due to age and the severe aesthetic changes produced by the pathology. Body image has meaning and is relevant in the practice of sex, especially for women. Thus, dissatisfaction with appearance leaves many insecure, leading them to deny or block the possibility of starting emotional relationships, in such a way that not accepting oneself means, as a result, refusing sex27,33.

– The important thing is that you have someone to talk to, even if it is to fight! This is important! Sitting, talking, that’s what matters to me (Older woman, 63 years old, Porto Alegre).

– I did not sleep with him for fifteen years, but we were the best friends we had (Older woman, 76 years old, Araranguá).

– I only miss his company! (Older woman, 83 years old, Manaus).

Sexuality is a physiological function that minimizes emotional and subjective aspects, feelings and affections, companionship, and tenderness among couples29. However, some of the women mentioned this broader dimension, focusing on experiences that do not only include physical aspects and bring up a view of sexual interaction as a complex process in which friendship, empathy, communication skills, and even spirituality are part19.

– My sexuality was booming! Not long ago, I went for a gynecological exam, and a nurse asked me about sex. I said: I’m old, but I date like everyone else! (Older woman, 84 years old, Araranguá).

This 84-year-old woman is a wheelchair user and came from a conservative family. She married a man who was also a wheelchair user, and rediscovered her sexuality after becoming a widow. The statement shows open-mindedness concerning the ever-present possibilities of remaking and recreating love relationships, reiterating that sexuality permeates all phases of the human life cycle, from birth to death6.

Finally, concerning gender, older men perceive sexuality linked to the biological and sexual act’s performance, showing intense suffering in the face of their physiological limitations because of illness. On the other hand, women affirm that they do not feel the need for sex, and are trained to control or hide their desires. However, some older adults enjoy pleasurable relationships even in old age, and older women perceive the exercise of sexuality beyond the biological sphere, including affection, tenderness, and companionship.

Healthy masculinities and femininities mean inhabiting and loving one’s own body, enjoying it in erotic relationships and accepting losses and limitations11. In situations of aging and illness, the male obligation to show power and virility at any cost and female conformity to end sexual life without considering possibilities of overcoming losses can become painful and unbearable.

In this study, gender-modulated variability34 in the perceptions and experiences reported by the respondents when talking about sex in their lives is clear, evidencing how much the nuances of gender shape different behaviors and expectations concerning the exercise of sexuality in old age.


Difficulty talking about sex with dependent older adults

Questions about the sexuality of dependent older adults, which were part of the research roadmap, were not investigated and questioned in more than half of the interviews. The interviewers, all health professionals, or students in the field, showed two types of justification for not asking the question: “the older adult showed no interest in the subject” or “the interviewer felt uncomfortable asking”.

When affirming the discomfort of talking about sexuality, one can think of the researcher’s difficulty as a cultural projection of prejudice, which believes this subject is not suitable for older adults. Research35 suggests that both in the academy and health care, professionals have little knowledge about sexuality in aging and are unable to address the topic adequately. As a result, they display negative attitudes or avoid talking about it.

In the case of health professionals, there are at least two problems in approaching the theme. On the one hand, they feel inhibited from asking questions of a sexual nature, considering them to lack respect. On the other hand, it is common for the elderly to be ashamed and not have the courage to ask questions about the subject because they fear being misinterpreted. Because of ignorance, taboo, and cultural pressure, many experience guilt and shame for feeling sexual desire36, and these may be the same reasons that affected researchers, most of whom work in the health field.

Several barriers hinder the discussion about sexuality with older adults, such as lack of confidence and experience, little knowledge, shame, and prejudice concerning the topic37. Pascual38 argues that our society has a negative concept of old age, especially in the sexual sphere. As a result, the subject is not talked about, older adults are considered asexual, and relatives set obstacles to prevent them from being sexually active.

Health professionals and field researchers are members of the societies in which they operate, so they may share with respondents and the population moralistic or conservative viewpoints and express opinions that reflect only common sense39.

In the research on dependent older adults, the high number of older adults for whom the question about sexuality was not asked reveals the interviewer’s embarrassment. Silence signals malaise in this delicate topic, particularly in the face of the older adults in a state of limitation and dependence.

Silence can also bring attention to the need to talk about a forbidden subject with the most significant possible number of actors: older adults, family, caregivers, health professionals, researchers, and managers, contributing to demystifying prejudice and pointing to the idea that sexual activity has no expiration date.


Final considerations

Active aging advocates the possibility of having sex until the end of life2,19. In this sense, the inclusion of this question in a survey of dependent older adults was an opportunity to know how older men and women experience, at the limit, hardships in this area.

One of the limitations of this paper is the relatively small sample of participants who have talked about the subject. However, what has been heard shows how relevant the sexual issue is, either through the underlying taboos or the repression that implies suffering for some older adults, who continue to have desires and wants to relate. In this sense, the research contributed to the deconstruction of the idea that older adults are asexual40, understanding that the exercise of sexuality is part of this stage of life41,42.

It is believed that talking openly about sex with older adults, including those who are dependent and, therefore, with performing limitations, contributes to breaking the prejudice and taboos surrounding this subject.


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