Sexual Health for Older Women Implications for nurses and other healthcare providers

This article presents findings from a review of the evidence regarding sexual health for older women from MEDLINE, SCOPUS and the Cumulative Index to Nursing and Allied Health (CINHAL) databases. A total of 10 articles based on primary studies, reporting about the sexuality or sexual health of older women (and older people), and published between 2002–2012, were deemed suitable. The major themes that emerged from the available literature suggest that the sexual health of older people is affected by factors such as physical changes, mental health, changes to their relationship with their husband, chronic ill health and other psychosocial situations. It is concluded that nurses and other healthcare providers have a range of interventions that can be adopted to promote sexual health among older women. These interventions may focus on improving the older woman’s sexual health assessment; increasing awareness and knowledge about sexuality in later life; pharmacological and psychotherapeutic therapies; using alternative techniques to achieve better sexual functioning; addressing partner and relationship issues, and advocating the importance of sexual health through media and policy development.

Sexual Health for Older Women Implications for nurses and other healthcare providers Joshua K. Muliira and *Rhoda S. Muliira T he World Health Organization (WHO) defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality, and not merely as the absence of disease, dysfunction or infirmity. 1It is also widely recognised that sexuality is a central aspect of being human; international organisations such as the WHO have reaffirmed this recognition by delineating human sexual rights.The WHO states that sexuality should be free of coercion, discrimination and violence, and that all humans have a right to access sexual and reproductive healthcare services; seek, receive and impart information related to sexuality; access sexual education; possess and retain sexual health of the highest possible standard; be respected and maintain dignity regarding their body; decide to be sexually active or not; consent to marriage, and to pursue a satisfying, safe and pleasurable sexual life. 1 Sexuality contributes to a human being's dignity and social life.[10][11][12] A study of the sexual healthcare needs of older people found that 68% of the older women sampled had never disclosed their sexual problems to their healthcare provider; 4 various factors have been identified which contribute to such a trend. 7,10,11,13,14iven this background, the aim of the present discourse is to review the available literature on issues germane to the sexual health of the elderly population.Given the increased standards of living and advances in medicine, the average lifespan of people in different parts of the world is likely to increase.Therefore, evidence-based policies are needed to be contemplated for this growing population of elderly people.Although the population structure in Oman is generally 'youthful' , recent affluence has increased the life expectancy for Omanis to 72.61 years for men and 76.43 years for women. 15In order to lay the groundwork for meeting future challenges, this study reviews the available literature on sexual functioning among the elderly population.

Methods
A strategy was formulated to identify articles reporting primary studies relevant to the subject of the sexual health of older women or older people.Trial searches were conducted to finalise search terms, and this helped to maximise the number of relevant citations.The search terms used were "Older women", "Female older adults", "Older people", "Sexual health", "Sexual well-being", "Care" and "Nursing care".These search terms were used both individually and in various combinations in order to locate articles concerning sexual health and older women or older people in the MEDLINE, SCOPUS and the Cumulative Index to Nursing and Allied Health (CINHAL) databases.Other databases were not searched as it was observed that several articles were already repeated in all three databases.A total of 10 articles based on primary studies, reporting on the sexuality or sexual health of older women (and older people), and published between 2002-2012, were used to formulate the foundation for this review.The 10 articles were included regardless of the methods and instruments used in each study.Other literature on the subjectnot necessarily primary studies-was used to "there are no age limits to enjoying a healthy sex life". 3owever, in order to maintain sexual health some individuals may require professional help.Despite this, it is common for nurses and other healthcare providers to perceive sexuality and sexual health to be relevant only to those in the reproductive age group.They tend to neglect the fact that affection and sexual intimacy contribute to healthy relationships and individual well-being for people of all ages, and that sexuality may increase as humans get older.Contrary to the commonlyheld belief, there is empirical evidence to suggest that sexual interest is not significantly impacted by ageing. 4Studies conducted in the last decade confirm that sexual concerns are common among people as they age, and specifically show that more older women report problems with sexual function compared to older men. 5 Unfortunately, the sexual concerns of older women tend to receive less attention 5 and be undermined by social misconceptions concerning older women as sexual beings. 2 For instance, in some societies, older women are perceived to be asexual. 6Other misconceptions related to the sexuality of older women include the belief that their sexual problems are part of the normal ageing process and therefore do not warrant serious attention. 7This pervasive perception of older women as asexual beings is not supported by the scientific literature, 6 and may be indirectly propagating a denial of their sexual rights and of the healthcare necessary to maintain their sexual health.
This issue appears to be global.Epidemiological studies conducted in the USA show that sexual dysfunction is more prevalent among older women (43%) in comparison to older men (31%). 5The most prevalent sexual problems among old women are hypoactive sexual desire disorder (43%), vaginal dryness (39%) and anorgasmia (34%). 8The high prevalence of sexual health problems and the misconceptions about older women's sexuality highlight a health need that should be addressed by nurses and other healthcare providers.This health need can be met through integrating appropriate interventions to promote sexual health into the regular healthcare provided to older women.However, some studies which have surveyed samples of healthcare providers have found that healthcare professionals frequently have difficulties support the discussion of the main points.

Results
The findings of the 10 studies reviewed [Table 1] show that older women frequently engage in satisfying sexual activity but also frequently suffer from sexual dysfunctions such as low sexual desire, difficulty with vaginal lubrication and anorgasmia.Very few older women discuss their sexual problems or concerns with healthcare providers, although some older women are willing to discuss their sexual problems.The barriers experienced by older women when seeking treatment for sexual problems include the gender of the healthcare provider; their own attitudes towards later-life sexuality; the attribution of sexual problems to the normal ageing process; shame or fear; the perception of older women's sexual problems as 'not serious' , and a lack of knowledge concerning sexual health-related services.The healthcare provider's personal perceptions can be a barrier to addressing older women's sexual health concerns as these may inhibit them from discussing sex-related matters with older female patients.The discussion below articulates the importance of sexual health, the factors affecting older women's sexual health and some of the interventions that nurses and other healthcare providers can adopt to promote sexual health in this population.

Discussion
Sexual health for older women has been linked to positive health outcomes, and is associated with psychological health and quality of life. 16,17Among women (regardless of age), aspects of sexual health such as sexual satisfaction are reported to be associated with high vitality scores and positive wellbeing. 18,3Therefore, it is essential that the healthcare professional assist in safeguarding the sexual health of the elderly population and be vigilant on matters related to sex and sexuality among the elderly.Politi et al. emphasise that communicating about sexual history may impact patients' screening behaviours, their willingness to disclose relevant personal health information, and may help to develop a good relationship with their healthcare provider. 11On the other hand, the failure to recognise the importance of sexual health may impose barriers and devalue the sexuality of adults. 2 Therefore nurses and other healthcare providers should be constantly aware that older women, even those living with chronic illnesses or health problems, need to have their sexual health needs met and that sexual health has physical, physiological, psychological, emotional and spiritual benefits. 3,19 c t o r s i n f l u e n c i n g t h e s e x u a l h e a lt h o f o l d e r w o m e n A variety of factors influence the sexual functioning and health of women as they age.The most commonly-encountered factors are the hormonal and physiological changes associated with the menopause, changes in physical or mental health, the adverse effects of medications or health interventions and the capability to engage in sexual activity.4,20 As women age, a decline in circulating oestrogen levels results in significant changes to their genitalia, such as the thinning of the uterine and vaginal walls, a shrinkage of the width and length of the vagina, a loss of vaginal wall elasticity and decreased or delayed vaginal lubrication.21,22 Subsequently, changes in the vaginal mucus membranes increase the vulnerability to infections and may induce pain during intercourse.21,22 Additionally, pain during sexual penetration can lead to sexual dysfunctions such as vaginismus and dyspareunia.23 In some women the labia (minora and majora) significantly atrophy with age, leaving the clitoris exposed to direct stimulation which can sometimes become painful.23 In other older women, the cervix may descend downwards into the vagina, and when this is combined with the loss of the fat pad over the symphysis pubis, it can lead to pain due to direct pressure over the bone during intercourse.21,22 The other major factor influencing the sexual health of older women is chronic ill health.Chronic diseases tend to impede sexual functioning.Health problems such as dementia, multiple sclerosis, spinal cord injuries, diabetes, hypothyroidism, renal failure and depression have been particularly reported to have an adverse effect on sexual health among the elderly population.22,24 The impact of chronic ill health on the sexual health of older women is further worsened by the treatments used to manage the multiple chronic health problems that can affect older people.The medications commonly used by older people, such To compare the prevalence and type of sexual concerns, and the interest in and experience with discussing these concerns with physicians for women aged 65 and over.
1) All women aged 65 and over reported having one or more sexual concerns, with a mean of 12 concerns per woman.
2) A total of 68% of the older women were less likely to have heard the topic of sexual health raised by their physicians.
3) A total of 97% of the older women would have discussed their sexual concerns if the physician had asked them.
4) The older women wanted physicians to inquire about their sexual health and partners sexual functioning.To determine the prevalence of and risk factors for the frequency of sexual activity, satisfaction and sexual dysfunction among middle aged and older women.
2) Sexual dysfunction was more common among older women who were not white by race, and had lower education levels and psychological stress.
3) Healthcare providers need to be aware of older women's continuing interest in sexual activity, and should screen for sexual dysfunction and treat any dysfunction with care and sensitivity.To describe the prevalence of sexual activity, behaviour and problems, and the association of these variables with age and health status.
1) Sexual problems are frequent among older women and these include low desire (43%), difficulty with vaginal lubrication (39%) and the inability to climax (34%).
2) Only 22% of participants reported having discussed sexual matters with their physician after the age of 50 years.
3) Physicians' knowledge about the sexual behaviour of older patients should be utilised to improve patients' education, counselling, and their ability to identify sexual health problems.
Wang et al. as antidepressants, antipsychotics, antiepileptics and anticholinergics, have mechanisms of action which have an effect on neurotransmitter systems and can negatively impact sexual desire and sexual arousal; this can make older women unable to have or enjoy sex. 22,24The other classes of medication that have been noted to affect sexual health and function include antihypertensives, diuretics and steroids; alcohol abuse and illicit drug use have also shown to have a negative impact on sexual function. 6ther specific factors which are a barrier to the achievement of sexual health among older women include chronic pain, cognitive impairment, environmental restrictions and poor body image. 4,20any older women living with a caregiver who is their child, or in long-term care settings such as nursing homes, experience limitations to their sexuality because of factors such as the disapproval of their caregivers or nurses, feelings that sexuality is inappropriate, and the lack of necessary privacy.
Nurses and other healthcare providers need to be aware of and address these factors during the assessment, planning and delivery of healthcarenot only to ensure sexual health promotion, but also to ensure the delivery of holistic quality healthcare to older women.

i n t e r v e n t i o n s t o p r o m o t e t h e s e x u a l h e a lt h o f o l d e r w o m e n
One of the critical interventions that nurses and other healthcare providers can implement to promote the sexual health of older women is to explore the barriers and factors affecting sexual health during health assessments. 11,25The discussion of sexual history with older people is an important part of physical and emotional health assessment. 11Older women are interested in discussing sexual concerns with nurses and other healthcare providers, and most of those who discuss their sexual problems with a healthcare provider find these discussions to To describe experiences of middle-aged and older women in communicating about sexual health and intimate relationships with their healthcare providers.
1) Not all women thought healthcare providers should ask about sexual issues unless the questions were directly related to a health problem.2) Women were not satisfied with the questions about sexual issues on medical forms.3) Healthcare providers should ask questions about sexual health in a way that is sensitive to the woman's needs and in a non-judgmental manner.To investigate the sexual activities of older women, their levels of sexual and life satisfaction, and to examine the relationship between sexual activity and sexual/life satisfaction.1) Sexual activity was positively associated with sexual satisfaction (r = 0.32, P <0.001).

Woloski
2) Older women were interested in continuing their sexual activity.
3) Sexual activity was significantly associated with quality of life, but differed according to the experiences the women had had in the past.4) Healthcare professionals should deepen their knowledge about sexuality in older age, develop specific techniques of sexual assessment and initiate active communication with women about this sensitive issue.To ascertain whether older adults had unanswered questions about their sexuality and whether they were comfortable discussing sexual health with nurses.
2) Most respondents (47.1%) wanted to be asked about their sexual health during healthcare visits.
3) Most respondents (86%) reported being comfortable discussing sexual health and not being embarrassed.4) 56.9% of the women were willing to talk to physicians and nurses about sexual issues.5) Physicians and nurses have the potential to enhance communication with older adults regarding issues of sexual health that impact quality of life.To describe the prevalence and covariates of sexual activity and satisfaction in older community-dwelling women.
2) Emotional and physical closeness to the partner was considered more important than experiencing orgasm.
3) Sexual satisfaction increased with age and did not require sexual activity.4) Greater emphasis on specific sources of satisfaction may be more useful than focusing only on female sexual activity or dysfunction.

GPs = general practitioners; RRISK = Reproductive Risk Factors for Incontinence Study; OR = odds ratio; CI = confidence interval.
be helpful. 4,20Although earlier reports showed that older women found communicating with healthcare providers about their personal sexual health to be particularly difficult, 7,11 more recent studies show that this attitude is changing in some countries. 9urses are especially suited to carrying out the health assessment of older women's sexual health because they are routinely involved in patient and family health education, and spend the most time with patients in all healthcare settings.
The other interventions that nurses and healthcare providers can implement to promote the sexual health of older women are those focusing on improving knowledge about sexuality.Having knowledge about sexuality in later life is associated with a more positive attitude towards sexuality among older people. 26Therefore sexual health education is very important in modifying older people's attitudes towards sex. 13Nurses and other healthcare providers need to know that it is crucial to teach patients about issues related to sexual performance and expectations because the knowledge gained from such interactions can help patients adapt to the bodily changes and changes in sexuality caused by the ageing of women and their husbands. 27Educating older women about the typical bodily changes caused by ageing may also help to normalise their experiences and reduce distress about the meaning of certain symptoms and experiences. 13,26Addressing and increasing older people's knowledge about the impact of physical health problems on sexual health provides the opportunity to moderate their sexual performance expectations and improves their emotional wellbeing. 14nother potential category of interventions are those that address partner and relationship issues.One of the most important factors affecting the sexual activities of older women is being in an intimate relationship with another person. 27,28he presence of a husband is very important and changes in the husband's health condition or sexual functioning significantly affects the woman. 29,30herefore interventions that focus on supporting and improving older women's relationships with their husbands and older women's health are critical to sexual health promotion. 20Depending on the care setting and environment, nurses can encourage the husbands of older women to visit more regularly, and talk or demonstrate affection in privacy.
Maintaining physical intimacy through cuddling and touching is central to to the sexual satisfaction and well-being of older people when penetrative sex is no longer possible. 10Interventions focusing on the older woman's husband should mainly aim at promoting positive intimate experiences, improving communication, dealing with negative emotions and harmonising sexual wishes and desires. 22Social factors are very important, especially in the nursing care of older women, because after mid-life most women have limited social recognition and support for sexual relationships, and because most cultures and media are silent on the subject of sexuality in later life. 32This support and recognition can be given to older women by nurses during nursing care.
Nurses and other healthcare providers can also suggest to older women that they use alternative techniques to achieve better sexual function.Some of the alternative techniques that can be adopted by older women who cannot tolerate penetrative sex for very long include asking their husbands to enjoy longer periods of foreplay, using techniques such as kissing, petting, embracing, stroking different body parts, or trying new sexual positions which may cause less pain. 23,33Older women can also practise Kegel exercises to increase vaginal muscle tone and use lubricating creams to compensate for and reduce vaginal dryness. 23,30,32Older women usually describe intimacy in broader terms than simply sexual intercourse, and therefore alternative aspects of sexual expression are highly regarded and are most likely to lead to sexual satisfaction. 28here are also pharmacological and psychotherapeutic interventions that can be used to improve the sexual functioning of older women.The management of the physiological changes secondary to the reduced oestrogen levels that affect the appearance and functioning of the genital area of older women can be done using psychotherapy and supplementary hormonal treatment when symptoms are severe. 21,22However nurses and other healthcare providers should be extremely careful and vigilant when an older woman chooses to use supplemental hormonal treatments, because of the potential complications and risks such as embolism, cancer, stroke, etc. that are associated with these treatments.Hormonal treatment can comprise oestrogen with or without testosterone.Oestrogen is necessary for genital lubrication and testosterone helps to increase sexual desire. 23A combination of oestrogen and testosterone seems to have a better effect on the various aspects of sexual functioning and psychological well-being than oestrogen therapy alone; 22 however, the pharmacological facilitation of sexual arousal can only be successful when the treatment also focuses on psychological and social factors. 22,33Psychotherapy techniques can be used when addressing physical health problems affecting the sexual functioning of older women. 14If the nurse or health care provider is not competent in psychotherapy techiques, he or she can refer the patient (or advocate referral) to a healthcare professional who can provide these intervetions.
It is also important to note that psychotherapeutic interventions are most effective when both the woman and her husband are involved.Some of the problems that are commonly managed using psychotherapy include low sexual desire, arousal problems, difficulties in climaxing and problems with sexual satisfaction. 22The referral of older women to other forms of psychological treatment such as sex therapy and cognitive interventions are recommended for those with low sexual desire, and those who need detailed education about how to achieve adequate stimulation. 31,33The technique of cognitive restructuring is used for patients with dysfuctional thoughts and those whose partners have behaviours that can inhibit sexual desire and arousal or cause insufficient physical stimulation. 22,33nterventions to promote the sexual health of older women can also take the form of professional advocacy and policy development on issues related to sexual health.In most countries, the media and culture depict older people as asexual. 20,31This misconception can be corrected by delivering healthcare that values and addresses the sexual needs of older people.Unfortunately, it is often considered inappropriate to use the media, scientific publications and other professional forums to encourage older women to engage in regular and appropriate activities that make them feel sexually attractive and aroused.At the policy level, the sexual health of older people is mostly neglected as it is assumed to be irrelevant and of no benefit to their quality of life. 10Nurses and healthcare providers are generally more likely to be effective than any other group in advocating for policies that promote the sexual health of older people.Such policies could, for example, include supporting and participating in policies that oblige the reimbursement of costs for nursing interventions that focus on sexual health or that support the integration of sexual health-related competencies in the training and curricula of the healthcare professions.Therefore issues related to sexual health promotion for older women during patient care or at the level of policy development present a unique opportunity for healthcare providers to fulfill an important health need and subsequently enhance the well-being of older people. 28

Conclusion
Although the sexual health of the older generation is often neglected, a substantial proportion of older women remain interested and engaged in sexual activities.Nurses and other healthcare providers have many interventions that can be adopted to promote sexual health among older women.These interventions may focus on improving the older woman's sexual health assessment; increasing awareness and knowledge about sexuality in later life; pharmacological and psychotherapeutic therapies; using alternative techniques to achieve better sexual functioning; addressing partner and relationship issues; and advocating the importance of sexual health through media and policy development.
This review has several implications for practice.First, older women expect nurses and other healthcare providers caring for them to address their sexual health needs.Second, promoting and addressing the sexual health of older women enhances their general health and well-being.Third, ensuring that interventions focusing on sexual health are integrated into care plans for older women will enhance the quality of their health care and ensure their right to sexual health.Finally, nurses are better positioned to implement interventions focusing on sexual health for older women because of their regular and extensive contact with patients during healthcare.

Farrell
et al. 9 2012 N = 101.Female and male residents (80 years and over) of retirement communities and participants in fitness classes.Washington, USA.Cross-sectional study.A 24-item investigatordeveloped survey.

Table 1 :
Studies focusing on sexual health for older women