Sex and the older man Wendy Norton and Penny Tremayne

Sexual health is an important part of an individual’s physical and emotional wellbeing. Sexuality and sexual wellbeing are often associated with young people and therefore the needs of the older person can be overlooked. Such discrimination is unjustifiable given that statistics show a rise in sexually transmitted infections (STIs) and new diagnoses of HIV in the older man. These worrying trends emphasise the legitimate need for nurses to address sexuality and sexual wellbeing as an essential component of health care. Key words: Sexuality ■ Holistic health ■ Sexually transmitted disease ■ HIV


ith a population that is living longer (Age UK, 2014), it is imperative that nurses have a knowledge and understanding of the older person so that interventions can be tailored to their needs and requirements. Nurses should be able to recognise that old age is not a static state, but rather a continuously evolving process that can not only be very fulfilling, but also requires adaptation (sometimes pleasing, sometimes not) to existing and new ways of being. For the purposes of this article, the ‘older man’ will be defined as men aged over 50 years (Family Planning Association (FPA), 2011). The FPA (2011) goes on to highlight that despite the range of, and differing sexual health needs within, the over50 age group, there is a recurring theme that these people are largely invisible to mainstream health-service provision (FPA, 2011). Unfortunately, Garrett (2014) identifies that the older person also remains relatively sidelined in terms of governmental recognition of their needs in sexual health policy documents. This is disappointing considering that sexuality bridges the whole of the human life span from birth to death (Langer, 2009). However, given the relationship between general and sexual health, there tends to be a disproportionate focus on women’s health, albeit sometimes prompted through, for example, child birth and cervical screening (Corona et al, 2010). The Men’s Health Forum (2015) highlights that men visit their GP 20% less often than women, and are less likely to seek associated health promotion. While Evans (2011) considers health and sexual wellbeing to comprise a range of domains (Table  1)—sexual wellbeing integral to holistic care; sexual wellbeing associated with other health conditions; and sexual wellbeing including specific sexual problems; and sexual health—it is important to acknowledge Wendy Norton, Senior Lecturer; Penny Tremayne, Senior Lecturer, Faculty of Health and Life Sciences, School of Nursing and Midwifery, De Montfort University, Leicester Accepted for publication: January 2015


that there are other common themes. These themes are: challenges to sexual wellbeing, and the need for information to prevent sexual ill-health and to facilitate access and availability of support services (Department of Health (DH), 2013a).

What is sexual health? In 2001, the DH published the first national strategy for sexual health and HIV to help modernise services around the needs of patients and service users, tackle inequalities, and improve the sexual wellbeing of the nation. This Government strategy proposed a comprehensive and holistic approach to sexual wellbeing: ‘Sexual health is an important part of physical and mental health. It is a key part of our identity as human beings together with the fundamental human rights to privacy, a family life and living free from discrimination. Essential elements of good sexual health are equitable relationships and sexual fulfilment with access to information and services to avoid the risk of unintended pregnancy, illness or disease.’ (DH, 2001a: 5) This definition highlights the importance of nurses recognising sexual health as multidimensional, encompassing more than just penetrative sex (Bauer et al, 2007). However, 13 years on, sexual wellbeing remains a key public health concern. Although much focus has been placed on the sexual wellbeing of young people, The Framework for Sexual Health Improvement (DH, 2013a), which superseded the national strategy, does recognise the importance of addressing sexual health needs across the life course. This guidance sets out the different information, services and interventions needed as people move through their lives. However, it remains to be seen how this guidance will be translated in clinical practice. The Framework for Sexual Health Improvement refers to the older person demographic as ‘people aged over 50’ (DH, 2013a: 20). However, sexual health statistics recorded by Public Health England (PHE) report on age groups of 45–64 years and 65+ years (PHE, 2014a). This makes interpretation of data challenging and prevents a clear focus to inform effective service provision.

Foundations of sexual wellbeing Experiences older men go through are different from those of older women.The International Longevity Centre (ILC) (2014) identifies that 1.2  million older men experience a moderate or high degree of social isolation, and that 700 000 older men experience a high level of loneliness. The older man is less likely to have contact with children, other family and friends. Arguably, this can make the older man vulnerable and may lead to behaviours that put him at greater risk, such as a poor diet, smoking and drinking (ILC, 2014). This could also lead to the pursuit of sexual gratification

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SEXUAL HEALTH and risky behaviours. Holden et al (2005) found that 27% of men aged 70 or older desired more frequent sexual activity and, to satisfy this need, some of them admitted paying for the use of commercial sex services. Older people may also engage in sexual tourism, seek partners or escorts via internet dating, or ‘purchase’ the services of a sex worker or engage in sexual tourism. This can lead to an increased risk of sexually transmitted infections (STIs). However, older people are often seen as asexual—that is, without sexual desires or feelings, with many health professionals assuming that sexuality is unimportant, or irrelevant, to this age group. Indeed, even the National Service Framework for Older People (DH, 2001b) fails to make any reference to the older person’s sexuality needs. This neglect may be a consequence of media images of lust and sex being reserved solely for young and attractive people—which only serve to reinforce the myth that older people are, or should be,‘sexually retired’ (Minichiello et al, 2005).However, despite society’s perception of who fits into the ‘sexually active’ category, and a general belief that sexual desires decrease with age, older people generally maintain sexual interest and remain sexually capable into their 90s (Gott, 2005a). PHE (2014b) identifies that gay, bisexual and other men who have sex with men (MSM) constitute an estimated 5.5% of the male population in the UK. Sexuality in the older person is often an unacknowledged taboo, but this is reinforced when an older person is attracted to another person of the same sex.This can result in a fear of rejection and further isolation, which is especially the case for those who ‘come out’ in later years and therefore may be faced with the possible stigma of both ageism as well as homophobia (DH, 2003). More recently, Public Health England (2014b) highlighted that at least 36% of older men report hiding their sexual identity throughout their lives. In later life, people’s perceptions of what constitutes sex may change, with more emphasis being placed on love, closeness and companionship (Gott and Hinchliff, 2003). Touching, holding hands, hugging and kissing are all communication strategies denoting intimacy, emotional support and comfort, which prevent feelings of loneliness. Something that also needs to be considered are the sex, sexuality and intimate relationship needs of the older person in a care home (Royal College of Nursing (RCN), 2011).Ward et al (2005) highlight that sexual behaviour is most often noted when exhibited by men and often deemed disruptive and problematic. Therefore, health professionals need to be mindful of their attitude and the facilitation of an appropriate physical environment that embraces sexual rights (World Health Organization (WHO), 2006).

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Associated aspects of sexual wellbeing Associated aspects of sexual wellbeing can be a good indicator of general health and wellbeing. While ageing changes in mid-life are well known for women, the male ‘andropause’ is relatively unacknowledged (Knight and Nigam, 2008). There are a number of physiological changes that can be related to diminished blood flow, and hormonal and neurological changes (Mahan Buttaro et al, 2014). A gradual decline in testosterone output can lead to: an increase in body fat, usually centrally, as well as visceral body fat; reduction of the muscle and bone mass; erectile dysfunction (ED) and reduced libido; and an increased risk of anaemia

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Table 1. Adapted three domains of health and sexual wellbeing as applied to the older man Sexual wellbeing integral to holistic care

Sexual wellbeing associated with other health conditions

Specific sexual problems and sexual health

Sexual orientation Desire and performance Sexual relationships Reproductive health Expressions of sexuality

Andropause Erectile dysfunction Pathophysiological changes of the prostate gland Loss of libido Body image

Sexually transmitted infections HIV Psychosexual issues

Source: Evans, 2011

(Knight and Nigam, 2008). All of these can contribute towards compromising sexual function in the older male, but other influencing factors are comorbidities such as hypertension, obesity, heart disease, urogenital tract conditions, neurovascular complications, polypharmacy and decreased physical endurance. Corona et al (2010) found that more than half of middle-aged and older men had one or more comorbidities. According to Mahan Buttaro et al (2014), older men’s sexual concerns focused primarily on erectile difficulties and those who were in poor health were less likely to be sexually active and more likely to have sexual problems. ED is an early indicator of cardiovascular disease (Cox, 2008; White, 2013). Cox (2008) describes the penis as a barometer of cardiovascular health; the small penile vessels can serve as a forewarning of vascular damage. Cox (2008) also considers how erectile dysfunction can be related to endothelial dysfunction (when the endothelial cells do not function normally.) Dysfunction of these cells can result from a number of disease processes, such as hypertension, dyslipidaemia (an abnormal amount of lipids in the blood), diabetes and lifestyle choices, such as smoking—which in turn impair the ability of arteries to dilate, leading to ED.While the advent of medications such as sildenafil (Viagra) have proven to be a useful support, there are a number of noteworthy contraindications and side-effects that mean they may not be an option for all older men. Another age-related issue that can influence the male reproductive system is that the size of the prostate gland can increase. This is called benign prostatic hypertrophy and can lead to the prostate compressing the urethra, which in turn can compromise micturition (urination) (Knight and Nigam, 2008). Further, prostate cancer and its treatment—through possible damage to the autonomic nerve supply or muscle—can compromise the desire for sex, lead to ED, and impair the ability to ejaculate and have an orgasm. Such difficulties can also affect those who have had a colostomy or ileostomy because of rectal or bowel cancer (Taylor, 2008). For those men who have had bladder cancer and a urostomy, irreversible impotence can be the result. Deteriorating physical capacity can affect the older man in terms of exercise tolerance, agility and mobility (Herbert, 2006). Changes to previous sexual practice may have to be considered and explored, especially as there are a number of benefits to remaining sexually active. While it can bring love, closeness and intimacy, it can also improve sleep, reduce anxiety, enhance selfworth, prevent social disengagement and decrease depression


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■ Level

1: Permission for the client to express concerns regarding sexuality— this may be by asking a cue question—for example, people who have had an amputation often have concerns about their sex life. Is there anything you would like to ask me? ■ Level 2: Limited information provided—this could be in the form of a leaflet, which could then be ‘followed up’ in the form of posing a question. For example, did that answer all your questions? Did you find it helpful? Do you have any further questions at all? ■ Level 3: Specific suggestions made—the following two levels require additional knowledge and skill. At this level, it is about addressing the individual’s problems, aspirations and expectations. ■ Level 4: Intensive therapy given—this specialist level can focus on psychosexual as well as physical needs. Source: Annon, 1976 (adapted from Davis and Taylor (2006))

(Forte et al, 2006; Watters and Boyd, 2009; Corona et al, 2010). Body image is also a significant factor in the older man. They have to adapt to changes such as thinning hair on the scalp, yet an increased amount of hair in the nose, ears and eyebrows (Herbert, 2006). Loss of subcutaneous fat in the face and weakening facial muscles can contribute to sagging, loose skin and the formation of jowls (Knight and Nigam, 2008). While the ageing man can arguably fair better than the ageing woman in terms of societal perception (greying and thinning hair can be viewed as ‘distinguished’ or a sign of virility (Forte et al, 2006)), the ageing man may still encounter issues with confidence and self-esteem, even if older men report that they are more sexually active than older women (Mahan Buttaro et al, 2014).

Specifics of sexual health illnesses and problems Healthcare providers play an important role in assessing and managing normal and pathological ageing changes in order to improve the sexual health of older adults. Poor health and frequent use of medications to treat illnesses associated with ageing can affect sexual functioning. Common classes of drug, such as antihypertensives, antidepressants and antipsychotics may decrease sexual desire or arousal, or cause orgasm or ejaculatory difficulties. It is important that nurses understand the potential for drug-induced sexual problems and the negative impact they can have on men’s adherence to treatment regimes (Conaglen and Conaglen, 2013). Some men may be using phosphodiesterase type-5 inhibitors such as sildenafil to treat erectile dysfunction. However, these drugs should be used with caution and with recommended dosage adjustments owing to known side-effects. The wide availability of sildenafil, and the recent focus on the rise in STI and HIV rates in the older age group, is forcing society to acknowledge that older people are still sexually active. The concerning statistics on STIs in the older man may be a result of the previous neglect of sexual health information, education and public health campaigns targeting this age group. Increasing life expectancy and loss of stigma associated with divorce have been cited as possible reasons for the increase in the divorce rate among older people. In 2011, nearly 9  500 men aged 60 or over were divorced (Office for National Statistics, 2013). Although the prevalence of sexual activity may


decline with age, research indicates that a substantial number of men and women engage in vaginal intercourse, oral sex and masturbation, even in their 80s and 90s (Lindau et al, 2007). However, they may be less informed about the risks of these sexual behaviours, or the need to practise safer sex. For example, this age group may be less likely to use condoms, as they associate their use with pregnancy prevention rather than as protection against STIs (Gott, 2005b). The latest statistics show that in England in 2013, STI diagnoses in men in the 45–64 age group included 3483 with chlamydia, 2224 with gonorrhoea, 1731 with anogenital herpes, 727 with syphilis, 3167 with anogenital warts (PHE, 2014a). Although the numbers are lower for the 65+ age group, the data tables still report 242 cases of chlamydia, 117 cases of gonorrhoea, 163 men with anogenital herpes, 40 with syphilis and 329 with anogenital warts (PHE, 2014a). According to the latest HIV statistics, there were 6000 people newly diagnosed with HIV in the UK in 2013, three-quarters (4477) of whom were men (PHE, 2014c).This report also draws attention to the changing age distribution of those newly diagnosed. In 2004, one in fourteen (n=587) adults diagnosed were 50 years or older compared with nearly one in six (n=974) in 2013, 308 of whom were men having sex with men (PHE 2014c). Late diagnosis of HIV is the most important predictor of morbidity and one-year mortality (PHE, 2014d). This justifies its inclusion as a key indicator in the Public Health Outcomes Framework (DH, 2013b). The earlier HIV is diagnosed, the sooner treatment can be started to improve the individual’s prognosis and prevent onward transmission. Late diagnosis of HIV is more common in older age groups (half of those aged over 50) compared with younger age groups (one-third of those aged 16 to 19) (Smith et al, 2010). This may be the result of missed opportunities to screen for HIV owing to misconceptions that they are not an at-risk group, despite many of the clinical indicator conditions (such as bacterial pneumonia, dementia, recurrent herpes zoster) being more common in older people (PHE, 2014d). As life expectancy for people living with HIV improves, it is essential they receive appropriate care to manage their comorbidities alongside their HIV infection.

Role of the nurse Many older people would like the opportunity to discuss sexual concerns with a health professional, but may be reluctant to do so because they are embarrassed or believe that the problems they are experiencing relate to the normal ageing process (Heath, 2012). It could be argued that other barriers preventing older people from accessing the sexual health advice they need are similar to those reported for young people—for example, associated stigma, lack of confidence, lack of information and education. There have been huge steps forward in providing ‘young people friendly’ services, but little has been done to encourage access to sexual health services for the older age group. To facilitate discussion, the nurse may benefit from using the PLISSIT model (Annon, 1976) (Permission, Limited Information, Specific Suggestions, Intensive Therapy), which is a tool that helps health professionals in their interventions with clients on issues of sexuality (Davis and Taylor, 2006).The PLISSIT model identifies four levels of intervention (Box 1).

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Box 1. The four levels of the PLISSIT model

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SEXUAL HEALTH To enable nurses to offer holistic care, it is essential that they gather as full a history as possible. An integral aspect therefore should be a sexual health assessment and history. By identifying potential problems and issues, the nurses can then signpost the older person or refer them on to other services. The health education offered should be specific and personalised rather than generalised (Lau-Walker, 2014). Nurses should aim to make ‘every contact count’, which should be a feature across all healthcare settings, primary, secondary and tertiary, to address health inequalities (NHS, 2012).

Conclusion Sexuality remains important for many older men. Accordingly, sexual risk-taking behaviour is not confined to the younger age group. While the incidence of STIs among older adults may be small compared with younger adults, the numbers are increasing year by year, so their sexual health needs should not be overlooked. Given the relationship between sexual health and general health, the older man can become marginalised, so it is essential that sexual wellbeing is included in health care that is holistic, specific and opportunistic. The Government highlights the need to build an honest and open culture to enable everyone to make informed and responsible choices about relationships and sex (DH, 2013). Healthcare professionals must acknowledge their own prejudices and question some of the assumptions they make regarding the sexuality needs of older men if this ambition is BJN to be achieved.

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if society regards older men as ‘sexually retired’, sexuality may still be very important to them

n Through

self-reflection, health professionals should address taboos, prejudices, barriers and assumptions, and thereby perceive sexual health as a central component rather than an optional addition

n Nurses

in all healthcare settings need to expand their knowledge and awareness of sexual health issues that may affect the older man

n There

should be a routine health assessment programme for all older men in the primary care setting, including discussion of the impact of certain health conditions and medications

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Sex and the older man.

Sexual health is an important part of an individual's physical and emotional wellbeing. Sexuality and sexual wellbeing are often associated with young...
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