Older Adults and Sexual Risk-Taking Behaviors

Older Adults and Sexual Risk-Taking Behaviors

Introduction

Older adults (aged 50 and older) are becoming one of the fastest growing demographic in the United States. It is estimated that by 2020, older adults will comprise 53 million of the population and will double to 88.5 million by 2050 (DeLamater, 2012; Muzacz & Smith-Akinsulure, 2013). There are over 2 million older adults living in nursing homes and assisted living facilities across the United States (Lichtenberg, 2014). This estimated demographic shift has raised concerns of the potential strain on health care resources by health care providers and researchers (Marshall, 2011). The US faces a significant public health issue due to the continued increase of the older adult population and access to quality health care. In recent years, the focus has shifted to recognize sexual health and sexuality as important components of older adults’ lives (Ponyten, 2013). Researchers argue that sexual needs remain important at all ages and age does not eliminate sexual desire (Watters & Boyd, 2009). Sex is a core aspect of human life and sexual activity is a significant human need (Tsatali, Tsolaki, Christodoulou, & Papaliagkas, 2011). Thus, health care providers and researchers recognize that sexuality is an important quality of life matter for older adults (Foster, Clark, & Holstad, 2012a; Gelfand, 2000). The goal within the aging research has transitioned to ensuring older adults experience exceptional quality of life yet when examining quality of life in older adults, sex and sexuality are overlooked (Taylor-Jane & Gow, 2015). Sexuality and sexual expression remain a taboo and understudied topic in aging literature. Additionally, older adult sexuality is underrepresented in counseling and family studies literature as well (Muzacz & Smith-Akinsulure, 2013).

Researchers have established that sexuality and sexual expression are vital aspects to older adults’ health and continued improvement in quality of life. Empirical studies examining the sexual practices of older adults over 50 suggest sexual activity remain in their sexual relationships. A substantial proportion of older adults report being sexually active after age 65 and some continue to report sexual activity well into their 70s and 80s (DeLamater, 2012; Pilowsky, 2015). Additionally, older adults are steadily increasing in the rates of STI and HIV/AIDS. In fact, the rates and prevalence of STIs and HIV in older adults has begun to parallel those of the younger generations (Ponyten, 2013). Some scholars credit the steady increase to older adults underestimating their sexual risk (Foster et al, 2012a; Pilowsky, 2015). Due to neglect and avoidance of addressing sexual health in the older adult population, older adults face health disparities in their quality of life. Thus, the purpose of the critical analysis is to: 1) address the sexual politics of older adults; 2) identify the rates and prevalence of STI and HIV risk in older adults; 3) pinpoint the barriers in their access to quality of care for health care providers and clinicians; and 4) provide future directions in education, research, and policy to continue to address older adult sexuality.

Literature Review

The aging literature has rarely addressed the benefits of continued sexual behaviors in older adults. Research is scarce in addressing the rates and trends of sexual practices and STIs in older adults (Ponyten, 2013). There is little data on the benefits of sexual activity for quality of life and data on policy regarding housing and sexual health care for older adults (DeLamater, 2012). Regular sexual activity is related to higher quality of intimate relationships, lower rates of depressive symptoms, higher self-esteem, lower pain sensitivity, and improved cardiovascular health (DeLamater, 2012; Syme & Cohn, 2016; Taylor-Jane & Gow, 2015). In one of the largest samples of older adults and sexuality, 75% of 57-64 years old, 50% of 65-74 years old, and 26% over age 75 years old report being sexually active (Lichtenberg, 2014). Older adults experience significant transitions in their romantic relationships such as partner loss through death, divorce, remarriage, or separation resulting in large proportions starting new relationships and being exposed to new sexual partners (Pilowsky, 2015; Watters & Boyd, 2009). Thus, elevating their risk to STIs and HIV/AIDS. Researchers credit the elevated sexual risk in older adults to: increased numbers of new partners due to longer life, lack of awareness of sexual activity by healthcare and counseling professionals, lack of communication about sexual health and HIV risk by physicians, omission of STI and HIV prevention programs, decreased condom use and lower rates of STI testing, and introduction of erectile dysfunction medication for sexual functioning (Ponyten, 2013).

Older Adult Sexual Politics

There are several influences to the lack of research and programs dedicated to aging and sexuality. The older adult sexual politics in conjunction with ageism significantly impacts research, policy, and education regarding older adult sexuality. Expanding on the existing work of Patricia Hill Collins (2004), the researcher alters the concept of sexual politics to apply to the aging population. Therefore, the author defines older adult sexual politics as a set of beliefs and social practices shaped by gender, race, sexual orientation, and socioeconomic status (SES) that demonstrate older adult men and women’s’ treatment of one another as well as how older adults perceive themselves and are treated by others (Collins-Hill, 2004). Older adult sexual politics occurs at the intersection of age, gender, race, and sexual orientation that older adults encounter. They experience distinctive inequalities based on their placement in the systems of gender, race, class, and sexuality (Collins-Hill, 2004). Sexual politics acknowledges the intersection of power and oppression in the lives of this vulnerable population (Melancon & Braxton, 2015). Older adult sexual politics focuses on the discrimination and separation older adults experience at the intersections of the age, gender, race, sexual orientation, and SES identities. Older adults must navigate the gender, age, race, and class systems simultaneously, which reveal how communities in academia and policy have denied older adults complex personhood (Melancon & Braxton, 2015). Older adult sexual politics highlight that discrimination for each identity influences the disparities of care present within structural, institutional, and individual systems.

Older adult sexual politics manifest in creating negative stereotypical images of older adult sexuality and expression, which limit their access to health care related to sexual concerns and sexual risk. Societal structures exist that neglect the sexual needs of older adults (Deacon, Minichiello & Plummer 1995; Rubin 1968). The impact is apparent at the societal level via policies, research, and practices in sexual health care services. The consistent ambivalence surrounding older adults’ sexuality corresponds with recent increases in STI and HIV rates (Syme & Cohn, 2016). Sexual expression in older adults is a neglected topic of research. Most of the literature examines older adult sexuality from a biomedical perspective (DeLamater, 2012; Marshall, 2011). Research focusing on the problems of sexual functioning in later life creates a pathological view and influences the stereotypes of aging present in society (DeLamater, 2012). The widespread denial of sexuality in older adults has a harmful influence that goes beyond the individual adult’s sexual life. It impacts medical, psychological aspects of the individual as well as relationships and self-image (Rubin, 1968). Additionally policies and procedures regarding sexual expression and sexuality in residential institutions and nursing homes for older adults are inadequate. The goal of the critical analysis is to address how the inequalities within the sexual politics of older adults have led to discrepancies in care directed at improving the quality of life of older adults.

Ageism

A prominent component within the older adult sexual politics is ageism. Ageism is the age-based systematic stereotyping and discrimination that exists in societal attitudes and values illustrated in overt and covert ways (Ivey, Wieling, & Harris, 2000). Ageism refers to stereotypical images of older adults being helpless, depressed, and sexless (Lichtenberg, 2014). Aging sexual stereotypes include viewing older adults as being asexual, undesirable, and incapable of sexual behaviors (Crooks & Baur, 2011; Minichiello, Hawkes, & Pitts, 2011; Syme, & Cohn, 2016). Ageist stereotypes are culturally derived and contribute to the prevailing resistance to accepting sexual activity being relevant in later life (Crooks & Baur, 2011; Deacon et al., 1995; Langer, 2009; Palmore, 2004). These false and pervasive narratives reinforce discrimination within societal structures such as nursing homes, residential care facilities, and institutionalized care facilities for older adults (Langer, 2009; Syme, & Cohn, 2016). Generally aging discrimination in long-term care institutions are often underreported, disregarded, and left untreated (Syme, & Cohn, 2016). In fact, men report facing more aging sexual discrimination and women report lower incidences (Syme, & Cohn, 2016).

It is important to note that age does not abolish the need or the capacity for sexual activity (Deacon et al., 1995; Rubin, 1968). Yet, there persists a strong resistance and denial to accept the sexual desires and activity of older adults (Marshall, 2011; Rubin, 1968). This prejudice dominates the current views of sexuality in older adults (Tsatali et al., 2011). Oftentimes older adults have been found to internalize these negative beliefs, which impact their sexual relationships (Syme & Cohn, 2016). Older adults tend to adopt the stereotypes and ageist attitudes imposed on them by society in sex behavior (Rubin, 1968). These attitudes also negatively impact their self and body image, thereby decreasing their quality of life (DeLamater, 2012). Older adults will then suppress their sexual needs and feelings (Deacon et al., 1995). Then older adults avoid seeking help for sexual concerns due to sexual stigma and stigma-related beliefs about their sex lives in older age (Syme, & Cohn, 2016). In essence, researchers must begin to address the sexuality of older adults while considering the vital impact sexual politics and ageism have on their access to care and sexual expression. The critical analysis will begin by addressing generation cohort effects on sexual risk-taking in older adults. Next, the rates and prevalence of condom use, STIs, and HIV/AIDS risk will be identified. The analysis will conclude with a summary of the inequities present in health care and therapeutic services for older adults and suggestions for addressing older adult sexuality in education, research, and policy.

Methods

To conduct the critical analysis, the author searched published articles between 1980 and 2016 using the Academic Search Complete and PsychoINFO databases, using keywords “older adult” and “risky sexual behaviors” and “sexual risk” and “sexuality” and “elderly” as the search terms. Articles that were selected for inclusion had these search terms in either the article title, keywords, or abstract. Then, studies were found searching through the relevant articles’ reference lists for additional studies. This snowball sampling of studies was restricted to only articles with titles that met the inclusion criteria for the analysis. To qualify for the analysis, studies had to incorporate older adults and sexuality or sexual risk as the primary dependent or independent variable or use adults aged 50 and older in the sample. The search procedure yielded 35 studies for critical analysis.

Results

Before addressing the sexual risk-taking of older adults, there must be consideration regarding the cohort and gender effects of aging on sexuality and sexual expressions. Scholars suggest there are strong cohort effects on the sexual decision-making and behaviors of older adults (Rowntree, 2014). DeLamater (2012) advises the differences between generational cohorts are due to the time periods in which each cohort is born, and socialized. Those born in 1925 to 1935 were children during the great depression (DeLamater, 2012). These children are now the older adult population over 60. These children were exposed to conservative messages surrounding sexual purity, conceptive use only pertaining to preventing unplanned pregnancy, and privacy with sexual disclosure.

Baby boomers generation

Those born in the years of 1946 to 1964 were one of the largest generation of babies born in the US of 75 million with the peak of those births in 1957 with nearly 4.3 million (Adams, Oye, & Parker, 2003). This cohort of children is significant to the aging research because as they approach later life, they will be the largest cohort of elders in US history (Adams et al., 2003). These adults are relevant to sexuality and aging because during the years of the sexual resolution in the late 1960s, they were adolescents and young adults (DeLamater, 2012). Thus, they developed more liberal attitudes about sexuality (DeLamater, 2012). Researchers assert that these adults place high importance on sexual well-being, have more permissive attitudes about sexual expression, emphasize maintaining sexual activity throughout the lifespan, and exhibit a sense of control over their lives (DeLamater, 2012; Langer, 2009; Marshall, 2011; Muzacz, & Smith-Akinsulure, 2013; Rowntree, 2014; Syme, & Cohn, 2016). These significant changes in expectations and expression based on generation cohorts are shifting the value policymakers, researchers, and health care practitioners are placing on sexuality in later life. Thus, the narrative created by older adult sexual politics and ageism must be reconstructed to fit this new wave of older adults that do value and prioritize sexual needs and behaviors in later life in contrast to previous cohorts.

Physiological effects on sexual functioning

Few empirical studies exist studying the sexual risk-taking of older adults based on gender. Even fewer exist examining the sexual behaviors of older adult women. However, researchers promote there are important gender differences of sexual risk and sexual behaviors of older adults. Additionally, research examining the sexual health of older adults emphasizes the physiological differences between the gender and how these impact sexual functioning. According to Marshall (2011), research on sexuality and aging has overemphasized sexual dysfunction shaping the older adult sexual politics to include a pathological perspective on the sexual practices of older adults. There are mixed findings that address whether the biological aspects to aging limit sexual expression of older adults. DeLamater (2012) illustrates there is little evidence that the physical transitions that accompany aging affect sexual functioning. In contrast, Ponyten (2013) adds that physiological changes affect sexual responses and inhibit their sexual function as they age. There are important relationship shifts that impact relationship formation in older adults and biological differences to sexual functioning of men and women that impact sexuality as well.

Men

Older men experience different relationship transitions than women in later life. Older men are more likely to be married or remarry if divorced or widowed in later life than women (Allgeier & Allgeier, 2000; Deacon et al., 1995; Syme, 2014). Also due to women outliving men in later life, there are more sexual partners available to men in a majority of residential care facilities. They report more opportunities and frequency of sexual activity, including sexual intercourse, than women (DeLamater, 2012).

There are biological changes in men that may lead them to use erectile dysfunction medication increasing their exposure to sexual risk. Men experience difficulty in maintaining an erection, report less orgasms, and longer refractory periods (Allgeier & Allgeier, 2000; Deacon et al., 1995; DeLamater, 2012; Syme, 2014; Willert & Semans, 2000; Woodard & Rollin, 1981). These hormonal changes lead to testosterone depletion and decreased force and volume of ejaculation (Jagus & Benbow, 2002; Tsatali et al., 2011). In fact, the most common reported sexual concern is erectile dysfunction (37%) (Tsatali et al., 2011). Older men tend to remain sexually active longer with their use of erectile dysfunction medication, hence putting them at greater sexual risk (Pilowsky, 2015). Men can engage in sex longer from the medication increasing their number of sexual partners and exposure to sexual risk.

Women

Women experience differing life transitions in comparison to men. Women tend to live longer than men and are more likely to experience singlehood or widowhood in the loss of a partner with few possibilities of remarriage than men (Crooks & Baur, 2011; Deacon et al., 1995; DeLamater, 2012; Pilowsky, 2015). Due to women experiencing new sexual relationships, they are at risk for being infected with STIs and HIV with these new sexual partners (Pilowsky, 2015). Also, women can now explore their sexuality without the burden of becoming pregnant, which influences lower conceptive usage and higher likelihood of sexual activity with multiple partners (Crooks & Baur, 2011; Deacon et al., 1995; Foster et al., 2012a).

There are biological changes in women that may increase their exposure to sexual risk. After menopause, there is a decrease in vaginal secretions, muscle tension, vaginal lubrication, and vaginal contractions (Allgeier & Allgeier, 2000; Deacon et al., 1995; Gelfand, 2000; Syme, 2014; Willert & Semans, 2000; Woodard & Rollin, 1981). The most common problems reported by women is low desire (43%) and vaginal lubrication (39%), and inability to climax (34%) due to low estrogen deficiency stemming from menopause (Tsatali et al., 2011). The vaginal dryness and thinning of the vaginal wall may facilitate easier transmission of STIs and HIV/AIDs during sex (Ponyten, 2013; Slinkard & Kazar, 2011; Tsatali et al., 2011). Also after menopause, women no longer need to use birth control to prevent unwanted pregnancies; hence, women may not see the need for conceptive use as before menopause (Pilowsky, 2015).

Sexual risk-taking

Researchers are concerned at the rising rates of sexual risk-taking within this population. Scholars have found that adults over 50 years old report low condom usage in sexual interactions. In fact, only 20% of men and 24% of women reported using a condom during their last sexual interaction (Pilowsky, 2015). Additionally, they found condom usage tended to decline with age with only 17.1% for those 60-69 years old using condoms (Jena, Goldman, Kamdar, Lakdawalla, & Lu, 2010; Pilowsky, 2015). Low conceptive use, including no birth control usage by women due to post-menopause and low condom usage by both men and women, have increased the prevalence of STIs in the older adult population. Rates of new cases of Chlamydia have remained constant in those aged 55-64 and those 65 years and older (Ponyten, 2013). For men aged 55-64 years, new diagnoses of Syphilis were similar to those of younger counterparts (Ponyten, 2013). However, rates for Syphilis were more common in younger women than older women aged 55-64 (Ponyten, 2013). These statistics show that overall STIs continue to be identified in the older adult population.

There is a steady risk of older adults with substance use or addiction because of older adults living longer lives. The number of older adults seeking substance abuse treatment has increased in recent years (Pilowsky, 2015). Researchers have estimated that adults aged 50 and older with substance abuse and addiction is projected to double to 5.7 million by 2020 (Pilowsky, 2015). In fact, the baby boomer generation has the largest rates of drug use than previous cohorts (Han, Gfroerer, Colliver, & Penne, 2009). Thus, the need for substance abuse services treatment will increase and increase the need to consider older adults in treatment options as well (Han et al., 2009). These projections are concerning because studies have demonstrated that individuals with substance use abuse or addiction are more likely to engage in high-risk sexual behaviors than nondrug users (Pilowsky, 2015). The uniqueness of substance use and addiction in the older adult population is that there are increased incidences of misuse or overindulgence because most will have co-occurring disorders. Many older adults have one or more medical disorders, and both the medical disorder and prescription drugs affect sexual function (Jagus & Benbow, 2002). Many older adults will then combine their prescription drug use with erectile dysfunction medication or drugs or alcohol. Specifically, common pharmacological causes of sexual dysfunction are alcohol and tobacco (Deacon et al., 1995). This will impact their sexual relationships in increasing the likelihood of sexual risk while lowering their physical and sexual well-being. Despite the rising concern by health care providers and researchers, little research exists on the influence of prescription drugs combined with alcohol or drugs on sexual functioning (DeLamater, 2012).

HIV/AIDs risk

HIV/AIDs contraction and disease is also steadily rising in the older adult population. A vast majority of the research in sexual risk-taking in the older adult population is about HIV/AIDs rates. Systemic research about the sexual behavior of older adults in the United States is fairly recent following the examination of HIV/AIDS in older adults in 1990s (Schick et al., 2010). Presently, HIV diagnosis in the older adult population is the most published literature (Ponyten, 2013). The statistics provide evidence that HIV/AIDs diagnosis needs to be a concern for researchers and policymakers in this vulnerable population. The US Center for Disease Control and Prevention (CDC) estimated that in 2011, “3,951 new HIV cases were among adults aged 50-54, 2,312 cases aged 55-59, 1,229 cases aged 60-64, and 948 cases among those aged 65 and older” (Pilowsky, 2015, p. 52). In fact, it is estimated that by 2015, 50% of the US HIV diagnosis will be aged 50 years and older (Foster, Clark, Holstad, & Burgess, 2012b; Ponyten, 2013). Older adults report exposure to HIV through sexual intercourse with no condoms, alcohol use, and injection drug use (Brooks, Buchacz, Gebo, & Mermin, 2012; Foster et al., 2012b). Health care providers note that the higher rates of prevalence of HIV are related to the aging of the already HIV-infected population; however, there is growing evidence that the rate of HIV in older adults is not insubstantial but developing (Ponyten, 2013). Additionally, older adults living with HIV have a disproportionally higher incidence of coexisting medical disorders (Pilowsky, 2015). These adults are living with HIV as well as a coexisting medical disorder. Older adults are particularly vulnerable because most are likely to be diagnosed later in the course of the disease or receive a late diagnosis increasing their risk of morbidity (Brooks, Buchacz, Gebo, & Mermin, 2012; Pilowsky, 2015). Foster and colleagues (2012b) caution health care providers that older adults report little knowledge, personal awareness, or interests in preventing HIV thus increasing their risk due to their ignorance. Therefore when considering sexual risk-taking in older adults, health care providers and researchers will need to take into account that most older adults will have coexisting medical or substance use disorders that will factor into their treatment.

Health Care Providers

A majority of the literature on aging and sexuality has used samples from health care providers such as physicians and nurses. The literature emphasizes these professionals are more likely to have opportunities to notice sexual risk in older adults. Yet, the consensus in the literature is that health care providers do not recognize sexual risk in older adults. Scholars have highlighted health care professionals’ reluctance to acknowledge the sexual needs of older adults (Ponyten, 2013). Oftentimes, physicians do not discuss sexual behavior with older adults. In fact, in a survey of 3,005 adults aged 57-85, only 38% of men and 22% of women reported discussing their sexual behaviors with their physicians (Pilowsky, 2015). Physicians are less likely to ask older patients about their sexual history because they perceive older adults to not be at risk for STIs or because of their own uneasiness (Pilowsky, 2015). Research has shifted to elaborating on the experiences of older adults and why they are reluctant to bring up sexual concerns with physicians. Fewer than 40% of men and 25% of women report discussing sex with their physicians since age 50 and are less likely to do so over the age of 65 (Muzacz, & Smith-Akinsulure, 2013). Older adults are more hesitant to discuss sexual concerns with their physicians. They fear dismissal of their concerns, the physician will be uncomfortable talking about sexual concerns, and the physician will not provide treatment assistance for them (Lichtenberg, 2014). Actually older adults prefer their physician bring up sexual problems as a part of their assessment into their health (Lichtenberg, 2014). Pilowsky (2015) asserts the strongest predictor of STI and HIV testing is being suggested for the testing by their physician. However, if physicians and nurses are not broaching the topic of sexuality with older adults then older adults will continue to be vulnerable to sexual risk.

Long-term care facilities

Another subgroup of health care providers that are more likely to notice sexual risk in older adults are those in long-term care facilities such as nursing homes, and residential care facilities and institutions. Older adults report staying in a long-term care facility can be a barrier to sexual expression and that institutions tend to hamper engagement in sexual activity (Langer, 2009; Mahieu & Gastmans, 2015; Rowntree & Zufferey, 2015). Barriers to sexual expression include: overall lack of privacy in residential care settings; knowledge and attitudes of staff, residents, and family members; the amenities available; the lack of communication about sex and sexuality; poor health; and lack of a partner (Mahieu & Gastmans, 2015; Rowntree & Zufferey, 2015). Oftentimes, it is the staff and their beliefs about aging and sexuality that limits sexual interactions in long-term care facilities. Residents report staff displaying reactions such as rejection, disgust, and anger when they encounter older adults sexual expressions (Ehrenfeld, Bronner, Tabak, Alpert, & Bergman, 1999; Watters & Boyd, 2009). These reactions impact what behaviors older adults use to engage in sexual activity and even the frequency of sexual engagement. It seems that those in leadership in long-term care settings take extreme or all or none positions in regards to the older adult’s sexuality. Administrators assume lack of capacity in older residents coupled with the fear of abuse charges or facility investigations, which leads the facility to deprive those older adults, who have the capacity to engage in sexual activity, the right to do so causing more harm (Lichtenberg, 2014). Generally speaking, the values and attitudes health care providers and those in long-term care present are shaped by ageism and age-related stigmas.

Clinicians/Therapists

A growing body of research when examining older adult sexuality is looking into therapeutic services older adults receive and the attitudes of therapists. There is a dearth of research in gerontology issues that only 3.2% of articles from 1986-1994 addressed later life family concerns in the family therapy field (Willert & Semans, 2000). Ivey and colleagues (2000) sampled from marriage and family therapists, therapists-in-training, and non-therapists on ageist attitudes in their practice of marriage and family therapy. They found that training and clinical experience does not eliminate age-related biases and clinicians are not immune to ageist attitudes in practice (Ivey et al., 2000). Clinicians often ignore or minimize the sexual needs of older adults. Family therapists are often not trained or experienced in treating older couples with sexual concerns (Willert & Semans, 2000). They may, unknowingly, inhibit older adults from speaking frankly about sexuality with counselors (Adams et al., 2003; Muzacz & Smith-Akinsulure, 2013). Researchers suggest creating an environment that is accepting and supportive to discuss sexual concerns and behaviors with clients (Woodard & Rollin, 1981). Counselors can introduce topics of safer sex and condom use in sessions as well (Muzacz, & Smith-Akinsulure, 2013).

Discussion

The critical analysis has addressed the relevant research and literature on sexual risk-taking in the older adult population. The author has provided statistical and physiological evidence of sexual risk in older adults via their conceptive use behaviors, STI and HIV/AIDS rates, and biological transitions from aging. The author will explore future directions in education, research, and policy through the older adult sexual politics framework.

Education

Researchers suggest creating educational programs for both older adults and health care professionals as prevention methods. Programs can be created that have educational interventions for older adults that cover an array of topics on sexual expression and safe sex practices (Ponyten, 2013; Syme, 2014; Willert & Semans, 2000). The education should promote the perceptions that sexual expression is a part of the adulthood and is across the lifespan (Deacon et al., 1995; Willert & Semans, 2000). The program should have age appropriate interventions designed to increase understanding and provide skills to reduce sexual risk in older adults (Foster et al., 2012b; Langer, 2009; Ponyten, 2013; Willert & Semans, 2000). The same tactics apply to educational efforts for health care providers and those in long-term care facilities. Education must focus on shifting professionals towards more permissive attitudes (Ehrenfeld et al., 1999; Syme, & Cohn, 2016; Zeiss, & Godley-Kasi, 2001). Additionally, marriage and family therapy programs should incorporate into the curriculum training on recognizing ageist attitudes and gain experience in working with age-diverse populations (Ivey et al., 2000). In order to begin this, researchers recommend having professionals examine their own level of comfort-ability with their own sexuality and older adult sexuality (Syme, 2014; Woodward & Rollin, 1981). However within the older adult sexual politics framework, professionals may view incorporating education for professionals and adults as unnecessary because older adults are not sexual nor are being exposed to sexual risk. The framework promotes that older adult sexuality is nonexistent; thus, educational efforts have no purpose in health care and residential systems despite statistics to say otherwise. Currently, there are few educational programs for older adults and health care professionals on sexual risk-taking and how to reduce that risk.

Research

Research dedicated to older adult sexuality is steadily increasing. The demographic shift within the population has led to more prominence to studying aging and sexuality. Researchers have preliminary statistics on the rates of condom use, STI and HIV/AIDs rates in older adults; however, there are suggestions for further improvement and inquiry into this topic area. Literature on sexual risk behaviors in the US population has focused predominately on adolescents and young adults samples. There is a dearth of longitudinal studies examining older adult sexuality over time throughout the generation cohorts and as the older adult continues to age (Zeiss, & Godley-Kasi, 2001). Published literature is sparse with few longitudinal studies of sexual behavior in older adults and many national sexuality surveys concentrate mainly on younger populations (Ponyten, 2013). Many national studies of sexual behaviors have not surveyed individuals older than 50s or 60s or sample sizes of older adults have been too small to be representative of older men and women in the general population. The few large-scale national studies of the sexual experiences of older adults have focused on condom use or been exclusive to one gender (Schick et al., 2010). This type of sampling limits what researchers know on sexual risk within the older adults population.

Then many studies use variations of age to determine older adult population; meaning there is no consistent range for age to encompass the older adult population. This inconsistency in studying the exact ages or grouping all ages together can be problematic for comparison studies and making inferences about the older adult demographic. Next, to inquire about sexual expression, few studies have asked about sexual frequency, behaviors, or other assessments to examine sexual behaviors (Taylor-Jane, & Gow, 2015). These studies have limited sexual activity to vaginal intercourse, which limits the complexity of older adult sexuality. Based on biological changes, defining older adult sexuality to only include sexual activity does not adequately illustrate the sexual expressions of older adults, therefore imposes a bias on the study of their sexuality. Sexual expression should be interpreted as a broad range of physical acts including intercourse, masturbation, fondling, kissing, hugging, and emotional intimacy (Crooks & Baur, 2011; Deacon et al., 1995). When researchers neglect to consider older adult sexuality to mean all of these actions and more, they are perpetuating the older adult sexual politics and ageism into their research study.

Additionally, research is limited in examining older adult sexuality from various perspectives. A majority of the empirical studies on aging and sexuality have used specific populations such as health care providers, nurses, college students, select samples of older adults, and small and local samples (Syme, & Cohn, 2016). A small number of studies have asked college students’ attitudes toward older adult sexuality. Few studies have investigated how many older adults discuss sex with social workers, psychologists, or therapists (Ivey et al., 2000; Muzacz, & Smith-Akinsulure, 2013). Even less studies have investigated the attitudes of the older adults themselves (Syme, & Cohn, 2016). Research on older adults residing in long-term care facilities and their feelings on sexuality are rarely explored (Watters & Boyd, 2009). If the field continues to de-value empirical investigations into the experiences of older adults and their sexuality, this silencing will continue to perpetuate the sexual politics and ageism of older adults. More work must be done to include older adult’s perspectives on their sexuality into this body of research.

Last, researchers recommend that more diversity in specific groups within sampling is needed. Researchers propose incorporating more racial/ethnic and sexual minorities into research studies involving older adults. African Americans report low condom use and less comfort in talking with partners about sex and their partner’s sexual history (Foster et al, 2012a). Also, Hispanic individuals comprise the fastest-growing group of adults 80-95 (Muzacz, & Smith-Akinsulure, 2013). In fact, 49% of men and 70% of women over 50 live with AIDS of African American or Hispanic descent (Muzacz, & Smith-Akinsulure, 2013). Ethnic minorities are the highest number of those affected by STIs, and HIV/AIDs within the older adult population. Thus, researchers are encouraging further examination into older adult ethnic minorities. Additionally, sexual orientation is rarely examined as well in older adult sexuality. An overwhelming component of examining sexual orientation in the older adult population has focused primarily on men who have sex with men (MSM). Little exploration has involved samples with mainly older adults who identify as lesbian or bisexual. Those older adults that identify as LGBT range about 1.0 to 3.5 million older adults (Muzacz, & Smith-Akinsulure, 2013). Yet this specific subgroup lacks substantial empirical study, even though they make up a fair quantity of the STI and HIV/AIDS rates, and substance abuse rates. Scholars advise that there are less affirmative health care programs for LGBT identified older adults (Muzacz, & Smith-Akinsulure, 2013). Many residents rarely disclose their sexual orientation or may feel the need to hide their sexual orientation and go back into the closet (Mahieu & Gastmans, 2015; Syme, 2014). Despite this, there is growing research in the sexual behaviors of gay and lesbian older adults (Deacon et al., 1995). A richer, more complex picture of aging and sexuality is looking to explore late-life sexualities of gay and lesbian populations (Marshall, 2011).

Policy

There is little evidence that policymakers are changing policy in healthcare to address sexual risk in older adults. Perhaps the older adult sexual politics framework influences the lack of action in policy. Researchers suggest offering comprehensive training to address personal sexual values and biases to improve healthcare services (Watters & Boyd, 2009). Lichtenberg (2014) promotes creating staff policies about sexuality and capacity assessment in long-term care facilities using annual trainings and case presentations. Facilities should create an overall plan to encourage an atmosphere of awareness, privacy, and openness to the sexual health of the residents (Lichtenberg, 2014). Additionally, having documentation of sexual issues and providing staff training on how to document such things is critical as well involving the family is crucial as well (Lichtenberg, 2014). Researchers are endorsing global trainings and programs to be created to address the sexual politics and ageism in the health care system and aging field. Syme and Cohn (2016) support the recommendation stating understanding aging stigma and stigma-related attitudes will reduce the stigma through targeted and tailored interventions. Willert and Semans (2000) stresses that society must redefine sexuality and reconstruct sexual expectations and narratives that sexuality is a natural experience of older people and that there are myriad ways to express sexuality. These ideas will begin to expose the older adult sexual politics framework and eliminate the influence of ageism in institutions. Until this time, older adults will remain vulnerable to sexual risk and lack the necessarily resources to reduce risk.

Limitations

The critical analysis has several strengths in its argument for more work to be completed into older adult sexuality; however, it is not without limitations. In the search for empirical studies, the author incorporated studies that categorized older adults broadly. The author did not include or exclude articles based on the age range of the samples. The author targeted their analysis of sexual risk over a broad range of ages and not a specific age range. This inclusion criteria limits the inferences and generalizability of sexual risk-taking in the older adult population. Sexual risk-taking looks different between different subgroups of ages when one incorporates the biological differences in sexual interactions in the older adult population. Then because of the few studies that included diverse samples of race and ethnicity, socioeconomic class, and sexual orientation, the author was unable to fully incorporate discussions about how sexuality is demonstrated in each intersecting identity. Last, the author was able to pinpoint the inequalities that older adults face within health care and residential care systems using the older adult sexual politics framework. Yet, this framework was created for this critical analysis and has not been used in the aging literature. The author has found evidence for and stated that evidence in the analysis, yet there has not been empirical study of the older adult sexual politics framework. Despite these limitations, the critical analysis adds to the discussion on the growth of the older adult sexuality topic area.

Conclusions

Older adult sexuality continues to be an increasing topic of interest in empirical study. Researchers have at least established that older adults are vulnerable to STIs, HIV/AIDs, substance abuse/addiction, and other coexisting medical disorders. Even though older adults go through significant physiological changes, this in no way hinders their sexual behaviors in expression, activity, and frequency. Yet due to ageism and other stigmas, older adults are facing discrimination and oppression regarding their sexual freedoms that are influencing their susceptibility to sexual risk and access to quality care. Sexual well-being continues to be essential as we age and older adults will continue to face health disparities and their quality of life will be jeopardy without proper action being implemented in education, research, and policy.

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