ORIGINAL RESEARCH

Sexuality as experienced by older women

Renata Fernandes do Nascimento^I; Maria José Sanches Marin^II; Sueli Moreira Pirolo^III; Maria Ribeiro Lacerda^IV

^I Nurse. Master in Health and Aging from the Medical School of Marília. São Paulo, Brazil. E-mail: renatafnascimento@hotmail.com
^II Nurse. Ph.D. in Nursing. Lecturer in the Discipline of Collective Health of the Medical School of Marília. São Paulo, Brazil. E-mail: marnadia@terra.com.br
^III Nurse. Ph.D. in Nursing. Lecturer in the Course of Clinical Nursing of the Medical School of Marília. São Paulo, Brazil. E-mail: pirolo@famema.br
^IV Nurse. Ph.D. in Nursing. Lecturer at the Graduate Program of the Federal University of Paraná. Curitiba, Paraná, Brazil. Email: mrlacerda55@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.20892

ABSTRACT

Objectives: to interpret the sexuality experienced by older woman, and construct an explanatory theoretical model. Method: in this qualitative study based on Grounded Theory, data was collected in 2014 and 2015 by semi-structured interviews of a sample of 34 elderly women at the University Open to the Third Age and the Marília Union of Retirees and Pensioners (Certificate of submission for ethical appreciation No. 34866914.0.0000.5413). Results: the categories elaborated were: perceiving changes resulting from aging of interviewee and companion; pondering that sexuality continues with aging; social and cultural difficulties arising in the experience of sexuality; and seeking alternatives in order to adapt the experience of sexuality. Conclusion: the sexuality experienced by older women is permeated by physical and emotional changes, and social and cultural difficulties. Seeking alternatives for their experience, they go through adaptive processes.

Keywords: Sexuality; aged; aging; women.

INTRODUCTION

This study addresses aging and the object of the research was the sexuality of older women. Important repercussions on sexuality take place in the aging process; a plethora of prejudices and social attitudes toward these changes pose difficulties for the expression of sexuality by this population. Thus, those who have a desire for a full experience end up experiencing feelings of guilt and shame¹.

With regard to women, it is necessary to assume that at all ages, sexual experiences must be safe, free of repression, violence, and disease. Therefore, in order to achieve sexual health, there is a need to recognize and adequately address sexual desires and to treat clinical conditions and their vulnerabilities². However, although many seek health care, few professionals do research on sexual complaints³.

Ineffective care for the sexuality of older women can also be related to the current health care model in which the work process follows the biomedical logic and continues to be centered on protocols, with practices that are uncoupled with the real health needs of the people⁴.

Thus, it is understood that sexuality in old age presents specificities and its understanding brings benefits to health promotion, interfering with the well-being and quality of life of the elderly. Based on the questioning of how tolder women experience sexuality, this study aimed to interpret this experience and build a theoretical model to explain it.

LITERATURE REVIEW

In recent years, the conception and practice of sexuality have undergone changes, broadening their scope. A broad, unlimited sexual life is determined by the principle of pleasure and exercised in the field of freedom⁵.

Sexuality is the way subjects express their sex, being an important component in the structuring of the personality. It can be demonstrated by gestures, intonations, ornaments, voice. It covers the psychological, cultural, spiritual and social dimensions, and its bodily manifestation includes senses, feelings, and emotions⁶.

For psychoanalysis, sexuality involves a series of activities that promote the satisfaction of a physiological need, but it is not limited to the sexual act. It has been argued that because theresponse to sexual pleasure involves the biopsychosocial and spiritual dimensions, it forms a dialectical unit that includes sexual well-being associated with the concept of health in its completeness⁷.

This illustrates its complexity, highlighting that sexual behaviors, relationships, and meanings are rooted in a set of experiences. Each individual has a subjective experience of sexuality, as the marks of past relationships produce conscious and unconscious representations that will be reflected throughout life³.

However, there is little evidence that changes associated with aging necessarily lead to decreased sexual activity, since hormonal changes are treatable and the expression of sexuality contributes to well-being⁸.

METHODOLOGY

Qualitative research in the interpretative modality supported in the Theory Based on Data (TBD), which has the aim to develop a theoretical reference by means of empirical data from a given social reality⁹.

The objective of this study was submitted to the Human Research Ethics Committee of the Medical School of Marília, being approved under Opinion nº 776,774/2014, CAAE: 34866914.0.0000.5413. The subjects involved in the research received information as to the objectives and methodology of the study. Their participation was confirmed after acceptance and signing of the Informed Consent Term.

The places where thestudy was conducted were the University Open to the Third Age and the Union of Retirees and Pensioners of Marília, and data collection took place from August to November 2014. After analyzing the data, there was a need for an additional collection, which occurred from April to June 2015.

Semi-structured interviews were conducted using a script with questions about identification and presence of diseases, and the main question about the experience of sexuality in old age. We assigned a letter and identification number of each respondent (I), as I1, I2...

The sample consisted of 34 older women distributed into four groups. The exclusion criterion was theinability to understand verbal commands and respond to them. The inclusion criterion was age above 60 years.

During the interviews of 10 older women aged between 60 and 69 years and who have a partner, it was verified that most of them experience sexuality through sexual intercourse. Thus, the need arose for a second group composed of seven older women, aged over 70 years, who live with a partner. These reported that changes, mainly related to the partner, brought about by aging interfered in the experience of sexuality. The third group, composed of eight older women who live alone, aged between 60 and 69 years, and demonstrated to adapt their sexual experience and find alternatives to overcome their affective needs. The fourth group consisted of nine older women aged 69 years and over who have no partner and also adapt their sexuality beyond the sexual act.

Data analysis followed the Glasserian coding model, composed of two stages - the substantive and the theoretical; the first stage is subdivided into two moments - open and selective coding¹⁰.

In the open coding stage, after each interview, a detailed analysis of the testimonies was carried out, line by line, leading to the next interview. The sample groups were gradually defined by this method. The codes were written with the gerund form of the verbs in order to induce a reflection on the actions and promote theoretical sensitivity¹⁰.

In order to make the open codes more abstract, they were grouped and analyzed by means of questions about the phenomenon studied and, later, compared and clustered according to their similarities, forming the subcategories. During the analysis, the subcategories were compared and regrouped, giving rise to categories¹⁰.

As the categories were being reorganized, there was a need to carry out a further data collection to answer the questions that emerged from the comparative analysis, and this way, new categories emerged. This process of regrouping the data and connecting the categories is called selective coding⁹.

Theoretical coding was used to find relationships between categories and brought a specific and global relationship between the core and all the other categories. The data were scrutinized and then grouped into codes, which form the theory that explains the phenomenon⁹.

Regarding the theoretical codes, Glaser identified that the phenomenon is a process that must be understood in categories of five Cs, namely: a cause that leads to the phenomenon, a consequence that its occurrence triggers, two intervening conditions that can affect the phenomenon, and a central category¹⁰.

In the case of the data of the present investigation, the theoretical explanatory model is composed by the central category Experience of sexuality by older women, because this represents the connection of the other categories. The causal condition is represented by the category Realizing changes brought about by the own aging and that of the partner .

In the experience of sexuality, the elderly have to face intervening conditions that modify the way in which they experience sexual issues. These are represented by the categories : Pondering that sexuality remains despite aging and Presenting social and cultural difficulties in the experience of sexuality . As a consequence of the phenomenon, we have the category: Seeking alternatives to adapt sexuality.

The theoretical validation of the model is the verification of the abstraction of data, giving it internal consistency and trustworthiness. The proposed theoretical model was validated by four subjects, one from each sample group, who experienced the phenomenon. There was anagreement of all these subjects, and the concepts and relations of the theoretical model were, therefore, legitimized.

RESULTS AND DISCUSSION

The study had the participation of 34 older women, whose age ranged from 60 to 84 years. With regard to schooling, all were literate, and 19 had Higher Education degree, indicating a higher number of years of schooling than the majority of women in the same age group who live in Brazil. This finding may indicate that they have greater possibilities of access to health services to meet their needs.

As for the people with whom the elderly women lived in the household, 11 reported living alone with the husband, 10 lived alone, six lived with the husband and other relatives, one lived with the mother, and six with children or siblings. The most frequent diseases were Diabetes Mellitus, hypertension, thyroid diseases and hypercholesterolemia.

Four categories and respective subcategories were identified in the interpretation of the reports about the phenomenon Experience of sexuality by older women , as described below.

Category 1: Realizing changes brought about by the own aging and that of the partner

The elderly women relate the natural losses in this phase of life with decreasing frequency and desires. There are biological, psychological and social changes that can influence the way the older women experience their sexuality, which is shaped by life experiences¹¹.

The understanding of these modifications varies between subjects, with different representations of aging in each case. With regard to the meaning of aging, it was found that despite identifying negative aspects of old age, the women understand that this phase can offer plenty of opportunities ¹². Another study found that for many elderly people, aging is a natural process and a certain passivity towards sexuality happens ¹³.

With regard to the subcategory addressing the influence of the aging and sickness of the partner over sexuality , it is noticed that the older women give little attention to their sexuality because their companion is not able to respond to their needs.

The difference is that my husband is aging. He is 83 years old. It is an older sexuality, he has coagulation problems. Then we avoid sex. (I13)

Aging brings a greater chance of developing disabilities and, among elderly couples, men develop serious illnesses before women. This causes trouble to maintain intimate relationships, leading couples even to avoid them ¹⁴.

In the subcategory decreased sensitivity to touch and frequency and sexual desires, it was observed that women relate this decrease to the changes inherent to the aging process. They end up experiencing sexuality according to their possibilities, as can be seen in the following speech.

I see it as something natural. There was not a lack of interest, there was a decrease in the frequency of relations, but they exist and are still pleasurable. (I10)

Category 2: Pondering that sexuality remains despite aging

This category indicates that changes in aging do not prevent positive sexual experiences. The literature brings notes that meet what was mentioned by the interviewees. Sexuality is recognized as a component that involves feelings of attraction and desire toward the partner and that it is possible to enjoy sexual satisfaction at this stage of life ^15-18. Moreover, it is possible to explore sexuality, live new experiences and learn alternative forms of expression¹⁶.

The subcategory understanding sexuality as a physiological need that lasts a lifetime reveals the need for contact with the other in order to meet an inherent human need regardless of age.

[...] we seek each other if we need each other. So we have these physiological needs, which we do in part. (I1)

There is also evidence that sexual desire and potential persist and this leads the elderly to seek intimacy in their relationships¹⁷. The pattern of sexual response is modified, but the elderly can adapt and the relationships of seduction can be more recognized and practiced than the sexual relationship itself¹⁸.

In the subcategory perceiving herself prepared for sexuality, the older women believe that this is an unfolding of the experiences that they had throughout life.

Even after 60, he was always very active, very pleasant. So I never had a problem with sexuality. (I12)

Sexual satisfaction has a strong relationship with positive self-esteem, mental and physical health, interaction between partners, and better marital relationships¹⁹.

Category 3: Presenting social and cultural difficulties in the experience of sexuality

The data points out that stereotypes exert a great influence on the experience of sexuality. There are women who feel pressured to meet cultural norms and others who do not surrender to labeling. Society deprives the elderly of exercising their sexuality autonomously, causing them to restrain their affective impulses and even sideline them ²⁰.

Notwithstanding, the perpective of health professionals it that the relation between sex and sexuality in old age needs to move forward, because the conception of asexual elderly permeates the social environment of reality, even in the presence of new technologies²¹. Literature review shows that effective nursing care for the elderly requires knowledge about the specificities of the elderly, interest in working with this age group, and positive attitudes towards the aging process²². In line with this, the promotion of the health of the elderly requires teamwork and proactivity²³. However, studies addressing sexuality as an integral part of everyday life are scarce, which makes it more difficult to experience it in old age with naturalness ²¹.

There are elderly people who have experienced traumatic sexual intercourse in adult life and, when they reach old age, they choose not to practice it ¹⁸. Negative experiences in sexual encounters, with frustrations, disappointments, and demands, affect self-esteem and self-confidence and can lead to feelings of fear, causing repeated failures in the next relationships²⁴.

In the subcategory lack of privacy at home, it was evidenced that the fact that of living with other generations causes the elderly to lose privacy and space to experience their sexuality. Thus, it is difficult to express desires²⁵.

[...] then, sometimes we get a little constrained, although they [daughters] are adults, we won't expose ourselves before them [...]. (I1)

With regard to the subcategory overlaying sexuality in old age with prejudice, some older women reported that involvement with other partners leads to financial or affective dependence and that, in the case of the elderly, there is apreference for younger women.

Men of my age prefer younger women. For the girls, those who want to lean on a retired person, there is a lot. I can't deal with that. (I20)

Another element that society deems important for the experience of sexuality is the presence of a partner. Thus, unmarried or widowed seniors are prevented from satisfying their sexual needs and from having any intimate contact in other partners²⁶.

Category 4: Seeking alternatives to adapt sexuality

In old age, altered sexual functions make the older women express their sexuality beyond the sexual intercourse, preferring caresses, dialogue, and kisses to reach pleasure²⁷.

As for the subcategory attending networks of social interaction, leisure, physical and manual activity , it was observed that the elderly women seek activities as a way to keep themselves occupied.

[...] I think that dedicating myself to activities outside thehome has helped me to be a healthy person, to meet other people [...]. (I2)

The elderly women conquer their freedom and discover leisure by engaging in groups of coexistence, old age dances or social institutions²⁸.

This adaptive capacity is related to the use of resources in the various moments of life. In this perspective, the theory of selection, optimization, and compensation considers that these mechanisms act throughout the life in the production of an adaptive aging, and the gains and losses result from the interaction between environmental resources and personal resources²⁹.

The subcategory performing the incomplete sexual act, with games and caresses, demonstrates that women value the exchange of caresses, attention, and dialogue, even when the sexual act is not complete.

I think, at this age, it is the touch, the affection, the being together, this is already very good. And if we end up in the sexual relationship itself, in the sexual act, then it is complete. (I2)

In the subcategory maintaining a positive self-perception, it was noted that the elderly feel beautiful and seek to strengthen aspects that support their positive self-image.

I feel fulfilled when I get dressed, when I use perfume, when I go out, doing my knitting, talking, listening to music. (I21)

As for the influence of self-image in the adaptation of sexuality, it was observed that a positive image of the body and sexuality is more frequent, as well as a reduction of menopausal symptoms such as anxiety, depression, and decreased libido, among elderly women who regularly practice physical activities²⁹.

CONCLUSION

Addressing sexuality among older women represents a major challenge. However, the method used in the research favored the immersion in the data and made it possible to capture a clear understanding of how the phenomenon behaves.

Thus, in general lines, we found the theoretical model that the experience of sexuality among older women is permeated by physical and emotional changes and social and cultural difficulties. However, sexuality is sustained throughout life, with the search for alternatives for its experience, going through adaptive processes.

Among the limitations identified in the study is the difficulty for single women and widows to dialogue about their sexual experience. Furthermore, in the ​​health area, the scientific production on the theme is mostly focused on biological issues, which made difficult the necessary interlocution with the literature.

Finally, the findings of the present study suggest new inquiries. The main one would be the investigation of the possible improvements in the experience of sexuality among older people who receive support from health professionals.

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