Psychotherapy in old age: older adults’ sexual distress concerning their sexual well-being

ABSTRACT Age and sexual difficulties show a relevant influence in older adults’ sexual well-being (SWB). The objective of this study was to assess sexual issues that affect SWB, revealed by older adults in person-centered therapy, using qualitative research. Interviews with 114 older participants, aged 65 to 82 years, living in the community were submitted to content analysis. Eight main themes emerged from the results of the content analysis: Partner unavailability, family issues, physical changes, worries about hygiene, sexual dysfunctions, fear of physical abuse, and sexual transmitted diseases. This study was relevant toward identifying the sexual issues older adults feel regarding their SWB, as shared in therapy. Older adults referred their greatest issues to be partner unavailability, sexual dysfunctions and physical changes due to aging.


Introduction
The population is aging significantly, as the result of increases in average life expectancy and improvements in health intervention (United Nayions [UN], 2017). However, these marked demographic changes cause major health challenges, namely physical/motor (e.g., decreased levels of functional capacity), psychological (e.g., increased levels of depression and loneliness) and biological/somatic (e.g., increased chronic diseases; World Health Organization [WHO], 2010). In particular, sexual health is an essential multidimensional aspect of well-being and quality of life of older people (WHO, 2010). Several studies associate sexual activity in older adults with greater enjoyment of life, greater emotional well-being and higher levels of overall health (Smith et al., 2019).
Portugal is currently an aging country and one of the oldest in the world. In 2020, 18% of Europe's general population was 65 years and older and 22,4% in Portugal, (UN, 2017). Moreover, in a previous study of older people residing in Portugal, 40-60% of their responders reported being sexually satisfied (Traeen et al., 2018).

Sexual well-being in old age
Sexual activity in the senior population can be significantly affected by some biophysiological factors, such as changes in testosterone levels, somatic effects of chronic diseases and decreased functionality (Rezasoltani et al., 2016). However, sexual activity also seems to be very affected by several psychosocial factors such as the relational quality and the possibility of having a partner, the sexual past, the youthful social standards of beauty, the lack of privacy, the social and cultural perspective of phallocentric sexuality and the lack of information on sexual desire in older adults (Traeen et al., 2016). All of these factors can affect sexual well-being (Traeen et al., 2016).
Sexual well-being (SWB) has been not sufficiently explored in the literature and it is defined as a part of overall well-being and can positively influence aging well. It may include sexual interest, functioning, satisfaction, healthy intimate relationships, and sexual self-esteem . Since SWB definition has no consensus in the literature, qualitative methods have been mostly used by researchers .
Different obstacles to SWB in old age have been highlighted (Traeen et al., 2016). Some older adults report difficulties with sexual expression and in maintaining intimacy (Gareri et al., 2014). Some reveal difficulties in managing the physical changes resulting from aging, which can affect sexual self-concept and decrease attractiveness (Traeen et al., 2016;. Approximately one third of older women report vaginal dryness, significant decreases in sexual desire and increased urinary incontinence. Similarly, nearly one in two men 65 years and older report some degree of erectile dysfunction. Moreover, nearly half of older women and men do not seek help for their sexual problems, indicating embarrassment and financial cost as their main reasons However, more than half of the men and women seeking professional help report improvements in sexual function (Traeen et al., 2016).
There are different therapeutic schools and approaches regarding sexuality in old age (Peterson). Among the main problems addressed by older adults in therapy are depressive symptoms and mourning (Bryant & Chiu, 2017), anxiety, social isolation, loss of meaning and life goals, and family problems (Edwards et al., 2019;Hyams et al., 2017;. Similarly, older adults seek help from sexual therapy due to lack of sexual desire, particularly older women, and erectile dysfunction, particularly older men (Morton, 2017). Given the guilt and restrictions associated with sexual activity in old age, as well as the decreased quantity and quality of sexual arousal, so many of the sexual problems in the older adults seem to be directly associated with the psychosocial dimension (Iveniuk & Waite, 2018;Ribeiro-Gonçalves et al., 2021).

Sex therapy with older adults
Sex therapy is greatly influenced by the cognitive behavioral perspective, which has a more focused approach to sexual dysfunctions throughout the life cycle, including old age (Cooper et al., 2013). Similarly, the dynamic approach has made an important contribution to the study and promotion of adequate psychosexual development in older adults (Hildebrand et al., 2018). Systemic couples therapy has provided important and expanding evidence on addressing affective-sexual issues in older adults . Although there are not many studies, person-centered therapy (PCT) also seems to be an increasingly important approach to promote sexual health and wellbeing and manage psycho-emotional challenges at an advanced age in a variety of contexts, focusing on sexuality as an essential aspect of one's overall well-being (Cooper et al., 2013;von Humboldt & Leal, 2015a, 2015b, 2015c. Overall, research with older adults highlights the many benefits of PCT (Cooper et al., 2013). PCT was initially developed by Carl Rogers and it is essentially based on the experiencing and communication of attitudes (e.g., congruence, unconditional positive regard and empathy) (Cooper et al., 2013;Rogers, 1951). Moreover, PCT regards older adults as an integrated whole (Rogers, 1951). Individuals are seen as creative, potentially fully functioning, congruent and social, hence they have the resources needed for personal change (Cooper et al., 2013). This therapy has already been shown to have positive effects on various health dimensions of older adults, such as increasing happiness and reducing death anxiety (Heidari et al., 2016); significantly increasing self-esteem (von Humboldt & Leal, 2015b;von Humboldt et al., 2013von Humboldt et al., , 2014; promoting a more well-adjusted aging (von Humboldt & Leal, 2015b); increasing and promoting a sense of coherence (von Humboldt & Leal, 2015b); improving and motivating physical activity (von Humboldt & Leal, 2015b); better management and expression of emotions (von Humboldt & Leal, 2015b); and improving overall well-being and quality of life (Cooper et al., 2013). However, the literature supporting the sexual health and well-being benefits of PCT in older adults is very scarce (Cooper et al., 2013).
The literature on person-centered psychotherapeutic approach in older adults has several gaps, especially in the field of sexuality (Cooper et al., 2013). Several studies highlight the need for research addressing the therapeutic effectiveness of the person-centered approach to the well-being and sexual health of older people (Cooper et al., 2013). Studies are needed to establish a comparative approach between PCT and other therapeutic approaches to the treatment of sexual difficulties and promotion of sexual health in old age (Cooper et al., 2013). Studies in this field are also characterized by having small samples (Cooper et al., 2013;von Humboldt et al., 2013). Moreover, sexual health in LGBT older people has been little studied and is poorly known, and PCT can be a promising resource for this population (Koops & Frith, 2021;Steelman, 2018). Studying the sexuality of older adults in a therapeutic context is becoming increasingly relevant (Cooper et al., 2013). Therefore, the goal of this study is to evaluate sexual issues that affect SWB, which older adults show in a PCT.

Recruitment and sampling
Contacts were made with community centers and life-long learning centers between September and December, 2019. The recruitment phase for this qualitative study started by telephone and through personal contact with potential participants. The researchers collected contact information from consenting participants and scheduled an interview with them.
Data analysis was performed using the information provided by the sample during unstructured interviews. One hundred and fourteen Portuguese participants aged 65 to 82 years, were recruited. The interviews were held weekly and in an individualized format in participants' homes, with eight sessions for each participant with an average total time of 45 minutes per session (see Table 1). All interviews were conducted in an appropriate setting and under the theoretical and practical assumptions of the person-centered approach (PCA). In this sense, the interviewer mainly adopted a non-directive posture during the data collection process (von Humboldt & Leal, 2015b). During the interviews, themes focused mainly on the challenges of living and expressing sexuality in old age were addressed. After this data collection process, an in-depth reading of the interviews was carried out and a subsequent content analysis following the proposal of Neuendorf (2002). The ISPA-Institute and the William James Research Center Ethics and Coordination Committee approved this study.

Data analysis
In order to develop the content analysis, a codebook was initially created in which each category and/ or important conceptualization of the content obtained in the interviews was assigned to a code. The replicability and reliability rules of the coding process have been respected (e.g., mutually exclusive codes, consistently applied codes, coding process implemented by more than one coder; Erlingsson & Brysiewicz, 2017). All interviews were independently coded by two clinical psychologists. Also, in order to evaluate the reliability of the process Cohen's kappa was calculated (k = .89).
The coding process, after consensus on the main themes and subthemes found, was subsequently subjected to a categorization process. In this, the main themes were grouped by clear and independent categories, discussed by consensus between the two coders. First, the thematic elements were isolated and then reorganized and grouped to give an organization and structure to the information through the content (Neuendorf, 2002).
Finally, a result interpretation matrix was made, which was fundamental for the theoretical and empirical discussion of the contents obtained. Figure 1 shows the process of data collection and analysis following the guidelines of Neuendorf (2002).

Results
Outcomes indicated eight non-mutually exclusive themes that embodied different narratives reported by participants during psychotherapy when challenged on their SWB in old age. Participants did not always clearly use the word 'challenged,' however their narratives indicated contexts and indicators consistent with the perception of being challenged on their SWB. The themes are inclusive, unless otherwise indicated and the information shared by each participant may contribute to different topics. Content analysis revealed eight major themes: partner unavailability, family issues, physical changes due to aging, worries about hygiene, sexual dysfunctions, fear of physical abuse, communication issues and concerns about sexual transmitted diseases. All names are pseudonyms.

Theme 1: Partner unavailability
Approximately 40% of these participants (n = 46) verbalized that not having a partner available for sexual activity negatively affected their SWB. The main reason indicated by participants was death of partner: 'Since he was gone, sex is gone as well' (Kylie; female; 70 years old). Some participants reported their partner's cognitive decline as relevant for making them sexually unavailable. Indeed, spouses who care for their partners experience a drop of interest in aspects related to sexuality, mainly due to pre-dementia or dementia symptoms. 'In the past she was interested, now it's not the same. She forgets my name. I feel no intimacy with her and I sometimes feel I am with a stranger' (Cole; male; 70 years old).
Other participants reported unavailability of their partners because of drug and alcohol abuse. People who are heavily involved in alcohol and drugs commit much less to an intimate relationship: 'The person I am currently with has a heavy drug addiction. I don't even know how or why we're still together but I am deeply in love with them. Unfortunately, as expected, they are physically distantremarkably, in fact. So much so, that we've gone as long as months without seeing each other. Sex happens even less often and if it does, it just lasts about 5 minutes, best case scenario. After that, they immediately leave and go back to their habits, like nothing happened. I truly don't know what aspect makes me love them so much and I am aware that my current love life is a lie, but I just can't see myself shaking this toxic relationship off' (Sofia; female; 69 years old). Other participants felt their partner was unavailable for behavioral reasons: "In my opinion, narcissists are the type of people with whom it is the most difficult to sustain a minimally decent and healthy relationship, seeing as how they only value their needs. The woman with whom I am in a relationship now is significantly younger than I am (I have always been into younger women) -I am in my 70's and she is in her 50's, closing in on her 60's. As both of us got more into the relationship, she started becoming significantly more emotionally and physically distant -we would rarely see each other, sex became duller -her lack of contribution made me have to put much more effort into it, and it also made me feel as if she was only having sex with me because it further validated her appearance. And that only kept feeding her narcissism. Needless to say, I took the liberty of ending the relationship rather quickly once she started treating me as an underling" (Peter, male; 72 years old).

Theme 2: Family issues
Participants (n = 22) indicated that family negatively interfered with their SWB. Victor reported that 'after almost thirty years of marriage, I divorced my wife because it just was not working out. My family was not very fond of this decision, even though my wife and I agreed it was best for the best of us. Obviously, I wanted to move on from my marriage and find a new partner.' (Victor; male; 70 years old).
Lara added that 'when it comes to relationships, it can be very demotivating to maintain any intimate relationship. The man that I fell in love with, on the other hand, came from a relatively poor background. Well, my family would always criticize me for my preference, saying he was not worthy and just bad-mouthed him. My partner was aware of this and, understandably, began losing his patience until he eventually reached his breaking point' (Lara; female; 65 years old).
Some participants verbalized difficulties with their families accepting their gender identity. 'I am a 70-year-old woman and, while growing up, was always confused about my sexual preference -I was attracted to women and, knowing how opposed to homosexuality my family was, I found myself lonely. I lived a life in prison since I was married to another man and had two daughters. Very recently, I had guts to get out of the closet and eventually got together with another woman, the love of my life. Even though after my courageous step, they still critique me and do not accept my relationship, neither of us truly care about it' (Cora; female; 65 years old).

Theme 3: Physical changes due to aging
Participants (n = 20) indicated that physical changes due to aging were a concern for their SWB. With aging, the body undergoes changes, causing physical limitations and aesthetic changes. 'Along with wrinkles and white hair, there are many differences that affect the way we feel and perform in bed,' verbalized Irina (female; 78 years old). Some participants highlighted physical limitations. As Laura indicated 'each one has his own way of expressing sex, however we face more limitations, for instance I cannot see my vagina anymore. My hips don't let me do that anymore' (Laura; female; 69 years old).
Female participants were keener to point out differences concerning their self-image: 'As a female, for almost all my life I have been self-conscious about my self-image. Being older now, that factor has not changed and I always feel like I have to please him with my looks and whenever I have sex with a partner.' (Coco; female; 65 years old). Interestingly, men did not attribute physical changes in their partner as one of the factors associated with less sex, but rather their partner's lack of motivation. Ivan verbalized that 'It looks like she's no longer interested on sex' (Ivan; male; 75 years old).

Theme 4: Worries about hygiene
Participants (n = 16) indicated their concern and hesitation regarding sex with their partners due to lack of attention to their intimate hygiene, namely body and sex toys. Additionally, these participants were concerned with possible sexual infections and other negative health consequences. Daniel reported that 'A few moments prior to the act, it came to my surprise that she doesn't even regularly clean her vagina, seeing no problem when I confronted her about it. For me, on the other hand, that was a big problem. Needless to say, we didn't have sex that night and I don't think we will anytime soon, as we're currently on bad terms following that night.' (Daniel; male; 72 years old). Ariana added that 'not washing your hands before sex can lead to yeast infections. I know how dangerous it is for both my partner and myself to touch my vagina (specifically my vulva) with unwashed hands. At least for me, it is difficult to stop sexual passion midway to tell him to go wash his hands, besides it being awkward and, generally, end up ruining the mood. So, the majority of times, each time he initiates foreplay, I have to come up with an excuse as to why we should not do it. I don't know how to tell him and it is sending our relationship down a steep hill' (Ariana; male; 71 years old).
Some participants were also concerned with the hygiene of their sex toys. 'I am a female and, though this should be common sense, I found out hard way about how important it is to keep sex toys clean -I never really paid attention to it until the moment I got an infection from using them dirty for so long and, afterward, unknowingly, passing it on to my partner.' (Julia; female; 66 years old).

Theme 5: Sexual dysfunctions
Fourteen participants pointed out that sexual difficulties negatively affected their SWB. Sexual dysfunctions affect the ability to participate in the sexual act with satisfaction, desire, excitement, and orgasm. Mary verbalized that 'I am not satisfied with my sexual performance, so my sexual desire decreases and my sexual expression is not positive either' (Mary; male; 69 years old). Daniel explained that 'lately, I have been having trouble with erectile dysfunction. This started happening some months ago and since then, ninety percent of my sexual interactions have ended with me not even being able to reach orgasm, making it extremely embarrassing for the both of us, especially for myself' (Daniel; male; 67 years old). Jorge added that 'I am a 65 years old male who has a lifetime history of STDs -I was young and naive and didn't know any better and didn't use protection during sexual encounters. Now I'm completely unable to perform sexually' (Jorge; male; 65 years old). Indeed, when older individuals experience sexual dysfunctions or difficulties, problems also arise in remaining sexually active: 'It is not easy to be sexually active with sexual problems' (Sofia; female; 79 years old).

Theme 6: Fear of physical abuse
Some participants (n = 10) feared being physical abused and consequently avoided intimate relationships. Rita indicated that 'Personally, I have never been sexually assaulted, but my childhood best friend has. When she told me how scarring it was in the aftermath, I got so scared that I began to get overdefensive whenever someone would get within one meter of my personal bubble. It definitely did not help my social life, much less my sexual life. As an old woman, I feel that I should not be submitted to that situation, so I just have sex with myself' (Rita; female; 68 years old). Some participants shared previous negative experiences, including sexual abuse and rape, which limited their current availability for sex. 'As a young and conventionally attractive woman, I would always feel uneasy when going outside alone -creepy men of all ages would constantly look me up and down. Well, one day I had the unfortunate luck of crossing paths with a man who, apparently, didn't care about it and he ended up raping me. Indeed, I was traumatized and still am. Now I live in fear of, after all these years, going through the same experience again and I still haven't considered finding a partner, in fear of history repeating itself' (Kika; female; 70 years old). Michael added that 'whenever I try to have sexual intercourse with someone, I get hesitant, as my mind recalls, quite possibly, the most frightening moment of my life -when I, as a ten-year-old boy, was overpowered by my own father and was, sexually, taken advantage of. And though I have had a couple of attempts of sexual relationships since I was abused, they were not anything special because, just the thought of being close with someone in the same room, completely terrified me' (Nicolau; male; 72 years old).
Participants also referred the fear of new relationships as opportunities for being abused: 'After my husband died, I am alone and I don't want to risk my safety with a new relationship. There are many violent people out there' (Stella; female; 71 years old).

Theme 7: Communication issues
A few participants (n = 9) were challenged by communication issues. Some mentioned their partner did not hear them, and consequently they were not being understood, which affected their sexual expression. 'When my wife and I argue, we need time apart to reflect and we need to not engage in sexual intercourse' (Christina; female; 79 years old). Communication is important as there are shared fears and innermost desires, and that makes all the difference. In this context, some participants referred that they did not feel understood, which created problems in their intimacy: 'In addition to having to communicate with our partner, it is important to know how to express yourself, if we are misunderstood, there will be misunderstandings, which could be avoided,' explained Francisco (male; 81 years old). Some participants felt misunderstood in relation to eroticism and missed romantic demonstrations of love. Carolina explained, 'If I don't feel loved, I will not express myself sexually' (Carolina, female; 65 years old). Gabriela added that 'eroticism is essential for my relationship and it is associated with a healthy love life. If I stop being erotic, or if he stops being erotic, we will not enjoy the moment in the best way' (Gabriela, female; 65 years old).

Theme 8: Concerns about sexual transmitted diseases
Participants (n = 5) were concerned about getting sexual transmitted diseases (STDs). Indeed, worries about STDs can get in the way of satisfactory sexual relationships. 'As a female, I have always been terrified of STDs. Reading about them on the internet, made that fear much worse and, as of now, I have not had any sexual partners because, after my research on this topic, I was left with the conclusion that I am going to get a STD each time I have sex' (Rute, female; 66 years old). Other participants without a long-term partner were particularly concerned about STDs. 'During my whole life, I have had more than a handful of sexual partners, with whom I had unprotected sex. Back then, I was completely misinformed about how easy it was (and is) to get an STD. Luckily, I managed to not get infected during that time period. Now, I am terribly scared of getting into new relationships' (Orianda, female; 69 years old). Bruce added that 'my partner and I recently had sex for the first time since we started dating. That half-witted, on the spur of the moment decision is going to haunt our relationship until its very last second because it gave me genital warts. And, if the pain is unbearable while urinating, I have not even dared think about how it would be during sex' (Bruce, male; 68 years old).

Discussion
This study has the objective to fill a knowledge gap about the richness and variety of older adults' perceptions of challenges to their SWB.

Theme 1: Partner unavailability
Unavailability of a partner was the most cited theme by these participants. Most reasons for unavailability were death, dementia or chronic illness. Demographic asymmetry in older populations is one of the factors that can most impact sexual activity in old age. Overall, in western societies, there are more women over 65 than men; there are also more older women without partners than men, and more women in households than men. This demographic imbalance influences the sexual demand and receptivity in older adults. In fact, in this context, absence of a partner due to death or divorce negatively influenced older adults' SWB (Traeen et al., 2016). Moreover, some older couples, where there is dementia in a partner, report being sexually active, but there are consistently high sexual problems, and seeking clinical help is uncommon (Lindau et al., 2018). They often report significant changes in the couple's relationships, including less reciprocity, changes in responsibilities and roles, decreased shared activities and increased conflict (Holdsworth & McCabe, 2017). Likewise, caregivers of people with chronic disease and dementia are often also their partners, which increases the likelihood of emotional and physical overload in caregivers, fostering communication problems, less marital cohesion and less sexual initiative, hence negatively contributing to lower levels of SWB (Foley, 2015). The presence of chronic disease and dementia seems to decrease the amount of sexual activity and decrease sexual and relational well-being and satisfaction between partners (Dow & Malta, 2017;Foley, 2015;Nogueira et al., 2017). This de-eroticization associated with care and illness can have a great impact on the SWB of older adults (Dow & Malta, 2017).

Theme 2: Family issues
Family issues were a challenge to older adults' SWB. Indeed the sex life of older adults can be greatly influenced by the family dynamics. The establishment of new affective or sexual relationships by older adults can be hampered or even limited by their children, mainly due to social, economic and moral factors (Foley, 2015). In this sense, older people who take the initiative to create new intimate relationships may end up being estranged and rejected by their families (Traeen et al., 2016).
The family often internalizes some social myths that hinder sexual expression among older adults. The idea that sexuality is nonexistent in old age may generate feelings of rejection toward older adults' family members, but may also raise family fears associated with the occurrence of risk behaviors that may affect the health of older adults (Traeen et al., 2016). Families often benefit from greater awareness about the importance of sexual life for older adults' well-being and health and the importance of maintaining decision-making regarding their own sexual activity and autonomy (Wolff et al., 2016).

Theme 3: Physical changes due to aging
Participants felt challenged by physical changes due to aging and reported that this affected their SWB. In Western societies, aging is seen as a loss-filled phenomenon, both physical and cognitive, so the way people look at themselves in old age can be biased (von Humboldt & Leal, 2014a, 2014bvon Humboldt et al., 2013). Moreover, in advanced age it may be difficult to understand one's social value and usefulness in society, which may have direct consequences on the general self-esteem and sexual self-concept of older adults (von Humboldt & Leal, 2017). Also, physical problems arising from aging (e.g., chronic illnesses) can negatively influence older people's self-image, sexual responsiveness, sexual desire and sexual arousal (von Humboldt & Leal, 2017). Also, the decrease in testosterone levels that occur in senior age can contribute to a decrease in sexual desire (von Humboldt & Leal, 2017). This possible negative effect of aging, together with the possible decrease in functional capacity, can also affect the initiative of older people to seek partners and their openness to new partners (von Humboldt & Leal, 2017). Moreover, the very decrease in self-concept may have implications on the mood, well-being and overall quality of life of older adults (von Humboldt & Leal, 2017).
Physical appearance and self-perception, particularly body image and a sense of attractiveness, are often influenced by external social and cultural indicators (e.g., bodily ideals of beauty) and interpersonal relationships and comparisons, which may thus affect intimacy and sexuality of older adults (Traeen et al., 2016). Issues of body satisfaction and physical appearance suffer more changes in adolescence and early adulthood, but body changes, particularly weight and shape, and fat redistribution in old age may again cause some discomfort in the sexual field (Traeen et al., 2016). Other indicators, such as hair loss and decreased skin elasticity, may also induce older adults to see their body in another way, and to question some aspects of their sexual desire and SWB (Pearce et al., 2013;Traeen et al., 2016).

Theme 4: Worries about hygiene
Older participants seemed to have significant concerns about hygiene that affected their SWB, especially in what concerns body, sex toys and possible consequent sexual infections or other negative health consequences. Being sexually available, for some adults, includes feeling hygiene as relevant (Traeen et al., 2016). Thus, several studies that address satisfaction and sexual desire have been associated with various aspects of positive body image, self-perceived sense of attractiveness, and feelings of body satisfaction (Traeen et al., 2016;Woertman & van den Brink, 2012). Hence, sexual desire does not depend only on the sense of attraction toward the other, but also on satisfaction and well-being with oneself (Dow & Malta, 2017).

Theme 5: Sexual dysfunctions
Not surprisingly, our results indicate that sexual dysfunctions or difficulties negatively influence older adults' SWB. High levels of sexual dysfunctions or sexual difficulties are linked to sexual problems in later life (von Humboldt & Leal, 2017). Many older people report that they or their partners have some kind of sexual difficulty . Approximately one third of older people report at least one problem with their sexual function. However, almost two thirds of older people indicate that they feel the need to maintain an active sex life . These difficulties can affect the couple's psychological well-being and quality of life and are a major cause of depression and frustration . However, not all older people report that these problems affect their daily lives and sexual desire. Among the main strategies older adults use to deal with these difficulties are avoiding the topic and practicing masturbation . Moreover, when older people engage in sexual activity they seem to demonstrate higher quality in their relationship with their partner, better cardiovascular health and some more toned muscles (DeLamater & Koepsel, 2014).
The prevailing model of sexuality, especially in western countries, is phallocentric, that is, erection is the main criterion for the occurrence of sexual activity, hence failure or difficulty in performing sexual activities may affect SWB and involve neglecting the exploration of other possibilities of sexual stimulation that may enhance a more romantic and erotic sexuality, especially in old age (DeLamater & Koepsel, 2014). Additionally, sexual expression of older adults has been largely focused on sexual dysfunctions in a medicalized perspective and not on a salutogenic view, particularly of individuals who are not in committed relationships (Watson et al., 2016;. To prevent the decline of romanticism and increase sexual desire, a renegotiation of sex and erotic relations is often suggested, in which other types of sexual activity that do not require erection are sought (e.g., mutual genital touching, masturbation; Hinchliff et al., 2017;Watson et al., 2016). Indeed, SWB may also depend on a certain deviation from usual penetrative activities, and new stimuli and intimate experiences taken together may promote greater closeness, and may promote greater sexual satisfaction and well-being (DeLamater & Koepsel, 2014). The pleasure that comes from these activities can restore previously established bonds and improve SWB and relational quality between partners (Gillespie, 2016).

Theme 6: Fear of physical abuse
Some older participants feared physical abuse and this was specifically evident for those with a previous history of physical abuse. This result is consistent with a previous study, where approximately half of their sample treated for physical and sexual abuse had documented histories of revictimization and consequent mistrust in current intimate relationships (Friedman et al., 2017). Frailty, illness, and care dependency entail an increased risk of serious health damage because of physical violence or trauma in old age (Yon et al., 2017). Moreover, older adults' suffering is often not voiced, because of fear, shame, or dependence upon abusers, or it may not be acknowledged because of an existing disease (Berzlanovich et al., 2018). Indeed, older physical abuse seems to affect one in six older adults worldwide, however it is still a neglected global public health priority, in particular when compared with other types of violence (von Humboldt et al., 2018;Yon et al., 2017). Older victims of abuse often experience feelings of isolation, unsatisfaction within their intimate sexual life, powerlessness, alienation, guilt, shame, fear, anxiety, post-traumatic disorder and experiences of depression, and a greater risk of death (Yon et al., 2017). It is also known that sexual desire being associated with an important component of spontaneity and relaxation, ends up being very affected by situations or ghosts of abuse and mistreatment (Gillespie, 2016).

Theme 7: Communication issues
Some participants were concerned on how communication issues affected their SWB. Communication problems in married life are among the main variables contributing to relational difficulties, general malaise and sexual problems (Gillespie, 2016). The adaptive dialogue in the couple allows for the conciliation and retribution of affection, enhancing sexual desire (Gillespie, 2016). In particular, the feeling of being heard and validated by other seems to be essential and is associated with a higher problem solving rate between couples (Rosen et al., 2015). In addition, older people who have partners and who indicate that they have an active and satisfying sex life report that communication about sexual interests and desires has helped the couple synchronize sexually, and that it also contributes to the decline of sexual inhibition, thereby contributing to a better expression of sexual needs (Gillespie, 2016).
Similarly, high levels of SWB are associated with processes of intimate communication, emotional closeness, and satisfaction in a couple's relationship, which is positively associated with better chronic disease management, disease prevention, and overall health promotion and reduced likelihood of risk behaviors (Rosen et al., 2015;Traeen et al., 2016Costa & von Humbldt, 2020. Also, older couples can use maturity, relational experience and mutual knowledge as a resource to overcome the difficulties experienced through emotional expression and dialogue (Gillespie, 2016).

Theme 8: Concerns about sexual transmitted diseases
Lastly, these participants indicated their concern with sexual transmitted diseases as negatively affecting their SWB, particularly when they engage in sexual activities with new partners. Rates of STDs are increasing among older adults (Lyons et al., 2017). Many sexually active older people are aware of STDs and, to a certain extent, how to prevent them, although additional education seems necessary. A major issue is how to support older people in keeping up with trends in sexual health prevention. Educational initiatives need to be more inclusive for older people, especially older men, people with low education and others with less knowledge about STDs and safe sex (Lyons et al., 2017).

Limitations
This study shows a number of limitations. Participants were not from different ethnic backgrounds and most of them showed moderate and high levels of education and income, which may have biased the results. Particularly in the area of sexuality, PCT studies have found it difficult to recruit participants; probably due to the conservative, punitive and contemptuous pattern of sexuality in old age in western countries (Cooper et al., 2013). Many studies of PCT in older adults use self-report measures exclusively to evaluate outcomes, because of the difficulty in obtaining other more objective measures (Cooper et al., 2013). Studies of PCT, and other existential approaches, are in effect underestimated by research, whose methodological criteria to test the effectiveness of psychotherapeutic outcomes favors cognitive and behavioral interventions (Cooper et al., 2013).
This study did not include adults under age 65, which did not allow for comparing themes, such as, availability of a partner, STDs, or sexual abuse, and assessing unique themes for each age group. Future studies should allow the comparison of sexual distress and SWB in different age groups. Moreover, since the data was collected prior to the pandemic, the perspective of this relevant period is lacking. Future research should be enriched with the older adults' perspective through the pandemic as well.
In spite of these limitations, a major strength of this study is that all participants were community dwelling. Studies of PCT, particularly in the area of sexuality, can be an important resource for older people, with important social and health implications in the community (Cooper et al., 2013;Dulmen et al., 2017). Another strength is that the present study is valuable for promoting a higher SWB and quality of life in general among older adults. As indicated by the World Health Organization, studies are needed to find out how and which variables can promote successful aging, where sexuality is an essential dimension for the general well-being of older adults (WHO, 2010). Additionally, these results are relevant since older adults are still not sufficiently frequent in psychotherapy sessions.

Implications for practice and policy
The current study may be a relevant resource given the current need for validating results empirically in person-centered psychotherapeutic interventions; a current need for validation akin to that of humanistic-existential research, in the 1940s and 1950s (Dulmen et al., 2017). This study also allows the development of more and better research to identify the mechanisms that promote change in older adults in the therapeutic context and it may promote changes in the sexual satisfaction of these older adults. Moreover, this study can contribute to an integral and reflective approach to sexuality in older adults, counteracting the main trends in sexuality studies, for example focused only on sexual behavior. Indeed, this study provides rich information to health professionals and older people about their sexual issues and links both to the aging process, as well as to government policies that may promote sexual health in later life. In addition, the challenges for older adults living in the community include finding help, information, and health support.
In sum, our study pointed out that older adults felt their SWB mostly challenged by the unavailability of a partner, family issues, physical changes due to aging, worries about hygiene, sexual dysfunctions, fear of physical abuse, communication issues and concerns about sexual transmitted diseases. Further research in the context of psychotherapy is essential toward a deeper understanding of the needs and challenges of older adults, as well as for the adequate design and implementation of intervention programs to manage the aforementioned challenges among community-dwelling older adults.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Data availability statement
Data available on request due to privacy/ethical restrictions.

Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of ISPA -Instituto Universitário (Protocol code: SFRH/BPD/ 116114/2016; Date of approval: 11/7/2016). The study did not involve experimental protocols. Informed consent was obtained from all subjects.