The results of the content analysis highlighted eight non-mutually exclusive themes related to older adults’ perspectives on challenges about their SWB: 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.
This study has the objective to fill a knowledge gap about the richness and variety of older adults’ perceptions of challenges to their SWB.
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 (DeLamater, 2012; Træen 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 (Harris, Adams, Zubatsky, & White, 2011; 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; O’Shaughnessy, Lee, & Lintern, 2010). 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 (Hill, 2015).
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 (DeLamater, 2012; Foley, 2015; Hillman, 2012). In this sense, older people who take the initiative to create new intimate relationships may end up being estranged and rejected by their families (Hillman, 2012).
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 towards 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 (DeLamater & Koepsel, 2014; Rheaume & Mitty, 2008). 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 (DeLamater, 2012; Wolff, Spillman, Freedman, & Kasper, 2016).
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 (Hillman, 2012; Katz, 2010; von Humboldt, Leal, & Pimenta, 2013, 2014). 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 (DeLamater, 2012; Katz, 2010). 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 (Bachmann & Lieblum, 2004; von Humboldt & Leal,2017). Also, the decrease in testosterone levels that occur in senior age can contribute to a decrease in sexual desire (Davis & Tran, 2001; Graziottin, 2000). 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 (DeLamater, 2012). Moreover, the very decrease in self-concept may have implications on the mood, well-being and overall quality of life of older adults (DeLamater, 2012).
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 (Cash, 2004; Træen 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 (Clarke & Korotchenko, 2011; Roy & Payette, 2012). 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, Thøgersen-Ntoumani, & Duda, 2013; Træen et al., 2016).
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 (Træen 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 (Træen et al., 2016; Woertman & van den Brink, 2012). Hence, sexual desire does not depend only on the sense of attraction towards the other, but also on satisfaction and well-being with oneself (Hill, 2015; Zept, 2010).
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 (DeLamater, 2012). Many older people report that they or their partners have some kind of sexual difficulty (Hinchliff, Tetley, Lee, & Nazroo, 2017). 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 (Camacho & Reyes-Ortiz, 2005). These difficulties can affect the couple's psychological well-being and quality of life and are a major cause of depression and frustration (Hinchliff et al., 2017). 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 (Hillman, 2012; Hinchliff et al., 2017).Moreover, Brody's review (2010) indicated that 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 (Brody, 2010; DeLamater, 2012).
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, 2012; 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, Stelle, & Bell, 2016; von Humboldt, Ribeiro-Gonçalves, Low, & Leal, 2020).
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 (DeLamater, 2012; Gillespie, 2016).
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, Avila, Rizvi, Partida, & Friedman, 2017). Frailty, illness, and care dependency entail an increased risk of serious health damage because of physical violence or trauma in old age (Yon, Mikton, Gassoumis, & Wilber, 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, Schleicher, & Rásky, 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, Monteiro, & Leal, 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 (Zept, 2010).
These 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 (Byers, 2005; Zept, 2010). 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 (Byers, 2005; Rosen, Heiman, Long, Fisher, & Sand, 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 (Byers, 2005; DeLamater, 2012; Rosen et al., 2015; Træen et al., 2016; von Humboldt et al., 2016). 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).
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).
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, person-centered therapy 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 (Bentrott & Margrett, 2011; von Humboldt & Leal, 2014). Many studies of person-centered therapy 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; von Humboldt & Leal, 2014). Studies of person-centered therapy, 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 (Sousa, 2012).
In spite of these limitations, a major strength of this study is that all participants were community dwelling. Studies of person-centered therapy, 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, McCormack, & Eide, 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; WHO, 2015). Additionally, these results are relevant since older adults are still not sufficiently frequent in psychotherapy sessions. Studies of psychotherapy with older adults may be an essential 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; Sousa, 2012). These studies also allow the development of more and better research to identify the mechanisms that promote change in older adults in the therapeutic context (Sousa, 2012) and that promotes changes in the sexual desire of these older adults (Zept, 2010). Still, studies of person-centered therapy in the area of sexuality 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 behaviour (Bentrott & Margrett, 2011; Dulmen et al., 2017; WHO, 2010).
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 towards 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.