Chapter 13: Sexuality & Aging: Nursing Considerations

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Welcome back to the Deep Dive.

Today, we are going to make things a little bit awkward.

Just a little.

Okay, maybe a lot.

We are tackling a subject that, let's be honest, usually results in nervous giggling, deflected eye contact, or just total silence in the break room.

Right.

But here's the reality.

If you're a nursing student or working RN or anyone involved in holistic care, you cannot opt out of this conversation.

No, you can't because your patients aren't opting out of it.

I mean, it's happening whether you talk about it or not.

Exactly.

So we are diving into Chapter 13 of Gerontologic Nursing, the fifth edition by

the topic is sexuality and aging.

And the mission today is pretty straightforward.

We need to strip away the giggle factor.

We need to look at the hard physiology, the pharmacology, and the sociology of what happens to you in intimacy as we age.

And we need to figure out how to actually talk about it without turning bright red because if we can't talk about it, we are failing our patients, period.

So set the stage for us.

What are we actually working with here?

Because I feel like for a long, long time, the medical community just sort of pretended this didn't exist.

Oh, that's not just a feeling.

That is historical fact.

The source text makes a fascinating point right out of the gate.

Up until 2007, we were essentially flying blind regarding older adult sexuality.

2007.

That is, I mean, that's yesterday, historically speaking.

It was wild.

Right.

That was the year the National Social Life Health and Aging Project or NSHE was published.

And before that, we had almost no comprehensive nationally representative data on older adult sexual norms.

So doctors and nurses were just operating on assumptions, on anecdotes, and frankly, on stereotypes.

No.

NSHEP was the first time we had a real judder line for what normal actually looks like.

Which means there are likely senior nurses practicing today who were trained before we even had solid data on this.

Precisely.

And that lack of data fueled a lot of the myths that we are, still fighting today.

So let's get into the core theme then.

The big headline from the text seems to be that sexuality doesn't have an expiration date.

It's not like a carton of milk that goes bad the day you turn 65.

It absolutely doesn't.

And we need to be very precise about our definitions here.

The text references the World Health Organization's definition of sexuality.

If you're listening to this and you're thinking, sexuality equals intercourse, you are missing about 90 % of the picture.

Right.

Because that is the trap, isn't it?

We think about the mechanics, you know, tab A into slot B.

Exactly.

The WHO definition includes sex.

Yes, of course it does.

But it also includes gender identities, roles, eroticism, pleasure, intimacy, and reproduction.

So it's everything.

It encompasses thoughts, fantasies, beliefs.

It is a central aspect of being human, from birth until death.

Let's drill down on that word intimacy.

The text brings up a concept called touch deprivation.

I've heard this referred to as skin hunger.

Skin hunger is a great term for it.

Look, humans are tactile creatures.

We have a fundamental physiological need to touch and be touched.

And in older adults, especially those in long -term care facilities, this need is systematically starved.

And this creates a conflict, doesn't it?

Because you have a resident who is, like you said, starving for contact, and you have staff who are trained to maintain professional boundaries.

That is the friction point.

The text highlights that non -sexual touch, holding a hand, stroking a cheek, a lingering hug is vital for emotional regulation.

But caregivers often misinterpret this.

How so?

Well, if a male resident reaches out to hold a nurse's hand or touches an arm, it gets flagged.

It gets charted as inappropriate behavior.

Or assaultive or erotic.

And suddenly a desperate attempt for basic human connection is treated as a behavioral problem to be medicated or, you know, managed.

We have to separate the need for intimacy from sexual aggression.

They are not the same thing.

This feeds right into the asexual stereotype.

I think society generally views older adults in two buckets.

Either they are completely asexual, you know, grandma knitting in the corner, or if they do express interest, they are dirty.

The dirty old man trope.

Right.

It's one extreme or the other.

The reality, according to the text, is that older adults regard sexual activity as a critical component of life.

It maintains self -esteem.

We know self -worth often takes a nosedive after retirement.

You lose your job title, maybe your physical strength.

Sexual identity is one of the few things you can hold on to.

It's a way to express loyalty and affection.

But there's a logistical barrier here, specifically for heterosexual women.

The text points out that the math just doesn't work out.

The demographics are brutal.

We call it the gender imbalance.

The Administration on Aging cites that women who reach age 65 have a life expectancy of an additional 20 .4 years.

20 .4.

For men, it's only 17 .8 years.

So the dating pool shrinks.

Drastically.

Older women often find themselves without partners simply because they outlive them.

And the text makes a really important distinction here.

The so -called asexuality of many older women is often circumstantial, not biological.

It's not that they don't have the desire.

They just don't have the opportunity.

Exactly.

And yet nurses are reluctant to bring this up.

The text lists the reasons.

Ageist beliefs, fear of offending.

But I think the biggest one is just lack of training.

It's the I don't know what to say syndrome.

If you don't know the answer, you don't ask the question.

And the consequence of that silence.

The consequence is that we discharge patients from hospitals or we manage them in nursing homes with treatable sexual dysfunctions.

We fix their hip.

We manage their diabetes.

But we leave them miserable because we are too embarrassed to ask about their sex life.

Let's fix that right now.

Let's talk physiology.

Because if we are going to assess this, we need to know what's normal aging versus what's actually a problem.

Right.

The mantra here is slowing down is normal.

The text outlines the sexual response cycle excitement, plateau, orgasm resolution.

The four phases.

Yep.

And across the board for both men and women, every single phase of the cycle elongates with age.

So it takes longer to get the engine running?

It takes longer to reach excitement.

Lubrication takes longer.

Erection takes longer.

And the refractory period, that's the recovery time after orgasm before you can go again, gets significantly longer.

But and this is key for the listener.

This is not dysfunction.

No, that is the critical takeaway.

A change in timing is not an impairment.

It just requires an adjustment in expectations and technique.

If a patient thinks I'm broken because it takes me 20 minutes instead of two, our job is to say, no, your body is just 70.

That is how it works now.

And that's OK.

Let's look at the men first.

I see the term male menopause on magazine covers all the time.

Is that a real clinical thing?

Clinically?

No.

The medical community really dislikes that term because it implies a sudden drop like what happens to women with estrogen.

For men, it's much more gradual.

So what's the better term?

The preferred term in the text is ADAM.

A -D -A -M.

Break that down.

It stands for androgen decline in the aging male.

It's a slow, steady taper of testosterone.

Production goes down and clearance from the body also goes down.

And what does ADAM look like in a physical assessment?

What are the signs?

You'll see decreased muscle mass, maybe some mood lability or decreased energy.

But specifically for sexuality, you see erections that are less firm and of shorter duration.

The ejaculation is also less forceful and there is less pre -ejaculatory fluid.

Everything is just a bit less intense.

The text mentions a screening tool specifically for this, right?

Yes.

The ADAM Questionnaire.

It's a simple 10 -question screening tool.

It asks things like, do you have a decrease in libido or are you falling asleep after dinner?

If they flag on that, you follow up with blood work, check their testosterone levels and a PSA.

The prostate specific antigen test.

Right.

You have to rule out other pathology like prostate cancer.

Okay.

Now for women, the change is much less subtle.

Menopause is a cliff, not a slow decline.

It is.

You have a very sharp decrease in estrogen and adrenal androgens.

And the physical changes can be quite uncomfortable.

The big one to know for your exams is atrophic vaginitis.

Just the name sounds painful.

Well, it can be.

It describes the thinning of the vaginal walls,

the rugae, those are the little ridges inside that allow for expansion.

They flatten out.

So the vagina actually shortens and narrows and lubrication decreases significantly.

And all of that leads to dyspareunia.

Dyspareunia, which is just the medical term for painful intercourse.

And the text states this affects about one third of sexually active women over 65.

One third.

One in three.

That is huge.

It is huge.

And it creates this vicious cycle.

The pain leads to fear of pain.

That fear causes involuntary spasms of the vaginal muscles.

That's a condition called vaginismus.

So even if she wants to be intimate, her body is physically locking down to protect itself.

It's a protective mechanism, but it completely shuts down the possibility of intimacy.

And if a nurse just assumes, oh, low libido is normal for older women, they miss this completely.

They miss that she wants intimacy, but hurts too much to have it.

That's it.

Exactly.

And the treatment is often incredibly simple, which we'll get to later.

But you have to identify the problem first.

You have to ask.

Okay.

Before we get to the fixes, we have to talk about the silent culprits.

The text has a table, table 13 to one, that lists how common medications sabotage sexuality.

This section blew my mind.

It is the most common iatrogenic cause of sexual dysfunction.

Iatrogenic, meaning we, the healthcare providers, cause this with our prescriptions.

So let's run through the heavy hitters.

What's at the top of the list?

Antihypertensives.

Blood pressure meds.

Specifically beta blockers and thiazide diuretics.

These are standard of care for heart health.

They are prescribed to millions of people, but they are notorious for causing erectile dysfunction in men and decreasing desire in women.

And here's the clinical scenario I see in my head.

You have a male patient with high blood pressure.

You prescribe a beta blocker.

He comes back in three months and his pressure is sky high again.

Why?

Because he stopped taking the pill.

He chose his erection over his blood pressure.

We see this noncompliance constantly.

If you don't warn them about the potential side effect or offer an alternative medication, they will just quit the med and they won't tell you why.

What about antidepressants?

That's another huge category.

SSRIs and tricyclics.

These are interesting.

They can inhibit desire for sure, but they are famous for blocking orgasm, especially in women.

It's called anorgasmia.

So you can get aroused.

You can participate.

But you physically cannot cross the finish line.

And you can imagine how incredibly frustrating that is for patients.

And alcohol.

I feel like people use alcohol to get in the mood.

Shakespeare said it best.

It provokes the desire, but it takes away the performance.

It's a central nervous system depressant.

It might lower your inhibitions, but it creates a physiological barrier to arousal and performance.

And one more category the book highlights.

Anticholinergics.

Yep.

These can impair ejaculation.

The takeaway for the students listening is so simple.

If a patient complains of a new sexual problem, do not just assume it's aging.

Look at the med list.

If you started a new beta blocker two weeks ago, that's your prime suspect.

It's not just the meds though, is it?

It's the diseases themselves.

Section three of the chapter, specifically box 13 to one, outlines the impact of all these chronic illnesses.

Right.

The pathologic conditions create both physical and psychological barriers.

Let's look at cardiac issues.

The classic movie trope.

The old man has a heart attack in bed.

Exactly.

And that fear is pervasive.

If a patient has angina or a history of a myocardial infarction, they or their partner are often terrified that sex will kill them.

They view an elevated heart rate as a harbinger of doom, not excitement.

So they just abstain out of fear.

Correct.

Then look at diabetes.

It's a vascular and neurological wrecker.

Since arousal relies on good blood flow and intact nerve sensation, diabetes is a leading cause of ED in men and reduced sensation or lubrication in women.

And what about something like arthritis?

That seems purely mechanical.

It is, but it's debilitating.

If your hips or your knees are chronically inflamed, traditional positions like the missionary position can be excruciating.

Pain is the ultimate killer of desire.

And the text also mentions surgeries, specifically things like prostatectomies, mastectomies, and ostomies.

These aren't just mechanical, are they?

No, these strike at the core of body image and self -esteem.

A mastectomy changes how a woman views her own femininity and desirability.

An ostomy having a colostomy bag creates a massive fear of odor or spillage during intimacy.

It's not just, can I perform?

It's, am I still desirable?

That's the core question they're asking themselves.

Okay, I want to pivot to a section of the text that I think catches a lot of people off guard.

The text spends a significant amount of real estate on HIV in older adults.

The HIV paradox.

Why is it a paradox?

Well, because we have spent 40 years thinking of HIV and AIDS as a disease of the young.

But the data shows a rising incidence in people over 55.

And tragically, the progression from diagnosis to full -blown AIDS is often faster in older adults.

Because their immune systems are already waning due to normal aging.

It's called immunosenescence.

So the virus has less of a fight on its hands.

So why is this happening?

What is driving these infection rates in the nursing home demographic?

It is a perfect storm of biology and sociology.

First, let's talk biology.

Remember atrophic vaginitis, that thinning vaginal tissue we talked about.

Right.

Thin tissue tears easily.

We're talking about micro tears during intercourse.

Those tears provide a direct superhighway for the virus to enter the bloodstream.

So an older woman is physiologically more vulnerable by transmission than a 25 -year -old.

Wow, I never would have connected those two things.

What about the sociology piece?

It comes down to condoms, or really the lack of them.

Older women who are post -menopausal have stopped worrying about pregnancy for decades.

In their mental model, condoms are for birth control.

If you can't get pregnant, why use one?

They completely forget the infection control part.

They don't see themselves at risk.

And there's a power dynamic too, right?

Absolutely.

Remember that gender imbalance.

If an older woman finally finds a partner after years of being alone, and he says, oh, I don't like using condoms, she is statistically much less likely to argue.

She doesn't want to risk losing the relationship.

That is a really difficult dynamic.

And I imagine the diagnosis gets missed because doctors aren't looking for it in that population.

100%.

A 75 -year -old presents with weight loss, fatigue, and night sweats.

The doctor thinks cancer.

They think tuberculosis.

They do not think HIV.

So the diagnosis comes late, often when the immune system is already crashed.

Let's move to another incredibly sensitive area.

Cognitive impairment,

dementia, and sexuality.

This is where the lines get really, really blurry in a clinical setting.

This is, I think, the hardest part of long -term care nursing.

The text discusses what is often labeled as hypersexuality or inappropriate sexual behavior.

Things like public masturbation, stripping, propositioning staff.

Yes.

And the knee -jerk reaction in a facility is to stop it.

Immediately.

Mr.

Jones, put your pants on.

But the text urges us to perform a root cause analysis.

We have to be detectives, not just disciplinarians.

We do.

We have to ask why.

Is Mr.

Jones stripping because he's trying to be sexual?

Or is the room 80 degrees and he's overheating?

Or his clothes are too tight.

Exactly.

Is he touching himself because he's masturbating, or does he have a urinary tract infection and he's in pain?

Is his bladder full?

Is he just bored?

So behavior is communication.

Always.

Especially in dementia.

And if it is a sexual need, if he is masturbating because he has a need for release, the management shouldn't be shame or punishment.

It should be privacy.

So you don't scold him?

You don't.

You gently guide him from the hallway to his room.

You close the door and you give him dignity.

What about relationships between residents with dementia?

This is the ultimate ethical question.

Can two people with Alzheimer's consent to a sexual relationship?

This is the gray area.

The nursing role here is to assess capacity.

Does the resident recognize their partner?

Do they understand the nature of the act?

Is there any coercion involved?

That sounds incredibly difficult to assess.

It is.

Sometimes we have to involve families or surrogate decision makers.

But the text is clear.

A diagnosis of dementia does not automatically strip a person of their right to intimacy.

We have to balance safety with autonomy.

It's a constant balancing act.

We've covered the myths, the physiology, the meds, the complex cases.

Now for the listener who is thinking, okay, I get the theory, but how do I actually start this conversation on a Tuesday morning during rounds?

The awkwardness hurdle.

It is the biggest barrier to assessment.

It really is.

The text suggests the PLISSIT model.

That's P -L -I -S -S -I -T.

Walk us through that framework.

It's a stepped approach and it's brilliant because it's designed to let you handle what you can and refer what you can't.

It gives you a roadmap so you aren't just winging it.

Okay, start with P.

P stands for permission.

This is just raising the topic.

You are giving the patient permission to talk about it.

You might say something like, many of my patients who've had heart surgery have concerns about intimacy.

Is this something on your mind?

That's low pressure.

It normalizes it immediately.

Hmm, very.

Next is L -I, limited information.

This is where you give basic facts to correct myths.

For example, it is actually normal for it to take longer to get an erection now that you're taking this new blood pressure medication.

You aren't doing deep therapy.

You're just providing concrete facts.

Okay, so after P and L -I, we have S -S.

S -S is specific suggestions.

This is actionable, practical advice.

Here is a water -based lubricant that might help with dryness.

Or have you tried taking your pain medication about 30 minutes before you plan to be intimate?

So this is where we get into problem solving.

And finally,

I -T is intensive therapy.

This is for deep -seated psychological issues or complex dysfunction that's beyond our scope.

This is where you recognize, okay, this is above my pay grade.

And you refer them to a sex therapist, a urologist, a gynecologist.

And realistically, most bedside nurses are going to live in the P, L -I, and S -S zones.

Exactly.

You don't have to be a sex therapist.

You just have to be willing to open the door to the conversation.

Box 13 -2 gives some tips for the interview itself.

What stands out to you there is most important.

The environment matters.

You can't ask these deeply personal questions when the door is open and the housekeeper is mopping the floor.

It needs to be private, quiet, eye -level.

And the language.

The text is very specific about language.

It's huge.

The text explicitly says, to use the word partner, instead of husband or wife.

To be inclusive of LGBTQ plus patients.

Right.

You don't know your patient's orientation.

If you ask a 70 -year -old man, do you have a wife?

And he's gay, he might just say no.

And the conversation ends right there.

If you ask, do you have a partner?

You signal that you are a safe person to talk to.

And avoiding slang is a big one.

Please keep it professional.

But also avoid vague euphemisms.

Don't say down there.

Say genitals.

Say pain with intercourse.

Be direct and clinical.

If you are embarrassed, the patient will be embarrassed.

You set the tone.

So when we're charting this, the text distinguishes between two main diagnostic labels.

What are they?

Yes.

There is ineffective sexuality patterns and sexual dysfunction.

And they're different.

What's the core difference?

Ineffective sexuality patterns is usually about a concern, a conflict, or a change in life.

Maybe a recent widow who is struggling with the idea of dating again.

Or someone worried about how their mastectomy will affect their image.

It's more psychosocial.

And sexual dysfunction.

That's more physical.

It's the actual inability to perform or enjoy the act.

The ED, the dyspareunia, the vaginismus we talked about.

One is often about coping and adjustment.

The other is about physical mechanics.

So we've assessed, we have a diagnosis.

Let's talk interventions, section seven.

What can we actually do to help?

Education is the single biggest intervention we have.

Let's look at the women first.

For atrophic vaginitis, that dryness and thinning, the number one intervention is recommending water -based lubricants.

Why do you emphasize water -based?

That seems like a small detail.

It is a crucial detail.

Patients will often grab whatever's in the medicine cabinet.

Petroleum, jelly, Vaseline, baby oil.

You cannot use oil -based products.

Two big reasons.

First, they can harbor bacteria and cause really difficult to treat infections in that already thin, vulnerable tissue.

Second, and this is critical, if they are using condoms for STI prevention,

oil breaks down latex.

It literally dissolves the condom.

Withdraw immediately after ejaculation.

It's an incredibly practical piece of advice that you're not going to find in most standard care plans.

The text also has a diagram, figure 13 to one, about positioning.

Yes.

This is for our patients with arthritis or other physical limitations.

If you have a patient with severe hip arthritis, the missionary position can be excruciating.

The nurse can teach side -lying positions or using pillows under the knees for support to make intimacy possible again.

We also need to talk about the institutional barriers.

If you're living in a nursing home, privacy is basically nonexistent.

It is the biggest environmental barrier.

But nurses can fix this.

It costs zero dollars.

It's as simple as creating and using a do not disturb sign.

Groundbreaking technology.

Truly.

It's about respecting that this is their home.

Or if a resident has a roommate, schedule private time.

You can ask the roommate if they'd like to go to the activity room for bingo for an hour.

You facilitate that space.

And for married couples in the facility.

Push the beds together.

It drives me crazy when I see a married couple of 50 years in a facility with two twin beds separated by a nightstand.

Let them sleep together.

We need to train our snap that intimacy is a right, not a problem behavior.

Finally, the text touches on the LGBTQ plus experience in aging.

We call this the double burden.

These older adults face ageism because they are old and they face homophobia because they are gay.

And they often have less support.

Right.

They are often less likely to have children to support them.

And tragically, many who have been out their whole lives will go back in the closet when they enter a nursing home because they are terrified of discrimination from staff or other residents.

So the intervention is creating a culture of safety.

Absolutely.

It's about validating their relationships, treating their partners as family, not assuming heterosexuality.

It's about signaling with your words and actions that they are safe with you.

This has been a massive topic.

If we zoom out, what is the core message here for our listeners?

The message is that success isn't always intercourse.

We get so hung up on performance.

The real goal of nursing care here is satisfaction, adaptation, and intimacy.

Maybe that means sex.

Maybe that just means holding hands without being judged.

But it means recognizing that the need for connection is a vital sign of quality of life.

I think that is the perfect evaluation metric.

Do we help them maintain their connection?

Exactly.

I want to leave our listeners with a challenge.

We talked about bias.

I want you to honestly check your own knee -jerk reaction.

Next time you are in clinicals, if you were to walk into a residence room and see two older adults being intimate,

what is your first feeling?

Is it disgust?

Is it humor?

Is your first instinct to run to the nurse's station and make a joke about it?

Or do you feel respect for their humanity and their continued capacity to love and connect?

That reaction tells you everything you need to know about where you need to grow as a clinician.

A huge thank you to Sue E.

Miner and the authors of Gerontologic Nursing for this incredible, important material.

And thank you to you, the listener, for sticking with us through the awkwardness.

Keep asking the hard questions.

This is the Last Minute Lecture Team signing off.

Stay curious.