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The increase in the world elderly population brings with it attempts to ensure healthy aging, offering quality of life for individuals in this age group (Beard et al., 2016; Steptoe et al., 2014; WHO, 2015). Human sexuality represents one of the main aspects considered in the concept of quality of life, and sexual satisfaction in the elderly is related to improving the quality of life in this population (Delamater & Karraker, 2009; Giami, 2002).
Despite the decline in the elderly’s sexual activity and the fact that its prevalence varies between 26 and 73%, several sexual behaviors are observed which indicate the importance of sexuality for older individuals (Freak-poli et al., 2017; Laumann et al., 2007). Sexual difficulties have been reported in this age group, in both genders: in women, 55% report some type of sexual problem, the most prevalent being loss of desire, little vaginal lubrication and difficulty in reaching orgasms, and among men, although desire remains relatively stable throughout life, most complain of erectile dysfunction (Træen et al, 2016).
Research on sexuality in the elderly has mainly explored sexual dysfunctions, individual factors and biological aspects, with quantitative investigations predominating (DeLamater J, 2012). However, there are few studies on the elderly’s own perceptions of their difficulties or facilities and on factors related to marital relationship and the non-genital experience of human sexuality (Nienaber et al., 2014; Gott & Hinchliff, 2003)
In a recent literature review of qualitative studies on sexuality in the elderly, it was found that society’s perceptions of their being asexual or sexually incapable have a negative influence on the expression of sexuality by this age group. The worsening of older people’s and their partners’ physical health - and not exclusively their age - as well as the couple’s level of intimacy influence their sexuality in different ways, without a linear relationship between sexual dysfunction and sexual satisfaction (Gewirtz -Meydan et al., 2018).
The concepts of sexuality, sexual desire and sexual satisfaction seem to change with aging, and the elderly’s understanding of such issues is important (Trudel et al., 2014). In elderly couples, aspects of their relationship, such as the partner’s characteristics and length of relationship, influence the quality of the sexual relationship, differing between genders (Morton et al., 2014).
In qualitative analysis studies, elderly couples who reported sexual satisfaction showed greater synchrony and communication in the relationship, as well as mutual empathy and openness to new sexual experiences. The expression of sexual desire was influenced by the sexual roles developed in the relationship and the partner’s emotional state (Frederick et al., 2016; Ménard et al., 2015).
Few studies involving these aspects are found in the scientific literature, and there is a need for qualitative studies addressing sexuality in elderly couples (Fileborn et al., 2017; Garrett, 2014; Witherow et al., 2017). A better understanding of sexual satisfaction in elderly couples requires a comprehensive approach to contextual factors between partners. Understanding the marital relationship in the elderly through their own perceptions and how it influences the couple’s sexual satisfaction can contribute to improving the quality of life of this age group.
This study aimed to understand the experience of sexuality in elderly couples monitored at the geriatric outpatient clinic of a referral hospital in northern/northeastern Brazil.
Methods
This is a descriptive and exploratory study of qualitative nature. The researchers intended to understand the experience of sexuality in elderly couples by learning about and analyzing aspects of sexual activity, sexual satisfaction and marital relationship throughout life.
Sample
The choice of the participants for the research was made through the understanding of the functionality and profile of the patients followed in the geriatric outpatient clinic of a reference hospital in Pernambuco, Brazil. The main researcher followed this service during two months (March and April, 2019) and explained the objectives of the research to the responsible geriatric doctors, who suggested elderly couples who might be available for the interviews.
The elderly, after screening by the preceptors in order to assess the inclusion (at least one of the spouses’ being monitored at the outpatient clinic) and exclusion criteria (dementia syndrome or inability to speak), were approached in the waiting room for medical consultation. Twelve couples were approached during the data collection period (May, June and July, 2019), and six of them agreed to participate in the research, signing the Informed Consent Form (ICF).
Procedures
The couples who signed the ICF were taken to a private room by the main researcher and participated in the interview (whose duration varied between 30 and 60 minutes), conducted by the researcher himself. The interview was carried out at different times for each spouse, without a pre-established order, in order to avoid any embarrassment.
Initially, a questionnaire was applied for socio-demographic data collection referring to sex, age group, marital status, education, employment status, ethnicity, religion, origin, place of birth, family income, length of time living together, number of children and psychiatric history. Then, a semi-structured interview was conducted, and the following question was used as a triggering factor: How do you understand sexuality and sex? Throughout the interview, guiding questions were used with reference to the importance of sex, individual sexual satisfaction and in the relationship, factors that influence the couple’s sexual satisfaction and the approach to sexuality in medical consultations. The interviews were closed at the end of the 6th couple’s interview, as the research objective was achieved and the contents began to be repeated.
The interviews were audio-recorded, literally transcribed and identified according to the nomenclature W (wife) and H (husband) followed by numbers to characterize the participants. The analysis was carried out according to Minayo (2013), using the content analysis technique (thematic modality) and comprising the following steps: pre-analysis - free reading to apprehend in an unstructured way important aspects of the material and then organize and hypothesis formulation / reformulation; exploration of the material - reaching core text comprehension through categorization - and interpretation of the results obtained.
The research risks were minimal and there was no identification, in the participants, of any discomfort or psychological demand, with no psychiatric / psychological support being necessary. The study was approved by the Research Ethics Board, according to CAAE 07936018.4.0000.5201.
Results
The sample consisted of six heterosexual couples (12 participants), who were interviewed individually. The participants’ age ranged from 55 to 77 years (mean 63.6). The couple’s relationship time ranged from 22 to 54 years (mean 35.3); they were mostly retired or pensioners with an average family income of 1.3 minimum wages. The minimum age variation (55 years) is explained by the age of two wives who were both not attended to by the abovementioned geriatric service. The remaining socio-demographic data of the study population are described in Table 1.
Table 1 Complementary sociodemographic data.
| Age | Race | Number of children | Religion | Relationship time | Clinical diseases | |
| Couple 01 H W | 67 55 | Pardo Pardo | 11 | Protestantism Catholicism | 22 22 | Coronary disease Diabetes Mellitus |
| Couple 02 H W | 63 51 | Pardo White | 2 | Catholicism Catholicism | 32 32 | Parkinson disease None |
| Couple 03 H | 72 | Pardo | 4 | None | 37 | Stroke |
| W | 58 | Pardo | Catholicism | 37 | High blood pressure | |
| Couple 04 H W | 68 63 | Pardo Pardo | 3 | None Protestantism | 44 44 | None None |
| Couple 05 H W Couple 06 H W | 68 62 77 70 | Black Pardo Pardo Pardo | 2 5 | None Catholicism Catholicism Catholicism | 23 23 54 54 | Diabetes Mellitus Bowel cancer Diabetes Mellitus High blood pressure |
The thematic groups that emerged from the interviews and their categories are described in Table 2 and throughout the text. The participants’ statements according to the themes will be illustrated with quotations throughout the text, with the couples being identified by numbers from 1 to 6; males by the letter H (husband) and females by the letter W (wife).
Table 2 Thematic groups and categories that emerged from the interviews with the elderly couples.
| Thematic groups | Thematic categories |
|---|---|
| Experience of sexuality throughout life | Decreased sexual satisfaction Importance of sexuality |
| Contextual factor | The male partner’s characteristics Occurrences and difficulties in living together Perceptions of the partner’s sexual difficulties |
| Desire, sex drive and (non) sexual satisfaction | Sexual activity restricted to the genital area Incapacity for the sexual act and suffering |
| Discussion on sexuality in medical consultations | Sexual desire decreased in women Shame and few opportunities |
The experience of sexuality throughout life
The first thematic group addresses the changes perceived by couples in relation to sexual satisfaction and the importance of sexuality throughout life. As illustrated in the quotations below, it was noticed, in most statements, that sexual satisfaction decreased with advancing age.
“There’s a great difference; in the past, it was all good.” (H1)
“Today, I don’t notice anything else; I did in the past; it was all good, but today there isn’t; it isn’t good; there isn’t.” (W1)
“No, at the beginning, there was a great sex drive, and it was very good. If we didn’t stop it, we would do it all day.” (H6)
“For me, sex was almost an obligation; it wasn’t for pleasure.” (W6)
Only one husband (H2) reported improvement in sexual satisfaction with his wife over time, and this finding was interesting because it differed from the discourse of the wife (W2), who had the perception that the couple’s sex life was unsatisfactory, despite the fact that they were sexually active at the moment. This was the only couple who differed in their statements regarding sexual satisfaction through life. The quotations below illustrate this difference in discourse.
“I think that it’s not very good. We haven’t done it as often as we did before. It’s not that we don’t do it, but I think that something is missing for us to revive it.” (W2)
“I think it’s better because after you have been together for thirty some years and still have, how do you say it, the drive to have sex with that person regularly. I believe it has changed for better.” (H2)
The participants had different perceptions of the importance given to sexuality throughout their lives, but they tended to consider that, at the present time, sexuality was not as important as it used to be before, although they found sex important and very good. This category is illustrated below:
“Not anymore, now; it’s not really so important. It used to be; I used to like having sex a lot.” (H4)
“For me, it was important in the past; nowadays, I think that I have stopped; I think that, nowadays, I take care of two grandchildren; one is ten years old, and he is an autist, and there the one who is five years old. And I dedicate myself to the church, attend my services, go to the afternoon prayers.” (W4)
“I have the drive, but not as much as when I was young; it’s different when you are young... it’s like when you are at war. Then, after a certain age, your mind starts changing, and your body reacts. Your thoughts change.” (H5)
“In the past, it was important, not now. I’m not interested in it anymore.” (W5)
Contextual factors
The second thematic group refers to the problems that were revealed through the marital relationship throughout life and that interfered in the elderly couples’ sexual life. The male partner’s characteristics was widely perceived by almost all the wives and had a negative influence on marital and sexual quality. The personality traits that were characterized as robustness in rude attitudes and behaviors were the most frequent in the wives’ discourse, but passivity and lack of attitude in certain situations were also reported.
“[...] his personality is that he is a very difficult person; he’s very rude; he has always been, but he’s become worse over time; then, it kept hurting, hurting, hurting me.” (W1)
“I think he should have, be more ... how can I put it ... be more active, you know?” (W2)
“I don’t know if I felt hurt; things during the whole relationship, as time passed, the impoliteness, all the rudeness ... I think this remains in our subconscious.” (W6)
Events occurring to the couple and difficulties in living together had a limiting effect on sexual life over the relationship. For example, the unfaithfulness of one of the spouses that had not been forgiven by the other partner and resulted in persistent heartaches, loss of intimacy and interest in sexual activity. Difficulties in living together, such as fights during the relationship, were also attributed as reasons for change in sexual life and reported by almost all the women as factors that caused hurt feelings and decreased sexual desire.
“So, I think that caused the desire to decrease; we were constantly fighting; every time he came, he didn’t fight ... but I did.” (W1)
“[...] at first, everything was fine, then, suddenly it got cold because he did a lot of bad things to me, I think I had sex only with him because ... I think it wasn’t even because I had pleasure; we had a home, you know?” (W3)
“[...] until one day when he said ..., he compared me to a street drunkard; he said it was better to sleep with a drunkard than ... then, he said a name ..., with him in bed than sleeping with a ... then, he cursed me. Then, what did I do? I started sleeping in the living room, do you understand?” (W4)
“When the person is well treated, you know, the person feels good. But every time something hurts you, you start disliking it, the pleasure, do you understand?” (W5)
The other spouse’s perceptions of one’s sexual difficulties emerged in the statements, and it was understood that most of the wives perceived their husbands’ sexual difficulties (notably erectile dysfunction) and their associated suffering. The impressions about the effects of such difficulties on their mental health also emerged, as in the example provided by W2, who realized that her husband’s main problem was psychological, although he also had an erectile dysfunction. What we found in the husbands’ discourse was different, as they rarely perceived their wives’ sexual difficulties or desires, except for H5, who realized that his wife’s illness (bowel cancer) made her more fragile and uninterested in sex.
“Yes, once or twice, depending on how he is feeling. He wants to do it, but he can’t.” (W1)
“But as I say, it wasn’t even a question of erection, for example, of thinking that he had sequelae; no, that’s not it. It’s more like ..., I think it has affected him more psychologically, in his case.” (W2)
“Today, with her, I think she actually doesn’t want to do it, and today I’m the one who doesn’t want it anymore. It’s over for me; I joke; I fool around; I tell her that we sleep in the same house but sleep separately.” (H4)
“In fact, I feel a little bit like ... she’s sick, you know? She is sick and so, she can’t; I complain about this, she complains about that ... the fact is that it has happened, and now it’s all together.” (H5)
Desire, sex drive and (non) sexual satisfaction
The third thematic group refers to the preferences for sexual activities expressed in the statements and their relationship with the sexual desires and difficulties encountered. Most husbands understood sexual activity as restricted to the genitals, with the phallocentric pattern predominating in their sexual relations throughout life, unlike women, who reported romantic and intimacy factors as the most important in their sexual relations. Such differences are noted in the quotations below:
“No, no. Sex is basically only penetration.” (H1)
“I think it’s only penetration; it’s only when you penetrate that you feel pleasure.” (H3)
“I think it’s caress. I've always stressed that; first you have to create the atmosphere, the caress, love, to be able to have normal sex, with pleasure, do you understand?” (W4)
“I think so, I think that first there is love, what you need, affection, and then the person will try to feel something, right? It’s not just coming and taking it and wanting you to give it, isn’t it, doctor?” (W6)
The incapacity and suffering in not performing the sexual act was very prevalent in the husbands’ discourse, since most of them had sexual desire, but suffered with significant erectile dysfunction, making it impossible to perform the sexual act. The feeling of frustration and anguish in the husbands’ discourse due to non-sexual fulfillment and the attempts to solve this problem are highlighted. Some wives also reported psychological distress in relation to this, as can be seen in couple 1.
“I get aroused, but I can’t; the desire comes; do you understand, doctor? Only God knows how much I feel it.” (H1)
“I am aroused, so when it comes and the act doesn’t happen, then I feel pain; I feel pain in the bottom of my belly; then, I feel that desire.” (W1)
“At home, having a wife and doing nothing with her, I mean... it’s like you’re dead. I try, try, try and try, and I can’t.” (H3)
“Ah, as I said, I will always have desire, but I need money and I need pills. I really get aroused; nowadays, I don’t feel it so much because the potency is less and less.” (H4)
Unlike the husbands’, it was observed that the wives’ sexual desire had faded, but the factors involved ranged from their partners’ erectile dysfunction (W1), repressive religious morals (W5) and clinical conditions (depression and cancer). Anguish and suffering were also found in the wives’ discourse, and some of them even questioned whether they themselves had a problem.
“I am aroused, but it’s not possible, you know; then, I prefer to stop; then, I prefer to stop and pretend that it doesn’t exist.” (W1)
“You start feeling that you have faded, that you’re dull. Suddenly when you are stimulated, like when watching a film, I realize that is not true. So, it’s a question of being stimulated, you know, doctor? I was already thinking that I had a the problem.” (W2)
“Today, I think that I could sum it up about myself like this: I don’t feel like taking care of myself anymore; I don’t have what other women have anymore, do you understand?” (W4)
“At first I had desire, then, in confession, the priest asked about the sin against chastity, and I don’t cheat on my husband, so he said: “and what about masturbating?”; I used to masturbate, and this is a sin against chastity... then, after that, that was it, the desire disappeared.” (W5)
Discussion on sexuality in medical consultations
The fourth thematic group refers to the factors that influence the approach to sexuality in consultations with health professionals. In the participants’ discourse, it was observed that aspects related to sexuality were rarely addressed by doctors during consultations, and shame and few opportunities to ask questions were the reasons most often reported, as illustrated below:
“I never asked any questions; I think I was ashamed to ask.” (W3)
“And there’s another thing, when I go to the doctor’s at the health care unit where I live, the doctor does not have enough time because it is very fast, 10 minutes, because there are a lot of people waiting, so there is no way for me to talk.” (W4)
“It is sometimes a little embarrassing to ask the doctor, when we are not used to talking about it.” (W5)
It is noteworthy that, during the interviews, the participants got in tune with the main researcher and asked him questions about sex education as well as made clinical requests. There was empathy from the interviewer at those moments.
Discussion
The main findings in this qualitative study refer to changes in sexual satisfaction throughout life, contextual factors that influenced the sexual relationship, sexual desire and incapacity to fulfill it (especially in husbands) in addition to difficulties in discussing sexuality during medical consultations. The present study identified the dissatisfaction of most of the elderly couples regarding their sex life, with a decrease in sexual satisfaction over time, not only associated with aging, but due to contextual and clinical factors.
The husbands complained predominantly of erectile dysfunction and their suffering was very noticeable when they were unable to perform the sexual act, which, according to most of their statements, was the main factor for dissatisfaction. This finding is consistent with the phallocentric view shared by husbands in relation to sexual activity with their wives, given the fact that erectile-function loss was the main factor that they attributed to sexual dissatisfaction. “Normal” sexuality understood as being solely a result of penis-vagina penetration creates a binarism between functional/dysfunctional and capacity/incapacity in husbands, and it is also observed in other qualitative studies (Erens et al., 2019; Fileborn et al., 2015; Lodge & Umberson, 2012).
Men’s psychological suffering due to erectile dysfunction is frequently reported in other studies (Fileborn et al., 2017; Hinchliff et al., 2017; Tetley et al., 2018), and the main expressions of this suffering are loss of self-confidence and self-perception of masculinity as well as fear of not improving sexual function (Sinković & Towler, 2018).
Qualitative studies have reported that redefining the meaning of sexuality throughout life and adapting to other sexual behaviors, such as hugs, caress, kisses and erotic exploration of other parts of the body are strategies used by elderly couples in the face of sexual difficulties (Ayalon et al., 2019; Gott & Hinchliff, 2003). In this study, such adaptation was not observed for the participating couples in the face of their sexual difficulties. In fact, it is still seldom found in other studies on the elderly’s sexuality (Erens et al., 2019). Little communication between the partners and cultural patterns of sexual relationship with an emphasis on the genitals can explain this difficulty in adjusting in the couples’ sexual behavior.
It is noteworthy that, in qualitative studies, age increase and the presence of clinical diseases are not perceived as the only causal factors in the worsening of sexual life in elderly couples; nevertheless, relational, cultural and psychological factors are addressed in that type of investigation. The present study showed that all wives perceived their husbands’ sexual difficulties and they reported three main factors involved in sexual dissatisfaction with their husbands: difficulties of living together, husbands’ personality characteristics and the low couple’s level of intimacy. In contrary, all husbands didn’t perceived their wifes’ sexual difficulties and that show us the difference in perceptions. Qualitative studies (Ferreira et al., 2015; Hinchliff et al., 2017) show that the ability to perceive the other’s feelings and differentiation about oneself are relevant aspects for the quality of the relationship and preservation of sexual satisfaction and desire of elderly couples. In our sample, most couples were dissatisfied with their marital relationship, which was marked by old unresolved events and traditional relationship patterns.
The finding in this study that sexual desire in wives was faded (or perhaps suppressed?) is noteworthy because it was different from that for their husbands, who reported a lot of desire and little sexual fulfillment. The perception of sexual desire by elderly women themselves has been explored in several studies (Ferreira et al., 2015; Fileborn et al., 2015; Freixas et al., 2015; Karen et al., 2010; Ravanipour et al., 2013) showing the fluidity and multiplicity of associated factors, such as clinical illnesses, religion, gender relations, marital conflicts and cultural patterns, as characteristics.
It is pertinent to observe how the influence of socio-cultural and religious factors was decisive for some wives in this study, notably in W5, for whom the priest’s figure was castrating in the face of her desire to masturbate. This finding was not part of the research objectives and represents an unexpected category. The silence surrounding sexuality - the difficulty and repression in talking about it - is one of the most important aspects of the sexuality stigma in elderly women.
The silence in the face of aspects related to sexual health is also manifested during medical consultations. Cultural and psychological barriers limit the elderly’s spontaneous communication before a doctor, and feelings of shame, discomfort and fear are common in studies attempting to understand this problem (Ayalon et al., 2018; Fileborn et al., 2017). Qualitative studies with family doctors found that they had difficulty in addressing sexuality in the elderly and, when they did, it was related to physiological issues. Doctors specialized in sexology tended to perceive sexuality as irrelevant to the elderly (Ateret et al., 2018; Levkovich et al., 2018). In another study, doctors’ perceptions of the elderly’s sexual demands differed according to gender: men complained more about the erection difficulty and were easier to deal with; women’s complaints were more related to relationship problems and required more time to resolve (Levkovich et al., 2019).
The study in question found that the elderly couples’ sexual activity and satisfaction decreased throughout their lives, and it was understood that contextual and socio-cultural factors had a great influence on this change. The couples’ anguish in the face of sexual dissatisfaction was quite noticeable and did not result only from increasing age and the onset of clinical diseases, but mainly from aspects such as the husband’s personality and unresolved old events.
The phallocentric pattern of sexual activity and the husbands’ rigidity to change this pattern were perceived in the couple’s dynamics, and the absence of the female voice in such dynamics was understood as a perpetuating factor of this process. The women’s difficulty in expressing their desires and the repression of aspects related to their sexuality are historical. Aging is a process of change and the experience of this process in the face of sexual dissatisfaction can make it more difficult. A satisfactory experience of sexuality by elderly couples can be a means of energizing the subjects and of improving their quality of life.
This study privileged the approach to elderly couples, understanding sexuality throughout their lives from the perspective of both genders, which has seldom been performed in research on sexuality. The main researcher’s reflexivity effort when conducting the interviews was noteworthy in view of the mutual empathy developed between him and the participants at several moments, such as those when the participants asked questions and made requests, as described in the fourth thematic group. Subjectivity is an aspect that is not often explored in research on human sexuality, and it was possible to do it in this study.
As limitations of the study, we have the small number of participants (12 participants) resulting from the difficulty in recruiting individuals due to physical constraints of one of the spouses that prevented the couple’s concomitant presence. The participants’ socio-economic profiles and cultural aspects were similar, which limited a greater diversity of impressions to be understood.
The sexuality of elderly couples is little explored in the scientific literature and future studies involving hetero / homo-affective relationships among the elderly would be important, as well as understanding other dyadic factors and identifying different coping strategies used in the face of sexual difficulties.
Contribuições dos autores
Luiz Antônio Santos: Contextualização; Validação; Metodologia; Análise formal; Redação do rascunho original
Leopoldo Barbosa: Contextualização; Validação; Supervisão; Metodologia; Supervisão
Maria do Carmo Vieira Cunha: Contextualização; Validação; Supervisão; Metodologia; Supervisão
Maria Athina Bandeira: Investigação; Validação
Paulo Gomes: Redação - revisão e edição
