The exercise of sexuality among the elderly and associated factors

Objective: To analyze factors that interfere with the exercise of sexuality among the elderly. Methods: A cross-sectional study of 235 elderly persons enrolled at the Open University of the Third Age of the Federal University of Pernambuco was carried out. The dependent variable was the exercise of sexuality, which was investigated in terms of perception of sexuality, thinking about sex, what the elderly person does when he or Palavras-chave: Envelhecimento. Sexualidade. Educação em Saúde. http://dx.doi.org/10.1590/1809-98232016019.160028


IntrODuCtIOn
Old age is often marked by negative stereotypes related to decline and the loss of function, meaning it is important for health professionals to visualize all the features of elderly persons, including their sexuality.Such a term goes beyond the sexual act and expresses itself in a number of ways.Caresses and touching play a key role in the exercise of sexuality. 1xuality among the elderly is a continuation of a process begun in childhood.It is an inherent part of the individual, present in every act of his or her life.Each person determines, in a particular and individual manner, how sexuality is manifested, communicated, felt and expressed. 2sed on the perspective that sexuality is a continuation of the existence of the individual and that even if the practice of sex is reduced or the elderly individuals themselves internalize negative stereotypes about their sexuality, the subject in question should be addressed by health services, using health education as a means of constructing new concepts about the sexuality of the elderly.The objective of the present study was therefore to analyze factors that interfere in the exercise of sexuality among elderly persons.

MethOD
An analytical, cross-sectional study with a quantitative approach was carried out at the Universidade Aberta à Terceira Idade (University of the Third Age) (UnATI) of the Universidade Federal de Pernambuco (Pernambuco Federal University) (UFPE) and is part of a dissertation work.
A sample error of 0.05%, prevalence of sexually active elderly persons of 0.5% (based on data taken from a pilot study), and a level of confidence of 95% were used to calculate the sample.The population was elderly persons (n=605) enrolled on courses offered by UnATI in the 1 st semester of 2012, resulting in a sample of 224 women and 11 men.There was a significant predominance of women, who make up the majority of the students of the courses offered, resulting in a disparity in the sample, of which only 4.7% were men.For this reason, the sample design was stratified by gender, in order to qualify the evaluation of the results.
Those eligible for the study were all elderly persons enrolled on the courses offered during the investigation period, excluding those with impaired communication and/or cognition which would interfere with data collection during the realization of the interviews.
The exercise of sexuality was investigated using the following aspects: conception of sexuality: an open question, with answers subsequently grouped into six categories: sexuality is not just sex (n=10); it involves feelings and touching between a couple (n=7); it is part of life, promoting happiness for the elderly person/couple (n=31); sexuality is having sex (n=138); pleasure/desire in the sexual act (n=10); bodily needs (n=10).For statistical analysis the categories found were organized into two blocks: perception of sexuality from a holistic perception and sexuality based on genitality.
In the holistic vision, sexuality is understood through the expression and experience of being a woman and being a man, not simply through the sexual act, and is characterized by love, affection, and giving, with the valuing of feelings such as companionship, partnership, hugs, caresses and kisses.[5][6][7] In a vision based on genitality, sexuality is related to sex and reduced to the genitals and coitus.When the meaning of sexuality relates only to having sex, it implies that when the elderly stop having sex, they become asexual. 6,8,9 T independent variables were represented by socio-demographic data (gender, age, marital status, education and religion), health status (selfperceived health), morbidities, medical diagnosis, physical exercise and self-perceived body image, which was evaluated using the Stunkard, Sorensen and Sunkard questionnaire. 10 Data was collected between May and June 2012, when the elderly persons were recruited in UnATI by a researcher who informed them about the study and its objectives, based on their interest.The interview took place in an individual room, allowing privacy between the researcher and the interviewee.Four previously trained graduate students took part in the data collection.To adjust for possible inconsistencies in the data collection protocol, a pilot study was carried out, and three questions were reformulated.Interviews were chosen as a data collection technique, with the application of a semi-structured instrument.
At the end of data collection, a database was constructed using the EpiInfo 3.5.2program, with data entered using the double entry system.This database was then transferred to the R program version 2.15.0 for statistical analysis.The Spearman and Kendall coefficients were employed in bivariate analysis.
The generalized linear regression model included all variables that achieved p≤0.20 in bivariate analysis.The Student's t-test was applied to each of the parameters to verify significance, adopting a p≤0.05 value for the rejection of the null hypothesis of the study.
The present study was carried out in accordance with the ethical precepts of Resolution nº 196/96 and was approved by the UFPE Ethics Committee under CAAE nº 01651112.5.0000.5208.The participants were fully informed about the aims of the study as well as its risks and benefits.At the end of the interviews, the elderly persons signed a Free and Informed Consent Form and later received educational material regarding sexuality.

resuLts
Of the 235 elderly persons interviewed, 95.3% were female.A total of 54% of the sample was aged between 60 and 69 years.In terms of marital status, 36.6% were single, while 34% were married.A total of 64.7% had nine years of schooling or more, while 3.8%, all of whom were women, had no education; 97% said they were religious, of whom 66.4% were catholic, 16% were evangelical protestants, 13.6% were spiritualists and 0.9% had other religious beliefs.
In terms of the self-perception of health, 42.1% described their health as good and 41.3% said it was fair.Systemic arterial hypertension (61.3%) and diabetes (14.9%) were the most commonly cited morbidities.A total of 64.7% performed physical exercise, defined as a minimum of three times a week with a minimum duration of 30 minutes for each session, with walking the most frequently cited activity.Regarding body image, 53.6% considered themselves dissatisfied due to body fat and 6.8% due to thinness.Genitality (67.2%) was significant as a conception of sexuality.Of the total sample, 51.5% described thinking spontaneously about sex, while in terms of sexual desire, 71.1% reported indifference, 20% sought sexual relations with their partner, 6.8% auto-eroticized and 2.1% did not respond.A total of 32.3% of those interviewed were sexually active while auto-eroticization was described by 23%.The variables that crossed with the variables of exercise of sexuality and which were significant in terms of the Spearman and Kendall correlations were analyzed using bivariate correlation (Table 3).They were later analyzed in the multiple regression model, in which only variables with p≤0.05 were considered.
In generalized linear regression, the logit link function was used for all significant bivariate analyzes of the parameters of the exercise of sexuality with the independent variables.There was a statistically significant link between conception of sexuality and years of study ( p=0.012), with elderly persons with nine or more years of study being more likely (85.08%) to have a holistic conception of sexuality.
In terms of the analysis of thinking about sex and sexual activity, there was a significant relationship with the performance of physical exercise.The parameter calculated indicates that the probability of elderly persons thinking about sex and engaging in sexual activity is lower (55.11% and 63.98%, respectively) among those who performed exercise.No statistical significance was observed with respect to autoeroticization.

DIsCussIOn
Sexuality in old age remains permeated by taboos that describe it as an embarrassing subject to talk about, which remains little discussed in health services and in social contexts.While the elderly people interviewed were willing to take part, some refused to participate as they considered themselves ineligible due to no longer being sexually active.Everyone, however, irrespective of whether they have a sexual relationship or not, maintains their sexuality.
To understand the sexuality of the elderly, it is necessary to consider how factors such as culture, religion and education influence the sexual behavior of elderly persons and determine how sexuality will be experienced during this stage of life. 6Sexuality in aging should not be viewed as incompatible, as it is present in all stages of human development, even though sexual activity may decrease or be absent among the elderly. 11e exercise of sexuality during the aging process needs to be understood as a positive experience from the viewpoint of both health professionals and the elderly, provided he or she desires it.Whether through campaigns, educational activities or routine medical appointments, the issue needs to be incorporated and present in the health care of the elderly.In general, the elderly persons investigated in this study felt dissatisfied with their body image in relation to overweight, especially females.The body image variable was significant in the binary correlation of the study, and body satisfaction was related to the has sex.Dissatisfaction could be related to changes associated with aging, with waist circumference the measurement most frequently related to this negative perception. 13though sexual practice is part of the expression of sexuality, the conception of the elderly is still rooted in genitality, even though it is not the only form.Only 20.4% reported that sexuality involves more than sex, being linked with well-being, affection, companionship and the relationship of the individual with themselves and others.
The sense that sexuality represents the sexual act remains common among the elderly, as well as the denial of other forms of sexuality, such as eroticism, affection and prazer. 14Therefore, knowledge about the fullness of the sexual experience is necessary for health professionals involved in the sexual education of the elderly, through strategies that allow dialogue and discussion on the topic.
Using the sexual quotient questionnairefemale version with 38 elderly women, Polizer and Alves 15 observed that interest in sex and sexual desire continue in this age range, with 29% and 34.2% of those interviewed describing their sexual satisfaction as good to excellent and fair to good, respectively.In the present study, although 67.7% of respondents did not engage in sexual activity, thinking about sex was present in 51.5% of those interviewed, showing that even in the aging phase the presence or absence of a partner does not prevent the occurrence of sexual desire.
In this study, although 67.7% of respondents did not have sex, thinking about sex was present in 51.5%, showing that even in the aging phase the presence or absence of a partner does not prevent the occurrence of sexual desire.
Recognizing that sex continues in old age means considering that elderly persons are also exposed to diseases related to unprotected sex.In a study by Bezerra et al. 16 , however, the elderly persons themselves did not recognize this scenario of vulnerability, indicating the need for public policies that meet this demand among older persons, as well as treating chronic diseases such as hypertension and diabetes.
Often the regularity of sexual intercourse is related to the presence of a fixed partner 17 , corroborating the study of Ferreira et al. 18 where the investigated elderly persons said that sex with a partner was an obligation, or was only performed to satisfy the other, or for no reason at all.The disappointments and resentments experienced in the life of a couple have also been described as factors that interfere with sexual practice, and were found in greater numbers among women. 8ndau et al. 19 reported that the prevalence of sexual activity declines with age, and that women are less likely to have intercourse than men at all ages, with those who continued sexual practice indicating at least one problem that interfered with sex.The women described vaginal dryness and decreased sexual desire, while men mentioned difficulty with erections as factors that interfered with sexual activity.The elderly persons described an interest in continuing sex, which they considered an aspect of satisfaction with life 20 , meaning that health professionals should include issues involving sexuality in their clinical activities with the elderly.
No scientific evidence was found that discussed the relationship between physical exercise and the reduction of thinking about sex or sexual activity.Although in the final analysis the holistic conception of sexuality was significant among elderly persons who had nine years or more of study and those who practiced physical exercise, exhibiting a lower probability of thinking about sex and sexual activity, the bivariate correlations should be noted, as they infer that other factors may influence the experience of sexuality of elderly persons.

COnCLusIOn
Studies on sexuality in old age are of paramount importance in the field of Gerontology and Geriatrics, allowing new spaces to be opened in the clinical practice of health professionals to discuss the health of the elderly, considering that sexuality is part of the promotion of the well-being and quality of life of the elderly.
Further studies that address the issue of sexuality in old age should be considered, with a view to promoting the health of older people in a more holistic and less biologistic sense, where individuals should be viewed in their entirety and not be reduced to chronic diseases, to which people are more vulnerable in their advancing years.
It can be concluded from the present study that a range of factors interfere with the exercise of sexuality among the elderly, including social, cultural and physiological issues.These should be considered in the promotion of the sexual education of older persons within a health education strategy.

Table 1 .
Characterization of elderly persons interviewed based on sociodemographic variables, health conditions and self-image scale.Recife, Pernambuco, 2012.

Table 2 .
Exercise of sexuality as described by elderly persons, with regard to conception of sexuality, thinking about sex, what to do when experiencing sexual desire, sexual practices and auto-eroticization.Recife, Pernambuco, 2012. 12

Table 3 .
Binary correlation of exercise of sexuality variable with independent variables.Recife, Pernambuco, 2012.
a: Kendall correlation; b: Spearman correlation

Table 4 .
Generalized linear regression of exercise of sexuality variable with significant variables from binary correlation.Recife, Pernambuco, 2012.