Aging, sexuality and nursing care: the elderly woman’s look

Objective: to analyze the perception of elderly women about sexuality and practice of nursing care in this context. Method: a descriptive qualitative study. Fifty elderly women from Guanambi City - Bahia State were interviewed in 2016. Data collection technique was direct interview by using an unstructured script. Analysis of the semantic content described was carried out, and two empirical categories: the elderly woman’s view of nursing care in the promotion of sexual health and experience of sexuality in the elderly; and nursing care in the context of women’s aging . Results: it has been noted that the elderly women are afraid to talk about sexuality, especially with health professionals. By influences of society, they often exclude this issue of health care for elderly women. Final considerations: changes must be thought about assistance provided in relation to sexuality.


INTRODUCTION
Population aging is a phenomenon observed worldwide, being a reflection of the change in some health indicators, especially the decrease in fertility and mortality, and the increase in life expectancy. There is a change in the age pattern, as well as in the movement around public policies aimed at ensuring the active aging of the population (1) .
It should be considered that there are differences in aging for men and women, since there is clearly a numerical superiority of women in the Brazilian population, often related to mortality from external causes and reaching more men, which requires specific and differentiated care in aging (2) .
Thus, the way elderly women accept old age directly interferes with their well-being, as advancing age is often associated with disability. Functional losses mean that women do not experience sexuality effectively in the elderly (3) .
It can be observed that physical changes in women are more evident than in men throughout life. Hormonal losses move organically with their self-image and, consequently, with their self-esteem, so understanding the physiological peculiarities of senescence may make older women more satisfied with their sexuality (4)(5) .
Although the biological and hormonal changes inherent in aging are considered as negative aspects, not all women present these disorders, thus valuing other means of personal satisfaction (6) . It is known that experiencing sexuality is considered a positive point in old age, but it is still little approached by health professionals and by society (4) , and many aspects influence the way the elderly experience sexuality, such as the lack of information and guidance and the prejudice of society (7) .
It is important to report that sexuality and the body are intrinsically linked to care as a social practice of nurses, because they are professionals who take care of the body in which sexuality is manifested, but to talk about sexuality is still taboo and even forbidden even in health services (8) .
Thus, the discussion of issues inherent to sexuality includes a constant rethinking of health professionals and society, so that these issues can be addressed by nurses, without reducing them to the biological aspects and seeking to encompass the perceptions of the body, pleasure and displeasure , among other aspects and emerging values related to contemporary sexuality.
It is important to include the discussion of sexuality systematically in nursing care routines, which require changes in the health paradigm and work dynamics, as well as reflections on personal values and social interpretations, in order to contribute to the collective task of to minimize the taboos and prejudices that follows this aspect of human health (9) . Despite this, there are gaps in the discussion about sexuality in different publics and age groups, especially in aging. There is also little in-depth understanding of how nursing professionals should deal with sexuality issues (10) .
In this perspective, nursing needs to understand the unfolding of sexuality that contributes to subsidize new approaches of integral care that can demystify taboos related to the interface with nursing care, such as social practice of nurses, especially in care for the elderly women (8) .

OBJECTIVE
To analyze the perception of elderly women about sexuality and practice of nursing care in this context.

Ethical aspects
The research was carried out according to Resolution 466 of 2012 of the Brazilian Health Board (Conselho Nacional de Saúde). It was approved by the Research Ethics Committee of the Faculdade Independente do Nordeste (FAINOR), and all participants signed the Free and Informed Consent Term (FICT) (11) .

Type of study
It was a qualitative, descriptive and exploratory research that is a type of study that has been used to describe a circumscribed (descriptive) social situation or to explore certain (exploratory) questions that the researcher could hardly address with the quantitative method (12) .

Study setting
The study setting was the municipality of Guanambi, which is a municipality located in Bahia State countryside. Participants were elderly women defined by sampling for convenience and by saturation, which is that after successive applications. If the data does not add any new property to the field of study, it indicates the moment when the researcher should stop the data collection, allowing to generalize the results for the set or group studied (12) .

Data source
Fifty elderly women were included in the study, however, saturation was achieved after analysis of 39 interviews. The eligibility criteria were: women aged 60 or over who accepted to participate in the research.

Collection and organization of data
Data collection was carried out based on the records of the Family Health Units (FHU) of the municipality. Firstly, a random survey of the location of the elderly women in each area of assignment was carried out, in partnership with the FHU, for later the same being approached in their residence.
The technique of data collection was the direct interview with the use of an unstructured script, composed of two guiding questions that addressed the elderly's perception about sexuality and about nursing care in the promotion of sexual health in the elderly. The data were collected from March to June of the year 2016, and each interview lasted, on average, 40 minutes. All interviews were recorded before the participant's authorization for later transcription, ensuring the reliability and privacy of personal data obtained.
Aging, sexuality and nursing care: the elderly woman's look Souza CL, Gomes VS, Silva RL, Santos ES, Alves JP, Santos NR, et al.

Data analysis
Data processing was analyzed using the semantic content analysis technique and was divided into three phases: data ordering: in which the collected empirical material (documents and transcriptions of the interviews) was organized with the identification of the elderly by number and the transcription of the audios in the whole; classification of data; and analysis itself (13)(14) .
In the second stage, the classification of the data occurred and two empirical categories were raised: the elderly woman's view of nursing care in the promotion of sexual health and experience of sexuality in the elderly; and nursing care in the context of women's aging. In the third and last phase of the data treatment, a detailed analysis of the results was performed to describe and discuss the results.

RESULTS
The majority was married, between 60 and 79 years old, had children, lived in their own residence, lived in the municipality in the urban region and almost all participants did not attend the complete elementary school. Below we will discuss the categories of analysis raised from the perception of the elderly about sexuality.
As seen in Chart 1, older women reported feeling repressed by society to talk about the issue, as they are often judged, thus "shame" predominating when they talk about their sexuality, as well as at the same time that doubts and the desire to acquire knowledge can arise, consequently generated from this prejudice in thinking that they should no longer have doubts or talk about sexuality in the elderly.

The elderly woman's view of nursing care in the promotion of sexual health and experience of sexuality in the elderly
The expression of sexuality is intimately linked to the appreciation of the body, the sexual life, affection and affection, which does not end with aging. Nevertheless, society and the elderly themselves still have taboos, myths and sociocultural prejudices when it comes to sexuality, bringing consequences and influences to their lives (6,15) .
It is understood that sexuality is not only the expression of the biological body, it is related to being, with the power to communicate with the body, with desires, thoughts, self-esteem, characterized by the will to live, dating, finally, is expressed in various ways, each in its own way for each individual (16) .
Many factors contribute to model definitions of sexuality in different societies, such as differentiated way with social groups, religiosity, living conditions, networks of sociability, patterns of relations between the sexes and use of the body, as well as experiences lived throughout life (17) .
It is also perceived that sexuality, as a result of a historical process, is influenced by various institutions, such as the family, society and the church. Already seen as impure, relating to sexuality, exclusively to reproduction and not to pleasure. Concept that can limit dialogues between the elderly and the health professionals making it a dark subject, experienced but not treated (15) .
The problems that most interfere in the quality of the elderly women's sexuality are lack of information, shame and prejudice of themselves in relation to their age, which makes it difficult to talk about the subject with health professionals. In this sense, it is fundamental that these professionals gain the confidence and credibility of these elderly women so that they expose their desires and desires (7) .
Disrespect for the expression and experience of sexuality is much feared by the elderly. This directly affects their behavior when seeking health services, reducing the frequency with which nursing professionals seek to deal with these issues, as well as the fear of consulting with male nurses.
It is known that among all health professionals, the nurse is the one who is most present in several care settings, among which the health care for women in the Family Health Strategy (FHS) is cited, most of the activities within the unit, highlighting the promotion of the patient-nurse bond (16) .
Through the nurse's care, the women will be able to create a bond with the professional, since it is he who will follow up in several consultations of the different programs addressed, it is remarkable that the female nurses will feel to have a stronger bond (18) .
It is common to observe that in some professions there is a process of feminization, when female participation reaches 90%. It is known that nursing is historically a profession with a greater predominance of women. However, it can be considered that there is a change in progress in this setting, since the growing presence of the male contingent in nursing (19) . Thus, the masculine universe within nursing is still little accepted in the services of the Basic Attention, mainly in care and attention to the woman, therefore it is also responsible for the preventive examinations of cervical cancer, family planning and Fear of prejudice and judgments.
Sexuality is very common among couples, but after marriage.
No longer having sexual intercourse, it does not matter anymore.
Sexuality is currently being trivialized.
There is a fear in talking about sexuality.
Lack of seriousness of professionals to address the issue.
Have more information and communication.
Never have gone to a gynecologist or performed a preventive.

Lack of meetings and lectures.
Need for more mature people to address the issue.
Thus, there is a real need for health professionals, especially nursing professionals, to educate and discuss the theme of sexuality as a strategy in the construction of concepts that idealize the elderly as a free person to experience it detached from prejudices, taboos and myths built socially that the woman when she reaches the advanced age ceases to be sexual, adhering to sexuality.
In this sense, the two empirical categories are discussed: the elderly woman's view of nursing care in the promotion of sexual health and experience of sexuality in the elderly; and nursing care in the context of women's aging. In addition to the fear of judgment, among others, the elderly feels uncomfortable doing a gynecological examination with male professionals, and this is also a great factor of insecurity and lack of stimulation in seeking health professionals, which was noticeable in speech of one of the elderly: Ah, it has to be a priority and so people are usually embarrassed by the situation of taking a test with men, for women I think it would be more comfortable to perform with a woman. (Elderly 9) Nursing care in relation to the elderly's sexuality should not be limited to performing the Pap smear, but in realizing that each elderly woman needs specific care presented with the advancement of their senescence, as well as hormonal changes. Sexual desire does not end with advancing age. The elderly is often underestimated in analyzes of sexual behavior. Research shows that most of the 60 to 70 year old people have an active sex life and most of them are related to fixed partners (16) .
The fixed presence of the sexual partner is recognized as a positive aspect for the continuity of sexual relations, contributing favorably to the sexual reduction of the elderly women, since the same ones in their prevalence are widows (21) . It is evidenced that elderly women who do not have a fixed partner have a significant decline in sexual relations, unlike the elderly women who have their partner.
Considering the aforementioned needs, professionals must take into account factors, such as low income and level of education, as they end up interfering with the way they understand sexuality. Nurses are an important tool in the health education of these women, since they are the professionals who have the most access and proximity (22)(23) .
It would be nice if there were lectures with people our age", this was a very frequent talk in the interviews, the need for an orientation was emphasized by the elderly women. They also claimed to have doubts about the body's own functioning, which they often fail to clarify due to lack of openness in the dialogue.
Aging in a society with prevailing religious characteristics may be even more complicated, as the deprivations experienced by the female population are large, having their desires and doubts repressed by the fear of social and religious judgment.
After marriage is right, not before marriage. It's natural and it has to happen. (Elderly 11) In a study conducted by Uchôa et al (2016), it can be observed that 15.5% of the elderly consider religion as a factor that inhibits sexuality. The consequence of this position can be the repugnance to the sexual pleasure, mainly by the old women (24) .
This fact may be associated with religion considering sexuality only the sexual act, and not understanding and passing on the other activities of its responsibility which often cause discomfort and shame on the part of women (18) .
In this sense, this increase in the number of nurses must follow up health demands of people, especially of the elderly, when the subject is sexuality, since often a withdrawal occurs because the professional is a man, as seen in the statements of some the elderly. Nurses need to prepare to meet this female demand, build trust, strategize and build a bond with patients.
It is necessary to participate more in the meetings, ... create more confidence in the part of the man so that the women feel more confident so they do not get embarrassed and end up relying on the presence of the male nurse. (Elderly 4) According to the elderly women interviewed, most of the time they are looking for health units, nursing professionals do not speak much about the subject, they do not adequately guide, since each elderly woman has her particularity and her way of facing aging, exposing her desires and, above all, expose the will to live intensely "the best age".

Well, health has never been discussed about sex, if it was the case like in the public health center, there had never been an interview or a meeting about sex, ... It's tight [vaginal canal] it makes it difficult to penetrate, but it treats me very well and I try to use a medicine to soften, flex 20 days before to be able to take the exam, I'm going to do this exam, the preventive, I do preventive [private] and I do mammography every year. (Elderly 3)
For these women, sexuality is directly linked to the sexual act, to the corporal pleasure that involves only the couple. In many speeches, they present the perception that sexuality is basically to reproduce / procreate and satisfy the other, and that it merely expresses the desire for satisfaction and pleasure. Therefore, it is necessary that nurses use strategies of approximation within the basic unit, to provide comfort to these elderly women when they are approached about the theme and, mainly, to reflect along with the elderly other ways of living their sexuality (16) .
Nursing must first know its own judgment about the third age and sexuality, in order to be able to intervene naked of any prejudice. Thus, it is observed that the majority of actions of nursing professionals are directed to chronic diseases (20) .

I think so; you should approach yes [sexuality]. It is necessary to talk for us to understand, but there are many things that we do not understand, it is difficult to answer [the interview], because it is a difficult subject. (Elderly 4)
The elderly women said that the lack of assistance to their sexuality in the health services considering that sexuality is directly related to sex, since, often, they are subject of neglect and prejudice by the health professionals, who see them as asexual. When questioned about how they are treated in these services and about what is lacking for good care, there are answers about the professionals' lack of preparation to receive this public.
Aging, sexuality and nursing care: the elderly woman's look Souza CL, Gomes VS, Silva RL, Santos ES, Alves JP, Santos NR, et al. new concept of sexuality, which embraces affection, affection, compression and companionship.
It is essential and indispensable that these elderly women be watered by information that emerge from their own characteristics and experiences, bringing with them experiences and expectations already experienced in their youth making this religious society understand that the need for knowledge on this subject is independent of sexual practice (25) .
In this context, another reason that leads to the elderly not to live their sexuality in the third age is the lack of information. This lack of information is the great difficulty found in the elderly in providing an improvement in the quality of sexual life and in their sexuality as a whole, generating the lack of individualized care for each elderly woman, since not all of them will have the same hormonal and physiological changes age (26) .
Although not all women are negatively influenced by the hormonal changes of menopause, these changes, added to those of aging, tend to increase in this phase of life (6) .
A study showed that approximately one-third of the elderly believe that having sexual dysfunctions is normal, assuming they have these changes, but do not seek the health professional. In this sense, the reason why the elderly does not seek the health professional is because they think that they do not have to continue exercising their sexuality. However, the suspension or abandonment of it can accelerate aging, thus negatively reflecting the health of the elderly (15) .
Sexuality has to be discussed and better conceptualized with the elderly, to encourage healthy practices of living that sexuality and to differentiate from sex, sexual intercourse without stigmata, so that each of them discovers the pleasure of exposing their sexuality. Thus, this will be another factor that will contribute to an autonomous and full life of this population that can never practice this sexuality without judgment (22) .
The lack of communication between professionals and the elderly, as well as the lack of specific programs, a series of conversations, support groups and other activities that focus on information and orientation on the elderly's sexuality were common themes in the responses.
It is known that there is assistance focused on sexual health in the Basic Health Units, but the lack of reception of the elderly by the professional is proven in the interviews when they report how nursing care should be directed to the studied subject: For the elderly, the prejudices and judgments of the society greatly disrupt the relationship between health professional and user, because if there is no bonding of respect and trust between health professionals and elderly women, they tend not to expose their doubts and opinions for fear of the judgment that will be made about them.
Health promotion policies have emerged worldwide as an important tool in the search for the construction of the expanded concept of health that prioritizes actions to improve the quality of life of the elderly, but almost exclusively in the case of chronic degenerative diseases (27) .
It is perceived that the professionals look at the elderly only as having chronic-degenerative diseases and forget the part of their sexuality. In this way, they weaken the link between professional and patient on the subject, preventing the adherence of the service provided by the professional (28) .
It is reaffirmed that nursing care for the elderly is essential for actions to be permeated by health promotion in all areas that may be affected during aging, not only chronic diseases, but also issues of physical and mental well-being involving mainly sexuality, a subject little discussed in the health of the elderly (27) .
In a study of 345 elderly women about adherence to the service provided by nursing on sexuality, it was observed that, although 40% demonstrated the need to talk about the subject with the professionals, only 35% used the health service and sought effective help from the nursing team. Of these, only 1/3 adhered to the plan proposed by professionals (28) .
Nursing must seek adequate care for the peculiarity of each elderly woman, taking into account that they are beings that are inserted in different contexts and with specific needs. The search for trust should be a continuous action of the nurse. The fact of being taxed as asexual beings, also leaves the aid weakened.
Older women are afraid to talk about sexuality, often because of their restrictive education, especially with health professionals. By the very influences of society, there is no specific training of professionals to attend this public on sexual health. The suggestion of the elderly is that the health professionals offer lectures, waiting rooms and conversation wheels among a group of elderly women of the same age, besides the nursing consultations in a space of bond and trust, in order to clarify the doubts concerning sexual health.

Nursing care in the context of women's aging
Nursing was inserted in the public sphere of work from the 19 th century, with the creation of the first nursery school, historically female, at St. Thomas Hospital in London under the direction of Florence Nightingale (28) . From the insertion of the nurse as a health professional, a work model was created based on a rigid hierarchy with specific norms of conduct that implied several rules. In this sense, it is considered that these standards, aimed at a professional female, may have led to the silence that currently persists about nursing care with the body and sexuality, which interferes in the nursing care practices until the days gift (29) .
Michel Foucault, a French philosopher, argued that once sexuality presents itself as the domain of knowledge, it becomes the object of power relations, providing the basis for understanding what is called the "device of sexuality" (8) . This allowed sexuality to become the target of great discussion in the scientific and social environment.
In this context, the elderly and society need to understand that sexuality is not a sexual act, but a set of factors that will provide pleasure and well-being and that it needs a domain of Aging, sexuality and nursing care: the elderly woman's look Souza CL, Gomes VS, Silva RL, Santos ES, Alves JP, Santos NR, et al. knowledge of itself, so that this sexuality is experienced without taboos and prejudice.
Based on the growing concern about the health and well-being of women, it is necessary that social movements, particularly feminist and women's movements, and health professionals, especially the in order to understand and assist them with the broader needs of the human being and the elderly, valuing the articulation between preventive and care activities (30) .
Nevertheless, the existence of public health policies aimed at the reproduction and sexuality of women, such as the family planning of women in the reproductive period, alone do not guarantee an integral service to this clientele in practice, and can be observed through the Family Health Strategy (FHS). In FHS, attention to the elderly refers to reductionist actions aimed only at chronic degenerative diseases, such as hypertension and diabetes, not glimpsing other dimensions, such as sexuality (2) .
These questions become clear when the older woman says: The elderly usually does not receive assistance beyond chronic diseases, since they are no longer part of the reproductive period. Thus, nurses play a fundamental role in sensitizing older women to the importance of living their sexuality, justifying that sexuality does not only involve sex or sexual intercourse, but is a subjective set of factors that involve women's health (29) .
In fact, the female organism experiences the inherent wear of those peculiar to the age, but this decrease does not necessarily mean a deficit, since there are alternatives to intervene, attenuate and compensate for the effects of this wear and tear, which affects the ability of older women to continue performing their daily activities and also expressing their sexuality in the way they prefer (3) .
Nursing care in female aging has been ineffective in the conception that older women have about sexuality, since it is still surrounded by taboos and barriers, such as the shame and prejudice historically associated with the aging of women (3,5) .
In this setting, nursing care is essential for specific actions to be effective and promote women's health in all its aspects, including those involving sexuality in the elderly, since it is understood that aging has inherent alterations to its process. Therefore, the professional must have skills to deal with the diversity of situations experienced by each person (27) .
In addition, care should extrapolate the reproductive age barrier, since sexuality goes beyond sexual intercourse, being a very broad concept and influenced by social and cultural aspects (24) .
The elderly's sexuality in the midst of physiological difficulties and sociocultural barriers cannot go unnoticed by nursing, since this is a humanized science that should not consider this care as null, since sexuality does not end when it grows old, it must be well worked out in every older woman a way to expose this sexuality within one's expectations (5) .
The elderly reaffirmed the need for nursing care with a focus on sexual health and sexuality of elderly women, which can be observed in one of the statements of the elderly when questioned about care and nursing care in this context: Nursing has important tools to deal with the decline of body and organism changes due to aging. It should be considered that this transition generates doubts, imbalances and anguish, and it is up to the professionals to act in the psychological and emotional preparation, as well as give support and alternatives to soften the physical changes (17) .
Sexual aging has a clear biological imprint on women, as there is a constant reduction of estrogens at this stage which is responsible for the involution of the reproductive organs, atrophy of the vulva, fallopian tubes, vagina, pelvic ligaments, sagging of the breasts and reduction of vaginal lubrication. This stage, which is determined by the end of reproductive capacity, triggers profound aesthetic modifications, self-image and self-esteem of the elderly woman (30) .
It is important to emphasize that each human being is unique and that, in the aging of the woman, there can be an imbalance of the functions of the body caused by disease or vulnerability. Nurses must be able to follow the elderly up in this transition, through the sharing of knowledge and scientific evidence to contribute to the confrontation of this issue with naturalness, so as to allow the elderly to experience in a healthy and pleasurable way this stage of life (28) .

Study limitations
This study opens the way and leaves questions to be answered by new research. We know what the elderly think about their sexuality and health services, but how do health professionals see the elderly woman's sexuality? If the fear of women is with male professionals, what justifies this block between professional and patient since the nursing category is predominantly female? These are questions that, if answered, can bring a solution to this gap between professional and elderly, when it refers to sexuality.

Contributions to Nursing
Therefore, in addition to developing health programs, it is necessary to create strategies for the insertion of elderly women into the health service, and to promote professional training so that, in fact, the health care and promotion policy for the elderly is comprehensive. This was a difficulty evidenced by the elderly woman herself, when she reflected on the nursing care aimed at sexuality and the sexual health of a woman after the reproductive period.

FINAL CONSIDERATIONS
This study aimed to discuss the view of the elderly woman on sexuality. Thus, it was found that understanding how the elderly think and feel about their sexuality is important not only to understand aging associated with sexuality, but fundamental to know and develop strategies that attenuate the effects of senescence related to sexuality, in order to guarantee the experience of the same in a positive way.
This process depends, above all, not only on the elderly, but also on professional health care and, in this regard, to contribute to care directed towards sexual health in the elderly. The article shows the lack of training of health professionals to meet this demand. They must get rid of prejudices, taboos and, mainly, criticisms.
Factors related to the elderly women's sexuality should be better worked in health practice, with constant reflection on the part of service users and professionals about mechanisms that generate values and attitudes in relation to the issue. In this way, quality care was provided and adapted to each individual.