Abstract
Objective
To analyze the perspectives of sexual unwellness (SU) of Portuguese and Slovenian older adults was the objective of this study. A qualitative research was carried out, in which these perceptions were analyzed at a cultural level.
Methods
The sample of this study consisted of 136 older participants, between 65 and 96 years of age. Participants were of two different nationalities and lived in the community. Participants were interviewed, and all interviews were carried out through the process of literal transcription and subsequent content analysis.
Results
Eight key mutually exclusive themes emerged from the interviews: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex; and difficulties meeting new people. Unavailability of partner was the most important theme (17.9%) for the studied sample and specifically among Portuguese participants. Conversely, difficulties meeting new people were the least reported theme (6.8%) for the entire sample. For Slovenians traditional values were most relevant with respect to feeling sexually unwell.
Conclusions
Older adults from two different countries reported diverse sexual experiences. Eight mutual-exclusive themes were extensively illustrated.
Policy Implications
These findings are evidence for cultural-adapted interventions and policy making in the context of older adults’ sexual well-being, particularly in terms of its relation with aging well.
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Introduction
Oder adults have been stereotyped, both explicitly and implicitly, as being asexual or naturally lacking sexual desires (Liu et al., 2016). However, senior individuals are sexually active, albeit more, so among men versus women (Liu et al., 2016). Worldwide, approximately 60% of adults between 45 and 59 years old have intercourse at least once a week and at age 75, 25% still do so. Moreover, among this age group, 75% have intercourse once a month or more (Harvard Health Publishing, 2020). Another study indicated that 39.5% of older women and 67.0% of older men between 65 and 74 years old remain sexually activity (von Humboldt et al., 2020a, b). When older adults have partners, 64% of men and 68% of women are report being satisfied with their sex lives. Fewer older people without partners (18% of men and 28% of women) are pleased with their sex lives (Harvard Health Publishing, 2020). High levels of sexual activity and the absence of sexual issues are positively have been correlated with subjective well-being among older adults, regardless health, family relations or demographic factors (Carneiro et al., 2019; Ribeiro-Gonçalves et al., 2022; von Humboldt et al., 2020). Between 40 and 70 years of age, psychological well-being and the lack of psychological distress are key factors in women’s overall satisfaction with their sex lives and their sexual well-being (SWB) (Hinchliff et al., 2019).
Portugal and Slovenia show similar cultural aspects; they are both European and Westernized cultures, hence the context of social values and stereotypes tend to be similar, and regarding the experience of sexuality, both countries show conservative approaches. In addition, the two countries have an increasing number of older people who are isolated and with a feeble support network, Moreover, projections indicate that Portugal will have a more pronounced aging of the population until 2080 (EuroNews, 2016; von Humboldt et al., 2018, 2022).
The quality of life in old age in Portugal and Slovenia are also similar, since the unsatisfactory living conditions of this population, and the less adaptive habits can affect older adults’ SWB, particularly knowing that social and community support in both contexts are still not adequate (EuroNews, 2016; Trigueirão, 2020).
Little empirical attention has been paid to SWB, with this both directly and indirectly contributing to successful aging (von Humboldt et al., 2020a, b) and satisfaction with life, quality of life, and overall psychological well-being (Træen & Villar, 2020). This psychosocial concept pertains to sexual interest, functioning, satisfaction, healthy intimate relationships, and sexual self-esteem (Syme et al., 2015; von Humboldt et al., 2020a, b).
Moreover, research indicates that emotional and physical well-being are correlated with older people’s SWB, including their general sense of happiness (Hinchliff et al., 2019; von Humboldt & Leal, 2014a, b, 2015a, b, 2017; von Humboldt et al., 2013a, b, c, 2014a, b, c).
Sexual distress encompasses a variety of relevant aspects, such as biopsychosocial factors and cultural and health care contexts and has been associated with a higher sexual dissatisfaction and increased sexual avoidance (Syme et al., 2015).
Sexual distress is different from sexual dysfunction. Distress is an indicator of suffering while dysfunction pertains to difficult or painful sexual experiences (Cuenca-Barrales et al., 2019). Although physical issues in old age can have a strong impact in reducing frequency of sexual activity (Syme et al., 2015), literature concerning SU suggests that the most referred indicator is the lack of intimacy and affection, whilst the least verbalized indicator is poor sexual health (von Humboldt et al., 2020a, b). These findings corroborate previous studies wherein psychological and relational opposed to physical health factors most influence older people’s sexual satisfaction (Syme et al., 2015). Older adults may be challenged with the loss or incapacity of a partner. Married older people report having more sexual activity than do their widowed or single counterparts (Liu et al., 2016). Older adults whose partners are in less than ideal health, cognitive impaired, or institutionalized report that these factors greatly interfere with their sexual performance and lessen its importance (Kumar & Sharma, 2017). Conversely, emotional intimacy can dampen the suffering associated with sexual difficulties. Older people are at higher risk for chronic illnesses, many of which (including medical treatment) can affect their SWB. Hence, the link between intimacy and sexual distress may be particularly relevant for older couples (Štulhofer et al., 2019). Indeed, single women and female patients are more likely to suffer from sexual distress (Cuenca-Barrales et al., 2019). General psychological disorders like anxiety and depression, especially when treated with medications, can affect sexual expression by lowering desire, energy, and the level motivation for engaging in sexual activity (Syme et al., 2015). Older people may also experience declines and losses in functioning which can lead to psychological distress, isolation, and even loneliness (World Health Organization (WHO), 2015; Ferreira-Valente, et al., 2019). Some long-term conditions from age 50 onward affect sexual function.
Health problems can decrease sexual desire, hinder sexual positions, increase anxiety around, for example, sexual activity triggering a heart attack, and negate overall SWB (Bouman, 2013). Financial problems seem to be linked to a poor sexual functioning. Older people with a lower socioeconomical status, especially women, are more likely to rate their sexual performance as poor (Hamilton & Julian, 2014). Attitudes and beliefs towards aging can also impact older people’s sex lives. Negative stereotypical beliefs appear to be fueled by religious values and views. For example, sexual intercourse may be seen as a primarily reproductive activity, which may underline a restrictive perspective of the sexual function (Štulhofer et al., 2018). Research supports previous findings that significant life events, especially untoward changes in one’s health, can have a negative impact on older adults’ sex lives (Fileborn et al., 2015). Moreover, other factors, such as the bio-medicalization of sexuality in old age, body changes, work difficulties, and family disputes can negatively influence sexual activity availability and enhance SU (von Humboldt et al., 2020a, b). Sexual distress is significantly correlated with the demand for professional help worldwide (Hinchliff et al., 2019). There are also cultural differences in perspectives of SU in older age (von Humboldt et al., 2020a, b). Hald et al. (2019) found remarkable cultural differences in suffering as it pertains to sexual problems, with men from southern Europe (e.g., Portugal) being more prone than their Danish and Norwegian counterparts. Sexual distress can affect older adults’ health (Smith et al., 2019). Older adults with poor or unsatisfactory sex lives tend to rate their health as poor and experience lower levels of well-being. Poorer sexual performance seems to negatively influence older adults’ psychological well-being, happiness, and self-esteem, with sexuality being an important structuring pole for their identity and personality (Carneiro et al., 2019; Ribeiro-Gonçalves et al., 2022; von Humboldt et al., 2020). Sexual difficulties such as erectile function among men and decreased sexual desire among women (Kumar & Sharma, 2017) are negatively related to cardiovascular problems, diabetes, depression, and other illnesses (Camacho & Reyes-Ortiz, 2005). In particular, Gledhill and Schweitzer (2013) highlighted that the socially constructed nature of a sexual identity centered around sexual penetration is negatively affected by men’s sexual dysfunction. Some older adults who feel too much emphasis on the functional versus relational aspects of sex, with the latter equating penetration with sexual desire, may have disappointing sexual experiences (Gewirtz-Meydan et al., 2020). In addition, medications for erectile augmentation fail to address relationship quality (Gledhill & Schweitzer, 2013). Sexual difficulties can have a negative impact on relationships and psychological well-being, with both being a significant source of distress in later life (Hinchliff et al., 2019). Sexual difficulties have been found to negatively impact older people’s psychological well-being and interpersonal relationship quality (Fileborn et al., 2015).
Particularly, when evaluating the Portuguese and Slovenian contexts, some similarities that may be influencing the sexual experience in old age, were found. Sexuality is still an intimidating topic and may reflect some prejudgment about old age in both countries (Klavs et al., 2006; Simetinger & Otorepec, 2017; von Humboldt et al., 2020a, b, 2022). Further, aging of the population is increasing significantly in Portugal and Slovenia, in line with an existing insufficient approach to sexuality in old age; both in research and in the health contexts (von Humboldt et al., 2022; WHO, 2015). Hence, there is a current need to analyze the two contexts simultaneously and comparatively. Moreover, it is likely that the current generations of adults want to be prepared to deal with the aging process itself.
Very little is known about what makes older people feel unwell and dissatisfied with their sexual lives. These knowledge gaps also point to a need to better understand what successful sexual aging constitutes, particularly in terms of its connection with the general well-being of older adults (Štulhofer et al., 2018, 2019). Cross-cultural studies are also lacking (von Humboldt et al., 2020a, b). Accordingly, this cross-cultural study sheds light on older Portuguese and Slovenian persons’ perspectives on the key factors that have had a negative influence on their SWB.
Method
Participants
Our participants were recruited through community centers, senior’s universities, and other learning centers. Contact was made initially by telephone and face-to-face contact. At this point, potential participants were made aware of the main objectives of this study and were invited to participate, and their questions were clarified. Interested participants provided contact information so that interviews could be scheduled. Inclusion criteria for this study were (1) age equal to or above 65 years; (2) understanding the purpose of and agreeing to take part in the study; (3) agreeing to a Mini Mental State Examination (MMSE) screening test; and (4) not undergoing medical and psychotherapeutic treatments for sexual problems. No monetary compensation was offered. Participants provided informed consent prior to being interviewed. Semi-structured interviews were recorded and transcribed in full, and subsequently subjected to a content analysis. Here, the aim was to analyze participants’ perceptions of those who contribute to their SU. One hundred and thirty-six older adults who were, on average, 71.55 years of age took part. Nearly two-thirds (62.5%) were women, 86% were married or had a partner, 27.9% lived alone, and 31.6% were high school and/or post-secondary graduates. The majority of our participants had a family annual income equal to or less than 25.000 € and 74.3% were retired (see Table 1). Participants lived in the regions of Lisbon and Algarve. The study was accepted by the ethics committee at the William James Research Center at the ISPA-Institute. All recruitment and analytical procedures were in keeping with the ethical standards of the 1964 Helsinki Declaration for research with human subjects and its later amendments or comparable ethical standards.
Data Analysis
A brief and general reading of the interviews was first carried out by evaluators of the content of the interviews. The analysis was carried out by two experienced researchers. The analysis started with a codification process to classify data according to the nature of its content and to group this content into categories. This classification was made from the different references that the participants made to the construct or themes of the construct. A numeric code was assigned to each category so that we had a list of codes (Sampaio & Lycarião, 2018). This list of category codes was then grouped into more general topics constituting main themes. To ensure that divergences in the coding process would not influence our findings, the two researchers reviewed the entire coding list, until they reached consensus. This stepwise approach makes replicability possible (e.g., mutually exclusive and consistently applied codes). After obtaining a set of main themes, two researchers manually coded a random sample of participants with the aim of improving interpretive convergence (Saldaña, 2009). This permitted critical evaluations of the coding process and small modifications in the coding structure (see Fig. 1). Cohen’s Kappa was used to assess the agreement between the researchers regarding the codifications made for each interview, within the different categories. Cohen’s Kappa shows a very good reliability for both samples (kPort = 0.86; kSlov = 0.75) for the following categories: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex and difficulties to meet new people. A descriptive quantification process was also undertaken wherein averages, and percentages across categories were calculated (Bengtsson, 2016; Elo et al., 2014; Erlingsson & Brysiewicz, 2017).
Results
Sexual unwellness (SU) was found to have culturally diverse meanings among our older Portuguese and Slovenian interviewees. Eight key mutually exclusive themes emerged: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex; and difficulties meeting new people. The information shared by each participant could have added to different themes. These themes are outlined below.
Theme 1: Unavailability of Partner
The physical absence of a partner or unavailability for incapacity or illness was the most indicator of SU (n = 42). This theme was reported mainly by Portuguese participants (nPort = 36). Six Slovenian participants verbalized this theme. When illness compromises a partner’s autonomy and availability, being a caregiver of that partner can become a burden and, in turn, negatively affect SWB. Teresa explains: “I help my partner in everything, but I cannot help him with sexual relations, because sexuality is individual, it is something special that belongs to each one individually” (Teresa; female, 81 years old). It is important to remember that people with dementia experience significant decrements in their cognitive and physical functioning and their ability to navigate their living environments, with these hampering the expression of intimacy and sexuality. “I think I am no longer able to express myself sexually” says Paul (male, 80 years old). Additionally, 37% of our participants had lost a partner, mainly through widowhood, and this strongly compromised the ability to have sex and their SWB. As Alfreda pointed out “I am alone, my man died, what can I do? I feel that sex is dead for me, it is just a distant memory” (Alfreda; female, 65 years old). Klara added “If you have a partner, they you can happily do everything you wish or the years and health status allow you. Occasional partners and occasional sex are not enough.” (Klara; female, 80 years old).
Theme 2: Traditional Values
Participants (n = 39) also indicated that traditional values were an obstacle to their SWB. This theme was mostly reported by Slovenian participants (nSlov = 22 versus nPort = 17). Looking back at sexuality after age 60 suggests a theme, which, in general, speaks to cultural denial such as through negating sex in older age. Nicole says: “We are used to following the idea that having a sex life is only for the youngest. And this is wrong. Older people also have this right” (Nicole; female, 66 years-old). Culture and certain traditions accompanied participants throughout life and seemed to restrict their sex lives. This theme was dominant (67%) among older women. As Susan verbalized “Sometimes I feel ashamed, or I don't want to talk about my sex life, because taking into account my culture, having sex at this age is not seen as a good thing” (Susan; female, 67 years old). Additionally, religious values were reported as negatively impacting SWB. Francisca reported that “I am focus on God, I do not think about sex anymore. It is a sin, if it is not made to procreate. I already had my five children and I am done with it” (Francisca; female, 87 years old).
Theme 3: Body Restrictions
The third most prominent theme, body restrictions (n = 37), was mostly reported by Portuguese participants (nPort = 33 versus nSlov = 4). Falls were pointed out as restrictive factor because falls contributed to physical incapacity and a lengthy recovery process. Missing at least one limb can be problematic. Jimmy told “My two legs were bad for long time, and it was always challenging to satisfy any sexual partner for two main reasons – for one, evidently, my overall physical appearance, it doesn’t get simpler than that, she would just reject me from the moment she would lay their eyes on me; then, if I was lucky enough to get it on with a partner, that relationship would end rather quickly because, from a sexual standpoint, it would be too unsatisfying and need to much work to come.” (Jimmy; male, 76 years-old). Additionally, falls affect mobility in old age. Gabriela emphasized “Even only going outside to take out the trash and to go to the grocery store is already painful. Asking my family for help is just out of question as that makes me feel like I am nothing but a burden to them. So, I stay at home all day doing absolutely nothing and wishing I could easily go to my partner’s home, spend more time with them and grow more intimate because, honestly, with my mobility limitations, our sexual relationship has only been growing more and more distant.” (Gabriela; male, 73 years-old). Older adults may show sensorial impairment, such as loss of vision, hearing, and agility, all of which may restrict their autonomy and SWB. Nuno verbalized that “I am very aware of seeing less and, because I don’t intend to make driving a living hell for other people, do everything to avoid being in the road, unless needed. Unfortunately for me, I have no other means of transportation so all I am able to do is stay at home, when I could be hanging out with friends, or making them, meeting new people I might be attracted and actively exploring my dating and sexual life.” (Nuno; male, 71 years-old). Chronic conditions may negatively affect SWB for these older adults. Erica reported that “Sex is a huge part of my love life. In fact, I would go so far as to say that I’m addicted to it. So, when I got diagnosed with osteoporosis, the doctor told me that I should keep sexual activity to minimum, as well as its intensity. Unfortunately, I made the mistake of not listening to him and ended up breaking my hip during sex. As I’m old, it took a large amount of time to recover and, due to that, I’m now unable to have sex for a long time.” (Nina; female, 70 years-old).
Theme 4: Low Self-Esteem and Well-Being
Some participants (n = 28) indicated that low self-esteem and well-being was an obstacle to their SWB. This theme was mostly reported by Slovenian participants (nSlov = 17 versus nPort = 11). “Regardless of my problems, when I feel beautiful and feel that my presence causes a positive feeling for my partner, this makes me feel happy, and that will be expressed in my sexual activities,” verbalized Emily (female, 67 years old). Physical activity seems to be a favorable factor facilitating positive bodily changes that enhance self-esteem and confidence. Physical activity allows older adults to become more active and more able to perform daily living activities, including sexual activities. “We both started going to the gym a little bit and ended up also increasing our sexual intimacy,” verbalized Mia (female, 68 years old). Some participants pointed out that low self-esteem compromised their sex life. Valuing what is young, beautiful, new, to the detriment of the old, interferes with older adults’ self-esteem, as their opinions about themselves may be compromised. “Babies are cute, teenagers are wonderful, adults are fantastic and older adults are the most beautiful, because we have already gone through all the stages. And sex is great” reported Diana (female, 87 years old). Other participants reported that low well-being negatively affected their SWB. “My low well-being has a big negative impact; and it is still important for me to have sex” (Natasa; female, 76 years old).
Theme 5: Poor Social Support
Some participants (n = 27) indicated that poor social support was detrimental to their SWB. This theme was mostly reported by Portuguese participants (nPort = 25 versus nSlov = 2). Older adults with less social support are more prone to depression. Filipa verbalized “One of the things I appreciate the most at this age is attention and emotional support – especially from my grandchildren. Yet I feel like anything besides my needs is often looked over by family members and my peers. It has had a negative impact on my mental health and, subsequently, on my sexual life – I no longer feel motivated to talk, interact and make bonds with other people” (Filipa; female, 72 years old). Some participants highlighted that their family did not support their choice of partner. “My sex drive has always been high so I have been with a handful of partners throughout my life, something that goes against my family’s approval. Plus, now that I’m older, I get many more looks of disapproval from others around me whenever I see someone that I am attracted to and try to make conversation to them. Eventually, over the years, I just stopped approaching people in general,” Adam explained (Adam; male, 70 years old). Some participants felt lonely and abandoned by their families. Kim said “Due to small complications with my health, my family decided it was too much work to sustain me so they got me a nurse, even though it is evident that my health issues aren’t that aggravated. Honestly, it just seemed like a poor excuse to get rid of me, which really hurt me mentally. It also negatively influenced my capability of socializing with others, having intimacy and sex, due to how depressed I became” (Kim; female, 70 years old).
Theme 6: Dissatisfaction with Physical Appearance
Dissatisfaction with physical appearance was detrimental to the SWB of Portuguese (nPort = 23) participants per se and mostly for older women (88%). Appearance can negatively affect sexual expression. Laura reported that “It is normal that I am not as beautiful as I used to be, but even so, I would like to be more beautiful to have more confidence and not doubt myself on my sex life” (Laura; female, 77 years-old). Although female participants seemed to report this theme more frequently, some men verbalized this theme. “Of course, I no longer have those abs, and beautiful muscles, so sometimes I’m afraid. I don’t like to receive “no” as an answer and that’s why I don’t even ask if she wants to have a more intimate moment with me,” reveals Tim (male, 67 years old). Dissatisfaction with body image can be related to increases in weight, especially in women, and lead to more dissatisfaction with one’s physical appearance and a decrease in or an absence of intimate relationships. “If I don’t feel good about my body, I won’t be confident to express myself sexually to my partner,” says Olga (female, 80 years old). Overweight people are relatively more physically restricted. Sofia affirmed “I am an old women and, even though I try to stay in shape, I have been overweight for almost all my life due to the amount of medication I take daily for other diseases. Surprisingly, I have had (and still have) many sexual partners. But sexual activity is very limited because of my lack of agility and stamina. And even though most of them are understanding and eager to help me, I cannot help to think that, at some point in the relationship, they’re just doing it out of sorrow and sympathy.” (Sofia; female, 71 years old). Caring for one’s own body and clothing, is also a way of expressing sexuality. Miriam expressed that “I like to dress well, I think it shows my feelings, my personality, my life, including my appetite for sexual life” (Miriam; female, 68 years old).
Theme 7: Pain During Sex
The seventh most prominent theme was pain during sex, and this was pertinent to Portuguese participants alone (nPort = 22). Medical conditions and interventions may hinder one’s sexual life, particularly with respect to pain during performance. Sara explained, “Due to some surgeries done during my life, due to my pregnancy, now, being 68 years old, ninety-percent of times I have sex with my husband (when I have it, because it happens very rarely), I get injuries in that region due to penetration, which can be extremely painful causing me to not be able to carry on with sex” (Sara; female, 67 years old). Due to the thinning and dryness of the vaginal walls after menopause, for some women sex becomes more painful. Cristina explained “because vaginal walls become so thin, they become more sensitive, and also, because they become so dry, they’re less tolerant to friction that originates from penetration, which is not ideal whatsoever for pleasurable sex” (Cristina; female, 69 years old). Testicle pain and swelling can sometimes be caused by getting sexually aroused but not ejaculating. David affirmed “I do not like to admit but I have a huge problem ejaculating—regardless of how sexually aroused I become and how attracted I am to my partner, more often than I would like to admit, I just cannot ejaculate. Not only does that crush the ambient, but it also leaves me almost curled in a ball due to the sheer and stinging pain that it causes” (David; male, 87 years old). With menopause, women stop producing estrogen, and this can cause significant changes in their body and sexuality, such as vaginal dryness, natural lubrication decreases, which usually causes discomfort during penetration. Catherine admitted “Initially I was in pain, and I thought about stopping.” (Catherine; female, 81 years old). After a long time without practicing sexual activities, re-engaging in routine sex can be painful, and for that reason, older adults stop expressing themselves sexually. “If something causes me pain, I don’t want to continue doing it,” says Alexia (female, 78 years old). After several years, older adults may believe that they have enjoyed their sex life and that painful intercourse will not enhance sexual satisfaction. “I can live without expressing myself sexually, so if it causes me pain, I will not practice,” says Lily (female, 83 years old).
Theme 8: Difficulties Meeting New People
The least most important theme for these participants was difficulties meeting new people. This theme was mostly reported by Portuguese participants (nPort = 15 versus nSlov = 1). Beatrix reported that “I am generally afraid and overthink every single thing. Each time I try doing something I get these negative thoughts and “what if’s” overcrowd my mind, especially when trying to make conversation with someone I am attracted to. As a consequence, I just close myself in my shell and it is now been a significant amount of time since I have tried sexually engaging with a partner” Lily (Beatrix; female, 81 years old). Older adults can lack experience out of their comfort zone, mainly because of physical limitations. Martha says “While I still worked, I’d have at least one reason to get out of bed, exit the house and interact with others throughout the day. Ever since I retired, I started seeing no motive to go outside, so I just stayed inside and became sedentary. It is now been a couple of years since I have had a partner” (Martha; female, 78 years old). Some participants expressed boredom and monotony because they were afraid to engage in new experiences. “I have major difficulties when it comes to getting out of my comfort zone whether it’d be – meeting new people, socializing, taking part in events that might interest me or even, who knows, going on a rollercoaster ride – I am afraid of the outer world. Because of this lack of experiences, I have become a rather boring and monotonous person, so it becomes hard for other people to connect with me on an intimate sex level – I have nothing interesting to offer,” explained Gustavo (male, 67 years old). Older adults do not often attend social gatherings as this can be mentally and, sometimes, physically draining. Sam explained “I have been an introvert my whole life – it is just the way I am and I can’t help it. Despite my friends and family always having tried to bring me into parties and alike, I still refrain from going for the simple fact that I’ve experienced anxiety attacks while being among crowds too much noise – I want to avoid embarrassment. Though, I am still left with the thought of what it would be like meeting a partner and perhaps, who knows, sharing a thriving sexual relationship with them” (Sam; male, 78 years old). Talking to people and establishing a connection with them can also be seen as a challenge. Mary reported that “I’ve had my whole life to meet people and make friends, but I’m just not good at it. What changes if I try to get to know new people at this age? I have my old friends and I don’t need new ones. I know this does not make my sex life better, since I feel lonely once my partner died” (Mary; female, 70 years old). Tanja added that “I am a widow, no more sex for me. Now it is difficult to find new partners. And sometimes they are not good for relationships.” (Tanja, male, 66 years old).
Discussion
The aim of this cross-cultural study was to respond to the knowledge gap around older adults’ perceptions of factors that negatively influence their SWB. We found that older adults from different cultures perceived SU in diverse ways. The eight key themes arising from our data analysis were unavailability of partner, traditional values, body restrictions, low self-esteem and well-being, poor social support, dissatisfaction with physical appearance, pain during sex, and difficulties meeting new people. Unavailability of a partner was the most poignant indicator of SU, albeit mainly among Portuguese participants. In the Western countries, there are more women than older men who are living alone, and this disparity influences their rates of sexual activity and quality of life (Træen et al., 2016). Often the lack of a partner is due to widowhood. Widowhood is a predictor of loneliness, with this increasing the probability of being alone by 193% (Yang, 2020). The loss of spouse also increases mortality (Liu et al., 2019), decreases satisfaction with life (Nakagawa & Hülür, 2021), and is an indicator of poorer health and quality of life (Holm et al., 2019). All such factors limit widowed older people’s ability to have lived moments of intimacy and sexuality (Træen et al., 2016). Health status also seems to greatly influence aloneness in later life (Forward et al., 2020; Ilgaz & Gözüm, 2019). Cognitive difficulties, declines in autonomy and functional capacity, and chronic diseases are key causes of an ability to seek out sexual partners (Forward et al., 2020; Khanna & Metgud, 2020). Sensory losses (e.g., hearing loss, loss of sight) can hamper relational interaction (Kumar & Sharma, 2017), particularly among those living with neurodegenerative diseases (Cott & Tierney, 2013; Hancox et al., 2019). In addition, potential partner may need to assume the role of caregiver, with this not favoring marital relational equality and health (Liu et al., 2016). Older adults’ younger family members can sometimes be opposed to them forming new relationships. There can be discomfort around outsiders disrupting a family nucleus or material heritage (Hancox et al., 2019). However, being alone can be significantly influenced by the quality and quantity of older adults’ social support networks. When older adults have significant daily support, much of the caregiving that would be assigned to a partner can be carried out by a broader support network (Wu & Sheng, 2019). Traditional values were the second most prevalent indicator of SU, albeit mainly for Slovenian participants. Cultural, religious, and moral ideals contribute to passivity, resistance, and decline, and the inhibition of sexual behaviors in older age (Træen et al., 2016). Moreover, sex continues to be seen as a privilege of the young and beautiful (Træen et al., 2016). In this sense, there is a systematic denial of the merits of older individuals’ sexual pleasures and desires, with this perhaps manifesting as a lack of interest in sexual activity in later life (Foley, 2015). Likewise, the loss of reproductive capacity after menopause may contribute to the idea that women no longer wish to engage in sexual activity, mainly due to the persistence of a model of sexuality centered around child-bearing (Træen et al., 2016), and older men and andropause (Kumar & Sharma, 2017). Likewise, religious values often impact sexuality in older age (Liu et al., 2016). In particular, Judeo-Christian values promote the avoidance of sexuality and sexual pleasure (McFarland et al., 2010; Træen et al., 2016). Although there is not much scientific evidence on the relationship between religiosity and the experience of sexuality in later life (McFarland et al., 2010), religious values often place a strong emphasis on sex as a reproductive act (McFarland et al., 2010; Træen et al., 2016). All such beliefs can appropriate myths around asexuality and disinterest in older age (Liu et al., 2016). Religious beliefs can have a particular influence in situations where there is sex outside of marriage and in the practice of masturbation (Kumar & Sharma, 2017; McFarland et al., 2010). For single older people per se, there is also a negative relationship between satisfaction and sexual frequency and religiosity, particularly in older women (McFarland et al., 2010). Religious values can also influence the way in which older caregivers have more negative and restrictive attitudes about sexuality (Liu et al., 2016). Body restrictions were the third most common indicator of SU, mainly among Portuguese participants. Chronic diseases can decrease libido and provoke psychological consequences that influence various dimensions of self-perception, such as levels of self-esteem and self-concept (DeLamater & Koepsel, 2014; Hinchliff et al., 2017). For example, among older men, a lack of sexual pleasure has been linked to hypertension (DeLamater & Koepsel, 2014). Some medications, particularly those used to treat chronic cardiovascular disease, can negatively affect sexual desire and influence sexual expression among older people (Hinchliff et al., 2017). In addition, energy levels and negative moods can be influenced by chronic diseases, affect sexual function and sexual performance, and lead to decreases in positive self-regard (Rezasoltani et al., 2016). As such, adequate surveillance of chronic conditions and the maintenance of a healthy lifestyle can contribute to the prevention and reduction of sexual issues (DeLamater & Koepsel, 2014). Falls are also a major cause of immobility and loss of functionality. Functional capacity is essential for the occurrence of sexual activity in the older adults, although men and women have different risk profiles (Ek et al., 2018; Tran & Phan, 2017). In women, previous falls, living alone and instrumental dependence are associated with falls with significant consequences; in men, impaired chair stands, low systolic blood pressure, and previous falls are associated with falls of significant consequence (Ek et al., 2018). All such scenarios can potentially limit older people’s sexual experiences through enhanced physical limitations and dependence, and psychological vulnerability (Porta et al., 2020). It is reasonable to infer that there is an association between sexual life and health in older age (Lindau & Gavrilova, 2010). The four most pointed indicator of SU was low self-esteem and well-being, with this resonating most among Slovenian participants. A decrease in self-esteem and self-concept influences sexual function and sexual performance (Rezasoltani et al., 2016). The sense of self-esteem is closely linked to one’s sense of usefulness and purpose in life after retirement (Liu et al., 2016). Likewise, being healthy and independent, having a partner and feeling competent are generally identified as relevant precursors to positive self-concept in the older adults (Pinquart & Sörensen, 2001). Aging and the perceived loss of beauty is one of the most important threats to the self-esteem and sexual expression among older women (Kumar & Sharma, 2017), although beauty standards are also being increasingly pertinent among men (Kumar & Sharma, 2017). High levels of self-esteem can influence older adults’ self-confidence, resulting in a greater relational initiative (Liu et al., 2016). Furthermore, the availability of health resources and relational support are some of the variables that are also associated with self-concept (Choi et al., 2011; Pinquart & Sörensen, 2001). In most countries, aging is deeply associated with loss, such as the loss of the support network, physical capacities, cognitive skills, and usefulness at work. This mindset contributes to negative perceptions of older people and lower self-esteem among older people themselves (Katz, 2010). Decreases in self-concept and general well-being have implications for the mood and the psychological availability of older people, and consequently, their initiative to seek and openness to new partners (Katz, 2010). On the other hand, family support and regular physical activity can enhance older people’s sexual health and self-esteem (Liu et al., 2016). Poor social support was an indicator of SU in this study, mainly for Portuguese participants. Among older adults, reliable, close, and important people are generally family members who might also occupy caregiver and confidant roles; family support can be an important resource for older adults at the end of life (Porta et al., 2020). However, family relationships that are conflicting or negative often give rise to obligatory support, with this negatively affecting older people’s physical and mental well-being and consequently, their sexual health and availability (Merz & Huxhold, 2010). Adult children sometimes hinder finding and/or do not support a new partner, which may create a physical and psychological divide between older adults and their children (Bøen et al., 2012; Palacios-Ceña et al., 2012). In fact, social support relationships can allow common relationships to open up the possibility to potential partners (Bøen et al., 2012; Træen et al., 2016), and this is important because having a partner is a predictor of sexual inactivity (Palacios-Ceña et al., 2012). Furthermore, being married may help old people to feel younger and to be more health-conscious (Wong & Waite, 2015). Family issues can also influence the emotional stability of older adults such as through enhanced anxiety, and this can affect sexual expression and function (Dang et al., 2020; Xu et al., 2017). Furthermore, as the theory of socioemotional selectivity suggests, older people invest more time and energy into the quality rather than the quantity of supportive relationships (Dai et al., 2016). As such older people’s closest support resources (e.g., family) most influence their emotional states (Dang et al., 2020). Dissatisfaction with physical appearance was a frequent indicator of SU, mainly among Portuguese participants. Sexual activity in later life is closely associated with body image and sexual self-concept, particularly when it comes to initiating sexual behaviors (Liu et al., 2016). The way people experience their self-concept differs by sex. For example, while men’s self-concept is mainly associated with career development, women’s revolves more around social relationships (Jankowski et al, 2014; Pinquart & Sörensen, 2001). Women in general seem to be less satisfied than men with their bodies, particularly with regard to sexuality; however, older women seem to be less vulnerable and dissatisfied than younger women (Homan & Boyatzis, 2009; Træen et al., 2016). Older people’s self-concept influences how they perceive themselves and their sense of self-efficacy and self-sufficiency, and consequently, their propensity for specific sexual activities (Liu et al., 2016). Sexual satisfaction in later life has also been associated with positive body image and perceived attractiveness (Woertman & van den Brink, 2012), with body hypervigilance and shame perhaps diverting attention away from sexual pleasure and enhancing sexual difficulties (Claudat & Warren, 2014). Our youth-oriented and consumption-oriented culture marginalized older adults. Modern images of older bodies are limited to problematic bodies whereas younger bodies are associated with trendy lifestyles, appearances, and behaviors (Oberg & Tornstam, 2001). Nutrition is also essential. Weight loss among older adults can lead to cachexia and energy deficits which negatively impact their sex lives (Nieuwenhuizen et al., 2010; Oberg & Tornstam, 2001). Recent research has increasingly valued the practice of physical exercise, anti-aging elixirs, and sexual stigma (Foley, 2015). For example, older people, who engage in physical activity feel more confident about their image, are more sexually active and report fewer sexual issues (Smith et al., 2019). Accordingly, physical activity is likely to have a positive impact on older people’s body image, self-concept, and sexual satisfaction (Smith et al., 2019). Pain during sex was the second least indicator of SU, particular for Portuguese participants. Discomfort during sexual intercourse is a common problem in older women, especially in postmenopausal women, often decreasing sexual initiative (Ambler et al., 2012). Loss of sexual interest can result from a conditional expectation of significant discomfort during intercourse, but high anxiety can also cause sexual pain by decreasing blood flow to the vaginal area (Ambler et al., 2012; Laumann & Waite, 2008). However, using lubricants can lessen sexual pain during penetration (Kumar & Sharma, 2017). Small doses of estrogen vaginal cream can improve lubrication and decrease pain during intercourse; however, responses to estrogen often vary (Ambler et al., 2012; Sinković & Towler, 2018). Likewise, therapies to prevent vaginal pain among menopausal women can delay or prevention subsequent declines in sexual desire. The strong associations between psychological status, health in general, social factors, and sexual function highlight a need for primary health care practitioners to explore with older women how such factors concomitantly affect sexual dysfunction (Ambler et al., 2012; Sinković & Towler, 2018). Research suggests that yoga can be an effective pain reliever (Teut et al., 2016). However, chronic pain is often a problem that more holistically influences an individual’s general well-being, requiring a more general approach and is particularly important in preventing the influence of pain on sexual health (Teut et al., 2016). Discomfort with sex was a significant correlate for searching professional support for both older women and men Married Portuguese women with higher education are more likely to seek professional help. Among Portuguese men, level of education and religiosity play a role. It may be that older Portuguese women are more likely to disclose a need for professional help because a large number of doctors are trained in sexual medicine in Portugal (Hinchliff et al., 2019). Difficulties meeting new people were the least common indicator of SU, and this was mentioned mainly by Portuguese participants. Marked behavioral inhibition can be a warning sign of emotional distress among older adults, including sadness, depression, and anxiety (Freak-Poli et al., 2017). In this sense, it is essential to promote autonomy and to respect older adults’ decisions to engage in new affective and sexual relationships. Health professionals and family members need to be aware of the difficulties that older adults feel when it comes to expressing their sexuality (Freak-Poli et al., 2017). Older adults have difficulties finding new love relationships when they lose partners, with long-standing myths about “old” as asexual further hindering rather than helping them (Kumar & Sharma, 2017). Creating new relationships is closely associated with social networks and support, with adult children, friends, neighbors, and broader ties to a community being fundamental to older adults’ well-being and motivation (Jin et al., 2020). Other studies report negative associations between intergenerational social support and filial expectations, and older adults’ depressive symptoms among older adults which, in turn, dampen expressions of sexuality (Ding et al., 2020). Moreover, the perception among older adults that love and a new marriage is unacceptable in later life has been associated with less social activity (Kim et al., 2020). On the other hand, online relationships are becoming increasingly common in later life. Approximately one-third of older men and one-sixth of older women indicate that they have used the internet for sexual and amorous purposes (Træen et al., 2018). The use of the internet for sexual/relational purposes was higher among partnered people who were satisfied with their current level of sexual activity (Træen et al., 2018). Online relationships appear to be intimate and long-lasting; for some older people, cybersex is a routine practice (Træen et al., 2018). Still, older Portuguese men are less likely to view pornography, purchase of sexual products, and search for partners with commitment objectives over the internet (Træen et al., 2018).
The findings of this study indicate that specific themes that contribute to SU on both countries. Unavailability of partner was the most important theme (17.9%), especially for Portuguese participants. Conversely, difficulties meeting new people were the least reported theme (6.8%) for Portuguese and Slovenian participants. Slovenian participants reported that traditional values were most relevant to their SU.
It must be noted that these two countries show some socio-cultural similarities. Portugal and Slovenia are ranked among the safest countries in the world, which can contribute to a better quality of life, comfort and safety among older adults, even with frailty. In addition, the two countries show a mild climate, which may be associated with healthier lifestyles, in particular, sun exposure, and a Mediterranean diet (Institute for Economics and Peace (IEP), 2021; Veiga, 2019). Portugal and Slovenia also share common psychosocial factors that may have influenced current traditional values in these countries, particularly those relating to the experience of sexuality, such as the existence, in both countries, of dictatorial periods in the first half of the twentieth century; resulting in general repression, as well as sexual repression (Mazat, 2011; Veiga, 2019).
This study encompasses a number of limitations. The sample was not as ethnically diverse as we had hoped. We lack knowledge of SU perspectives among older people born outside of Slovenia and Portugal. Qualitative studies also tend to be subject to the researcher's prejudice (e.g., incidence of personal values), although researchers are not necessarily fully conscious of this (Goll et al., 2015). As such, researchers with a broad range of theoretical-practical knowledge are more likely to engage in richer and more objective analyses (Goll et al., 2015). In addition, although the older people in this study consented to being interviewed, their contributions may have been limited by their physical or intellectual autonomy (Goll et al., 2015; Kuh et al., 2014a; WHO, 2015). Furthermore, it is important to consider that the comparisons made between the data found in the two countries were not representative, and the results should not be generalized.
On the other hand, in qualitative studies with older adults, difficulties tend to occur in the focus and exploration of the topic addressed, often due to the long trajectory of life and lived experiences. Older adults tend to disperse from the central theme of the interview to parallel themes, and this deviation can create noise when analyzing the data (Kuh et al., 2014a, b; Monteiro et al., 2017; Phoenix, 2018). In semi-structured interviews, older adults tend to refer and feel tired and bored, which can influence the resources of attention and the quality of the information transmitted (Elder et al., 2015; Hinchliff et al., 2017). The quality of information being transmitted might also decline when interviews require abstract or demanding thinking (Monteiro et al., 2017; WHO, 2015; Zibad et al., 2017). Our study also has several strengths. The sample was diverse with respect to certain sociodemographic characteristics such as income. Many participants had also experienced significant age-related losses, including sexual expression. In these respects, the topic of sexuality was approached within a safe context. Seeking the perspectives of older people from two different countries allowed for more robust or culturally different conclusions to be drawn about the SWB. This study contributes to a better understanding of essential and little-explored aspects of sexual health that can inform clinical prevention and intervention work. Likewise, this study offers empirical substance with which to structure sexual health interventions, mainly plans and action programs for sexual psychoeducation in different cultural contexts. This qualitative study on the SWB also allows older adults to reflect on aspects of their sexual health that are often overlooked due to long-standing myths about sexuality in later life. It should also be noted that future interventions targeting older groups will need to address individual beliefs, as well as structural and social factors (i.e., transportation issues, social networks) to optimize participation. The results of this qualitative study indicate that it is necessary that older participants understand the need for and the importance of a community-based qualitative study, which may contribute significantly to understanding SWB and sexual health. An approach that explores the indicators that can harm or improve SWB is essential to spread knowledge and promote public dialogue that can challenge existing stereotypes and myths that render sexual activity and wellness as matters of importance for younger generations. Studies that promote older people’s perspectives about issues of sexuality play a very important social role in changing policies. This study is part of the international body of research that, as stated by the World Health Organization and the World Association for Sexual Health, contribute to the monitoring and evaluation of the sexual health of the older adults. Furthermore, this article is part of the body of research that contributed to changes in national policies, namely with the establishment of the national sexual health day which was unanimously approved in the Portuguese parliament on June 9th of this year (SPSC, 2021). In addition to affecting social policy change, we need to think about the clinical consequences of SU and preferably much earlier in the life course (Træen & Villar, 2020). Research about and the applicability of sexual health in later life has to be elaborated upon from a preventive rather than a reactive perspective.
Availability of Data and Material
This manuscript has associated data in a data repository.
Code Availability
No software application or custom code was used for the coding process.
References
Ambler, D. R., Bieber, E. J., & Diamond, M. P. (2012). Sexual function in elderly women: A review of current literature. Reviews in Obstetrics & Gynecology, 5, 16–27. https://doi.org/10.3909/riog0156
Bengtsson, M. (2016). How to plan and perform a qualitative study using content analysis. NursingPlus Open, 2, 8–14. https://doi.org/10.1016/j.npls.2016.01.001
Bøen, H., Dalgard, O. S., & Bjertness, E. (2012). The importance of social support in the associations between psychological distress and somatic health problems and socio-economic factors among older adults living at home: A cross sectional study. BMC Geriatrics, 12, 27–39. https://doi.org/10.1186/1471-2318-12-27
Bouman, W. P. (2013). Sexuality in later life. In T. Dening., A. Thomas (Eds.). The Oxford textbook of old age psychiatry (pp.703–723). Oxford: Oxford University Press.
Camacho, M. E., & Reyes-Ortiz, C. A. (2005). Sexual dysfunction in the elderly: Age or disease? International Journal of Impotence Research, 17(S1), S52–S56. https://doi.org/10.1038/sj.ijir.3901429
Carneiro, F. A., Costa, P. A., & Leal, I. (2019). Psychometric analysis of the Portuguese version of the family sense of coherence. Psicologia, Saúde & Doenças, 20(3), 838–858. https://doi.org/10.15309/19psd200322
Choi, K. -B., Jang, S. -H., Lee, M. -Y., & Kim, K. -H. (2011). Sexual life and self-esteem in married elderly. Archives of Gerontology and Geriatrics, 53(1), e17–e20. https://doi.org/10.1016/j.archger.2010.08.011
Claudat, K., & Warren, C. S. (2014). Self-objectification, body self-consciousness during sexual activities, and sexual satisfaction in college women. Body Image, 11(4), 509–515. https://doi.org/10.1016/j.bodyim.2014.07.006
Cott, C. A., & Tierney, M. C. (2013). Acceptable and unacceptable risk: Balancing everyday risk by family members of older cognitively impaired adults who live alone. Health, Risk & Society, 15(5), 402–415. https://doi.org/10.1080/13698575.2013.801936
Cuenca-Barrales, C., Ruiz-Villaverde, R., & Molina-Leyva, A. (2019). Sexual distress in patients with hidradenitis suppurativa: A cross-sectional study. Journal of Clinical Medicine, 8(4), 532. https://doi.org/10.3390/jcm8040532
Dai, Y., Zhang, C. -Y., Zhang, B. -Q., Li, Z., Jiang, C., & Huang, H. -L. (2016). Social support and the self-rated health of older people. Medicine, 95, 24–38. https://doi.org/10.1097/md.0000000000003881
Dang, Q., Bai, R., Zhang, B., & Lin, Y. (2020). Family functioning and negative emotions in older adults: the mediating role of self-integrity and the moderating role of self-stereotyping. Aging & Mental Health, 1–8. https://doi.org/10.1080/13607863.2020.1799940
DeLamater, J., & Koepsel, E. (2014). Relationships and sexual expression in later life: A biopsychosocial perspective. Sexual and Relationship Therapy, 30, 37–59. https://doi.org/10.1080/14681994.2014.939506
Ding, Z., Yang, Q., Xiong, J., Yang, L., & Yin, S. (2020). The relationship between filial expectations and depressive symptoms in Chinese older adults: The mediating role of intergenerational social support. Journal of Adult Development, 28(2), 162–169. https://doi.org/10.1007/s10804-020-09360-2
Elder, W. B., Morrow, S. L., & Brooks, G. R. (2015). Sexual self-schemas of gay men. The Counseling Psychologist, 43, 942–969. https://doi.org/10.1177/0011000015606222
Ek, S., Rizzuto, D., Fratiglioni, L., Calderón-Larrañaga, A., Johnell, K., Sjöberg, L., & Welmer, A. -K. (2018). Risk factors for injurious falls in older adults: The role of sex and length of follow-up. Journal of the American Geriatrics Society, 67(2), 246–253. https://doi.org/10.1111/jgs.15657
Elo, S., Kääriäinen, M., Kanste, O., Pölkki, T., Utriainen, K., & Kyngäs, H. (2014). Qualitative Content Analysis. SAGE Open, 4(1), 215–244. https://doi.org/10.1177/2158244014522633
Erlingsson, C., & Brysiewicz, P. (2017). A hands-on guide to doing content analysis. African Journal of Emergency Medicine, 7(3), 93–99. https://doi.org/10.1016/j.afjem.2017.08.001
EuroNews. (2016). O envelhecimento da Europa exige respeito [Europe's aging demands respect]. Retrieved from https://pt.euronews.com/next/2016/11/15/o-envelhecimento-da-europaexige-respeito
Ferreira-Valente, A., Sharma, S., Torres, S., Smothers, Z., Pais-Ribeiro, J., Abbott, J. H., & Jensen, M. P. (2019). Does religiosity/spirituality play a role in function, pain-related beliefs, and coping in patients with chronic pain? A systematic review. Journal of Religion and Health, 1–55. https://doi.org/10.1007/s10943-019-00914-7
Fileborn, B., Thorpe, R., Hawkes, G., Minichiello, V., Pitts, M., & Dune, T. (2015). Sex, desire and pleasure: Considering the experiences of older Australian women. Sexual and Relationship Therapy, 30(1), 117–130. https://doi.org/10.1080/14681994.2014.936722
Foley, S. (2015). Older adults and sexual health: A review of current literature. Current Sexual Health Reports, 7, 70–79. https://doi.org/10.1007/s11930-015-0046-x
Forward, C., Khan, H. T. A., & Fox, P. (2020). The health and well-being of older women living alone in the United Kingdom and beyond: A scoping review. Journal of Women & Aging, 1–14. https://doi.org/10.1080/08952841.2020.1788365
Freak-Poli, R., Kirkman, M., De Castro Lima, G., Direk, N., Franco, O. H., & Tiemeier, H. (2017). Sexual activity and physical tenderness in older adults: Cross-sectional prevalence and associated characteristics. The Journal of Sexual Medicine, 14(7), 918–927. https://doi.org/10.1016/j.jsxm.2017.05.010
Gewirtz-Meydan, A., Levkovich, I., Mock, M., Gur, U., Karkabi, K., & Ayalon, A. (2020). Sex for seniors: How physicians discuss older adult’s sexuality. Israel Journal of Health Policy Research, 9, 8–17. https://doi.org/10.1186/s13584-020-00366-5
Gledhill, S., & Schweitzer, R. D. (2013). Sexual desire, erectile dysfunction and the biomedicalization of sex in older heterosexual men. Journal of Advanced Nursing, 70(4), 894–903. https://doi.org/10.1111/jan.12256
Goll, J. C., Charlesworth, G., Scior, K., & Stott, J. (2015). Barriers to social participation among lonely older adults: The influence of social fears and identity. PLoS ONE, 10, 1–17. https://doi.org/10.1371/journal.pone.0116664
Hald, G. M., Graham, C., Štulhofer, A., Carvalheira, A., Janssen, E., & Træen, B. (2019). Prevalence of sexual problems and associated distress in aging men across 4 European countries. The Journal of Sexual Medicine, 16(8), 1212–1225. https://doi.org/10.1016/j.jsxm.2019.04.017
Hamilton, L. D., & Julian, A. M. (2014). The relationship between daily hassles and sexual function in men and women. Journal of Sex & Marital Therapy, 40(5), 379–395. https://doi.org/10.1080/0092623x.2013.864364
Hancox, J. E., van der Wardt, V., Pollock, K., Booth, V., Vedhara, K., & Harwood, R. H. (2019). Factors influencing adherence to home-based strength and balance exercises among older adults with mild cognitive impairment and early dementia: Promoting activity, independence and stability in early dementia (PrAISED). PLoS ONE, 14(5), e0217387. https://doi.org/10.1371/journal.pone.0217387
Harvard Health Publishing. (2020, October). Attitudes about sexuality and aging. Retrieved at May 13, from https://www.health.harvard.edu/stayinghealthy/attitudes-about-sexuality-and-aging
Hinchliff, S., Carvalheira, A. A., Štulhofer, A., Janssen, E., Hald, G. M., & Træen, B. (2019). Seeking help for sexual difficulties: Findings from a study with older adults in four European countries. European Journal of Ageing, 17(2), 185–195. https://doi.org/10.1007/s10433-019-00536-8
Hinchliff, S., Tetley, J., Lee, D., & Nazroo, J. (2017). Older adults’ experiences of sexual difficulties: Qualitative findings from the English Longitudinal Study on Ageing (ELSA). The Journal of Sex Research, 55, 152–163. https://doi.org/10.1080/00224499.2016.1269308
Holm, A. L., Berland, A. K., & Severinsson, E. (2019). Factors that influence the health of older widows and widowers - A systematic review of quantitative research. Nursing Open, 6(2), 591–611. https://doi.org/10.1002/nop2.243
Homan, K. J., & Boyatzis, C. J. (2009). Body image in older adults: Links with religion and gender. Journal of Adult Development, 16, 230–238. https://doi.org/10.1007/s10804-009-9069-8
Ilgaz, A., & Gözüm, S. (2019). Health promotion interventions for older people living alone: A systematic review. Perspectives in Public Health, 139(5), 255–263. https://doi.org/10.1177/1757913918803980
Institute for Economics & Peace (IEP). (2021). Global Peace Index 2021. Author.
Jankowski, G. S., Diedrichs, P. C., Williamson, H., Christopher, G., & Harcourt, D. (2014). Looking age-appropriate while growing old gracefully: A qualitative study of ageing and body image among older adults. Journal of Health Psychology, 21(4), 550–561. https://doi.org/10.1177/1359105314531468
Jin, Y., Si, H., Qiao, X., Tian, X., Liu, X., Xue, Q. -L., & Wang, C. (2020). Relationship between frailty and depression among community-dwelling older adults: The mediating and moderating role of social support. The Gerontologist, 60(8), 1466–1475. https://doi.org/10.1093/geront/gnaa072
Katz, S. (2010). Sociocultural perspectives on ageing bodies. In D. Dannefer & C. Phillipson (Eds.), The SAGE Handbook of Social Gerontology (pp. 357–366). SAGE Publications.
Khanna, A., & Metgud, C. (2020). Prevalence of cognitive impairment in elderly population residing in an urban area of Belagavi. Journal of Family Medicine and Primary Care, 9(6), 2699. https://doi.org/10.4103/jfmpc.jfmpc_240_20
Kim, J. Y., Xu, H., Cruz, G., Saito, Y., & Østbye, T. (2020). Acceptance of love and remarriage among older adults in the Philippines. Journal of Aging and Health, 33(5–6), 331–339. https://doi.org/10.1177/0898264320981246
Klavs, I., Rodrigues, L. C., Weiss, H. A., & Hayes, R. (2006). Factors associated with early sexual debut in Slovenia: Results of a general population survey. Sexually Transmitted Infections, 82(6), 478–483. https://doi.org/10.1136/sti.2006.019984
Kuh, D., Cooper, R., Hardy, R., Richards, M., & Ben-Shlomo, Y. (2014a). A life course approach to healthy ageing. Oxford University Press.
Kuh, D., Karunananthan, S., Bergman, H., & Cooper, R. (2014b). A life-course approach to healthy ageing: Maintaining physical capability. Proceedings of the Nutrition Society, 73, 237–248. https://doi.org/10.1017/s0029665113003923
Kumar, A., & Sharma, M. (2017). Basics of human andrology. Springer.
Laumann, E. O., & Waite, L. J. (2008). Sexual dysfunction among older adults: Prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57–85 years of age. The Journal of Sexual Medicine, 5(10), 2300–2311. https://doi.org/10.1111/j.1743-6109.2008.00974.x
Lindau, S. T., & Gavrilova, N. (2010). Sex, health, and years of sexually active life gained due to good health: Evidence from two US population based cross sectional surveys of ageing. BMJ, 340, c810–c810. https://doi.org/10.1136/bmj.c810
Liu, H., Jiang, Q., & Feldman, M. W. (2019). Widowhood and mortality risk of older people in rural China: Do gender and living arrangement make a difference? Ageing and Society, 40(9), 1939–1955. https://doi.org/10.1017/s0144686x19000436
Liu, H., Waite, L. J., Shen, S., & Wang, D. H. (2016). Is sex good for your health? A national study on partnered sexuality and cardiovascular risk among older men and women. Journal of Health and Social Behavior, 57(3), 276–296. https://doi.org/10.1177/0022146516661597
Mazat, N. (2011). Tito's Yugoslavia: The genesis of an original state in the context of the Cold War (1945–1965). História, 39.
McFarland, M. J., Uecker, J. E., & Regnerus, M. D. (2010). The role of religion in shaping sexual frequency and satisfaction: Evidence from married and unmarried older adults. The Journal of Sex Research, 48(2–3), 297–308. https://doi.org/10.1080/00224491003739993
Merz, E. M., & Huxhold, O. (2010). Wellbeing depends on social relationship characteristics: Comparing different types and providers of support to older adults. Ageing and Society, 30, 843–857. https://doi.org/10.1017/s0144686x10000061
Monteiro, A., von Humboldt, S., & Leal, I. (2017). How do formal caregivers experience the sexuality of older adults? Beliefs and attitudes towards older adults’ sexuality. Psychology, Community & Health, 6, 77–92. https://doi.org/10.5964/pch.v6i1.216
Nakagawa, T., & Hülür, G. (2021). Life satisfaction during the transition to widowhood among Japanese older adults. Gerontology, 1–12.https://doi.org/10.1159/000512859
Nieuwenhuizen, W. F., Weenen, H., Rigby, P., & Hetherington, M. M. (2010). Older adults and patients in need of nutritional support: Review of current treatment options and factors influencing nutritional intake. Clinical Nutrition, 29(2), 160–169. https://doi.org/10.1016/j.clnu.2009.09.003
Oberg, P., & Tornstam, L. (2001). Youthfulness and fitness - Identity ideals for all ages? Journal of Aging & Identity, 6(1), 15–29. https://doi.org/10.1023/A:1009524612420
Palacios-Ceña, D., Carrasco- Garrido, P., Hernández- Barrera, V., Alonso- Blanco, C., Jiménez- García, R., & Fernández- de- las- Peñas, C. (2012). Sexual behaviors among older adults in Spain: Results from a population- based national sexual health survey. The Journal of Sexual Medicine, 9(1), 121–129. https://doi.org/10.1111/j.1743-6109.2011.02511.x
Phoenix, C. (2018). Why qualitative research is needed in gerontology and how we can do it better. The Journals of Gerontology: Series B, 73, e81–e85. https://doi.org/10.1093/geronb/gby079
Pinquart, M., & Sörensen, S. (2001). Gender differences in self-concept and psychological well-being in old age: A meta-analysis. Journal of Gerontology, 4, 195–213. https://doi.org/10.1093/geronb/56.4.P195
Porta, S., Martínez, A., Millor, N., Gómez, M., & Izquierdo, M. (2020). Relevance of sex, age and gait kinematics when predicting fall-risk and mortality in older adults. Journal of Biomechanics, 105, 109723. https://doi.org/10.1016/j.jbiomech.2020.109723
Rezasoltani, P., Merghati-Khoei, E., Pirak, A., & Yazdkhasti, M. (2016). Sexuality and elderly with chronic diseases: A review of the existing literature. Journal of Research in Medical Sciences, 21, 136–145. https://doi.org/10.4103/1735-1995.196618
Ribeiro-Gonçalves, J. A., Pereira, H., Costa, P. A., Leal, I., & de Vries, B. (2022). Loneliness, social support, and adjustment to aging in older Portuguese gay men. Sexual Research and Social Policy 19, 207–219. https://doi.org/10.1007/s13178-021-00535-4
Saldaña, J. (2009). The coding manual for qualitative researchers. Sage Publications.
Sampaio, R., & Lycarião, D. (2018). Eu quero acreditar! Da importância, formas de uso e limites dos testes de confiabilidade na Análise de Conteúdo [I want to believe! The importance, forms of use and limits of reliability tests in Content Analysis]. Revista De Sociologia e Política, 26(66), 31–47. https://doi.org/10.1590/1678-987318266602
Sinković, M., & Towler, L. (2018). Sexual aging: A systematic review of qualitative research on the sexuality and sexual health of older adults. Qualitative Health Research, 29(9), 1239–1254. https://doi.org/10.1177/1049732318819834
Smith, L., Grabovac, I., Yang, L., Veronese, N., Koyanagi, A., & Jackson, S. E. (2019). Participation in physical activity is associated with sexual activity in older english adults. International Journal of Environmental Research and Public Health, 16, 489–503. https://doi.org/10.3390/ijerph16030489
Simetinger, G., & Otorepec, I. (2017). Sexuality education in Slovenia. The Journal of Sexual Medicine, 14(5), e350. https://doi.org/10.1016/j.jsxm.2017.04.732
Sociedade Portuguesa de Sexologia Clínica. (2021). Dia Nacional da Saúde Sexual [Sexual Health National Day]. Retrieved in June, 13 from Dia Nacional da Saúde Sexual – SPSC.
Štulhofer, A., Hinchliff, S., & Træen, B. (2019). Relationship intimacy, sexual distress, and help-seeking for sexual problems among older European couples: A hybrid dyadic approach. International Journal of Impotence Research, 32(5), 525–534. https://doi.org/10.1038/s41443-019-0214-z
Štulhofer, A., Jurin, T., Graham, C., Enzlin, P., & Træen, B. (2018). Sexual well-being in older men and women: Construction and validation of a multi-dimensional measure in four European countries. Journal of Happiness Studies, in Press. https://doi.org/10.1007/s10902-018-0049-1
Syme, M. L., Cordes, C. C., Cameron, R. P., & Mona, L. R. (2015). Sexual health and well-being in the context of aging. In P. A. Lichtenberg, B. T. Mast, B. D. Carpenter, & J. Loebach Wetherell (Eds.), APA handbooks in psychology®. APA handbook of clinical geropsychology, Vol. 2. Assessment, treatment, and issues of later life (p. 395–412). American Psychological Association.
Teut, M., Knilli, J., Daus, D., Roll, S., & Witt, C. M. (2016). Qigong or yoga versus no intervention in older adults with chronic low back pain - A randomized controlled trial. The Journal of Pain, 17(7), 796–805. https://doi.org/10.1016/j.jpain.2016.03.003
Træen, B., Carvalheira, A., Kvalem, I. L., Štulhofer, A., Janssen, E., Graham, C. A., & Enzlin, P. (2016). Sexuality in older adults (65+) - An overview of the recent literature, Part 2: Body image and sexual satisfaction. International Journal of Sexual Health, 29, 11–21. https://doi.org/10.1080/19317611.2016.1227012
Træen, B., Carvalheira, A., Kvalem, I. L., & Hald, G. M. (2018). European older adults’ use of the Internet and social networks for love and sex. Cyberpsychology: Journal of Psychosocial Research on Cyberspace, 12(3). https://doi.org/10.5817/cp2018-3-1
Træen, B., & Villar, F. (2020). Sexual well-being is part of aging well. European Journal of Ageing, 17(2), 135–138. https://doi.org/10.1007/s10433-020-00551-0
Tran, T. V., & Phan, P. T. (2017). Serious psychological distress, sex, and falls among the elderly. Journal of Women & Aging, 30(1), 75–84. https://doi.org/10.1080/08952841.2016.1265373
Trigueirão, S. (2020). Meio milhão de idosos vivem sozinhos em Portugal. A maioria são mulheres [Half a million elderly people live alone in Portugal. Most are women]. Retrieved from https://www.publico.pt/2020/06/23/sociedade/noticia/meio-milhao-idososvivem-sozinhos-portugal-maioria-sao-mulheres-1921576
Veiga, E. (2019). What makes Slovenia one of the safest countries in the world. BBC News. Retrieved from https://www.bbc.com/portuguese/internacional-48232878
von Humboldt, S., Carneiro, F., & Leal, I. (2020). Older lesbian, gay, and bisexual adults: What predicts adjustment to aging? Sexuality Research and Social Policy, 18, 1042–1048. https://doi.org/10.1007/s13178-020-00507-0
von Humboldt, S., & Leal, I. (2014a). Adjustment to aging in old adulthood: A systematic review. International Journal of Gerontology, 8(5), 108–113. https://doi.org/10.1016/j.ijge.2014.03.003
von Humboldt, S., & Leal, I. (2014b). What influences older adults’ subjective well-being: A systematic review. Revista Argentina De Clínica Psicológica, 23, 219–230.
von Humboldt, S., & Leal, I. (2015a). The old and the oldest old: Do they have different perspectives on adjustment to aging? International Journal of Gerontology, 9(3), 156–160. https://doi.org/10.1016/j.ijge.2015.04.002
von Humboldt, S., & Leal, I. (2015b). The orientation to life questionnaire: Validation of a measure to assess older adults’ sense of coherence. Educational Gerontology, 41(6), 451–465. https://doi.org/10.1080/03601277.2014.983373
von Humboldt, S., & Leal, I. (2017). Correlates of adjustment to aging among the young-old and the oldest-old: A comparative analysis. Educational Gerontology, 43(4), 175–185. https://doi.org/10.1080/03601277.2016.1272355
von Humboldt, S., Leal, I., & Pimenta, F. (2013a). Analyzing adjustment to aging and subjective age from Angolan and Portuguese community-dwelling older adults’ perspectives. International Journal of Gerontology, 27(4), 209–215. https://doi.org/10.1016/j.ijge.2013.05.001
von Humboldt, S., Leal, I., & Pimenta, F. (2013b). Staying well in old age: Predicting older adults’ wellness. Health SA Gesondheid, 18(1), 717–726. https://doi.org/10.4102/hsag.v18i1.717
von Humboldt, S., Leal, I., & Pimenta, F. (2014a). Does spirituality really matter? - A study on the potential of spirituality to older adult’s adjustment to aging. Japanese Psychological Research, 56, 114–125. https://doi.org/10.1111/jpr.12033
von Humboldt, S., Leal, I., & Pimenta, F. (2014b). What predicts older adults’ adjustment to aging in later life? The impact of sense of coherence, subjective well-being and socio-demographic, lifestyle and health-related factors. Educational Gerontology, 40(9), 641–654. https://doi.org/10.1080/03601277.2013.860757
von Humboldt, S., Leal, I., Pimenta, F., & Niculescu, G. (2013c). In the eyes of older adults: Self-reported age and adjustment in African and European older adults. Health SA Gesondheid, 18(1), 712–722. https://doi.org/10.4102/hsag.v18i1.712
von Humboldt, S., Leal, I., Pimenta, F., & Maroco, J. (2014c). Assessing adjustment to aging: A validation study for the adjustment to aging scale (AtAS). Social Indicators Research, 119(1), 455–472. https://doi.org/10.1007/s11205-013-0482-9
von Humboldt, S., Low, L., & Leal, I. (2020a). Are older adults satisfied with their sexuality? Outcomes from a cross-cultural study. Educational Gerontology, 46, 284–293. https://doi.org/10.1080/03601277.2020.1744805
von Humboldt, S., Monteiro, A., & Leal, I. (2018). How do older adults experience intergenerational relationships? Different cultures, ambivalent feelings. Educational Gerontology, 44(8), 501–513. https://doi.org/10.1080/03601277.2018.1520528
von Humboldt, S., Ribeiro-Gonçalves, J. A., Costa, A., Low, G., Benko, E., & Leal, I. (2022). Sexual well-being in older adults: A qualitative study with older adults from Portugal and Slovenia. Sexuality Research and Social Policy. https://doi.org/10.1007/s13178-022-00709-8
von Humboldt, S., Ribeiro-Gonçalves, J. A., Costa, A., Low, G., & Leal, I. (2020b). Sexual expression in old age: How older adults from different cultures express sexually? Sexuality Research and Social Policy, 1–15. https://doi.org/10.1007/s13178-020-00453-x
Woertman, L., & van den Brink, F. (2012). Body image and female sexual functioning and behavior: A review. The Journal of Sex Research, 49(2–3), 184–211. https://doi.org/10.1080/00224499.2012.658586
Wong, J. S., & Waite, L. J. (2015). Marriage, social networks, and health at older ages. Journal of Population Ageing, 8, 7–25. https://doi.org/10.1007/s12062-014-9110-y
World Health Organization (WHO). (2015). World report on ageing and health. Author.
Wu, F., & Sheng, Y. (2019). Social support network, social support, self-efficacy, healthpromoting behavior and healthy aging among older adults: A pathway analysis. Archives of Gerontology and Geriatrics, 85, 103934. https://doi.org/10.1016/j.archger.2019.103934
Xu, L., Liu, J., Mao, W., & Chi, I. (2017). Family relationships, friend network, and worry: A comparison among Chinese older adults in immigrant, transnational, and nonmigrant families. Journal of Ethnic & Cultural Diversity in Social Work, 28(3), 317–333. https://doi.org/10.1080/15313204.2017.1344950
Yang, F. (2020). Widowhood and loneliness among Chinese older adults: The role of education and gender. Aging & Mental Health, 18, 1–10. https://doi.org/10.1080/13607863.2020.1732293
Zibad, H. A., Foroughan, M., Shahboulaghi, F. M., Rafiey, H., & Rassouli, M. (2017). Perception of spiritual health: A qualitative content analysis in Iranian older adults. Educational Gerontology, 43, 21–32. https://doi.org/10.1080/03601277.2016.1231521
Acknowledgements
The authors would like to say special thanks to Katarina Babnik for her contribution to the data collection in Slovenia.
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This work was supported by the Portuguese Foundation for Science and Technology (FCT), under Grant [number SFRH/BPD/116114/2016].
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SVH: study concept and design, analysis and interpretation of data, recruitment of subjects, preparation of manuscript; JR: preparation of manuscript; JARG: preparation of manuscript; EB: preparation of manuscript; GL: study concept Title page listing all authors and affiliations and design, interpretation of data IL: study concept and design, interpretation of data. All authors read and approved the final manuscript.
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von Humboldt, S., Rolo, J., Ribeiro-Gonçalves, J.A. et al. What Distresses Sexual Well-Being Among Older Adults in Different Cultures? A Qualitative Study with Slovenian and Portuguese Older Adults. Sex Res Soc Policy 20, 377–390 (2023). https://doi.org/10.1007/s13178-022-00765-0
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DOI: https://doi.org/10.1007/s13178-022-00765-0