Sexual Health is Often the Neglected Component of Care

Margaret C Gibson, PhD, CPsych
Psychologist
Veterans Care Program
Parkwood Hospital Site
St. Joseph's Health Centre
London, Ontario

Sexual health is defined by the World Health Organization as the integration of the physical, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.¹ Sexual health includes elements that are sensory, cognitive, emotional, physical, spiritual, functional, relational, social, cultural and historical. It reflects our basic concepts of ourselves as male, female, man, woman, child, mother, father, partner, lover and friend. Sexual health includes overt sexual behaviours, but is about much more than behaviours alone. It is about who we are, about our connections to others with whom we share both basic evolutionary drives and the capacity for profound interpersonal bonds. Sexual health involves having a sense of comfort with the life course of one's own sexuality. It is an integral part of overall psychological well-being and quality of life.

"In our experience, old folks stop having sex for the same reasons they stop riding a bicycle--general infirmity, thinking it looks ridiculous, no bicycle " Alex Comfort

Sexual thoughts, feelings, interests and behaviours persist across the lifespan. The best predictor of current sexual interest is past sexual interest. The best predictor of current sexual behaviour is past sexual behaviour, tempered by present opportunity. In 1974, Alex Comfort, a pioneering advocate for respect of sexuality in the elderly, wrote: "In our experience, old folks stop having sex for the same reasons they stop riding a bicycle--general infirmity, thinking it looks ridiculous, no bicycle…"² Unfortunately, however, for the elderly, sexual health is an often neglected aspect of well-being. Comfort says the greatest reason for this "is the social image of the dirty old man and the asexual, undesirable older woman."²

While these negative stereotypes are still encountered twenty-five years later, progress is occurring. There is a growing body of literature that can assist the health care provider to become more sensitive and helpful regarding sexual issues and the elderly. Publications address sexual health education,³ sexual health programming and policy development,⁴ the health professional's role,⁵ responding to inappropriate sexual behaviour⁶ and disease-related hypersexuality,⁷ sexual assessment,⁸ and talking to the elderly about sex.⁹

Typical impact of dementia on sexual behaviour

Gradual decline in initiation of sexual activity (hypersexuality is possible) Sequencing problems Disorientation to person, place Continuing need for affection, reassurance, comfort, touch

Promoting sexual health in the context of dementia is a particularly challenging task.¹⁰ Often the potential impact of the disease on sexual functioning is avoided by both health care providers and family members. As a result, behavioural changes in this area are unanticipated and provoke crises in care planning and delivery. As an alternative, information about the changes that can occur in sexual functioning as dementia progresses can be included in education provided for family members about other aspects of the disease process. Prepared family members can better cope when their values and expectations come into conflict with the changing behaviours and changing image of their wife, husband, father or mother.

Spouses, and other family members as appropriate, can be helped to understand that there may be changes in sexual behaviours as there are in other behaviours as the dementia progresses. Typical changes may include a gradual decline in the initiation of sexual activity, although hypersexuality occurs in some instances. The same sequencing problems that impair independence and self-care in other